Cardiovascular Disease in the Pregnant Patient

Patient with a peak gradient of _________ are at high risk of MI

>100mmHg

What drug class is contraindicated for pregnancy that is used to treat heart disease?

ACE inhibitors

What is the BEST treatment of MR in pregnant patients?

AFTERLOAD reduction

What are the risk factors associated with acute MI during pregnancy?

- HTN - DM - Thrombophilia - smoking - Age greater than 35 - Black race - preeclampsia - postpartum hemorrhage - blood transfusion requirement

Is tetrology of fallot a contraindication for pregnancy?

- If it is corrected, pregnancy is usually well tolerated - If uncorrected, it may be a contraindication

What are the anesthetic implications associated with tetrology of fallot?

- maintain NSR, SVR and RV preload - Avoid increases in Pulm vascular resistance - Epidural is better than spinal/GA - Rapid onset of IV drugs becauase R to L shunt - SLOW uptake of inhalation agents because of R to L shunt

What conditions are peripartum cardiomyopathy associated with?

- multiple gestation - obesity - advanced maternal age - women who breast feed

What are the most common causes of noncongenital MR?

- myxomatous degeneration - ischemis papillary msucle disease - rheumatic fever - endocarditis

What is a person's PAP who has pulmonary HTN?

usually >25 at rest without cardiac disease

What is the preferred delivery method in patients with mild to moderate AS?

vaginal delivery

How is the severity of AS classified?

valve area or peak pressure gradient across the valve

How should you manage a pregnant patient with an aortic dissection?

- Aggressive BP control with vasodilator - BB decreases force of ventricular ejection, which reduces sheer stress - IV opioids minimize pain - Aline/CVP - Before 28 weeks = surgical repair and pregnancy continues - Beyond 32 weeks = Csection followed immediately by aortic repair

Describe the pathophysiology of AR.

- Aortic valve fails to close properly - Regurg results in LV overload - Leads to LV dilation and hypertrophy - Eventually decreased LV contractility - Decrease in EF and SV - LVEDV increases - a competent mitral valve can protect pulmonary circulation from initial increases in LVEDV and LVEDP - Eventually, further increases in LVEDV and LVEDP, leads to Pulmonary edema - Onset usually 15-20 years after rheumatic diseas

What is the etiology of MI in pregnant patients?

- Coronary athlerosclerosis - Coronary thrombosis - Coronary dissection - Pheochromocytosis - Cocaine abuse - Pregnancy induced hypertension (PIH) - Ergot alkaloid administration

What is the best medical management in patients with AR?

- Digoxin, salt restriction diuretics - Direct vasodilators - used as substitutes for ACE inhibitors during pregnancy

What is the preferred anesthesia/analgesia for labor in patients with previous MI?

- EPIDURAL

How does peripartum cardiomyopathy present itself? (s/sx)

- Initially: symptoms of mild URI, chest congestion, fatigue - Rapidly progress to florid cardiac failure: biventricular hypokinesis, low CO, elevated filling pressures, ventricular ectopy - (From Patty's slide): Fatigue, SOB, edema, chest pain, palpitations, pulmonary edema

What is the pathophysiology of chronic MR?

- Less hemodynamic stress on LV - LA gradually dilates and increases compliance - Afib may develop and produce palpitations - develops over years

What are the characteristics of Marfan's Syndrome?

- Long, slender extremities - joint laxity - other musculoskeletal abnormalities - MVP - dilation of the ascending aorta (may progress to dissecting aneurysm, aortic incompetence or rupture of aorta)

Where is the most common point of origin of an aortic dissection?

- MOST COMMON = ascending aorta - 2nd = descending throacic aorta just distal to the origin of the Left SCV

What are some indications/diseases which initiate csection?

- Marfan syndrome with aortic root involvement - Severe AS - Aortic dissesction - Recent MI - Severe heart failure during previous delivery

What is the preferred vasopressor for patients with HOCM?

- Phenylepherine

What are signs and symptoms of AR?

