Ch.20 Anesthesia for patients with cardiovascular disease

1
Ch.20 Anesthesia for patients with cardiovascular
disease

• R1 ???

2
Introduction

• Cardiovascular disease most frequently
  encountered in anesthetic practice
• ??? ?? ??? ????? ??
• ?? ??? ?? adrenergic response
• ???, endotracheal intubation, ????, ???? , fluid
  shifts, ??? ??? ?? circulatory effects ?? ???? ?
• Choice of anesthetic agent is not as important as
  how the agent is used and an understanding of the
  underlying pathophysiology

3
Cardiac risk factors
4

• ?? ???? ???
• Perioperative myocardial infarction
• Pulmonary edema
• Congestive heart failure
• Arrhythmias
• Thromboembolism
• Cardiovascular complication
• 25-50 of deaths following noncardiac surgery

5
Clinical predictors of increased perioperative
cardiovascular risk

• Mj predictor ?? ?
• Noninvasive cardiac evaluation
• ?? ??? ??
• Unstable coronary syndrome
• Congestive heart failure
• C/I of elective op
• 1? ??? MI
• Uncompensated heart failure
• Severe aortic or mitral stenosis

6
Mx of intermediate or minor predictors
7
Cardiac risk stratificationfor non cardiac
surgical procedures

• ????? 2-5?? ???
• Poorly controlled HTN? wide intraOP BP swing? ??
  ??
• intraOP HTN? cardiac morbidity? hypotension?? ??
• Well-managed general anesthesia?? spinal ??
  epidural anesthesia? hemodynamic effect? ?? ???
  ?? ??

8
HYPERTENSION
9
Preoperative considerations

• HTN leading cause of death and disability
  most frequent preOP abNL in surgical Pt
• Overall prevalence 20-25
• Mj risk factor for
• Cardiac, cerebral, renal and vascular disease
• Cx
• MI, CHF, stroke, renal failure
• Peripheral occlusive disease, aortic dissection
• LVH, carotid bruits cardiac mortality ??

10
Definitions

• BP measurements
• Affected by posture, time, emotional state,
  recent activity, drug intake, equipment,
  technique
• Stage 3 (accelerated or severe HTN) renal
  dysfunction ??
• Malignant HTN gt210/120 ?Hg with papilledema,
  encephalopathy

11
Pathophysiology

• Idiopathic(essential) or less commonly secondary
• renal dis., primary hyperaldosteronism,
  Cushings syndrome, acromegaly ,pheochromocytoma,
  pregnancy, estrogen therapy ?
• Essential hypertension? course of the disease
• Cardiac output ??, but, SVR appears in NL
• Cardiac output ??, but, SVR becomes high
• Chronic increase in cardiac afterload? concentric
  LVH, altered diastolic function ??
• Cb autoregulation ??? NL Cb blood flow? ??

12
Pathophysiology(2)

• Mechanisms remain elusive but
• Vascular hypertrophy
• Hyperinsulinemia
• intracellular Ca ??
• ?? smooth muscle? renal tubular cell ?? Na ?? ??
• Sympathetic nervous system overactivity
• Overactivity of renin-angiotensin-aldosterone
  system important tole in accelerated HTN

13
Long-term treatment

• Drug therapy
• progression of HTN ???
• Stroke, CHF, CAD, renal damage ?????
• LVH, altered Cb autoregulation?? ?? ??
• ??? single-drug therapy? ?? ??
• Low doses of a thiazide diuretic for most
  patients
• ACE inhibitor Lt ventricular dysfunction or
  heart failure ?
• 
  1st-line choice
• ACEI or ARB (angiotensin-receptor blocker)
  hyperlipidemia, chr. Renal dis., DM? optimal
  initial single agent
• ß-adrenergic blocker, calcium channel blocker
• 1st-line agent for CAD
• Elderly Pt. diuretic with or without
  ß-adrenergic blocker, or calcium channel blocker
  alone

14
HYPERTENSION

• PREOPERATIVE MANAGEMENT

15

• ??? HTN Pt.? ???? HTN? ??? op room? ???
• Untreated or poorly controlled hypertensive Pt.
• Intraoperative episodes of MI, arrhythmias, both
  hypertension and hypotension
• ??? ???? ?? ? vasoactive drug ??? post-op Cx? ??
  ? ??
• Altered Cb. Autoregulation??? ??? BP ??? Cb.
  Perfusion ??? ??? ? ??? ??

16

• Antihypertensive drug? ?? ???? ??
• ????? intraop hypotension ?? ??? ?? ?? ACE
  inhibitor ??? ????? ?
• ??? ?? perioperative HTN ??? ???? parenteral
  antihypertensive agent ??? ???
• 110 ?Hg ??? sustained preoperative diastolic BP
  ??? (?? end-organ damage ?? ??) ??? ?? BP
  control? ? ? ??? ?? ??

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History

• Severity and duration of the HTN, drug therapy,
  hypertensive complication ??
• Sx of MI, ventricular failure, impaired Cb
  perfusion, peripheral vascular dis.
• Pts record of compliance with the drug regimen
• Questions should concern
• Chest pains, exercise tolerance
• Shortness of breath(?? ??)
• Dependent edema, postural lightheadedness,
• Syncope, amaurosis, claudication
• Adverse effects of current antihypertensive drug

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Physical examination laboratory evaluation

• Ophthalmoscopy
• Visible changes in the retinal vasculature
• Arteriosclerosis? ?? ??? hypertensive damage ???
  ??? ??
• Physical findings
• S4 gallop LVH
• Pulm rale S3 gallop CHF
• ASx carotid bruits
• atherosclerotic vascular dis.? ??
• Doppler?? ???? hymodynamically significant
  blockage? r/o ? ? ??

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Physical examination laboratory evaluation(2)

• BP ??? supine and standing position ???? ?? ?
• Orthostatic changes
• Volume depletion
• Excessive vasodilation
• Sympatholytic drug therapy
• ?? ?? preoperative fluid ??? induction ?? severe
  hypotension ?? ? ??

20
Physical examination laboratory evaluation(3)

• ECG ?? ??
• Evidence of ischemia, conduction abNL, old
  infarction, LVH, strain
• NL ECG? CAD or LVH ???? ??? ? ??
• Echocardiography more sensitive of LVH
• CXR
• Boot-shaped heart LVH ??
• Frank cardiomegaly
• Pulmonary vascular congestion

21
Physical examination laboratory evaluation(4)

• Renal function
• Serum Cr, BUN level? ?? ??
• S-electrolyte diuretics, digoxin ?????? ???
  ??? ?? ???? ??
• Mild to moderate hypokalemia(3-3.5mEq) taking
  diuretics Pt., ?? ??? ??
• K replacement? ?? ??? digoxin ?? ??? ??
• Hypomagnesemia ??? ???? ?? ??
• Hyperkalemia taking K-sparing diuretics or ACE
  inhibitors(?? impaired renal function?)

