Colorado Review of Anesthesia for SurgiCenters and ... · Tetralogy of Fallot Tricuspid atresia...
Transcript of Colorado Review of Anesthesia for SurgiCenters and ... · Tetralogy of Fallot Tricuspid atresia...
Anesthetic considerations in Adults with Congenital Heart Disease
Dr. Mark Twite MA MB BChir FRCP
Director of Congenital Cardiac Anesthesiology
Associate Professor
Department of Anesthesiology
University of Colorado, Anschutz Medical Campus &
Children’s Hospital Colorado
CRASH Vail, Colorado 2018
Colorado Review of Anesthesia for SurgiCenters and Hospitalsand Ski Holiday!
No Financial Disclosures
CRASH Vail, Colorado 2018
Colorado Review of Anesthesia for SurgiCenters and Hospitals
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Ameristar Casino, Blackhawk, CO
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Objectives
Understand and Discuss the:
1. Changing epidemiology of congenital heart disease (CHD)
2. Current outcomes for patients with CHD
3. Perioperative anesthetic approach to adults with CHD undergoing non-cardiac surgery
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• 37yr old female in Atrial Flutter presents for TEE, EP study and ablation
• Tricuspid Atresia s/p Fontan
‐ Non-alcoholic cirrhosis (elevated LFTs and low albumin)
‐ Protein losing enteropathy
‐ Hypoxia. Baseline Sats 75-85% in air. Polycythemia Hct 65
‐ Pacemaker Dual Chamber DDD at 70bpm
• Medications
‐Apixaban, Aspirin
‐L-Arginine
‐Digoxin, Quinapril, Sotalol
‐Furosemide, Spironolactone
‐Melatonin, Valium, Ambien, Tramadol
Case
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• 37yr old female in Atrial Flutter presents for TEE, EP study and ablation
• Echocardiogram 9/2016 TTE
1. History of Tricuspid atresia, status post initial class (RA to PA)Fontan, with subsequent Fontan conversion to intra-cardiac lateral tunnel Fontan through the RA body
2. Subjectively there remains normal LV systolic function.
3. Dilated IVC without respiratory collapse. Low velocity flow within IVC suggests IVC pressure is greater than 15 mm Hg .
4. The Glenn anastomosis is not well visualized, though there is normal respiratory variation in SVC flow suggestive of no obstruction within the Fontan pathway.
5. Trivial mitral regurgitation, mild mitral stenosis (mean gradient 5.6 mmHg).
6. Mildly dilated left ventricle with subjectively normal function. Hypoplastic right ventricle is not well seen.
7. No pericardial effusion.
Case
Mark Twite, MB Anesthetic Considerations in Adults with Congenital Heart Disease
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• 37yr old female in Atrial Flutter presents for TEE, EP study and ablation
• Cardiac Cath
CATH (Denver, 2010) no fenestration, unobstructed PA's, Fontan 11-12 mmHg, no change with volume challenge, small angiographic right to left shunt seen likely from the suture line of the lateral tunnel.
