Final Flashcards
Heart failure classification
Comfortable at rest
Slight limitation of physical activity
Class II mild
Heart failure classification
Marked limitation of physical activity
Less than ordinary activity results in fatigue, palpitation, or dyspnea
Class III. Moderate
Heart failure classification
Symptoms of cardiac insufficiency at rest
Unable to carry out any physical activity without discomfort
Severe
Class IV
Type of cardiomyopathy
Systolic dysfunction
Eccentric LV enlargement
Dilated (congestive) cardiomyopathy
Type of cardiomyopathy
Diastolic dysfunction
Concentric hypertrophy
Dynamic outflow obstruction
Obstructive cardiomyoptahy
Abnormal diastolic dysfunction.
Abnormal E:A
Restrictive cardiomyopathy
Failure of LV leads to increased ____________
LVEDP
LVH
Best vasopressor for heart failure patient
Ephedrine better than phenylephrine
NE better than ephedrine
Vasopressin if cant get NE
Highest mortality post transplant is when
Within first 6 months
90% of heart transplant is due to
Idiopathic or ischemic dilated cardiomyopathy
6 contraindications to heart transplant
Severe elevation in PVR
Psych factors/compliance
Irreversible renal, hepatic, pulmonary function
Co-existing disease with poor prognosis
Uncontrolled malignancy
Active infectious process
Minimize ischemic time of donor heart. Usually less than
4 hours
Donor heart is denervated and electrical activity
ECG appearance
Cannot cross suture line
2 P waves
Due to denervation which sympathomimetic have no effect
Indirect bc loss of SNS, PNS innervation to heart
Use direct: epi, NE, isoproterenol
Management of RV failure after transplant (4)
Optimize preload (starling pyramid)
Provide early inotropic support
Maintain low PVR
Consider mechanical support (IABP, RV assist device)
3 drug classes ot maintain low PVR
Nitrates
Prostaglandins
Nitric Oxide
Post transplant considerations for anesthesia
No hemodynamic response to DL and light anesthesia and pain
Induction in heart failure patients (3)
Slower induction
Maintenance of compensatory mechanisms
More potent vasopressors
4 indications for VADs
Heart failure
Circulatory support during surgery
Recovery from MI
Destination therapy
LVADs are dependent on
Reasonable RV function
Normal PAP
Often used to improve pulmonary hypertension and RV function
Epoprosterenol (Flolan)
Nitric oxide
TEE findings that contraindicated LVAD placement
AI
PFO
VSD
ASD
Severe RV dysfunction
Unique considerations of VAD hemodynamics
Inconsistent LV ejection
Use MAP instead of SBP/DBP
Optimize RV function
Current durable VADS have _______ flow
Non-pulsatile continuous flow
What 2 things decrease LVAD flow
Hypovolemia and increased afterload
TEE exam after LVAD implantation watch for
SUCKDOWN
Need adequate preload
Post-implantation management of LVAD includes
Anticoagulation
Avoid high pump speeds
Prior to surgery should assess
Patient function
End organ damage
Doppler/US available
Anesthesia plan for pt with LVAD
Faster fuller vasodilation
Post implant LVAD hemodynamic goals
MAP
Pulse pressure
MAP 70-80. Avoid >90mmHG
PP 10 mmHG
No _________ for LVAD patients
Spinal or epidural
Anesthesia for LVAD patients
Avoid hypovolemia and pulmonary hypertension
If in doubt about pump function during arrest you should do what?
