VALVULAR

DISEASE
 PRINCIPLES

PATH OF LEAST RESISTANCE VOLUME VS PRESSURE HEART NEEDS BLOOD MORE WORK MORE FOOD

fluid flows due to

volume expands and coronaries fill in working heart needs
difference in pressure
weakens muscle diastole more oxygen

fluid flows down least

pressure grows and coronaries enter the
resistance
strenghtens muscle muscle
high to low pressure
 Oxygen delivery
O2 in
CO x blood

SV x HR Hb x SaO2

PRELOAD AFTERLOAD

CONTRACTILITY
 Blood pressure

CO

SV x HR

PRELOAD AFTERLOAD

CONTRACTILITY
 Blood pressure

arrhytmias - SVT/AF/brady/VT....
CO
atropine/glyco
isoprenaline
norad/ adrenaline
pain / agitation

SV x HR

PRELOAD AFTERLOAD

CONTRACTILITY
 Blood pressure

arrhytmias - SVT/AF/brady/VT....
CO
atropine/glyco
isoprenaline
norad/ adrenaline
pain / agitation

SV x HR

FLUID STATUS
IVT, meds
blood products PRELOAD AFTERLOAD
urine output
venodilation
insensible loss CONTRACTILITY
diarrhoea

REGURGITATION
 Blood pressure

arrhytmias - SVT/AF/brady/VT....
CO
atropine/glyco
isoprenaline
norad/ adrenaline
pain / agitation

SV x HR

FLUID STATUS
IVT, meds
blood products PRELOAD AFTERLOAD
urine output
venodilation
insensible loss CONTRACTILITY
diarrhoea
HF
REGURGITATION hypertrophy / dilataton
milrinone / dobutamine / dopamine
Ca
 Blood pressure

arrhytmias - SVT/AF/brady/VT....
CO
atropine/glyco
isoprenaline
norad/ adrenaline
pain / agitation

SV x HR

FLUID STATUS
IVT, meds SVR / PVR
blood products PRELOAD AFTERLOAD metaraminol
urine output norad / argi / adrenaline
venodilation IABP
insensible loss CONTRACTILITY
diarrhoea STENOSIS
HF
REGURGITATION hypertrophy / dilataton
milrinone / dobutamine / dopamine
Ca
Aortic stenosis

Aortic regurgitation

Mitral stenosis

Mitral regurgitation
 Aortic stenosis
old age

congenital - bicuspid valve

rheumatic fever

systolic murmur
2nd R intercostal radiating to
neck
 Aortic stenosis
CO
arrhytmias - SVT/AF/brady/VT....
FLUID STATUS atropine/glyco
IVT, meds isoprenaline
blood products
norad/ adrenaline
urine output
venodilation pain / agitation
insensible loss
diarrhoea
SV x HR

REGURGITATION
SVR / PVR
metaraminol
PRELOAD AFTERLOAD norad / argi / adrenaline
IABP

CONTRACTILITY STENOSIS

HF
hypertrophy / dilataton
milrinone / dobutamine / dopamine
Ca
Aortic stenosis
 Aortic stenosis
PRE- OP POST OP

HYPERTOPHIC HEART HYPERTOPHIC HEART

non-compliant non-compliant
difficult to relax/fill difficult to relax/fill
ischemia ischemia
often hypertensive
FIXED CARDIAC OUTPUT
work against high pressure NO LONGER WORKING AGAINST
cannot increase SV HIGH PRESSURE
needs volume ++++ to maintain
HEMODYNAMIC GOALS CO
SINUS RHYTM -atrial kick 40%
MAINTAIN CONTRACTILITY
OPTIMISE CORONARY FILLING
SLOW HR
MAINTAIN AFTERLOAD
 Aortic regurgitation
Dilatation of aortic root
connective tissue disorders
syphillis

Acute
aortic dissection
endocarditis

diastolic murmur
2nd R intercostal
 Aortic regurgitation
CO
arrhytmias - SVT/AF/brady/VT....
FLUID STATUS atropine/glyco
IVT, meds isoprenaline
blood products
norad/ adrenaline
urine output
venodilation pain / agitation
insensible loss
diarrhoea
SV x HR

