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RegionalRegional anesthesiaanesthesia in the in the highhigh--riskrisk cardiaccardiac paparturrturientient
M. VercauterenM. Vercauteren, MD, , MD, PhDPhDUniversityUniversity HospitalHospital AntwerpAntwerp, BELGIUM, BELGIUM
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The The highhigh--riskrisk parturientparturient
MaternalMaternal diseasedisease : : sometimessometimes worseworse or or betterbettereffecteffect of pain & of pain & laborlabor & & bearingbearing down : down :
CO , PAPCO , PAP--SVRSVR--PVRPVRpostdeliverypostdelivery autotransfusion : PCWP autotransfusion : PCWP
DeliveryDelivery maymay help to help to solvesolve probleproblemm–– bleedingbleeding , , preeclampsiapreeclampsia / HELLP/ HELLP–– CPR, CPR, somesome cardiaccardiac diseasesdiseases
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High risk High risk parturientparturient
understandunderstand diseasedisease involvedinvolveddiseasedisease pregnancypregnancyddiseaseisease laborlabordiseasedisease fetusfetusimpact of impact of anesthesiaanesthesiaimpact of impact of perinatalperinatal drugsdrugs
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MortalityMortality riskrisk
<1%<1%•• ValvularValvular regurgitationregurgitation / / prolapsprolaps /mild PS/mild PS•• RepairedRepaired, , ASDASD, VSD, VSD
11--15%15%•• Stenotic Stenotic lesionslesions, , severesevere PSPS, , previousprevious AMIAMI•• MetalicMetalic valvesvalves
>25%>25%•• NYHA III/NYHA III/IVIV, , severesevere AoSAoS, Marfan, PHT, Marfan, PHT•• LV LV dysfunctiondysfunction, , arrhythmiasarrhythmias, , cyanosiscyanosis
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CardiacCardiac disordersdisorders
ValvularValvular diseasediseaseIschemicIschemic diseasediseaseSeptalSeptal defectsdefectsCardiomyopathyCardiomyopathyPrimaryPrimary PulmPulm. . HypertensionHypertensionOthersOthers : : •• MarfanMarfan, , ToFToF, Eisenmenger, Eisenmenger’’s complexs complex
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ValvularValvular : in : in generalgeneral
LifeLife treatheningtreathening risksrisks•• EndocarditisEndocarditis ((newnew guidelinesguidelines ?)?)•• OxytocinOxytocin ((nevernever in bolus) in bolus) •• EmbolismEmbolism•• PulmonaryPulmonary hypertensionhypertension / / edemaedema•• ArrhythmiasArrhythmias•• BloodlossBloodloss
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PulmonaryPulmonary
PulmonaryPulmonary edemaedema•• CongestiveCongestive heartheart failurefailure•• FluidFluid retentionretention / return (/ return (preloadpreload) ) afterafter birthbirth•• ExcessiveExcessive fluidsfluids ((prehydrationprehydration + drugs) + drugs) •• AutotransfusionAutotransfusion & return (& return (preloadpreload) ) afterafter birthbirth•• ProceedProceed withwith epiduralepidural , , furosemidefurosemide ????•• ColloidsColloids ??
Acute Acute pulmonarypulmonary hypertensionhypertension•• Stress, Stress, hypertensionhypertension, pain, , pain, SVRSVR, , HRHR, drugs, drugs
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ArrhythmiasArrhythmias
More More withwith mitralmitral valvevalve diseasediseaseReducedReduced cardiaccardiac fillingfilling (time)(time)•• Effect Effect onon coronarycoronary perfusionperfusion
AccentuatedAccentuated byby•• OxytocinOxytocin•• EphedrineEphedrine
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BloodBlood lossloss
MayMay bebe enhancedenhanced byby•• AvoidanceAvoidance of of oxytocicsoxytocics•• AnticoagulantsAnticoagulants (more TE risk)(more TE risk)•• OperativeOperative deliverydelivery
SpecificSpecific problemsproblems•• LessLess capacitycapacity toto compensatecompensate•• ββ--blockerblocker useuse
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MaternalMaternal and and fetalfetal outcomeoutcome
MaternalMaternal (0.6(0.6--2%) & 2%) & fetalfetal mortalitymortalityPreterm Preterm deliverydelivery, , lowerlower BWBWIUGR and IUGR and ApgarApgar<8<8InstrumentalInstrumental deliverydelivery ((lessless stressfulstressful))•• butbut identicalidentical CC--sectionsection raterate
MalhotraMalhotra et al, 2004et al, 2004
n=312 n=312 valvularvalvular vsvs 321 321 healthyhealthy parturientsparturients
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ValvularValvular defectsdefectsRegurgitationRegurgitation•• mitralmitral insufficiencyinsufficiency•• mitralmitral valvevalve prolapsprolaps•• aorticaortic insufficiencyinsufficiency
Stenotic Stenotic conditionsconditions•• mitralmitral stenosisstenosis•• aorticaortic stenosisstenosis•• pulmonicpulmonic stenosisstenosis
Mixed Mixed diseasediseaseCorrectedCorrected problemsproblems
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RegurgitationRegurgitation : : avoidavoid........
