Challenging Case Coming Up

[soccerboy2288]

Hey all, I have a challenging case coming up and wanted to see how people would approach it:

76yo HTN, CAD (DES in LAD 7yrs ago), iCMY EF: 30-35% (anterior, anteroseptal, apical akinesis on TTE), Severe MR, pHTN w/ PAP 83 but Normal RV and RVSF (This was based on TTE that was obtained as outpatient 3 months ago, so presumptively not in heart failure at the time. No RHC data available. Assuming its from severe MR. systemic BP appears to be normotensive), Mild COPD, DM on insulin, ESRD on PD. Patient is not on BB because he has baseline bradycardia (last HR in 60s). Getting Fem-Pop bypass for toe gangrene and cellulitis so relatively time sensitive. Probaby takes 3-4hrs. Facility has no iNO.

How would you approach it (would you even approach it? ha). What do you think about him not being on BB due to low baseline HR? Would you place a PAC?

Initially considered GETA with pre-induction A-line and post-induction central line. Have NE, Vaso, Epi availalble. But I was also considering Epidural anesthesia with minimal sedation (I would still line the patient up). I feel like en epidural would be able to provide hemodynamic stability if titrated in slowly and start a phenylephrine/vaso drip to give back the reduced afterload. At the same time its 3-4 hrs which is a bit long.

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[dhb]

I would do a block for toe amputation.
But since they are going down the fem-pop alley : spinal vs epidural

 

[coffeebythelake]

Hey all, I have a challenging case coming up and wanted to see how people would approach it:

76yo HTN, CAD (DES in LAD 7yrs ago), iCMY EF: 30-35% (anterior, anteroseptal, apical akinesis on TTE), Severe MR, pHTN w/ PAP 83 but Normal RV and RVSF (This was based on TTE that was obtained as outpatient 3 months ago, so presumptively not in heart failure at the time. No RHC data available. Assuming its from severe MR. systemic BP appears to be normotensive), Mild COPD, DM on insulin, ESRD on PD. Patient is not on BB because he has baseline bradycardia (last HR in 60s). Getting Fem-Pop bypass for toe gangrene and cellulitis so relatively time sensitive. Probaby takes 3-4hrs. Facility has no iNO.

How would you approach it (would you even approach it? ha). What do you think about him not being on BB due to low baseline HR? Is this the right facility to do it without iNO? Would you place a PAC?

Initially considered GETA with pre-induction A-line and post-induction central line. Have NE, Vaso, Epi availalble. But I was also considering Epidural anesthesia with minimal sedation (I would still line the patient up). I feel like en epidural would be able to provide hemodynamic stability if titrated in slowly and start a phenylephrine/vaso drip to give back the reduced afterload. At the same time its 3-4 hrs which is a bit long.

Regional Block, minimal to no sedation
GA is going to be more risky even with cardiac stable induction and art line, pressers, inotropes

 

[DrOwnage]

Not sure how proximal they're working on the vessel, but I'm assuming a femoral nerve block is out of the question. Morning labs to check PD is adequate, pre-induction art line, honestly +/- on central line, but have stuff ready. Low lumbar epidural with lidocaine 1-2% slow bolus to get good level while maintaining hemodynamics. Sedation with propofol 20-40mcg/kg/min plus 0.4-0.5 mcg/kg/min of precedex without loading dose. Should maintain good minute ventilation with this combo without getting too hypercarbic. Maybe small dose of glyco to ensure HR doesn't dip due for mitral regurg purposes. Manifold setup with vaso, epi, norepi drips ready (vaso and epi push doses ready). Shes mounting those PAPs in the 80s, so like you said her RV is in good shape somehow, which is one of the most important factors. Might not hurt to get a TTE in preop to take a look at see nothing appears glaringly awful since its been a couple of months. Draw ABGs throughout the case, if shes getting too hypercarbic or slightly acidotic would prefer to throw in an LMA and uptitrate the prop and precedex to tolerate it while giving PS.

 

[vector2]

A couple things when looking at pts like this:

1. Is the pt a candidate for revascularization? You mentioned a DES to LAD but do they have other vessels which have tight stenoses that need intervention? This is important because it affects your hemodynamic management vis a vis how low you can drop systemic afterload to help the MR without compromising coronary perfusion.

