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Pathophysiology > Week 2 CHD/Valular disease > Flashcards

Week 2 CHD/Valular disease Flashcards

1
Q
  1. Question: A 68-year-old patient with a history of severe aortic stenosis (AS) and compensated left ventricular hypertrophy is undergoing elective non-cardiac surgery. Intraoperatively, which hemodynamic parameter should be most meticulously managed to avoid exacerbating the patient’s condition?
A

HR

Avoid tachycardia: reduced diastolic filling time causes poor O2 delivery to thick myocardium
Avoid bradycardia: low CO and inability to compensate with increased SV due to fixed LV space

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2
Q
  1. Question: A patient with severe mitral regurgitation (MR) due to rheumatic heart disease presents for surgery. During anesthesia, which of the following is a key management strategy?
A

avoid excess IVF to prevent HF

Avoid bradycardia & high SVR
Maintain forward SV and CO

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3
Q
  1. Question: In a patient with aortic regurgitation (AR) and left ventricular dilation, which anesthetic management strategy is the least appropriate?
A

Inducing mild hypotension to reduce regurgitant volume

Least = maintaining low HR
Best = modest increase in HR and modest decrease in SVR

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4
Q
  1. Question: A 72-year-old patient with chronic aortic stenosis (AS) and concentric left ventricular hypertrophy is scheduled for aortic valve replacement. During the perioperative period, which parameter should be most rigorously controlled?
A

increased afterload

(bc the hypertrophied heart cannot tolerate the increase SVR)

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5
Q
  1. Question: A patient with severe mitral stenosis (MS) and atrial fibrillation (AF) is undergoing elective surgery. What is the most critical aspect to manage intraoperatively?
A

Maintain a controlled, moderate HR

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6
Q
  1. Question: In a patient with advanced tricuspid regurgitation (TR) and right ventricular (RV) dilation, what is the key anesthetic management strategy?
A

avoid hypoTN to maintain CPP (use inotropes cautiously)

Maintain intravascular fluid volume and maintain high CVP to facilitate RV preload and RV filling

Avoid high CO2, hypoxia, hypotension → worsen RVF

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7
Q
  1. Question: For a patient with compensated hypertrophic obstructive cardiomyopathy (HOCM) undergoing non-cardiac surgery, which anesthetic consideration is most critical?
A

avoid tachycardia

goal is to maintain CO

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8
Q
  1. Question: During a complex spine surgery, a patient with mixed valvular heart disease (severe aortic stenosis and moderate mitral regurgitation) experiences sudden hypotension. What is the most appropriate initial management step?
A

immediate use of vasopressor

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9
Q
  1. Question: A 68-year-old patient with severe aortic regurgitation (AR) is scheduled for elective non-cardiac surgery. Which hemodynamic goal is most critical during surgery?
A

slightly increased HR to reduce diastolic regurgitant

also avoid abrupt increases in SVR

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10
Q
  1. Question: In a patient with severe mitral stenosis (MS) and atrial fibrillation (AF), which management strategy is most critical during anesthesia?
A

maintenance of a controlled, moderate HR

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11
Q
  1. Question: A patient with compensated hypertrophic obstructive cardiomyopathy (HOCM) is undergoing non-cardiac surgery. Which anesthetic consideration is most critical?
A

avoid tachycardia

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12
Q
  1. Question: A 25-year-old patient with a history of unrepaired atrial septal defect (ASD) is scheduled for noncardiac surgery. Which of the following anesthetic considerations is most important?
A

Avoid air bubbles in all IV lines due to risk for paradoxical emboli

Avoid drop in PVR and increase in SVR

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13
Q
  1. Question: A patient with a history of ventricular septal defect (VSD) repaired in childhood now presents for elective surgery. Which of the following findings on preoperative evaluation would be most concerning?
A

evidence of RV hypertrophy

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14
Q
  1. Question: During the anesthesia for a patient with Tetralogy of Fallot (TOF), which of the following interventions is most likely to decrease the right-to-left shunt?
A

increasing SVR

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15
Q
  1. Question: A patient with Eisenmenger syndrome is undergoing a non-cardiac surgery. What is the most appropriate strategy for fluid management in this patient?
A

