How To Look To Patient Data

History Taking

o Growtho Exercise Intoleranceo Recurrent Chest Infection o Syncopal Attacks o Squatting

ECG , Echo & Cardiac Cath.

Systolic & Diastolic Dysfunction

Reduced Fractional Shortening

Systolic Dysfunction

Diastolic Dysfunction

Ventricular Hypertrophy

Obstructive Volume

Before Repair

e.gvalvular

& outflow

obst.

After Repair

e.g Homograft conduit

Before Repair

e.gLt . to Rt.

shunt

After Repair

e.g•Pulmonary valve regurge ( F4 )•MV repair

Concentric Eccentric

Anaesthetic considerations :

Consider determinants of coronary perfusion & myocardial oxygen balance

• Heart rate changes • Hypotension • Myocardial contractility

Anaesthetic considerations

increase wall

thickness

coronary filling become

s diastoli

c

coronary perfusion

depends on bl. p. & hr

Maintain heart rate to

decrease regurgitant

fraction

Syst. DysfunctionIn Dialted

type

RV LVanaesthet

ic myocardia

l depressio

nDecrease driving filling

pressure of coronary arteries

Coronary ischemia

Diast. Dysfunction

In Hypertrophi

c & 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 Arrhythmias Associated With Specific Surgical ProceduresSurgical 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

Severity of hypertension of base line PAH correlated with the incidence of major complications ( pulmonary hypertensive crisis or cardiac arrest )

Pulmonary hypertension

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 dataHematocrit value

Increase More Blood ViscocityIncrease More Blood Viscocity

Hyperviscosity Hyperviscosity symptomssymptoms

Decreased oxygen Decreased oxygen deliverydelivery

Blood Indicies :

Increase Blood Increase Blood Viscosity Viscosity

Increase Blood Increase Blood Viscosity Viscosity

Hyperviscosity Symptoms At Hyperviscosity Symptoms At Lower Hematocrit ValueLower Hematocrit Value

Hyperviscosity Symptoms At Hyperviscosity Symptoms At Lower Hematocrit ValueLower 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 .

SummaryGeneral 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

SummaryRisk 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

THANK YOUTHANK YOU