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6902 test 2 > Valvular Disease > Flashcards

Valvular Disease Flashcards

(65 cards)

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1
Q

What valves are open in systole?

A

Aortic & Pulmonic

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2
Q

What valves are open in diastole?

A

Mitral & Tricuspid

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3
Q

Murmur btwn S1 and S2

A

Stenosis of AV or PV

Regurg of TV or MV

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4
Q

Path of blood flow through the heart

A 
Superior/Inferior Vena Cava to 
RA
through Tricuspid valve
to RV
through pulmonic valve to
Pulmonary arteries to lungs to
Pulmonary veins to
LA
through the Mitral Valve to
LV
through Aortic valve to the aorta
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5
Q

Murmur btwn S2 and S1

A

Regurg of AV or PV

Stenosis of MV or TV

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6
Q

What is the most common arrhythmia produced by valvular disease?

A

Afib

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7
Q

Patients can have _____ with normal coronaries?

A

Angina

Due to the inability to meet O2 demand vs. CA stenosis. Ventricles hypertrophy creating further demand ischemia

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8
Q

Stenotic lesions require

A

suppressing HR to prolong diastole

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9
Q

Regurgitant lesions require

A

reducing afterload to reduce the regurgitant fraction

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10
Q

Hypertrophy is diagnosed by CXR when

A

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

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11
Q

Mechanical valves pros and cons

A

Last 20-30 years but require anticoagulation

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12
Q

Lab values with mechanical valves

A

elevated LDH
decreased haptoglobin
increased reticulocytes (increased RBC turnover)

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13
Q

AHA recommendation for first line prevention of bacterial endocarditis

A

oral and physical hygiene

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14
Q

Specific verbiage on abx endocarditis prophylaxis

A

Administered NOT to individuals with high cumulative lifetime risk of contracting endocarditis but to pts with highest risk of adverse outcomes if they dvlp endocarditis

heart valve pts
previous hx of endocarditis
congenital heart disease
heart transplant pts

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15
Q

Which valve is bicuspid?

A

Mitral-

4-6 cm2

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16
Q

Mitral stenosis

A

rheumatic heart disease - very rare in US
Iatrogenic - heart catheterization

S/S:
DOE, orthopnea, PND from high left atrial pressures

Murmur:
Snap in diastole and rumbling diastolic murmur hart at the apex or left axilla

Diagnosis: ECHO
< 1.0 cm is severe and LAP is > 25 mmHg (also = PHTN)

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17
Q

Pathophys as MS progresses

A

pulmonary venous pressure rises to counter increased LA pressure

As the orifice narrows, ever-increasing pressure gradient is created which creates transudation fluid in the pulmonary interstitial space and increases work of breathing

Pulmonary edema when pulmonary venous pressure > plasma oncotic pressure

afib
PHTN

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18
Q

Treatment of MS

A

diuretics to reduce LAP and volume
Afib treated by rate control using BB, CCB, dig
Require anticoag
Surgery indicated when PHTN develops

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19
Q

Goal with MS

A

Prevent decreases in CO or produce pulmonary edema

A sudden SVR decrease results in tachycardia, which results in a CO decrease

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20
Q

MS causing CHF

A

precipitated with excessive fluids
trende
autotransfusion via uterine contractions

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21
Q

Which pressor is preferred in MS?

A

Vasopressin bc has minimal effects on pulmonary artery pressure

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22
Q

Things to avoid with MS

A 
increasing pulmonary artery pressure by:
hypercarbia
hypoxemia
lung hyperinflation
lung water increases
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23
Q

Anesthetic types in MS

A 
Neuraxial if not anticoagulated
GA - not ketamine pancuronium  bc HR increase, histamine release (atracurium, succ)
N2O can increase PVR
DES with sudden large changes 
Lg amts of fluid

Infusion of drugs that maintain bradycardia - fentanyl helpful

Light anesthesia can evokes sympathetic stimulation and SVR/PVR increases

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24
Q

Mitral Valve Regurg

A

More common than MS

decrease in CO and SV as forward flowing volume flows backwards into the LA.

