Download Anesthesia for non-cardiac surgery in patients with heart failure

Anaesthesia for non-cardiac surgery
in patients with heart failure
Daniela Filipescu, MD, PhD, DEAA
Associate Professor of Anaesthesia & Intensive Care Medicine
Department of Cardiac Anaesthesia & Intensive Care Medicine II
Emergency Institute for Cardiovascular Diseases
Bucharest, Romania
CEEA Kosice 12014
Conflict of interest ?
EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
EuSOS Cohort
46539
Total2012;
Mortality
1682 (4%)
Lancet
380:1059-1065
19 million major
procedures in
Europe
42%of
complications and
death due to
cardiac
complications
Approx 319000
deaths caused by
perioperative
cardiac
complications
Heart failure - definition
• An abnormality of cardiac structure or
function leading to failure of the heart to
deliver oxygen at a rate commensurate with
the requirements of the metabolizing tissues,
despite normal filling pressures (or only at the
expense of increased filling pressures).
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Stages of heart failure (HF)
Valchanov KP & Arrowsmith JE. EJA 2012 29(3):121-128
HF - Epidemiology
√ 2% of the adult population experience HF in developed countries
√ 6-10% in those > 65 years
√ Chance of developing HF in a lifetime is 1 in 5 individuals
√ 25 % increase in HF prevalence by 2030
√ HF is seen in up to 10% of non-cardiac surgical patients
√ HF is noted 1 in 8 death certificates
√ 30-day mortality 10%
√ 1-year mortality 24-33%
√ 80% of the HF death occur in individuals aged > 65
Mebazaa A et al. Circulation 2014;130; 410-418
Maile MD et al. Anesth Analg 2014;119: 522-532
Beattie WS & Wijeysundera DN. Anesth Analg 2014;119: 506-508
Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145
HEART FAILURE
15,000,000
26,000,000
6,000,000
Perioperative outcome in HF patients
elective
emergency
urgent
Control
CAD
HF
Hernandez AF et al. JACC 2004;44:1446
Perioperative outcome
 38 000 patients
 1. patients with HF or AF are at substantially higher risk of
postoperative mortality than patients with CAD, and this risk is
higher than previously appreciated by perioperative cardiac risk
prediction models
 2. patients with HF undergoing routine minor surgical
procedures are not low risk (4% risk of mortality within 30 days
of purportedly minor outpatient surgical procedures, such as a
colonoscopies, bronchoscopies, and cystoscopies)
 3. mortality rates are particularly high for those patients
undergoing surgery within 4 weeks of an incident diagnosis of
HF or AF and further highlighted by the risk carried by a recent
HF rehospitalization on postoperative mortality.
Van Diepen S et al. Circulation 2011; 124:289-296
Perioperative outcome
Unadjusted 30-day perioperative mortality (blue), rehospitalization (red), and
cardiac rehospitalization (green).
van Diepen S et al. Circulation. 2011;124:289-296
Myocardial infarction, mortality and noncardiac
complications after noncardiac surgery in
preoperative HF patients
Maile MD et al. Anesth Analg 2014;119: 522-532
Myocardial infarction, mortality and noncardiac
complications after noncardiac surgery in
preoperative HF patients
Maile MD et al. Anesth Analg 2014;119: 522-532
Acute vs
chronic
Left-sided
vs rightsided
HF-PEF vs
HF-REF
Heart
failure
Systolic vs
diastolic
High CO
vs Low
CO
Preserved vs. reduced ejection fraction HF
Classification
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
Ejection
Fraction
≤40%
Description
Also referred to as systolic HF. Randomized clinical trials have mainly
enrolled patients with HFrEF and it is only in these patients that
efficacious therapies have been demonstrated to date.
≥50%
Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is challenging
because it is largely one of excluding other potential noncardiac
causes of symptoms suggestive of HF. To date, efficacious therapies
have not been identified.
a. HFpEF, Borderline
41% to 49%
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved
>40%
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
Left ventricular function and long-term
survival after vascular surgery
Flu W-I et al. Anesthesiology 2010; 112(6):1316-1324.
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Rapid change
in HF signs
and
symptoms
Pulmonary
and systemic
congestion
Urgent need
for therapy
Acute
heart
failure
Gheorghiade M, J Am Coll Cardiol 2009
Clinical scenarios in AHF syndrome
• CS 1.
Dyspnea and/or congestion with elevated SBP (>140mmHg)
• CS 2.
Dyspnea and/or congestion with normal SBP (100-140 mmHg)
• CS 3.
Dyspnea and/or congestion with low SBP (<100 mmHg)
• CS 4.
Dyspnea and/or congestion with signs of ACS
• CS 5.