2. Is the pt euvolemic (physical exam, CXR, BNP)? Severe MR + HFrEF is good recipe for volume overload and it's possible that some lasix would improve his filling pressures.

3. Don't get too hung up with the BB. His EF is down and he has severe MR, which along with other regurgitant lesions does better at HR closer to 80-90 anyway.

4. Dont get too hung up on iNO. It may have some benefit in the acutely failing RV but keep in mind that this person has post capillary pulm HTN. When you dilate his pulm vasculature, you do decrease the RV afterload but you also decrease the afterload resisting the retrograde regurgitation of blood from the pulmonary veins. Additionally there are alternatives to iNO like putting nitroglycerin in a nebulizer, flolan, etc, or starting milrinone.

5. Epidural sounds good in theory but I think it'll be exceedingly difficult to get this person flat for a few hrs without significant respiratory compromise or hypercarbia. If they do decompensate during regional/MAC with those kind of PAPs, you're gonna need a miracle to pull them out of the death spiral. If vascular insists on proceeding with a fem pop in this facility, I'm going a-line, GETA, two big IVs, milrinone/vaso, and TEE. But honestly, I'd rather just punt and have pt get PNB then Ray amputate the toe, continue antibiotics, transfer somewhere where he can get a mitraclip and get medically optimized, then do the fempop with GETA.

 

[Arch Guillotti]

minimal to no sedation

No way. I put this guy to sleep every time. Art line, 2 IV's. MAYBE central line.

 

[MoMoGesiologist]

No way. I put this guy to sleep every time. Art line, 2 IV's. MAYBE central line.

Why not epidural with sedation? Seems like it would cause less cardiopulmonary issues

 

[MoMoGesiologist]

A couple things when looking at pts like this:

1. Is the pt a candidate for revascularization? You mentioned a DES to LAD but do they have other vessels which have tight stenoses that need intervention? This is important because it affects your hemodynamic management vis a vis how low you can drop systemic afterload to help the MR without compromising coronary perfusion.

2. Is the pt euvolemic (physical exam, CXR, BNP)? Severe MR + HFrEF is good recipe for volume overload and it's possible that some lasix would improve his filling pressures.

3. Don't get too hung up with the BB. His EF is down and he has severe MR, which along with other regurgitant lesions does better at HR closer to 80-90 anyway.

4. Dont get too hung up on iNO. It may have some benefit in the acutely failing RV but keep in mind that this person has post capillary pulm HTN. When you dilate his pulm vasculature, you do decrease the RV afterload but you also decrease the afterload resisting the retrograde regurgitation of blood from the pulmonary veins. Additionally there are alternatives to iNO like putting nitroglycerin in a nebulizer, flolan, etc, or starting milrinone.

5. Epidural sounds good in theory but I think it'll be exceedingly difficult to get this person flat for a few hrs without significant respiratory compromise or hypercarbia. If they do decompensate during regional/MAC with those kind of PAPs, you're gonna need a miracle to pull them out of the death spiral. If vascular insists on proceeding with a fem pop in this facility, I'm going a-line, GETA, two big IVs, milrinone/vaso, and TEE. But honestly, I'd rather just punt and have pt get PNB then Ray amputate the toe, continue antibiotics, transfer somewhere where he can get a mitraclip and get medically optimized, then do the fempop with GETA.

You would request this patient have a cath prior to their vascular surgery?

Agree that iNO for those with pHTN 2/2 left heart disease or volume overload may get worsening pulmonary edema

 

[Choo]

Not sure how proximal they're working on the vessel, but I'm assuming a femoral nerve block is out of the question.

Why?

 

[sethco]

A couple things when looking at pts like this:

1. Is the pt a candidate for revascularization? You mentioned a DES to LAD but do they have other vessels which have tight stenoses that need intervention? This is important because it affects your hemodynamic management vis a vis how low you can drop systemic afterload to help the MR without compromising coronary perfusion

Just to play Devils advocate, let's say you do a Cath and it comes back that he had a lesion that requires stenting. He still needs anti-platelet agents afterward. How long do you want to stop these for the Fem-Pop? Pt still has gangrene that has to be addressed. What is the patient has multiple lesions that can't be stented and instead they need surgical revascularization?

