Cardiomyopathies are diseases of the heart muscle that cause it to be structurally and functionally abnormal without other known causes like coronary artery disease. There are several types including dilated, hypertrophic, restrictive, arrhythmogenic right ventricular, and Takotsubo cardiomyopathy. Anesthesia management aims to minimize negative inotropic effects, maintain appropriate preload and afterload, and prevent hypotension, arrhythmias, and tachycardia. Goals depend on the type of cardiomyopathy and whether systolic or diastolic dysfunction predominates. Close monitoring is important due to potential hemodynamic instability from anesthesia and surgery.

1. Cardiomyopathy and Anesthetic
Chalanges

2. Introduction
• Cardiomyopathies are diseases of heart muscle
• A contemporary definition for cardiomyopathy is
a myocardial disorder in which the heart muscle
is structurally and functionally abnormal in the
absence of coronary artery disease,
hypertension, valvular disease, and congenital
heart disease sufficient to explain the observed
myocardial abnormality.
• Heart is unable to pump an adequate supply of
blood around the body.

3. Types of cardiomyopathy
• Dilated Cardiomyopathy : Ventricles enlarge and weaken, may also
inherited but also result from alcohol, heavy metals, cocaine, viral
infection, Peri-partum
• Hypertrophic cardiomyopathy : Heart muscle enlarges and thickens,
Usualy inherited , HOCM
• Restrictive Cardiomyopathy : Ventricle stiffens , may caused by
amyloidosis, hemochromatosis, Scleroderma , Radiation-induced
and some cancer treatment
• Arrhythmogenic Right Ventricular Dysplasia: Characterized by
replacement of the muscle by fibrous scar and fatty tissue. RV tends
to be most affected.
• Takotsubo Cardiomyopathy (Stress induced or Broken heart
syndrome) caused by extreme emotional or physical stress

4. Systolic dysfunction
• Main feature of Dilated cardiomyopathy (DCM).
• Decrease in myocardial contractility that is usually global, reducing left
ventricular ejection fraction.
• Initially compensation occurs with enlargement of the left ventricular cavity
allowing an increase in stroke volume with an associated increase in force of
contraction as described by the Frank–Starling relationship.
• Eventually, these compensatory mechanisms fail, cardiac output decreases,
and left ventricular failure ensues.
• Up to 14% of the elderly population has echogenic evidence of systolic
dysfunction.

5. Diastolic dysfunction
• Main feature of Hypertrophic and Restrictive cardiomyopathy, but some
diastolic dysfunction can occur in the dilated form.
• Characterized by impaired left ventricular filling with consequential raised
left ventricular filling pressures. During diastole, a healthy left ventricle
undergoes active relaxation (an ATP-dependent process) after closure of the
aortic valve. This relaxation continues during early left ventricular filling after
mitral valve opening. In late diastole, left ventricular filling is passive and
dependent on the compliance of the ventricle.
• Diastolic dysfunction can be caused by either impairment of active
relaxation or a reduction in left ventricular compliance or a combination of
both.
• Active relaxation is most commonly affected by ischaemia, while a reduction
in ventricular compliance may be due to intrinsic myocardial changes
including fibrosis or external restriction due to pericardial disease.

7. Pre Anesthetic Check up
There might be no signs or symptoms in the early stages of
cardiomyopathy. But as the condition advances, signs and
symptoms usually appear, including:
• Breathlessness with exertion or even at rest
• Swelling of the legs, ankles and feet
• Bloating of the abdomen due to fluid buildup
• Cough while lying down
• Fatigue
• Heartbeats that feel rapid, pounding or fluttering
• Chest discomfort or pressure
• Dizziness, lightheadedness and fainting

8. Dilated Cardiomyopathy
• Most common cardiomyopathy, third most common cause of CHF
and most common indication for heart transplantation
• Reduces global myocardial contractility, leading to left ventricular
(LV) or biventricular dysfunction.
• DCM presents with decrease in LV ejection fraction (LVEF),
congestive heart failure (CHF) and ventricular arrhythmias.
• Initially, the ventricle dilates to increase the force of contraction
and stroke volume (Frank–Starling relationship);
• however, these compensatory mechanisms gradually fail,
progressive ventricular failure ensues and cardiac output (CO)
decreases
• Pulmonary and systemic embolism can occur as blood stasis in
dilated and hypocontractile cardiac chambers
• Treatment include drugs, cardiac resynchronisation therapy, intra-
aortic balloon pump (IABP) , Heart Transplant

