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Similar to Cardiomyopathy
Cardiomyopathy
- 1. CARDIOMYOPATHY & ANAESTHESIA DR. ABHIJITS. NAIR Consultant Anaesthesiologist, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad.
- 2. Cardiomyopathy = heartmuscle disease • deterioration of the function of the myocardium for any reason • Risk of dysrhythmias or sudden cardiac death EXTRINSIC INTRINSIC SYSTOLIC DIASTOLIC
- 4. Pathophysiology • Systolic dysfunction •Diastolic dysfunction
- 7. TYPES: Dilated: • Ischemic,valvular • Non-ischemic infections, chemotherapeutic agents, drug abuse, alcohol, peripartum, hypothyroidism, Sickle cell disease, Muscular dystrophies Hypertrophic:(septal hypertrophy-idiopathic hypertrophic, Secondary to Hypertension) Restrictive Takotsubo
- 9.
- 10. Infections • HIV • Coxsackievirus • CMV • Toxoplasmosis • Chagas’ disease • Trichinosis • Leptospirosis • Lyme disease
- 11. Abuse • Alcohol • Cocaine •Methamphetamines • Heroin
- 12.
- 13. Anthracyclines A drop inLVEF of >10% or to <50% is considered an indication for discontinuation of these agents
- 14. Prevention • Infusion • Liposomalencapsulation • Dexrazoxane: EDTA like chelator • Follow recommended cumulative dose • Carvedilol/ ACEI/ARB
- 15.
- 17. Imaging • 2D ECHO(limited ability) • SPECT(Single-photon emission computed tomography) • Equilibrium RadioNuclide Angiocardiography (ERNA) • Cardiac MRI: myocardial edema, inflammation, and fibrosis • Iodine-MIBG
- 18. Management of CIC •GREY AREA • Standard HF management • Acute: diuretics+ Nitrates?, NIV/Opioids • NO SNP • Inotropes/ vasopressors: in cardiogenic shock only
- 20. PPCM • ‘Idiopathic cardiomyopathypresenting with heart failure secondary to left-ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found’ Eur J Heart Fail. 2010 Aug;12(8):767-78. doi: 10.1093/eurjhf/hfq120. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Sliwa et al. Mortality: 20-50%!!
- 21. Peripartum( 1:100-1:1000) • Lasttrimester up to 5 months
- 22. Causes: • Obesity • myocarditis •Drugs? • Smoking • Alcoholism • Multiple pregnancies • African-American descent • Poor nourishment
- 23. Management: • Beta blockers/ACEI/ARB/Diuretics •Bromocriptine/ pentoxyphylline • AICD • Anticoagulation
- 24. S & Sof DCM: • Tachycardia • SOB • Ascites/ oedema • Regurgitation/ arrhythmias/ Thrombus • Biventricular dysfunction
- 25. Management: • ARB/ACEI • Betablockers • Diuretics • Anti-arrhythmics • Anticoagulants • Biventricular pacing
- 26. Cardioplasty • DOR procedure •LVAD • Cardiac transplant Left ventricular reconstructive surgery with D free flap
- 27. Anaesthesia goals • Avoidtachycardia • Sinus rhythm • Avoid negative inotropic agents • Prevent increases in afterload • Maintain adequate preload in the presence of elevated LVEDP
- 28. Monitoring • A/C line •PA catheter • TEE • CCO
- 29. HCM • HOCM (Obstructive) • HHCM ( Hypertensive) • IHSS (idiopathic hypertrophic subaortic stenosis)
- 30. HCM • Autosomal dominant •Young adults • SCD • Family history of sudden death • Significant LV hypertrophy(> 30 mm) • Unexplained syncope • Non-sustained VT
- 31.
- 32. Management • Beta blockers •Anti-Arrhythmics • AICD • Myomectomy
- 33. LVOTO • Common atIVS • dynamic LVOTO in sub-aortic region during systole • exacerbated when there is under filling of LV with forceful sub-aortic narrowing • velocity of blood in the outflow tract draws the anterior mitral valve leaflet towards IVS • SAM: Anterior leaflet pulled from posterior MV leaflet—> obstruction
- 35. Anaesthesia goals • Sinusrhythm • Low heart rate • Reduction in sympathetic activity to reduce chronotropy and inotropy • Maintain LV filling • maintenance of SVR • Invasive monitoring
- 36. • “ Defibrillatorpaddles throughout surgery”
- 37. Alerts/ contraindications • Inotropicagents : if the arrest is thought to be due to LVOT obstruction as this will only increase the obstruction • Regional Anaesthesia • Vasodilators
- 39. Restrictive • Idiopathic • Endomyocardialfibrosis • Amyloidosis(common) • Sarcoidosis • Haemachromatosis • Eosinophilic endocarditis
- 40. Presentation • SOB • Biventriculardysfunction( Diastolic more common) • Low volume pulse • Regurgitant murmurs • IIIrd heart sound
- 41. Management • Lower theelevated filling pressures caused by low ventricular compliance without reducing cardiac output • ACEI or β-blockade/ diuretics • Anti-arrhythmics • Anticoagulants • Disease modifying drugs • Heart transplantation!
- 42.
- 43. Alerts • Digoxin relativelycontraindicated in amyloidosis ( arrhythmogenic) • Cardioversion of patients in AF : complete heart block due to existing intrinsic pacemaker damage
- 44. Anaesthesia goals: • Adequatefilling pressures • Sinus rhythm • Manage electrolyte disturbances • Maintain SVR in the presence of relatively fixed cardiac output • KETAMINE!
- 45. Anaesthesia & RCM •vasodilatation, myocardial depression, reduced venous return, IPPV: Compromises CO • Spontaneous respiration desirable
- 46. Takotsubo cardiomyopathy • Transient,reversible, left ventricular dysfunction causing severe hypotension and can mimic an acute coronary event Described by Sato et al in 1990
- 47.
- 49. Management: • No evidence-basedguidelines • Supportive • Beta blockers, ACE inhibitors, diuretics • Anticoagulation • Possibility of recurrence in similar situation
- 51. Conclusion • Understand thepathology • Avoid worsening of heart function • Sinus rhythm • Invasive monitoring • Electrolyte imbalance/ arrhythmia • Judicious use of vasopressor / inotrope • Multimodal analgesia • Look for DIASTOLIC DYSFUNCTION