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Hensley’s Practical Approach to
Cardiothoracic Anesthesia
Sixth Edition
Editors
GLENN P. GRAVLEE, MD
Professor and Vice Chair for Faculty Affairs
Department of Anesthesiology
University of Colorado School of Medicine
Aurora, Colorado
ANDREW D. SHAW, MB, FRCA

Professor and Chair, Department of Anesthesiology and Pain Medicine
Faculty of Medicine and Dentistry
University of Alberta
Edmonton, Alberta, Canada
K ARSTEN B ARTELS, MD, MS

Assistant Professor of Anesthesiology, Medicine, and Surgery
Aurora, Colorado
Acquisitions Editor: Keith Donnellan
Editorial Coordinator: Lauren Pecarich
Marketing Manager: Julie Sikora
Senior Production Project Manager: Alicia Jackson
Design Coordinator: Terry Mallon
Senior Manufacturing Coordinator: Beth Welsh
Prepress Vendor: Aptara, Inc.
6th edition https://t.me/Anesthesia_Books

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Dedication
Frederick Allen Hensley, Jr., MD

(1953–2013)
We dedicate this book to the memory of Frederick Allen Hensley, Jr., MD, who most
knew simply as “Rick.” As a young academician at Penn State Hershey Medical Center
in the late 1980s, Rick developed a cardiac anesthesia teaching manual for local
residents, fellows, and perfusionists. While preparing this manual, he recognized the
wider need for a point-of-care reference book on cardiac anesthesia. He then sought to
address this deficiency by compressing a readable, comprehensive cardiac anesthesia
textbook into a pocket-sized paperback package. Its mission would be to provide
clinical recommendations supported by their briefly-explained underlying scientific
principles. Practical clinical relevance and conciseness were deemed more important
than lengthy narratives and prodigious reference lists. Hensley recruited his Hershey
friend and colleague, Donald E. Martin, MD, to co-edit this book. Together they
envisioned a multiauthor text representing multiple teaching hospitals, so they recruited
chapter authors who were recognized for clinical expertise and experience. To achieve
thoroughness without sacrificing readability, Rick and Don thought that the chapters
should be formatted as outlines. As editors, they delicately pursued practical clinical
advice while avoiding parochial institutional practices.
Their vision flew in the face of the prevailing approach to both medical textbooks and
handbooks. At the time, comprehensive medical textbooks predominantly were lengthy
tomes with thousands of references. Much shorter paperback handbooks typically
presented single-institution “how-we-do-it” guidelines without scientific foundation or
expert consensus. Hardly anything existed between those extremes. Undaunted, Hensley
and Martin advanced their proposal to Little, Brown and Company, which accepted it,
a nd The Practice of Cardiac Anesthesia was born in 1990. The book was warmly
received by busy residents and fellows. Residency and fellowship program directors
embraced it for its unique blend of quality, thoroughness, and conciseness. Part-time
practitioners of cardiac anesthesiology also found it useful, in part because hardwired
computers, cell phones with endless “apps,” and wireless internet access had not
reached anesthesia work stations. The book’s success brought another edition and a new
name in 1995: A Practical Approach to Cardiac Anesthesia . And so on through five
editions and to a series of paperback subspecialty books carrying the rubric “A
Practical Approach to. . .,” all using Rick’s visionary approach. Accordingly, the
current editors have named this sixth edition Hensley’s Practical Approach to
Cardiothoracic Anesthesia in honor of Rick Hensley.
Chronology of Frederick A. Hensley’s postdoctoral education and primary career

appointments and positions:
1979–1983: Milton S. Hershey Medical Center, Penn State University College of
Medicine: Internship, Anesthesiology Residency and Cardiac Anesthesia Fellowship
1984–1995: Penn State University College of Medicine, Assistant Professor, Associate

Professor, and Professor and Director of Cardiac Anesthesia, Department of
Anesthesiology
1995–2000: Sinai Hospital of Baltimore, Anesthesiologist-in-Chief and Medical

Director of Perioperative Services; Associate Professor, Department of Anesthesiology
and Critical Care Medicine, The Johns Hopkins University School of Medicine
2001–2009: Imogene Bassett Healthcare (Cooperstown, New York), Anesthesiologist

in Chief, and Chief of Perioperative Services; Clinical Professor of Anesthesiology,
College of Physicians and Surgeons of Columbia University
2009–2013: University of Alabama at Birmingham, Benjamin Monroe Carraway

Endowed Professor of Anesthesiology, Department of Anesthesiology, Director,
Division of Cardiothoracic Anesthesiology (2009–2011), Vice Chair of Clinical
Anesthesia (2011–2013)
Contributors
Darryl Abrams, MD
Assistant Professor
Department of Medicine
Division of Pulmonary, Allergy, and Critical Care
Columbia University Medical Center
New York, New York
Rabia Amir, MD
Clinical Fellow
Department of Anesthesiology, Critical Care and Pain Medicine
Harvard Medical School
Resident Physician
Beth Israel Deaconess Medical Center
Boston, Massachusetts
James M. Anton, MD
Clinical Associate Professor
Baylor College of Medicine
Chief
Division of Cardiovascular Anesthesiology
Texas Heart Institute, Baylor St. Luke’s Medical Center
Houston, Texas
Yanick Baribeau
Undergraduate Research Student
Department of Anesthesia, Critical Care and Pain Medicine
Brandi A. Bottiger, MD
Adult Cardiothoracic Anesthesia Fellowship Director
Assistant Professor
Duke University
Durham, North Carolina
Daniel Brodie, MD
Associate Professor
New York, New York
John F. Butterworth, IV, MD

Professor and Chairman
Virginia Commonwealth University
Chief of Anesthesiology
Virginia Commonwealth University Health System
Richmond, Virginia
Javier H. Campos, MD
Professor
Department of Anesthesia
University of Iowa Health Care
Executive Medical Director
Perioperative Services
Director of Cardiothoracic Anesthesia
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Pedro Catarino, MD
Consultant Cardiothoracic Surgeon
Papworth Hospital
Cambridge, United Kingdom
Joseph C. Cleveland, Jr., MD

Professor
Department of Surgery, Division of Cardiothoracic Surgery
University of Colorado Anschutz Medical Campus
Cardiothoracic Surgeon
University of Colorado Hospital
Aurora, Colorado
Charles D. Collard, MD
Clinical Professor of Anesthesiology
Attending Anesthesiologist
Houston, Texas
John R. Cooper, Jr., MD

Clinical Professor of Anesthesiology
Houston, Texas
Laurie K. Davies, MD
Associate Professor
Department of Anesthesiology and Surgery
University of Florida
Medical Director
University of Florida Health
Gainesville, Florida
Ronak G. Desai, DO
Assistant Professor of Anesthesiology
Cooper Medical School of Rowan University
Division Head, Regional Anesthesia
Cooper University Hospital
Camden, New Jersey
Alan Finley, MD
Associate Professor of Anesthesiology and Perioperative Medicine
Medical University of South Carolina
Charleston, South Carolina
Amanda A. Fox, MD, MPH

Division Chief of Cardiovascular and Thoracic Anesthesiology
Department of Anesthesiology and Pain Management
University of Texas Southwestern Medical School
Dallas, Texas
Steven M. Frank, MD
Professor
Department of Anesthesiology and Critical Care Medicine
Johns Hopkins School of Medicine
Baltimore, Maryland
Satoru Fujii, MD
Clinical Fellow
London Health Sciences Centre
London, Ontario, Canada
Chandrika R. Garner, MD, FASE

Assistant Professor
Wake Forest School of Medicine
Winston-Salem, North Carolina
Thomas E. J. Gayeski, MD, PhD

Professor
Department of Anesthesiology and Perioperative Medicine
University of Alabama at Birmingham School of Medicine
Birmingham, Alabama
Mark A. Gerhardt, MD, PhD

Associate Professor
The Ohio State University College of Medicine
The Ohio State University Wexner Medical Center
Columbus, Ohio
Neville M. Gibbs, MBBS, MD, FANZCA

Clinical Professor
The University of Western Australia
Perth, Australia
Specialist Anaesthetist
Department of Anaesthesia
Sir Charles Gairdner Hospital
Nedlands, WA, Australia
Glenn P. Gravlee, MD
Professor and Vice Chair for Faculty Affairs
Aurora, Colorado
Michael S. Green, DO, MBA

Chair and Program Director
Drexel University College of Medicine
Hahnemann University Hospital
Philadelphia, Pennsylvania
Jonathan Hastie, MD
Assistant Professor
New York, New York
Nadia B. Hensley, MD
Assistant Professor
Johns Hopkins University School of Medicine
Baltimore, Maryland
Eugene A. Hessel, II, MD

Professor of Anesthesiology and Surgery (Cardio-thoracic)
University of Kentucky College of Medicine
Attending Physician
Anesthesiology
Chandler Medical Center
Lexington, Kentucky
Jordan R. H. Hoffman, MD, MPH

Cardiothoracic Surgery Fellow
Department of Surgery
Division of Cardiothoracic Surgery
Aurora, Colorado
Jay C. Horrow, MD, MS, FACC

Professor
Matthew S. Hull, MD
Adult Cardiothoracic Anesthesiology Fellow
Birmingham, Alabama
S. Adil Husain, MD
Professor of Surgery and Pediatrics
Chief, Section of Pediatric Cardiothoracic Surgery
University of Utah School of Medicine
Primary Children’s Hospital
Salt Lake City, Utah
David Philip Jenkins, MB, BS

Consultant Cardiothoracic Surgeon
Papworth Hospital
Rebecca Y. Klinger, MD, MS

Assistant Professor
Duke University
Colleen G. Koch, MD, MS, MBA, FACC

Professor and Chair
Baltimore, Maryland
Megan P. Kostibas, MD
Instructor
Baltimore, Maryland
David R. Larach, MD, PhD

Chief (retired)
Division of Cardiac Anesthesiology
The Heart Institute
St. Joseph Medical Center
Towson, Maryland
Michael G. Licina, MD
Professor of Anesthesiology
Anesthesia Institute
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Vice Chair
Department of Cardiothoracic Anesthesia
Cleveland Clinic
Cleveland, Ohio
Jerry C. Luck, Jr., MD✝

Professor of Medicine
Penn State College of Medicine
Heart and Vascular Institute
Penn State Health Milton S. Hershey Medical Center
Hershey, Pennsylvania
Feroze U. Mahmood, MD
Professor
Department of Anesthesiology, Critical Care and Pain Medicine
Harvard Medical School
Director of Cardiovascular Anesthesia
S. Nini Malayaman, MD
Assistant Professor
Donald E. Martin, MD
Professor Emeritus
Penn State College of Medicine
Shannon J. Matzelle, MBBS, FANZCA

Specialist Anaesthetist
Department of Anaesthesia
Sir Charles Gairdner Hospital
Nedlands, WA, Australia
Thomas M. McLoughlin, Jr., MD

Chair, Department of Anesthesiology
Lehigh Valley Health Network
Allentown, Pennsylvania
Professor of Surgery, Division of Surgical Anesthesiology
University of South Florida Morsani College of Medicine
Tampa, Florida
Anand R. Mehta, MBBS

Assistant Professor of Cardiothoracic Anesthesia
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Staff Physician
Department of Cardiothoracic Anesthesia
Cleveland Clinic
Cleveland, Ohio
Benjamin N. Morris, MD
Assistant Professor
Medical Director
Cardiovascular Intensive Care Unit
Wake Forest Baptist Medical Center
John M. Murkin, MD, FRCPC

Senate Professor
Department of Anesthesia and Perioperative Medicine
Schulich School of Medicine and Dentistry
University of Western Ontario
London, Ontario, Canada
Gary Okum, MD
Professor of Clinical Anesthesiology and Perioperative Medicine and Surgery
Department of Anesthesiology and Perioperative Medicine and Surgery
Jay D. Pal, MD, PhD

Associate Professor
Department of Surgery
Division of Cardiothoracic Surgery
University of Colorado Anschutz Medical Campus
Surgical Director, Mechanical Circulatory Support
Aurora, Colorado
Nirvik Pal, MBBS, MD

Assistant Professor
Cardiothoracic Division
Virginia Commonwealth University
Richmond, Virginia
Kinjal M. Patel, MD
Assistant Professor of Anesthesiology
Division Head, Vascular Anesthesia
Cooper University Hospital
Camden, New Jersey
Ferenc Puskas, MD, PhD

Professor
University of Colorado Denver School of Medicine
Aurora, Colorado
James G. Ramsay, MD
Professor of Anesthesiology and Perioperative Care
University of California San Francisco
San Francisco, California
Medical Director
Cardiovascular Intensive Care Unit
Anesthesiology and Perioperative Care
Moffitt Hospital
San Francisco, California
Jacob Raphael, MD
University of Virginia
Charlottesville, Virginia
Anne L. Rother, MBBS, FANZCA

Staff Anesthesiologist
Monash Medical Centre
Clayton, VIC, Australia
Roger L. Royster, MD
Professor and Executive Vice Chair
Soraya M. Samii, MD, PhD

Associate Professor
Associate Program Director, Division of Cardiac Electrophysiology
Penn State Health Heart and Vascular Institute
Milton S. Hershey Medical Center
Jack S. Shanewise, MD, FASE

Professor
Columbia University
Chief of Cardiothoracic Anesthesiology
New York, New York
Linda Shore-Lesserson, MD, FAHA, FASE

Zucker School of Medicine at Hofstra/Northwell
Vice Chair, Academic Affairs
North Shore University Hospital
Northwell Health
Manhasset, New York
Peter Slinger, MD, FRCPC

Professor
University of Toronto
Staff Anesthesiologist
Toronto General Hospital
Toronto, Ontario, Canada
Alann Solina, MD
Professor and Chair
Chief of Anesthesia and Medical Director of Operating Room Services
Cooper University Health Care
Camden, New Jersey
Andrew N. Springer, MD
Assistant Professor, Clinical Anesthesiology
The Ohio State University College of Medicine
The Ohio State University Wexner Medical Center
Columbus, Ohio
Mark Stafford-Smith, MD, CM, FRCP, FASE

Vice Chair of Education
Professor
Duke University
Breandan L. Sullivan, MD
Assistant Professor
Medical Director, CTICU
Aurora, Colorado
Erin A. Sullivan, MD, FASA

Associate Professor
Program Director, Adult Cardiothoracic Anesthesiology Fellowship
University of Pittsburgh School of Medicine
Chief, Division of Cardiothoracic Anesthesiology
Associate Chief Anesthesiologist
UPMC Presbyterian Hospital
Pittsburgh, Pennsylvania
Matthew M. Townsley, MD, FASE

Associate Professor
Birmingham, Alabama
Benjamin C. Tuck, MD
Assistant Professor
Birmingham, Alabama
Kamen Valchanov, MD, BSc

Consultant Anaesthetist
Department of Anaesthesia and Intensive Care
Papworth Hospital
Michael H. Wall, MD, FCCM

JJ Buckley Professor and Chair
University of Minnesota Medical Center
Minneapolis, Minnesota
Nathaen S. Weitzel, MD
Associate Professor
Medical Director of Inpatient Operations
Aurora, Colorado
______________
✝Deceased.
Preface
WE ARE PLEASED TO PRESENT the sixth edition of a book that now exceeds a quarter
century of longevity. The subspecialty of cardiothoracic anesthesiology continues to
evolve, just as this book aspires to evolve with it. As it was for the first edition in 1990,
our mission is to provide an easily accessible, practical reference to help trainees and
practitioners prepare for and manage anesthetics within the subspecialty. As a result of
Don Martin’s retirement from full-time clinical practice and of Frederick Hensley’s
premature passing in 2013, Glenn Gravlee welcomes co-editors Andrew Shaw and
Karsten Bartels to this edition. Each new editor brings a fresh and multi-institutional
perspective that includes expertise in cardiothoracic anesthesia and critical care as well
as clinical experience in both North America and Europe. Dr. Bartels also offers
expertise in perioperative acute and chronic pain management.
The title of the sixth edition has changed to “Hensley’s Practical Approach to
Cardiothoracic Anesthesia” to honor Rick Hensley (see Dedication) and to
acknowledge the incorporation of noncardiac thoracic anesthesia topics, which was
actually done in previous editions without titular recognition. This edition also adds 23
links to video clips spread across Chapters 5, 11, 12, and 19. In addition to the Key
Points at the beginning of each chapter (locations marked in text margins also), all
chapters now include several Clinical Pearls, which are short, key clinical concepts
located in the text section where their subject matter is presented. Highlighting of key
references constitutes another new feature. Although we tried to keep overlap between
chapters to a minimum, we allowed it when we believed that differences in content or
perspective merited retention.
The sections have been subtly reorganized to flow from basic science on to general
tenets of intraoperative management, then to specific cardiothoracic disorders, and to
conclude with sections on circulatory support and perioperative management. Some
previous chapters have been reconfigured or merged, such as Induction of Anesthesia
and Precardiopulmonary Bypass Management (Chapter 6) and Anesthetic Management
of Cardiac and Pulmonary Transplantation (Chapter 17). A chapter on blood
management supersedes one on blood transfusion. The growth of minimally invasive
valve procedures inspired the creation of a separate chapter for aortic valve procedures
as well as one for those involving the mitral and tricuspid valves, each with the addition
of video clips emphasizing echocardiography. Rapid development of extracorporeal
membrane oxygenation in adults now merits a full chapter. Robotic surgical techniques
for cardiac and thoracic surgery earn expanded coverage in Chapter 13. We decided to
concede the huge topic of congenital heart disease in children to other textbooks, while
retaining and updating the one on adult congenital heart disease.
We hope that learners enjoy this book’s content as much as we enjoyed planning,
reviewing, and editing it.
Glenn P. Gravlee, MD
Andrew D. Shaw, MB, FRCA
Karsten Bartels, MD, MS
Acknowledgments
Each edition of this book has involved a broad team effort of authors, physician editors,
development editors, copy editors, typesetters, and publishing and graphics experts. The
editors thank the 69 authors representing 37 institutions for their timely and tireless
efforts. On the publishing side, we thank Wolters Kluwer for their continued support of
this book. In particular, Keith Donellan gets warm thanks and appreciation for his
dedication, experience, and wisdom. Special thanks go to Louise Bierig, whose
expertise, persistence, and detail orientation during developmental editing proved
indispensable.
Contents
Contributors
Preface
Acknowledgments
SECTION I: CARDIOVASCULAR PHYSIOLOGY AND PHARMACOLOGY
1. Cardiovascular Physiology: A Primer

Thomas E. J. Gayeski
2. Cardiovascular Drugs
Nirvik Pal and John F. Butterworth
SECTION II: GENERAL APPROACH TO CARDIOTHORACIC ANESTHESIA
3. The Cardiac Surgical Patient

Ronak G. Desai, Alann Solina, Donald E. Martin, and Kinjal M. Patel
4. Monitoring the Cardiac Surgical Patient

Mark A. Gerhardt and Andrew N. Springer
5. Transesophageal Echocardiography
Jack S. Shanewise
6. Induction of Anesthesia and Precardiopulmonary Bypass Management

Ferenc Puskas, Anand R. Mehta, Michael G. Licina, and Glenn P. Gravlee
7. Management of Cardiopulmonary Bypass

Neville M. Gibbs, Shannon J. Matzelle, and David R. Larach
8. The Postcardiopulmonary Bypass Period: Weaning to ICU Transport

Benjamin N. Morris, Chandrika R. Garner, and Roger L. Royster
9. Blood Management
Nadia B. Hensley, Megan P. Kostibas, Steven M. Frank, and Colleen G. Koch
SECTION III: ANESTHETIC MANAGEMENT FOR SPECIFIC DISORDERS
AND PROCEDURES
10. Anesthetic Management of Myocardial Revascularization

Michael S. Green, Gary Okum, and Jay C. Horrow
11. Anesthetic Management for the Surgical and Interventional Treatment of Aortic
Valvular Heart Disease
Benjamin C. Tuck and Matthew M. Townsley
12. Anesthetic Management for the Treatment of Mitral and Tricuspid Valvular Heart
Disease
Rabia Amir, Yanick Baribeau, and Feroze U. Mahmood
13. Alternative Approaches to Cardiothoracic Surgery with and without

Cardiopulmonary Bypass
Anand R. Mehta, Peter Slinger, James G. Ramsay, Javier H. Campos, and Michael G.
Licina
14. Anesthetic Management for Thoracic Aortic Aneurysm and Dissection

Amanda A. Fox and John R. Cooper, Jr.
15. Anesthetic Management for Surgery of the Lungs and Mediastinum

Peter Slinger and Erin A. Sullivan
16. Anesthetic Management for Adult Patients with Congenital Heart Disease
Laurie K. Davies, S. Adil Husain, and Nathaen S. Weitzel
17. Anesthetic Management of Cardiac and Pulmonary Transplantation

James M. Anton, Anne L. Rother, Charles D. Collard, and Erin A. Sullivan
18. Arrhythmia, Rhythm Management Devices, and Catheter and Surgical Ablation
Soraya M. Samii and Jerry C. Luck, Jr.
19. Anesthetic Considerations for Patients with Pericardial Disease

Matthew S. Hull and Matthew M. Townsley
SECTION IV: CIRCULATORY SUPPORT

20. Cardiopulmonary Bypass: Equipment, Circuits, and Pathophysiology
Eugene A. Hessel, II
21. Coagulation Management During and After Cardiopulmonary Bypass

Jacob Raphael, Alan Finley, S. Nini Malayaman, Jay C. Horrow, Glenn P. Gravlee,
and Linda Shore-Lesserson
22. Devices for Cardiac Support and Replacement

Jordan R. H. Hoffman, Jay D. Pal, and Joseph C. Cleveland, Jr.
23. Intraoperative Myocardial Protection

Pedro Catarino, David Philip Jenkins, and Kamen Valchanov
24. Extracorporeal Membrane Oxygenation for Pulmonary or Cardiac Support

Darryl Abrams, Jonathan Hastie, and Daniel Brodie
SECTION V: PERIOPERATIVE MANAGEMENT
25. Postoperative Care of the Cardiac Surgical Patient

Breandan L. Sullivan and Michael H. Wall
26. Protection of the Brain During Cardiopulmonary Bypass

Satoru Fujii and John M. Murkin
27. Pain Management for Cardiothoracic Procedures

Brandi A. Bottiger, Rebecca Y. Klinger, Thomas M. McLoughlin, Jr., and Mark
Stafford-Smith
Index
I
Cardiovascular Physiology and
Pharmacology
1 Cardiovascular Physiology: A Primer
Thomas E. J. Gayeski
I. Introduction
II. Embryologic development of the heart
III. Electrical conduction
IV. Cardiac myocyte
A. Sarcomere
V. Organization of myocytes
VI. Length–tension relationship
VII. A heart chamber and external work
A. The chamber wall
B. Atria
C. Ventricle
D. Preload and compliance
E. Ventricular work
F. Starling curve
G. Myocardial oxygen consumption
VIII. Control systems
IX. The cardiovascular control system
X. Stretch receptors: Pressure sensors
XI. Atrial baroreceptors
XII. Arterial baroreceptors
XIII. Effectors and physiologic reserves for the healthy individual
XIV. The cardiovascular system integration
XV. Effect of anesthesia providers and our pharmacology on the
cardiovascular system
A. The surgical patient
B. The anesthetic choice
C. Treating the cause: Goal-directed therapy
KEY POINTS
1. The heart has a fibrous skeleton that provides an insertion site at

each valvular ring. This fibrous structure also connects cardiac
myocytes so that “stretch” or preload results in sarcomeres
lengthening and not cells sliding past each other.
2. Contractility changes as a result of myoplasmic Ca2+ concentration
change during systole.
3. Relaxation following contraction is an active process requiring ATP
consumption to pump Ca2+ into the sarcoplasmic reticulum (SR) as
well as across the sarcolemma.
4. The fundamental unit of tension development is the sarcomere.
5. The endocardium receives blood flow only during systole while the
epicardium receives blood flow throughout the cardiac cycle. The
endocardium is more susceptible to infarction.
6. Oxygen or ATP consumption occurs during release of actin–myosin
bonds during relaxation of this bond. The main determinants of
myocardial oxygen consumption are heart rate (HR), contractility,
and wall tension.
7. The external stroke volume (SV) work the ventricle does is to raise
the pressure of a SV from ventricular end-diastolic pressure (VEDP,
right or left) to mean arterial pressure (pulmonary or systemic,
respectively).
8. The cardiovascular system regulates blood pressure (BP) and
exemplifies a negative feedback loop control system. Sensors
throughout the cardiovascular system detect pressure through
stretch. Hence, compliance changes impact pressure sensors.
9. Physiologic reserves are expansion factors allowing the
cardiovascular system to maintain BP. These reserves are HR (3-
fold range), contractility (complex but significant range), systemic
vascular resistance (SVR; 15-fold range), and venous capacitance
(∼1.3-fold range).
10. Venous capacitance reserve is approximately 1,500 mL in a 70-kg
adult.
I. Introduction
As a physiologic primer for cardiac anesthesiology, this chapter requires
compromise and choices! The studies of cardiac anatomy, physiology, pathology,
and genomics are decades to centuries old, continue to evolve, and have a vast
literature. Our focus is on presenting physiologic principles important to adult
clinical management in the operating room (OR). The first compromise is that I
will barely touch embryology and I chose not to discuss pediatric cardiac
physiology. To complement our view, a detailed description and discussion of
adult cardiac physiology can be found in Ref. [1]. A thorough understanding of the
physiologic concepts contained herein will facilitate the anesthetic care of both
healthy patients and those with cardiovascular disease.
II. Embryologic development of the heart
A. The cardiovascular system begins to develop during week 3 of gestation as the
primitive vascular system is formed from mesodermally derived endothelial
tubes. At week 4, bilateral cardiogenic cords from paired endocardial heart
tubes fuse into a single heart tube (primitive heart). This fusion initiates forward
flow and begins the heart’s transport function.
B. The primitive heart evolves into four chambers: Bulbus cordis, ventricle,
primordial atrium, and sinus venosus, eventually forming a bulboventricular loop
with initial contraction commencing at 21 to 22 days. These contractions result in
unidirectional blood flow in week 4.
C. From weeks 4 to 7, heart development enters a critical period, as it divides into
the fetal circulation and the four chambers of the adult heart.
D. A fibrous skeleton composed of fibrin and elastin forms the framework of four
rings encircling the four heart valves as well as intermyocyte connections.
E. The fibrous skeleton
1. 1 Serves as an anchor for the insertion into the valve cusps
2. Resists overdistention of the annuli of the valves (resisting incompetence)
3. Provides a fixed insertion point for the muscular bundles of the ventricles
4. Minimizes intermyocyte sliding during ventricular filling and contraction
III. Electrical conduction
A. Purkinje fibers are made up of specialized cardiac myocytes that conduct
electrical signals faster (2 m/sec) than normal myocytes (0.3 m/sec). This speed
difference results in coordinated chamber contraction.
B. Purkinje fibers exist in the atrium and ventricles in the subendocardium. Hence,
they can be accessed from within the respective chambers.
C. The fibrous skeleton slows the direct spread of electrical conduction between
myocytes as well as between atrium and ventricles.
D. Coordinated chamber contraction depends on Purkinje signal conduction, not on
intermyocyte conduction. This sequence consists of a coordinated contraction in
the atrium followed by a delay as the Purkinje signal passes through AV node,
which is in turn followed by coordinated contraction of ventricles.
E. Action potential
1. A membrane potential is the difference in voltage between the inside of the cell
and the outside.
2. In a cell this membrane potential is a consequence of the ions and proteins
inside and outside the cell.
3. There is a predominance of potassium (K+) and negatively charged proteins
(anions, A−) inside the cell and sodium (Na+) and chloride (Cl−) outside the
cell (Fig. 1.1).
4. At rest, potassium ions can cross the membrane readily while sodium and
chloride ions have a greater difficulty in doing so.
5. Ion channels regulate the ability of Na, K, and calcium (Ca2+) to cross the
membrane. They open or close in response to a stimulus, most frequently a
chemical stimulus.
6. Membrane differences in ion channel concentrations and characteristics are
cell-type specific.
7. At rest, the negative ions within the cell predominate, resulting in a negative
transmembrane voltage. The resting voltage is referred to as the resting
membrane potential.
FIGURE 1.1 Major ionic content inside and outside a cell. A - represents negatively charged proteins within the cell. Under
normal conditions at rest, membrane potentials are negative, meaning that the voltage is more negative within the cell than
outside of it.
8. Stimulation of a cell results in a change in membrane potential characteristic

for that cell type because of a choreographed sequence of ion channels opening
and closing. The plot of this sequence is referred to as an action potential.
F. Excitation–contraction coupling in the heart
1. The intricacies of ion channel opening due to a Purkinje action potential are
beyond the scope of this chapter. However, these intricacies are important for
anesthesiologists, because clinicians prescribe and administer drugs that
directly affect their characteristics.
2. Excitation–contraction coupling starts when a Purkinje cell action potential
triggers Ca2+ ion channels to open resulting in the diffusion of Ca2+ ions (flux)
across the sarcolemma principally within the T-tubule system (Fig. 1.2).
3. 2 The flux of Ca2+ across the sarcolemma is only about 1% of the Ca2+ needed
for contraction. However, this Ca 2+ serves as a trigger for sarcoplasmic
reticulum (SR) Ca2+ ion channel opening and causes a graded release of Ca2+
to create the Ca2+ concentration needed for tension development. Graded
release refers to the fact that the internal SR release of Ca2+ is dependent on the
initial cytoplasmic Ca2+ concentration resulting from the external Ca2+ influx.
This graded response is very different than the all-or-none response of skeletal
muscle.
4. Three very important proteins within the SR are responsible for controlling
calcium flux: The Ca2+ release channel, the sarco-endoplasmic reticulum
calcium ATPase (SERCA-2), and the regulatory protein of SERCA-2
(phospholamban).
5. From relaxation to contraction, cytosolic Ca2+ concentration varies
approximately 100-fold.
FIGURE 1.2 Relation of cardiac sarcoplasmic reticulum to surface membrane and myofibrils. The SRL and C overlie the
myofilaments; they are shown separately for illustrative purposes. SL, sarcolemma; C, cisterna; T, transverse tubule; SR L,
longitudinal sarcoplasmic reticulum; Z, Z disc.
FIGURE 1.3 Schematic representation of actin–myosin dependence on Ca2+–troponin binding for tension development to
occur. A, actin; M, myosin; TM, tropomyosin; Ca ++, ionized calcium. (From Honig C. Modern Cardiovascular Physiology.
Boston/Toronto: Little, Brown and Company; 1981.)
6. The myoplasmic (intracellular) Ca2+ concentration principally depends on the

external Ca2+ concentration, the sympathetic tone (sarcolemma Ca2+ ion
channel conductance), and the amount of Ca2+ stored in the SR.
7. Any increase in contractility via any drug results from increased myoplasmic
Ca2+ concentration during systole! During systole, Ca2+ binds to troponin and
results in a conformational change of tropomyosin. This change allows actin
and myosin to interact, resulting in shortening of a sarcomere (Fig. 1.3) and
oxygen consumption (see later).
CLINICAL PEARL Intracellular calcium flux is critical to the initiation of myocardial
sarcomere contraction, and many anesthetic drugs impair this flux.
8. Myoplasmic Ca2+, and hence contractility, is affected by all inhalational agents

and some intravenous anesthetic induction drugs.
9. Intracellular acidosis presents a common physiologic reason for decreased
Ca2+–troponin affinity. As compared to extracellular pH, intracellular pH is
greatly buffered because of intracellular proteins. Intracellular pH is normally
less than extracellular pH. When either intracellular or extracellular pH
changes, transmembrane reequilibration occurs. Because of the greater
intracellular buffering capacity, the rate of intracellular pH change is delayed
relative to extracellular pH changes.
10. 3 Finally, for contraction to cease, Ca 2+ must be unbound from troponin and
removed from the myoplasm. Ca2+ is actively pumped into the SR as well as
across the sarcolemma. Normally, approximately 99% of calcium is pumped
back into the SR at a price of about 20% of total myocyte oxygen consumption.
IV. Cardiac myocyte
A. Sarcomere
1. 4 The fundamental unit of tension development is the sarcomere, which is
composed of myosin, actin, troponin, and tropomyosin (Fig. 1.3).
2. Actin molecules link to form a chain and two chains intertwine to form a helix.
Within each groove of this helix, tropomyosin sits with troponin bound to it
intermittently along its length. This complex is known as a thin filament. The
length of the thin filament is approximately 2 μm. In the absence of calcium, the
actin sites of the thin filament are not available for binding to myosin.
3. About midway along the thin filament, the Z disc anchors the thin filaments in
place in a regular pattern as schematized below. The Z disc is a strong
meshwork of filaments that forms a band to anchor the interdigitated thin
filaments.
4. Myosin molecules aggregate spontaneously, thereby forming the thick filaments.
These filaments are approximately 1.6 μm long. These thick filaments are held
in place by M filaments and are interdigitated among the thin filaments. At the
center of each thick filament is a zone that has no myosin “heads.” Each myosin
head contains an actin-binding site and ATPase.
5. Together, troponin and tropomyosin and intramyocyte Ca 2+ concentration
regulate the percentage of possible actin and myosin interactions that
participate in the shortening strength of the sarcomere.
6. As long as Ca++ is bound to troponin, actin and myosin remain adjacent to each
other. During exposure of unbound actin to myosin, they bind together to shorten
a sarcomere. After this binding, uncoupling occurs because of the ATPase
bound to myosin. This energy-dependent step, requiring oxygen consumption,
occurs multiple times within each sarcomere during a cardiac cycle. As long as
actin and myosin continue to bind and unbind, the actin–myosin complex
continues to shorten the sarcomere as the ventricular chamber contracts in
systole.
7. Depending on preload (pre-existing “stretch” prior to contraction), the
sarcomere length, or the distance between Z discs, physiologically ranges from
1.8 to 2.2 μm.
8. Intracellular calcium concentration establishes how many actin–myosin sites
interact at any instant. The sarcomere length (Z-disc separation length)
establishes the maximum number of actin and myosin heads that could
potentially interact at any instant. Increasing the number of heads that do
interact results in an increase in contractility (see below).
V. Organization of myocytes
A. A cardiac myocyte is approximately 12 μm long. Hence, each myocyte only has
about 6 sarcomeres in series from end to end. Each cardiac capillary is
approximately 1 mm in length, hence it serves about 80 cardiac myocytes along
its length.
B. As mentioned under embryology, collagen fibers link cardiac myocytes together.
In a given layer, myocytes are approximately in parallel. These collagen fiber
links connect adjacent, parallel myocytes and form a skeleton. Coupled with the
Purkinje system’s coordinated stimulation of myocytes, this skeleton allows for a
summation of the simultaneous shortening of each myocyte into a concerted
shortening of the ventricle.
C. This collagen structure also limits the cardiac myocyte from being overstretched,
thereby minimizing the risk of destroying a cell or reducing actin–myosin
exposure through overstretching [Ref. 1, p. 9].
D. To add complexity, longitudinal alignment of the cardiac myocytes differs in
overlapping layers from epicardium to endocardium. Hence, shortening in each
layer results in distortion between the layers.
E. 5 Given that blood supply comes from the surface of the heart, this distortion
results in partial occlusion of penetrating arteries supplying blood to the inner
layers of the myocardium.
F. Consequently, the endocardium is more vulnerable to ischemia than the
epicardium. Blood flow to the endocardium occurs primarily during systole
while that to the epicardium occurs during the entire cardiac cycle.
CLINICAL PEARL Systolic contraction impairs coronary arterial blood flow
penetrating from epicardium to endocardium, which potentially places the
endocardium at risk for ischemia.
VI. Length–tension relationship
A. Consider this thought experiment. There is an idealized, single cardiac myocyte
that is 12 μm long with 6 sarcomeres in series. All distances between Z discs
(sarcomere lengths) are equal for each of the 6 sarcomeres (12 μm = 6 × 2 μm).
As the cardiac myocyte length changes, the length of each sarcomere changes
proportionately. This single myocyte is suspended so that a strain gauge measures
the tension that the myocyte generates at rest and during contraction.
FIGURE 1.4 Top three schematic diagrams represent actin (thick filaments penetrating Z disc) and myosin (thin filaments
forming sheaf between Z disc) filaments at three sarcomere lengths 1.9, 2.2, and 2.8 μm. Bottom graph represents percent
of maximum tension development versus sarcomere length for strips of cardiac muscle. Note that the fibrous cardiac
skeleton inhibits sarcomere stretch from approaching a sarcomere length of 2.8 μm. (Modified from Honig C. Modern
Cardiovascular Physiology. Boston/Toronto: Little, Brown and Company; 1981.)
1. The idealized myocyte is stretched between two fixed points.

2. The tension caused by the force of stretching the muscle at rest and created by
the muscle during contraction is measured.
3. The muscle is stretched at rest over a range of 10.8 to 16.2 μm. Consequently,
the sarcomere lengths vary between 1.8 and 2.7 μm as this myocyte contracts.
4. At each sarcomere length, two fixed myoplasmic Ca2+ concentrations are set
within the cell: Zero concentration (rest) and a known value (contraction).
5. Myocyte tension is measured for both Ca2+ concentrations.
6. Plotting resting tension as a function of length results in a resting length–
(passive) tension plot.
7. Recording peak tension as a function of myocyte length, a length–(active)
tension curve can be plotted for the given Ca2+ concentration as depicted in
Figure 1.4.
B. Compliance
1. In our idealized myocyte model, a measured amount of tension resulted when
the sarcomere was stretched between 1.8 and 2.7 μm. In plotting this passive
tension resulting from passive stretch of the sarcomeres, note that there is very
little passive tension required to stretch the sarcomeres until the compliance of
the cell membrane started to play a role.
2. As the sarcomeres become stretched beyond 2.2 μm in intact cardiac muscle,
the fibrous skeleton restricts further stretching. The fibrous skeleton resistance
to stretch results in a rapid change in tension with very little change in length
(very low compliance).
3. The slope of the line of this resting relationship between length and tension is
the equivalent of ventricular compliance as will be discussed below.
C. Contractility
1. At a given Ca2+ concentration, a fraction of troponin molecules will bind Ca2+
molecules.
2. This Ca2+ binding to each troponin results in a conformational change in its
corresponding tropomyosin that allows opposing actin and myosin head pairs,
their exposure regulated by these tropomyosin molecules, to interact.
3. For this conformational change at the given Ca2+ concentration, the percentage
of the actin and myocytes heads opposed to each other is determined.
4. If one repeats the above mental experiment with a different known Ca2+
concentration, a new contracting length–(active) tension curve is plotted.
5. For a range of Ca2+ concentrations in cardiac myocytes, a family of length–
tension curves results.
6. For a given length, only through a change in myoplasmic Ca2+ concentration can
active tension change.
7. In considering the family of curves in the context of ventricular contractility, the
contractility is higher when for any given length the developed tension is
greater. In vivo, determining contractility of the ventricle is complicated by the
interactions of preload and afterload on any measurements.
D. Intracellular Ca2+ concentration
1. The range of myoplasmic Ca2+ concentrations during contraction varies
depending upon Ca2+ fluxes across the sarcolemma at the initiation of
contraction and the Ca2+ released from the SR.
2. The transmembrane flux of Ca2+ across the sarcolemma is only about 1% of
Ca2+ present during contraction. However, small changes in this transmembrane
flux impressively alter the amount of Ca2+ released from the SR.
3. The SR response is graded. The more Ca2+ that crosses the sarcolemma, the
more Ca2+ is released from the SR.
4. Examples of increasing sarcolemmal Ca2+ flux include increasing epinephrine
levels and increasing external Ca2+ concentration (a CaCl2 bolus).
5. Increased acute SR Ca2+ stores result from increased Ca2+ flux across the
sarcolemma and increased heart rate (HR)—Treppe effect.
E. Oxygen consumption
1. As described above, each interaction of actin and myosin results in a
submicron shortening of the sarcomere.
2. Physiologic (15%) shortening requires multiple submicron shortenings.
3. 6 For the sarcomere to shorten 15%, many actin–myosin interactions take
place.
4. Each submicron interaction requires ATP for release of the actin–myosin head.
It is relaxation of the actin–myosin interaction that requires energy and
consumes oxygen.
5. Remember that the more actin–myosin cycles in a unit of time, the greater the
oxygen consumption!
6. The three main determinants of myocardial oxygen consumption are:
a. HR: more beats at the same number of actin–myosin interactions
b. Contractility: more interactions per beat
c. Wall tension: more interaction for a given sarcomere length change
CLINICAL PEARL The main determinants of myocardial oxygen consumption are
HR contractility, and wall tension.
VII. A heart chamber and external work
A. The chamber wall
1. To form a ventricular chamber, individual myocytes are joined together via
collagen fibrin strands. This joining of myocytes, along a general orientation
but not end to end, results in a sheet of muscle with myocytes oriented along a
similar axis.
2. Several such layers form the ventricular wall. These layers insert on the
valvular annuli.
3. Because of the rapid electrical distribution of the signal through the Purkinje
system, the layers contract synchronously resulting in shortening of the muscle
layers and a reduction in the volume of the chamber itself.
B. Atria
1. Atrial contraction contributes approximately 20% of the ventricular filling
volume in a normal heart and may contribute even more when left ventricular
end-diastolic pressure (LVEDP) is increased. In addition to the volume itself,
the rate of ventricular volume addition resulting from atrial contraction may
play a role in ventricular sarcomere lengthening.
C. Ventricle
1. For a given state of contractility (myoplasmic Ca2+ concentration), sarcomere
length determines the wall tension the ventricle can achieve as discussed
above. The aggregate shortening of the sarcomeres in the layers of cardiac
myocytes results in wall tension that leads to ejection of blood into the aorta
and pulmonary artery (PA).
2. The active range of sarcomere length is only 1.8 to 2.2 μm or ∼15% of its
length. Falling below 1.8 μm results from an empty ventricle and an empty
heart cannot pump blood. The collagen fiber network inhibits the stretching of
sarcomeres much above 2.2 μm. This integration of structure and function is
important in permitting survival. If there were no skeleton, overstretch would
lead to reduced emptying that would lead to more overstretch and no cardiac
output (CO).
D. Preload and compliance
1. Preload
a. Where clinicians speak of preload, muscle physiologists think of sarcomere
length. The clinician’s surrogate for initial sarcomere length should be end-
diastolic ventricular volume, and not ventricular pressure. Compliance, a
variable that can be dynamic, relates pressure and length.
b. As discussed above, the sarcomere length determines how many actin–myosin
heads interact for a given myoplasmic Ca2+ concentration at any instant.
c. Measuring sarcomere length is essentially impossible clinically. As a
surrogate indirect estimate of sarcomere length, clinicians measure a chamber
pressure during chamber diastole. This pressure measurement is the
equivalent of the myocyte resting tension measurement above.
d. A more direct surrogate estimate of sarcomere length is chamber volume. As
echocardiography is commonly available, estimates of volumes serve as
direct estimates of preload (e.g., chamber pressure at the end of filling cycle)
and remove some assumptions about chamber compliance that are necessary
when using a pressure estimate.
e. A plot of the relationship between resting chamber pressure and resting
chamber volume results in a curve similar to the resting length–tension curve
for the myocyte.
f. The slope of this curve at any point (change in volume over the change in
pressure at that point) is the compliance of the chamber at that point. The
pressure–volume curve is nonlinear, and its slope varies depending on
ventricular volume (Figs. 1.5 and 1.6). Ventricles become much less
compliant as sarcomere length surpasses 2.2 μm because of the collagen fiber
skeleton.
g. Nonischemic changes in compliance generally occur over long time periods.
However, ischemia can change ventricular compliance very quickly. Thick
ventricles, ventricles with scar formation, or ischemic ventricles have a lower
compliance than normal ventricles. Less compliant ventricles require a higher
pressure within them to contain equal volume (sarcomere length) as compared
to a more compliant ventricle.
h. While preload is most commonly considered in the left ventricle, it is
important in all four chambers. Both congenital heart disease and cardiac
tamponade can make that very apparent.
E. Ventricular work
1. For a sarcomere length between approximately 1.8 and 2.2 μm (preload) with a
given systolic myoplasmic Ca2+ concentration (contractility), the cardiac
myocyte will shorten, develop tension that increases with increased sarcomere
length, and eject blood from the ventricle to create a stroke volume (SV).
FIGURE 1.5 Idealized pressure–volume loop. Area within the loop represents LVSW. Dividing SV (Point B minus Point A
volumes) by BSA results in SVI. The area within this indexed loop is the LVSWI. P-V, pressure-volume; IV, intraventricular;
MV, mitral valve; LVESV, left ventricular end-systolic volume; LVEDP, left ventricular end-diastolic pressure; AV, aortic
valve; LVESP, left ventricular end-systolic pressure; LV, left ventricle; P, pressure; V, volume; EDV, end-diastolic volume;
ESV, end-systolic volume; SV, stroke volume.
2. 7 In ejecting this SV, the ventricle performs external work. This work
comprises raising intraventricular pressure from end-diastolic pressure to peak
systolic pressure. In the absence of valvular heart disease, the systolic left and
right ventricular pressures closely match those in the aorta and PA,
respectively.
FIGURE 1.6 The Starling curve. STIM, stimulation; Max., maximum.
3. Normal blood pressures (BPs) in the aorta and PA are not dependent on body
size and vary little among normal subjects. By normalizing SV to stroke volume
index (SVI) (SV divided by body surface area [BSA]), the variability of SVI
among subjects becomes relatively small.
4. Hydrodynamically, the external work of a ventricle is the area within the
pressure volume loop seen in Figure 1.5. The definitions of various points and
intervals are defined in the legend. This indexed work for the left ventricle
(LVSWI) is derived by multiplying the SVI in milliliters times the difference in
arterial mean pressure and ventricular pressure at the end of diastole
(commonly estimated as atrial pressure or PA wedge pressure) times a constant
(0.0136) to convert to clinical units:
LVSWI = SVI ∗ (SBP mean - LVEDP) ∗ 0.0136 (g m/m2)
5. The normal resting values for SVI and LVSWI are approximately 50 mL/m2 and
50 g m/m2, hence they are relatively easy to remember.
6. In performing this work, the efficiency of the ventricle (ratio of external work
done to energy consumed to do it) approaches that of a gasoline engine, which
is only 10%. This is an astonishingly inefficient process given that our lives
depend on it!
7. Since external work is the product of pressure difference and SV, work does
not distinguish between these two variables. Evidence suggests that the
ventricles can do volume work somewhat more efficiently (require less
oxygen) than pressure work. The reasoning may relate to how many actin–
myosin cycles are required to shorten a sarcomere to a given distance. The
hypothesis is that it takes fewer actin–myosin cycles to shorten the same
distance for volume work compared to pressure work. This principle may
explain an underlying reason for success using vasodilators to treat heart
failure.
F. Starling curve
1. For a given myoplasmic Ca2+ concentration (contractile state), varying the
sarcomere length between 1.9 and 2.2 μm increases the amount of external
work done. For a ventricle with a normal compliance, a sarcomere length of
2.2 μm corresponds to one with an LVEDP of 10 mm Hg.
2. By plotting the relationship of LVEDP with LVSWI, a Starling curve is
generated.
3. By changing the contractile state and replotting the same relationship, a new
curve develops, resulting in a family of Starling curves idealized in Figure 1.6.
G. Myocardial oxygen consumption
1. Except for very unusual circumstances, substrate for ATP and phosphocreatine
(PCr) production is readily available. Without external oxygen delivery, the
intracellular oxygen content is capable of keeping the heart contracting for
seconds. Carbohydrate and lipid stores can fuel the heart for almost an hour,
albeit very inefficiently and unsustainably. Hence, capillary blood flow is
crucial to maintain oxidative metabolism.
2. Myoglobin is an intracellular oxygen store. Its affinity for oxygen falls between
those for hemoglobin and cytochrome aa3. The maximum oxygen concentration
required in mitochondria for maximal ATP production is just 0.1 mm Hg
(Torr)! Myoglobin oxygen concentration is high enough to buffer interruptions
in capillary flow only for seconds. Compared to high-energy phosphate buffers,
this myoglobin buffer is small relative to their ATP consumption rates.
3. Nevertheless, myoglobin’s intermediate oxygen affinity enhances unloading of
oxygen from the red cell into the myocyte and also serves to distribute oxygen
within the cell.
4. Commonly atherosclerotic disease limits blood flow to regions of the heart,
reducing oxygen delivery and cell oxygen tension. When this PO2 falls below
0.1 Torr, ATP production decreases along with myocardial wall motion.
5. Capillaries are approximately 1 mm (1,000 μm) in length, apparently
regardless of the organ system in which they are located. In the heart a cardiac
myocyte is ∼12 μm in length, so each capillary supplies multiple cardiac
myocytes (∼1,000/12). In contrast, a skeletal muscle fiber (cell) is perhaps 150
mm long. Since capillary length is the same (1 mm), each skeletal muscle
capillary supplies a very small fraction of any given muscle cell (1/150 or
0.7%).
6. There are multiple levels of arteriolar structure. The lower-order, or initial,
arterioles contribute to systemic vascular resistance (SVR) and the higher-
order, or distal, arterioles regulate regional blood flow distribution at the local
level. The intricacies are beyond the scope of this chapter.
7. Capillary perfusion is organized so that several capillaries are supplied from a
single higher-order arteriole.
8. This structure yields regions of perfusion on the scale of mm3 for the regional
blood flow unit. Hence, the smallest volumes for “small vessel infarcts” should
be this order of magnitude. As the vessel occlusions become more proximal,
the infarct size grows.
9. Because length of cardiac myocytes is small relative to the capillary length,
infarction due to small vessel disease only affects local zones. If the cardiac
myocyte had a 15 cm length like a skeletal myocyte, the consequences of a local
infarct would affect the whole length and have a much larger impact.
10. Adequate production of ATP is dependent on mitochondrial function.
Approximately 30% of cardiac cell volume is occupied by mitochondria.
Given the substrate distribution and the ability to produce ATP within this
volume, oxygen availability is the limiting factor for maintaining ATP
availability. Mitochondria can maximally produce ATP when their cell PO 2 is
0.1 Torr!
11. Before ATP production is compromised, the entire oxygen difference from
ambient air—∼150 Torr—to 0.1 Torr—has already happened!
12. Phosphocreatine (PCr) is an intracellular buffer for ATP concentration. The
cell readily converts ATP into PCr and vice versa. PCr is an important energy
reserve and also serves to transport ATP between mitochondria and myosin
ATPase.
13. Myosin ATPase activity is responsible for 75% of myocardial ATP
consumption. The remaining 25% is consumed by Ca2+ transport into the SR
and across the sarcolemma.
14. The mitochondrion’s role in determining the response to ischemia is evolving.
Intracellular signaling pathways in response to hypoxia may direct the cell to
necrosis or even apoptosis.
VIII. Control systems
A. The space program put man in space. As importantly, it brought many technical
advances. In the world of systems development, control systems were central.
These systems allowed us to perform tasks in unexplored environments under
unimagined conditions. In simplest concept, they permitted real-time sensing of
system variables that resulted in regulation of system output. In the jargon, a
feedback loop is that portion of the system that takes signal from within the
system and returns that signal to a system input that in turn affects system output.
B. Circulating levels of Ca2+, thyroid hormones, antidiuretic hormone, and BP are
only a few of the system variables and/or outputs that utilize a feedback loop to
maintain a “normal blood level.” A feedback loop is referred to as a negative
feedback loop if a deviation of the system 8 output from the desired output,
called set point, is returned toward that set point through the system response to
that deviation. Blood levels of all of the above protein moieties are controlled
through negative feedback loop systems. In contrast, positive feedback loops
increase the deviation from the normal level in response to deviation. Outside the
physiology of the immune system, physiologic systems with positive feedback
loops are generally pathologic. As considered below, perhaps the most studied
biologic negative feedback loop is the cardiovascular system.
C. A simple example
1. A simple, manual system consists of a voltage source, a wall switch, and a light
bulb. The system turns electrical energy into light through manually turning a
light switch. Automation of this output would include a light detector (sensor)
that senses light level. If the ambient light level gets below a defined level, the
sensor sends a signal to a controller that turns the light bulb on and vice versa
for high light levels. A further refinement of this automated system is one that
keeps the light level constant at a defined light level (set point). In this negative
feedback system, light level is referred to as a regulated variable. If the light
level is above the set point, the constant light-level system (CLLS) does not
turn on the light and adjusts the blinds to reduce the amount of light. However,
when the light level gets below this set point, the CLLS controls the amount of
light coming from the blinds and would add a light bulb if needed such that the
light level at the light sensor remains constant. This control requires that the
output from the light bulb must vary. One way to vary the light output is to
control the voltage (input) to the light bulb. This new variable light bulb
intensity is referred to as an effector because it changes the response to meet
system requirements. The component of the system that regulates the voltage is
called the regulator. This CLLS system has a negative feedback loop because
CLLS increases light output if natural (or artificial) light decreases and vice
versa.
FIGURE 1.7 Diagram of a control system with a feedback loop. If the system response to a disturbance is to return the
regulated variable back to the original set point, the system is a negative feedback system. Many physiologic systems are
negative feedback systems.
2. The components of this CLLS consist of inputs to a light source (voltage),

