Week 3

Question 1

Week 3: Anesthetic Management for Patients with Cardiovascular Disease

Coronary Artery Disease

• Cardiac anesthesia provider needs a..
  
  • Good understanding of normal and altered cardiac physiology
  • Working knowledge of the pharmacology of anesthetics, vasoactive, and cardio-active drugs
  • To be familiar with the physiologic alterations associated with cardiovascular procedures
• Preventing myocardial Ischemia
  
  • Avoid factors known to increase _______(1)
    
    • Myocardial oxygen consumption (MVO2) is defined by the equation: MVO2 = _______(2) x ______(a)
• Principle determinants of MVO2
  
  • _______(3)
  • _______(4)

Answer 1

Answers:

1. MV02
2. coronary blood flow
   a. arteriovenous difference in O2 content.
3. Wall tension
4. Contractility

Question 2

Myocardial O2 Balance with CAD

• Typically _______(1) at rest
• Exercise/stress increases _______(2)
  
  • Ischemic symptoms develop
  • O2 requirements greater than existing coronary blood flow
  • Coronary vascular _______(3) is exceeded
• Ischemic symptoms develop
  
  • _______(4)
  • Alterations in electrophysiology, metabolism, function
• Obstructions
  
  • Large epicardial conductance vessels → The _______(5) have generally been viewed as conductance vessels that pose ______(a) to CBF.
  • Normally, the resistance is _______(6)
• As the percent of stenosis increases, the resistance across the stenotic area increases
  
  • Resistance begins to increase when lumen is reduced by > _______(7)
  • Further restrictions, resistance increases dramatically
  • _______(8), resistance across stenosis triples
  • Small changes in vessel diameter can dramatically increase resistance and decrease CBF

Answer 2

Answers:

1. asymptomatic
2. MVO2
3. reserve
4. Angina
5. epicardial coronary arteries
   a. minimal resistance
6. almost zero
7. 50%
8. 80-90% stenosis

Question 3

Remember Laplace’s Law

• Wall tension is directly proportional to _______(1) and radius
• Wall tension in inversely proportional to _______(2)
• Can decrease MVO2 by:
  
  • Decreasing _______(3)
  • Preventing or promptly treating ventricular _______(4)

Study the illustaration on GoogleDoc

LV Wall Stress = (LV Pressure) x (Radius) / 2(LV Wall Thickness)

HFrEF: Expected increased Radius and Decreased wall thickness

HFpEF: Increased Wall thickness BUT decreased Radius

Answer 3

Answers:
1. intracavitary pressure
2. wall thickness
3. intraventricular pressure
4. distention

Question 4

Preload and Afterload

Preload
- Volume of blood in ventricles at end of diastole (end diastolic pressure)
- Increased in: _______(1), _______(2) of cardiac valves, _______(3)

Afterload
- Resistance left ventricle must overcome to circulate blood
- Increased in: _______(4), _______(5)

Athlete: Increased Thickness of Myocardium but body accommodates accordingly

Stucy the Myocardial Oxygen Supply Graphic Chart

Answer 4

Answers:
1. Hypervolemia
2. Regurgitation
3. Heart Failure
4. Hypertension
5. Vasoconstriction

Question 5

Coronary Blood Flow

• Critical factors/modifiers
  
  • Perfusion pressure
  • Vascular tone of the coronary circulation
  • Heart rate (time available for perfusion)
  • Severity of intraluminal obstructions
  • Presence of collateral circulation
• What area of the heart is most vulnerable to ischemia?
  
  • _______(1) of the LV

Myocardial O2 balance with CAD: Compensatory Mechanisms

• Collateral circulation
  
  • Develops and matures over time
  • Physiologic bypass of the obstructed vessels
  • Heart can generate new blood flow if an important vessel becomes obstructed
• Resting CBF maintained by progressive _______(2) at the microcirculation
  
  • As proximal stenosis increases, autoregulation seeks to preserve flow
  • Basal flow can increase _______(3) times with maximal vasodilation
• Coronary vascular reserve progressively decreases and flow becomes _______(4)

Answer 5

Answers:

1. Subendocardium
2. vasodilation
3. 4-5
4. pressure dependent

Question 6

Hemodynamic Goals for Coronary Artery Disease

Parameter | Goal
— | —
Preload | Keep the heart small: decrease wall tension (diameter) and LVEDP; increase perfusion pressure gradient
Afterload | Maintain: Hypertension is better than hypotension
Contractility | Depress (if LV function is normal)
Rate | Slow
Rhythm | Sinus
MVO2 | Monitor for and treat “supply” —related issues
CPB | Elevated filling pressures are usually not needed after CABG

Small, Steady, Slow, and Sinus
CPB=Cardiopulmonary Bypass

Preoperative Evaluation

• Goals:
  
  • Define risk
  • Determine need for further testing
  • Form a safe anesthetic plan
  • Need for additional medications (_______(1) or anti-hypertensives)
  • Interventional therapies
  • Surgery
• Recognize the S & S of uncontrolled HTN, myocardial ischemia, CHF, valvular heart disease, and cardiac dysrhythmias

What are the risks of a perioperative event? ______(2)

Answer 6

Answers:
1. beta blockers
2. Arrhythmias, MI, heart failure, death

Question 7

Goldman Cardiac Risk Index

• Studied over 4,000 patients aged 50 years or older who were having elective, major noncardiac procedures
• Found 6 _______(1) of complications
• Complications increased with number of risk factors present

Table 1. Revised Cardiac Risk Index

Lee Variables
1. _______(2)
2. Ischemic heart disease (includes any of the following: history of myocardial infarction; history of positive exercise test; current complaint of chest pain that is considered to be secondary to myocardial ischemia; use of nitrate therapy; electrocardiography with pathologic Q waves)
3. _______(3)
4. History of cerebrovascular disease
5. Preoperative treatment with _______(4)
6. Preoperative serum creatinine > 2.0 mg/dL

No. of Variables | Risk of Major Postoperative Cardiac Complication
— | —
0 | 0.4%
1 | 0.9%
2 | 7.0%
≥3 | 11.0% High risk

Adapted from reference 19.

