Cardiac Anesthesiologist and Global Capacity Building to Tackle Rheumatic Heart Disease

RHEUMATIC HEART DISEASE (RHD) is considered the neglected disease of tropics and endemic in several low- middle-income countries (LMIC).1Kwan G.F. Mayosi B.M. Mocumbi A.O. et al.Endemic cardiovascular poorest billion.Circulation. 2016; 133: 2561-2575Crossref PubMed Scopus (61) Google Scholar It still an important cause preventable morbidity mortality associated with among children young adults. The has seen a sharp decrease most high-income (HIC) and, primarily, LMICs Asia Africa face brunt RHD, which also imposes huge economic burden.2Watkins D.A. Johnson C.O. Colquhoun S.M. al.Global, regional, national burden rheumatic heart disease, 1990-2015.N Engl J Med. 2017; 377: 713-722Crossref (461) In addition, RHD significant maternal mortality.3A review deaths South during 1998: National Committee on Confidential Enquiries into Deaths.S Afr Med J. 2000; 90: 367-373PubMed For precise understanding it needs to be appreciated that are more populous (more than five times HICs) remains single common adult adolescent patients need cardiac surgery.4Zilla P. Morton Bolman III, R. Boateng al.A glimpse hope: surgery (LMICs).Cardiovasc Diagn Ther. 2020; 10: 336-349Crossref Furthermore, provide very different levels surgical services for their populations. There been impressive growth capacity countries; even so, there wide gap between intervention and/or those who actually receive it. diversity healthcare facilities these led availability state-of-the art select few (affluent), majority (poor underprivileged) having rely overwhelmed public hospitals. situation low-income worse. American Heart Association (AHA) recently published scientific statement this subject, aim examine current state-of-the-art management identify gaps diagnosis treatment globally can inform strategies reducing burden.5Kumar R.K. Antunes M.J. Beaton A. al.and On behalf Council Lifelong Congenital Disease Health Young; Cardiovascular Stroke Nursing; Clinical Cardiology. Contemporary implications closing gap: A from Association.Circulation. 142: e337-e357Crossref (25) Preventive should form back bone sustainable control while effective therapeutic options implemented suffering RHD. AHA emphasized importance echocardiographic screening research promotion, as well primary secondary prophylaxis failure, atrial fibrillation, percutaneous interventions, have discussed. Even though approach management, described statement, may rational HICs, not so resource-limited mostly burden. Hence, editorial mainly addresses anesthesiologist regarding valvular especially LMICs, highlight challenges faced possible future subject. imperative optimal care provided within available resources suffer Rheumatic younger dominated by mitral pathology LMICs. Due inadequate nutrition, sanitation, medical care, many recurrent episodes endocarditis, severe stenosis (MS) develops years initial episode. Sliwa al reported 71% prevalence valve newly diagnosed urban RHD.6Sliwa K. Carrington M. al.Incidence characteristics African adults: Insights Soweto study.Eur 2010; 31: 719-727Crossref (169) data 3,343 low-income, LMIC, upper-middle-income revealed were (median age 28 years) predominantly female (66.2%).7Zuhlke L. Karthikeyan G. Engel M.E. al.Clinical outcomes 3343 adults 14 countries: two-year follow-up Global Registry (the REMEDY study).Circulation. 134: 1456-1466Crossref (133) contrast, fever rare latency period three-to-four decades bout symptoms. Consequently, present fourth-to-fifth decade life. Thus, related patient socioeconomic circumstances. unavailability suitable replacement valves addressing difficulties adherence anticoagulation distinctly elderly HICs.4Zilla often fairly late pulmonary hypertension (PH), congestive failure (CCF) dilatation left atrium (LA) common, along fibrillation due distortion depolarization pathways. author LA size large 12-to-14 cm some disease. As highlighted transvenous balloon valvotomy (BMV) preferred choice pure MS repeated if restenosis after previous BMV. progressive number BMVs performed per year HICs reported.8Desnos C. Lung B. Himbert D. al.Temporal trends commissurotomy: 30 experience.J Am Assoc. 2019; 8e012031Crossref (10) This contrary where increasing, centers performing BMVs, they struggling meet population. observed over indications BMV widened considerably, cardiologists now consider only thrombus or regurgitation (MR) contraindication. limited role play BMV, procedures under local anesthesia light sedation. patients, monitored required, yet others presenting CCF, urgent necessitate presence manage ventilation periprocedural period. required acute MR, one serious complications incidence MR depends expertise operating team vary 0.9% 7.5%.9Pillai A.A. Balasubramonian V.R. Munuswamy H. al.Acute cardiogenic shock following valvuloplasty: Echocardiographic findings surgery.Catheter Cardiovasc Interv. 