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Cardiac disease Part II

Nicole Weiss, MD Tulane University, December 13, 2012. Cardiac disease Part II. Time Crunch…. Valvular Heart Disease Hypertrophic Cardiomyopathy The Transplanted Heart Congenital Heart Disease Simple Shunts Complex Shunts Antibiotic Prophylaxis Pacemaker Classification.

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Cardiac disease Part II

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  1. Nicole Weiss, MD Tulane University, December 13, 2012 Cardiac disease Part II

  2. Time Crunch… • Valvular Heart Disease • Hypertrophic Cardiomyopathy • The Transplanted Heart • Congenital Heart Disease • Simple Shunts • Complex Shunts • Antibiotic Prophylaxis • Pacemaker Classification

  3. New York Classification of Functional Heart Disease Class I: Asymptomatic except during Severe Exertion Class II: Symptomatic with Moderate Activity Class III: Symptomatic with Minimal Activity Class IV: Symptomatic at Rest

  4. Valvular Disease

  5. Mitral Stenosis • Most common etiology is rheumatic disease • Symptoms develop 20-30 years later when mitral valve area decreases from 4-6 cm2 to less than 2cm2 • Prone to Pulmonary Hypertension & Pulmonary Edema as Left Atrial Pressures Increase

  6. Anesthetic Goals for Mitral Stenosis • Pulmonary Artery Catheter? • Yes, pulmonary artery pressures help guide fluid management • Patients are prone to volume overload and pulmonary edema • SVR? • High, flow through the stenotic valve is limited and the heart cannot compensate for decreases in preload • Heart Rate? • Normal Sinus Rhythm, Filling is dependent on atrial kick, but too low and the cardiac output may not be sufficient • Supraventricular Tachycardia may cause sudden hemodynamic collapse

  7. Clinical Correlations • Ephedrine or Phenylephrine? • Phenylephrine • Ketamine? • Bad • Pancuronium? • Bad • Neuraxial Anesthesia? • Spinal probably not the best choice • Epidurals give us time to stabilize the hemodynamics

  8. Aortic Stenosis • Critical Valve Area: 0.5-0.7 cm2 • Similar management to MS • Management Goals: • Normal Intravascular Volume • High SVR • Normal Sinus Heart Rate (60-90) • Cardiac Output does not increase with exertion • Myocardial Oxygen Demand High (Hypertrophied Ventricle)

  9. Aortic & Mitral Regurgitation • Management Goals: • Fast Heart Rate (80-100) • Decreased Afterload to Promote Forward Flow • Mitral Regurgitation Pulmonary Artery Waveform: • Large V Wave, Rapid Y Descent

  10. A 70 y/o male with severe aortic stenosis has a preinduction HR of 63 and BP of 125/70. Following induction, his HR is 90 and BP is 85/45. The EKG has a new ST Elevation. Drug of Choice? • Epinephrine • Isoproterenol • Calcium Chloride • Phenylephrine • Ephedrine

  11. Pulse Variations • Bisferiens Pulse • Characteristic of Aortic Regurgitation • First Systolic Peak=LV Ejection • Second Systolic Peak= Reflected Pressure Wave in the Periphery • Pulses Tardus et Parvus • Characteristic of AorticStenosis • Delayed Pulse Wave with a Diminished Upstroke

  12. Hypertrophic Cardiomyopathy

  13. Hypertrophic Cardiomyopathy • Diastolic Dysfunction • Dynamic Obstruction of the LV Outflow Tract (25% of patients) • Caused by Narrowing in the Subaortic Area by Systolic Anterior Motion (SAM) of the Anterior Mitral Valve Leaflet Against the Hypertrophied Septum • Supraventricular & Ventricular Arrhythmias

  14. Anesthetic Management • Factors that Worsen Obstruction: • Enhanced Contractility • Decreased Ventricular Volume • Decreased LV Afterload • B-Blockers & Ca-Channel Blockers • Amiodarone for Arrhythmias • Ideal Anesthetic: Halothane • Decreases Myocardial Contractility • Maintains SVR • Avoid: Nitrates, Digoxin, Diuretics

  15. The Transplanted Heart

  16. The Transplanted Heart • Denervated • No sympathetic or parasympathetic input • Resting Heart Rate 100-120 (no vagal) • Responsive to catecholamines • Low cardiac output, slow to pick up • EKG shows two P waves

  17. Pharmacology • Direct agents are the best: • Epinephrine & Isoproterenol • Indirect vasopressors also work, but are dependent on catecholamine stores • Heart rate is NOT affected by: • Anticholinergics • Pancuronium • Meperidine • Opiods • Cholinesterase Inhibitors

  18. A patient has a heart rate of 110 after heart transplant. The most likely etiology is: • Altered Barorecepter Sensitivity • Cardiac Denervation • Compensation for a fixed Stroke Volume • Cyclosporine • Prednisone

  19. Left to Right (Simple) Shunts

  20. Qp : Qs= (CaO2-CvO2)/(CpvO2-CpaO2) • Ratios < 1 • Right->Left • Ratios >1 • Left->Right • Ratios = 1 • No Shunting or Bidirectional Shunts of Equal Magnitude

