1. Cardiovascular disease in obstetrics Tom Archer, MD, MBA UCSD Anesthesia

2. Heart Disease in Pregnancy (Developed World) Less post-streptococcal rheumatic valve disease (MS, AS). More repaired congenital heart disease.

3. Maternal Outcome Correlates with NYHA functional class. How much can the patient do before she gets symptoms? Let’s hear it for the history!

4. Risk factors for maternal cardiac events Poor NYHA class Cyanosis Myocardial dysfunction Prior arrhythmia Prior heart failure/stroke. Siu SC Circulation 2001;104;515-521

5. CV in pregnancy– Big Picture Increase O2 demand  Increased CO Stable BP with increased CO means decreased SVR. Slight increase in HR

6. CV in pregnancy– Big Picture Pregnancy will make stenotic lesions more symptomatic. Patient may need interventional procedure (valvuloplasty) or termination of pregnancy.

7. Tricuspid Pulmonic Pulmonary capillaries Mitral Aortic stenosis Resistance arterioles Aortic stenosis at rest  Cardiac output not sufficient to cause critically high LV intracavitary pressure / LV failure. LV dilation / hypertrophy

8. Tricuspid Pulmonic Pulmonary capillaries (edema) Mitral Aortic Stenosis Resistance arterioles– decreased SVR Aortic stenosis with increased cardiac output / arteriolar vasodilation: Decreased SVR  Fall in systemic BP and / or increase in LV intracavitary pressure  ischemia or LV failure. LV failure / ischemia

9. CV in pregnancy– Big Picture AI and MR are often well tolerated in pregnancy. Decreased SVR helps forward flow.

10. Repaired Congenital Heart Disease Patients with no sx. SBE prophylaxis (amp/gent, vanco/gent) ?1% incidence of CHD in infant  alert pediatrics Otherwise, “good to go”

11. Small ASD, VSD or PDA No IV bubbles (L  R shunt can reverse). Epidural LOR with saline, not air Pain  increased SVR  increased L  R shunt  ?RV failure? Slow onset epidural preferred. Avoid sudden drop in SVR which could cause R  L shunt and maternal hypoxia.

12. Small ASD, VSD or PDA Memorize (and avoid) causes of pulmonary artery vasoconstriction: –Alveolar hypoxia –Hypothemia –Hypercarbia –Acidosis –Pain Increased PA pressure can convert L  R shunt into R  L.

13. www.med.yale.edu/.../cardio/chd/e_a sd/index.html 30-50% of congenital heart patients will have an ASD as part of their disease complex. home.cc.umanitoba.ca/~soninr/PS.ht ml

14. Coarctation of aorta Uncorrected, is a very dangerous lesion in pregnancy. Increased afterload for heart, decreased perfusion for uterus. Risks: LV failure, aortic rupture, endoaortitis. More common in males. www.mayoclinic.org/coarctation- aorta/about.html

15. www-clinpharm.medschl.cam.ac.uk/.../index.html Dilated collaterals in coarctation

16. www.med.yale.edu/.../c_coarct_1815204/index.html Descending thoracic aortic coarctation repaired with stent

17. http://www.nhlbi.nih.gov/health/dci/Diseases/tof/tof_what.html Tetralogy of Fallot

19. Marcus JT

20. Dong SJ. Smith ER. Tyberg JV. Changes in the radius of curvature of the ventricular septum at end diastole during pulmonary arterial and aortic constrictions in the dog. [Journal Article] Circulation. 86(4):1280-90, 1992 Oct.

21. Tetralogy of Fallot Patients with corrected TOF should have periodic echocardiograms. Corrected TOF probably “good to go.” May have conduction abnormalities. Uncorrected TOF needs careful hemodynamic management b/o potential shunts R > L or L > R.

22. Uncorrected Tetralogy of Fallot Two needs: –Maintain SVR to avoid increasing R  L shunt. –Maintain RV filling pressure to maintain pulmonary perfusion (LUD and fluid boluses).

