valvularHeartSurgeryMar08 - Anesthesia for Valvular Heart...

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Anesthesia for Valvular Heart Surgery Charles E. Smith, MD Professor of Anesthesia Director, Cardiothoracic Anesthesia MetroHealth Medical Center Case Western Reserve University
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Objectives Pathophysiology Aortic valve: AS, AI Mitral valve: MS, MR Tricuspid valve: TR Hemodynamic Goals Anesthetic management
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Aortic Stenosis May occur at 3 levels: 1. Valvular 2. Subvalvular 3. Supravalvular
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Valvular Aortic Stenosis 1. Calcification + fibrosis of normal tricuspid valve- very common 2. Calcification + fibrosis of congenital bicuspid AV 3. Rheumatic- uncommon since antibiotics
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Aortic Stenosis Normal AVA: 2-4 cm 2 Severe AS: AVA < 1cm 2 If normal LV- mean PG > 50 mmHg If poor LV function- mean PG may be low!
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Pathophysiology of Aortic Stenosis Chronic LV pressure overload Concentric LVH to ↓ wall stress LVH → ↓ diastolic compliance, ↓ coronary blood flow + imbalance of MVO2 supply- demand ↓ diastolic compliance → ↑LVEDP + LVEDV Myocardial ischemia bc LVH, ↑ wall stress, ↓ diastolic coronary perfusion + ↓ coronary flow reserve
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Hemodynamic Goals: AS SR is crucial. Cardiovert SVTs promptly Optimal HR 60-80. Tachycardia → ischemia + ectopy. Bradycardia → low CO due to fixed SV Adequate preload essential but difficult to predict bc diastolic dysfunction [TEE useful] Maintain contractility. Avoid myocardial depressants Treat hypotension promptly- phenylephrine, volume, Trendelenburg
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AS: Considerations Drugs to maintain CPP: Phenylephrine Norepinephrine Atrial kick – crucial. HR 60-80 preferred Spinal + epidural anesthesia poorly tolerated if preload or HR
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AS: Management Premed: young+ anxious get benzos.
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