Perioperative Critical Care Cardiology 2nd edition J.L.Atlee A.Gullo G.Sinagra J.- L.Vincent J.L.Atlee • A.Gullo • G.Sinagra • J.-L.Vincent (Eds) Perioperative Critical Care Cardiology 2nd edition 3 1 JOHNL.ATLEE ANTONINOGULLO Department ofAnesthesiology Department ofAnaesthesia and University ofWisconsin (Madison) Intensive Care Medical College ofWisconsin (Milwaukee) Policlinic University Hospital Hartland,USA Catania,Italy GIANFRANCOSINAGRA JEAN-LOUISVINCENT Cardiovascular Department Department ofIntensive Care Ospedali Riuniti and University Erasme University Hospital ofTrieste,Italy Brussels,Belgium Library ofCongress Control Number:2006937626 ISBN-10 88-470-0557-4 Springer Milan Berlin Heidelberg New York ISBN-13 978-88-470-0557-0 Springer Milan Berlin Heidelberg New York Springer is a part ofSpringer Science+Business Media springer.com © Springer-Verlag Italia 2007 This work is subject to copyright.All rights are reserved,whether the whole or part ofthe material is concerned,specifically the rights of translation,reprinting,re-use of illustra- tions,recitation,broadcasting,reproduction on microfilms or in other ways,and storage in data banks.Duplication ofthis publication or parts thereofis only permitted under the provisions of the Italian Copyright Law in its current version,and permission for use must always be obtained from Springer.Violations are liable for prosecution under the Italian Copyright Law. 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Cover design:Simona Colombo,Milan,Italy Typesetting:Graphostudio,Milan,Italy Printer:Arti Grafiche Nidasio,Assago,Italy Printed in Italy Preface to the 2nd edition Perioperative critical care cardiology (PCCC) includes the cardiovascular management of patients with any underlying diseases or imposed conditions (whether natural or iatrogenic) that involve or affect the heart–including, acute or chronic mechanical heart failure (HF).This can result from ischemic heart disease, diabetes mellitus, uncontrolled hypertension, arrhythmias that compromise heart function, circulatory shock, or dilated or obstructive car- diomyopathy. Patients needing therapy for HF are especially challenging to clinicians involved their perioperative care. While PCCC has traditionally been within the context of anesthesia and surgery,we now must consider the implications of other therapeutic interven- tions outside of surgery in critically ill patients. Thus, we may become involved in any stage of their care,including specialized diagnostics,nonsur- gical interventions,both during and after such intervention,all ofwhich occur outside of traditional OR settings. Interventions can include percutaneous coronary angioplasty; aortic, endovascular or intracranial aneurysm repair; specialized imaging (magnetic resonance imaging and the like); radiation oncology;etc.Any ofthese “non-OR”interventions performed in a critically ill patient require the same level of care provided to surgical patients,including: 1) preprocedural patient evaluation and risk stratification; 2) periprocedural care; 3) post-procedural care (post-anesthetic care unit) and 4) any needed critical care (intensive care unit) for whatever reason.Also, as perioperative physicians,we must be able to anticipate and plan for any needed therapy that may improve our patient’s well-being or physical status. Professor Gullo generously provided me with the opportunity to organize the topics for this 2nd edition of Perioperative Critical Care cardiology.I gave this serious thought at the time of A.P.I.C.E. 20, and we agreed there to the Table of Contents. I hope this volume adequately addresses the “idealls” set forth above. The first chapter addresses sudden death (SD) in HF,including strategies for stratifying risk and therapy. An important conclusion is that despite advances in therapy for improving the prognosis for these patients, SD remains a leading cause for death.As the authors suggest,new,non-pharmaco- logic strategies (discussed in more detail later in this book) may offer some VI Preface hope. However, most, today, are ill-affordable to most of the world. Our best hope for now may be high-risk behavior modification,including more healthy diets and exercise.Next,two chapters address 1) the etiology and pathophysi- ology of HF, and 2) cardiac protection for non-cardiac surgery. The first of these is required reading for anyone who treats patients with or at risk for HF. The second addresses drug-protection