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Proceedings of the Southern European

Veterinary Conference
- SEVC -
Sep. 30-Oct. 3, 2010, Barcelona, Spain

Next SEVC Conference:

Sep. 30-Oct. 2, 2011 - Barcelona, Spain

Reprinted in the IVIS website with the permission of the SEVC - AVEPA
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Reprinted in IVIS with the permission of the SEVC Close this window to return to IVIS www.ivis.org

Anaesthesia
Anaesthesia for patients with cardiovascular disease
Louise Clark

Davies Veterinary Specialists,

Hitchin, Hertfordshire, UK

Functions of the cardiovascular system, which comprises the heart, vascular beds and their
autonomic control systems, include delivery of oxygen to the tissues and removal of carbon
dioxide from the tissues. Thus cardiovascular disease may refer to pathology related to any
of the above components including; congenital and acquired cardiac diseases, vascular
diseases and autonomic dysfunction. This pathology may ultimately limit tissue oxygen
delivery and may result in anaesthesia related morbidity and mortality.
We will concentrate on the management of patients with congenital and acquired cardiac
disease.

Pre-operative examination and patient stabilisation:

Pre-operative examination
Ideally the specific diagnosis and magnitude of cardiac dysfunction should be established
prior to presentation for anaesthesia. Liaison with a veterinary cardiologist can help
optimise the condition prior to anaesthesia. In some cases, there may not be the luxury of
time or expertise to aid in the diagnosis or an animal with cardiac dysfunction may present
for emergency surgery – for example the dog with a severe murmur presenting on a
weekend for emergency surgery on a ruptured globe.
There is no single absolute predictor of ability to “withstand” anaesthesia, but exercise
tolerance is a reasonable indicator of cardiovascular fitness in dogs. Cats, because of their
ability to “hide” cardiac disease can be more difficult to assess. In addition to a thorough
history and clinical examination, electrocardiography should be carried out prior to
anaesthesia on any patient with an audible arrhythmia. Radiography may allow
interpretation of chamber enlargement, diagnosis of pleural and pericardial effusions and
assessment of volume status including volume overload (venous congestion) and pulmonary
oedema. Where available, echocardiography gives the best assessment of structural cardiac
disease. Routine haematology and biochemistry may help in the diagnosis of co-existing
disease and should be undertaken where electrolyte abnormalities may be present due to
drug therapy eg diuretics, or where low cardiac output states or venous congestion may
have affected other organs eg liver. Anaemia should be avoided because the animal with
cardiovascular dysfunction will not tolerate the rise in cardiac output required to maintain
tissue oxygen delivery. Additional investigations may be necessary for cases where cardiac
dysfunction is secondary to another disease process, e.g. hyperthyroidism,
phaeochromocytoma. Evaluation of cardiac markers may be indicated.

Patient stabilisation

The aim is to reduce the risk posed by anaesthesia. Ideally this process should take place
over an adequate time period in order to achieve optimal results – ideally at least a week.
The general approach is that of addressing volume overload and pulmonary oedema via
diuretic administration, improving cardiac contractility, reducing cardiac workload by

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2010 - Barcelona, Spain
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“offloading” the left ventricle, and by controlling arrhythmias. The exact approach will be
determined by the diagnosis and severity of the disease process.
It should be borne in mind that the presence of cardiac drugs may further complicate
stabilisation and anaesthesia:
• Digoxin increases bradyarrhythmias
• Loop and thiazide diuretics can cause hypokalemia and hypovolaemia (elevated
BUN/creat)
• Beta blockers can cause bronchoconstriction
• ACE inhibitors may potentiate hypotensive effects of ACP.......
Thus repeat investigations may be required after stabilisation to ensure not only that the
cardiovascular disease has improved, but that complications arising from therapy are
addressed.
Some changes occur secondarily to cardiac disease and may influence tissue oxygen
delivery:
• Pulmonary oedema limits gas exchange & reduces lung compliance. It usually
resolves with treatment of the underlying disease although vasodilators & additional
diuretics may be required.
• Right heart failure leads to venous congestion, hepato-splenomegaly, pleural and
pericardial effusions and ascites. It may be necessary to drain pleural and pericardial
effusions in addition to treating the underlying disease process. Hepato-
splenomegaly may impair liver function.
• Polycythaemia occurs secondarily to chronic hypoxia, such as in a right>left shunting
PDA or a VSD. It increases viscosity and thus cardiac work.
• Cats with hypertrophic cardiomyopathy (HCM) may be at risk from embolic disease
• Systemic hypertension may be present in cats with HCM and feline hyperthyroidism
• Arrhythmias may improve as cardiac function improves, but may not! A benign
tachyarrhythmia in a conscious animal may result in significant hypotension, a fall in
coronary perfusion and a self reinforcing deterioration in an anaesthetised animal.
Thus meticulous anaesthetic management to prevent deterioration due to
hypoxaemia, hyper or hypocapnia or excessive sympathetic stimulation must be
planned. Appropriate anti-arrhythmic drugs should be prepared. Where there is a
severe brady-arrhythmia that does not respond to atropine or isoprenaline, the
placement of a temporary pacemaker should be considered!

