aorticStenosisPregnancy

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Unformatted text preview: Aortic Stenosis in Pregnancy Aortic Brendan Astley MD Brendan & Norman Bolden MD Norman Nov 2006 18 year old G1P0 Spanish speaking female speaking PMH- “Heart condition” since age 12 (no further PMHfollow-up) follow-up) SOB and CP at rest and exertion worse over last SOB two years two PSH- none Medications- PNV Allergies- NKDA FH- unknown SH- no tobacco, EtOH or drug use Physical Exam Physical Vitals BP 104/62 HR 79 temp 36.6 RR 18 Vitals sat 100% sat Height 4’10” Weight 99lbs. now 119lbs. Height Heart– IV/VI systolic murmur… cresendo-decresendo murmur with no diastolic component, heard best at R upper sternal border, radiation to carotids bilaterally, no JVD, no 3rd or 4th heart sound JVD, Airway– nml, Mal I Lungs– CTA Bil., no w/r/r Abd– NT gravid uterus, soft Ext– no edema good pulses distally Labs: B positive Labs: BNP 5.5 WBC 8.71, Hg 12.5, Hct WBC 36.8, Plts 256 36.8, Na 136, K 3.9, Cl 108, Na CO2 21, BUN 5, Cr 0.5, CO Glu 71 Glu Ca 8.5 TSH 0.9, RPR, NR, HIV, TSH VZ immune, RI, GC/ chlam, hep B all negative chlam, Plan: Admit to Plan: antepartum unit (social admission) to facilitate consultations by Maternal/Fetal Medicine, Cardiology, NICU and Anesthesiology. Cardiology Cardiology Murmur appreciated and echo performed: on Murmur 9/15 showing AS <.6cm2, probable bicuspid 9/15 probable valve and EF 65%. valve Pt followed for change in symptoms…. Mid Oct. at about 35 wks. Gestation she Mid complains of increased CP and SOB especially with exertion but also at rest. .1%-1.4% pregnancies with clinically significant cardiac problems cardiac Mortality from these .5%-2.7% Cardio cont’d Cardio Echo shows peak gradient of 62mmHg Echo and .58cm2 orifice by the continuity and equation. equation. Velocity waveform is asymmetric which Velocity usually equates with less than severe stenosis. stenosis. CXR- WNL, no cardiopulmonary disease – CXR abnormalities may include enlarged CXR aorta, cardiomyopathy and possibly pulm. edema edema Expected EKG changes with AS Expected Left ventricular hypertrophy (LVH) There are many different criteria for LVH. Sokolow + Lyon (Am Heart J, 1949;37:161) Sokolow (Am – S V1+ R V5 or V6 > 35 mm V1+ Cornell criteria (Circulation, 1987;3: 565-72) (Circulation, – SV3 + R avl > 28 mm in men SV3 – SV3 + R avl > 20 mm in women SV3 Framingham criteria (Circulation,1990; 81:815-820) (Circulation,1990; – – – R avl > 11mm, R V4-6 > 25mm avl S V1-3 > 25 mm, S V1 or V2 + V1-3 R V5 or V6 > 35 mm, R I + S III > 25 mm V5 Romhilt + Estes (Am Heart J, 1986:75:752-58) (Am – Point score system Point Left atrial abnormality (dilatation or hypertrophy) Left M shaped P wave in lead II shaped prominent terminal negative component to P wave in lead V1 prominent ? Suggestions for Anesthetic Plan Suggestions Anesthesia for Vaginal Delivery Anesthesia Monitors for Vaginal delivery Monitors Anesthesia for C/S Anesthesia Monitors for C/S. Monitors Maternal-Fetal Medicine, Cardiology , NICU, and Maternal-Fetal Anesthesia develop working plan. Anesthesia ***If possible, avoid C/S. If vaginal delivery, ***If must avoid valsalva. must Anesthesia for Vaginal Delivery Anesthesia Neuroaxial anesthesia… – Continuous Spinal Single shot spinal not reasonable for prolonged labor Reliable block Intrathecal narcotics avoid the sympathectic block with Intrathecal ensuing hypotension Intrathecal narcotics not effective for second stage of labor. Intrathecal Small doses of intrathecal LAs added to narcotics improve Small analgesia while limiting hemodynamic consequences. analgesia Chance for spinal headache Anesthesia for Vaginal Delivery Anesthesia Neuroaxial anesthesia… – Epidural Pros…titratable to produce minimal hemodynamic Pros…titratable changes, adequate anesthesia possible for vaginal or C-section, if performed properly no spinal headaches headaches Cons…higher failure rate compared with spinal Anesthesia for Vaginal Delivery Anesthesia IV Narcotic analgesia (PCA) – Pros…would offer patient some analgesia Pros…would (most still report 8-10/10 pain despite Fentanyl PCA) Fentanyl – Cons… Respiratory Depression (mother and Cons… fetus), Sedation (mother and fetus), N/V, decreased beat to beat variability on fetal heart rate tracing. heart – Cons….Would not effectively control the pain Cons….Would from second stage of labor and therefore would not attenuate the increase in HR associated with delivery. associated Stages of Labor Stages 1st stage – 2 phases: – llatent phase encompasses the onset of pain atent to the first noticed change in cervical dilation to – Maximal dilation phase…begins around 3 cm Maximal 2nd stage – Maximal cervical dilation 10cm until delivery of fetus until 3rd stage – After delivery of fetus until delivery of placenta delivery Board Questions?? Board During the first stage of labor, the pain of During uterine contractions is transmitted via spinal cord segments.. spinal – A…T6 to L1 – B…T6 to L5 – C…T10 to L1 – D…T10 to S1 – E…T10 to S5 Answer is….C Anesthesia for C-section Anesthesia General anesthesia… – Pros…good airway control, minimal hemodynamic Pros…good changes compared to epidural/spinal boluses to start case, can treat hemodynamic changes rapidly with close monitoring close – Cons…possible difficult airway, aspiration risks, Cons…possible tachycardia and/or hypertension on induction or emergence, caution with volatile agents and hypotension or myocardial depression hypotension Hospital Course Hospital Induced to L & D at 35 weeks. Arterial line placed Swan-Ganz catheter placed Early epidural also placed by anesthesia Continuous Telemetry monitoring Pitocin was started on the night of 11/7 Pitocin and by morning she was well dilated and contracting regularly contracting PCWP/CVP readings PCWP/CVP 11/7 1950hrs: PCWP 10-11, CVP 5-7, good UOP 2330hr: PCWP 10-13 11/8 11/8 0100: PCWP 7-9…complains of CP 0100: 0300:CVP 15-16, trop .15 0300:CVP 0500: PCWP 11-15, CO 5L/min 0500: 0800: trop <.1 (nml) Wedge maintained in above normal range Wedge Delivery at 1130am Hospital Course cont’d Hospital No symptoms of AS during induction No course. course. Ready for delivery in AM with forceps No valsalva by mother and epidural No working well with slow dosing. working PCWP and urine output maintained PCWP throughout delivery with fluids and gentle epidural dosing. epidural Hospital Course cont’d Hospital After forceps delivery pt transferred to StepDown on esmolol drip due tachycardia. Drip stopped in CCU 11/8 and gentle diuresis Drip started with Lasix. started Stable vital signs throughout hospital stay. Day #3 post-forceps delivery patient transferred Day home with 6 week follow-up with cardiology for possible valve replacement. possible Physiologic Changes during pregnancy pregnancy Beginning to change at 5 weeks…10 fold Beginning increase in uterine blood flow at term increase Cardiovascular : Blood volume 35%, CO Cardiovascular 40-50%, SV 30%, HR 15-20% 40-50%, Cardiovascular : SVR 15%, sys and diastolic Cardiovascular BP 10mmHg BP Pulmonary Changes: O2 consumption 20%, Pulmonary RR 15%, MV 50%, TV 40%, alv vent. 70% RR ERV 20%, FRC 20% Aortic Stenosis Aortic In the past Rheumatic Valvular degeneration In was the primary cause was Congenitally bicuspid valves become calcified Congenitally and cause stenosis most commonly now…(1-2% of population) of Senile degeneration can also occur 30% of patients older than 85 have significant 30% changes changes Risk for sudden death with AS increases when Risk grad. >50mmHg and orifice less than .8cm2 grad. Normal Anatomy Normal Aortic stenosis Anatomy Aortic AS 2D echo AS Symptoms Symptoms Rheumatic AS patients may remain Rheumatic asymptomatic for 40 years asymptomatic Bicuspid valve patients will develop Bicuspid symptoms between 15-65 years of age symptoms Calcifications of the valve usually occur Calcifications after age 30 after THE TRIAD…. The triad… The Any one of these symptoms being present Any is ominous and the patient’s life expectancy is less