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Cardiac Anesthesia VI Offpump, MiniCab, and assorted extras

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Cardiac Anesthesia VI. Off-pump, Mini-Cab, and assorted extras. Vincent Conte, MD ... 'Off-Pump' (OPCAB) or 'Beating Heart' bypass was a technique that was developed ... – PowerPoint PPT presentation

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Title: Cardiac Anesthesia VI Offpump, MiniCab, and assorted extras


1
Cardiac Anesthesia VIOff-pump, Mini-Cab, and
assorted extras
  • Vincent Conte, MD
  • Clinical Assistant Professor
  • FIU College of Nursing and Health Sciences
  • Anesthesiology Nursing Program

2
  • Off-Pump
  • CABG
  • Procedures

3
Off-Pump CABG
  • Off-Pump (OPCAB) or Beating Heart bypass was
    a technique that was developed about 7 years ago
    as a new, revolutionary technique
  • Initially, the numbers showed an across the board
    decrease in EVERY complication at the 1 and 3
    years marks
  • HOWEVER, at the 5 year mark, the mortality rate
    of Off-Pump CABG was significantly higher that of
    the ON-PUMP group and re-stenosis rates were
    almost double as well

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Off-Pump CABG
  • So much for new and revolutionary
  • The technique is still used so it is important to
    have a working knowledge of it and its anesthesia
    implications
  • The main thing that is missing is the CPB Machine
  • The heart is exposed and a special
    retractor/STABILIZING device called an Octopus
    is placed to isolate and stop the movement of the
    site to be grafted to

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OPCAB
  • This is accomplished by the use of small suction
    cups that raise and stabilize the area of the
    heart to be grafted
  • Unfortunately, no matter how carefully the
    Octopus is placed, it still places extrinsic
    pressure on the heart and will compromise CO to
    some degree
  • To counteract that, the patient is usually fluid
    loaded prior to the placement of the retractor

12
OPCAB
  • At Baptist, it was our protocol to infuse 1.5-2L
    prior to the placement of the Octopus
  • Once the Octopus was placed, we used either
    inotropes or NTG (whichever way we needed to go)
    to keep the BP at 90-100mm Hg while the Octopus
    was in place
  • The lower pressure would decrease the degree of
    contractility of the heart and decrease the
    degree of overall movement

13
OPCAB
  • No matter how well the Octopus was placed, there
    is still some residual movement and if the
    hearts contractility can be kept to a minimum,
    that extra movement can be minimized
  • There were even times when we would use
    inhalational agents to depress the myocardium and
    use a Neosynephrine or Levophed drip to maintain
    BP at 90-100

14
OPCAB
  • These patients would also be extubated a lot
    sooner than the patients who had been placed on
    CPB
  • Muscle Relaxants would be titrated to keep 1-2
    twitches during the procedure and at the end,
    reversal would be given prior to transfer, and by
    the time we would get to the unit, spontaneous
    ventilation would usually have begun

15
OPCAB
  • Also, since early extubation is part of the goal,
    you would go easier on the narcotics and use
    Fentanyl in the 2-5mcg/kg range so their effect
    would be minimal when it was time to resume
    spont. Ventilation and possible early extubation
  • Usually some Fentanyl would be titrated in at the
    end once spont. vent. resumed prior to extub
    using resp. rate as the end point of titration

16
OPCAB
  • When it first came into favor it was all the
    rage!!!
  • Everyone was using it as a selling point and
    there were PR wars between the hospitals that we
    did it and THEY did not, etc.
  • Once the 5 year data came out, it almost stopped
    overnight!!! BUT NO ADDS THIS TIME!!

17
  • Minimally
  • Invasive
  • Surgery

18
Minimally Invasive Cardiac Surgery
  • Standard heart surgery typically requires
    exposure of the heart and its vessels through a
    median sternotomy
  • A Minimally Invasive approach allows access to
    the heart through SMALL incisions and without
    instituting CPB in some cases
  • Minimally Invasive surgery is applicable to the
    broadest range of complex cardiac cases

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Minimally Invasive Surgery
  • Minimally invasive procedures, in properly
    trained hands, can be used safely to perform up
    to 2-vessel bypass procedures and to repair or
    replace diseased heart valves
  • Todays current technologys high degree of
    flexibility and precision have allowed surgeons
    to successfully perform difficult cases involving
    both multi-vessel bypass, mitral valve repair,
    multi valve operations, and aortic valve
    replacement