34: 260-268Crossref (5) Acute results hemodynamic disturbance, leading hypotension shock, without edema. complication lead adverse prognoses requires intensive therapy correction. author's experience, was vascular resistance, mean artery (PA) pressure, right ventricular (RV) end-diastolic pressure continued remain elevated postoperative tracheal extubation.10Tempe D.K. Mehta N. Mohan J.C. al.Early changes emergency traumatic insufficiency valvotomy: Report 6 cases.Anesthesiology. 1998; 89: 1583-1585Crossref (4) This, perhaps, signifies measures PH RV dysfunction, such use inodilators (milrinone levosimendan) elective maintenance normocarbia, diligently prolonged underscores careful selection based severity regard, scoring system developed predict occurrence useful.11Padial L.R. Abascal V.M. Moreno P.R. al.Echocardiography development valvuloplasty Inoue technique.Am Cardiol. 1999; 83: 1240-1243Abstract Full Text PDF (47) Although steadily suffers drawback skilled cardiologist backed surgeon anesthesiologist, addition high cost. limit performed. attempt bring down cost, reuse single-use devices practiced, Cardiological Society India protocol India.12Kapoor Vora Natraj al.Guidance cardio-vascular catheters India: consensus document.Indian 69: 357-363Abstract (22) other alternative would revisit closed (CMV) used early days, find place patients. CMV first operations history second half 20th century because excellent immediate lasted decades. series including 5,000 Stanley John 24-year survival rate 78.3% requiring reoperation.13John S. Shyam Prasad K.M. Ravikumar E. al.Closed commissurotomy stenosis. Obsolete relevant?.Indian Thorac Surg. 1991; 7: 8-12Crossref (2) compared at week procedure, shown significantly better regard transmitral gradient area times.14Tokmakoglu Vural Ozatik M.A. Closed versus stenosis.J Valve Dis. 2001; 281-287PubMed Therefore, believes continue perform (which simple surgery) part training budding surgeons anesthesiologists. view cost involved open-heart limits its masses Most clinicians outdated surgery, but actively practice it.15Sherawat R.C. Dixit Yadav al.The era catheter-based interventions: 20-year center Cardiothorac 2015; 273-279Google Readoption could save thousands lives poor parts Asia.16Antunes commissurotomy-a cheap, reproducible successful way treat 12: 146-149Crossref (1) Reoperation, necessary feasible carries acceptable rates mortality.17Radhakrishnan B.K. Sreekatan Panicker V.T. al.Outcomes valvotomy. retrospective cohort study.Heart Surg Forum. 22: E207-E212Crossref (3) potential viable option world readily available. Open (OMC) relief subvalvular obstructive elements dealt much direct vision,18Spencer F.C. plea early, open commissurotomy.Am 1978; 95: 668-670Crossref (13) preferentially HICs. From above discussion, appears follows: facility available, CMV, feasible, procedure OMC replacement, contraindication heavily calcified valve, lesion procedure. Another major concern pregnancy pregnant women, 88% women had etiology.19Beaton Okello Scheel al.Impact maternal, fetal neonatal low-resource setting.Heart. 105: 755-760Crossref developing world.20Haththotuwa H.R. Attygalle Jayatilleka A.C. al.Maternal Sri Lanka.Int Gynecol Obstet. 2009; 104: 194-198Crossref (17) hyperdynamic circulation poses additional burden, manifested time pregnancy. No mild allowed continue. However, all others, ideally ahould trimester,21Sharma J.B. V. Mishra al.Comparative study outcome undergoing before pregnancy.Ind 2018; 70: 685-689Crossref although CMV22Pavankumar Venugopal Kaul U. experience.Scand 1988; 11-15Crossref (37) Scholar,23Stephen S.J. Changing patterns childhood Lanka.J Coll 1992; 19: 1276-1284Crossref (23) BMV24Kalra G.S. Arora Khan J.A. al.Percutaneous pregnancy.Cathet cardiovasc Diagn. 1994; 33: 28-30Crossref (48) successfully any term adversely affecting fetus. superiority terms shown.25de Souza Martinez Jr E.E. Ambrose comparison pregnancy.J 37: 900-903Crossref (120) Ideally, counseled appropriately cardiologist/obstetrician delay marriage/pregnancy until treated. pregnancy, choose later get pregnant. worst scenario when presents near term, CCF. Urgent CMV/BMV well. Ventilatory assistance burdened responsibility ventilation, transport catheterization laboratory, post-BMV extubation At times, cesarean section MS. challenging, evidence-based guidelines anesthetic technique suggested individualized.26Gomar Errando C.L. Neuroaxial anaesthesia obstetrical disease.Curr Opin Anaesthesiol. 