Anesthesia for the Patient With Congential Heart Disease For Non by HC120924015348

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									 Anesthesia for the Patient With
 Congential Heart Disease
 For Non Cardiac Surgery




Ri 許逵翔/蔡易臻/羅偉成/ CR 章宏吉/ V.S. 黃啟祥
Background

   Continuous improvement in medical care and
    surgical treatment longer the lifespan of
    congential Heart Disease (CHD) patient

   1.2 million adults (>16 years) living with various
    forms of CHD in the U.S.
The recommendations
-How to care CHD patient?-

   Centers that have multi-disciplinary CHD programs
    and staff

   Every pediatric cardiology program in the center
    should identify a specialized, dedicated CHD
    program for the transition of their patients.
       這是過渡期(兒童期) 須有小兒心臟專家

   Patients with moderate or severe ACHD should be
    transferred to a dedicated ACHD program for urgent
    or acute care
For Anesthesia
-How to care about CHD patient?-

   Dedicated cardiac anesthesia team with
    expertise in the management of CHD



   Well consultative services and interacts at all
    levels
Who is actually repaired?


   Very few types of congenital heart disease
    are truly fixed with no residual problems
   Except :
       PDA ligation
       Uncomplicated secundum ASD
       Uncomplicated VSD
Pathophysiology of chronic CHD

     ventricular overload
     repeated myocardial ischemia
     altered coronary artery supply
     chronic hypoxemia
     inadequate myocardial protection
     Alter normal development of cardiovascular system

   Consequences of Congenital Heart Disease
Consequences of Congenital Heart
Disease
   CHF
   Hypoxemia, cyanosis
   Polycythemia
   Pulmonary vascular disease
   Previous surgical sequence
   Alter normal growth and cardiovascular
    development
Key in approaching the CHD patient


   Most important consideration in approaching
    the patient :
       potential to develop or exacerbate low systemic
        cardiac output


   The other possible risk factors :
       contractile dysfunction
       the pressure- or volume-loaded ventricle
       pulmonary hypertension
       end-organ dysfunction
Atrial septal defect

   most successful ASD repairs carry little risk
    of late complications
   However, if the defect closed late
       pulmonary hypertension may develop in 20~30
        years
       Persistent atrial arrhythmias
Ventricular Septal Defect


   If the VSD is non-complicated
       the defect is closed early
       no residual VSD of significance
       no associated lesions ex. outflow obstruction,
        subaortic membrane, heart block
     Function are likely to be normal

   However, in complicated patient
       LV dysfunction, pulmonary hypertension may
        developed
Aortic Coarctation


   Persistent systemic hypertension
       independent of any residual obstruction
       likely due to changes in SVR in response to the presence
        of a coarctation
       Most common in older children
   Recurrent stenosis
       Most common in infant(20%), few by age 3 years(<1%)
   LV hypertrophy
   Increased risk of sudden death
Atrioventricular Canal Defects


   These patients have large left-to-right shunts,
    excessive pulmonary blood flow
       CHF
       Pulmonary hypertension
   The most common problems after repair
       valvar regurgitation (especially mitral)
       residual VSD
       occasionally pulmonary hypertension
     TETRALOGY OF FALLOT


Park: Pediatric Cardiology for Practitioners, 5th ed.
                      Tetralogy of Fallot



PA
stenosis                             Overriding
                                     Aorta


                                      Large VSD



  RV
  hypertrophy

http://www.mdconsult.com/das/patient/body/132412227-
3/0/10041/18088_en.jpg                                 Kliegman: Nelson Textbook of Pediatrics, 18th ed.
                     Tetralogy of Fallot

   • Palliative procedures
                      Central shunt




Park: Pediatric Cardiology for Practitioners, 5th ed.
                     Tetralogy of Fallot

   • Total correction




   • Repair VSD, PA stenosis
Park: Pediatric Cardiology for Practitioners, 5th ed.
                       Tetralogy of Fallot

    • “Fixed but not cured”
    • Major problem
       – Abnormal RV loading (pressure & volume)
       – Obstruction of RV outflow tract (RVOT)
          reconstruction
      Pulmonary arteriosus
           Truncus
Rastelli procedureatresia
for TGA
with pulmonary stenosis




