Anesthesie voor

de cardiaal belaste patiënt

Prof. Dr. Carlo Missant, MD, PhD

Departement Cardiovasculaire Wetenschappen – Anesthesie

Universitaire Ziekenhuizen Leuven

Les co-assistenten anesthesie 2014

Referenties

• Clinical Anesthesia (Barash), 6th edition

• Miller's Anesthesia, 7th Edition

• Kaplan’s Cardiac Anesthesia, 6th edition

Inleiding

• Hoge Incidentie Ischemische Hartziekte

– Ouder wordende populatie

– Vaak niet gediagnosticeerd

• Intra-operatieve Myocardischemie = Verhoogd Risico postop MI

• Postoperatief myocardinfarct = Predictor van overleving na

chirurgie

Magnitude of the problem

Trial Patients

(n)

Date Overall

Mortality

Cardiac

Mortality

Myocardial

Infarction

MACCE

Patients at increased cardiac risk

DECREASE

I, II, IV

3893 1996-2008 3.5% (cardiac death, MI)

POISE 8351 2002-2007 2.7% 1.6% 4.4% 6.4% (Cardiovascular death,

non-fatal MI, non-fatal

cardiac arrest)

Sabaté et al. 3387 2007-2008 1.9% 0.6% 4.3% (Cardiiovascular death,

MI, angina, non fatal

cardiac arrest,

arrhythmia, heart

failure, stroke)

Unselected patient population

Lee et al. 4315 > 50J.,

No emergencies

1989-1994 1.5% 0.3% 1.3% 2.5% (Cardiac death, MI,

cardiac arrest, AV III,

pulmonary edema)

Boersma et

al.

108593 1991-2000 1.7% 0.5%

16 mio inhabitants

800.000 non-cardiac surgical

procedures p.a.

15.200 perioperative deaths p.a.

5.000 cardiovascular deaths p.a.

Schouten O.

Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-

risk patients undergoing non-cardiac surgery: Rationale and design of the DECREASE-IV study.

Am Heart J 2004;148:1047–52

Magnitude of the problem

Circulation. 2002;106:2366-2371

Vascular surgery

Anesthesiology 2003; 99:270–4

CABG

Preoperative

evaluation: •Recognition of the patient at

increased cardiac risk

• Risk analysis and

stratification

• Supplemental testing

Outcome

Preoperative

optimisation: • Revascularization

• Antiplatelet therapy

• Statins

• PBB

• α2-Agonists

The patient at increased cardiac risk

European Journal of Anaesthesiology 2010, 27:92–137

Available evidence

Available evidence

Inleiding

• Identification of the patient at risk

• Risk modification strategies:

– Preoperative revascularization

– Pharmacological treatment

• Peroperative medical therapy

• Cardiac preconditioning

• Monitoring

• Anesthesie voor de hartfalen patiënt

Lee’s Revised Cardiac Risk Index

• 6 onafhankelijke risicofactoren

– Hoog risico chirurgie

– VG van ischemische hartziekte

– VG van congestief hartfalen

– VG van CVA

– IDDM

– Serum creatinine > 2 mg/dl

• Aantal risicofactoren ~ kans op majeure cardiale complicatie

– Acuut myocardinfarct

– Longoedeem

– Ventrikelfibrillatie

– Cardiac arrest

0 : 0.5%

1 : 1.3%

2 : 4%

3 of meer : 9%

Circulation 1999;100(10):1043-9

Preoperatieve oppuntstelling

Active cardiac conditions

1. Unstable coronary syndromes

Unstable/severe AP

recent MI (< 30d)

2. Decompensated heart failure

NYHA IV

worsening, new-onset

3. Significant Arrhythmias

AV-block II Mobitz, AV-block III

Symptomat. ventr. Arrhythmias

SV Arrhythmias (HF > 100)

Symptomat. Bradycardia

Recent diagnosis of VT

4. Severe valvular disease

AS (ΔPmean > 40mmHg, AVA < 1cm²,

symptomat.)

