Bradiarritmias en el postoperatorio de cirugía cardiaca
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Bradiarritmias en el postoperatorio de cirugía cardiaca
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Bradiarritmias en el postoperatorio de cirugía cardiaca
- 1. BRADIARRITMIAS EN EL POSTOPERATORIO DE CIRUGÍA CARDIACA Alejandro Paredes C. MD, MSc. Cardiólogo Electrofisiólogo Profesor Asistente Adjunto Santiago, Agosto 2021.
- 2. GENERALIDADES Taqui-Bradiarritmias no son infrecuentes en el postoperatorio de Cx. Cardiaca. Representan un aumento en la morbi- mortalidad, prolongaciones de estadías hospitalarias y costos económicos asociados. Bradicardias: la mayoría de las veces los episodios son transitorios.
- 3. INTRODUCCIÓN • Necesidad de marcapasos definitivo (MPD) después de cirugía cardíaca: 0,4-6%. • Mecanismos: Traumatismo mecánico – Isquemia daño en sistema de generación & conducción del impulso. • Considerar anomalías estructurales o electrofisiológicas preexistentes no diagnosticadas. • Identificación de pacientes en alto riesgo de requerir MPD.
- 5. FACTORES A CONSIDERAR Paciente • Edad • Enfermedad cardiaca estructural • Trastornos del sistema de conducción previos. • Comorbilidades extracardiacas Tipo de cirugía y/o intervención • Trauma e inflamación • Estrés hemodinámico • Injuria/Isquemia • Fármacos • Trastornos hidroelectrolíticos
- 8. › Fisiológicas: Reposo, jóvenes, deportistas. › Acción farmacológica: Betabloqueadores, Calcio-antagonistas, Amiodarona. › Patológicas: › Disregulación autonómica › “Descargas” vagales › Isquemia REVERSIBLES › Alteraciones Electrolíticas › SAHOS › Hipotiroidismo › Enfermedad del tejido excitoconductor (Degenerativa) IRREVERSIBLES
- 10. › Disfunción, enfermedad del nodo sinusal o síndrome del seno enfermo. › Incidencia máxima entre 7ª y 8ª décadas. › Entidades: › Bradicardia sinusal persistente (<40 lpm durante el día). › Pausas o paradas sinusales › Bloqueo de salida sinoauricular. › Incompetencia cronotrópica. › Taquicardia auricular (incluidos FA o flutter auricular) › Síndrome de bradicardia-taquicardia.
- 11. › Primera indicación de MP en el mundo. › Lugar del bloqueo determina comportamiento y potencial tratamiento. › Primer grado › Segundo grado Benignos › Mobitz I o Wenckebach › Mobitz II › 2:1 › “Alto grado” Malignos › Tercer grado o BAVC
- 15. CIRUGÍA CARDIACA • Reemplazo valvular + CRM: bradicardia es causada principalmente por BAV de alto grado o completo y requieren MP definitivo en 2- 4% de los pacientes. • CRM: disfunción del nodo o BAV con requerimiento de MP en 0.4- 1.1% de los pacientes. • Estimulación permanente podría llegar hasta 20-24% después de algunos procedimientos en estenosis aórtica calcificada o reemplazo tricuspídeo.
- 16. CIRUGÍA CARDIACA • Reemplazo valvular mitral: se asocia a trastorno de la conducción AV en 30% de los casos y a BAVC en 1.5% de los pacientes. • Atriotomía lateral derecha o accesos transeptales superiores pueden generar ENS, bradicardias sinusales o ritmos de la unión persistentes. • Trasplante cardiaco ortotópico: • ENS es común y tiene necesidad de MPD en hasta 21% de los casos (promedio 8%) vs BAVC con 4.5% • Necesidad de marcapaso definitivo es mucho menor con técnica bicava (2-4%) vs biatrial (10-14%). • Presencia frecuente de incompetencia cronotrópica por pérdida de control autonómico. • Tiempo de espera sugerido en caso de bradicardia sintomática: 3 semanas.
- 17. Otros MIOCARDIOPATÍA HIPERTRÓFICA • Necesidad de MPD va de 10-33% para alcoholización septal y 3-4% para miectomía quirúrgica. • Riesgo aumenta de 2% a 10% en presencia de trastornos ECG previos. • 60% de BCRD en alcoholización septal. • Hasta 90% desarrollan BCRI post miectomía. CARDIOPATÍAS CONGÉNITAS • Presentación a edades tempranas. • ENS aumenta el riesgo de arritmias auriculares. • ENS-BAV aumentan la mortalidad. • Etiología multifactorial. • Presencia de múltiples electrodos.