BradycardiaBradycardia -- DysrhythmiaDysrhythmia•• IncreasesIncreases LV LV fillingfilling time, more time, more regurgitationregurgitation•• EphedrineEphedrine betterbetter thanthan phenylephrinephenylephrine
PreloadPreload & & afterloadafterload increaseincrease•• LRA LRA desirabledesirable ((fluidfluid preloadingpreloading !)!)•• AfterloadAfterload decreasedecrease : AVR : AVR benefitsbenefits more more thanthan MVRMVR
MyocardialMyocardial depressiondepression : LVF!: LVF!•• LV LV enlargementenlargement : : earlierearlier in AVRin AVR
BeneficialBeneficial effect of effect of pregnancypregnancy (BV, SVR, HR)(BV, SVR, HR)
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MitralMitral valvevalve stenosisstenosis
frequent, frequent, severesevere ifif areaarea <1cm<1cm22
diastolicdiastolic pressurepressure gradientgradient & & durationdurationLA LA dilateddilated //thrombusthrombus //arrhythmiaarrhythmia(AF)(AF)•• maternalmaternal mortalitymortality significantlysignificantly increasedincreased
ifif tachycardiatachycardia oror AFAF•• reducedreduced LVF and LVF and atrialatrial enlargementenlargementballoon balloon valvuloplastyvalvuloplasty possiblepossibleCHFCHF, , PEPE, , secondsecond PHTPHT, , RVFRVF, , TricITricI
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AorticAortic valvevalve stenosisstenosis
IschemiaIschemia (O(O22 supplysupply, , workloadworkload, LV , LV wallwall))
NYHA NYHA •• MayMay bebe severesevere butbut symptomlesssymptomless
EchocardiographyEchocardiography•• LV LV hypertrophyhypertrophy, , gradientgradient , , valvularvalvular areaarea•• <1cm<1cm22 : : severesevere, <0.6cm, <0.6cm22 : : criticalcritical
BetablockerBetablocker : LVF ??: LVF ??•• more more fillingfilling time and time and coronarycoronary flowflow
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Stenotic defects : Stenotic defects : avoidavoid........
SVR SVR increaseincrease and and tachycardiatachycardia•• ketamineketamine , , atropine , atropine , ephedrineephedrine
severesevere bradycardiabradycardia : : phenylephrinephenylephrine ??markedmarked afterloadafterload reductionreduction•• LRA : OK LRA : OK ifif moderate AL moderate AL decreasedecrease
hypovolemiahypovolemia : : normonormo--volemicvolemic expansionexpansionmyocardialmyocardial depressiondepression, , dysrhythmiasdysrhythmiaseepinephrinepinephrine in in locallocal anestheticsanesthetics
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OtherOther valvularvalvular problemsproblemsMitralMitral valvevalve prolapsprolaps•• AvoidAvoid tachycardiatachycardia, AL , AL reductionreduction,,……..‘‘OperatedOperated’’ patientspatients•• HF, PHT and HF, PHT and arrhythmiaarrhythmia maymay persistpersist•• AnticoagulationAnticoagulation : : heparinheparin betterbetter ??
–– ProtamineProtamine, LMWH , LMWH bleedingbleeding risk <12h?risk <12h?–– WarfarinWarfarin : PPSB : PPSB oror FFPFFP–– BleedingBleeding oror thromboembolismthromboembolism ? ?
Mixed Mixed problemsproblems : predominant ? : predominant ?
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CoronaryCoronary arteryartery diseasediseaseIncreasedIncreased risk risk whenwhen•• in in thirdthird trimester , trimester , deliverydelivery <2weeks<2weeks•• CC--sectionsection•• ageage <30yrs , diabetes , <30yrs , diabetes , hypertensionhypertension
laborlabor : : epiduralepiduralCC--sectionsection : : epiduralepidural > > spinalspinalphenylephrinephenylephrine > > ephedrineephedrineLV LV failurefailure : GA+ : GA+ lowlow--dosedose EA ?EA ?