CATH (Denver, 2013) Fontan pressures 18 mmHg, PCWP 14 mmHg, small veno-venous collaterals off left innominate embolized, 100% FiO2 and improved Fontan pressure to 11 mmHg
CATH (Denver, 2016) hepatic wedge 19 mmHg, hepatic vein 15 mmHg (transhepaticgradient 4 mmHg), Fontan 13, RPA 11, LPA 12, PCWP 9. Fick CO 5.06. S/P 10ml/kg bolus PA increased to 17, PCWP to 14, Fick CO 5.74. With 100% O2, PA pressure decreased to 13, PCWP to 12, Fick CO 5.69, with 40 ppm iNO PA pressure 14 , PCWP 13, CO 5.64
Case
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• Most common congenital disorder of newborns‐ 1% of live births‐ Leading cause of infant deaths in the USA‐ Accounts for more than half of all deaths from congenital anomalies worldwide
• Estimated 1.5 million adults living in USA with CHD
• NIH funded CHD research from 2005 – 2015‐ 663 CHD research projects for a total cost of $991 million
• 70% Basic science (Cardiac developmental biology most common)• 27% Clinical• 3% Both
Congenital Heart Disease
Van der Bom Nat Rev Cardiol 2011Burns Pediatr Cardiol 2017
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Changing Epidemiology: Adults and Children in Quebec
Marelli Circulation 2007 & 2014
Median age with severe CHD
Year Median Age (yrs)
1985 11
2000 17
2010 25
All CHD
Severe CHD
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Changing Epidemiology: Mortality
Distribution of Age at Death in Patients With Congenital Heart Disease in 1987 to 1988 and 2004 to 2005. Histogram bars depict the proportion of all deaths (x-axis) according to age at death (y-axis). Bold black curves with diamonds represent the corresponding age at death distribution in the general Quebec population Khairy J Am Coll Cardiol 2010
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Classification of CHD Complexity
Simple Moderate Severe
Atrial septal defect Anomalous pulmonary venous drainage
Single ventricle palliation
Ventricular septal defect Atrioventricular canal defect
Transposition of the great arteries
Patent ductus arteriosus Coarctation of the aorta Truncus arteriosus
Tetralogy of Fallot Tricuspid atresia
Pulmonary atresia
Eisenmenger syndrome
Simple defects have a favorable natural history unless they are unrepaired with a significant L to R shunt which may then develop Eisenmenger syndrome
Mark Twite, MB Anesthetic Considerations in Adults with Congenital Heart Disease
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Long term Survival by complexity of CHD
95% 90% 80%
Simple Moderate Severe
Atrial septal defect Anomalous pulmonary venous drainage
Single ventricle palliation
Ventricular septal defect Atrioventricular canal defect
Transposition of the great arteries
Patent ductus arteriosus Coarctation of the aorta Truncus arteriosus
Tetralogy of Fallot Tricuspid atresia
Pulmonary atresia
Eisenmenger syndrome
Long term survival > 20 years Warnes J Am Coll Cardiol 2008
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CHD Pathophysiology
Valve stenosis & regurgitation
Atrial stretch, connections, synchrony,
residual lesions
Outflow stenosis, dilation,
compression
Ventricular function, rhythm, geometry,
residual lesions
Heart Failure Arrhythmias
Pulmonary Hypertension
Cyanosis & Bleeding COMORBIDITIES
Congenital & Acquired
Lesion Specific
1. Single Ventricle
Left vs Right, PLE
Thromboembolic
Liver Dysfunction
2. Tetralogy of Fallot
PI, RV Dilation
3. TGA
Baffle stenosis, coronaries
Lesion Specific
1. Single Ventricle
Left vs Right, PLE
Thromboembolic
Liver Dysfunction
2. Tetralogy of Fallot
PI, RV Dilation
3. TGA
Baffle stenosis, coronaries
Special Situations
Pregnancy, laparoscopy, regional & neuraxial
Special Situations
Pregnancy, laparoscopy, regional & neuraxial
Endocarditis prophylaxisEndocarditis prophylaxis
Psychosocial
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Changing Surgical techniques: TGA
1975 Jatene Arterial Switch Operation
DoubleDouble SwitchSwitchTransfer
coronary buttonsLecomptemaneuver
1960 Senning-Mustard
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Changing Surgical techniques: TA Stage 1 BT Shunt
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Changing Surgical techniques: TA Stage 2 Glenn Shunt
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Changing Surgical techniques: TA Stage 3 Fontan
AtrioPulmonary Lateral Tunnel Extracardiac
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Effects of anesthetic agents
aKetamine can depress contractility in vitro and in catecholamine depleted patients.
bDexmedetomidinecan increase MAP during loading dose administration.