Like Arch, I have no problem doing this case with GETA, an arterial and central line, and maybe (if becomes unstable or significant blood loss) a TEE

 

[Choo]

Block the femoral nerve. Slide medial - block the obturator and sciatic.

 

[dabears505]

Prop, sux, tube, roc, suggamadex. Good luck.

 

[vector2]

You would request this patient have a cath prior to their vascular surgery?

Agree that iNO for those with pHTN 2/2 left heart disease or volume overload may get worsening pulmonary edema

Just to play Devils advocate, let's say you do a Cath and it comes back that he had a lesion that requires stenting. He still needs anti-platelet agents afterward. How long do you want to stop these for the Fem-Pop? Pt still has gangrene that has to be addressed. What is the patient has multiple lesions that can't be stented and instead they need surgical revascularization?

Like Arch, I have no problem doing this case with GETA, an arterial and central line, and maybe (if becomes unstable or significant blood loss) a TEE

To clarify, I didnt mean send pt for a new cath. I meant look at his cath or cath report from when he got stented and see if other vessels were significantly occluded, CTO, diffusely diseased, how the collaterals were etc. If he is relatively well vascularized then I am prioritizing MR hemodynamic mgmt over CAD. If not, I cant be as permissive with HR and MAP. In either case, I'd be using TEE to guide it.

In the devil's advocate scenario where some intern orders a stress echo and it comes back positive and this guy goes for a new cath and/or viability study, and then it's determined he needs revascularization of some sort, obviously we're prioritizing the heart, chopping off the gangrene, and then going for CABG or whatever before the fem pop.

 

[dchz]

A couple things when looking at pts like this:

1. Is the pt a candidate for revascularization? You mentioned a DES to LAD but do they have other vessels which have tight stenoses that need intervention? This is important because it affects your hemodynamic management vis a vis how low you can drop systemic afterload to help the MR without compromising coronary perfusion.

2. Is the pt euvolemic (physical exam, CXR, BNP)? Severe MR + HFrEF is good recipe for volume overload and it's possible that some lasix would improve his filling pressures.

3. Don't get too hung up with the BB. His EF is down and he has severe MR, which along with other regurgitant lesions does better at HR closer to 80-90 anyway.

4. Dont get too hung up on iNO. It may have some benefit in the acutely failing RV but keep in mind that this person has post capillary pulm HTN. When you dilate his pulm vasculature, you do decrease the RV afterload but you also decrease the afterload resisting the retrograde regurgitation of blood from the pulmonary veins. Additionally there are alternatives to iNO like putting nitroglycerin in a nebulizer, flolan, etc, or starting milrinone.

5. Epidural sounds good in theory but I think it'll be exceedingly difficult to get this person flat for a few hrs without significant respiratory compromise or hypercarbia. If they do decompensate during regional/MAC with those kind of PAPs, you're gonna need a miracle to pull them out of the death spiral. If vascular insists on proceeding with a fem pop in this facility, I'm going a-line, GETA, two big IVs, milrinone/vaso, and TEE. But honestly, I'd rather just punt and have pt get PNB then Ray amputate the toe, continue antibiotics, transfer somewhere where he can get a mitraclip and get medically optimized, then do the fempop with GETA.

Who needs to study for oral boards when i can just read this forum?

Pretty spot on here, although i don't know if i'd diurese pre op. Severe MR is meh since all anesthetics make MR better. Agree it's most likely type 2 PHTN. Given RV is working well on TTE in normal loading conditions i'm not too worried about not having iNO.

No one has mentioned this yet, but EF of 30-35% with Severe MR is the scariest part of this case, (it means the theoretical equivalent EF if this pt didn't have MR would be way lower) but if they're living fine i'm pretty sure the forward flow gets better with propofol.

I wouldn't shy away from GETA here. I see no reason this case can't be done at this facility unless you don't have an ICU at the hospital just in case something goes wrong during the case. I would however shy away from doing this case at an ASC.

Why not epidural with sedation? Seems like it would cause less cardiopulmonary issues

See I think a lot of people fall into the mindset that regional and neuroaxial techniques are the magic bullets for people with heart disease. I think that's pretty far from the truth and can lull people into trouble. what specific cardpulm issue are you worried about?? if you get into trouble with those issues would you not emergently intubate anyways and switch to GETA? PPV helps the left side w/ MR, and remember oversedation and hypoxia and hypercarbia also hurts you with the pHTN. I'd say neuroaxial techniques are a wash, and continuous spinal is way more reliable than an epidural in this case.