effectors that can vary light levels (blinds, light bulb), a sensor that detects the
amount of light (a light detector), and a comparator that compares the signal
from the sensor to a set point (the light level at which the system turns on or
off). Finally, a controller, based on sensor input, varies the voltage to vary
blind openness and/or light bulb output. The controller is the combination of
the comparator and the regulator. Finally, the disturbances to the regulated
variable as well as other systems impacting that variable are schematized (Fig.
1.7).
3. To be complete, there are positive feedback systems as well. In a positive
feedback system, the response of the system increases the difference between
the regulated variable and a set point. When positive feedback occurs, the
system frequently becomes unstable and usually leads to system failure. In
physiology, typically pathology causes positive feedback. An example of this
pathology is the response of the cardiovascular system to hypotension in the
presence of coronary artery disease. Hypotension leads to a demand for an
increase in HR, SVR, and contractility. If the resulting increase in oxygen
consumption leads to ischemia, contractility will decrease, leading to further
demands that eventually result in system failure.
IX. The cardiovascular control system
A. The simple control system model can be used to develop a model of the
cardiovascular system. This model is useful if it predicts the system response to
system disturbances. Modified from Honig [Ref. 1, p. 249], components in Figure
1.6 can be broken down into sensor, controller, and effector functions. The
following discussion will summarize concepts for each function.
B. For the sensor functions, the two best-characterized sensors—the baroreceptors
in the carotid sinus and the volume and HR sensors in the right atrium—will be
outlined in detail.
C. Regulation of a variable is defined as the variable remaining fixed despite
changes in its determinants. The primary regulated variable in the cardiovascular
system is BP, the regulation of which occurs via a negative feedback loop.
D. Our survival requires a wide range of CO and SVR. Since BP changes only by
perhaps ±25% from our being asleep to maximal exercising, CO increasing is
offset by SVR decreasing and vice versa. The physiologic range for each is
approximately 4- to 6-fold.
CLINICAL PEARL Baroreceptors typically regulate BP within a range of ±25% as a
result of 4- to 6-fold variations in CO and SVR.
E. Individual organ survival is preserved as a consequence of system integration. It
is noted from above that a well-conditioned subject can increase CO 4-fold
while a sedentary person can only increase 2-fold. However, while running, his
blood flow to skeletal muscle must be 100-fold greater than its minimum value.
This apparent disparity—4-fold increase in CO but 100-fold increase to skeletal
muscle—can coexist because blood flow to other organs is reduced.
F. The brain is the site of the comparator and regulator. Together the comparator
and the regulator make up the controller. While anatomic sites for individual
comparator and regulator functions are known, the specifics of interaction of
these sites and regulation of control balance (what effector is utilized and how
much) are largely unknown.
G. For this review, details of the sympathetic and parasympathetic outputs will not
receive focus. As outputs from the controller, the nervous system signals
recruitment and derecruitment of the effectors in a predictable fashion through
release of norepinephrine (NOR) and acetylcholine (ACH) as indicated in Figure
1.8.
H. T he effectors of the cardiovascular system—heart, venous system, and
arterial system—respond to changes in system demand. Fundamentally, the
cardiovascular system must maintain BP in a normal range despite a wide range
of demand, for example, exercise, eating or limitations of effector reserves such
as dehydration and ischemic and valvular heart disease. To adapt, the effectors
have a range over which they can expand their capacities. Globally, each effector
has an expandable range known to physiologists as physiologic reserve.
I. Effective feedback control requires functioning sensors, a controller, and
effectors to have the desired effect—in this case regulation of BP. The
understanding of complexities and capacities of the sensors, comparators, and
effectors as well as system integration provides a clinical basis for reducing
surgical and anesthetic risk.
X. Stretch receptors: Pressure sensors
A. The simplified view of BP regulation presented herein is useful for organizing
priorities in maintaining BP. Integration of BP regulation is more complex and
requires meeting the demands of competing organs.
B. Excepting the splanchnic circulation, organs are organized in parallel with either
the aorta or PA as their source of BP and the respective veins as the collecting
system and reservoir.
C. As a consequence, blood flow to the individual organs can be locally adjusted
and/or centrally integrated. This organization allows for individual independent
organ perfusion while, or as long as, aortic or PA BP is maintained.
D. Additional sensor sites and variables sensed include systemic and pulmonary
veins, heart chambers with venous blood volumes, HR, SVR, and ventricular
volumes being sensed. Experiments looking at cardiovascular system responses
to isolated disturbance in these locations have demonstrated their existence.
E. All known pressure-sensitive sensors in the cardiovascular system are stretch
receptors. They respond to wall stretch and not container pressure. Hence,
compliance of the receptor site impacts receptor signal. Compliance pathology
becomes central to understanding disease of this aspect.
F. In addition to the volume of a chamber, the rate of change of that volume is
sensed and commensurate afferent signals are sent to the brain.
G. Consequently, depending on the sensor location, sensor signals provide data that
reflect BP, venous capacitance, SVR, ventricular contractility, SV, HR, and other
parameters. Most of the knowledge of these sensor sites is inferred from indirect
experiments.
XI. Atrial baroreceptors
A. Within the right atrium, there are receptors at the junction of the superior and
inferior venae cavae with the atrium (B fibers) and in the body of this atrium (A
fibers, Fig. 1.9). The corresponding impulses from the respective nerves are seen
on the left.
FIGURE 1.8 This simplified representation omits input to the brain from sensors throughout the vascular tree and the
ventricular chambers. As discussed in the text, there are multiple inputs to the brain not represented in this simplified view.
Input to the brain includes signals from sensors (receptors) that monitor blood volume, CO, SVR, and HR. Input to the
effectors occurs through the sympathetic and parasympathetic systems with neural transmitters indicated. NOR,
norepinephrine; ACH, acetylcholine; SA, sinoatrial. (Modified from Honig C. Modern Cardiovascular Physiology.
Boston/Toronto: Little, Brown and Company; 1981.)
B. A fibers, seen in both atria, generate impulses during atrial contraction,

indicating that they detect HR (Fig. 1.9).
C. B fibers are located only in the right atrium and impulses occur during systole
when the atrium is filling. Minimum frequency occurs as filling of the atrium
begins at the end of systole. Maximum frequency of B fiber impulses occurs just
prior to AV valve opening and this frequency is linearly proportional to right
atrial volume. B fibers detect atrial volume filling. When combined with A
fiber information, CO can be derived potentially.
FIGURE 1.9 The A fibers (stretch receptors) are located in the body of the atrium and fire during atrial contraction and
sense atrial contraction rate or HR. The B fibers (stretch receptors) are located at the intersection of the inferior vena cava
(IVC) and superior vena cava (SVC). Their neural signals occur during ventricular systole when the atria are filling. Hence,
they sense atrial volume. (From Honig C. Modern Cardiovascular Physiology. Boston/Toronto: Little, Brown and Company;
1981.)
D. The B receptor impulse rates (volume receptor) have adrenal, pituitary, and renal
effects. These effects form another negative feedback loop control system that
regulates volume in the long term through the adrenal–pituitary–renal axis.
E. In addition to these B fiber signals, results from system-oriented whole animal
experiments indicate that there are additional volume receptors throughout the
cardiovascular system. Not surprisingly, large systemic veins, pulmonary veins,
as well as right and left ventricles all have effects on the cardiovascular system
that are volume dependent. The observed effects on CO, SVR, and BP clearly
indicate that there is a control system that integrates these additional receptors to
maintain homeostasis.
XII. Arterial baroreceptors
A. The baroreceptors in the carotid sinus are the first described sensors of BP.
Additional arterial baroreceptors have been discovered in the pulmonary and
systemic arterial trees including a site in the proximal aorta.
B. “The carotid sinus baroreceptor monitors BP” is a rapid response to the common
question of where BP is sensed. However, the details of what is sensed in this
location are less frequently known [Ref. 1, p. 246].
C. Figure 1.10 shows signals from a single neural fiber emanating from the
baroreceptor. A step change in mean BP from 50 to 330 mm Hg is plotted along
with the neural discharge of the carotid sinus fiber. There is a change in the
neural frequency reflecting the step change in BP and then a leveling to a new
steady-state discharge rate, indicating a signal correlating with mean BP.
D. In Figure 1.11, the single neural fiber signal from a carotid sinus nerve can be
seen for a pulsatile “BP waveform.”
E. Different neural firing rates are present during the upstroke of BP (possibly
related to contractility), the dicrotic notch (possibly related to SVR in the
peripheral circulation), and down slope following the notch (possibly related to
SVR). Hence, the oscillatory shape of the BP waveform results in signals that
may contain more information than simply a BP.
F. The aortic baroreceptor is located near or in the aortic arch. Infrequently, cardiac
anesthesiologists can become acutely aware of its presence. When distorted
secondary to the placement of any aortic clamp, the resulting aortic baroreceptor
signal results in an acute and dramatic increase in BP. The presumed mechanism
is that the clamp distorts the aortic baroreceptor. This distortion results in a
signal that BP has precipitously fallen. Despite the fact that the carotid
baroreceptor has no such indication, hypertension ensues, thus representing
imperfect system integration. Immediately releasing a partial-occlusion clamp
(when possible) usually promptly returns the BP to a more normal level. When
release is not feasible, short, rapid-acting intervention—pharmacologic
vasodilation or reverse Trendelenburg positioning—is required.
FIGURE 1.10 The nerve discharge frequency (shown in blue) from the baroreceptor recording changed from ∼30
pulses/sec to 160 pulses/sec within 1 second after the response reached a steady state. Note that there was a transient
change during the rapid response phase as well.
G. Cardiovascular effectors
1. BP is the product of CO, or HR times SV, times SVR plus right atrial pressure
(RA):
FIGURE 1.11 Note the relationship between the upslope of arterial pressure (dP/dt), the downslope (SVR), and the notch
(SVR) and the action potential characteristics.
2. Organ perfusion is dependent on the difference between arterial pressure and

RA and organ resistance. For homeostasis, a focus on perfusion is important in
our view of BP.
3. The organs in the body are in parallel and the SVR is dependent on the
individual resistance in a simple way (1/SVR = Σ1/Ri where Ri is the value of
each individual organ in the systemic circulation). Clinicians seldom consider
the resistance of individual organs.
4. SV is dependent upon contractility, preload, and afterload [Eq. (1)].
Sympathetic tone sets contractility, preload, and SVR. The myoplasmic Ca 2+
concentration, the fraction of blood inside the thorax versus total blood volume,
and the SVR are all functions of sympathetic tone.
CLINICAL PEARL SV for both the right and left ventricles depends upon contractility,
preload, and afterload.
5. HR is dependent on the sympathetic tone as well.
XIII. Effectors and physiologic reserves for the healthy individual
A. The range that each of the effectors can contribute to maintaining BP through
increasing CO, changing SVR or shifting venous blood into or out of the thorax in
the face of everyday life requirements (sleeping to climbing a mountain) is
referred to as physiologic reserve.
B. Knowing the physiologic range for each effector gives a framework to consider
which reserves can be utilized to support BP in the OR.
C. Clinical situations in which additional physiologic reserves are not available
(because of pathology or exceeding a range) may increase risk and jeopardize
outcome.
D. Heart rate
1. A normal resting HR is perhaps 60 beats per minute (bpm). A maximum
attainable HR in a 25 year old would be 220, as compared to 170 in a 55 year
old. Hence, an average expansion factor is ∼2.5- to 3.5-fold.
2. The clinician must keep in mind that of the three main determinants of oxygen
demand—HR, contractility, and wall tension—HR correlated best with
ischemia in patients under anesthesia.
E. 9 Systemic Vascular Resistance
1. Within the systemic vascular tree, the organs in our body emanate from the
aorta or the PA (recognizing the lung and liver as more complex circulations).
This arrangement is referred to as organs in parallel.
2. Because of the large diameters of the normal aorta and PA, there is no
physiologically important decrease in mean BP along either of their lengths.
Consequently, each organ experiences the same mean BP. Through its own
resistance, the organ determines its blood flow.
3. In normal life, organ blood flow requirements are met without compromising
BP. Metabolic requirements (substrate supply, oxygen supply, and demand,
waste removal) are met through local adjustment of each organ’s own blood
flow.
4. The cardiovascular system maintains BP through its effectors via central
nervous system (CNS) control responding to the impact of local organ
resistance.
5. Looking at Equation (1), if BP is regulated, when SVR is high then CO must be
proportionately lower and vice versa. What is the observed range of SVR? For
a severely dehydrated person or one with a very bad left ventricle (have cared
for both), the cardiac index might be 33% of normal (1.2 LPM/M2 [Eq. (1)]).
The corresponding SVR would be three times the normal value (3,600 dyne
sec/cm5 [Eq. (1)]). For a well-trained athlete who, during maximal exercise,
would increase CO 7-fold, the SVR would be ∼15% of normal (∼200 dyne
sec/cm5 [Eq. (1)]).
F. Contractility
1. Contractility is not a commonly measured clinical variable because of the
difficulty in direct measurement due to the impact of afterload and preload on
its estimate. The clinician is left to estimate any changes.
2. A consequence of an increase in contractility is the ability to increase wall
tension in the left ventricle. This increased tension will lead to an increase in
ejection rate of blood from the ventricle and ejection fraction (EF) under
normal conditions. While there are differences in how trained and untrained
healthy subjects achieve the increase, both can increase LVEF from a value of
approximately 0.60 to one of approximately 0.80. This 33% increase in EF
contributes to a modest but important increase in CO.
G. Intravascular volume: Venous capacitance
1. Total blood volume can be estimated from body weight. In the ideal 70-kg
person, an estimate of blood volume is 70 mL/kg or about 5 L. This blood
volume is considered euvolemia.
2. The distribution of that volume between intrathoracic and extrathoracic (or
systemic) circulations is roughly 30% and 70%, respectively.
3. In each of these two compartments, approximately one-third of the blood is in
the arteries and capillaries and two-thirds are in the venous system.
4. The pulmonary veins hold 1,100 mL and the systemic veins hold 2,400 mL
(totaling about two-thirds of the blood volume).
5. Relaxation of venous tone increases venous capacity for blood. If there is no
change in blood volume, this decreases right atrial volume, which leads in turn
to decreases in volume in the other cardiac chambers.
6. Since atrial pressure equals ventricular end-diastolic pressure (VEDP),
returning those pressures to their original values requires infusion of volume.
When venous capacitance is at its largest, the amount of intravascular volume
required to return these volumes to their original values is referred to as the
venous capacitance reserve.
7. In addition to the blood volume defined as euvolemia, the intrathoracic and
extrathoracic compartments can expand by 30%, or approximately 300 and
1,200 mL, respectively.
8. 10 Thus, 1,500 mL of intravascular volume is a quantitative estimate of this
venous capacitance reserve for this 70-kg person.
9. This reserve intravascular volume, when added to a euvolemic blood volume
(5 L in a 70-kg subject), and the total intravascular volume would be 6.5 L.
10. While sustaining (i.e., “defending”) BP as the primary regulated variable,
maintaining CO in the face of any reduction in total blood volume, for example,
standing or hemorrhage, is another important task of the cardiovascular system.
Through shifting blood into the thoracic circulation from the systemic veins, the
sympathetic nervous system attempts to maintain pulmonary blood volume at
the expense of systemic volume. In the setting of reduced circulating blood
volume, protection of pulmonary blood volume coupled with increasing HR
and contractility defends BP maintenance.
11. Recognize that anesthetics, both regional and general, alter the ability of the
sympathetic nervous system to defend BP. In the presence of pathology,
understanding how individual anesthetics interfere with each of the reserves
may reduce the anesthetic risk through choosing the anesthetic approach that
preserves the most physiologic reserves.
12. In pathologic states that chronically elevate right- or left-sided atrial pressures,
venous dilation results in an increase in “euvolemic” blood volume.
13. Particularly in the systemic venous system, this increase in capacity can be
large. While there is no experimental data, anecdotal observations of mitral
valve patients going on cardiopulmonary bypass clearly demonstrate this fact.
However, the extent to which increased volumes can be recruited to maintain
intrathoracic volume in normal life, which is the key to maintaining preload,
remains unknown. For any patient, a portion of that additional volume is
available in circulatory emergencies (e.g., hemorrhage), but the intravascular
volume at the time of the emergency critically impacts this response.
14. Like hemorrhage, chronic diuresis leads to a contracted venous bed. Hence,
caring for patients who are chronically or acutely hypovolemic secondary to
diuresis must include understanding the state of their venous volume status
(capacitance).
15. Of note, chronic diuretic administration leads to venoconstriction. However, an
acute dose of furosemide will venodilate the patient with heart failure and
actually lower intrathoracic blood volume by shifting blood into the dilated
systemic veins.
H. Lymphatic circulation: A final reserve?
1. Interstitial space lies between the capillaries and intracellular space. Clinically
this system is rarely discussed except as part of the so-called “third spacing,”
but physiologically it plays a vital role. For our purposes, the lymphatic system
protects organs from edema. Its role in recruitment of volume in times of high
sympathetic tone—for example, severe hemorrhage—will be discussed.
2. The characteristics of this space help prevent fluid accumulation in two ways
—its low compliance and transport of fluid through the lymphatic conduits [2].
3. The collagen matrix is a gel and this structure results in the interstitial space
having a low compliance. Consequently, fluid entering the interstitial space
raises interstitial pressure rapidly (low compliance) and this increase in
interstitial pressure opposes further transudation of fluid across capillaries.
4. The lymphatics are tented open by a collagen matrix. Because of this tenting,
lymphatics are not compressed when the interstitium is edematous. On the
contrary, lymphatic diameter and drainage increase during edematous states.
5. This increased interstitial pressure also increases lymphatic drainage as the
higher interstitial pressure increases the pressure gradient between interstitial
space and right atrial pressure (the lymphatics drain into the systemic venous
system).
6. Consequently, more fluid leaves the interstitium via lymphatic drainage when
more fluid enters the lymphatics across the capillary.
7. Proteins pass across the capillary membrane although at markedly reduced
rates compared to water and solutes. With normal capillary integrity (e.g., no
inflammatory response), approximately 4% of intravascular proteins cross the
capillary membrane each hour.
8. Interstitial fluid exchange between capillary blood and interstitial space is
dynamic during the convective transport of blood down a capillary. Exchange
occurs as fluid leaves the capillary at the arteriole end and returns at the venous
end. The expansion factor for this exchange is approximately 8-fold. Hence,
crystalloid administration equilibrates across the vascular and interstitial
volumes rapidly (minutes). Colloid, if capillary integrity is intact, remains
longer (hours).
9. Remember that the time constant for colloids remaining intravascular can be
markedly reduced in the presence of the inflammatory response. The
inflammatory response is part of every surgical procedure.
10. With severe hemorrhage accompanied by maximal sympathetic stimulation,
interstitial and intracellular fluid may contribute up to 2.5 L of fluid to
intravascular volume [3]. While this recruitment of intracellular and
interstitial fluid compensates for intravascular depletion acutely, this depletion,
particularly of intracellular volume, does so at the expense of cell function.
This eventually induces cellular acidosis, which compromises cell function.
11. All three of these compartments—intracellular, interstitial, and intravascular—
have a dynamic relationship with equilibrium being reached in minutes after
volume administration, change in sympathetic tone, or administration of
vasoactive drugs.
12. Physiologists define the interstitial space as a fluid space outside the
intracellular and intravascular spaces that contains protein and solutes. Its
structural composition causes it to be a markedly noncompliant space. This
space equilibrates with the intracellular and intravascular spaces by
dynamically exchanging fluid, electrolytes, and proteins with both. This results
in a so-called “third space” volume that is very difficult to measure. The
clinical impact of this third space appears minimal in the average surgical case.
However, in severe hemorrhage as described above in H.10, failure to account
for its contribution to intravascular replenishment may lead to volume
underresuscitation. Since the inflammatory response during surgery affects the
integrity of all membranes, the normal equilibrium among intracellular,
intravascular, and interstitial fluid spaces changes. Most often, the
noncompliant nature of interstitial space likely minimizes its effects on fluid
homeostasis.
13. Under normal conditions minimal fluid accumulation occurs in space outside of
organs, referred to here as potential space. However, when fluid leaks out into
this potential space (a body cavity) due to reduced oncotic pressure or
capillary integrity, pathologic accumulations such as pleural effusions and/or
ascites can ensue. If fluid is removed from these spaces during surgery (e.g.,
opening the chest or abdomen), fluid from the adjacent organs will rapidly
replace this extra-organ fluid and subsequently reduce intravascular volume
and potentially induce hypotension.
14. In summary, for major hemorrhage, consideration of volume resuscitation
requirements must include intracellular, interstitial, intravascular, and potential
space compartments. Particularly when sympathetic tone is abruptly altered (as
can happen with induction of anesthesia), the extent of circulatory collapse may
be greater than anticipated as fluid within these compartments equilibrates at
the new level of sympathetic tone.
I. Brain: The controller
1. It is beyond the scope of this chapter, and to an extent of our knowledge, to
detail the neural pathways, interactive signaling, and psychological influences
on the cardiovascular system response. Accordingly, our brain as the controller
is considered a black box. In this view, this controller is designed to maintain
BP assuming that all the effectors are recruitable.
2. Making the controller a black box may be justifiable on another level. Although
system integration can be characterized for a given patient at the moment, the
pharmacology clinicians utilize affects system integration through direct and
indirect effects on effectors and perhaps on the controller and sensors as well.
Other medications affect the ability of the CNS to stimulate responses through
receptor or ganglion blockade. For anesthesiologists, in many situations, our
clinical management must replace system integration. By understanding the
pharmacology present and its effect on the cardiovascular system, clinical
judgment dictates a plan to control BP regulation. This control responsibility
must include temporizing and maintaining BP variability. Unable to rely on the
cardiovascular system alone, the clinician physiologist manipulates the effector
responses to maintain BP while remaining cognizant of the state (presence or
absence) of physiologic reserves in the face of upcoming disturbances.
3. Understanding the impact of patient comorbidities anticipates the limitations in
physiologic reserves and their availability for recruitment during stress.
Through goal-directed therapy, recognition of necessary compromises for
adjustment of anesthetic approach can reduce the risk of morbidity and
mortality.
4. One aspect of goal-directed therapy is fluid management. Per Gan et al., the
“cornerstone of Goal-directed Fluid Therapy is the use of an algorithm . . .
based on physiology and medical evidence . . .”
XIV. The cardiovascular system integration
A. In normal, healthy subjects (no disease or anesthetics present), the
cardiovascular system response to physiologic stress is predictable and
reproducible. In its simplest form, if BP is altered, the integrated system
response—sensors, controller, and effectors—senses the alteration and returns
BP toward the original set point. This negative feedback permits us to lead our
lives without considering the consequences or preparing for the disturbances to
this system. As each effector is recruited to regulate BP, it can contribute less to
compensating for an additional stress. It is easy to take the range and automaticity
of this system response for granted.
B. In healthy subjects, the utilization of reserves depends on training levels,
hydration status, and psychological state, among others. The compensatory limits
of healthy humans are set through a complex physio–psycho state that ends with
not being able to go on, that is, hitting the wall.
C. For patients, the response of effectors may be limited by effector pathology. The
most common limiting factor is ischemic heart disease.
D. To maintain BP in the face of hypotension the cardiovascular system responses
are predictable.
1. HR and contractility increase resulting in increased myocardial oxygen
consumption. Wall tension may be increased or decreased. Since HR is a
primary determinant of the onset of myocardial ischemia under anesthesia, its
elevation is of particular concern.
2. Oxygen supply response is complex. Assuming no blood loss or alteration of
oxygenation, increased HR leads to a reduction of diastolic time. Hence,
endocardial perfusion time will be reduced. A decrease in diastolic systemic
pressure may decrease the capillary perfusion pressure gradient (systemic
diastolic pressure minus LVEDP) depending on the impact of hypotension on
LVEDP.
3. Intervention: The anesthesiologist will most likely administer phenylephrine in
response to patient hypotension. SVR will increase, and blood volume will
shift from the systemic veins into the thoracic veins, increasing preload and
leading to an increase in SV. BP will rise, HR will fall, contractility will be
reduced, diastolic time will lengthen, and perhaps coronary perfusion pressure
will rise as well. However, remember that phenylephrine has a finite half-life
and that the BP response to it not only consumes physiologic reserves but also
may initiate renal compromise through reduced renal blood flow leading to
renal insufficiency. Consider using this half-life time to mitigate the cause of
the hypotension so that continued use of phenylephrine is unnecessary.
a. Response time required
(1) Responding to hypotension is an everyday occurrence for an anesthesia
provider. Defining hypotension is somewhat difficult. For normal
subjects, physiologists would arrive at a value of around a mean BP of
50 to 60 mm Hg for preservation of organ function. Induced (i.e.,
intentional) hypotensive anesthesia challenges that value, and data
indicate that a sitting position is different from a supine one. A prevalent
clinical definition of hypotension is “±25% of the preoperative value.”
Given patient anxiety in the immediate preoperative period, determining
that value is not always easy. Clinicians face this dilemma and must
resolve it intraoperatively.
(2) If a neuron goes without oxygen, it has a lifespan of minutes. Given that
reality, sacrificing all other organ functions to maintain BP is essential
on the time scale of minutes.
(3) For the kidney, even renal insufficiency created during surgery can
recover. Consequently, temporarily sacrificing renal perfusion may be
acceptable to protect the neuron. However, postoperative creatinine
increases of 0.3 mg/dL have been associated with increased mortality for
the next year. It remains unclear how long the kidneys can tolerate a
phenylephrine infusion without increasing creatinine concentration.
(4) For a cardiac myocyte, the time constant falls somewhere between
several minutes and several hours. The exact time constant is unclear for
an individual myocyte, but normally it certainly approaches an hour.
After 4 hours, the magic window for thrombolysis to be effective, 50%
of myocytes will survive. Therefore, compromising myocardial oxygen
supply and demand to preserve neurons is acceptable as a temporizing
measure.
(5) As an aside, cardiac anesthesiologists in the postbypass period are
confronted with BP management in the patient who frequently has a
history of hypertension, renal insufficiency, peripheral vascular disease,
and whose aorta has been recently cannulated (potentially increasing the
risk of rupture with even modest hypertension). Systolic pressures are
often kept under 100 mm Hg in this setting.
4. If 100 mm Hg should be lower than the magic 25%, how long will it take at that
pressure to cause damage? The answer is unclear, but such pressures are
routinely maintained way beyond a few minutes.
5. As outlined above, phenylephrine administration elicits a potentially adverse
physiologic impact if sustained. As the new controller of the sympathetic
system, the anesthesia provider needs to consider why the hypotension
occurred, if that reason is going to continue or get worse, how long the
remaining physiologic reserves can maintain homeostasis in the face of further
challenges, and finally the extent to which the ongoing management will
negatively affect renal function.
6. These considerations are crucial in determining the likelihood of sustained—
that is, through the course of the operation and the early postoperative period—
hemodynamic stability of the patient.
7. Frequently, volume management is critical to this decision. Consider that if,
instead of administering phenylephrine above, a volume challenge was
administered and the BP response was an increase, the oxygen demand and
supply benefits would remain. However, instead of consuming physiologic
reserves through phenylephrine use, the controller would be providing
physiologic reserves through increased venous capacitance and decreased
SVR, and perhaps improving renal blood flow to reduce the chance of renal
injury. The glycocalyx notwithstanding, sufficient fluid administration remains
a crucial part of anesthetic care. “Masking” hypovolemia with vasopressors
can lead to adversity!
8. Achieving the balance between the need for short-term intervention and long-
term stability is the responsibility of the controller, i.e., the provider’s brain,
during anesthesia.
CLINICAL PEARL Masking hypovolemia with vasopressors is potentially more
harmful than excessive fluid administration.
XV. Effect of anesthesia providers and our pharmacology on the cardiovascular
system
A. The surgical patient
1. White-coat hypertension is common. Some attribute this hypertension to the
fight-or-flight response necessary for survival! The perioperative period is
certainly a time of increased anxiety for many patients. In the context of their
cardiovascular system, the anxiety represents an input that most likely alters the
response at the controller level. Since non-white-coat hypertension may
contribute to cardiac-related complications perioperatively, a patient who is
hypertensive in the preoperative area will be given an anxiolytic as the first
step to determine if the elevated BP is chronic or not.
2. If the anxiolysis reduces the BP to the normal range, clinicians attribute the
hypertension to anxiety and proceed. If it does not, the hypertension is
attributed to an altered set point for BP and one must consider the risks and
benefits, as ill defined as they are, before proceeding.
B. The anesthetic choice
1. For a healthy patient, for low-risk surgery, numerous retrospective studies
suggest that, barring severe anesthetic overdose, in the presence of today’s
monitoring standards, anesthetic technique has little bearing on adverse patient
outcomes [4]. Low surgical risk in the setting of normal physiologic reserves
(HR, SVR, and venous volume) protects homeostasis to the extent that the
margin for error is great. Provocative statement? Perhaps, but the American
Society of Anesthesiologists closed claims database supports this view.
2. For the high-risk patient with comorbidities related to diabetes, vascular or
ischemic or valvular heart disease for high-risk surgery, consideration of their
physiologic cardiac reserves becomes extremely important. The entire
perioperative period subjects the patient to increased risk. Understanding the
consequences of the patient’s pathology on their physiologic reserves and use
of clinical management approaches to reduce the risk should influence the
anesthetic choice through goal-directed therapy [5].
3. In this chapter, physiologic reserves in the context of normal physiology were
presented. The principles related to ventricular function, determinants of
myocardial oxygen consumption, and physiologic reserves apply in the
pathologic situation as well.
4. Of all the physiologic reserves discussed, one reserve is minimally affected by
pathology during surgery and is not shown to affect outcomes adversely, except
perhaps for gastrointestinal (GI) surgery and major trauma. That reserve is
venous capacitance. Volume management constricts, replenishes, or expands
venous capacitance reserve. The principle that “An empty heart cannot pump
blood!!!” is true. In my personal experience as an anesthesiologist and as a
consultant to others, the number of patients resuscitated from hypovolemia far
exceeds the number who have incurred congestive heart failure from too much
fluid.
5. Incorporating fluid management into goal-directed therapy is of paramount
importance if we are to minimize risk for the patient with cardiovascular
disease.
C. Treating the cause: Goal-directed therapy
1. When clinical signs and symptoms do not agree with clinical judgment and their
conclusions, more data are necessary. Two very useful monitors in the setting
of unresponsive hypotension under general anesthesia may be the PA catheter
and the transesophageal echocardiography (TEE) examination.
2. The PA catheter has been both touted and maligned as a monitoring tool, but
continues to be used in cardiac surgery. Using physiologic and clinical
principles based on the PA catheter to guide management over an extended
perioperative period, Rao et al. [6] demonstrated reduced myocardial
reinfarction rates in patients undergoing noncardiac surgery. Many large
randomized clinical trials have not shown a benefit to PA catheter–guided
monitoring in critically ill patients (Sandham et al.: 1,994 patients; Warszawski
et al.: 676 patients; Harvey et al.: 1,041 patients [7–9]). While such definitive
randomized trial studies are still lacking in the context of cardiac surgery,
observational data indicate that not all cardiac surgery patients benefit from a
PA catheter [10].
3. A national survey demonstrated that clinicians did not understand or know how
to apply the physiologic principles underlying the interventions guided by PA
catheter data. Certainly, the mere presence of a PA catheter could not improve
outcome, in other words, “The yellow snake does no good when inserted” [11].
Its use is reserved for high-risk patients and needs to be accompanied by a
thorough understanding of its principles and technology, both in the OR and the
intensive care unit.
CLINICAL PEARL Many clinicians who use PA catheters lack adequate understanding
of the physiologic information provided by these catheters.
4. The ultrasound (TEE or other) probe is the optimal tool for assessing
ventricular volume status and regional wall motion abnormalities. An
experienced echocardiographer can assess the volume status of the ventricle
(intrathoracic blood volume) within a minute and almost as quickly can assess
ventricular systolic function. These two data elements provide immediate help
in clinical management of unresponsive hypotension. Particularly in a setting
where ventricular compliance can change rapidly (ischemia, acidosis, and
sepsis), filling pressures from the PA catheter may or may not reflect volume
status (actually more physiologically: sarcomere length or end-diastolic
volume) of the ventricles. TEE is an essential tool precisely because it more
accurately assesses cardiac preload under all conditions. As an example, TEE
can assess the state of venous capacitance through observation of the impact of
Trendelenburg and reverse Trendelenburg positions on diastolic volumes. With
increasing availability of three-dimensional echocardiography, real-time
echocardiographic measurement of CO becomes more and more accessible.
The availability of all physiologic reserves—HR, contractility, venous
capacitance—can then be assessed. A drawback to TEE monitoring is its
limited availability in the postoperative period (i.e., once the patient has been
awakened and extubated), hence transthoracic echocardiography (TTE) skills
can contribute importantly to intravascular volume assessment both before and
after surgery.
5. However, if the physiologic principles of preload, afterload, and contractility
are not well understood, then their application to a circulatory problem such as
hypotension will be unsound. There are two approaches to this problem: ignore
it or develop goal-directed protocols. Learning the principles of goal-directed
therapy can allow you to scientifically manage fluid therapy for most patients.
The detailed application of goal-directed therapy is complex and varied, and it
extends beyond the scope of this chapter. The studies of Walsh et al. [ 12] and
Hamilton et al. [13] demonstrate the complexity of this topic.
REFERENCES
1. Honig C. Modern Cardiovascular Physiology. Boston/Toronto: Little, Brown and
Company; 1981.
2. Mellander S, Johansson B. Control of resistance, exchange, and capacitance functions
in the peripheral circulation. Pharmacol Rev. 1968;20:117–196.
3. Mellander S. Comparative studies on the adrenergic neuro-hormonal control of
resistance and capacitance blood vessels in the cat. Acta Physiol Scand Suppl.
1960;50(176):1–86.
4. Neumann MD, Fleisher LA. Risk of anesthesia. In: Miller RD, Eriksson LI, Fleisher
LA, et al., eds. Miller’s Anesthesia. 8th ed, Philadelphia, PA: Elsevier Saunders;
2015:1056–1084.
5. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid
administration reduces length of hospital stay after major surgery.
Anesthesiology. 2002;97:820–826.
6. Rao TL, Jacobs KH, El-Etr AA. Reinfarction following anesthesia in patients with
myocardial infarction. Anesthesiology. 1983;59(6):499–505.
7. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use
of pulmonary-artery catheters in high-risk surgical patients. New Engl J Med.
2003;348:5–15.
8. Richard C, Warszowski J, Anguel N, et al. Early use of the pulmonary artery catheter
and outcomes in patients with shock and acute respiratory distress syndrome: a
randomized controlled trial. JAMA. 2003;290:2713–2720.
9. Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of
pulmonary artery catheters in management of patients in intensive care (PAC-Man): a
randomized controlled trial. Lancet. 2005;366:472–477.
10. Schwann NM, Hillel Z, Hoeft A, et al. Lack of effectiveness of the pulmonary
artery catheter in cardiac surgery. Anesth Analg. 2011;113:994–1002.
11. Iberti TJ, Fischer EP, Leibowitz AB, et al. A multicenter study of physicians’
knowledge of the pulmonary artery catheter. Pulmonary Artery Catheter Study
Group. JAMA. 1990;264(22):2928–2932.
12. Walsh SR, Tang TY, Farooq N, et al. Perioperative fluid restriction reduces
complications after major gastrointestinal surgery. Surgery. 2008;143(4):466–468.
13. Hamilton MA, Mythen MG, Ackland GL. Less is not more: a lack of evidence for
intraoperative fluid restriction improving outcome after major elective
gastrointestinal surgery. Anesth Analg. 2006;102(3):970–971.
2 Cardiovascular Drugs
Nirvik Pal and John F. Butterworth
I. Introduction
II. Drug dosage calculations
A. Vasoactive inotrope scoring
III. Drug receptor interactions
A. Receptor activation
IV. Pharmacogenetics and genomics
V. Guidelines for prevention and treatment of cardiovascular disease
A. CAD
B. CHF
C. Hypertension
D. Atrial fibrillation prophylaxis
E. Resuscitation of patients in cardiac arrest after cardiac surgery
F. Resuscitation after cardiopulmonary arrest
VI. Vasopressors
A. α-Adrenergic receptor pharmacology
B. Vasopressin pharmacology and agonists
C. Angiotensin II
VII. Positive inotropic drugs
A. Treatment of low CO
B. cAMP-dependent agents
C. cAMP-independent agents
VIII. β-Adrenergic receptor–blocking drugs
A. Actions
B. Advantages of β-adrenergic–blocking drugs
C. Disadvantages
D. Distinguishing features of β-blockers
E. Clinical use
IX. Vasodilator drugs
A. Comparison
B. Specific agents
X. Calcium channel blockers
A. General considerations
B. Clinical effects common to all CCBs
C. Specific intravenous agents
XI. Pharmacologic control of HR and rhythm
A. Overview of antiarrhythmic medications
B. Supraventricular arrhythmias
XII. Diuretics
A. Actions
B. Adverse effects
C. Specific drugs
XIII. Pulmonary hypertension
KEY POINTS
1. Drug errors are a common cause of accidental injury to patients.

