Cardio Exam 3: Tsu VHD/Shock

Surgical Treatment & Procedures

• Balloon valvuloplasty

• Valve repair

• Valve replacement

  • Bioprosthetic replacement

  • Mechanical replacement

KNOW

Balloon Valvuloplasty

• Commonly for _____

• Requires pre-procedureal _____ to rule out thrombus formation

• Possibly for aortic stenosis if pt is too high-risk for cardiac surgery

mitral stenosis, TEE

Valve Repair

• Fixing and preserving the pt’s native valve

• _____ preferred over _____, if possible

  • Lower operative mortality

  • Better long-term outcomes

  • Preservation of left ventricular function

  • No anticoagulation

valve repair, replacement

Valve Replacement

• _____

• Transcatheter aortic valve implantation (TAVI)

• Mechanical valves

  • 1st generation: _____

  • 2nd generation: _____

  • 3rd generation: _____

• Bioprosthetic valves

  • _____ (_____)

  • _____ (_____)

open heart surgery, Ball and cage, single tilting disk, bileaflet tilting disk, porcine, pig, bovine, cow

Bioprosthetic vs Mechanical Valves

• Bioprosthetic (Tissue)

  • Advantages

    • _____

  • Disadvantages

    • _____ – will need _____

less thrombogenic, low durability, replacement in 5-10 years

Bioprosthetic vs Mechanical Valves

• Mechanical (Prosthetic)

  • Advantages

    • _____

  • Disadvantages

    • _____ → _____

    • Can have _____

high durability, highly thrombogenic, lifelong anticoag, clicking sound

Choose the best type of valve replacement based on the following factors

	Bioprosthetic	Mechanical
Young Pt
RFs for Bleeding
Refuses or C/I to Anticoag

Mechanical, Bioprosthetic, Bioprosthetic

Antithrombotic therapy Bioprosthetic

• _____ thrombogenicity

• Depends on _____ of replaced valve

• Recommendations

  • Bioprosthetic Aortic Valve

  • Bioprosthetic Mitral Valve → _____

lower, location, anticoag

Antithrombotic therapy Bioprosthetic

• Bioprosthetic Aortic Valve

  • _____ indefinitely (_____)

  • Optional: _____ 75mg daily for _____ IF _____

Baby Aspirin, add clopidogrel, 3-6 months, TAVI

Antithrombotic therapy Bioprosthetic

• Bioprosthetic Mitral Valve → _____

  • _____ with _____, then _____

Anticoag, Warfarin, INR 2-3 for 3 months, Aspirin, Baby Aspirin

Antithrombotic Therapy Mechanical

• _____ thrombogenicity

• Depends on _____ of replaced valve

• Recommendations

  • Mechanical Aortic Valve

    • _____ with INR 2-3 indefinitely*

  • Mechanical Mitral Valve

    • _____ with INR 2.5-3.5 indefinitely

  • Bridge with _____ or _____ if INR _____therapeutic

  • _____ if additional RFs for thromboembolism (_____, _____, _____, Hx of _____)

  • ACC/AHA recommendation for INR _____ if pt has additional RFs for thromboembolism

Higher, location, Warfarin, Warfarin, IV UFH, SC LMWH, sub, Add baby aspirin, Afib, low EF, older age, TE, 2.5-3.5

Antithrombotic Therapy Summary

• Aortic

  • BioProsthetic (Porcine or Bovine)

    • Baby Aspirin: _____

    • Warfarin: _____

  • Mechanical (Any Generation)

    • Baby Aspirin: _____

    • Warfarin: _____

add clopidogrel if transcatheter, none, none, INR 2.5-3.5 for 3 months only

Antithrombotic Therapy Summary

• Mitral

  • BioProsthetic (Porcine or Bovine)

    • Baby Aspirin: _____

    • Warfarin: _____

  • Mechanical (Any Generation)

    • Baby Aspirin: _____

    • Warfarin: _____

if additional TE RFs, INR 2-3, if additional TE RFs, INR 2.5-3.5

Use of DOACs in valvular disease

• Dabigatran, Apixaban, Rivaroxaban, Edoxaban (DARE)

• Use is C/I with mechanical heart valves

• Studies show increased risk of _____ + _____ compared to warfarin

mechanical heart valves, TE, bleeding

Pregnancy and VHD

• _____ generally preferred if women wishes to have children in the future

• Optimal regimen for mechanical valve based on discussion of maternal and fetal risks

• Warfarin increases risk of congenital fetal abnormalities, fetal loss and hemorrhagic complications

  • If mother is willing, _____ could be continued in _____ if daily dose is <_____

  • Most choose to use _____ due to warfarin congenital effects

• LMWH does not cross placenta

  • _____

  • Must be monitored closely with anti-Xa levels

• UFH IV can be a last-line option

• Low-dose aspirin added for high-risk patients

Bioprosthetic valve, warfarin,1st trimester, 5 mg, LMWH injection, BID SQ injections

A 30 year-old female requires mitral valve replacement for severe mitral valve prolapse. Which statement regarding valve replacement is most accurate for this patient?

