Sara: Anesthesia for Left Side Valve Disease

Question 1

What 2 conditions can lead to pulmonary issues?

Answer 1

regurge

stenosis

Question 2

With stenosis, what is important?

Answer 2

contractility

Question 3

With regurge, what is important?

Answer 3

Decreased afterload is really important.

Question 4

What is important in all valve lesions?

Answer 4

preload

Question 5

What are important during the preoperative evaluation? (3)

Answer 5

Detailed history of disease, listen to heart

AHA protocol and guidelines

Echo w/in 6 months for all valvular lesions

Question 6

What is the most common MAJOR valve lesion?

Answer 6

aortic stenosis

Question 7

What are the common causes of aortic valve lesions? (3)

Answer 7

congenital bicuspid valve

degeneration

atherosclerotic/rheumatic

Question 8

You note LVH on preop ECG and you hear a systolic murmur.

Systolic mumur = _____________.

Answer 8

related to flow

Question 9

All diastolic murmurs are pathological. True or false?

Answer 9

True

Question 10

In normal valves, no real pressure gradient across the valve. True or false?

Answer 10

true

Question 11

What happens as a result of stenosis relating to pressure gradient?

Answer 11

Increase stenosis = increase pressure gradient

Otherwise, there is no real pressure gradient in normal valves.

Question 12

What are consequences of aortic stenosis? (5)

Answer 12

Avoid hypotension!

Atrial kick contributes to 25% of filling instead of 15-20%

Increase in LV systolic and diastolic presssures

Longer ejection time

Decrease in aortic pressure

Note: All lead to decreased O2 supply → ischemia

Question 13

What is the triad of stenosis?

Answer 13

Angina (even with patent coronaries)

Syncope

Heart failure

Question 14

What is normal EF?

Answer 14

55%

Question 15

How do you anesthetically manage AS pts in relation to preload? (4)

Answer 15

Keep intravascular volume normal to high

Avoid venous dilation (NO EPIDURAL/SPINAL)

HR slow to normal ( to allow greater diastole time to increase filling)

Aggressive treatment of atrial rhythm

Question 16

How do you anesthetically manage AS pts in relation to afterload? (2)

Answer 16

Keep diastolic pressure up to perfuse coronaries

Aggressively treat hypotension with alpha agonist

Question 17

Causes of valvular disease due to: (3)

Answer 17

congenital

rheumatic

degenerative (calcification is most common)

Question 18

Critical aortic stenosis is when the aortic valve orifice is reduced to ____-_____ cm².

Answer 18

0.5 - 0.7

Normal is 2.5-3.5 cm²

Question 19

What is hypertrophic cardiomyopathy characterized by? (2)

Answer 19

dynamic obstruction of left ventricular outflow tract

associated with mitral valve abnormality

• systolic anterior motion (SAM)
• mitral regurgitation

Question 20

What factors tend to worsen hypertrophic cardiomyopathy ventricular outflow? (3)

Answer 20

increased contractility

decreased ventricular volume

decreased left ventricular afterload

Question 21

Anesthetic management of HOCM? (5)

Answer 21

Volume loading

Decrease contractility

Beta blockade

Keep systemic pressure high

TEE vs PA catheter

Note: Phenylephrine and other pure alpha agonists are ideal vasopressors.

Question 22

What is known as “disease of diastole”?

Answer 22

aortic regurge

Question 23

Aortic regurgitation can be chronic or acute. True or false?

Answer 23

True

Question 24

What changes to the ventricle for pt with aortic regurge?

Answer 24

hugely dilated heart

produces volume overload of the left ventricle

Question 25

What are the consequences of aortic regurge? (3)

Answer 25

"Eccentric" hypertrophy dilatation Very high LV CO, but low SV Tachycardia and peripheral vasodilation to maintain forward flow is good

Question 26

How is acute vs. chronic regurge characterized by? (

Answer 26

Chronic allows LV to dilate and acute does not → LVED Chronic sees higher volumes vs acute sees higher pressures

Question 27

What is aortic regurge also known as?

Answer 27

aortic insufficiency

Question 28

Anesthetic management of AI/AR relating to preload: (4)

Answer 28

Keep volume high Keep SVR high High normal heart rate is best Avoid bradycardia, want more time in diastole

Question 29

Anesthetic management of AI/AR relating to contractility: (2)

Answer 29

Maintain contractility Use epi, dobutamine

Question 30

Anesthetic management of AI/AR relating to afterload: (1)

Answer 30

Reduced afterload is essential Use arterial not venous dilators Note: Arterial dilator (nicardipine). Avoid nitros.

Question 31

Mitral stenosis is most commonly \_\_\_\_\_\_\_\_\_\_\_\_. Affects more males/females?

Answer 31

rheumatic pregnant females (2:1)

Question 32

In mitral stenosis, what anatomic changes occur?

Answer 32

dilated atrium resulting in SVT, particularly afib blood stasis promotes thrombi to form loss of normal atrial systole

Question 33

What in short do you need to remember relating to mitral stenosis?

Answer 33

pressure gradient b/n LA and LV needed to get through the thickened valve

Question 34

What do you think happens to ventricular filling when there is mitral stenosis? What happens as a result? (3)

Answer 34

decreased * Left atrial dilatation * A-fib * Pulmonary edema

Question 35

Anesthetic management relating preload for MS: (4)

Answer 35

Keep volume high, but not too high (fine line) Avoid venodilation Low heart rate is best (tachy leads to PEdema) Aggressive treatment for tachycardia

Question 36

Anesthetic management of MS relating to afterload: (1)

Answer 36

maintain in normal range \*\*Unloading is pathology of LV

Question 37

What are the consequences of MR? (4)

Answer 37

Left atrial dilatation → a fib Left ventricular dilatation (eccentric) Low forward CO syndrome Biventricular failure

Question 38

Anesthetic management of MR relating to preload: (1)

Answer 38

high normal HR is best

Question 39

Anesthetic management of MR relating to contractility: (1)

Answer 39

Keep ventricular size down to maintain forward CO.

Question 40

Anesthetic management of MR relating to afterload: (1)

Answer 40

Reducing afterload is important!

Question 41

To summarize, for stenotic lesions: (2) for regurgitant lesions: (2)

Answer 41

preload dominates (CPP in AS), HR low reduce afterload, HR high