- Pounding sensation in the chest - exertional dyspnea (first sign of diminished cardiac reserve) - orthopnea - paroxysmal nocturnal dyspnea - diaphoresis - Symptoms of LV failure

What are the signs and symptoms associated with Aortic Dissection?

- SOB - Syncope - Tachycardia - Ischemic extremity - Differential BP in arms - Differential pulses in lower extremities - CXR=widening mediastium/hemothorax - Abdominal/thoracic/interscapular pain

What should you avoid when caring for a patient with a Left to right shunt?

- abrupt changes in SVR - air embolism - SAB because they are contraindicated

How is the severity of MS classified?

- according to the residual valve area: *mild= >1.5cm2 *moderate= 1.0 -1.5cm2 *Severe= <1.0cm2

What is the pathophysiology associated with ACUTE MR?

- acute volume load into LA - blood pumped into noncompliant LA - Forward CO decrease - pulmonary congestion ensues - If survive acute phase, PAP rise and RHF may occur

What are the clinical manifestations of Eisenmenger's Syndrome?

- arterial hypoxemia - RVF - dyspnea - clubbing of the nails - polycythemia - engorged neck veins - peripheral edema - cyanosis - chest pain - syncope

What are the most significant symptoms of MI is pregnant patients?

- chest pain - dyspnea - diaphoresis - poor exercise tolerance - syncope *these may occur in normal pregnant patients, so a troponin level is helpful

What are the signs and symptoms of MS?

- chest pain - dyspnea - palpitations - pulmonary edema - hemoptysis - thromboembolism

What are the symptoms of CHRONIC MR?

- chronic weakness and fatigue (b/c low CO) - Afib common - LV dilation and hypertrophy - prominent atrial waves may occur

Define coarctation of the Aorta.

- congenital lesion consisting of a discrete narrowing of the descending aorta - most commonly distal to the left subclavian artery with proximal HTN and distal hypo perfusion

What is Marfan's Syndrome?

- defect in fibrillin synthesis due to a mutation of its gene on chromosome 15

High pulmonary arterial pressures result in what?

- dyspnea - hemoptysis - Pulmonary edema

What are the symptoms of ACUTE MR?

- dyspnea - pansystolic murmur - third heart sound in severe cases - LVH on ECG - atrial arryhtmias

What is the preferred anesthetic technique for pregnancy in pts with AR?

- epidural - administration of epidural early in labor prevents pain associated increase in SVR

What is the ideal anesthetic for patients with HOCM?

- epidural - single shot spinal relatively contraindicated because rapid onset of sympathectomy

Where is the murmur of AR best heard?

- left sternal border, 3rd intercostal - usually high-pitched, blowing decrescendo diastolic murmur

Why is Afib associated with a higher risk of maternal morbidity?

- loss of atrial kick - higher ventricular rate decreases CO - increased risk of pulmonary edema

What is the pathophysiology associated with a transplanted heart?

- no afferent/efferent autonomic or somatic innervation - lack of vagal innervation = basal HR 100-120 - Reflex slowing of HR does not occur - Drugs that act via vagus nerve have no cardiac effects, although they stimulate cholinergic receptors - only DIRECT acting sympathomimetic agents work - chronic denervation results in "up-regulation" of cardiac beta receptors, leading to greater sesitivity to beta stimulatin - chronotropic response to stress is delayed - adequate CO depends on maintenance of adequate preload

What is the most common tachyarythmia associated with MVP?

- paroxysmal SVT

What are the late signs of AR?

- peripheral edema - congestive hepatomegaly - ascites

What does the prognosis of patients with MVP depend on?

- presence of absence of coexisting cardiovascular disease (HOCM, Marfan's, ASD, CAD)

What is the definition of MS?

- prevents emptying of the LA resulting in LA dilation and higher LA and pulmonary arterial pressures - MV leaflets thicken, calcify and fuse near chordae over 20-30 years

When does peripartum cardiomyopathy manifest?

- rare - manifests during last month of pregnancy or first 5 months postpartum

With delivery of the fetus, what occurs in the mother to help with resuscitation?

- reduces aorotcaval compression - improves VR - Decreases maternal metabolic demands - improves effectiveness of chest compressions

What is the pathophysiology of MVP?

