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Cardiac Flashcards

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1
Q

What is aortic stenosis

A

Obstruction to left ventricular systolic outflow across the aortic valve

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2
Q

What are the causes of Aortic stenosis?

A

o Age-related degeneration + calcification of aortic leaflets with subsequent stenosis (develops 60-80 years)
o Presence of congenital bicuspid rather than tricuspid aortic valve (develops 30-50 years)
o Rheumatic heart disease
o Infective endocarditis

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3
Q

What are the clinical features of Aortic stenosis on history?

A

Chest pain/dyspnoea/syncope

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4
Q

What are the clinical features of Aortic stenosis on exam?

A

Displaced hyperdynamic apex beat
Mid systolic ejection murmur maximal over aortic area and extending into carotids
Loudest with patient sitting up and in full expiration (RILE right sided louder on inspiration, left sided on expiration)

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5
Q

What are Ix for Aortic stenosis?

A

ECG - LVH and LV strain
TTE - Valve area, Mean gradient, jet velocity
Coronary angiogram

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6
Q

How do you assess severity of aortic stenosis?

A

symptoms are not reliable - assessed on TTE findings

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7
Q

What is the criteria for LVH on ECG?

A

Sokolov- lyon criteria - R waves V5 or V6 + S wave in V1 > 35mm

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8
Q

What is DI for aortic stenosis?

A

Ratio of LVOT velocity to AV velocity
<0.25 = severe AS
Helps to identify severe AS in failing low flow AS

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9
Q

What are the class I indications for aortic stenosis surgery?

A

(1) severe AS
(2) asymptomatic severe AS with LVEF <50%
(3) asymptomatic severe AS undergoing CABG or surgery on the aorta or other heart valves

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10
Q

What are the haemodynamic goals for aortic stenosis?

A

Slow, full and tight

  • Low normal HR (avoid tachycardia)
  • Maintain sinus rhythm
  • Increase LV preload (maintain a full ventricle)
    o Optimize intravascular fluid volume to maintain venous return + LV filling
  • Increase SVR
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11
Q

What is mitral regurg?

A

Retrograde blood flow into the left atrium resulting from an incompetent mitral valve

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12
Q

What are causes of MR?

A

Primary MR: Leaflet, chordal, papillary muscle abnormalities eg endocarditis, rheumatic fever

Secondary: LV dilation causing abnormal MV function eg myocardial ischaemia

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13
Q

What are the clinical features of mitral regurg on history?

A

Fatigue, weakness
Acute MR presents as pulmonary oedema/cardiogenic shock

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14
Q

What are the clinical features of mitral regurg on exam?

A

Apical pan-systolic murmur with radiation to axilla
displaced + forceful apex beat

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15
Q

What are Ix for mitral regurg?

A

ECG - LVH, AF
CXR - LA + LV enlargement
TTE - dilated LA, hyperdynamic LV, pulm HTN
Coronary angiogram - exclude ischaemia

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16
Q

What are TTE signs that indicate disease severity for mitral regurg?

A
  • Regurgitant volume (>60mls/beat = severe)
  • Regurgitant fraction (>50% = severe)
  • Regurgitant orifice area (>0.4cm2)

EF < 60% also suggests significant LV dysfunction

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17
Q

What is the medical management of acute and chronic mitral regurg?

A

Acute - afterload reduction eg with SNP
Chronic - antihypertensives eg ACE-i

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18
Q

What is the surgical indications for mitral regurg?

A

Only definitive treatment!

Repair is preferred to replacement

Class I indications include:
-Acute severe MR
- symptomatic patients with severe primary MR despite medical mx and LVEF > 30%
- asymptomatic patients with severe MR but with evidence of declining LV function

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19
Q

What patients are not suitable for surgical management of mitral regurg?

A

Patients with EF <30% or a left ventricular end-systolic dimension >55 mm do not experience improvement with mitral valve surgery

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20
Q

What are you haemodynamic goals for managing mitral regurg?

A

o Maintain sinus rhythm
o High normal HR ≈80bpm
o Maintain preload
o Maintain contractility
o Decrease afterload (avoid increases in SVR)

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21
Q

What are the causes of mitral stenosis?

A
  • Rheumatic (most common)
  • Congenital
  • Other - RA/SLE/carcinoid
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22
Q

What are the clinical features of mitral stenosis on history?

A

Dyspnoea, Orthopnoea, PND

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23
Q

What are the clinical features of mitral stenosis on exam?

A

AF (irregular pulse)
If pulm HTN then right ventricular heave, palpable P2, Loud P2
Low-pitched rumbling diastolic murmur

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24
Q

What are signs of severe mitral stenosis on exam and Ix?