MS symptomatic (progressive dyspnea on

exertion, exertional presyncope, or HF)

Unstable cardiac conditions

1) Unstable angina pectoris

2) Acute heart failure

3) Significant cardiac arrhythmias

4) Symptomatic valvular heart disease

5) Recent MI (< 30d)

6) Residual myocardial ischemia

No surgery (unless emergency)

Evaluation and Treatment

before Non-cardiac Surgery

Preoperatieve oppuntstelling

Emergency: 2-5x increased risk

Chirurgisch risico

Chirurgisch risico

Functional capacity 1 MET 40 years, 70kg VO2 = 3.5 ml/kg/min

< 4 MET: Perioperative complications

Climb a flight of stairs? AHA

ESC

Functionele capaciteit

Clinical risk factors

1) IHD

2) Congestive heart failure

3) Cerebrovascular disease

4) Diabetes mellitus (also NIDDM)

5) Renal insufficiency (independent from serum-

creatinine)

Clinical risk factors

1) IHD (angina / MI)

2) Heart failure

3) Stroke / TIA

4) Renal dysfunction (serum creatinine ≥ 2mg/dL or crea-clearance <60mL/min)

5) Diabetes mellitus (IDDM)

Clinical risk factors

12-lead-ECG

Ind.: ≥ 1 risk factor + ≥ intermediate-risk-surgery

No risk factor + vascular surgery

Ind.: ≥1 risk factor + Intermediate/high risk surgery

No risk factor + ≥65 years + ≥ Intermediate-Risk-

Surgery

Noordzij PG et al.

Prognostic Value of Routine Preoperative

Electrocardiography in Patients

Undergoing Noncardiac Surgery.

Am J Cardiol 2006;97:1103–1106

Supplemental testing

Ind.:

Dyspnea of unknown origin

Patients with current or prior HF

with worsening dyspnea or other change in clinical status within 12 months

Echocardiography

Resting LV-Function: not predictive for ischemic events

LVEF < 35%: Sensitivity 50%, Specifity 91% in predicting cardiac death/non-fatal MI

Supplemental testing

Treadmill-ECG, Stress-Echo, Stress-MRI, Myocardial Perfusion Imaging Purpose

Objective assessment of functional capacity

Detection of ischemia

Detection of inducible arrhythmias

Estimation of perioperative cardiac risk

and of long-term prognosis

In general:

Myocardial ischemia at low exercise workloads = high perioperative risk

Extensive ischemic reaction = high perioperative risk

Ind. Vascular surgery: MET < 4 and ≥ 3 RF

Evtl. intermediate risk/vascular surgery: MET < 4 and 1-2 RF

Ind. High risk surgery + > 2 RF + poor exercise tolerance

Evtl. High or intermediate risk surgery + 1-2 RF + poor exercise

Supplemental testing

Peroperatieve strategie

• Pre-operatieve revascularisatie

• Anesthetic approach

• Medicatie

– Betablokkers

– Ace inhibitie

– Statines

– Aspirine

• Preconditioning

• Monitoring

Coronary artery revascularization before

elective major vascular surgery: CARP Trial – Prospective, randomized, multicenter trial

– 510 patients undergoing major vascular surgery

– Angiographycally proven CAD (EF <20% excluded)

– Randomized to preoperative revascularization (59% CABG

and 41% PTCA) or routine medical treatment

2.7 y mortality: 22% vs. 23%

Rate of MI within 30 days after surgery:

12% vs. 14% (n.s.)

NEJM 351:2795-2804, 2004

Pre-operatieve revascularisatie

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(17):1763-9

– Prospective single center randomised trial

– 101 patients: preop. revascularisation vs. medical

treatment

– Revascularization did not improve 30-day outcome p =

0.30

– Also, no benefit during 1-year follow-up p = 0.48

Pre-operatieve revascularisatie

• Indications for coronary revascularization are identical

to those in the non-operative setting

• Revascularization “to get the patient through surgery”

is never indicated

• Timing of subsequent surgery is crucial

• The risk of delaying surgery has to be taken into

account

• CABG vs. PTCA: no prospective randomised trials

Pre-operatieve revascularisatie

Patient met coronaire stent

• Ballondilatatie

• Bare metal stent (BMS)

• Drug eluting stent (DES)

• Aspirine + Clopidogrel:

BMS: 4-6 weeks

DES: 1 year

• Aspirine: Levenslang

Patiënt met coronaire stent

Patient met coronaire stent

Peroperatieve medicatie

• Betablokkers

• Ace inhibitie

• Statines

• Aspirine

London MJ

Perioperative β-Adrenergic Receptor Blockade

Physiologic Foundations and Clinical Controversies

Anesthesiology 2004; 100:170–5

Improvement myocardial O2-balance Antiarrhythmic effects

Optimization of myocardial

metabolism

Anti-inflammatory

Plaque-stabilization

( Shear stress)

Perioperatieve Beta-Blockade

Peri-operatieve beta-blokkers

Mangano et al. N Engl J Med 335:1713-20, 1996

Poldermans et al. N Engl J Med 341:1789-94; 1999

Devereaux PJ et al; Lancet 2008;371:1839-47.