Goldman created RICHES
Risky Surgery
Ischemic Heart Dse
Congestive Heart Failure
History of CVD
Endocrine (insulin use)
Serum Creatinine > 2.0

RCRI = REVISED CARDIAC RISK INDEX
Pathological Q waves usually indicate current or prior myocardial infarction. SEE BELOW

Answer 7

Answers:
1. independent predictors
2. High-risk type of surgery
3. Congestive heart failure
4. insulin

Question 8

Patients with Symptomatic CAD

• Preoperative Evaluation may show changes in frequency or pattern of angina symptoms
• Some patients may have more atypical or undiagnosed (_______(1)) features
  
  • _______(2)
  • _______(3)
  • _______(4)
• Unstable angina is associated with high perioperative risk of MI
• Perioperative period associated with _______(5) an ______(6) in endogenous catecholamines (increasing risk of MI)
• Upregulate/Downregulate? Maintain ______(7) of patients normal MAP

Answer 8

Answers:
1. silent
2. Elderly
3. Women
4. Diabetics
5. hypercoagulable state
6. increase
7. 20%

Question 9

Preoperative Evaluation: HISTORY

• HTN: severity and duration, medications
• Smoking
• High cholesterol
• Symptoms of any conditions
  
  • Myocardial ischemia
  • Ventricular failure
  • PVD
  • Diabetes (_______(1) of CAD, _______(2) and _______(3))
  • Chest pain, exercise tolerance, SOB
  • Edema
• Valvular Disease
  
  • Angina, dyspnea, syncope, CHF

Answer 9

Answers:
1. higher incidence
2. silent MI
3. ischemia

Question 10

PHYSICAL EXAM

• HEART SOUNDS
  
  • MURMURS
  • PMI LATERAL TO NORMAL (CARDIOMEGALY)
  • _______(1) (LVH)
    
    • S4 gallop associated with left ventricular hypertrophy (LVH), is a specific heart sound heard during a cardiac examination, indicating a _______(2) or hypertrophic left ventricle. This sound is caused by the atria contracting forcefully to overcome the _______(3) of the stiff ventricle during ______(a).
      
      • It’s often an indication of underlying heart conditions, such as ______(b), that have led to _______(4) and _______(5).
• CAROTID BRUITS (VASCULAR DISEASE AFFECTING CORONARY CIRCULATION)

Answer 10

Answers:
1. S4 GALLOP
2. stiff
3. resistance
a. late diastole
b. hypertension or aortic stenosis
4. thickened heart muscle walls
5. reduced ventricular compliance

Question 11

LUNG SOUNDS

• Pulmonary RALES and _______(1) (CHF)
  
  • S3 gallop is a heart sound that typically occurs just after the S2 (second heart sound). It’s often described as a “lub-dub-ta” sound and is associated with heart failure or conditions leading to increased filling pressures. The sound is produced when a large amount of blood enters a _______(2) or failing ventricle, causing vibrations in the ventricular walls — large bc volume overload “CHF!!”
    
    • While it can be normal in______(a), in older individuals, it often indicates a pathological state like _______(3).
    • Memory Device: Think S4 for as a Strong Fort! S3 as a Dilated Sea!

BLOOD PRESSURE MEASUREMENT (SUPINE AND STANDING)
- ORTHOSTATIC CHANGES (VOLUME DEPLETION, HEMORRHAGE, EXCESSIVE VASODILATION)
- One study showed: Admission ______(b) was the best predictor of response to laryngoscopy (_______(4)?)

Answer 11

Answers:
1. S3 GALLOP
2. dilated
a. children or young adults
3. congestive heart failure
b. BP and HR
4. anxiety

Question 12

Electrocardiogram

• Provides info on state of the myocardium and coronary circulation
• Rate, Bundle branch blocks, lv
• Old injuries/infarcts
• Pacer spikes
• Conduction abnormalities

ECG Changes during Myocardial Infarction (MI)

Location of MI | Leads Affected | Vessel Involved | ECG Changes
— | — | — | —
Anterior wall | V2 to V4 | Left anterior descending artery (LAD) - Diagonal branch | Poor R-wave progression ST-segment elevation T-wave inversion
Septal wall | V1 and V2 | Left anterior descending artery (LAD) - Septal branch | R wave disappears ST-segment rises T-wave inverts
Lateral wall | I, aVL, V5, V6 | Left coronary artery (LCA) - Circumflex branch | ST-segment elevation
Inferior wall | II, III, aVF | Right coronary artery (RCA) - Posterior descending branch | T-wave inversion ST-segment elevation
Posterior wall | V1 to V4 | Left coronary artery (LCA) - Circumflex branch Right coronary artery (RCA) - Posterior descending branch | Tall R waves ST-segment depression Upright T waves

Posterior wall only one with _______(1)
Lateral wall is the only one without _______(2), whilst Posterior wall has _______(3) T Waves
The LAD causes loss of _______(4), whilst poster wall inc _______(5)
Posterior wall as a _______(6) MI of Anterior wall MI — _______(7) of LAD infarct

Answer 12

Answers:
1. ST-depression
2. T-wave inversion
3. Upright
4. R-wave progression
5. R waves
6. reciprocal
7. mirror image