- redundant valve that prolapses into the ventricle during systole - can be secondary to or associated with ASD, endocarditis, MS

What is the preferred method of delivery in theses patients?

- remains controversial - vaginal: epidural for pain free 1st stage and instrmented delivery for 2nd stage - SLOW induction of epidural is essential - Single shot should be AVOIDED

Where should chest compressions be performed on the pregnant patient?

- slightly above the center of the sternum to adjust for the elevation of the diaphragm.

What are the s/sx of AS?

- syncope - angina - dyspnea - fatigue

What is the 4 minute rule?

- there should be initiation of Csection within 4 minutes of cardiac arrest with neonatal delivery within 5 minutes - this optimizes resuscitation of the mother

Why should intubation be performed immediately in the pregnant patient in cardiac arrest

- to facilitate oxygenation and ventilation - to prevent aspiration

What causes acute AR?

- trauma - infective endocarditis

Is rupture of the aorta fatal?

- typically is fatal

Where does rupture of the aorta usually occur and what does is produce?

- typically occurs in the pericardial space and left pleural cavity - produces pericardial tamponade and hemothorax

What is hypertrophic obstructive cardiomyopathy? (HOCM)

- uncommon form of cardiomyopathy - affects the inteverventricular outflow tract - Characterized by: LVH, decreased left chamber size, LV dysfunction

What is the etiology of peripartum cardiomyopathy?

- unknown - suggested: viral myocardidits, immune-mediated injury, hemodynamic stress of pregnancy, nutritional deficiencies, small-vessel CAD, excessive salt intake, peripartum fluid shifts.

How do you classify severe aortic stenosis?

- valve area <0.8 - 1.0 cm2 - peak gradient >40to50 mmHg

Patients with HOCM are at an increased risk for sudden death from ________________>

- ventricular arrythmias

What medical conditions are associated with MVP?

- von Willebrand's disease - Ehlers-Danlos dyndrome - kyphoscoliosis - pectus excavatum - osteogenesis imperfecta - myotonic dystophy - Marfan's syndome

How is aortic dissection defined?

- when blood moves through a tear in the aortic intima and separates the intima from the adventitia. A false lumen can result which can reconnect with the true lumen anywhere along the course of the dissection.

When do AS lesions become hemodyanmically significant?

- when valve diameter is 1/3 normal size

What is the cause of AR in 75% of patients

-Rhumatic heart disease - but can be attributed to congenital bicuspid valve, endocarditis, or dilated aortic annulus

What induction medications should be utilized for patients with AS?

-etomidate - titrate opioids - LESS PROPOFOL if at all

Replacement of the ascending aorta in asymptomatic patients is recommended when the root diameter is >_______.

5.5cm

During labor and delivery, CO and myocardial oxygen demand increase by what %?

50%

What are the major causes of cardiac arrest during pregnancy?

1. Amniotic fluid embolism 2. Hemorrhage (DIC, placental abruption, placenta previa, uterine atony) 3. Anesthetic complications 4. Hypermagnesemia 5. Medication errors or allergy 6. Preexisting heart disease (congenital/acquired) 7. Sepsis 8. Trauma 9. Venous thromboembolism

What 3 lesions produce a Right-to-Left shunt?

1. Atrial septal defects 2. Ventricular septal defects 3. Patent ductus arteriosus

What are the anesthetic implications in pregnant patients with coarc of the aorta? (6)

1. Avoid decreases in SVR 2. Avoid increases in Blood volume 3. Avoid increases in myocardial inotropy 4. Avoid increases in cardiac output 5. Aggressively control blood pressure 6. Epidural is better to maintain hemodynamic stability

What happens to the following physiologic changes during pregnancy by the third trimester 1. Blood volume 2. CO 3. HR 4. SVR/PVR

1. Blood volume INCREASES by 50% 2. CO INCREASES by 40% 3. HR INCREASES by 25% 4. SVR/PVR REDUCED

What are the disadvantages of Csection delivery in a patient with previous MI?

1. Higher risk of blood loss 2. Increased risk of infection 3. Greater postpartum pain 4. Delayed ambulation 5. Greater risk for pulmonary morbidity after delivery

What is the most common cause of Eisenmenger's Syndrome?