23. Patent Ductus Arteriosus Common in premature babies with increased pulmonary vascular resistance. Can lead to cyanosis (R  L shunt) or CHF (L  R shunt). R  L shunt will cause cyanosis in LEs, with higher SpO2 in R arm. Oximeter or arterial line on feet will pick up R  L shunt and accidental ligation of the aorta. Hoarseness can be d/t damage to recurrent laryngeal nerve at aortic arch. http://health.yahoo.com/media/mayoclinic/images/image_popup/r7_patentd uctus.jpg

24. www.rjmatthewsmd.com/Definitions/pop/22fig.htm With PDA shunt can be R  L or L  R, depending on the pulmonary resistance. Shunt can be R  L after birth, then reverse to L  R as pulmonary resistance falls, then become R  L again as Eisenmenger’s syndrome develops (long term pulmonary hypertension).

25. Eisenmenger’s Syndrome Increased pulmonary flow (L  R shunt due to ASD, VSD or PDA) causes hypertrophy of pulmonary arteries  pulmonary hypertension  reversal of shunt to R  L with cyanosis. Need to correct L  R shunt BEFORE it reverses. Need to correct L  R shunt despite normal ABGs.

26. www.rjmatthewsmd.com/Definitions/po p/23jfig.htm Eisenmenger’s syndrome with pulmonary artery hypertrophy. Patient is thin, cyanotic and may have clubbing. tchin.org/portraits/angela-1.htm www.radiofreeithaca.net/search/Hippocrates

27. Pulmonary Hypertension (PH) What’s the difference from Eisenmenger’s Syndrome? Eisenmenger’s Syndrome has increased PVR (hypertrophic changes, incresaed muscularity) plus a R  L hole in the heart (ASD, VSD or PDA).

28. PH, Eisenmenger’s Syndrome, AS, MS and Coarctation of Aorta Keep SVR up to avoid inc in CO and / or dec BP Keep SVR up to avoid inc R  L shunt

29. Pulmonary hypertension— What causes it? Exactly how does it kill patients?

30. What is the flow-limiting resistance in the entire circulation? Normally it is NOT the pulmonary circulation or any of the heart valves. Normally it is the systemic resistance arterioles (<0.1 mm in diameter)

31. Pulmonary vascular resistance in normal lung Normally, increased CO causes decreased Pulmonary Vascular Resistance via recruitment and distention of pulmonary capillaries. Normally, PA pressure stays the same despite increased CO.

32. Passive Influences on PVR: Capillary Recruitment and Distension http://www.lib.mcg.edu/edu/eshuphysio/program/section4/4ch4/s4ch4_19.htm

33. Tricuspid Pulmonic Pulmonary vasculature Mitral Aortic Resistance arterioles Normal circulation at rest. Cardiac output is limited by SVR. Heart gives body tissues what they “ask for”.

34. Tricuspid Pulmonic Pulmonary vascular resistance falls Mitral Aortic Resistance arterioles– decreased SVR Normal circulation during exercise / arteriolar dilation: SVR falls, CO increases. Pulmonary resistance falls.

35. http://www.pathguy.com/lectures/hipbp.gif

36. Pulmonary hypertension Acute pulmonary thromboembolism

37. Pulmonary hypertension Chronic pulmonary thromboembolism

38. Pulmonary hypertension develops when pulmonary arteries develop abnormal resistance When pulmonary vessels become high resistance (fibrosis, muscular hypertrophy) they can NOT dilate or recruit and PA pressure rises with increased CO.

39. High pulmonary resistance at rest Slight bowing of IV septum into LV cavity. Minimal RV distention Minimal LV compression Resistance arterioles

40. Fixed or increased pulmonary resistance and / or increased CO  RV distention and failure  Intraventricular septal bulging  poor LV filling  fall in CO / BP  death. RV distention and failure LV cavity compressed (diastole) Resistance arterioles—decreased SVR

41. How does pulmonary hypertension kill patients? By causing the interventricular septum to bow into the LV cavity, diminishing its capacity. Cardiac output falls, BP falls, patient dies.

