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THIS IS CASE REPORT OF HOCM PATIENT,WHICH WAS FOR ORTHO.SURGERY. ANAESTHESIA CONDUCTED SUCCESSFULLY.

THIS IS CASE REPORT OF HOCM PATIENT,WHICH WAS FOR ORTHO.SURGERY. ANAESTHESIA CONDUCTED SUCCESSFULLY.

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  • 1. Anaesthesia for HOCM patient Dr. Nilesh Parikh MD,PDCC (Card.Anaes) Consultant Anaesthesiologist NADIAD
  • 2. HypertrophicObstructiveCardiomyopathy Dr. Nilesh Parikh
  • 3. Here is a patient named Kamlaben B Patel 85 yrs.Old,having # N/F, requring DHS Surgery.pt. is a known case of HTN Since 15 yrs. and she istaking Tab Amlodepine-Atenolol combination.Patient has been investigated and diagnosed tohave HOCM by 2D ECHO., how would you proceedfor this case?
  • 4. Hypertrophic obstructive cardiomyopathy Overview• Background• Pathophysiology• Clinical picture• Diagnosis• Treatment• Anesthetic consideration 4
  • 5. Hypertrophic Obstructive CardioMyopathy (HOCM) is a raregenetic disorder characterized by left ventricular outflow tract(LVOT) obstruction. Clinical presentation ranges from absence of symptoms tosudden death. These patients presents considerable challenges and requiresmaintenance of desired hemodynamic parameters andmanagement of specific complications. Factors like Tachycardia, Hypovolemia, Vasodilation andincreased cardiac contractility leads to exacerbation of theobstruction. Decrease in venous return and SVR or increase inmyocardial contractility worsens the LVOT obstruction. These patients are highly prone to arrhythmias like AF & VT Management of anesthesia in these patients posesconsiderable challenges for the anesthesiologist.
  • 6. BackgroundPrevalence of HCM: 1:500 to 1:1000 individuals ○ This occurrence is higher than previously thought, suggesting a large number of affected but undiagnosed peopleMen affected by almost 2:1 ratio over womenGlobal disease with most cases reported from USA, Canada, Western Europe, Israel, & Asia Most common cause of SCD, age < 40 yr Most common cause of SCD, in competitive athletes
  • 7. Normal Anatomy 7
  • 8. Hypertophic cardiomyopathy (HOCM) 8
  • 9. Hypertrophic cardiomyopathy (HOCM) 9
  • 10. Pathophysiology of HOCMInvolves 4 interrelated processes: – Left ventricular outflow obstruction – Diastolic dysfunction – Myocardial ischemia – Mitral regurgitation
  • 11. Pathophysiology• Hypertrophy: in any region of left ventricle• SAM: systolic anterior motion of anterior MV leaflet against hypertrophic septum (Bernoulli effect) dynamic pressure gradient across LV outflow tract midsystolic intraventricular obstruction of the flow• SAM - Septal Contact dynamic obstruction increased by:  afterload  preload  contractility 11
  • 12. Pathophysiology• Diastolic Dysfunction - Due to prolongation of isovolumic relaxation time (AV closure to MV opening) -  LV filling pressure -  Ventricular volume - Atrial contribution to ventricular filling ~ 75%• Poor Compliance -  LVEDP for any LVEDV -  CPP gradient - Subendocardial ischemia 12
  • 13. Symptoms:Dyspnea on exertion (90%) - Reduced diastolic relaxation & LV fillingAngina (70-80%) - Inadequate myocardial perfusionSyncope (20%) - Vasovagal attack/ transient arrhythmias Palpitation (10%) - AF - Loss of atrial contribution in LV filling - Rapid rate - 50 % pts of AF manifests as systemic embolisation
  • 14. Hypertophic cardiomyopathy (HOCM)• Lab studies: – Blood test: non specific – Genetic testing: for high risk group• ECG: – ST-T wave abnormalities – LV hypertrophy, LA enlargement – Axis deviation (left > right) – Conduction abnormalities (P-R prolongation, BBB) – A-fib (poor prognostic sign) 14
  • 15. ElectrocardiogramLV strain patternLBBB/ RBBB / Lt ant hemiblock
  • 16. ECG
  • 17. Hypertophic cardiomyopathy (HOCM)• Two - Dimensional Echocardiography and Doppler • MR and Mitral prolapse • Flow velocity: > 4.0 m/s • LV outflow gradient: > 50 mm Hg • EF : high to normal • Small LV cavity • Left atrial enlargement • Septal thickness: 4-6 mm thicker than normal • The hallmarks: – SAM of Mitral valve – Asymmetric septal hypertrophy 17
  • 18. X ray Cardiomegaly LA enlargement Small aortaPulmonary edema
  • 19. CXRHOCM Cardiac enlargement > 1/2 thoracic width 19
  • 20. Hypertophic cardiomyopathy (HOCM)• Goals: –  Ventricular contractility » Myocardial depression –  Ventricular volume » Volume loading –  Ventricular compliance and outflow tract dimensions –  Pressure gradient across the LVOT – Vasoconstriction 20
