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J - Health Assessment Final > Valvular Disease (Exam II) > Flashcards

Valvular Disease (Exam II) Flashcards

1
Q

Prevalence of valvular heart disease in the U.S. ________ %.

A
  • 2.5%
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2
Q

The most frequently encountered cardiac valve lesions produce ________overload or _______overload on the LA or LV.

A
  • Pressure overload (stenosis)
  • Volume overload (regurgitation)
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3
Q

Preoperative evaluation of patients with valvular heart disease includes assessments of what 3 factors?

A
  • Severity of cardiac disease
  • Degree of impaired myocardial contractility
  • Presence of associated major organ system disease (JVD, Kidneys, DM)
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4
Q

Compensatory mechanisms for valvular disease:

A
  • ↑ SNS activity
  • Myocardial Hypertrophy
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5
Q

How will you evaluate the History and Physical Examination of Valvular Disease Patients?

A
  • METs score (exercise tolerance)
  • Cardiac reserve
  • NYHA Functional Classification Class
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6
Q

What are the NYHA Functional Classification of Patients with Heart Disease classes and descriptions?

A

I - Asymptomatic.
II - s/s with activity but relieved by rest.
III - s/s w/ minimal activity, relieved by rest.
IV - s/s at rest

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7
Q

What causes murmurs?

A
  • Turbulent blood flow across abnormal valves (pathological)
  • Increased flow across normal valves (functional/pregnancy)
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8
Q

What valve issues will produce a systolic murmur?

A
  • Aortic Stenosis
  • Mitral Valve Regurgitation
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9
Q

What valve issues will produce a diastolic murmur?

A
  • Aortic Regurgitation
  • Mitral Valve Stenosis
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10
Q

Describe a mid-systolic murmur.

A
  • Occur between distinct S1 and S2 heart sounds
  • Crescendo (louder)–decrescendo (softer) pattern
  • Can be functional
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11
Q

Where is the best place to hear a mid-systolic murmur

A

Right upper sternal border

If murmur radiates towards right carotids, possible aortic stenosis.

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12
Q

What murmur merges with S1 and S2

A
  • Holosystolic Murmur
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13
Q

Where is the best place to hear a Holosystolic Murmur?

A
  • Apex of the heart
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14
Q

Holosystolic Murmur that radiates to the left axilla correlates to what valvular issue?

A
  • Mitral regurgitation
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15
Q

What murmur follows S2?

A
  • Diastolic Murmur

Lub, Dub, Murmur - easiest one to hear

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16
Q

Aortic Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Right upper sternal border
  • Midsystolic crescendo-decrescendo mumur
  • Radiation to carotids
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17
Q

Aortic Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Left Sternal border
  • Early diastolic murmur
  • May have ↑ systolic murmur d/t ↑ SV
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18
Q

Mitral Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Apex
  • Mid-diastolic murmur
  • Radiation to left axilla
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19
Q

Mitral Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Apex
  • Holosystolic murmur
  • Radiation to the left axilla
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20
Q

Name the auscultation locations.
Aortic:
Pulmonic:
Tricuspid:
Mitral:

A
  • Aortic: 2nd ICS RSB
  • Pulmonic: 2nd ICS LSB
  • Tricuspid: 5th ICS LSB
  • Mitral: 5th ICS Left Mid-Clavicular
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21
Q

Diagnostics EKG:

Broad notched P waves on the ECG suggest _________ enlargement.

A

*atrial enlargement

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22
Q

Right ventricular hypertrophy will result in a _________ axis deviation?

A
  • Right
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23
Q

This is the most common dysrhythmia presented in valvular disease.

A
  • Atrial fibrillation
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24
Q

CXR diagnostics for valvular disease patients.

A
  • Cardiomegaly
  • Left mainstem bronchus elevation
  • Valvular calcifications
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25
Q

What diagnostic tool can be used to assess:
* Cardiac anatomy and function
* Presence of hypertrophy
* Cavity dimensions
* Valve area
* Transvalvular pressure gradients
* Magnitude of valvular regurgitation
* Significance of murmurs
* Ventricular EF
* Evaluate prosthetic valve function

A

Echocardiogram

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26
Q

What is the purpose of angiography? (x5)

A
  • Assess for presence and severity of valvular stenosis and/or regurgitation
  • Diagnose CAD
  • Assess for Intracardiac shunting
  • Assess Transvalvular pressure gradients
  • Delineate clinical vs echocardiographic findings
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27
Q

Describe a mechanical valve

A
  • Valve can be metal or carbon alloy
  • Very durable, can last 20-30 years
  • Cons: Highly thrombogenic
  • Younger patients
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28
Q

Which type of prosthetic valve is longer lasting?

A

Mechanical

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29
Q

What type of valve replacement is thrombogenic?