43. Marcus JT

44. Dong SJ. Smith ER. Tyberg JV. Changes in the radius of curvature of the ventricular septum at end diastole during pulmonary arterial and aortic constrictions in the dog. [Journal Article] Circulation. 86(4):1280-90, 1992 Oct.

45. How do we keep PH from killing patients? Keep Pulmonary Vascular Resistance down. Keep Systemic Vascular Resistance up. Prevent increases in CO. This same logic applies to any stenotic cardiac lesion, such as AS!

46. Hemodynamic management of all stenotic cardio- pulmonary lesions (PH, Eisenmenger’s, MS, HOCM, AS, Coarctation) Keep systemic vascular resistance up and CO down. Keep R and L sided filling pressures up. Avoid anemia and vasodilating anesthetic techniques. In PH, keep PVR as low as possible (avoid hypoxia, acidosis, hypothermia, consider pulmonary vasodilators) Pulmonary vasodilators: NO, Flolan (prostacyclin), sildenafil, bosentan (Tracleer)

47. Pulmonary hypertension PA catheter for actual measurement of PA pressure and titration of pulmonary vasodilators.

48. In MS, HOCM and AS Keep HR down “Slow and tight” for stenotic CV lesions.

49. Pulmonary Hypertension Specific drug Rx: –Inhaled O2 –Inhaled NO –IV, SQ, inhaled, oral: Epoprostenol = prostacyclin = Flo-Lan –Endothelin antagonist: Bosentan (Tracleer) –Oral sildenafil (Viagra).

50. PH and Esiensmenger’s High alveolar PAO2. Avoid: pain, hypercarbia, hypothermia, acidosis Maintain adequate SVR to avoid need to inc CO. Use phenylephrine, not ephedrine.

51. R  L shunts Cyanosis not corrected by increased FIO2. Watch out for IV bubbles  brain or heart infarction. Keep systemic vascular resistance up to avoid increased R  L shunt. Avoid infant crying and other things (alveolar hypoxia, hypothermia, acidosis, hypercarbia) which increase pulmonary vascular resistance.

52. LA RA LV RV High SVR, Minimal R  L shunt Ao PA Low pulmonary vascular resistance Normal, compensated patient with ASD, VSD or PDA-- high SVR and low pulmonary vascular resistance  minimal R  L shunt. Compensated patient with POTENTIAL R  L shunt.

53. LA RA LV RV Decreased SVR  desaturation Increased pulmonary vascular resistance  desaturation Ao PA Decompensated patient with ASD, VSD or PDA-- Decreased SVR or increased pulmonary vascular resistance  increased R  L shunt and increased arterial desaturation. Decompensated patient with REAL R  L shunt.

54. What lowers SVR? Exercise Spinal or epidural anesthesia. Vasodilating anesthetics (sevoflurane, isoflurane, desflurane) Sodium nitroprusside Hydralazine Oxytocin Fever Squatting RAISES SVR (Tetralogy of Fallot).

55. Repeat CS. Epidural anesthesia. Delivery with inc in HR and CO, oxytocin bolus with decrease SVR and BP, increase in CO and SV. Bolus oxytocin (10 U in this example) dramatically lowers SVR and CO usually increases. CO can increase because volume status is adequate, aortocaval compression has been relieved, and oxytocin, by contracting the uterus, causes autotransfusion.

56. Anesthesiology 2008; 108:802–11 Copyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Hemodynamic Changes Associated with Spinal Anesthesia for Cesarean Delivery in Severe Preeclampsia Robert A. Dyer, F.C.A. (S.A.),* Jenna L. Piercy, F.C.A. (S.A.),† Anthony R. Reed, F.R.C.A.,† Carl J. Lombard, Ph.D.,‡ Ensemble of hemodynamic effects of oxytocin in 15 patients at C-section: Decrease in SVR Increase in CO:

57. What raises pulmonary vascular resistance? Alveolar hypoxia Acidosis Hypothermia Crying Pain (catecholamines)

58. L  R shunts Volume overload to LV. Can cause CHF. Can manage with reduction in systemic vascular resistance (vasodilating anesthetics). Over time L  R shunt can lead to Eisenmenger’s syndrome