A
  • Small pulse pressure
  • Soft S1
  • Pulm HTN
  • TTE: small valve area (<1cm2), gradient across valve > 10mmHg, pulm Sys > 50
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25
What is the medical management for mitral stenosis?
o Anticoagulation for prevention of systemic embolic events o Ventricular rate control with β blockers/non-dihydropyridine calcium channel blockers/digoxin & aggressive treatment of tachyarrhythmias o Treat congestive heart failure with diuretics + sodium restriction
26
What is the surgical managment of mitral stenosis?
- surgical valvotomy - MV replacement - Percutaneous balloon mitral valvotomy
27
What are the haemodynamic goals of mitral stenosis?
o Low normal HR (avoid tachycardia) o Maintain sinus rhythm o Maintain preload o Increase SVR
28
What are the causes of aortic regurgitation?
- Leaflet abnormalities eg IE, congenital bicuspid aortic valve - Aortic root or ascending aorta abnormalities eg Ehler's Danlos, Marfan's, aortic dissection
29
What are the clinical features of aortic regurg on history?
- Dypsnoea, fatigue, syncope, chest pain
30
What are the clinical features of aortic regurg on examination?
- Collapsing pulse - Wide pulse pressure - Low diastolic pressure - Decrescendo high pitched early diastolic murmur along left sternal border
31
What are Ix for aortic regurg?
ECG - LVH CXR - aortic dilation, enlarged LV TTE - regurgitation and quantification of severity
32
What are TTE signs that indicate disease severity for aortic regurg?
- Regurgitant volume (>60mls/beat = severe) - Regurgitant fraction (>50% = severe) - Regurgitant orifice area (>0.3cm2)
33
What is the medical treatment of aortic regurg?
- acute: afterload reduction eg SNP, diuretics for pulm oedema - chronic: vasodilator therapy eg ACE-i, diuretics for heart failure
34
What is indications for surgical management of aortic regurg?
- acute AR and cardiogenic shock - Severe AR undergoing other cardiac surgery - LVEF <50% - Severe AR with LVEF >50% but LV dilation
35
What are the haemodynamic goals for Aortic Regurg?
- Heart rate high/normal - Avoid increases in afterload/decrease it if possible - Maintain preload - Maintain contractility - Maintain SR
36
What is the definition of cardiac failure?
complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood – as a result the heart fails to meet oxygen demand
37
What is the classficiation of heart failure based on EF?
Heart failure with reduced ejection fraction (HF-REF) Heart failure with preserved ejection fraction (HF-PEF)
38
What are the clinical features of cardiac failure on history?
o LV failure – exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea o RV failure – ankle/sacral/abdominal swelling, anorexia, nausea
39
What are the clinical features of cardiac failure on exam?
LV failure - Pulsus alterans, Hypotension, Displaced LV apex beat (with dilation), basal inspiratory crackles RV failure - Peripheral oedema/raised JVP/pulsatile liver, RV heave
40
What Ix can you do for cardiac failure?
- BNP (<100 = unlikely heart failure, >500 = likely) - Renal dysfunction - ECG - BBB, previous ischaemia, AF - CXR - cardiomeagly, pulmonary congestion - TTE - LVEF, measures of RV function too
41
What is the clinical classification for severity of heart failure?
NYHA 1 = no symptoms 2 = symptoms with ordinary exertion 3 = symptoms with less than ordinary exertion 4 = symptoms at rest
42
What is the medical treatment for heart failure?
-ACE-i, Beta blockers, diuretics, statins - Cardiac resynchronisation therapy - NYHA Class 3 or 4 with LVEF <35% and QRS duration 120-150 msec - ICD if EF <30% or <40% and inducible arrhythmias on studies
43
What is the grading score for angina?
Canadian cardiovascular society angina Class I - angina during strenuous activity Class II - slight limitation due to angina Class III - moderate limitation during everyday living Class IV - severe limitation due to angina
44
What are the class I indiciations for CABG?
- >50% left main disease - >70% blockage both LAD and circumflex (equivalent to left main disease) - Triple vessel disease with LVEF <50% - Single or 2 vessel CAD with large area of viable myocardium at risk
45
How long should non-cardiac surgery be avoided after MI in the absence of coronary intervention?
60 days
46
How long should non-cardiac surgery be avoided after BMS?
30 days
47
How long should non-cardiac surgery be avoided after DES?
12 months, can be considered after 6 months
48
What are the ECG definitions of a STEMI?
ST elevation at J point in V2-3 >2mm >1mm in any other lead