The authors suggest referring to drug package inserts or the
Physicians’ Desk Reference to check any unfamiliar drug before it is
prescribed or administered.
2. Generic sterile, injectable drugs represent a “low margin” product
line for manufacturers so these agents are subject to periodic
shortages when one of the few manufacturers has production issues.
3. Patients undergoing cardiac surgery may quickly recover from the
need for drug support, unlike patients with chronic heart failure
(CHF) receiving the identical drug(s).
4. Hemodynamic improvement has been well established with usage of
vasoactive and inotropic medications but overall survival outcomes
are still a matter of much debate and research.
5. Vasoactive drugs are often combined to offset unneeded side effects
(e.g., milrinone + phenylephrine) or to take advantage of sequential
steps in a biochemical pathway (epinephrine + milirinone).
I. Introduction
Numerous potent drugs are used to control heart rate (HR) and rhythm, blood
pressure (BP), and cardiac output (CO) before, during, and after surgery. Patients
undergoing cardiovascular and thoracic operations are particularly likely to
receive one of these agents. This chapter reviews the indications, mechanisms,
dosing, drug interactions, and common adverse events for these drugs. Drug errors
are common causes of accidental injury to patients, particularly in hospitalized,
critically ill patients. Therefore, we suggest that the package insert or Physicians’
1 Desk Reference [1] (which contains the package insert information) be
consulted before any unfamiliar drug is prescribed or administered [2].
Fortunately, it has never been easier to obtain drug information. Convenient
sources of drug information include numerous books and websites, some of which
are provided at the end of this chapter [2,3]. Using a “smart” mobile telephone,
many physicians now maintain a readily updated library of drug information in
their 2 hand or pocket at all times. Note, that generic sterile, injectable drugs
represent a “low margin” product line for manufacturers so these agents are subject
to periodic shortages when one of the few manufacturers has production issues.
II. Drug dosage calculations
1. Drugs are administered in increments of weight or units. Unfortunately, drugs are
not labeled in a uniform manner. Dilution of drugs and calculations are often
necessary. Fortunately, most modern infusion pumps do these calculations for the
operator, limiting the opportunity for mistakes.
2. To determine the dose rate (μg/min): Calculate the desired per-minute dose.
Example: A 70-kg patient who is to receive dopamine at 5 μg/kg/min needs a
350 μg/min dose rate.
3. To determine the concentration (μg/mL): Calculate how many micrograms of
drug are in each milliliter of solution. To calculate concentration (μg/mL),
simply multiply the number of milligrams in 250 mL by 4.
4. To determine the volume infusion rate (mL/min): Divide the dose rate by the
concentration (μg/min ÷ μg/mL = mL/min). The infusion pump should be set for
this volume infusion rate.
A. Vasoactive inotrope scoring [4–6]
Common clinical practice is to have patients receive multiple vasopressors and
inotropes to achieve maximal clinical benefit while minimizing side effects from
the medications. In order to achieve equivalence or “common grounds” for
clinical assessment and progress vasoactive inotrope score was used which has
been extended with addition of newer medications in this class.
III. Drug receptor interactions
A. Receptor activation
Can responses to a given drug dose be predicted? The short answer is: Partially.
The more accurate answer is: Not with complete certainty. Many factors
determine the magnitude of response produced by a given drug at a given dose.
1. Pharmacokinetics relates the dose to the concentrations that are achieved in
plasma or at the effect site. In brief, these concentrations are affected by the
drug’s volume of distribution and clearance, and for drugs administered orally,
by the fractional absorption [7].
2. Pharmacodynamics relates drug concentrations in plasma or at the effect site
to the drug effect.
a. Concentration of drug at the effect site (receptor) is influenced by the
concentration of drug in plasma, tissue perfusion, lipid solubility, and protein
binding; diffusion characteristics, including state of ionization (electrical
charge); and local metabolism.
b. Number of receptors per gram of end-organ tissue varies.
(1) Upregulation (increased density of receptors) is seen with a chronic
decrease in receptor stimulation. Example: Chronic administration of β-
adrenergic receptor antagonists increases the number of β-adrenergic
receptors.
(2) Downregulation (decreased density of receptors) is caused by a chronic
increase in receptor stimulation. Example: Chronic treatment of asthma
with β-adrenergic receptor agonists reduces the number of β-adrenergic
receptors.
c. Drug receptor affinity and efficacy may vary.
(1) Receptor binding and receptor activation by an agonist produces a
biochemical change in the cell. Example: α-Adrenergic receptor agonists
increase protein kinase C concentrations within smooth-muscle cells. β-
Adrenergic receptor agonists increase intracellular concentrations of
cAMP.
(2) The biochemical change may produce a cellular response. Example:
Increased intracellular protein kinase C produces an increase in
intracellular [Ca2+], which results in smooth-muscle contraction.
Conversely, increased intracellular concentrations of cAMP relax
vascular smooth muscle but increase the inotropic state of cardiac
muscle.
(3) The maximal effect of a partial agonist is less than the maximal effect of a
full agonist.
(4) 3 Receptor desensitization may occur when prolonged agonist
exposure to receptor leads to loss of cellular responses with agonist–
receptor binding. An example of this is the reduced response to β1-
adrenergic receptor agonists that occurs in patients with chronic heart
failure (CHF), as a result of the increased intracellular concentrations of
β-adrenergic receptor kinase, an enzyme which uncouples the receptor
from its effector enzyme adenylyl cyclase.
(5) Other factors including acidosis, hypoxia, and drug interactions can
reduce cellular response to receptor activation.
IV. Pharmacogenetics and genomics
In the future, pharmacogenetics, or how drug actions or toxicities are influenced by
an individual’s genetic make-up, may become a tool in helping anesthesiologists
select among therapeutic options. The genetic profile of an individual may impact
the degree to the patients will respond to adrenergic therapies, including
vasopressors. Life-threatening arrhythmias, such as long QT syndrome, may result
from therapy with a number of commonly prescribed agents, and relatively
common genetic sequence variations are now known to be an underlying
predisposing factor. Droperidol, which is highly effective and safe at small doses
for preventing or treating postoperative nausea, has been shown (at larger doses)
to cause QT-interval lengthening and increase risk of Torsades de Pointes in a
small cohort of susceptible patients. Therefore, a larger number of patients will be
deprived of this useful medication because of our inability to identify a small
number of patients who have the genetic predisposition for this rare but disastrous
complication. Industry and academia are rapidly progressing toward simple assay-
based genetic screens capable of identifying patients with these and other risks for
adverse or inadequate drug responses, including heparin or warfarin resistance.
Unfortunately, at the present time, commercially available screens are rare and
have not been sufficiently evaluated to be considered the standard care. As such,
detailed family history is the only practical means through which we can identify
such genetic risks. At the same time, genetic variations may occur spontaneously or
be present in a family but not be manifested with symptoms (phenotypically silent).
Hence, continuous monitoring for adverse or highly variable drug responses,
particularly those related to arrhythmias or BP instability, is the cornerstone of
cardiovascular management in the perioperative period.
V. Guidelines for prevention and treatment of cardiovascular disease
Drug treatment and drug prevention for several common cardiovascular diseases
have been described in clinical practice guidelines published by national and
international organizations. We provide references for the convenience of our
readers. Because these recommendations evolve from year to year, we strongly
recommend that readers check whether these guidelines may have been updated
since publication of this volume.
A. Coronary artery disease
1. Primary prevention (see Refs. [8–12])
2. Established disease (see Refs. [13–15])
3. Preoperative cardiac evaluation and prophylaxis during major surgery (see
Refs. [16–20])
B. CHF (see Refs. [21–24])
C. Hypertension (see (Ref. [8])
D. Atrial fibrillation prophylaxis (see Ref. [25])
E. Resuscitation of patients in cardiac arrest after cardiac surgery (see Ref.
[26])
F. Resuscitation after cardiopulmonary arrest (see Ref. [27])
VI. Vasopressors
A. α-Adrenergic receptor pharmacology (Fig. 2.1)
1. Postsynaptic α-adrenergic receptors mediate peripheral vasoconstriction (both
arterial and venous), especially with neurally released norepinephrine (NE).
Selective activation of cardiac α-adrenergic receptors increases inotropy while
decreasing the HR. (Positive inotropy from α-adrenergic agonists can only be
demonstrated in vitro or by selective drug administration in coronary arteries to
avoid peripheral effects that normally overwhelm the cardiac actions.)
FIGURE 2.1 Schematic representation of the adrenergic receptors present on the sympathetic nerve terminal and vascular
smooth-muscle cell. NE is released by electrical depolarization of the nerve terminal; however, the quantity of NE release is
increased by neuronal (presynaptic) β2-receptor or muscarinic–cholinergic stimulation and is decreased by activation of
presynaptic α2-receptors. On the postsynaptic membrane, stimulation of α1- or α2-adrenergic receptors causes vasoconstriction,
whereas β2-receptor activation causes vasodilation. Prazosin is a selective α1-antagonist drug. Note that NE at clinical
concentrations does not stimulate β2-receptors, but epinephrine (E) does. (From Opie LH. The Heart: Physiology from the Cell
to the Circulation. Philadelphia, PA: Lippincott Williams & Wilkins; 1998:17–41, with permission.)
2. α-Adrenergic receptors on presynaptic nerve terminals decrease NE release
through negative feedback. Activation of brain α-adrenergic receptors (e.g.,
with clonidine) lowers BP by decreasing sympathetic nervous system activity
and causes sedation (e.g., with dexmedetomidine). Postsynaptic α2-adrenergic
receptors mediate constriction of vascular smooth muscle.
3. Drug interactions
a. Reserpine interactions. Reserpine depletes intraneuronal NE and chronic use
induces a “denervation hypersensitivity” state. Indirect-acting
sympathomimetic drugs show diminished effect because of depleted NE
stores, whereas direct-acting or mixed-action drugs may produce exaggerated
responses because of receptor upregulation. This is of greater laboratory than
clinical interest because of the rarity with which reserpine is now prescribed
to patients, but it illustrates an important concept about indirect-acting
adrenergic agents.
b. Tricyclic (and tetracyclic) or antidepressant and cocaine interactions. The
first two categories of drugs block the reuptake of catecholamines by
prejunctional neurons and increase the catecholamine concentration at
receptors. Interactions between these drugs and sympathomimetic agents can
be very severe and of comparable or greater danger than the widely feared
monoamine oxidase (MAO) inhibitor reactions. In general, if
sympathomimetic drugs are required, small dosages of direct-acting agents
represent the best choice.
4. Specific agents
a. Selective agonists
(1) Phenylephrine (Neo-Synephrine) [28]
(a) Phenylephrine is a synthetic noncatecholamine.
(b) Actions. The drug is a selective α1-adrenergic agonist with minimal
β-adrenergic effects. It causes vasoconstriction, primarily in
arterioles.
(c) Offset occurs by redistribution and rapid metabolism by MAO;

there is no catechol O-methyltransferase (COMT) metabolism.
(d) Advantages. A direct agonist with short duration (less than 5
minutes), it increases perfusion pressure for the brain, kidney, and
heart in the presence of low SVR states. When used during
hypotension, phenylephrine will increase coronary perfusion
pressure without altering myocardial contractility. If hypertension is
avoided, myocardial oxygen consumption (MVO2) does not increase
substantially. If contractility is depressed because of ischemia,
phenylephrine will sometimes produce an increased CO from an
increase in coronary perfusion pressure. It is useful for correcting
hypotension in patients with CAD, hypertrophic subaortic stenosis,
tetralogy of Fallot, or valvular aortic stenosis.
(e) Disadvantages. It may decrease stroke volume (SV) and CO
secondary to increased afterload; it may increase pulmonary
vascular resistance (PVR); it may decrease renal, mesenteric, and
extremity perfusion. Reflex bradycardia, usually not severe, may
occur but will usually respond to atropine. Phenylephrine rarely
may be associated with coronary artery spasm or spasm of an
internal mammary, radial, or gastroepiploic artery bypass graft.
(f) Indications for use
(i) Hypotension due to peripheral vasodilation, low SVR states
(e.g., septic shock, or to counteract effects of nitroglycerin).
(ii) For patients with supraventricular tachycardia (SVT), reflex
vagal stimulation in response to increased BP may terminate
the arrhythmia; phenylephrine treats both the hypotension and
arrhythmia.
(iii) It can oppose right-to-left shunting during acute cyanotic spells
in tetralogy of Fallot.
(iv) Temporary therapy of hypovolemia until blood volume is
restored, although a drug with positive inotropic action (e.g.,
ephedrine or epinephrine) usually is a better choice in patients
without CAD (or hypertrophic obstructive cardiomyopathy),
and in general, vasoconstrictors should not be viewed as
effective treatments for hypovolemia.
(g) Administration. Intravenous (IV) infusion (central line preferable)
or IV bolus
(h) Clinical use
(i) Phenylephrine dose
(a) IV infusion: 0.5 to 10 μg/kg/min.
(b) IV bolus: 1 to 10 μg/kg, increased as needed (some patients
with peripheral vascular collapse may require larger bolus
injections to raise SVR).
(c) For tetralogy of Fallot spells in children: 5 to 50 μg/kg IV
as a bolus dose.
(ii) Mixing
(a) IV infusion: Often mix 10 or 15 mg in 250 mL IV fluid (40
or 60 μg/mL).
(b) IV bolus: Dilute to 40 to 100 μg/mL.
(iii) Nitroglycerin may be administered while maintaining or
increasing arterial BP with phenylephrine. This combination
may serve to increase myocardial oxygen supply while
minimizing increases in MVO2.
(iv) Phenylephrine is the vasopressor of choice for short-term
correction of excessive vasodilation in most patients with
CAD or aortic stenosis.
CLINICAL PEARL Phenylephrine can be used for hypotension related to low SVR states,
but only as a temporizing therapy for hypovolemia.
b. Mixed agonists
(1) Dopamine (Intropin) [28]
See Section VII.
(2) Ephedrine
(a) Ephedrine is a plant-derived alkaloid with sympathomimetic
effects.
(b) Actions
(i) Mild direct α-, β1-, and β2-adrenergic agonists
(ii) Indirect NE release from neurons
(c) Offset. Five to 10 minutes IV; no metabolism by MAO or COMT;
renal elimination
(d) Advantages
(i) Easily titrated pressor and inotrope that rarely produces
unexpected excessive responses
(ii) Short duration of action with IV administration (3 to 10
minutes); lasts up to 1 hour with intramuscular (IM)
administration
(iii) Limited tendency to produce tachycardia
(iv) Does not reduce blood flow to placenta; safe in pregnancy
(v) Good agent to correct sympathectomy-induced relative
hypovolemia and decreased SVR after spinal or epidural
anesthesia
(e) Disadvantages
(i) Efficacy is reduced when NE stores are depleted.
(ii) Risk of malignant hypertension with MAO inhibitors or
cocaine
(iii) Tachyphylaxis with repeated doses (thus rarely administered
by continuous infusion)
(f) Indications
(i) Hypotension due to low SVR or low CO, especially if HR is
low, and particularly with spinal or epidural anesthesia
(ii) Temporary therapy of hypovolemia until circulating blood
volume is restored, although, as previously noted, in general
vasoconstrictors should not substitute for definitive treatment
of hypovolemia
(g) Administration. IV, IM, subcutaneous (SC), by mouth (PO)
(h) Clinical use
(i) Ephedrine dose: 5 to 10 mg IV bolus, repeated or increased as
needed; 25 to 50 mg IM.
(ii) Ephedrine is conveniently mixed in a syringe (5 to 10 mg/mL)
and can be given as an IV bolus into a freely running IV line.
(iii) Ephedrine is a useful, quick-acting, titratable IV pressor that
can be administered via a peripheral vein during anesthesia.
(3) Epinephrine (Adrenaline)
See subsequent Section VII: Positive inotropic drugs.
(4) NE (noradrenaline, Levophed) [28,29]
(a) NE is the primary physiologic postganglionic sympathetic
neurotransmitter; NE is also released by adrenal medulla and
central nervous system (CNS) neurons.
(b) Actions
(i) Direct α1- and α2-adrenergic actions and β1-adrenergic agonist
action
(ii) Limited β2-adrenergic effect in vivo, despite NE being a more
powerful β2-adrenergic agonist than dobutamine in vitro
(c) Offset is by redistribution, neural uptake, and metabolism by MAO

and COMT.
(d) Advantages
(i) Direct adrenergic agonist. Equipotent to epinephrine at β1-
adrenergic receptors
(ii) Redistributes blood flow to brain and heart because all other
vascular beds are constricted.
(iii) Elicits intense α1- and α2-adrenergic agonism; may be effective
as vasoconstrictor when phenylephrine (α1 only) lacks
efficacy
(e) Disadvantages
(i) Reduced organ perfusion: Risk of ischemia of kidney, skin,
liver, bowel, and extremities
(ii) Myocardial ischemia possible; increased afterload, HR.
Contractility may increase, be unchanged, or even decrease.
Coronary spasm may be precipitated.
(iii) Pulmonary vasoconstriction
(iv) Arrhythmias
(v) Risk of skin necrosis with SC extravasation
(f) Indications for use
(i) Peripheral vascular collapse when it is necessary to increase
SVR (e.g., septic shock or “vasoplegia” after
cardiopulmonary bypass [CPB])
(ii) Conditions in which increased SVR is desired together with
cardiac stimulation
(iii) Need for increased SVR in which phenylephrine has proved
ineffective
(g) Administration. IV only, by central line only
(h) Clinical use
(i) Usual NE starting infusion doses: 15 to 30 ng/kg/min IV (adult);
usual range, 30 to 300 ng/kg/min.
(ii) Minimize duration of use; monitor patient for oliguria and
metabolic acidosis.
(iii) NE can be used with vasodilator (e.g., sodium nitroprusside or
phentolamine) to counteract α-stimulation while leaving β1-
adrenergic stimulation intact; however, if intense
vasoconstriction is not required, we recommend that a
different drug be used.
(iv) For treating severe right ventricular (RV) failure associated
with cardiac surgery, the simultaneous infusion of NE into the
left atrium (through a left atrial catheter placed
intraoperatively) plus inhaled nitric oxide (NO) and/or
nitroglycerin by IV infusion is useful. The left atrial NE
reaches the systemic vascular bed first and it is largely
metabolized peripherally before it reaches the lung where it
might increase PVR (had the NE been infused through a
venous line) (Table 2.1).
CLINICAL PEARL Epinephrine is a direct α1- and α2- and β1- and β2-agonists not
dependent on release of endogenous NE. In the setting of a dilated left ventricle (LV) and
myocardial ischemia, epinephrine may increase coronary perfusion pressure and reduce
ischemia.
(5) Interactions with MAO inhibitors
(a) MAO is an enzyme that deaminates NE, dopamine, and serotonin.
Thus, the MAO inhibitors treat severe depression by increasing
catecholamine concentrations in the brain by inhibiting
catecholamine breakdown. Administration of indirectly acting
adrenergic agonists or meperidine to patients taking MAO inhibitors
can produce a life-threatening hypertensive crisis. Ideally, 2 to 3
weeks should elapse between discontinuing the hydrazine MAO
inhibitor phenelzine and elective surgery. Nonhydrazine MAO
inhibitors (isocarboxazid, tranylcypromine) require 3 to 10 days for
offset of effect. Selegiline at doses 10 mg or less per day should
present fewer adverse drug interactions than other MAO inhibitors.
TABLE 2.1 Acute treatment of pulmonary hypertension and RV failure
(b) The greatest risk of inducing a hyperadrenergic state occurs with

indirect-acting sympathomimetic drugs (such as ephedrine), because
such agents release the intraneuronal stores of NE that were
increased by the MAO inhibitor. Because dopamine releases NE, it
should be initiated with caution in the MAO-inhibited patient.
(c) In MAO-inhibited patients, preferred drugs are those with purely
direct activity: epinephrine, NE, isoproterenol, phenylephrine,
vasopressin, and dobutamine. All pressor drugs should be used
cautiously, in small dosages with BP monitoring and observation of
the electrocardiogram (ECG) for arrhythmias.
B. Vasopressin pharmacology and agonists [30–34]
1. Actions
a. Vasopressin is an endogenous antidiuretic hormone that in high concentrations
produces a direct peripheral vasoconstriction through activation of smooth-
muscle V1 receptors. Vasopressin has no actions on β-adrenergic receptors,
so it may produce less tachycardia than epinephrine when used for
resuscitation after cardiac arrest. Vasopressin has been administered intra-
arterially in a selective fashion to control gastrointestinal bleeding.
b. Vasopressin produces relatively more vasoconstriction of skin, skeletal
muscle, intestine, and adipose tissue than of coronary or renal beds.
Vasopressin causes cerebrovascular dilation.
2. Advantages
a. Vasopressin is a very potent agent which acts independently of adrenergic
receptors.
b. Some studies suggest that vasopressin may be effective at maintaining
adequate SVR in severe acidosis, sepsis, or after CPB, even when agents such
as phenylephrine or NE have proven ineffective.
c. Vasopressin may restore coronary perfusion pressure after cardiac arrest
without also producing tachycardia and arrhythmias, as is common when
epinephrine is used for this purpose. However, current guidelines make
vasopressin a second order choice after epinephrine for cardiac arrest.
3. Disadvantages
a. Vasopressin produces a variety of unpleasant signs and symptoms in awake
patients, including pallor of skin, nausea, abdominal cramping,
bronchoconstriction, and uterine contractions.
b. Decreases in splanchnic blood flow may be of concern in patients receiving
vasopressin for more than a few hours, particularly when vasopressin is
coadministered with agents such as α-adrenergic agonists and positive
inotropic drugs. Increases in serum concentrations of bilirubin and of “liver”
enzymes are common.
c. Vasopressin may be associated with a decrease in platelet concentration.
d. Lactic acidosis is common in patients receiving vasopressin infusion (but
these patients are generally critically ill and already receiving other
vasoactive agents).
4. Clinical use
a. Vasopressin has been used as an alternative to epinephrine in treating
countershock-refractory ventricular fibrillation (VF) in adults. The 2015
American Heart Association (AHA) Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science [27] states that
there is no evidence that substitution of vasopressin for epinephrine during
resuscitation has benefit. The typical vasopressin resuscitation dose is 40
units as an IV bolus.
b. Vasopressin has been used in a variety of conditions associated with
vasodilatory shock, including sepsis, the “vasoplegic” syndrome after CPB,
and for hypotension occurring in patients receiving ACE inhibitors (or
angiotensin receptor blockers [ARB]) and general anesthesia. Typical adult
doses range from 4 to 6 units/hr. We have found this drug to be effective and
useful, but sometimes associated with troublesome metabolic acidosis. We
speculate that the latter may be the result of inadequate visceral perfusion.
c. Vasopressin is also used for diabetes insipidus as antidiuretic hormone
replacement. Oftentimes intranasal route is utilized for that.
d. Clinical perspective [32]:
4 Russell in his editorial compares and contrasts the results of three trials
VASST, VANISH, VANCS (see reference above). The primary end-points in
VASST was 28-day mortality, VANISH was kidney failure free days, and in
VANCS was mortality and severe complications. VASST and VANISH were
for septic shock whereas VANCS was for cardiac surgery–related
vasoplegia. Outcome benefits in primary end-points were seen in VANCS,
probably attributed to “lower” serum levels of vasopressin whereas no
outcome benefit in primary end-points were seen in the other two trials. Also,
at the cellular level it may be hypothesized that this may be due to difference
in interaction of macro-circulation versus the micro-circulation, with the
macro-circulation showing improvement in hemodynamics while the micro-
circulation experiencing increased oxygen debt and injury to the glycocalyx
with addition of vasopressors in the presence of inflammatory cytokines.
C. Angiotensin II [35–37]
Action: Naturally occurring vasopressor as part of the renin–angiotensin–
aldosterone–system (RAAS). During distributive shock, especially sepsis, it has
been seen that there is synergistic downregulation of angiotensin receptor (AT-
R1, AT-R2) by local release of nitric oxide (NO) and other proinflammatory
cytokines. Exogenous angiotensin II acts on these receptors and plays a role in
repleting and countering this effect and maintaining the vascular tone of the
macro-circulation thus improving hemodynamics.
Dose: 0.02 micrograms/kg/min to maximum of 0.04 micrograms/kg/min, titrate
to effect of mean arterial pressure (MAP) between 65 and 75 mm Hg [35]
Side effects: Improves macro-circulation improving hemodynamics but may
adversely affect micro-circulation at higher doses.
VII. Positive inotropic drugs
A. Treatment of low CO [28,38–41]
1. Goals. Increase organ perfusion and oxygen delivery to tissues.
a. Increase CO by increasing SV, HR (when appropriate), or both.
b. Maximize myocardial oxygen supply (increase diastolic arterial pressure,
diastolic perfusion time, and blood O2 content; decrease left ventricular end-
diastolic pressure [LVEDP]).
c. Provide an adequate MAP for perfusion of other organs.
d. Minimize increases in myocardial oxygen demand by avoiding tachycardia
and LV dilation.
e. Metabolic disturbances, arrhythmias, or cardiac ischemia, if present, should
be treated concurrently.
f. Drug treatment of critically ill patients with intrinsic myocardial failure may
include the following cardiac stimulants:
(1) β1-Adrenergic stimulation
(2) Phosphodiesterase (PDE) inhibition
(3) Dopaminergic stimulants
(4) Calcium sensitizers (increase calcium sensitivity of contractile proteins)
(5) Digoxin
2. Monitoring. Positive inotropic drug dosing is most effectively regulated using
data from the arterial line, a monitor of CO, and/or echocardiography. In
addition, monitoring of mixed venous oxygen saturation can be extremely
valuable. The inotropic drug dosage can be titrated to CO and BP endpoints,
together with assessment of organ perfusion, for example, urine output and
concentration.
B. cAMP-dependent agents
1. β-Adrenergic and dopaminergic receptor agonists
a. Similarities among sympathomimetic drugs
(1) β1-Agonist effects are primarily stimulatory.
(2) β2-Agonists cause vasodilation and bronchodilation, and they also

increase HR and contractility (albeit with less potency than β1-agonists).
(3) Postsynaptic dopaminergic receptors mediate renal and mesenteric
vasodilation, increase renal salt excretion, and reduce gastrointestinal
motility. Presynaptic dopaminergic receptors inhibit NE release.
(4) Diastolic ventricular dysfunction. Cardiac β-receptor activation
enhances diastolic ventricular relaxation by facilitating the active,
energy-consuming process that pumps free intracellular Ca2+ into storage
sites. Abnormal relaxation occurring in ischemia and other myocardial
disorders leads to increased diastolic stiffness. By augmenting diastolic
relaxation, β-adrenergic receptor agonists reduce LVEDP and heart size
(LV end-diastolic volume [LVEDV]), improve diastolic filling, reduce
left atrial pressure (LAP), and improve the myocardial oxygen supply–
demand ratio.
(5) Systolic ventricular dysfunction. More complete ventricular ejection
during systole will reduce the LV end-systolic volume. This reduces
heart size, LV systolic wall tension (by Laplace’s law), and MVO2.
(6) Myocardial ischemia. The net effects of β-receptor stimulation on
myocardial O2 supply and demand are multifactorial and may be difficult
to predict. MVO2 tends to increase as HR and contractility rise, but MVO2
is reduced by lowering LVEDV. β-Agonists improve O2 supply when
LVEDP is decreased, but can worsen the supply–demand ratio
particularly if HR rises or diastolic BP is lowered.
(7) Hypovolemia is deleterious to the patient with heart failure just as it is
for the patient with normal ventricular function; however, volume
overload may lead to myocardial ischemia by restricting subendocardial
perfusion.
(8) There is a risk of tissue damage or sloughing when vasoactive drugs
extravasate outside of a vein. In general, catecholamine
vasoconstrictors may be given through peripheral IV lines provided that
(a) No central venous catheter is available.
(b) The drug is injected only into a free-flowing IV line.
(c) The IV site is observed during and after the injection for signs of
infiltration or extravasation.
b. Dobutamine (Dobutrex) [28,42]
(1) Dobutamine is a synthetic catecholamine formulated as a racemic
mixture.
(2) Actions
(a) Direct β1-agonist, with limited β2- and α1-effects. Dobutamine has
no α2 or dopaminergic activity.
(b) Dobutamine increases cardiac inotropy principally via its β1 (and
perhaps also by α1) agonism, but HR is increased only by the β1-
effect.
(c) On blood vessels, dobutamine is predominantly a vasodilator drug.
Mechanisms for vasodilation include the following:
(i) β2-mediated vasodilation that is only partially counteracted by
(−) dobutamine’s α1-constrictor effects
(ii) The (+) dobutamine enantiomer and its metabolite, (+)-3-O-
methyldobutamine, are α1-antagonists. Thus, as dobutamine is
metabolized, any α1-agonist actions of the drug should
diminish over time.
(3) Offset. Offset of action is achieved by redistribution, metabolism by

COMT, and conjugation by glucuronide in liver; an active metabolite is
generated. Plasma half-life is 2 minutes.
(4) Advantages
(a) At low doses there is generally less tachycardia than with
“equivalently inotropic” doses of isoproterenol or dopamine, on the
other hand some studies show that “equivalently inotropic” doses of
epinephrine produce LESS tachycardia than dobutamine.
(b) Afterload reduction (SVR and PVR) may improve LV and RV
systolic function, which can benefit the heart with right and/or LV
failure.
(c) Renal blood flow may increase (due to a β2 effect), but not as much
as with comparable (but low) doses of dopamine or dopexamine.
(5) Disadvantages
(a) Tachycardia and arrhythmias are dose related and can be severe.
(b) Hypotension may occur if the reduction in SVR is not fully offset by
an increase in CO; dobutamine is an inotrope but is not a pressor.
(c) Coronary steal is possible.
(d) The drug is a nonselective vasodilator: Blood flow may be shunted
from kidney and splanchnic bed to skeletal muscle.
(e) Tachyphylaxis has been reported when infused for more than 72
hours.
(f) Mild hypokalemia may occur.
(g) As a partial agonist, dobutamine can inhibit actions of full agonists
(e.g., epinephrine) under certain circumstances.
(6) Indications. Low CO states, especially with increased SVR or PVR.
(7) Administration. IV only (central line is preferable, but dobutamine has
little vasoconstrictor activity, minimizing risk of extravasation).
(8) Clinical use
(a) Dobutamine dose: IV infusion, 2 to 20 μg/kg/min. Some patients may
respond to initial doses as low as 0.5 μg/kg/min and, at such low
doses, HR usually does not increase.
(b) Dobutamine increases Mvo2 to a lesser degree than CO. Dobutamine
increases coronary blood flow to a greater degree than dopamine
when either agent is given as a single drug. However, addition of
nitroglycerin to dopamine may be equally effective.
(c) Dobutamine acts similar to a fixed-ratio combination of an inotropic
drug and a vasodilator drug. These two components cannot be
titrated separately.
(d) In patients undergoing coronary surgery, dobutamine produces more
tachycardia than epinephrine when administered to produce the
same increase in SV.
(e) When dobutamine is given to β-blocked patients, SVR may increase.
(f) Routine administration of dobutamine (or any other positive
inotrope) is not recommended [43].
c. Dopamine (Intropin) [28]
(1) Dopamine is a catecholamine precursor to NE and epinephrine found in
nerve terminals and the adrenal medulla.
(2) Actions
(a) Direct action: α1-, β1-, β2-adrenergic, and dopaminergic (DA1)
agonist
(b) Indirect action: Induces release of stored neuronal NE
(c) The dose versus response relationship is often described as if
“carved in stone”; however, the relationship between dose and
concentration and between dose and response is highly variable
from patient to patient. We provide this chart because it is expected,
not because we endorse its accuracy!
(3) Offset is achieved by redistribution, uptake by nerve terminals plus

metabolism by MAO and COMT.
(4) Advantages
(a) Increased renal perfusion and urine output at low-to-moderate
dosages (partially due to a specific DA1-agonist effect)
(b) Blood flow shifts from skeletal muscle to kidney and splanchnic
beds.
(c) BP response is easy to titrate because of its mixed inotropic and
vasoconstrictor properties.
(5) Disadvantages
(a) There is a significant indirect-acting component; response can
diminish when neuronal NE is depleted (e.g., in patients with CHF).
(b) Sinus, atrial, or ventricular tachycardia (VT) and arrhythmias may
occur.
(c) Maximal inotropic effect less than that of epinephrine.
(d) Skin necrosis may result from extravasation.
(e) Renal vasodilating effects are overridden by α-mediated
vasoconstriction at dosages greater than 10 μg/kg/min with risk of
renal, splanchnic, and skin necrosis. Urine output should be
monitored.
(f) Pulmonary vasoconstriction is possible.
(g) MVO2 increases, and myocardial ischemia may occur if coronary
flow does not increase commensurately.
(h) In some patients with severe HF, the increased BP at increased
doses may be detrimental. Such patients benefit from adding a
vasodilator.
(6) Indications
(a) Hypotension due to low CO or low SVR (although other agents are
superior for the latter indication)
(b) Temporary therapy of hypovolemia until circulating blood volume is
restored (but vasoconstrictors should not substitute or delay primary
treatment of hypovolemia)
(c) “Recruiting renal blood flow” for renal failure or insufficiency
(widely used for this purpose, but limited evidence basis)
(7) Administration: IV only (preferably by central venous line)
(8) Clinical use
(a) Dopamine dose: 1 to 20 μg/kg/min IV.
(b) Often mix 200 mg in 250 mL IV solution (800 μg/mL).
(c) Good first choice for temporary treatment of hypotension until
intravascular volume can be expanded or until a specific diagnosis
can be made.
(d) Correct hypovolemia if possible before use (as with all pressors)
(e) After cardiac surgery if inotropic response is not adequate at
dopamine doses of 5 to 10 μg/kg/min, we recommend a switch to a
more powerful agonist such as epinephrine, or a switch to or
addition of milrinone.
(f) Consider adding a vasodilator (e.g., nitroprusside) when BP is
adequate and afterload reduction would be beneficial (or better
still, reduce the dose of dopamine).
d. Dopexamine [28]
(1) Actions
(a) Dopexamine is a synthetic analog of dobutamine with vasodilator
action. Its cardiac inotropic and chronotropic activity is caused by
direct β2-agonist effects and by NE actions (due to baroreceptor
reflex activation and neuronal uptake-1 inhibition) that indirectly
activate β1-receptors. In CHF, there is selective β1-downregulation,
with relative preservation of β2-receptor number and coupling. The
latter assume greater than normal physiologic importance, making
dopexamine of theoretically greater utility than agents with primary
β1-receptor activity. Although dopexamine has been used in Europe
for nearly two decades, the drug will likely never be available in
the United States.
(b) Receptor activity
α1 and α2: Minimal
β1: Little direct effect, some indirect; β2: Direct agonist
DA1: Potent agonist (activation increases renal blood flow)
(c) Inhibits neuronal catecholamine uptake-1, increasing NE actions
(d) Hemodynamic actions
(2) Offset. Half-life: 6 to 11 minutes. Clearance is by uptake into tissues

(catecholamine uptake mechanisms) and by hepatic metabolism.
(3) Advantages
(a) Lack of vasoconstrictor activity avoids α-mediated complications.
(b) Decreased renovascular resistance might theoretically help preserve
renal function after ischemic insults.
(4) Disadvantages
(a) Less effective positive inotrope than other agents (e.g., epinephrine,
milrinone)
(b) Dose-dependent tachycardia may limit therapy.
(c) Tachyphylaxis
(d) Not approved by the U.S. Food and Drug administration for release
in the United States.
(5) Indications. Treatment of low CO states
(6) Administration. IV
(7) Clinical use
(a) Dopexamine dose: 0.5 to 4 μg/kg/min IV (maximum 6 μg/kg/min).
(b) Hemodynamic and renal effects similar to the combination of
variable doses of dobutamine with dopamine 1 μg/kg/min (renal
dose) or fenoldopam 0.05 μg/kg/min.
e. Epinephrine (Adrenaline) [28]
(1) Epinephrine is a catecholamine produced by the adrenal medulla.
(2) Actions
(a) Direct agonist at α1-, α2-, β1-, and β2-receptors
(b) Dose response (adult, approximate)
(c) Increased contractility with all dosages, but SVR may decrease,
remain unchanged, or increase dramatically depending on the
dosage. CO usually increased but, at extreme resuscitation dosages,
α-receptor–mediated vasoconstriction may cause a lowered SV due
to high afterload.
(3) Offset occurs by uptake by neurons and tissue and by metabolism by
MAO and COMT (rapid).
(4) Advantages
(a) This drug is direct acting; its effects are not dependent on release of
endogenous NE.
(b) Potent α- and β-adrenergic stimulation results in greater maximal
effects and produce equivalent increases in SV with tachycardia
after heart surgery than dopamine or dobutamine.
(c) It is a powerful inotrope with variable (and dose-dependent) α-
adrenergic effect. Lusitropic effect (β1) enhances the rate of
ventricular relaxation.
(d) BP increases may blunt tachycardia due to reflex vagal stimulation.
(e) It is an effective bronchodilator and mast cell stabilizer, useful for
primary therapy of severe bronchospasm, anaphylactoid, or
anaphylactic reactions.
(f) With a dilated LV and myocardial ischemia, epinephrine may
increase diastolic BP and decrease heart size, reducing myocardial
ischemia. However, as with any inotropic drug, epinephrine may
induce or worsen myocardial ischemia.
(5) Disadvantages
(a) Tachycardia and arrhythmias at higher doses.
(b) Organ ischemia, especially kidney, secondary to vasoconstriction,
may result. Renal function must be closely monitored.
(c) Pulmonary vasoconstriction may occur, which can produce
pulmonary hypertension and possibly RV failure; addition of a
vasodilator may counteract this.
(d) Epinephrine may produce myocardial ischemia. Positive inotropy
and tachycardia increase myocardial oxygen demand and reduce
oxygen supply.
(e) Extravasation from a peripheral IV cannula can cause necrosis; thus,
administration via a central venous line is preferable.
(f) As with most adrenergic agonists, increases of plasma glucose and
lactate occur. This may be accentuated in diabetics.
(g) Initial increases in plasma K+ occur due to hepatic release, followed
by decreased K+ due to skeletal muscle uptake.
(6) Indications
(a) Cardiac arrest (especially asystole or VF); electromechanical
dissociation. Epinephrine’s efficacy is believed to result from
increased coronary perfusion pressure during cardiopulmonary
resuscitation (CPR). Recently, the utility of high-dose (0.2 mg/kg)
epinephrine was debated, the consensus as summarized in the 2015
AHA Guidelines [27] is that there is no outcome benefit to “high-
dose” epinephrine.
(b) Anaphylaxis and other systemic allergic reactions; epinephrine is the
agent of choice.
(c) Cardiogenic shock, especially if a vasodilator is added
(d) Bronchospasm
(e) Reduced CO after CPB
(f) Hypotension with spinal or epidural anesthesia can be treated with
low-dose (1 to 4 μg/min) epinephrine infusions as conveniently and
effectively as with ephedrine boluses [(12)].
(7) Administration. IV (preferably by central line); via endotracheal tube
(rapidly absorbed by tracheal mucosa); SC
(8) Clinical use
(a) Epinephrine dose
(i) SC: 10 μg/kg (maximum of 400 μg or 0.4 mL, 1:1,000) for the
treatment of mild-to-moderate allergic reactions or
bronchospasm.
(ii) IV: Low-to-moderate dose (for shock, hypotension): 0.03 to
0.2 μg/kg bolus (IV), then infusion at 0.01 to 0.30 μg/kg/min.
High dose (for cardiac arrest, resuscitation): 0.5 to 1.0 mg
IV bolus; pediatric, 5 to 15 μg/kg (may be given
intratracheally in 1 to 10 mL volume). Larger doses are used
when response to initial dose is inadequate.
Resuscitation doses of epinephrine may produce extreme
hypertension, stroke, or myocardial infarction. A starting dose
of epinephrine exceeding a 0.15 mcg/kg (10 μg in an adult) IV
bolus should be given only to a patient in extremis! Moderate
doses (0.03 to 0.06 μg/kg/min) of epinephrine are commonly
used to stimulate cardiac function and facilitate separation
from CPB.
(b) Watch for signs of excessive vasoconstriction. Monitor SVR, renal
function, extremity perfusion.
(c) 5 Addition of a vasodilator (e.g., nicardipine, nitroprusside, or
phentolamine) to epinephrine can counteract the α-mediated
vasoconstriction, leaving positive cardiac inotropic effects
undiminished. Alternatively, addition of milrinone or inamrinone
may permit lower doses of epinephrine to be used. We find
combinations of epinephrine and milrinone particularly useful in
cardiac surgical patients.
f. NE (noradrenaline, Levophed)
See the preceding Section VI: Vasopressors.
g. Isoproterenol (Isuprel)
(1) Isoproterenol is a synthetic catecholamine.
(2) Actions
(a) Direct β1- plus β2-adrenergic agonist
(b) No α-adrenergic effects
(3) Offset. Rapid (half-life, 2 minutes); uptake by liver, conjugated, 60%
excreted unchanged; metabolized by MAO, COMT
(4) Advantages
(a) Isoproterenol is a potent direct β-adrenergic receptor agonist.
(b) It increases CO by three mechanisms:
(c) Increased HR
(d) Increased contractility S increased SV
(e) Reduced afterload (SVR) S increased SV
(f) It is a bronchodilator (IV or inhaled).
(5) Disadvantages
(a) It is not a pressor! BP often falls (β2-adrenergic effect) while CO
rises.
(b) Hypotension may produce organ hypoperfusion, hypotension, and
ischemia.
(c) Tachycardia limits diastolic filling time.
(d) Proarrhythmic.
(e) Dilates all vascular beds and is capable of shunting blood away
from critical organs toward muscle and skin.
(f) Coronary vasodilation can reduce blood flow to ischemic
myocardium while increasing flow to nonischemic areas producing
coronary “steal” in patients with “steal-prone” coronary anatomy.
(g) May unmask pre-excitation in patients with an accessory AV
conduction pathway (e.g., Wolff–Parkinson–White [WPW]
syndrome).
(6) Indications
(a) Bradycardia unresponsive to atropine when electrical pacing is not
available.
(b) Low CO, especially for situations in which increased inotropy is
needed and tachycardia is not detrimental, such as the following:
(c) Pediatric patients with fixed SV
(d) After resection of ventricular aneurysm (small fixed SV)
(e) Denervated heart (after cardiac transplantation)
(f) Pulmonary hypertension or right heart failure
(g) AV block: Use as temporary therapy to decrease block or increase
rate of idioventricular foci. Use with caution in second-degree
Mobitz type II heart block—may intensify heart block.
(h) Status asthmaticus: IV use mandates continuous ECG and BP
monitoring.
(i) β-Blocker overdose
(j) Isoproterenol should not be used for cardiac asystole. CPR with
epinephrine or pacing is the therapy of choice because
isoproterenol-induced vasodilation results in reduced carotid and
coronary blood flow during CPR.
(7) Administration. IV (safe through peripheral line, will not necrose skin);
PO
(8) Clinical use and isoproterenol dose. IV infusion is 20 to 500 ng/kg/min.
2. PDE inhibitors
a. Inamrinone (Inocor) [28]
(1) Inamrinone is a bipyridine derivative that inhibits the cyclic guanosine
monophosphate (cGMP)–inhibited cAMP-specific PDE III, increasing
cAMP concentrations in cardiac muscle (positive inotropy) and in
vascular smooth muscle (vasodilation).
(2) Offset
(a) The elimination half-life is 2.5 to 4 hours, increasing to 6 hours in
patients with CHF.
(b) Offset occurs by hepatic conjugation, with 30% to 35% excreted
unchanged in urine.
(3) Advantages
(a) As a vasodilating inotrope, inamrinone increases CO by augmenting
contractility and decreasing cardiac afterload.
(b) Favorable effects on MVO2 (little increase in HR; decreases
afterload, LVEDP, and wall tension)
(c) It does not depend on activation of β-receptors and therefore retains
effectiveness despite β-receptor downregulation or uncoupling
(e.g., CHF) and in the presence of β-adrenergic blockade.
(d) Low risk of tachycardia or arrhythmias
(e) Inamrinone may act synergistically with β-adrenergic receptor
agonists and dopaminergic receptor agonists.
(f) Pulmonary vasodilator.
(g) Positive lusitropic properties (ventricular relaxation) at even very
low dosages.
(4) Disadvantages
(a) Thrombocytopenia after chronic (more than 24 hours)
administration.
(b) Will nearly always cause hypotension from vasodilation if given by
rapid bolus administration. Hypotension is easily treated with IV
fluid and α-agonists.
(c) Increased dosages may result in tachycardia (and therefore increased
MVO2).
(d) Less convenient than milrinone because of photosensitivity and
reduced potency
(5) Administration. IV infusion only. Do not mix in dextrose-containing
solutions.
(6) Clinical use
(a) Inamrinone loading dose is 0.75 to 1.5 mg/kg. When given during or
after CPB, usual dosage is 1.5 mg/kg.
(b) IV infusion dose range is 5 to 20 μg/kg/min (usual dosage is 10
μg/kg/min).
(c) Used in cardiac surgical patients in a manner similar to milrinone
(d) The popularity of this agent has steadily declined since the
introduction of milrinone, largely due to milrinone’s lack of an
adverse action on platelet function. Inamrinone is included here
mostly for completeness.
b. Milrinone (Primacor) [28]
(1) Actions
(a) Milrinone has powerful cardiac inotropic and vasodilator
properties. Milrinone increases intracellular concentrations of
cAMP by inhibiting its breakdown. Milrinone inhibits the cGMP-
inhibited, cAMP-specific PDE (commonly known by clinicians as
“type III”) in cardiac and vascular smooth-muscle cells. In cardiac
myocytes, increased cAMP causes positive inotropy, lusitropy
(enhanced diastolic myocardial relaxation), chronotropy, and
dromotropy (AV conduction), as well as increased automaticity. In
vascular smooth-muscle cells, increased cAMP causes
vasodilation.
(b) Hemodynamic actions
(2) Onset and offset. When administered as an IV bolus, milrinone rapidly

