Valvular Heart Disease (Exam II)

Question 1

What is the incidence of valvular disease in the US population?

Answer 1

2.5%

Question 2

What is the NYHA Functional Classification of Patients with Heart Disease?

Answer 2

I - Asymptomatic.
II - s/s with activity but relieved by rest.
III - s/s w/ minimal activity, relieved by rest.
IV - s/s at rest

Question 3

What causes a murmur?

Answer 3

turbulent flow across a heart valve
or
↑ flow across normal valves

Question 4

Systolic murmurs are caused by what valve pathologies?

Answer 4

• Aortic/Pulmonic Stenosis
• Mitral/Tricuspic Regurgitation

midsytolic or holosystolic

Question 5

Diastolic murmurs are caused by what pathologies?

Answer 5

• Aortic/Pulmonic Regurgitation
• Mitral/Tricuspid Stenosis

Question 6

_____ murmurs follow S2.

Answer 6

Diastolic

Question 7

Midsystolic murmurs occur when?

Answer 7

Between S1 and S2 sounds

Question 8

Which murmur type exhibits a crescendo-decrescendo pattern?

Answer 8

Mid-systolic Murmurs

can be functional/least limiting

Question 9

What characterizes holosystolic murmurs?

Answer 9

S1 and S2 merging

most scary

Question 10

Where is the aortic valve auscultated?

Answer 10

2ⁿᵈ ICS, right sternal border

Question 11

Where is the pulmonic valve auscultated?

Answer 11

2ⁿᵈ ICS, left sternal border

Question 12

Where is the tricuspid valve auscultated?

Answer 12

5th ICS, left sternal border

Question 13

Where is the mitral valve auscultated?

Answer 13

5th ICS, mid-clavicular line

Question 14

What factors seen on a chest x-ray would indicate valvular disease?

Answer 14

• Cardiomegaly
• Left Bronchus Elevation
• Valvular Calcifications

Question 15

What signs seen on an EKG could indicate valvular disease?

Answer 15

• LA enlargement (broad, notched p-wave)
• Axis deviations
• Dysrhythmias

Question 16

What type of valve replacement is thrombogenic?

Answer 16

Mechanical

Question 17

What are bioprosthetic valves made from?

Answer 17

Porcine or bovine

Question 18

Which type of prosthetic valve is longer lasting?

Answer 18

Mechanical

Question 19

Who is most commonly affected by mitral stenosis?

Answer 19

• Women
• Rheumatic patients

Question 20

What is the normal mitral valve orifice surface area?

Answer 20

4 - 6 cm²

Question 21

At what surface area do symptoms for mitral valve stenosis start to develop?

Answer 21

< 2 cm²

Question 22

What are the s/s of mitral stenosis?

Answer 22

• Exertional dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Pulmonary edema
• Pulmonary HTN
• A-Fib

*opening snap early in diastole

Question 23

How is mitral stenosis treated?

Answer 23

• Rate control (80bpm goal): BB, CCB, DIG
• ↓LAP (diuretics)
• Anticoagulation
• Surgical correction

Question 24

What EKG abnormalities are common with mitral stenosis?

Answer 24

• Notched P waves
• A-Fib

Question 25

What are the anesthetics goals for a patient with mitral stenosis?

Answer 25

Maintain normal parameters for HR, volume status, and afterload.

Question 26

What is more common, mitral stenosis or regurgitation?

Answer 26

Regurgitation (2% of US population)

Question 27

What type of murmur would be auscultated with mitral regurgitation?

Answer 27

Holosystolic murmur at the cardiac apex

Question 28

What less invasive cath lab procedure is used to treat mitral regurgitation?

Answer 28

Mitra-clip | repair >>> replacement

Question 29

What β-blocker is preferred for mitral regurgitation?

Answer 29

Carvedilol | ...can also give ACE-I

Question 30

What are the anesthetic goals for mitral regurgitation patients?

Answer 30

- Improve LV stroke volume - Decrease Regurg - Avoid bradycardia - Avoid ↑ SVR | FAST, FULL, FORWARD

Question 31

What heart rate would you want to maintain with mitral regurgitation?