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Premedication

• Reduce preoperative anxiety
• Mild to moderate preop. HTN
• Anxiolytic agent (midazolam)
• Antihypertensive agents should be continued
• With a small sip of water
• Central a2-adrenergic agonist (clonidine 0.2mg)
• Sedation ??
• Intraop. Anesthetic ??? ??
• Periop. HTN ??
• Profound intraop. Hypotension and bradycardia ??

23
HYPERTENSION

• INTRAOPERATIVE MANAGEMENT

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Objectives

• Maintain an appropriate stable BP range
• Long-standing or poorly controlled HTN
• Cb blood flow? autoregulation ??
• ?? ???? ?? ?? ?? BP ??
• HTN, with tachycardia
• MI, ventricular dysfunction ?? ??
• Marked HTN(gt180/120 ?Hg) in preop.
• High-NL range(150-140/90-80 ?Hg) ??

25
Monitoring

• Direct intraarterial pr. Monitoring
• With wide swings in BP
• Cardiac preload or afterload? ? ??? ????Mj
  surgical procedures
• ECG monitoring
• Detecting signs of ischemia
• Urinary output
• Renal impairment?? 2?? ??? procedure
• Invasive hemodynamic monitoring
• LVEDV,CO?? ?? PCWP12-18mmHg? ?? ??

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Induction

• Induction, intubation period of hemodynamic
  instability
• ??? induction? hypotension, intubation? ??
  hypertensive response ??
• Induction? hypotensive response?
• anesthetic agents? antihypertensive agents?
  additive circulatory depressant effets?
  ??(vasodilator cardiac depressants ??)
• ??? HTN ??? ?? volume depleted state
• Sympatholytic agents ?? ???? protective
  circulatory reflex ????? ??

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Induction(2)

• 25???? endotracheal intubation? severe
  hypertension ??
• ??? ? duration of laryngoscopy ?? ?
• Intubation? deep anesthesia ???? ??
• Intubation ? Hypertensive response ??? ??
• ?? ?????? 5-10?? ?? ???? ??
• Bolus opiod(fentanyl 2.5-5?/? alfentanil 15-25
  ?/? sufentanil 0.25-0.5 ?/? remifentanil 0.5-1
  ?/?)
• Lidocaine 1.5?/? iv or intratracheally
• ß-adrenergic blockade c esmolol 0.3-1.5?/?
  propranolol 1-3? labetalol 5-20?
• Topical airway anesthesia

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Choice of anesthetic agentsa. Induction agents

• Regional anesthesia??? HTN Pts.? ????? ? ?? ????
  ??
• ??? propofol, barbiturates, benzodiazepines,
  etomidate? equally safe
• Ketamine
• Sympathetic stimulation??? elective op.?? C/I
• Benzodiazepine or propofol ?? ???? ????

29
Choice of anesthetic agentsb. Maintenance agents

• Volatile agents(N2O), balanced technique (opioid
  N2O muscle relaxant), or totally IV
  techniques
• Volatile agent
• Vasodilation and relatively rapid reversible
  myocardial depression gt BP? ?? ?? ??
• ????? sufentanil? ?? autonomic suppression?? BP
  control ????? ??

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Choice of anesthetic agentsc. Muscle relaxants

• Pancuronium ??? ???? ???? ?? ??
• Pancuronium induced.
• vagal blockade, neural release of catecholamines
• Can exacerbate HTN in poorly controlled Pts
• Large doses of tubocurarine, metocurine,
  atracurium, mivacurium? hypotension ??

31
Choice of anesthetic agentsd. Vasopressors

• HTN Pts? endogenous catecholamine?? exogenous
  sympathetic agonist? ?? ??
• Small dose of a direct-acting agent
  (phenylephrine 25-50?)
• High vagal tone small dose ephedrine (5-10?)
• ??? Sympatholytics ????? ?? ??? epinephrine 2-5 ?
  ??? ?? ??
• Improper dosing of epinephrine? significant
  cardiovascular morbidity ?? ??

32
Intraoperative hypertension

• Anesthetic depth ??? ?? ?? ?? ?? parenteral
  agent? ?? ??
• Antihypertensive therapy ?? ? inadequate
  anesthetic depth, hypoxemia, hypercapnia ? ?? ???
  ???? ???? ?
• ß-adrenergic blockade
• Good ventricular function and elevated heart rate
• C/I in bronchospastic disease
• Nicardipine
• Preferable for bronchospastic disease
• Sublingual nifedipine? reflex tachycardia? MI ??
  ? ? ???delayed onset ??

33
Intraoperative hypertension(2)

• Nitroprusside
• Most rapid and effective agent for the
  intraoperative treatment of moderate to severe
  HTN
• Nitroglycerin
• Less effective but useful in treating or
  preventing MI
• Fenoldopam
• Improve or maintain renal function
• Hydralazine
• Sustained BP control
• Delayed onset, can cause reflex tachycardia
• Reflex tachycardia? labetalol ??? combined a-
  ß-adrenergic blockade ???? ?? ? ??

34
Intraoperative hypertension(3)
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Postoperative management

• Postop HTN? ??? poorly controlled HTN Pts?? ???
  ???
• Close BP monitoring in recovery room early
  postop period
• Marked sustained elevations in BP
• MI and CHF
• Formation of wound hematomas
• Disruption of vascular suture lines
• HTN in recovery period? ??
• Respiratory abNL, pain, volume overload, bladder
  distention
• Labetalol useful in HTN and tachycardia
• Nicardipine useful in HTN with slow heart rate
• ?? MI? ????? bronchospasm ?? ??
• Oral intake ????? ??? medication ??

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ISCHEMIC HEART DISEASE
37
Preoperative considerations

• O2 supply? ???? metabolic oxygen demand
• Ischemia result from
• Marked increase in myocardial metabolic demand
• Reduction in myocardial O2 delivery
• Common causes
• Severe HTN or tachycardia
• Coronary arterial vasospasm or anatomic obx.
• Severe hypotension, hypoxemia, anemia
• Severe aortic stenosis or regurgitation

38
Preoperative considerations(2)Artherosclerosis
of the coronary arteries

• Major risk factors
• Hyperlipidemia, HTN, diabetes, cigarette smoking
• Increasing age, male sex, positive family history
• Obesity, menopause, high estrogen oral pills
• History of cerebrovascular or pph vascular
  disease
• High estrogen oral contraceptives (with smoking)
• Sedentary lifestyle,coronary-prone behavior
  pattern
• Clinical manifestation
• Sx of myocardial necrosis (infarction)
• ischemia (usually angina)
• Arrhythmias (including sudden death)
• Ventricular dysfunction (CHF) gt ischemic
  cardiomyopathy

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Unstable angina

• Defined as
• ??? ???? severity, frequency (1? 3? ??), or
  duration of anginal attacks (crescendo angina)
• Angina at rest
• New onset of angina(2? ??) with severe or
  frequent episodes(1? 3? ??)
• ?? severe underlying coronary dis, MI? ??
• ?? ? ?? ?? coronary care unit ?? ??
• Anticoagulation with heparin
• Together with aspirin, iv nitroglycerin,
  ß-blockers, calcium channel blockers
• 24-48h?? ?? ??? coronary angiography??
  angioplastry or emergency surgical
  revascularization ??

