Valvular heart disease

Question 1

What are the four heart sounds?

Answer 1

S1
S2
S3
S4

Question 2

What is the S1 heart sound?

Answer 2

closure of the mitral and tricuspid valve “lub”

Question 3

What is the S2 heart sound?

Answer 3

closure of the aortic and pulmonic valve “dub”

Question 4

What is the S3 heart sound?

Answer 4

suggests congestive heart failure

Question 5

What is the S4 heart sound?

Answer 5

suggests poor ventricular compliance

Question 6

Where should you listen for the aortic valve sounds?

Answer 6

right of sternal border at 2nd ICS

Question 7

Where should you listen for the pulmonic valve sounds?

Answer 7

left of sternal border at 2nd ICS

Question 8

Where should you listen for the mitral valve sounds?

Answer 8

left midclavicular line at 5th ICS

Question 9

Where should you listen for the tricuspid valve sounds?

Answer 9

left of sternal border at 4th ICS

Question 10

Which valvular diseases are associated with eccentric hypertrophy? (select 2)
a. mitral stenosis
b. mitral regurgitation
c. aortic stenosis
d. aortic regurgitation

Answer 10

b. mitral regurgitation
d. aortic regurgitation

Question 11

The ____________________________ open to let blood flow from the atria to the ventricles

Answer 11

atrioventricular valves (mitral and tricuspid)

Question 12

The ___________ open to let blood flow from the ventricles to the aorta and pulmonary artery respectively

Answer 12

semilunar valves (aortic and pulmonary)

Question 13

Valvular stenosis is a ____________ to forward flow during systole

Answer 13

fixed obstruction

Question 14

Stenosis results in

Answer 14

pressure overload–> concentric hypertrophy

Question 15

Concentric hypertrophy means that the

Answer 15

sarcomeres are added in parallel

Question 16

Valvular regurgitation occurs when the

Answer 16

valve is incompetent

Question 17

Flow re-enters the chamber through the incompetent valve during

Answer 17

diastole

Question 18

Regurgitation results in

Answer 18

volume overload–> eccentric hypertrophy

Question 19

Eccentric hypertrophy means that the

Answer 19

sarcomeres are added in series

Question 20

Which valves have chordae tendineae?

Answer 20

atrioventricular valves (mitral & tricuspid)

Question 21

Following aortic valve replacement for aortic stenosis, the left ventricular end-systolic volume will be:
a. increased due to afterload reduction
b. increased due to decreased transvalvular gradient
c. decreased due to a reduction in impedance to ventricular ejection
d. unchanged

Answer 21

c. decreased due to a reduction in impedance to ventricular ejection

Question 22

The smaller the aortic valve orifice, the more

Answer 22

pressure the ventricle must produce to eject its stroke volume

Question 23

Normal aortic valve orifice size is

Answer 23

2.5-2.5 cm2

Question 24

Severe aortic stenosis is

Answer 24

<0.8 cm2

Question 25

Etiologies of aortic stenosis include

Answer 25

a bicuspid aortic valve (most common)
rheumatic fever
infective endocarditis

Question 26

Compensatory mechanisms for aortic stenosis include

Answer 26

increased thickness of the LV wall
decreased compliance
smaller chamber radius

Question 27

The classic presentation of aortic stenosis includes

Answer 27

syncope
angina
dyspnea

Question 28

___________ should be avoided in the patient with severe aortic stenosis due to risk of CV collapse

Answer 28

spinal anesthesia

Question 29

In the patient with severe aortic stenosis, chest compressions during CPR are often

Answer 29

ineffective due to the high transvalvular pressure gradient required

Question 30

The arterial waveform of aortic stenosis may show

Answer 30

pulsus tardus and pulsus parvus

Question 31

Anesthetic goals for aortic stenosis for HR, heart rhythm, preload, afterload, contractility, and PVR.

Answer 31

Full, slow, constricted
heart rate–> avoid tachycardia
heart rhythm–> NSR (maintain atrial kick)
preload–> increase
afterload–> maintain or increase
contractility–> maintain
pulmonary vascular resistance–> normal

Question 32

A mean transvalvular pressure gradient (LV to aorta) of ________________- is also diagnostic for severe AS

Answer 32

> 40 mmHg

Question 33

______________ occurs in up to 90% of patients with severe aortic stenosis.

Answer 33

Acquired von Willebrand disease–> b/c the von Willebrand molecule is damaged when it passes through the stenotic valve

Question 34

What should be given if LV dysfunction occurs in the aortic stenosis patient?

Answer 34

inotropes to maintain contractility

Question 35

Aortic insufficiency leads to

Answer 35

volume overload & eccentric hypertrophy

Question 36

Aortic insufficiency can be an ______________ or ___________ problem

Answer 36

acute or chronic

Question 37

The arterial waveform of aortic insufficiency shows

Answer 37

an increased pulse pressure with bisferiens pulse (biphasic peaks)

Question 38

Before initiating cardiopulmonary bypass in the patient with aortic regurgitation,

Answer 38

cardioplegia must be injected retrograde (through the coronary sinus) or directly into each coronary ostia

Question 39

Anesthetic goals for aortic insufficiency for heart rate, heart rhythm, preload, afterload, contractility, and pulmonary vascular resistance are:

Answer 39

full, fast, and forward
heart rate–> elevate
heart rhythm–> NSR
preload–> maintain or increased
afterload–> decrease
contractility–> maintain
pulmonary vascular resistance–> maintain

Question 40

Acute aortic insufficiency leads to

Answer 40

rapid CV instability
left ventricular failure can result from acute dilation leading to increased wall tension and impaired contractility

Question 41

Acute AI is usually caused by

Answer 41

endocarditis
can also result from aortic root dissection from aneurysm or trauma

Question 42

Conditions associated with chronic AI include

Answer 42

valvular calcification
Marfan syndrome
Ehler-Danlos syndrome
ankylosing spondylitis

Question 43

Etiologies of aortic regurgitation include

Answer 43

incompetent valve or dilation of the aortic root or its supporting structures

Question 44

Conditions that increase the regurgitant volume include:

Answer 44

1. bradycardia (longer diastolic filling time)
2. increased SVR (increased aorta-LV pressure gradient)
3. large valve orifice (larger area for the blood to return through)