Valvular Disease

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Valvular Disease
2014-02-10 18:27:33

Patho test 2
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  1. Red color on echo
    blood flow towards transducer
  2. blue color on echo
    blood flow away from transducer
  3. what color are higher velocities shown on echo
    lighter shades
  4. during systole (S1) what valves open and close
    • av/pv open
    • mv/tv- close (split sound b/c mv closes before tv)
  5. during diastole (S2)what valves open and close
    • av/pv close
    • mv/tv open
  6. third heart sound heart sound is abnormal if heard in anyone but a _____ and what is it associated with
    • child
    • ventricular dilation
  7. 4th heart sound
    ventricular hypertrophy when have ischemia or in older adults
  8. regur/insufficiency occurs when
    leaking or backflow of blood across a closed valve
  9. stenosis occurs when
    obstruction or forward flow across an open valve
  10. aortic stenosis can be heard during what part of heart sound
    s1 during systole when av/pv open
  11. mitral regurg can be heard during what part of heart sound
    s1 during systole when mv/tv valves close
  12. aortic regurg is heard during what part of heart sound
    s2 diastole when av/pv close
  13. mitral stenosis is heard during what part of heart sound
    s2 diastole when mv/tv open
  14. what is common etiology for aortic stenosis
    rheumatic fever
  15. symptom development for aortic stenosis
    • congenital=0-30 years
    • rheumatic =60-70 years (adhesion and fusion of leaflets, also calcification)
    • degenerative= >70 years ( become inflexible b/c of calcium deposits at base
  16. how many valves does aortic valve have normally?
    How many when stenosis occurs
    • 3 valves or cusps
    • 2 valves or cusps
  17. what is the normal aortic valve size?
    at what size does this become an issue
  18. 3.5- 4.0 cm2
    critical when area is <0.8 cm2 b/c systolic gradient between aorta and ventricle can exceed 150 mmHg (b/c trying to push blood through stenotic valve)
  19. what happens to ventricle with aortic stenosis
    • concentric hypertrophy b/c of increased afterload
    • -this reduces wall stress
    • -reduces ventricular compliance
    • LVEDp increases
    • -Left atrial pressure increases
    • *cardiac size unchanged but wall thickens
  20. what will aortic stenosis look like on pressure volume loop
    • shifted to right and taller, because ventricle is having to increase pressure to eject blood to body,
    • increased EDV
  21. what type of murmur will you hear with aortic stenosis
    • harsh systolic ejection murmur- late peaking
    • s4 gallop from hypertrophy
    • *always listen for this especially in older patients b/c severe aortic stenosis is contradicted with regional or spinal anesthesia
  22. What are the symptoms of aortic stenosis and what is median survival rate of each
    • angina-5 years
    • syncope on exertion (big one)- heart can not meet demand when moving - 3 years
    • CHF- 2 years
    • *75% of patients will die within 3 years without valve replacement
  23. what is test of choice for aortic stenosis
    echo 2D/color Doppler- test of choice for lesions
  24. Treatment of symptomatic aortic stenosis
    • medical therapy- tx symptoms not cause
    • aortic valve replacement- wait until symptoms appear to do replacement

    can also do percuataneous aortic valvotomy- beneficial in adolescents and young adults or if patient to sick for replacement
  25. what is must for anesthesia requriements and aortic stenosis
    • NSR- b/c ventricle relies on atrial kick for filling
    • *avoid hypotension b/c decrease in BP results in ischemia and decreased CO
    • -this is why regional anesthetics are not used
  26. Aortic regurg etiologies
    abnormalities of leaflets- rheumatic, bicuspid, degenerative, endocarditis

