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Pathophysiologic Consideration In Patients With Congenital Heart Disease

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Pathophysiologic Consideration In Patients With Congenital Heart Disease SAMIA SHARAF .MD Professor Of Anaesthesia .. Ain Shams University How To Look To Patient Data ... – PowerPoint PPT presentation

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Title: Pathophysiologic Consideration In Patients With Congenital Heart Disease


1
Pathophysiologic Consideration In Patients
With Congenital Heart Disease
SAMIA SHARAF .MD
Professor Of Anaesthesia .. Ain Shams University
2
Classification Of Congenital Heart Lesions
  • Obstructive lesions eg.
  • Aortic stenosis coarctation of aorta
  • Increased pulmonary blood flow eg.
  • ASD VSD PDA
  • Decreased pulmonary blood flow lesions eg.
    Tetralogy of fallot tricuspid atresia
    pulmonary atresia

3
Classification Of Congenital Heart Lesions
4
Clinical Presentation Of Children With CHD
  • Cyanosis ( due to hypoxia )
  • Respiratory system abnormalities
  • Cardiac failure
  • Arrhythmias

5
Cyanosis Pathophysiologic Effects of Hypoxia
  • (1) Growth
  • (2) Heart
  • Exercise intolerance
  • myocardial dysfunction
    ventricular compliance and contractility
  • Irreversible myocardial damage .
  • Increased sympathetic tone
    down regulation of beta receptors
    cardiomyopathy

6
  • (3) Hematology
  • A major adaptive response to chronic hypoxia
  • Red cell mass
  • Polycythemia Secondary
    Spherocytosis
  • Blood viscosity
  • Risk of thromboembolic events

7
Hemostasis
Polycythemia
Coagulation abnormalities
Primary fibrinolysis
DIC
8
Mechanism of coagulation abnormalities
Increased blood viscosity
DIC Hypercoag. blood tendency to bleed
Increase intravascular strains
Fibrin deposition platlet aggreg.
Thrombocytopenia Low Fibrinogen Other Factor
Level
Consumpution of platlets , fibrinogen , factor V
, VIII
9
(4) CNS
  • Chronic hypoxia causes impairment of neurologic
    development and increase risk of neurologic
    damage .
  • Brain abscess Rt. Lt. shunt
  • Cerebrovascular thrombosis and hemorrhage .

10
Respiratiry System Abnormalities
  • Anatomical abnormalities of airway
  • Pulmonary abnormalities associated with or
    pulmonary blood flow .

11
Anatomical Abnormalities Of Airway
  • Short trachea eg. interrupted aortic arch
  • large airway obstruction ( trachea bronchi )
  • Compression by enlarged aorta or pulmonary
    artery .
  • Upwards displacement and increase angle of
    bifurcation of trachea by enlarged LA .

12
  • Small airway obstruction
  • Compression of lung parenchyma by enlarged
    heart and vessels .
  • Pulmonary hypertension .

13
Pulmonary Changes Associated With Pulmonary
Blood Flow
  • Patients with chronic hypoxia
  • Slight of alveolar ventilation
  • pulmonary venous PO2 is high
  • V/Q mismatch alveolar
    pulmonary venous O2 gradient
  • Physiological dead space end
    tidal CO2 is lower than arterial PaCO2

14
Pulmonary Changes Associated With Pulmonary
Blood Flow
  • Obstruction of small airway
  • Pulmonary congestion pulmonary
    compliance , lung water Impaired gas
    exchange
  • Progressive of pulmonary vascular
    resistance due to hypertrophy in muscular layer
    of pulmonary arteries reverse of left to
    right shunt

15
Cardiac Failure
  • Causes of limited cardiac reserve
  • (1) Increased cardiac workload
  • Pressure overload
  • ventricular outflow tract obstruction
  • SVR blood
    viscosity
  • Volume overload
  • Valvular insufficiency
  • Single ventricle
  • Left right shunt

16
  • (2) Myocardial contractility
  • Prolonged workload of myocardium
  • Vascular supply to ventricles
  • Blood hyperviscosity
  • Chronic hypoxia

17
Compansatory Mechanism
  • Ventricular hypertrophy
  • Adrenergic system changes
  • Activation of B receptors
  • Renal system compansation
  • Salt water retention
  • Renin secretion

18
Arrhythmias
  • Types
  • Congenital
  • Acquired
  • Etiology
  • Intrinsic electrophysiology abnormalities
  • Damage from chronic hypoxia hemodynamic stress
  • Surgical injury eg. F4 , Fontan operation ,
    atrial correction of TGA

19
Congenital Conduction System Abnormalities
  • Congenital complete atrioventricular block
  • Wolf Parkinson white syndrome
  • Supraventricular tachycardia
  • Arrhythmias associated with Ebstien anomaly