against myocardial ischemia, arrhyth- mias and HF in noncardiac surgical patients. Prof. Gombotz and colleagues deal with anesthetic preconditioning as protection in a later chapter (CH 14) on prevention and management of cardiac dysfunction during and after car- diac surgery. Chapters 4-6 address hypertensive crises, atrial fibrillation and diabetes mellitus in patients with HF,and bedside monitoring for circulatory failure.CH 6 is especially interesting in that it discusses the merits and disad- vantages of available, relatively noninvasive strategies for bedside hemody- namic monitoring,a field of technology that is rapidly evolving.CH 7 by Prof. Auler et al. on perioperative cardiac risk stratification was a “must” for this work,and is up to date and current with the available literature.CH 8 by Prof. Vincent and Holsten addresses invasive and noninvasive monitoring in patients with acute HF;including,an analysis of the advantages and disadvan- tages of pulmonary artery catheter (PAC) monitoring.A relatively noninvasive alternative is needed.Two chapters follow,one on electrocardiography in heart failure and another on pacemaker and internal cardioverter-defibrillator ther- apies in HF,interposed between which is an extremely relevant chapter on the management of patients with acute HF.In addition to monitoring and drugs for management of acute HF,this latter chapter also addresses devices as ther- apy for acute HF.Next,Prof.Weil and colleagues provide us with a up-to-date review of recent advances in cardiopulmonary resuscitation, a topic not addressed in the first edition of this work. The management of circulatory shock is discussed by Prof.Vincent and Rapotec in the following chapter. It describes four types of circulatory shock (hypovolemic, distributive, cardio- genic and obstructive),which dictates the diagnosis and management of each. Prevention and management of cardiac dysfunction after cardiac surgery fol- lows (Prof.Gombotz and colleagues),and this in turn by a chapter on differen- tial monitoring and therapy for systemic or pulmonary arterial hypertension. The last chapter,based on a registry of data in Trieste,Italy,reviews the natur- al history ofdilated cardiomyopathy. Again,I express my appreciation to Prof.Gullo for recruiting me to orga- nize the topics for this edition of PCCC,and to my co-editors Profs.A.Gullo, G. Sinagra, and J-L Vincent for their valauable contributions and support in this collegial,international effort. Milwaukee,November 2006 John L.Atlee,MS (Pharmacology) MD,FACA,FACC,FAMA Preface to the 1st edition The peri-operative period represents a crucial phase not only for the patient,but also for the surgical and anaesthesiological team which must coordinate harmo- niously to ensure the patient’s rapid functional recovery.Therefore,an interdisci- plinary approach to peri-operative care is essential,both in terms of clinical competency and of instrumental monitoring.Obviously,patient monitoring and all diagnostic and treatment procedures must be modulated in relation to the actual situation.Above all,the pre-operative evaluation of the patient’s health conditions and surgical needs has to follow standardized protocols.It is impor- tant to determine the functional state of the patient and,in particular,the func- tional reserves ofthe cardiovascular system. Determining the surgical indications and carrying out the intervention both depend on the rigorous control ofthe patient’s homeostasis throughout the peri- operative phase.Anesthesiological protocols are by now codified and familiar to all experienced operators.On this basis,I wished to offer votaries ofthis field,in particular anesthesiologists,surgeons,cardiologists,internists and intensive care physicians,an update on the more relevant problems that arise during peri-oper- ative care. The focus of this volume is on surgery patients (including those undergoing non-cardiac interventions) whose clinical conditions require special strategies for the prevention and eventual treatment ofcritical conditions. Considering the innumerable pathophysiological and clinical situations that may develop in the peri-operative period,continuous education is essential.It is particularly opportune to stress the importance offirst-hand experience and the ability to interpret the multiplicity of the hemodynamic complications that can occur in the delicate phase ofthe peri-operative period. Sure progress has come from the availability