    dilation of aortic annulus- aortic aneurysm dissection, inflammatory, inheritable
  27. what is dilation of aortic annulus
    when valve pulls apart and dosnt close like it should
  28. Aortic regurg means patient has decreased CO and the severity of the regurg depends on
    • time available for regurg to occur
    • the pressure gradient across the aortic valve (determined by SVR)
    • magnitude of regurg is increased with decreased heart rate
  29. what do you want the heart rate of a patient with aortic regurg
    • want it elevated so it has less time to regurg
    • over 80 b/min
  30. eccentric ventricular hypertrophy
    • chronic from aortic regurg
    • -fiber elongation and replication of sarcomeres
    • -ventricular cavity enlarges to allow for extra volume, b/c it has no choice but to compensate for the extra volume
  31. aortic regurg patho
    • enlarged ventricular volume
    • ventricle dilates which leads to decreased contractility
    • -pressure volume curve shifts to the right
    • -widened pulse pressure
    • -imbalance between myocardial supply and demand because of decreased Diastolic bp, so you get decreased perfusion= decreased supply
    • -increased LV size (wall stress) increased demand
  32. what does pressure volume loop do with aortic regurg
    shifts to the right and looks more rounded because end diastolic volume is increased
  33. symptoms of aortic regurg
    • pulmonary venous congestion (dyspnea on exertion)
    • -inadequate CO (fatigue, and decreased exercise tolerance)
    • -usually a latent period where the heart compensates, then when heart fails you get symptoms
  34. physical exam of aortic regurg
    • first heart sound soft or absent
    • -diastolic decrescendo blowing murmur
    • hyperdynamic LV apical pulse
    • bounding pulses
    • S4, S3 gallop= advanced aortic insufficiency
    • apical rumble- Austin flint murmur
  35. Austin flint murmur
    • caused from aortic regurg
    • due to vibration of the anterior leaflet of the mitral valve as it is buffeted simultaneously by the blood jets from the left atrium and aorta
    • -heard best along right sternal border
  36. what is test of choice for aortic regurg
    test of choice =echo 2d/color doppler

    • ECG=- Left atrial enlargement and LV enlargement
    • cardiac cath -helpful to look at coronary arteries if patient is older. or good to grade regurg
  37. treatment of asymptomatic aortic regurg
    • medical therapy- tx symptoms not the cause
    • -serial check up with echo
    • -endocarditis prophylaxis
    • -vasodilators- nifedipine, hydralazine (decrease systolic htn and improve left ventricular function)
    • -diuretics
  38. treatment of symptomatic aortic regurg
    • aortic valve replacement
    • -recommended before onset of dysfunction even if no signs or symptoms
  39. anesthesia management and aortic regurg
    • maintain forward flow
    • **avoid bradycardia, want heart rate above 80
    • avoid increase in SVR- b/c wont be able to pump forward
    • minimize myocardial depression
    • *general anesthesia is best choice for this
  40. mitral valve regurg etiologies
    • -alteration of the leaflets, commissures, annulus (rheumatic, MVP, endocarditis)
    • -alteration of LV or LA size and function
    • papillary muscle ischemia
    • hypertrophic cardiomyopathy
    • LV enlargement- cardiomyopathy
    • LA enlargement from mitral regurg (mr makes mr worse)
  41. mitral regurg patho
    • decrease in forward left ventricular stroke volume and cardiac output
    • amount is dependent on:
    • -size of mitral valve
    • -heart rate
    • -pressure gradient across the mitral valve
    • Myocardial ischemia is uncommon
  42. isolated mitral regurg (no other issues) is less dependent on what
  43. atrial kick
  44. rheumatic fever induced mitral regurg exhibits what
    marked left atrial enlargement and atrial fib
  45. pressure volume loop and mitral regurg
    • increased ventricular volume shift the diastolic pressure curve to the right, stroke volume increases because ventricle can now eject blood into the low pressure of left atrium
    • -blood goes forward or backward to the path of least resistance
  46. patho of chronic compensated mitral regurg
    * similar to aortic regurg
    • eccentric hypertrophy
    • -increased preload
    • -increased afterload
    • -increased total stroke volume and forward stroke volume and LVESV returns to normal
    • Increased LA size
    • -increased LA compliance
    • -large volume at lower pressure
  47. uncompensated mitral regurg patho
    • decreased contractility
    • -decreased SV
    • -increased LVEDV

    further dilation leads to progressive MR
  48. symptoms of mitral regurg
    • fatigue and weakness
    • dyspnea and orthopnea
    • right sided heart failure
    • MVP syndrome (if present)
    • *symptoms depend on slowly MR develops, the slower it develops the more time it has to compensate
  49. physical exam for mitral regurg
    • holosystolic apical blowing murmur- radiates to axilla
    • -laterally displaced apical pulse
    • -split S2 (but is obscured by murmur)
    • -S3 gallop (increased volume during diastole)
  50. Test of choice for mitral regurg
    test of choice= echo 2d/ color doppler

