Anesthesia for Patients with The Long QT Syndrome

Transcription

1 Anesthesia for Patients with The Long QT Syndrome Richard Ing MBBCh, FCA (SA) Department of Anesthesiology University of Colorado Section of Pediatric Anesthesiology Children s Hospital Colorado Richard.ing@childrenscolorado.org

2 No disclosures Eternal optimism No conflicts of interest

3 Risk Factors for SCD in Young People Structural Congenital Heart Disease Congenital Coronary Anomalies Acute Myocarditis Hypertrophic and other Cardiomyopathies Wolff-Parkinson-White Syndrome (WPW) Channelopathies: Long QT syndrome

4 Objectives : Long QT Syndrome Understand the electrophysiology leading to sudden unexplained cardiac death in patients with cardiac channelopathies. Define which types of commonly administered anesthetic medications are safe and which exacerbate the Long QT Syndrome. Outline an approach to anesthesia in these patients Compare and contrast other forms of cardiac channelopathies.

5 It is Estimated that 10-35% of Sudden Unexplained Cardiac Death(SUCD): Due to Cardiac Channelopathies Schwartz PJ et al. A molecular link between the sudden infant death syndrome and the Long QT Syndrome N Engl J Med 343:

6 What Are Cardiac Channelopathies? Clinical Syndromes Myocardial Ion Channels Changes in Heart Electrical System Na + K + Ca 2 + Genetic Acquired Altered Ion Channel Protein Permeability ECG Changes, Life-Threatening, Pro-Arrhythmic, SUCD

7 Why Are the Cardiac Channelopathies Important? Lethal Cardiac Arrhythmias in Patients With These Syndromes are Treatable Risks of Anesthetic Drugs and Adjuvants on ECG Markers of Torsadogenicity. Staikou C et al. BJA 112(2)

8 Recent Case Study 3 year old 15 kg boy collapsed on the playground at school. CPR was promptly initiated AED used to cardiovert ventricular fibrillation Presented to us : further work up revealed prolonged QT interval Underwent internal defibrillator pacemaker insertion

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10 Objective 1 Understand the electrophysiology leading to sudden unexplained cardiac death in patients with cardiac channelopathies.

11 Gap jcn. Gap jcn. Gap jcn. Gap jcn. Ito Ikr Ikr Iks Iks Ik1 Na Ca Na Ca Na Ca Na 0 mv -40 mv -70 mv -90 mv Phase 1 Phase 4 Phase 2 Phase 0 Phase 3 Dr Kanter R. per kind favor

12 Cardiac Channelopathy Excess intracellular surplus of positive ions Delays ventricular repolarization (Prolongs the QT interval) Causes early after depolarizations, particularly in the subendocardium. Heterogeneous depolarization: Torsades de pointes

13 Cardiac Channelopathies The Long QT Syndrome The Short QT Syndrome The Brugada Syndrome Catecholaminergic Polymorphic VT Sick Sinus Syndrome Cardiac Conduction Disease Familial Atrial Fibrillation Grant AO. Cardiac Ion Channels. Circ Arrhythm Electrophysiol 2009: 2: Silva J et al. Curr RX Options in CVS Med :

14 NY City Office of Chief Medical Examiner 274 Autopsy Negative SUD Major Channelopathy Genes since 2008 (KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, RyR2) 141 infants 13.5% Channelopathy 133 non-infants 19.5% Channelopathy Wang D et al. Cardiac Channelopathy Testing in 274 SUD. Forensic Science Int : 2014

15 Long QT Syndrome Most episodes of torsades de pointes, end abruptly in LQTS 4-5% of cardiac arrests fatal Despite this, LQTS Accounts for ± 1000 deaths each year in the United States. Majority in children and young adults. Hobbs JB, Peterson DR, Moss AJ, et al. Risk of aborted cardiac arrest or sudden cardiac death during adolescence in the long-qt syndrome. JAMA Sep (10):

16 90% Activity Auditory Sleep Long-QT Syndrome Long QT 1-14 Genes: KCNQ1 KCNH2 SCN5A ANK2 KCNE1 KCNE2 KCNJ2 CACNA1C CAV3 SCN4B AKAP9 ANTA1 KCNQ1 KCNE1cv Locus: 11p15.5 7q35-q36 3p21 4q25-q27 21q22.1-q q q23-q p13.3 Proteins: Kv7.1 HERG Nav1.5 Ankyrin-B mink, Isk MiRP1 kir2.1,irk1 Cav1.2 Caveolin-3 Navβ.4 AKAP9/yotiao Α-Syntropin KvLQT1 mink, Isk Ionic Currents: I Ks I Kr I Na Several I Ks Webster G, et al Circulation 2013: 127:

17 The Long QT Syndrome Prolonged Ventricular Repolarization (intracellular positive charge) Predisposes to, Torsades de pointes Syncope and Sudden Death. 1:2000 live births annual mortality 1% 14 genetic forms 90-95% LQTS1-3 Majority AD, less than 1% AR Jervell-Lange-Nielson & Romano-Ward Deafness

18 What we need to know about the QT interval Bradycardia prolongs QT Tachycardia shortens QT Bazett [QT/(RR) 1/2 ] Fridericia [QT/(RR) 1/3 ] Framingham [QT (1-RR)] Hodges and Colleagues [QT-1.75(HR-60) Al-Khatib SM, et al. JAMA April 23/ (289):16;

19 Normal Values QTc QTc Rating 1-5 yrs Adult Male Adult Female Normal <440 ms <430 ms <450 Borderline Prolonged >460 >450 >470 Schulein S. Long QT SAJAA 16(3)

20 16 year old 24 hours post-op orthopedic surgery with a Ropivicaine epidural He is ready to go home.