achieves its maximal effect. The elimination half-life of milrinone is
considerably shorter than that of inamrinone.
(3) Advantages
(a) Used as a single agent, milrinone has favorable effects on the
myocardial oxygen supply–demand balance, due to reduction of
preload and afterload, and minimal tendency for tachycardia.
(b) Milrinone does not act via β-adrenergic receptors and it retains
efficacy when β-adrenergic receptor coupling is impaired, as in
CHF.
(c) It induces no tachyphylaxis.
(d) Milrinone has less proarrhythmic effects than β-adrenergic receptor
agonists.
(e) When compared to dobutamine at equipotent doses, milrinone is
associated with a greater decrease in PVR, greater augmentation of
RV ejection fraction, less tachycardia, fewer arrhythmias, and
lower MVO2.
(f) This drug may act synergistically with drugs that stimulate cAMP
production, such as β-adrenergic receptor agonists.
(g) Even with chronic use, milrinone (unlike inamrinone) does not cause
thrombocytopenia.
(4) Disadvantages
(a) Vasodilation and hypotension are predictable with rapid IV bolus
doses.
(b) As with all other positive inotropic drugs, including epinephrine and
dobutamine, independent manipulation of cardiac inotropy and SVR
cannot be achieved using only milrinone.
(c) Arrhythmias may occur.
(5) Clinical use [21]:
(a) Milrinone loading dose: 25 to 75 (usual dose is 50) μg/kg given
over 1 to 10 minutes. Often it is desirable to administer the loading
dose before separating the patient from CPB so that hypotension can
be managed more easily.
(b) Maintenance infusion: 0.375 to 0.75 μg/kg/min (usual maintenance is
0.5 μg/kg/min). Dosage should be reduced in renal failure.
(6) Indications
(a) Low CO syndrome, especially in the setting of increased LVEDP,
pulmonary hypertension, RV failure
(b) To supplement/potentiate β-adrenergic receptor agonists
(c) Outpatient milrinone infusion has been used as a bridge to cardiac
transplantation.
(d) Clinical perspective: [44–46]
No effect on mortality at 1 year or arrhythmia.
CLINICAL PEARL Milrinone increases intracellular concentration of cAMP. Milrinone
used as a single inotropic agent has favorable effects on myocardial supply/demand balance
reducing preload and afterload and has a low tendency to produce tachycardia.
3. Glucagon
a. Glucagon is a peptide hormone produced by the pancreas.
b. Actions. Glucagon increases intracellular cAMP, acting via a specific
receptor.
c. Offset of action of glucagon occurs by redistribution and proteolysis by the
liver, kidney, and plasma. Duration of action is 20 to 30 minutes.
d. Advantages. Glucagon has a positive inotropic effect even in the presence of
β-blockade.
e. Disadvantages
(1) Consistently produces nausea and vomiting
(2) Tachycardia
(3) Hyperglycemia and hypokalemia
(4) Catecholamine release from pheochromocytomas
(5) Anaphylaxis (possible)
f. Indications for glucagon include the following:
(1) Severe hypoglycemia (especially if no IV access) from insulin
overdosage
(2) Spasm of sphincter of Oddi
(3) β-blocker overdosage
g. Administration. IV, IM, SC
h. Clinical use
(1) Glucagon dose: 1 to 5 mg IV slowly; 0.5 to 2 mg IM or SC.
(2) Infusion: 25 to 75 μg/min.
(3) Rarely used (other than for hypoglycemia) because of gastrointestinal
side effects and severe tachycardia.
C. cAMP-independent agents
1. Calcium [28]
a. Calcium is physiologically active only as the free (unbound) calcium ion
(Cai).
(1) Normally, approximately 50% of the total plasma calcium is bound to
proteins and anions and the rest remains as free calcium ions.
(2) Factors affecting ionized calcium concentration:
(a) Alkalosis (metabolic or respiratory) decreases Cai.
(b) Acidosis increases Cai.
(c) Citrate binds (chelates) Cai.
(d) Albumin binds Cai.
(3) Normal plasma concentration: [Cai] = 1 to 1.3 mmol/L.
b. Actions of calcium salts
c. Offset. Calcium is incorporated into muscle and bone and binds to protein,
free fatty acids released by heparin, and citrate.
d. Advantages
(1) It has rapid action with duration of approximately 10 to 15 minutes (7-
mg/kg dose).
(2) It reverses hypotension caused by the following conditions:
(a) Halogenated anesthetic overdosage
(b) Calcium-blocking drugs (CCBs)
(c) Hypocalcemia
(d) CPB, especially with dilutional or citrate-induced hypocalcemia, or
when cardioplegia-induced hyperkalemia remains present
(administer calcium salts only after heart has been well reperfused
to avoid augmenting reperfusion injury)
(e) β-Blockers (watch for bradycardia!)
(3) It reverses cardiac toxicity from hyperkalemia (e.g., arrhythmias, heart
block, and negative inotropy).
e. Disadvantages
(1) Minimal evidence that calcium salts administered to patients produce
even a transient increase in CO.
(2) Calcium can provoke digitalis toxicity which can present as ventricular
arrhythmias, AV block, or asystole.
(3) Calcium potentiates the effects of hypokalemia on the heart (arrhythmias).
(4) Severe bradycardia or heart block occurs rarely.
(5) When extracellular calcium concentration is increased while the
surrounding myocardium is being reperfused or is undergoing ongoing
ischemia, increased cellular damage or cell death occurs.
(6) Post-CPB coronary spasm may occur rarely.
(7) Associated with pancreatitis when given in large doses to patients
recovering from CPB.
(8) Calcium may inhibit clinical responses to epinephrine and dobutamine
[47].
(9) Calcium given by bolus administration to awake patients may produce
chest pain or nausea.
f. Indications for use
(1) Hypocalcemia
(2) Hyperkalemia (to reverse AV block or myocardial depression)
(3) Intraoperative hypotension due to decreased myocardial contractility
from hypocalcemia or CCBs
(4) Inhaled general anesthetic overdose
(5) Toxic hypermagnesemia
g. Administration
(1) Calcium chloride: IV, preferably by central line (causes peripheral vein
inflammation and sclerosis).
(2) Calcium gluconate: IV, preferably by central line.
h. Clinical use
(1) Calcium dose
(a) 10% calcium chloride 10 mL (contains 272 mg of elemental calcium
or 13.6 mEq): adult, 200 to 1,000 mg slow IV; pediatric, 10 to 20
mg/kg slow IV
(b) 10% calcium gluconate 10 mL (contains 93 mg of elemental calcium
or 4.6 mEq): adult, 600 to 3,000 mg slow IV; pediatric, 30 to 100
mg/kg slow IV
(c) During massive blood transfusion (more than 1 blood volume
replaced with citrate-preserved blood), a patient may receive
citrate, which binds calcium. In normal situations, hepatic
metabolism quickly eliminates citrate from plasma, and
hypocalcemia does not occur. However, hypothermia and shock
may decrease citrate clearance with resultant severe hypocalcemia.
Rapid infusion of albumin will transiently reduce ionized calcium
levels.
(d) Ionized calcium levels should be measured frequently to guide
calcium salt therapy. Adults with an intact parathyroid gland quickly
recover from mild hypocalcemia without calcium administration.
(e) Calcium is not recommended during resuscitation (per 2015 AHA
Guidelines) [27] unless hypocalcemia, hyperkalemia, or
hypermagnesemia are present.
(f) Calcium should be used with care in situations in which ongoing
myocardial ischemia may be occurring or during reperfusion of
ischemic tissue. “Routine” administration of large doses of calcium
to all adult patients at the end of CPB is unnecessary and may be
deleterious if the heart has been reperfused only minutes earlier.
(g) Hypocalcemia is frequent in children emerging from CPB.
(h) Digoxin (Lanoxin)
2. Digoxin is a glycoside derived from the foxglove plant.
a. Actions
(1) Digoxin inhibits the integral membrane protein Na–K ATPase, causing
Na+ accumulation in cells and increased intracellular Cai, which leads to
increased Ca2+ release from the sarcoplasmic reticulum into the
cytoplasm with each heartbeat, ultimately causing a mildly increased
myocardial contractility.
(2) Hemodynamic effects
(a) Digoxin
b. Hemodynamics in CHF
c. Offset. Digoxin elimination half-life is 1.7 days (renal elimination). In

anephric patients, half-life is more than 4 days.
d. Advantages
(1) Supraventricular antiarrhythmic action
(2) Reduced ventricular rate in atrial fibrillation or flutter
(3) An orally active positive inotrope which is not associated with increased
mortality in CHF
e. Disadvantages
(1) Digoxin has an extremely low therapeutic index; 20% of patients show
toxicity at some time.
(2) Increased MVO2 and SVR occur in patients without CHF (angina may be
precipitated).
(3) The drug has a long half-life, and it is difficult to titrate.
(4) There is large interindividual variation in therapeutic and toxic serum
levels and dosages. The dose response is nonlinear; near-toxic levels
may be needed to achieve a change in AV conduction.
(5) Toxic manifestations may be life-threatening and difficult to diagnose.
Digoxin can produce virtually any arrhythmia. For example, digitalis is
useful in treating SVT, but digitalis toxicity can trigger SVT.
(6) Digoxin may be contraindicated in patients with accessory pathway SVT.
Please refer to Digoxin use for SVT in Section VIII.E.
f. Indications for use
(1) Supraventricular tachyarrhythmias (see Section VIII.E)
(2) CHF (mostly of historical interest for this condition)
g. Administration. IV, PO, IM
h. Clinical use (general guidelines only)
(1) Digoxin dose (assuming normal renal function; decrease maintenance
dosages with renal insufficiency)
(a) Adult: Loading dose IV and IM, 0.25 to 0.50 mg increments (total 1
to 1.25 mg or 10 to 15 μg/kg); maintenance dose, 0.125 to 0.250
mg/day based on clinical effect and drug levels
(b) Pediatric digoxin (IV administration)
(2) Digoxin has a gradual onset of action over 15 to 30 minutes or more;

peak effect occurs 1 to 5 hours after IV administration.
(3) Use with caution in the presence of β-blockers, calcium channel
blockers, or calcium.
(4) Always consider the possibility of toxic side effects.
(a) Signs of toxicity include arrhythmias, especially with features of
both increased automaticity and conduction block (e.g., junctional
tachycardia with a 2:1 AV block). Premature atrial or ventricular
depolarizations, AV block, accelerated junctional tachycardia, VT
or VF (may be unresponsive to countershock), or gastrointestinal or
neurologic toxicity may also be apparent.
(5) Factors potentiating toxicity
(a) Hypokalemia, hypomagnesemia, hypercalcemia, alkalosis, acidosis,
renal insufficiency, quinidine therapy, and hypothyroidism may
potentiate toxicity.
(b) Beware of administering calcium salts to digitalized patients!
Malignant ventricular arrhythmias (including VF) may occur, even if
the patient has received no digoxin for more than 24 hours. Follow
ionized calcium levels to permit use of smallest possible doses of
calcium.
(6) Therapy for digitalis toxicity
(a) Increase serum [K+] to upper limits of normal (unless AV block is
present).
(b) Treat ventricular arrhythmias with phenytoin, lidocaine, or
amiodarone.
(c) Treat atrial arrhythmias with phenytoin or amiodarone.
(d) β-Blockers are effective for digoxin-induced arrhythmias, but
ventricular pacing may be required if AV block develops.
(e) Beware of cardioversion. VF refractory to countershock may be
induced. Use low-energy synchronized cardioversion and slowly
increase energy as needed.
(7) Serum digoxin levels
(a) Therapeutic: Approximately 0.5 to 2.5 ng/mL. Values of less than
0.5 ng/mL rule out toxicity. Values exceeding 3 ng/mL are definitely
toxic.
(b) Increased serum concentrations may not produce clinical toxicity in
children or hyperkalemic patients, or when digitalis is used as an
atrial antiarrhythmic agent.
(c) “Therapeutic” serum concentrations may produce clinical toxicity in
patients with hypokalemia, hypomagnesemia, hypercalcemia,
myocardial ischemia, hypothyroidism, or those recovering from
CPB.
(8) Because of its long duration of action, long latency of onset, and
increased risk of toxicity, digoxin is not used to treat acute heart failure.
(9) For all indications, digoxin is much less widely used in recent years.
3. Levosimendan [48–53]
a. Actions
(1) Binds in Ca-dependent manner to cardiac troponin C, shifting the Ca2+
tension curve to the left. Levosimendan may stabilize Ca2+-induced
conformational changes in troponin C.
(2) Its effects are maximized during early systole when intracellular Ca2+
concentration is greatest and least during diastolic relaxation when Ca2+
concentration is low.
(3) Levosimendan also inhibits PDE III activity.
(4) Hemodynamic actions
b. Advantages
(1) Does not increase intracellular Ca2+
(2) Does not work via cAMP so should not interact with β-agonists or PDE
inhibitors
c. Disadvantages
(1) Unknown potency relative to other agents
(2) Has not received regulatory approval in the United States.
d. Indications
Where approved, drug’s indications include acute heart failure and acute
exacerbations of CHF.
e. Administration
(1) IV
f. Clinical use
(1) 8 to 24 μg/kg/min
(2) Despite its biochemical actions on PDE, levosimendan is not associated
with increased cAMP, so it may have reduced tendency for arrhythmias
relative to sympathomimetics.
(3) Clinical perspective (see reference above):
No difference in 30-day mortality.
VIII. β-Adrenergic receptor–blocking drugs [3,54]
A. Actions
These drugs bind and antagonize β-adrenergic receptors typically producing the
following cardiovascular effects:
B. Advantages of β-adrenergic-blocking drugs

1. Reduce MVO2 and decrease HR and contractility.
2. Increase the duration of diastole, during which majority of blood flow and
oxygen are delivered to the LV.
3. Synergistic with nitroglycerin for treating myocardial ischemia; blunt reflex
tachycardia and increased contractility secondary to nitroglycerin,
nitroprusside, or other vasodilator drugs.
4. Have an antiarrhythmic action, especially against atrial arrhythmias.
5. Decrease LV ejection velocity (useful in patients with aortic dissection).
6. Antihypertensive, but should not be first-line agents for essential hypertension.
7. Reduce dynamic ventricular outflow tract obstruction (e.g., tetralogy of Fallot,
hypertrophic cardiomyopathy).
8. Use of these agents is associated with reduced mortality after myocardial
infarction, chronic angina, CHF, and hypertension.
C. Disadvantages
1. Severe bradyarrhythmias are possible.
2. Heart block (first, second, or third degree) may occur, especially if prior
cardiac conduction abnormalities are present, or when IV β-blockers and
certain IV calcium channel blockers are coadministered.
3. May trigger bronchospasm in patients with reactive airways.
4. CHF can occur in patients with low ejection fraction newly receiving large
doses. Elevated LVEDP may induce myocardial ischemia because of elevated
systolic wall tension.
5. Signs and symptoms of hypoglycemia (except sweating) are masked in
diabetics.
6. SVR may increase because of inhibition of β2-vasodilation; use with care in
patients with severe peripheral vascular disease or in patients with
pheochromocytoma without α-blockade treatment.
7. Risk of coronary artery spasm is present in rare susceptible patients.
8. Acute perioperative withdrawal of β-blockers can lead to hyperdynamic
circulation and myocardial ischemia.
D. Distinguishing features of β-blockers
1. Selectivity. Selective β-blockers possess a greater potency for β1 than for β2-
receptors. They are less likely to cause bronchospasm or to increase SVR than
a nonselective drug. However, β 1-selectivity is dose-dependent (drugs lose
selectivity at higher dosages). Caution must be exercised when an asthmatic
patient receives any β-blocker.
2. Intrinsic sympathomimetic activity (ISA). These drugs possess “partial
agonist” activity. Thus, drugs with ISA will block β-receptors (preventing
catecholamines from binding to a receptor) but also will cause mild stimulation
of the same receptors. A patient receiving a drug with ISA would be expected
to have a greater resting HR and CO (which shows no change with exercise)
but a lower SVR compared to a drug without ISA.
3. Duration of action. In general, the β-blockers with longer durations of action
are eliminated by the kidneys, whereas the drugs of 4 to 6 hours duration
undergo hepatic elimination. Esmolol, the ultrashort–acting β-blocker (plasma
half-life, 9 minutes), is eliminated within the blood by a red blood cell
esterase. After abrupt discontinuation of esmolol infusion (which under most
circumstances we do not recommend), most drug effects are eliminated within
5 minutes. The duration of esmolol does not change when plasma
pseudocholinesterase is inhibited by echothiophate or physostigmine.
E. Clinical use
1. β-Blocker dosage
2. Begin with a low dose and slowly increase until desired effect is produced.
3. For metoprolol IV dosage use 1 to 5 mg increments (for adults) as tolerated
while monitoring the ECG, BP, and lung sounds. IV dosage is much smaller
than oral dosage because first-pass hepatic extraction is bypassed. The usual
acute IV metoprolol dose is 0.02 to 0.1 mg/kg.
4. If β-blockers must be given to a patient with bronchospastic disease, choose a
selective β1-blocker such as metoprolol or esmolol and consider concomitant
administration of an inhalation β2-agonist (such as albuterol).
5. Treatment of toxicity. β-agonists (e.g., isoproterenol, possibly in large doses)
and cardiac pacing are the mainstays. Calcium, milrinone, inamrinone,
glucagon, or liothyronine may be effective because these agents do not act via
β-receptors.
6. Assessment of β-blockade. When β-blockade is adequate, a patient should not
demonstrate an increase in HR with exercise.
7. Use of α-agonists in β-blocked patients. When agonist drugs with α- or both
α- and β-actions are administered to patients who are β-blocked, for example,
with an epinephrine-containing IV local anesthetic test dose, a greater elevation
of BP can be expected owing to α-vasoconstriction unopposed by β 2-
vasodilation. This may produce deleterious hemodynamic results (increased
afterload with little increased CO).
8. Esmolol is given by IV injection (loading dose), often followed by continuous
infusion. (For details on esmolol dosing for SVT, see Section VIII.E.) It is of
greatest utility when the required duration of β-blockade is short (i.e., to
attenuate a short-lived stimulus). Esmolol’s ultrashort duration of action plus
its β1-selectivity and lack of ISA make it a logical choice when it is necessary
to initiate a β-blocker in patients with asthma or another relative
contraindication. It is also useful in critically ill patients with changing
hemodynamic status.
9. Labetalol is a combined α- and β–antagonist- (α/β ratio = 1:7), which produces
vasodilation without reflex tachycardia. Labetalol is useful for preoperative or
postoperative control of hypertension. During anesthesia, its relatively long
duration of action makes it less useful than other agents for minute-to-minute
control of HR and BP. However, treatment with labetalol or another β-
adrenergic receptor antagonist will reduce the needed dosage of short-acting
vasodilators.
10. β-Adrenergic receptor antagonist withdrawal. Abrupt withdrawal of chronic β-
blocker therapy may produce a withdrawal syndrome including tachycardia and
hypertension. Myocardial ischemia or infarction may result. Thus, chronic β-
blocker therapy should not be abruptly discontinued perioperatively. The
authors have seen this syndrome complete with myocardial ischemia after
abrupt discontinuation of esmolol when it had been infused for only 48 hours!
11. Certain β-adrenergic receptor blockers are now part of the standard therapy of
patients with Class B through Class D CHF. The drugs most often used are
carvedilol and metoprolol-XL, and these agents have been shown to prolong
survival in heart failure. β-adrenergic receptor blocker therapy is associated
with improved LV function and improved exercise tolerance over time. These
agents counteract the sympathetic nervous system activation that is present with
CHF. In animal studies, β-adrenergic receptor blocker therapy reduces
“remodeling,” which is the process by which functional myocardium is
replaced by connective tissue. Importantly, not all β-adrenergic receptor
blockers have been shown to improve outcome in CHF, so reduced mortality
should not be considered a “class effect” of β-adrenergic receptor blockers.
IX. Vasodilator drugs [28]
A. Comparison
1. Sites of action
2. Mechanisms of action
a. Direct vasodilators: Calcium channel blockers, hydralazine, minoxidil,
nitroglycerin, nitroprusside.
b. α-adrenergic blockers: Labetalol, phentolamine, prazosin, terazosin,
tolazoline.
c. Ganglionic blocker: Trimethaphan.
d. ACE inhibitor: Enalaprilat, captopril, enalapril, lisinopril.
e. ARBs: Candesartan, irbesartan, losartan, olmesartan, valsartan, telmisartan.
f. Central α2-agonists (reduce sympathetic tone): Clonidine, guanabenz,
guanfacine.
g. Calcium channel blockers (see Section X).
h. Nesiritide: Binds to natriuretic factor receptors.
3. Indications for use
a. Hypertension, increased SVR states. Use arterial or mixed drugs. First-line
agent for long-term treatment of essential hypertension should be thiazide
diuretic with ACE inhibitors, ARBs, calcium channel blockers, β-blockers, as
secondary choices. Other oral agents are not associated with outcome benefit.
b. Controlled hypotension. Short-acting drugs are most useful (e.g.,
nitroprusside, nitroglycerin, nicardipine, clevidipine, nesiritide, and volatile
inhalational anesthetics).
c. Aortic valvular regurgitation. Reducing SVR will tend to improve oxygen
delivery to tissues.
d. CHF. Vasodilation reduces MVO2 by lowering preload and afterload (systolic
wall stress, due to reduced LV size and pressure). Vasodilation also improves
ejection and compliance. More importantly, ACE inhibitors and ARBs inhibit
“remodeling” and increase longevity in patients with heart failure.
e. Thermoregulation. Vasodilators are often used during the cooling and
rewarming phases of CPB to facilitate tissue perfusion and accelerate
temperature equilibration. This is especially important during pediatric CPB
procedures and others involving total circulatory arrest where an increased
CBF promotes brain cooling and brain protection during circulatory arrest.
f. Pulmonary hypertension. Vasodilators can improve pulmonary hypertension
that is not anatomically fixed. Presently, inhaled NO is the only truly selective
pulmonary vasodilator.
g. Myocardial ischemia. Vasodilator therapy can improve myocardial O 2
balance by reducing MVO2 (decreased preload and afterload), and nitrates and
calcium channel blockers can dilate conducting coronary arteries to improve
the distribution of myocardial blood flow. ACE inhibitors prolong lifespan in
patients who have had a myocardial infarction.
h. Intracardiac shunts. Vasodilators are used in the setting of nonrestrictive
cardiac shunts, especially ventricular septal defects and aortopulmonary
connections, to manipulate the ratio of pulmonary artery (PA) to aortic
pressures. This allows control of the direction and magnitude of shunt flow.
4. Cautions
a. Hyperdynamic reflexes. All vasodilator drugs decrease SVR and BP and
may activate baroreceptor reflexes. This cardiac sympathetic stimulation
produces tachycardia and increased contractility. Myocardial ischemia
resulting from increased myocardial O2 demands can be additive to ischemia
produced by reduced BP. Addition of a β-blocker can attenuate these reflexes.
b. Ventricular ejection rate. Reflex sympathetic stimulation will also increase
the rate of ventricular ejection of blood (dP/dt) and raise the systolic aortic
wall stress. This may be detrimental with aortic dissection. Thus, addition of
β-blocker (or a ganglionic blocker) is of theoretical benefit for patients with
aortic dissection, aortic aneurysm, or recent aortic surgery.
c. Stimulation of the renin–angiotensin system is implicated in the “rebound”
increased SVR and PVR when some vasodilators are discontinued abruptly.
Renin release can be attenuated by concomitant β-blockade, and renin’s
actions are attenuated by ACE inhibitors and ARBs.
d. Intracranial pressure (ICP). Most vasodilators will increase ICP, except for
trimethaphan and fenoldopam.
e. Use of nesiritide for decompensated CHF was associated with increased
mortality.
B. Specific agents
1. Direct vasodilators
a. Hydralazine (Apresoline)
(1) Actions
(a) This drug is a direct vasodilator.
(b) It primarily produces an arteriolar dilatation, with little venous
(preload) effect.
(2) Offset occurs by acetylation in the liver. Patients who are slow
acetylators (up to 50% of the population) may have higher plasma
hydralazine levels and may show a longer effect, especially with oral
use.
(3) Advantages
(a) Selective vasodilation. Hydralazine produces more dilation of
coronary, cerebral, renal, and splanchnic beds than of vessels in the
muscle and skin.
(b) Maintenance of uterine blood flow (if hypotension is avoided).
(4) Disadvantages
(a) Slow onset (5 to 15 minutes) after IV dosing; peak effect should
occur by 20 minutes. Thus, at least 10 to 15 minutes should separate
doses.
(b) Reflex tachycardia or coronary steal can precipitate myocardial
ischemia.
(c) A lupus-like reaction, usually seen only with chronic PO use, may
occur with chronic high doses (more than 400 mg/day) and in slow
acetylators.
(5) Clinical use
(a) Hydralazine dose
(i) IV: 2.5 to 5 mg bolus every 15 minutes (maximum 20 to 40 mg)
(ii) IM: 20 to 40 mg every 4 to 6 hours
(iii) PO: 10 to 50 mg every 6 hours
(iv) Pediatric dose: 0.2 to 0.5 mg/kg IV every 4 to 6 hours, slowly
(b) Slow onset limits use in acute hypertensive crises.
(c) Doses of vasodilators can be reduced by the addition of hydralazine,
decreasing the risk of cyanide toxicity from nitroprusside or
prolonged ganglionic blockade from trimethaphan.
(d) Addition of a β-blocker attenuates reflex tachycardia.
(e) Patients with CAD should be monitored for myocardial ischemia.
(f) Enalaprilat, nicardipine, and labetalol are replacing hydralazine for
many perioperative applications, but hydralazine continues to be
used for control of acute postoperative hypertension.
b. Nitroglycerin (glyceryl trinitrate) [28]
(1) Actions
(a) Nitroglycerin is a direct vasodilator, producing greater venous than
arterial dilation. A nitric acid–containing metabolite activates
vascular cGMP production.
(b) Peripheral venous effects. Venodilation and peripheral pooling

reduce effective blood volume, decreasing heart size and preload.
This effect usually reduces MVO2 and increases diastolic coronary
blood flow.
(c) Coronary artery
(i) Relieves coronary spasm.
(ii) Flow redistribution provides more flow to ischemic
myocardium and increases endocardial-to-epicardial flow
ratio.
(iii) There is increased flow to ischemic regions through collateral
vessels.
(d) Myocardial effects
(i) Improved inotropy due to reduced ischemia
(ii) Indirect antiarrhythmic action (VF threshold increases in
ischemic myocardium because the drug makes the effective
refractory period more uniform throughout the heart)
(e) Arteriolar effects (higher dosages only)
(i) Arteriolar dilatation decreases SVR. With reduced systolic
myocardial wall stress, MVO2 decreases, and ejection fraction
and SV may improve.
(ii) Arteriolar dilation often requires large doses, exceeding 10
μg/kg/min in some patients, whereas much lower doses give
effective venous and coronary arterial dilating effects. When
reliable peripheral arteriolar dilation is needed to control a
hypertensive emergency, we suggest that nicardipine,
nitroprusside, or clevidipine are often better choices (and can
be used together with nitroglycerin).
(2) Offset occurs by redistribution, metabolism in smooth muscle and liver.
Half-life in humans is 1 to 3 minutes.
(3) Advantages
(a) Preload reduction (lowers LV and RV end-diastolic and LA and RA
pressures)
(b) Unlike nitroprusside, virtually no metabolic toxicity
(c) Effective for myocardial ischemia
(i) Decreases infarct size after coronary occlusion
(ii) Maintains arteriolar autoregulation, so coronary steal unlikely
(d) Useful in acute exacerbations of CHF to decrease preload and
reduce pulmonary vascular congestion
(e) Increases vascular capacity; may permit infusion of residual pump
blood after CPB is terminated
(f) Not nearly as photosensitive as nitroprusside
(g) Dilates pulmonary vessels and can be useful in treating acute
pulmonary hypertension and right heart failure
(h) Attenuates biliary colic and esophageal spasm
(4) Disadvantages
(a) It decreases BP as preload and SVR decrease at higher dosages.
This may result in decreased coronary perfusion pressure.
(b) Reflex tachycardia and reflex increase in myocardial contractility
are dose related. Consider reducing dose or administering a β-
blocker (if BP is satisfactory).
(c) It inhibits hypoxic pulmonary vasoconstriction (but to a lesser extent
than nitroprusside). Monitor PO2 or supplement inspired gas with
oxygen.
(d) It may increase ICP.
(e) It is adsorbed by polyvinyl chloride IV tubing. Titrate dosage to
effect; increased effect may occur when tubing becomes saturated.
Special infusion sets that do not adsorb drug were often used in the
past, but are expensive and unnecessary.
(f) Tolerance. Chronic continuous therapy (for longer than 24 hours) can
blunt hemodynamic and antianginal effects. Tolerance during
chronic therapy may be avoided by discontinuing the drug (if
appropriate) for several hours daily.
(g) Dependence. Coronary spasm and myocardial infarction have been
reported after abrupt cessation of chronic industrial exposure.
(h) Methemoglobinemia. Avoid administering doses greater than 7
μg/kg/min for prolonged periods.
(5) Clinical use
(a) Nitroglycerin dose
(i) IV bolus: A bolus dose of 50 to 100 μg may be superior to
infusion for acute ischemia. Rapidly increasing levels in
blood may cause more vasodilation than the same
concentration when produced by a constant infusion (and thus
may be more likely to produce hypotension).
(ii) Infusion: Dose range, 0.1 to 7 μg/kg/min.
(iii) Sublingual: 0.15 to 0.60 mg.
(iv) Topical: 2% ointment (Nitropaste), 0.5 to 2 inches every 4 to 8
hours; or controlled-release transdermal nitroglycerin patch,
0.1 to 0.8 mg/hour. Nitrate-free periods of 10 to 12 hours
(e.g., at night) needed to prevent tolerance.
(b) Unless non-polyvinyl chloride tubing is used, infusion requirements
may decrease after the initial 30 to 60 minutes.
(c) Nitroglycerin is better stored in bottles than in bags if storage for
more than 6 to 12 hours is anticipated.
(d) When administered during CPB, venous pooling may cause
decreases in pump reservoir volume.
CLINICAL PEARL Nitroglycerin is a direct vasodilator producing greater venous pooling
than arterial dilation. Venous pooling caused by dilation decreases heart size and preload
reducing MvO2 and usually lessens ongoing ischemia.
c. Nitroprusside (Nipride) [28]

(1) Actions
(a) Sodium nitroprusside (SNP) is a direct-acting vasodilator. The
nitrate group is converted into NO in vascular smooth muscle,
which causes increased cGMP levels in cells.
(b) It has balanced arteriolar and venous dilating effects.
(2) Advantages
(a) SNP has a very short duration of action (1 to 2 minutes) permitting
precise titration of dose.
(b) It has pulmonary vasodilator in addition to systemic vasodilator
effects.
(c) SNP is highly effective for virtually all causes of hypertension
except high CO states.
(d) A greater decrease in SVR (afterload) than preload is produced at
low dosages.
(3) Disadvantages
(a) Cyanide and thiocyanate toxicity may occur.
(b) SNP solution is unstable in light and so must be protected from light.
Photodecomposition inactivates nitroprusside over many hours but
does not release cyanide ion.
(c) Reflex tachycardia and increased inotropy (undesirable with aortic
dissection because of increased shearing forces) respond to β-
blockade.
(d) Hypoxic pulmonary vasoconstriction is blunted and may produce
arterial hypoxemia from increased venous admixture.
(e) Vascular steal. All vascular regions are dilated equally. Although
total organ blood flow may increase, flow may be diverted from
ischemic regions (previously maximally vasodilated) to
nonischemic areas that, prior to SNP exposure, were appropriately
vasoconstricted. Thus, myocardial ischemia may be worsened.
However, severe hypertension is clearly dangerous in ischemia, and
the net effect often is beneficial. ECG monitoring is important.
(f) Patients with chronic hypertension may experience myocardial,
cerebral, or renal ischemia with abrupt lowering of BP to “normal”
range.
(g) Rebound systemic or pulmonary hypertension may occur if SNP is
stopped abruptly (especially in patients with CHF). SNP should be
tapered.
(h) Mild preload reduction due to venodilation occurs (but to a lesser
extent than nitroglycerin); fluids often must be infused if CO falls.
(i) Risk of increased ICP (although ICP may decrease with control of
hypertension)
(j) Platelet function is inhibited (no known clinical consequences).
(4) Toxicity
(a) Chemical formula of SNP is Fe(CN)5NO. SNP reacts with
hemoglobin to release highly toxic free cyanide ion (CN–).
(b) SNP + oxyhemoglobin S four free cyanide ions +
cyanomethemoglobin (nontoxic).
(c) Cyanide ion produces inhibition of cytochrome oxidase, preventing
mitochondrial oxidative phosphorylation. This produces tissue
hypoxia despite adequate PO2.
(d) Cyanide detoxification
(i) Cyanide + thiosulfate (and rhodanase) S thiocyanate.
Thiocyanate is much less toxic than cyanide ion. Availability
of thiosulfate is the rate-limiting step in cyanide metabolism.
Adults can typically detoxify 50 mg of SNP using existing
thiosulfate stores. Thiosulfate administration is of critical
importance in treating cyanide toxicity. Rhodanase is an
enzyme found in liver and kidney that promotes cyanide
detoxification.
(ii) Cyanide + hydroxocobalamin S cyanocobalamin (vitamin B12).
(e) Patients at increased risk of toxicity:
(i) Those resistant to vasodilating effects at low SNP dosages
(requiring dose greater than 3 μg/kg/min is necessary for
effect)
(ii) Those receiving a high-dose SNP infusion (greater than 8
μg/kg/min) for any period of time. In this setting, frequent
blood gas measurements must be performed, and consideration
must be given to the following:
(a) First and foremost, decrease dosage by adding another
vasodilator or a β-blocker.
(b) Consider monitoring mixed venous oxygenation (see
Chapter 4).
(iii) Those receiving a large total dose (greater than 1 mg/kg) over
12 to 24 hours.
(iv) Those with either severe renal or hepatic dysfunction.
(f) Signs of SNP toxicity
(i) Tachyphylaxis occurs in response to vasodilating effects of
SNP (increased renin release can be inhibited with β-
blockade).
(ii) Elevated mixed venous PO2 (due to decreased cellular O2
utilization) occurs in the absence of a rise in CO.
(iii) There is metabolic acidosis.
(iv) No cyanosis is seen with cyanide toxicity (cells cannot utilize
O2; therefore, blood O2 saturation remains high).
(v) Chronic SNP toxicity is due to elevated thiocyanate levels and
is a consequence of long-term therapy or thiocyanate
accumulation in renal failure. Thiocyanate is excreted
unchanged by the kidney (elimination half-life, 1 week).
Elevated thiocyanate levels (greater than 5 mg/dL) can cause
fatigue, nausea, anorexia, miosis, psychosis, hyperreflexia,
and seizures.
(g) Therapy of cyanide toxicity
(i) Cyanide toxicity should be suspected when a metabolic
acidosis or unexplained rise in mixed venous PO2 appears in
any patient receiving SNP.
(ii) As soon as toxicity is suspected, SNP must be discontinued
and substituted with another agent; lowering the dosage is not
sufficient because clinically evident toxicity implies a marked
reduction in cytochrome oxidase activity.
(iii) Ventilate with 100% O2.
(iv) Mild toxicity (base deficit less than 10, stable hemodynamics
when SNP stopped) can be treated by sodium thiosulfate, 150
mg/kg IV bolus (hemodynamically benign).
(v) Severe toxicity (base deficit greater than 10, or worsening
hemodynamics despite discontinuation of nitroprusside):
(a) Create methemoglobin that can combine with cyanide to
produce nontoxic cyanomethemoglobin, removing cyanide
from cytochrome oxidase:
(1) Give 3% sodium nitrite, 4 to 6 mg/kg by slow IV
infusion (repeat one-half dose 2 to 48 hours later as
needed), or
(2) Give amyl nitrite: Break 1 ampule into breathing
bag. (Flammable!)
(b) Sodium thiosulfate, 150 to 200 mg/kg IV over 15 minutes,
should also be administered to facilitate metabolic
disposal of the cyanide. Note that thiocyanate clearance is
renal dependent.
(c) Consider hydroxocobalamin (vitamin B12) 25 mg/hr.
Note: These treatments should be administered even during
CPR; otherwise, O2 cannot be utilized by body tissues.
(5) Clinical use
(a) SNP dose: 0.1 to 2 μg/kg/min IV infusion. Titrate dose to BP. Avoid
doses greater than 2 μg/kg/min: Doses as high as 10 μg/kg/min
should be infused for no more than 10 minutes.
(b) Monitor oxygenation.
(c) Solution in a bottle or bag must be protected from light by wrapping
in metal foil. Solution stored in the dark retains significant potency
for 12 to 24 hours. It is not necessary to cover the administration
tubing with foil.
(d) Because of the potency of SNP, it is best administered by itself into
a central line using an infusion pump. If other drugs are being
infused through the same line, use sufficient “carrier” flow so that
changes in one drug’s infusion rate does not change the quantity of
other drugs entering the patient per minute.
(e) Infusions should be tapered gradually to avoid rebound increases in
systemic and PA pressures.
(f) Use this drug cautiously in patients with concomitant untreated
hypothyroidism or severe liver or kidney dysfunction.
(g) Continuous BP monitoring with an arterial catheter is recommended.
d. NO [55]:
(1) Actions
(a) NO is a vasoactive gas naturally produced from L-arginine
primarily in endothelial cells. Before its molecular identity was
determined it was known as endothelium-derived relaxing factor.
NO diffuses from endothelial cells to vascular smooth muscle,
where it increases cGMP and affects vasodilation, in part by
decreasing cytosolic calcium. It is an important physiologic
intercellular signaling substance and NO or its absence is
implicated in pathologic conditions such as reperfusion injury and
coronary vasospasm.
(b) It is inhaled to treat pulmonary hypertension, particularly in
respiratory distress syndrome in infancy.
(2) Offset. NO rapidly and avidly binds to the heme moiety of hemoglobin,
forming the inactive compound nitrosylhemoglobin, which in turn
degrades to methemoglobin. NO’s biologic half-life in blood is
approximately 6 seconds.
(3) Advantages
(a) Inhaled NO appears to be the long-sought “selective” pulmonary
vasodilator. It is devoid of systemic actions.
(b) Unlike parenterally administered pulmonary vasodilators, inhaled
NO favorably affects lung V/Q relationships, because it vasodilates
primarily those lung regions that are well ventilated.
(c) There is low toxicity, provided safety precautions are taken.
(4) Disadvantages
(a) Stringent safety precautions are required to prevent potentially
severe toxicity, such as overdose or catastrophic nitrogen dioxide–
induced pulmonary edema.
(b) Methemoglobin concentrations may reach clinically important
values, and blood levels must be monitored daily.
(c) Chronic administration may cause ciliary depletion and epithelial
hyperplasia in terminal bronchioles.
(d) NO is corrosive to metal.
(5) Clinical use
(a) NO is inhaled by blending dilute NO gas into the ventilator inlet gas.
Therapeutic concentrations range from 0.05 to 80 parts per million
(ppm). The lowest effective concentration should be used, and
responses should be carefully monitored. The onset of action for
reducing PVR and RVSWI is typically 1 to 2 minutes.
(b) NO must be purchased prediluted in nitrogen in assayed tanks, and
an analyzer must be used intermittently to assay the gas stream
entering the patient for NO and nitrogen dioxide. NO usually is not
injected between the ventilator and the patient (to avoid overdose),
and it must never be allowed to contact air or oxygen until it is used
(to prevent formation of toxic nitrogen dioxide).
(c) NO has been used to treat persistent pulmonary hypertension of the
newborn, other forms of pulmonary hypertension, and the adult
respiratory distress syndrome with variable success and to date no
effect on outcomes.
e. Nesiritide [56–58]
(1) Actions
(a) Nesiritide binds to A and B natriuretic peptide receptors on
endothelium and vascular smooth muscle, producing dilation of both
arterial and venous systems from increased production of cGMP. It
also has indirect vasodilating actions by suppressing the
sympathetic nervous system, the RAAS, and endothelin.
(b) Diuretic and natriuretic effects. Although nesiritide as a “cardiac

natriuretic peptide” would be expected to have major diuretic and
natriuretic effects, the agent seems most effective at this in healthy
patients.
(c) Nesiritide may be hydrolyzed by neutral endopeptidase. A small
amount of administered drug may be eliminated via the kidneys.
(2) Current clinical use. Despite early studies suggesting that use of
nesiritide was associated with reduced mortality in HF patients
compared to the use of standard positive inotropic agents, more recent
clinical trial data found that nesiritide offered no advantage over
standard agents for acute decompensated HF.
(a) Typical doses are as follows:
(i) 2 μg/kg loading dose
(ii) 0.01 μg/kg/min maintenance infusion
(b) α-Adrenergic blockers [3,54]
2. Labetalol (Normodyne, Trandate)
See preceding β-adrenergic receptor blocker section in which this agent was
presented. It is widely used during and after anesthesia for BP control.
a. Phentolamine (Regitine)
b. Actions
(1) Competitive antagonist at α1-, α2-, and 5-hydroxytryptamine (5-HT,
serotonin) receptors
(a) Primarily arterial vasodilation with little venodilation
(b) Offset occurs by hepatic metabolism, in part by renal excretion.
Offset after IV bolus occurs after 10 to 30 minutes.
(2) Advantages
(a) Good for high NE states such as pheochromocytoma.
(b) Antagonizes undesirable α-stimulation. For example, reversal of
deleterious effects of NE extravasated into skin is achieved by local
infiltration with phentolamine, 5 to 10 mg in 10-mL saline.
(c) Has been combined with NE for positive inotropic support with
reduced vasoconstriction after CPB.
(3) Disadvantages
(a) Tachycardia arises from two mechanisms:
(i) Reflex via baroreceptors
(ii) Direct effect of α2-blockade. Blockade of presynaptic
receptors eliminates the normal feedback system controlling
NE release by presynaptic nerve terminals. As α2-stimulation
decreases NE release, blockade of these receptors allows
increased presynaptic release. This results in increased β1-
sympathetic effects only, as the α-receptors mediating
postsynaptic α-effects are blocked by phentolamine.
Myocardial ischemia or arrhythmias may result. Thus, the
tachycardia and positive inotropy are β-effects that will
respond to β-blockers.
(b) Gastrointestinal motility is stimulated and gastric acid secretion
increased.
(c) Hypoglycemia may occur.
(d) Epinephrine may cause hypotension in α-blocked patients
(“epinephrine reversal”) via a β2-mechanism.
(e) Arrhythmias occur.
(f) There is histamine release.
(g) It is increasingly difficult to obtain from the manufacturer.
(4) Clinical use
(a) Phentolamine dose
(i) IV bolus: 1 to 5 mg (adult) or 0.1 mg/kg IV (pediatric)
(ii) IV infusion: 1 to 20 μg/kg/min
(b) When administered for pheochromocytoma, β-blockade may also be
instituted.
(c) β-Blockade will attenuate tachycardia.
(d) Phentolamine has been used to promote uniform cooling of infants
during CPB prior to deep hypothermia and circulatory arrest (dose,
0.1 to 0.5 mg/kg).
c. Phenoxybenzamine (Dibenzyline)
(1) Actions
(a) Noncompetitive antagonist at α1- and α2-receptors
(b) Primarily arterial vasodilation with little venodilation
(2) Offset occurs by hepatic metabolism, in part by renal excretion.