Listen for humming
ICD settings intraop for pt with LVAD
Rate of 100
Tachytherapies off
Parameters of VAD console
Pump flow
Pump speed
Pump power
Pulsatility
Flow 4-6 lpm
Speed 8000
Power 4-8
Pulsatility 4-6
Biggest risk of VADs
Infection
Stroke
Left to right shunts aka
Acyanotic
3 congenital defects associated with left-to-right shunts
ASD
VSD
PDA
Right-to-left shunts aka
Cyanosis
Common cyanotic congenital defects
Tetralogy of Fallot
Transposition of great arteries
Single ventricles
Defect which typically allows parallel circulation physiology to exist
TGA and turn us arteriosus
4 classes of meds used in medical mgmt of LV failure in perioperative period
Diuretics
Digoxin
ACE inhibitors
Beta blockers
3 potential causes of pulmonary hypertension in pt with existing or repaired CHD
Presence of long-standing large nonrestrictive defects
Elevated LVEDP, PAP, or PA stenosis
Decreased O2 sat
Predictors of mortality with Eisenmenger syndrome
Syncope Age at presentation Poor functional class Atrial dysrhythmias Elevated RAP Low O2 sat Severe RV dysfunction Trisomy 21
Findings in Eisenmenger’s Syndrome
Loud pulmonic 2nd heart sound
PT murmur
EKG RVH
Impaired exercise tolerance
Palpitations
Hemoptysis
Syncope
Heart failure
Primary goals of anesthetic management in patient with pulmonary hypertension
Minimize increases in PVR
Maintain SVR
Factors increasing pulmonary output
Decreased PVR
Increased SVR
Causes of decreased PVR
Hypocapnia
Pulmonary vasodilator
Causes of increased SVR
SNS stimulation
Vasoconstrictor
Hypothermia
Factors increasing systemic output
Increased PVR
Decreased SVR
Causes of increased PVR
Hypoxemia
Hypercapnia
High hematocrit
PPV
Cold
Metabolic acidosis
Alpha-adrenergic stimulation
Causes of decreased SVR
Vasodilators
Spinal/epidural
Deep GETA
Hyperthermia
7 measures to prevent and treat acute pulmonary hypertension
Hyperventilate (normocapnia)
Correct acidosis
Avoid SNS stimulation
Normothermia
Minimize intrathoracic pressure
Inotropic support
Inhaled nitric oxide
Coagulation alterations in pt with cyanotic heart disease that may lead to coagulopathy and/or thrombosis
Low levels of vit-k dependent clotting factors, VWF, factor V (elevated INR)
Ventricular dysrhythmias are most frequently encountered in patiens with
Significantly decreased RV or LV function
Acute hypoxemia
Supraventricular dysrhythmias occur in
20-45% of pt with previous atrial surgery
Dilated cardiomyopathy typically involves
Systolic dysfunction
Eccentric hypertrophy
Obstructive cardiomyopathy typically involves
Diastolic dysfunction
Concentric hypertrophy
Restrictive cardiomyopathy typically involves
Diastolic dysfunction
Abnormal filling
Induction in heart failure patients involves
Slower induction
Maintenance of compensatory mechanisms
More potent vasopressors (ephedrine, NE, vasopressin)
Indications for VADs
Heart failure
Circulatory support during surgery
Recovery from MI
Destination therapy
LVADs are dependent on
reasonable RV function
Normal PAP
2 drugs often used to improve pulmonary hypertension and RV function
Epoprosterenol (Flolan)
Nitric Oxide
TEE findings which may contraindicated LVAD
AI
PFO
VSD
ASD
Severe RV dysfunction
Unique considerations of VAD hemodynamics
Inconsistent LV ejection
Use of MAP exclusively
Optimizing RV function
Post implant management of LVAD includes
Anticoagulation
Avoid high pump speeds (<9800rpm)
Prior to surgery should assess
Patient function
End organ damage
Have doppler/US available
Avoid what with LVAD
Hypovolemia
Pulmonary HTN
CPR but defibrillated as needed
If in doubt about pump function during arrest do what
Listen for humming of motor
Biggest risks of LVAD
Infection
Stroke
ASD large shunt when
> 20mm
Risks with ASD
Pulmonary blood flow increased
Atrial dysrhythmias
Emboli stroke
Pulmonary HTN
Effects on heart of ASD
RV enlargement
VSD closure typically for defects >
5mm
Risks of VSD
Endocarditis
AI
Coarctation of aorta results in
Chronic pressure overload of LV (compensatory hypertrophy)
Always hypertensive
Most common cyanotic congenital heart disease
Tetralogy of Fallot
Even after tetralogy of Fallot corrected continue to have
Hypoxemia
RV dysfunction
Tetralogy of Fallot associated with what dysrhythmias
Ventricular
4 components of tetralogy of Fallot
Narrowing PA
Thickening RV
Displacement of aorta over VSD
VSD
Blalock-Taussig shunt considerations
Relieves poor oxygenation symptoms
Affects BP and pulse ox on operative side
Palliative repair for single ventricle
Fontan repair
3 congenital defects associated with L to R shunt in adult
ASD/VSD
Coarctation of aorta
Congenital aortic valve disease
Correction of transposition of great vessels
Epstein’s abnormality of tricuspid
