Download Assessment of Cardiac Function * Am I that Different?

Assessment of Cardiac Function
Am I that Different?
Disty Pearson, PA-C
Boston Adult Congenital Heart and Pulmonary
Hypertension Service
Boston Children’s Hospital
CHD Patients Reaching Adulthood
Pediatric patients
Adult patients
30
50
50
40
60
70
1965
1985
2005
Williams et al. J Am Coll Cardiol 2006
ACHD: Increased Hospitalizations
• Average age 52.3 -53.8 years
• 2x ↑ in ACHD hospitalizations
• ↑ complexity  ↑ comorbidities
• ↑ comorbidities  ↑ costs
Opotowsky AR et al. J Am Coll Cardiol 2
Age at Time of Death
Khairy et al JACC 9-28-2010
Adult in the CICU?
ACHD Surgery: PHIS 20022008
n = 3061 cases
39 free-standing pediatric institutions
is the strongest predictor of postop survival
Average annual ACHD surgical volume 2000-2008
Surgeries/year
80
60
40
20
0
1
Pediatric centers
Kim Y et al Circulation 2011
ACHD: Causes of Death
Verheugt CL et al. Eur Heart Journal 2010
Coronary Disease In ACHD
• CHD specific
–
–
–
–
Anomalous coronaries
Compression of coronaries
Supply/demand imbalance
Surgical stenosis at re-implantation sites (ASO,
Ross, Bentall)
• Cardiovascular risk factors
– DM, HTN, obesity, cholesterol, smoking
coarctation
• Aging population over 60
Evaluation
• High index of suspicion
– EKG
• where the abnormal is normal
• Changes from baseline?
– Biomarkers (critical eye)
– Change in hemodynamics
– Rhythm change
Evaluation
• Echo – new wall motion abnormalities
• Ischemia testing w imaging – if time
allows
• Nuclear, MRI, Echo, cardiac CT
• Delayed enhancement – hibernating
myocardium
• Catheterization – diagnostic &
intervention
Normal EKG
Inferior Myocardial Infarction
Coronary Compression
John J Ryan et al Department of Medicine, Section of Cardiology and Department of
Pathology, University of Chicago,
Heart Failure in ACHD
Heart Failure in ACHD
• Right heart failure
• Left heart failure HFREF (reduced EF)
– 20% of TOF LV systolic dysfunction (Ghai 2002)
– Systolic dysfunction in TOF predictor of mortality
(Broberg 2011)
– scars, myocardial protection, dysynchrony (BBB,
PPM) obstructive lesions, LV noncompaction
• Diastolic dysfunction HFPEF (preserved EF)
– Can affect both the right and the left ventricle
Probability of Heart Failure by
Age and Dx
Norozi
American Journal of Cardiology 2006 97, 1238-1243DOI: (10.1016/j.amjcard.2005.10.065)
Copyright © 2006 Elsevier Inc.
Diastolic Dysfunction
• The inability of the LV to adequately fill at
low or normal atrial pressures associated
with abnormalities of diastolic
distensability, filling, or relaxation of the
LV
Gaasch & Zile 2004
Diastolic Dysfunction
• Risk factors for DD
–
–
–
–
–
–
–
Increased age
HTN
Obesity
Diabetes
Dyslipidemia
Linked to atrial and ventricular arrhythmias
Renal failure
Pearson
Pressure-Volume Loop
Alsaddique etal 2009
Lacalzada et al; Evaluation of Left Ventricular Diastolic Function by Echocardiography
Diastolic Dysfunction
• Exacerbated by
–
–
–
–
–
–
Tachycardia (less diastolic filling time)
Reduced LV volume
Inotropes - causing tachycardia
High PEEP
Obesity
Compression (effusions, other ventricle)
Evaluative Tools
• Biomarkers
• Direct measurement
of pressures
– RA, LA (PCWP)
– Swan Ganz catheters
– Continuous cardiac
output (CCO)
• Echocardiogram
• Cardiac CT, MRI
Pearl
ASD
ASD with Aging
Shunt
increases
RV progressive
dilation/dysfunction
Right sided failure
LAp increases
LVedp increases
ASD with Aging
•
Closure
–
–
–
–
LA pressure increases
PCW increases
PAp increases
Further worsening left heart diastolic dysfunction and right
heart systolic dysfunction
– Arrhythmia
• Pre-closure
–
–
–
–
Treat systemic HTN
Targeted vasodilator therapy
Fenestrated closure
BMI optimization
Baggage
Comorbidities
• Neurologic ICU concerns
– Stroke
– Metabolic derangement
– Decrease metabolism of narcotics/anesthetics
• Psychiatric
– >30% of adults w CHD meet diagnostic criteria for a
psychiatric diagnosis
– Kovacs A et al. Int J Cardiol 2009, Zomer A et al. Am J Cardiol 2013)
– Aspects of treatment experienced as repeated
trauma
– Rourke Pediatric Oncology Nursing, Stuber Pediatrics
– Syndromes (22q11.2 deletion…..)
Comorbidities
• Hepatic function
– Hep C, congestion, fibrosis
Wu Cong Heart Disease 2011
• Chronic hypoxemia and secondary
erythrocytosis
– Impaired immune function
– Infectious issues
• Impaired renal function
Diller GP et al. J Am Coll Cardiol 2011
CoMorbidities
• Pulmonary dysfunction
– Pectus, prior surgeries, diaphragmatic disease
– Restrictive/obstructive disease
– Need preoperative PFTs
• Venous insufficiency
Valente AM et al. J Am Coll Cardiol 2010
Take Home
• Growing adult population
• Increased incidence of
–
–
–
–
Arrhythmia
Heart failure
Coronary issues
Comorbidities with direct impact on ICU care
• Evaluation starts with a high index of
suspicion
Partner
• ACHD colleagues
– We love to help
• ACHD patients
– We must set an example to dediction to
• life long care
• Heart healthy habits
– Reasonable BMI
– Exercise
– Healthy diet
It Takes A Team
Boston Adult Congenital Heart Service 2013