21 Transmural Dispersion of Repolarization (Tp-e) (TDR) Myocardial wall repolarization is heterogeneous (Tp-e) = measure of transmural dispersion of repolarization (TDR) TDR ms Staikou c, et al. BJA 112(2): (2014) TDR>75 ms LQTS Associated with TdP

22 Transmural dispersion of repolarization (TDR) Epicardial cells have the shortest repolarization period. Midmyocardial cells (M cells) have the longest repolarisation. Lower density of K+ channels. This transmural dispersion of repolarization (TDR) is a normal phenomenon. In LQTS, TDR can become exaggerated.

23 T p-e /QT ratio as an index of Tp-e / QT ( ) 0.28 TdP is a risk in LQTS arrhythmogenesis Gupta p et al. T p-e /QT ratio as an index of arrhythmogenesis Jnl of Electrocardiology 41(2008)

24 Risk Stratification LQTS Congenital LQTS Syncope QTc Genotype Mutation type Drug-induced TdP Older age, females Heart disease Electrolyte imbalance Renal or hepatic dysfunction Bradycardia or long pauses >1 QT prolonging Med Genetic predisposition Goldenberg I, Moss AJ. Long QT syndrome. J Am Coll Cardiol. 2008;51: Drew BJ, Circulation. 2010;121:

25 Risk stratification for the diagnosis of LQTS Syncope With stress 2 Without stress 1 Congenital deafness 0.5 Family member with LQTS 1 SCD in immediate family <30 yrs 0.5 Low heart rate for age, children 0.5 QTc interval 480 msec msec msec, men 1 Torsade de pointes 2 T-wave alternans 1 Notched T-wave in 3 leads 1 Probability of LQTS according to total score: low < 1, intermediate 2 3, high > 4. Goldenberg I, et al. Corrected QT variability in serial electrocardiograms in long QT syndrome: the importance of the maximum corrected QT for risk stratification. J Am Coll Cardiol 2006; 48:

26 Testing for LQT1 syndrome Exercise: Lack of QT shortening during exercise Epinephrine infusion test : QTc prolongs >30 ms at an incremental doubling dose of <0.1mcg/kg/min LQT1 have a compromised slow component of the delayed rectifier potassium current (I Ks ) A + test is 76% predictive of LQT1 Does not rule out others forms of LQT Vyas H, Hejlik J, et al. Epinephrine QT stress testing in the evaluation of congenital long-qt syndrome: diagnostic accuracy of the paradoxical QT response. Circulation 2006; 113:

27 Syndactaly & LQTs 8 Timothy Syndrome Congenital Deafness & LQTs 1 & 5 Jervell & Lange Nielson Syndrome The classic presentation of JLNS Deaf child who experiences syncopal episodes during: stress, exercise, or fright. 50% with JLNS had cardiac events before age three years. >50% of untreated children with JLNS die prior to age 15 years. Soon An H et al. Sudden Cardiac Arrest during anesthesia in a 30- month old boy with Syndactaly. J Korean Med Sci 2013 : 28: Tranebjærg L. Et al. Gene Reviews. nhttp:// Holland JJ. Cardiac arrest under anaesthesia in a child with previously undiagnosed Jervell and Lange-Nielsen syndrome. Anaesthesia Feb;48(2):

28 Torsades de Pointes: 50 Years Later, Can We See It Coming? TdP is the signature arrhythmia of long QT syndrome Microvolt T wave alternans showing promise in screening for LQTS Davis Am. Circ Arrhythm Electrophysiol Feb;9(2) Editorial Alexander ME, et al. Microvolt t-wave alternans with exercise in pediatrics and congenital heart disease: limitations and predictive value. Pacing Clin Electrophysiol Jul;29(7): Dessertenne F. Ventricular tachycardia with 2 variable opposing foci. Arch Mal Coeur Vaiss. 1966;59:

29 "short-long-short sequence" (SLS) pattern as an initiating mode of Torsade de Pointes (TdP). Noda T et al. Classification and mechanism of Torsade de Pointes initiation in patients with congenital long QT syndrome Eur Heart J Dec;25(23):

30 Not All Acquired LQTS = Torsades de pointes Drugs: Anti-Arrhythmics : ( Class I, III) Cisapride and Erythromycin, Clindamycin Organo phosphate poisoning Antidepressants Ondansetron, Droperidol, Haloperidol Electrolytes: Low Calcium, Low Magnesium Other: SAH, CMO, Myocardial infarction, Starvation Diets, Anorexia Nervosa. Right sided neck dissection Viskin S. Long QT Syndromes and torsades de pointes Lancet 1999:

31 Objective 2 Define which types of commonly administered anesthetic medications are safe and which exacerbate the Long QT Syndrome.