Offset after IV bolus occurs after 10 to 30 minutes.
(3) Advantages
(a) Used for high NE states such as pheochromocytoma
(b) Given PO to prepare patients for excision of pheochromocytoma
(c) Slow onset and prolonged duration of action (half-life of roughly 24
hours)
(4) Disadvantages
(a) Tachycardia arises from two mechanisms:
(i) Reflex via baroreceptors
(ii) Direct effect of α2-blockade. Blockade of presynaptic
receptors eliminates the normal feedback system controlling
NE release by presynaptic nerve terminals. As α2-stimulation
decreases NE release, blockade of these receptors allows
increased presynaptic release. This results in increased β1-
sympathetic effects only, as the α-receptors mediating
postsynaptic α-effects are blocked by phentolamine.
Myocardial ischemia or arrhythmias may result. Thus, the
tachycardia and positive inotropy are β-effects that will
respond to β-blockers.
(b) “Stuffy” nose and headache are common.
(c) Creates marked apparent hypovolemia; adequate preoperative
rehydration may result in marked postoperative edema.
(d) No IV form
(5) Clinical use
(a) Phenoxybenzamine dose
(b) PO dose: 10 mg (adult) bid.
(c) Increase dose gradually up to 30 mg tid—limited by onset of side
effects or by elimination of hypertension.
(d) When administered for pheochromocytoma, β-blockade should not
be added until phenoxybenzamine dose has reached a steady state,
unless there is exaggerated tachycardia or myocardial ischemia.
(e) Some authors advocate doxazosin or calcium channel blockers
rather than phenoxybenzamine for preoperative preparation of
pheochromocytoma, arguing that there are fewer side effects
(preoperatively and postoperatively) with these agents.
d. Prazosin, doxazosin, and terazosin
(1) Actions. A selective α1-competitive antagonist, prazosin’s main
cardiovascular action is vasodilation (arterial and venous) with
decreased SVR and decreased preload. Reflex tachycardia is minimal.
(2) Offset occurs by hepatic metabolism. The half-life is 4 to 6 hours.
(3) Advantages
(4) Virtual absence of tachycardia
(5) The only important cardiovascular action is vasodilation.
(6) Disadvantages. Postural hypotension with syncope may occur,
especially after the initial dose.
(7) Indications. Oral treatment of chronic hypertension (but is not a first-line
agent).
(8) Administration. PO
(9) Clinical use
(a) Prazosin dose: Initially 0.5 to 1 mg bid (maximum 40 mg/day).
(b) Prazosin is closely related to two other α1-blockers with which it
shares a common mechanism of action:
(i) Doxazosin (Cardura). Half-life: 9 to 13 hours. Dose: 1 to 4
mg/day (maximum 16 mg/day).
(ii) Terazosin (Hytrin). Half-life: 8 to 12 hours. Dose: 1 to 5
mg/day (maximum 20 mg/day).
3. ACE inhibitors
a. Captopril (Capoten)
(1) Actions
(a) In common with all ACE inhibitors, captopril blocks the conversion
of angiotensin I (inactive) to angiotensin II in the lung. This
decrease in plasma angiotensin II levels causes vasodilation,
generally without reflex increases in HR or CO.
(b) Many tissues contain ACE (including heart, blood vessels, and
kidney), and inhibition of the local production of angiotensin II may
be important in the mechanism of action of ACE inhibitors.
(c) Plasma and tissue concentrations of kinins (e.g., bradykinin) and
prostaglandins increase with ACE inhibition and may be
responsible for some side effects.
(d) Captopril, enalaprilat, and lisinopril inhibit ACE directly, but
benazepril, enalapril, fosinopril, quinapril, and ramipril are
inactive “prodrugs” and must undergo hepatic metabolism into the
active metabolites.
(2) Offset occurs primarily by renal elimination with a half-life of 1.5 to 2
hours. Dosages of all ACE inhibitors (except fosinopril) should be
reduced with renal dysfunction.
(3) Advantages (in common with all ACE inhibitors)
(a) Oral vasodilator that improves outcomes in chronic hypertension
(b) No tachyphylaxis or reflex hemodynamic changes
(c) Improved symptoms and prolonged survival in CHF, hypertension,
and after MI
(d) May retard progression of renal disease in diabetics
(e) Antagonizes LV remodeling after myocardial infarction
(4) Disadvantages (in common with all ACE inhibitors)
(a) Reversibly decreased renal function, due to reduced renal perfusion
pressure. Patients with renal artery stenosis bilaterally (or in a
single functioning kidney) are at particular risk of renal failure.
(b) Increased plasma K+ and hyperkalemia may occur, due to reduced
aldosterone secretion.
(c) Not all angiotensin arises through the ACE pathway (“angiotensin
escape”).
(d) ACE inhibition also leads to accumulation of bradykinin (which may
underlie side effects of ACE inhibitors).
(e) Allergic phenomena (including angioedema and hematologic
disorders) occur rarely. Captopril may induce severe dermatologic
reactions.
(f) Many patients develop a chronic nonproductive cough.
(g) Chronic use of ACE inhibitors (and ARBs) appears associated with
exaggerated hypotension with induction of general anesthesia.
(h) Severe fetal abnormalities and oligohydramnios may occur during
second- and third-trimester exposure.
(5) Indications
(a) Hypertension
(b) CHF
(c) Myocardial infarction (secondary prevention)
(d) For all indications, outcome benefits appear to be a drug class
effect; any ACE inhibitor will provide them.
(e) Prevention of renal insufficiency (in the absence of renal artery
stenosis), especially in at-risk population (diabetics)
(6) Administration. PO
(7) Clinical use
(a) Captopril dose
(i) Adults: 12.5 to 150 mg PO in two or three daily doses, with
the lower doses being used for the treatment of heart failure
(ii) Infants: 50 to 500 μg/kg daily in three doses
(b) Children older than 6 mos: 0.5 to 2 mg/kg/day divided into three
doses
(c) Interactions. ACE inhibitors interact with digoxin (reduced digoxin
clearance) and with lithium (Li intoxication). May predispose to
exaggerated hypotension with anesthesia. Captopril interacts with
allopurinol (hypersensitivity reactions), cimetidine (CNS changes),
and insulin or oral hypoglycemic drugs (hypoglycemia).
b. Enalapril (Vasotec)
(1) Actions. An oral ACE inhibitor used to treat hypertension and CHF,
enalapril is very similar to captopril (see Section a). The drug must first
be converted to an active metabolite in the liver.
(2) Clinical use. Enalapril dose: 2.5 to 40 mg/day PO in one or two divided
doses.
c. Enalaprilat (Vasotec-IV)
(1) Actions. Enalaprilat is an IV ACE inhibitor that is the active metabolite
of enalapril. It is used primarily to treat severe or acute hypertension and
is very similar to captopril (see Section a).
(2) Offset is by renal elimination, with a half-life of 11 hours.
(3) Advantages
(a) This drug has a longer duration of action than nitrates, thereby
avoiding the need for continuous infusion. It can help extend BP
control into the postoperative period.
(b) Unlike hydralazine, reflex increases in HR, CO, and MVO2 are
absent.
(4) Disadvantages
(a) There is a longer onset time (15 minutes) than with IV nitroprusside.
Peak action may not occur until 1 to 4 hours after the initial dose.
(b) Pregnancy. Oligohydramnios and fetal abnormalities may be
induced. Use during pregnancy should be limited to life-threatening
maternal conditions.
(5) Enalaprilat IV dose
(a) Adults: 1.25 mg IV slowly every 6 hours (maximum 5 mg IV every 6
hours). In renal insufficiency (creatinine clearance less than 30
mL/min), initial dose is 0.625 mg, which may be repeated after 1
hours; then 1.25 mg.
(b) Pediatrics: A dosage of 250 μg/kg IV every 6 hours has been
reported to be effective in neonates with renovascular hypertension.
d. Other oral ACE inhibitors include: Benazepril (Lotensin), Fosinopril
(monopril), Lisinopril (prinivil, zestril), Quinapril (accupril), Ramipril
(altace), Aceon (perindopril), Mavik (trandolopril), Univasc (moexipril)
4. ARBs
a. Actions
(1) Plasma concentrations of angiotensin II and aldosterone may increase
despite treatment with ACE inhibitors because of accumulation of
angiotensin or because of production catalyzed via non-ACE–dependent
pathways (e.g., chymase).
(2) Selective angiotensin type-1 receptor (AT1) blockers prevent angiotensin
II from directly causing the following:
(a) Vasoconstriction
(b) Sodium retention
(c) Release of NE
(d) LV hypertrophy and fibrosis
(e) Angiotensin type-2 receptors (AT2) are not blocked: Their actions
including NO release and vasodilation remain intact.
b. Advantages
(a) Oral vasodilator
(b) No tachyphylaxis or reflex hemodynamic changes
(c) ARBs have minimal interaction with CYP system, so few drug
interactions.
(d) Improved symptoms and survival in CHF, hypertension, and after MI
(e) Stroke prevention in hypertension and LV dysfunction
(f) May retard progression of renal disease (particularly in diabetics)
(g) Antagonizes LV remodeling after myocardial infarction
(h) Lacks common side effects of ACE inhibitors (cough, angioedema)
c. Disadvantages
(a) There is the potential for decreased renal function, due to reduced renal
perfusion pressure. Patients with renal artery stenosis bilaterally (or in a
single functioning kidney) are at particular risk.
(b) Increased plasma K+ and hyperkalemia may occur, especially when
clinicians fail to recognize the consequences of reduced aldosterone
secretion.
d. Indications
(a) Intolerance of ACE inhibitors—outcome benefits of ACE inhibitors in
hypertension, CHF, after MI and for renal protection in diabetes appear
to be largely shared by ARBs
(b) Hypertension
(c) CHF
(d) Prevention of renal insufficiency (in the absence of renal artery stenosis)
in at-risk population (diabetics)
(e) Data are inconclusive as to whether there is an outcome benefit to adding
ARBs to an ACE inhibitor.
e. Specific agents
(a) Available oral ACE Inhibitors include Losartan (Cozaar), Irbesartan
(Avapro), Candesartan (Atacand), Eprosartan (Teveten), Telmisartan
(Micardis), Valsartan (Diovan), and Olmesartan (Benicar)
5. Direct renin inhibitor. Aliskiren is the single member of this class. It is used
for the treatment of hypertension and has the same side effects and
contraindications as the ARBs. It is dosed at 150 to 300 mg in a single daily
dose.
6. Central α2-agonists
a. Clonidine (Catapres)
(1) Actions
(a) Clonidine reduces sympathetic outflow by activating central α2-
receptors thereby reducing NE release by peripheral sympathetic
nerve terminals.
(b) Clonidine is a partial agonist (activates receptor submaximally but
also antagonizes effects of other α2-agonists).
(c) There is some direct vasoconstrictor action at α2-receptors on
vascular smooth muscle, but this effect is outweighed by the
vasodilation induced by these receptors.
(d) Has “local anesthetic” effect on peripheral nerve and produces
analgesia by actions on spinal cord when administered via epidural
or caudal route.
(e) Has been added to intermediate-duration local anesthetics (e.g.,
mepivacaine or lidocaine) to nearly double the duration of
analgesia after peripheral nerve blocks.
(2) Offset
(a) Long duration (β half-life; 12 hours)
(b) Peak effect 1.5 to 2 hours after an oral dose
(3) Advantages
(a) α2-Agonists potentiate general anesthetics and narcotics through a
central mechanism. This effect can reduce substantially doses of
anesthetics and narcotics required during anesthesia.
(b) There are no reflex increases in HR or contractility.
(c) Clonidine reduces sympathetic coronary artery tone.
(d) It attenuates hemodynamic responses to stress.
(e) Prolongs duration of spinal and nerve block for regional anesthesia.
(4) Disadvantages
(a) Rebound hypertension prominent after abrupt withdrawal.
(b) Clonidine may potentiate opiate drug effects on CNS.
(c) Sedation is dose-dependent.
(5) Clinical use
(a) Clonidine dose
(i) Adult: 0.2 to 0.8 mg PO daily (maximum 2.4 mg/day). When
used as anesthetic premedication, the usual dose is 5 μg/kg
PO.
(ii) Pediatrics: 3 to 5 μg/kg every 6 to 8 hours.
(b) Rebound hypertension frequently follows abrupt withdrawal.
Clonidine should be continued until immediately before the
operation, and either it should be resumed soon postoperatively (by
transdermal skin patch, nasogastric tube, or PO) or another type of
antihypertensive drug should be substituted. Alternatively, clonidine
can be replaced by another drug 1 to 2 weeks preoperatively.
(c) Intraoperative hypotension may occur.
(d) Transdermal clonidine patches require 2 to 3 days to achieve
therapeutic plasma drug levels.
(e) Guanabenz and guanfacine are related drugs with similar effects and
hazards.
(f) Use of clonidine may improve hemodynamic stability during major
cardiovascular surgery.
(g) Clonidine attenuates sympathetic responses during withdrawal from
alcohol or opioids in addicts.
(h) It may reduce postoperative shivering.
(i) It may be added to intermediate-duration local anesthetic solutions
prior to peripheral nerve blocks to prolong the duration of action.
7. Other vasodilators
a. Fenoldopam
(1) Actions
(a) Fenoldopam is a short-acting DA-1 receptor agonist which causes
peripheral vasodilation. The mechanism appears to be through
stimulation of cAMP.
(b) Unlike dopamine, fenoldopam has no α- or β-adrenergic receptor
activity at clinical doses and thus no direct actions on HR or
cardiac contractility.
(c) Fenoldopam stimulates diuresis and natriuresis.
(2) Advantages
(a) Relative to other short-acting IV vasodilators, fenoldopam has
almost no systemic toxic effects.
(b) Fenoldopam alone among vasodilators stimulates diuresis and
natriuresis comparable to “renal dose” (0.5 to 2 μg/kg/min)
dopamine.
(c) Fenoldopam, unlike dopamine, reduces global and regional cerebral
blood flow.
(3) Disadvantages
(a) As is true for other dopaminergic agonists, fenoldopam may induce
nausea in awake patients.
(4) Clinical use
(a) Fenoldopam is an appropriate single agent to use whenever a
combination of a vasodilator and “renal dose” dopamine is
employed; for example, for hypertensive patients recovering after
CPB.
(b) Fenoldopam carries no risk of cyanide or of methemoglobinemia
and may have theoretical advantages over both nitroprusside and
nitroglycerin for control of acute hypertension.
(c) For treatment of urgent or emergent hypertension in adults we initiate
fenoldopam at 0.05 μg/kg/min and double the dose at 5- to 10-
minute intervals until it achieves BP control. Doses of up to 1
μg/kg/min may be required.
(d) The limited data available in pediatrics suggest that weight-adjusted
doses at least as great as those used in adults are necessary.
(e) For inducing diuresis and natriuresis, we have found that doses of
0.05 μg/kg/min are effective in adults.
b. Alprostadil (Prostaglandin E1, PGE1, Prostin VR)
(1) Actions. This drug is a direct vasodilator acting through specific
prostaglandin receptors on vascular smooth-muscle cells.
(2) Offset occurs by rapid metabolism by enzymes located in most body
tissues, especially the lung.
(3) Advantages
(a) Alprostadil selectively dilates the ductus arteriosus (DA) in
neonates and infants. It may maintain patency of an open DA for as
long as 60 days of age and may open a closed DA for as long as 10
to 14 days of age.
(b) Metabolism by lung endothelium reduces systemic vasodilation
compared with its potent pulmonary vascular dilating effect.
(4) Disadvantages
(a) Systemic vasodilation and hypotension
(b) May produce apnea in infants (10% to 12%), especially if birth
weight is less than 2 kg. Fever and seizures are also possible.
(c) Expensive agent
(d) Reversible platelet inhibition
(5) Administration. Infused IV or through umbilical arterial catheter
(6) Indications for use
(a) Cyanotic congenital heart disease with reduced pulmonary blood
flow.
(b) Severe pulmonary hypertension with right heart failure.
(7) Clinical use
(a) Alprostadil dose: Usual IV infusion starting dose is 0.05 μg/kg/min.
The dose should be titrated up or down to the lowest effective
value. Doses as great as 0.4 μg/kg/min may be required.
(b) IV alprostadil is sometimes used in combination with left atrial NE
infusion for treatment of severe pulmonary hypertension with right
heart failure.
c. Epoprostenol (PGI2) is used for the long-term treatment of primary
pulmonary hypertension and pulmonary hypertension associated with
scleroderma. Epoprostenol (Veletri, Flolan) may be used for severe
pulmonary arterial hypertension (WHO Class I) both in IV or inhaled form.
The IV form is more common when patients are placed on a sustained infusion
through a central venous access. Major harms from epoprostenol are
embryonal–fetal malformations and platelet dysfunction leading to potential
bleeding diathesis. In order to use it by inhaled route, patients ideally need to
be intubated, which is typical in most perioperative situation. The acute
treatment of pulmonary hypertension and RV failure is summarized in Table
2.1.
X. Calcium channel blockers [3,54]
1. Tissues utilizing calcium. Calcium is required for cardiac contraction and
conduction, smooth-muscle contraction, synaptic transmission, and hormone
secretion.
2. How calcium enters cells. Calcium ions (Ca2+) reach intracellular sites of
action in two ways, by entering the cell from outside or by being released from
intracellular storage sites. These two mechanisms are related because Ca2+
crossing the sarcolemma acts as a trigger (Ca-induced Ca release), releasing
sequestered Ca2+ from the sarcoplasmic reticulum into the cytoplasm. These
processes can raise intracellular free Ca2+ concentrations 100-fold.
3. Myocardial effects of calcium. The force of myocardial contraction relates to
the free ionized calcium concentration in cytoplasm. Increased [Ca2+] causes
contraction and decreased [Ca2+] permits relaxation. At the end of systole,
energy-consuming pumps transfer Ca2+ from the cytoplasm back into the
sarcoplasmic reticulum, decreasing free cytoplasmic [Ca2+]. If ischemia
prevents sequestration of cytoplasmic Ca2+, diastolic relaxation of myocardium
is incomplete. This abnormal diastolic stiffness of the heart raises LVEDP.
4. Myocardial effects of CCBs. CCBs owe much of their usefulness to their
ability to reduce the entry of the “trigger” current of Ca2+. This reduces the
amount of Ca2+ released from intracellular stores with each heartbeat.
Therefore, all CCBs in large enough doses reduce the force of cardiac
contraction, although this effect often is counterbalanced by reflex actions in
patients. Clinical dosages of some CCBs, such as nifedipine and nicardipine,
do not produce myocardial depression in humans.
5. Vascular smooth muscle and the cardiac conduction system are particularly
sensitive to Ca2+ channel blockade. All CCBs cause vasodilation.
6. Site selectivity. CCBs affect certain tissues more than others. Thus, verapamil
in clinical dosages depresses cardiac conduction, whereas nifedipine does not.
7. Direct versus indirect effects. Selection of a particular CCB is based
primarily on its relative potency for direct cellular effects in the target organ
versus its relative potency for inducing cardiovascular reflexes.
B. Clinical effects common to all CCBs
1. Peripheral vasodilation
a. Arterial vasodilation reduces LV afterload, and this helps offset any direct
negative cardiac inotropic action.
b. Venous effects. Preload usually changes little because venodilation is
minimal, and negative inotropy often is offset by reduced afterload. However,
if CCBs reduce myocardial ischemia and diastolic stiffness, filling pressures
may decrease.
c. Regional effects. Most vascular beds are dilated, including the cerebral,
hepatic, pulmonary, splanchnic, and musculoskeletal beds. Renal blood flow
autoregulation is abolished by nifedipine, making it pressure-dependent.
d. Coronary vasodilation is induced by all CCBs. These drugs are all highly
effective for coronary vasospasm.
e. CCBs versus nitrates
(1) Unlike nitrates, CCBs do not incite tachyphylaxis.
(2) Unlike nitrates, several CCBs are associated with increased bleeding.
f. Reversal of vasodilation. α-Agonists such as phenylephrine often restore BP
during CCB-induced hypotension, but usual doses of calcium salts are often
ineffective.
2. Depression of myocardial contractility. The degree of myocardial depression
that occurs following administration of a CCB is highly variable, depending on
the following factors:
a. Selectivity. The relative potency of the drug for myocardial depression
compared with its other actions is an important factor. Nifedipine and other
dihydropyridines are much more potent as vasodilators than as myocardial
depressants; clinical dosages that cause profound vasodilation have minimal
direct myocardial effects. Conversely, vasodilating dosages of verapamil may
be associated with significant myocardial depression in some patients.
b. Health of the heart. A failing ventricle will respond to afterload reduction
with improved ejection. An ischemic ventricle will pump more effectively if
ischemia is reversed. As CCBs reduce afterload and ischemia, CO may rise
with CCB therapy in certain situations. Direct negative inotropic effects may
not be apparent.
c. Sympathetic reflexes can counteract direct myocardial depression and
vasodilation due to CCBs.
d. Reversal of myocardial depression. Calcium salts, β-agonists, and PDE
inotropes all can be used to help reverse excessive negative inotropy and
heart block. Electrical pacing may be needed.
3. Improving myocardial ischemia
a. CCBs may improve oxygen supply by the following actions:
(1) Reversing coronary artery spasm
(2) Vasodilating the coronary artery, increasing flow to both normal and
poststenotic regions. Diltiazem and verapamil appear to preserve
coronary autoregulation, but nifedipine may cause a coronary steal.
(3) Increasing flow through coronary collateral channels
(4) Decreasing HR (prolonging diastolic duration during which
subendocardium is perfused) with verapamil and diltiazem
b. CCBs may improve oxygen consumption by
(1) Diminishing contractility
(2) Decreasing peak LV wall stress (afterload reduction)
(3) Decreasing HR (by verapamil and diltiazem)
4. Electrophysiologic depression
a. Spectrum of impairment of AV conduction
(1) Verapamil. Clinical doses usually produce significant electrophysiologic
effects. Thus, verapamil has a high relative potency for prolonging AV
refractoriness compared with its vasodilating potency.
(2) Dihydropyridines. On the other hand, nifedipine and other drugs of this
class in dosages that produce profound vasodilation have no effect on
AV conduction.
(3) Diltiazem is intermediate between nifedipine and verapamil.
b. AV node effects. The depression of AV nodal conduction by CCBs may be
beneficial for its antiarrhythmic effect.
c. Sinoatrial (SA) node effects. Diltiazem and verapamil decrease sinus rate,
whereas nifedipine and nicardipine often increase HR slightly.
d. Ventricular ectopy due to mitral valve prolapse, atrial or AV nodal disease,
and some forms of digitalis toxicity may respond to CCBs.
5. Clinical uses
a. Myocardial ischemia mainly for symptom reduction; note that outcome benefit
is not well established for CCBs.
b. Hypertension (outcome benefits are better established for thiazide diuretics
and ACE inhibitors; short-acting CCBs have been associated with worsened
outcomes)
c. Hypertrophic cardiomyopathy by relieving LV outflow obstruction
d. Cerebral vasospasm following subarachnoid hemorrhage (nimodipine)
e. Possible reduction of cyclosporine nephrotoxicity with concomitant CCB
therapy in transplant recipients. Also, CCBs may potentiate the
immunosuppressive action of cyclosporine.
f. Migraine prophylaxis
C. Specific IV agents
1. Diltiazem (Cardizem)
a. Diltiazem is a benzothiazepine calcium blocker.
b. Actions. Diltiazem has a selective coronary vasodilating action, causing a
greater increase in coronary flow than in other vascular beds.
c. Offset occurs by hepatic metabolism (60%) and renal excretion (35%).

Plasma elimination half-life is 3 to 5 hours. The active metabolite is
desacetyldiltiazem.
d. Advantages
(1) Diltiazem often decreases HR of patients in sinus rhythm.
(2) It is effective in treating and preventing symptoms of classic or
vasospastic myocardial ischemia. Diltiazem does not improve outcome
in these conditions.
(3) Used for rate control of SVT (see Section VIII.E).
(4) Perioperative hypertension can be controlled with IV diltiazem.
e. Disadvantages
(1) Sinus bradycardia and conduction system depression are possible.
(2) No evidence for outcome benefit in hypertension or CAD relative to
other agents
f. Indications
(1) Myocardial ischemia, both classic angina and coronary artery spasm
(2) Hypertension
(3) SVT, including atrial fibrillation or flutter (see Section VIII.E)
(4) Sinus tachycardia, especially intraoperative or postoperative
(5) Diltiazem dose (adult) (see Section VIII.E)
2. Nicardipine (Cardene)
a. Actions. A dihydropyridine calcium blocker with actions closely resembling
those of nifedipine (see Section VII), nicardipine is primarily a vasodilator
without clinically important negative cardiac inotropy. It is used most
commonly for treatment of hypertension.
b. IV nicardipine
(1) The IV preparation is a highly effective vasodilator that is widely used in
surgical patients, causing only minimal HR increase and no increase in
ICP. Nicardipine lacks the rebound hypertension that can follow
nitroprusside withdrawal. Nicardipine causes less venodilation than
nitroglycerin.
(2) Offset. Metabolism occurs in the liver, with plasma α and β half-lives of
3 and 14 minutes, respectively. When IV administration is stopped, 50%
offset vasodilation occurs in approximately 30 minutes.
(3) Clinical use. Nicardipine IV is effective for control of perioperative
hypertension; it also improves diastolic LV function during ischemia by
acceleration of myocardial relaxation (lusitropy). Nicardipine can
elevate plasma cyclosporine levels.
c. Nicardipine dose: PO: 60 to 120 mg in three daily doses; IV: 1 to 4 μg/kg/min
in adults, titrated to BP. The drug causes phlebitis when infused for more than
12 hours through a peripheral IV catheter.
3. Verapamil (Calan, Isoptin) (see Section VIII.E).
4. Clevidipine [59]: Ultra–short-acting calcium channel blocker. IV use only.
a. Actions: Reducing peripheral vascular resistance, increasing CO and reducing
BP. This agent is used for perioperative control of hypertension. Plasma half-
life approximately 1 minute. Reduced 4.5% of systemic BP in 2 to 4 minutes
(https://resources.chiesiusa.com/Cleviprex/CLEVIPREX_US_PI.pdf). Full
recovery of BP can be expected in 5 to 15 minutes after infusion is stopped.
b. Metabolism: Plasma and tissue esterases. No contraindication in liver and
kidney disease. Supplied as an emulsion. Potential allergic reactions to
patients with egg allergy, soy allergy, abnormal lipid metabolism. The
manufacturer suggests severe aortic stenosis as a contraindication, we believe
that it can be used avoiding any drastic drop in BP. We have typically used it
for transfemoral aortic valve replacement to control the BP after valve
deployment.
c. Dose: Initiate at 1 to 2 mg/hr. Change the dose by 1 to 2 mg/hr every 5 to 10
minutes until goal is achieved. Usually maximum dose achieved is 16 mg/hr or
less. Per manufacturer due to lipid load, it should be restricted to 21 mg/hr
per 24-hour period.
XI. Pharmacologic control of HR and rhythm
A. Overview of antiarrhythmic medications [3,25,60]
Antiarrhythmic drugs are classified through the Vaughan Williams classification.
1. Antiarrhythmic drugs available in IV form [3,27,60]

a. Procainamide (Pronestyl, Procan-SR)
(1) Class IA antiarrhythmic
(2) Dosing
(a) Loading dose
(i) IV: 10 to 50 mg/min (or 100 mg every 2 to 5 minutes) up to 17
mg/kg.
(ii) Pediatric IV: 3 to 6 mg/kg given slowly.
(b) Maintenance dose
(i) Adult: IV infusion, 2 mg/kg/hr; PO, 250 to 1,000 mg every 3
hours
(ii) Children: IV infusion, 20 to 50 μg/kg/min; PO, 30 to 50
mg/kg/day divided into four to six doses.
(3) Pharmacokinetics
Therapeutic plasma level is usually 4 to 10 μg/mL. With bolus
administration, the duration of action is 2 to 4 hours. Metabolism is both
hepatic (50%, N-acetylprocainamide) and renal. Slow acetylators are
more dependent on renal elimination. Patients with reduced renal
function require lower maintenance doses, and need close monitoring of
serum levels and the ECG QT intervals.
(4) Adverse effects
(a) High serum levels or rapid loading may cause negative inotropic
and chronotropic effects, leading to hypotension and hypoperfusion.
Overdose may require pacing and/or β-agonist therapy.
(b) High serum levels of procainamide and/or its principal active
metabolite (N-acetylprocainamide) induce QT prolongation and
Torsades de Pointes. Discontinuation of therapy should be
considered if the corrected QT interval exceeds 450 ms.
(c) CNS excitability may occur with confusion and seizures.
(d) A lupus-like syndrome may be seen with long-term therapy.
b. Amiodarone (Cordarone)
(1) Class III antiarrhythmic agent
(2) Dosing
(a) PO: 800 to 1,600 mg/day for 1 to 3 weeks, gradually reducing
dosage to 400 to 600 mg/day for maintenance.
(b) IV
(i) Loading: For patients in a perfusing rhythm, 150 mg over 10
minutes in repeated boluses until sustained periods of sinus
rhythm occur. For patients in pulseless VT/VF, more rapid
bolus administration may be warranted. Patients often require
2 to 4 or more boluses for a sustained response.
(ii) Maintenance: 1 mg/min for 6 hours, then 0.5 mg/min thereafter,
with the goal of providing approximately 1 g/day.
(3) Pharmacokinetics. The drug is metabolized hepatically, but has very
high lipid solubility that results in marked tissue accumulation. The
elimination half-life is 20 to 100 days. Hence, for patients treated
chronically, it is usually unnecessary to “reload” amiodarone when
doses are missed during surgery, and postoperatively patients usually
resume their preoperative dosing.
(4) Adverse effects
(a) Amiodarone is an α- and β-receptor noncompetitive antagonist, and
therefore has potent vasodilating effects, and can render negative
inotropic effects. Hence, vasoconstrictors, IV fluid, and
occasionally β-agonists are required for hemodynamic support,
especially during the IV amiodarone loading phase.
(b) Amiodarone blocks potassium channels and typically prolongs the
QT interval, but is only rarely associated with Torsades de Pointes.
The risk of torsades on amiodarone therapy is poorly correlated
with the QT interval, and QT prolongation on amiodarone, if not
excessive, does not usually require cessation of therapy.
(c) Amiodarone use may cause sinus bradycardia or heart block due to
β-receptor blockade, and patients requiring sustained IV
amiodarone therapy sometimes require pacing or low doses of
supplemental β-agonists.
(d) The side effects of long-term oral dosing (subacute pulmonary
fibrosis, hepatitis, cirrhosis, photosensitivity, corneal
microdeposits, hypothyroidism, or hyperthyroidism) are of little
concern during short-term (days) IV therapy.
(e) This drug may increase the effect of oral anticoagulants, phenytoin,
digoxin, diltiazem, quinidine, and other drugs.
c. Lidocaine (lignocaine, xylocaine)
(1) Class IB antiarrhythmic
(2) Dosing
(a) Loading dose: 1 mg/kg IV, a second dose may be given 10 to 30
minutes after first dose. Loading dose is sometimes doubled for
patients on CPB who are experiencing VF prior to separation. The
total dose should not exceed 3 mg/kg.
(b) Maintenance dose: 15 to 50 μg/kg/min (i.e., 1 to 4 mg/min in adults).
(3) Pharmacokinetics. Duration of action is 15 to 30 minutes after
administration of a bolus dose. Metabolism is hepatic, and 95% of
metabolites are inactive. However, for infusions lasting more than 24
hours, serum levels should be monitored. Many factors that reduce
hepatic metabolism will increase serum levels, including CHF, α-
agonists, liver disease, and advanced age.
(4) Adverse effects
(a) CNS excitation may result from mild-to-moderate overdose,
producing confusion or seizures. At higher doses, CNS depression
will ensue, producing sedation and respiratory depression. At still
higher doses lidocaine will produce severe myocardial depression.
(b) Lidocaine, like other antiarrhythmics with sodium-channel–blocking
properties (amiodarone, procainamide), slows ventricular
excitation. Hence, patients with AV nodal block who are dependent
upon an idioventricular rhythm may become asystolic during
lidocaine therapy.
2. Drug therapies for bradyarrhythmias [3,27,60]
a. Atropine
(1) Dosing. IV bolus: In adults, use 0.4 to 1 mg (may repeat); in children, use
0.02 mg/kg (minimum 0.1 mg, maximum 0.4 mg, may repeat).
(2) Pharmacokinetics. The HR effects of IV atropine appear within seconds,
and effects last as long as 15 to 30 minutes; when given IM, SC, or PO,
offset occurs in approximately 4 hours. There is minimal metabolism of
the drug, and 77% to 94% of it undergoes renal elimination.
(3) Adverse effects. Atropine is a competitive antagonist at muscarinic
cholinergic receptors, and its adverse effects are largely systemic
manifestations of this receptor activity.
(a) Tachycardia (undesirable with coronary disease)
(b) Exacerbation of bradycardia by low dosages (0.2 mg or less in an
adult)
(c) Sedation (especially in pediatric and elderly patients)
(d) Urinary retention
(e) Increased intraocular pressure in patients with closed-angle
glaucoma. Atropine may be safely given, however, if miotic eye
drops are given concurrently.
b. Glycopyrrolate
(1) Dosing (adults). 0.1 mg IV, repeated at 2- to 3-minute intervals
(2) Differences from atropine. Less likely to cause sedation, but also less
likely to produce tachycardia and less likely to be effective for treatment
of critical bradycardia. This agent may be chosen to manage mild
intraoperative bradycardia, or as an antagonist to the HR slowing effects
of neostigmine when reversing neuromuscular blockade. Atropine
remains the drug of choice in severe or life-threatening sinus bradycardia
and glycopyrrolate should not be used for this purpose!
c. Isoproterenol (Isuprel)
(1) General features. Isoproterenol is a synthetic catecholamine with direct
β1- and β2-agonist effects, and thus has both positive inotropic (through
β1-mediated enhanced contractility plus β2-mediated vasodilation) and
positive chronotropic effects. Isoproterenol is the drug of choice for drug
treatment of bradycardia with complete heart block.
(2) Dosing. IV infusion is 0.02 to 0.50 μg/kg/min.
(3) Pharmacokinetics. The agent is used as a continuous infusion, and has a
short half-life (2 minutes) making it titratable. It is partly metabolized in
the liver (MAO, COMT) and partly excreted unchanged (60%).
(4) Adverse effects
(a) The major potential adverse effect of isoproterenol is myocardial
ischemia in patients with CAD, because the combination of
tachycardia, positive inotropy, and hypotension may create a
myocardial oxygen supply–demand mismatch.
(b) The agent may provoke supraventricular arrhythmias, or may unmask
pre-excitation in patients with an accessory AV conduction pathway
(e.g., WPW syndrome). This agent is increasingly difficult to obtain
from the manufacturer in the United States.
B. Supraventricular arrhythmias [3,25,27]
1. Therapy-based classification
a. General. SVT often foreshadows life-threatening conditions that may be
correctable in the surgical patient. Hence, the initial management of the
hemodynamically stable surgical patient who suddenly develops SVT should
not be on heart-directed pharmacologic therapies, but rather on potential
correctable etiologies that may include hypoxemia (O2 saturation),
hypoventilation (end-tidal CO2), hypotension (absolute or relative
hypovolemia due to bleeding, anaphylaxis, etc.), light anesthesia, electrolyte
abnormalities (K+ or Mg2+), or cardiac ischemia (HR, nitroglycerin).
b. Hemodynamically unstable patients. Patients with low BP (e.g., systolic BP
less than 80 mm Hg), cardiac ischemia, or other evidence of end-organ
hypoperfusion require immediate synchronous DC cardioversion. While some
patients may only respond transiently to cardioversion in this setting (or not at
all), a brief period of sinus rhythm may provide valuable time for correcting
the reversible causes of SVT (see earlier) and/or instituting pharmacologic
therapies (see later). During cardiac or thoracic surgery, patients may
experience SVT during dissection of the pericardium, placement of atrial
sutures, or insertion of the venous cannulae required for CPB. If
hemodynamically unstable SVT occurs during open thoracotomy, the surgeon
should attempt open synchronous cardioversion. Patients with critical
coronary lesions or severe aortic stenosis with SVT may be refractory to
cardioversion, and thus enter a malignant cascade of ischemia and worsening
arrhythmias that requires the institution of CPB. Hence, early preparation for
CPB is recommended before inducing anesthesia in those cardiac surgery
patients judged to be at exceptionally high risk for SVT and consequent
hemodynamic deterioration.
c. Hemodynamically stable patients
(1) Adenosine therapy (Table 2.2)
TABLE 2.2 The response of common supraventricular tachyarrhythmias to IV adenosine
(a) In certain patients the SVT involves a re-entrant pathway involving

the AV node. These rhythms typically have a regular R–R interval,
and are common in relatively healthy patients. Adenosine
administered as a 6 mg IV bolus (repeated with 12 mg if no
response) may terminate the SVT.
(b) Many of the rhythms commonly seen in the perioperative period do
not involve the AV node in a re-entrant pathway, and AV nodal
block by adenosine in such cases will produce only transient
slowing of the ventricular rate. This may lead to “rebound”
speeding of the tachycardia following the adenosine effect.
Adenosine should be avoided in cases where the rhythm is
recognizable and known to be refractory to adenosine (atrial
fibrillation, atrial flutter). The hallmark of atrial fibrillation is an
irregularly irregular R–R interval.
(c) Junctional tachycardias are common during the surgical period
(particularly after surgery for congenital heart disease in children),
and sometimes convert to sinus rhythm in response to adenosine,
depending on the proximity of the site of origin to the AV node.
Ventricular arrhythmias exhibit no response to adenosine since
these rhythms originate.
2. Rate control therapy
a. Rationale for rate control. In most cases, ventricular rate control is the
mainstay of therapy.
(1) Lengthening diastole serves to enhance LV filling, thus enhancing SV.
(2) Slowing the ventricular rate reduces Mvo2 and lowers the risk of cardiac
ischemia.
b. Rationale for drug selection. The most common selections are IV β-blockers
or calcium channel blockers because of their rapid onset.
(1) Among the IV β-blockers, esmolol has the shortest duration of action,
rendering it titratable on a minute-to-minute basis, and allowing
meaningful dose adjustments during periods of surgery that provoke
changes in hemodynamic status (i.e., bleeding, abdominal traction). The
drug has obligatory negative inotropic effects that are problematic for
patients with severe LV dysfunction.
(2) Both IV verapamil and IV diltiazem are calcium channel blockers that are
less titratable than esmolol, but nonetheless rapidly slow the ventricular
rate in SVT. Moreover, IV diltiazem has less negative inotropic action
than verapamil or esmolol and is therefore preferable in patients with
heart failure.
(3) IV digoxin slows the ventricular response during SVT through its
vagotonic effects at the AV node, but should be temporally supplemented
with other IV agents because of its slow onset (approximately 6 hours).
c. Accessory pathway rhythms. AV nodal blockade can reduce the ventricular
rate in WPW, and improve hemodynamic status. However, 10% to 35% of
patients with WPW eventually develop atrial fibrillation. In this case, the
rapid rate of atrial excitation (greater than 300 impulses/min), normally
transmitted to the ventricle after “filtering” by the AV node, is instead be
transmitted to the ventricle via the accessory bundle at a rapid rate. The
danger of inducing VT/VF in this scenario is exacerbated by treatment with
classic AV nodal blocking agents (digoxin, calcium channel blockers, β-
blockers, and adenosine) because they reduce the accessory bundle refractory
period. Hence, WPW patients who experience atrial fibrillation should not
receive AV nodal blockers. IV procainamide slows conduction over the
accessory bundle, and is an option for treating AF in patients with accessory
pathways.
d. Specific rate control agents [3,27,60]
(1) Esmolol
(Please also see the earlier section on β-blockers.)
(a) Dosing. During surgery and anesthesia, the standard 0.25 to 0.5
mg/kg load (package insert) may be accompanied by marked
hypotension. In practice, reduced IV bolus doses of 12.5 to 25 mg
are titrated to effect, followed by an infusion of 50 to 200
μg/kg/min. Transient hypotension during the loading phase may
usually be managed with IV fluid or vasoconstrictors
(phenylephrine).
(b) Pharmacokinetics. Esmolol is rapidly eliminated by a red blood
cell esterase. After discontinuation of esmolol, most drug effects are
eliminated within 5 minutes. The duration of esmolol action is not
affected when plasma pseudocholinesterase is inhibited by
echothiophate or physostigmine.
(c) Adverse effects
(i) Esmolol is a potent, selective β1-receptor antagonist, and may
cause hypotension through both vasodilation and negative
inotropic effects.
(ii) Compared to nonselective β-blockers, esmolol is less likely to
elicit bronchospasm, but should still be used with caution in
patients with known bronchospastic disease.
(2) Verapamil
(a) Dosing
(i) IV load (adults): 5 to 15 mg, consider administering in 1 to 2
mg increments during surgery and anesthesia, or in unstable
patients. Dose may be repeated after 30 minutes.
(ii) Maintenance IV: 5 to 15 mg/hr.
(iii) PO (adults): 40 to 80 mg tid to qid (maximum 480 mg/day).
(iv) Pediatric dose: 75 to 200 μg/kg IV; may be repeated.
(b) Pharmacokinetics. Elimination occurs by hepatic metabolism, and
plasma half-life is 3 to 10 hours, so lengthy intervals (hours)
between dose increments for IV infusions should be utilized to
avoid cumulative effects.
(c) Adverse effects
(i) Verapamil blocks L-type calcium channels and may cause
hypotension because of both peripheral vasodilation and
negative inotropic effects, especially during the IV loading
phase. The vasodilatory effects may be mitigated by
administration of IV fluid or vasoconstrictors (i.e.,
phenylephrine). Patients with severe LV dysfunction may not
tolerate IV verapamil, and may be better candidates for IV
diltiazem (see later).
(ii) Verapamil (given chronically) reduces digoxin elimination and
can raise digoxin levels, producing toxicity.
(3) Diltiazem
(a) Dosing (adult)
(i) IV loading: 20 mg IV over 2 minutes. May repeat after 15
minutes with 25 mg IV if HR exceeds 110 bpm. Smaller doses
or longer loading periods may be used in patients who have
myocardial ischemia, hemodynamic instability, or who are
anesthetized.
(ii) Maintenance: Infusion at 5 to 15 mg/hr, depending on HR
control.
(iii) PO dose: 120 to 360 mg/day (sustained-release preparations
are available).
(b) Pharmacokinetics. Metabolism is both hepatic (60%) and renal
excretion (35%). Plasma elimination half-life is 3 to 5 hours, so
lengthy intervals (hours) between dose increases for IV infusions
should be utilized to avoid cumulative effects.
(c) Adverse effects
(i) Diltiazem, like all calcium channel blockers, elicits
vasodilation and may evoke hypotension. At the same time,
partly due to its afterload reducing properties, IV diltiazem is
less likely to compromise CO in patients with reduced LV
function (relative to other AV nodal blockers) and is the drug
of choice for rate control in this circumstance.
(ii) Sinus bradycardia is possible, so diltiazem should be used
with caution in patients with sinus node dysfunction or those
also receiving digoxin or β-blockers.
(4) High-dose IV magnesium sulfate
(a) Dosing. Regimens including a 2 to 2.5 g initial bolus, followed by a
1.75 g/hr infusion, are described.
(b) Issues with use. High-dose magnesium is used rarely for SVT, but
may nonetheless successfully provide rate control for patients with
SVT. In some cases, rates of conversion to sinus rhythm exceeding
placebo or antiarrhythmic agents have been noted. The use of these
high magnesium doses requires close monitoring of serum levels,
and should be avoided in patients with renal insufficiency. An
increased requirement for temporary pacing due to the AV nodal
blockade has also been noted. Magnesium potentiates
neuromuscular blockers; thus, this agent can cause life-threatening
hypoventilation in spontaneously breathing patients who have
residual blood levels of these agents.
e. Cardioversion of SVT
(1) Limitations of pharmacologic or “chemical” cardioversion
(a) The 24-hour rate of spontaneous conversion to sinus rhythm for
recent-onset perioperative SVT exceeds 50%, and many patients
who develop SVT under anesthesia will remit spontaneously within
hours of emergence.
(b) Most of the antiarrhythmic agents with activity against atrial
arrhythmias have limited efficacy when utilized in IV form for rapid
chemical conversion. Although 50% to 80% efficacy rates are cited
for many IV antiarrhythmics in uncontrolled studies, these findings
are an artifact of high placebo rates of conversion (approximately
60% over 24 hours). Although improved rates of chemical
cardioversion are seen with high doses of IV amiodarone
(approximately 2 g/day), the potential for undesirable side effects in
the perioperative setting requires further study.
(c) Most agents have adverse effects, including negative inotropic
effects or vasodilation (amiodarone, procainamide). In addition,
these agents may provoke polymorphic ventricular arrhythmias
(Torsades de Pointes). While less common with amiodarone, newer
IV agents that exhibit high efficacy for converting atrial fibrillation
(i.e., ibutilide) exhibit rates of torsades as high as 8%.
(2) Rationale for cardioversion. In the operating room, chemical
cardioversion should be aimed mainly at patients who cannot tolerate (or
do no respond to) IV rate control therapy, or who fail DC cardioversion
and remain hemodynamically unstable. Intraoperative elective DC
cardioversion in an otherwise stable patient with SVT also carries
inherent risks (VF, asystole, and stroke). Moreover, the underlying
factors provoking SVT during or shortly after surgery are likely to persist
beyond the time of cardioversion, inviting recurrence. Hence, when
elective DC cardioversion is considered, it may be prudent to first
establish a therapeutic level of an antiarrhythmic agent that maintains
sinus rhythm (i.e., procainamide, amiodarone), with a view to preventing
SVT recurrence following electrical cardioversion. Guidelines for
administration of IV procainamide and amiodarone are provided in an
earlier section of this chapter (see Section XI.A.1.).
f. SVT prophylaxis for postoperative patients [27]
SVT may occur during the days following surgery, and occurs within the first
4 postoperative days in up to 40% of cardiac surgeries. Many postoperative
prophylaxis regimens have been evaluated, and are discussed in recent
reviews. Prophylactic administration of a number of drugs typically used to
slow AV nodal conduction (particularly β-blockers and amiodarone) may
reduce the incidence of postoperative atrial fibrillation (particularly after
cardiothoracic surgery), but by no means eliminate the problem. Nonetheless,
antiarrhythmic prophylaxis should be considered in selected patients at high
risk for hemodynamic or ischemic complications from postoperative SVT.
g. Potential arrhythmogenic drugs: Table 2.3
TABLE 2.3 QT-prolonging drugs (partial listing emphasizing agents used
perioperatively)
XII. Diuretics [61]

