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Cardiac Assessment in the Operating Room Allison K. Cabalka, MD Associate Professor of Pediatrics Consultant, Pediatric Cardiology Mayo Clinic.

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Presentation on theme: "Cardiac Assessment in the Operating Room Allison K. Cabalka, MD Associate Professor of Pediatrics Consultant, Pediatric Cardiology Mayo Clinic."— Presentation transcript:

1 Cardiac Assessment in the Operating Room Allison K. Cabalka, MD Associate Professor of Pediatrics Consultant, Pediatric Cardiology Mayo Clinic

2 Objectives 1.Rhythm issues encountered in the operating room 2.Discuss the use of echocardiography in the OR

3 Objectives 1.Rhythm issues encountered in the operating room 2.Discuss the use of echocardiography in the OR

4 Rhythm Issues in the OR Tachyarrhythmias –Supraventricular tachycardia (SVT) –Atrial flutter/fibrillation (AF/Fib) –VT/VF Junctional Rhythm –Too fast OR too slow Conduction abnormalities –Advanced 2° or 3° (complete) heart block

5 Diagnosis: Monitor Strips Evaluate rate, regularity, rhythm Is every QRS preceded by a P wave? Narrow or wide complex? What is the rate compared to what you expect?

6 Normal Sinus Rhythm Look for a P wave in front of every QRS –But not so far in front that it is ‘behind’ Change leads to be sure

7 Junctional Ectopic Tachycardia Common post-operative arrhythmia –Originates from AV node –Particularly in postop TOF/Fontan patient Heart rates >150 beats per minute Loss of AV synchrony –Look for AV dissociation Slower P wave rate –Easy to diagnose with pacing wires postop

8 Junctional Ectopic Tachycardia

9 Treat with IV Amiodarone –Load 5-10 mg/kg IV –Drip infusion of total of 10 mg/kg/24 hrs Alternative or complimentary –Cooling –Reduction of sympathetic stimulation (Epinephrine) –Correct Ca++ and Mg+ levels –Volume replacement

10 AV Node Independent Re-Entry Atrial fibrillation –Irregularly irregular –No organized atrial contractility –Easy to see on direct visualization or by TEE Atrial flutter –Regular atrial rate, variable conduction –Also can be seen by TEE or visualization

11 Diagnosis AV node independent re-entry Atrial flutter

12 Complete AV Block Common postop complication –3.7-6% incidence of surgical postoperative complete AV block –Recognition of AV dissociation with slower escape rate P wave rate is greater than QRS rate Otherwise this may be AV dissociation with accelerated junctional rhythm!

13 Postoperative Complete AVB

14 Complete AV Block Temporary pacing wires used in interval –Daily threshold checks –Pulse oximeter monitoring ECG monitor picks up pacing spike Recommendation for observation to see if resolves within 7-10 days –If not, permanent pacing system warranted

15 Objectives 1.Rhythm issues encountered in the operating room 2.Discuss the use of echocardiography in the OR

16 Echo: Background Echo has been utilized in the OR for the last 20 years –Miniaturization of probe allows application of TEE to all pts coming to the OR for CHD surgery Mini-TEE, mini-multiplane, Acunav longitudinal imaging Performed by either the cardiologist or the anesthesiologist –The key to this is proper training and experience with the diagnosis and evaluation of congenital heart disease

17 Echo in the OR Echocardiography is a key part of non- invasive imaging in the operating room –Evaluate the preoperative anatomy Be sure nothing was ‘missed’ Confirm the surgical plan –Evaluate the repair before leaving the OR Residual defects Guide revision Available modalities: TTE or Epicardial

18 Utility of TEE? Mayo Clinic: 1002 pts during CHD surgery –Mean age 9 yrs; range 4d to 85 yrs Prebypass or postbypass major impact in ~14% of cases –52 pts had immediate revision (“cost-effective”) Most useful in complex valve repairs or in complex outflow tract reconstructions –Less impact in PAPVR, ASD, simple tricuspid valve repair, aortic arch repair Randolph G, Hagler D et al J Thorac Cardiovasc Surg 2003

19 Echo in the OR Pre-operative echo evaluation –Document baseline ventricular function –Assessment of AV valve function –Confirmation of anatomy and surgical plan –Are there any additional defects that need to be addressed surgically? Especially atrial septal defect ?Bubble study to confirm intact atrial septum

20 Post-Bypass Echo: Function Evaluation of air in the left heart –Adequate venting Ventricular function –Comparison with pre-bypass imaging –Evaluation of intervention with medications and inotropic support Volume status –Is the heart underfilled or distended?

21 Post-Bypass Echo: Anatomy Critical for evaluation of residual defects –Outflow tract stenosis Alignment as parallel as possible (often transgastric views needed) –Valve repair Be sure volume status is sufficient, BP stable –Residual shunts –Atrioventricular valve Critical if repair undertaken Leaflet motion/paravalve leak in replacement

22 Post-operative Evaluation Echo can be correlated with surgeon’s evaluation –Pressure line monitoring i.e. RV to PA pressure post-TOF repair –Blood gas sampling for shunt i.e. SVC line and PA blood gas sampling

23 Review of TEE and applications to pediatric CHD –Intraoperative TEE –Catheterization and TEE guidance –TEE during non-cardiac surgery in the CHD patient Description of typical probe positions and views obtained Kamra K, et al, Pediatr Anes, 2011

24 Mid-Esophageal View (0-30º) Typical 4-chamber view –AV valves Ventricular function Atrial septum Segments of ventricular septum –Inlet

25 Mid-Esophageal View (60-90º) Typical long-axis view –AV valves in different plane Ventricular function Atrial septum Segments of ventricular septum Outflow tracts –RVOT and LVOT

26 Mid-Esophageal (30º) Typical view to see aortic leaflets Coronary origins Proximal RVOT and pulmonary valve PA bifurcation

27 Deep Trans-Gastric View (0º) Left ventricle LVOT Right ventricle (rotate rightward) RVOT Ventricular function

28 Deep Trans-Gastric View (90º) Anteflex probe and rotate right/left LVOT and aortic valve Outlet ventricular septum Tricuspid valve inflow/function

29 Epicardial Echo When TEE not available Standard use transthoracic probes –Sterile sleeve –Surgeon images in epicardial position Image orientation may not be quite ‘standard’ –Understanding of baseline anatomy and surgical repair

30 Epicardial Echo Reported use of Epicardial or Epi+TEE in 8% of CHD OR cases May be useful for difficult to see ‘areas’ such as PA branches and coronaries Use of Epicardial Echo JCVTS Hospital for Sick Children Toronto Dragalescu A, et.al, JCVTS 2011 in press

31 Epicardial Echo RVOT Free wall: “PLAX view” Aorto-PA Sulcus: “PLAX view”

32 Epicardial Echo RVOT Free wall: “PLAX view” Aorto-PA Sulcus: “PLAX view”

33 Epicardial Echo RV Free wall: “Subcostal view” SVC-Aorto Sulcus: “Subcostal long axis”

34 Epicardial Echo RV Free wall: “Subcostal view” SVC-Aorto Sulcus: “Subcostal long axis”

35 Conclusion One must pay careful attention to rhythm issues in the operating room –Most will involve a decision about placement of pacing wires Intraoperative echo is very useful for pre and post-bypass evaluation of anatomy, surgical repair and cardiac function –Epicardial echo may be used if TEE is unavailable

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