CARDIAC ANESTHESIA PART III

DENNIS STEVENS CRNA, MSN, ARNP JULY 2006 FLORIDA INTERNATIONAL UNIVERSITY PRINCIPLES OF ANESTHESIOLOGY NURSING III NGR 6094

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OBJECTIVES Discuss location of cardiac valves in relation to structures of the heart. Explain the physiologic function of cardiac valves within the cardiac circulatory system. State pertinent factors that should be evaluated in the preoperative period for patients with valvular heart disease. Discuss anesthetic considerations related to valvular repair or replacement surgical procedures. Explain weaning criteria from cardiopulmonary bypass.

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CARDIAC SKELETON Tough fibrous rings surround the AV valves and act as points of attachment Two additional fibrous annuli develop in relation to the bases of the aorta and the pulmonary trunk Annulus fibrosis is the fixation point for cardiac musculature and plays an important role in the structure, function, and efficiency of the heart

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CHAMBERS OF THE HEART The atria are smaller and thinner walled than the ventricles Ventricles have a thicker myocardial layer and make up much of the bulk of the heart Atria are storage units and conduits for blood that is emptied into the ventricles Ventricles must propel blood through pulmonary or systemic circulation

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RIGHT ATRIUM RA serves as a reservoir for the RV Muscle wall thickness of ~2 mm RA receives blood from SVC, IVC, and coronary sinus RA consists of two parts: Anterior, thin-walled trabeculated portion Posterior, smooth-walled portion Interatrial septum Fossa ovalis cordis

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RIGHT VENTRICLE RV ejects blood into the pulmonary arteries for oxygenation and removal of CO2 by the lungs Tricuspid valve Pulmonary valve Muscle wall thickness 4-5 mm Papillary muscles have attachments to the ventricular walls and chordae tendineae Chordae tendineae are attached to the cusps of the tricuspid valve Chordae tendineae and papillary muscles help to prevent the eversion of the tricuspid valve

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LEFT ATRIUM LA acts as a reservoir for oxygenated blood from pulmonary veins and a pump during ventricular diastole Provides a 20 - 30% increase in left ventricular enddiastolic volume (LVEDV), atrial kick Compromised patients rely on this kick to maintain an adequate CO LA located superiorly and posteriorly to other cardiac chambers Muscle wall thickness ~3 mm Mitral valve connects LA to LV Atrial wall is smooth, may contain a central depression

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LEFT VENTRICLE LV ejects blood into the aorta LV wall thickness is ~8 to 15 mm Ventricular septum separates the RV and LV cavities Upper third of septum smooth endocardium Remaining two thirds of septum and rest of ventricular wall covered with trabeculae carneae Present in the LV are two large papillary muscles Chordae tendineae of each muscle are attached to the cusps of the mitral valve

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CARDIAC VALVES Cardiac valves ensure a one-way flow of blood through the heart Open and close in response to pressure gradients that exist above or below the valves AV or semilunar Calculation of valve area accurate way to determine valvular pathology Echocardiography used in the diagnosis of valvular disease

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ATRIOVENTRICULAR VALVES TRICUSPID VALVE Situated within the right AV orifice Three leaflets of unequal size: Anterior Septal Posterior Leaflets attached to chordae tendineae, which are attached to papillary muscles Normal tricuspid valve area is 7 cm2

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ATRIOVENTRICULAR VALVES MITRAL VALVE Situated in the left AV orifice Two major leaflets connected by commissural tissue: Anteromedial Posterolateral Normal mitral valve area is 4 6 cm2 Has papillary muscles and chordae tendineae attached to the leaflets

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SEMILUNAR VALVES Aortic and pulmonary valve configuration is similar The cusps of the aortic valve are slightly thicker due to being subjected to higher pressures Semilunar valves situated within the outflow tracts of their corresponding ventricles Each valve is composed of three cusps Above the aortic valve is a dilation known as the sinus of Valsalva Normal valve area of the aortic valve is 1 - 3 cm2

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VALVULAR HEART DISEASE General evaluation: Regardless of the lesion or its cause, preoperative evaluation should be primarily concerned with determining the severity of the lesion and its hemodynamic significance, residual ventricular function, and the presence of secondary effects on organ function Concomitant coronary artery disease should be evaluated Myocardial ischemia may present in patients with severe aortic stenosis or regurgitation

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VALVULAR HEART DISEASE

History: Should focus on symptoms related to ventricular function: Questions should concern exercise tolerance, fatigability, and pedal edema and shortness of breath in general, when lying flat, or at night Inquire about chest pains and neurologic symptoms and prior procedures Review of medication should be evaluated

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VALVULAR HEART DISEASE Special diagnostic studies: Echocardiography, angiography, and cardiac catheterization provide significant diagnostic and prognostic information about valvular lesions More than one valvular lesion may be found Important to note: Severity of lesion Degree of ventricular impairment Hemodynamic significance of abnormality Concomitant coronary artery disease