Cardiac pathology
Different disease processes produce different haemodynamic changes which influence drug
selection and anaesthetic management. We will BRIEFLY consider the goals of anaesthesia
in common conditions:

Acquired cardiovascular conditions:

Mitral valve disease:
During systole a proportion of the ejected fraction flows back into the atrium. This causes a
fixed, low-output condition. Progression of the disease leads to ventricular failure,
pulmonary oedema and possible atrial fibrillation secondary to atrial enlargement. Thus,
aims of anaesthesia are to:
• Avoid decreased contractility
• Mildly reduce systemic vascular resistance (SVR) to promote forward flow
• Maintain/slightly increase HR - bradycardia cannot be compensated for by increased
stroke volume (SV).

Dilated cardiomyopathy (DCM):

DCM is characterised by severe ventricular dysfunction with chamber dilation and decreased
contractility. Ventricular arrhythmias are common and sometimes appear in the Dobermann

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2010 - Barcelona, Spain
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without classic echocardiography changes. There are significant breed differences and Boxer
dogs suffer from arrhythmogenic right ventricular cardiomyopathy (ARVC). Animals with
DCM/ARVC can die suddenly under GA and appropriate management of ventricular
arrhythmias is imperative.
• Maintain cardiac output
• Avoid factors reducing myocardial oxygen balance
• Avoid/manage arrhythmias

Cardiac tamponade:
• Pericardial effusions are the most common cause of tamponade. Drainage prior to
anaesthesia should be carried out to relieve pressure on the right ventricle.
• Cardiac output is heart rate dependent.
• Ensure adequate pre-load – excessive diuretic use may compromise pre-load.

Sick sinus syndrome:

Where refractory brady-arrhythmias are present, it is safest to place a temporary
transvenous pacing wire, or have transthoracic pacing available.

Traumatic myocarditis/myocardial contusions:

Myocardial injuries are common in the trauma patient. Arrhythmia production may be
delayed for 48 hours. Treatment is aimed at suppressing life threatening arrhythmias and
preserving tissue oxygen delivery. Anti-arrhythmic therapy should only be used where
adequate analgesia, oxygen supplementation, fluid therapy and electrolyte support has
failed to improve arrhythmias and where cardiac output appears compromised or
arrhythmias are life threatening.

Hypertension:
Consideration of hypertension is out with the scope of this lecture, but the reader should be
aware that control/treatment of the underlying disease is advised prior to anaesthesia e.g.
feline hyperthyroidism

Hypertrophic cardiomyopathy (HCM):

Myocardial disease accounts for nearly all acquired cardiac disease in the cat. HCM is a
disease of diastole in that the ventricle does not relax properly and thus ventricular filling is
compromised. Systolic function tends to be reserved, but the chambers stiffen and
compliance is reduced ultimately resulting in cardiac failure. Cats are also at risk form aortic
thromboembolism. In addition there may be systolic anterior motion of the mitral valve
which may cause dynamic aortic outflow obstruction. This tends to worsen at high heart
rates, when contractility is increased and when afterload is decreased.
• Treat CHF
• Prevent heart rate increases
• Suppress contractility
• Suppress ventricular arrhythmias
• Maintain SVR
• Maintain filling pressures
• Studies suggest improvement with low dose medetomidine administration in cats
without CHF

Congenital cardiovascular conditions:

In many cases congenital cardiac conditions are an incidental finding that present without
clinical signs. Thus management is not challenging beyond the problems associated with
small and immature subjects which include:

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2010 - Barcelona, Spain
Reprinted in IVIS with the permission of the SEVC Close this window to return to IVIS www.ivis.org

• Physiological immaturity – hypoglycaemia, increased volume of distribution of drugs,

hypoalbuminaemia, anaemia, decreased hepatic function affecting drug metabolism
• Hypothermia – small subjects, long procedures inside the thoracic cavity.
• Technical difficulties – IV/arterial access, ventilation, surgical access

However, some consideration should be given to the haemodynamic implications of the

congenital abnormality. It is imperative that any animal that has a right-to-left shunt is
identified. In these cases, un-oxygenated blood from the pulmonary circulation enters the
systemic circulation, cyanosis that is unresponsive to oxygen therapy and polycythaemia are
present. They pose a major anaesthetic challenge and should be considered as high risk
cases. Some congenital abnormalities may pre-dispose to R>L shunting during anaesthesia
if pulmonary pressures are greater than systemic blood pressure. Most congenital cardiac
cases have left to right shunting, this is common in patent ductus arteriosus (PDA) and
atrial and ventricular septal defects. The consequence is volume overload of the left (PDA)
right (ASD) or both (VSD) ventricles.

