Kardiomiopati Peripartum: Manajemen Anestesi Terbaru
Indonesia
Abstract
Kardiomiopati peripartum (KMPP) atau Peripartum cardiomyopathy (PPCM) adalah kelainan jantung idiopatik dengan karakteristik disfungsi sistolik dan simptom gagal jantung pada akhir masa kehamilan atau beberapa bulan setelah kehamilan tanpa sebab lain yang mengancam jiwa maternal dengan risiko morbiditas dan mortalitas postpartum cukup tinggi. Penelitian terbaru dalam pemahaman tentang patofisiologi PPCM menunjukkan proses yang melibatkan faktor endotel dan faktor toksik kardio, seperti sFlt-1 dan 16 kDa prolaktin, sehingga kemampuan jantung beradaptasi terhadap kehamilan normal terlampaui pada ibu yang sudah rentan terhadap serangan jantung. Terapi spesifik PPCM belum dapat ditentukan. Bromokriptin yang bekerja memblok pelepasan prolaktin dari glandula pituitaria, pada beberapa penelitian awal menghasilkan perbaikan fraksi ejeksi ventrikel kiri secara bermakna. Penelitian lebih lanjut dengan jumlah sampel yang lebih besar masih harus dilakukan untuk terapi ini. Prinsip manajemen direkomendasikan sesuai dengan patofisiologi yang terjadi. Optimalisasi atau reduksi preload baik dengan reduksi natrium maupun cairan dan penggunaan diuretika, menurunkan afterload dengan vasodilator, dan memperbaiki kontraktilitas jantung dengan inotropik, dromotropik, atau inodilator adalah strategi utama yang direkomendasikan. Tidak ada perubahan strategi dalam manajemen terapi ini, tetapi pilihan teknik anestesi saat ini lebih berkembang ke analgesi/anestesi regional. Pemahaman penggunaan dosis dan konsentrasi anestetika lokal menjadi penting untuk mencapai target dalam strategi yang direkomendasikan.
Peripartum Cardiomyopathy: Update in Anesthesia Management
Abstract
Peripatum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricle systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause for heart failure is identified, life-threatening, and postpartum high morbidity and mortality risk. Recent studies in the understanding of PPCM pathophysiology indicate that there’s processes involving endothelial and cardio-toxic factors such as e.g. sFlt-1 and 16 kDa prolactin, leading the heart’s capacity to adapt to a normal pregnancy may be exceeded in some women already susceptible to cardiac insult. Spesific therapy for PPCM can not be determined. Bromocriptine that blocks the release of a hormone called prolactine from the pituitary gland in some preliminary studies improved left ventricular ejection fraction significantly. Further research with larger sample size remains to be done for this therapy. Management principles for PPCM are recommended in accordance with the pathophysiology. Depending on the volume status, preload has to be optimized by either fluid administration or sodium restriction and diuretics, decrease afterload using vasodilator, and improve contractility by using inotropic, dromotropic, or inodilator are the main strategies. There is no change in management strategy for PPCM, but regional analgesia/anesthesia preferably for now. Understanding the dose and concentration administration of local anesthethic drugs are important to achieve targets recommendation.
Downloads
References
Behrens I, Basit S, Lykke JA, Ranthe MF, Wohlfahrt J, Bundgaard H et al. Hypertensive disorders of pregnancy and peripartum cardiomyopathy: A nationwide cohort study. PLoS ONE 14(2): e0211857.
Monteiro R, Salman M, Malhotra S, Yentis S. Cardiomyopathy. Analgesia, Anaesthesia and Pregnancy. A Practical Guide, 4th ed. Singapore, Cambridge University Press, 2019; 94: 283–85.
Vidovich MI. Cardiovascular disease. In: Chesnut DH, Wong CA, Tsen LC, Ngan Kee WD, Beilin Y, Mhyre JM et al, editors. Chesnut’s Obstetric Anesthesia Principles and Practice. 6th ed. Philadelphia: Elsevier; 2020, 987–1032
Billson J, Vollmer L. Peripartum cardiomyopathy: a review of the literature. Obstetrics & Gynaecology Forum. 2014; 24 (1): 9–13.
Vakilian F, Tara F, Moosavi F. Peripartum cardiomyopathy (a literature review). Rev Clin Med. 2014; 1 (4): 194–99.
Grixti S, Magri CJ, Xuereb R, Fava S. Peripartum cardiomyopathy. Brit J Hosp Med. 2015; 76 (2): 95–100.
Davis MB, Arany Z, McNamara DM, Goland S, Elkayam U. Peripartum cardiomyopathy. JACC. 2020; 75 (2):207–21.
Hepner DL, Kodali BS, Segal S. Pregnancy and obstetric complications. Dalam: Fleisher LA, eds. Anesthesia and Uncommon Diseases, 6th ed. Philadelphia, Elsevier-Saunders, 2012; 19: 537–72.
Saraswat N, Virmani P, Kakkar A, Gupta A, Kaur M. Peripartum cardiomyopathy – an insight. The Indian Anaesthetists’ Forum. 2020; 21 (1): 4–9.
Ekizler FA, Cay S. A novel marker of persistent left ventricular systolic dysfunction in patients with peripartum cardiomyopathy: monocyte count-to-HDL cholesterol ratio. BMC Cardiovascular Disorders. 2019; 19: 114.
Koenig T, Hilfiker-Kleiner D, Bauersachs J. Peripartum cardiomyopathy. Herz. 2018; 43(5): 431–37.
Carvalho B, Jackson E. Cardiovascular and respiratory disorders: structural heart disease in pregnant women. Dalam Gambling DR, Douglas MJ, Mckay RSF, eds. Obstetric Anesthesia and Uncommon Disorders, 2nd ed. Cambridge: Cambridge University Press, 2008; 1: 1–28.
Bhattacharyya A, Basra SS, Sen P, Kar B. Peripartum cardiomyopathy. A review. Texas Heart Institute Journal 2012; 39(1): 8–16.
Chandrasekhar S, Tolpin DA, Mangano DT. Anesthetic management of the pregnant cardiac patient. Dalam: Suresh MS, Segal BS, Preston RL, Fernando R, Mason CLT, eds. Shnider and Levinson’s Anesthesia for Obstetrics, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2013; 30: 484–523.
Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buchmann E, et al. Current state of knowledge on etiology, diagnosis, management and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010; 12: 767–78.
Ben-David B, Miller G, Gavriel R, Gurevitch A. Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Regional Anesthesia & Pain Medicine 2000; 25: 235–39.
Karamaz A, Kaya S, Turhanoglu S, Ozyilmaz MA. Low-dose bupivacaine-fentanyl spinal anesthesia for transurethral prostatectomy. Anesthesia 2003; 58: 526–30.
Cenkowski MJ, Maguire D, Kowalski S, Al Gurashi FA, Funk D. Hemodynamic effects of low-dose bupivacaine spinal anesthesia for cesarean section: A randomized controlled trial. Saudi J Anaesth. 2019 Jul-Sep; 13(3): 208–14.
Harker E, Smiley R. Managing cardiac morbidities during pregnancy. Dalam: Santos AC, Epstein JN, Chaudhuri K, eds. Clinical Anesthesiology Guide Obstetric Anesthesia, McGraw-Hill, 2015; 21: 288–329.
Jurnal Anestesi Obstetri Indonesia
