Cardiomyopathies Flashcards
Dilated cardiomyopathy
Primary CM
LV or Biventricular dilation
systolic dysfunction
thin wall with dilation of LV
Chambers are enlarged but hypokinetic resulting in clot formation
Concentric LVH
response to increased workload such as increased afterload
Eccentric hypertrophy
thinned LV wall
caused by fluid overload
Dx of DC
ECG shows LBBB afib Chest xray shows enlarged chambers Echo - RWMA that do not correlate to CAD Angio- normal right heart cath - high PAOP, high SVR, low CO
Apical ballooning/Takosubo
temporary DCM
stress
women > men
high catecholamine state so inotropes are contraindicated and negative inotropes are used like BB, CCB,
IABP
Medical treatment of DC
similar to HF
risk of embolization and need anticoagulation
AICDs
Hypertrophic CM
ventricular tachyarrhythmias
sudden death
progressive diastolic HF
most common genetic CV disease
can result in LVOT obstruction, ischemia, arrhythmias
During systole, a hypertrophied septum accelerates blood flow (venture effect) through a narrowed LVOt.
Dx of HCM
Echo
Obsturction with gradients of 30 mmHg is significatnt
50 mmHg mandates surgical or PCI
Drug of choice for HCM
amiodarone
HCM complications
avoid Valsalva bc increases the LVOT
Increase in HR and contractility or decrease in preload after afterload will worse LVOT obstruction
Maintain NSR
What should cause you to think HCM in young person?
LV hypertrophy on ECG
systolic murmur
Medical mgmt. of HCM
BB to reduce tachycardia Afib CCB to improve diastolic relation antyi-arrhythmics Diuretics
Septal ethanol ablation
reduce the size of the ventricular septum
Anesthesia for HCM
optimize preload avoid increases in contractility avoid increase in HR prevent afterload reductions prevent SNS activation by relieving anxiety and pain
Regional and GA are safe
Induction - do not cause SVR drops or increase HR and contractility
Myocardial depression is beneficial
Blunting DL is essential
PPV and large TV can cause preload drops and worsen LVOT - so use faster, small TV
Lap surgeries with insufflation can reduce preload and worsen the reflective HR increase and contractility changes
avoid histamine releasing drugs
If hypotension occurs in HCM pt
avoid inotropic agents - ephedrine, dopamine, dobutamine, NE as they worsen the LVOT
Use vasopressin or phenylephrine
Vasodilators will worsen obstruction
Pregnant and HCM
hypotension treated with phenylephrine
pulmonary edema - treat with phenylephrine and esmolol to slow HR and prolong diastole and decrease contractility
diuretics can worsen the event by increasing HR
labor produces catecholamine release
epidural anesthesia encourage
oxytocin can cause vasodilation and tachycardia
Septal myopathy
via aortic approach
more efficacious than ethanol ablation
CPB
TEE used
risk of HB during the procedure
Peripartum cardiomyopathy
rare
EF < 45%
treatment same as HF
diuretics
vasodilators like NTG and hydralazine
ACI teratogenic
Secondary cardiomyopathy with restrictive physiology
causes: amyloidosis - speckled protein deposits in ventricle
HF w/o cardiomegaly or systolic dysfunction
Myocardium becomes stiff
Diastolic dysfunction but normal systolic
Both ventricles affected
afib common
Dx of secondary cardiomyopathy w restrictive physiology
no evidence of hypertrophy
CXR can show pulmonary congestion and pleural effusions w/o cardiomegaly
ECHO shows diastolic dysfunction with normal EF
anesthesia for secondary SM with restrictive
same as for pts with tamponade
Avoid los of NSR and bradycardia
Preload is important
Acute pericarditis
viral infection
after myocardial infarct
Chest pain, pericardial friction rub, diffuse ST elevation
Angina worsens w inspiration, better when pt leans forward
treated w/ SNAIDS
Pericardial effusion
more fluid than normal in pericardial sac
if chronic, large volume accommodation is possible
not evident on CXR until 1-2L develop
l
US can detect sooner
Tamponade
effusion under pressure
as little as 100 mL acute incrase can cause tamponade
CVP is elevated
Kussamaul’s sign - distension of jugular vein during inspiration
Pulsus paradoxus - when SBP changes more than 10 mmHg during inspiration
Beck’s triad
Echo = can detect 20 ML
CXR - water bottle heart
Beck’s triad
muffled heart sounds
increasing JVD
hypotension
Anesthesia w/ tamponade
GA and PPV can cause CV collapse from vasodilation and myocardial depression
Pericardiocentesis is performed under local anesthetic to temporize the insult of GA
After hemodynamics improved, then surgery can be performed
DOC is ketamine as does not decrease inotropy
Art line, CVL
- maintain preload, afterload, contractility - ketamine
- after tamponade is relieved, expect hypertension and have vasodilators ready
Constrictive pericarditis
pericardium adheres to the heart and eliminates the pericardial space/candy caots the heart with a hard shell
S/S: increased CVP - w/o other signs of heart disease low Co fatigue JVD ascites edema TEE - can dx pericardial thickening
pulm congestion absent
anesthesia for constrictive pericarditis
minimize changes in HR, SVR, preload, contractility
Opioid and benzos can be used with low dose PIA
Paralytics with minimal circulatory effects
Invasive monitoring
Gas sampling