    • ECG= LAE, LVH
    • cardiac cath- helpful if patient older to look at coranaries
  51. mitral regurg treatment
    • medical
    • diuretics
    • vasodilators
    • ACEI
    • SBE- prophylaxis endocarditis

    • Surgical
    • -symptomatic patient even if EF normal
    • -MV replacement
    • -relief of symptoms
    • **repair is preferred to replacement- maintains functional aspects of mitral valve apparatus, restores valve competence, avoids prosthesis
    • -if valve can not be preserved replacement is needed
  52. anesthesia mgmt. and mitral regurg
    • avoid bradycardia
    • prevent increase in SVR
    • minimize drug induced depression
    • ***Tx afib immediately
    • maintain NS or slightly elevated
  53. Mitral valve prolapse
    prolapse of one or both mitral leaflets into left atrium during systole
  54. what is the most common type of valvular disease
    mitral regurg with mitral valve prolapse
  55. what is MVP associated with
    marfans disease, rheumatoid carditis, myocarditis, thyrotoxicosis, lupus
  56. symptoms of MVP
    • chest pain
    • palpitations
  57. Physical exam and MVP
    • mid-systolic click
    • last systolic murmur (if associated with Mitral regurg)
  58. prognosis of MVP
    • often benign
    • rare complications
    • -endocarditis
    • -progressive MR (acute or chronic)
    • -thromboembolism
    • -atrial and ventricular dysrythmias
  59. diagnosis and treatment of MVP
    • echo 2d/color
    • b-blockers (hyperadrenergic symptoms, palpitations)
    • aspirin (TIAs without etiology)
    • SBE prophylaxis (if associated with MR)
    • Severe symptomatic MR- same as chronic MR
  60. MVP and anesthesia management
    • same as Mitral regurg
    • -based on degree of regurg
    • -affected by size of ventricle
    • Ventricular arrhythmias may occur intra op
    • -respond to lidocaine or BB
    • -deep anesthesia decreases risk of arrhythmias
    • ***most patients are asymptomatic and do not require special care except SBE
  61. mitral stenosis etiologies
    • rheumatic- almost all cases in adults
    • -mitral annular Ca+ (rare)- calcium accumulation
    • -congenital- rare
  62. Normal Mitral valve size and when do symptoms begin
    • 4-6 cm2
    • symptoms begin <1.5 cm2
    • critical ms <1 cm2
  63. pressure volume loop and mitral stenosis
    • decreased stroke volume
    • restricted left ventricular filling
    • -does not come over as far to the right as normal because of decreased filling
  64. patho of mitral stenosis
    • LA hypertension:
    • -pulmonary interstitial edema
    • -pulmonary HTN (passive= obligatory to reserve forward flow) (reactive= vascular changes in 40%, protects interstitium from edema and leads to right sided heart failure)
    • LA stretch and atrial fib
    • -increased heart rate thus decreased LV filling
    • -decreased atrial kick thus decreased LV filling
    • -atrial thrombus formation and embolus
    • Limited LV filling and decreased CO
  65. symptoms of mitral stenosis
    • dyspnea- pulmonary venous congestion
    • fatigue- b/c diminished CO
    • inability to tolerate increased volume
    • inability to tolerate increased heart rate b/c of decreased filling and increased LA pressure/pv congestion
    • hemoptysis
  66. physical exam of mitral stenosis
    • loud s1
    • opening snap
    • diastolic apical rumble (murmur)
    • -may be associated with MR or AS
  67. test of choice for mitral stenosis
    echo 2d/ color Doppler is test of choice

    ECG=afib, LAE, RAE, RVH
  68. medical treatment of mitral stenosis
    • medical therapy- tx symptoms not cause
    • diuretics-for congetstion
    • dig, beta and ca channel blockers for afib rate control
    • anticoagulation- for afib and LA clots
    • SBE prophylaxis
  69. surgical treatment for mitral stenosis
    • surgical therapy treats cause
    • percuataneous ballon valvuloplasy- non calcified pliable valve
    • more calcified needs replacment
    • open commisurotomy- valve repair
  70. mitral stenosis and anesthesia
    • maintain SR
    • avoid tachycardia
    • judicious fluid therapy because excess fluid can precipitate failure