Cardiovascular complications are estimated to account for 25% to 50% of deaths following noncardiac surgery. Perioperative myocardial infarction (MI), pulmonary edema, systolic and diastolic heart failure, arrhythmias, stroke, and thromboembolism are the most common diagnoses in patients with preexisting cardiovascular disease.
Regardless of the level of preoperative blood pressure control, many patients with hypertension display an accentuated hypotensive response to induction of anesthesia, followed by an exaggerated hypertensive response to intubation.
Patients with extensive coronary artery disease, a history of MI, or ventricular dysfunction are at risk of adverse cardiovascular complications.
The sudden withdrawal of antianginal medication perioperatively—particularly β-blockers—can precipitate a sudden, rebound increase in ischemic episodes.
The overwhelming priority in managing patients with ischemic heart disease is maintaining a favorable myocardial supply–demand relationship. Autonomic-mediated increases in heart rate and blood pressure should be controlled with deeper planes of general anesthesia or adrenergic blockade, vasodilators, or a combination of these.
Intraarterial pressure monitoring is reasonable in most patients with severe coronary artery disease and major or multiple cardiac risk factors who are undergoing any but the most minor procedures. Central venous (or rarely pulmonary artery) pressure can be monitored during prolonged or complicated procedures involving large fluid shifts or blood loss.
The principal hemodynamic goals in managing mitral stenosis are to maintain a sinus rhythm (if present preoperatively) and to avoid tachycardia, large increases in cardiac output, and both hypovolemia and fluid overload by judicious administration of intravenous fluids.
Anesthetic management of mitral regurgitation should be tailored to the severity of regurgitation as well as the underlying left ventricular function. Factors that exacerbate the regurgitation, such as slow heart rates and acute increases in afterload, should be avoided.
Maintenance of normal sinus rhythm, heart rate, vascular resistance, and intravascular volume is critical in patients with aortic stenosis. Loss of a normally timed atrial systole often leads to rapid deterioration, particularly when associated with tachycardia.
Bradycardia and increases in systemic vascular resistance (SVR) increase the regurgitant volume in patients with aortic regurgitation, whereas tachycardia can contribute to myocardial ischemia. Excessive myocardial depression should also be avoided. The compensatory increase in cardiac preload should be maintained, but excessive fluid replacement can readily result in pulmonary edema.
In patients with congenital heart disease, an increase in SVR relative to pulmonary vascular resistance (PVR) favors left-to-right shunting, whereas an increase in PVR relative to SVR favors right-to-left shunting.
The presence of shunt flow between the right and left hearts, regardless of the direction of blood flow, mandates the meticulous exclusion of air bubbles or particulate material from intravenous fluids to prevent paradoxical embolism into the cerebral or coronary circulations.
The goals of anesthetic management in patients with tetralogy of Fallot should be to maintain intravascular volume and SVR. Increases in PVR, such as might occur from acidosis or excessive airway pressures, should be avoided. The right-to-left shunting tends to slow the uptake of inhalation anesthetics; in contrast, it may accelerate the onset ...