REGURGITATION
SVR / PVR
metaraminol
PRELOAD AFTERLOAD norad / argi / adrenaline
IABP

CONTRACTILITY STENOSIS

HF
hypertrophy / dilataton
milrinone / dobutamine / dopamine
Ca
Aortic regurgitation
 Aortic regurgitation
PRE- OP POST OP

DILATED HEART DILATED HEART

poor contractility poor contractility
low diastolic pressures INOTROPES OFTEN
high systolic pressures improved diastolic pressures

HYPERDYNAMIC NO LONGER EXTRA VOLUME

NO IABP!! need euvolemia

HEMODYNAMIC GOALS
LIMIT REGURGITATION
HIGHER HR limits filling time
LOWER SVR promotes forward flow
MAINTAIN CONTRACTILITY
NORMOVOLEMIA
 Mitral stenosis

rheumatic fever

usually well tolerated due to

compliant L atrium
pregnancy and AF -> decomp

dyspnoea, LRTI, SOBoE

AF
 Mitral stenosis
CO
arrhytmias - SVT/AF/brady/VT....
FLUID STATUS atropine/glyco
IVT, meds isoprenaline
blood products
norad/ adrenaline
urine output
venodilation pain / agitation
insensible loss
diarrhoea
SV x HR

REGURGITATION
SVR / PVR
metaraminol
PRELOAD AFTERLOAD norad / argi / adrenaline
IABP

CONTRACTILITY STENOSIS

HF
hypertrophy / dilataton
milrinone / dobutamine / dopamine
Ca
Mitral stenosis
 Mitral stenosis
PRE- OP
POST OP

HYPERTOPHIC LA and RV
small LV HYPERTOPHIC LA and RV
HIGH PULMONARY PRESSURES inotropes if HF
viagra small LV but usually good function

HEMODYNAMIC GOALS PULMONARY PRESSURES

SINUS RHYTM (often AF) hopefully reduced
MAINTAIN CONTRACTILITY caution with fluids immediately
HIGHER AFTERLOAD (coronary filling) post op
SLOW HR
AVOID increasing PA pressures prone to arrhythmias
sympathetic stim. -> more backflow -> oedema
hypoxia, hypercarbia, acidosis, lung
hyperexpansion, nitorus oxide
caution with fluids

afterload reduction does not promote forward flow

 Mitral regurgitation
leaflet, chordal or papillary
muscle abnormalities
secondary to left ventricular
dysfunction

ACUTE
 Mitral regurgitation
CO
arrhytmias - SVT/AF/brady/VT....
FLUID STATUS atropine/glyco
IVT, meds isoprenaline
blood products
norad/ adrenaline
urine output
venodilation pain / agitation
insensible loss
diarrhoea
SV x HR

REGURGITATION
SVR / PVR
metaraminol
PRELOAD AFTERLOAD norad / argi / adrenaline
IABP

CONTRACTILITY STENOSIS

HF
hypertrophy / dilataton
milrinone / dobutamine / dopamine
Ca
Mitral regurgitation
 Mitral regurgitation
PRE- OP POST OP

DILATED HEART DILATED HEART

poor L contractility poor contractility
high systolic pressures (high SV) INOTROPES OFTEN
falsely high EF
AF
NO LONGER EXTRA VOLUME
HEMODYNAMIC GOALS need euvolemia
High normal heart rate
• Adequate preload
• Low systemic vascular resistance
• Low pulmonary vascular resistance

LOW BP - inotropes + IVT, avoid norad

 SUMMARY

SLOW
STENOSIS Sort of full
SQUEEZE

FAST
REGURGITATION FULL
FORWARD FLOW
 SUMMARY

HR
SLOW
STENOSIS Sort of full PRELOAD
SQUEEZE
AFTERLOAD

FAST HR

REGURGITATION FULL PRELOAD

FORWARD FLOW
AFTERLOAD
CONTRACTILITY