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Adv. Phys & Health Assessment > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

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1
Q

Which valvular heart diseases result in pressure overload? Volume overload?

A
  • Pressure overload - mitral stenosis, aortic stenosis
  • Volume overload - mitral regurgitation, aortic regurgitation
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2
Q

What are the 4 classes of the NY Heart Association functional classification of patients with heart disease?

A

1 - asymptomatic
2 - symptoms with ordinary activity but comfortable at rest
3 - symptoms with min activity but comfortable at rest
4 - symptoms at rest

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3
Q

What are the S/S of impaired myocardial contractility?

A
  • Dyspnea, anxiety, and resting tachycardia (caused by inc SNS activity)
  • Orthopnea
  • Easy fatigability
  • Heart failure: Basilar rales, JVD, and 3rd heart sound
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4
Q

What is the difference between a functional vs pathologic murmur?

A

Functional - innocent murmur, physiologic murmur
Pathological - structural defects in the heart

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5
Q

What is the difference between a midsystolic and holosystolic murmur?

A

Midsystolic - occurs between distinct S1 and S2 heart sounds
Holosystolic - merges with S1 and S2

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6
Q

What are the causes of a midsystolic murmur?

A

functional, aortic stenosis, or hypertrophic cardiomyopathy

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7
Q

What are the causes of a holosystolic murmur?

A

mitral regurgitation, tricuspid regurgitation

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8
Q

What are the causes of a diastolic murmur? When is it heard?

A

aortic regurgitation, mitral stenosis
S2

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9
Q

What can cause a late systolic murmur?

A

mitral valve prolapse

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10
Q

Which murmurs can be heard at the apex?

A

MS, MR, mitral valve prolapse

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11
Q

Which murmurs can be heard at the left sternal border?

A

functional and AR

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12
Q

Which murmurs can be heard at the lower left sternal border?

A

tricuspid regurg and hypertrophic cardiomyopathy

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13
Q

Which murmur can be heard at the right upper sternal border?

A

AS

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14
Q

Which murmur increases with squatting, decreases with standing and Valsalva?

A

AS

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15
Q

Which murmurs increase with handgrip or BP cuff inflation?

A

AR and MR

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16
Q

Which murmur increases with tachycardia?

A

MS

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17
Q

Which murmur increases with inspiration?

A

Tricuspid regurg

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18
Q

Which murmurs increase with Valsalva and standing?

A

mitral valve prolapse and hypertrophic cardiomyopathy

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19
Q

Which murmur increases with exercise?

A

functional

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20
Q

Which murmur may also have a systolic murmur due to increased SV?

A

AR

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21
Q

Which murmur has an opening snap after S2, loud S1, and radiation to left axilla?

A

MS

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22
Q

Which murmurs radiate to the left axilla?

A

MR and MS

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23
Q

Which murmur has a midsystolic click?

A

mitral valve prolapse

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24
Q

Which murmur is associated with prominent JVD and signs of R HF?

