Anaesthetic implications in a patient

with poor LV function

Dr Sanjula Virmani
Professor
Department of Anaesthesiology and Intensive Care

G B Pant Hospital, New Delhi
LV function can be defined in terms of
LV systolic function and
LV diastolic function
Systolic dysfunction
Changes in preload and afterload
(characterized by LV remodeling with an
increase in the size of left ventricle and a
change in LV geometry).
Decrease in myocardial contractility
Increase in heart rate
Increase in diastolic filling pressures
Diastolic dysfunction
Abnormalities of
Diastolic distensibility
Myocardial relaxation
Ventricular filling
The ventricle's passive elastic properties
Heart rate (which determines how much time
is available for ventricular filling). Thus,
impaired diastolic function can be aggravated
by tachycardia.
Pathogenesis
Poor LV function
Coronary artery disease
Hypertention
Valvular heart disease
Cardiomyopathies
LV Remodeling
Alterations in Myocyte Biology
Excitation contraction coupling
Myosin heavy chain (fetal) gene expression
Beta-adrenergic desensitization
Hypertrophy
Myocytolysis
Cytoskeletal proteins
Myocardial Changes
Myocyte loss
Necrosis
Apoptosis
Autophagy
Alterations in extracellular matrix (Matrix degradation Myocardial fibrosis)
Alterations in Left Ventricular Chamber Geometry
LV dilation
Increased LV sphericity
LV wall thinning
Mitral valve incompetence
Left ventricular remodelling (Geometry)

Determinants of LV function
LVEDP (5-12 mm Hg)
LAP (2-12 mm Hg)
PCWP (4-12 mm Hg)
CVP (1-5 mm Hg)
Calculations and measurements:
CI (25-42 L/min/m
2
)

SVI (40-60 mL/beat/m
2
)
SWI (45-60 g.m/m
2
)
EF
Determinants of LV function cont.
The most useful parameter in daily practice is
the LVEF fraction.
EF> 50% is considered to be normal
EF between 35 to 50% is moderately
depressed
EF < 35% represents a severely depressed
function

Preoperative preparation of the
patient
If not an emergency
Identify any active cardiac conditions
Identify and stratify the risk involved in the
surgery
Assess the patients functional capacity and
clinical risk factors
Optimise the medical therapy
Consider coronary revascularization

Assess the patients clinical features
Markers of cardiac risk
Patients cardiac status
Order tests only when results may change
management
Interventions that may result from specialised
tests include delaying surgery, coronary
revascularization, medical optimization,
additional specialists involvement, modified
intra-op and post-op monitoring or modifying the
surgical location.
Conditions in which the patients should undergo evaluation
and treatment (patient specific factors) as per ACC/AHAA
2007 guidelines categorised as Class I, Level B
Functional status should be evaluated
Underlying cardiac conditions apparently stable
Stable angina
Distant MI
Prior HF
Moderate valvular heart disease
Identify comorbid conditions
DM
Stroke
Renal insufficiency
Pulmonary disease
Estimated energy requirements for various
activities, based on Duke Activity Status Index
1 MET Can you
Take care of yourself
Eat, dress, or use toilet
Walk indoors around the house?
Walk 1 to 2 blocks on level ground at 2-3 mph
<4 METS Can you
Do light work around the house, such as dusting or washing dishes?
4 METS Can you
Climb a flight of stairs or walk up a hill?
Walk on level ground at 4 mph?
Run a short distance?
Do heavy work around the house?
Participate in moderate recreational activities
10 METS Can you
Participate in strenuous sports such as swimming, singles tennis, football

Risk stratifications in patients undergoing noncardiac
surgery (procedure related factors)
Lees Revised Cardiac Risk Index.
Circulation 1999; 100: 1047
Clinical variable Points
High-risk surgery (i.e.,
intraperitoneal , intrathoracic,
or suprainguinal vascular
surgery)

1
CAD 1
CHF 1
History of cerebrovascular
disease
1
Insulin treatment for DM 1
Preop serum creatinine >2.0
mg per DL
1
Risk Class Points Risk of
complications
I. Very low 0 0.4
II. Low 1 0.9
III. Moderate 2 6.6
IV. High 3+ 11
Noninvasive stress test
To be considered only if the test results have a
potential to change patient management
In patients with normal ECG, who are able to
exercise-Exercise ECG testing
In patients with abnormal resting ECG-stress
cardiac imaging
In patients who are unable to perform
adequate exercise-pharmacologic stress
imaging
Coronary Angiography
Unstable coronary syndromes
Stress test is uncertain in high risk patient
undergoing major surgery
Possible indication for coronary
revascularization
Optimise medical therapy
-blockers
Low dose aspirin
Statins
2 agonists
Calcium channel blockers
Nitrates

Fleisher LA, et al 2009 ACCF/ AHA focused update on perioperative Beta
Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative
Cardiovascular Evaluation and Care for Noncardiac Surgery. A Report of the
American College of Cardiology Foundation/ American Heart Association Task
Force on Practice Guidelines. Circulation 2009; 120: 169-276
Continue beta-blocker therapy in patients who
are already receiving these agents for angina, HT,
or other ACC/AHA class I indications (Level of
evidence C)
Initiation recommended
in those undergoing vascular surgery who have
ischaemia on preoperative testing ( Class IIa)
CAD or high cardiac risk (more than 1 clinical risk
factors undergoing intermediate risk surgery)



