cardiac assessment in the operating room
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Cardiac Assessment in the Operating Room. Allison K. Cabalka, MD Associate Professor of Pediatrics Consultant, Pediatric Cardiology Mayo Clinic. Objectives. Rhythm issues encountered in the operating room Discuss the use of echocardiography in the OR. Objectives. - PowerPoint PPT PresentationTRANSCRIPT
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Cardiac Assessment in the Cardiac Assessment in the Operating RoomOperating Room
Allison K. Cabalka, MD
Associate Professor of Pediatrics
Consultant, Pediatric Cardiology
Mayo Clinic
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Objectives
1. Rhythm issues encountered in the operating room
2. Discuss the use of echocardiography in the OR
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Objectives
1. Rhythm issues encountered in the operating room
2. Discuss the use of echocardiography in the OR
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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
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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?
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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
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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
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Junctional Ectopic Tachycardia
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Junctional Ectopic Tachycardia
• 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
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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
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DiagnosisAV node independent re-entry
Atrial flutter
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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!
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Postoperative Complete AVB
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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
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Objectives
1. Rhythm issues encountered in the operating room
2. Discuss the use of echocardiography in the OR
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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
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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
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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
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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
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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?
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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
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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
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• 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
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Mid-Esophageal View (0-30º)
• Typical 4-chamber view– AV valves
• Ventricular function• Atrial septum• Segments of
ventricular septum– Inlet
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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
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Mid-Esophageal (30º)
• Typical view to see aortic leaflets
• Coronary origins
• Proximal RVOT and pulmonary valve
• PA bifurcation
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Deep Trans-Gastric View (0º)
• Left ventricle
• LVOT
• Right ventricle (rotate rightward)
• RVOT
• Ventricular function
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Deep Trans-Gastric View (90º)
• Anteflex probe and rotate right/left
• LVOT and aortic valve
• Outlet ventricular septum
• Tricuspid valve inflow/function
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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
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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 JCVTSHospital for Sick Children
Toronto 2007-2009
Dragalescu A, et.al, JCVTS 2011 in press
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Epicardial EchoRVOT Free wall:“PLAX view”
Aorto-PA Sulcus:“PLAX view”
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Epicardial EchoRVOT Free wall:“PLAX view”
Aorto-PA Sulcus:“PLAX view”
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Epicardial EchoRV Free wall: “Subcostal view”
SVC-Aorto Sulcus:“Subcostal long axis”
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Epicardial EchoRV Free wall: “Subcostal view”
SVC-Aorto Sulcus:“Subcostal long axis”
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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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