A

tricuspid regurg

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25
Which murmur lacks an aortic regurg murmur or ejection click?
hypertrophic cardiomyopathy
26
Where can the 4 heart valves be auscultated?
- Aortic: 2nd ICS RSB - Pulmonic: 2nd ICS LSB - Tricuspid: 5th ICS LSB - Mitral: 5th ICS MCL
27
Which valves are open during diastole and closed during systole?
mitral and tricuspid
28
Which valves are closed during diastole and open during systole?
aortic and pulmonic
29
What EKG change indicates atrial enlargement?
broad, notched P waves
30
What EKG change indicates ventricular hypertrophy?
L/R axis deviation
31
How is cardiomegaly defined on x-ray?
When the heart is > 50% of internal width of thoracic cage
32
What causes a left mainstem bronchus elevation on xray?
enlargement of left atrium
33
How can the presence and severity of valvular heart disease be diagnosed?
Angiography
34
Differentiate between the 2 types of valves. What kinds of patients get each?
Mechanical - young pts with longer life expectancy (can last 20-30 years) and need anticoagulation (highly thrombogenic) Bioprosthetic - older patients (lasts 10-15 years) that do not need anticoagulation (low thrombogenic potential)
35
What can pregnant women take for anticoagulation?
subcutaneous standard/LMWH and low-dose aspirin instead of warfarin - warfarin can cause fetal defects/death
36
Which valvular issue is associated with rheumatic heart disease?
MS
37
MS is asymptomatic for ______ and primarily effects women or men?
20-30 years, women
38
What is the normal mitral valve orifice area? When do symptoms of MS develop?
4-6 cm^2 when valve < 2 cm^2
39
What does the sub-valvular apparatus of the mitral valve consist of?
left ventricular free wall, two papillary muscles, and the chordae tendineae
40
What causes a funnel-shaped, “fish-mouth” mitral valve?
Calcification of the annulus and leaflets d/t turbulent flow through deformed valve → narrowing at apex
41
What are the S/S of MS?
Orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, increased WOB, dyspnea on exertion, pulmonary HTN, inc LA pressure and pulmonary venous pressure, Right-sided HF, Atrial fibrillation
42
How can mitral stenosis be diagnosed?
CXR and echo show calcification, elevated left main bronchus, left arterial enlargement and thrombus EKG - notched P waves and AF
43
How is mitral stenosis treated?
Control HR - BB, CCB, digoxin Dec LAP - diuretics Anticoagulation Surgical intervention - Percutaneous valvotomy, surgical commissurotomy, or valve replacement
44
What are the main anesthetic goals for a patient with mitral stenosis?
- normal HR, normal volume, normal afterload - avoid pulmonary edema and HTN - avoid ketamine d/t inc HR and histamine releasing NMBs
45
What is mitral regurg associated with?
- IHD - Ruptured papillary muscle - Endocarditis - Mitral valve prolapse - Cardiomyopathy
46
Describe the patho of MR
Eccentric hypertrophy of LA and LV to inc compliance Dec in forward LV SV and CO LA volume overload causes pulmonary congestion
47
What are the S/S of MR?
IHD hx, endocarditis, papillary muscle dysfunction, cardiomegaly, a-fib, holosystolic murmur at apex that radiates to axilla
48
How is MR diagnosed?
EKC and CXR show LA and LV hypertrophy, cardiomegaly, and a-fib - echo shows LA thrombus
49
Differentiate between the treatment of Asymptomatic vs symptomatic MR
- Symptomatic → mitral valve surgery even if normal EF or if EF > 30% and LV end-systolic dimension is less than 55 mm - Asymptomatic → surgery if LV EF 30-60% or LV end-systolic dimension greater than 40 mm
50
Differentiate between MV repair vs replacement. Which one is preferred?
repair restores valve competence and maintains the functional aspects of the mitral valve apparatus MV repair > MV replacement
51
EF < ___% has little improvement with MV surgery
30%
52
What are the alternative treatments other than surgery for MR?
Vasodilators, biventricular pacing, ACE-I, β-blockers (carvedilol)
53
______ is the minimally invasive surgery for severe MR when open surgery is not option
Transcatheter mitral valve repair (TMVR) MitraClip
54
What are the anesthesia goals for a patient undergoing surgery with MR?
Improve forward LV SV and decrease regurgitant fraction - maintain CO, normal-inc HR (avoid bradycardia), avoid inc SVR (vasopressors to reduce afterload) - volatiles - prevent inc BP and SVR
55
What is AS associated with?
Aging (60-80 years old) and bicuspid aortic valve (30-50 years old)
56
____ is the most common congenital valvular abnormality
BAV - bicuspid aortic valve
57
What is the patho of AS?
Obstruction to ejection of blood into the aorta causes inc LV pressure, inc myocardial oxygen requirements and dec myocardial oxygen delivery - AR and LV hypertrophy
58
What is a normal aortic valve area? What area indicates AS?
- Normal valve area 2.5-3.5 cm^2 - Severe AS valve area < 1cm2
59
What are the S/S of AS?
- Symptomatic when severe/critical - angina, syncope, dyspnea on exertion - symptoms correlate with avg time to death; 75% of symptomatic pts die within 3 years w/o valve replacement
60
How is AS diagnosed?
- CXR - prominent ascending aorta d/t post-stenotic aortic dilation, AV calcification - ECG - LV hypertrophy, ST depression, T wave inversion - echo - shows BAV vs TAV, thick/calcificed, valve area and pressure gradients - exercise testing for asymptomatic pt with known AS - elevated BNP and dec EF
61
What are the treatment options for AS?
- Balloon valvotomy for adolescents/young adults with congenital or rheumatic aortic stenosis - Transcatheter aortic valve replacement (TAVR) - relieves symptoms of AS - regression of LV hypertrophy and inc EF
62
What are the anesthetic goals for a patient undergoing surgery with AS?
- Prevention of hypotension (phenylephrine) and decreased CO - maintain NSR: avoid bradycardia (need atrial contraction for CO) and tachycardia (dec LV filling; tx w/ esmolol) - GA > epidural or spinal - avoid opioids that cause histamine release, ketamine, pancuronium, and atracurium
63
What is associated with aortic regurg?
- Endocarditis - Rheumatic fever - Bicuspid aortic valve (BAV) - Anorexigenic drugs (phentermine, methamphetamine) - Acute AR: Endocarditis or aortic dissection
64
What is the patho of AR?
- Decreased CO d/t regurgitant SV during diastole - Combined LV pressure and volume overload - magnitude depends on HR and SVR
65
What are the S/S of AR?
- Low-pitched diastolic rumble - Austin-Flint murmur - Hyperdynamic circulation: wide PP, dec DBP, bounding pulses - end-stage involves LV failure - dyspnea, orthopnea, fatigue and coronary ischemia - acute AR - Acute AR – severe LV volume overload, coronary ischemia, rapid deterioration LV function, and HF
66
How is AR diagnosed?
EKG and CXR - LV enlargement and hypertrophy Echo - Leaflet prolapse or perforation and associated aortic abnormalities
67
How is AR treated?
- Medical - dec systolic HTN, LV wall stress, and improve LV function (diuretics, ACE-I, CCB) - Surgical - depends on etiology of AR; AVR for pathologies of valve; Aortic root replacement for etiology related to the aortic root - acute AR - immediate surgical intervention
68
What are the anesthetic goals for a patient with AR?
- maintain forward LV SV - avoid bradycardia - HR > 80 bpm - avoid inc SVR (LV failure) - min myocardial depression (vasodilator to reduce afterload and inotrope to inc contractility) - GA, pancuronium could be useful - maintain fluid volume to provide adequate proload

Adv. Phys & Health Assessment (21 decks)

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