 

[dchz]

Regional Block, minimal to no sedation
GA is going to be more risky even with cardiac stable induction and art line, pressers, inotropes

What regional block would you do for this case?

In this case, my "cardiac stable" induction is propofol, roc, tube. I don't think it's more risky, since most regional techniques will convert you to general (at which point the risk is now regional risk + general risk). Although some would convince themselves that having no tube in for their general makes it better.

 

[MoMoGesiologist]

Does anyone else worry about intubation and PPV when pt has high PA pressures? Normal RV fxn is reassuring. I’ve seen lung txp pts code with intubation. Or am I over-worrying about pHTN and intubation?

 

[vector2]

Does anyone else worry about intubation and PPV when pt has high PA pressures? Normal RV fxn is reassuring. I’ve seen lung txp pts code with intubation. Or am I over-worrying about pHTN and intubation?

I'm not worried in the setting of preserved RV function. Excellent preoxygenation, maintain coronary perfusion pressure, induce, get the tube in quick and minimize apneic time, keep pao2 over 95, pco2 32-35, and don't go too crazy with tidal volumes or PEEP.

 

[codeb1ue]

In a patient with severe pulmonary hypertension, I am always worried about the risk of hypoxia and hypercarbia with sedation. I also would elect for controlled ventilation with GA.

 

[soccerboy2288]

Good to hear everyone's input. To clarify, when he had his cath/stenting 7yrs ago, his other arteries only had mild CAD.

As dschz mentioned above, I'm very concerned about his EF being 30% with severe MR.

When he becomes hypotensive with induction of epidural or GA, whats your pressor of choice? Vaso can give me back the reduction in afterload, but is unfavorable since it would increase afterload without inotropy in the setting of a reduced EF. Perhaps Epi/NE, though this can increase PVR.

I was thinking an epidural would be favorable since it would reduce the afterload (favoring increased forward flow) without depressing the cardiac function too much. The big issue is whether the patient can remain supine for so long as mentioned above. But having to intubate the patient emergently sounds like a pain too (perhaps etomidate will be a good choice in such situation, though I don't like the medication too much personally).

 

[dchz]

When he becomes hypotensive with induction of epidural or GA, whats your INOTROPE of choice?

But having to intubate the patient emergently sounds like a pain too (perhaps PROPOFOL will be a good choice).

Fixed it for ya , my inotrope of choice would be epi, 10mcg pushes at a time.

 

[deleted697535]

Interesting case.

Regionalists really want to believe that a block or neuraxial would 'save' this patient from a GA or indeed straight up save him but theres very little actual evidence that regional improves mortality consistently. There are plenty of regional/neuraxial trials that say one thing and a whole other one that says the opposite. So id say either GA or neuraxial. Doesnt really matter as long as you recognise the conflicts.

As for the 'severe pulm HTN' - how did you get a PA pressure from a TTE? Thats right heart cath info. Was it RVSP? That doesnt exactly correlate with PA pressures.

We see these numbers all the time but if the patient isnt a resp cripple on home O2, bosentan, riocig etc with a respirologist following him around regularly then what does the number actually mean? Probably not as much as we like to think.

Tbh no way id do neuraxial on this guy. 3-4 hours in the vascular OR is actually 5-6 hours. Plus im not talking to this dude for hours with light sedation. Hes gonna get squirrly around 2-3 hours in unless you snow him even with precedex. Some would do this with neuraxial and that fine but i wouldnt

The op itself isnt very sore at all, so we dont need it for post op.

So to do the case:
Pre-op art, tee avail, dob, norepi, epi, vaso available, no cvp or pac. Dialysed the night before
intra - GETA with fent/midaz 2cc prop, roc
post op - whatever. should do daily trops for 3 days

This is a fairly standard vascular case/exam q

He should have an ICD placed too.

Nitric oxide has never saved the day for anyone. Mil dob vaso all probably better therapies for right heart

 

[MoMoGesiologist]

Interesting case.