Question 13

Abnormal “Q” waves

• Highly suggestive of _______(1)
• 30% of myocardial infarctions occur without symptoms (silent MI) with highest incidence in _______(2) and _______(3)
• Presence of _______(4) on preoperative EKG in a high risk patient = high indication of increased perioperative risk and possible active ischemia
• THINK Young, African American Athlete- Do Not Ignore this abnormality

Preoperative Evaluation might include:

• CXR
• ECHO results (LVH, DIASTOLIC AND SYSTOLIC FUNCTION ESPECIALLY IN HEART FAILURE)
• Cardiac tests
• LABORATORY FINDINGS
• RENAL: SERUM CREATININE AND _______(5)
• POTASSIUM (DIURETICS, DIGOXIN OR RENAL IMPAIRMENT, EKG CHANGES/ECTOPY)
• Magnesium
• Hemoglobin/Hematocrit

Answer 13

Answers:
1. past MI
2. diabetics
3. hypertensives
4. Q wave
5. BUN LEVELS

Question 14

Surgical Procedure Risk

• Major vascular procedures associated with _______(1)
• ACC/AHA risk stratification
• Other high risk procedures
  
  • Abdominal
  • Thoracic
  • Orthopedics

TABLE 21–3 Cardiac risk1 stratification for noncardiac surgical procedures.

Risk Stratification | Procedure Examples
— | —
Vascular (reported cardiac risk often more than 5%) | Aortic and other major vascular surgery Peripheral vascular surgery
Intermediate (reported cardiac risk generally 1% to 5%) | Intraabdominal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery
Low2 (reported cardiac risk generally less than 1%) | Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Ambulatory surgery

Which of the following is the higher stratification surgery? A carotid endarterectomy, intrathoracic surgery, or peripheral vascular surgery?
Ans: _______(2)

PLEASE STUDY
2014 ACC/AHA guidelines

Answer 14

Answers:
1. highest incidence of complications
2. PVS

Question 15

Importance of Exercise Tolerance

• _______(1) is one of the most important determinants of perioperative risk and the need for further testing and invasive monitoring
• Good exercise tolerance suggests that the myocardium can be stressed without failing (climbing two flights of stairs or walking 4 blocks) — _______(2)
• Assessed with a questionnaire that assesses daily activity
  
  • (hip/knee issues?) — _______(3) mean you are cardiac crippled, just restricted movement
• Treadmill testing

Answer 15

Answers:
1. Exercise tolerance
2. 4 METS Equivalent
3. does not necessarily

Question 16

TABLE 21-2

TABLE 21–2 Estimated energy requirements for various activities.

Can you …

1 MET
- Take care of yourself?
- Eat, dress, or use the toilet?
- Walk indoors around the house?
- Walk a block or 2 on level ground at 2 to 3 mph (3.2 to 4.8 kph)?

4 METs
- Do light work around the house like dusting or washing dishes?

Can you …

4 METs
- Climb a flight of stairs or walk up a hill?
- Walk on level ground at 4 mph (6.4 kph)?
- Run a short distance?

• Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?
• Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?

Greater than 10 METs
- Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

TABLE 21-13

TABLE 21–13 Modified New York Association functional classification of heart disease.

Class | Description
— | —
I | Asymptomatic except during severe exertion
II | Symptomatic with moderate activity
III | Symptomatic with minimal activity
IV | Symptomatic at rest

Choice of Anesthetic - Regional

• Regional anesthesia
  
  • Dense analgesia
  • Blockade of afferent and efferent nerve conduction (_________(1))
• Major disadvantages
  
  • Hypotension from sympathetic block
  • ______(a) in wall tension with volume loading could precipitate subendocardial ischemia w/ CAD
    
    • _________(2) may be better
      
      • _________(3) is your best choice
    • _________(4) may be problematic after return of vascular tone

Answer 16

Answers:
1. catecholamine release is suppressed
a. Increase
2. Alpha-agonist
3. Phenylephrine
4. Large volume loads

Question 17

Choice of Anesthetic: General

• General anesthesia with Opioids
  
  • Lack of myocardial depression (desirable in patients with markedly impaired ventricular function)
  • Suppression of stress response
  • Reduction of HR
  • Hemodynamic stability
• Can supplement with volatile anesthetics
• Muscle relaxants
• Emergence: relatively comfortable and hypothermia avoidance

Selection of Anesthetic

• There is no ideal anesthetic for _______(1)
• Opioids
  
  • Advantages: lack of myocardial depression, stable hemodynamic state and reduction of heart rate
    
    • High dose valuable only in the patient with _______(2)
• Inhalational
  
  • Dose-dependent hemodynamic changes, reversible, titratable myocardial depression, suppression of sympathetic responses to surgical stress
    
    • _______(3) the myocardium from ischemia and reperfusion injury and reduces infarct size
• Adjuncts: propofol, midazolam, dexmedetomidine

Answer 17

Answers:
1. patients with CAD
2. severe myocardial dysfunction
3. Protect

Question 18

Treatment of Intraoperative Problems

• Sinus tachycardia
  
  • Increase anesthesia
  • Beta blockers
• Increase PCWP
  
  • NTG (add inotrope or alpha agonist if decrease in BP)
  • _______(1)
  • _______(2) with good LV function
• HTN
  
  • Anesthesia,
  • vasodilators,
  • beta blocker if tachycardia

Answer 18

Answers:
1. Restrict fluids
2. Volatile anesthetic

Question 19

Treatment of Intraoperative Problems

• Hypotension
  
  • Volume, if hypovolemic
  • ______(a) agonist, if transient and not hypovolemic
    
    • _______(1)
  • Inotrope
    
    • Associated with increased PCWP and decrease CO
      
      • Increase MVO2 offset by increased CPP and decreased ventricular size
  • Neo/NTG
    
    • Maintains perfusion pressure and keeps heart small
      
      • _______(2)

Answer 19

Answers:
a. Alpha
1. phenylephrine
2. Good for ischemic changes

Question 20

Valvular Heart Disease

Valve Review Sheet

• Please print and review the Valve Review Worksheet, which I posted for you under Module 1.
• This is a very _______(1) guide to keep with you during your Clinical rotation.