Isolated right ventricular failure
Mebazza A, Gheoghiade M et al. Crit Care Med 2008;S129
Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573
Steps to preoperative evaluation
• Patient Risk Factors
Clinical predictors
Functional capacity
Revised Cardiac Risk Index
 4315 patients, > 50 years old
 Major elective noncardiac surgery
 Six independent risk factors






High risk surgery AAA, vascular,thoracic, abdominal, ortho
History ischemic heart disease
History CHF
History cerebrovascular disease
Preoperative insulin use
Preoperative serum Cr > 2.0 mg/dl
Lee, Circulation 1999
Revised Cardiac Risk Index
Revised cardiac risk index
Incidence of cardiac events
0 points
0.4%
1 point
0.9%
2 points
7%
≥3 points
11%
Lee, Circulation 1999
Development and Validation of a Risk Calculator for
Prediction of Cardiac Risk After Surgery Clinical Perspective
by Prateek K. Gupta, Himani Gupta, Abhishek Sundaram, Manu Kaushik, Xiang Fang, Weldon J.
Miller, Dennis J. Esterbrooks, Claire B. Hunter, Iraklis I. Pipinos, Jason M. Johanning, Thomas G.
Lynch, R. Armour Forse, Syed M. Mohiuddin, and Aryan N. Mooss
American College of Surgeons National Surgical Quality Improvement Program (NSQIP)
MICA model
Circulation 2011;124(4):381-387
Kristensen, SD et al.
European Journal of
Anaesthesiology 2014;
31(10):517-573
Functional capacity
Can you …
1 MET
Can you …
Can you …
4 MET
Can you …
Take care of yourself ? Eat, dress,
use the toilet ?
Climb 2 flights of stairs or walk
uphill
Walk indoors around the house ?
Run a short distance
Walk 100 m on level ground, at 35km/h
Do heavy work around the
house (scrubbing floors, lifting,
moving heavy furniture
Participating in strenuous
sports like tennis, swimming,
football, basketball, skiing?
>10 MET
4 MET
1 MET: the oxygen consumption (VO2) of a 70 kg, 40 y.o. man at rest…3.5 cc/kg/min
Steps to preoperative evaluation
1. Patient Risk Factors
2. Surgical Risk Factors
Surgical risk
Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573
Domi et al. International Archives of Medicine 2014
Steps to preoperative evaluation
1. Patient Risk Factors
2. Surgical Risk Factors
3. Preoperative Testing
Who & How
Heart failure
Kristensen, SD et al.
European Journal of
Anaesthesiology 2014;
31(10):517-573
Kristensen, SD et al.
European Journal of
Anaesthesiology 2014;
31(10):517-573
Natriuretic peptides
Preoperative NT-pro- BNP > 1740 pg/ml was associated with a 6.9-fold
univariate relative risk for in-hospital major cardiac events
Farzi S et al. Br J Anaesth 2013;110:554-560
Postoperative BNP& NT-pro- BNP are independently associated with
increased risk of mortality, myocardial infarction and cardiac failure at 30
days and more than 180 days after surgery
Postoperative natriuretic peptides measurement enhanced risk stratification
for the composite outcomes of death or nonfatal MI 30 days and at least
180 days after noncardiac surgery as compared with a preoperative
measurement alone
Rodseth RN et al. Anesthesiology 2013;119:270-283
Rodseth RN et al. J Am Coll Cardiol 2013
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Steps to preoperative evaluation
1. Patient Risk Factors
2. Surgical Risk Factors
3. Preoperative Testing
4. Perioperative Management
Risk reduction strategies
• In patients with newly discovered heart failure, if
possible, non-cardiac surgery should be postponed so it
can be performed under optimal medical therapy, in a
stable patient.
Heart failure
Kristensen, SD et al.
European Journal of
Anaesthesiology 2014;
31(10):517-573
Beta-blockers
Anti-platelet
drugs
Kristensen, SD et al.
European Journal of
Anaesthesiology
2014; 31(10):517573
1. Perioperative cardiovascular complications in these high-risk elderly all-comer
surgical patients with known cardiovascular disease are relatively rare, but once
they occur, the case fatality is high.
2. Perioperative bleeding complications are more frequent, but their case
fatality is extremely low.
3. Patterns of interruption of chronic aspirin therapy before major non-cardiac
surgery are not predictive for perioperative complications (neither
cardiovascular, nor bleeding).
4. Simple baseline clinical factors are better predictors of outcomes than
antithrombotic drug interruption patterns
Pay attention to your drugs!
Anesthesia and heart failure
Preoperative
evaluation
and
optimization
Adequate
monitoring
Volemic and
transfusion
strategies
Quality anesthesia
Standard monitoring
• 2/3 lead ECG (leads II and V5 are standard of
care but adding V4 gives best sensitivity for
ischemia)
• Pulse oximetry, capnography
• Invasive arterial pressure monitoring
• Right heart catheterization in selected cases
Kristensen, SD et al. European Journal of Anaesthesiology 2014; 31(10):517-573
Intraoperative hypotension
Bijker et al, Anesthesiology 2012
Complex monitoring- cardiac output
and volume responsiveness
Pulsecontour/transpulmonary
thermodilution
Transoesophageal
echocardiography
Pulmonary artery
catheter
Neuraxial anesthesia versus general anesthesia
Forest plots for mortality 0 to 30 days
Guay J et al. Anesthesia & Analgesia. 119(3):716-725, September 2014
Kristensen, SD et al.
