ANESTHESIOLOGY AND THE HEART DEVELOPMENTS IN CRITICAL CARE MEDICINE AND ANESTHESIOLOGY Volume 23 For a list of the volumes in this series see final page of the volume. ANESTHESIOLOGY AND THE HEART edited by T. H. STANLEY and R. J. SPERRY Department ofA nesthesiology, The University of Utah Medical School, Salt Lake City, Utah, U.S.A. KLUWER ACADEMIC PUBLISHERS DORDRECHT I BOSTON I LONDON ISBN-13: 978-94-010-7379-0 e-ISBN-13: 978-94-009-1966-2 DOl: 10.1007/978-94-009-1966-2 Published by Kluwer Academic Publishers, P.O. Box 17,3300 AA Dordrecht, The Netherlands. Kluwer Academic Publishers incorporates the publishing programmes of D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press. Sold and distributed in the U.S.A. and Canada by Kluwer Academic Publishers, 101 Philip Drive, Norwell, MA 02061, U.S.A. In all other countries, sold and distributed by Kluwer Academic Publishers Group, P.O. Box 322, 3300 AH Dordrecht, The Netherlands. Printed on acid-free paper All Rights Reserved © 1990 by Kluwer Academic Publishers Softcover reprint of the hardcover 1s t edition 1990 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. TABLE OF CONTENTS Preface vii List of Contributors ix Assessment of the Patient with Ischemic Cardiac Disease Dennis T. Mangano, Ph.D., M.D. Evaluating the Right Ventricle 13 Pierre Foex, M.D. Cardiovascular physiology of Congenital Heart Disease 25 Alan Jay Schwartz, M.D., M.S.Ed. Myocardial Lymphatics and Cardiac Function 37 John P. Williams, M.D. Pathophysiology of the Coronary Circulation 53 Pierre Foex, M.D. The Aging Heart 65 Stanley Muravchick, M.D., Ph.D. Hypertension: Is It Really Important? 69 Edward D. Miller, Jr., M.D. Perioperative Myocardial Ischemia: Diagnosis and Treatment 79 Dennis T. Mangano, Ph.D., M.D. Beta-Adrenergic Blocking Drugs 91 Robert G. Merin, M.D. Aging, Autonomic Function and Cardiovascular Homeostasis 101 Stanley Muravchick, M.D. The Cardiac Patient and Atrial Natriuretic Hormone 105. Edward D. Miller, Jr., M.D. Preoperative Hypokalemia and the Cardiac Patient 111 K. C. Wong, M.D., Ph.D. Calcium Channel Blocking Drugs 119 Robert G. Merin, M.D. Cardiovascular Pharmacology: What's New (And Useful)! 125 Paul G. Barash, M.D. Anesthetic Management of the Child with Congenital Heart 133 Disease for Noncardiac Surgery Alan Jay Schwartz, M.D., M.S.Ed. vi Anesthesia and the Renin-Angiotensin System 141 Edward D. Miller, Jr., M.D. Controversies in Cardiac Monitoring 147 Paul G. Barash, M.D. Nitrous Oxide and the Compromised Heart 163 Pierre Foex, M.D. Inhalation Anesthetics in Patients with Cardiac Disease 177 John H. Tinker, M.D. Opioids in Patients with Cardiac Disease 191 Theodore H. Stanley, M.D. Is Isoflurane Contraindicated in Patients with Coronary 231 Artery Disease? Robert G. Merin, M.D. Cardiovascular Effects of Local Anesthetics 239 Benjamin G. Covino, Ph.D., M.D. Pulmonary Edema: Is Your Fluid Management Breathtaking? 251 Paul G. Barash, M.D. Should We All Have A Sympathectomy at Birth? Or At Least 263 Preoperatively? Michael F. Roizen, M.D. Cardiopulmonary Bypass 267 John H. Tinker, M.D. Anesthesia for Carotid Artery Surgery 285 Jeffrey Katz, M.D. Regional Anesthesia for Patients with Cardiac Disease 295 Benjamin G. Covino, Ph.D., M.D. Anesthesia for Vascular Surgery 305 Michael F. Roizen, M.D. PREFACE Theodore H. Stanley, M.D. Anesthesiology and the Heart contains the Refresher Course manuscripts of the presentations of the 35th Annual Postgraduate Course in Anesthesiology which took place at The Cliff Conference Center in Snowbird, Utah, February 16-20, 1990. The chapters reflect new data and concepts within the general framework of "evaluating myocardial function," "pharmacology and the cardiac patient," "anesthesia for patients with cardiac disease," and "stress, cardiopulmonary bypass, coagulation problems and related issues." The purposes of the textbook are to 1) act as a reference for the anesthesiologists attending the meeting, and 2) serve as a vehicle to bring many of the latest concepts in anesthesiology to others within a short time of the formal presentation. Each chapter is a brief but sharply focused glimpse of the interests in anesthesia expressed at the conference. This book and its chapters should not be considered complete treatises on the subjects addressed but rather attempts to summarize the most salient points. This textbook is the eighth in a continuing series documenting the proceedings of the Postgraduate Course in Salt Lake City. We hope that this and the past and future volumes reflect the rapid and continuing evolution of anesthesiology in the late twentieth century. vii LIST OF CoNTIUBUTDRS Bailey, P.L. Department of Anesthesiology, The University of Utah School of Medicine, Salt Lake City, UT 84132, U.S.A. Barash, P. Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, U.S.A. Covino, B.G. Department of Anesthesia, Brigham and Women's Hospital, Boston, MA 02115, U.S.A. Foex, P. Nuffield Department of Anesthetics, The Radcliffe Infirmary, Oxford OX2 6HE, United Kingdom Katz, J. Department of Anesthesiology, University of Texas Health Science Center at Houston, Houston, TX 77030, U.S.A. Mangano, D.T. Department of Anesthesia, University of California, San Francisco, CA 94102, U.S.A. Merin, R. Department of Anesthesiology, University of Texas Health Science Center at Houston, Houston, TX 77019, U.S.A. Miller, E.D. Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, NY 10032, U.S.A. Muravchick, S. Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, U.S.A. Roizen, M.F. Department of Anesthesiology and Critical Care, University of Chicago Medical Center, Chicago IL 60612, U.S.A. Schultz, J.R. Department of Anesthesiology, The University of Utah School of Medicine, Salt Lake City, UT 84132, U.S.A. ix x Stanley, T. H. Department of Anesthesiology, The University of Utah School of Medioine, Salt Lake City, UT 84132, U.S.A. Tinker, J.H. Department of Anesthesia, University of Iowa College of Medicine, Iowa City, IA 52242, U.S.A. Williams, J.P. Department of Anesthesiology, University of Texas at Houston, Houston, TX 77030, U.S.A. Wong, K.C. Department of Anesthesiology, The University of Utah School of Medicine, Salt Lake City, UT 84132, U.S.A. ASSESSMENT OF THE PATIENT WlTII ISCHEMIC HEART DISEASE DENNIS T. MANGANO, PH.D., M.D. The patient with llID usually has one of the many symptom complexes associated with varying degrees of ventricular dysfunction. Assessment of a patient with llID presenting for surgery is usually conducted over a very brief period of time and therefore requires a rather intense assessment of the patient's cardiac status. Other factors add to the difficulties involved in this assessment: 1) The age of the population presenting for surgery is increasing; 2) surgical procedures are becoming more complex; and 3) cost containment procedures will limit the number and type of preoperative tests used to assess risk in patients with llID, and there will be increasing pressure on us to expedite such an assessment (e.g., come-and-go, come-and-stay surgery). Thus, more than ever, we must know what specific tests are available for assessment of these patients and what information we can obtain from these tests to determine peri operative risk, preoperative therapeutics, intraoperative monitoring, choice of anesthetic, and postoperative care. llID is a significant problem and will probably remain so well into the 1990s. This is substantiated by several statistics accumulated in the early 1980s from the United States. It is estimated that 10 million patients have llID in the United States today, 4 million of whom have had previous myocardial infarctions. In anyone year, approximately 1.5 million patients develop a new myocardial infarction and 700,000 deaths are attributed to IHD per year. Surgical procedures performed each year on these patients include approximately 800,000 cardiac catheterizations, with 285,000 coronary artery bypass grafts and an equal number of coronary angioplasties. It is estimated that of the 20 million patients in the United States that undergo surgery each year, approximately 1 to 2 million have llID or are at high risk for it. Thus, the problem is significant to anesthesiologists. It appears that the prognosis for patients with IHD is related to the development and severity of dysrhythmias, myocardial infarction and ventricular dysfunction. Before proceeding with a discussion of the tests used for IHD, it is important to review the significance of dysrhythmias, infarction and dysfunction in patients with IHD. T. H. Stanley and R. J. Sperry (eds.),Anesthesioiogy and the Heart, I-Il. © 1990 Kll4Wer Academic Publishers.