Quiz 10 - Valvular Heart Disease

Question 1

1. What are the major factors that affect flow across any valvular lesion?

Answer 1

1. The valve area
2. Square root of hydrostatic pressure
3. Time duration of transvalvular flow

Question 2

2. What are the goals in management of patients with regurgitant lesions?

Answer 2

Reduce or minimize flow across the mitral or aortic lesion

Question 3

3. What are the goals in management of patients with stenotic lesions?

Answer 3

maximize and enhance stenotic flow across the mitral or aortic valve

Question 4

4. What types of valvular lesions can respond to changes in loading conditions: Regurgitant vs. stenotic lesions?

Answer 4

Regurgitant

Question 5

5. What types of valvular lesions are generally considered fixed and do not respond to changes in loading conditions: Regurgitant vs. stenotic lesions?

Answer 5

Stenotic

Question 6

6. What are some of the causes of Aortic Stenosis?

Answer 6

• Idiopathic (calcified degeneration)
• Congenital (bicuspid instead of tricupid valve)
• Endocarditis
• Other (Paget’s dz, Lupus)

Question 7

7. What are some of the presenting symptoms in patients with severe Aortic Stenosis?

Answer 7

Angina
Syncope
CHF

Question 8

8. Would you expect to hear a systolic or diastolic murmur with Aortic Stenosis?

Answer 8

Systolic murmur

Question 9

9. What pathophysiology would you expect in the patient with severe Aortic Stenosis?

Answer 9

Obstruction to LV Ejection
Pressure gradient created across the valve
Chronic LV pressure overload
LV Hypertrophy

Question 10

10. What are some of the reasons that patients with severe Aortic Stenosis develop cardiac ischemia?

Answer 10

• Hypertrophied LV muscle mass
• Increased Systolic pressure
• Prolongation of Ejection (short diastolic time)
• relative decrease in capillary density (more area requires O2 to travel further to cells)
• High incidence of concomitant coronary artery disease

Question 11

11. What is the single most important hemodynamic goal in managing patients with severe Aortic Stenosis?

Answer 11

Will need higher pressure gradient to push blood through valves….AVOID HYPOTENSION!

Question 12

12. What are some of the causes of Aortic Regurgitation?

Answer 12

• Rheumatic Heart disease
• Endocarditis
• Aortic root disection
• Trauma
• Connective Tissue disorders
• Dexfenfluramine (half of the Phen/fen appetite suppressant combo)

Question 13

13. Do patients with aortic regurgitation develop eccentric or concentric hypertrophy?

Answer 13

Eccentric hypertrophy

Question 14

14. Would you expect to hear a systolic or diastolic murmur with Aortic Regurgitation?

Answer 14

Diastolic murmur

Question 15

15. Do patients with Aortic Regurgitation develop volume or pressure overloading?

Answer 15

Volume overload

Question 16

16. What factors contribute to reduced coronary perfusion pressure in patients with Aortic Regurgitation?

Answer 16

• Lower diastolic pressure

- Increased LVEDP (Slide 34)

Question 17

17. What are some of the symptoms that patients with Aortic Regurgitation develop?

Answer 17

• Long asymptomatic period during which the LV undergoes progressive eccentric hypertrophy
• CHF
• Angina (Slide 29)

Question 18

18. How would you manage heart rate and blood pressure in a patient with severe Aortic Regurgitation?

Answer 18

-Increase Heart Rate:
Increased HR reduces diastolic time and reduces regurgitant fraction. Also raises diastolic BP and decreases LVEDP.
-Decrease SVR
Afterload reduction is helpful in improvien forward flow
-Increase preload
Because of increased LV volumes, need increased preload to maintianforward flow. Avoid hypovolemia (Slide 37)

Question 19

19. What are some of the causes of Mitral Stenosis?

Answer 19

• Rheumatic (Women x4 > Men)
• Congenital
• Rheumatoid arthritis
• Systemic Lupus erythematous
• Carcinoid Syndrome (Slide 41)

