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Apex Review > Valvular heart disease 2 > Flashcards

Valvular heart disease 2 Flashcards

1
Q

Which drugs are most likely to contribute to hemodynamic instability in the patient who is symptomatic from severe mitral stenosis? (select 2)
a. nitrous oxide
b. phenylephrine
c. ephedrine
d. furosemide

A

a. nitrous oxide
c. ephedrine

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2
Q

The anesthetic goals for mitral stenosis are

A

“full, slow, and constricted”

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3
Q

The ____________ the mitral valve area, the more pressure the left atrium must produce to move blood into the left ventricle

A

smaller

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4
Q

Normal mitral valve area is

A

4-6 cm 2

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5
Q

Severe mitral valve stenosis is

A

<1 cm2

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6
Q

In the US, the most common cause of mitral stenosis is

A

endocarditis and mitral calcification

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7
Q

In developing nations, the most common cause of mitral stenosis is

A

rheumatic fevere

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8
Q

Increased left atrial pressure can lead to

A

pulmonary hypertension

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9
Q

As mitral stenosis progresses, the left atrium is _____________- while the left ventricle is ______________

A

chronically overfilled; chronically underfilled

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10
Q

Mitral stenosis progresses so that there is ___________– stroke volume, and the body maintains blood pressure by

A

lower; increasing systemic vascular resistance

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11
Q

Anesthetic goals for mitral stenosis in terms of HR, heart rhythm, preload, afterload, contractility, and pulmonary vascular resistance are

A

heart rate–> low side of normal
heart rhythm–> NSR
preload–> maintain
afterload–> maintain
contractility–> maintain
pulmonary vascular resistance–> avoid increase

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12
Q

If the patient has pulmonary hypertension, it is important to avoid

A

hypoxia, hypercarbia, hypothermia, and acidosis

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13
Q

Blood stasis in the left atrium is prone to

A

thrombus formation

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14
Q

Patients with mitral stenosis may be on _______________, so be wary of ______________________

A

anticoagulants; neuraxial blockade

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15
Q

___________ is preferred over ____________ with mitral stenosis because a rapid decline in BP will cause a significant reduction in CO.

A

epidural; spinal

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16
Q

The following can suggest severe mitral stenosis

A

transvalvular pressure gradient (LA to LV) >10 mmHg
pulmonary artery systolic pressure >50 mmHg

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17
Q

Possible etiologies of mitral stenosis include

A

rheumatoid arthritis
lupus
congenital defect
left atrial myxoma
carcinoid syndrome
iatrogenic following mitral valve repair

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18
Q

Tachyarrhythmia treatment for the patient with mitral stenosis includes

A

amiodarone, beta-blockers, calcium channel blockers, digoxin, and cardioversion

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19
Q

After suffering a myocardial infraction, a patient presents with a left ventricular papillary muscle rupture and mitral regurgitation. Which factors will worsen this patient’s condition? (select 3)
a. increased heart rate
b. decreased heart rate
c. increased SVR
d. decreased SVR
e. increased LV to LA pressure gradient
f. decreased LV to LA pressure gradient

A

b. decreased heart rate
c. increased SVR
e. increased LV to LA pressure gradient

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20
Q

Mitral insufficiency causes ______________ & _______________ hypertrophy

A

volume overload & eccentric

21
Q

Common causes of mitral regurgitation include

A

mitral valve prolapse, myxomatous of the mitral valve, and ischeic heart disease

22
Q

Mitral insufficiency can be an

A

acute or chronic problem

23
Q

What four things should be avoided with mitral insufficiency?

A

slower heart rate
increased pressure gradient between the LV & LA
increased SVR
increased size of valve orifice

24
Q

What are the anesthetic goals for mitral insufficiency?

A

full, fast and forward

25
Q

What are the anesthetic goals for mitral insufficiency in terms of heart rate, heart rhythm, preload, afterload, contractility, and pulmonary vascular resistance?

A

heart rate–> elevated
heart rhythm–> NSR
preload–> maintain or increase
afterload–> decrease
contractility–> maintain
pulmonary vascular resistance–> avoid increase

26
Q

After mitral valve repair, there’s a risk of

A

systolic anterior motion (SAM) of the anterior leaflet, leading to outflow obstruction

27
Q

Treatment for systolic anterior motion includes

A

increasing intravascular volume and increasing afterload (phenylephrine)

28
Q

Unlike patients with aortic or mitral stenosis, _____________ can be useful because it promotes forward flow and reduces the regurgitant fraction.

A

sympathectomy

29
Q

Etiologies of mitral insufficiency include

A

rheumatic fever
ischemic heart disease
papillary muscle dysfunction
ruptured chordae tendineae
endocarditis
mitral valve prolapse
left ventricular hypertrophy
SLE
RA
carcinoid syndrome

30
Q

Which valvular disorders are associated with a systolic murmur?
a. mitral insufficiency
b. aortic stenosis
c. mitral stenosis
d. aortic insufficiency

A

a. mitral insufficiency
b. aortic stenosis

31
Q

Where can aortic stenosis murmurs be heard?

A

systolic murmur heard at the right sternal border
think ASSS

32
Q

Where can aortic regurgitation murmurs be heard?

A

diastolic murmur heard at the right sternal border
think ARDS

33
Q

Where can mitral stenosis murmurs be heard?

A

diastolic murmur heard at the apex and left Axilla
think MSDA

34
Q

Where can mitral regurgitation murmurs be heard?

A

systolic murmur heard at the apex and left axilla
think MRSA

35
Q

A murmur may _____________ in intensity with very severe disease

A

decrease- not enough flow passes through the valve to make a sound

36
Q

Anesthetic considerations for transcatheter aortic valve replacement with a SAPIAN valve include (select 2):
a. cardiac standstill
b. cardiopulmonary bypass
c. rapid ventricular pacing
d. ministernotomy

A

a. cardiac standstill
c. rapid ventricular pacing

37
Q

What is a TAVR?

A

minimally invasive method of replacing the aortic valve in patients with aortic stenosis

38
Q

The most common aortic valve replacements are the

A

Edwards SAPIAN
Medtronic CoreValve
anesthetic considerations vary based on the valve selected

39
Q

________________ can occur if the valve doesn’t seat properly

A

acute aortic insufficiency

40
Q

The SAPIAN valve requires

A

rapid ventricular pacing (to produce cardiac standstill) and valvuloplasty prior to deploying the valve

41
Q

The CoreValue is

A

self-expanding, so it doesn’t require rapid ventricular pacing or valvuloplasty

42
Q

Other complications of TAVR include

A

stroke
acute hemodynamic instability
coronary occlusion
perivalvular leak
dysrhythmias
aortic annular injury
& hemorrhage due to vascular injury

43
Q

TAVR can be performed under

A

general anesthesia or MAC

44
Q

Additional anesthetic considerations for TAVR include

A

perfusion on stand-by if the need for emergent CPB arises
fluoroscopy bed- patients will receive dye (risk of allergic reaction and renal injury) & you will need to protect self from radiation

45
Q

What are the three surgical approaches to TAVR?

A
  1. transfemoral
  2. transaortic
  3. transapical (antegrade)
46
Q

Acute hemodynamic instability should prompt consideration of

A

vascular injury (hemorrhage)- have plenty of large-bore IV access & blood in the room

47
Q

___________ can occur if the native valve folds to obstruct a coronary artery or if a mispositioned valve obstructs a coronary artery. The patient will present with signs of

A

coronary occlusion; myocardial ischemia

48
Q

Valvuloplasty can cause ______________________. The patient may require ___________________

A

annular rupture (pericardial tamponade or CV collapse); aortic root repair or replacement

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