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Chronic stable angina

• Chest pain
• Substernal, exertional, radiating to the neck or
  arm, relieved by rest or nitroglycerin
• Nonexertional ischemia, silent ischemia? ??
• DM ???? silent ischemia ?? ??
• ?? artherosclerotic lesion? 50-75 occlusion ???
  ??? ?? ??
• Stenotic segment? 70? ???? maximum compensatory
  dilatation?? ??? blood flow? ????? increased
  metabolic demand?? ??
• Emotional upset, hyperventilation?? ?? coronary
  vasospasm ?? transient transmural ischemia? ??
  (Prinzmetals angina)

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Treatment of ischemic heart dis

• The general approach
• Progression? ??? ?? coronary risk factor ??
• Exercise tolerance ??? ?? lifestyle ??
• Complicating medical condition ??
• HTN, anemia, hypoxemia, thyrotoxicosis, fever,
  infection, adverse drug effects ?
• Coronary lesion ??
• Percutaneous coronary intervention
• PCI (angioplasty with or without stenting,
  or atherectomy)
• Coronary artery bypass surgery
• Pharmacological agents
• Calcium channel blockers vasospastic angina
• ß-blockers exertional angina adequate
  ventricular function
• Nitrates both types of angina

42
Treatment of ischemic heart disa. nitrates

• Relax all vascular smooth muscle (?? vein)
• venous tone return (cardiac preload)? ?????
  wall tension? afterload? ???? myocardial O2
  demand? ????
• Dilate coronary arteries
• Flow? radius? 4??? ????? stenotic site? ??? ?????
  blood flow? ???? ??
• ?? ????? subendocardial blood flow? ??
• ??? ??? collateral? ??? ??
• Acute ischemia ?? ? frequent anginal episode? ???
  ??
• Negative inotropic effect? ??

43
Treatment of ischemic heart disb. calcium
channel blockers

• Cardiac afterload? ?? myocardial O2 demand? ?????
• coronary vasodilation ?? blood flow? ?? O2 ???
  ????
• Nifedipine hypotension, reflex tachycardia
• Sublingual ? fast-onset preparation? ???? MI?
  ????? ?
• Slow-release form RT? ?? ventricular
  dysfunction ? ???
• Amlodipine similar to nifedipine but no effect
  on heart rate

44
Treatment of ischemic heart disb. calcium
channel blockers(2)

• Verapamil diltiazem greater effects on
  cardiac contractility AV conduction
• HR? ?? O2 demand ??
• Ventricular dysfunction, conduction abNL,
  bradyarrhythmia ?? ? ?? ????? ?
• ventricular dysfunction?? ? Diltiazem? ?? ??
• Nicardipine nimodipine same effects as
  nifedipine
• Nimodipine SAH ?? Cb vasospasm ??
• Nicardipine iv arterial vasodilator

45
Treatment of ischemic heart disc. ß-adrenergic
blocking agents

• HR? contractility? ?? myocardial oxygen demand?
  ????
• Membrane stabilization Intrinsic
  sympathomimetic properties
• Low dose beneficial for compensated CHF
• Nonselective ß-receptor blockade
• C/I in significant ventricular dysfunction,
  conduction abNL, bronchospastic dis, Vasospastic
  angina
• ß2-adrenergic receptors blockade
• Can mask hypoglycemic Sx in awake DM Pt.
• Delay metabolic recovery from hypoglycemia

46
Treatment of ischemic heart disd. other agents

• ACE inhibitors
• Prolong survival in CHF or LV dysfunction
• Digoxin
• Rapid ventricular response ??? artrial
  fibrillation
• Cardiomegaly Pt (?? Sx ?? ??)
• Chronic aspirin therapy ?? ?? ?? ??
• Inducible sustained ventricular tachycardia or
  ventricular fibrillation
• Automatic internal cardioverter-defibrillator
  (ICD) ?? ??

47
ISCHEMIC HEART DISEASE

• PREOPERATIVE MANAGEMENT

48

• Perioperative outcome? disease severity?
  ventricular function? ??
• Extensive(3-vessel or Lt main) CAD, recent Hx of
  MI, or ventricular dysfunction
• gt greatest risk for cardiac complications
• Perioperative MI ? non-Q wave infarction????
  mortality rates? 50? ??
• Preop. PCI high-risk Pt?? cardiovascular Cx ?
  ???? ??? ??
• ?? postsurgical bleeding? ?? ?? PCI ?? ?? 2??
  ????? ?
• Chronic stable angina ? perioperative risk? ?????
  ??
• CABG ?? coronary angioplasty Hx? ?? ????
  perioperative risk ???? ??
• Preop. ß-blocker
• Periop. Mortality ? postop. Cardiovascular Cx ??
  ??

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History

• Questions Sx, Tx, Cx, ??? evaluation ? ??
• Sx
• Include chest pains, dysnea, poor exercise
  tolerance, syncope or near syncope
• Ability to do light work at home or climb one
  flight of stairs slowly -gt 4 metabolic
  equivalents(METs)
• Very sedentary lifestyle? ?? severe dis.?? ???
  asymptomatic ? ? ??
• Easy fatigability or shortness of breath?
  compromised ventricular function ??

50
Physical examination Routine laboratory
evaluation

• Serum cardiac enzymes
• Cardiac-specific troponins (T or I), creatine
  kinase (MB isoenzyme), lactate dehydrogenase
  (LDH, type 1 isoenzyme)
• Serum digoxin levels excluding drug toxicity
• ECG
• Baseline ECG CAD ?? ??? 2550?? NL
• Very straight ST underlying CAD? ??
• m/c baseline abNL nonspecific ST- T-wave
  changes
• Prior infarction infarct ??? lead?? Q waves or
  loss of R waves
• First-degree AV block, bundle-branch block,
  hemiblock ?? ??? ? ??
• Persistent ST-segment elevation Ix of LV
  aneurysm
• Long QT interval ventricular arrhythmia ?? ??
• gt drug toxicity? electrolyte imbalance? r/o?
  ?? Op.
• Chest film
• Screening test in excluding cardiomegaly or pulm.
  Congestion

51
Specialized studiesa. Holter monitoring

• Continuous ambulatory electrocardiographic
  monitoring
• Arrhythmias, antiarrhythmic drug therapy,
  severity frequency of ischemic episode ??? ??
• ??? frequent ischemic episodes on Holter
  monitoring correlates well with intraop. And
  postop. Ischemia
• Excellent negative predictive value for postop.
  Cardiac complications

52
Specialized studiesb. exercise
electrocardiography

• ?? Baseline ST-segment abNL unable to
  increase HR because of fatigue, dyspnea, or drug
  therapy
• Sensitivity is 65,
• Specificity is 90
• NL test NOT exclude CAD
• Low exercise level??? myocardial ischemic
  response? peri op. Cx ??? ??