Regionalists really want to believe that a block or neuraxial would 'save' this patient from a GA or indeed straight up save him but theres very little actual evidence that regional improves mortality consistently. There are plenty of regional/neuraxial trials that say one thing and a whole other one that says the opposite. So id say either GA or neuraxial. Doesnt really matter as long as you recognise the conflicts.

As for the 'severe pulm HTN' - how did you get a PA pressure from a TTE? Thats right heart cath info. Was it RVSP? That doesnt exactly correlate with PA pressures.

We see these numbers all the time but if the patient isnt a resp cripple on home O2, bosentan, riocig etc with a respirologist following him around regularly then what does the number actually mean? Probably not as much as we like to think.

Tbh no way id do neuraxial on this guy. 3-4 hours in the vascular OR is actually 5-6 hours. Plus im not talking to this dude for hours with light sedation. Hes gonna get squirrly around 2-3 hours in unless you snow him even with precedex. Some would do this with neuraxial and that fine but i wouldnt

The op itself isnt very sore at all, so we dont need it for post op.

So to do the case:
Pre-op art, tee avail, dob, norepi, epi, vaso available, no cvp or pac. Dialysed the night before
intra - GETA with fent/midaz 2cc prop, roc
post op - whatever. should do daily trops for 3 days

This is a fairly standard vascular case/exam q

He should have an ICD placed too.

Nitric oxide has never saved the day for anyone. Mil dob vaso all probably better therapies for right heart

Why daily trops x3 days?

 

[Ronin786]

Interesting case.

Regionalists really want to believe that a block or neuraxial would 'save' this patient from a GA or indeed straight up save him but theres very little actual evidence that regional improves mortality consistently. There are plenty of regional/neuraxial trials that say one thing and a whole other one that says the opposite. So id say either GA or neuraxial. Doesnt really matter as long as you recognise the conflicts.

As for the 'severe pulm HTN' - how did you get a PA pressure from a TTE? Thats right heart cath info. Was it RVSP? That doesnt exactly correlate with PA pressures.

We see these numbers all the time but if the patient isnt a resp cripple on home O2, bosentan, riocig etc with a respirologist following him around regularly then what does the number actually mean? Probably not as much as we like to think.

Tbh no way id do neuraxial on this guy. 3-4 hours in the vascular OR is actually 5-6 hours. Plus im not talking to this dude for hours with light sedation. Hes gonna get squirrly around 2-3 hours in unless you snow him even with precedex. Some would do this with neuraxial and that fine but i wouldnt

The op itself isnt very sore at all, so we dont need it for post op.

So to do the case:
Pre-op art, tee avail, dob, norepi, epi, vaso available, no cvp or pac. Dialysed the night before
intra - GETA with fent/midaz 2cc prop, roc
post op - whatever. should do daily trops for 3 days

This is a fairly standard vascular case/exam q

He should have an ICD placed too.

Nitric oxide has never saved the day for anyone. Mil dob vaso all probably better therapies for right heart

Why doesn't RVSP correlate with PA pressures? At worst you underestimate your jet and the PASP is higher than you actually are able to record. Sure you don't get a diastolic pressure or a mean PA pressure. But guess what, 85mmhg is bad pHTN unless this dude has a tight AF pulmonic valve and a whole other host of issues.

 

[vector2]

Echo:swan correlation for PAPs is pretty good for left heart disease (r=0.84) but not quite as good for other causes of PH (r=0.58).

Limitations and strengths of doppler/echo pulmonary artery systolic pressure-right heart catheterization correlations: a systematic literature review - PubMed

D PASP-RHC correlations were high and between-method differences less in patients with left heart pathology but were poorer for right heart diseases and studies with proportionately more normal PASPs on RHC for which further study is needed.

www.ncbi.nlm.nih.gov

 

[T-burglar]

The mild COPD and hopefully well controlled lung water mean peak pressures will be nice and low, should be a simple GETA. Especially with a non dilated well functioning RV. Severe MR with a low EF brings into question the cardiac output , but the heart rate is 60 , so something requires a closer look. I can’t stand it when echo reports mention everything in excruciating detail except the cardiac output. At least report a LvOT VTI.

 

[vector2]

The mild COPD and hopefully well controlled lung water mean peak pressures will be nice and low, should be a simple GETA. Especially with a non dilated well functioning RV. Severe MR with a low EF brings into question the cardiac output , but the heart rate is 60 , so something requires a closer look. I can’t stand it when echo reports mention everything in excruciating detail except the cardiac output. At least report a LvOT VTI.