9. Dilated Cardiomyopathy

11. Anesthetic Management
• Optimization of CHF at least for a week before the
planned surgery is advisable.
• Treating Cardiologist should be available during
perioperative period
• In critically ill or high-risk procedures or those in
whom CHF management is not fully optimized, IABP
can be inserted preoperatively
• Premedication -short acting anxiolytic/sedative like oral
Alprazolam or Midazolam.
• General anesthesia with Regional analgesia
(? Anticoagulants), Regional Anesthesia or nerve blocks
which has minimal hemodynamics effects

13. Monitoring
• Basic monitoring,
• central venous pressure (CVP) monitoring allows preload and central
venous saturation (ScVO2) assessment provides an access for
administering inotropes and vasoconstrictors.
• Direct arterial pressure monitoring enables early identification of
hemodynamic changes.
• Pulmonary artery pressure monitoring is useful in sick patients or
high-risk surgery or those in whom large fluid shifts is anticipated.
• Cardiac output Monitor : Pulse Index Continuous Cardiac Output
monitoring (PiCCO), and Lithium Dilution Cardiac Output (LiDCO)
• Transesophageal echocardiography (TEE) : identifies causes of
hypotension, response to inotropes or fluid loading, estimates
preload, diastolic dysfunction, CO, regional wall motion and valve
function.
• Monitoring tools are similar to all types of cardiomyopathies

14. Anaesthetic technique :
• May become haemodynamically unstable due to the depressant effect
of anaesthetics, fluid shifts and blood loss, which add to poor
myocardial function.
• Regional Anesthesia: Hypotension, severe Bradycardia
• Thiopentone, propofol and inhalational agents cause vasodilation and
myocardial depression.
• Etomidate, ketamine and narcotics have minimal haemodynamic
effects.
• Benzodiazepines and nitrous oxide may cause cardiovascular
depression.
• Narcotics provide haemodynamic stability, and a balanced anaesthetic
technique should be used. Slow induction should be carried out.
• High-risk patients include those with LVEF <25%, pulmonary capillary
wedge pressure >20 mmHg, cardiac index <2 L/min/m2, pulmonary
artery hypertension, raised CVP and mitral and tricuspid regurgitation.
• Inotropic support is commonly required, and inodilators such as
dobutamine, phosphodiesterase inhibitors may be used.
• Vasoconstrictor agents: phenylephrine or norepinephrine - to
counteract the vasodilatory effect of anaesthetics and inodilators to
maintain mean arterial pressure >60 mmHg.
• Arrhythmias can be managed with lidocaine, amiodarone, diltiazem or
cardioversion/defibrillation may be required
• Adequate pain management is must in postop period

15. Goals of Anesthesia in DCM
• Minimize negative inotropic effect of
anesthetic drugs
• Maintain preload despite increased LVEDP
• Prevent increase in afterload
• Maintain perfusion, Control Arrhythmias,
Hypotension, Tachycardia

16. Post-partum cardiomyopathy
• It is a rare form of DCM : Four Criteria:
- That occurs from the third trimester of pregnancy until the
first 5 months after delivery. ( 1 in 3000–10,000 pregnancies)
- Absence of another identifiable cause of Heart failure
- Absence of cardiac symptoms or disease before late
pregnancy
- Left ventricular dysfunction – EF < 45%
• CHF, Arrythmias and thromboembolism is main cause of
mortality,
• Early delivery may be advised
• Goals of anaesthesia, anaesthetic technique and monitoring
are similar to DCM
• Oxytocin reduces SVR and ergometrine increases afterload
and should be used carefully