23
Minimally Invasive Surgery
  • Minimally invasive technology also is used to
    repair congenital defects (ASDs, VSDs)
  • Additionally, the minimally invasive approach is
    applicable for aortic valve replacement,
    especially in elderly patients, and is well
    suited for patients who have had prior valve
    procedures

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MIDCAB
  • Minimally Invasive Direct Coronary Artery Bypass
    is a minimally invasive approach to conventional
    CABG
  • MIDCAB is beating heart surgery and unlike
    conventional sternotomy, only requires a 3-5
    incision placed between the ribs
  • MIDCAB results in a faster recovery, fewer
    complications, and less pain after surgery

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MIDCAB
  • Advantages of the MIDCAB are
  • Shorter length of stay (often d/ced in 2-3 days
    postop)
  • Faster Recovery (reduced risk of complications
    can return to normal activity within 2 weeks)
  • Less Bleeding and Blood trauma (the damage to the
    blood from the CPB machine is avoided smaller
    incision-less blood loss)
  • Lower Infection rate
  • Available to more patients (poor candidates for
    conventional CPB may be candidates for less
    invasive techniques)
  • Less Cost (25 less than conventional CABG
    surgery)

28
MIDCAB
  • The drawback to the MIDCAB procedure is that it
    requires a Surgeon with a high amount of
    expertise in the procedure and is only
    recommended to be used in CABGs involving two
    vessels or less
  • There is also limited data about long-term
    re-stenosis rates or mortality like with the
    Off-pump cases
  • What most surgeons are doing, is going back to
    conventional sternotomy and CPB especially for
    multivessel disease for CABGs and using the
    Minimally Invasive procedures for Valve surgery
    in healthy patients with good to moderate LVF

29
Anesthetic Management
  • Anesthetic management of minimally invasive
    procedures varies depending on the procedure
  • For MIDCABs a double lumen tube is placed and
    the left lung is dropped to provide exposure for
    the procedure
  • In minimally invasive valve surgery, a regular
    ETT can be placed and CPB is instituted via a
    Fem/Fem connection and the heart is put at rest
    through the use of CPB

30
Anesthetic Management
  • Like with the Off-pump, the MIDCAB usually
    requires volume loading to compensate for the
    pressure placed on the heart by extrinsic
    retractors
  • The L Lung is usually dropped to aid in the
    procedure and give better exposure to the surgeon

31
Anesthetic Management
  • INDUCTION This can be achieved with a combo of
    Propofol (Etomidate), Vec (Zem), and Fentanyl _at_
    7.5-10mcg/kg
  • MAINTENANCE Continuous Propofol infusions can be
    used, as well as Inhalational agents, O2 and N2O
    (no CPB), Fentanyl, and Vec (Zem)
  • EMERGENCE Reversal can be done with normal
    agents (Neostig and Robinul)

32
AHA Statement
  • The American Heart Association has been carefully
    monitoring minimally invasive procedures and
    their outcomes
  • While all the surgeries appear promising, the
    conclusion of the AHA is that they need much more
    study before they are recommended over
    conventional methods

33
AHA Statement
  • Information is being gathered and scrutinized at
    many medical centers across the country
  • If these surgeries can be refined to the point
    where they are no more invasive than angioplasty,
    they will end up having a distinct advantage over
    angioplasty
  • However at this point they are more invasive than
    angioplasty and require GA instead of MAC

34
AHA Statement
  • Based on the preceding, at this point in time,
    minimally invasive surgeries are considered
    experimental and are NOT recommended over more
    conventional, time tested techniques
  • This may change as more data is collected, but at
    this time no recommendation can be made for or
    against them

35
  • Pacemakers

36
Pacemakers
  • Definitions of common terms
  • Pacemaker The mechanical system which achieves
    pacing
  • Electrode Part of the pacemaker that is in
    contact with the myocardium
  • Bipolar An electrode system in which BOTH
    electrodes are in touch with the myocardium
  • Unipolar An electrode system in which one
    electrode is in the heart and the other is NOT in
    the heart (usually the pacer itself is the OTHER
    lead)

37
Pacemakers
  • General types of pacing
  • ASYNCHRONOUS This type of Pacer has NO sensing
    capability to detect R waves. This form of
    pacing is in competition with the hearts own
    beat and has been known to cause V-fib at times
    (R on T)
  • SYNCHRONOUS This Pacer has the appropriate
    circuit to detect intrinsic R waves

38
Pacemakers
  • 3) SEQUENTIAL Also called A-V sequential, it
    paces the atrium first then paces the ventricle
    after a set time period (A-V interval usually
    set in milliseconds)

