Exam 2 - Valvular Heart Disease Flashcards by Brandon Simpson

What is the NYHA Functional Classification of Patients with Heart Disease?

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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What causes a murmur?

Turbulent flow across abnormal valves
Increased flow across normal valves

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Describe functional vs physiologic murmurs?

Functional: innocent murmur
Physiologic: due to conditions outside the heart as opposed to structural defects

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Systolic murmurs are caused by what valve pathologies?

Aortic/Pulmonic Stenosis
Mitral/Tricuspic Regurgitation

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Diastolic murmurs are caused by what pathologies?

Aortic/Pulmonic Regurgitation
Mitral/Tricuspid Stenosis

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Aortic stenosis
Timing:
Location:
Maneuvers:

Timing: midsystolic crescendo-decrescendo - may radiate to carotids
Location: 2nd ICS RSB
Maneuvers: Increases with squatting, decreases with valsalva and standing

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Aortic Regurgitation
Timing:
Location:
Manuevers:

Timing: Early diastolic
Location: Left sternal border
Maneuvers: Increases with hand grip or blood pressure cuff

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Mitral stenosis
Timing:
Location:
Maneuvers:

Timing: Mid-diastolic, radiates to left axilla
Location: Apex
Maneuvers: Increases with tachycardia

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Mitral Regurgitation:
Timing:
Location:
Maneuvers:

Timing: Holosystolic - radiates to left axilla
Location: Apex
Maneuvers: Increases with hand grip of blood pressure cuff inflation

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Tricuspid regurgitation
Timing:
Location:
Maneuvers:

Timing: Holosystolic
Location: Lower left sternal border
Maneuvers: Increases with inspiration

Will have signs of RH failure

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Mitral valve prolapse
Timing:
Location:
Maneuvers:

Timing: Late systolic
Location: Apex
Maneuvers: Increaes with standing or valsalva

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What 3 findings could you have in patients with valvular disorders?

Heart failure
A fib
Angina pectoris from increased myocardial O2 demand d/t enlarged heart

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What factors seen on a chest x-ray would indicate valvular disease?

Cardiomegaly
Left Bronchus Elevation
Valvular Calcifications

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What signs seen on an EKG could indicate valvular disease?

LA enlargement (broad, notched p-wave)
Axis deviations
Dysrhythmias
Ischemia/previous MI

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What defines cardiomegaly?

If the heart size is >50 % of the internal width of the thoracic cage

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Describe the characteristics of mechanical valves?

Made of metal
Very durable (20-30 years)
Highly thrombogenic (requires anticoagulation)
Preferred in young patients

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Describe the characteristics of bioprosthetic valves?

Porcine or bovine
Shorter lasting (10-15 years)
Low thrombogenic potential
Better for elderly patients (less inflammatory response, doesnt require anticoagulation)

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What should be done for a patient with a mechanical heart valve on warfarin who is having a major surgery?

D/C warfarin 3-5 days pre op
Use heparin or LMWH as a bridge until after surgery

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Who is most commonly affected by mitral stenosis?

Women
Rheumatic patients

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What is usually the first sign of rhuematism?

Acute vision changes

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What is the normal mitral valve orifice surface area?

4 - 6 cm²

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

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< 2 cm²

What are the s/s of mitral stenosis?

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Exertional dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary edema
Pulmonary HTN
A-Fib

How is mitral stenosis treated?

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Rate control (80bpm goal) - tachycardia ↓ LV filling and ↑ LAP
↓LAP (diuretics)
Anticoagulation
Surgical correction

What drug is preferred to treat hypotension in patients with mitral stenosis? Why?

- Phenylephrine - Increases SVR but does not increase HR

What 3 drugs are avoided in patients with mitral stenosis?

- Ketamine - Pancuronium and Atracurium (causes histamine release)

What is the primary cause of mitral regurgitation?

Usually d/t CAD Ishcemia causes papillary muscle dysfunction

Why is mitral repair preferred to mitral replacement in patients with regurg?

Repair restores the valves competence and functionality of the MV apparatus Loss of the MV apparatus causes impaired LV ejection and geometry

What are other treatments for MR?

- MitraClip - Vasodilators (ACE-I) - Biventricular pacing - Carvedilol

What heart rate would you want to maintain with mitral regurgitation?

Normal to slightly increase HR *Bradycardia will increase LV volume overload.*

What do you want to avoid in MR patients?

- Increased SVR, causes decompensation of LV - Give afterload reducer (nitroprusside)

What is the saying for anesthesia for patients with MR?

Full, fast, and forward

What is the most common congenital valvular abnormality?

Bicuspid aortic valve (1-2%)

What is the normal surface area of the aortic valve?

2.5 - 3.5 cm²

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

< 1 cm²

What type of hypertrophy is seen in aortic stenosis?

Concentric hypertrophy

What symptoms are seen with aortic stenosis becomes critical?

- Angina - Syncope - Dyspnea on exertion

____% of aortic stenosis patients will die within three years without a valve replacement

75%

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

- ST depression - T-wave inversion

CXR findings for aortic stenosis?

- Prominent ascending aorta - Aortic valve calcification

What surgical treatments are available for aortic stenosis?

- Balloon valvotomy for younger patients - TAVR

What patients cannot undergo a TAVR?

Patients with a bicuspid AV

What should be avoided in patients with aortic stenosis?

- Hypotension - Decreased CO - Bradycardia - Tachycardia

What is not effective for patients with aortic stenosis?

CPR - impossible to create an adequate SV

Induction concerns for aortic stenosis?

- GETA preferred - Avoid decreased SVR and hypotension (phenylephrine) - Avoid tachycardia (esmolol)

Aortic regurgatation is primarily caused by:

- Endocarditis (drug use) - Rheumantic fever - Bicuspid aortic valves

CV symptoms of aortic regurgitation?

- Widened pulse pressure - Decreased DBP - Bounding pulses

Anesthetic considerations for aortic regurgitation?

- Avoid bradycardia (> 80 bpm) - lends to LV volume overload - Avoid increased SVR - GETA

What is the most sensitive indicator of left ventricular myocardial ischemia?

Wall motion abnormalities on Echo

What abnormal pulse is cardiac tamponade associated with?

pulsus paradoxus

What is the best TEE view intra op to monitor for myocardial ischemia?

Transgastric mid-papillary left ventricular short axis view

What medication class blocks angiotensin at the receptor?

ARB - losartan

Sildenafil and ____ are in the same drug class

Milrinone

Exam 2 - Valvular Heart Disease Flashcards

(53 cards)