49
What are the types of cardiomyopathy?
Dilated cardiomyopathy Hypertrophic Restrictive Arrhythmogenic
50
What are some causes of dilated cardiomyopathy?
idiopathic + familial, alcohol, post-viral, peripartum, drugs (doxorubicin), Duchenne’s muscular dystrophy, haemochromatosis
51
What is the anaesthetic goals for dilated cardiomyopathy?
* Maintain sinus rhythm * Adequate volume loading * Normal SVR * Avoid myocardial depression
52
What are some causes of hypertrophic cardiomyopathy?
- Unknown cause but likely genetic -> possibly autosomal dominant in >50% cases
53
What are the anaesthetic goals for hypertophic cardiomyopathy
Maintain a ‘large ventricle’ since dynamic obstruction is reduced Goals: o Low/normal HR o Maintain sinus rhythm o Adequate volume loading – avoid hypovolemia o High normal SVR o Low ventricular contractility (inotropes contraindicated as LVOT exacerbated by increased myocardial contractility)
54
What are some causes of restrictive cardiomyopathy?
- commonest is amyloid - others include idiopathic, eosinophilic endomyocardial disease
55
What are the anaesthetic goals for restrictive cardiomyopathy?
- Spontaneous respiration is preferable to avoid PPV compromising venous return - Ketamine is useful for induction because it increases myocardial contractility + peripheral resistance - Goals: o Maintain sinus rhythm o Adequate volume loading o High normal SVR o Avoid myocardial depression
56
What scale can be used to assess AF severity?
Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCSSAF) scale Class 0 - 4 of increasing symptoms due to AF (none, minor, mild, moderate and severe)
57
What are anaesthetic goals for AF?
- Treatment of acute onset AF (shock if unstable or rate control if stable) - Venticular rate control (HR <100) - Consideration of need for anticoagulation and bleeding risk
58
When does does a PPM need to be reversed to an aysynchronous mode?
- when the patient is pacemaker dependent - EMI <15cm to source - Risk of inappropriate inhibition otherwise
59
When does a ICD need to be re-programmed?
If the patient is pacemaker dependent as magnet will not affect pacing and at risk of inappropriate inhibition otherwise
60
What are the causes of prolonged QT?
Acquired - Drugs eg amiodarone, droperidol, methadone, electrolytes eg low K or Mg Congential
61
What is the management of prolonged QT?
- All patients should be on beta blockers with HR <130 - Electrolytes should be normal - Check AICD if they have
62
What is the intraop managment of patient with prolonged QT?
- Adequate monitoring - Avoid excessive sympathetic activity - laryngoscopy, intubation - Avoid drugs
63
What is brugada syndrome?
-Familial disorder (autosomal dominant) characterized by spontaneous idiopathic ventricular fibrillation - Issues with Na channel
64
What are the ECG findings in Brugada syndrome?
pattern of ST-segment elevation in leads V1 to V3 either: - elevated ST segment with T wave inversion - saddleback/humped ST segment
65
What are the clinical features on history in pulm HTN?
dyspnoea, angina (RV ischaemia), syncope (low CO with failing RV), oedema
66
What are the clinical features on exam in pulm HTN?
- Elevated JVP - RV heave - Loud P2 (forceful closure of pulm valve) - +/- pansystolic murmur of TR
67
What are the Ix used in pulm HTN?
o CXR – prominent pulmonary vessels, cardiomegaly, parenchymal lung disease o ECG – right axis deviation, RV strain or hypertrophy, RBBB o ABG – hypoxemia o RFTs – low DLCO, obstructive or restrictive pattern o CT chest or V/Q scan – abnormal perfusion o 6MWT – reduced total distance (normal >400m) predicts worse prognosis, monitors treatment response o Echocardiography – systolic pulmonary artery pressure (estimated from velocity of TR & right atrial pressure using Bernoulli equation – SPAP = 4v2 + RAP), right atrial enlargement, reduced tricuspid annular phase systolic excursion (TAPSE), pericardial effusion o Right heart catheterisation – gold standard for diagnosis
68
What are your global intraop goals for patients with pulm HTN?
- Avoid increases in PVR - Maintain RV contractility - Maintain afterload
69
Whats the criteria for RBBB?
QRS > 0.12 secs Secondary R wave in V1 or V2 Wide slurred S wave in leads I, V5, V6
70
What are anaesthetic implications of a post cardiac transplant patient?
- Meticuluous aseptic technique - Maintain preload as Preload dependent - Use direct acting agents eg ephedrine, metaraminol - consider steroid dosing

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