Pathophysiology of Valvular Heart Disease

• Causes chronic volume and _______(2) overload
• Ventricular Hypertrophy: increased left ventricular mass
• Pressure overload: Concentric (_________(3), normal chamber size)
• Volume Overload: Eccentric (_________(4) and dilated cardiac chamber)

2 types of hemodynamic overload → HF

Answer 20

Answers:
1. handy
2. pressure
3. increase in ventricular wall thickness
4. normal wall thickness

Question 21

History and Physical

• Should have a high index of suspicion if patient has a history of rheumatic fever, IV drug abuse, genetic disorders (i.e., _______(1)), heart surgery as a child, or heart murmurs
• Exercise tolerance usually decreased
• Exhibit signs/symptoms of heart failure to include:
  
  • dyspnea, orthopnea, fatigue, pulmonary rales, jugular venous congestion, _______(2) congestion, or edema
• Angina can occur in patients with hypertrophied _______(3)
• A-Fib often accompanies _______(4) of the atria

Tests to evaluate valvular heart disease:

• Echocardiography with doppler
  
  • Measures size and function of the chambers
  • Pressure gradients of the valves
  • Valve area measurements
  • Severity of disease determined
• EKG: Evidence of ischemia, arrhythmias, atrial enlargement, ventricular hypertrophy
• CXR: enlargement of chambers, pulmonary HTN, pulmonary edema and effusions
• Cardiac Cath: used before surgery to diagnosis ______(5), measurement of heart pressures in the chambers and pressure gradients across valves

Answer 21

Answers:
1. Marfans
2. hepatic
3. left ventricle
4. enlargement
5. CAD

Question 22

Transesophageal Echocardiography (TEE)

• Can be used in the OR during valve surgery
• Evaluate severity of valvular disease, structural and functional changes
• Evaluation of the valve repair or function of artificial valves
• Systolic and diastolic function of the Left and right ventricles before and after _______(1)
• Determines postsurgical management

Pressure-Volume Loops

• Please watch and review the videos by the Khan Academy posted under Module 6:
• Pressure in the left heart – Part I
• Pressure in the left heart – Part II
• Pressure in the left heart – Part III
• These videos were absolute _______(2)

(Know these, compare these, know what they’re describing, how do they change due to pathology)

Answer 22

Answers:
1. bypass
2. basura

Question 23

Pressure-Volume Loops

• Plots LV pressure against volume through one complete cardiac cycle
• Each valvular lesion has a unique profile that suggests compensatory physiologic changes by the left ventricle

Match the event/description with the valve action (answer below the next img)

A. Aortic Valve Closes
B. Aortic Valve Opens
C. Mitral Valve Opens
D. Mitral Valve Closes

1. End Systolic Volume
2. Beginning of Systole
3. End Diastolic Volume
4. Represents Preload
5. Beginning of Ventricular Filling

Preload is represented by the point just before the mitral valve closes, indicating the ventricle is at its maximum volume in diastole.

Please study the Pressure Volume Loop graph

P-V Loops: Valve disease

• Definitely qs on this
  
  • A = normal - LV
  • B = mitral stenosis
  • C = aortic stenosis
  • D = mitral regurgitation (chronic)
  • E = aortic regurgitation (chronic)

Aortic Stenosis (AS) “______(a)”

Pathology of Aortic Stenosis

• Most common valvular disease in the U.S.
• Normally, composed of 3 semilunar cusps
• Classified as valvular, subvalvular, or supravalvular obstruction
• Concentric hypertrophy develops: thickened ventricular wall with normal chamber size

Answer 23

Answers:
A -> 1. End Systolic Volume
B -> 2. Beginning of Systole
C -> 3. End Diastolic Volume
D -> 5. Beginning of Ventricular Filling

a. FULL, SLOW, AND CONSTRICTED

Question 24

Pathophysiology of Aortic Stenosis

• Decreasing LV compliance accompanies ______(a) LV end-diastolic pressure
• Contractility and ejection fraction can be maintained until ______(b) disease process
• Atrial contraction account for 40% of the ventricular filling (normally 20%)
• Clinical factors associated with AS:
  
  • ______(c)
• Causes:
  
  • ______(d) (more common in developing countries)
  • Calcification of tri-leaflet
  • Congenital _______(1) valve

Presentation of Aortic Stenosis

• Angina
  
  • Angina can occur in the absence of CAD
  • Thickened myocardium is susceptible to ischemia and elevated LV end-diastolic pressures that decrease coronary perfusion pressure
  • ADP/LVEDP=CPP
• Syncope
• CHF
  
  • Tighter AS, LV systolic pressure increases to a level where LV hypertrophy cannot normalize the wall tension so the heart starts to dilate with symptoms of systolic dysfunction and decreasing cardiac output concomitant with symptoms of.
  • AS is S.A.D. → syncope, angina, _______(2) (from CHF/pulmonary involvement)
• Life expectancy with symptoms of:
  
  • Angina: ______(e) years
  • Appearance of syncope: ______(f) years
  • Appearance of CHF: ______(g) years

Answer 24

Answers:
a. elevated
b. late
c. Older, male, smoker, HTN, Hyperlipidemia
d. Rheumatic fever
1. bicuspid
2. dyspnea
e. 5
f. 3-4
g. 1-2

Question 25

P-V loop for Aortic Stenosis

• Left ventricle is working at higher intraventricular pressure to generate normal SV
• Elevated wall tension stimulated ______(1) replications of sarcomeres
• Increased contractility to accomplish the pressure work

