Jochen Steppan, MD, DESA. Cardiac Disease and Implications of Ophthalmic Surgery

Transcription

1 Jochen Steppan, MD, DESA Cardiac Disease and Implications of Ophthalmic Surgery Ophthalmic Anesthesia Society, 2017

2 Objectives 1. Identify patients presenting for ophthalmological surgery who are at increased perioperative risk due to severe cardiovascular disease 2. Discuss perioperative management strategies for patients with severe cardiovascular disease presenting for ophthalmological surgery

3 Outline 1. Cardiac risk assessment 2. High risk program JHU Ophthalmic surgery 3. Management of: Pulmonary hypertension Severe aortic stenosis Congestive heart failure and ventricular assist devices Coronary artery disease

4 Not a new topic

5 2014 ACC/AHA Guidelines Unstable angina, NSTEMI, or STEMI Decompensated heart failure High grade arrhythmias Valvular heart disease Use of risk calculators:

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7 Revised Cardiac Risk Index High Risk surgery Ischemic heart disease Congestive heart failure Cerebrovascular disease Preoperative insulin Preoperative creatinine >2mg/dl Points Risk (%)

8 Preoperative Testing Electrocardiogram Echocardiogram Noninvasive cardiac stress testing Invasive cardiac testing

9 ECG Preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease or other significant structural heart disease, except for low-risk surgery No preoperative ECG (B)

10 Echocardiogram If dyspnea and unknown LV function (C) If heart failure worsened (C) Reassessment in stable patients can be considered (C) RA LA RV LV

11 Stress test Exercise stress test Not needed if at least moderate exercise tolerance of 4 METS (B) If elevated risk and poor exercise tolerance it may be reasonable (B) Pharmacological stress test Reasonable in elevated risk patients with poor functional capacity (B)

12 Revascularization No routine preoperative angiography Indications for CABG or percutaneous transluminal coronary angioplasty are the same as in non-surgical settings Cumulative mortality and morbidity of both the coronary revascularization and the non-cardiac surgery

13 Coronary artery stents

14 Only part of the picture valve disease pg

15 Identification of high risk groups Dedicated person of contact Director of Perioperative Medicine, High Risk Cardiovascular Disease Partner with primary care teams Pulmonary hypertension clinic Adult congenital heart disease clinic Perioperative evaluation clinic Educational outreach to involved departments and sub divisions

16 Pulmonary arterial hypertension Rama krishna et al., 2005 Lai et al., 2007 Price et al., 2010 Memts oudis et al., 2010 Kaw et al., 2011 Meyer et al., 2013 Patients (n) Morbidity (%) Mortality (%)

17 Adult congenital heart disease Maxwell et al, 2013, Anesthesiology

18 Ventricular assist devices Barbar a et al., 2005 Baht et al., 2007 Ahme d et al., 2010 Anaout akis et al., 2010 Morga n et al., 2011 Garetti et al., 2013 Patients (n) Morbidity (%) Mortality (%) Davis et al, 2015, ASAIO J Kirklin et al, 2015, J Heart Lung Tranplant

19 Severe aortic stenosis Mortality depends on symptoms: 3-9 % if symptomatic AS 1-3 % if asymptomatic AS Morbidity depends on comorbidities: UpToDate: August 2017 Miklos et al, 2004, Am J Med

20 Role outline for PAH

21 Key questions 1) Do the benefits of the surgery outweigh the PH-associated risks of the procedure? 2) Is the patient medically optimized? 3) How will medications be managed perioperatively? 4) Are procedural modifications necessary to mitigate risk? 5) Should the procedure be moved from its usual location? 6) How should anesthesia staffing be allocated? 7) What is the optimal postoperative disposition? 8) Is the patient a candidate for extracorporeal life support (ECMO) Just another couple of pages! se.jpg

22 Benefits of the surgery 1) Do the benefits of the surgery outweigh the risks? Topical vs. regional vs. general anesthesia Complications Regional: OCR, IV LA, brainstem anesthesia, hemorrhage IOP control OCR: bradycardia, AVB -> atropine No nitrous if intraocular gas is used

23 Medical optimization 2) Is the patient medically optimized? Multidisciplinary approach Partner with primary care teams Cardiology Pulmonary hypertension clinic Adult congenital heart disease clinic Perioperative evaluation clinic Symptoms at rest Especially dyspnea when lying flat

24 Medications 3) How will medications be managed perioperatively? Atropine fro myadriasis and cyclopiegia Tachycardia Scopolamine CNS excitement Phenylephrine for capillary decongestion and pupillary dilatation Palpitations, hypertension, bradycardia Epinephrine to lower IOP, aqueous secretion Hypertension, tachycardia

25 Medications Timolol (BB) for glaucoma Light headedness, bradycardia, worsened asthma Acetylcholine Hypotension, bradycardia, bronchospasm Echothiopate Iodide (CHE inhibitor) for miosis Prolongs Suxs and ester local anesthetics

26 Logistics 4) Are procedural modifications necessary to mitigate risk? 5) Should the procedure be moved from its usual location? 6) How should anesthesia staffing be allocated? 7) What is the optimal postoperative disposition? 8) Is the patient a candidate for extracorporeal life support

