1.Hemodynamic burden (volume overload or pressure overload)
3.Eventual cardiac muscle dysfunction, CHF, or sudden death
Aortic or Pulmonic Stenosis
Incompetence of the mitral or tricuspid valve
Stenosis of the mitral or tricuspid valve
Incompetence of the aortic or pulmonic valve
Heart Rate control: Beta-blockers, Ca channel blockers, and digitalis
BP & Afterload Control: ACE inhibitors and vasodilators
Heart Failure Control: Diuretics, inotropes, and vasodilators
Broad/Notched P waves (P mitrale): LA enlargement typical of mitral valve disease
Anticoagulation in Patients with Prosthetic Heart Valves
Warfarin discontinued 3-5 days preoperatively
IV heparin/LMWH is administered until surgery
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.
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.
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
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
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.
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)