7. How To Look To Patient Data DATA

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

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

10. 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

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

12. 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

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

14. 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

15. 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

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

17. 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 )

18. ANAESTHETIC CONSIDERATIONS Avoid Factors Rapidly Increasing PVR

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

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

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

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

23. 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

24. 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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