20
Acquired Conduction System Abnormalities
  • Non surgical rare
  • Surgical by
  • cardioplegia
  • mechanical retraction
  • ischemia
  • metabolic
    abnormalities

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23
Anaesthetic Risk factors affecting anaesthetic
risk in congenital heart disease
Cyanotic heart disease
Pulmonary disease
Myocardial dysfunction
Cardiovascular impairment
Arrhythmias
Magnitude of surgery
Anaesthetic risk
24
How To Reduce Anaesthetic Risk ??
25
Consultation
26
Role Of Surgeon
  • Case discussion
  • Pts. with CHD may not tolerate
  • Abdominal laparoscopic procedures
  • ( eg. stenotic valvular lesions , single
    ventricle )
  • Absorption of CO2 ( C.O.P dependant low PVR) .
  • One lung ventilation
  • Prone position ( Fontan pt. )

27
Role Of Pediatric Cardiologist
Preoperative consultation sometimes add a little
benefit to anesthiologist !!!!!
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Efficacy Of Repairs For CHD Lesions
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40
How To Look To Patient Data
41
History Taking
  • Growth
  • Exercise Intolerance
  • Recurrent Chest Infection
  • Syncopal Attacks
  • Squatting

42
ECG , Echo Cardiac Cath.
Systolic Diastolic Dysfunction
Systolic Dysfunction
Reduced Fractional Shortening
43
Diastolic Dysfunction
Ventricular Hypertrophy
Concentric
Eccentric
Obstructive
Volume
Before Repair e.g valvular outflow obst.
After Repair e.g Homograft conduit
Before Repair e.g Lt . to Rt. shunt
  • After Repair
  • e.g
  • Pulmonary valve regurge
  • ( F4 )
  • MV repair

44
Anaesthetic considerations
Consider determinants of coronary perfusion
myocardial oxygen balance
  • Heart rate changes
  • Hypotension
  • Myocardial contractility

45
Anaesthetic considerations
CONCENTRIC Ventricular Hypertrophy
RV
LV
46
  • Residual Shunts
  • Occasionally present after repair of ASD , VSD
    F4
  • Small patch leaks are hemodynamically benign

47
Dysrhythmias Atrial ventricular types
increase mortality and morbidity
Arrhythmias Associated With Specific Surgical
Procedures
  • Ostium secondum ASD
  • P-R interval is prolonged in 20-30 of patients
  • AF , atrial flutter with advancing age

48
  • VSD
  • RBBB
  • Atrial ectopic , junctional beats , premature
    ventricular beat
  • Late onset of complete heart block or ventricular
    arrhythmias are rare
  • Repair of F4
  • RBBB complete heart block
  • Mustard or Senning operation
  • Sinus nodal dysfunction
  • Bradycardia
  • A-V block , AF

49
Pulmonary hypertension
Severity of hypertension of base line PAH
correlated with the incidence of major
complications ( pulmonary hypertensive crisis or
cardiac arrest )
50
Cardiovascular risk of PAH
  • Major perioperative hemodynamic deterioration
    mainly pulmonary hypertensive crisis and acute
    right ventricular failure and cardiac arrest .
  • Data to look for
  • Mean pulmonary artery pressure gt 25 mmHg
  • Severity of base line PH
  • Subsystemic PAP lt 70 of syst. bl.
    pressure
  • Systemic PAP 70 100 of syst. bl.
    pressure
  • Suprasystemic PAP gt 70 of syst. bl.
    pressure
  • ( based on mean pressures )

51
ANAESTHETIC CONSIDERATIONS Avoid Factors
Rapidly Increasing PVR
52
Laboratory data Hematocrit value
Increase More Blood Viscocity
Hyperviscosity symptoms
Decreased oxygen delivery
53
Blood Indicies
Increase Blood Viscosity
Hyperviscosity Symptoms At Lower Hematocrit Value
54
Phlebotomy Done to relieve hyperviscosity
symptoms with hematocrit gt 65 in absence of
iron deficiency anaemia or signs of dehydration
55
  • Hemostatic values
  • Prolonged PT , PTT , APTT values most frequently
    seen in cyanotic patients
  • Thrombocytopenia is related to degree of
    polycythemia .

56
Summary General associated risk factors in CHD
  • Severe form of isolated lesion
  • Complex lesions
  • Concurrent infectious disease
  • Congestive heart failure
  • Acute hemodynamic deterioration
  • Previous palliative or corrective procedures

57
Summary Risk criteria of hemodynamic critical
impairment in perioperative period in CHD
  • Arterial saturation lt 75
  • Hematocrit gt 65
  • Qp / Qs gt 2 1
  • LV outflow tract gradient gt 50 mmHg
  • RVOT gradient gt 50 mmHg
  • PVR gt 6 wood units

58
THANK YOU
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