Balance fluid administration with close monitoring of hemodynamics

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16
Q
  1. Question: In managing a patient with transposition of the great arteries (TGA) repaired with an atrial switch procedure, which of the following is a key anesthetic consideration?
A

vigilant monitoring for bradycardia d/t SA node dysfunction

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17
Q
  1. Question: A 30-year-old patient with a history of L-TGA (Levo-Transposition of the Great Arteries) is undergoing a major abdominal surgery. Which of the following considerations is most critical in the anesthetic management of this patient?
A

vigilant monitoring for systemic ventricular arrhythmias

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18
Q
  1. Question: In a patient with coarctation of the aorta, what is the primary anesthetic goal during non-cardiac surgery?
A

ensuring adequate cerebral perfusion pressure

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19
Q
  1. Question: A 20-year-old patient with a history of congenital aortic stenosis, who had a balloon valvuloplasty in childhood, presents for elective orthopedic surgery. Which of the following is the most critical anesthetic consideration for this patient?
A

strict avoidance of tachycardia to reduce myocardial oxygen demand

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20
Q
  1. Question: A 35-year-old patient with a history of Marfan syndrome and aortic root replacement is undergoing a laparoscopic procedure. What is the most important anesthetic consideration in this case?
A

strict control of blood pressure to avoid stress on the aortic root

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21
Q
  1. Question: A 30-year-old patient with a history of unrepaired ventricular septal defect (VSD) is scheduled for non-cardiac surgery. Which of the following anesthetic considerations is most critical in this patient?
A

Maintenance of systemic vascular resistance to avoid exacerbation of left-to-right shunt

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22
Q
  1. Question: How does aortic stenosis (AS) primarily alter left ventricular (LV) hemodynamics?
A

concentric hypertrophy

of the LV/diastolic dysfunction → elevated LV filling pressures, reduced SV, reduced CO

23
Q
  1. Question: What is the expected pathophysiological response of the left ventricle (LV) to mixed valvular lesions?
A

A complex pattern of both concentric and eccentric remodeling

24
Q
  1. Question: In valvular regurgitation, how does the LV adapt pathophysiologically?
A

by decreasing preload, causing eccentric remodeling

25
Q
  1. Question: How does the Frank-Starling mechanism operate in the context of valvular heart disease to sustain LV function?
A

through increased contractility in response to enhanced end-diastolic volume

26
Q
  1. Question: Why does a bicuspid aortic valve predispose patients to aortic stenosis?
A

The abnormal architecture makes the leaflets susceptible to constant low-shear stress that leads to thickened and calcified leaflets (usually in 50-60s)

27
Q
  1. Question: Which clinical manifestation in advanced aortic stenosis indicates severe disease and the need for intervention?
A

Exertional dyspnea d/t diastolic dysfunction.

Symptoms: classic triad including dyspnea, chest pain (angina) and syncope (SAD)

28
Q
  1. Question: During noncardiac surgery, why is it essential to avoid tachycardia in patients with aortic stenosis?
A

increases myocardial O2 consumption

Tachycardia significantly increases myocardial oxygen demand. It reduces diastolic filling time and reduces O2 delivery to the myocardium

29
Q
  1. Question: What is the primary compensatory mechanism of the left ventricle (LV) in response to chronic aortic regurgitation?
A

eccentric hypertrophy

30
Q
  1. Question: Why does acute aortic regurgitation lead to more rapid decompensation compared to chronic aortic regurgitation?
A

D/t sudden volume overload without compensatory LV remodeling.

Risk for coronary ischemia and LV dysfunction/failure

31
Q
  1. Question: During anesthesia in a patient with severe aortic regurgitation, why is it important to avoid bradycardia?
A

Bradycardia increases the amount of regurgitant volume

32
Q
  1. Question: During the induction of anesthesia for AR, why is slow titration of propofol beneficial?
A

to reduce/maintain a low normal SVR to minimize regurgitant blood flow

while maintaining CO and myocardial O2 delivery

33
Q
  1. Question: What primary compensatory mechanism is seen in the left atrium in response to mitral stenosis?
A

Atrial dilation and geometric remodeling

to counteract the increase in LAP

34
Q
  1. Question: Why does exertional dyspnea occur in patients with mitral stenosis (MS)?
A

pulmonary venous pressure increases

causing transudation of fluid into the pulmonary interstitial space, reduced pulmonary compliance, pHTN, RHF

35
Q
  1. Question: During anesthesia, why is the avoidance of tachycardia crucial in patients with mitral stenosis?
A

to enhance diastolic filling time

tachycardia = reduced CO

36
Q
  1. Question: How does the right atrium primarily respond to tricuspid regurgitation (TR)?
A

Dilation to accommodate increased volume

with minimal increase in RAP d/t high compliance of RA

37
Q
  1. Question: Why are medications targeting pulmonary hypertension used in managing tricuspid regurgitation?
A

To decrease PVR.