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AORTIC VALVE REPLACEMENT Disease of the aortic valve may present as valvular stenosis, insufficiency, or a combination of the two Most commonly occurs as a result of rheumatic disease and may occur secondary to calcific degeneration Usual preoperative diagnosis: severe AS with syncope, chest pain or CHF; aortic insufficiency with CHF Most conditions require valve replacement Three most commonly used prostheses: Porcine bioprostheses Mechanical prostheses Cryo-preserved homografts

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AORTIC VALVE REPLACEMENT Surgical procedure, on full CPB, is usually performed through a median sternotomy Cardioplegia administration is achieved either antegrade or retrograde After the heart is arrested , the aorta is opened to expose the aortic valve Calcium deposits must be debrided to allow the prosthetic valve to be securely seated Prosthesis lowered into the annulus and securely sutured in place

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MITRAL VALVE REPAIR OR REPLACEMENT Mitral valve repair or replacement is utilized typically for: Correction of post-rheumatic mitral valvular stenosis or insufficiency Mitral valve prolapse Degenerative mitral insufficiency Repair following endocarditis Usual preoperative diagnosis: class III or IV CHF secondary to mitral insufficiency or mitral stenosis Mitral valve repair; for mitral regurgitation secondary to posterior leaflet abnormalities Mitral valve replacement; for severe rheumatic calcific mitral stenosis

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TRICUSPID VALVE REPAIR Insufficiency of the tricuspid valve is almost always due to left-side valvular disease Congenital conditions may persist into early adulthood necessitating consequent replacement Tricuspid repair is normally possible in the absence of primary involvement of tricuspid leaflets Procedure usually accomplished on CPB either with the heart fibrillating or during a brief period of aortic cross-clamping and diastolic arrest Temporary pacing wires are usually inserted

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Anesthesia and OR set-up: Standard machine, suction, and defibrillator check Airway set-up: #8.0 oral ETT Nasal cannula for preoperative line placement Oral gastric tube placed following TEE at end of case IV poles with at least two double infusion pumps IVs set-up and flushed, devoid of air in tubing; 1L NS (x2) with blood tubing for PIV and cordis

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Anesthetic interview: H&P, labs, diagnostic tests; stress test, echo, cardiac catheterization, availability of blood and blood products Patient education Confirm patient ID band to patient ID plate Verify consent

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Premedication: Benzodiazepines and opioids Medications: STP mixed Fentanyl Versed Succinylcholine and NDMR Neosynephrine, ephedrine, and NTG Ancef 1 Gm mixed

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Pre-induction: Anesthesia monitors applied; ECG (obtain baseline), NIBP, pulse oximeter (band-aid type) Oxygen at 3L/NC Additional sedation Insertion of PIVs Invasive monitoring placed; PA catheter (obtain CO) Administration of ATB

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Induction of anesthesia; opioids, STP, muscle relaxant Laryngoscopy and intubation; secure ETT Volatile anesthetic agent (N2O not used) Obtain post-induction CO/CI Maintain MAP in 70s TEE completed

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Pre-cardiopulmonary bypass: Disconnect ETT (lungs down for sternotomy) Lower MAP (<70) during aortic/RA cannulation May be asked to hand bag Heparin is calculated (300U/kg) and administered; aspirate blood (via cordis) pre/post heparin and protamine administration ACT checked (>400 sec.) acceptable Expect hypotension with direct surgical manipulation Empty and record urinary output

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Cardiopulmonary bypass Discontinue all IV fluids, turn off ventilator and gases, disconnect ETT from circuit, ask if any infusions should be maintained during CPB Withdraw PA catheter 4-5 cm Cardioplegia administered Continued dosing of fentanyl, versed, and NDMR prn Monitor urinary output Calculate drug dosages for post-bypass infusions

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Weaning CPB While rewarming check TOF; redose NDMR, versed, and fentanyl prn. During rewarming sweating may be present Surgeon will ask for lungs to be inflated Place on ventilator when directed Obtain CO/CI and TEE when off pump (insert OGT) Protamine when requested Defibrillation with internal paddles and AV pacing is at times necessary

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VALVULAR REPAIR OR REPLACEMENT Putting it all together Prepare for transport Emergency equipment Resuscitation medications ICU note to include: Transported with monitors Ambu 100% O2 Record: VS, PA, CVP, and CO/CI Ventilator settings; rate, volume, FIO2, PEEP, PS

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NEW ALTERNATIVES TO TRADITIONAL PROCEDURES Percutaneous valve replacement Currently focused on the aortic valve Patient population: Patients who are deemed too sick for traditional valve replacement With minimally invasive procedure; diseased valve is not removed it is propped open and an artificial valve is wedged into the stenotic opening Uncertain whether they will function and last as well as traditional valve replacements Could replacing a valve become an overnight procedure!!!...

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REFERENCES Morgan, G.E., Mikhail, M.S., and Murray, M.J. (2002). Clinical Anesthesiology. (3rd Ed.) New York, NY: McGraw-Hill. Nagelhout, J.J. and Zaglaniczny, K.L. (2005). Nurse Anesthesia. (3rd Ed.) St. Louis, MO: ElsevierSaunders. Wasnick, J.D. (1998). Handbook of Cardiac Anesthesia and Perioperative Care. Boston, MA: ButterworthHeinemann.