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Congenital and Acquired Valvular Lesions
Examples of congenital valvular diseaseExamples of acquired valvular disease
  • Bicuspid aortic valve—aortic stenosis (AS), aortic regurgitation
  • Congenital mitral stenosis
  • Marfan’s—aortic regurgitation
  • Pulmonic stenosis
  • Mitral cleft (atrioventricular canal defect)—mitral regurgitation
  • Rheumatic heart disease—mitral stenosis, mitral regurgitation, AS, aortic regurgitation
  • Mitral valve prolapse—mitral regurgitation
  • Myocardial infarct, papillary muscle rupture—mitral regurgitation
  • Mitral annular calcification—mitral stenosis, mitral regurgitation
  • Elderly—AS
  • Ascending aortic aneurysm—aortic regurgitation
  • Endocarditis—mitral regurgitation, aortic regurgitation
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  • Left-sided valve lesions are more poorly tolerated than right-sided lesions
  • The valves can be either regurgitant or stenotic
    • Regurgitation can be caused by a perforation, vegetation, chordal tear, prolapsed or redundant leaflet tissue, widened annulus, or coaptation failure due to restricted leaflets
    • Stenosis is mainly due to calcified leaflets; if the valve is fused (e.g., bicuspid aortic valve), then it may become calcified

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Hemodynamic Management of Patients with Valve Lesions
PathologyAfterloadPreloadHeart rateContractility
Aortic stenosisMaintainMaintainLow normal (50–70 bpm)Maintain
Aortic regurgitationDecreaseMaintainHigh normal (70–90 bpm)Maintain
Mitral stenosisMaintainMaintainLow normal (50–70 bpm)Maintain
Mitral regurgitationDecreaseMaintainHigh normal (70–90 bpm)Maintain
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  • Over 90% of pulmonic valve lesions are congenital
  • Right-sided lesions will follow the same principles as left-sided lesions. However, if pulmonary hypertension is present, pulmonary vascular resistance (PVR) will be much more difficult to manipulate than systemic vascular resistance (SVR). Maintaining oxygenation and providing adequate ventilation is extremely important for these patients

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Hemodynamic Management for Right-Sided Valve Lesions
PathologyAfterloadPreloadHeart rateContractility
Tricuspid stenosisMaintainMaintainLow normalMaintain
Tricuspid regurgitationDecreaseMaintainHigh normalMaintain
Pulmonic stenosisMaintainMaintainLow normalMaintain
Pulmonic insufficiencyDecreaseMaintainNormal (60–80 bpm)Maintain
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  • Hypertrophy of left ventricle (LV) from increased workload
  • Maintain afterload to perfuse the coronaries. Decreasing the afterload will decrease the coronary perfusion pressure. A higher perfusion pressure is also needed due to the LVH, with a thicker myocardium
  • Keep the heart rate lower to allow more time in diastole to perfuse the coronaries, and to fill thick and stiff LV (LVH). The duration of systole does not change with HR
  • It is also important to keep the patient in sinus rhythm. Patients with LVH are more dependent on atrial contraction (LV filling) for cardiac output. Normally, atrial contraction will contribute 20% to cardiac output, but in patients with LVH, it can contribute up to 40%
  • In severe AS, a spinal anesthetic would be contraindicated because of the drop in afterload that usually occurs. Whether an epidural would be safe is controversial: the drop in afterload is somewhat less abrupt but still present
  • Administering sedation would be appropriate, if carefully monitored. Increasing levels of sedation could result in dramatic decreases in afterload
  • Appropriate monitoring should always be a consideration, ...

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