European Journal of
Anaesthesiology
2014; 31(10):517573
Principles of anaesthetic management
Principles of anaesthetic management
Principles of anaesthetic management
Postoperative risk stratification
Surgical Apgar score
Surgical Apgar score
10
7
Adjusted complication
rate
3%
9.1%
<5
32.9%
Haynes AB et al, Surgery, 2011
Perioperative acute heart failure (AHF)
A significant diagnostic and therapeutic challenge
Clinical scenarios:
• Pulmonary oedema
• Left/right/biventricular congestive HF
•Cardiogenic shock
Clinical signs
Echocardiography
Plasma biomarkers
.
Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145
Perioperative HF triggers
Hypertension
Tachyarrhythmias
Anemia
Hyper-coagulability
Inapropiate fluid management
Pain
Surgical stress
Myocardial ischaemia
Acute valve diseases
Pulmonary emboli
Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Therapeutic approach of AHF
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Tacon CL et al. Intensive Care Med 2012;38:359-367
Effects of inotropic therapy
Groban L et al.Anesthesia & Analgesia. 103(3):557-575, September 2006.
Pharmacological effects of levosimendan
Enantiomer of {[4-(1,4,5,6-tetrahydro-4-methyl-6-oxo3-pyridazinyl)phenyl]hydrazono}propanedinitrile.
a) increased cardiac contractility mediated by calcium
sensitisation of troponin C
b) vasodilation through the opening of potassium channels
on the sarcolemma of smooth muscle cells in the
vasculature
c) cardioprotection through the opening of mitochondrial
potassium channels in the cardiomyocytes
Nieminen MS, et al. Heart, Lung and Vessels. 2013; 5(4): 227-245
Why is calcium sensitisation a better
approach?
Contraction
% cell shortening
Control
Other inotrope,
e.g. dobutamine
Levosimendan
15
0
Calcium transient
O2 demand
not increased
[Ca2+]i
0.35
O2 demand;
arrhythmias
0.20
500 ms
Lancaster M & Cook S. Eur J Pharmacol 1997:97
Effects of levosimendan on mortality and
hospitalization
A meta-analysis of
randomized controlled
studies
Data from 5,480 patients
in 45 clinical trials
(1999-2010)
Landoni G, et al. Crit Care Med
2012;40:634–646
Effects of levosimendan on mortality
Global
17.4 vs.23.3%
Cardiac surgery
5.8 vs. 12.9 %
Levosimendan in patients taking betablockers
1.5
Change in
cardiac output
+
1.0
-
p=0.01
0.5
0
0
Change in
PCWP
Patients on -blockers do not
have lessened levosimendan
effects, as is the case with
dobutamine.
Dobutamine
Although -blockers interfere
with the action of a -agonist
(dobutamine), there is no
such effect with
levosimendan because it acts
as a calcium sensitiser.
+
Levosimendan
-2
-4
•
-
p=0.03
•
-6
-8
Follath F et al. Lancet 2002:196
Invasive monitoring
Intra-arterial line
Insertion of an intra-arterial line should only be
considered in patients with persistent HF and a low
systolic blood pressure despite treatment.
Pulmonary artery catheterization
Right heart catheterization does not have a general
role in the management of AHF, but may help in the
treatment of a minority of selected patients with
acute (and chronic) HF
Pulmonary artery catheterization should only be
considered in patients:
(i) who are refractory to pharmacological
treatment;
(ii) who are persistently hypotensive;
(iii) in whom LV filling pressure is uncertain;
(iv) who are being considered for cardiac surgery.
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Mechanical support
Intra-aortic balloon pump
Percutaneous cadiopulmonary bypass system
Mechanical assist devices
Percuaneous assist devices
Intraaortic balloon support for myocardial
infarction with cardiogenic shock
IABP-SHOCK II trial
300 patients in the IABP group
298 in the control group
Mortality at 30 days: 39.7% vs. 41.3%
Thiele H et al. NEJM 2012;367:1287-96
Options for mechanical circulatory support
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Ultrafiltration
Conflicting evidence regarding efficacy
Can be done in the ward, on a
peripheral vein
Is reserved for refractory congestion
• Peristent pulmonary oedema
• Severe hyponatremia
• Resistance to diuretics
McMurray JJV et al. European Heart Journal 2012;33:1787-1847
Bart B. N Engl J Med 2012
Approach to perioperative heart failure
Develop differential diagnosis for cause, treat repairable lesions.
Initiate resuscitation measures: maximize oxygenation/ventilation, control
postoperative pain/tachycardia, correct acid-base and electrolyte abnormalities.
Evaluate and optimize preload, afterload, contractility, heart rate and rythm
• Preload- volume load vs. diuresis based on evaluation of volume status
• Afterload- if high, consider dilation with nytroglicerine, sodium nitroprusside; if low consider
augmentation with norepinephrine
• Contractility - use inotropic agents
• Establish stable heart rate and rhythm
Use mechanical assistance for patients refractory to above measures.
Soussi S et al. Curr Opin Anesthesiol 2014;27:140-145
Take home message
Management …