A

Mechanical

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30
Q

Describe a bioprosthetic valve:

A
  • Valve can be Porcine or bovine
  • Short lasting. 10-15 years
  • Low thrombogenic potential
  • Elderly patients
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31
Q

What are bioprosthetic valves made from?

A

Porcine or bovine

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32
Q

Patients with valvular disease undergoing surgery will discontinue what medication 3 to 5 days before surgery?

A
  • Warfarin

Oftentimes, patients are on some sort of bridge therapy (heparin).

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33
Q

Warfarin is not recommended in the _______ trimester because it can lead to spontaneous termination of pregnancy.

Pregnant moms are usually on _________ or ____.

A
  • First

Pregnant moms are usually on LMHW or ASA.

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34
Q

Name this valve disorder:
* Rare in the US
* Usually occurs d/t Rheumatic heart disease
* Primarily affects women
* Asymptomatic for 20-30 years

A
  • Mitral Stenosis
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35
Q

Who is most commonly affected by mitral stenosis?

A
  • Women
  • Rheumatic patients
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36
Q

What is the normal mitral valve orifice surface area?

At what surface area do symptoms for mitral valve stenosis start to develop?

A
  • 4-6 cm2
  • Symptoms develop when the mitral valve orifice is less than 2 cm2**
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37
Q

How will mitral valve stenosis affect the following
LA volume and pressure:
LV contractility:
SV:

A
  • LA volume ↑/ LA pressure ↑
  • No change in LV contractility
  • SV ↓
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38
Q

Mitral Valve Stenosis Signs and Symptoms: (PPP AOD)

A
  • DOE
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Pulmonary edema
  • Pulmonary HTN
  • Atrial fibrillation

Think fluid backing up into the lungs.

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39
Q

What will you see on Mitral Valve Stenosis CXR? (MEPS)

A
  • Mitral calcification
  • Pulmonary edema or vascular congestion
  • Elevated left main bronchus
  • Straightening of left heart border
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40
Q

What will you see on Mitral Valve Stenosis Echo? (LAE LAT C)

A
  • Calcification
  • Left atrial thrombus
  • Left atrial enlargement
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41
Q

Mitral Valve Stenosis will enlarge the left atria, which will show a _________ on the EKG.

__-____ can also be seen in mitral valve stenosis.

A
  • notched P-wave

A-fib can also be seen in mitral valve stenosis.

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42
Q

Mitral Valve Stenosis Treatment

A
  • Rate control w/ β-blockers, CCB, digoxin
  • ↓ Left atrial pressure w/ Diuretics
  • Anticoagulation therapy
  • Surgical correction- Valve replacement
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43
Q

Mitral Valve Stenosis Anesthetic Considerations

A
  • Maintain normal parameters for HR, volume status, and afterload
  • Prevent/Treat ↓CO or pulmonary edema
  • Maintain SVR and BP (Neo, Vaso)
  • Avoid Pulmonary HTN
  • Treat diuretic-induced complications (low K+)
44
Q

What position do we not want to use with mitral stenosis? Why?

A

No Trendelenburg, can ↑CHF

45
Q

Neuraxial Anesthesia Considerations for Mitral Valve Stenosis Pts?

A
  • Maintain BP
  • Maintain Normal HR
  • Make sure the patient has adequate preload
  • avoid tachycardia
46
Q

What induction agent do you want to avoid in patients with mitral valve stenosis?

A
  • Ketamine (↑HR)
  • Atracurium (↑ Histamine release)
47
Q

Name this valve disorder:
* Occurs in 2% of the US population
* Associated with IHD, Ruptured papillary muscle, Endocarditis, and Cardiomyopathy

A
  • Mitral Regurgitation
48
Q

What is more common, mitral stenosis or regurgitation?

A

Regurgitation (2% of US population)

49
Q

What conditions will you see eccentric hypertrophy?

A
  • Mitral Valve regurgitation
  • Aortic Valve regurgitation
50
Q

What type of heart wall thickening happens with aortic stenosis?

A
  • Concentric Hypertrophy
51
Q

Mitral valve regurgitant volume is dependent on two things:

A
  • Size of the mitral valve orifice
  • The pressure gradient across the mitral valve
52
Q

What type of murmur would be auscultated with mitral regurgitation?

Other Mitral Valve Regurgitation Symptoms (x2):

A
  • Holosystolic murmur at apex that radiates to the axilla
  • Cardiomegaly
  • Atrial fibrillation
53
Q

Causes of Mitral Valve Regurgitation: (HEP)

A
  • History of IHD
  • Endocarditis
  • Papillary muscle dysfunction
54
Q

Mitral Valve Regurgitation Findings:
- EKG?
- CXR?
- ECHO?