53
Specialized studiesc. myocardial perfusion scans

• Exercise ?????? underlying ECG ??? ?? ??
  Thallium-201 or technetium-99m ???? myocardial
  perfusion imaging ??
• Dipyridamole ???? exercise? ??? hyperemic
  response ??
• Best for detecting 2- or 3-vessel disease
• NL perfusion scan? negative predictivive value? ?
  99

54
Specialized studiesd. echocardiography

• Regional and global ventricular function
• At rest, following exercise or with dobutamine
• Dobutamine ?? ? new or worsening wall motion
  abNL? ?? ischemia ???
• Dobutamine stress echo LBBB? ??? ??
• Ejection fraction 50??? ?? periop. Morbidity ???

55
Specialized studiese. coronary angiography

• Noncardiac surgery ?? PTCA or CABG? ?? ??? ?? ?
  ?? ??? ?? ??
• Location and severity of occusion ? coronary
  vasospasm? ?? ??
• Lt main coronary a.? ?? LV ??? ???? significant
  stenosis? ?? ??
• Indicators of significant ventricular dysfunction
• Ejection fraction lt 0.5
• LVEDP gt 18mmHg after injection of contrast
• Cardiac index lt 2.2 L/min/m2
• Marked or multiple wall motion abnormalities

56
Premedication

• ?? fear, anxiety, pain? ??
• Sympathetic activation? ?? ?
• Overmedication? hypoxemia, resp. acidosis,
  hypotension ??? ? ???? ???
• Benzodiazepine, alone or with opioid are m/c used
• Or morphine, 0.10.15 ?/?, and scopolamine
  0.20.4 ?, IM
• O2 via nasal cannula
• Perioperative medication? ?? ???? ????? ?
• ???? antianginal medication? ??? sudden ischemic
  episode(rebound) ??
• Prophylactic ß-blocker reduce intraop and
  postop ischemic episodes

57
ISCHEMIC HEART DISEASE

• INTRAOPERATIVE MANAGEMENT

58

• Adversely affect the myocardial oxygen
  demand-supply relationship
• Activation of sympathetic system plays a Mj role
• HTN enhanced contractility increase myocardial
  O2 demand
• Tachycardia increase demand and reduce supply

59
Objectives

• Maintaining a favorable myocardial supply-demand
  relationship
• Autonomic-mediated increase in HR and BP? deep
  anesthesia or adrenergic blockade? ??
• ??? coronary perfusion pressure or a. O2 content
  ?? ???
• a. diastolic pressure? 50?Hg ???? ??
• LVEDP? ??? ??? ventricular wall tension?
  ?????(afterload) subendocardial perfusion? ????
• ??? Hb (gt 9-10 ?/?)? a. O2 tension(gt 60?Hg) ??

60
Monitoring

• Severe CAD? Mj or multiple cardiac risk factor?
  ?? ?? ???? intraarterial pr. Monitoring
• Large fluid shift or blood loss ???? ?? ??? CVP
  or pulm. a. pr.? ??
• Pulm. a. pr.? ?? ventricular dysfunction??? ??
  (ejection fraction lt 40-50)
• Intraop. detection of ischemia
• Recognition of ECG change
• Hemodynamic manifestation
• Regional wall motion abNL on TEE

61
Monitoringa. electrocardiography

• T wave change
• Inversion, tenting, or both
• Pregressive ST-segment depression
• down-sloping horizontal ST depression? ??
  specific
• New ST elevation severe ischemia, vasospasm,
  infarction
• Lead II for inferior wall ischemia and arrhythmia
• Lead V3 for anterior wall ischemia

62
Monitoringb. hemodynamic monitoring

• HTN, tachycardia m/c hemodynamic abNL
• Hypotension progressive ventricular
  dysfunction? ??
• Ischemia? ?? PCWP? ??? ??
• Wedge waveform?? prominent v wave? ??? ?? acute
  MR? ??

63
Monitoringc. TEE(transesophageal
echocardiography)

• Detecting global and regional cardiac dysfunction
  valvular function
• ?? ECG ?? ?? venticular wall motion? ??? ?? ???
• Decreased systolic wall thickening? ??? index for
  ischemia

64
Internal cardioverter-defibrillator management

• Surgical electrocautery ??? ?? ??
• Ventricular fibrillation?? ???? ICD firing
• Cautery artifact? ?? pacemaker function ??
• Rate-responsive sensor ???? pacing rate ??
• ????? defibrillator ?? ? ?

65
Choice of anesthesiaa. regional anesthesia

• Extremities, perineum, lower abd. ??? regional
  anesthesia? ?? ??? ? ? ??
• Spinal or epidural anesthesia? BP ??? ??
  phenylephrine(25-50?)? ??? iv fluid? ??
• Bradycardia ??? ephdrine (5-10?) ??
• Prior volume loading?? marked hypotension ??
• Epinephrine (2-10?) ?? ??

66
b. general anesthesia1. induction

• Moderate to severe CAD
• 3-vessel dis, Lt main dis, or ejection fraction lt
  40)
• ??? ????(a. BP reaches its lowest acceptable
  limit)? intubation? vasopressor response? ??
• ??? ??? ??, ??? titration
• Eyelid reflex ??? ? ?? muscle relaxant ??,
  controlled ventilation ??

67
b. general anesthesia2. Choice of agents

• Induction agents
• Ketamine indirect sympathomimetic effect? C/I
• Benzodiazepine ketamine EFlt30?? ??
• Opioid ??? cardiac depression ??
• High dose opioid? withdrawal of elevated baseline
  sympathetic tone?? ??? cardiac depression ?? ? ??

68
b. general anesthesia2. Choice of agents

• Maintenance agents
• ?? opioid-volatile anesthetic technique ??
• N2O? opioid ??? cardiac depression ??
• All volatile agent? demand? supply?? ? ???
• ??? ischemia ??? oxygenation Hct check ?
  hemodynamic abNL (hypotension, HTN, tachycardia)
  ??
• ?? ?? ??? iv NTG start

69
b. general anesthesia2. Choice of agents

• Muscle relaxants
• Rocuronium, vecuronium, pipecuronium, doxacurium
• Vecuronium or atracurium? opioid? ??? severe
  bradycardia ??
• Succinylcholine autonomic ganglia, cardiac
  muscarinic receptor ?? ? HR? BP? ?? ??
• Reversal CAD ???? ? ?? ??
• Atropine ?? glycopyrrolate ???? ??? tachycardia ??

70
ISCHEMIC HEART DISEASE

• POSTOPERATIVE MANAGEMENT

71

• ??? oxygenation? ? ??? ?? ??
• Shivering meperidine 20-30? iv ??
• Hypothermia forced-air surface warmer ??
• Postop pain? ??
• Fluid overlead ??? ??? poor ventricular functon
  ?? ? CXR ??
• Pulm. Congestion furosemide 20-40 ? iv
• Non-Q-wave infarction ? 50????? chest pain ????
  routine postop 12-lead ECG ??