• PeriOperative ISchemic Evaluation trial: POISE trial

• 190 hospitals, 8351 patients

• Start metoprolol 2-4 u voor chirurgie tot 30 d postop

• ↓ MI in metoprolol group vs placebo (4.2 vs 5.7%)

BUT : – ↑ stroke in metoprolol group (1.0 vs 0.5%)

– ↑ mortality in metoprolol group (3.1 vs 2.3%)

• β-blockers ↑ risk, especially in context of anemia +

hypotension

Cardiac

Morbidity Myocardial

Infarction

Stroke

Death

1.) Withdrawal of beta-blockers: NEVER !!!

Shammash JB

Perioperative β-blocker withdrawal and mortality in vascular surgical patients.

Am Heart J 2001;141:148-53

2.) Early start: 30d (or at least 1 week) preop. (ESC);

days to weeks preop. (AHA)

3.) Titration: 60-70/min (ESC); 60-80/min (AHA)

4.) Contraindication: RR < 100mHg (ESC); Hypotonus (AHA)

Beta-blockers: wat is er bewezen?

Beta-blokkers

Ace-inhibitoren

• Inhibitie van angiotensine converting enzyme

• Bloeddrukverlagend effect

• Orgaanpreservatie

– Endotheelfunctie

– Anti-inflammatoire eigenschappen

– Anti-atherogenese

Ace-inhibitoren: QUO VADIS study

• Quinapril vs. Placebo in cardiac surgery

• 4 weeks before untill 1 year after surgery

• Reduction in postoperative cardiovascular events in

quinapril group

• Recent review: conflicting results

Am Heart J 2007; 154:407-14

Ace-inhibitoren

• Perop gebruik gepaard met hypotensie!

– Vooral in combinatie met beta-blokkers

– Ace-inhibitoren = AII receptor blokkers

– Respons op vasopressie beperkt

• Ace-inhibitoren STOP 1 dag preop indien anti-hypertensivum

+ zo snel mogelijk postop herstarten

• Ace-inhibitoren VERDER indien LV systolische dysfunctie en

stabiele klinische toestand

Ace-inhibitoren: ESC guidelines

Geen guidelines

Statines

Statines

Lindenauer PK

Lipid-Lowering Therapy and In-Hospital Mortality Following Major Noncardiac Surgery.

JAMA. 2004;291:2092-2099

NNT: 85

AHA-Indications:

1) Statins should be continued

2) Vascular surgery

3) 1 risk factor + Intermediate Risk Surgery

ESC-Indications:

1) Statins should be continued

2) Statins should be started in high-

risk surgery patients, optimally

between 30 days and at least 1

week before surgery

Statines

Statines

Aspirine

• Aspirin: antithrombotic and anti-inflammatory activity,

particularly relevant in patients with plaque instability

• Widely used, but evidence in perioperative period is limited

• Reduces the incidence of MI, especially in individuals with

serologic evidence of inflammation (Ridker et al. NEJM 336:973-9, 1997)

• Early administration improves outcome following CABG

(Mangano DT. NEJM 347:1307-17, 2002)

• Should not be stopped lightly preoperatively

– In patients at risk for IHD, withdrawal of ASA was associated with 3 fold

risk of adverse cardiac events (OR 3.14) (Eur Heart J 2006; 27:2667-74)

– Bleeding risk >> potential cardiac benefit

Mangano et al NEJM 347:1307-17, 2002

Aspirine

Aspirine: ESC 2014 Guidelines

Cardiaal belaste patiënt

What is really important ?