2005; 18: 507-512Crossref (34) logical that, except MS, precede section; however, usual practice. Considering physiology pathophysiology epidural general mild-to-moderate Adequate monitoring delivery, alterations occur 24 hours delivery. answer question (valve <1 cm2) easy one. occur, unfortunately, uncommon preserve well-being. consequences decreased venous return systemic resistance disastrous. spinal hazardous despite ability reduce abolish stress response pain. Modest-dose opioid-based anesthesia, readiness resuscitate baby, useful situation.27Amini Yaghmaei remifentanil parturient edema.Middle East 20: 585-589PubMed Scholar,28Coskun Mahli Korkmaz al.Anaesthesia caesarean multi-valvular hypertension: case report.Cases 2: 9383Crossref (11) remifentanil-based PA catheter transesophageal echocardiography (TEE) moderate PH.29Weiner M.M. Vahl T.P. Kahn R.A. Case scenario: Cesarean complicated stenosis.Anesthesiology. 2011; 114: 949-957Crossref Regional using extension block labor analgesia reported. Increments small doses (plain solution) administered obtain adequate level analgesia.30Kuczkowski van Zundert Anesthesia disease: state art.J Anesth. 2007; 21: 252-257Crossref Successful techniques31Kocum Sener Caliskan al.Epidural hypertension.J Vasc 24: 1022-1023Abstract (6) Scholar, 32Kubota Marimoto Y. Kemmotsu O. Anesthetic hypertension.Masui. 2003; 52: 177-179PubMed 33Saxena K.N. Wadhwa parturients series.J Obstet Anaesth Crit Care. 9: 46-49Crossref combined anesthesia34VanHelder T. Smedstad K.H. Combined primigravida disease.Can Anaesth. 45: 488-490Crossref single-shot recommended fear collapse. Whatever used, extremely monitoring, invasive arterial central lines, infuse inotropes fluid. Autotransfusion delivery consideration guiding volume therapy. administration oxytocin infusion ergometrine, uterine hemorrhage desirable. room further area, come perhaps multicenter trial will required. limiting factor clinical With knowledge, no exclusively indicated contraindicated. key success seems hemodynamics. Women replaced mechanical require appropriate management. challenging prothrombotic state. issue fact vitamin K antagonist (warfarin) provides crosses placenta, posing risk fetus, trimester; whereas, low-molecular- weight heparin (LMWH) does cross placenta increased thrombotic mother. ACC/AHA suggest reasonable warfarin trimester, dose less 5 mg/day achieve international normalized ratio. needing mg/day, LMWH trimester.35Nishimura Otto C.M. Bonow R.D. al.2014 AHA/ACC Guideline Management Patient Valvular Disease: report College Cardiology/American Task Force Practice Guidelines.Circulation. 2014; 129: e521-e643Crossref (1149) 50% thrombosis occurred whom transition trimester.36van Hagen I.M. Roos-Hesselink J.W. Ruys T.P.E. al.Pregnancy valve: Data European Cardiology registry (ROPAC).Circulation. 132: 132-142Crossref (184) sufficient anti-Xa (0.8-1.2 U/ml) low-dose aspirin (in third trimesters) avoid complications.35Nishimura controversy (with embryopathic effects) risk) continues, method undetermined.37D'Souza Ostro Shah P.S. al.Anticoagulation valves: systematic meta-analysis.Eur 38: 1509-1516Crossref (93) types lesions aortic (stenosis regurgitation) mixed ten, isolated predominant lesion.7Zuhlke Mitral repair standard RHD38Krishna Moorthy Sivalingam Dillon al.Is worth repairing children? Long-term aggressive patients.Interact 28: 191-198Crossref present. lack stumbling choice. same, financial reasons, newer techniques, transcatheter implantation edge-to-edge repair, hand, well-equipped demands proficiency TEE anesthesiologist. Finally, presentation, deal dysfunction Preoperative strong predictor mortality.39Mentias Patel al.Effect pressures long regurgitation.J 67: 2952-2961Crossref (30) Scholar,40Tang Liu X. Lin al.Meta-analysis evolution implantation.Am 119: 91-99Abstract (28) complexity explained.41Tempe prognostic disease.J 683-685Abstract Fortunately, postcapillary type resolves soon patients42Tempe Hasija Datt al.Evaluation 23: 298-305Abstract Scholar,43Madhavan Puri G.D. Thingnam S.K.S. al.Perioperative center, prospective, observational study.J 29: 1524-1532Abstract expected good outcome. Indeed, unaffected (systolic 50-79 mmHg).44Enter D.H. Zaki Duncan B.F. contemporary analysis surgery. Is factor?.J 151: 1288-1297Abstract (14) stenosis, unlikely se, instead diastolic dysfunction. familiar focus levosimendan), meticulous acid-base equal pose great challenge vasodilators, via inhaled route, practiced conclusion, eventual near-elimination goal. Until then, existing addressed. must understood state-of-the-art, gold standard, standard-of-care therapies, interventions largely bulk exists. factors accounted deciding what constitutes given situation. respect, multidisciplinary is, course, crucial factor, anesthesiologists fulfill share responsibilities providing particular, readoption seriously considered, field lady targeted. skills procedures, wherever inseparable component building offer solution health problem. Section Editor Journal Cardiothoracic Vascular Anesthesia.