than 5 years… expectancy ANGINA SYNCOPE CHF Angina Angina This is the initial symptom in 50-70% of This patients. Most commonly occurring with exertion exertion May be present without CAD b/c of… – Increased myocardial O2 consumption, with increased myocardial thickness and increased afterload afterload – Also increased LVEDP impairing flow to Also subendocardial layers subendocardial Syncope Syncope First symptom in 15-30% of patients Once this occurs the average life Once expectancy is 3-4 years expectancy Origin of syncope is controversial, Origin however it may be related to uncompensated decrease in SVR with exercise exercise CHF CHF Due to diastolic dysfunction (increased LV Due thickness) or systolic dysfunction (increased afterload or decreased myocardial contractility) afterload Once LV failure occurs the average life Once expectancy is 1-2 years expectancy All AS patients are at increased risk of sudden All death, as previously stated and…. death, Only 18% of patients are alive 5 years after the Only peak systolic gradient is >50mmHg or the orifice <0.7cm2 <0.7cm Pathophysiology Pathophysiology Stage 1: asymptomatic—mild stenosis – Normal stroke volume maintained as gradient Normal between LV and aorta increases between – Higher gradient results in concentric LV Higher hypertrophy hypertrophy Pathophysiology Pathophysiology Stage 2: moderate stenosis—symptomatic – Dilation as well as hypertrophy occur in this Dilation stage stage – Decreased EF may be noted (due to Decreased decreased contractility) decreased – Increased LVEDP and LVEDV leads to Increased increased myocardial work and O2 consumption….at risk myocardium consumption….at Pathophysiology Pathophysiology Stage 3: critical AS Stage – Valve area is less than .5cm2/m2 and EF decreases further with further increases in LVEDP LVEDP – Pulmonary edema when LA >25-30 mmHg – RV failure will develop if sudden death does RV not occur first not Calculation of Stenosis Calculation Gorlin equation: AV area (cm2)= )= CO (L/min)/ CO Mean pressure gradient1/2 Mean This is the simplified version of the Gorlin This equation (Hakki equation) equation Continuity equations Continuity AV area=LVOT velocity/AV velocity x LVOT area AV ---LVOT calculation can have errors because it’s an area squared. an AV area= CO/(HR x systolic ejection period x AV 44.3 x gradient in mmHG1/2) ---Gorlin equation 44.3 ---Gorlin weak under low CO states weak Hakki equation—based on the fact that HR x sys Hakki ejection period x 44.3= 1000; therefore AV Area= CO/ sq root of gradient (mmHg) Area= PA Cath PA Because of increased LVEDP stretching Because the mitral annulus a prominent v wave can be observed with disease progression. LA hypertrophy develops and the A wave becomes prominent becomes Example to follow on next slide… Arterial line Arterial Pulsus parvus (narrow pulse pressure) Pulsus tardus (delayed upstroke) These features make the wave appear These overdampened overdampened Hemodynamic profile Hemodynamic AS– increase LV preload and SVR – Decrease HR – Keep contractile force and PVR constant Preload – because of Decreased LV Preload compliance as well as Increased LVEDP preload augmentation is needed – (caution with nitro) Hemodynamics continued Hemodynamics Heart rate– no extremes of HR – Increase HR = decreased coronary perfusion – Sinus rhythm important for added EF Contractility – avoid B-blockers they can increase LVEDP avoid and decrease CO and Hemodynamics continued Hemodynamics SVR– most of afterload is due to stenotic SVR– lesion, therefore it’s fixed. lesion, – If SBP is decreased the patient can develop If subendocardial ischemia subendocardial – Early alpha-adrengic agonists needed as Early treatment treatment PVR– this stays normal until very late in PVR– the disease process the Toronto study Toronto 1986-2000 of 49 pregnancies in women 1986-2000 with AS with – Mild AS (>1.5cm2 or grad<36mmHg) – Mod AS (1.0-1.5cm2 or grad 36-63mmHg) – Severe AS (<1.0cm2 or grad >63mmHg) All women had functional NYHA class