Am I that Different Disty Pearson PAC Boston Adult Congenital Heart and Pulmonary Hypertension Service Boston Childrens Hospital CHD Patients Reaching Adulthood Pediatric patients ID: 612543
Download Presentation The PPT/PDF document "Assessment of Cardiac Function" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Assessment of Cardiac Function Am I that Different?
Disty Pearson, PA-CBoston Adult Congenital Heart and Pulmonary Hypertension ServiceBoston Children’s Hospital Slide2
CHD
Patients Reaching Adulthood
Pediatric patients
Adult patients
1985
2005
1965
70
30
50
50
Williams et al
.
J
A
m
Coll
Cardiol
2006
40
60Slide3
Opotowsky AR et al.
J Am Coll Cardiol
2009
Average age 52.3 -53.8 years
2x ↑ in ACHD hospitalizations
↑ complexity
↑ comorbidities
↑ comorbidities
↑ costs
ACHD: Increased HospitalizationsSlide4
Khairy
et al JACC 9-28-2010Age at Time of DeathSlide5
Adult in the CICU?Slide6
ACHD Surgery: PHIS 2002-2008
n = 3061 cases
39 free-standing pediatric institutions
Kim Y et
al Circulation 2011
is the strongest predictor of postop survivalSlide7
ACHD: Causes of Death
Verheugt CL et al.
Eur Heart Journal
2010Slide8
Coronary Disease In ACHD
CHD specificAnomalous coronariesCompression of coronariesSupply/demand imbalance
Surgical stenosis at re-implantation sites (ASO, Ross, Bentall)Cardiovascular risk factorsDM, HTN, obesity, cholesterol, smoking coarctation Aging population over 60Slide9
Evaluation
High index of suspicionEKG where the abnormal is normal Changes from baseline?
Biomarkers (critical eye)Change in hemodynamicsRhythm changeSlide10
Evaluation
Echo – new wall motion abnormalitiesIschemia testing w imaging – if time allowsNuclear, MRI, Echo, cardiac CTDelayed
enhancement – hibernating myocardium Catheterization – diagnostic & interventionSlide11
Normal EKGSlide12
Inferior Myocardial Infarction Slide13
Coronary Compression
John J
Ryan et al Department of Medicine, Section of Cardiology and Department of Pathology, University of Chicago,Slide14
Heart Failure in ACHDSlide15
Heart Failure in ACHD
Right heart failureLeft heart failure HFREF (reduced EF)20% of TOF LV systolic dysfunction (Ghai 2002)Systolic dysfunction in TOF predictor of mortality
(Broberg 2011)scars, myocardial protection, dysynchrony (BBB, PPM) obstructive lesions, LV noncompactionDiastolic dysfunction HFPEF (preserved EF)
Can affect both the right and the left ventricle Slide16
American Journal of Cardiology
2006 97, 1238-1243DOI: (10.1016/j.amjcard.2005.10.065)
Copyright © 2006 Elsevier Inc.
Probability of Heart Failure by Age and
Dx
NoroziSlide17
Diastolic DysfunctionThe inability of the LV to adequately fill at low or normal atrial pressures associated with abnormalities of diastolic
distensability, filling, or relaxation of the LV Gaasch & Zile 2004Slide18
Diastolic DysfunctionRisk factors for DD
Increased ageHTNObesityDiabetesDyslipidemiaLinked to atrial
and ventricular arrhythmiasRenal failure
PearsonSlide19
Pressure-Volume Loop
Alsaddique etal 2009
Lacalzada et al; Evaluation of Left Ventricular Diastolic Function by EchocardiographySlide20
Diastolic DysfunctionExacerbated
byTachycardia (less diastolic filling time) Reduced LV volumeInotropes - causing tachycardiaHigh PEEP
ObesityCompression (effusions, other ventricle)Slide21
Evaluative Tools
Biomarkers
Direct measurement of pressuresRA, LA (PCWP)Swan Ganz cathetersContinuous cardiac output (CCO)EchocardiogramCardiac CT, MRISlide22
PearlSlide23
ASDSlide24
ASD with Aging
LVedp
increases
LAp
increases
Shunt increases
RV progressive
dilation/
dysfunction
Right sided failureSlide25
ASD with Aging
Closure
LA pressure increasesPCW increasesPAp increasesFurther worsening left heart diastolic dysfunction and right heart systolic dysfunctionArrhythmia
Pre-closureTreat systemic HTN
Targeted vasodilator therapy
Fenestrated
closure
BMI optimizationSlide26
BaggageSlide27
Comorbidities
Neurologic ICU concernsStrokeMetabolic derangement
Decrease metabolism of narcotics/anestheticsPsychiatric>30% of adults w CHD meet diagnostic criteria for a psychiatric diagnosisKovacs A et al.
Int J Cardiol 2009, Zomer A et al.
Am J
Cardiol
2013)
Aspects
of treatment experienced as repeated traumaRourke Pediatric Oncology Nursing,
Stuber PediatricsSyndromes (22q11.2 deletion…..)Slide28
Comorbidities
Hepatic function Hep C, congestion, fibrosis
Wu Cong Heart Disease 2011Chronic hypoxemia and secondary erythrocytosisImpaired immune function– Infectious issues
Impaired renal function
Diller
GP et al.
J Am
Coll
Cardiol 2011Slide29
CoMorbidities
Pulmonary dysfunctionPectus, prior surgeries, diaphragmatic diseaseRestrictive/obstructive disease
Need preoperative PFTsVenous insufficiency
Valente AM et al.
J Am
Coll
Cardiol
2010Slide30
Take Home
Growing adult population Increased incidence ofArrhythmiaHeart failureCoronary issuesComorbidities with direct impact on ICU care
Evaluation starts with a high index of suspicion Slide31
PartnerACHD colleagues
We love to helpACHD patientsWe must set an example to dediction to life long careHeart healthy habits
Reasonable BMIExerciseHealthy dietSlide32
It Takes A Team
Boston Adult Congenital Heart Service 2013