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Dysfunction Diastolic and Implication

in Anathesia

Baiq Ria Raissa Fala

H1A 009 041

dr. Ni Made Ayu Suria, Sp. An
Complications during and after non-
cardiac surgery are a continuous concern
for medicalsocieties, as it was shown in
the latest multi-center study with this topic
that mortality aftersurgery in Europe is
much bigger than expected and
previously estimated - 4%.
Congestive cardiac failure (CCF) is a
common and debilitating condition. It is
characterised by impaired ventricular
performance resulting in fatigue, exercise
intolerance, an increased incidence of
ventricular arrhythmias and a shortened
life expectancy
The three major risk factors for the
development of heart failure are age,
hypertension and coronary artery disease.
In the UK up to 4% of deaths are
attributable to heart failure and 40% of
patients will die within one year of
heart failure is associated
with a substantial increase in morbidity
and mortality.This review will examine the
underlying pathophysiological principles
of CCF and apply those principles to the
clinical management of patients.
Definition of Heart Failure
Congestive heart failure (CHF) is a
common condition with a poor prognosis.
In CHF, the heart is unable to pump blood
at a rate commensurate with the
requirements of the metabolizing tissues or
can do so only from an elevated filling
Thereare several factors that work
concurrently in CHF. Pathologically, the
heart muscle exhibits progressive changes
in myocyte myofilaments, decreased
contractility, myocyte apoptosis and
necrosis, abnormal fibrin deposition in the
ventricle wall, myocardial hypertrophy,
and changes in the ventricular chamber
In many pathologic states, the onset of
heart failure is preceded by cardiac
hypertrophy, the compensatory response
of the myocardium to increased
mechanical work. The pattern of
hypertrophy reflects the nature of the
In addition to the physical changes, CHF is
characterized by a complex constellation of
neurohumoral and inflammatory processes.
Catecholamines cause numerous deleterious
effects on the myocardium, including direct
toxicity to myocytes, induction of myocyte
apoptosis, myocardial remodeling, down-
regulation of adrenergic receptors, facilitation
of arrhythmias, and potentiation of
autoimmune effects on heart muscle.
Preoperative Evaluation
The new 2014 Joint Task Force European
Society of Cardiology (ESC)/ European
Society ofAnesthesiology (ESA) guidelines
on perioperative assessment and
management of cardiac riskin non-
cardiac surgery has upgraded previous
recommendations regarding
preoperative evaluation of patients
scheduled for non-urgent non-cardiac
The need for preoperative cardiac
evaluation also depends on the urgency
of surgery. Emergency surgical
procedures (such as ruptured abdominal
aortic aneurysms or major trauma) results
or indications are not influenced by
cardiac assessment, but perioperative
management of such cases is crucial in
these cases.
Cardiac evaluation in urgent but non-
emergency interventions will not influence
the decision to perform the intervention,
but can contribute to reducing peri
procedural cardiac risk.
Anesthetic Considerations and
Operative Management
Patientswith CHF do not make good
candidates for elective surgery. The
presence of CHF has been described as
the single most important factor for
redicting postoperative cardiac morbidity
Evidence of leftsided heart failure is
associated with a poor prognosis. Patients
with ejection fractions of less than 40
percent, determined by radioisotope
imaging, have a 1-year cumulative
mortality of 30 percent. If surgery is
necessary, the drugs and techniques
chosen to provide anesthesia are
selected with the goal of optimizing CO
Clinicalanesthesiologists are commonly
involved in the management of patients
treated with ACEIs. The role of ACEIs and
their possible interaction with anesthetic
agents must be an integral part of clinical
decision-making during anesthesia.
Hemodynamic variation during
anesthesia is mainly related to specific
effects of anesthetic agents on the
sympathetic nervous system. Those
patients with volume depletion and
extended sympathetic blockade can
have reduced vascular capacitance
resulting in decreased venous return,
reduced CO and severe arterial
should be vigilant and readily
have vasopressors, necessary fluids, and
other resuscitative measures for treatment
of unexpected hemodynamic instability
during anesthesia and surgery
The use of diuretics, especially
spironolactone, can also raise certain
concerns for the clinical anesthesiologist.
Spironolactone, being used as a
potassium-sparing diuretic, should be
carefully monitored before surgery. Serum
potassium concentration should be
measured immediately before operation
to detect hyperkalemia in heart failure
patients treated with spironolactone
Renalinsufficiency, advanced age,
potassium supplementation,
decompensated CHF, and a
spironolactone dose larger than 25 mg/d
increase the risk of hyperkalemia as a
consequence of spironolactone therapy.
cardiac depression produced by the
combined effects of a volatile anesthetic
and CHF is greater than that effect in the
absence of CHF. Opioids,
benzodiazepines, and etomidate are
acceptable considerations, since they
produce little or no direct myocardial
nitrous oxide added to diazepam does
not seem to produce cardiac depression.
In the presence of severe CHF, the use of
opioids as the only drug for maintenance
of anesthesia may be justified. Monitoring
is adjusted to the complexity of the
propofol is commonly used to induce and
maintain anesthesia and sedation for surgery,
systemic hypotension and reduced CO can
occur in patients with or without intrinsic
cardiac disease.
Propofol reduces total arterial resistance and
increases total arterial compliance derived
from aortic impedance in CHF patients. The
myocytes in the CHF patient are more
sensitive to the negative effects of propofol
on velocity of shortening
Ingeneral, propofol has a direct and
negative effect on myocyte contractile
processes in the setting of CHF
Regarding operative management of the
patient with CHF, the medical community has
witnessed an increase in available surgical
The clinical anesthesiologist must be able to
identify which class, based on The New York
Heart Association (NYHA) classification, the
patient with CHF is in. This system is the most
commonly used to identify staging of heart
failure. It is based completely on the patients
subjective reporting of activity
Inpatients with severe conduction
abnormalities, such as complete
atrioventricular block, temporary or
permanent endocavitary pacing should
be performed urgently. Outcomes are
betterif biventricular pacing is used.
The fact that intra-operative
haemodynamic instability is associated
with post-operative complications allows
for risk stratification at the end of surgery.
Inconclusion, the perioperative role of
anaesthesiologists (physicians trained in
anaesthesia and intensive care medicine)
has changed, increasing the workload
and responsibility
Theanaesthesiologists have a leading role
in perioperative management of patients
with heart failure by identifying patients
who require pre-operative evaluation and
optimisation by a team of integrated
multi-disciplinary specialists including
anaesthesiologists, cardiologists and
surgeons, and when appropriate an
extended team