72
VALVULAR HEART DISEASE

• 1. General evaluation of patients

73
1. General evaluation of patients

• ????
• Severity of lesion
• Hemodynamic significance
• Residual ventricular function
• Presence of secondary effects on pulmanary,
  renal, hepatic function
• CAD, MI ?? ??

74
History

• Ventricular fuction? ??? Sx? ?? ??? lab data?
  focus??? ?
• Exercise tolerance
• Fatigability
• Pedal edema
• Shortness of breath in general(dyspnea)
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Review of medication efficacy, side effects ?
• Digoxin AF ?? ???? ventricular rate ??
• Digoxin toxicity
• Arrhythmia
• N/V
• Confusion
• Altered color perception or scotomas

75
Physical examination

• Signs of CHF
• Lt sided
• S3 gallop
• Pulmonary rales
• Rt sided
• Jugular venous distention
• Hepatojugular reflux
• Hepatosplenomegaly
• Pedal edema
• Auscultation?? valvular dysfunction? ? ? ???
  echocardiographic study? ?? ??

76
Laboratory evaluation

• LFT chronic Rt sided failure? ?? hepatic
  dysfunction ??
• ABGA
• PT, aPTT reversal of anticoagulants
• ECG ?? nonspecific
• Special studies
• Echocardiography, radionuclide angiography,
  cardiac catheterization
• ??? ??
• ?????? ?? valve? ??? ?? ?????
• Lesion? severity? ?????
• ?? ??? ventricular impairment? ??????
• ?? ??? ???? ???? ??? ????
• CAD? ??? ?????

77
VALVULAR HEART DISEASE

• 2. Premedication

78
2. Premedication

• NL ventricular function ?? ????? standard dose?
  premedication ??
• Poor ventricular function reduced doses
• ?? ?? ?? ??? ???? ???? ??
• Supplemental O2 pulm. HTN or ??? pulm. dis.

79
Antibiotic prophylaxis anticoagulation Mx

• abNL? ?? endocarditis ???? ??
• Bacteremic events dental, oropharyngeal or
  nasopharyngeal, gastrointestinal, genitourinary
  surgery or I D
• General guideline? ?? ??? prophylaxis ??
• Anticoagulant? ???? ? 1-3?? ??
• Thromboembolic Cx ??? ??? embolism or thrombus
  Hx, AF, prosthetic mechanical valve? ?? ??
• Mitral or tricuspid position? caged-ball
  mechanical (Starr-Edwards) prosthesis valve? ??
  ??? ?? ??
• Tilting disc (St. Jude) valve? intermediate
• Bioprostheses (porcine or bovine tissue valve)?
  ?? ??
• ?? 3?? warfarin? ????, ?? 2-3?? restart
• Thromboembolic risk ?? ??? ?? 1?? anticoagulation
  ?? ? Vit.K or FFP ??? reverse ??
• Surgical hemostasis? ??? ?? ??? 12-24??? IV
  heparin therapy ??

80
(No Transcript)
81
VALVULAR HEART DISEASE

• 3. Specific valvular disorders

82
MITRAL STENOSISPreoperative considerations

• ?? acute rheumatic fever? delayed Cx? ??
• Female? 2/3
• Acute disease??? ??? 2? ??? stenotic process ???
• Progressive fusion calcification of valve
  leaflets
• Sx? ??? 20-30? ?
• Mitral valve orifice? ?? (4-6 ?)?? 2 ????
• 50???? mitral regurgitation ??,
• 25?? rheumatic involvement of aortic valve
  ?? (stenosis or regurgitation)

83
MITRAL STENOSISPathophysiology

• Rheumatic process
• Valve leaflets to thicken, calcify, funnel shaped
• Annular calcification
• Mitral commissures fuse, chordae tendinae fuse
  and shorten, valve cusps become rigid
• ?? valve leaflet? ???? bowing or doming
• LA pr.? acute elevation? pulm. Capillary? ??
• Mean pulm. Capillary pr? 25?Hg??? ?? pulm. Edema
• Chr. Elevation? pulm. Lymph flow ??? ?? ?????
  irreversible increases in PVR pulm. HTN ??
• Lung compliance ???? chronic dyspnea ??
• RV afterload ??? RVF ???? RV dilatation, TV or
  PV regurgitation ??

84
MITRAL STENOSISPathophysiology (2)

• MS AF?? embolic event ??
• To the cb. Circulation, or pulm.
• Emboli, pulm. Infarction, hemoptysis, recurrent
  bronchitis ??
• 10-15?? chest pain ??
• Emboli in coronary circulation or acute RV pr
  overload ??
• Enlarged LA? Lt recurrent laryngeal n. ??
  hoarseness ?? ??

85
MITRAL STENOSISTreatment

• Sx ????? 5-10?? ???, ???? 2-5? ?? ??
• Significant Sx ?? ?? surgical correction (open
  valvuloplasty) ??
• Recurrent MS ??? valve replacement ??
• Percutaneous transseptal balloon valvuloplasty
• Selected young or pregnant Pt, older Pt.(poor
  surgical candidates)
• Medical Mx supportive
• Limitation of physical activity, sodium
  restriction, diuretics
• Digoxin AF rapid ventricular response ???
• ß-adrenergic blocker mild to moderate Sx
• Emboli or high risk(40???, large atrium with chr.
  AF)
• -gt anticoagulation

86
MITRAL STENOSISAnesthetic management

• Objectives
• Maintain a sinus rhythm
• Avoid tachycardia, CO ??, hypovolemia, fluid
  overload
• Monitoring
• Full hemodynamic monitoring
• Direct intraarterial pressure, pulmonary artery
  pressure
• ??? ????? pulm. Edema ??
• PCWP? transvalvular gradient? ??
• ECG ??? ????? notched P wave ???
• CVP ?? prominent cv wave? secondary tricuspid
  regurgitation? indication

87
MITRAL STENOSISAnesthetic management(2)

• Choice of agents
• Spinal epidural anesthesia? vasodilating
  effect? ?? ??
• Ketamine? sympathetic stimulation?? ???,
• pancuronium? tachycardia ????? ??? ?
• Opioid? volatile agent?? ?? ??? ? ? ??
• Volatile agent
• Halothane HR ??? vasodilating ??? ??
• ?? volatile agent ?? ?? ??
• N2O? PVR? ??? ???? ? ???? ??
• Intraop. Tachycardia??? Deepening anesthesia with
  opioid, ß-blocker ??
• AF ????? diltiazem or digoxin?? ventricular rate
  ??
• Sudden SVT ??? cardioversion ??? ?? ??
• Phenylephrine?? ß-adrenergic agonist activity?
  ???? ephedrine?? ??

