Valvular Heart Disease

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  1. Valvular Disease Progression
    • 1.Hemodynamic burden (volume overload or pressure overload)
    • 2.CV compensation
    • 3.Eventual cardiac muscle dysfunction, CHF, or sudden death
  2. Systolic Murmur
    • Aortic or Pulmonic Stenosis
    • Incompetence of the mitral or tricuspid valve
  3. Diastolic Murmur
    • Stenosis of the mitral or tricuspid valve
    • Incompetence of the aortic or pulmonic valve
  4. Drug Therapy
    • Heart Rate control: Beta-blockers, Ca channel blockers, and digitalis
    • BP & Afterload Control: ACE inhibitors and vasodilators
    • Heart Failure Control: Diuretics, inotropes, and vasodilators
  5. ECG
    Broad/Notched P waves (P mitrale): LA enlargement typical of mitral valve disease
  6. Anticoagulation in Patients with Prosthetic Heart Valves
    • Warfarin discontinued 3-5 days preoperatively
    • IV heparin/LMWH is administered until surgery
  7. Antibiotic Prophylaxis Conditions
    • 1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair. 
    • 2. Previous infective endocarditis
    • 3. Congenital Heart Disease: Unprepared cyanotic disease (palliative shunts and conduits), Completely repaired heart defects with prosthetic material/device 6 months after placement, repaired congenital heart disease with residual defects ay the site or adjacent to the site. 
    • 4. Cardiac transplantation recipients who develop cardiac valvulopathy. 
    • 5. Dental procedures that manipulate the gingival tissues or periapical regions of teeth or oral mucosa perforation
    • 6. For invasive procedures (incision/biopsy) on the respiratory tract or infected skin, skin structures, or musculoskeletal tissue
    • 7. NOT for GI or GU procedures.
  8. Mitral Stenosis
    • Info: Rheumatic heart disease is most common cause, Symptoms begin when the orifice size has decreased at least 50%. AFib in 30% of cases 
    • Path: Mechanical obstruction to the LV diastolic filling, increased LA pressure, increased pulmonary pressure, pulmonary edema
    • Leads to: CHF, pulmonary HTN, and RV failure
    • Anesthesia: Prevent decreased CO or pulmonary edema, sudden SVR decrease may not be tolerated since an increase in HR ay decrease CO. Avoid ketamine due to increase in HR. 
    • Afib tx: Cardioversion or B-blockers, Ca channel blockers, or digoxin.
  9. Mitral Regurgitation
    • Info: Papillary muscle dysfunction, mitral annular dilation or rupture of chordae tendinae
    • Path: decreased forward LV stroke volume and CO, LA volume overload, and pulmonary congestion and/or cardiogenic shock
    • Regurgitation fraction: 1.Size of the valve, 2.HR/ventricular ejection, 3.Pressure gradients across the mitral valve (LV compliance and impedance to LV ejection)
    • Tx: Symptomatic patients received ACEi or Beta-blockers and biventricular pacing
    • Anesthesia: Prevent Bradycardia, Prevent increase in SVR, minimize drug induced myocardial depression, monitor regurgitant flow
  10. Mitral Valve Prolapse
    • Prolapse of one or both mitral leaflets into the LA w/ or w/o regurgitation
    • S/S: Mid-systolic click and late systolic murmur
    • Anesthesia: Same principles as mitral valve regurgitation. Prevent Bradycardia, Prevent increase in SVR (also significant decrease in SVR @ induction), minimize drug induced myocardial depression, monitor regurgitant flow. Minimize sympathetic activation, maintain fluid balance
  11. Aortic Stenosis
    • Risk Factors: Degeneration/ calcification of the aortic leaflets (stenosis) and presence of a bicuspid aortic valve
    • Severe: Gradients over 50mm Hg and area under 0.8cm2. 
    • Info: uncreased LV pressure needed to maintain forward SV. 
    • Anesthesia: Maintain normal sinus rhythm, avoid brady/tachy-cardia, avoid hypotension, optimize IV fluid volume to maintain venous return and LV filling. (avoid decreased SVR). Bradycardia require prompt tx w/ glyco, atropine, or ephedrine. Tachycardia tx w/ esmolol. SVT tx w/ cardioversion.
  12. Aortic Regurgitation
    • Info: Decreased CO due to regurgitation of SV from the aorta into the LV during diastole. 
    • Magnitude determined by: 1. time for the regurgitant flow to occur (HR), 2.Pressure gradient across the aortic valve. (Decrease: tachycardia and peripheral vasodilation)
    • Steps: LV volume overload, LV hypertrophy, LVEDV increase, pulmonary edema
    • S/S: diastolic murmur along the left sternal border
    • Tx: vasodilators and inotropic drugs
    • Anesthesia: Avoid bradycardia, avoid increases in SVR, minimize myocardial depression
  13. Tricuspid Regurgitation
    • Info: Often caused by annular dilation secondary to RV enlargement or pulmonary HTN. 
    • Path: Hemodynamic consequence of RA volume overload
    • Anesthesia: Maintain IV fluid volume and CVP, avoid increased pulmonary artery pressure (hypoxemia and hypercarbia), PPV and vasodilating drugs may be deleterious is they decrease venous return.

Card Set Information

Valvular Heart Disease
2015-09-11 00:05:00
Valvular Heart Disease

Anesthesia for Valvular Heart Disease
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