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SeptumSeptum defects defects
LeftLeft toto RightRight shunt : shunt : avoidavoid
•• SVR SVR increasesincreases•• severesevere SVR SVR decreasedecrease (ASD)(ASD)•• volume volume overloadoverload , , tachycardiatachycardia (VSD)(VSD)
RightRight toto LeftLeft shunt (PHT) shunt (PHT) •• FallotFallot’’s s TetralogyTetralogy, Eisenmenger, Eisenmenger’’s complexs complex•• AvoidAvoid prepre-- and and afterloadafterload reductionreduction
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PerinatalPerinatal//ParipartumParipartum DilatedDilated CMCM••LRA LRA beneficialbeneficial : : afterloadafterload reductionreduction
HypertrophicHypertrophic ObstructiveObstructive CMCM•• strictlystrictly normovolemianormovolemia, , avoidavoid tachycardiatachycardia•• nono inotropicsinotropics oror afterloadafterload reductionreduction•• MVR MVR frequentlyfrequently presentpresent•• preferablypreferably vaginalvaginal deliverydelivery•• RA : RA : ‘‘lowlow--LALA dosedose’’ techniquetechnique•• ifif CC--sectionsection : : generalgeneral anesthesiaanesthesia
CardiomyopathyCardiomyopathy
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PulmonaryPulmonary HT HT CausesCauses ((functionalfunctional and and structuralstructural))•• PrimaryPrimary•• SecundarySecundary : : CHDCHD, , HIVHIV, , SLESLE, , TEDTED, , COPDCOPD……
TreatmentTreatment•• NitricNitric oxideoxide•• ProstacyclinProstacyclin ((VDVD, , PLTPLT, , AntiAnti--InflInfl, , ……))•• EndothelinEndothelin receptor receptor antagonistsantagonists•• PhosphodiesterasePhosphodiesterase inhibitorsinhibitors•• ViagraViagra, , VasopressinVasopressin
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PulmonaryPulmonary HT : HT : avoidavoid........HypoxiaHypoxia , , hypercapniahypercapnia , stress, stressketamineketamine , N, N220 0 PG , PG , oxytocinoxytocin , , ergometrineergometrineMyocardialMyocardial depressiondepressionBradycardiaBradycardiaAfterloadAfterload reductionreductionPreloadPreload reductionreduction
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WhatWhat aboutabout clinicalclinicalpracticepractice and and experienceexperience ??
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LaborLabor analgesiaanalgesiaLowLow dosedose epiduralepidural mostlymostly wellwell toleratedtoleratedStress response : Stress response : mitigatesmitigates ValsalvaValsalvaeffectseffects byby decreasingdecreasing the the pushingpushing reflexreflexMore More stablestable hemodynamicshemodynamics duringduringcontractionscontractions and and expulsionexpulsion (forceps)(forceps)AL AL decreasedecrease : benefit in : benefit in regurgitationregurgitationCSE / CSE / EpiduralEpidural : : nono locallocal anestheticsanesthetics ??•• opioidopioid, , neostigmineneostigmine, , clonidineclonidine, adrenaline, adrenaline……
CSA ?CSA ?
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LaborLabor CSA : CSA : AdvantagesAdvantages
AdjustableAdjustable, , titratabletitratableOpioidOpioid alonealone : F 15: F 15--2525µµg, S 5g, S 5--7.57.5µµggLaborLabor : : rapidrapid conversionconversion toto CSCSLowerLower doses (?)doses (?)•• notnot in most in most reportsreports ((leakageleakage ?)?)