39
Pacemakers
  • Three-letter system
  • First Letter Indicates the chamber that is paced
    (A,V,D)
  • Second Letter Indicates the chamber that is
    sensed (A,V,D,O)
  • Third letter Indicates the mode of action (O, I,
    T, B, D)

40
Pacemakers
  • Definition of letters
  • O Asynchronous or no programming
  • A Atrium
  • V Ventricle
  • D Dual (both Atria and Ventricle)
  • I Inhibited
  • T Triggered
  • B Burst (rarely seen)

41
Pacemakers
  • Examples
  • VOO (AOO) A simple Ventricular or Atrial
    Asynchronous non-sensing pacemaker
  • VVI Paces the ventricle senses the ventricle
    and is inhibited by a rate set above its rate
  • DVI Paces both Atria and Ventricle the
    ventricle is sensed and it is inhibited if the
    rate is higher than its set rate
  • DDI Both are Paced Both are sensed and it is
    inhibited

42
Anesthetic Management
  • The first step in Anesthetic management is to
    know WHY they have the Pacemaker (Complete heart
    block, Sick Sinus Syndrome, Bradycardia, etc.)
  • If they have a condition that requires a Pacer,
    then keep the pacer as is and keep a magnet at
    hand to use if necessary
  • Bovey activity may interfere with the pacer so if
    that happens, you may need to place the magnet on
    the pacer to put it into the VOO mode

43
Anesthetic Management
  • If they have a condition that they DO NOT need
    the pacer to live, then the pacer is usually
    placed in an asynchronous mode
  • Still keep the magnet handy in case there is
    interference and you need to put it into its VOO
    mode
  • If the patient has an AICD, this needs to be
    DEACTIVATED prior to surgery AT ALL TIMES

44
Anesthetic Management
  • One should apply the following measures to
    decrease the possibility of adverse effects due
    to electrocautery
  • Bipolar cautery should be used if available
  • If unipolar cautery is used, place the grounding
    pad as far away from the pacer as possible
  • Electrocautery should NOT be used within 15cm of
    the Pacer

45
Anesthetic Management
  • 4) Pacemakers should be programmed to
    asynchronous in the preop suite by the pacer tech
    or be done with a magnet in the OR if needed
  • 5) Provisions for alternative temp. pacing should
    be readily available (pads for transcutaneous,
    crash cart in room)

46
  • Break
  • Time!!!

47
Valve Replacement Surgery
  • The only additional step for Valve replacement
    surgery that changes it from CABG management
    techniques is the DE-AIRING step after the valve
    has been repaired/replaced
  • The patient is placed in a head down position and
    using the TEE usually as a guide, the heart is
    allowed to fill up by the pump tech just partly
    clamping the venous return line and the cross
    clamp being slowly released

48
Valve Surgery
  • The surgeon will usually massage the heart and
    shake it a little to dislodge any air that may be
    trapped on the walls or in the muscle
  • You can see the air on the TEE as a shower of
    little white specks and they will gradually
    decrease as they are circulated and withdrawn by
    the pump and filtered out

49
Valve Replacement
  • The surgeon will also usually put another vent or
    drain and put it to suction below the cross clamp
    to suck out as much of the air as possible prior
    to release of the aortic cross clamp
  • This is just another step to prevent any air
    embolizing to the brain

50
Valve Replacement
  • I have found through personal experience that
    Inotropes are needed about 50 more often with
    valve surgeries than in CABG surgery
  • I think since the heart is actually being opened
    and the tissue is being cut and sewn, that there
    is a much higher degree of direct myocardial
    damage so even with short pump runs, the heart
    needs more help to get really going again after
    bypass

51
  • TEE
  • Transesophageal
  • Echocardiography

52
TEE
  • The first use of TEE was in 1975 and had a very
    limited range and very little ability to change
    the angle of the view
  • In modern equipment with provision of multiple
    planes of view, multiple frequency of probes,
    color flow mapping, pulse and continuous wave
    doppler and digital image processing, the quality
    and utility of todays TEEs have expanded its
    use 100 fold

53
TEE
  • The common indications for TEE are
  • Assessment of valvular function both intra and
    postop
  • Evaluation of Mitral valve repair and prosthetic
    valve surgery
  • Assessment of Global LVF and regional wall motion
    abnormalities (RWMA)
  • Assessment of the aorta for arteriosclerosis,
    calcification and dissections