1. Larve VSD 2. Large Patent Ductus Arteriosus 3. ASD

Maternal risks associated with Coarc of the Aorta include: (5)

1. Left ventricular failure 2. Aortic rupture or dissection 3. Endocarditis (need prophylactic antibiotics) 4. Bicuspid aortic valve 5. Aneurysm in the circle of Willis

What are the maternal complications that can occur during CPR?

1. Liver laceration 2. Uterine rupture 3. Hemothorax 4. hemiparicardium

What are the anesthetic management goals of the pregnant patient with AS?

1. Maintain NSR (because they have a fixed SV) 2. Atrial kick is imperative to CO 3. Maintenance of adequate SVR 4. Maintenance o intravascular volume and VR 5. Avoidance of aortocaval compression 6. Avoidance of myocardial depression during GA

What are the goals of anesthetic management for a pregnant patient with MS?

1. Maintenance of slow heart rate and sinus rhythm 2. Aggressive treatment of Afib 3. Avoidance of aortocaval compression 4. Maintenance of adequate VR 5. Maintenance of adequate SVR 6. Prevent pain, hypoxemia, hypercarbia, acidosis which may increase pulmonary vascular resistance

What are the anesthetic considerations in a patient with peripartum cardiomyopathy?

1. Na/water restriction 2. diuretics 3. Afterload reduction 4. Inotropic support 5. Anticoagulatin 6. Delivery of infant if near term 7. ACE inhibitors AFTER birth 8. SLOW titration of epidural

What are the risk factors for Aortic Dissection?

1. Preeclampsia 2. Coarcation of the aorta 3. Marfan's Syndrome 4. Ehlers-Danlos Syndrome 5. Systemic HTN 6. Turner's Syndrome 7. congenitally biscupid aortic valve

What are the hemodynamic goals of a pregnant patient with primary pulmonary HTN? (5)

1. Prevent increases in pulm vascular resistance by avoiding hypoxemia, acidosis, hypercarbia 2. maintain intravascular volume and VR 3. Avoid aortocaval compression 4. Maintain adequate SVR 5. Avoidance of myocardial depression during GA

What are the goals of anesthetic management in pregnant patients with MR?

1. Prevention of increases in SVR 2. Maintenance of a normal to slightly increased HR in SINUS rhythm 3. Aggressive treatment of acute Afib and HTN 4. Avoidance of aortocaval compression 5. Maintenance of VR 6. Prevention of increases in central vascular volume 7. Avoidance of myocardial depression during GA 8. Prevention of pain, hypoxemia, hypercarbia and acidosis (increases PVR)

What are the 4 main predictors of a cardiac event occurring during pregnancy?

1. Prior cardiac event (HF, stroke, dysrhythmia) 2. NYHA functional class >2 or cyanosis 3. Left heart obstruction: MV<2cm2, AV <1.5cm2, LV outflow tract gradient >30 4. Reduced LF function (EF<40%)

What 2 things to patients with HOCM require to ensure adequate ventricular filling?

1. SLOW HR 2. Modest expansion of intravascular volume - AVOID: increases in myocardial contractility, decreases in SVR

What are anesthetic concerns related to the pregnant patient with a transplanted heart?

1. They are immunosuppressed 2. Require stress dose of corticosteroids 3. Strict aseptic technique is required 4. Slow induction of epidural 5. Ketamine should be used for induction of GA

Describe the Classification of aortic dissections according to DeBakey et al.

1. Type I: extends beyond ascending aorta into the descending aorta 2. Type II: confined to the ascending aorta 3. Type III: originate in the descending aorta - IIIA: remains above the diaphragm - IIIB: extends below the diaphragm

What are the 4 components of the lesion Tetraology of Fallot?

1. VSD 2. RVH 3. pulmonic stenosis with right ventricular outflow tract obstruction 4. overriding aorta (the aortic outflow tract receives blood from both the right and left ventricles

What is the most common cyanotic defect in adults?

Eisenmenger Syndrome

Why do women with severe MS not tolerate the CV demands of pregnancy?