A. Actions
Most IV diuretics act at the loop of Henle in the kidney to block resorption of
electrolytes from the tubule. Loop diuretics block the sodium–potassium–
chloride transporter. Thiazide diuretics block the electroneutral sodium–chloride
transporter. Amiloride and triamterene block apical (non–voltage-gated) sodium
channels. Spironolactone binds and inhibits the mineralocorticoid receptor. This
action increases excretion of water and electrolytes (Na, Cl, K, Ca, and Mg)
from the body.
B. Adverse effects
1. Effect shared by all diuretics
a. Cross-sensitivity with sulfonamides (except ethacrynic acid)
2. Effects shared by thiazides and loop diuretics
a. Skin reactions
b. Interstitial nephritis
c. Hypokalemia
d. Hypomagnesemia (effects of thiazides and loop diuretics are diminished by
potassium-sparing diuretics such as spironolactone or triameterene)
e. Risk of hyponatremia greater with thiazides than with loop diuretics
3. Effects specific to loop diuretics
a. Increased serum uric acid
b. Ototoxicity. Deafness, usually temporary, may occur with large drug doses or
coadministration with an aminoglycoside antibiotic. One possible mechanism
for this is drug-induced changes in endolymph electrolyte composition.
4. Effects of thiazide diuretics
a. Hypercalcemia
b. Hyperuricemia
c. Mild metabolic alkalosis (“contraction” alkalosis)
d. Hyperglycemia, glucose intolerance
e. Hyperlipidemia
f. Rare pancreatitis
5. Effects of potassium-sparing diuretics
a. Hyperkalemia (sometimes with metabolic acidosis)
b. Gynecomastia (with increased doses of spironolactone)
c. Amiloride excreted by kidneys, so duration prolonged in renal failure
CLINICAL PEARL Diuretics should be used to induce diuresis, not to diagnose the
characteristics or severity of acute kidney injury.
C. Specific drugs
1. Loop diuretics
a. Furosemide (Lasix)
(1) Pharmacokinetics. Renal tubular secretion of unchanged drug and of
glucuronide metabolite. Half-life of 1.5 hours.
(2) Clinical use
(a) Dosing
(i) Adults: The usual oral dosing is 20 to 320 mg in two daily
doses. The usual IV starting dose for patients not currently
receiving diuretics is 2.5 to 5 mg, increasing as necessary to a
200 mg bolus. Patients already receiving diuretics usually
require 20 to 40 mg initial doses to produce a diuresis. A
continuous infusion (0.5 to 1 mg/kg/hr) at approximately 0.05
mg/kg/hr in adults produces a more sustained diuresis with a
lower total daily dose compared with intermittent bolus
dosing. Patients resistant to loop diuretics (e.g., after long-
term dosing in hepatic failure) may benefit from combinations
of furosemide and thiazide diuretics.
(ii) Pediatric: 1 mg/kg (maximum, 6 mg/kg). The pediatric infusion
rate is 0.2 to 0.4 mg/kg/hr.
(b) Because furosemide is a sulfonamide, allergic reactions may occur
in sulfonamide-
sensitive patients (rare).
(c) Furosemide often causes transient vasodilation of veins and
arterioles, with reduced cardiac preload.
b. Bumetanide (Bumex)
(1) Pharmacokinetics. Combined renal and hepatic elimination. Half-life is
1 to 1.5 hours.
(2) Clinical use
(a) Dosing: The usual oral dosing is 25 to 100 mg in two or three daily
doses. 0.5 to 1 mg IV, may be repeated every 2 to 3 hours to a
maximum dose of 10 mg/day.
(b) Myalgias may occur.
c. Ethacrynic acid (Edecrin)
(1) Pharmacokinetics. Combined renal and hepatic elimination
(2) Clinical use
(a) Dosing: 50 mg IV (adult dose) or 0.5 to 1 mg/kg (maximum 100 mg)
titrated to effect
(b) Usually is reserved for patients who fail to respond to furosemide or
bumetanide, or who are allergic to sulfonamides (thiazides and
furosemide are chemically related to sulfonamides)
2. Thiazide diuretics
a. Mechanism/pharmacokinetics. The mechanism of the antihypertensive effect
of thiazide diuretics remains the subject of debate. All thiazides increase the
urinary excretion of sodium and chloride, acting on the sodium-chloride
symporter in the distal renal tubules.
3. Potassium-sparing diuretics
a. Amiloride (Midamor)
(1) Mechanism/pharmacokinetics
Amiloride works by inhibiting sodium channels in renal epithelium of the
late distal tubule and collecting duct. This mildly increases the excretion
of sodium and chloride. Amiloride decreases the lumen-negative voltage
across the membrane, decreasing the excretion of K+, H+, Ca2+, and
Mg2+. Amiloride has 15% to 25% oral bioavailability. It has a roughly
21-hour half-life and is predominantly eliminated by the renal excretion
of the intact drug.
(2) Clinical use
Amiloride is a weak diuretic, so it is almost never used as a sole agent,
but most commonly in combination with other, stronger diuretics (such as
thiazides or loop diuretics) to augment their diuretic and antihypertensive
effects and reduce the risk of hypokalemia.
(a) Dosing: Usual dose is 5 to 10 mg/day in one or two doses added to
a loop or thiazide diuretic. Doses more than 10 mg/day have rarely
been given.
(b) This agent is also available as a combination product with
hydrochlorothiazide (Moduretic).
b. Eplerenone (Inspra)
This agent has the same mechanism of action as spironolactone and it is
used for the same indications. It is an effective antihypertensive. It has
been shown to prolong life in patients with LV dysfunction following
myocardial infarction.
(2) Dosing: The drug is initiated at 25 mg/day and may be increased to 100
mg/day as tolerated by the patient.
c. Spironolactone (Aldactone)
Spironolactone is a competitive antagonist to the mineralocorticoid
receptor found in the cytoplasm of epithelial cells in the late distal tubule
and collecting duct. Thus, it opposes the actions of endogenous
aldosterone. After binding the receptor, the aldosterone–receptor
complex migrates to the cell nucleus, regulating production of a series of
“aldosterone-induced proteins.” The aldosterone-induced proteins
ultimately increase transepithelial sodium–chloride transport, and the
lumen-negative transepithelial membrane potential, increasing the
secretion of K+ and H+ into the tubular lumen. Spironolactone
antagonizes these effects. Spironolactone has also been shown to inhibit
the cardiac remodeling process and to prolong life in patients with
chronic HF. The side effects of spironolactone include hyperkalemia and
gynecomastia. Spironolactone has about a 65% oral bioavailability and a
very short half-life. It has active metabolites with prolonged (16-hour
half-life) actions.
(2) Clinical use
Spironolactone is a weak diuretic, so it is almost never used as a sole
agent, but most commonly in combination with other, stronger diuretics
(such as thiazides or loop diuretics) to augment their diuretic and
antihypertensive effects and reduce the risk of hypokalemia.
Spironolactone prolongs life in patients with heart failure and is now
part of standard therapy for symptomatic patients with this condition.
(a) Dosing: The usual dose is 12.5 to 25 mg/day, but this may be
increased as needed up to 100 mg/day in one or two daily doses.
This agent is also available as a combination product with
hydrochlorothiazide (Aldactazide).
d. Triamterene
This agent is believed to have the same mechanism of action as
amiloride and it is used for the same indications as amiloride. It is
approximately one-tenth as potent as amiloride. Triamterene has 50%
oral bioavailability and a half-life of roughly 4.5 hours. It is eliminated
through hepatic biotransformation to an active metabolite that is excreted
in the urine.
(2) This agent is usually given in doses of 50 to 150 mg/day in one or two
doses in combination with thiazide or loop diuretics. It is also found in a
combination product with hydrochlorothiazide (Dyazide).
4. Osmotic diuretics
a. Mannitol
(1) Mechanism/pharmacokinetics. Mannitol is an osmotic diuretic that is
eliminated unchanged in urine. It is also a free-radical scavenger.
(2) Clinical use
(a) Unlike the loop diuretics (e.g., furosemide), mannitol retains its
efficacy even during low glomerular filtration states (e.g., shock).
(b) Diuresis with this agent may have protective effects in some clinical
scenarios (i.e., CPB, poor renal perfusion, hemoglobinuria, or
nephrotoxins), possibly related to free-radical scavenging.
(c) As an osmotically active agent in the bloodstream, it is sometimes
used to reduce brain water content, cerebral edema and ICP.
Mannitol is administered routinely (as prophylaxis) by many
clinicians during anesthesia for patients with intracranial mass
lesions.
5. Dosing: Initial dose is 12.5 g IV to a maximum of 0.5 g/kg.
6. Adverse effects
a. It may produce hypotension if administered as a rapid IV bolus.
b. It may induce transient pulmonary edema as intravascular volume expands
before diuresis begins.
XIII. Pulmonary hypertension [62–64]:
For therapeutic treatment, there are essentially three established pathways that are
targeted: the nitric oxide pathway, the prostacyclin pathway and endothelin
receptor pathway. In perioperative settings (Table 2.1), iNO, milrinone, PGI2
(Flolan) are the most useful. For oral therapy, essentially it is the endothelin
pathway–mediated drugs. Depending on their “WHO Functional Class” patients
may be on multiple drug therapy. Several novel compounds are also being tried
now-a-days that are still experimental (see reference above).
ACKNOWLEDGMENTS
The authors acknowledge the contributions of coauthors in previous editions: Dr.
Jeffrey Balser and Dr. David Larach.
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II
General Approach to Cardiothoracic
Anesthesia
3 The Cardiac Surgical Patient
Ronak G. Desai, Alann Solina, Donald E. Martin, and
Kinjal M. Patel
I. Introduction
II. Patient presentation
A. Clinical perioperative risk assessment—multifactorial risk indices
B. Functional status
C. Genomic contributions to cardiac risk assessment
D. Risk associated with surgical problems and procedures
III. Preoperative medical management of cardiovascular disease
A. Myocardial ischemia
B. Congestive heart failure
C. Dysrhythmias
D. Hypertension
E. Cerebrovascular disease
IV. Noninvasive cardiac imaging
A. Echocardiography
B. Preoperative testing for myocardial ischemia
V. Cardiac catheterization
A. Overview
B. Assessment of coronary anatomy
C. Assessment of left ventricular function
D. Assessment of valvular function
VI. Interventional cardiac catheterization
A. Percutaneous coronary intervention (PCI)
B. Preoperative management of patients with prior interventional
procedures
VII. Management of preoperative medications
A. β-Adrenergic blockers
B. Statins (HMG-CoA inhibitors)
C. Anticoagulant and antithrombotic medication
D. Antihypertensives
E. Antidysrhythmics
KEY POINTS
1. Inability to climb two flights of stairs showed a positive predictive

value of 82% for postoperative pulmonary or cardiac complications.
2. Silent ischemia is more common in the elderly and in diabetic
patients, with 15% to 35% of all myocardial infarctions (MIs)
occurring as silent events.
3. Isolated asymptomatic ventricular arrhythmias, even nonsustained
ventricular tachycardias (VTs), have not been associated with
complications following noncardiac surgery.
4. Patients with left bundle branch block (especially those right
coronary artery disease) in whom a Swan–Ganz catheter is being
placed are at risk of developing complete heart block during passage
of the pulmonary artery catheter.
5. Preoperative hypertension at levels below 180/110 mm Hg has not
been found to be an important predictor of increased perioperative
cardiac risk, but may be a marker for chronic cardiovascular
disease.
6. In patients undergoing cardiac surgery, the presence of carotid
stenosis increases the risk of postoperative stroke from
approximately 2% in patients without carotid stenosis to 10% with
stenosis of greater than 50%, and to 11% to 19% with stenosis of
>80%.
7. Percutaneous coronary intervention (PCI) is not therapeutically
beneficial when used solely as a means to prepare a patient with
coronary artery disease for noncardiac surgery.
8. Elective noncardiac surgery requiring interruption of dual
antiplatelet therapy (DAPT) should not be scheduled within 1 month
of bare metal stent (BMS) placement or within 6 months of drug-
eluting stent (DES) placement.
9. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II
receptor blockers appear to cause perioperative hypotension, so it is
prudent to hold these agents the morning of surgery but restart them
as soon as the patient is euvolemic postoperatively.
I. Introduction
Cardiovascular disease is our society’s biggest health problem. According to
Centers for Disease Control and Prevention (CDC) data from 2015, heart disease
alone affects 24.8 million Americans, or about 12% of the population [1]. Of the
35 million Americans hospitalized in 2010, 3.9 million (11.1%) had heart disease
[2]. Heart disease remains the leading cause of death in patients greater than age
65, with an age-adjusted death rate of 170 per 100,000 population [3]. According
to the Society of Thoracic Surgeons (STS) database, 178,780 coronary artery
bypass procedures were performed in 2015, which represents a 62% decrease
since 2003 and is associated with an increase in the number of percutaneous
coronary interventions (PCIs), including angioplasties and stents [4]. In contrast,
the number of valve procedures (72,453 in 2015) has increased, with the number
of valve repair procedures growing faster than the number of valve replacements
[5].
The primary goal of preoperative evaluation and preparation for cardiac surgical
procedures is to maximally reduce the patient’s risk for morbidity and mortality
during surgery and the postoperative period. The factors that are important in
determining perioperative morbidity and anesthetic management must be assessed
carefully for each patient.
II. Patient presentation
A. Clinical perioperative risk assessment—multifactorial risk indices
Multifactorial risk indices, which identify and assign relative importance to many
potential risk factors, have become increasingly sophisticated over the last three
decades. They are used to weigh multiple risk factors into a single risk estimate,
to determine an individual patient’s risk of morbidity and mortality following
heart surgery, to guide therapy, and to “risk adjust” the surgical outcomes of
populations. One of the first multifactorial risk scores was developed by
Paiement, in 1983 [6], which identified eight simple clinical risk factors:
1. Poor left ventricular (LV) function
2. Congestive heart failure (CHF)
3. Unstable angina or myocardial infarction (MI) within 6 months
4. Age greater than 65 years
5. Severe obesity
6. Reoperation
7. Emergency surgery
8. Severe or uncontrolled systemic illness
Recent models still incorporate many of these eight factors.
The preoperative clinical factors that affect hospital survival following heart
surgery have been studied by multiple authors from the 1990s until the present
time [5,7–11]. The initial studies focused on coronary artery bypass grafting
(CABG) surgery, but more recent indices have been validated for valvular
surgery and combined valve and CABG surgery as well. Recent models from
data collected by the STS (Table 3.1) provide odds ratios of mortality associated
with a number of predictors.
In 2001, Dupuis and colleagues developed and validated the cardiac risk
evaluation (CARE) score, which incorporated similar factors but viewed them
more intuitively in a manner similar to the American Society of Anesthesiologists
(ASA) physical status [11]. In 2004, Ouattara and colleagues [12] compared the
CARE score to two other multifactorial indices, the Tu score [13] and
EuroSCORE [7]. Their analysis found no difference among these scores in
predicting mortality and morbidity following cardiac surgery. However, the STS
continues to report more specific predictors that provide valuable risk data on
CABG, valve, and combined procedures based on increasing volumes of
cumulative data, making this perhaps the most robust of the risk indices.
TABLE 3.1 Multifactorial indices of cardiovascular risk for cardiac surgical procedures:
summary of risk factors in recent multifactorial indices
B. 1 Functional status. For patients undergoing most general and cardiac surgical
procedures, perhaps the simplest and single most useful risk index is the patient’s
functional status, or exercise tolerance. In major noncardiac surgery, Girish and
colleagues found the inability to climb two flights of stairs showed a positive
predictive value of 82% for postoperative pulmonary or cardiac complications
[14]. This is an easily measured and sensitive index of cardiovascular risk that
accounts for a wide range of specific cardiac and noncardiac factors.
The level of exercise producing symptoms, as described classically by the
New York Heart Association (NYHA) and Canadian Cardiovascular Society
classifications, predicts the risk of both an ischemic event and operative
mortality. During coronary revascularization procedures, operative mortality for
patients with class IV symptoms (e.g., cardiac-induced dyspnea at rest) is 1.4
times that of patients without preoperative CHF [15].
CLINICAL PEARL The patient’s functional status can be a useful marker of
cardiovascular risk and help determine the necessity for preoperative cardiac stress
testing.
C. Genomic contributions to cardiac risk assessment. Genetic variations are the
known basis for more than 40 cardiovascular disorders. Some of these, including
familial hypercholesteremia, hypertrophic cardiomyopathy, dilated
cardiomyopathy, and “channelopathies” such as the long QT syndrome, are
known as monogenetic disorders, caused by alterations in one gene. These
usually follow traditional Mendelian inheritance patterns, and their genetic basis
is relatively easy to identify. Genetic testing is able to identify these diseases in
up to 90% of patients before they become symptomatic, allowing prophylactic
treatment and early therapy. For example, genetic identification of the subtype of
long QT syndrome can determine an affected patient’s risk of dysrhythmias
associated with exercise, benefit from β-blockers, or need for implantable
cardioverter defibrillator (ICD) placement [16].
Genomic medicine’s greatest recent expansion may reside in its application to
chronic diseases such as coronary artery and vascular diseases. However, these
disorders are multifactorial, influenced by environmental and genetic risk
factors. Even when caused solely by genetic factors, it is often due to a complex
interaction of many genes. Nevertheless, genetic information can be used to
determine a patient’s susceptibility to disease, and this information can guide
prophylactic therapy. Commercial tests are currently available for susceptibility
to atrial fibrillation (AF) and MI. Genetic variants have been found that help to
determine susceptibility to perioperative complications, including postoperative
MI and ischemia. Similarly, genetic information may be used to determine
variations in patient susceptibility to drugs, as for example a single allele
variation can render patients much more sensitive to warfarin. Gene therapy may
also target drug delivery to specific tissues [16].
D. Risk associated with surgical problems and procedures. The complexity of the
surgical procedure itself may be the most important predictor of perioperative
morbidity for many patients. Most cardiac surgical procedures include
cardiopulmonary bypass, which carries its own risks. These risks include a
systemic inflammatory response and also the potential for microemboli and
hypoperfusion, often involving the central nervous system (CNS), kidneys, lungs,
and gastrointestinal tract. The extent of morbidity is proportional to the duration
of cardiopulmonary bypass.
Procedures on multiple heart valves or on both the aortic valve and coronary
arteries carry higher morbidity and mortality rates than procedures involving
only a single valve or CABG alone. The mortality rate over the last decade for
each procedure, for patients in the Society of STS database, is approximately
2.3% for CABG, 3.4% for isolated valve procedures, and 6.8% for valve
procedures combined with CABG [5,15,17]. Additionally, the robust STS
database (accessed at http://riskcalc.sts.org/stswebriskcalc/#/) can also be used
to calculate a patient’s statistical likelihood of morbidity and mortality based on
several individual risk factors (Table 3.1).
III. Preoperative medical management of cardiovascular disease
A. Myocardial ischemia. In patients with known coronary artery disease (CAD),
the most important preoperative risk factors are: (i) the amount of myocardium at
risk; (ii) the ischemic threshold, or the heart rate at which ischemia occurs; (iii)
the patient’s ventricular function or ejection fraction (EF); (iv) the stability of
symptoms (because recent acceleration of angina may reflect a ruptured coronary
plaque); and (v) adequacy of current medical therapy.
1. Stable ischemic heart disease (SIHD). Also known as chronic stable angina,
most often results from obstruction to coronary artery blood flow by a fixed
atherosclerotic coronary lesion in at least one of the large epicardial arteries.
In the absence of such a lesion, however, the myocardium may be rendered
ischemic by coronary artery spasm, vasculitis, trauma, or hypertrophy of the
ventricular muscle, as occurs in aortic valve disease.
Neither the location, duration, or severity of angina, nor the presence of
diabetes or peripheral vascular disease (PVD), indicate the extent of
myocardium at risk, or the anatomic location of the coronary artery lesions.
Therefore, the clinician must depend on diagnostic studies, such as myocardial
perfusion imaging (MPI), stress echocardiography, and cardiac catheterization
to assist in establishing risk. Some centers use cardiac computed tomography
(CT) scanning for this purpose due to its high sensitivity for detecting coronary
calcification and coronary artery disease. However, the test still lacks a high
enough specificity to be recommended as a definitive test.
In patients with SIHD, a reproducible amount of exercise, with its associated
increases in heart rate and blood pressure (BP), often precipitates angina. This
angina threshold, which can be determined on preoperative exercise testing, is
an important guide to perioperative hemodynamic management. Stable angina
often responds to medical therapy as well as to PCI. Patients are referred for
CABG surgery when their symptoms are refractory to medical therapy and they
are not candidates for PCI.
CLINICAL PEARL Preoperative stress testing can help determine the ischemic
threshold, or the heart rate at which ischemic symptoms develop. This can help guide
hemodynamic management during the operative procedure.
a. Principles of the medical management of SIHD [18]
(1) Aspirin at 75 to 162 mg daily
(2) β-adrenergic blockade as initial therapy when not contraindicated
(3) Calcium antagonists or long-acting nitrates as second-line therapy, or as
first-line therapy when β-blockade is contraindicated
(4) Use of angiotensin converting enzyme (ACE) inhibitors indefinitely in
patients with LV EF <40%, diabetes, hypertension, or chronic renal
failure
(5) Annual influenza vaccine
(6) Risk reduction:
(a) Lipid management—via lifestyle modifications, dietary therapy to
reduce saturated fat and trans-fat intake, and moderate- to high-dose
statin therapy to reduce low-density lipoproteins.
(b) BP control—reduce to less than 140/90 for patients with coronary
disease initially treated with ACE inhibitors and/or β-blockers,
with the addition of thiazide diuretics and calcium channel blockers
as necessary.
(c) Smoking cessation
(d) Diabetes control
(e) Weight loss
(f) Diet and exercise
2. Acute coronary syndrome (ACS). Sometimes called unstable angina pectoris,
crescendo angina, or unstable coronary syndrome.
a. Presentation:
(1) Rest angina, within the first week of onset
(2) New-onset angina markedly limiting activity, within 2 weeks of onset
(3) Angina that is more frequent, of longer duration, or occurs with less
exercise. These symptoms often indicate rapid growth, rupture, or
embolus of an existing plaque. Patients in this category have a higher
incidence of MI and sudden death, and increased incidence of left main
coronary occlusion. The clinical factors important in determining the risk
of MI or death in patients with unstable angina are shown in Table 3.2.
TABLE 3.2 Risk factors for death or MI in patients with unstable angina
b. Medical management for ACS. Diagnostic and revascularization procedures

are central to the management of most patients with ACS. Most often, medical
therapy accompanies or precedes these interventions. Medical management of
unstable angina or of a non-ST segment elevation MI (non-STEMI) has two
parts: (i) anti-ischemic therapy and (ii) long-term dual antiplatelet therapy
(DAPT). Medical anti-ischemic therapy depends largely on the presence or
absence of ongoing ischemia and must be accompanied by an aggressive
approach to secondary prevention or risk factor modification (Tables 3.3 and
3.4).
c. 2 Myocardial ischemia without angina may be manifested by fatigue, rapid
onset of pulmonary edema, cardiac arrhythmias, syncope, or an “anginal
equivalent,” most often characterized as indigestion or jaw pain. Silent
ischemia occurs more often in elderly and in diabetic patients, for whom 15%
to 35% of all MIs occur as silent events, documented only on routine
electrocardiogram (ECG). Whether related to coexisting disease or delayed
therapy, silent ischemia has been associated with an unfavorable prognosis.
d. Interval between prior infarction and surgery
In the noncardiac surgical population, the occurrence of an MI within the 30
days before surgery is a significant preoperative risk factor [19]. Bernstein
[8] assigns additional risk to an MI occurring within 48 hours before surgery.
Eagle et al. [20] conclude that CABG has increased risk in patients with
unstable angina, early postinfarction angina (within 2 days of a non-STEMI
and during an acute MI), and that risk may be reduced by delaying CABG for
3 to 7 days after MI in stable patients. Coronary revascularization procedures,
however, offer improved survival in patients with unstable angina and LV
dysfunction secondary to ongoing ischemia.
TABLE 3.3 Medical therapy for unstable angina: anti-ischemic therapy
CLINICAL PEARL Operative risk for CABG in stable postinfarction patients can be
reduced by delaying surgery for 3 to 7 days. If the patient has reversible ischemia with
significant myocardium at risk, early coronary revascularization offers improved survival.
B. Congestive heart failure
1. Clinical assessment and medical management of heart failure. Ventricular
dysfunction can occur almost immediately in association with an ischemic
event. If no infarction occurs and the myocardium is reperfused, the ventricle
recovers function quickly. Short episodes of ischemia followed by reperfusion
may actually precondition the heart, so when it is exposed to more severe
ischemia, the size and severity of MI is reduced. An MI may be associated with
“stunned” myocardium, which recovers function within days to weeks, or
“hibernating” myocardium, which may recover months after infarction and
revascularization. Ventricular dysfunction and HF have been classified into
four stages, A through D, based on cardiac structural changes, symptoms of HF,
and presence of serum biomarkers (e.g., B-type natriuretic peptide, N-terminal
pro-B–type natriuretic peptide). Stage A refers to patients at high risk for HF
without overt structural heart disease or symptoms of HF. Stage B patients have
structural heart disease, but do not demonstrate signs or symptoms of HF.
Patients with structural heart disease who have previously had or currently
have symptoms are classified as stage C. Patients with refractory HF who
require specialized interventions are classified as stage D. Management
depends on the stage of the disease. Figure 3.1 details the current treatment
algorithm for stages C and D HF. ACE inhibitors and angiotensin II receptor
blockers are usually used as first-line therapy, with the addition of β-blockers,
aldosterone antagonists, diuretics, and implanted devices for more severely
affected patients (Fig. 3.1).
TABLE 3.4 Acute coronary syndrome (ACS) and stable ischemic heart disease (SIHD):
the role of dual antiplatelet therapy (DAPT)
FIGURE 3.1 Treatment of HFrEF stages C and D. For all medical therapies, dosing should be optimized and serial
assessment exercised. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI,
angiotensin receptor-neprilysin inhibitor; BP, blood pressure; bpm, beats per minute; C/I, contraindication; COR, Class of
Recommendation (lower numbers and letters indicate stronger recommendation); CrCl, creatinine clearance; CRT-D, cardiac
resynchronization therapy–device; Dx, diagnosis; GDMT, guideline-directed management and therapy; HF, heart failure;
HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; Hydral-Nitrates, hydralazine
and/or nitrates; K+, potassium; LBBB, left bundle branch block; LVAD, left ventricular assist device; LVEF, left ventricular
ejection fraction; MI, myocardial infarction; NSR, normal sinus rhythm; and NYHA, New York Heart Association. (Reprinted
with permission Circulation. 2017;136:e137–e161 ©2017 American Heart Association, Inc.)
2. Perioperative morbidity. Preoperative evidence of CHF or ventricular

dysfunction is associated with increased operative mortality. Recent series
summarized in Table 3.1 show a significantly increased risk of postoperative
morbidity or mortality in patients with preoperative CHF and cardiogenic
shock.
C. Dysrhythmias
1. Incidence. While cardiac dysrhythmias are common in patients presenting for
cardiac surgery (up to 75%), life-threatening dysrhythmias occur less than 1%
of the time.
2. Supraventricular tachycardia (SVT). Atrial fibrillation (AF) and flutter, the
most common SVTs, increase in frequency with increasing age in the presence
of organic heart disease. Initial management consists of heart rate control via
intravenous (IV) calcium channel blockers (e.g., verapamil, diltiazem) or β-
blockers. Stable reentrant tachycardias can initially be managed acutely with
vagal maneuvers or adenosine to reduce heart rate and potentially convert the
SVT to sinus rhythm. SVT(s) with hemodynamic instability may require urgent
cardioversion. Those with AF are also managed with anticoagulation to reduce
stroke risk. More recently, surgical and catheter-based ablation have become
more common, especially in patients unresponsive to medical therapy.
3. 3 Ventricular arrhythmias and ventricular tachycardias (VTs). Ventricular
dysrhythmias have been classified according to clinical presentation (stable or
unstable), type of rhythm (sustained or nonsustained VT, bundle branch
reentrant or bidirectional VT, Torsades de pointes, ventricular fibrillation), or
associated disease entity. Ventricular arrhythmias may lead directly to sudden
cardiac death, especially if they occur in the setting of acute or recent
infarction. However, isolated asymptomatic ventricular arrhythmias, even
nonsustained VT, have not been associated with complications following
noncardiac surgery. Patients with preoperative ventricular arrhythmias
associated with LV dysfunction and an EF <30% to 35% are often managed
with the prophylactic implantation of an ICD. Those not controlled with or not
candidates for ICD therapy are managed medically with β-blockers as the first-
line therapy. Amiodarone is the second-line drug used to prevent sudden
cardiac death, with studies showing some survival benefit. Sotalol can also be
effective, though it has greater proarrhythmic effects [21].
4. Bradycardia. Anesthetics frequently affect sinus node automaticity but rarely
cause complete heart block. Asymptomatic patients with ECG-documented AV
conduction disease rarely require temporary pacing perioperatively. However,
symptomatic patients, or patients with Mobitz II or complete heart block,
require preoperative evaluation for permanent pacing. Patients with a recent MI
or with both first-degree AV block and bundle branch block may need
temporary transvenous, epicardial, or transcutaneous pacing perioperatively.
4 Of note, patients with left bundle branch block in whom a Swan–Ganz
catheter is being placed may need a transcutaneous pacemaker because of the
risk of inducing right bundle branch block, and thus complete heart block.
Although the risk is still quite low, patients with a left bundle branch block and
right-sided CAD may be at particular risk during the passage of a Swan–Ganz
catheter.
D. Hypertension
Systemic hypertension is one of the most common diseases of adulthood and is
perhaps the most treatable cause of cardiovascular morbidity, including MI,
stroke, PVD, renal failure, and HF. The contribution of hypertension to
perioperative morbidity and the implications for anesthetic management depend
on (i) BP level, both with stress and at rest; (ii) the etiology of hypertension; (iii)
pre-existing complications of hypertension; and (iv) physiologic changes due to
drug therapy.
1. Blood pressure level. Data summarized in the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC
7) report in 2003 indicate that cardiovascular risk begins to increase at BP
above 115/75 and doubles with each increment of 20/10 [22, 22a]. Patients
with blood pressures of 120 to 129/<80 are considered to have elevated blood
pressures [22a]. Stage I hypertension is defined as SBP 130 to 139/DBP 80 to
89. Stage II hypertension is now defined as SBP ≥140/DBP ≥90. Blood
pressure lowering medication should be started for patients who have the
following:
Stage I hypertension with previous cardiovascular events.
Stage I hypertension with estimated 10 years atherosclerotic disease risk of
10% or higher.
Stage II hypertension [22a]. Those with blood pressures >160/100 usually
require combination drug therapy [22].
5 In contrast to the usual emphasis on the resting, unstimulated BP, the
patient’s preoperative BP under stress, as in the preoperative clinic or holding
area, may be a better predictor of perioperative morbidity. Intraoperative
cardiac morbidity in the form of dysrhythmias and ischemic ECG changes may
be more frequent in stage 3 hypertensive patients with awake systolic BP
greater than 180 mm Hg and diastolic BP of greater than 110 mm Hg, and this
morbidity may be reduced by preoperative treatment. In these patients the
benefits of improving hypertensive control preoperatively should be weighed
against the risks of delaying surgery. BP lower than 180/110 has not been found
to be an important predictor of increased perioperative cardiac risk, but it may
be a marker for chronic cardiovascular disease [19].
2. Etiology. The most common “primary” or “essential” hypertension is likely
caused by a combination of multiple genetic and environmental factors, with the
genetic contribution (at least) being irreversible. However, it is important
preoperatively to exclude the 5% to 15% of patients with treatable causes of
secondary hypertension, risk factors for which are shown in Table 3.5. The
most common causes of secondary hypertension are renal, endocrine, or drug
related, which account for an additional 5% to 10% of hypertensive patients.
Other rare disorders are found in less than 1% of patients (Table 3.6). A
laboratory investigation of secondary hypertension, when indicated, should
include urinalysis, creatinine, glucose, electrolytes, calcium, ECG, and chest
films. More extensive testing is usually not indicated unless BP cannot be
controlled or a high clinical suspicion exists [22]. Pheochromocytoma,
although very rare, is particularly important because of its potential morbidity
in association with anesthesia. Therefore, it should be ruled out preoperatively
in patients with headache, labile or paroxysmal hypertension, abnormal pallor,
or perspiration, even if delay of surgery is required.
3. Sequelae of hypertension. The hypertensive state can lead to sequelae most
evident in the heart, CNS, and kidney. In particular, patients with established
hypertension may exhibit (i) LV hypertrophy leading to decreased ventricular
compliance and deleterious effects upon myocardial oxygen supply and
demand; (ii) neurologic symptoms, such as headache, dizziness, tinnitus, and
blurred vision that may progress to cerebral infarction; and (iii) renal vascular
lesions leading to proteinuria, hematuria, and decreased glomerular filtration
progressing to renal failure.
4. Antihypertensive therapy. Today antihypertensive medications are the most
prescribed class of medications. The primary objective of antihypertensive
therapy is to reduce cardiovascular morbidity by lowering the BP. However,
specific classes of antihypertensive agents are effective in preventing end organ
damage, especially to the heart and the kidney, and beyond that are directly
associated with lowering the BP. The recommended antihypertensive drug
classes for patients with specific comorbid conditions are shown in Table 3.7
[22].
TABLE 3.5 Risk factors for secondary hypertension
TABLE 3.6 Causes of hypertension
E. Cerebrovascular disease
1. 6 The association of preoperative CVD with increased perioperative
neurologic dysfunction. Central nervous system (CNS) dysfunction of at least
some degree is common after cardiopulmonary bypass, with temporary
postoperative neurocognitive defects occurring in up to 80% of patients and
stroke in 1% to 5% [23]. Arrowsmith et al. found that aortic atherosclerosis is
associated with the highest risk of adverse neurologic events (odds ratio 4.52)
and that a history of neurologic disease ranked second, with an odds ratio of
3.19 [24]. Patients with a history of stroke are more likely to have a
perioperative stroke. Even in the absence of a prior cerebral ischemic event,
the presence of carotid stenosis increases the risk of postoperative stroke from
approximately 2% in patients without carotid stenosis to 10% with stenosis of
greater than 50%, and to 11% to 19% with stenosis of greater than 80% [25].
TABLE 3.7 Antihypertensive therapy for patients with other systemic diseases
2. Genetic factors. Genetic factors may modify the risk or severity of

postoperative CNS injury. Genes related to thrombotic factors and
inflammatory factors such as platelet receptors, C-reactive protein, and
interleukin-6 have been associated with the risk of postoperative cognitive
dysfunction.
3. Effect of the surgical procedure. Cardiopulmonary bypass may increase the
risk of postoperative cognitive dysfunction, but neurologic deficits are still
seen following off pump coronary artery bypass surgery, likely because of
effects such as BP lability, low cardiac output, the systemic inflammatory
reaction to the procedure, or manipulation of the ascending aorta.
As may be expected, several authors have shown increased postoperative
cerebral dysfunction following open aortic or mitral valve procedures
compared to CABG. However, in these series, the duration of cardiopulmonary
bypass was also longer for the valve procedures, making it difficult to establish
a causal relationship. Even though it is apparent that carotid artery stenosis
represents a risk factor for perioperative stroke, it is not nearly as clear that
simultaneous carotid endarterectomy reduces this risk. Therefore, recent texts
advise against combined carotid endarterectomy and CABG procedures [26].
Rather, at the present time epiaortic scanning via ultrasound to modify the
surgical technique during the cardiac procedure, and possibly neurophysiologic
monitoring, may offer more benefit [26].
CLINICAL PEARL Carotid stenosis is an important risk factor for perioperative stroke
during cardiac surgery. However, simultaneous carotid endarterectomy with CABG does
not clearly reduce stroke risk and is not routinely recommended even when carotid
stenosis exceeds 50%.
IV. Noninvasive cardiac imaging
A. Echocardiography. Transthoracic echocardiography provides specific
preoperative assessment of several types of cardiac abnormalities. Two-
dimensional (2D) and Doppler echocardiography together provide quantitative
assessment of the severity of valvular stenoses or insufficiency (see Chapter 12)
and of pulmonary hypertension. Assessment of regional wall motion provides a
more sensitive and specific assessment of the existence and extent of MI than a
surface ECG. 2D echocardiography provides a quantitative assessment of global
ventricular function, or EF. Echocardiography can detect even small pericardial
effusions and anatomic cardiac abnormalities, including atrial septal defects
(ASDs) and ventricular septal defects (VSDs), aneurysms, and mural thrombi.
Perioperative transthoracic echocardiography can predict postoperative
cardiac events in noncardiac surgical patients at increased clinical cardiac risk.
Decreased preoperative systolic function on echocardiography has been
associated with postoperative MI, pulmonary edema, and “major cardiac
events,” such as ventricular fibrillation, cardiac arrest, or complete heart block.
LV hypertrophy, mitral regurgitation (MR), and increased aortic valve gradient
on preoperative echo also appear to predict postoperative “major cardiac
events.”
B. Preoperative testing for myocardial ischemia. Commonly used noninvasive
testing modalities to evaluate for myocardial ischemic risk for both cardiac and
noncardiac surgical patients are described in this section. Patients undergoing
cardiac surgery will often require preoperative cardiac catheterization (Section
V) to identify any correctible coronary lesions.
1. Exercise tolerance testing. The exercise tolerance test (ETT) is often used as
a simple and inexpensive initial test to evaluate chest pain of unknown etiology.
It is also used preoperatively to determine functional capacity and identify
significant ischemia or dysrhythmias for risk stratification. ETT is rarely useful
as a screening test in asymptomatic patients. To better address the prognostic
value of the ETT, the Duke risk score was developed [27]. This risk score
equals the exercise time in minutes, minus five times the extent of the ST
segment depression in millimeters, minus four times the level of angina with
exercise (0—no angina, 1—typical angina, 2—typical angina requiring
stopping the test). The score typically ranges from −25 to +15. These values
correspond to low-risk (with a score of ≥+5), moderate-risk (with scores
ranging from −10 to +4), and high-risk (with a score of <−11) categories.
a. Limitations of ETT
(1) Inability to exercise because of systemic disease, particularly PVD.
(2) Abnormal resting ECG precluding ST segment analysis (paced rhythm,
left bundle branch block, LV hypertrophy, digoxin therapy).
(3) β-Blocker therapy that prevents the patient from achieving 85% of his or
her maximum permissible heart rate.
2. Stress echocardiography. Stress echocardiography can use exercise stress or
pharmacologic stress, with dobutamine, to increase myocardial work.
Abnormally contracting myocardial segments seen on stress echocardiography
are classified as either ischemic, if their reduced contraction pattern is in
response to stress, or infarcted, if their contractility remains consistently
depressed before, during, and after stress.
Sixteen studies evaluated in the 2007 ACC/AHA Guidelines for
Perioperative Cardiovascular Evaluation for noncardiac surgery showed that
0% to 33% of open vascular surgery patients who had a positive preoperative
dobutamine stress echocardiogram (DSE) subsequently suffered a
postoperative MI or death. The negative predictive value was much higher—
93% to 100% [19]. Wall motion abnormalities at low workloads were
especially important predictors of short- and long-term outcomes. DSE has
indications similar to pharmacologic perfusion imaging with comparable
sensitivity, but possibly increased specificity.
For patients with poor acoustic windows due to body habitus or severe lung
disease, myocardial contrast agents (sonicated albumin microspheres) are now
available to improve imaging. Still, for some patients, a difficult
echocardiographic window or global poor ventricular function may preclude
its use. This test may be relatively contraindicated for those patients with
conditions that render them more susceptible to the deleterious effects of
hypertension and tachycardia (e.g., MI, an intracranial or abdominal aneurysm,
or other vascular malformation).
CLINICAL PEARL Preoperative stress testing can help determine how much
myocardium is “at risk” for ischemia. This information can identify which noncardiac
surgical patients may benefit from a preoperative coronary evaluation and possible
intervention.
3. Radionuclide imaging. Radionuclide stress imaging is used to assess the
perfusion and the viability of areas of myocardium. This technique cannot
provide an anatomic diagnosis of a cardiac lesion. It is a more sensitive and
specific test than ETT and can provide an assessment of global LV function as
well. Myocardial perfusion imaging (MPI) is a nuclear technique employing
intravenous radioisotopes, either thallium-201 or the cardiac-specific
technetium-99 perfusion agents, sestamibi (Cardiolite), or tetrofosmin
(Myoview), as an indicator of the presence or absence of CAD.
Exercise stress or pharmacologic stress is necessary to increase coronary
blood flow for the test. Pharmacologic vasodilators are preferable but
contraindicated in patients with severe bronchospastic lung disease, in which
case dobutamine may be used. The available pharmacologic vasodilators—
adenosine (Adenoscan), dipyridamole (Persantine), and regadenoson
(Lexiscan)—are used to produce maximal coronary vasodilation of
approximately four to five times resting values. Vessels with fixed coronary
stenoses will not dilate, resulting in less isotope reaching the myocardium.
Myocardium underperfused by these vessels will show up as a “defect” on
stress scans when compared to surrounding myocardium supplied by
nonobstructed coronaries. When compared to the images acquired at rest, any
defects still present—fixed or persistent defects—are suggestive of nonviable
or infarcted myocardium. Defects present on stress and not at rest, termed
reversible defects, suggest viable myocardium at risk for ischemia when
stressed. The technique used to acquire these images is single-photon emission
computed tomography (SPECT).
In the studies of noncardiac surgical patients reviewed by the ACC/AHA
Task Force on Perioperative Cardiovascular Evaluation, reversible defects on
nuclear perfusion scanning identified 2% to 20% of patients suffering
postoperative MI or cardiac death. The negative predictive value of a normal
scan is much better, at approximately 99%. Fixed defects did not usually
predict perioperative cardiac events. The sensitivity and specificity of nuclear
perfusion imaging is similar for pharmacologic and stress-based techniques
[19]. The predictive value of the test can be improved by using it in high-risk
subgroups.
Contraindications to pharmacologic stress with dipyridamole, adenosine,
or regadenoson are:
unstable angina or MI within 48 hours.
severe primary bronchospasm.
methylxanthine ingestion within 24 hours.
allergy to dipyridamole or aminophylline.
for adenosine only, first-degree heart block (PR interval >0.28 seconds) and
recent oral dipyridamole ingestion (<24 hours ago).
Pharmacologic vasodilators should be used in patients who cannot exercise,
or who have a medical condition (e.g., cerebral aneurysm) that would
contraindicate exercise. Pharmacologic stress testing with vasodilators, such as
adenosine or dipyridamole, is also preferable to exercise or dobutamine in
patients with left bundle branch block, because of misleading septal changes
with exercise or catecholamines, which lead to false positive tests.
4. Positron emission tomography (PET) scan. PET scanning techniques use
different radioisotopes than SPECT imaging. These isotopes decay with a
higher-energy photon with a shorter half-life and can assess both regional
myocardial blood flow and myocardial metabolism on a real-time basis. PET
scanning techniques can be combined with CT and magnetic resonance imaging
(MRI) to provide PET metabolic and anatomic information simultaneously.
5. Magnetic resonance imaging. MRI has been used for some time to provide
both high-resolution and three-dimensional (3D) imaging of cardiac structures.
It is now becoming important in perfusion imaging, atherosclerosis imaging,
and coronary artery imaging. With the development of dedicated
cardiovascular MRI scanning, molecular imaging techniques and biochemical
markers are providing the capacity for MRI diagnosis of cardiac function.
Changes in molecular composition of the myocardium can change its magnetic
moment and MRI signal, allowing MRI to detect lipid accumulation, edema,
fibrosis, rate of phosphate turnover, and intracellular pH in ischemic areas.
Finally, MRI imaging can be gated to the cardiac cycle, allowing rapid and
accurate assessment of myocardial function. Gated images are used to detect
regional myocardial abnormalities that may be caused by ischemia, infarction,
stunning, hibernation, and postinfarct remodeling. MRI is the diagnostic
technique of choice for arrhythmogenic right ventricular (RV) dysplasia and
can differentiate myocardial infiltration and diastolic dysfunction associated
with sarcoidosis, hemochromatosis, amyloidosis, and endomyocardial fibrosis.
Contrast-enhanced MRI has a higher sensitivity and specificity than either CT
scan or TEE in aortic dissection. Dobutamine stress MRI is an accurate and
rapid test for myocardial ischemia that may eventually replace dobutamine
echocardiography.
MRI can be used to diagnose CAD involving the native major epicardial
arteries with an accuracy of approximately 87% and is even better for
assessing saphenous vein and internal mammary artery graft patency. However,
it is still not commonly used clinically for this purpose.
6. Computed tomography. Since its introduction into clinical practice in 1973,
CT has undergone significant advances. CT for calcium scoring has been
utilized clinically to estimate cardiac risk, but is not effective for defining
atherosclerotic disease. With the development of a higher temporal resolution
scan, in conjunction with contrast injection, coronary imaging is now possible.
As these imaging techniques advance in the cardiology arena, they can be used
for imaging the pericardium, cardiac chambers, and great vessels. However,
imaging protocols require aggressive β-blockade to achieve heart rates of 60
bpm or less in order to decrease image blurring and improve resolution.
Cardiac CT with calcium scoring is gaining widespread acceptance due to its
excellent negative predictive value in determining coronary artery disease in
patients without significant risk factors (advanced age, diabetes, hypertension).
However, patients at higher risk for coronary artery disease should still be
tested via other more established diagnostic techniques at this time.
V. Cardiac catheterization
A. Overview. Cardiac catheterization still is considered the gold standard for
diagnosis of cardiac pathology before most open heart operations and for
definition of lesions of the coronary vessels. More than 95% of all patients
undergoing open heart operations have had catheterization prior to the procedure.
The remaining 5% are assessed only by noninvasive techniques, such as
echocardiography and Doppler flow studies. They typically have pathologic
findings, such as an atrial or ventricular septal defect, that are adequately defined
by noninvasive means.
As an invasive procedure, serious complications occur in approximately 0.1%
of patients and include stroke, heart attack, and death. Significant access site
complications occur in approximately 0.5%.
If only coronary anatomy is to be delineated, often only a systemic-arterial or
left-sided catheterization will be performed. However, if any degree of LV
dysfunction, valvular abnormality, pulmonary disease, or impaired RV function
exists clinically, a right-sided (Swan–Ganz) catheterization usually will also be
performed. A range of normal hemodynamic values obtained from right- and left-
sided catheterization is included in Table 3.8.
Interpretation of catheterization data emphasizes the following areas, detailed
below.
TABLE 3.8 Normal hemodynamic values obtained at cardiac catheterization
FIGURE 3.2 Representation of coronary anatomy relative to the interventricular and atrioventricular valve planes.
Coronary branches are L MAIN, left main; LAD, left anterior descending; D, diagonal; S, septal; CX, circumflex; OM,
obtuse marginal; RCA, right coronary artery; CB, conus branch; SN, sinus node; AcM, acute marginal; PD, posterior
descending; PL, posterolateral left ventricular; RV, right ventricle; RAO 30, right anterior oblique 30 degree view; LAO 60,
left anterior oblique 60 degree view. (Reproduced from Baim DS, Grossman W. Coronary angiography. In: Grossman W,
Cardiac Catheterization and Angiography. 7th ed. Philadelphia, PA: Lea & Febiger; 2005:203, with permission.)
B. Assessment of coronary anatomy

