valvular heart disease

Question 1

TAVR and type of anesthesia

Answer 1

aortic valve replacement for aortic stenosis (GA or MAC)

Question 2

TAVR and SAPIAN valve

Answer 2

requires balloon valvuloplasty
need for rapid ventricular pacing (160-200BPM)
apnea during deployment
pacing pads in case pacing goes unwell
valve in valve (another valve) if deployment doesn’t go great

Question 3

TAVR and core valve

Answer 3

if core valve is used, dont need valvuloplasty or rapid ventricular pacing
if it doesn’t deploy properly, retrieve and re deploy

Question 4

best place to listen for aortic stenosis

Answer 4

A
2nd ICS at right sternal border

Question 5

s1 and where to listen

Answer 5

C (tricuspid area) or D (mitral area)
left of sternal border at 4th ICS (apex) or
mid clavicular line on left at 5th ICS (apex)
closure of mitral and tricuspid valves, end of LV filling and beginning of isovolumic contraction

Question 6

s2 and where to listen

Answer 6

A (aortic) or B (pulmonic area)
right or left sternal border at 2nd ICS
closure of pulmonic and aortic valves
beginning of diastole, onset of isovolumic relaxation

Question 7

s3

Answer 7

suggests flaccid and inelastic heart- think HF

Question 8

s4

Answer 8

caused by atrial systole, heart before s1, think poor compliance

Question 9

what happens to EF with concentric hypertrophy

Answer 9

normal

Question 10

what happens to EF with eccentric hypertrophy

Answer 10

reduced

Question 11

replication of sarcomeres with concentric hypertrophy are in

Answer 11

parallel

Question 12

replication of sarcomeres with eccentric hypertrophy are in

Answer 12

series

Question 13

normal aortic valve orifice

Answer 13

2.5-3.5cm^2

Question 14

severe aortic stenosis aortic valve orifice

Answer 14

<0.8cm^2

Question 15

etiologies of aortic stenosis (3)

Answer 15

bicuspid aortic valve and calcification of valve leaflets
rheumatic fever
infective endocarditis

Question 16

what does this pressure volume loop indicate?

Answer 16

aortic stenosis
PV loop height increases
EDV and ESV also increase (shift to the right)

Question 17

classic presentation of aortic stenosis (pneumonic)

Answer 17

SAD
syncope, angina, dyspnea

Question 18

anesthetic management of AS patient
(preload, contractility, HR, SVR, PVR)

Answer 18

“full slow and constricted”
slower side of NSR
increase preload
maintain contractility
maintain or increase SVR
maintain PVR (dont increase)

Question 19

this arterial waveform is indicative of a patient with

Answer 19

aortic stenosis
lower systolic upstroke, delayed peak
pulsus parvus (waveform of small amplitude and narrow PP)
dichrotic notch may not be present, may look “dampened” overall
pulsus tardus

Question 20

what does this pressure volume wave form represent

Answer 20

chronic aortic regurgitation

Question 21

what does this pressure volume wave form represent

Answer 21

mitral stenosis

Question 22

what does this pressure volume wave form represent

Answer 22

chronic mitral regurgitation

Question 23

what does this pressure volume wave form represent

Answer 23

chronic mitral regurgitationc

Question 24

conditions associated with chronic AI (4)

Answer 24

valvular calcification, marfan, ehlers danlos, ankylosing spondylitis

Question 25

anesthetic management of a patient (type) with AI (HR, preload, contractility, SVR, PVR)

Answer 25

"full fast forward" HR increase preload maintain or increase contractility maintain SVR decrease PVR maintain regional anesthesia: sympathectomy will reduce after load and regurgitant fraction (this is beneficial)

Question 26

what is this arterial line waveform indicative of

Answer 26

aortic insufficiency sharp upstroke, low DBP, wide PP biphasic systolic peaks (biferens pulse)

Question 27

normal mitral valve orifice

Answer 27

4-6cm^2

Question 28

which trans valvular gradient pressure and PASP are indicative of MS (and orifice size)

Answer 28

LA-LV gradient above 10mmHg with PASP >50mmHg (severe MS orifice <1cm^2)

Question 29

most common cause of MS

Answer 29

rheumatic fever

Question 30

other etiologies of MS include (6)

Answer 30

RA, SLE, congenital defect, left atrial myxoma, carcinoid syndrome, iatrogenic following mitral valve repair

Question 31

pathophysiology of MS (including compensation)

Answer 31

lower EDV, SV, CO--> body compensates by increasing SVR (since BP=COxSVR)

Question 32

anesthetic management of MS (HR, preload, contractility, SVR, PVR)

Answer 32

full slow and constricted slower side of normal HR maintain preload maintain contractility maintain SVR (tx HoTN with vasoconstrictor like neo or vaso) avoid increase in PVR if INR <1.5, neuraxial anesthesia ok (stasis in LA means increased risk of thrombosis)

Question 33

after suffering an MI, a patient presents with LV papillary muscle rupture and MR. what should the anesthetic management be? think HR, pressure gradient, SVR

Answer 33

increased to normal HR (avoid bradycardia) decrease LV to LA pressure gradient decrease SVR "full fast and forward for MR"

Question 34

etiologies of mitral insufficiency (10)

Answer 34

rheumatic fever ischemic heart disease papillary muscle dysfunction ruptured chordae tendinae endocarditis mitral valve prolapse LVH SLE RA carcinoid syndrome

Question 35

what does the pressure volume loop look like for acute versus chronic mitral insuffeciency?

Answer 35

Question 36

conditions that would worsen mitral insufficiency

Answer 36

slower HR increased pressure gradient between LV and LA increased SVR increased size of valve orifice

Question 37

anesthetic management of mitral regurg (HR, preload, contractility, SVR, PVR) anesthesia type that is beneficial

Answer 37

full, fast, fwd HR: increased preload: maintain or increase contractility: maintain SVR: decrease PVR: avoid increase Regional anesthesia: sympathectomy reduces SVR, promotes forward flow, and reduces regurg. however, reducing aortic DBP can compromise CPP

Question 38

which valvular disorders are associated with a systolic murmur?

Answer 38

mitral insufficiency (atrial systole/atrial kick problem) aortic stenosis

Question 39

ASSS mnemonic

Answer 39

aortic stenosis is a systolic murmur heard at the right sternal border may be able to be palpated as a thrill, LVP can exceed 350mmHg

Question 40

ARDS mnemonic

Answer 40

aortic regurgitation and diastolic murmur heard at the right sternal border characterized as a high pitched blowing murmur

Question 41

MSDA mnemonic

Answer 41

mitral stenosis is a diastolic murmur heard at the apex and the left axilla opening snap followed by an intensely rumbling murmur (pressure of LA can reach up to 35mmHg)

Question 42

MRSA mnemonic

Answer 42

mitral regurg is a systolic murmur heard at the apex and left axilla holosystolic, characterized by a swishing sound