Deleted for utter wrongness

 

[anbuitachi]

i'd do GA for this case. i want the controlled ventilation.
last thing i want is to emergently convert. we have no idea how difficult a case this may be for the surgeon, and they can easily go over 3-4 hours, and last thing you want to do is blast sedation at a moving patient with this hx/emergently tubing.

also for those who mentioned epidural, dont they usually ask for decent dose of heparin for these cases?

and someone already mentioned, if this patient isnt a cripple at home on home O2, and all sorts of phtn drugs and isnt out of breath all the time, the case should go fine barring any major surgery screw ups

i would do 2 IV , art line. no central line needed unless i cant get decent access.

 

[nimbus]

also for those who mentioned epidural, dont they usually ask for decent dose of heparin for these cases?

Heparin is okay as long as it is given an hour or more after the epidural. Epidurals were standard for open AAAs during residency and lumbar drains are standard for TEVAR nowadays.

 

[deleted162650]

Heparin is okay as long as it is given an hour or more after the epidural. Epidurals were standard for open AAAs during residency and lumbar drains are standard for TEVAR nowadays.

One time I asked MMM about an indwelling epidural cath during heparinization for an aneurysm repair. He looked me square in the face and said:

“Don’t wiggle it.”

 

[Radetzky]

The LV is going to be your problem here, not the RV. It could easily crap out with the drop in coronary perfusion pressure induced by your general or regional or whatever.

I would use norepi followed by epi if required. I wouldn’t worry about the increase in SVR if the cause of your hypotension is drugs that drop the SVR..

A swan will not be particularly useful cos you’ll stick it in and the number will be low from the get go and then what number will you be targeting from there on in?

Although it’s been mentioned in passing, what is this guys level of function at home? I would be very very skeptical if he’s “usually fine”. I would suspect he’s pretty impaired. This guy does not have a lot of quality life left in him. I would ask the vascular surgeons to have a discussion whether this surgery and the associated recovery are consistent with what he wants with his life rather than just ploughing ahead with major replumbing (they may have already done so).

 

[pgg]

Even if they reported an LVOT VTI, there is about a 0.0001% chance (at least at my shop) that the cardiologist reported enough LV volumetric and/or mitral quantitative data to calculate an accurate CO given the regurgitation. And even if by some miracle they did MV / AV continuity and then reported it, I don't trust making the CSA of the mitral annulus a perfect circle, not one bit.

This patient has MR not AI (at least, the OP didn't mention any AI), so forward flow through the LVOT is the CO. Don't really need to do any continuity math to get an LV CO from an LVOT VTI. Just need an LVOT diameter and the HR. Unless I'm misunderstanding you.

 

[vector2]

This patient has MR not AI (at least, the OP didn't mention any AI), so forward flow through the LVOT is the CO. Don't really need to do any continuity math to get an LV CO from an LVOT VTI. Just need an LVOT diameter and the HR. Unless I'm misunderstanding you.

Nope, you're right. Total brainfart- was thinking AI.

 

[T-burglar]

Yeah I meant the forward cardiac output which is the major parameter that cuts right through all the bull**** and tells you what you’re really dealing with in so many cases. Even moderate MR can be significant if it’s the straw that breaks the forward cardiac outputs back when there is other heart disease present

 

[anbuitachi]

Heparin is okay as long as it is given an hour or more after the epidural. Epidurals were standard for open AAAs during residency and lumbar drains are standard for TEVAR nowadays.

oh good point. forgot about those lumbar drains. hopefully we can change guidelines for spinals soon

 

[deleted697535]

oh good point. forgot about those lumbar drains. hopefully we can change guidelines for spinals soon

What do you mean for 'spinals'?
Asra 2018 update doesn't discrimate btwn neuraxial techniques for iv heparin. 4-6 hours pre, and normal ptt then do your neuraxial. Restart iv heparin 1 hour after or 24 hours if bloody tap.

