Download Pathophysiologic consideration in patients with congenital heart

How To Look To Patient Data
DATA
History Taking
o Growth
o Exercise Intolerance
o Recurrent Chest Infection
o Syncopal Attacks
o Squatting
ECG , Echo & Cardiac Cath.
Systolic & Diastolic Dysfunction
Systolic Dysfunction
Reduced Fractional Shortening
Diastolic Dysfunction
Ventricular Hypertrophy
Concentric
Eccentric
Obstructive
Before
Repair
e.g
valvular
&
outflow
obst.
After Repair
e.g
Homograft
conduit
Volume
Before
Repair
e.g
Lt . to Rt.
shunt
After
Repair
e.g
•Pulmonary
valve regurge
( F4 )
•MV repair
Anaesthetic considerations :
Consider determinants of coronary
perfusion & myocardial oxygen balance
• Heart rate changes
• Hypotension
• Myocardial contractility
Anaesthetic considerations
Cardiomyopathy
RV
increase wall
thickness
coronary
filling
becomes
diastolic
coronary
perfusion
depends on
bl. p. & hr
LV
anaesthetic
myocardial
depression
Decrease driving
filling pressure
of coronary
arteries
Coronary
ischemia
Maintain heart rate
to decrease
regurgitant
fraction
Syst. Dysfunction
In Dialted type
Diast.
Dysfunction
In Hypertrophic
& restrictive
type
Residual Shunts :
o Occasionally present after repair of ASD ,
VSD & F4
o Small patch leaks are hemodynamically
benign
Dysrhythmias :
Atrial & ventricular types increase mortality and
morbidity
Arrhythmias Associated With Specific
Surgical Procedures
Ostium secondum ASD :
• P-R interval is prolonged in 20-30% of patients
• AF , atrial flutter with advancing age
VSD :
•RBBB
•Atrial ectopic , junctional beats , premature ventricular
beat
•Late onset of complete heart block or ventricular
arrhythmias are rare
Repair of F4 :
•RBBB & complete heart block
Mustard or Senning operation :
•Sinus nodal dysfunction
•Bradycardia
•A-V block , AF
Pulmonary hypertension
Severity of hypertension of base line PAH correlated with the
incidence of major complications
( pulmonary hypertensive crisis or cardiac arrest )
Cardiovascular risk of PAH
Major perioperative hemodynamic deterioration
mainly pulmonary hypertensive crisis and acute right
ventricular failure and cardiac arrest .
Data to look for :
o Mean pulmonary artery pressure > 25 mmHg
o Severity of base line PH :
Subsystemic PAP < 70% of syst. bl. pressure
Systemic PAP = 70 – 100 of syst. bl. pressure
Suprasystemic PAP > 70 of syst. bl. pressure
( based on mean pressures )
ANAESTHETIC CONSIDERATIONS
Avoid Factors Rapidly Increasing PVR
Laboratory data
Hematocrit value
HCT.
Decompansated
Erythrocytosis
Increase Red Cell Mass
Increase
Erythropoitin
Level
Increase More Blood Viscocity
Hyperviscosity
symptoms
Decreased oxygen
delivery
Blood Indicies :
Iron Deficiency Anaemia
Microspherocytosis
Low Hemoglobin
Concentration
Rigid Cell
Membrane
Increase Blood Viscosity
Hyperviscosity Symptoms At Lower
Hematocrit Value
Phlebotomy
Done to relieve hyperviscosity symptoms with
hematocrit > 65 % in absence of iron deficiency
anaemia or signs of dehydration
Hemostatic values
•Prolonged PT , PTT , APTT values most
frequently seen in cyanotic patients
•Thrombocytopenia is related to degree of
polycythemia .
Summary
General associated risk factors in CHD
 Severe form of isolated lesion
 Complex lesions
 Concurrent infectious disease
 Congestive heart failure
 Acute hemodynamic deterioration
 Previous palliative or corrective procedures
Summary
Risk criteria of hemodynamic critical impairment
in perioperative period in CHD
•
•
•
•
•
•
Arterial saturation < 75 %
Hematocrit > 65 %
Qp / Qs > 2 : 1
LV outflow tract gradient > 50 mmHg
RVOT gradient > 50 mmHg
PVR > 6 wood units
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