1. Cardiomyopathy – anaesthetic challenges Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics, Phd (physio) Mahatma Gandhi Medical college and research institute puducherry, India

2. Definition Cardiomyopathies are diseases of the heart muscle and may present with cardiac dysfunction Classification Dilated Obstructive (HOCM) Restrictive

4. Dilated cardiomyopathy (DCM) is defined by a large heart cavity with impaired systolic function of one or both ventricles. (a). Fractional myocardial shortening < 25% and/or ejection fraction < 45%; and (b). left ventricular end diastolic diameter > 117%

5. Pathophysiology- systolic dysfunction Global reduction in myocardial contractility Decreased LV ejection fraction LV dilates Increased LVEDV Frank starling law – better contraction Compensation fails LVF Diastolic dysfunction is trivial

6. Treatment sickle cell disease, muscular dystrophy, excess alcohol, hypothyroidism, and some chemotherapy agents Treat the cause if any Warfarin ?? Along with cardio active drugs

8. Clinical features fatigue,hypotension oliguria Pulmonary edema, orthopnea Ascitis,Edema AV ring dilation and regurgitation Arrhythmias, LBBB and poor progression, ECHO Forward failure Backward failure LV / RV

9. Treatment ACE inhibitors ARBs Diuretics Other therapies include beta-blockers, spirono lactone, digoxin, biventricular pacing, and anticoagulants. Medical treatment –control of CCF - > 1 week.

10. Anaesthetic concerns 1) Myocardial depression should be avoided 2) normovolemia should be maintained 3) Avoid overdose of drugs during induction as circulation time is slow. 4) Ventricular after load is avoided 5) Avoid sudden hypotension when regional anaesthesia is a choice

11. Preoperative check up History and findings of CCF Routine ECHO – EF <25%, Regurgitant lesions- danger signs ACE inhibitors stop ?? Electrolytes Volume status, continue anti aryhthmics Anxiolysis

12. Anaesthetic concerns Volume ( spinal. 10 % fall is significant in DCM ) Rhythm ( ECG monitoring and control) Less inhalational agents – more narcotics Ketamine, etomidate in ideal doses CVP – OK ?? Only RV preload TEE PAC – worth but outcomes similar !! Hemoglobin

13. Interest has been generated regarding use of xenon in patients with DCM, because of its minimal effect on heart rate, arterial and LV pressures, myocardial contractility, and regional chamber stiffness

14. Postoperative period Post operative HDU Oxygenation volume RA to counter pain Anti arrhythmic to continue

15. Peripartum cardiomyopathy (PPCM) Peripartum cardiomyopathy (PPCM) has an incidence of 1 in 4000 live births, and has a quoted mortality of between 20% and 50%. PPCM usually presents post 36 weeks but may develop for up to 5 months postpartum. It may recur in subsequent pregnancies; cardiology assessment should be performed prior to further conceptions.

16. PPCM ( PCM) It is a diagnosis of exclusion. an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. The left ventricle may not be dilated but the ejection fraction is nearly always reduced below 45%.

17. What is PPCM ?? Non ischemic dilated cardiomyopathy

18. How does it happen ?? 1 in 3000 – 4000 births Auto antibodies against fetal cells – myocardium abnormal cardiac response to hemodynamic changes associated with pregnancy. Proinflammatory cytokines Coronary microangiopathy

19. Almost same symptoms ACE inhibitors ?? Amlodepine.diuretics, digoxin -- ok LMWX – heparin OK Levosimendan is used as an intravenous infusion at the rate of 0.1–0.2 μg/kg/min in cardiac failure with or without a loading dose of 3–12 μg/kg over 10 minutes

20. Anaesthetic technique Controlled GA with RSI, diuretics after delivery, avoidance of methergin Fetal safety CSEA Spinal bupi fentanyl -- beware of anticoagulation Epidural volume extension technique – 1 ml spinal bupi + epidural saline 10 ml.

21. Hypertrophic cardiomyopathy

22. Hypertrophic cardiomyopathy (HCM) is an autosomal dominant condition. unexplained left ventricular hypertrophy which may be concentric or asymmetrical, diffuse or focal. Syncope, failure, hypotension

23. Hypertrophy of LV Diastolic dysfunction and defective relaxation Atrial kick needed Increased LVEDP – CPP ? Hypertrophied ventricle and more oxygen needed – ischemia Increased contraction – LVOT obstruction – MR

25. HOCM

26. Anaesthetic concerns maintenance of sinus rhythm; reduction in sympathetic activity to reduce chronotropy and inotropy; maintenance of left ventricular filling; the maintenance of systemic vascular resistance.

27. Morphine, atracurium

28. Symptomatic patients Major surgery IBP, TEE included Chamber size (DCM) Vs Wall thickness (HOCM)

29. Cardiac arrest in HCM The use of inotropic agents is contraindicated if the arrest is thought to be due to LVOT obstruction as this will only increase the obstruction. Alpha -Agonists, i.v. fluids, and rapid correction of arrhythmias are more appropriate measures. The application of external defibrillator pads is recommended before induction of anaesthesia.

30. Use vasopressors than inotropes in HOCM

31. Restrictive cardiomyopathy

32. Restrictive cardiomyopathy Endomyocardial fibrosis Idiopathic Amyloidosis, sarcoidosis, haemachromatosis, and eosinophilic endocarditis

33. What happens ?? Diastolic dysfunction Both LV and RV-- but RV more Normal systolic function No enlargement Elevated pressures and backward failure

34. Goals to maintain adequate filling pressures; sinus rhythm to be maintained if possible; to manage electrolyte disturbances; to maintain SVR in the presence of relatively fixed cardiac output.

36. Cardiac grid We have to understand the basic of ragaa and tune our technique to suit the disease and surgery

37. Arrhythmogenic Right Ventricular Cardiomyopathy progressive fibro fatty replacement of RV myocardium, initially with typical regional and later global RV and some LV involvement, with relative sparing of the septum. CHF and arrhythmia are the factors

38. Thank you all !! Understand the principles