Same for heparin for cpb

 

[vector2]

Yeah I meant the forward cardiac output which is the major parameter that cuts right through all the bull**** and tells you what you’re really dealing with in so many cases. Even moderate MR can be significant if it’s the straw that breaks the forward cardiac outputs back when there is other heart disease present

I do find it crazy that the OP's pt has a HR in the 60s with an EF that low and severe MR unless his heart is massively dilated. Shall we do some quick back of the napkin math given a 3.5L CO, EF 35%, HR 60, and severe MR with a regurgitant fraction of 50%?

To achieve what is already an abysmal 3.5 l/min cardiac output:

3500 / 60 (HR) = ~58 ml SV
58 ml * 2 = 116 ml (forward + MR stroke volumes)
116 / 0.35 =

331ml end-diastolic volume.


Pretty staggering considering >200ml is the cutoff for severe per ASE guidelines.

 

[anbuitachi]

I do find it crazy that the OP's pt has a HR in the 60s with an EF that low and severe MR unless his heart is massively dilated. Shall we do some quick back of the napkin math given a 3.5L CO, EF 35%, HR 60, and severe MR with a regurgitant fraction of 50%?

To achieve what is already an abysmal 3.5 ml/min cardiac output:

3500 / 60 (HR) = ~58 ml SV
58 ml * 2 = 116 ml (forward + MR stroke volumes)
134 / 0.35 =

331ml end-diastolic volume.


Pretty staggering considering >200ml is the cutoff for severe per ASE guidelines.

what is this crazy math? i dont follow

 

[anbuitachi]

in a different scenario, if this patient with severe MR, but ok RV and lungs, theoretically, how would you change your anesthetic drugs and vent settings? increase inspiratory pressure to decrease back flow? decrease FiO2 and RR to increase vasoconstriction? Crank up some nitrous??

 

[dchz]

in a different scenario, if this patient with severe MR, but ok RV and lungs

This is the same scenario...

 

[Radetzky]

in a different scenario, if this patient with severe MR, but ok RV and lungs, theoretically, how would you change your anesthetic drugs and vent settings? increase inspiratory pressure to decrease back flow? decrease FiO2 and RR to increase vasoconstriction? Crank up some nitrous??

Are you suggesting that increasing the PVR will decrease the regurgitant fraction? I’m not sure it would have any effect.

 

[vector2]

in a different scenario, if this patient with severe MR, but ok RV and lungs, theoretically, how would you change your anesthetic drugs and vent settings? increase inspiratory pressure to decrease back flow? decrease FiO2 and RR to increase vasoconstriction? Crank up some nitrous??

Normally PVR is about 1/4th of SVR. Marginally increasing PVR isn't really going to do much to help the MR, but it is going to put an unnecessary higher strain on the RV. In decompensated MR, you're much better off using vasodilators which will aid in forward flow and clinical symptoms by decreasing SVR and improving pulmonary congestion*



*assuming you don't have concomitant ongoing ischemia, tight coronary stenoses, RV pressure overload etc

 

[T-burglar]

in a different scenario, if this patient with severe MR, but ok RV and lungs, theoretically, how would you change your anesthetic drugs and vent settings? increase inspiratory pressure to decrease back flow? decrease FiO2 and RR to increase vasoconstriction? Crank up some nitrous??

Lmao

I would time a valsalva for every systole to stop the mr

 

[pgg]

Are you suggesting that increasing the PVR will decrease the regurgitant fraction? I’m not sure it would have any effect.

Yeah the vast majority of the regurgitant fraction just blows up the left atrium.

 

[T-burglar]

With respect to the original post, this is a patient that will not be harmed by a typical GETA and the surgery itself is not going to involve much stress on the patient either. This case is a dime a dozen where I work and I don’t see why anyone would call it challenging. No offense.

The real question is where is his cardiac surgery consultation in the chart? When is his MVR or clip? If this patient was scheduled for something bigger like an open aortic procedure I would have him evaluated for exercise capacity. Something tells me he can’t exercise without a rise in lung water and his cardiac output doesn’t increase much. a clip might be an option if another procedure is too urgent for open MVR.

Hemodynamic support for a larger procedure without a mitral procedure first would be ECMO, impella, or IABP. A sufficiently major procedure I would ask to have the device placed prophylactically. A major aortic procedure makes placing of support hardware complicated but an acceptable configuration can usually be found. E.g. I’ve done a thoracoabdominal aneurysm with an axillary impella.