Friesen SCVA 2017
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Consensus Statements
Circulation, October 2017
Circulation, January 2017
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Time-series analysis: referral to specialized ACHD
centers and ACHD patient mortality
Mylotte Circulation 2014
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Studied 482 adults with CHD from 12 centers in the USA• Most common presenting arrhythmia:
‐ Intra-atrial re-entrant tachycardia (IART) 61.6% (increased with CHD complexity)‐ Atrial fibrillation (AF) 28.8% increased with age to surpass IART at 50yrs of age‐ Focal atrial tachycardia 9.5%
Atrial Arrhythmias
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Risk factors for developing atrial arrhythmias: ‐ single ventricle‐ previous intracardiac repair‐ systemic right ventricle‐ pulmonary hypertension
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Adults with CHD and atrial arrhythmias:• x 4 increase of heart failure• x 2 increase in death
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Atrial arrhythmias frequent cause of sudden cardiac death (43%)Increasing incidence with complexity of CHD
‐ Eisenmenger‐ Transposition of great arteries (atrial switch)‐ Single ventricles lesions palliated to Fontan circulation
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Single Center study in USA of Fontan patients• 10, 20 and 30 year freedom from arrhythmias of 71%, 42% and 24%• SCD 52 of 1052 Fontan patients (5%) with 65% due to arrhythmias
Congenital Heart Disease 2017 (12) 17‐23
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Factors leading to arrhythmias in CHD
Escudero Can J Cardiol 2013
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Risk estimates for arrhythmias across CHD
PACES / HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in ACHD Heart Rhythm 2014
Sim
ple
Mod
erat
eS
ever
e
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Majority of SCD victims unrecognized with an area under the curve of 0.6 for the discriminative ability of current guidelines Critical clinical reasoning essential when deciding on ICD placement in adult CHD patients
Implantable Cardioverter-Defibrillator
Mark Twite, MB Anesthetic Considerations in Adults with Congenital Heart Disease
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ACHD Heart Failure
Norozi Am J Cardiol 2006DiNardo Sem Cardiothoracic Vasc Anes 2012Stefanescu Curr Treat Options Cardio Med 2014
Single Ventricle palliated to Fontan
Single ventricle has both the systemic and pulmonary resistances in series
y
Tetralogy of Fallot
Pulmonary regurgitation causes RV dilation and dysfunction, abnormal septal configuration, altered RV-LV interaction and LV dysfunction
Subsystemic RV
1. D-TGA palliated with a Mustard/Senning atrial switch
2. ccTGA Cor
onar
y A
rter
y D
isea
se –
focu
s on
prev
enti
on
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Heart Liver Transplant
Transplantation February 2018 Volume 102 Number 2
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Heart Liver Transplant
UNOS Database 1987 – 2015
• 61437 Heart Tx
• 190 CHLT
• 41 had CHD
• 30 day, 1 and 5 year survival 95%, 86% and 83%
• CHLT with and without CHD comparable
• Trend towards better survival for CHLT compared with isolated Heart Tx for CHD
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CHD Pathophysiology
Valve stenosis & regurgitation
Atrial stretch, connections, synchrony,
residual lesions
Outflow stenosis, dilation,
compression
Ventricular function, rhythm, geometry,
residual lesions
Heart Failure Arrhythmias
Pulmonary Hypertension
Cyanosis & Bleeding COMORBIDITIES
Congenital & Acquired
Lesion Specific
1. Single Ventricle
Left vs Right, PLE
Thromboembolic
Liver Dysfunction
2. Tetralogy of Fallot
PI, RV Dilation
3. TGA
Baffle stenosis, coronaries
Lesion Specific
1. Single Ventricle
Left vs Right, PLE
Thromboembolic
Liver Dysfunction
2. Tetralogy of Fallot
PI, RV Dilation
3. TGA
Baffle stenosis, coronaries
Special Situations
Pregnancy, laparoscopy, regional & neuraxial
Special Situations
Pregnancy, laparoscopy, regional & neuraxial
Endocarditis prophylaxisEndocarditis prophylaxis
Psychosocial
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Thank you
Mark Twite, MB Anesthetic Considerations in Adults with Congenital Heart Disease