Statins
Beneficial effect on systemic atherosclerosis
Improve atherosclerotic plaque stability (
antithrombogenic, antiproliferative)
Inhibit leucocyte adhesion

Lipid lowering effect (decrease cholesterol, increase HDL)
Pleiotropic effects
Increase endothelial NO synthetase
Generation of ROS
Decrease endothelin I production
Improve thrombogenic profile
Decrease inflammation
Decrease CRP levels
Inhibition of atherosclerosis
Fleisher et al. ACC/AHA 2007 perioperative
guidelines. J Am Coll Cardiol 2007; 17: 206
Statins should be continued in patients
currently taking statins. Class I (level of
evidence B)
Statin use is reasonable in patients undergoing
vascular surgery with or without clinical risk
factors. Class IIa (Level of evidence B)
Fleisher et al. ACC/AHA 2007 perioperative
guidelines. J Am Coll Cardiol 2007; 17: 206
Alpha 2 agonists for perioperative control of
HT maybe considered for patients with known
CAD or at least 1 clinical risk factor. Class IIIb
(Level of Evidence B)

Fleisher et al. ACC/AHA 2007 perioperative
guidelines. J Am Coll Cardiol 2007; 17: 206
Nitroglycerin : As a prophylactic agent to
prevent MI its usefulness is unclear and the
recommendation for its prophylactic use must
take into account the anaethetic plan and
patient haemodynamics as well as recognise
that vasodilation and hypovolaemia can occur.
Class IIIb (Level of evidence C)
Other previously prescribed medication should
continue in the perioperative period
Aspirin
Medication for HT, CHF, arrhythmias

A combination of -blockers, low dose aspirin and statins
is most promising
Devereaux et al. How strong is the evidence for the use of
perioperaative beta blockers in non-cardiac surgery? Systematic
review and meta-analysis of randomised controlled trials. BMJ
2005; 331: 313-21
Limited role for coronary
revascularization and benefit
apparently limited to left main disease

Revascularization failed to affect any outcome
measure, including mortality or the development of MI
out to 6 years of follow up (CARP Study)
Mc Falls EO, et al. Coronary-artery revascularization before elective
major vascular surgery. N Engl J Med 2004; 351: 2795-2804
Poldermans D et al. A clinical randomized trial to evaluate
the safety of a noninvasive approach in high risk
patients undergoing major vascular surgery: the
DECREASE-V Pilot study. J Am Coll Cardiol 2007; 49:
1763-1769

Management of patients with prior PCI
Anaesthetic agents

General Anaesthesia:
Opioids: cardiovascular stability but are associated with
prolonged postoperative mechanical ventilation
Volatile anaesthetics: decrease troponin release, and
enhance LV function compared with propofol, midazolam
or balance anaesthesia with opioids
Neuraxial anaesthetic technique (spinal/epidural):
sympathetic blockade and decrease both preload and
afterload
Monitored anaesthesia care: local anaesthesia
supplemented by IV sedation/analgesia
Anaesthetic considerations
blocker dose titrated to achieve a target HR of 60bpm
Continue aspirin, statin and when indicated ACE
inhibitor
Anaemia promptly identified and treated
ECG-baseline, immediately after surgery and on first 2
days after surgery
Creatinine kinase-MB and troponin-after surgery and
on the following day
Inotropes which increase myocardial oxygen demand
should be avoided
Perioperatively pain well controlled
Maintenance of body temperature in a normothermic
range
Intraoperative and postoperative surveillance for
myocardial ischaemia and infarction, arrhythmias and
venous thrombosis
Anaesthetic considerations cont.
TEE
TEE is beneficial in altering patients
haemodynamic management, but requires
additional education for interpretation.
Routine use is not cost-effective, but
emergent use to determine the cause of
acute, persistent or life-threatening
haemodynamic abnormality is indicated. Class
IIa (level of Evidence C)
Anaesthetic considerations cont.
PAC
PAC insertion is reasonable in patients at risk
for major haemodynamic disturbances. The
decision to insert must be based on patients
disease, surgical procedure and practice or
experience in the use of PAC. Class IIb (Level of
Evidence B)
Anaesthetic considerations cont.
IABP
Documented use in unstable coronary
syndromes and severe CAD undergoing urgent
non cardiac surgery
Use is associated with complications
Currently there is insufficient evidence to
determine the benefits vs. risks of
prophylactic placement
Anaesthetic considerations cont.

No study has clearly demonstrated a change in
outcome from the routine use of PAC, ST-
segment monitor, TEE

The choice of anaesthetic technique and
intraoperative monitors is best left to the
discretion of the anaesthesia care team.
Postoperative management
Surveillance for:
Myocardial ischaemia
Arrhythmias and conduction disorders
Haemodynamic monitoring to continue
Postoperative pain management
Patient controlled analgesia techniques are associated
with greater patient satisfaction and lower pain scores
Epidural or spinal opiates
The care team should take responsibility for long
term care of the patient by way of routine
prophylactic medical therapy/diagnostic testing.


Conclusion
Successful perioperative evaluation and
management of a high risk cardiac patient
undergoing noncardiac surgery requires
careful teamwork and communication
between surgeon, anaesthesiologist and
patients primary caregiver.