 

[Hork Bajir]

would time a valsalva for every systole to stop the mr

Lmao why not go hands free and stick an IABP in the PA

 

[Hoya11]

Hey all, I have a challenging case coming up and wanted to see how people would approach it:

76yo HTN, CAD (DES in LAD 7yrs ago), iCMY EF: 30-35% (anterior, anteroseptal, apical akinesis on TTE), Severe MR, pHTN w/ PAP 83 but Normal RV and RVSF (This was based on TTE that was obtained as outpatient 3 months ago, so presumptively not in heart failure at the time. No RHC data available. Assuming its from severe MR. systemic BP appears to be normotensive), Mild COPD, DM on insulin, ESRD on PD. Patient is not on BB because he has baseline bradycardia (last HR in 60s). Getting Fem-Pop bypass for toe gangrene and cellulitis so relatively time sensitive. Probaby takes 3-4hrs. Facility has no iNO.

How would you approach it (would you even approach it? ha). What do you think about him not being on BB due to low baseline HR? Would you place a PAC?

Initially considered GETA with pre-induction A-line and post-induction central line. Have NE, Vaso, Epi availalble. But I was also considering Epidural anesthesia with minimal sedation (I would still line the patient up). I feel like en epidural would be able to provide hemodynamic stability if titrated in slowly and start a phenylephrine/vaso drip to give back the reduced afterload. At the same time its 3-4 hrs which is a bit long.

count me in the general with an aline camp
i wouldnt rule out an LMA either if this is a frail old thin person without an obvious contraindication, and get them breathing spontaneously asap

nothing wrong with an epidural slowly dosed and then sedation - depends on how the person is behaving, if i feel they will need a lot of sedation/they are demented then they are definitely going to sleep. someone who was reasonable and with it i would consider an epidural.

 

[deleted697535]

nothing wrong with an epidural slowly dosed and then sedation

Well there is really. Some pulmonary hypertension guys would disagree with you. And oral examiners wouldnt like it phrased that way either.

By acknowledgement that sedation can exacerbate pulm htn with hypoxia hypercarbia etc, that's probably a better way of phrasing it...

And also with sedation : we haven't yet discussed the potential repercussion injury post clamp release. Sedation could make this even worse.

Lastly with sedative. What would you use? And how? Midaz no, ppf possibly but that has issues. Precede probably best but not as good sedative as ppf

All that to say, epidural and sedative would probably go fine but we have to tip our hat to what could go wrong with it

 

[cchoukal]

Having done a fair number of such patients over the years, I would say the following:

Totally agree with the others who have stated that post-cap pHTN is not nearly as threatening as pre-cap pHTN. This patient has the former. Still, 80/x is pretty high, and I think vaso is the right choice for pressor, and he probably needs a higher HR.

Regarding the GA vs regional camp. You're basically trading off the hemodynamic hit from PPV (which can be considerable, particularly in pre-cap pHTN) for the hit caused by hypoxemia/hypercarbia which is inevitable in a regional + sedation scenario. I used to be of the mind that PPV was the worse of these. As I did more of these cases, my experience caused me to shift in that thinking, so I usually put these patients to sleep so I can avoid hypoxemia/hypercarbia. That said, I will often do sedated/topicalized intubations so I can slowly convert them from spontaneous ventilation to PPV, and I do find there's less of a hemodynamic hit than with paralysis and immediate transition from spont to PPV. Maybe overkill (you could use a bunch of epi and vaso and maybe get the same tragectory), but that's what I do.

 

[deleted697535]

That said, I will often do sedated/topicalized intubations so I can slowly convert them from spontaneous ventilation to PPV, and I do find there's less of a hemodynamic hit than with paralysis and immediate transition from spont to PPV. Maybe overkill (you could use a bunch of epi and vaso and maybe get the same tragectory), but that's what I do.

I'm so glad to read this. I remember having sh1t flung at me on this site repeatedly for mentioning that I do this reasonably often in my sickest patients. A lot of people can't get their head around it.

It is a good option.

 

[nimbus]

PASP of 80 with a systemic pressure of 180 and normal CO is a much different animal from PASP 80 with a systemic pressure of 80. I imagine this patient is the former which is pretty common. And I’ve also seen PASP drop from 80 drop to 50 with induction (and sometimes just deepening) of GA.