cardiomyopathy anaesthetic challenges dr. s. parthasarathy md., da., dnb, md (acu), dip. diab. dca,...
TRANSCRIPT
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Cardiomyopathy – anaesthetic challenges
Dr. S. Parthasarathy MD., DA., DNB, MD (Acu),
Dip. Diab. DCA, Dip. Software statistics, Phd (physio)
Mahatma Gandhi Medical college and research institute puducherry , India
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Definition
• Cardiomyopathies are diseases of the heart muscle and
may present with cardiac dysfunction
• Classification
• Dilated
• Obstructive (HOCM)
• Restrictive
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• Dilated cardiomyopathy (DCM) is defined by a large
heart cavity with impaired systolic function of one or
both ventricles.• (a). Fractional myocardial shortening < 25% and/or
ejection fraction < 45%; and • (b). left ventricular end diastolic diameter > 117%
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Pathophysiology- systolic dysfunction
• Global reduction in myocardial contractility• Decreased LV ejection fraction • LV dilates • Increased LVEDV • Frank starling law – better contraction • Compensation fails • LVF• Diastolic dysfunction is trivial
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Treatment
• sickle cell disease, muscular dystrophy, excess alcohol, hypothyroidism, and some chemotherapy agents
• Treat the cause if any• Warfarin ?? • Along with cardio active drugs
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Clinical features
• fatigue,hypotension oliguria
• Pulmonary edema , orthopnea
• Ascitis ,Edema
• AV ring dilation and regurgitation
• Arrhythmias, LBBB and poor progression,
• ECHO
Forward failure
Backward failure LV / RV
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Treatment
• ACE inhibitors • ARBs • Diuretics• Other therapies include beta-blockers, spirono
lactone, digoxin, biventricular pacing, and anticoagulants.
• Medical treatment –control of CCF - > 1 week.
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Anaesthetic concerns 1) Myocardial depression should be avoided
2) normovolemia should be maintained
3) Avoid overdose of drugs during induction as
circulation time is slow.
4) Ventricular after load is avoided
5) Avoid sudden hypotension when regional
anaesthesia is a choice
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Preoperative check up
• History and findings of CCF • Routine • ECHO – EF <25% , Regurgitant lesions- danger
signs • ACE inhibitors stop ?? • Electrolytes • Volume status , continue anti aryhthmics• Anxiolysis
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Anaesthetic concerns
• Volume ( spinal . 10 % fall is significant in DCM ) • Rhythm ( ECG monitoring and control) • Less inhalational agents – more narcotics • Ketamine , etomidate in ideal doses • CVP – OK ?? Only RV preload• TEE • PAC – worth but outcomes similar !! • Hemoglobin
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• Interest has been generated regarding use of xenon
in patients with DCM, because of its minimal effect
on heart rate, arterial and LV pressures, myocardial
contractility, and regional chamber stiffness
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Postoperative period
• Post operative HDU • Oxygenation • volume • RA to counter pain • Anti arrhythmic to continue
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Peripartum cardiomyopathy (PPCM)
• Peripartum cardiomyopathy (PPCM) has an incidence of 1 in
4000 live births, and has a quoted mortality of between
20% and 50%.
• PPCM usually presents post 36 weeks but may develop for
up to 5 months postpartum.
• It may recur in subsequent pregnancies;
• cardiology assessment should be performed prior to further
conceptions.
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PPCM ( PCM) It is a diagnosis of exclusion.
• an idiopathic cardiomyopathy presenting with heart
failure secondary to left ventricular systolic
dysfunction towards the end of pregnancy or in the
months following delivery, where no other cause of
heart failure is found.
• The left ventricle may not be dilated but the ejection
fraction is nearly always reduced below 45%.
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What is PPCM ??
• Non ischemic dilated cardiomyopathy
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How does it happen ??
• 1 in 3000 – 4000 births
• Auto antibodies against fetal cells – myocardium• abnormal cardiac response to hemodynamic
changes associated with pregnancy. • Proinflammatory cytokines • Coronary microangiopathy
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• Almost same symptoms • ACE inhibitors ?? • Amlodepine .diuretics, digoxin -- ok • LMWX – heparin OK • Levosimendan is used as an intravenous
infusion at the rate of 0.1–0.2 μg/kg/min in cardiac failure with or without a loading dose of 3–12 μg/kg over 10 minutes
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Anaesthetic technique • Controlled GA with RSI, diuretics after delivery,
avoidance of methergin • Fetal safety • CSEA • Spinal bupi fentanyl • -- beware of anticoagulation • Epidural volume extension technique – • 1 ml spinal bupi + epidural saline 10 ml.
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• Hypertrophic cardiomyopathy
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Hypertrophic cardiomyopathy
• Hypertrophic cardiomyopathy (HCM) is an autosomal dominant condition.
• unexplained left ventricular hypertrophy which may be concentric or asymmetrical, diffuse or focal.
• Syncope, failure , hypotension
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Hypertrophy of LV
Diastolic dysfunction and defective relaxation
Atrial kick needed
Increased LVEDP – CPP ?
Hypertrophied ventricle and more oxygen needed – ischemia
Increased contraction – LVOT obstruction – MR
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HOCM
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Anaesthetic concerns
• maintenance of sinus rhythm;• reduction in sympathetic activity to reduce
chronotropy and inotropy;• maintenance of left ventricular filling;• the maintenance of systemic vascular
resistance.
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Morphine , atracurium
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• Symptomatic patients
• Major surgery
• IBP, TEE included
Chamber size (DCM) Vs
Wall thickness (HOCM)
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Cardiac arrest in HCM
• The use of inotropic agents is contraindicated if the
arrest is thought to be due to LVOT obstruction as
this will only increase the obstruction.
• Alpha -Agonists, i.v. fluids, and rapid correction of
arrhythmias are more appropriate measures.
• The application of external defibrillator pads is
recommended before induction of anaesthesia.
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Use vasopressors than inotropes in HOCM
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• Restrictive• cardiomyopathy
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Restrictive cardiomyopathy
• Endomyocardial fibrosis • Idiopathic
• Amyloidosis, sarcoidosis, haemachromatosis, and eosinophilic endocarditis
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What happens ??
• Diastolic dysfunction • Both LV and RV-- but RV more • Normal systolic function • No enlargement• Elevated pressures and backward failure
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Goals
• to maintain adequate filling pressures;• sinus rhythm to be maintained if possible;• to manage electrolyte disturbances;• to maintain SVR in the presence of relatively
fixed cardiac output.
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Cardiac grid
• We have to understand
the basic of ragaa and
tune our technique to
suit the disease and
surgery
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Arrhythmogenic Right Ventricular Cardiomyopathy
• progressive fibro fatty replacement of RV
myocardium, initially with typical regional and later
global RV and some LV involvement, with relative
sparing of the septum.
• CHF and arrhythmia are the factors
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Thank you all !!
Understand the principles