Volumes of 60% or more are severe MR

Chronic MR results in remodeling of LV in attempt to compensate for loss of CO. the LA remodels to become more compliant for increase filling volume. Acute MR, the presentation is pulmonary edema and/or cardiogenic shock bc these remodeling have taken place

systolic apic murmur that radiates to the axilla

ECHO

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25
Survival with MR
Survival better if surgery when EF is > 60% Pts with EF <30% do not improve with surgery Symptomatic pts should have surgery
26
Repair vs replacing Mitral valve
Repair. Mitral apparatus is part of normal LV chamber and replacement changes this geometry. Repair preserves LV unction
27
Treatment of MR
Vasodilators to reduce afterload in acute MR but not chronic | Symptomatic pts - ACEI and BB and pacing
28
Goals of anesthesia in MR
1. prevent bradycardia - increases the regurg fraction 2. prevent increase in SVR - prevent the LV from increasing forward flow 3. minimize cardiac depression 4. monitor the regurgitant volume Volume is extremely important Fast, full, forward - HR elevated, full volume, maintain forward flow through SVR reduction
29
Anesthesia meds in MR
Afterload can be reduced with SNP or NTG Regional provides decrease in SVR PIA can decrease SVR and increase HR (but do depress contractility and may need to consider narcotic induction with anticholinergics for HR control)
30
Vent settings in MR
normal rate - too fast will result in poor venous return
31
MitraClip
percutaneous valve repair | prominent in elderly high risk pts
32
Mitral valve prolapse
most common valvular disorder in the US typically benign dx ECHO with 2 mm or more prolapse Anesthesia the same as MR
33
If you detect in preop a pt with systolic click, and pt is asymptomatic, does this warrant a cardiac consult?
Nope
34
Aortic valve
separates the LV from the aorta, preventing the backflow of blood into the heart during ventricular relaxation Normal is 2.5-3.5 cm2
35
Aortic stenosis
Common Dvlps due to degeneration and calcification of the aortic leaflets which narrows the aortic valve Risks: atherosclerosis, htn, DM, smoking, male, bicuspid aortic valve
36
Pts with BAV and aortic aneurysms
should have repair when the diameter reaches 55 mm of the aneurysm or 50 mm if family hx of rupture
37
AS symptoms
angina syncope DOE CHF <5 year life expectancy Independent risk factor for perioperative risk Sytolic murmur that radiates into the neck ECG shows LVH
38
Pathophys of AS
the need to increase LV pressure to maintain SV LVT obstruction - causes increase systolic pressure, causing LV failure due to remodeling angina bc of the increased O2 demand of the enlarged LV Subendocardial blood flow is depressed from the compression from the increased LVP
39
Critical AS
AR gradient >50 .8 cm2 ECHO Surgical AVR - most combined with CABG
40
AS and BNP
increases from pt baseline can predict worsening of symptoms
41
After aortic valve replacement - and AS
LV remodeling begins to reverse and the EF increases
42
Aortic stenosis
high risks for perioperative complications most pts also have CAD Want pt in sinus rhythm bc loss of atrial kick and dramatically reduce CO Hypotension reduces CA flow and potentiates a failing LV Aggressive treatment of hypotension is warranted
43
CPR in aortic stenosis pts
ineffective bc cannot generate enough stroke volume across a stenotic valve to perfuse the heart
44
Anesthesia in AS
no neuraxial bc of sympathetic blockade leading to hypotension and preload reduction Induction should be with drugs that do not lower SVR - opioids are useful. Benzos and etomidate Push drugs slowly Volume Alpha agonists preferred bc do not cause tachycardia Ketamine avoided due to HR increases Avoid NTG bc reduces preload Avoid PIA bc sino-atrial-depressing Maintenance should be aimed at maintain SVR and CO *N2O with opioids cerebral oximetry due to emboli breaking off
45
Hypertrophic cardiomyopathy
