Valvular Disease and Ventricular Function

Medical Pharmacology Chapter 43: Adult Cardiac Procedures

Valvular Disease and Ventricular Function Analysis

Echocardiography is useful in detecting
- Valvular dysfunction
- Ventricular dilatation/hypertrophy
- Ventricular dysfunction -- wall motion anomalies; abnormally low ejection fraction

Large tricuspid valve vegetation (left); Left Atrial Myxoma (right)

Large Left Ventricular Thrombus
- "Very large LV thrombus. Initially visible in the parasternal axes.
- In the apical four chamber it occupies a substantial portion of the LV apex and when the transducer is angulated more inferior the enormous size of the thrombus is evident"
- Courtesy of University of Chicago Echocardiography Laboratory

Radionuclide Angiocardiography
- Pulmonary vascular anomalies, such as pulmonary emboli
- Rationale for imaging to detect pulmonary emboli
- Pulmonary emboli common (25-50,000 deaths per year; 25 percent autopsy incidence)
- Most reliable signs: sudden dyspnea/hypoxemia [less reliable signs: sub-sternal pressure; hemoptysis; pleuritic pain]
- Pulmonary emboli: maybe lethal, but treatable
- Imaging techniques confirm clinical sign and screen high-risk patients
- Diagnostic methodology:
- Nuclear medicine (isotope tagging) Ventilation/Perfusion Scan (V/Q)
- Based on IV injection of isotope-tagged microspheres, which "embolize" an insignificant number of capillaries-- as a result "MAP PERFUSION"
- Ventilation images are obtained by patient inhalation of radioactive Xe 133
- Ventilation images and perfusion images are then compared
  - Normal pulmonary ventilation Corresponding abnormal perfusion image
    - The presence of several large focal perfusion defects not managed by ventilation defects indicates a high probability of pulmonary embolism.
      - Images courtesy of Creighton University School of Medicine, Special Pulmonary Imaging

Electron Beam Tomography
- Electron beam capture tomography and visualization of pulmonary emboli (yellow arrows); images courtesy of Dr. Patrick Sheedy, Mayo Clinic, MN
- - Electron Beam Tomography: Pulmonary Emboli (images courtesy of Imatron )

Primary Reference: Ross, AF, Gomez, MN. and Tinker, JH Anesthesia for Adult Cardiac Procedures in Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds) Mosby, St. Louis, Mo., pp. 1659-1698, 1998.
Primary Reference: Shanewise, JS and Hug, Jr., CC, Anesthesia for Adult Cardiac Surgery, in Anesthesia, 5th edition, vol 2, (Miller, R.D, editor; consulting editors, Cucchiara, RF, Miller, Jr.,ED, Reves, JG, Roizen, MF and Savarese, JJ) Churchill Livingston, a Division of Harcourt Brace & Company, Philadelphia, pp. 1753-1799, 2000.

Primary Reference: Wray Roth, DL, Rothstein, P and Thomas, SJ Anesthesia for Cardiac Surgery, in Clinical Anesthesia, third edition (Barash, PG, Cullen, BF, Stoelting, R.K, eds), Lippincott-Raven Publishers, Philadelphia, pp. 835-865, 1997.

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