- 18. FACTORES DE RIESGO • Edad avanzada • Sexo femenino • Necesidad de reoperación • Cirugía valvular previa (7.7% vs 2.2%) • Anomalías de conducción preexistentes: • Intervalo PR> 200 ms • Bloqueos de rama izquierda (BRI)
- 20. TAVI • Necesidad de MP definitivo: 14.2% (CoreValve: 20.8% - Edwards- Sapien: 5.4%). • Presencia de BCRIHH es frecuente postprocedimiento (19-55%). • FR: trastornos de conducción previos, anatomía valvular y tipo de prótesis utilizada. • Tiempo de espera: 2-3 días.
- 26. MANEJO • Marcapaseo temporal en caso de bradiarritmias sintomáticas. • Pacientes con MPD por ENS 30-40% se mantienen dependientes. Esta recuperación es menor en caso de bloqueos AV (65-100% para BAVC). • Tiempos de observación en el postoperatorio: 5 a 7días.
- 28. PALABRAS FINALES • Arritmias son frecuentes en el postoperatorio de Cx. Cardiaca • Taquiarritmias > Bradiarritmias • La mayoría de los trastornos son transitorios y se recuperan espontáneamente. • Identificación de población de alto riesgo. • Proporcionar a los pacientes información precisa sobre el riesgo de MP definitivo en relación con su intervención.
- 29. BRADIARRITMIAS EN EL POSTOPERATORIO DE CIRUGÍA CARDIACA ALEJANDRO PAREDES C. faparedes@uc.cl www.slideshare.net/JanoMD @montecristomd
Editor's Notes
- Arrhythmias are a known complication after cardiac surgery and represent a major cause of morbidity, increased length of hospital stay, and economic costs. Transient bradyarrhythmias may be managed with temporary pacing wires placed at surgery, but significant and persistent atrioventricular block or sinus node dysfunction can occur with the need for permanent pacing.
- La mayoría de las veces los episodios son transitorios. The right bundle branch block (RBBB) was the most frequently noted abnormality. Bradyarrhythmias may decrease cardiac output in patients with relatively fixed stroke volumes.
- Those undergoing aortic valve replacement are at exceptionally high risk because of the proximity of the valve to the conduction tissue. Up to 8.5% of patients may require a permanent pacemaker after aortic valve replacement. The presence of proximal disease of the left anterior descending coronary artery also seems to increase the risk.
- Bradyarrhythmias may decrease cardiac output in patients with relatively fixed stroke volumes.
- Because the aortic valve is anatomically located near the bundle of His, while the mitral valve is close to the atrioventricular node, atrioventricular block after aortic valve surgery has a lower threshold for recommending pacing compared with the mitral valve
- Methods Data was collected retrospectively from a single tertiary institution from October 2018 to April 2019 inclusive of 403 patients. Incidence of PPM implantation after various cardiac operations was evaluated. A univariate analysis was carried out to identify the independent risk factors related to PPM implantation. Results Ten patients required a PPM (2.48%). The most common indication for PPM implantation post-cardiac surgery was complete heart block (N = 7, 70%) followed by bradycardia/pauses (N = 2, 20%) and sick sinus syndrome (N = 1, 10%). PPM implantation after coronary artery bypass graft (CABG) surgery was the lowest (0.63%), while combined CABG and valve operations had the highest incidence (5.97%). Independent risk predictors for PPM implantation included female gender (p =0.03), rheumatic heart disease (p = 0.008), pulmonary hypertension (p=0.01), redo operations (p = 0.002), mitral valve procedures (p = 0.001), tricuspid valve procedures (p = 0.0003) and combined mitral and tricuspid valve procedures (p = 0.0001). Average length of intensive care unit (ICU)/high-dependency unit (HDU) stay was significantly prolonged for patients who required a PPM post-cardiac surgery. Conclusion As clinicians, it can be challenging to provide our patients with accurate information on the risk of PPM implantation relative to their operation. A unit-specific data may be a more accurate method of informing our patients on this risk.
- Bradyarrhythmias are particularly common after valve surgery and are a consequence of direct surgical injury and local edema. Significant risk factors for high-degree AVBs include perivalvular calcification, older age, preoperative left bundle branch block, left ventricular aneurysmectomy, left main coronary artery stenosis, number of bypassed arteries, and cardiopulmonary bypass time.