32 Crediblemeds.org 13 pages (pdf) all the drugs to be cautious with or avoid

33 Anesthetic Strategy LQTs Continue β-blocker Quiet comfortable Premed High risk of Torsades 30 mg/kg Propofol Excellent Dexmedetomidine Fentanyl Avoid: Droperidol Ondansetron Catecholamines Phenylephrine Hypothermia Ketamine, Thio, Sux Caution Sevoflurane Desflurane Staikou et al. BJA 108 (5)

34 The safety of Modern Anesthesia for Children with Long QT Syndrome Retrospective. <18 yr old, 8 sites. 103 patients underwent 158 general anesthetics. 51% GA episodes : LQTs & 49% GA: incidental. 76% β-blockers and 47% sedation on day of surgery. Tiva: 19% Gas: 30% Combination of Tiva & Gas: 51% Zero : Droperidol use 6.2% TdP neonates, infants in the LQTs related anesthetics Whyte A et al. The safety of Modern Anesthesia for children with Long QT Syndrome Anesth Analg Oct;119(4):932-8 PMID

35 Objective 3 Compare and contrast other forms of cardiac channelopathies.

36 Sleeper: Attacked by a Nocturnal demon that Squats on his Chest and Suffocates him. Choking, gasping, groaning, gurgling, frothing at the mouth, labored breathing without wheezing or stridor, screaming, and other signs of terror." In Japan, pok-kuri; the Philippines: bangungot or batibat; and the Hmong Vietnam call it tsob tsuang. In Thailand, the being to fear is the phi am or 'widow ghost who comes to steal away the souls of young men. Some men defend themselves from phi am by wearing lipstick at night, so that the ghost mistakes them for women and leaves them alone. Nightmare death syndrome, Brugada Syndrome (David Hambling, FORTEAN TIMES, February 2006)

37 Brugada Syndrome (BrS) Channelopathy with RV conduction delay and ST segment changes. (RVOT) R precordial ST elevation Fever may unmask (coved type ST segment elevation > 0.2 mv and negative T-wave deflection in > 1 lead (V1-V2) Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992;20:

38 Differential Diagnosis R or L BBB, LVH, AMI, Ischemia, Acute myocarditis RV ischemia or infarction Dissecting aortic aneurysm Acute PE Heterocyclic antidepressant overdose Duchenne MD Thiamine deficiency Hypercalcemia Hyperkalemia Cocaine intoxication Marijuana use ARVC, LQTS, type 3 Wilde et al. European Heart Journal (2002) 23, Kloesel b et al. Anesthetic management of patients with Brugada syndrome CJA 2011:58:

39 Antzelevich s theory, intrinsic heterogeneity produces the transmural dispersion of repolarization (TDR) between the epicardium and endocardium, which may lead to local pre-excitation termed phase 2 reentry, triggering VF Dizon JM

40 Anesthetic Drug Considerations Fentanyl Thiopentone Midazolam Isoflurane, Sevo, N 2 O Isoproterenol (R x ST^) Vecuronium Rocuronium Lidocaine (care) Amiodarone Quinidine Atropine Brugada Contra indicated Propofol infusions (care) Bupivicaine Β blockers α agonists Dexmedetomidine Neostigmine Metaclopramide Procainamide Flecainide Epidural block caution Valsalva Noradrenaline Inamura M et al. CAN J ANESTH : 4 pp Kloesel B et al. Can J Anesth :

41 Concluding remarks

42 Survivors of Cardiac Arrest Approximately 2/3 have an inherited cardiac disease Channelopathies & SUCD is survived less frequently (28%) than structural inheritable cardiac pathology Behere SP, Weindling SN Inherited arrhythmias: The cardiac channelopathies Ann Pediatr Cardiol Sep-Dec; 8(3): van der Werf C, et al. Diagnostic yield in sudden unexplained death and aborted cardiac arrest in the young: The experience of a tertiary referral center in The Netherlands. Heart Rhythm. 2010;7:1383 9

43 Tp-e/QT

44 LQT Syndrome Brugada Congenital deafness SUCD blood relatives Torsades risk B Blockers recommended Correct any abnormal Electrolytes Phenytoin for Torsades Stress free anesthetic preferred Caution use of Sevoflurane Crediblemeds.org Isoproterenol recommended For ECG related ST changes Caution use of Propofol Brugadadrugs.org

45 Denversouthmetrofoundation.org Placement of Automated External Defibrillators (AEDs) in schools that have students with an identified cardiac need. Over 415 AED s in Colorado schools since 2006

46 Ambulance Drones Alec Momont Travel 100km/hr GPS technology ciencetech/article /The-ambulancedrone-save-life-Flyingdefibrillator-reach-speeds- 60mph.html