Cardiomyopathies

Question 1

Dilated cardiomyopathy

Answer 1

Primary CM

LV or Biventricular dilation
systolic dysfunction
thin wall with dilation of LV

Chambers are enlarged but hypokinetic resulting in clot formation

Question 2

Concentric LVH

Answer 2

response to increased workload such as increased afterload

Question 3

Eccentric hypertrophy

Answer 3

thinned LV wall

caused by fluid overload

Question 4

Dx of DC

Answer 4

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

Question 5

Apical ballooning/Takosubo

Answer 5

temporary DCM
stress
women > men
high catecholamine state so inotropes are contraindicated and negative inotropes are used like BB, CCB,

IABP

Question 6

Medical treatment of DC

Answer 6

similar to HF
risk of embolization and need anticoagulation
AICDs

Question 7

Hypertrophic CM

Answer 7

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.

Question 8

Dx of HCM

Answer 8

Echo
Obsturction with gradients of 30 mmHg is significatnt
50 mmHg mandates surgical or PCI

Question 9

Drug of choice for HCM

Answer 9

amiodarone

Question 10

HCM complications

Answer 10

avoid Valsalva bc increases the LVOT

Increase in HR and contractility or decrease in preload after afterload will worse LVOT obstruction

Maintain NSR

Question 11

What should cause you to think HCM in young person?

Answer 11

LV hypertrophy on ECG

systolic murmur

Question 12

Medical mgmt. of HCM

Answer 12

BB to reduce tachycardia
Afib
CCB to improve diastolic relation
antyi-arrhythmics
Diuretics

Question 13

Septal ethanol ablation

Answer 13

reduce the size of the ventricular septum

Question 14

Anesthesia for HCM

Answer 14

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

Question 15

If hypotension occurs in HCM pt

Answer 15

avoid inotropic agents - ephedrine, dopamine, dobutamine, NE as they worsen the LVOT

Use vasopressin or phenylephrine

Vasodilators will worsen obstruction

Question 16

Pregnant and HCM

Answer 16

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

Question 17

Septal myopathy

Answer 17

via aortic approach
more efficacious than ethanol ablation

CPB
TEE used
risk of HB during the procedure

Question 18

Peripartum cardiomyopathy

Answer 18

rare
EF < 45%

treatment same as HF
diuretics
vasodilators like NTG and hydralazine

ACI teratogenic

Question 19

Secondary cardiomyopathy with restrictive physiology

Answer 19

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

Question 20

Dx of secondary cardiomyopathy w restrictive physiology

Answer 20

no evidence of hypertrophy

CXR can show pulmonary congestion and pleural effusions w/o cardiomegaly

ECHO shows diastolic dysfunction with normal EF

Question 21

anesthesia for secondary SM with restrictive

Answer 21

same as for pts with tamponade

Avoid los of NSR and bradycardia

Preload is important

Question 22

Acute pericarditis

Answer 22

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

Question 23

Pericardial effusion

Answer 23

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

Question 24

Tamponade

Answer 24

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

Question 25

Beck’s triad

Answer 25

muffled heart sounds
increasing JVD
hypotension

Question 26

Anesthesia w/ tamponade

Answer 26

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

Question 27

Constrictive pericarditis

Answer 27

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

Question 28

anesthesia for constrictive pericarditis

Answer 28

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