- A complete heart block might also develop following an AFib catheter or surgical ablation procedure, especially when radiofrequency energy is delivered nearby the septal región. Predictive factors for bradyarrhythmias after heart transplantation include older donor age, longer donor ischemic time, and longer aortic cross-clamp time. Sinus node function after orthotopic heart transplantation often improves over long-term followup, but recovery might proceed over weeks to months. Possible causes of sinus node dysfunction include surgical trauma, sinus node artery damage, or ischaemia and prolonged cardiac ischaemic times AV block is less common and is probably related to inadequate preservation of the donor heart.
- Transient atrioventricular block after alcohol septal ablation is observed in approximately 15% to 50% of patients and usually resolves within 24 hours. Protocols for implantation of a PPM varied from study to study, but most implanted a PPM if complete atrioventricular block was present >24 hours after alcohol septal ablation although actual time of implant varied with a range of 2 to 7 days.
- Significant risk factors for high-degree AVBs include perivalvular calcification, older age, preoperative left bundle branch block, left ventricular aneurysmectomy, left main coronary artery stenosis, number of bypassed arteries, and cardiopulmonary bypass time. Those undergoing aortic valve replacement are at exceptionally high risk because of the proximity of the valve to the conduction tissue. Up to 8.5% of patients may require a permanent pacemaker after aortic valve replacement. The presence of proximal disease of the left anterior descending coronary artery also seems to increase the risk.
- Si bien los estudios han demostrado que el TAVI es una alternativa no inferior a los reemplazos quirúrgicos de la válvula aórtica (AVR por sus siglas en inglés), se ha informado que las tasas de MPP después del TAVI son significativamente más altas, alcanzando porcentajes tan altos como el 34% frente al 2-8% en AVR quirúrgico.
- Patients receiving selfexpanding valves required permanent pacing more frequently than those receiving a balloon-expandable valve (15.9% vs. 3.7%; p . 0.001).
- Male sex, baseline conduction disturbances, and intraprocedural AV block emerged as predictors of PPM implantation after TAVR. This study provides useful tools to identify high-risk patients and to guide clinical decision making before and after intervention.
- Methods: Components of the score included pre-TAVR left and right bundle branch block, sinus bradycardia, second-degree AV block, and transfemoral approach. The scoring systemwas applied to 917 patients undergoing TAVR at our institution from November 2011 to February 2017.We assessed its predictive accuracy by looking at two components: discrimination using the C-statistic and calibration using the Hosmer-Lemeshow goodness of fit test. Results: Ninety patients (9.8%) required PPM. The scoring system showed good discrimination with C-statistic score of 0.6743 (95% CI: 0.618-0.729). Higher scores suggested increased PPM risk, that is, 7.3% with score≤3, 19.23% with score 4-6, and 37.50% with score≥7. Patients requiring PPM were older (81.4 versus 78.7 years, P = .002). Length of stay and in-hospital mortality was significantly higher in PPM group. Conclusions: The NIS database derived PPM risk prediction model was successfully validated in our database with acceptable discriminative and gradation capacity. It is a simple but valuable tool for patient counseling pre-TAVR and in identifying high-risk patients.
- Dispositivos capaces de generar estímulos eléctricos lo suficientemente intensos como para favorecer la despolarización del miocardio.
- In case of complete AV block occurring in the first 24 hours after aortic and mitral valve surgery and persisting for 48 hours, resolution within the next 1 to 2 weeks is unlikely and earlier implantation of a PM can be considered in order to reduce post-operative length
- Temporary electrical pacing may be required in symptomatic bradycardias. In some cases, when the conduction defect does not revert, permanent pacing may be necessary. Temporary epicardial atrial and ventricular pacing wires placed at the time of surgery usually facilitate temporary pacing. The frequent challenge with postoperative bradycardia is often to determine how long to wait to allow recovery of sinus node function or atrioventricular conduction after surgery before implantation of a permanent pacemaker. Recovery is common with long-term followup. Among patients who receive permanent pacing, only 30% to 40% of patients with SSS remain pacemaker dependent. The rate of recovery is less with AVB. Among patients with complete heart block, 65% to 100% remain dependent. A usual practice is to implant a permanent pacemaker if symptomatic complete AVB or severe SSS persists longer than 5–7 days postoperatively. If underlying intrinsic rhythm is absent or temporary pacing leads fail, permanent pacing may be performed earlier.