• Careful evaluation of history / clinical examination

• Estimation of cardiac risk with simple risk factors / scores

• Protocol-based strategy

• Restrictive indications for additional testing

• Preoperative revascularization only in very selected cases

• Structurized management of patients with coronary stents

Myocardprotectie

• Ischemische preconditioning

• Farmacologische preconditioning

• Postconditioning

Ischemische preconditioning

Murry et al. Circulation 1986

Farmacologische preconditioning

Anesthesiology

1999; 91:1437-46

ATP – K kanaal

blokker

Farmacologische preconditioning

Schultz, J. E. J. et al. Circ Res 1996;78:1100-1104

Farmacologische postconditioning

0

10

20

30

40

50

60

Control Isoflurane Desflurane Sevoflurane

Preckel B et al. Br J Anaesth 1998; 81: 905 –

912

* *

Infa

rct siz

e %

Mechanism of preconditioning

inhibition of the

opening of MPTP is

key step in

preconditioning

induced

cardioprotection

Monitoring of peroperative ischemia

• ECG

• PAC

• TEE

ECG

• Inferior: II, III, aVF

• Lateraal: I, aVL, V4-V6

• Septaal: V1,V2

• Anterior: V3,V4

• Anteroseptaal: V1-V3

• Anterolateraal: V1-V6

Transmural infarction

Stop blood supply

Subendocardial ischemia

Subendocardial ischemia

ECG

ECG routine monitoring

• Afleiding II: P-waves -> arrythmie

• Afleiding V5: meest sensitief voor ischemie

• In geval van per-operatieve ischemie:

ST-analyse en 12 lead ECG

Pulmonary artery catheter

• Zie les hemo-

dynamische

monitoring

Pulmonary artery catheter: PCWP

The measurement is obtained when the inflated balloon impacts into a

slightly smaller branch of the pulmonary artery. This is where the arterial

pressure exceeds the venous pressure and the venous pressure exceeds

the alveolar pressure, thereby creating a continuous column of blood from

the catheter tip to the left atrium when the balloon is inflated. Pulmonary

venous pressure is the best indicator of left atrial pressure except when

there is venoocclusive disease. AND ONLY WHEN THE PA CATHETER

IS IN ZONE 3 of the lung.

Transoesophagale echocardiografie

• Fluid and hemodynamic management more

challenging and important than anesthetic

choice/products

• Two major hemodynamic goals

– Preserving cardiac output

– Minimisation of myocardial work

• Consider invasive monitoring including CO for all

major surgery

• Regional versus general anesthesia? Flat position?

Intra – operatief management

General vs. Regional anesthesia

Congest Heart Fail. 1999;5(6):248-253

Anesthetic agents

• No cook book approach

• Removal of sympathetic tone may lead to CV

collapse during anesthetic induction.

• Agents should be chosen to maintain

hemodynamic stability and take into account

coexisting renal or hepatic insufficiency

• High doses of the potent inhalation agents are

poorly tolerated in this population.

1. Preserving cardiac output

– Preload

• Higher than usual central venous pressure

• Tachycardia

• Aggressive treatment of arrhythmias (atrial kick !)

– Afterload

• Avoid acute increase in afterload (dramatic drop in CO)

• Maintain perfusion pressure

– Contractility

• Increased sympathetic tone lost after induction of anesthesia

• Dobutamine / phosphodiesterase inhibitors

2. Minimisation of myocardial work

Major hemodynamic goals

1. Preserving cardiac output

2. Minimise myocardial work / reducing oxygen demand

– Avoid tachycardia

– Avoid hypovolemia

– Avoid hypoxia and hypercapnia

– Avoid anemia

– Reduction afterload – maintain diastolic blood pressure

– Effective postoperative analgesia and PONV prevention

Major hemodynamic goals

Oxygen delivery Oxygen demand

Oxygen carrying

capacity

Coronary blood flow

Diastole

1/HR Perfusion

pressure

Coronary Vascular

Resistance

Heart rate

Contractility

Wall tension

Afterload

Preload

Myocardial oxygen balance

Anesthesie

Zuurstofaanbod Zuurstofverbruik

Zuurstofdragende

capaciteit

Coronaire bloedflow

Diastoleduur

1/HR Perfusiedruk

DABP - LVEDP

Vasculaire weerstand

Hartritme

Contractiliteit

Systolische

wandspanning

Syst

BP

EDV

Daling sympathische activiteit

Milde daling contractiliteit

Afterload reductie

Nitraten: venodilatatie + arteriodilatatie

Zuurstofaanbod Zuurstofverbruik

Zuurstofdragende

capaciteit

Coronaire bloedflow

Diastoleduur

1/HR Perfusiedruk

DABP - LVEDP

Vasculaire weerstand

Hartritme

Contractiliteit

Systolische

wandspanning

Syst

BP

EDV

DOSIS: 0.1 - 7 µg/kg/min

Conclusie

• Hoogrisico patiënten!!

• Pre-operatieve screening

• Peroperatief medicatiebeleid

• Peroperatieve ischemie monitoring

• European Heart Journal (2014) 35, 2383–2431