Adult Cardiac Procedures:  Anesthesia Considerations

• Overview: Patient History Issues
  •  Assessment of coronary vascular disease
    •  History recent myocardial infarction
    • Resuscitation/hospitalization associated with myocardial arrhythmias
    •  Cardiac drug use
    •  Symptomatology Associated with Severity of CoronaryVascular Disease
  •  Patient history following myocardial infarction (range of  severity)
    •  Better prognosis: short hospitalization; uneventful recovery
    •  Poorer prognosis: if patient required--
      • intra-aortic balloon pump following myocardial infarction
      • defibrillation
  •  Assessment of patients cardiovascular status based on post-infarction drug regimen (chronic) 
    • Normal/hyperdynamic cardiac function: ß-adrenoceptor blocking drugs (e.g.,metoprolol (Lopressor); propranolol (Inderal))
    • Severe left ventricular dysfunction (hypotensive state): balloon support; inotropic agents, e.g. dopamine (Intropin) & dobutamine (Dobutrex), nitrate

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Hemodynamic Classification

Clinical Condition (hemodynamic)	Cardiac Index (liters/minute/meter2)	Pulmonary Capillary Wedge Pressure (PCWP)	Therapeutic Intervention
Normal/hyperdynamic	> 3	< 12	ß-adrenoceptor blocker
Hypovolemia (reduced perfusion)	< 2.7	< 9	increased intravascular volume and then reassess
Left ventricular failure (mild)	< 2.5	18-22	diuretics (e.g. chlorothiazide (Diuril)); nitrates
Left ventricular failure (severe) {adequate blood pressure}	< 1.8	> 22	BP dependent-possibly nitrates; vasodilators
Left ventricular failure (severe);hypotension	< 1.8	> 22	Dependent on extent of hypotension: balloon pump, dopamine (Intropin), dobutamine (Dobutrex) {positive inotropic agents}; nitrates

{Adapted from Pasternak, Braunwald and Sobel: Acute myocardial infarction: In Braunwald, editor: Hard Disease,ed 4, Philadelphia, WB Saunders, 1992,  p 1250 {also, Table 68-2 from Ross, AF, Gomez, MN. and Tinker, JH Anesthesia for Adult Cardiac Procedures in  Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds)  Mosby, St. Louis, Mo., pp. 201-218, 1998.

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• Terms, definitions
• Preoperative Assessment of the coronary vasculature

Analysis of Cardiovascular Function

Primary Reference: Shanewise, JS and Hug, Jr., CC, Anesthesia for Adult Cardiac Surgery, in Anesthesia, 5th edition,vol 2, (Miller, R.D, editor; consulting editors, Cucchiara, RF, Miller, Jr.,ED, Reves, JG, Roizen, MF and Savarese, JJ) Churchill Livingston, a Division of Harcourt Brace & Company, Philadelphia, pp. 1753-1799, 2000.

• Echocardiography

  

  "Dilated left ventricle with mitral chordal calcification"-courtesy of Daniel Shindler, M.D., used with permission (http://www2.umdnj.edu/~shindler/echo.html)

  1.  

• "Transesophageal echocardiography (TEE)  demonstrating a markedly enlarged ascending aorta.  The aortic valve appears normal, but the leaflets fail to coapt in diastole, allowing a centrally directed jet of aortic insufficiency"-courtesy of The University of Chicago's Echocardiography Lab, (http://cardiology.uchicago.edu/pages/echo-home/echo-pages/echo-cases-alpha.html)

2. Overall ventricular function +/-stress challenge {dobutamine (Dobutrex) challenge}: ejection fraction

3. Ventricular wall motion anomalies

4. Mitral valve regurgitation, secondary to left ventricular dilatation or papillary muscle rupture/dysfunction

• Exercise Electrocardiography

  • Notation of heart rate & systolic blood pressure at which ischemia was evidenced {suggestion: make effort to maintain heart rate and BP at a reduced level during the perioperative time frame} 

  • Observe which ECG leads indicate ischemic change -- these ECG leads may be the most helpful leads to monitor during anesthesia

  • Ventricular dysfunction  unmasked during exercise-- (e.g.,premature ventricular contractions {PVCs}, hypotension, rales}

    • reason the possibility of potential  intraoperative problems which would influence monitoring, anesthetic approaches and therapeutic responses

• Coronary Angiography & Left Ventriculography

  • Atherosclerotic lesion location --may be suggestive of:

    •  most appropriate  electrocardiographic leads to monitor

    • potential complications, e.g. ventricular dysfunction (hypokinesis), cardiac arrhythmias

  • Patency status of previous bypass grafts (internal mammary artery/saphenous vein); also:

    • identifies threvious percutaneous transluminal coronary angioplasty (PTCA)

  • Adequacy of previous PTCA

  • Characteristics of  atherosclerotic coronary disease, diffuseness of disease; and assessment of distal portions of coronary arteries

    • cardiopulmonary bypass complications: related to revascularization completeness

  • May reveal coronary vasospastic disorder (Prinzmetal's angina)

  • Evidence of ventricular dysfunction:

    • Hypokinesis (poor ventricular contraction {regional})

    • Dyskinesia

    • Akinesis  (absence of ventricular contraction in a region)

    • Aneurysm

    • High left ventricular end diastolic pressures {>15 mm Hg}; ejection fraction < 0.5; and left ventricular and diastolic pressures increasing by > 5 mm mm Hg following contrast

• "Normal left coronary angiogram. Left  anterior oblique view (45 degrees) {Left}; Left coronary angiogram.  Left anterior oblique view.  Narrow area from disease proximal end of circumflex and top of anterior descending.  Male age 37. Severe angina not controlled by medical treatment": courtesy of SouthBank University, London; used with permission (http://www.skiagram.com/im0.html)

• Radionuclide Angiocardiography

  • Adequacy of myocardial perfusion {thallium uptake study} +/-stress [exercise, dobutamine (Dobutrex) challenge]

  • Myocardial infarction identification: (technetium 99 uptake)

  • valuation ventricular function (equilibrium-gated blood pool imaging)

    • estimation of ejection fraction

  • Uncovering inducible myocardial ischemia {stress thallium scan indicates  reperfusion to ischemic regions}

• Primary Reference:  Ross, AF, Gomez, MN. and Tinker, JH Anesthesia for Adult Cardiac Procedures in  Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds)  Mosby, St. Louis, Mo., pp. 201-218, 1998.
• Primary Reference: Shanewise, JS and Hug, Jr., CC, Anesthesia for Adult Cardiac Surgery, in Anesthesia, 5th edition,vol 2, (Miller, R.D, editor; consulting editors, Cucchiara, RF, Miller, Jr.,ED, Reves, JG, Roizen, MF and Savarese, JJ) Churchill Livingston, a Division of Harcourt Brace & Company, Philadelphia, pp. 1753-1799, 2000.
• Primary Reference: Wray Roth, DL, Rothstein, P and Thomas, SJ Anesthesia for Cardiac Surgery, in Clinical Anesthesia, third edition  (Barash, PG, Cullen, BF, Stoelting, R.K, eds), Lippincott-Raven Publishers, Philadelphia, pp. 835-865, 1997

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