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Questions and Answers
What is the primary factor influencing the timing of intervention in valvular heart disease?
In chronic pressure overload, what is the relationship between hypertrophy and compliance?
Which of the following indices of contractility is most reliable in valvular heart disease?
What is the effect of acute increases in volume on LVEDP?
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Which of the following is a characteristic of ejection phase indices of contractility?
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What is the primary goal of anesthetic management in mitral stenosis?
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What is a common complication of mitral stenosis?
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What is the definition of mitral valve prolapse?
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What is a characteristic of patients with severe mitral stenosis?
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What is the approximate prevalence of mitral valve prolapse in the population?
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What is the primary factor that determines the natural history of valvular heart disease?
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What is the effect of chronic change on the pressure-volume loop in valvular heart disease?
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Which of the following is a characteristic of isovolumetric indices of contractility?
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What is the relationship between afterload and ejection phase indices of contractility?
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What is the primary advantage of using end-systolic pressure volume relationship (ESPVR) to measure contractility?
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Why is the end-systolic pressure volume relationship (ESPVR) a more reliable measure of contractility in valvular heart disease?
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What is the primary reason for avoiding tachycardia in patients with mitral stenosis?
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What is the primary benefit of using a balanced anesthetic technique in patients with mitral stenosis?
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Study Notes
Valvular Heart Disease
- Growing practice despite a decrease in rheumatic heart disease due to an aging population and innovations in surgical intervention
- Variable physiologic and hemodynamic aberrations influenced by anesthetic intervention
- Natural history of disease is important to determine timing of intervention and anesthetic management
Pressure-Volume Loops
- Acute increases in volume produce marked increases in LVEDP
- Chronic change tends to shift the curve to the right, allowing higher volumes to be tolerated
Kaplan Measures of Contractility
- Contractility is the ability to generate force at a given preload
- Isovolumetric Indices (Vmax, dP/dT) are relatively insensitive to loading conditions and poorly reflect basal contractility
- Ejection Phase Indices are directly proportional to preload and vary inversely with afterload, making them unreliable in most valvular disease
- End Systolic Pressure Volume Relationship (ESPVR) is a more precise estimate of contractility and is independent of preload
Mitral Stenosis
- Preload reserve is decreased, resulting in reduced LVEDV and LVEDP
- Stroke volume is reduced
- Approximately 1/3 of patients with severe disease develop atrial fibrillation, increasing the risk of thromboembolic events
- Procedures for mitral stenosis include percutaneous mitral commissurotomy, open commissurotomy, and valve repair or replacement
Anesthetic Management of Mitral Stenosis
- Primary goals: control ventricular rate, maintain normal to increased preload, and maintain normal afterload
- Monitoring: PAC trends may be useful, but won't accurately reflect LV volume; TEE is recommended
- Avoid tachycardia and pulmonary vasoconstriction
- Sedation: valuable for avoiding tachycardia, but avoid oversedation leading to hypoventilation
- Induction: most are acceptable, except ketamine; opioid induction if needed
- Maintenance: balanced technique with narcotic and low-dose volatile, plus nitrous oxide, with concerns about pulmonary HTN
Mitral Valve Prolapse
- Affects 1-2.5% of the population, more commonly in young women
- Etiology may be related to thyrotoxicosis, Marfan syndrome, SLE, myocarditis, or rheumatic disease
- Definition: valve leaflet prolapse > 2mm
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Description
Test your knowledge of valvular heart disease, its natural history, and the impact of anesthetic intervention on patient outcomes. This quiz covers key concepts in cardiac anesthesia, including the management of heart rate, inotrope usage, and vasodilators/vasoconstrictors.
