Pathophysiologic consideration in patients with congenital heart disease
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Pathophysiologic Consideration In Patients With Congenital Heart Disease. SAMIA SHARAF .MD. Professor Of Anaesthesia .. Ain Shams University. Classification Of Congenital Heart Lesions. Obstructive lesions eg. Aortic stenosis – coarctation of aorta

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Pathophysiologic Consideration In Patients With Congenital Heart Disease

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Pathophysiologic consideration in patients with congenital heart disease

Pathophysiologic Consideration In Patients With Congenital Heart Disease

SAMIA SHARAF .MD

Professor Of Anaesthesia .. Ain Shams University


Classification of congenital heart lesions

Classification Of Congenital Heart Lesions

  • Obstructive lesions eg.

    Aortic stenosis – coarctation of aorta

  • Increased pulmonary blood flow eg.

    ASD – VSD – PDA

  • Decreased pulmonary blood flow lesions eg. Tetralogy of fallot – tricuspid atresia – pulmonary atresia


Pathophysiologic consideration in patients with congenital heart disease

Classification Of Congenital Heart Lesions


Clinical presentation of children with chd

Clinical Presentation Of Children With CHD

  • Cyanosis ( due to hypoxia )

  • Respiratory system abnormalities

  • Cardiac failure

  • Arrhythmias


Cyanosis pathophysiologic effects of hypoxia

Cyanosis Pathophysiologic Effects of Hypoxia

(1) Growth

(2) Heart

  • Exercise intolerance :

    myocardial dysfunction ventricular compliance and contractility

  • Irreversible myocardial damage .

  • Increased sympathetic tone down regulation of beta receptors cardiomyopathy


Pathophysiologic consideration in patients with congenital heart disease

(3) Hematology

  • A major adaptive response to chronic hypoxia

    Red cell mass

    Polycythemia Secondary Spherocytosis

  • Blood viscosity

  • Risk of thromboembolic events


Hemostasis

Hemostasis :

Polycythemia

Coagulation abnormalities

Primary fibrinolysis

DIC


Mechanism of coagulation abnormalities

Mechanism of coagulation abnormalities

Increased blood viscosity

DIC Hypercoag. blood & tendency to bleed

Increase intravascular strains

Thrombocytopenia & Low Fibrinogen & Other Factor Level

Fibrin deposition

&

platletaggreg.

Consumpution of platlets ,

fibrinogen , factor V , VIII


4 cns

(4) CNS

  • Chronic hypoxia causes impairment of neurologic development and increase risk of neurologic damage .

  • Brain abscess : Rt. – Lt. shunt

  • Cerebrovascular thrombosis and hemorrhage .


Respiratiry system abnormalities

Respiratiry System Abnormalities

  • Anatomical abnormalities of airway

  • Pulmonary abnormalities associated with or pulmonary blood flow .


Anatomical abnormalities of airway

Anatomical Abnormalities Of Airway

  • Short trachea eg. interrupted aortic arch

  • large airway obstruction : ( trachea & bronchi )

  • Compression by enlarged aorta or pulmonary artery .

  • Upwards displacement and increase angle of bifurcation of trachea by enlarged LA .


Pathophysiologic consideration in patients with congenital heart disease

  • Small airway obstruction :

  • Compression of lung parenchyma by enlarged heart and vessels .

  • Pulmonary hypertension .


Pulmonary changes associated with pulmonary blood flow

Pulmonary Changes Associated With Pulmonary Blood Flow

Patients with chronic hypoxia

  • Slight of alveolar ventilation

  • pulmonary venous PO2 is high

  • V/Q mismatch alveolar – pulmonary venous O2 gradient

  • Physiological dead space end tidal CO2 is lower than arterial PaCO2


Pulmonary changes associated with pulmonary blood flow1

Pulmonary Changes Associated With Pulmonary Blood Flow

  • Obstruction of small airway

  • Pulmonary congestion pulmonary compliance , lung water & Impaired gas exchange

  • Progressive of pulmonary vascular resistance due to hypertrophy in muscular layer of pulmonary arteries reverse of left to right shunt


Cardiac failure

Cardiac Failure

Causes of limited cardiac reserve :

(1) Increased cardiac workload

Pressure overload :

ventricular outflow tract obstruction

SVR blood viscosity

Volume overload :

* Valvular insufficiency

* Single ventricle

* Left – right shunt


Pathophysiologic consideration in patients with congenital heart disease

(2) Myocardial contractility:

  • Prolonged workload of myocardium

  • Vascular supply to ventricles

  • Blood hyperviscosity

  • Chronic hypoxia


Compansatory mechanism

Compansatory Mechanism

  • Ventricular hypertrophy

  • Adrenergic system changes

    Activation of B receptors

  • Renal system compansation

    *Salt & water retention

    *Renin secretion


Arrhythmias

Arrhythmias

Types :

* Congenital

* Acquired

Etiology :

  • Intrinsic electrophysiology abnormalities

  • Damage from chronic hypoxia – hemodynamic stress

  • Surgical injury eg. F4 , Fontan operation , atrial correction of TGA


Congenital conduction system abnormalities

Congenital Conduction System Abnormalities

  • Congenital complete atrioventricular block

  • Wolf – Parkinson white syndrome

  • Supraventricular tachycardia

  • Arrhythmias associated with Ebstien anomaly


Acquired conduction system abnormalities

Acquired Conduction System Abnormalities

  • Non surgical : rare

  • Surgical by :

    * cardioplegia

    * mechanical retraction

    * ischemia

    * metabolic abnormalities


Anaesthetic risk factors affecting anaesthetic risk in congenital heart disease

Anaesthetic Risk factors affecting anaesthetic risk in congenital heart disease

Pulmonary disease

Cyanotic heart disease

Myocardial dysfunction

Cardiovascular impairment

Arrhythmias

Magnitude of surgery

Anaesthetic risk


How to reduce anaesthetic risk

How To Reduce Anaesthetic Risk ??


