Definition

1. Definition Hypertrophic cardiomyopathy (HCM) is a rare, genetic myocardial abnormality, defined by the presence of a hypertrophied, non dilatedleft ventricle in the absence of other known causes www.anaesthesia.co.in anaesthesia.co.in@gmail.com

2. Normal heart HCM heart

3. Hypertrophic cardiomyopathyWHO Report 1995 • Idiopathic hypertropic sub aortic stenosis • Hypertropic obstructive cardiomyopathy • Asymmetric septal hypertrophy

6. Factors increasing LVOT obstruction

7. Factors reducing LVOT obstruction

8. Demography • Prevalence – 0.2 % • Male = female • All age groups, young adults • Variable presentation Morphology Functional status

9. Symptomatology • Asymptomatic • Dyspnoea – pulmonary congestion • Chest pain _ high O2 demand • Palpitation – tachyarrhythmia • Syncope – near death situation • Sudden death - VF

10. Physical signs • Pulsus bisferiens • Loud s4 • Loud systolic murmur Increases with valsalva Decreases with squatting

11. Diagnosis • ECG - LVH, septal Q wave & arrhythmias • CXR – unimpressive • Doppler ECHO

12. Diagnosis • ECHO - ASH (septal & free wall thickness ratio), early Aortic valve closure & delayed diastolic filling • ECHO features help in quantifying severity LV – Aorta flow gradient Septal wall thickness Systolic ant wall motion of MV & MR Degree of diastolic dysfunction

13. Treatment • Medical – β blockers Verapamil Amiodarone • Surgical - Septal myomectomy • Non surgical – Alcohol septal ablation Dual chamber pacing ICD

14. Anesthesiologist & HCM • Cardiac & noncardiac surgery • Peripartum management • Post op ICU care

15. Premedication • Sedation & anxiolysis is desirable BZD – good choice • Anticholinergics • Preop i.v fluid supplementation • IE prophylaxis ?? JAMA 1997 Circulation 2007

16. Induction • Invasive monitoring: IBP, CVP, PCWP & TEE • Preloading • I.V induction Avoid sudden decrease in SVR • Minimize intubation response Volatile agents and beta antagonist Brief laryngoscopy

17. Maintenance • Volatile anesthetic based Halothane vs other agents Volatile anesthetics & junctional rhythm • Opioid based, not a likely choice • NDMR Pancuronium & atracurium

18. Management of hypotension • Monitor loading condition • I.V fluid boluses • Αlfa adr. agonist • Avoid beta adr. agonist • Maintain normal sinus rhythm

19. Management of hypertension • Increase delivery of volatile anesthetics • Avoid systemic vasodilators • Beta antagonist

20. HCM & pulmonary edema • Monitor loading condition • Careful fluid bolus • Alfa agonist • Avoid morphine, diuretics*, prop up, NTG

21. Parturient & HCM • Pregnancy induced physiological changes Increased preload vs decreased SVR • Labour associated alterations Increase in circulating catecholamines Aortocaval compression Valsalva during second stage

22. Labour analgesia • Initial hesitancy to use spinal analgesia - Loubser et al Anesthesiology 1984; 60: 228 • Single shot intrathecal morphine - Abboud et al Br J Anaesth 1984; 56: 1351 • Epidural analgesia with low conc. LA + opioid - Autore et al Anesthesiology 1999; 90: 1205

23. Management of caesarean section • Spinal not advocated • Epidural anesthesia safe but with caution • General anesthesia hemodynamic goal applies as to general population • Oxytocin

24. Cardiac Risk of Non cardiac Surgery in Patients with HCM • Positive predictors for cardiac events Length of surgical time Major surgery Intensity of monitoring • Non predictors Age Degree of LVOTO Prior MI Severity of MR Type of anesthesia Septal thickness Haering JM Anesthesiology: 85: 1996

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