  21. Factors Altering Shunts • SVR • Increase: • Phenylephrine, Norepinephrine, Ketamine • Decrease: • Propofol, Inhaled Agents (Iso, Sevo, Des), Dexmetomidine • Nitroprusside, Nitroglycerin, Nicardipine, Milrinone, Fenoldopam, Adenosine • PVR • Increase: • Hypercapnea, Acidosis, Hypoxemia, Positive Pressure Ventilation, Hypothermia, Reactions to the ETT

  22. Shunts & Induction of Anesthesia • R->L Shunt • Longer Inhalation Induction • Shorter IV Induction • L->R Shunt • Shorter Inhalation Induction • Longer IV Induction

  23. Compared with a normal patient, which of the following is true in a patient with a right->left intracardiac shunt? (More than one answer) • Inhalation Induction is slowed • Induction rate for halothane is affected more than the induction rate for nitrous oxide • IV induction is more rapid • Increased doses of IV agents are required

  24. AtrialSeptal Defects • OstiumSecundum • Most Common • Area of FossaOvalis • Usually Isolated Defects • Usually Asymptomatic • Ostium Primus & Sinus Venosus • Associated with Other Cardiac Defects • Large OstiumPrimum can cause a Large Shunt and Mitral Regurgitation • AtrioventricularSeptal Defects • Endocardial Cushion Defects • Contiguous Atrial & Ventricular Defects • Associated with Downs • Large Shunts

  25. Ventricular Septal Defects • Most common congenital defect • Small VSDs often close during childhood • Restrictive are associated with small L->R • Large defects produce large L->R shunts that vary with SVR and PVR • Large VSDs are surgically repaired before pulmonary disease and Eisenmenger develop

  26. Patent DuctusArteriosus • Closes within 15 hrs • Factors that Keep Open: • High Prostaglandins • Hypoxemia • Nitric Oxide • Factors that Close • Low Prostaglandins • High Oxygen • Endothelin-1 • Norepinephrine • Ach • Left Untreated-> Eisenmenger

  27. Right to Left (Complex) Shunts

  28. Tetralogy of Fallot RV Obstruction (Infundibular Spasm) RVH VSD Overriding Aorta 20% have PulmonicStenosis

  29. Management of Tetralogy • Two components of Shunt (R->L) • Fixed (Obstruction of the Outflow Tract) • Dynamic (PVR: SVR or Qp:Qs) • Decrease the Shunt • Propranolol • Propranolol decreases infundibular spasm • SVR • Keep SVR high!

  30. Tetralogy of Fallot… • Four Parts? • RV Outflow Obstruction, RVH, Overriding Aorta, VSD • Ketamine? • Maintains SVR • Propranolol? • Decreases Infundibular Spasm • Prostaglandin E1? • Keeps PDA open • Augments Pulmonary Blood Flow in the case of Right Ventricular Obstruction

  31. Tricuspid Atresia • Small RV • Large LV • Limited Pulmonary Blood Flow • Arterial Hypoxemia • ASD: Mixes oxygenated with deoxygenated, Ejects through LV • Pulmonary Blood Flow is via a VSD, PDA, or Bronchial Vessels

  32. Fontan Procedure Anastamosis of the Right Atrial Appendage to the Pulmonary Artery Used to correct decreased pulmonary Artery blood flow or for patients with a single ventricle • After CPB: • Maintain increased right atrial pressures to • Facilitates pulmonary blood flow • Patients with a Fontan: • Monitor CVP (which equals the PAP ) • Follow intravascular fluid volume, pulmonary pressures and detect LV impairment

  33. Transposition of the Great Arteries • Parallel Systems • Treatment: • Prostaglandin E • Balloon AtrialSeptoplasty • Decrease PVR, Increase SVR

  34. Hypoplastic Left Heart • LV Hypoplasia • MV Hypoplasia • AV Atresia • Aortic Hypoplasia • Prone to Ventricular Arrhythmias • Increased Pulmonary Blood Flow-> Systemic & Myocardial Ischemia • Delicate Balance Between PVR & SVR

  35. TruncusArteriosus • Increased Pulmonary Blood Flow-> • Myocardial Ischemia • Management: • Phenylephrine & Fluids • PEEP

  36. Anastamosis of the right atrium to the pulmonary arter (Fontan procedure is useful surgical treatment for each of the following except: • Tricuspid Atresia • Hypoplastic Left Heart Syndrome • Pulmonary Valve Stenosis • TruncusArteriosus • Pulmonary Artery Atresia

  37. Appropriate therapy for “tet spells” include (may be more than one): • 1. Propranolol • 2. Dobutamine • 3. Phenylephrine • 4. Ephedrine

  38. Antibiotic Prophylaxis • High Risk: • Previous Infective Endocarditis • Prosthetic Valves • CHD (some) • Transplants • Procedure Type • None for GI/GU • Bronchoscopy- depends • Dental Procedures- depends

  39. Pacemaker Codes • Chamber Paced • OAVD • Chamber Sensed • OAVD • Response to Sensing • OTID

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