see: [EMCrit - Critical Aortic & Mitral Regurgitation](cubox://card?id=6948681985581646272), [[ECHO]], - [AHA 2020 valvular heart disease management](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923), [Oh’s valve lesions table](x-devonthink-item://49C9C33E-BFC4-4CAE-99BB-110FA7246880?page=379) #incomplete > [!Key Points] > The end point of all valvular diseases is: > - heart failure and dilation > - valves become regurgitant > - ECG shows LVH as ventricles expand > - LBBB develops as heart and conduction system stretches and is a poor prognostic sign > > suspect acute structural heart disease with pulm oedema and normal cardiac silhouete on CXR # Basic concepts ## Valve regurgitation **management:** - minimise afterload to decrease regurgitant flow (target lowest MAP needed for organ perfusion - decrease pulmonary congestion and volume overload - avoid bradycardia to ↓ time for regurgitant flow - early consult for mechanical circulatory support # Aortic stenosis see [[Aortic stenosis#intubation and RSI with aortic stenosis]], [[ECHO]] > needs to be rate controlled, worse when tachycardic - symptoms progress from SOB --> CHF --> syncope - murmur: systolc into neck - ECG: LVH, LBBB - AS is graded as severe if the AVA is reduced to 1 cm2 or less a cause of exercise-induced syncope (ddx would be HOCM) ## anaesthetic risks of AS - AS leads to concentric LV hypertrophy and a poorly compliant ventricle which is **highly dependent on pre-load** for adequate diastolic filling - If you drop the pre-load (or the aortic end-diastolic pressure) – e.g. by vasodilation - LV filling is poor & stroke volume low - Also dependent on diastolic filling time – so causing tachycardia is also bad (atrial fibrillation is very bad as highly dependent on atrial “kick” – normal heart = 20% of diastolic ventricular filling but in AS up to 40%) The anesthetic management of patients with AS should not involve any medication that could have negative inotropic, tachycardic, or vasodilatory effects. Furthermore, every effort should be made to ensure that the patient stays in sinus rhythm. In patients with AS, the atrial kick may contribute as much as 40% of the total CO. # Aortic Regurgitation > - needs to go fast to maintain cardiac output > - think **aortic dissection** if new early diastolic murmur and any degree of chest pain or risk factors - need afterload reduction (arterial vasodilation) - murmur; diastolc, lower left sternal border **causes:** - [[Rheumatic fever|rheumatic heart disease]] - bicuspid valve - [[Aortic dissection]] - marfan - [[Endocarditis]] # Mitral Stenosis > classic: pregnant woman delivering --> cardiovascular collapse - Atrial fibrillation is common - blood backs up into left atrium, ten lungs --> **CHF** - AF can cause decompensation - haemoptysis - when AF occurs they can crash due to loss of kick look for **left atrial hypertrophy** on ECG # Mitral Regurgitation > Ischaemia + shock + new murmur = ruptured cordae tendinae/papillary muscle sudden ↑ in LA preload due to regurgitant volume during systole → ↑ LA pressure and wall stress → ↑ pulm capillary wedge pressure → pulmonary oedema *causes* - [[Endocarditis]] - papillary muscle rupture - from [[ACS|AMI]] - posterior medial papillary muscle supplied from PDA ∴ ==inferior-posterior MI== can cause this - [[Rheumatic fever|rheumatic heart disease]] causing chordal rupture - myxomatous disease - chest trauma - secondary/"functional" MR due to non-valvular heart disease → dilated LV and MV annulus → MR # Mitral valve prolapse - myxomatous degeneration of valve