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Anaesthetic Implications in a Patient With Poor LV Function by Dr Sanjula Virmani
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Transcript of Anaesthetic Implications in a Patient With Poor LV Function by Dr Sanjula Virmani
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Anaesthetic implications in a patient
with poor LV function
Dr Sanjula Virmani
ProfessorDepartment of Anaesthesiology and Intensive Care
G B Pant Hospital, New Delhi
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LV function can be defined in terms of
LV systolic function and
LV diastolic function
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Systolic dysfunction
Changes in preload and afterload
(characterized by LV remodeling with an
increase in the size of left ventricle and a
change in LV geometry).
Decrease in myocardial contractility
Increase in heart rate
Increase in diastolic filling pressures
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Diastolic dysfunction
Abnormalities of
Diastolic distensibility
Myocardial relaxation
Ventricular filling
The ventricle's passive elastic properties
Heart rate (which determines how much timeis available for ventricular filling). Thus,impaired diastolic function can be aggravatedby tachycardia.
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Pathogenesis
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Poor LV function
Coronary artery disease
Hypertention
Valvular heart disease Cardiomyopathies
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LV Remodeling Alterations in Myocyte Biology
Excitation contraction coupling
Myosin heavy chain (fetal) gene expression
Beta-adrenergic desensitization
Hypertrophy
Myocytolysis
Cytoskeletal proteins
Myocardial Changes Myocyte loss
Necrosis
Apoptosis
Autophagy
Alterations in extracellular matrix (Matrix degradation Myocardial fibrosis)
Alterations in Left Ventricular Chamber Geometry LV dilation
Increased LV sphericity
LV wall thinning
Mitral valve incompetence
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Left ventricular remodelling (Geometry)
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Determinants of LV function
LVEDP (5-12 mm Hg)
LAP (2-12 mm Hg)
PCWP (4-12 mm Hg)
CVP (1-5 mm Hg)
Calculations and measurements:
CI (25-42 L/min/m2)
SVI (40-60 mL/beat/m2
) SWI (45-60 g.m/m2)
EF
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Determinants of LV function cont.
The most useful parameter in daily practice is
the LVEF fraction.
EF> 50% is considered to be normal
EF between 35 to 50% is moderately
depressed
EF < 35% represents a severely depressedfunction
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Preoperative preparation of the
patient
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If not an emergency
Identify any active cardiac conditions
Identify and stratify the risk involved in the
surgery
Assess the patients functional capacity and
clinical risk factors
Optimise the medical therapy
Consider coronary revascularization
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Assess the patients clinical features Markers of cardiac risk
Patients cardiac status
Order tests only when results may changemanagement
Interventions that may result from specialisedtests include delaying surgery, coronaryrevascularization, medical optimization,additional specialists involvement, modifiedintra-op and post-op monitoring or modifying thesurgical location.
C diti i hi h th ti t h ld d l ti
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Conditions in which the patients should undergo evaluation
and treatment (patient specific factors) as per ACC/AHAA
2007 guidelines categorised as Class I, Level B
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Functional status should be evaluated
Underlying cardiac conditions apparently stable
Stable angina
Distant MI
Prior HF Moderate valvular heart disease
Identify comorbid conditions
DM
Stroke
Renal insufficiency
Pulmonary disease
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Estimated energy requirements for various
activities, based on Duke Activity Status Index
1 MET Can you Take care of yourself
Eat, dress, or use toilet
Walk indoors around the house?
Walk 1 to 2 blocks on level ground at 2-3 mph
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Risk stratifications in patients undergoing noncardiac
surgery (procedure related factors)
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Lees Revised Cardiac Risk Index.