1. Procedure. Radiopaque contrast is injected through a catheter placed at the
coronary ostia to delineate the anatomy of both the right and left coronary
arteries. Multiple views are important to define branch lesions, decrease
artifacts at points of tortuosity or vessel overlap, and determine more clearly
the degree of stenosis, particularly in eccentric lesions. Two common
projections of the coronary arteries are the right anterior oblique (RAO) and
the left anterior oblique (LAO) views (Fig. 3.2).
2. Interpretation. The degree of vessel stenosis generally is assessed by the
percent reduction in diameter of the vessel, which in turn correlates with the
reduction in cross-sectional area of the vessel at the point of narrowing.
Lesions that reduce vessel diameter by greater than 50%, reducing the cross-
sectional area by greater than 70%, are considered significant. Lesions are also
characterized as either focal or segmental. There is a great deal of
interobserver variability in interpretation with particular concern regarding
intermediate lesions (50% to 70%) and their physiologic significance. Adjunct
imaging techniques include fractional flow reserve (FFR) and intravascular
ultrasound (IVUS) that may assist in defining the need for revascularization of
these vessels.
C. Assessment of left ventricular function. Both global and regional measures of
ventricular function can be obtained from catheterization data.
1. Global ventricular measurements
a. Left ventricular end-diastolic pressure (LVEDP) . An elevated value above
15 mm Hg usually indicates some degree of ventricular dysfunction. LVEDP
is an index that may reflect either systolic or diastolic dysfunction and is
acutely affected by preload and afterload. Without examining other indices of
function, an isolated measurement of elevated LVEDP simply indicates that
something is abnormal. Associated with a normal LV contractile pattern and
cardiac output, an elevated LVEDP measurement may indicate a decrease in
LV compliance.
b. Left ventricular EF (LVEF)
(1) Calculation. EF is defined as the volume of blood ejected (stroke
volume [SV]) per beat divided by the volume in the LV before ejection.
The SV is equal to the end-diastolic volume (EDV) minus the end-
systolic volume (ESV). The equation for EF determination is therefore:
(2) Mitral regurgitation. An EF of greater than 50% is normal in the

presence of normal valvular function. However, in the presence of
significant mitral regurgitation MR, an EF of 50% to 55% suggests
moderate LV dysfunction, because part of the volume is ejected
backward into a low-resistance pathway (i.e., into the left atrium).
2. Regional assessment of ventricular function. LV contraction observed during
ventriculography provides a qualitative assessment of overall ventricular
function but is not as specific as the calculated EF.
Routine ventriculography is less commonly performed when concerns for
contrast volume, patient instability, or prior assessment of function are present.
Qualitative regional differences in contraction may be evident. For
examination, the heart is divided into segments. The anterior, posterior, apical,
basal, inferior (diaphragmatic), and septal regions of the LV are examined ( Fig.
3.3). Motion of each one of these particular regions is defined as normal,
hypokinetic (decreased inward motion), akinetic (no motion), or dyskinetic
(outward paradoxical motion) in relation to the other normally contracting
segments. Regional wall motion abnormalities are usually secondary to prior
infarction or acute ischemia. However, very infrequently myocarditis as well
as rare infiltrative processes by myocardial tumors may lead to regional wall
motion abnormalities.
D. Assessment of valvular function. This section will be limited to a brief
discussion of the methods utilized to study lesions of the aortic and mitral valves.
The specific hemodynamic patterns of acute and chronic valvular disease will be
discussed in Chapters 11 and 12.
1. Regurgitant lesions
a. Qualitative assessment. A relative scale of 1+ to 4+ (4+ being the most
severe) is used to quantify the severity of valvular incompetence during the
injection of echogenic contrast dye. Visual inspection is utilized to determine
the intensity and rapidity of washout of dye from the LV after aortic root
injection (aortic regurgitation) or from the left atrium after ventricular
injection (MR).
b. Pathologic V waves. In patients with mitral regurgitation MR, the pulmonary
capillary wedge trace may manifest giant V waves. Normal or physiologic V
waves are seen in the left atrium at the end of systole and are secondary to
filling from the pulmonary veins against a closed mitral valve. With valvular
incompetence, the regurgitant wave into the left atrium is superimposed on a
physiologic V wave, producing a giant V wave (Fig. 3.4).
2. Stenotic lesions. The severity of valvular stenosis can be determined only by
knowing the pressure drop across the stenotic valve and the simultaneous flow
across the stenosis during either systolic ejection or diastolic filling. One
cannot uniformly assess the severity of stenosis solely by examining the
pressure gradient across the valve.
Gorlin and Gorlin [28] described an equation for determining valve area
based on these two factors in the American Heart Journal in 1951. A simplified
version of this equation is:
FIGURE 3.3 Orientation of apical four-chamber, apical two-chamber, and apical long-axis views in relation to the bull’s-eye
display of the left ventricular (LV) segments (center). The center diagram depicts the commonly accepted numbering system
used to identify LV wall segments. Top panels show actual images, and bottom panels schematically depict the LV wall
segments in each view. (Reprinted with permission from Recommendations for Cardiac Chamber Quantification by
Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of
Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1–39.)
With the peak pressure gradient and cardiac output given on the
catheterization report, a quick estimate of either aortic or mitral valve area can
be made. For greater accuracy, the denominator of the Gorlin equation is
corrected for systolic ejection time (aortic valve) or diastolic filling time
(mitral valve). Values for normal and abnormal valve areas are discussed in
Chapters 11 and 12.
Remember that catheterization data represent only one point in time, and
medical management may have changed the hemodynamic pattern and
catheterization results at the time of cardiac operation.
FIGURE 3.4 Left ventricular (LV) and pulmonary capillary wedge (PC) pressure tracings taken in a patient with
ruptured chordae tendineae and acute mitral insufficiency. The giant V wave results from regurgitation of blood into a
relatively small and noncompliant left atrium; ECG illustrates the timing of the PC V wave, whose peak follows ventricular
repolarization, as manifest by the T wave of the ECG. (Reproduced from Grossman W. Profiles in valvular heart disease.
In: Grossman W, Baim DS, eds. Cardiac Catheterization, Angiography, and Intervention. 7th ed. Philadelphia, PA: Lea &
Febiger; 2005:642, with permission.)
VI. Interventional cardiac catheterization

A. PCI. In 1977, Andreas Gruentzig brought therapeutic options to cardiac
catheterization practice with the first percutaneous transluminal coronary
angioplasty (PTCA). Multiple technologies have been advanced since the initial
balloon dilation. Current technology has evolved to include niche devices
including rotational coronary atherectomy (e.g., Rotablator), various
thrombectomy techniques, distal protection devices for saphenous vein graphs,
vascular closure devices, and coronary stents [29].
However, post-PCI restenosis, a recurrent blockage resulting from a local
vascular response to injury, occurs in one-third of balloon dilations and limits
their effectiveness. Intracoronary stents were developed to provide local
stabilization for PCI-induced coronary dissection and to prevent restenosis.
Their widespread use has significantly reduced the need for emergent coronary
bypass surgery. The original bare metal stents (BMS) reduced restenosis rates
significantly, while DES covered with polymer-based antiproliferative
medications have reduced restenosis rates an additional 39% to 61% [30–32].
The need for emergency coronary artery bypass graft surgery (CABG) has
dramatically decreased with the use of coronary artery stents. Emergency CABG
in patients undergoing PCI decreased from 2.9% before the use of stents to 0.3%
with stents [33–35]. In 2009 the National Cardiovascular Data Registry (NCDR)
reported the rate of emergency CABG following PCI as 0.4% [36].
Several studies have reported on the frequency of procedure-related
indications for emergent CABG following PCI. These include dissection (27%),
acute vessel closure (16%), perforation (8%), and failure to cross the lesion
(8%). Three-vessel disease was also present in 40% of patients requiring
emergency CABG [34]. The strongest predictors of the need for emergency
CABG in several studies, however, are cardiogenic shock (OR = 11.4), acute MI
or emergent PCI (OR = 3.2 to 3.8), multivessel or three-vessel disease (OR = 2.3
to 2.4), and complicated (type C) coronary lesion (OR = 2.6) [34]). In-hospital
mortality for emergency CABG after PCI ranges from 6% to 15% [34,37,38].
When comparing CABG to PCI revascularization for patient survival, the 2011
American College of Cardiology Foundation/American Heart Association
Guideline for CABG suggests improved survival in patients with greater than
50% left main coronary artery stenosis (class I evidence). In patients with three-
vessel disease and greater than 70% stenosis or proximal left anterior
descending disease plus additional major stenosis, CABG imparts improved
survival over PCI as well (class I). Either CABG or PCI may improve survival
in those who survive sudden cardiac death due to VT caused by significant
coronary artery stenosis (class I) [39].
7 Though a large proportion of patients come for surgery with a history of PCI
at some time in the past, it is now well established that PCI is not beneficial
when used solely as a means to prepare a patient with coronary artery disease for
surgery.
B. Preoperative management of patients with prior interventional procedures
1. Postcoronary stent antiplatelet therapy and stent thrombosis
a. Coronary artery stent thrombosis
Coronary artery stents are effective in preventing restenosis, but as foreign
bodies they increase the long-term, and perhaps even permanent, risk of
coronary artery thrombosis. Metal stents are associated with the greatest
inflammatory response in the first 4 to 6 weeks, which then leads to
reepithelialization and a decrease in the risk of subsequent thrombosis after
approximately 6 weeks. In contrast, DES are designed to inhibit inflammation
and so these stents remain exposed for a much longer period of time, and so
are associated with a much longer risk of stent thrombosis, extending at least
to (and perhaps much longer than), 1 year. Unfortunately, there is no reliable
way to determine when endothelialization actually occurs.
Because thrombosis occurs quickly, in comparison to restenosis, it is
associated with a very high risk (greater than 50% in some series) of MI and
death. Therefore, antiplatelet therapy is required to reduce the risk of
thrombosis. Antiplatelet therapy may be particularly useful in the
perioperative period, with the associated thrombotic risk during that time.
b. Antiplatelet agents
Aspirin and clopidogrel have been the mainstays of antiplatelet therapy. Since
they work by different mechanisms, they have at least an additive, or perhaps
superadditive effect. Ticlopidine is approximately as effective as clopidogrel
in reducing the risk of thrombosis, but does have greater side effects. More
recently, prasugrel, ticagrelor, and vorapaxar have been introduced, which
may provide new therapeutic options preoperatively. Table 3.9 compares the
properties of all of these agents except vorapaxar.
Prasugrel and ticagrelor have both been found to have more consistent
inhibition of platelet activity when compared to clopidogrel, suggesting a
reduced risk of stent thrombosis, and of consequent MI and death. They are
frequently used as second-line agents in patients at high risk for stent
thrombosis, but there is growing evidence for their efficacy as primary agents
in patients requiring DAPT. Additionally, ticagrelor appears to have a similar
efficacy and a much more rapid onset and shorter duration, because of its
reversible binding to P2Y12 adenosine diphosphate (ADP) receptors.
Vorapaxar blocks the action of thrombin on the platelet PAR-1 receptor,
providing yet a third mechanism of inhibiting platelet activation.
TABLE 3.9 Antiplatelet agents commonly used to prevent coronary stent thrombosis
TABLE 3.10 Risk factors for coronary stent thrombosis
c. Prevention of coronary artery stent thrombosis

Continuous treatment with the combination of aspirin and a P2Y12 ADP
antagonist after PCI reduces major adverse cardiac events (MACE). On the
basis of randomized clinical trials, aspirin 75 to 100 mg (81 mg in the United
States) daily should be given indefinitely [40].
Regarding, P2Y12 inhibitors (thienopyridines), their duration of therapy is
dependent on the indication for stent placement (SIHD vs. ACS). A SIHD
indication suggests P2Y12 inhibition after BMS placement should be continued
for a minimum of 1 month, as the second part of DAPT. For DES, a SIHD
indication for stent placement suggests a minimum of 6 months therapy with
P2Y12 inhibitors in all patients [40]. For patients presenting with ACS, DAPT
is indicated for a minimum of 12 months (6 months if elevated bleeding risk)
(see Table 3.4).
In the United States, there are currently four approved drug-eluting stents
(DES): sirolimus-eluting stents (SES), paclitaxel-eluting stents (PES),
zotarolimus-eluting stents (ZES), and everolimus-eluting stents (EES). Each of
these stents is presumed to be associated with delayed healing and a longer
period of risk for thrombosis compared with BMS, and requires a longer
duration of DAPT. Current guidelines recommend at least 6 months of DAPT
following any DES in order to avoid late (after 30 days) thrombosis. As of
July 2016, there is also an approved bioabsorbable stent available for the
treatment of coronary artery disease.
There is a growing trend among cardiologists to extend DAPT beyond 1
year (possibly indefinitely) provided the patient has not had any overt
bleeding episodes and is not at a high risk for bleeding complications. Late
stent thrombosis risk (after 1 year) is likely higher in DES than in BMS and
has been observed at a rate of 0.2% to 0.4% per year. The greatest risk of
stent thrombosis is within the first year regardless of stent type and ranges
from 0.7% to 3% depending on patient and lesion complexity [41].
Risk factors for both early and late stent thrombosis are shown in Table
3.10. In addition, of course, any subsequent surgery would result in increased
thrombotic risk in the perioperative period.
CLINICAL PEARL For patients with SIHD in whom coronary stent placement is required,
DAPT should be continued for a minimum of 1 month after BMS placement and 6 months
after DES placement. In patients requiring coronary stent placement after ACS, DAPT should
be continued for at least 12 months.
d. 8 Perioperative antiplatelet therapy in patients with coronary artery
stents
According to current recommendations, elective noncardiac surgery requiring
interruption of DAPT should not be scheduled within 1 month of BMS
placement or within 6 months of DES placement [39]. Urgent or emergent
surgeries require communication between the patient’s cardiologist,
anesthesiologist, and the surgical team. However, most guidelines recommend
that, for those procedures which cannot be delayed, if the thienopyridine must
be stopped, it should be stopped as close to surgery as possible, and restarted
as soon as possible postoperatively, and aspirin should be continued if at all
possible [40,42]. In cardiac surgery, the preoperative use of aspirin has
resulted in greater blood loss and need for reoperation, but no increase in
mortality, and is in fact associated with an increased saphenous vein graft
patency rate [19].
VII. Management of preoperative medications
A. β-Adrenergic blockers. β-Adrenergic blockers are used commonly for the
treatment of hypertension, stable and unstable angina, as well as for MI. These
drugs can also be used to treat SVT (including that due to pre-excitation
syndromes), LV systolic dysfunction (if not severe) and the manifestations of
systemic disease ranging from hyperthyroidism to migraine headaches. β-Blocker
therapy is beneficial in the perioperative period, and the magnitude of the benefit
is directly proportional to the patient’s cardiac risk [44]. Further, abrupt
withdrawal of β-blockers can lead to a rebound phenomenon, manifested as
nervousness, tachycardia, palpitations, hypertension, and even MI, ventricular
arrhythmias, and sudden death. Many authors have found that preoperative
treatment with β-blocking agents reduces perioperative tachycardia and lowers
the incidence of ischemic events [19,43]. Therefore, administration of β-blockers
should continue for patients on treatment chronically [44]. Continuation of
preoperative β-blockade therapy intraoperatively and postoperatively is also
essential to avoid rebound phenomenon.
B. Statins (HMG-CoA inhibitors). Statins are used chronically to reduce the levels
of low-density lipoproteins. However, they have also been shown to slow
coronary artery plaque formation, increase plaque stability, improve endothelial
function, and exhibit antithrombogenic, anti-inflammatory, antiproliferative, and
leukocyte-adhesion–limiting effects. All of these effects would be expected to
reduce both short- and long-term cardiovascular morbidity. Several large recent
studies have shown that preoperative statin use resulted in a significant reduction
in postoperative mortality and MACE [45–47].
Currently, we are unaware of the duration of statin use needed to provide a
beneficial effect or whether discontinuing statins several days preoperatively
will reduce their protective effect. However, until more is known, it would be
wise to continue statins preoperatively in those patients already taking the drugs,
while recognizing the small incremental risks of hepatotoxicity and
rhabdomyolysis.
C. Anticoagulant and antithrombotic medication
1. Warfarin—approaches to preoperative therapy for patients taking chronic
warfarin for (a) AF, (b) mechanical prosthetic heart valve, or (c)
DVT/pulmonary embolus were published by the American College of Chest
Physicians in 2012 [48]. An approach to risk stratification for
thromboembolism is shown in Table 3.11. Warfarin should be stopped 5 days
prior to surgery and restarted within 12 to 24 hours after surgery. A suggested
approach to periprocedural anticoagulation bridging with low–molecular-
weight heparin is shown in Table 3.12.
2. Factor Xa inhibitors (e.g., rivaroxaban, apixaban) are a newer generation of
oral medications that have been approved for stroke prevention in patients in
AF. Additionally, dabigatran, a direct thrombin inhibitor, is a potent,
nonpeptide small molecule that reversibly inhibits both free and clot-bound
thrombin. It has also been approved for stroke prevention in patients with AF.
Though peak effect occurs in 2 to 4 hours after administration, its estimated
half-life is 15 hours with normal renal function. Based on the pharmacokinetics,
in patients with normal renal function (eGFR >50 cc/min) discontinuation of
two doses results in a decrease in the plasma level to about 25% of baseline
and discontinuation of four doses will decrease the level to about 5% to 10%
[49]. Restarting dabigatran for patients on chronic therapy after cardiac surgery
should be delayed until 48 to 72 hours postoperatively due to the drug’s quick
onset of action [50].
3. Antithrombotic and antiplatelet therapy with agents such as clopidogrel
(Plavix), cilostazol (Pletal), or combinations of agents should be stopped 1
week preoperatively, if possible. Because of a concern for longer duration of
action, ticlopidine (Ticlid) should be discontinued 2 weeks preoperatively,
using other agents as a bridge to surgery, if needed. Glycoprotein IIb/IIIa
Inhibitors (eptifibatide, tirofiban, abciximab) should be stopped approximately
48 hours preoperatively. Fondaparinux (Arixtra), a low-molecular heparin
compound, should be stopped 5 days preoperatively (5 half-lives).
TABLE 3.11 Preoperative risk stratification for perioperative thromboembolism
D. Antihypertensives
9 Preoperatively, chronic antihypertensive medications should usually be
continued until the morning of surgery, and be begun again as soon as the patient
is hemodynamically stable postoperatively. Continuation of β-blockers and α-2
agonists until the morning of surgery are particularly important because of the
risks of rebound hypertension with sudden withdrawal of these drugs. In contrast,
patients receiving ACE inhibitors and angiotensin II receptor blockers appear to
be particularly prone to perioperative hypotension, so several authors
recommend holding these agents the morning of surgery but restarting them as
soon as the patient is euvolemic postoperatively [51].
TABLE 3.12 Suggested periprocedural anticoagulation bridging strategies
E. Antidysrhythmics
Preoperative patients may require any of a large number of oral antidysrhythmic
agents, including amiodarone, or calcium channel blockers. Therapy for
dysrhythmias should be continued perioperatively.
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4 Monitoring the Cardiac Surgical Patient
Mark A. Gerhardt and Andrew N. Springer
I. Introduction
II. Cardiovascular monitors
A. Electrocardiogram (ECG)
B. Intermittent noninvasive blood pressure (BP) monitors
C. Physics and technical aspects for accurate intravascular pressure
measurements
D. Arterial catheterization
E. Central venous pressure (CVP)
F. Pulmonary artery catheter (PAC)
G. Cardiac output (CO)
H. Echocardiography
III. Temperature
A. Indications: Cardiopulmonary bypass (CPB) and hypothermia
B. Sites of measurement
C. Risks of temperature monitoring
D. Recommendations for temperature monitoring
IV. Renal function
A. Indications for monitoring
B. Urinary catheter
C. Electrolytes
D. Acute kidney injury (AKI)
V. Neurologic function
B. Indications for monitoring neurologic function
C. Physiologic and metabolic monitoring
D. Monitors of central nervous system (CNS) electrical activity
E. Monitors of regional cerebral metabolic function
F. Near-infrared spectroscopy (NIRS) and cerebral oximetry
G. Monitors of CNS embolic events
H. Monitors of splanchnic perfusion and venous function
VI. Cardiac surgical procedures with special monitoring considerations
A. Off-pump coronary artery bypass (OPCAB)
B. OPCAB monitoring
C. Deep hypothermic circulatory arrest (DHCA)
D. Thoracoabdominal aortic aneurysm (TAAA)
VII. Additional resources
KEY POINTS
1. For cardiac anesthesia, a five-electrode surface Electrocardiogram

(ECG) monitor should be used. Ischemic changes should be
assessed by toggling from monitor mode to diagnostic mode.
2. After a rapid pressure change (performed by flushing the pressure
line and known as the “pop test”), an underdamped system will
continue to oscillate for ≥3 oscillations. Underdamped systems
overestimate systolic blood pressure (sBP) and underestimate
diastolic blood pressure (dBP). An overdamped system will not
oscillate thus underestimating systolic and overestimating diastolic
pressures. A critically damped system will settle to baseline after
only one or two oscillations and will reproduce systolic pressures
accurately.
3. Air within a catheter or transducer causes most pressure monitoring
errors.
4. Placement of an art line prior to induction is indicated in all major
cardiac procedures and most thoracic, major vascular and
neurosurgical procedures.
5. The radial artery pressure may be significantly lower than the aortic
pressure at the completion of cardiopulmonary bypass (CPB) and
for 5 to 30 minutes following CPB.
6. The central venous pressure (CVP) c wave always follows the ECG
R wave and is useful for interpreting CVP waveforms.
7. The current consensus is that pulmonary artery catheter (PAC)
placement benefits high-risk and complex patients. Patients with
preserved left ventricular (LV) function can often be managed with
CVP and TEE.
8. The PAC should be withdrawn 2 to 5 cm when initiating CPB to
decrease risk of PA occlusion/infarction or rupture.
9. SVO2 provides a global assessment of whether oxygen delivery
(ḊO2) is meeting oxygen consumption (V̇O2) requirements. Normal
SVO2 is 75% with a 5% change considered significant. A decreased
SVO2 results from decreased ḊO2 or increased (V̇O2). Normal ḊO2
is four times the value of a normal (V̇O2).
10. When a pulmonary capillary wedge pressure/pulmonary artery
occlusion pressure (PCWP/PAOP) waveform appears
spontaneously, confirmation that the pulmonary artery catheter
(PAC) balloon is deflated followed by withdrawal of the PAC until
a PA waveform appears should be immediately performed.
11. Systolic pressure variation (SPV), pulse pressure variation (PPV),
and stroke volume variation (SVV) depend on the interaction
between intrathoracic pressure and arterial blood pressure to
accurately indicate whether a patient is volume responsive. These
may have some role in cardiac surgery prior to sternotomy and after
chest closure, but are inaccurate while the chest is open and during
CPB.
12. Monitoring temperature at one core site and one shell site is
recommended. PAC temperature is recommended for core
temperature, and bladder or rectal temperature for shell temperature.
13. The risk of dysrhythmia is increased following CPB. Administration
of KCl and MgSO4 to a goal of K+ ≥4.0 mEq/L and Mg++ ≥2.0
mg/dL will attenuate electrolyte-mediated risk of myocardial
conduction abnormalities.
14. Administration of calcium should be delayed until after reperfusion
of neural tissue (15 to 20 minutes after aortic cross-clamp removal).
Though low serum Ca++ may affect myocardial pumping function,
administration of calcium during potential neural ischemia–
reperfusion can result in neurotoxicity.
15. In cardiac surgical patients with ascending aortic atheroma identified
by epiaortic scanning, modification of the surgical technique and
neuroprotective strategies can reduce the incidence of neurologic
complications from ∼60% to almost 0%.
16. Splanchnic vasculature sequesters 70% of total body blood volume
(TBV). The initial physiologic compensation for hypovolemia is
transfer of blood from splanchnic vasculature to the central venous
compartment.
17. Off-pump CABG (OPCAB) patients may be very difficult to
monitor for ischemia, particularly during the most critical events of
the procedure. Some cardiac anesthesiologists favor SVO2 or ScvO2
monitoring for OPCAB.
I. Introduction
Patients presenting for cardiac surgery require extensive monitoring because
unstable hemodynamics and abnormal physiologic conditions associated with
cardiopulmonary bypass (CPB) are the norm rather than the exception. Mechanical
alterations (i.e., the surgical procedure) result in a “different patient” leaving the
operating room (OR) compared to the preoperative period. Special considerations
are required for minimally invasive cardiac surgery where the only two monitors
that provide reliable data may be the mean arterial pressure (MAP) and mixed
venous oxygen saturation (SVO2). Current trends in hemodynamic monitoring
include identification of target(s) for goal-directed therapy. Identification of
hypovolemic patients who will have a positive response to fluid administration
can be obtained with pulse pressure variation (PPV), systolic pressure variation
(SPV), and stroke volume variation (SVV) for example.
Several topics remain controversial: the role of ultrasound (USN) in central line
placement and pulmonary artery catheter (PAC) use in cardiac surgical patients.
The American Society of Anesthesiologists (ASA) revised clinical guidelines [ 1]
state “use real-time USN guidance for vessel localization and venipuncture when
IJ selected for cannulation.” This recommendation was met immediately with
criticism including, within the same paper, a survey of ASA members where the
majority did not agree with this recommendation. Analogous to clinical application
of USN for peripheral nerve block (PNB) placement, the incidence of procedural
complications and longer time for placement is only noted in novice anesthesia
personnel. In experienced hands, success rate is not improved with USN and there
is no difference in complications ± USN [2]. Reliance on technology has created
anesthesiologists who are unable to place an internal jugular (IJ) catheter based on
anatomical landmarks [3]. Furthermore, important critiques of this statement are
that it fails to recognize the clinical experience/judgment of the anesthesiologist,
particularly providing latitude to maintain anatomic-based skills for central line
placement.
FIGURE 4.1 Cardiac monitoring during cardiopulmonary bypass (CPB). ECG changes due to hypothermia during
initiation of CPB. Bradycardia progresses to frequent PVCs, followed by ventricular fibrillation. (From Mark JB. Atlas
of Cardiovascular Monitoring. New York: Churchill Livingstone; 1998, Figure 19.1.)
The PAC controversy has a long history. PAC critics cite the lack of studies
demonstrating an improved outcome with PAC (see discussion in PAC section
II.F.2). However, it is imperative to note: (1) most clinicians do not know how to
correctly interpret PAC data [ 4]; (2) many studies used septic/SIRS patients with
microvascular and/or mitochondrial pathology; and (3) PAC has been traditionally
utilized for estimating left ventricular end-diastolic volume (LVEDV). The use of
pressure in the proximal pulmonary artery (PA) as a surrogate for LVEDV simply
does not work. Transesophageal echocardiography (TEE) is more consistent as a
monitor for hypovolemia. However, an understanding of the nuances of waveform
morphology of the arterial line, CVP and PAC can provide a wealth of information
which can then be confirmed via TEE.
This chapter does not discuss TEE or point-of-care testing including coagulation
monitoring (activated clotting time [ACT], thromboelastography [TEG], rotational
thromboelastometry [ROTEM]). These topics are presented elsewhere. Finally,
some topics (e.g., temperature monitoring) are only discussed as it relates to
cardiac surgical procedures.
II. Cardiovascular monitors
A. Electrocardiogram (ECG). The intraoperative use of the ECG facilitates the
intraoperative diagnosis of dysrhythmias, myocardial ischemia, and cardiac
electrical silence during cardioplegic 1 arrest (Fig. 4.1). A five-lead system,
including a V5 lead, is preferable for cardiac surgical patients. Use of five
electrodes (one lead on each extremity and one precordial lead) allows the
simultaneous recording of the six standard frontal limb leads as well as one
precordial unipolar lead.
1. Indications
a. Diagnosis of dysrhythmias
b. Diagnosis of ischemia
c. Diagnosis of electrolyte disturbances
d. Monitor effect of cardioplegia during aortic cross-clamp
2. Techniques
a. The three-electrode system. This system utilizes electrodes only on the right
arm, left arm, and left leg. The potential difference between two of the
electrodes is recorded, whereas the third electrode serves as a ground. Three
ECG leads (I, II, III) can be examined.
The three-lead system has been expanded to include the augmented leads. It
identifies one of the three leads as the exploring electrode and couples the
remaining two at a central terminal with zero potential. This creates leads in
three more axes (aVR, aVL, aVF) in the frontal plane. Leads II, III, and aVF
are most useful for monitoring the inferior wall, and leads I and aVL for the
lateral wall. Several additional leads have been developed for specific
indications (Table 4.1).
TABLE 4.1 ECG lead placement. Bipolar and augmented leads for use with three electrodes
b. The five-electrode system. All limb leads act as a common ground for the
precordial unipolar lead. The unipolar lead usually is placed in the V5
position, along the anterior axillary line in the fifth intercostal space, to best
monitor the left ventricle (LV). The precordial lead can also be placed on the
right precordium to monitor the right ventricle (RV; V4R lead).
(1) Advantages. In patients with coronary artery disease, the unipolar V5
lead is the best single lead in diagnosing myocardial ischemia;
moreover, 90% of ischemic episodes will be detected by ECG if leads II
and V5 are analyzed simultaneously. Therefore, a correctly placed V5 and
limb leads should enhance diagnosis of the vast majority of
intraoperative ischemic events.
(2) Epicardial electrodes. Cardiac surgeons routinely place ventricular
and/or atrial epicardial pacing wires at the conclusion of CPB prior to
sternal closure. In addition to AV pacing, these pacing wires can be
utilized to record atrial and/or ventricular epicardial ECGs.
(3) Esophageal. Esophageal leads can be incorporated into the esophageal
stethoscope for the detection of posterior wall ischemia and atrial
dysrhythmias.
(4) Endotracheal. ECG leads embedded into the endotracheal tube may be
useful in pediatric cardiac patients for diagnosing atrial dysrhythmias.
3. Computer-assisted ECG interpretation. Computer programs for online
analysis of dysrhythmias and ischemia are currently widely available with a
60% to 78% sensitivity in detecting ischemia compared with the Holter
monitor. Typically, the current ECG signal is displayed along with a graph
showing the trend (e.g., ST depression) over a recent time period, usually the
past 30 minutes.
4. ECG filters. ECG can be analyzed via monitor mode or diagnostic mode.
Diagnostic mode has a low- and high-frequency filter set at 0.05 Hz and 100
Hz, respectively. The diagnostic mode is identical to the ECG data obtained by
a 12-lead ECG. Most monitors default to the monitor mode which eliminates
any electrical signal below 0.5 Hz and above 40 Hz. The resulting ECG
eliminates the majority of artifacts, particularly the 60-Hz interference from
electrically powered devices. The ECG, in monitor mode, unfortunately
distorts the ST segment. Thus ischemia monitoring is not reliable. Monitors can
be toggled to diagnostic mode to assess the ECG.
5. Myocardial ischemia detection via ECG monitoring. ECG was the first
monitor historically to be utilized to diagnose ischemia. Subendocardial
ischemia results in ST segment depression whereas transmural myocardial
ischemia is detected as ST segment elevation (Fig. 4.2). Myocardial blood
flow anatomically originates from the epicardial surface of the heart and
penetrates to the endocardium. Coronary perfusion transpires during both
systole and diastole in the RV whereas LV perfusion is limited to diastole.
Mechanically the endocardium is subjected to higher pressures than the
epicardium. Thus the endocardium is typically compromised before the entire
thickness of the myocardium. ST segment depression is routinely observed
prior to ST segment elevation.
FIGURE 4.2 Myocardial ischemia. Shown are ECG tracings depicting subendocarial ischemia (left) and transmural ischemia
). ST segment depression results from subendocardial ischemia. This patient had left main coronary disease and the ST
depression worsened as her heart rate increased (63 → 75 → 86 beats/min). Transmural ischemia (full thickness) produces ST
segment elevation and frequently results from proximal coronary artery occlusion. This patient underwent a redo CABG and
had acute thrombosis of a saphenous vein graft. (From Mark JB. Atlas of Cardiovascular Monitoring. New York: Churchill
Livingstone; 1998, Figures 11.1 and 11.2.)
6. Recommendations for ECG monitoring. ECG is an ASA standard monitor.

Five-electrode surface monitor is recommended for cardiac surgery. Correct
lead placement is imperative to optimize ECG monitoring. Typically, leads V5
and II are monitored. Automated ST segment analysis and trend history are
helpful adjuncts to diagnose ischemia. Additionally ECG is the gold standard
monitor to diagnose arrhythmias.
B. Intermittent noninvasive blood pressure monitors
1. Indications in the cardiac patient. Cardiac surgical patients have every
indication for arterial catheter assessment and therefore preinduction arterial
line placement is essential. Noninvasive cuff methods for measuring blood
pressure (BP) are not adequate because BP measurement every three minutes is
not practical and may cause injury. Furthermore noninvasive devices will not
function when dysrhythmia alters a machine-recognized pattern, pulsatile flow
is absent during CPB or when continuous-flow left ventricular assist devices
(LVADs) are used.
2. Continuous noninvasive blood pressure monitors. Continuous noninvasive
arterial pressure monitoring is a newer modality that has shown some promise
in critical care settings. These systems provide a continuous arterial waveform
equivalent to that provided by an arterial catheter. The majority of these
devices use the volume clamp technique, in which measurements are obtained
via one or more finger cuffs with integrated photoplethysmography sensors. BP
is measured by dynamic inflation of the finger cuff in systole and diastole so
that a constant volume is measured in the finger via the photoplethysmography
sensor. An arterial waveform can then be reconstructed based on the pressure
in the cuff. Monitors using applanation tonometry have also been used, typically
with the radial artery. This technique measures the pressure required to flatten
a segment of the artery and records this as the MAP. A proprietary algorithm
then recreates the arterial waveform and systolic blood pressure (sBP) and
diastolic blood pressure (dBP) are determined from this. Both methods have
been validated against invasive arterial BP monitoring in critical care settings.
The volume clamp technique has been evaluated with reasonable results
intraoperatively with cardiac surgery patients [5]. However, during cardiac
surgery, frequent blood draws (arterial blood gas [ABG], ACT, electrolytes,
glucose) and periods of nonpulsatile flow (CPB) are required. Hence, invasive
arterial catheterization is indicated.
C. Physics and technical aspects for accurate intravascular pressure
measurements. Invasive monitors via intravascular catheters are required to
safely administer a cardiac anesthetic. Arterial pressure can be measured by
placing a catheter (“art line”) in a peripheral artery or femoral artery. Central
venous access is obtained to measure the central venous pressure (CVP) and to
serve as a conduit for PAC placement to measure intracardiac pressures. The
components of a system of intravascular pressure measurement are the
intravascular catheter, fluid-filled connector tubing, a transducer, and an
electronic analyzer and display system.
1. Characteristics of a pressure waveform. Pressure waves in the
cardiovascular system can be characterized as complex periodic sine waves.
These complex waves are a summation of a series of simple sine waves of
differing amplitudes and frequencies, which represent the natural harmonics of
a fundamental frequency. The first harmonic, or fundamental frequency, is equal
to the heart rate (Fig. 4.3A and B), and the first 10 harmonics of the
fundamental frequency will contribute significantly to the waveform.
2. Properties of a monitoring system
a. Frequency response (or amplitude ratio) is the ratio of the measured
amplitude versus the input amplitude of a signal at a specific frequency. The
frequency response should be constant over the desired range of input
frequencies—that is, the signal is not distorted (amplified or attenuated). The
ideal amplitude ratio is close to 1. The signal frequency range of an
intravascular pressure wave response is determined by the heart rate. For
example, if a patient’s heart rate is 120 beats/min, the fundamental frequency
is 2 Hz. Because the first 10 harmonics contribute to the arterial waveform,
frequencies up to 20 Hz will contribute to the morphology of an arterial
waveform at this heart rate.
IGURE 4.3 A: Generation of the harmonic waveforms from the fundamental frequency (heart rate) by Fourier analysis. B:
he first six harmonics are shown. The addition of the six harmonics reproduces an actual BP wave. The first six harmonics are
uperimposed, showing a likeness to, but not a faithful reproduction of, the original wave. The first 10 harmonics of a pressure
ave must be sensed by a catheter–transducer system, if that system is to provide an accurate reproduction of the wave. C:
ressure recording from a pressure generator simulator, which emits a sine wave at increasing frequencies (horizontal axis). The
equency response (ratio of signal amplitudeOUT to signal amplitudeIN) is plotted on the vertical axis for a typical catheter–
ansducer system. The useful band width (range of frequency producing a “flat” response) and the amplification of the signal in
e frequency range near the natural frequency of the system are shown. (A–C: From Welch JP, D’Ambra MN. Hemodynamic
onitoring. In: Kofke WA, Levy JH, eds. Postoperative Critical Care Procedures of the Massachusetts General Hospital. Boston,
MA: Little, Brown and Company; 1986:146, with permission.) D: Amplitude ratio (or frequency response) on the vertical axis is
otted as a function of the input frequency as a percentage of the natural frequency (rather than as absolute values). In the
ndamped or underdamped system, the signal output is amplified in the region of the natural frequency of the transducer system; in
e overdamped system, a reduction in amplitude ratio for most input frequencies is seen. This plot exhibits several important points:
) If a catheter–transducer system has a high natural frequency, less damping will be required to produce a flat response in the
inically relevant range of input frequencies (10 to 30 Hz); (ii) For systems with a natural frequency in the clinically relevant range
usual case), a level of “critical” (optimal) damping exists that will maintain a flat frequency response. D, damping coefficient.
From Grossman W. Cardiac Catheterization. 3rd ed. Philadelphia, PA: Lea & Febiger; 1985:122, with permission.)
b. Natural frequency (or resonant frequency), a property of all matter, refers

to the frequency at which a monitoring system itself resonates and amplifies
the signal. The natural frequency ( fn) of a monitoring system is directly
proportional to the catheter lumen diameter (D), inversely proportional to the
square root of three parameters: The tubing connection length (L), the system
compliance (ΔV/ΔP), and the density of fluid contained in the system (δ ).
This is expressed as follows:
To increase fn and thereby reduce distortion, it is imperative that a pressure-

sensing system be composed of short, low-compliance tubing of reasonable
diameter, and filled with a low-density fluid (such as normal saline).
Ideally, the natural frequency of the measuring system should be at least 10
times the fundamental frequency to reproduce the first 10 harmonics of the
pressure wave without distortion. In clinical practice, the natural frequency of
most measuring systems is in the range from 10 to 20 Hz. If the input frequency
is close to the system’s natural frequency (which is usually the case in clinical
situations), the system’s response will be amplified (Fig. 4.3C). Therefore,
these systems require the correct amount of damping to minimize distortion.
c. The damping coefficient reflects the rate of dissipation of the energy of a
pressure wave. Figure 4.3D shows the relationship among frequency
response, natural frequency, and damping coefficient.
When a pressure-monitoring system with a certain natural frequency
duplicates a complex waveform with any one of the first 10 harmonics close
to the natural frequency of the system, amplification will result if correct
damping of the catheter–transducer unit is not performed. The problem is
compounded when the heart rate is fast (as in a child or a patient with a rapid
atrial rhythm), which increases the demands of the system by increasing the
input frequency (Fig. 4.4).
IGURE 4.4 Comparison of three catheter–transducer systems with the same natural frequency (15 Hz) under different
onditions of heart rate. Pressures are displayed as systolic–diastolic (mean). The reference BP for all panels is 100/50. A: A
itically damped system (ζ = 0.6) provides an accurate reproduction until higher heart rates (greater than 150) are reached. B: An
nderdamped system (ζ = 0.2) shows distortion at lower rates, leading to overestimation of systolic and underestimation of diastolic
C: An overdamped system (ζ = 0.8) demonstrates underestimation of systolic pressure and overestimation of diastolic
essure. Also note that diastolic and mean pressures are affected less by the inadequate monitoring systems. fn, natural
equency; ζ, damping coefficient.
CLINICAL PEARL Correct damping of a pressure-monitoring system should not affect the
natural frequency of the system.
Both the natural frequency and the damping coefficient of a system can be
estimated using an adaptation of the square wave method known as the “pop”
test. The natural frequency is estimated by measuring the time period of one
oscillation as the system settles to baseline after a high-pressure flush. The
damping coefficient is calculated by measuring the amplitude ratio of two
successive peaks (Fig. 4.5).
After a rapid pressure change (performed by flushing the pressure line), an
2 underdamped system will continue to oscillate for a prolonged time. In
terms of pressure monitoring, this translates to an overestimation of systolic
BP and an underestimation of diastolic BP. An overdamped system will not
oscillate at all but will settle to baseline slowly, thus underestimating systolic
and overestimating diastolic pressures. A critically damped system will settle
to baseline after only one or two oscillations and will reproduce systolic
pressures accurately. An optimally or critically damped system will exhibit a
constant (or flat) frequency response in the range of frequencies up to the fn of
the system (Fig. 4.3D). If a given system does not meet this criterion,
components should be checked, especially for air, or the system replaced.
Even an optimally damped system will begin to distort the waveform at higher
heart rates because the 10th harmonic exceeds the system’s natural frequency
(Fig. 4.4).
IGURE 4.5 The “pop” test allows one to derive fn and ζ of a catheter–transducer system. The test should be done with the
atheter in situ, as all components contribute to the harmonics of the system. The test involves a rapid flush (with the high-pressure
ush system used commonly), followed by a sudden release. This produces a rapid decrease from the flush bag pressure and,
wing to the inertia of the system, an overshoot of the baseline. The subsequent oscillations about the baseline are used to calculate
and ζ. For example, the arterial pulse at the far left of the figure is followed by a fast flush and sudden release. The resulting
scillations have a definite period, or cycle, measured in millimeters. The natural frequency fn is the paper speed divided by this
eriod, expressed in cycles per second, or Hz. If the period were 2 mm and the paper speed 25 mm/s, fn = 12.5 Hz. For
fn, a faster paper speed will give better reliability. The ratio of the amplitude of one induced resonant wave to the next,
, is used to calculate damping coefficients (right column). A damping coefficient of 0.2 to 0.4 describes an underdamped
ystem, 0.4 to 0.6 an optimally damped system, and 0.6 to 0.8 an overdamped system. (From Bedford RF. Invasive blood pressure
onitoring. In: Blitt CD, ed. Monitoring in Anesthesia and Critical Care Medicine. New York: Churchill Livingstone; 1985:59, with
3. Strain gauges (transducer). The pressure-monitoring transducer can be