A
  • EKG: A-fib
  • CXR: Cardiomegaly, LA/LV hypertrophy
  • ECHO: Left atrial thrombus
55
Q

Mitral Valve Regurgitation repair is recommended for patients with EF between ____ to ____ % .

For EF < ____%, sugurical intervention will not help.

A
  • 30 to 60%

For EF < 30%, sugurical intervention will not help.

56
Q

What less invasive cath lab procedure is used to treat mitral regurgitation?

A
  • Mitraclip
57
Q

What are the pharmacological/medical treatments for mitral valve regurgitation?

A
  • Vasodilators
  • Biventricular Pacing
  • ACE-inhibitors
  • BB’s
58
Q

What β-blocker is preferred for mitral regurgitation?

A

Carvedilol

59
Q

Anesthetic Considerations for Mitral Valve Regurgitation:
* Goal?
* What do you want to prevent?
* HR we see?
* What are 2 things you want to avoid?

A
  • Goal: Improve forward SV and ↓ regurgitant fraction
  • Prevent ↓ CO
  • HR: Normal to slightly increased HR (90 bpm)
  • Avoid Bradycardia can lead to LV volume overload
  • Avoid increased SVR (use nitro)
60
Q

How will neuraxial anesthesia affect the SVR of Mitral Valve Regurgitation Patients?

A
  • ↓ SVR
61
Q

Mitral regurg anesthetic considerations:

Maintenance of ________ ______ _______ is very important for maintaining left _______ volume and _______ ______.

A

Maintenance of intravascular fluid volume is very important for maintaining left ventricular volume and cardiac output.

62
Q

What are the two factors that cause Aortic Stenosis?

A
  • Calcifed aortic leaflets d/t aging
  • Bicuspid aortic valve (BAV)
63
Q

What type of pathology would cause early-life development of aortic stenosis?

A

Bicuspid Aortic Valve

64
Q

Bicuspid Aortic Valve is the most common _______ valvular abnormality, and it affects __- __% of the population.

A

Congenital

1-2%

65
Q

What is the normal surface area of the aortic valve?

What is the surface area of a severely stenotic aortic valve?

A

2.5 - 3.5 cm²

< 1 cm²

66
Q

Aortic Stenosis mumur pattern?

Where does the murmur radiate? What does it mimic?

A
  • Crescendo–decrescendo pattern
  • Murmur radiates to the neck, mimics carotid bruit
67
Q

What pathology would be expected for a systolic or mid-systolic murmur hear in the right upper sternal border?

A

Aortic Stenosis

68
Q

What symptoms are seen when aortic stenosis becomes critical?

Symptoms correlate with an average time to death of?

A
  • Angina pectoris (↑Risk of peri-op mortality and MI)
  • Syncope
  • DOE (dyspnea on exertion)

Within 2-5 years

69
Q

______ % of symptomatic pts with aortic stenosis die within 3 years without valve replacement

A
  • 75%
70
Q

What EKG characteristics would be seen for a patient with aortic stenosis? (x3)

A
  • LV hypertrophy
  • ST Depression
  • T wave inversion
71
Q

What CXR characteristics would be seen for a patient with aortic stenosis?

A
  • Prominent ascending aorta
  • Aortic valve calcification
72
Q

What echo characteristics would be seen for a patient with aortic stenosis?

A

Discern b/w 3 or 2-leaflet valve
Thickened and calcified
Valve area and transvalvular pressure gradients

73
Q

What exercise stress test characteristics would be seen for a patient with aortic stenosis?

A

Poor exercise tolerance &/or abnormal BP with exercise

74
Q

What non-surgical treatments are available for aortic stenosis?

When is treatment usually started?

A
  • Balloon valvotomy for adolescents/young adults
  • Transcatheter aortic valve replacement (TAVR)

When patients become symptomatic

75
Q

Anesthetic Considerations for Aortic Stenosis:
What do you want to prevent or avoid? (x5)
HR:
What do you want to optimize?

A
  • Prevent / avoid: hypotension, ↓CO, bradycardia, tachycardia, ↓SVR
  • Maintain NSR (80 bpm)
  • Optimize intravascular fluid volume.
76
Q

CPR is not effective for which valvular disorder?

A
  • Aortic Stenosis
77
Q

Why is General Anesthesia preferred over epidural or spinal for aortic stenotic patients?

A

General anesthesia is often preferred to epidural or spinal anesthesia because the sympathetic blockade produced by regional anesthesia can lead to significant hypotension.

78
Q

What pressor would you want to use if an aortic stenosis patient experience hypotension? Why?

A
  • Phenylephrine (α-agonist)

α-agonist do not cause tachycardia and therefore maintain diastolic filling time.

79
Q

What drug would you want to use if an aortic stenosis patient experience tachycardia?

A
  • Esmolol (short-acting β1 selective-blocker)
80
Q

What meds should you avoid with AS anesthetic considerations?