54
TEE
  • 5) Detection of intracardiac defects, masses, and
    vegetations
  • 6) To see optimal deairing after open heart
    surgery
  • 7) For quick evaluation of severe hypotension
    intra and postop by ruling out conditions like
    cardiac tamponade, poor LV volume status, RWMA,
    malfunction of prosthetic valves, or aortic
    dissection
  • 8) Inadequate or impossible transthoracic
    echocardiography

55
TEE
  • Although TEE is a fast and relatively
    non-invasive technique, its routine use for
    NON-cardiac surgery is yet to be established
  • Many studies have revealed that TEE is more
    sensitive than EKG for EARLY detection of
    ischemia
  • Studies showing the routine use, though, of TEE
    in non-cardiac surgeries as a benefit are limited
    in number and equivocal in outcome

56
TEE
  • With its use in Open Heart surgery, it is usually
    placed once GA is induced
  • The tip is covered with Xylocaine 2 Jelly and
    you can pass the probe blind but guide it down
    with your finger like an LMA or use your
    laryngoscope and pass it under direct vision
  • Most people pass it blind with a finger as a guide

57
TEE
  • It should always be fitted with a Bite Block in
    patients with teeth and the bite block needs to
    be placed BEFORE insertion
  • The appropriate depth is where you get the best
    picture but it should end up between 25-30cm
    depth from the teeth
  • Usually at this depth you will see the classic
    4-chamber view easily

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TEE
  • One of the views that you will need to see for a
    complete exam requires insertion to about 40cm
  • This is a cross-sectional view of the heart and
    is the classic Doughnut view or Transgastric
    view
  • This view is very useful for monitoring LVF,
    studying RWMA, ischemic changes, LV aneurysm and
    preload of the LV

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Common Clinical Applications of TEE
  • Left Ventricular function Assessment
  • Detection of Myocardial ischemia through RWMAs
  • Assessment of the Mitral valve and its repair
  • Assessment of Septal closures and repairs of
    Congenital Heart Diseases
  • Assessment of Air removal after Open Heart
    Surgery
  • Assessment of proper placement and function of
    Prosthetic valves
  • Evaluation for hypotension

63
Clinical Applications
  • 8) Evaluation of the Aorta for Cannulations and
    Dissections
  • 9) Detection of Intracardiac masses, thrombus, or
    valve vegetations
  • 10) Measurement of the Cardiac Output

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Complications of the TEE
  • TEE is very safe and atraumatic if placed
    correctly
  • There are some reported cases of Esophageal tears
    or perforations and burns
  • To avoid such complications the probe should be
    introduced with gentleness and care and if ANY
    resistance is encountered, the probe should be
    withdrawn and re-lubed and then another attempt
    can be made to place it

67
Absolute Contraindications
  • Absolute contraindications to TEE placement are
  • Presence of an Esophageal Stricture
  • Esophageal tumor
  • Recent suture lines as in gastric bypass
  • Diverticular disease of the esophagus

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Relative Contraindications
  • Relative contraindications include
  • Hiatal Hernia
  • Esophageal varices
  • Esophagitis
  • Unexplained Upper GI bleeding

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TEE
  • http//www.ucsf.edu/teeecho/content_pages/page6.ht
    m

72
References
  • http//www.ispub.com/ostia/index.php?xmlFilePathj
    ournals/ijpf/vol1n1/opcab.xml
  • http//www.cardiacengineering.com/cardiaca.htm
  • http//www.cardiacengineering.com/Midcabg.htm
  • http//www.cardiacengineering.com/bbac/PCRRT.pdf

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Scenario 1
  • 49 yo w/ chest pain and cath proven Three vessel
    disease for a bypass.
  • What questions do you want answered?
  • How will you proceed?
  • What lines and monitors will you use?
  • What will be your Anesthetic plan?

74
Scenario 2
  • 68 yo male w an acute MI and markedly reduced LVF
    with a Left Main Lesion on Cath.
  • What info do you want to know?
  • How will you proceed?
  • What is your anesthetic plan?

75
Scenario 3
  • 74 yo female with severe AS and a gradient of 70
    across her valve for an Aortic Valve replacement
  • What info do you want to know?
  • What is your anesthetic plan?
  • What lines and monitoring would you place in her?
  • How would you do your induction?

76
Scenario 4
  • 69 yo m with AR for a cysto for removal of an
    obstructing stone
  • What info do you want to know?
  • What hemodynamic parameters do you need to follow
    and what changes can you allow?
  • What is your anesthetic plan?
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