Answer 25

Answers:
1. parallel

Question 26

Anesthetic/Hemodynamic goals: AS
Apex: Think FULL, SLOW, and CONSTRICTED

• Preload:
  
  • You need preload — full to fill the noncompliant ventricle
• Afterload:
  
  • Need to maintain coronary perfusion gradient, AND ______(a) in BP with decrease CPP — risk of subendocardial ischemia and sudden death
• Contractility:
  
  • Need to ______(b) contractility to overcome the high-pressure gradient through the valve

Anesthetic/Hemodynamic Goals: AS

• Rate:
  
  • NORMAL: avoid ______(c) (decreases CO with fixed stroke volume) and ______(d) (ischemia with limited diastolic time for coronary perfusion)
• Rhythm:
  
  • Sinus rhythm (important in atrial contraction in LV filling);
  • _______(1) if hemodynamic compromise and arrhythmia
• MVO2:
  
  • avoid tachycardia and hypotension (ischemia is big risk)

Answer 26

Answers:
a. reduction
b. maintain
c. bradycardia
d. tachycardia
1. cardioversion

Question 27

Anesthetic Management

• Monitoring:
  
  • Standard, 5-Lead, A-Line, PA/TEE depends on type of surgery, defibrillator handy
• Induction:
  
  • Regional: SAB is relatively contraindicated in severe AS (sympathectomy)
  • General: heavy ______(1) technique, volatiles fine — dose dependent cardiac depression
• Maintenance:
  
  • Maintain HR, treat tachycardia immediately
  • Treat arrhythmias with ______(2)
  • Treat ______(3) immediately

Answer 27

Answers:
1. opioid/benzo
2. cardioversion
3. hypotension

Question 28

“The Death Spiral in AS”

• In severe or critical AS,
  
  • Any drop in ______(1) for any reason can result in the vicious cycle (emphasis on Systolic BP not DBP!)
  • Chest compressions are ineffective (difficult to generate enough mechanical force to create adequate SV across the stenotic valve)
  • Resulting in sudden death

Answer 28

Answers
1. SBP

Question 29

AORTIC VALVE

Trileaflet valve
Normal valve area-3-4 cm²

Severity of Aortic Stenosis
- Mild | Moderate | Severe
- Jet velocity (m/sec): <3.0 | 3.0-4.0 | >4.0
- Mean gradient (mm Hg): <25 | 25-40 | >40
- Valve area (cm²): >1.5 | 1.0-1.5 | <1.0

Which principles worsen the effects of aortic stenosis?

Answer 29

Answer:

The principles that worsen the effects of aortic stenosis include the concepts illustrated by the Bernoulli Equation where a drop in pressure equals more velocity through a narrowing. This is depicted by the increase in kinetic energy (KE) and the decrease in potential energy (PE) across the stenotic valve, indicating that the blood flow speeds up significantly as it passes through the narrowed valve area, leading to a pressure drop post-stenosis. The narrowed valve area (marked with “VALVE AREA”) is critical, as a smaller opening increases the velocity and pressure gradient, which can exacerbate the workload on the heart and worsen the condition.

Question 30

Pathophysiology of Aortic Insufficiency (AI)

• Rheumatic fever, _______(1), congenital _______(2), and _______(3) are among the most common causes of AI
• Acute AI causes: _______(4), _______(5) (Marfan syndrome), ______(a)
• Chronic AI: LV _______(6) (Stroke volume regurgitates back across the valve in diastole.)
• _______(7) hypertrophy (dilated LV with normal or thickened wall)

Answer 30

Answers:
1. aortic root dilation
2. bicuspid aortic valve
3. infective endocarditis
4. infective endocarditis
5. aortic dissection
a. after balloon valvotomy or failed surgical valve repair
6. diastolic volume overload
7. Eccentric

Question 31

P-V Loop in “acute” AI

• Acute AI:
  
  • _______(1) increase
  • SV may be _______(2), _______(3) or _______(4)
  • LV volume increasing during isovolumetric _______(5) (D-A segment)
  • EDP (A-B segment, B point) is _______(6)
  • Contractility is _______(7) (myocardium overstretched → eccentric)

P-V Loop in “chronic” AI

• EDV, ESV and SV _______(8)
• Cardiac output is _______(9)
• Contractility is _______(10)
• LV volume increasing during isovolumetric _______(11) (D-A segment)
• EDV (A-B segment, B point) is _______(12) — is this right? According to _______(13), LV dilation compensates for the increase in volume - this normalizes things up to a certain point, then causes _______(14)
• Diastolic reserve _______(15)

Answer 31

Answers:
1. EDV and ESV
2. increased
3. decreased
4. normal
5. relaxation
6. high
7. decreased
8. enlarged
9. normal
10. decreased
11. relaxation
12. normal
13. apex
14. LV failure
15. intact

Question 32

Anesthetic/Hemodynamic goals in AI
Apex: Think _______(1), _______(2), Forward

• Preload:
  
  • _______(3) slightly, necessary for forward flow
• Afterload:
  
  • _______(4)
• ______(a) augments forward flow; increase anesthetic depth or vasodilators (to decrease regurgitant fraction)
• Contractility:
  
  • Usually adequate; maintain with _______(5); _______(6) is ideal (does not increase afterload)
• Rate:
  
  • _______(7) — improves forward flow by decreasing diastolic duration and decreasing regurgitant flow and increasing EF
    
    • Different from _______(8) sheet!!
  • Also improves coronary perfusion
• Rhythm:
  
  • Usually _______(9)
• MV O2:
  
  • Usually not a problem

Heart Rate | Aortic Stenosis | Mitral Stenosis | Aortic Insufficiency | Mitral Insufficiency
Preload | Slow / normal | Slow / normal | O / _______(10) | O / _______(11)
Contractility | O | O | O | O
SVR | O | O | ↓ | O
PVR | Avoid | Avoid | _______(12) | Avoid

Answer 32

Answers:
1. Full
2. Fast
3. Increase
4. Decrease
a. Reduction
5. beta-agonists
6. dobutamine
7. Increase
8. valve review
9. sinus
10. Δ (Increase)
11. Δ (Increase)
12. Avoid

Question 33

Anesthetic Management in AI

• Monitoring and _______(1) management same as aortic stenosis
• Induction:
  
  • Regional: may have an advantage of decreasing _______(2) and therefore afterload
  • General: _______(3) may be useful to increase HR
• Maintenance:
  
  • Phenylephrine or _______(4) to treat hypotension?
    