  Park: Pediatric Cardiology for Practitioners, 5th ed.
       Tetralogy of Fallot

• Major problems following TOF repair
  – Progressive RV dysfunction
    • Predictor of late morbidity and mortality
    • Decreased exercise tolerance
    • Image tools
  – Development of ventricular arrhythmias
    • Unknown of prognostic significance
    • Indication for ablation, antiarrhythmic agents, or
      an implantable cardioversion-defibrillator (ICD)
  – Increased risk of sudden death
        Tetralogy of Fallot

• Factors reduced long-term survival
  – Older age (>4 years) at repair
  – Initial palliative shunting procedures
     • Especially central shunt
  – Significant residual RV hypertension
     • RV:LV > 0.5-0.75; RVOT obstruction, PA stnosis
  – Volume loading of the RV
            Tetralogy of Fallot

• Difficult to accurately predict
                               Positive pressure
                               ventilation
• Defining their risk factors for PVR ↑ their
   Intrathoracic                   and
   Pressure
  degree ↑of RV dysfunction
                                PR
   – Positive pressure ventilation (RV afterload ↑ and RV filling ↓) to
     decrease cardiac output in patients with significant PR and RV
     dysfunction
                           CO↓
   – Dysfunctional RV to compromise systemic cardiac output (via
                  RV
     decreased RV output, as well as ventricular interdependence
                  dysfunction
     causing decreased LV filling and function)


• Optimizing and maintaining RV function !!
         Tetralogy of Fallot
• Peri-OP
  – Optimizing and maintaining RV function
     • Avoided factors that increase PVR
         – Especially in free PR and RV dilation
     • Maintained RV filling
         – But excessive volume loading may also be poorly tolerated
     • Avoided drugs that significantly diminish RV contractility
  – Keeping heart rate approximately normal
  – Maintaining RV oxygen delivery by maintaining
    blood pressure and oxygen carrying capacity
     • Prevent tachycardia, hypotension, acidosis, and anemia
        Tetralogy of Fallot
• Post-OP
  – Invasive monitoring and postoperative care in an
    ICU setting
  – “Prophylactic” administration of inotropes to improve
    RV contractile
TRANSPOSITION OF THE
GREAT ARTERIES (TGA)
                 Transposition of
                the Great Arteries




http://www.mayoclinic.com/   Kliegman: Nelson Textbook of Pediatrics, 18th ed.
         Transposition of
        the Great Arteries
• Atrial baffle operation
• Atrial switch

• Mustard or Senning
  operation

• Physical repair
         TGA – Atrial Switch
• Reasonable functional status and fairly normal
  lives into their 3rd and 4th decade
• 15-20 year survival : 80-85%
• Long term
  –   Progressive deterioration of RV function
  –   Development of TR
  –   Signs and symptoms of right heart failure
  –   Arrhythmias (Ventricle & atrial) (tachycardia or SSS)
  –   Sudden death
       TGA – Atrial Switch
• Baffle leak
  – Intra-atrial shunting and hypoxemia
• Baffle obstruction of the systemic venous return
  – Superior vena cava syndrome, hepatic congestion,
    ascites, and peripheral edema
  – Protein-losing enteropathy (PLE) (alb < 3 mg/dl)
     • Decreased RV function, decreased cardiac index, and
       increased systemic venous pressure
• Baffle obstruction of the pulmonary venous side
  – Pulmonary edema or the development of pulmonary
    hypertension
                                    Baffle
                      Transposition of
                     the Great Arteries
   • Arterial switch
         – Since 1975, Jetene




http://radiology.rsnajnls.org/cgi/content-
nw/full/247/3/617/F10
Park: Pediatric Cardiology for Practitioners, 5th ed.
     TGA – Arterial Switch

• Anatomical repair
• Early hospital mortality < 3%
• 5-10 survivals >97-98%
Arterial switch operation the preferred
  procedure in most centers
    TGA – Arterial Switch

• Complication
  – Small incidence of supravalvar pulmonary
    arterial and aortic stenosis at the
    anastomotic sites
    • Can frequently be addressed by balloon
      dilatation.
  – Neoaortic valve (the anatomic pulmonary
    valve) regurgitation (25-30%)
  – Coronary ostial lesions (3-5%)
    • No evidence of myocardial ischemia
Anesthesia and Fontan
     Physiology
      Fontan operation(1968)
• Indication:
  patient of severe tricuspid
  atresia, hypoplastic left heart
  syndrome, etc.