1. A bioprosthetic valve will last longer than a prosthetic (mechanical) valve

2. Her goal INR would be 2.5–3.5 if she received a prosthetic (mechanical) valve

3. A prosthetic/mechanical valve would be better if she would like to have children in the future

4. If she receives a bioprosthetic bovine valve, she should be on aspirin and clopidogrel therapy

2, prosthetic lasts forever, NO continue warfarin or use LMWH, for transcatheter implantation (aortic position)

A 55 year-old male receives a mechanical mitral valve and mechanical aortic valve. His past medical history includes previous DVT and asthma. In addition to therapeutic heparin, which of the following anti-thrombotic regimens would be most appropriate?

A. Aspirin 81mg and warfarin to goal INR 2-3

B. Aspirin 81mg and warfarin to goal INR 2.5-3.5

C. Warfarin to goal INR 2-3

D. Warfarin to goal INR 2.5-3.5

B (increased TE risk)

A 78 year-old female presents with severe mitral stenosis. Her past medical history includes atrial fibrillation (stopped warfarin due to intracranial hemorrhage), HTN, and diabetes. Which of the following statements about this patient is most accurate?

1. Her mitral stenosis is likely due to rheumatic heart disease

2. A bioprosthetic valve will last >20 years in this pt

3. The best option for valve replacement would be a mechanical mitral valve

4. If the patient receives a bioprosthetic valve, she can use apixaban instead of warfarin

1, short-term valve (5-10 years), if on mechanical mitral valve = Warfarin, generally do not use DOACs

A 75-year old patient has severe aortic stenosis, and is considering valve replacement. Which of the following statements is most accurate?

1. If she receives a valve by transcatheter procedure, she should be on warfarin and clopidogrel

2. She needs to be on warfarin whether she receives a mechanical or bioprosthetic valve

3. If she receives a mechanical valve, she will need to be on warfarin lifelong with a goal INR of 2-3

3, Aspirin and Clopidogrel, only for mechanical valve

Shock

• Acute, generalized state of _____

• Defined as _____ mmHg OR _____ of at least _____ mmHg from baseline with _____ despite adequate fluid resuscitation

• Mortality ranges from 20-40%

inadequate perfusion of critical organs, systolic BP <90, reduction, 40, perfusion abnormalities

Goals and Monitoring of Shock

• Goal is to achieve and maintain:

  • Mean arterial pressure (MAP) _____ mmHg

  • Adequate _____

• Global monitoring

  • Assesses _____ of entire body

  • Includes systemic BP, oxygen tension, lactate

• Regional monitoring

  • Assess organ-specific oxygen delivery and utilization

  • Examples include coagulation abnormalities, impaired renal or hepatic dysfunction, cool extremities, cardiac ischemia, etc

>65, perfusion to critical organs, perfusion and oxygenation

Types of Shock

• _____

• _____

• _____

• _____

Cardiogenic, Obstructive, Hypovolemic, Distributive

Cardiogenic

• _____

• Ex. _____

• General Treatment: _____

heart fails to pump out blood, HF and valve dysfunction, increase CO and inotropes

_____

• Heart fails to pump out blood

• Ex. HF and Valve dysfunction

• General Treatment: Increase CO and Inotropes

Cardiogenic

Obstructive

• _____, but _____

• Ex. _____

• General Treatment: _____

Heart pumps well, outflow is obstructed, PE and tamponade, treat obstruction

_____

• Heart pumps well, but outflow is obstructed

• Ex. Pulmonary embolism and Tamponade

• General Treatment: Treat obstruction

Obstructive

Hypovolemic

• _____, but _____

• Ex. _____

• General Treatment: _____

Heart pumps well, not enough blood volume to pump, blood and fluid loss, IV fluids (crystalloids, colloids, blood)

_____

• Heart pumps well, but not enough blood volume to pump

• Ex. Blood + Fluid loss

• General Treatment: IV fluids (crystalloids, colloids, blood)

Hypovolemic

Distributive

• _____, but there is _____

• Ex. Anaphylaxis and Sepsis

• General Treatment: _____

heart pumps well, peripheral vasodilation, anaphylaxis and sepsis, IV fluids then vasopressors

_____

• Heart pumps well, but there is peripheral vasodilation

• Ex. Anaphylaxis and Sepsis

• General Treatment: IV fluids, THEN Vasopressors

Distributive

Which accurately describes shock due to massive blood loss after a trauma?

