Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++Table Graphic Jump Location|Download (.pdf)|PrintCongenital and Acquired Valvular LesionsExamples of congenital valvular diseaseExamples of acquired valvular diseaseBicuspid aortic valve—aortic stenosis (AS), aortic regurgitationCongenital mitral stenosisMarfan’s—aortic regurgitationPulmonic stenosisMitral cleft (atrioventricular canal defect)—mitral regurgitationRheumatic heart disease—mitral stenosis, mitral regurgitation, AS, aortic regurgitationMitral valve prolapse—mitral regurgitationMyocardial infarct, papillary muscle rupture—mitral regurgitationMitral annular calcification—mitral stenosis, mitral regurgitationElderly—ASAscending aortic aneurysm—aortic regurgitationEndocarditis—mitral regurgitation, aortic regurgitation++ Left-sided valve lesions are more poorly tolerated than right-sided lesionsThe 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 leafletsStenosis is mainly due to calcified leaflets; if the valve is fused (e.g., bicuspid aortic valve), then it may become calcified ++Table Graphic Jump Location|Download (.pdf)|PrintHemodynamic Management of Patients with Valve LesionsPathologyAfterloadPreloadHeart rateContractilityAortic stenosisMaintainMaintainLow normal (50–70 bpm)MaintainAortic regurgitationDecreaseMaintainHigh normal (70–90 bpm)MaintainMitral stenosisMaintainMaintainLow normal (50–70 bpm)MaintainMitral regurgitationDecreaseMaintainHigh normal (70–90 bpm)Maintain++ Over 90% of pulmonic valve lesions are congenitalRight-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 ++Table Graphic Jump Location|Download (.pdf)|PrintHemodynamic Management for Right-Sided Valve LesionsPathologyAfterloadPreloadHeart rateContractilityTricuspid stenosisMaintainMaintainLow normalMaintainTricuspid regurgitationDecreaseMaintainHigh normalMaintainPulmonic stenosisMaintainMaintainLow normalMaintainPulmonic insufficiencyDecreaseMaintainNormal (60–80 bpm)Maintain ++ Hypertrophy of left ventricle (LV) from increased workloadMaintain 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 myocardiumKeep 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 HRIt 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 presentAdministering sedation would be appropriate, if carefully monitored. Increasing levels of sedation could result in dramatic decreases in afterloadAppropriate monitoring should always be a consideration, no matter what the surgery. Minor ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.