    • _______(5)! INCREASES HR DESPITE INCREASE IN SVR

Pathophysiology of Mitral Stenosis

• ______(a) disease (80-90%), infective endocarditis (3.3%), mitral annular calcification (2.7%)
• Symptoms: fatigue, dyspnea on exertion, ______(b), _______(6) murmur
• Worsened in conditions that need increased CO (______(c))
• Blood stasis in left atrium (dilated LA) risk of _______(7) and _______(8)
• 20+ years before critical stenosis manifests (normal = ______(d) cm²; stenosis = 1.5 cm²)
• Develop _______(9) of voice? WTF?

Answer 33

Answers:
1. preload
2. SVR
3. Ketamine/Pancuronium
4. Ephedrine
5. EPINEPHRINE
a. Rheumatic
b. hemoptysis
6. diastolic
c. pregnancy, anemia, exercise
7. thrombus formation
8. SVT/A.Fib
d. 4-6
9. hoarseness

Question 34

Rheumatic fever/heart disease

• Rheumatic fever:
  
  • Childhood issue, usually in underdeveloped/developing countries where _______(1) are not routine
• Rheumatic heart disease:
  
  • Cardiac inflammation and scarring triggered by an autoimmune reaction to infection with _______(2)
  • Acute stage: consist of pancarditis (inflammation of the epicardium, myocardium, and endocardium)
  • Chronic stage: ______(b) (stenosis and/or insufficiency)
  • Stenosis usually starts in _______(3) and up to 2 years after rheumatic heart disease diagnosis (progressive calcification and fusion of leaflets)

Pathophysiology

• Decreased LV filling
  
  • Increased left atrial pressure and volume
    
    • Pulmonary vein pressure
      
      • Transudation of fluid into pulmonary interstitial space
      • Pulmonary compliance
        
        • Work of breathing
          
          • Progressive _______(4)
• Adaptation → Atrial Kick → Palpitations
• Adaptation → Lymphatic drainage and thickening of basement membrane → Pulmonary hypertension → _______(5)

Three clinical presentations: palpitations (d/t atrial kick), breathlessness, and Haemoptysis (rising _______(6)).

Answer 34

Answers:
1. antibiotics
2. Group A Streptococci (GAS)
b. valvular fibrosis
3. females
4. Dyspnea
5. Breathlessness
6. PHTN

Question 35

Anesthetic/Hemodynamic goals: MS

• DO NOT use _______(1) (CO2 buildup) to extubate- you will cause Right Sided Heart Failure
• APEX: THINK _______(2), Normal, Normal
• Preload:
  
  • good intravascular volume to maintain flow across stenotic valve, avoid _______(3)
• Afterload:
  
  • prevent _______(4); increase RV afterload due to pulmonary vasoconstriction (_______(5)); vasopressors for systemic hypotension
• Contractility:
  
  • sinus rhythm for adequate filling of LV
    
    • _______(6): atrial contraction contributes ______(a) % of SV
    • AS: ______(b)% of SV
    • Normal: 20% of SV
• Rate: Maintain at low end of normal; avoid and treat _______(7)
• Rhythm:
  
  • Control ventricular response in ______(c) (apex: stretch of conduction system _______(8) this)
• MV O2:
  
  • Not a problem usually
• Objective
  
  • Maintain NSR, avoid tachycardia and large increases in CO (both hypovolemia and fluid overload)
• Monitoring
  
  • TEE to help guide perioperative management (fluids)
  • Invasive monitoring dependent on type of surgery
  • Do not raise ETCO2 in preparing for extubation — raises _______(9) and decreases SVR
• Choice of agents
  
  • Sensitive to vasodilating effects of SAB or epidural (pregnancy?)
  • Vasopressors to maintain vascular tone (neo? Ephedrine?)
    
    • Avoid increased _______(10) — most likely Neo is the choice
    • Avoid intraoperative tachycardia (beta blockers, opioids)
    • Adequate level of anesthesia to avoid sympathetic stimulation — SVR, PVR increases

Heart Rate | Aortic Stenosis | Mitral Stenosis | Aortic Insufficiency | Mitral Insufficiency
Preload | Slow / normal | Slow / normal | O / Δ | O / Δ
Contractility | O | O | O | O
SVR | O | O | ↓ | O
PVR | Avoid | Avoid | _______(11) | Avoid

Answer 35

Answers:
1. hypercarbia
2. Normal
3. overhydration
4. increase
5. hypoxia and hypercarbia
6. MS (Mitral Stenosis)
a. 30
b. 40
7. tachycardia
c. atrial fib
8. crosses
9. PVR
10. HR (Heart Rate)
11. Avoid

Question 36

P-V Loop in Mitral Stenosis

• EDV and SV _______(1) (d/t limited flow into the left ventricle)
• LV generates low _______(2)
• Contractility is _______(3) (chronic under-filling of the LV)

Etiology of Mitral Regurgitation (MR)