88
MITRAL REGURGITATIONPreoperative considerations

• Chronic MR? ??
• Rheumatic fever
• Congenital or developmental abNL of valve
  apparatus
• Dilation, destruction, or calcification of mitral
  annulus
• Acute MR? ??
• Myocardial ischemia or infarction
• Infective endocarditis
• Chest trauma

89
MITRAL REGURGITATIONPathophysiology

• Systole ??? ??? LA? ???? forward stroke volume?
  ??
• LV? dilating increasing end-diastolic volume
• LV afterload? ????
• End-diastolic volume? ???? volume-overloaded? LV?
  ejection fraction? ????? CO? ????? ??? ? ??
• Eccentric Lt ventricular hypertrophy ??
• Regurgitant volume? valve orifice? ??, HR,
  systole ??? LV-LA pr. Gradient? ?? ???
• Atrial compliance ?? ????? ?? ??
• Acute MR??? atrial compliance? ???????? pulm.
  Congestion edema ??
• Long-standing MR??? low CO? ??? ??

90
MITRAL REGURGITATIONTreatment

• Medical treatment
• Digoxin, diuretics, vasodilators (ACE inhibitors)
  ?
• Afterlod ??? ??
• SVR ??? forward SV ??? regurgitant volume ????
• Surgical treatment
• Surgical valvuloplasty
• Valve replacement? ???? ??? ?? ??

91
MITRAL REGURGITATIONAnesthetic management

• Objectives
• MR? ??? LV function? ?? ??
• Slow HR, acute increase in afterload ?? ?
• HR 80100 bpm ??
• ????? ? ????? ?? acute increase in LV afterload?
  ?? ????? ?
• Monitoring
• Pulm. a. pr. Monitoring ??? (large v wave, rapid
  y descent)
• Color-flow Doppler TEE? ?? MR???? ????
• Choice of agent
• ??? ? ??? ventricular function? ?? ??? ???? ?????
  ? ??
• Spinal, epidural anesthesia are well tolerated
• ?? MR ??? volatile agent? depressant effect? ??
  ????? opioid-based anesthetic? ?? ??? ? ???
  bradycardia ??? ??? ?
• Opioid-based anesthetic? pancuronium ??? ???

92
MITRAL VALVE PROLAPSE Preoperative
considerations

• ??
• Midsystolic click with or without late apical
  systolic murmur
• ??? ??? ?? ??? ? 5?? ??
• Post. Mitral leaflet?? ?? ?? ??
• Marfan synd ?? connective tissue disorder?? ??
  incidence ??
• ??
• Auscultation ? ???? click ? ??
• Echocardiography ??? systolic prolapse of MV
  leaflets into the LA (confirm)

93
MITRAL VALVE PROLAPSEPreoperative considerations
(2)

• ????
• ??? asymptomatic, ????? myxomatous degeneration
• Chest pain, arrhythmias, embolic events, florid
  mitral regurgitation, infective endocarditis,
  rarely sudden death
• Ventricular volume (preload)? ???? ? prolapse ???
• ECG ?? ??, ???? inverted or biphasic T wave or
  ST-segment change
• PSVT ?? ??? arrhythmia
• ??? NL life span ??

94
MITRAL VALVE PROLAPSEAnesthetic management

• ??? asymptomatic?? special care? ???
• ?? ?? Ventricular arrhythmia ??? ?? lidocaine or
  ß-blocker? ?? ? ??
• Volatile agent? ??? ?? ???? ??? ?
• MR??? ventricular size ??? ????? hypovolemia?
  ventricular emptying? ???? factor(sympathetic
  tone ??, afterload ??)? ??? ?
• Vasopressor? phenylephrine ?? pure a-adrenergic
  agonist? ???

95
AORTIC STENOSIS Preoperative
considerations

• Valvular aortic stenosis? LV outflow? Obx ???? ??
  ?? ??
• ? ?? hypertrophic cardiomyopathy, discrete
  congenital subvalvular stenosis, or, rarely,
  supravalvular stenosis
• ?? congenital, rheumatic, degenerative? ??
• Rheumatic AS? aortic regurgiration or mitral
  valve disease ?? ??

96
AORTIC STENOSISPathophysiology

• AS? ?? LV outlet obx? ??? ????? ??? ventricle?
  compensation ?? SV? ???
• Critical AS
• Aortic valve orifice? 0.50.7?? ??? ??
• ??? transvalvular gradient? ? 50mmHg ??? ??? ??
  CO ???? ??
• Advanced aortic stenosis
• ?? Dyspnea on exertion, angina, orthostatic or
  exertional syncope
• LVH? ?? Lt ventricular compliance ??
• CO? ????? ?? ???? ?????, ????? exertion ?? ???
  ???? ??? dyspnea ??
• CAD ?? angina Sx ?? ? ??

97
AORTIC STENOSISTreatment

• ?? Sx ???? 2-5? ?? ??? ??
• CHF? digoxin, ????, ??? ??? ??
• ??? ??
• Percutaneous balloon valvuloplasty
• Aortic valve replacement

98
AORTIC STENOSIS Anesthetic management

• ??
• NL sinus rhythm, HR, intravascular volume ??
• ??? fixed SV ??? ?? CO? HR? ???
• HR 6090 bpm ??? ?
• Monitoirng
• Close monitoring of ECG BP
• Severe AS ? intraarterial pr. Monitoring ??
• ??? LVEDV ??? ?? PCWP? ???? ?? ??
• TEE useful for monitoring ischemia, ventricular
  preload, contractility, valvular function,
  effects of therapeutic interventions

99
AORTIC STENOSISAnesthetic management(2)

• Choice of agents
• Mild to moderate AS spinal, epidural ??
• Preload, afterload ??? ?? hypotension ??
• Severe AS ??? spinal, epidural C/I
• Opioid-based anesthetic technique
• Minimal cardiac depression
• Etomidate, combination ketamine benzodiazepine
• Volatile agent ??? ??? myocardial depression,.
  Vasodilation, loss of normal atrial systole ??

100
AORTIC STENOSISAnesthetic management(3)

• Choice of agents
• Tachycardia, HTN? ?? ??? ??
• ?-blocker? esmolol? short half life? ???
• Hypotension 25-50? of phenylephrine?? ??
• Intraop. SVT with hemodynamic compromise
• Immediate synchronized cardioversion
• Frequent ventricular ectopy iv lidocaine?? ??
• Amidarone? supraventricular ventricular
  arrhythmia ?? ????

101
AROTIC REGURGITATION Preoperative
Consideration

• ????? slowly, chronic?? ??
• ??? ??? acute?? ????? ?
• Chronic AR
• Aortic valve? aortic root? ???? ??
• By Congenital (bicuspid valve), rhematic fever
• Ascending aorta? ??? ?? ??
• Syphilis
• Annuloarortic extasia
• Ankylosing spondylitis
• Rhematoid psoriatic arthritis
• Acute AR
• Infective endocarditis
• Trauma
• Aortic dissection

102
AORTIC REGURGITATION Pathophysiology

• LV diastole ?? blood? back flow? ?? LV volume
  overload
• SV ??
• Systemic arterial diastolic pressure? SVR ??
• Total SV SV Regurgitant volume(rV)
• rV ????
• HR
• AV? ??? diastolic pressure gradient
• (diastolic arotic pr ? LV end diastolic
  pr)
• Slow HR ? rV ??
• BP ?? ? rV ??

