Arritmias en cirugía cardiaca
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Transcript of Arritmias en cirugía cardiaca
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Arritmias en cirugía cardiaca.
Luis Eduardo Rodríguez CastellanosInstituto Nacional de CardiologíaMéxico. 2012
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Prevalencia• Taquiarritmia supraventriculares: 33% (CABG)
40-50% (valvular)
• FA mas común (20-40%)
• La extrasistolia ventricular frecuente y TV no sostenida hasta 50%
• Existe alteraciones de la conducción en hasta 25% de los pacientes.
Braunwald´s Heart Disease . 9ª Edición.
Bojar.R. Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition. 2011
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Recomendaciones generales
•Identificación de causa. ▫Electrolitos en suero. ▫Cardiovascular: Pericarditis, isquemia,
protección miocárdica. ▫Respiratorio: hipoxia, acidosis. ▫Catéteres. ▫Fármacos. ▫Fiebre, ansiedad.
Bojar.R. Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition. 2011
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Taquicardia sinusal
•Tratar la causa.•Hiperdinamico y GC normal:
▫Betabloqueadores: Esmolol 0.25-0.5 mg/kg en 1 min, 50-200
mcg/kg/min Metoprolol 5 mg IV por 3 dosis seguido de
25-100 mg cada 12 hrs via oral.
•No utilizar calcioantagonistas
Bojar.R. Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition. 2011
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Extrasístoles supraventriculares TRATAMIENTO•Sulfato de Magnesio 2 gr en bolo.
•Betabloqueadores (1era elección )
•Otros: Amiodarona o caclioantagonistas.
Bojar.R. Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition. 2011
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Extrasistoles ventriculares
•Usualmente benignas limitadas y no modifican el pronostico.
•Disfunción ventricular, IAM reciente, isquemia activa, síntomas o frecuentes Tratamiento:▫Sulfato de Magnesio 2 gr en bolo. ▫Lidocaina 1 mg/kg bolo, 1-2 mg/min (1gr en
250 ml) Max 4 mg/min. ▫Amiodarona 150 mg en 15 min, 60 mg/h x 6
hrs, seguido de 30mg/hr x 18 hrs. Bojar.R. Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition. 2011
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FA perioperatoria
• INCIDENCIA CABG 30% Valvular 40% CABG + valvular 50%.
•Max Incidencia día 2. •95% se presenta en la 1era semana. •Aumenta mortalidad HR 1.2 • Incrementa la estancia hospitalaria 4.9 días •Costo extra 10, 000 dólares.
Nair, S. Atrial fibrillation after cardiac surgery. Annals of Cardiac Anaesthesia. 2010
Echahidi,N. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery. J. Am. Coll. Cardiol. 2008;51;793-801
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Funk, M. Incidence, Timing, Symptoms, and Risk Factors for Atrial Fibrillation After Cardiac Surgery . Am J Crit Care 2003;12:424-433
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FACTORES DE RIESGO▫Edad: 75% mas riesgo por cada década. ▫FA previa ▫Hombre ▫FEVI <40% ▫EPOC ▫IRC▫DM▫Valvulopatía reumática ▫Volumen auricular.
Echahidi,N. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery. J. Am. Coll. Cardiol. 2008;51;793-801
FA perioperatoria
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Funk, M. Incidence, Timing, Symptoms, and Risk Factors for Atrial Fibrillation After Cardiac Surgery . Am J Crit Care 2003;12:424-433
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Osranek,M. Left Atrial Volume Predicts the Risk of Atrial Fibrillation After Cardiac Surgery A Prospective Study. J. Am. Coll. Cardiol. Jul 24, 2006;
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Osranek,M. Left Atrial Volume Predicts the Risk of Atrial Fibrillation After Cardiac Surgery A Prospective Study. J. Am. Coll. Cardiol. Jul 24, 2006;
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Osranek,M. Left Atrial Volume Predicts the Risk of Atrial Fibrillation After Cardiac Surgery A Prospective Study. J. Am. Coll. Cardiol. Jul 24, 2006;
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Osranek,M. Left Atrial Volume Predicts the Risk of Atrial Fibrillation After Cardiac Surgery A Prospective Study. J. Am. Coll. Cardiol. Jul 24, 2006;
AUC: VA
>32ml/m2= 0.729
AUC: VA
>32ml/m2+ > 65 años
= 0.768
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Mecanismo •Refractariedad auricular heterogénea. •Múltiples ondas de reentrada. •Aumento de la actividad simpática
(< variabilidad R-R)•Inflamación
▫Leucocitosis▫Variaciones IL 6. ▫Estrés oxidativo ▫> Conexina 40.