I or All II disease when enrolled II 59% of patients, 29/49 had severe AS Silversides C.K., Colman J.M., Sermer M., Farine D., Sui S. C., Early and intermediate-term outcomes of pregnancy with congential Silversides aortic stenosis. American Journal of Cardiology 2003;91:11 aortic NYHA functional classification NYHA Class I – Asymptomatic Class II – Symptoms with greater than Class normal activity normal Class III – Symptoms with normal activity Class IV – Symptoms at rest Toronto study continued Toronto 10% of severe AS patients (3/29) had early cardiac 10% complications (pulmonary edema or atrial arrhythmias)… complications no complications in mild/mod groups 2, One pt. had AVA .5cm2, peak gradient 112mmHg, she developed pulmonary edema at 12 weeks had emergent aortic valvuloplasty then had a Ross procedure 4 years after delivery after The second pt. had gradient of 104mmHg; she had The postpartum hemorrhage, hypotension and subsequent pulmonary edema. Resection of her subaortic membrane was performed 17 months after delivery. was The third pt had a bicuspid valve AVA .7cm2, gradient of gradient 64mmHg, she had atrial arrhythmias during antepartum period. She underwent a Ross procedure 18 months postpartum. postpartum. Ross procedure Ross Pulmonary valve is removed and placed Pulmonary into Aortic valve position and a cadaver valve is placed into the pulmonary valve position position Advantages include no anticoagulation Advantages required; so their next pregnancy may not be as complicated and a longer duration of use for aortic valve should be possible, with a lower rate of infection post-op with Toronto Study continued Toronto 8% mild/mod AS had cardiac surgery in followup and 41% of severe AS group had postpartum cardiac surgery…10% with severe AS partum had cardiac complications during pregnancy had 12 pregnancies complicated by preterm birth, 12 resp. distress syndrome, IUGR resp. – Rate is similar general population No fetal or neonatal deaths Silversides CK, Colman JM, Sermer M, Farine D, Siu SC. Early and intermediate-term outcomes Silversides of pregnancy with congenital aortic stenosis. Am J Cardiol 2003;91(11):1386-9 Brazilian study Brazilian Study of 1000 women with heart disease Study followed between 1989-1999 followed HD-- Rheumatic HD 55.7%, Congenital HD-HD 19.1%, Chagas disease 8.5%, arrhythmias 5.1% and cardiomyopathies 4.3% 4.3% A subset of patients who had moderate to subset severe AS experienced 68.5% maternal morbidity…i.e. CHF & angina 2 needed Aortic valve replacement needed 1 sudden death Avila WS, Rossi EG, Ramires JA, Grinberg M, Bortolotto MR, Zugaib M, et al. Avila Pregnancy in patients with heart disease:experience with 1000 cases. Clin Cardiol 2003;26(3):135-42 2003;26(3):135-42 Anesthetic management goals Anesthetic Maintain Normal Sinus Rhythm: up to 20% Maintain of CO is provided by atrial kick in a normal patient and possibly up to 40% in AS pts. patient Maintain HR 70-90: Bradycardia Maintain decreases CO in pt with fixed stenotic lesion and tachycardia does not allow for diastolic filling of ventricles. diastolic Generous preload: maintain at normal to Generous high range. Anes. Management goals cont’d Anes. Close hemodynamic monitoring: Arterial line and Close with moderate to severe stenosis- PA cath/TEE to help delineate hypovolemia from CHF. Be prepared for cardioversion urgently prepared – Lidco may be useful No Valsalva and minimize pain. These could No affect preload and sympathetic response (HR, BP) and worsen her condition acutely. Narcotic based anesthetic preferred in unstable or severe AS patients (50-100mcg/kg IV) or After Hospital stay After Pt seen by cardiology follow up post-op Pt and Cardiothoracic surgery… and She was recommended for valve surgery She Cardiology has sent her letters warning of sudden death as this patient has no longer been coming to her appointments and is currently lost to follow up…with no valve replacement replacement ...
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