Chap 2 Valvular Heart Disease

Class
I II III IV

Description
Asymptomatic Symptoms with ordinary activity, no symptom at rest Symptoms with minimal activity, no symptom at rest Symptoms at rest

NYHA Classification of patients with heart disease

Normal left atrial pressure is 8 . Note in mitral stenosis it is 25/14. way high. Left atrial has to squeeze hard through a tight hole less LV filling

 Features

MITRAL STENOSIS

Delayed complication of RHD , may occur 15-20 years after RF Narrowing of the mitral valve rise in left atrial pressure which is transmitted to the pulmonary venous system Normal left ventricle

Symptoms
Dyspnea, orthopnea , PND (due to pul. congestion) backup Hemoptysis A. fib embolization

PE
Loud S1 Opening snap Loud P2 Low pitched late diastolic murmur (mid diastolic murmur) LA >> LV pressure during diastole

MITRAL STENOSIS (cont)

Diagnosis
ECG signs of left atrial enlargement, RVH (normal LV) A.fib CxR: straightening of the left heart border Dilation of pulmonary veins Echo : Narrowed, fish mouth shaped orifice

Medical therapy
Diuretics for pulmonary congestion Digoxin Anticoagulant

Surgical replacement
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Straightening of left border

MITRAL STENOSIS (cont)

Anesthesia Concerns
Maintain sinus rhythm , avoid tachycardia Avoid fluid overload and hypovolumia Avoid spinal/epidural nerve block Afterload reduction Beta blockers for tachycardia Diltiazem and digoxin in A fib Phenylephrine as vasoconstrictor

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Mitral Regurgitation
Causes
RHD Mitral valve prolapse Infective endocarditis Papillary muscle dysfunction (D3 post MI)

Pathophysiology
Left ventricular stroke volume is pumped backward into the left atrium causing left atrial pressure, CO

Symptoms
Due to backward regurgitant flow: dyspnea, orthopnea , PND
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Mitral Regurgitation (cont)

PE
Diffuse and hyperdynamic ventricular impulse Holosystolic murmur Wide splitting S2 S3 due to volume overload in left atrium

Diagnosis
EKG: left atrial enlargement and left ventricular hypertrophy Cx: enlarge left atrium Echo: may show ruptured chordae Cath: large v wave
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Mitral Regurgitation (cont)

Medical Therapy: Goals are
Increase forward flow by reducing afterload Reducing pulmonary venous congestion
Vasodilator e.g. ACE inhibitors Digoxin to ventricular rate in A fib ( digoxin prolong conduction through AV node ) Anti-coagulant to prevent embolization

Surgical replacement

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Mitral Regurgitation (cont)

Anesthesia Concerns
Maintain heart rate 80-100 bpm Inotrops and vasodilators to improve forward flow WATCH IV FLUIDS
Excess fluid will dilate the LV and worsen regurgitation

Spinal and epidural anesthetics are well tolerated but bradycardia must be avoided
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 Features

Mitral Valve Prolapse

Most frequent valvular lesion, especially in of younger women Redundancy and elongation of the chordae of the mitral valve Sudden tension produces the mid-diastolic click Abnormal closure of the valve produces the murmur of mitral regurgitation holosystolic murmur

Clinical Features
Most are asymptomatic Atypical chest pain, tachyarrhythmia Infective endocarditis Murmurs are accentuated by rising from supine position
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Mitral Valve Prolapse (cont)

Diagnosis
Echo reveals redundancy of the chordae Doppler detects regurgitation

Management
Over all prognosis is excellent Serious complication are rare Most patients do not require therapy Antibiotic prophylaxis with mitral regurg ampi/genta Beta blockers for palpitation
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Aortic Stenosis

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Aortic Stenosis
Causes
Congenital bicuspid valve -MCC RF

Pathophysiology
Pressure overload develops on the left ventricle due to a chronically-elevated resistance to outflow across the narrowed aortic valve 0.7-0.9 cm2 Left Ventricular Hypertrophy Diastolic dysfunction occur as a result of LVH S4 -Atrial kick : Impaired ventricular filling is compensated by a forceful atrial kick; therefore the atrial arrhythmia is poorly tolerated
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Aortic Stenosis (cont..)

Clinical Symptoms: There are three clinical symptoms
indicating poor prognosis Angina due to decrease oxygen supply to the subendocardium by the reduced ventricular diastolic compliance Syncope Dyspnea on exersion PE Diminished S2 the aortic component is of the second heart sound is greatly diminished due to the impaired motion of valve S4 Systolic ejection murmur, with LV pressure >> aortic 20 pressure during systole

Aortic Stenosis (cont..)

Dx
EKG left ventricular hypertrophy Echo Cardiac Cath. measures pressure gradient

Therapy
Aortic valve replacement

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Aortic Stenosis (cont..)

Anesthesia Concerns
Maintain normal sinus rhythm , HR( 60-90 bpm ) and intravascular volume Avoid bradycardia Spinal and epidural anesthetics are contraindicated in severe stenosis can lead to decrease in systemic vascular resistance Phenylephrine for hypotension (watch for reflex bradycardia) WATCH OUT FOR VASODILATION because it is associated with large reduction in blood pressure and coronary blood flow
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Aortic Regurgitation

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Aortic Regurgitation
Causes Rheumatic heart disease or congenital Infective endocarditis 3 Syphilis Aortic dissection Marfans syndrome Collagen vascular disease e.g. SLE Pathophysiology Regurgitant flow during diastole results in left ventricular dilatation and volume overload Reduction in systemic diastolic blood pressure leading to increased pulse pressure Widened pulse 25 pressure ( 160/50)

Aortic Regurgitation (cont..)

Clinical Features
Left ventricular failure (PND) due to volume overload Syncope, weakness due to reduction in the diastolic arterial pressure Angina- because reduce coronary blood flow (coronary arteries are perfused during diastole)

PE
High pitch blowing diastolic murmur Increase pulse pressure
Corrigan pulse rapid rise followed by a rapid fall of carotid pulse Pistol-shot femoral pulse bounding Duroziez sign diastolic bruit over the femoral artery De Mussets sign bobbing motion of head Quinckes pulse systolic blushing and then diastolic blanching of the fingernail bed

Aortic Regurgitation (cont..)

Dx
EKG left ventricular enlargement Cx left ventricular enlargement Echo Doppler

Therapy
Treat CHF Surgery

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Aortic Regurgitation (cont..)

Anesthesia Concerns Fast, full and forward
Maintain sinus rhythm ( slight tachy is desirable because it will give less time for regurg.) Low TPR and afterload (it will improve forward flow) Slight increase in preload Spinal and epidural anesthetics are well tolerated Avoid vasoconstrictors

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Chest areas from which sound from each valve is best heard.

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Phonocardiograms from normal and abnormal hearts.

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Patent ductus arteriosus.

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PDA
Persistence of connection between pulmonary artery and aorta LR shunt Small defect no symptoms Large defect
CHF(more blood to lungpul.hypertensionRVH) Delayed growth Infections

Treatment : surgical ligation

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Tetralogy of Fallot.
Most common congenital heart disease Pulmonary stenosis Overriding aorta( aorta comes out both from Left and Right ventricle), BIG aorta Ventricular Septal defect Right ventricular hypertrophy

Features

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Physiology HOT line: makhter@astate.edu