27 Switching gears - Management 0.gif

28 Intraoperative Management Pulmonary Hypertension Severe aortic stenosis Congestive heart failure Ventricular assist devices Coronary artery disease

29 Pulmonary hypertension Mean pulmonary artery pressure 25mmHg spap = ΔP + CVP Pulmonary valve CVP estimation ΔP = 4v 2 mpap ~ ⅔ spap

30 Classification Group 1: Pulmonary arterial hypertension Group 2: Due to left heart disease Group 3: Due to chronic lung disease / hypoxia Group 4: Chronic thromboembolic disease Group 5: Unclear or mulitfactorial

31 Right versus left ventricle Haddad F et al, Circulation,

32 Preoperative PH Management Supportive Therapy Oxygen Diuretics Anticoagulation Correct anemia CCB PH specific Prostacyclin PDE-5 inhibitors Endothelin receptor Surgical treatment Atrioseptostomy Transplant

33 PH specific medications Humbert M, Eur Resp Rev 2010

34 Intraoperative concern Volume load Decreased Contractility High afterload Arrhythmias RA LA RV LV

35 Intraoperative PH Management Coronary perfusion Euvolemia Support RV contractility Maintain normal rhythm Decrease PVR 100% FiO2 Hyperventilation Treat acidosis Normothermia Low tidal volumes Pain control Medications

36 s.jpg Mayo Foundation for Medical Education and Research Severe aortic stenosis Prevalence: 4-5% (80 years +) Syncope, Angina, Dyspnea Normal Valve area 2-4cm 2 Atherosclerosis, and bicuspid aortic valve Severe aortic stenosis: Valve area < 1.0 cm 2 Maximum velocity > 4.0 m/sec

37 Echo LV RV Aortic valve LA

38 Aortic Stenosis Thick heart High LVEDP Low compliance Stenosis High gradient / velocity Increased work

39 Preoperative AS Management

40 Preoperative concerns Pressure overload concentric LVH (wall stress) impaired diastolic relaxation decreased contractility Stiff ventricle: atrial kick increases from 20 to 40%

41 Preoperative concerns Poor coronary perfusion: CPP = AoDP - LVEDP Diastolic time AoDP determined by CO and SVR Hypotension risks ischemia Increases LVEDP Decreases contractility Decreases stroke volume/co Worsening Ischemia drops DBP The Spiral of Death Ensues

42 Intraoperative AS Management Coronary perfusion is key Preload Afterload Contractility Rate Rhythm Myocardial O 2 Maintain adequate ventricular volume, CPP, HR, and NSR Full Maintain CPP Maintain Maintain low normal Sinus (consider cardioversion or BB) Avoid tachycardia and hypotension

43 Congestive Heart Failure A clinical syndrome that is characterized by systemic perfusion inadequate to meet the body's metabolic demands as a result of impaired cardiac function.

44 Ventricular assist devices Fang JC, NEJM 2009

45 Common VADs

46 Most likely to encounter Second generation LVAD: Continious axial flow pumps (e.g. HeartMate II, HeartWare )

47 Preoperative Management Multidisciplinary team CRMD evaluation Coagulation management INR 2-3, consider heparin bridge Acquired vwd Right ventricle is key to provide LV preload Support ventricular contractility Volume status Fang JC, NEJM 2009

48 Intraoperative Management Perfusionist support Backup battery power supply Full stomach Doppler BP measurement Unassisted right ventricle Maintain adequate volume Avoid excessive increases in afterload Fang JC, NEJM 2009

49 Coronary artery disease Kristian Thygesen et al. Circulation. 2012;126:

50 Preoperative revascularization Extent of coronary artery disease and coronary anatomy Left main disease and extend 1, 2, or 3-vessel disease Risk stratification High, intermediate, low Syntax score Symptoms Diabetes Antianginal medications Example 2 vessel CAD Algorithm: Kristian Thygesen et al. Circulation. 2012;126:

51 Myocardial O 2 Balance Myocardial oxygen supply: 1) Coronary blood flow CPP = (AoDP-LVEDP) Diastolic time Collaterals 2) Oxygen content 1.34 x Hgb x SaO x PaO 2 3) Hgb O 2 dissociation curve 4) O 2 extraction (50% at rest) Myocardial oxygen demand: 1) Wall stress (PR/2h) 2) Heartrate 3) Contractility

52 Intraoperative Management Optimize oxygen carrying capacity 100% oxygen, optimize ventilation Consider transfusion Improve coronary blood flow Maintain BP and CO Beta Blockers (or calcium channel blocker) Assure adequate anesthetic depth Nitroglycerin Infusion ( mcg/kg/min) Consider Aspirin and IV heparin Cardiology for reperfusion therapy Intraaortic balloon pump Fang JC, NEJM 2009

53 Summary Risk assessment specific to ophthalmic surgery is lacking High risk patients go beyond risk calculators Preoperative optimization and resource allocation are key Multidisciplinary team work Intraoperative management requires detailed knowledge of the patients physiology Key concepts are: Pulmonary hypertension: RV function and PVR Coronary artery disease: Myocardial oxygen supply and demand

54 Questions? Jochen Steppan, MD, DESA Assistant Professor Division of Cardiac Anesthesia Director of Perioperative Medicine, High Risk Cardiovascular Disease

55 Thank you