How To Look To Patient Data
History Taking
o Growtho Exercise Intoleranceo Recurrent Chest Infection o Syncopal Attacks o Squatting
ECG , Echo & Cardiac Cath.
Systolic & Diastolic Dysfunction
Reduced Fractional Shortening
Systolic Dysfunction
Diastolic Dysfunction
Ventricular Hypertrophy
Obstructive Volume
Before Repair
e.gvalvular
& outflow
obst.
After Repair
e.g Homograft conduit
Before Repair
e.gLt . to Rt.
shunt
After Repair
e.g•Pulmonary valve regurge ( F4 )•MV repair
Concentric Eccentric
Anaesthetic considerations :
Consider determinants of coronary perfusion & myocardial oxygen balance
• Heart rate changes • Hypotension • Myocardial contractility
Anaesthetic considerations
increase wall
thickness
coronary filling become
s diastoli
c
coronary perfusion
depends on bl. p. & hr
Maintain heart rate to
decrease regurgitant
fraction
Syst. DysfunctionIn Dialted
type
RV LVanaesthet
ic myocardia
l depressio
nDecrease driving filling
pressure of coronary arteries
Coronary ischemia
Diast. Dysfunction
In Hypertrophi
c & restrictive
type
Residual Shunts :
o Occasionally present after repair of ASD , VSD & F4
o Small patch leaks are hemodynamically benign
Dysrhythmias :Atrial & ventricular types increase mortality and morbidity
Arrhythmias Associated With Specific Arrhythmias Associated With Specific Surgical ProceduresSurgical Procedures
Ostium secondum ASD :• P-R interval is prolonged in 20-30% of patients • AF , atrial flutter with advancing age
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
Severity of hypertension of base line PAH correlated with the incidence of major complications ( pulmonary hypertensive crisis or cardiac arrest )
Pulmonary hypertension
Cardiovascular risk of PAH
Major perioperative hemodynamic deterioration mainly pulmonary hypertensive crisis and acute right ventricular failure and cardiac arrest .
Data to look for : o Mean pulmonary artery pressure > 25 mmHg o Severity of base line PH : Subsystemic PAP < 70% of syst. bl. pressure Systemic PAP = 70 – 100 of syst. bl. pressure Suprasystemic PAP > 70 of syst. bl. pressure
( based on mean pressures )
ANAESTHETIC CONSIDERATIONS
Avoid Factors Rapidly Increasing PVR
Laboratory dataHematocrit value
Increase More Blood ViscocityIncrease More Blood Viscocity
Hyperviscosity Hyperviscosity symptomssymptoms
Decreased oxygen Decreased oxygen deliverydelivery
Blood Indicies :
Increase Blood Increase Blood Viscosity Viscosity
Increase Blood Increase Blood Viscosity Viscosity
Hyperviscosity Symptoms At Hyperviscosity Symptoms At Lower Hematocrit ValueLower Hematocrit Value
Hyperviscosity Symptoms At Hyperviscosity Symptoms At Lower Hematocrit ValueLower Hematocrit Value
Phlebotomy
Done to relieve hyperviscosity symptoms with hematocrit > 65 % in absence of iron deficiency anaemia or signs of dehydration
Hemostatic values
•Prolonged PT , PTT , APTT values most frequently seen in cyanotic patients
•Thrombocytopenia is related to degree of polycythemia .
SummaryGeneral 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
SummaryRisk criteria of hemodynamic critical impairment
in perioperative period in CHD
• Arterial saturation < 75 %• Hematocrit > 65 %• Qp / Qs > 2 : 1• LV outflow tract gradient > 50 mmHg• RVOT gradient > 50 mmHg• PVR > 6 wood units
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