• Results from any process that distorts the mitral leaflets, _______(4), papillary muscles, valve annulus or left ventricular geometry
• Organic MR
  
  • _______(5) (most common), rheumatic heart disease, mitral annular calcification, endocarditis
• Functional MR
  
  • May have normal mitral leaflets and chordal structures
  • Often occurs from ischemic heart disease (IHD) or dilated cardiomyopathy
• Secondary to abnormalities of _______(6)
  
  • Rupture with acute myocardial ischemia or infarction
  • Bacterial endocarditis
• Papillary muscle dysfunction
  
  • Ischemia of the _______(7) (blood supply from RCA)
• Chronic MR
  
  • Progressive
• Acute MR
  
  • Typically presents in ______(a)
  • Ventilator: increased Peak Pressure; Pink Frothy Sputum, cardiogenic shock
  • Significant increase in _______(8) and LAP with normal compliance
  • Precipitous ______(9) in LAP and PCWP — increased congestion
  • Changes may develop rapidly

Answer 36

Answers:
1. small
2. BP (Blood Pressure)
3. decreased
4. chordae tendineae
5. Mitral valve prolapse
6. chordae tendineae
7. posterior papillary muscle
a. pulmonary edema
8. LVAD (Left Ventricular Afterload)
9. increase

Question 37

Anesthetic/hemodynamic Goals: MR “_______(1), _______(2), _______(3)”

• Preload:
  
  • Maintain adequate preload for good forward flow
  • Do not overload (dilate both LV and worsen MR/pulmonary congestion)
• Afterload:
  
  • decrease SVR, arterial vasodilators (________(4) — can increase HR, and decrease SVR (beta 2 agonist));
  • afterload reduction augments forward flow and decreases regurgitation
• Contractility:
  
  • May be depressed; titrate myocardial depressants carefully
• Rate:
  
  • Increase slightly; avoid _______(5) which can increase regurgitant flow decreasing the ejected flow in the aorta
• Rhythm:
  
  • If atrial fib, control the ventricular response
• MvO2:
  
  • Compromised if MR coexists with ischemic heart disease

Heart Rate | Aortic Stenosis | Mitral Stenosis | Aortic Insufficiency | Mitral Insufficiency
Preload | Slow / normal | Slow / normal | O / Δ | O / Δ
Contractility | O | O | O | O
SVR | O / Δ | O | ↓ | O
PVR | O | Avoid | O | Avoid

Answer 37

Answers:
1. FULL
2. FAST
3. FORWARD
4. dobutamine
5. bradycardia

Question 38

Anesthetic Considerations

• Preop
  
  • _______(1) for anxiety to prevent increase in SVR or PVR
• Monitoring
  
  • Standard, 5-lead, A Line, CVP/PA, TEE
• Induction
  
  • Regional (careful with abrupt _______(2) in preload)
  • General (avoid _______(3))
• Maintenance
  
  • Preload, normal EtCO2
    
    • high levels of CO2 can lead to an _______(4) in PVR due to the constriction of pulmonary vessels, while low EtCO2 can _______(5) PVR.
  • Severe dysfunction may need _______(6)

P-V loop in Mitral Regurgitation

• Acute
  
  • EDV increases with high EDP
  • ESV normal or decreased, SV _______(7)
  • Ejected volume into the aorta is small depending on the regurgitant volume
• Chronic
  
  • EDV increased with normal EDP due to myocardial remodeling
  • ESV normal or _______(8)
  • _______(9) SV

Myocardial Remodeling

• Myocardial remodeling: Ventricular remodeling (or cardiac remodeling) refers to the changes in size, shape, structure, and function of the heart.
  
  • This can happen as a result of exercise (physiological remodeling) or after injury to the heart muscle (pathological remodeling).

Answer 38

Answers:
1. Versed
2. decrease
3. bradycardia
4. increase
5. decrease
6. dobutamine
7. increased
8. increased
9. Markedly increased

Question 39

Tricuspid Disease

Which one would lead to prominent A waves? Answer: _______(1)

Prominent is different from Cannon A-waves, cannon a waves cause include 3rd heart blocks, when there is a complete _______(2) on the tricuspid valve.

Answer 39

Answers:
1. Tricuspid stenosis
2. obstruction

Question 40

Pathophysiology of Tricuspid Stenosis (TS)

• Etiology
  
  • Congenital, rheumatic heart disease, or mechanical due to thrombus
• TS leads to ______(a) enlargement
• Preload dependence — the whole heart is dependent on blood flow from _______(1), which is having a hard time passing blood into the _______(2).
  
  • “Preload dependence” in tricuspid stenosis means that the right ventricle’s ability to pump blood effectively is heavily reliant on the volume of blood returning to it (preload). In tricuspid stenosis, the narrowed valve impedes blood flow from the right atrium to the right ventricle, making the ventricle highly sensitive to changes in preload. Adequate preload is crucial to maintain sufficient cardiac output, but the stenosis limits this, making management of fluid balance particularly important.
• Conduction system disease (A-Fib/flutter, _______(3))
• Physiology resembles the restriction to _______(4) into the heart as seen in ______(b)

Anesthetic/hemodynamic Goals of TS

Think Normal. Normal. Normal - what other valvular d/o has this chant? Ans: Mitral Stenosis
- Monitors: A-line, _______(5) and TEE
- Preload:
- Maintain normal
- Rate:
- Normal range
- Rhythm
- _______(6)

Answer 40

Answers:
a. right atrial
1. R.A. (Right Atrium)
2. R.V. (Right Ventricle)
3. SVT
4. venous return
b. cardiac tamponade
5. CVP (Central Venous Pressure)
6. normal sinus

Question 41

Pathophysiology of Tricuspid Regurgitation (TR)

• A valve lesion can be primary (due to a problem with the valve itself) or secondary (due to supporting structures, such as ventricular dilation or papillary muscle infarction). Sometimes a valve will have elements of both stenosis and regurgitation. Management targets the lesion of greater hemodynamic _______(1).