103
AORTIC REGURGITATION Pathophysiology

• Chronic AR
• LV ?? (cor bovinum)
• SV ?? ?? End diastolic vol ??
• ?? SV ejection fraction ??, EDP ESV ??
• Congestive heart failure ??
• rV? SV? 40 ?? ??? ??
• 60 ?? ? Severe AR
• Acute AR
• Sudden incompetence of AV, ?? ??? LV ? large
  rV ???? ??
• End diastolic pr ??? ?? ?Pul monary circulation?
  pr ?? ? acute pul congestion
• SV ??? ?? ? hypotenstion
• Myocardial oxygen demand ??
• By Musle dilatation hypertrophy
• Myocardial blood supply ??
• By Aorta? Low diastolic pr

104
AORTIC REGURGITATIONTreatment

• 1020 ? ??? ??
• ?? ?? ???? ? 5? ? ??
• Chronic AR
• Digitalis
• Diuretics
• ACE inhibitor (afterload reduction)
• Arterial blood pr ??
• Irreversible ventricular dysfunction ?? ?? ?? ??
• Acute AR
• Inotropic (dopamine or dobutamine) therapy
• Vasodilator (nitroprusside) therapy
• Early surgery ??

105
AORTIC REGURGITATION Anesthetic
management(1)

• ??
• HR? Upper normal limit (80100 beat/min) ??
• Bradycardia SVR ?? ? RV ????
• Tachycardia ? myocardial ischemia ??
• Excessive myocardial depression ??? ?
• Cardiac preload ??
• ??? ??? fluid replacement ?? pulmonary edema ???
• Monitoirng
• Full hemodynamic monitoring
• PCWP
• ???? ?? ? Acute AR ? MV? premature closure ??
• Large V wave ?LV dilatation ??
• Arterial pressure
• Very wide pulse pressure
• Color-flow Doppler TEE

106
AORTIC REGURGITATION Anesthetic
management(2)

• Choice of Agent
• Spinal epidural anesthesia ??
• ????? Vasodilation ?? ??? Isoflurane
  desflurane ??
• Musle relaxant Pancronium
• Bradycardia ??
• Nitroprusside
• Intraoperative afterload reduction
• Ephedrine
• Vasopresseor? hypotension? ??
• Phenylephrine (2450 Ug)
• Excessive vasodilaton ? ??
• ??? SVR ?? ?? AR ???? ? ?? ??

107
TRICUSPID REGURGITATION Preoperatinve
Consideration

• 7090 mild TR
• ????? ??? TR? ??
• Injecting Drug abuser? Infective endocarditis
• Rhematic fever
• Carcinoid syndrome
• Chest trauma
• Ebsteins anomaly (valve? ?? ??)

108
TRICUSPID REGURGITATION Pathophysiology

• Chronic LV failure
• Pul vascular pr ?? (Pul HTN)
• Thin walled RV ??
• Tricuspid anulus ??
• TR
• Chronic venous HTN
• Progressive hepatic dysfunction
• Cardiac cirrhosis
• Severe RV failure
• ????? ?? foramen ovale ?? Rt to Lt shunting
• Marked hypoxemia

109
TRICUSPID REGURGITATION Treatment

• ???? ??? ??? ? ??
• TR ?? ?? ????? ? ??
• Moderate, severe ??, ?? valve? ??? ?? tricuspid
  annuloplasty ??

110
TRICUSPID REGURGITATION Anesthetic Manegement

• ??
• ???? monitoring
• ??? RV SV? LV preload? ?? ?? Hypovolemia?
  hypoxia, acidosis ?? ?? RV afterload? ????? ???
  ??? ?
• PEEP?? ?? airway pr? ??? ?
• Venous return ????? RV preload ????
• Monitoring
• CVP RV ??? F/U ?? ??
• Pumonary artery pr RV afterload? LV preload ???
  ??
• Color-flow Doppler TEE TR? severity ??? ?? ???
  ?? ?? ??
• Choice of Agents
• ???? ??? ?? ??? ?? ??
• ?? ??? ??? ???? ?? coagulopathy ???? ???? ?
• ????? N2O? Pul HTN? ???? ???? ??

111
CONGENITAL HEART DIEASE
112
CONGENITAL HEART DISEASE Preoperative
Consideration

• All live birth? 1
• ?? ??? ???? ??
• ??
• Cyanosis
• Rt-to-Lt shunting
• Congestive heart failure
• Obstructive Lt ventricular out flow
• Pulmonary blood flow? ??? ??
• Shunting (PDA, foramen ovlae, VSD) ???? ?? ??? ??
• Transposition
• Total anomalous venous return
• Pulmonary atresia
• Cyanotic heart disease ??? chronic hypoxemia? ??
  ??
• Erythrocytosis ??
• High viscosity? ?? ?? ???

113
CONGENITAL HEART DISEASE Anesthetic Management -
obstructive lesion

• 1. Obstructive Lesion
• Pulmonary Stenosis
• Concentric Rt ventricular hypertrophy
• ???? Poststenotic dilation
• Valve? ?? (bicuspid, tiricuspid)? ?? ??
• Rt heart failure ?? ???
• ??? HR? ?? CO ????? ?? ?? ventricular filling ?
  ??? ??
• ??
• Percutaneous balloon valvuloplasty
• Anesthetic management
• ?? ?? ?? ?? HR ? preload ??
• PVR ?? ??

114
CONGENITAL HEART DISEASE Anesthetic Management
Lt to Rt shunt

• 2. Predominantly Left-to-Right (simple) shunts
• Atrial Septal Defect
• ?? ?? ?? ostium secundum ASD
• Fossa ovale area? ??
• ?? ?? ??? ??? ???? ??? ??
• ?? ??? ?? ??
• Recurrent pulmonary infections
• ?? ??? ???
• Congestive heart failure
• Pulmonary HTN
• Anesthetic management
• ??? ?? ?? ?? ?? ? ?? ??? tolerable
• SVR ??? Lt-to-Rt shunting? ????? ??

