Hensley's Practical Approach to Cardiothoracic Anesthesia

16. Anesthetic Considerations for Surgical Myectomy in Patients With Hypertrophic Cardiomyopathy 349

performing > 10 procedures per year. And in multivariable analysis, the lowest annual case vol ume (average < 1 case per year) was associated with greater early mortality (odds ratio [OR] 5.4, P < .001), greater risk of ventricular septal defects (OR 9.3, P < .001), increased incidence of complete heart block (OR 2.0, P < .001), and a higher likelihood of mitral valve replacement (OR 9.4, P < .001). 19 III. Anesthetic Considerations A. Preoperative Encounter Patients are usually admitted to the hospital in the morning of surgery. At the time of their preoperative appointment, a few days before the surgical date, they should be instructed not to skip their morning β-blocker or calcium channel blocker dose. Adequate hydration, even in the morning of surgery with clear liquids, is permitted and encouraged up until 2 hours before anesthesia 20 Some patients will have automatic ICD with pacing capabilities in place. These devices should be interrogated, and antitachycardia therapy should be disabled. If this is not feasible, placing a magnet over the ICD will disable the antitachycardia functionality and eliminate the risk of internal defibrillation related to the use of cautery. If the patient is pace maker dependent, the device should be switched to asynchronous mode as needed. Of note, faster than usual heart rate might worsen LVOT obstruction. Patients should be monitored after pacemaker settings changes. Heart rate might have to be adjusted if non-invasive blood pressure decreases from baseline or there are other signs of systemic hypoperfusion. After FIGURE 16.4 Complex long-segment septal hypertrophy may require both a transaortic approach (red arrow) and transapical approach (blue arrow). (From Hang D, Schaff HV, Ommen SR, Dearani JA, Nishimura RA. Combined trans aortic and transapical approach to septal myectomy in patients with complex hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg . 2018;155(5):2096-2102. Figure 2. Used with permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

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