Download Cardiomyopathy – anaesthetic challenges MGMC

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
Definition
• Cardiomyopathies are diseases of the heart muscle and
may present with cardiac dysfunction
• Classification
• Dilated
• Obstructive (HOCM)
• Restrictive
• 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%
Pathophysiology- systolic dysfunction
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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
Treatment
• sickle cell disease, muscular dystrophy, excess
alcohol, hypothyroidism, and some
chemotherapy agents
• Treat the cause if any
• Warfarin ??
• Along with cardio active drugs
Clinical features
• fatigue,hypotension
Forward failure
oliguria
• Pulmonary edema ,
Backward failure
orthopnea
LV / RV
• Ascitis ,Edema
• AV ring dilation and
regurgitation
• Arrhythmias, LBBB and
poor progression,
• ECHO
Treatment
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ACE inhibitors
ARBs
Diuretics
Other therapies include beta-blockers, spirono
lactone, digoxin, biventricular pacing, and
anticoagulants.
• Medical treatment –control of CCF - > 1 week.
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
anaesthesia is a choice
when
regional
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
Anaesthetic concerns
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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
• 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
Postoperative period
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Post operative HDU
Oxygenation
volume
RA to counter pain
Anti arrhythmic to continue
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.
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%.
What is PPCM ??
• Non ischemic dilated cardiomyopathy
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
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.
• Hypertrophic
cardiomyopathy
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
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
HOCM
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.
Morphine ,
atracurium
• Symptomatic patients
• Major surgery
• IBP, TEE included
Chamber size (DCM)
Vs
Wall thickness
(HOCM)
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.
Use vasopressors
than inotropes in
HOCM
• Restrictive
• cardiomyopathy
Restrictive cardiomyopathy
• Endomyocardial fibrosis
• Idiopathic
• Amyloidosis, sarcoidosis, haemachromatosis,
and eosinophilic endocarditis
What happens ??
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Diastolic dysfunction
Both LV and RV-- but RV more
Normal systolic function
No enlargement
Elevated pressures and backward failure
Goals
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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.
Cardiac grid
• We have to understand
the basic of ragaa and
tune our technique to
suit the disease and
surgery
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
Thank you all !!
Understand the principles