Echahidi,N. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery. J. Am. Coll. Cardiol. 2008;51;793-801
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Echahidi,N. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery. J. Am. Coll. Cardiol. 2008;51;793-801
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Prevención (FA perioperatoria)
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Crystal,E. Interventions on Prevention of Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery A Meta-Analysis. Circulation. 2002;106:75-80;
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Crystal,E. Interventions on Prevention of Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery A Meta-Analysis. Circulation. 2002;106:75-80;
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Crystal,E. Interventions on Prevention of Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery A Meta-Analysis. Circulation. 2002;106:75-80;
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Crystal,E. Interventions on Prevention of Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery A Meta-Analysis. Circulation. 2002;106:75-80;
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Burgess, D. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: a meta-analysis. European Heart Journal (2006) 27, 2846–2857
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Prevención (FA perioperatoria)
T. Levy, Randomized Controlled Study Investigating the Effect of Biatrial Pacing in Prevention of AtrialFibrillation After Coronary Artery Bypass Grafting. Circulation 2000
Estimulación Biatrial.
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Prevención (FA perioperatoria)
Crystal,E. Interventions on Prevention of Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery A Meta-Analysis. Circulation. 2002;106:75-80;
Estimulación Atrial.
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Prevención (FA perioperatoria)
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Tratamiento (FA perioperatoria)• Autolimitada• Recurrrente• No existe evidencia de control ritmo vs frecuencia en el
postQx. • Si se decide control de ritmo:
▫ FEVI normal: Antiarritmico x 1-3 meses. ▫ FEVI baja: individualizar.
• Si se decide control de frecuencia:▫ 1era elección: betabloqueadores.▫ Digoxina: FA+ ICC.
• Inestabilidad: cardioversión eléctrica. • Anticoagulación: mismos lineamientos FA no quirúrgica
Nair, S. Atrial fibrillation after cardiac surgery. Annals of Cardiac Anaesthesia. 2010
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Tratamiento (FA perioperatoria)
Echahidi,N. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery. J. Am. Coll. Cardiol. 2008;51;793-801
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Flutter auricular (tratamiento) SOBREESTIMULACION AURICULAR. • En modo AAI o AOO, asincronico.
• Amplitud 10-20 mA
• Inicia 10-15 latidos > frecuencia ventricular.
• Inicia 10 latidos < frecuencia de ondas F con incrementos de 10 latidos hasta capturar la auricula (usualmente >20-30%).
• Mantener la estimulación por 1 minuto y apagar subitamente.
• Reiniciar estimulación a 60 lpm. ( es frecuente la bradicardia sintomatica)
Bojar.R. Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition. 2011
Braunwald´s Heart Disease . 9ª Edición.
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• Bloqueo AV de diversos grados hasta 25%.
• Usualmente transitorio (<48 hrs)
• Causas: ▫Cardioplejia. ▫Fármacos▫Isquemia.
• Se recomienda MCD si la indicación persiste >4 días si factores de riesgo o hasta 10 días si no los hay. Braunwald´s Heart Disease . 9ª Edición.
Defectos de conducción
Bojar.R. Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition. 2011
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Bloqueo AV postQx Factores de riesgo
BAV persistente .
Glikson,M Indications, Effectiveness, and Long-Term Dependency in Permanent Pacing After Cardiac Surgery. Am J Cardiol 1997;80:1309–1313
El 40% no permaneció dependiente de marcapasos a 14 años .
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Bloqueo AV postQx
Koplan, B. Development and Validation of a Simple Risk Score to Predict the Need for Permanent Pacing After Cardiac Valve Surgery. J. Am. Coll. Cardiol. 2003;41;795-801
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Bloqueo AV postQx
Koplan, B. Development and Validation of a Simple Risk Score to Predict the Need for Permanent Pacing After Cardiac Valve Surgery. J. Am. Coll. Cardiol. 2003;41;795-801
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Bloqueo AV postQx
Koplan, B. Development and Validation of a Simple Risk Score to Predict the Need for Permanent Pacing After Cardiac Valve Surgery. J. Am. Coll. Cardiol. 2003;41;795-801
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Bloqueo AV postQx
Koplan, B. Development and Validation of a Simple Risk Score to Predict the Need for Permanent Pacing After Cardiac Valve Surgery. J. Am. Coll. Cardiol. 2003;41;795-801
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Bloqueo rama postQx
El-Khally, Z. Prognostic Significance of Newly Acquired Bundle Branch Block After Aortic Valve Replacement. Am J Cardiol 2004;94:1008–1011
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Bloqueo rama postQx
El-Khally, Z. Prognostic Significance of Newly Acquired Bundle Branch Block After Aortic Valve Replacement. Am J Cardiol 2004;94:1008–1011