Primary (TR with abnormal valve itself)
- Rheumatic heart disease, infective endocarditis, ______(a) syndrome, trauma

Secondary (more common)
- RV enlargement and annular dilation
- Associated with longstanding pulmonary HTN – Which valvular d/o may most likely cause this?
- Ans: Mitral insufficiency and _______(2)
- Most common in patients with _______(3) disease

Isolated TR: asymptomatic for many years
- Pulsatile neck veins (JVD due to congestion), _______(4) (through S1 and S2)
- ______(b) murmurs are also known as Pansystolic and include the murmurs of mitral regurgitation (MR), tricuspid regurgitation (TR)
- s/s include generalized weakness, early fatigue, fullness in _______(5)

Answer 41

Answers:
1. significance
a. carcinoid
2. stenosis
3. MV (Mitral Valve)
4. pansystolic murmur
b. Holosystolic
5. RUQ (Right Upper Quadrant)

Question 42

Anesthetic Management

• Maintain intravascular volume and CVP in the high-normal range
• Avoid Increased Pulmonary Vascular Resistance
  
  • Avoid hypoxia, hypercarbia, acidosis
  • What other surgical position should be avoided which may increase pvr? Ans: _______(1) position
• Avoid PEEP and high airway pressures, which can reduce venous return and increase RV afterload — all _______(2) in PVR

Please study Valvular Disease and Murmurs image

Answer 42

Answers:
1. trendelenburg
2. increases

Question 43

APEX:

• Aortic Stenosis
  
  • ASSS
  • Aortic Stenosis is Systolic murmur at r-Sternal Border
• Aortic Insufficiency
  
  • ARDS
  • Aortic Regurgitation is Diastolic murmur at r-Sternal Border (contradicts what the image says but based on apex)
• Mitral Stenosis
  
  • MSDA
  • Mitral Stenosis is Diastolic at the Apex and l-Axilla
• Mitral Insufficiency
  
  • MRSA
  • Mitral Regurgitation is Systolic murmur at Apex and l-Axilla (can also have holosystolic murmur - like tricuspid regurgitation)

Mitral valve prolapse _______(1).
PVCs most common ekg _______(2).

Keep SVR- slightly above normal
Maintain Preload
No _______(3)

TABLE 25.10 Hemodynamic Goals for Management of Mitral Valve Prolapse

Parameter | Goal
Preload | Maintain or increase
Afterload | Maintain
Contractility | Maintain
Heart rate | Maintain
Heart rhythm | Normal sinus rhythm

Answer 43

Answers:
1. id.
2. signs
3. ketamine

Question 44

Important Note:

There are many diagrams/illustrations starting on page 113 of the document which cannot be analyzed by ChatGPT to create the notes like this except the table information. Here is the list of the diagrams that you need to review:

Review Cardiac Phases
Review Pathologic Volume Loops
Review 2 Types of HF
Layers of the heart muscle
Review EKG MI
CVP Waveform

Answer 44

Review Cardiac Phases
Review Pathologic Volume Loops
Review 2 Types of HF
Layers of the heart muscle
Review EKG MI
CVP Waveform

Question 45

Name the 5 Components of CVP and what are their cardiac functions?

1. A wave: corresponds to _______(1).
2. C wave: occurs with the _______(2) of the tricuspid valve and the bulging of the valve into the right atrium during right ventricular contraction.
3. X descent: reflects atrial _______(3) and downward displacement of the tricuspid valve during right ventricular _______(4).
4. V wave: represents _______(5) when the tricuspid valve is closed.
5. Y descent: is the rapid _______(6) from the right atrium to the right ventricle after the opening of the tricuspid valve.

Answer 45

Answers:
1. atrial contraction
2. closure
3. relaxation
4. systole
5. venous filling
6. inflow

Question 46

TABLE 25.12 Hemodynamic Goals for Management of Hypertrophic Cardiomyopathy

Parameter | Goal
Preload | _______(1)
Afterload | _______(2)
Contractility | _______(3)
Heart rate | _______(4)
Heart rhythm | _______(5)

Answer 46

Answers:
1. Increase
2. Increase
3. Decrease
4. Maintain
5. Normal sinus rhythm

Question 47

Cardiac Tamponade

TABLE 25.7 Hemodynamic Goals for Management of Cardiac Tamponade

Parameter | Goal
Preload | _______(1)
Afterload | _______(2)
Contractility | _______(3)
Heart rate | _______(4)
Heart rhythm | _______(5)
Treatment | _______(6)

Answer 47

Answers:
1. Maintain or increase
2. Maintain
3. Maintain or increase
4. Maintain
5. Normal sinus rhythm
6. Pericardiocentesis, pericardial window

Question 48

Mid-cavity Ballooning Syndrome Following Ondansetron PDF

• Ondansetron induced - transient left ventricular apical ballooning syndrome, also known as tako-tsubo cardiomyopathy
  
  • Presents in postmenopausal women (________(1) and ________(2)) — temporary akinesis of left ventricle
  • Precipitated by emotional stress
  • Associated with chest pain, ekg change, and elevation of cardiac enzymes

Increasing SOB
Hx CP but normal activity
Syncope x2
Systolic Murmur LEft sternal border
150/90

EKG: Sinus, PVC, LV Hypert
TEE: Severe AS
PG: 64 mmHG
Mild AI
Moderate MR

Question: Representative P-V Loop of the Lesion Not Diagnosed

AI would not benefit from having a PA Cath

Answer 48

Answers:
1. asians
2. caucasians