1. Cardiogenic

2. Obstructive

3. Hypovolemic

4. Distributive

3

_____

• IV administration as IV push or titratable infusion

• α1, β1, β2 agonist

• Physiologic effects:

  • Vasoconstriction

  • Increased inotropic / chronotrophic activity

• Most common vasopressor used in life-threatening situations (cardiac arrest, pt is dead)

  • Usually 3rd or 4th line vasopressor in shock

EPI

Epinephrine 

• _____ administration as _____ or titratable _____

• _____

• Physiologic effects:

  • _____

  • _____ activity

• Most common _____ used in _____ (_____, _____)

  • Usually 3rd or 4th line vasopressor in shock

IV, IV push, infusion, alpha-1, beta-1, and beta-2 agonist, vasoconstriction, increased inotropic and chronotropic, vasopressor, life-threatening situations, cardiac arrest, pt is dead

_____

• IV administration as a titratable infusion

• Primarily α1 agonist, secondarily

• β1 agonist

• Physiologic effects:

  • Vasoconstriction

  • Increased inotropic / chronotrophic activity

• Preferred vasopressor in sepsis

  • Most common vasopressor in ICU

NE (Levophed)

NE (Levophed)

• _____ administration as a titratable _____

• _____

• Physiologic effects:

  • _____

  • _____ activity

• Preferred _____ in _____

  • Most common vasopressor in _____

IV, infusion, primarily alpha-1 agonist, secondarily beta-1 agonist, vasoconstriction, increased inotropic and chronotropic, vasopressor, sepsis, ICU

_____

• IV administration as a titratable infusion

• D, β1, α1 agonist (depends on dosing!)

• Physiologic effects:

  • Increased renal blood flow (low dose)

  • Increased inotropic / chronotrophic activity (medium dose, for bradycardia)

  • Vasoconstriction (high dose)

• Primarily used for cardiogenic shock in ICU

DA

DA

• _____ administration as a titratable _____

• _____

• Physiologic effects:

  • _____ (_____ dose)

  • _____ activity (_____ dose, for _____)

  • _____ (_____ dose)

• Primarily used for _____

IV, infusion, DA, beta-1, and alpha-1 agonist (depends on dosing), increased renal blood flow, low, increased inotropic and chronotropic, medium, bradycardia, vasoconstriction, high, cardiogenic shock in ICU

_____

• Intravenous administration as a titratable infusion

  • Also could be used for diabetes insipidus

• Adjunctive agent to NE in sepsis (NOT as monotherapy)

• Not affected by acidosis

• Physiologic effects:

  • Vasoconstriction

Vasopressin

Vasopressin

• _____ administration as a titratable _____

  • Also could be used for _____ insipidus

• _____

• Not affected by _____

• Physiologic effects:

  • _____

IV, infusion, diabetes, adjunctive agent to NE in sepsis (NOT as monotherapy), acidosis, vasoconstriction

General Adverse Effects of Vasopressors

• _____

• _____

• _____, Especially _____ → _____

Arrhythmias, tachycardia, tissue ischemia, digit ischemia, long-term (ICU)

Which medication primarily increases BP by stimulating only α-receptors?

1. Norepinephrine

2. Phenylephrine

3. Epinephrine

4. Dopamine

2

EE is a 56 year old male who presents with fever, persistent vomiting, and abdominal pain. A CT scan reveals an infected abdominal abscess.

• PMH: none

• Vitals: BP 80/56 mm Hg, HR 100 bpm, MAP 64 mm Hg, Temp 102

What findings determine that EE is in shock? What type of shock is it?

SBP is <90 and Distributive shock (sepsis)

EE is a 56 year old male who presents with fever, persistent vomiting, and abdominal pain. A CT scan reveals an infected abdominal abscess.

• PMH: none

• Vitals: BP 80/56 mm Hg, HR 100 bpm, MAP 64 mm Hg, Temp 102

If this initial management is not effective, what should be started next?

Vasopressors (NE is the vasopressor of choice in sepsis)

EE is a 56 year old male who presents with fever, persistent vomiting, and abdominal pain. A CT scan reveals an infected abdominal abscess.

• PMH: none

• Vitals: BP 80/56 mm Hg, HR 100 bpm, MAP 64 mm Hg, Temp 102

What is the initial management for shock in EE?

IV Fluids