PDA
Haemodynamic abnormalities associated with L>R shunting PDA include right ventricular
pressure & left ventricular volume overload, producing biventricular hypertrophy. Stroke
volume is partly directed through the PDA, reducing the volume entering the aorta, which
can predispose to hypotension, with a typically low diastolic pressure. In the juvenile
asymptomatic dog, anaesthesia is straightforward. Where cardiac failure is present,
adequate stabilisation should be allowed. Cardiac output should be maintained and SVR
slightly reduced. During duct ligation, transient bradycardia may occur; a baroreceptor
mediated response to increased diastolic pressure (stroke volume all directed through
aorta.)

General principles of anaesthesia in cardiovascular disease

Minimise exposure to cardiovascularly depressant drugs
Local, locoregional or neuraxial (epidural) techniques may be utilised to provide analgesia
and thus minimise the volatile agent requirement. Epidural anaesthesia can cause profound
hypertension. Sedation is not necessarily better than anaesthesia: sedative drugs have
adverse cardiovascular effects, patients are often poorly monitored, & do not have a
secured airway with availability of O2 and ventilation.

General drug selection

The choice of drugs will depend on specific patient requirements but aims are to:
• Provide adequate muscle relaxation and analgesia.
• Maintain an adequate cardiac output and adequate arterial blood pressure
• Reverse the haemodynamic disorder present eg increase SVR etc.
• Be appropriate for pre-existing disease eg renal failure
• Be familiar to the veterinary surgeon – NEVER use an unfamiliar drug in a sick
patient.
• Be fundamentally safe and NOT associated with documented increased risks eg
xylazine

Management and monitoring

• Mechanical ventilation - avoids hypoventilation (hypercapnia) which is associated
with arrhythmia formation but tends to reduce venous return and thus pre-load.
Careful positive pressure ventilation is generally advantageous.
• Surgical manipulation may limit cardiac output (impairment of ventricular filling) and
may cause arrhythmias. Lavage fluids should be warmed to avoid decreases in
contractility/arrhythmias.

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2010 - Barcelona, Spain
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• Appropriate monitoring techniques should be used, but are no substitute for sound
clinical judgement. The clinician must be able to interpret the information provided
and know the limitations of the equipment used. In the authors clinic
instrumentation will depend on the severity of the disease and the diagnosis but may
include ECG, pulse oximetry, capnography temperature and blood pressure (ABP) in
most cases. Major surgical cases will have blood gas analysis, central venous
pressure (CVP) monitoring and direct ABP monitoring.
• Fluid loss is poorly tolerated when cardiac output is preload dependent and fluids
should be replaced adequately, Over-transfusion especially with colloids and blood in
cases with left heart failure can result in pulmonary oedema. CVP monitoring can be
useful but gives an indication of right heart function only. Careful clinical observation
may be required in recovery where volume overload is suspected.

Balanced anaesthesia
The aim of a balanced anaesthetic technique, which uses a number of different drugs to
produce muscle relaxation, analgesia & narcosis, is to reduce cardiovascular depression to a
minimum, but the use of neuromuscular blockade is itself a complex procedure that requires
expertise and appropriate monitoring.
The author favours a technique that utilises high doses of opioids (fentanyl or alfentanil) in
order to minimise induction agent and volatile agent requirements.

Recovery
Risks in recovery include:
• Hypoxaemia secondary to pulmonary oedema, atelectasis and hypoventilation
• Arrhythmias
• Hypotension following withdrawal of inotropic support
• Pain which may affect ventilation
• Hypothermia especially when associated with shivering which increases metabolic
demand for O2
• Hypovolaemia especially following large surgeries with significant haemorrhage
Intensive nursing is required. Constant ECG monitoring, direct ABP & CVP plus urine output
monitoring may be required. O2 supplementation should be provided at least until body
temperature and cardiovascular parameters are normal. Blood gas analysis may be
required.

Bibliography:
1. Clutton R.E. Cardiovascular disease In BSAVA Manual of Small Animal Anaesthesia,
Eds: Seymour C & Duke-Novakovski T. BSAVA, Glos UK 2007; p200-219
2. Part IV, Cardiovascular Disorders In Small Animal Critical Care Medicine Eds: Hopper
K & Silverstein D. Saunders, St Louis, USA 2009; pp146-209

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2010 - Barcelona, Spain