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Cardiac Assessment in the Operating Room Allison K. Cabalka, MD Associate Professor of Pediatrics Consultant, Pediatric Cardiology Mayo Clinic Objectives 1. Rhythm issues encountered in the operating room 2. Discuss the use of echocardiography in the OR Objectives 1. Rhythm issues encountered in the operating room 2. Discuss the use of echocardiography in the OR Rhythm Issues in the OR • Tachyarrhythmias – Supraventricular tachycardia (SVT) – Atrial flutter/fibrillation (AF/Fib) – VT/VF • Junctional Rhythm – Too fast OR too slow • Conduction abnormalities – Advanced 2° or 3° (complete) heart block Diagnosis: Monitor Strips • • • • Evaluate rate, regularity, rhythm Is every QRS preceded by a P wave? Narrow or wide complex? What is the rate compared to what you expect? Normal Sinus Rhythm • Look for a P wave in front of every QRS – But not so far in front that it is ‘behind’ • Change leads to be sure Junctional Ectopic Tachycardia • Common post-operative arrhythmia – Originates from AV node – Particularly in postop TOF/Fontan patient • Heart rates >150 beats per minute • Loss of AV synchrony – Look for AV dissociation • Slower P wave rate – Easy to diagnose with pacing wires postop Junctional Ectopic Tachycardia Junctional Ectopic Tachycardia • Treat with IV Amiodarone – Load 5-10 mg/kg IV – Drip infusion of total of 10 mg/kg/24 hrs • Alternative or complimentary – Cooling – Reduction of sympathetic stimulation (Epinephrine) – Correct Ca++ and Mg+ levels – Volume replacement AV Node Independent Re-Entry • Atrial fibrillation – Irregularly irregular – No organized atrial contractility – Easy to see on direct visualization or by TEE • Atrial flutter – Regular atrial rate, variable conduction – Also can be seen by TEE or visualization Diagnosis AV node independent re-entry Atrial flutter Complete AV Block • Common postop complication – 3.7-6% incidence of surgical postoperative complete AV block – Recognition of AV dissociation with slower escape rate • P wave rate is greater than QRS rate • Otherwise this may be AV dissociation with accelerated junctional rhythm! Postoperative Complete AVB Complete AV Block • Temporary pacing wires used in interval – Daily threshold checks – Pulse oximeter monitoring • ECG monitor picks up pacing spike • Recommendation for observation to see if resolves within 7-10 days – If not, permanent pacing system warranted Objectives 1. Rhythm issues encountered in the operating room 2. Discuss the use of echocardiography in the OR Echo: Background • Echo has been utilized in the OR for the last 20 years – Miniaturization of probe allows application of TEE to all pts coming to the OR for CHD surgery • Mini-TEE, mini-multiplane, Acunav longitudinal imaging • Performed by either the cardiologist or the anesthesiologist – The key to this is proper training and experience with the diagnosis and evaluation of congenital heart disease Echo in the OR • Echocardiography is a key part of noninvasive imaging in the operating room – Evaluate the preoperative anatomy • Be sure nothing was ‘missed’ • Confirm the surgical plan – Evaluate the repair before leaving the OR • Residual defects • Guide revision • Available modalities: TTE or Epicardial Randolph G, Hagler D et al J Thorac Cardiovasc Surg 2003 Utility of TEE? • Mayo Clinic: 1002 pts during CHD surgery – Mean age 9 yrs; range 4d to 85 yrs • Prebypass or postbypass major impact in ~14% of cases – 52 pts had immediate revision (“cost-effective”) • Most useful in complex valve repairs or in complex outflow tract reconstructions – Less impact in PAPVR, ASD, simple tricuspid valve repair, aortic arch repair Echo in the OR • Pre-operative echo evaluation – Document baseline ventricular function – Assessment of AV valve function – Confirmation of anatomy and surgical plan – Are there any additional defects that need to be addressed surgically? • Especially atrial septal defect • ?Bubble study to confirm intact atrial septum Post-Bypass Echo: Function • Evaluation of air in the left heart – Adequate venting • Ventricular function – Comparison with pre-bypass imaging – Evaluation of intervention with medications and inotropic support • Volume status – Is the heart underfilled or distended? Post-Bypass Echo: Anatomy • Critical for evaluation of residual defects – Outflow tract stenosis • Alignment as parallel as possible (often transgastric views needed) – Valve repair • Be sure volume status is sufficient, BP stable – Residual shunts – Atrioventricular valve • Critical if repair undertaken • Leaflet motion/paravalve leak in replacement Post-operative Evaluation • Echo can be correlated with surgeon’s evaluation – Pressure line monitoring • i.e. RV to PA pressure post-TOF repair – Blood gas sampling for shunt • i.e. SVC line and PA blood gas sampling • Review of TEE and applications to pediatric CHD – Intraoperative TEE – Catheterization and TEE guidance – TEE during non-cardiac surgery in the CHD patient • Description of typical probe positions and views obtained Kamra K, et al, Pediatr Anes, 2011 Mid-Esophageal View (0-30º) • Typical 4-chamber view – AV valves • Ventricular function • Atrial septum • Segments of ventricular septum – Inlet Mid-Esophageal View (60-90º) • Typical long-axis view – AV valves in different plane • Ventricular function • Atrial septum • Segments of ventricular septum • Outflow tracts – RVOT and LVOT Mid-Esophageal (30º) • Typical view to see aortic leaflets • Coronary origins • Proximal RVOT and pulmonary valve • PA bifurcation Deep Trans-Gastric View (0º) • Left ventricle • LVOT • Right ventricle (rotate rightward) • RVOT • Ventricular function Deep Trans-Gastric View (90º) • Anteflex probe and rotate right/left • LVOT and aortic valve • Outlet ventricular septum • Tricuspid valve inflow/function Epicardial Echo • When TEE not available • Standard use transthoracic probes – Sterile sleeve – Surgeon images in epicardial position • Image orientation may not be quite ‘standard’ – Understanding of baseline anatomy and surgical repair Epicardial Echo • Reported use of Epicardial or Epi+TEE in 8% of CHD OR cases • May be useful for difficult to see ‘areas’ such as PA branches and coronaries Dragalescu A, et.al, JCVTS 2011 in press Use of Epicardial Echo JCVTS Hospital for Sick Children Toronto 2007-2009 Epicardial Echo RVOT Free wall: “PLAX view” Aorto-PA Sulcus: “PLAX view” Epicardial Echo RVOT Free wall: “PLAX view” Aorto-PA Sulcus: “PLAX view” Epicardial Echo RV Free wall: “Subcostal view” SVC-Aorto Sulcus: “Subcostal long axis” Epicardial Echo RV Free wall: “Subcostal view” SVC-Aorto Sulcus: “Subcostal long axis” Conclusion • One must pay careful attention to rhythm issues in the operating room – Most will involve a decision about placement of pacing wires • Intraoperative echo is very useful for pre and post-bypass evaluation of anatomy, surgical repair and cardiac function – Epicardial echo may be used if TEE is unavailable