17. Hypertrophic Cardiomyopathy
• Common genetic disorder of the heart
• Systolic function is normal or increased. Interstitial fibrosis and increased LV mass
lead to a small LV cavity and end-diastolic volumes which reduce stroke volume
despite a normal LVEF. LV hypertrophy develops mainly in the septum extending to
the anterior free wall
• Myocardial stiffness is increased, reducing chamber compliance, leading to
diastolic dysfunction, poor effort tolerance, atrial arrhythmias and diastolic failure.
LVEF diminishes at a later stage contributing to poor outcome
• Myocardial ischaemia occurs without CAD due to abnormal coronary arteries,
mismatch between coronary size and ventricular mass, increased oxygen
consumption due to hypertrophy and increased left ventricular end-diastolic
pressure (LVEDP) compromising coronary perfusion.
• The Basal septal hypertrophy encroaches into the LV outflow tract (LVOT) causing
obstruction and increasing blood flow velocity through the LVOT
• Medication includes beta blockers and calcium channel blockers which exert a
negative inotropic effect, decrease heart rate and increase diastolic filling time
improving coronary perfusion pressure and CO. They should be continued in the
perioperative period

20. Anaesthetic considerations
• Pre-operative assessment Patients without symptoms, may go undiagnosed at pre-
operative evaluation.
• Pre-anaesthetic evaluation should include NYHA functional class stratification, cardiac
and respiratory symptomatology, medications, arrhythmias, stroke or CHF and
presence of AICD.
• Adequate premedication and Pre-operative volume expansion
• Beta blockers or calcium channel blockers and hydration should be continued
preoperatively.
• If an AICD is present, its reprograming and deactivation of antitachycardia capability
should be carried out.
• Both general and neuraxial anaesthesia can be used with adequate monitoring .
• Monitoring as described in DCM

21. Restrictive Cardiomyopathy
• Less common
• Myocardium becomes rigid, noncompliant
• Diastolic dysfunction, Systolic function preserved
• Resembles constrictive pericarditis
• Anesthetic management in these patients is to
maintain intraoperative hemodynamic goal is fast, full
& tight that is avoid Bradycardia , Maintain
Contractility, Preload and Afterload.
• Caused by amyloidosis, hemochromatosis,
Scleroderma , Radiation-induced and some cancer
treatment

23. Arrhythmogenic Right ventricular
Cardiomyopathy

24. Takotsubo Cardiomyopathy
• It is a transient, reversible, left ventricular dysfunction causing severe
hypotension and can mimic an acute coronary event.
• Cardiac catheterization often reveals normal coronary arteries.
• EKG may show ST elevation and ECHO and ventriculogram studies
demonstrate left ventricular mid and apical ballooning with hypokinesia.
The basal segment of the left ventricle may be hyperkinetic.
• Mostly follows emotional or physiologic stressful situations such as
general anaesthesia, road traffic accidents, cerebral events,
pheochromocytoma, anaphylactic shock, antidepressant overdose and
attempted suicidal hanging and common in Postmenopausal women
• Occurrence of an adrenergic storm is the suggested cause and is
Reversible myocardial ischaemia
• A principle anaesthetic goal is to avoid psychological and physical stress
that could trigger acute cardiomyopathy in susceptible patients

25. Takotsubo cardiomyopathy - Transthoracic four-chamber view showing the
hypercontractile basal segment and the ballooning apical segment

26. Hemodynamic goals specific to type of
cardiomyopathy
Dilated (systolic failure):
Contractility: Maintain
Rate & rhythm: NSR
Afterload: maintain, may benefit from ↓
Preload: normal HR, avoid ↑ afterload
Hypertropic (Distolic failure):
Contractility: ↓
Rate & rhythm: strict NSR, avoid tachycardia
Afterload: maintain
Preload: full
Restrictive(diastolic failure):
Contractility: maintain
Rate & rhythm: sinus (atrial kick important), avoid bradycardia (SV relatively
fixed)
Afterload: maintain (coronary perfusion with ↑ LVEDP)
Preload: maintain normovolemia (but avoid ↑ LVEDP)

27. CONCLUSION
Anaesthesia administration for patients with
cardiomyopathy can lead to perioperative
morbidity and mortality during elective and
emergency surgery.
Therefore, anaesthesia and post-operative care
have to be planned and monitored, with the
knowledge of the type of cardiomyopathy and
their pathophysiology.

28. THANK YOU ALL