ofsophisticated means ofhemo- dynamic monitoring,particularly the noninvasive techniques such as trans- esophageal echocardiography (TEE) and intra-esophageal echo Doppler ultra- sound.In addition to methods for monitoring blood pressure,it is now routine to perform bedside monitoring of cardiac volumes,myocardial contractility,and organ perfusion based on entidal CO levels.These methods are now common- 2 place in modern clinical practice. In this context,the management of arrhythmias assumes an important role. The correct and timely diagnosis of arrhythmias and the appropriate use of the VIII Preface different anti-arrhythmic drugs depend on an accurate knowledge of current medical practices.Therefore,the chapter on temporary pacing for the treatment of dangerous arrhythmias is extremely important basically for the training process. The contributions on monitoring for myocardial ischaemia in the peri-opera- tive period and on the principal trials of novel clinical approaches to acute myocardial infarction are germane to this volume.Another interesting contribu- tion focuses on dilated cardiomyopathy and on the different therapeutic options for this disorder.In addition,two chapters are dedicated to the care of patients undergoing surgical intervention for myocardial revascularization. These patients require different strategies ofintervention to improve ventricular failure and to treat secondary complications due to cardiac dysfunction.Finally,this vol- ume could not fail to include a chapter on cardiogenic pulmonary edema that often characterizes the clinical iterofpatients with cardiac insufficiency. In light of this brief preface,I have valid motives to retain that this volume will arouse interest in both researchers and experts ofthis subject.It will also be informative for young physicians who are completing their training. I wish to thank all the authors for their valuable contributions and for helping to bring this initiative to a fulfillment.I particularly thank my friends and col- leagues J.L.Atlee and J.-L.Vincent,with whose efforts this volume became possi- ble. Trieste,November 2000 Antonino Gullo University Medical School Trieste,Italy Table of Contents 1.Sudden Death in Heart Failure:Risk Stratification and Treatment Strategies M.Zecchin,G.Vitrella,G.Sinagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2.Etiology and Pathophysiology ofHeart Failure P.Foëx,G.Howard-Alpe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3.Cardiac Protection for Noncardiac Surgery P.Foëx,G.Howard-Alpe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 4.Hypertensive Urgencies and Emergencies J.L.Atlee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 5.Heart Failure,Atrial Fibrillation,and Diabetes Mellitus A.Aleksova,A.Perkan,G.Sinagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 6.Circulatory Failure:Bedside Functional Hemodynamic Monitoring C.Sorbara,S.Romagnoli,A.Rossi,S.M.Romano . . . . . . . . . . . . . . . . . . . . . . 89 7.Perioperative Cardiac Risk Stratification F.R.B.G.Galas,L.A.Hajjar,J.O.C.Auler jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 8.Hemodynamic Monitoring in Patients with Acute Heart Failure J.-L.Vincent,R.Holsten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 9.Electrocardiography ofHeart Failure:Features and Arrhythmias J.L.Atlee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 10.Management ofPatients with Acute Heart Failure W.G.Toller,G.Gemes,H.Metzler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 11.Pacemaker and Internal Cardioverter-Defibrillator Therapies J.L.Atlee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 X Table of Contents 12.Updates on Cardiac Arrest and Cardiopulmonary Resuscitation G.Ristagno,A.Gullo,W.Tang,M.H.Weil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 13.Circulatory Shock:Hypovolemic,Distributive,Cardiogenic,Obstructive J.-L.Vincent,A.Rapotec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 14.Prevention and Management ofCardiac Dysfunction during and after Cardiac Surgery W.Moosbauer,A.Hofer,H.Gombotz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 15.Management ofSystemic and Pulmonary Hypertension P.Giomarelli,S.Scolletta,B.Biagioli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 16.Recent Advances in the Natural History ofDilated Cardiomyopathy: A Review ofthe Heart Muscle Disease Registry ofTrieste M.Moretti,A.Di Lenarda,G.Sinagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279