BetterBetter hemodynamichemodynamic stabilitystability•• RobsonRobson et al, BJA 1993; 70: 634et al, BJA 1993; 70: 634--88
hypotensionhypotension 2/20 2/20 ptsptsHeadacheHeadache lessless important important thanthan benefitsbenefits
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LaborLabor analgsiaanalgsia : : stenosisstenosisEpiduralEpidural•• HemmingsHemmings 1987, 1987, ShinShin 19931993•• SuntharalingamSuntharalingam 20012001•• AfterAfter MVR : MVR : NakaoNakao 20052005
Spinal Spinal •• KeeKee , n=3, , n=3, CSECSE , , startstart opioidsopioids alonealone•• VanhelderVanhelder 1998, 1998, CSECSE : mixed : mixed AoAo/M, /M, alsoalso II•• RansomRansom 1995, 1995, CSACSA : : sufentanilsufentanil•• Vd Velde 2003, Vd Velde 2003, CSACSA : : sufentanilsufentanil 2x (+ 2x (+ ropiropi))•• Pan & DPan & D’’Angelo 2004, Angelo 2004, CSECSE : : bupibupi + F + M+ F + M
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CC--section : section : regurgitationregurgitationEpiduralEpidural•• Mitral Valve Mitral Valve ProlapsProlaps
–– Tanaka 1994Tanaka 1994–– Ruiz Castro 1996Ruiz Castro 1996–– AlcontaraAlcontara 1987 1987
•• AoAo regurgitationregurgitation–– AldersonAlderson 1987 (+ 1987 (+ preeclampsiapreeclampsia : : deathdeath))–– ZangrilloZangrillo 2005 2005
•• BetweenBetween MV replacement & MV replacement & reoperationreoperation–– NakaoNakao 20052005
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CC--section : section : stenosisstenosisEpiduralEpidural•• AoAo StenosisStenosis
–– Brian 1993, Brian 1993, TamuraTamura 19971997–– ColcloughColclough 1990 /1990 /’’95, Peng 1997, 95, Peng 1997, XiaXia 2006 2006
•• PulmonicPulmonic stenosisstenosis–– ConwayConway 1994, Campbell 2003 (+ 1994, Campbell 2003 (+ AoIAoI))
•• Mitral Mitral stenosisstenosis–– ZiskindZiskind 1990, 1990, AfranguiAfrangui & & MalinowMalinow 19981998–– KubotaKubota 2003 (n=7), Pan & D2003 (n=7), Pan & D’’Angelo 2004Angelo 2004
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CC--section : section : stenosisstenosisSpinalSpinal•• SDSSDS : : MostafaMostafa 1984 (MS)1984 (MS)•• CSECSE : : BosoBoso 2008 (AS)2008 (AS)•• CSA CSA : Pittard & : Pittard & VucevicVucevic 1998 (AS)1998 (AS)
+ 2 + 2 editorialseditorials
SDS to SDS to bebe avoidedavoided !!!!!!
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LowLow dose CSE + EVE ?dose CSE + EVE ?
LewLew et alet al, , A & A 2004; 98: 810A & A 2004; 98: 810--44•• BH 5mg + EVE (6ml BH 5mg + EVE (6ml NaClNaCl 0.9%)0.9%)•• BH 8mg BH 8mg •• bothboth + + FentanylFentanyl 1010µµg)g)
•• qualityquality / / spreadspread : : identicalidentical•• fasterfaster MB MB recoveryrecovery•• hypotension : no hypotension : no differencedifference
vsvs
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SittingSitting or or laterallateral ??InglisInglis et al, et al, AnaesthesiaAnaesthesia 1995 (SDS)1995 (SDS)BembridgeBembridge, , AnaesthesiaAnaesthesia 1986 (SDS)1986 (SDS)PatelPatel et al, Can J et al, Can J AnesthAnesth 1993 (CSE)1993 (CSE)KohlerKohler et al, A A et al, A A ScandScand 2002 (SDS 32002 (SDS 3’’))CoppejansCoppejans et al, et al, AnesthAnesth AnalgAnalg 2006 (CSE)2006 (CSE)
SittingSitting injection of injection of hyperbarichyperbaric BB•• SlowerSlower / / lessless rostral rostral spreadspread•• LessLess ((laterlater) hypotension) hypotension•• More More epiduralepidural supplementationsupplementation
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RA for RA for nonnon--valvularvalvular diseasediseaseHOCM, PPCM, single HOCM, PPCM, single ventricleventricleAoAo dissection, dissection, coronarycoronary (CAD)(CAD)severalseveral case reports: case reports: CSE / CSE / CSACSA
HonigHonig et al, et al, AnAnäästhetiststhetist 1998 (CAD)1998 (CAD)IshiyamaIshiyama et al, A&A 2003 (HOCM)et al, A&A 2003 (HOCM)Ben Ben LetaifaLetaifa, , AnnAnn FrFr An An ReanRean 2002 (2002 (MarfanMarfan, , PuEdPuEd, MVI), MVI)OkutomiOkutomi et al, Acta et al, Acta AnaesthAnaesth ScandScand 2002 (HOCM, 2002 (HOCM, laborlabor))Dubois et al, Dubois et al, AnnAnn FrFr AnesthAnesth ReanimReanim 2003 (single 2003 (single ventrventr n=2)n=2)VelichovicVelichovic & & LeichtLeicht, IJOA 2004 (, IJOA 2004 (PPCMPPCM, n=3), n=3)LandauLandau et al, et al, ActaActa AnaesthAnaesth ScandScand 2004 (2004 (doubledouble outletoutlet RVRV))SmithSmith et al, IJOA 2008 (CAD, CS n=3, et al, IJOA 2008 (CAD, CS n=3, laborlabor n=1)n=1)
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RA for RA for nonnon--valvularvalvular diseasedisease
EisenmengerEisenmenger’’s s complexcomplex ????AtanasoffAtanasoff, Acta , Acta AnaesthesiolAnaesthesiol ScandScand 19901990ColeCole et al, BJA 2001et al, BJA 2001SakurabaSakuraba et al, J et al, J AnesthAnesth 20042004
MARTIN et al, RAPM 2002; 27: 509MARTIN et al, RAPM 2002; 27: 509--13 (13 (reviewreview))--103 103 anestheticsanesthetics + 21 + 21 laborlabor analgesiaanalgesia-- mortalitymortality : : overalloverall 14%, RA 5%, GA 18% (NS)14%, RA 5%, GA 18% (NS)
major major surgerysurgery : 24%, minor 5% (p<0.05): 24%, minor 5% (p<0.05)laborlabor RA : 24% !!RA : 24% !!