Consultation

Consultation


Role of surgeon

Role Of Surgeon

  • Case discussion :

  • Pts. with CHD may not tolerate :

  • Abdominal laparoscopic procedures

  • ( eg. stenotic valvular lesions , single ventricle )

  • Absorption of CO2 ( C.O.P dependant low PVR) .

  • One lung ventilation

  • Prone position ( Fontan pt. )


Role of pediatric cardiologist

Role Of Pediatric Cardiologist

Preoperative consultation sometimes add a little benefit to anesthiologist !!!!!


Pathophysiologic consideration in patients with congenital heart disease

Base line O2 saturation

Vital data

Murmurs

Gallops

Pulse in extremities

Planned followup

as needed

2-3 months interval

New echo

Unstable pt.

Major operation

History data

exact anatomy

Previous cardiac operation

Myocardial function status

Pediatric cardiologist consultation


Pathophysiologic consideration in patients with congenital heart disease

Efficacy Of Repairs For CHD Lesions


Pathophysiologic consideration in patients with congenital heart disease

How To Look To Patient Data


Pathophysiologic consideration in patients with congenital heart disease

History Taking

  • Growth

  • Exercise Intolerance

  • Recurrent Chest Infection

  • Syncopal Attacks

  • Squatting


Pathophysiologic consideration in patients with congenital heart disease

ECG , Echo & Cardiac Cath.

Systolic & Diastolic Dysfunction

Systolic Dysfunction

Reduced Fractional Shortening


Pathophysiologic consideration in patients with congenital heart disease

Diastolic Dysfunction

Ventricular Hypertrophy

Concentric

Eccentric

Obstructive

Volume

Before Repair

e.g

valvular

&

outflow obst.

After Repair

e.g

Homograft conduit

Before Repair

e.g

Lt . to Rt. shunt

  • After Repair

  • e.g

  • Pulmonary valve regurge

  • ( F4 )

  • MV repair


Pathophysiologic consideration in patients with congenital heart disease

Anaesthetic considerations :

Consider determinants of coronary perfusion & myocardial oxygen balance

  • Heart rate changes

  • Hypotension

  • Myocardial contractility


Pathophysiologic consideration in patients with congenital heart disease

Anaesthetic considerations

CONCENTRIC Ventricular Hypertrophy

Eccentric Ventricular Hypertrophy

Cardiomyopathy

increase wall thickness

Maintain heart rate to decrease regurgitant fraction

Syst. Dysfunction

In Dialted type

anaesthetic myocardial depression

Decrease driving filling pressure of coronary arteries

Coronary ischemia

Diast. Dysfunction

In Hypertrophic & restrictive type

coronary perfusion depends on

bl. p. & hr

RV

LV

coronary filling becomes diastolic


Pathophysiologic consideration in patients with congenital heart disease

  • Residual Shunts :

  • Occasionally present after repair of ASD , VSD & F4

  • Small patch leaks are hemodynamically benign


Pathophysiologic consideration in patients with congenital heart disease

Dysrhythmias :

Atrial & ventricular types increase mortality and morbidity

Arrhythmias Associated With Specific Surgical Procedures

Ostium secondum ASD :

  • P-R interval is prolonged in 20-30% of patients

  • AF , atrial flutter with advancing age


Pathophysiologic consideration in patients with congenital heart disease

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


Pathophysiologic consideration in patients with congenital heart disease

Pulmonary hypertension

Severity of hypertension of base line PAH correlated with the incidence of major complications

( pulmonary hypertensive crisis or cardiac arrest )


Pathophysiologic consideration in patients with congenital heart disease

Cardiovascular risk of PAH

  • Major perioperative hemodynamic deterioration mainly pulmonary hypertensive crisis and acute right ventricular failure and cardiac arrest .

  • Data to look for :

  • Mean pulmonary artery pressure > 25 mmHg

  • 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 )


Pathophysiologic consideration in patients with congenital heart disease

ANAESTHETIC CONSIDERATIONS

Avoid Factors Rapidly Increasing PVR


Pathophysiologic consideration in patients with congenital heart disease

Laboratory data

Hematocrit value

Increase More Blood Viscocity

Hyperviscosity symptoms

Decreased oxygen delivery


Pathophysiologic consideration in patients with congenital heart disease

Blood Indicies :

Increase Blood Viscosity

Hyperviscosity Symptoms At Lower Hematocrit Value


Pathophysiologic consideration in patients with congenital heart disease

Phlebotomy

Done to relieve hyperviscosity symptoms with hematocrit > 65 % in absence of iron deficiency anaemia or signs of dehydration


Pathophysiologic consideration in patients with congenital heart disease

  • Hemostatic values

  • Prolonged PT , PTT , APTT values most frequently seen in cyanotic patients

  • Thrombocytopenia is related to degree of polycythemia .


Pathophysiologic consideration in patients with congenital heart disease

Summary

General 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


Pathophysiologic consideration in patients with congenital heart disease

Summary

Risk 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


Pathophysiologic consideration in patients with congenital heart disease

THANK YOU


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