managed like AS
46
Repairing the AV
mechanical or bovine/porcine/human The Ross procedures uses the pat's pulmonic valve to replace the aortic valve
47
Aortic Regurg
Failure of the aortic leaflets to couple together Inflammatory or connective tiussue disease Acute AR from endocarditis or aortic dissection diastolic murmur along right sternal border and signs of volume overload LVH on ECG
48
Pathophys of AR
CO reductions from regurgitant blood flow during diastole. Produces volume overload. As time increases for backflow, so does the regurg. The pressure gradient also determines the amt of back flow (SVR). Regurg is decreased by tachycardia and peripheral vasodilation LV hypertrophies in response to increased filling volumes, consuming more O2 and reducing subendocardial blood flow Chronic changes are tolerate though remodeling As the LV fails, pulmonary edema dvlps Pts with acute AR manifest with ischemia and rapid deterioration into HF
49
signs of volume overload
widened PP Decreased DBP Bounding pulses Pulmonary congestion
50
Regurgitant jet volume
Regurgitantvolume=Leftventriclestrokevolume − Rightventriclestrokevolume Regurgitantvolume=(LVOTarea×LVOTVTI)−(Pulmonaryarteryarea × pulmonaryarteryVTI) ascending aortic SAX view
51
Surgery for AR
indicated with EF < 55% and LVESV increases to 55 mL or more (regurgitant volume) Acute AR is an emergency Ross procedure Aortic valve repair
52
Medical mgmt. for AR
Reduce HTN and improve LV function Vasodilators and inotropic agents like dobutamine Nifedipine or hydralazine
53
Anesthesia for AR
Fast, Full, Forward HR > 80 to reduce amt of time in diastole Abrupt SVR increases can cause LV failure - treat with vasodilator and inotrope GA - induction should not decrease HR or increase SVR to minimize regurg volume Maintenance with N2- plus PIA and/or opioid All PIA increase HR and decrease SVR Fluid status should be normal
54
Bradycardia and junctional rhythms and AR
Atropine or glycol before ephedrine bc ephedrine will incrase SVR
55
Tricuspid valve
separates the right atrium from the right ventricle papillary muscles/chordae tendinae prevent the prolapse of leaflets into the atria
56
TV regurg
Endocarditis PHTN RVH common - especially in athletes TV can be removed without much of an effect Signs are JVP increases, hepatomegaly, ascites, edema Treatment aimed at the cause of the TR and surgery is rare
57
TV regurg anesthesia
maintain IV volume in the high-normal range to ensure preload PPV and vasodilators bad if reduce venous return Avoid incrase in PVR Avoid hypoxemia, hypercarbia, N2O RAP monitoring for CVP trends
58
TV stenosis
very rare and usually exists with TR and MV/AV disease RAP is increased and RV effects are usually dependent on concurrent TR for remodeling of the ventricle eCHO
59
Pulmonic regurg
PHTN | rarely symptomatic
60
Pulmonic stenosis
congenital and corrected in childhood RHD, carcinoid, endocarditis, trauma Surgical valvotomy is used to relieve symptoms
61
TAVR
TAVR - severe symptomatic AS pts that inoperable or high risk higher risk of stroke, complete HB, LBBB, paravalvular regurg contraindicated in pts with BV lower 30 day and 1 year mortality, greater improvement in cardiac symptoms, reduced repeat procedures
62
SAVR
median sternotomy often with CABG apply defib pads TEE associated with higher bleeding risks and fib
63
Balloon valvotomy
MS | MR symptomatic pts with LV dysfunction (open heart with bypass)
64
MV repair
traditional sternotomy with CPB Partial sternotomy Right mini-thoracotomy Endoscopic approach Robotic procedure - take extra care for padding *all require GA
65
Left atrial appendage closure
combat the fact that most afib strokes occur from thrombus formation in the LAA Watchman LAAC device dvlped as an alternative to oral anticoag for nonvalve afib GA - takes 1 hr. anticoag needed, fluroscopy, TEE Must stay anticoagulated for 2 months

6902 test 2 (8 decks)

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