Ap2 Cardiac Valvular Disease

Front 1

1. What are the hemodynamic changes that can occur with valvular heart disease?

Back 1

a. Cardiac remodeling: Changes in heart size, shape and function
b. LV hypertrophy
i. Pressure overload: concentric VH
ii. Volume overload : eccentric hypertrophy
c. Systolic dysfunction:
i. Abnormal ventricular contractility
ii. Independent of Preload and afterload
d. Diastolic dysfunction:
i. Abnormal ventricular filling
ii. Requires increased ventricular filling pressures

Front 2

2. Aortic stenosis:
What is the normal annular size?

Back 2

Normal av size: 2.6-3.5 cm-2
b. Sx occur when reduced to 0.8 cm-2
c. SX: diastolic dysfunction;…decreased compliance, concentric LVH,

Front 3

Aortic Stenosis....

Back 3

fixed stroke volume!

Front 4

3. What are the goals of perioperative management w/ aortic stenosis?

Back 4

Keep afterload high!
a. HR: Nl/slow/sinus(crucial!) (need atrial kick!)
b. Preload: Nl volume to sl up (use of ntg can dangerously reduce CO)
c. Afterload (svr) Elevated (maintains coronary perfusion)
d. Contractility: Nl to high

Front 5

4. Operative management with AS?

Back 5

a. Light premedication: to keep pt calm, avoid tachycardia, and drop in svr
b. A-adrenergic agents : phenylephrine used for early and aggressive tx of any reductions in Bp
c. SVT: treat aggressively – shock (cardiovert)if needed atrial kick supplies up to 40% of ventricular filling

Front 6

5. Aortic Regurg: Acute condition side effects?

Back 6

a. Sudden and severe dyspnea, cardiovascular collapse and deterioration.
b. Places major volume load on LV: tachycardia, increased contractile state==LV failure

Front 7

6. Chronic Aortic regurg:

Back 7

a. asymptomatic for many years symptoms do not occur until after significant dilatation and myocardial dysfunction of the LV.

b. Eccentric LV H, due to volume overload

Front 8

7. Goals of anesthestic with AR:

Back 8

keep afterload low! Preload up
a. HR : elevated (90+ is best)
b. Preload: normal to full
c. Afterload (svr): Down!!!
d. Contractility: Nl (has no effect)

Front 9

8. What anesthetic technique is best with AR?

Back 9

a. Light premedication
b. Vasodilation with induction is beneficial to keeping the SVR low.
c. Preserve preload – full…
d. Adequately anesthetized patients before laryngoscopy is important to avoid sudden increase in BP
e. Medications on hand: Anticholinergics, Vasodilators, catecholamines

Front 10

9. Mitral Stenosis:

Back 10

a. Diastolic dysfunction: obstruction to LV inflow!
b. Mitral size: 4 – 6 cm-2
i. 1.5-2.0 moderate exercise induces symptoms
ii. 1.0-1.5 mild to mod exercise= symptoms
iii. <1.0 smallest compatible with life

Front 11

10. MS hemodynamic management:

Back 11

goals: forward flow dep on preload!
a. HR: controlled Sinus Rhythm (slower = better filling)
b. Preload: Full (too full can cause CHF though)
c. Afterload: Nl… also avoid hypoxia and hypercarbia that would cause pulmonary vasoconstriction
d. Contractility: Nl …

Front 12

11. What anesthetic technique is best with MS?

Back 12

a. Premedication: Light to maintain preload, but relaxed enough to avoid tachycardia
b. Medical management: Volume and betablockers!
c. May also benefit from ephedrine, to treat hypotension a vasoconstrictor with an inotropic effect.
d. Avoid Hypoxia, hypercarbia, acidosis, because they increase Pulmonary vascular resistence

Front 13

12. Mitral Regurgitation

Back 13

a. Characterized by volume overload
b. Acute MR (papillary rupture from acute MI)
i. Acute inc in LA and PAP= pulmonary congestion, edema and RV failure
c. Chronic MR
i. LA dilatation and eccentric LVH
ii. AFib (common—just keep Vent Rate controlled)

Front 14

13. Hemodynamics with MR:

Back 14

maintain forward flow ( FFF)- reduce afterload!
a. HR: Nl to elevated range (avoid bradycardia which will increase LV pressure)
b. Preload: Nl
c. Afterload: Keep low (vasodilate)
d. Contractility: Nl

Front 15

14. Medical management for MR:

Back 15

promote vasodilation and tachycardia
a. Premedication: Light
b. Goals: Maintain peripheral arterial dilatation, ventricular contractility, keeping HR @90.
c. Nipride is used to reduce afterload

Front 16

15. Pericarditis

Back 16

a. Etiology: Impaired LV filling; Fixed stroke volume: CO is dependent on HR!!!
b. HR: Keep UP
c. Preload: Keep UP
d. Afterload Keep UP
e. Contractility: Keep UP

Front 17

16. Medical management with Pericarditis?

Back 17

a. Epinephrine (catecholamines)
b. Volume