Question 20

20. What type of a murmur (systolic vs. diastolic) would you expect to hear in a patient with Mitral Stenosis?

Answer 20

Diastolic

Question 21

21. What are the most common presenting symptoms in a patient with severe Mitral Stenosis?

Answer 21

• CHF

- Atrial fibrillation (Slide 41)

Question 22

22. What pathophysiology would you expect in the patient with severe Mitral Stenosis?

Answer 22

-Left Atrium
Chronic obstruction to left atrial emptying during diastole
Chronic volume and pressure over-loading of the left atrium and structures behind it
-Right Ventricle
RV function is normal in absence of pulmonary hypertension (PHT)
Severe pulmonary hypertension will result in RV failure and secondary abnormalities of LV function
-Left Ventricle
LV function is usually normal
Decreased LVEF in about 1/3 of MS patients:
Rheumatic carditis
Chronic volume underloading
Concomitant CAD
Septal hypertrophy in patients with pulmonary hypertension (PHT) (Slide 45)

Question 23

23. What is the single most important hemodynamic goal in managing patients with severe Mitral Stenosis?

Answer 23

-Control Tachycarda/Decrease Heart Rate: Slow to allow time for ventricular filling (need longer diastolic time)

Question 24

24. What are some of the causes of Mitral Regurgitation?

Answer 24

• Rheumatic disease
• Endocarditis
• Mitral valve prolapse
• Mitral annular enlargement
• Ischemia,
• Myocardial infarction,
• Trauma,
• Fenfluramine diet suppressants (Slide 53)

Question 25

25. What type of a murmur (systolic vs. diastolic) would you expect to hear in a patient with Mitral Regurgitation?

Answer 25

Systolic murmur

Question 26

26. If a patient with severe Mitral Regurgitation has a preop LVEF of 35% and undergoes a mitral valve replacement, would you expect to see an increase or decrease in the postop LVEF after the valve procedure?

Answer 26

Decrease

Question 27

27. What pathophysiology would you expect in the patient with severe Mitral Regurgitation?

Answer 27

- Left ventricle UNLOADS into the left atrium - Chronic overload on the LV - Volume of regurgitate flow determined by: * Ventriculo-atrial gradient**Diastolic time***Size of the regurgitant orifice - Measurement of LV function tend to be slightly elevated * moderately depressed ejection fraction in a patient with MR may be indicative of a severely depressed inotropic state (Slide 57)

Question 28

28. How would you manage the heart rate and blood pressure in the patient with severe Mitral Regurgitation?

Answer 28

-INCREASE Heart Rate: Increased HR leads to a decrease in LV volume, increased forward flow, and decreaaed regurgitate fraction. -DECREASE Afterload: Increased contractility tends to increase forward flow and may reduce regurgitant fraction by constricting mitral annulus. -INCREASE Contractility: Afterload reduction is helpful in improving forward flow. (Slide 60)

Question 29

29. What is Hypertrophic Cardiomyopathy?

Answer 29

``` **Thick, Stiff Heart** CHARACTERISTICS -LVH (often marked in the septum) -Reduced diastolic compliance -Subvalvular pressure gradient - Ventricualr arrhythmias -Systolic anterior Motion (SAM) (Slide 62) ```

Question 30

30. What is systolic anterior motion (SAM) of the mitral valve?

Answer 30

Blood that is ejected into the LEFT VENTRICLE outflow tract at high velocity which creates VENTURI effect. This pulls the ANTERIOR leaflet of the mitral valve toward the septum during systole. This CREATES dynamic outflow tract obstruction and mitral regurgitation. (Slide 62)

Question 31

31. What do you want to avoid in the patient with Hypertrophic Cardiomyopathy?

Answer 31

Avoid anything that causes reduction in left ventricular volume: - Avoid Decrease preload, - Avoid Increase contractility - Avoid decrease afterload