                                    http://www.inova.org
        Physiology of Fontan
              patient




Red: artery
              Transpulmonary gradient(TPG)= CVP - LVEDP ≒ 5-8 mm Hg
Blue: vein
Underlying diseases in patient
    s/p Fontan operation
•   Protein loss enteropathy(3~15%)
•   Life-long stroke rate(2~3%)
•   Thromboembolism(20~30%)
•   Arrhythmia(>60% after OP 10 years)
•   Venous pressure elevation
•   Significant stasis of RA flow
•   Increased pulmonary venous resistance
•   Myocardialdysfunction
                          Stamm et al., J Thorac Cardiovasc Surg 2001;121:28
   Pre-OP assessment for Fontan
                  Patient
• Objective factors:
  NYHA class, heart rate response, delayed recovery from
  peak exercise
• Echocardiography for heart function
• Possible radiofrequency ablation for
  arrhythmia
• CVC monitor: venous filling, pulmonary artery
  pressure, mixed venous oxygen saturation
  ※May do CVC under image guidance
                                  Penny et al.. Br Heart J 1991;66:372
                                  Gewillig et al. J Am Coll Cardiol 1990;15:1424.
Peri-OP monitor for Fontan patient-
                 1

• Avoid large afterload and keep adequate
  preload
• Increased bleeding risk due to collateral
  vessels and high venous pressure
• Available pacemaker and defibrillator for
  arrhythmia
• Possible inotropic agent use:
  dopamine or Milrinone (Primacor,
  0.25ug/kg‧min)

           Dawit T. from Mayo Clinic, Pediatric Anesthesia,29 Feb 2008
Peri-OP monitor for Fontan patient-
                 2

• Positive ventilation:
  low mean airway pressures (<15-20 mm Hg),
  low ventilation rate with tidal volume(20ml/Kg),
  no PEEP use
  mild hyperventilation
• Nebulized pulmonary vasodilator:
  e.x.: Prostacyclin, NO, epoprostenol
  continuous use to lower pulmonary venous
  resistance
Peri-OP monitor for Fontan patient-
                 3

• Follow-up ABG:
  alkalization blood using sodium bicarbonate to
  minimize mean airway pressures


• “Hypovolemia and increases in pulmonary
  vascular resistance are poorly tolerated by
  patients who have had a Fontan procedure. “
           From Clinical Anesthesia Procedures of the Massachusetts General Hospital
   Post-OP care for Fontan
           patient
• Fenoldopam use to increase mesentary
  and renal blood flow for maintaining end-
  organ function
• Heparin use for prophylaxis of
  thromboembolism
• Hydration for adequate preload
       Take home message

•   TOF – Preserve RV function
•   TGA – Obstruction of repair site
    – Arterial switch need further follow-up data
•   Fontan patient: Hypovolemia and
    increases in pulmonary vascular
    resistance were major points in
    anesthesia.
• Thank you
                        Reference
•   Anesthesia for the Patient With Congenital Heart Disease For Non
    Cardiac Surgery
•   Park: Pediatric Cardiology for Practitioners, 5th ed.
•   Kliegman: Nelson Textbook of Pediatrics, 18th ed.
•   http://www.mdconsult.com/das/patient/body/132412227-
    3/0/10041/18088_en.jpg
•   http://kjronline.org/abstract/journal_figure.asp?img=05-
    AB.JPG&no=206&desc=desc6
•   http://www.mayoclinic.com/
•   http://radiology.rsnajnls.org/cgi/content-nw/full/247/3/617/F10
•   Anesthesia for Cardiac Surgery, 3rd ed.

								
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