1. expanded blood volume increases risk of pulmonary congestion and edema 2. physiologic tachycardia shortens LV filling time, which increases LA and PA pressures

What are the primary goals of anesthetic management in patients with Eisenmenger's Syndrome? (5)

1. maintenance of SVR 2. maintenance of intravascular volume and venous return 3. avoidance of aortocaval compression 4. prevention of pain, hypoxemia, hypercarbia, acidosis 5. avoidance of myocardial depression during GA

What are the goals of anesthetic management in patients with HOCM? (6)

1. maintenance of intravascular volume and VR 2. Avoidance of aortocaval compression 3. Maintenance of adequate SVR 4. Maintenance of a slow heart rate in sinus rhythm 5. Aggressive treatment of acute AF and other tachyarrythmias 6. Prevention of increases in myocardial contractility

What are the goals of anesthetic management in a pregnant patient with AR?

1. maintenance of normal to slightly elevated HR (they DO NOT tolerate bradycardia) 2. Prevention of increase in SVR 3. Avoidance of aortocaval compressiion 4. Avoidance of myocardial depression during GA

In a pregnant patient, what are the differential diagnoses of chest pain?

1. pre-eclampsia 2. hemorrhage 3. sickle cell crisis 4. acute pulmonary embolus 5. aortic dissection

What are the most common causes of MR in pregnancy?

1. rheumatic valvular disease 2. MVP

Describe the pathophysiology of MS.

1. stenotic valve prevents LV filling 2. LA enlarges 3. Pulmonary venous and arterial pressure increase 4. Right sided HF 5. Tricuspid valve insufficiency 6. Decreased SV and CO

Cocaine can cause myocardial ischemia as a result of what? (6)

1. tachycardia 2. hypertension 3. arrhythmias 4. coronary artery spasm 5. coronary thrombosis 6. acceleration of atherosclerotic disease

Maternal expulsive efforts at delivery results in an increase in oxygen consumption by what percent?

150

Expulsive efforts during delivery may result in a _____% increase in O2 consumption.

150%

What is normal aortic valve area?

2.6-3.5 cm2

A maternal arm-to-leg gradient less than ____mmHg is associated with good pregnancy outcomes and vaginal delivery is preferred.

20 mmHg

Uterine contractions result in auto transfusion of _____ to _____ mL of blood to central circulation.

300-500 mL

Each uterine contraction results in an autotransfusion of _________ mL of blood to the central circulation?

300-500mL - which increases preload, and further compromises balance between supply/demand

What is the normal MV area?

4-5 cm2

What syndrome does chronic L to R shunting cause?

Eisenmenger's Syndrome

What test is performed for a DEFINITIVE diagnosis of aortic dissection?

Aortography (MRI avoids radiation exposure)

What is the best way to prevent tachycardia during pregnancy in pts with MS?

Beta blockade

What kind of heart disease is the major cause of cardiac disease in pregnant women, accounting for 60-80% of all cases?

CONGENITAL heart disease

What is the preferred delivery method with severe AS?

Csection

When should epidurals be placed in Marfan's syndrome in order to reduce the CV stress and after load?

EARLY labor

What is the preferred anesthetic technique for someone with a left to right shunt?

EPIDURAL

What kind of test is the gold standard for evaluation of cardiac lesions?

Echo

What is the preferred anesthetic in laboring pts with MS?

Epidural or CSE

What are the effects of chronic left to right shunting?

Excessive pulmonary blood flow leads to pulmonary edema and pulmonary hypertension.

T/F: Previous MI is a contraindication for a trial of labor.

FALSE

What is the primary medical cause of nonobstretic maternal morbidity?

Heart disease

What is the newborn infant likely to suffer from after delivery from a mom receiving CPR?

Hyoxia and acidosis

Labor pain increases or decreases maternal catecholamines?

INCREASES

What may improve right ventricular function in these patients?

Inhaled nitric oxide because it selectively dilates the pulmonary vascular bed with minimal systemic hemodynamic effects

What drug that produces tachycardia should be avoided in MS? (think induction drug)

Ketamine

What drug should be avoided in the 3rd stage of labor in patients at risk for MI?

