How To Look To Patient Data DATA

History Taking o Growth o Exercise Intolerance o Recurrent Chest Infection o Syncopal Attacks o Squatting

ECG, Echo & Cardiac Cath. Systolic & Diastolic Dysfunction Reduced Fractional Shortening Systolic Dysfunction

Diastolic Dysfunction Ventricular Hypertrophy Obstructive Volume Before Repair e.g valvular & outflow obst. Before Repair e.g valvular & outflow obst. After Repair e.g Homograft conduit After Repair e.g Homograft conduit Before Repair e.g Lt. to Rt. shunt Before Repair e.g Lt. to Rt. shunt After Repair e.g Pulmonary valve regurge ( F4 ) MV repair After Repair e.g Pulmonary valve regurge ( F4 ) MV repair ConcentricEccentric

Anaesthetic considerations : Consider determinants of coronary perfusion & myocardial oxygen balance Heart rate changes Hypotension Myocardial contractility

Anaesthetic considerations Cardiomyopathy increase wall thickness coronary filling becomes diastolic coronary perfusion depends on bl. p. & hr Maintain heart rate to decrease regurgitant fraction Syst. Dysfunction In Dialted type RVLV anaesthetic myocardial depression Decrease driving filling pressure of coronary arteries Coronary ischemia Diast. Dysfunction In Hypertrophic & restrictive type

Residual Shunts : o Occasionally present after repair of ASD, VSD & F4 o Small patch leaks are hemodynamically benign

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

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

Severity of hypertension of base line PAH correlated with the incidence of major complications ( pulmonary hypertensive crisis or cardiac arrest ) Pulmonary hypertension

Cardiovascular risk of PAH Major perioperative hemodynamic deterioration mainly pulmonary hypertensive crisis and acute right ventricular failure and cardiac arrest. Data to look for : o Mean pulmonary artery pressure > 25 mmHg o 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 )

ANAESTHETIC CONSIDERATIONS Avoid Factors Rapidly Increasing PVR

Laboratory data Hematocrit value Decompansated Erythrocytosis HCT. Increase Erythropoitin Level Increase Red Cell Mass Increase More Blood Viscocity Hyperviscosity symptoms Decreased oxygen delivery

Blood Indicies : Microspherocytosis Iron Deficiency Anaemia Rigid Cell Membrane Low Hemoglobin Concentration Increase Blood Viscosity Hyperviscosity Symptoms At Lower Hematocrit Value

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

Hemostatic values Prolonged PT, PTT, APTT values most frequently seen in cyanotic patients Thrombocytopenia is related to degree of polycythemia.

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

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

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