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What is the most common cardiomyopathy??
What are causes of dilated cardiomyopathy??
often of unknown cause
- inflammatory --infectious (HIV)
- toxic (drugs)
- metabolic (thyroid complications)neuromuscular
What is a common reversible cause of cardiomyopathy??
acute viral myocarditis
What is the most common indication for heart transplant??
What is the main problem with dilated cardiomyopathy??
there is dilation of all the chambers of the heart but the main concern is the LV dilation
What are the main features of dilated cardiomyopathy??
- dilation of both atria and ventricles
- thrombi present in LV (bc blood is coagulating here)
- scarring and dilation of valves
- decreased systolic function
What are s/s of dilated cardiomyopathy?
- initially patient will experience s/s of HF
- CP on exertion that mimics angina
- ventricular dilation with valve complications (regurg)
- SVT and V dysrhythmias
- Sudden death (due to dysrhythmias)
- Systemic emboli (due to coag in dilated chambers)
What would you expect to see on an EKG of a patient with dilated cardiomyopathy??
- ST segment and T wave abnormalities
What would you expect to see on a chest xray of a patient with dilated cardiomyopathy??
dilated heart chambers
What would you expect to see on a echo of a patient with dilated cardio myopathy??
dilation of all four chambers with global hypokinesis (basically means the heart is trying to pump but it's not as effective as normal)
What would you expect to see on a heart cath of patient with dilated cardiomyopathy??
- increased pulmonary capillary wedge pressure
- increased SVR
- Low CO
What is hypertrophic cardiomyopathy??
left and/or right ventricular hypertrophy, often asymmetrical, which usually involves the interventricular septum
What is the most common genetic cardiovascular disease?
What are some hemodynamic abnormalities of hypertrophic cardiomyopathy??
- LV outflow obstruction
- diastolic dysfunction
- myocardial ischemia
- mitral regurg
What is LVOT obstruction??
basically on systole, the septum is so enlarged that is will squish the LV and will cause the mitral valve to move forward and block the outflow from the LV during contraction
What are the s/s of hypertrophic cardiomyopathy??
most patients are asymptomatic most of their life
Why is angina relieved by lying down with patients who have hypertrophic cardiomyopathy??
bc of the change in the LV size with the change in position.. it will decrease LVOT obstruction
what will an EKG present with hypertrophic cardiomyopathy??
What will an echo show on a patient who has hypertrophic cardiomyopathy??
What will a patients EF be with hypertrophic cardiomyopathy??
What will the results be of a heart cath with a patient with hypertrophic cardiomyopathy??
increased LVEDP and increased pressure gradients between left ventricle and aorta
What is a definite dx of hypertrophic cardiomyopathy??
endomyocardial biopsy and analysis
Any drug or event that decreases contractility, increases preload or increases afterload will ____ LVOT.
During surgery what are 3 things that are bad for patients with LVOT???
- SNS stimulation
- decreased volume
all of these cause increased obstruction of LVOT
What symptom during surgery would concern the CRNA that the patient my have undiagnosed HCM?
What dose of inhalation agents should you give patients with HCM?
moderate dose---this will produce only a slight decrease in contractility to prevent complications of obstructing LVOT
what should you treat hypotensive patients with in the OR with a hx of HCM?
other drugs are contraindicated bc they will increase contractility and HR to increase BP which increase LVOT obstruction
What symptoms should you prevent postoperatively in patients with HCM?
avoid all factors that would increase SNS activity and cause blockage of outflow
prompt treatment is CRUCIAL
What is restrictive cardiomyopathy??
restricted filling and reduced diastolic size of either or both ventricles with normal or near normal systolic function
What is the least common form of cardiomyopathy??
What is the cause of restrictive cardiomyopathy??
it is due to a systemic disease that produces myocardial infiltration and severe diastolic dysfunction
List characteristics of restrictive cardiomyopathy...
- severe diastolic dysfunction
- normal systolic function
- decreased ventricle compliance
- non dilated ventricles
- dilated atria
- fibrotic or infiltrated myocardium
What are two common cause of restrictive cardiomyopathy under the infiltrative classification?? what about under the endomyocardial classification??
amyloid and sarcoid
radiation and chemo toxicity
What are hallmarks of restrictive cardiomyopathy??
s/s of HF with mostly R sided findings
normal L and R ventricular size and systolic function with DILATED ATRIA
diastolic ventricular functional abnormalitites suggestive of reduced ventricular compliance or stiffness
AFIB IS COMMON
Heart block or dysrhythmias develop overtime
how can you determine the cause of restrictive cardiomyopathy??
How should you manage restrictive cardiomyopathy in the OR?
- prevent fluid overload
- maintain NSR and avoid decrease in HR
- maintain vascular volume and venous return to maintain CO
28 year old man with history of dyspnea on exertion for 2 years and recent palpitations. echo shows normal EF with septal thickening. Holter reveals frequent PVCs.. what kind of cardiomyopathy is this??
55 year old female with recent viral illness. progressive SOB, orthopnea and PND. CXR shows vascular congestion. Echo with 4 chamber dilation and EF 15%. what kind of cardiomyopathy is this??
43 year old female with Hodkins lymphoma treated with radiation and chemo. Presents with worsening SOB, weight gain, and fatigue. Echo reveals normal size ventricles with biatrial dilation. What kind of cardiomyopathy is this??
What is cor pulmonale??
the most important factor in this process is chronic alveolar hypoxia. Chronic hypoxia from COPD, a restrictive disease or respiratory insufficiency causes pulmonary vasoconstriction. Vasoconstriction leads to pulmonary hypertension. HTN leads to remodeling and increased PVR. Pulmonary HTN causes increased workload of the right ventricle and hypertrophy of the ventricle occurs overtime..
So basically you have right ventricle enlargement due to pulmonary HTN that can progress to right sided HF
What are s/s of cor pulmonale??
- peripheral edema
- if r sided failure --- dyspnea, JVD, hepatosplenomegaly
What will an EKG show with Cor Pulmonale??
- possible R sided hypertrophy
- peaked P waves in II,III and AVF
- Right axis deviation and RBBB
What can an Echo show you with Cor pulmonale??
it can tell you the estimate of pulmonary artery pressure as well as the size and function of the right atrium and ventricle
can also tell you of tricuspid or pulmonic valve regurg
What are the treatment goals with cor pulmonale??
- reduce the workload of the right side of the heart
- decrease PVR and pulmonary artery pressure
supplement O2 to maintain Pao2 >60
use diuretic and dig if right sided heart failure does not respond to treatment of hypoxia
What kind of anesthesia do you use with a patient with cor pulmonale??
whatever you want as long as the patient is deep enough to prevent bronchospams
Why are volatile anesthetics good with cor pulmonale??
they are bronchodilators
Why should you avoid opoids with cor pulmonale??
Why should high levels of blocks be avoided with cor pulmonale??
the patient can lose the ability to use their accessory muscle to aid with breathing leading to further complications