Adult Congenital Heart Disease: The New Reality Kathryn - - PDF document

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Adult Congenital Heart Disease: The New Reality

Kathryn Rouine-Rapp, MD Professor of Anesthesia I have nothing to disclose

Disclosures

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Outline

Historic perspective Our reality Common lesions Guidelines Pathways to expertise

Lorraine Sweeney 1938

PDA First person to survive surgery to correct

CHD

BCH

• Dr. Robert Gros

7 yo

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Eileen Saxon 1944

TOF First person to undergo BT(T) shunt Johns Hopkins Drs Blalock, Taussig, & Mr Thomas Age 15 months

“switching arteries sidetracks blood and

• xygen to otherwise starved lungs”

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Our Reality

1-3 million adults USA and CA with CHD 1.8 million Europe Survival to adulthood increased from

30% in 1940s to nearly 90% today

More adults vs children with CHD Median age 40 yrs FEBRUARY 23, 2014

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Our Reality

> 10000 adults with CHD

Increasing fraction of all non-cardiac

surgery

Majority underwent surgery non-

teaching hospitals

Increased morbidity and mortality

Maxwell et al. Anesthesiology. 2013 Oct; 119(4): 762-

9

Lesion classification

Complexity classification

Simple Moderate Severe 20-25% overall severe complexity 40% simple or “resolved” post intervention

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Patient status

Unoperated Palliated

• Surgical or device correction

Excellent uncomplicated result Residual defect Sequelae

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Lesions

Common lesions

VSD, ASD, PDA Pulmonary valve stenosis Aortic valve stenosis Coarctation of the aorta Atrioventricular-septal defects TOF TGA

ASD

One of most common defects Four types

Secundum (70% ) , central IAS,

associated MR

Primum (15-25% ), near AV valves,

associated cleft MV

Sinus venosus (10% ), associated w

anomalous PV

Unroofed coronary sinus (rare)

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http://www.doctortipster.com/wp-content/uploads/2011/07/interatrial-septal-defect2.gif https://apps.childrenshospital.org/clinical/mml/viewBLOB.cfm?MEDIA_ID=306

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Spectrum of severity

24 yo male asx athlete, murmur detected, secundum ASD 83 yo male, in OR for CABG, new “incidental” finding on TEE immediately prior to CPB, SV ASD & anomalous RUPV 54 yo female, presented with DOE and new onset atrial fibrillation with RVR, TTE w RVD, L to R ASD flow

VSD

Four types

Perimembranous (70% ) Muscular (20% ) Doubly-committed (subarterial)

(5% )

Inlet (5% )

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http://206.47.151.137/bcdecker/figures/acs/part11_ch01_fig29.gif

Spectrum of severity

Large defects = heart failure/sx Qp/Qs

pulmonary to systemic flow ratio defect size SVR and PVR

PHTN Infective endocarditis Device closure or surgery

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Tetralogy of Fallot

Most common cyanotic defect Four lesions

RVOTO (severity determines

cyanosis)

RVH VSD (PM) Overriding aorta

http://www.heartbirthdefect.com/images/birth-defects/621x440xtetralogy-of-Fallot.jpg.pagespeed.ic.4Xfv8mG3um.jpg

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Spectrum of severity

61yo male for atrial flutter ablation Shunt placement Shunt revision and PM Surgical repair (10yo) Proximal LPA hypoplasia Aneurysmal RVOT patch, PI RV EF 30% Decreasing exercise tolerance Not a candidate for percutaneous intervention

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Guidelines

2008 ACC/AHA consensus statement Adults with CHD : surgical (diagnostic,

interventional) procedures that require general anesthesia or conscious sedation in adults with moderate or complex CHD should be performed in a regional adult CHD center with an anesthesiologist familiar with adult CHD patients

Guidelines

2008 ACC/AHA consensus statement Adult patients with complex or high-risk CHD

should be transferred to an adult CHD center for urgent or acute problems

…and should have a cardiologist consultation

prior to procedures

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Simple lesions

Unoperated

Isolated mild

aortic or mitral valve lesion

Isolated ASD Small isolated VSD Isolated mild PV

stenosis

Operated

PDA Secundum ASD Sinus venosus

ASD wo residua

VSD wo residua

Cannesson et al Anesth 2009

Training

no established curriculum for education DiNardo, Baum, Andropoulous: pathways for

pediatric cardiac anesthesia fellowships depend on training prior to fellowship Anesth

• Analg. 2010 Apr 1;110(4):1121-5

Inconsistent experience during adult cardiac

anesthesia fellowships across USA (personal survey)

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Closed claim analysis

Factors: adverse events n = 21 11 (52% ) cardiac procedures 10 (48% ) noncardiac procedures cardiac procedures

surgical technique (73% ) intraoperative anesthetic care (55% )

noncardiac cases

postoperative monitoring/ care (50% ) CHD (50% ) preoperative assessment or

• ptimization (40% )

Maxwell BG et al. Congenit Heart Dis. 2015 Jan-Feb;10(1):21-9

Questions to consider

Status of patient

Unoperated, palliated, repaired

Lesion and classification

Simple, moderate, severe complexity

Functional status

NYHA

Standard of care & experts in your group When to say “no”

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Summary

Increasing population of adults with CHD who

need our care

Lesion classification Specific lesions Guidelines Training variability Reality of local care vs triage

THANK YOU

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