  • 21. Hypertophic cardiomyopathy (HOCM) Medications• Beta-Blockers: (Metoprolol, Propranolol, Atenolol, Sotalol )• Calcium Channel blockers: (Verapamil)• Antiarrhythmic: amiodarone and disopyramide• Antitussives: avoid coughing 21
  • 22. Hypertophic cardiomyopathy (HOCM) Beta - blockers Pressure gradient across LVOT –  Inotropic state of left ventricle. –  Diastolic dysfunction –  Lt. Ventricle compliance HR –  Myocardial oxygen consumption –  Myocardial ischemia potential 22
  • 23. Calcium Channel Blockers: VerapamilImproves symptoms and exercise capacity (patients without marked obstruction to LV outflow)Beneficial effect on ventricular relaxation and fillingBetter angina control than BBHemodynamic deterioration with CCB agents - lowering of the afterload in the presence of severe outflow tract gradients and high diastolic filling pressures
  • 24. Hypertophic cardiomyopathy (HOCM) Antiarrhythmics• Amiodarone (Cordarone) To date, Only one pharmacological agent, has been shown to reduce the incidence of arrhythmogenic sudden cardiac death 24
  • 25. Hypertophic cardiomyopathy (HOCM) Contraindication• Inotropic• Sympathomimetic• Nitrates • Except in patients with CAD• Digitalis • Except with uncontrolled A-fib.• Diuretics •  Preload and ventricular volume •  Outflow gradient 25
  • 26. Hypertophic cardiomyopathy (HOCM) Anesthetic considerations Pre-operative period• Pre-medication – Avoid anxiety producing tachycardia• -blocker and/or Ca++ channel blocker – Continue untill the day of surgery and postoperative• Avoid arrhythmia – Aggressive treatment of arrhythmia • Antiarrhythmic Meds • Cardioversion• Maintain adequate intravascular volume and preload 26
  • 27. Hypertophic cardiomyopathy (HOCM) Anesthetic considerations Inhalation Anesthetics• Negative inotropy• Decrease SAM-Septal contact• Ideal for dose dependant myocardial depression (Halothane > Enflurane > Isoflurane > Desflurane, Sevoflurane)• Avoid hypotension due to underlying hypovolemia 27
  • 28. Hypertophic cardiomyopathy (HOCM) Anesthetic considerations Regional anesthesia• Relatively contraindicated• Spinal should be avoided• Epidural can be given• Avoid bolus administration• Avoid hypotension • Replace intravascular volume • Use Vasopressors like noradrenaline and phenylephrine 28
  • 29. Hypertophic cardiomyopathy (HOCM) Anesthetic considerations IV Vasopressors• Phenylepherine /Noradrenaline – Low risk / high yield choice for hypotension – Augment perfusion and CPP – Decrease pressure gradient – Increase vagal reflex 29
  • 30. Hypertrophic cardiomyopathy (HOCM) Anesthetic considerations• MR with HOCM Inotropes and Vasodilators worsen ventricular ejection Vasoconstrictors improve ventricular ejection 30
  • 31. Here is a patient named Kamlaben B Patel 85 yrs.Old,having # N/F, requring DHS Surgery.pt. is a known case of HTN Since 15 yrs. and she istaking Tab Amlodepine-Atenolol combination.Patient has been investigated and diagnosed tohave HOCM by 2D ECHO., how would you proceedfor this case?
  • 32. What would we the choice ofAnaesthesia?? Spinal? Epidural? General anaesthesia
  • 33. I planned Epidural for this patient.Pt.taken in OT. Venous access with two peripheral lines.Oxygen started and connected with monitor. First dose inj.xylocaine 2% 15 cc given. Sooner after this dose, inj. Noradrenaline infusion started @ 1ml/hr.(4mg/50cc)It was incresed to 2ml/hr.as per need. (dose of Norad. is 0.04-0.4 mcg/kg/min) IV fluids inj.Hydrxyethyl starch 500 ml and one unit of Blood. Oxygen @3-4 lit/min given continuously. inj.Antibiotic, patoprazole, ondansetron given. Second dose of Epidural inj.Bupivacaine 3 cc given. Patient remained stable intra and post op. Shifed to ICU ,Where oxygen continued with monitoring. Patient’s vitals were as follow:
  • 34. Vital parameters of patient : HOCM-DHS 10/1/2013TIME HEART SYSTOLIC DIASTOLIC SPO2% RATE BP BP8:28 am 56 153 58 938:33 54 154 58 999:10 58 116 42 989:23 57 107 38 989:33 53 111 39 989:43 52 108 39 999:53 54 129 40 9910:03 54 148 44 10010:13 55 158 45 10010:23 54 156 45 9911:30 55 158 50 99
  • 35. Comments: Any patient with HTN and ECG changesalways get cardiac evaluation done. Patients with HOCM ,presenting for surgerywhere regional anaes. is preferred,Always maintainHemodynamics with vasopressors and fluids. Don’tgive any Inotropic or chronotropic agents. Keep Defibrillator available ,as pts. are highlyprone for Arrythmias. Pt’s preload should be maintained adequetely.
  • 36. Message: G/A TAKE CARE OF ME spinal EPIDURAL Thank you