115
CONGENITAL HEART DISEASE Anesthetic Management
Lt to Lt shunt

• Ventricular Septal Defects
• ?? ?? ??? ??? (2535)
• ??
• Membranous (m/c)
• Muscular
• Subpulmonary (supracristal) ? AR? ??
• Dependent factor
• ??? ??
• PVR ??
• ?? ???? ??
• Pulmonary-systemic blood flow ratio? 351? ????
• Pulmonary infection? CHF ? ??
• ??
• ?? VSD? ????? ???? electrocardiography?
  echocardiography ? f/u

116
CONGENITAL HEART DISEASE Anesthetic Management
Lt to Lt shunt

• Atrioventricular Septal Defects
• Endocardial cushion (AV canal) defect
• Down syndrome? ??
• Atrial level? ventriculum ??? large shunt ??
• ??? Lt-to-Rt shunt? ?? , ??? pul HTN ?????
• Rt to Lt shunt? ?? Eisenmenger syn ??
  cyanosis ???
• Patent Dutus Arteriosus
• Pulmonary Artery? aorta ??? communication? ????
  defect
• premature infant? ???? ??
• Anesthetic goal ASD ? VSD? ??
• Prtial Anormalous Venous Return
• ? ? ??? Pumonary vein? Rt side heart? drain ??
  defect
• ?? ??? ??? secundum ASD? ??

117
CONGENITAL HEART DISEASE Anesthesia
management Rt to Lt shunt

• 3. Predominantly Right-to-Left (complex) shunts
• Tetralogy of Fallot
• ??
• Rt ventricular obstruction (d/t infundibular
  stenosis)
• Rt ventricular hypertrophy
• VSD
• Overiding aorta
• RV obx? VSD? ?? oxygenated LV blood ?? ???
  unoxygenated RV blood? ?? aorta? ???
• 2025 Pumonary stenosis
• Sympathetic tone? ???? ??
• ???? hypercyanotic spell ? ???
• ??? severity? Rt ventricular obx (PS)? ??? ?? ??

118
CONGENITAL HEART DISEASEAnesthesia management
Rt to Lt shunt

• ??
• Prostaglandin E1 (0.050.2 ug/kg/min)
• PDA closure ????
• ?? modified Blalock-Taussing (Lt subclavian-
  pulmonary artery) shunt
• Pumonary blood flow ?? ??
• Anesthetic management
• IV voume? SVR ???? ?
• PVR? ????? ??? ??? ?
• Acidosis, excessive airway pressure..
• Induction
• Ketamine IV or IM SVR ?? ?? Rt-to-Lt shunt ???
• ?? ??? ?? ?? ???? uptake ? ??? ??? ??
• Histamine? ???? ????? ???? ?
• Hypercyanotic spell
• IV fluid, phenylephrine (5ug/kg)
• Propranolol (o.1ug/kg)
• Sodium bicarbonate -gt acidosis , hypoxemia ?? ??

119
CONGENITAL HEART DISEASEAnesthesia management
Rt to Lt shunt

• Tricuspid atresia
• Rt artrium blood? foramen ovale (or ASD)? ?? LA,
  LV??..
• LV blood? PDA (or VSD)? ?? Pulmonary circulation?
• ??? ? ?? cyanosis ??
• Early survival??
• PDA ?? ?? Prostaglandin E1
• Percutaneous Rashkind balloon atrial septostomy
• Cyanosis ?? ??
• Modified Blalock Taussing shunt
• Modified Fontan procedure (RA? Rt pul artery ??
  ??)
• ?? Systemic veins flow? LA? ??? ???? ??? ?????? ?
• Anesthetic management
• High systemic venous pressure
• Low PVR
• Low Lt artrial pressure ??

120
CONGENITAL HEART DISEASEAnesthesia management
Rt to Lt shunt

• Transposition of the Great Arteries (TGA)
• ??
• RV ?aorta, LV ?Pumonary artery ??
• Oxygenated blood? lung??
• Deoxygenated blood? systemic circulation?? ????
  ?
• Survival? ?? PDA, Foramen ovale, VSD ??
• Oxygenated blood? deoxygenated blood mixing?? ??
• ??
• Prostaglandin E1
• Rashkind septostomy
• Surgical correction ???
• Arterial switch procedure
• Aorta? PA ?? ??
• Coronary artery? ??? ??? PA? reimplat ?? ?
• Atrial switch (Senning) procedure

121
CONGENITAL HEART DISEASEAnesthesia management
Rt to Lt shunt

• Total Anomalous Venous Return
• ??
• Pul vein? Lt atrium?? ???? ?? SVC, IVC, coronary
  sinus, ductus venous? ??
• Deoxygenated blood? oxygenated blood? RA?? mixing
  ?
• Blood? foramen ovale? ASD? ?? Lt atrium?? ??
• ??
• Pul vein? Lt atrium?? ?? ??
• ASD closure

122
CONGENITAL HEART DISEASEAnesthesia management
Rt to Lt shunt

• Truncus arteriosus
• ??
• Single arterial trunk? pulmonary systemic
  circulation ?? supply
• Truncus? ?? VSD? ??? ??
• ??? ? PVR ????? pul blood flow ???? Heart
  failure? ??? ?
• ??
• VSD closure
• Rastelli repair
• Truncus?? Pul artery? ???? Rt ventricle? ??

123
CONGENITAL HEART DISEASEAnesthesia management
Rt to Lt shunt

• Hypoplastic Lt Heart Syndrome
• ??
• Undevelopment of the Lt ventricle
• Rt ventricle? ??? ?? ??
• Pul artery? ?? ?? PDA? ?? aorta? ???
• ??
• Norwood procedure
• Cardiac transplantation

124
THE PATIENT WITH A TRANSPLANTED HEART
125
Preoperative Consideration(1)

• ??
• ??? ??? ??? ???? ?? ??? autonomic influence? ????
  ??
• Cardiac impulse formation? conduction? ???? vagal
  influence? ??
• High resting heart rate (100-120 beats/min)
• Sympathetic fiber? ???? ??? catecholamine? ?? ???
  ????? ??? ??
• Cardiac output low-normal
• Coronary autoregulation ??

126
Preoperative Consideration(2)

• Focus
• ??? ??? functional status
• Immunosuppression? ?? ???
• Rejection
• ? 3?? ? ???? ?? ??
• ?? arrhythmia, exercise tolerance ??
• Monitoring
• Periodic echocardiographic evaluation
• Endomyocardial Bx ?? ??
• Athrosclerosis ?? ??
• Myocardial ischemia? infarction ??? silent
• Angiography ??
• Immunosuppressive therapy
• Cyclosporine, azathioprine, prednisone
• ???
• Nephrotoxicity, bone marrow suppression,
  hepatoxicity, opportunistic infections,
  osteoporosis

127
Anesthetic Management

• ?? ?? anesthetic technique ????
• Denervation ?? ??? HR? ?? reflex ??? ?? ??? rapid
  vasodilation? ??
• Direct-acting agent? Indirect vasopressor
  (Ephedrine, dopamine) ?? ? ???
• Myocardial neuron? catecholamine? ??
• Heart rate
• ?? Isoproterenol, dilute epinephrine(10ug/ml)
• Opioid? cholinesterase inhibitor? ?? bradycardia
  ???? ??
• Anticholinergics, pancuronium, meperidine? ?? HR
  ?? ??? ??
• Anticholinergic? reverse muscle relaxant? ??? ?
• Ach? Noncardiac muscarinic effect ??? ??
• Monitoring
• ECG ??? p wave ???
• Recipient own SA node