A
  • Ketamine = increase HR
  • Pancuruonium & atracurium = histamine release = hypoTN
  • Morphine / hydromorphone = histamine release= hypoTN
81
Q

Name the valve disorder:
* Failure of aortic leaflets caused by disease of the aortic leaflets or aortic root
* Caused by Endocarditis, Rheumatic fever, Bicuspid aortic valve (BAV), Anorexigenic drugs (phen-phen)
* Decrease CO d/t regurgitant SV
* Usually a slow onset

A
  • Aortic Regurgitation
82
Q

What are common causes of chronic aortic regurgitation?

A
  • Endocarditis/rheumatic fever
  • Bicuspid AV
  • Anorexigenic drugs
83
Q

What are the two common causes of acute aortic regurgitation?

A
  • Endocarditis
  • Aortic dissection
84
Q

The magnitude of aortic regurgitation is dependent on?

A
  • Time available for regurgitant flow (HR)
  • Pressure gradient across the aortic valve (SVR)
85
Q

↑ SVR in Aortic Valve regurgitation =

A
  • more regurgitant

Lower SVR, more flow forward

86
Q

Aortic Valve Regurgitation’s Effect on EF?

A
  • Decrease EF over time
87
Q

In what valvular condition will you hear a low-pitched diastolic rumble called an Austin-Flint murmur?

A
  • Aortic Regurgitation
88
Q

Aortic Regurgitation effect on:
- Pulse Pressure
- DBP
- Pulse Characteristics

A
  • Widened Pulse Pressure
  • Decrease DBP
  • Bounding Pulses
89
Q

What are the manifestations of LV failure in aortic regurgitation patients? (you’re FOCD)

A
  • Dyspnea
  • Orthopnea
  • Fatigue
  • Coronary ischemia
90
Q

Acute Aortic Regurgitation will result in severe ______ volume overload.

A
  • LV
91
Q

Three S&S of acute aortic regurgitation? (RIC)

A
  • Coronary Ischemia
  • Rapid Deterioration of LV function
  • Immediate Heart Failure
92
Q

What EKG characteristics would be seen for a patient with aortic regurg?

A

LV enlargement

93
Q

What CXR characteristics would be seen for a patient with aortic regurg?

A

Hypertrophy

94
Q

What ECHO characteristics would be seen for a patient with aortic regurg?

A

Leaflet prolapse or perforation

95
Q

What are the medical treatments for aortic regurgitation?

A
  • Decrease systolic HTN
  • Decrease LV wall stress
  • Improve LV function
  • Diuretics, ACE-I, CCB
96
Q

What are the surgical treatments for aortic regurgitation?

A
  • Aortic Valve Replacement
  • Aortic Root Replacement
97
Q

Anesthetic considerations for aortic regurgitation.
- Goal:
- Avoid:
- HR:
- Minimize:

A
  • Goal is to maintain forward LV SV
  • Avoid ↓HR, avoid ↑SVR
  • HR: > 80 bpm
  • Minimize myocardial depression (use vasodilator to ↓ afterload and Inotrope to ↑ contractility)
98
Q

What type of anesthesia is preferred for Aortic Regurgitation?

A
  • General Anesthesia
99
Q

Which of the following is the most sensitive indicator of left ventricular myocardial ischemia?
A. Wall Motion Abnormalities on the Echo
B. Appearance of V waves on the PCW tracing
C. ST segment changes in VS
D. Decrease in CO

A

A. Wall Motion Abnormalities on the Echo

100
Q

Cardiac tamponade is associated with?

A

Pulsus Paradoxus

101
Q

The MAP in a pt with a blood pressure of 180/60 mmHg is?

A

100

102
Q

Which of the following medications blocks angiotensin at the receptor?
A. Losartan
B. Lisinopril
C. Terazosin
D. Spironolactone

A

A

103
Q

Which of the following would be the best intra-operative TEE view to monitor for myocardial ischemia?
A. Midesophageal 4 chamber view
B. Midesophageal long axis view
C. Transgastric mid-papillary LV short axis view
D. Midesophageal two chamber view

A

C

104
Q

What is the minimum amount of time after angioplasty with a drug elut. stent that DAPT is continued elective surg?
A. 3 months
B. 1 year
C. 6 months
D. 18 months

A

B

105
Q

The effects of clopidogrel can be reversed with?
A. FFP
B. Aprotinin
C. Factor VIII
D. None of the above

A

D

106
Q

You made an infusion of dopamine with 200mg dopamine in 250 mL 800mcg/mL. What is the rate for 5 mcg/kg/min in a 70kg pt?

A

26 mL/hr

107
Q

Severe aortic stenosis is associated with a valve area less than ___ cm^2?

A

1

J - Health Assessment Final (23 decks)

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