Methergine - cause it is more likely to cause coronary artery spasm

What is the most commonly encountered valvular lesion in pregnancy?

Mitral Stenosis

Women with rheumatic AR usually have coexisting ________.

Mitral valve disease

What is the most common cardiac condition encountered during pregnancy?

Mitral valve prolaps. 12-17% of childbearing women

T/F: you should have Epi in your test dose in pts with AS?

NO

Is single shot spinal indicated for AS?

NO it is CONTRAINDICATED

What is the better vasoconstrictor in pts with MS?

Neo is better than ephedrine

What are the most common arrhythmias associated with pregnancy?

PACs and PVCs

What is the preferred vasopressor for previous MI pregnant patient?

Phenylepherine

With chronic AR, what is usually the first complaint pateints have?

Pounding in the chest, especially when lying down.

What can pregnancy lead to in the patient who has primary pulmonary HTN?

Pregnancy is usually poorly tolerated and can lead to RV failure.

What is the most common adverse occurrence after GA in patients with HOCM?

REVERSIBLE congestive heart failure

What is the most common cause of valvular heart disease?

Rheumatic heart disease

Balance between _______ and ________ determines shunt fraction and direction of shunting.

SVR and PVR

What technique should be avoided in MS and why?

Single shot spinal because of loss of SVR

What kind of lesions present the highest risk in an OB patient?

Stenotic lesions

In pregnancy, when is the risk of aortic dissection the greatest?

THIRD trimester

T/F: Marfan's Syndrome has a dominant pattern of inheritance.

TRUE

T/F: Optimal care of the mother is the best therapy for the fetus.

TRUE

T/F: Tetrology of Fallot is the most common congenital heart lesion associated with a right to left shunt.

TRUE

T/F: The sympathectomy and decreased catecholamines achieved with neuraxial anesthesia are beneficial to pts with MVP?

TRUE

T/F: Murmurs often decrease in intensity during pregnancy because of a decrease in SVR.

TRUE - usually mitral and aortic regurg

T/F: Those with primary pulmonary hypertension have a reactive pulmonary vasculature that can respond to vasodilator therapy.

TRUE, but remember those with Eisenmenger's syndrome do NOT.

T/F: patients tolerate pregnancy well, provided that the function of the transplant was stable before pregnancy.

TRUE, per chestnut

T/F: most patients with MVP tolerate pregnancy well.

TRUE, rarely any cardiac complicatiosn

T/F: There is a high mortality associated with AS?

TRUE, usually because symptoms appear late in the course of the disease

T/F: oxytocin, methargine, and prostaglandins all increase pulmonary vascular resistance.

TRUE. must be careful with administration after delivery

Maternal mortality with Eisenmenger's Syndrome is as high as 30-50% and 43% of these deaths are attributable to _________________.

Thromboembolism

What antibiotic will reduce SVR if infused too rapidly?

Vancomycin

When do symptoms of MS usually manifest?

When orfice is <2cm2

Is AR tolerated in pregnancy?

YES if there is no left ventricular dysfunction b/c 1. modest increase in HR, which shortens regurg time 2. pregnancy decreases SVR, favoring forward flow 3. greater blood volume, maintains filling pressures

Is acute AR life threatening?

YES! -abrupt increases in LVEDV and LVEDP. -LA and PAP rise rapidly. -Hemodynamic instability ensues -Emergency surgery is almost always necessary - POOR SURVIVAL

Does myocardial ischemia occur in patients with AR and why?

YES, becuase LV dilation and increased LV systolic pressure results in greater myocardial oxygen demand. There is also decreased coronary blood flow during diastole which results in lower myocardial perfusion

Do patients with MR tolerate Afib?

Yes, better than patients with MS

Aortic stenosis during pregnancy is usually caused by what?

congenital biscuspid valve

What do patient typically present with in tetrology of fallot?

cyanosis

What is the preferred induction agent for patients with previous MI?

etomidate and/or opioids

DUring pregnancy, what increases the risk for systemic embolization?

hypercoagulability state