Answer 31

Normal to slightly increase HR *Bradycardia will increase LV volume overload.*

Question 32

What type of pathology would cause early-life development of aortic stenosis?

Answer 32

Bicuspid Aortic Valve | ...most common congenital valvular abnormality

Question 33

What is the normal surface area of the aortic valve?

Answer 33

2.5 - 3.5 cm²

Question 34

What is the surface area of a severely stenotic aortic valve?

Answer 34

< 1 cm²

Question 35

What pathology would be expected for a systolic or mid-systolic murmur hear in the right upper sternal border?

Answer 35

Aortic Stenosis

Question 36

What symptoms are seen with aortic stenosis becomes critical?

Answer 36

- Angina - Syncope* - Dyspnea on exertion

Question 37

____% of aortic stenosis patients will die within three years without a valve replacement

Answer 37

75%

Question 38

What EKG characteristics would be seen for a patient with aortic stenosis?

Answer 38

- ST depression - T-wave inversion - LV hypertrophy

Question 39

What non-surgical treatments are available for aortic stenosis?

Answer 39

- Balloon valvotomy for younger patients - TAVR

Question 40

What type of anesthetic technique is generally better for patients with aortic stenosis?

Answer 40

General Anesthesia | Opioid induction agent

Question 41

What are common causes of chronic aortic regurgitation?

Answer 41

- Endocarditis/rheumatic fever - Bicuspid AV - Anorexigenic drugs

Question 42

What are the two common causes of acute aortic regurgitation?

Answer 42

- Endocarditis - Aortic dissection

Question 43

What two factors determine the degree of regurgitant blood flow from a dysfunctional aortic valve?

Answer 43

- Time available for flow (HR) - Pressure gradient (SVR)

Question 44

What type of murmur would be heard with aortic regurgitation?

Answer 44

Early to mid-diastolic murmur at left sternal border (Austin-Flint murmur)

Question 45

What blood pressure abnormalities are often seen with aortic regurgitation?

Answer 45

- Widened pulse pressure - Decreased DBP - Bounding pulses

Question 46

Anesthetic considerations for aortic regurge

Answer 46

- Avoid bradycardia, HR > 80 - Avoid ↑ SVR - Minimize myocardia depression (vasodilator to reduce afterload, inotrope to increase contractility) | GA is usual choice

Question 47

What disease frequently "co-exists" with valvular heart diease, increasing mortality..

Answer 47

Ischemic Heart Disease

Question 48

What are 3 pre-op signs of compensatory mechanisms for maintaining CO?

Answer 48

- Increased SNS - Myocardial hypertrophy - Current therapy (meds)

Question 49

Afib is closly related to which valve issues?

Answer 49

Mitral stenosis/regurge

Question 50

Define functional murmur

Answer 50

A heart murmur that is primarily due to physiologic conditions outside the heart, as opposed to structural defects in the heart itself.

Question 51

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

Answer 51

Aortic stenosis | can also pull legs up to test

Question 52

Aortic stenosis anesthetic considerations

Answer 52

- Prevent hypotension - Avoid brady or tachy cardia w/atropine, ephedrine, glycopyrrolate or esmolol - Optomize fluid volume - Aggressive treatment of hypotension w/phenylephrine | CRP is typically not effective so don't fuck up

Question 53

Which 2 murmurs increase with handgrip or blood pressure cuff inflation?

Answer 53

Aortic/mitral regurgitation

Question 54

All mitral murmurs can be heard best at the _______

Answer 54

Apex

Question 55

Which murmur increases with tachycardia?

Answer 55

Mitral stenosis

Question 56

Which murmur increases with inspiration?

Answer 56

Tricupsid regurgitation

Question 57

Which murmur has associated findings of prominent JVD and heart failure?

Answer 57

Tricupsid regurgitation

Question 58

Minor vs. Major - when do discontinue warfarin?

Answer 58

3-5 days prior to major surgery Heparin can be used as a bridge *try to avoid rebound hypercoagulation*

Question 59

What medications should be avoided w/mitral stenosis?

Answer 59

- Ketamine - Histamine releasing NMBs (pancuronium, atracurium) - Morphine (releases histamine)

Question 60

True/False.. Aortic stenosis is always associated with aortic regurge

Answer 60

True