Helps to maintain forward flow and CO.

38
Q
  1. Question: What is a key hemodynamic consequence of chronic tricuspid regurgitation (TR)?
A

Compromise r/t RV failure/low CO and pHTN

RV systolic dysfunction and low forward output

You want to maintain RV preload and normal/high HR to maintain CO. Avoid anything that increases PVR

39
Q
  1. Question: A patient with a mechanical heart valve is undergoing a procedure that requires temporary cessation of anticoagulation. What is the best approach to manage the risk of thrombosis during this period?
A

Stop warfarin 3-5 days prior, when INR is subtherapeutic transition to LMWH or IV heparin which should be continued until the day of surgery. Heparin can be restarted postop when risk of bleeding is reduced and continued until ac is achieved with oral therapy.

40
Q
  1. Question: A 35-year-old patient with a large ostium secundum ASD is scheduled for elective closure. Which hemodynamic change is most directly associated with this type of ASD?
A

-Ostium secundum ASD is associated with mitral valve prolapse and/or regurgitation
-Increased pulmonary blood flow and RV volume overload

41
Q
  1. Question: What is a likely long-term sequelae in a patient with an unrepaired large ASD?
A

L to R shunting increases pulmonary blood flow, causing volume overload of the lungs, RV, and RA → pHTN, ventricular remodeling, dysrhythmias

42
Q
  1. Question: A 4-year-old child is diagnosed with a moderately restrictive VSD. Which hemodynamic effect is most likely associated with this type of VSD?
A

Equalization of left and right ventricular systolic pressures which causes volume and pressure overload of the pulmonary circ.

43
Q
  1. Question: In patients with large, nonrestrictive VSDs, what is the most likely long-term complication if left untreated?
A

Development of Eisenmenger Syndrome

44
Q
  1. Question: A neonate with a significant PDA undergoes surgical ligation. What immediate hemodynamic change is typically observed following successful ductal closure?
A

Closure increases DBP,

increases SVR and decreases PVR

45
Q
  1. Question: What is a primary indication for the closure of a patent ductus arteriosus (PDA)?
A

development of significant left to right shunt with pulm overcirculation

46
Q
  1. Question: What is an important anesthetic goal when managing a neonate with PDA and severe pulmonary hypertension undergoing ductal closure?
A

maintaining a balance between systemic and PVR,

47
Q
  1. Question: During anesthesia for a patient with Ebstein Anomaly, what is a key consideration due to the atrialized right ventricle?
A

Maintaining adequate right ventricular preload to maintain CO

48
Q
  1. Question: What is the most appropriate initial response to a hyper-cyanotic spell in a patient with Tetralogy of Fallot during the perioperative period?
A

Administer 100% oxygen and positioning, increasing SVR

either pharmacologically or physically with squatting can decrease the amount of shunt, forcing more blood through the pulm circ, therefore improving oxygen sat

49
Q
  1. Question: Which of the following anesthetic considerations is crucial for a patient with Tetralogy of Fallot?
A

Maintaining a balance between pulmonary and systemic vascular resistance

50
Q
  1. Question: Why should the use of spinal anesthesia be approached with caution in patients with Eisenmenger Syndrome?
A

Neuraxial techniques such as epidurals, caution must be exercised due to risk of sudden hypotension worsening the R to L shunt

51
Q
  1. Question: In a patient with Eisenmenger Syndrome under anesthesia, what does a sudden drop in oxygen saturation without changes in ventilation indicate?
A

A sudden drop in O2 sat can indicate a decreased SVR and an increase in shunting leading to hypoxia

52
Q

Factors that decrease PVR (8)

A

100% FiO2
Hypocarbia
Alkalosis
Normothermia
Low mean away pressures or spont vent
Avoidance of catecholamine release
Meds: iNO, PGs, milrinone
Increased SVR: Alpha 1 agonists, Hypothermia, SNS stimulation

53
Q

Factors that increase PVR (8)

A

Hypoxia
Hypercarbia
Acidosis
Hypothermia
High mean airway pressures (PPV, PEEP)
Catecholamine release (pain, anxiety, light anesthesia)
Meds: neo/alpha 1 agonists, N2O, ketamine
Decreased SVR: Beta 2 agonists, Deep GA, Neuraxial anesthesia

Pathophysiology (10 decks)

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