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RA for RA for nonnon--valvularvalvular diseasedisease
SevereSevere pulmonarypulmonary hypertension ??hypertension ??BONNIN et al, BONNIN et al, AnesthesiologyAnesthesiology 2005; 102: 11132005; 102: 1113--77--N=14, 15 N=14, 15 pregnanciespregnancies--Vaginal : n=4 (RA) (1 Vaginal : n=4 (RA) (1 dieddied, 1 , 1 worseworse) ) --CS CS underunder GA : n=4 (1 GA : n=4 (1 dieddied, 2 , 2 worseworse) ) --CS CS underunder CSE : n=5 (1 CSE : n=5 (1 dieddied, 4 stable), 4 stable)-- mortalitymortality :: n=2 n=2 beforebefore deliverydelivery
overall 36%overall 36%a place a place forfor lowlow dosedose CSE ??CSE ??
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PerioperativePerioperative monitoringmonitoringECG , ECG , pulsepulse oxymetryoxymetryUS (US (EFEF?) ?) oror TEE (TEE (awakeawake ?)?)BloodBlood pressurepressure : : radialradial arteryartery•• AnticipatedAnticipated bloodblood loss, loss, prepre--eclampsiaeclampsia•• CO CO measurementmeasurement ??
Central Central venousvenous lineline ??WhatWhat willwill itit learnlearn ? Risk of ? Risk of arrhythmiasarrhythmiasPulmonaryPulmonary arteryartery cathetercatheter ??•• NYHA III/NYHA III/IVIV, , sheethsheeth onlyonly ? ? VascVasc trauma ?trauma ?
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ConclusionsConclusionsMultidisciplinaryMultidisciplinary approachapproach (at 24wks ?)(at 24wks ?)LowLow--dosedose epiduralepidural is is mostlymostly OK OK forfor laborlaborSingleSingle--dosedose spinalspinal mostlymostly notnot the best the best ideaideaProblemsProblems notnot solvedsolved afterafter birthbirth oror surgerysurgeryInvasiveInvasive monitoringmonitoring ? ? CC--sectionsection : : notnot alwaysalways best best choicechoiceAllAll RA RA techniquestechniques are are notnot the the samesame•• OutweighOutweigh PROPRO’’s and s and CONsCONs•• IndividualIndividual judgementjudgement
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HR
PL/AL
Contr
C-section
Ao-I
RA
Mi-I
RA
Mi-S
RA
CAD
RA>GA
SummarySummary : : avoidavoid……
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HR
PL/AL
Contr
C-section
Ao-S GA>RA
PS/PHT GA
L to R R to L
GA/RA GA
Eisenm GA PPCM HOCM
RA GA
SummarySummary : : avoidavoid……
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ConclusionsConclusions
ContraindicationsContraindications forfor RA (& RA (& pregnancypregnancy ?)?)•• FallotFallot’’s s tetralogytetralogy unlessunless repairedrepaired
–– GelsonGelson et al 2008, RA 67% (16pt / 26del)et al 2008, RA 67% (16pt / 26del)
•• EisenmengerEisenmenger’’s complexs complex•• AnticoagulationAnticoagulation•• HypertrophicHypertrophic subaorticsubaortic stenosisstenosis, HOCM, HOCM•• PrimaryPrimary pulmonarypulmonary hypertensionhypertension•• SevereSevere AoAo//pulmpulm stenosisstenosis (<0.6(<0.6--0.9cm0.9cm22))
AvoidAvoid ‘‘heroismheroism’’
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The most important part of The most important part of ‘‘patientpatient carecare’’is is ‘‘caringcaring forfor the the patientpatient’’
DavidDavid L.L.BrownBrownRAPM 2003RAPM 2003