Circulation 1999; 100: 1047Clinical variable Points
High-risk surgery (i.e.,
intraperitoneal , intrathoracic,
or suprainguinal vascular
surgery)
1
CAD 1
CHF 1
History of cerebrovasculardisease
1
Insulin treatment for DM 1
Preop serum creatinine >2.0
mg per DL
1
Risk Class Points Risk of
complications
I. Very low 0 0.4
II. Low 1 0.9
III. Moderate 2 6.6
IV. High 3+ 11
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Noninvasive stress test
To be considered only if the test results have apotential to change patient management
In patients with normal ECG, who are able to
exercise-Exercise ECG testing In patients with abnormal resting ECG-stress
cardiac imaging
In patients who are unable to performadequate exercise-pharmacologic stressimaging
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Coronary Angiography
Unstable coronary syndromes
Stress test is uncertain in high risk patient
undergoing major surgery
Possible indication for coronary
revascularization
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Optimise medical therapy
-blockers
Low dose aspirin
Statins
2 agonists
Calcium channel blockers
Nitrates
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Fleisher LA, et al 2009 ACCF/ AHA focused update on perioperative Beta
Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative
Cardiovascular Evaluation and Care for Noncardiac Surgery. A Report of the
American College of Cardiology Foundation/ American Heart Association TaskForce on Practice Guidelines. Circulation 2009; 120: 169-276
Continue beta-blocker therapy in patients who
are already receiving these agents for angina, HT,or other ACC/AHA class I indications (Level ofevidence C)
Initiation recommended
in those undergoing vascular surgery who haveischaemia on preoperative testing ( Class IIa)
CAD or high cardiac risk (more than 1 clinical riskfactors undergoing intermediate risk surgery)
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Statins Beneficial effect on systemic atherosclerosis
Improve atherosclerotic plaque stability (antithrombogenic, antiproliferative)
Inhibit leucocyte adhesion
Lipid lowering effect (decrease cholesterol, increase HDL)
Pleiotropic effects
Increase endothelial NO synthetase
Generation of ROS
Decrease endothelin I production
Improve thrombogenic profile
Decrease inflammation
Decrease CRP levels
Inhibition of atherosclerosis
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Fleisher et al. ACC/AHA 2007 perioperative
guidelines. J Am Coll Cardiol 2007; 17: 206
Statins should be continued in patients
currently taking statins. Class I (level of
evidence B)
Statin use is reasonable in patients undergoing
vascular surgery with or without clinical risk
factors. Class IIa (Level of evidence B)
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Fleisher et al. ACC/AHA 2007 perioperative
guidelines. J Am Coll Cardiol 2007; 17: 206
Alpha 2 agonists for perioperative control of
HT maybe considered for patients with knownCAD or at least 1 clinical risk factor. Class IIIb
(Level of Evidence B)
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Fleisher et al. ACC/AHA 2007 perioperative
guidelines. J Am Coll Cardiol 2007; 17: 206
Nitroglycerin : As a prophylactic agent to
prevent MI its usefulness is unclear and the
recommendation for its prophylactic use must
take into account the anaethetic plan andpatient haemodynamics as well as recognise
that vasodilation and hypovolaemia can occur.
Class IIIb (Level of evidence C)
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Other previously prescribed medication shouldcontinue in the perioperative period
Aspirin
Medication for HT, CHF, arrhythmias
A combination of -blockers, low dose aspirin and statinsis most promising
Devereaux et al. How strong is the evidence for the use ofperioperaative beta blockers in non-cardiac surgery? Systematic
review and meta-analysis of randomised controlled trials. BMJ
2005; 331: 313-21
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Limited role for coronary
revascularization and benefit
apparently limited to left main disease
Revascularization failed to affect any outcomemeasure, including mortality or the development of MI
out to 6 years of follow up (CARP Study)Mc Falls EO, et al. Coronary-artery revascularization before elective
major vascular surgery. N Engl J Med 2004; 351: 2795-2804
Poldermans D et al. A clinical randomized trial to evaluate
the safety of a noninvasive approach in high riskpatients undergoing major vascular surgery: the
DECREASE-V Pilot study. J Am Coll Cardiol 2007; 49:
1763-1769
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Management of patients with prior PCI
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h d
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Anaesthetic considerations
blocker dose titrated to achieve a target HR of 60bpm
Continue aspirin, statin and when indicated ACE
inhibitor Anaemia promptly identified and treated
ECG-baseline, immediately after surgery and on first 2days after surgery
Creatinine kinase-MB and troponin-after surgery andon the following day
Inotropes which increase myocardial oxygen demandshould be avoided
Perioperatively pain well controlled
Maintenance of body temperature in a normothermicrange
Intraoperative and postoperative surveillance formyocardial ischaemia and infarction, arrhythmias and
venous thrombosis
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Anaesthetic considerations cont.
PAC
PAC insertion is reasonable in patients at risk
for major haemodynamic disturbances. The
decision to insert must be based on patients
disease, surgical procedure and practice or
experience in the use of PAC. Class IIb (Level of
Evidence B)
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Anaesthetic considerations cont.
IABP
Documented use in unstable coronary
syndromes and severe CAD undergoing urgent
non cardiac surgery
Use is associated with complications
Currently there is insufficient evidence to
determine the benefits vs. risks of
prophylactic placement
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Anaesthetic considerations cont.
No study has clearly demonstrated a change in
outcome from the routine use of PAC, ST-
segment monitor, TEE
The choice of anaesthetic technique and
intraoperative monitors is best left to the
discretion of the anaesthesia care team.
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Postoperative management
Surveillance for: Myocardial ischaemia
Arrhythmias and conduction disorders
Haemodynamic monitoring to continue
Postoperative pain management Patient controlled analgesia techniques are associated
with greater patient satisfaction and lower pain scores
Epidural or spinal opiates
The care team should take responsibility for longterm care of the patient by way of routineprophylactic medical therapy/diagnostic testing.
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