described as a variable-resistance transducer. A critical part of the transducer
is the diaphragm, which acts to link the fluid wave to the electrical input. When
the diaphragm of a transducer is distorted by a change in pressure, voltages are
altered across the variable resistor of a Wheatstone bridge contained in the
transducer. This in turn produces a change in current, which is electronically
converted and displayed.
4. Sources of error in intravascular pressure measurement
a. Low-frequency transducer response. Low-frequency response refers to a
low-frequency range over which the ratio of output-to-input amplitude is
constant (i.e., no distortion). If the natural frequency of the system is low, its
frequency response will also be low. Most transducer systems used in clinical
anesthesia can be described as underdamped systems with a low natural
frequency. Thus, any condition that further decreases fn response should be
avoided. Air within a catheter–transducer 3 system causes most monitoring
errors. Because of its compressibility, air not only decreases the response of
the system but also leads to overdamping of the system. Therefore, the myth
that an air bubble placed in the pressure tubing decreases artifact by
increasing the damping coefficient is incorrect. A second common cause of
diminution of frequency response is the formation of a partially obstructing
clot in the catheter.
b. Catheter whip. Catheter “whip” is a phenomenon in which the motion of the
catheter tip itself produces a noticeable pressure swing. This artifact usually
is not observed with peripheral arterial catheters but is more common with
PAC or LV catheters.
c. Resonance in peripheral vessels. The systolic pressure measured in a radial
arterial catheter may be up to 20 to 50 mm Hg higher than the aortic pressure
due to decreased peripheral arterial elastance and wave summation (Fig. 4.6).
IGURE 4.6 Change of pulse pressure waveform morphology in different arteries. Arterial waveforms do not have a
ngle morphology. The central aortic waveform is more rounded and has a definite dicrotic notch. The dorsalis pedis and, to a
sser extent, the femoral artery show a delay in pulse transmission, sharper initial upstrokes (and thus higher systolic pressure),
nd slurring (femoral) and loss (dorsalis) of the dicrotic notch. The dicrotic notch is better maintained in the upper-extremity
essure wave (see Fig. 4.10). The small second “hump” in the dorsalis wave probably is due to a reflected wave from the
terial–arteriolar impedance mismatching. (From Welch JP, D’Ambra MN. Hemodynamic monitoring. In: Kofke WA, Levy JH,
Postoperative Critical Care Procedures of the Massachusetts General Hospital. Boston, MA: Little, Brown and Company;
986:144, with permission.)
d. Changes in electrical properties of the transducer. Electrical balance, or

electrical zero, refers to the adjustment of the Wheatstone bridge within the
transducer so that zero current flows to the detector at zero pressure.
Transducers should be electronically balanced periodically during a
procedure because the zero point may drift, for instance, if the room
temperature changes. The pressure waveform morphology may not change
with baseline drift of a transducer.
e. Transducer position errors. By convention, the reference position for
hemodynamic monitoring during cardiac surgery is the right atrium (RA). With
the patient supine, the RA lies at the level of the midaxillary line. Once its
zero level has been established, the transducer must be maintained at the same
level as the RA. If the transducer position changes, falsely high- or low-
pressure values will result. This can be significant especially when
monitoring CVP, PA pressure, or pulmonary capillary wedge pressure
(PCWP) where the observed change is a greater percentage of the measured
value. For example, if a patient has a MAP of 100 mm Hg and a CVP of 10
mm Hg, a 5 mm Hg offset due to transducer position would be displayed as a
5% or 50% change in the arterial or CVP pressures, respectively.
D. Arterial catheterization
1. Indications. Arterial catheterization (“art line,” or more commonly “A-line”) is
the gold standard in the monitoring of the cardiac surgical patient (Table 4.2).
Placement of an art 4 line prior to induction is imperative for a safe, smooth
anesthetic induction. Note that all four indications for an art line are applicable
even during routine cardiac surgery. Most thoracic, major vascular, and
neurosurgical procedures will also have ≥1 indication.
2. Sites of cannulation. Multiple cannulation sites have been used, with radial
and femoral being by far the most utilized.
The authors typically infiltrate ≥2.5 to 3 mL of 1% lidocaine. There are
issues unique to cardiac surgical procedures which may govern arterial/central
line insertion site. Patients may require mechanical assistance from an intra-
aortic balloon pump (IABP) which is inserted via the femoral artery. IABP is
positioned in the descending thoracic aorta immediately distal to the subclavian
artery. When inflation/deflation is correctly timed, the IABP improves LV
cardiac output (CO) by decreasing the end-systolic aortic pressure and
augmenting the LV diastolic pressure. Note that LV perfusion occurs only
during diastole whereas the RV is perfused in both systole and diastole.
CLINICAL PEARL The most common mistake during radial art line insertion is
infiltration of an inadequate volume of local anesthetic. Local anesthetic should eliminate
discomfort during placement and attenuate arterial vasoconstriction.
a. Radial artery. The radial artery is the most commonly utilized site. Non-
invasive blood pressure should be routinely measured in both arms prior to
placement of an art line to detect differences in pressure. Usually, a left radial
art line is preferred because: (1) the primary surgeon operates on the patient’s
right side and can compress the right arm vasculature; (2) most patients are
right dominant; and (3) improper placement of the sternal retractor can apply
pressure to the brachial plexus increasing risk of neural injury. An abnormal
arterial pressure wave can trigger evaluation of sternal retractor positioning.
TABLE 4.2 Arterial catheterization indications
(1) Technique. Ultrasound-guided radial artery cannulation is beneficial

when difficulty placing the catheter via the traditional method is
encountered or low flow states (shock), nonpulsatile flow during
extracorporeal membrane oxygenation (ECMO), LVAD or right
ventricular assist device (RVAD) or cardiac arrest.
CLINICAL PEARL Pulse oximetry (SpO2) may not be able to acquire a signal in patients
with low-flow states and/or cool peripheral extremities. Performing a PNB of the SpO2 digit
with 1 to 2 mL of plain local anesthetic frequently restores the SpO2 signal.
(2) Complications. Very few ischemic complications have been reported

from arterial catheterization even in patients with a positive Allen test
indicating limited collateral ulnar artery flow. Peripheral shunting
following CPB 5 manifesting as hypotension is occasionally observed.
The difference between central arterial pressures and radial art line can
exceed 25 to 30 mm Hg. This is a self-limited problem that dissipates as
thermal energy is more evenly distributed in the patient. Placement of a
femoral art line or passing off pressure tubing attached to the aortic
cannula from the surgical field can be used to confirm this diagnosis.
(3) Radial artery harvest. The radial artery is an alternative option for use
as a bypass conduit. Usually the radial artery to be harvested is known
preoperatively, and the contralateral radial artery can be used.
b. Femoral artery. A femoral art line is an option that has unique
considerations. The femoral artery is the site for placement of an IABP or the
arterial CPB cannula when the usual placement in the ascending aorta is not
possible. Aortic aneurysm and dissection are cases that may require this
option.
(1) Technique. The femoral artery typically lies at the midpoint between the
pubic tubercle and the anterior superior iliac spine. These bone
landmarks can be used to guide identification of the femoral pulse in
difficult cases.
(2) Contraindications. Cannulation of the femoral artery should be avoided
in patients with prior vascular surgery involving the femoral arteries or a
skin infection of the groin.
c. Aortic root. The surgeon can transiently assess BP by transducing the aortic
cannula or aortic root while the chest is open.
d. Axillary artery. The axillary artery is a superficial vessel with good access
to the central arterial tree.
Complications. The increased risk of cerebral embolus of air or debris
must be recognized. Flushing the arterial line must be performed with caution
and low pressure. Hemothorax risk is a known complication of axillary
arterial lines.
e. Brachial artery. The brachial artery is an easily accessible artery located
medially in the antecubital fossa.
Contraindications. Concern about compromised flow distal to catheter
placement has limited its use at many institutions. Brachial catheterization is a
secondary option or is not utilized in nonheparinized surgical procedures.
f. Ulnar artery. The ulnar artery is a secondary site. There is a risk of
compromised perfusion if attempted placement of the ipsilateral radial artery
is unsuccessful.
g. Dorsalis pedis and posterior tibialis arteries. In general, the distal location
increases distortion of the arterial wave. The dorsalis pedis artery is
technically easier to cannulate.
IGURE 4.7 Normal arterial waveform morphology. Components of the normal arterial waveform include (1) the systolic
) systolic peak pressure, (3) systolic decline, (4) the dicrotic notch, (5) diastolic runoff, and (6) end-diastolic pressure.
he area underneath the curve (shaded area on the left) divided by the beat period equals the mean arterial pressure (MAP). S,
ystole; D, diastole. (Modified from Mark JB. Atlas of Cardiovascular Monitoring. New York: Churchill Livingstone; 1998, Figures
1 and 8.2.)
3. Interpretation of arterial tracings. The arterial pressure waveform contains a

great deal of hemodynamic information. Normal radial artery waveform
morphology is shown in Figure 4.7. Different sites have a unique morphology
although the components are identical. The dicrotic notch marks the end of
systole/start of diastole. The waveform has three systolic components: systolic
upstroke (a graphical representation of δP/δt) to a peak (sBP), then decline to
the dicrotic notch, and diastolic runoff to a nadir (dBP).
a. Heart rate and rhythm. The heart rate can be determined from the arterial
pressure wave. This is especially helpful if the patient is being paced or if
electrocautery is being used. In the presence of numerous atrial or ventricular
ectopic beats, the arterial trace can provide useful information on the
hemodynamic consequences of these dysrhythmias (i.e., if an ectopic beat is
perfusing). The arterial waveform can also demonstrate the hemodynamic
effects of ventricular versus A-V pacing (Fig. 4.8).
b. Pulse pressure. The difference between the systolic and diastolic pressures
provides useful information about fluid status and valvular competence.
Pericardial tamponade and hypovolemia are accompanied by a narrow pulse
pressure on the arterial waveform. An increase in pulse pressure may be a
sign of worsening aortic valvular insufficiency or hypovolemia.
IGURE 4.8 VOO versus AV pacing. The CVP tracing during VOO pacing ( left) shows cannon waves due to systolic
ontraction of the right atrium (RA) from retrograde conduction. AV pacing ( right) shows a normal CVP tracing and a substantial
mprovement in arterial blood pressure, as demonstrated by the arterial waveform. (From Mark JB. Atlas of Cardiovascular
. New York: Churchill Livingstone; 1998, Figure 14.16.)
c. Respiratory variation and volume status. Hypovolemia is suggested by a

decrease in arterial systolic pressure with positive-pressure ventilation
(pulsus paradoxus). Positive intrathoracic pressure impedes venous return to
the heart with a more pronounced effect in the hypovolemic patient.
Respiratory variation of arterial sBP, stroke volume (SV), and pulse pressure
can be used as goal-directed parameters to identify patients who will respond
to fluid administration. This is discussed in greater depth below.
d. Qualitative estimates of hemodynamic indices. Inferences can be made
regarding contractility, SV, and vascular resistance from the arterial
waveform. sBP and dBP are the peak and nadir of the arterial waveform,
respectively. Contractility can be grossly judged by δP/δt, the rate of pressure
rise during systole keeping in mind that heart rate, preload, and afterload can
affect this parameter. SV can be estimated from the area under the aortic
pressure wave from the onset of systole to the dicrotic notch. Finally, the
position of the dicrotic notch correlates with the systemic resistance. A notch
appearing high on the downslope of the pressure trace suggests a high
vascular resistance, whereas a low resistance tends to cause a dicrotic notch
that is lower on the diastolic portion of the pressure trace. These elements are
incorporated into the algorithms of pulse pressure analysis monitors for
noninvasive CO.
e. Intra-aortic balloon counterpulsation timing. The arterial tracing should
show a characteristic pattern when an IABP is present. A properly timed
IABP should inflate the balloon starting at the dicrotic notch. The balloon
remains inflated throughout diastole, and actively deflates at the start of the
next systolic upstroke. Analysis of the arterial waveform should allow
appropriate adjustment of balloon inflation and deflation to optimize its
function (Fig. 4.9).
IGURE 4.9 Arterial waveform tracing with an intra-aortic balloon pump (IABP) at 1:2. Beats 2, 4, and 6 show a properly timed
flation of the balloon at the dicrotic notch, resulting in increased diastolic arterial pressure. Deflation of the balloon just prior to the
ystolic upstroke results in a drop in arterial pressure at the onset of systole and a reduced peak in the following beat. (From Mark
Atlas of Cardiovascular Monitoring. New York: Churchill Livingstone; 1998, Figure 20.1.)
4. Complications of arterial catheterization

a. Ischemia. The incidence of ischemic complications after radial artery
cannulation is low even in patients with abnormal flow patterns.
b. Thrombosis. Although the incidence of thrombosis from radial artery
catheterization is high, studies have not demonstrated adverse sequelae.
Recanalization of the radial artery occurs in a majority of cases. Patients with
increased risk include those with diabetes or severe peripheral vascular
disease.
c. Infection. With proper sterile technique, the risk of infection from cannulation
of the radial artery should be minimal. In a series of 1,700 cases, no catheter
site was overtly infected.
d. Bleeding. Although transfixing the artery will put a hole in the posterior wall,
the layers of the muscular media will seal the puncture. In a patient with a
bleeding diathesis, however, there is a greater tendency to bleed. Unlike
central venous catheters (CVCs), arterial catheters are not heparin bonded and
thus have increased risk of thrombus development.
5. Abnormal arterial waveform morphology. Cardiac abnormalities can provide
pathologic clues by altering the arterial (Fig. 4.10) waveform morphology,
providing diagnostic clues which are typically underappreciated.
E. Central venous pressure. CVP measures RA pressure and is affected by
circulating blood volume, venous tone, and RV function. Placement of a CVC
(central line) is indicated in most cardiac surgical procedures to provide a large-
bore conduit for rapid fluid administration and delivery of vasoactive drugs into
the central vascular compartments and/or a PAC. It is very important to recognize
that there are some complications that are secondary to central line placement,
not PAC insertion. This is pertinent to the controversial use of a PAC in cardiac
surgery. Complications of PAC insertion are much less frequent and often
transient (e.g., dysrhythmia). Although CVP has severe limitations in estimating
LVEDV, CVP can provide clinical clues that can trigger further therapeutic
action(s). Central line placement is indicated in essentially all cardiac surgery
procedures.
1. Indications
a. Monitoring. Monitoring of CVP is indicated for all cardiac surgical patients.
Anatomically, CVP is acquired at the junction of the RA, IVC, and SVC. The
first step to interpretation of CVP is correctly identifying the waveform
components. After eliminating all parameters that ↑ CVP (no mechanical
positive pressure breaths), the end-exhalation waveform mean pressure (Fig.
4.11) is the correct value. Central venous O2 saturation (ScvO2) is assessed
from SVC blood. SCVO2 reflects venous saturation from brain and upper
extremities and is typically 5% LESS than SVO2. Oximetric CVP catheters are
utilized without need to place a PAC. Normal SCVO2 is 70%.
IGURE 4.10 Arterial waveforms resulting from pathologic conditions. For the top four figures, the thick line represents a
ormal arterial waveform. (From Quick Guide to Cardiopulmonary Care. 3rd ed. Used with permission from Edwards Critical Care
b. Fluid and drug therapy. Central line access facilitates administration of

vasoactive drugs if required. A central line also facilitates rapid fluid
administration.
c. Special issues in cardiac surgery. One may elect to place a CVP catheter,
with delayed PAC placement in selected patients.
CLINICAL PEARL Placement of a PAC can be difficult in patients with numerous
congenital cardiac disorders, in those with anatomic distortion of the right-sided venous
circulation, or in those requiring surgical procedures of the right heart or implantation of a
right heart mechanical assist device. Insertion may need to be delayed until during the
surgery.
IGURE 4.11 Central venous pressure waveforms in a spontaneously breathing patient (top) and a patient receiving positive-
essure ventilation (bottom). Note that during inspiration, the CVP decreases in the spontaneously breathing patient, whereas it
creases during positive-pressure inspiration. CVP should be read at end expiration (dark horizontal lines) to avoid the effects of
hanging intrathoracic pressure. (From Pittman, JA, Ping JS, Mark JB. Arterial and central venous pressure monitoring. Int
nesthesiol Clin. 2004 Winter;42(1):13–30.)
2. Techniques. The IJ veins, subclavian (SC) veins, and the femoral veins are the
most common sites for catheter access to the central circulation (Table 4.3).
a. Internal jugular. The right IJ (RIJ) is the most common access route for
cardiac anesthesiologist because it is a straight pathway from insertion site to
RA. The RSC is the most tortuous. Additionally most anesthesiologists are
right handed and ergometrically the RIJ is the easier side to access.
TABLE 4.3 Central line insertion sites and complications
(1) Contraindications and recommendations. Relative contraindications

for IJ central line placement include the following:
(a) Presence of significant carotid disease
(b) Recent cannulation of the IJ (with the concomitant risk of
thrombosis)
(c) Contralateral diaphragmatic dysfunction
(d) Thyromegaly or prior neck surgery
In these cases, the IJ on the contralateral side should be considered. It
should be remembered that the thoracic duct lies in close proximity to the
left IJ and that laceration of the left brachiocephalic vein or superior
vena cava by the catheter is more likely with the left-sided approach.
This risk is due to the more acute angle between the left IJ and
innominate veins.
(2) Sonographic guidance. Ultrasound guidance of elective venous
cannulation has quickly gained controversial acceptance as the preferred
method for IJ catheter, particularly for inexperienced operators.
Ultrasound-guided IJ cannulation requires the ability to correctly
distinguish the easily compressible jugular vein from the carotid artery
(Fig. 4.12).
b. External jugular. The external jugular vein courses superficially across the
sternocleidomastoid muscle to join the subclavian vein close to the junction of
the IJ and SC veins. Its course is more tortuous, and the presence of valves
makes central line placement more difficult. The placement of rigid central
catheters (e.g., PAC introducer) via the external jugular increases the risk of
vessel trauma and is not recommended. Pliable central catheters and short
catheters can be used to acquire intravenous access.
IGURE 4.12 Ultrasound image of the internal jugular vein and carotid artery. Note that color flow visualizes blood flowing
way from the transducer as blue, while blood flowing toward the transducer is red. So, with the probe angled caudally, blood flow
the internal jugular vein returning to the heart is blue, while the blood travelling up from the aortic arch into the carotid artery is
. (From Barash P, Cullen B, eds. Clinical Anesthesia. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:747.)
c. Subclavian. The subclavian vein is readily accessible and thus has been
popular for use during cardiopulmonary resuscitation.
(1) Advantages. The main advantage to subclavian vein cannulation is its
relative ease and the stability of the catheter during long-term
cannulation. Left SC insertion of a PAC introducer is the second easiest
anatomical approach after the right IJ.
(2) Disadvantages
(a) Subclavian vein cannulation carries the highest rate of pneumothorax
of any approach. If subclavian vein cannulation is unsuccessful on
one side, an attempt on the contralateral side is contraindicated
without first obtaining a chest x-ray film. Bilateral pneumothoraces
can be lethal. Subclavian vein placement for cardiac surgery can be
associated with compression of the central line during sternal
retraction.
(b) The subclavian artery is entered easily.
(c) In a left-sided cannulation, the thoracic duct may be lacerated.
(d) The right subclavian approach may make threading the PAC into the
RA difficult because an acute angle must be negotiated by the
catheter in order to enter the innominate vein. The left subclavian
approach is recommended as the first option for PAC placement.
d. Arm vein
Techniques. Central access can be obtained through the veins of the
antecubital fossa (“long-arm CVP” or “peripherally inserted central catheter
—PICC”). This has a limited role in most cardiac surgical procedures.
3. Complications. The site-specific complications of CVP catheter insertion are
listed in Table 4.3. The most severe complications of CVP insertion usually are
preventable.
4. CVP interpretation
a. Normal CVP waveform morphology. The normal CVP trace is more
complex than the arterial waveform, containing three positive deflections,
termed the a, c, and v waves, and two negative deflections termed the x and y
descents. The CVP components (Table 4.4) represent mechanical events that
are altered by heart function and 6 arrhythmia (Table 4.5; Fig. 4.7, bottom).
The CVP c wave always follows the ECG R wave and is useful for
interpreting CVP waveforms.
b. Abnormal waves. A common abnormality in the CVP trace is loss of the a
wave secondary to atrial fibrillation (A-fib). In the presence of AV
dissociation, when RA contraction occurs against a closed tricuspid valve,
this produces a large “cannon A wave” that is virtually diagnostic. These
waves are also evident in VOO pacing (Fig. 4.8, left). Abnormal V waves can
occur with tricuspid valve insufficiency, in which retrograde flow through the
incompetent valve produces an increase in RA pressure during systole (Fig.
4.13, top).
TABLE 4.4 Components of the CVP waveform
TABLE 4.5 Differential diagnosis of RA-RV hemodynamic abnormalities
c. RV function. CVP offers direct measurement of RV filling pressure.

d. LV filling pressures. CVP (and other PAC-obtained data) have historically
been utilized as a tool to estimate LV filling pressures which in turn was
dogmatically an estimate of LVEDV. Parameters that distort this estimate
include LV dysfunction, decreased LV compliance (i.e., ischemia), pulmonary
hypertension, or mitral valvular disease (and TR with respect to CVP). In
patients with coronary artery disease but good ventricular function (ejection
fraction greater than 40% and no regional wall motion abnormalities
[RWMAs]), CVP correlates well with PCWP. However, because RV is a
thinner-walled chamber, the compliance of the RV is higher than that of the
LV. Therefore, for any given preload, CVP will be lower than either PA
diastolic pressure or PCWP. Although the absolute number has not been
shown to correlate with preload conditions and SV, evaluating trends over
time and cyclic changes during mechanical ventilation can help guide fluid
therapy.
IGURE 4.13 Top: CVP tracing showing a large v wave and steep y descent due to tricuspid regurgitation. The regurgitant
ow during systole obscures the x descent, causing a fusion of c and v waves. RV end-diastolic pressure is best estimated from
e tracing prior to the v wave, at the time of the R wave on the ECG. Bottom: V waves secondary to severe mitral regurgitation.
he tall systolic v wave in the PA wedge pressure (PAWP) trace also distorts the PA tracing, thereby giving it a bifid appearance.
VED pressure is best estimated by measuring PAWP at the time of the ECG R wave before the onset of the regurgitant v wave.
From Mark JB. Atlas of Cardiovascular Monitoring. New York: Churchill Livingstone; 1998, Figures 17.1 and 17.11.)
F. Pulmonary artery catheter (PAC)

1. Parameters measured
a. PA pressure reflects RV function, pulmonary vascular resistance (PVR), and
left atrial (LA) filling pressure.
b. PCWP is a more direct estimate of LA filling pressure. With the balloon
inflated and “wedged” in a distal branch PA, a valveless hydrostatic column
exists between the distal port and the LA at end diastole. This measurement is
often assumed to represent left ventricular end-diastolic pressure (LVEDP),
and further extrapolated to reflect LVEDV; both of these assumptions,
especially the latter, are fraught with potential errors.
c. CVP. A sampling port of the PAC is located in the RA and allows
measurement of the CVP.
d. CO. A thermistor located at the tip of the PAC allows measurement of the
output of the RV by the thermodilution technique. In the absence of
intracardiac shunts, this measurement equals LV output.
e. Blood temperature. The thermistor can provide a constant measurement of
blood temperature, which is an accurate reflection of core temperature.
f. Derived parameters. Advanced indices of ventricular performance and
cardiovascular status can be derived from the parameters measured by PAC.
g. SVO2. Oximetric PAC can measure real-time PA venous blood oxygen
saturation providing information on end-organ oxygen utilization. For standard
PACs, a blood gas sample can be drawn from the distal port, which will give
an intermittent SVO2. This measurement can be repeated to trend the value.
h. RV performance. New PAC technology allows for improved assessment of
RV function distinct from LV dysfunction.
TABLE 4.6 PAC Indications
2. Indications for PA catheterization. There is no consensus among cardiac

anesthesiologists regarding PAC use. PAC guidelines have been published [ 6].
In some institutions, cardiac surgery with CPB represents a universal indication
for PA pressure monitoring in adults; other institutions rarely use PAC [ 7,8]. In
the late 1990s several observational studies, randomized control trials, and
meta-analyses did not show positive outcome benefits with the use of the PAC.
Between 1994 and 2004, PAC use decreased 65% in medical intensive care
units (ICUs) and 63% in surgical ICUs. Proponents of the PAC ( Table 4.6)
suggest that timing of catheter placement, patient selection, interpretation of
PAC data, and early appropriate intervention are required for this monitor to
meaningfully affect patient outcome. Decreased mortality has been reported in
high-risk surgical patients in which PACs were inserted preoperatively and
interventions were protocol driven. In elective cardiac surgical patients,
Polanen reported in 2000 that PAC protocols reduce hospital and ICU length of
stay [9]. Therefore, the current consensus appears to be that PACs may have
benefits in 7 high-risk patients or those with special indications. However,
routine patients with preserved LV function can frequently be managed with
CVP and TEE alone. Differentiation of LV versus RV function and assessment
of intracardiac filling pressures during antegrade cardioplegia administration
(enhanced myocardial protection) are two indications that cannot be performed
with CVP alone. Discordance in right and left heart function occurs with
variable frequency where pressures measured on the right side (i.e., CVP) do
not adequately reflect those on the left side [10]. Knowledge of PAC
waveforms and the nuances of abnormal patterns (Table 4.7) should provide a
differential diagnostic list and direct examination by other monitoring
modalities, particularly TEE. For example, the sudden appearance of prominent
PA v waves should prompt investigation of the MV to assess MR.
a. Assessing volume status. While historically PAC measurements, particularly
PCWP, have been used as an indicator of a patient’s volume status, several
studies have demonstrated that these parameters are very poor at guiding fluid
administration. Given the increase in routine usage of intraoperative TEE in
cardiac surgery, we cannot advocate routine usage of PCWP for guidance of
volume resuscitation.
b. Diagnosing RV failure. The RV is a thin-walled, highly compliant chamber
that can fail during cardiac surgery either because of a primary disease
process (inferior myocardial infarction), inadequate myocardial protection, or
intracoronary air (predilection for the right coronary artery) as a result of the
surgical procedure. RV failure presents as an increase in CVP, a decrease in
the CVP to mean PA gradient, and a low CO. The data that can be acquired
from PAC can be tailored to calculating/measuring more complex
hemodynamic variables (Table 4.8) to quantitate cardiac function and assess
the effect of therapeutic interventions.
c. Diagnosing LV failure. Knowledge of PA and wedge pressures can aid in the
diagnosis of left-sided heart failure if other causes (ischemia, mitral valve
disease) are eliminated. TEE can aid in correlating the clinical paradigm to
PAC measurements. Simultaneous readings of high PA pressures and wedge
pressure in the presence of systemic hypotension and low CO are hallmarks of
LV failure.
TABLE 4.7 Differential diagnosis of PA-PCWP hemodynamic abnormalities
d. Diagnosing pulmonary hypertension. Note that with normal PVR, the PA

diastolic and wedge pressure agree closely with one another. This
relationship is lost with pulmonary hypertension.
e. Assessing valvular disease
(1) Tricuspid and pulmonary valve stenosis can be diagnosed by means of a
PAC by measuring pressure gradients across these valves, although in
adults TEE is the primary diagnostic modality for these lesions.
(2) Mitral valvular disease is reflected in the PA and wedge pressure
waveform morphology. Mitral insufficiency appears as an abnormal V
wave and an increase in pulmonary venous pressure from the regurgitant
flow into the LA. V waves can also appear in other conditions, including
myocardial ischemia, ventricular pacing, and presence of a ventricular
septal defect depending on the compliance of the LA. In patients with
chronic mitral valve insufficiency, the LA has a high compliance and a
large regurgitant volume will not always result in a dramatic V wave
(Fig. 4.13, bottom).
f. Early diagnosis of ischemia. PAC, ECG, and TEE can assist detection of
myocardial ischemia. Significant ischemia (transmural or subendocardial) is
often associated with a decrease in ventricular compliance, which is reflected
in either an increase in PA pressure or an increase in PCWP. In addition, the
development of pathologic V waves may occur secondary to ischemia of the
papillary muscle.
TABLE 4.8 Hemodynamic variables and normal values
g. Monitoring intracardiac filling pressures during antegrade cardioplegia.

Elevated mean PA and/or PCWPs during administration of cardioplegia into
the aortic root can be a sign of aortic insufficiency leading to LV distention,
indicating a need for further venting of the LV and possibly retrograde
cardioplegia. It is important to 8 remember that the PAC tip should be
withdrawn 2 to 5 cm once the patient is fully on bypass to prevent collapse of
the pulmonary arteries onto the catheter and cause an unintentional wedge.
3. Contraindications for PAC placement
a. Significant tricuspid/pulmonary valvular pathology: Tricuspid/pulmonary
stenosis, endocarditis, or mechanical prosthetic valve replacement.
b. Presence of a right-sided mass (tumor/thrombosis) that would cause a
pulmonary or paradoxical embolization if dislodged.
c. Left bundle branch block (LBBB): LBBB is a relative contraindication. The
incidence of transient right bundle branch block (RBBB) during PAC
placement is ∼5%. In a patient with LBBB, this can result in complete heart
block (CHB) when floating the PAC through the RV outflow track. Therefore,
external pacing should be immediately available for these patients. In
addition, floating of the PAC can be delayed until the chest is open, so that
CPB can be rapidly initiated should CHB occur and external pacing be
ineffective.
4. Interpretation of PA pressure data
a. Effects of ventilation. The effects of ventilation on PA pressure readings can
be significant in the low-pressure system of the right-sided circulation
because airway or transpleural pressure is transmitted to the pulmonary
vasculature.
(1) When a patient breathes spontaneously, the negative intrapleural pressure
that results from inspiration can be transmitted to the intravascular
pressure. Thus, low or even “negative” PA diastolic, wedge, and CVPs
may occur with spontaneous ventilation.
(2) Positive airway pressures are transmitted to the vasculature during
positive-pressure ventilation, leading to elevations in pulmonary
pressures. Mean airway pressure is the parameter which correlates most
closely with the changes in PA and CVP pressure measurements.
(3) The established convention is to evaluate pressures at end expiration.
The digital monitor numerical readout may give incorrect information
because these numbers reflect the absolute highest (systolic), lowest
(diastolic), and mean (area under pressure curve) values for several
seconds, which may include one or more breaths. Damping is not
accounted for by the monitor. Thus, inspection and interpretation of the
waveform data is required to correctly evaluate the clinical scenario.
b. Location of catheter tip. PA pressure measurements depend on where the tip
of the catheter resides in the pulmonary vascular tree. In areas of the lung that
are well ventilated but poorly perfused (West zone I), the readings will be
more affected by the changes in airway pressure. Likewise, even when the tip
is in a good location in the middle or lower lung fields, large amounts of
positive end-expiratory pressure (>10 mm Hg) will affect PA values ( Fig.
4.14).
(1) Occasionally, it may be difficult to see the transition from an RV to PA
waveform while inserting a PAC. Positioning within a PA can be
confirmed by observing a downward slope to the waveform in diastole,
representing arterial diastolic runoff, rather than an upward slope,
indicating passive RV diastolic filling.
(2) PAC position in the PA can also be confirmed using TEE.
5. LA pressure. In some patients (especially pediatric), direct LA pressure can
be measured after surgical insertion of an LA catheter via the LA appendage in
the open chest. LA catheters are also used in corrective surgery for congenital
lesions when PAC insertion is not possible. The LA pressure tracing is
comparable to the CVP tracing, with A, C, and V waves occurring at identical
points in the cardiac cycle. LA catheters are used to monitor valvular function
(after mitral valve replacement or mitral valvuloplasty) or to monitor LV filling
pressures, whether or not a PAC is available. LA pressure measured directly is
more accurate than that measured with a PAC because the effects of airway
pressure on the pulmonary vasculature are removed. However, LA pressure
does not necessarily reflect LVEDP in the presence of mitral valvular disease.
Air should be meticulously removed from LA flush systems to avoid
catastrophic air emboli.
6. Timing of placement. Select high-risk patients may require PAC placement
prior to induction. The discomfort that might be associated with placement
needs to be balanced with acquisition of hemodynamic data. In appropriately
sedated patients, placement of a PAC is not associated with any significant
hemodynamic changes. The hemodynamic data collected in the catheterization
laboratory may not accurately reflect the current hemodynamic status,
especially if the patient had episodes of myocardial ischemia during the
catheterization or may be experiencing ischemia when entering the operating
room.
7. Types of PACs. A variety of PACs are currently available for clinical use.
The standard thermodilution catheter has a PA port for pressure monitoring and
a thermistor for CO measurements at its tip, an RA port for CVP monitoring and
for injection of cold saline 30 cm from the tip, and a lumen for inflation of the
balloon. In addition, PACs are available that provide the following:
a. Venous infusion port (VIP). VIP PACs have a third port 1 cm proximal to the
CVP (31 cm from the tip) for infusion of drugs and fluids.
IGURE 4.14 Pressure waveforms from the pulmonary artery catheter (PAC) tip as it passes through the right-sided heart
hambers and into the pulmonary vasculature. Note that both CVP and PCWP waveforms exhibit a, c, and v waves. The shaded
oxes in the RV and PA waveforms demonstrate the upward slope during diastolic filling in the RV, versus the downward sloping
astolic runoff in the PA. This is a good method for distinguishing the waveforms when inserting a PAC. (From Mark JB. Atlas of
ardiovascular Monitoring. New York: Churchill Livingstone; 1998, Figure 3.1.)
CLINICAL PEARL A common novice error is to forget that the VIP and CVP port are
outside of the patient if the PAC has not yet been floated. Medications administered may then
extravasate into the protective sheath rather than be delivered to the patient.
b. Pacing. Pacing PACs have the capacity to provide intracardiac pacing. Pacing
PACs are seldom used for cardiac procedures because usually patients
already have a temporary pacing wire for symptomatic bradycardia prior to
anesthetic care. Epicardial pacing wires are routinely placed by the surgeon
intraoperatively for postoperative bradycardia.
(1) Pacing PACs have a separate lumen terminating 19 cm from the catheter
tip. When the catheter tip lies in the PA with a normal-sized heart, this
port is positioned in the RV. A separate sterile, prepackaged pacing wire
can be placed through this port to contact the RV endocardium for RV
pacing.
TABLE 4.9 Invasive oximetric monitors and clinical mechanisms of SVO2
(2) PACs with thermodilution and atrial or AV pacing with two separate
bipolar pacing probes have been shown to provide stable pacing before
and after CPB.
c. Mixed venous oxygen saturation (SvO2). Delivery of adequate oxygen to
meet the body tissue demand is best determined by SVO2 (Table 4.9). Special
fiber optic PACs 9 can be used to monitor SVO2 continuously. The normal
SvO2 is 75%, with a 5% to 10% increase or decrease considered significant.
Decreased oxygen delivery or increased oxygen utilization result in a
decreased SVO2. Four mechanisms can result in a significant decrease in
SVO2:
(1) Decrease in CO
(2) Decreased hemoglobin concentration
(3) Decrease in arterial oxygen saturation (SaO2)
(4) Increased O2 utilization. These mechanisms can be understood by
reviewing the oxygen consumption equation:
where V̇O2 is oxygen consumption, CO is cardiac output in L/min, Hgb is

the hemoglobin in g/dL, 13.8 is the amount of oxygen that can combine
hemoglobin (1 g of Hgb can bind 1.38 mL of O2, this factor is multiplied
by 10 to convert dL to L as Hgb is measured in g/dL), SaO 2 is arterial
saturation, and SVO2 is mixed venous saturation. Based on the equation, a
decrease in SVO2 can result from a decrease in either the CO, Hgb, or
SaO2, or an increase in V̇O2.
CLINICAL PEARL Changes in SvO2 or oxygen extraction ratio (Tables 4.10 and 4.11)
usually precede hemodynamic changes by a significant period of time, making this a useful
clinical adjunct to other monitors. Some cardiac anesthesiologists advocate SvO2 monitoring
for off-pump coronary artery bypass (OPCAB) procedures and any patient with severe LV
dysfunction and/or valve disease. Figure 4.15 presents a treatment algorithm utilizing SvO2
to guide management.
Attenuation of ḊO2 clinically is typically influenced by simultaneous
changes in all three ḊO2 parameters. We can compare the effects of the
individual mechanisms by varying them individually and comparing the results
with normal CO and ḊO2 (Table 4.11). Note that under normal conditions
V̇O2 consumes/requires 5.39 mL/kg O2/min resulting in an extraction ratio of
25.5%. Thus, under normal conditions the ḊO2 is four times greater than
required.
d. Ejection fraction catheter. PACs with faster thermistor response times can
be used to determine RV ejection fraction in addition to the CO. The
thermistor responds rapidly enough that the exponential decay that normally
results from a thermodilution CO has end-diastolic “plateaus” with each
cardiac cycle. From the differences in temperature of each succeeding plateau,
the residual fraction of blood left in the RV after each contraction is
calculated, as is RV stroke volume, end-diastolic volume, and end-systolic
volume. Monitoring these parameters can be helpful in patients with RV
dysfunction secondary to pulmonary hypertension, infarction, or reactive
pulmonary disease.
TABLE 4.10 Oxygen delivery variables and normal values
e. Continuous CO. PACs that use low-power thermal filaments to impart small
temperature changes to RV blood have been developed ( Intellicath, Baxter
Edwards; and Opti-Q, Abbott Critical Care Systems, Mountain View, CA,
USA). Fast-response thermistors in the PA allow for semicontinuous (every
30 to 60 seconds) CO determinations.
TABLE 4.11 Effects of hemoglobin and cardiac output (CO) on oxygen delivery
IGURE 4.15 Treatment algorithm utilizing SvO 2, SaO2, CO, hemoglobin concentration, and a measurement of volume status.
O, cardiac output; SvO2, mixed venous oxygen saturation; SaO2, arterial oxygen saturation; SPV, systolic pressure variation;
PV, pulse pressure variation; SVV, stroke volume variation. (Adapted from Quick Guide to Cardiopulmonary Care. 3rd ed. Used
ith permission from Edwards Critical Care Education.)
8. Techniques of insertion. The introducer is placed in a manner similar to that

described for CVP insertion. However, special care should be observed with
PAC placement, noting especially the following points:
a. Sedation. Because the patient is under a large drape for a longer period of
time, he or she should be asked questions periodically to check for
oversedation. A clear drape allows visual inspection of the patient’s color
and may produce a less suffocating feeling.
b. ECG monitoring during placement. It is essential to monitor the ECG during
placement of the catheter because dysrhythmias are the most common
complication associated with PAC insertion.
c. Pulse oximetry. Pulse oximetry gives an audible signal of rhythm and may
alert the physician to an abnormal rhythm.
d. Preferred approach. The right IJ approach offers the most direct route to the
RA and thus results in the highest rate of successful PA catheterization. The
left subclavian route is next most effective.
e. Balloon inflation. Air should be used for balloon inflation. If any suspicion
exists about balloon competency, the PAC should be removed and the balloon
inspected directly to avoid iatrogenic air embolism.
f. Waveform. A vast majority of cardiac anesthesiologists use waveform
analysis to guide placement of the PAC tip. TEE or the use of fluoroscopy can
aid placement in some situations. Representative waveforms are shown in
Figure 4.14.
9. Complications. Complications [11] can be divided into vascular access, PAC
placement/manipulation, and monitoring problems.
a. Vascular access. See Table 4.3 for complications of central venous
cannulation.
b. PAC placement/manipulation
(1) Cardiac arrhythmias. Reported incidence ranges from 12.5% to 70%.
PVCs are the most common arrhythmia. Fortunately, most arrhythmias
resolve with either catheter withdrawal or with advancement of the
catheter tip from the RV into the PA. There appears to be a higher
incidence when the patient is positioned in the Trendelenburg position
versus right-tilt position.
(2) Mechanical damage. Catheter knotting and entanglement of cardiac
structures, although rare, can occur. Damage to intracardiac structures
such as valves, chordae, and even RV perforation have been reported.
The presence of IVC filters, indwelling catheters, and pacemakers can
increase the risk of such complications. The incidence of knotting is
estimated at 0.03% and this complication can be decreased with careful
attention to depth of insertion and expected waveforms. To reduce the
risk of knotting, a catheter should be withdrawn if the RV waveform is
still present 20 cm after its initial appearance or when the absolute depth
of 60 cm is reached without a PA tracing.
(3) PA rupture. This is a rare complication with an incidence of 0.03% to
0.2%. Risk factors include pulmonary hypertension, age greater than 60,
hyperinflation of the balloon, improper (distal) catheter positioning, and
coagulopathy. During CPB, distal migration of the catheter tip may occur,
thus some advocate pulling the PAC back a few centimeters prior to
initiating bypass.
(4) Thrombosis. Although thrombus formation on PACs has been noted at 24
hours, the incidence of thrombogenicity substantially increases by 72
hours.
(5) Pulmonary infarction. It can occur as a complication of continuous distal,
wedging from catheter migration, or embolization of previously formed
thrombus.
(6) Infection. The incidence of bacteremia and blood stream infection related
to PAC is 1.3% to 2.3%. Additionally, the PAC can contribute to
endothelial damage of the tricuspid and pulmonary valves leading to
endocarditis.
(7) Other. Balloon rupture, heparin-induced thrombocytopenia (HIT)
secondary to heparin-coated catheters, anaphylaxis from latex (balloon)
allergy, and hepatic venous placement have all been included in PAC-
related complications.
c. Monitoring complications
(1) Errors in equipment and data acquisition. Examples include
inappropriate pressure transducer leveling and over/underdamping of
pressure system.
(2) Misinterpretation or misapplication of data. Misinterpretation can occur
when not considering ventilation modes, ventricular compliance changes,
or intrinsic cardiac/
pulmonary pathologies.
(3) Expense.
(4) If a PCWP/PAOP waveform appears spontaneously (indicating wedge
positioning 10 of the PAC), confirmation that the PAC balloon is
deflated followed by withdrawal of the PAC until a PA waveform
appears should be performed immediately.
10. Conclusions. PACs provide a wealth of information about the right and left
sides of the circulation. For this reason, they are used for every cardiac
surgical procedure in some institutions because their benefits are perceived to
outweigh the risks. Studies that show low-morbidity rates with PAC use
support this viewpoint. In other institutions, however, clinicians are more
selective about which patients require PACs, because use of PA monitoring has
not been demonstrated to incontrovertibly improve outcomes of cardiac
surgery. The widespread application of TEE may make intraoperative PAC
data less useful except for SVO2. Additionally, noninvasive CO monitoring may
also replace some uses of the PAC, although these monitors have technologic
obstacles to solve prior to routine use (without invasive monitoring) during
cardiac surgery. While there is increasing evidence that the risks of PA
catheterization may outweigh the benefits in some clinical settings, we strongly
feel that this device, especially with newer modalities such as continuous SVO2
measurement, provides data that are not easily obtainable by any other method.
The majority of studies that have failed to find a benefit for PA catheterization
have typically included patients in a medical intensive care or medical
cardiology setting. It is difficult to generalize these studies to the cardiothoracic
surgical population, as many medical ICU patients have derangements of
microvascular circulation and/or mitochondrial dysfunction, whereas surgical
ICU patients, while certainly at risk for developing these microcirculatory
abnormalities, tend to be earlier in the disease process. This may provide a
reason why PACs tend to be more useful in a surgical population. Given the
complexity of many cardiothoracic surgery cases, an anesthesia provider would
be at a severe disadvantage without the data provided by a pulmonary arterial
catheter. Indeed, based on data from a national registry of anesthesia outcomes,
it appears that PAC use had increased in cardiac surgery cases between 2010
and 2014 [12].
G. Cardiac output (CO)
1. Methods
a. Thermodilution with cold injectate. This method is the most commonly
utilized CO technique because of its ease of use and ability to repeat
measurements over time. The indicator is an aliquot of saline (typically 10
mL, which is at a lower temperature than the temperature of blood) injected
into the RA. The change in temperature produced by injection of this indicator
is measured in the PA by a thermistor and is integrated over time to generate a
value for RV output, which is equal to systemic CO if no intracardiac shunts
are present. This method requires no withdrawal of blood and no arterial line,
uses an inexpensive indicator, and is not greatly affected by recirculation.
CLINICAL PEARL Thermodilution CO underestimates the CO with right-side valvular
lesions, but remains accurate with mitral and aortic valve lesions (Fig. 4.16).
b. Continuous thermodilution. A thermal filament in the catheter heats blood
∼15 to 25 cm before its tip, thus generating a PA temperature change that is
measured via a distal thermistor. The input and output signals are correlated
to generate CO values.
c. RV ejection fraction. Improved preload estimates might be obtained with
this type of PAC [13].
2. Assumptions and errors. Specific errors in CO determination are mentioned
below:
a. Thermodilution method
(1) Volume of injectate. Because the output computer will base its
calculations on a specific volume, an injectate volume less than that for
which the computer is set will cause a falsely high value of CO, and vice
versa.
(2) Temperature of injectate. If the injectate temperature parameter is
incorrect, errors can occur. For example, an increase of 1°C will cause a
3% overestimation of CO. The controversy over iced versus room-
temperature injectate centers around the concept that a larger difference
between the injectate temperature and blood temperature should increase
the accuracy of the CO determination. Studies have not supported this
hypothesis, and the extra inconvenience of keeping syringes on ice,
together with the increased risk of infection (nonsterile water
surrounding the Luer tip), make the iced saline method a less attractive
alternative.
IGURE 4.16 Thermodilution curves recorded from a pulmonary artery catheter (PAC) thermistor. Cardiac output (CO) is
versely related to the area under the curve. The curves on the left (A, B, C) demonstrated normal, high, and low CO,
spectively. Curve D demonstrates an error in thermodilution technique. Curve E demonstrates a thermodilution curve in a patient
ith TR, where recirculation of the injected fluid results in distortion of the descending limb of the curve, causing an increase in the
ea under the curve and an underestimation of the CO. Curve F is representative of a patient who was recently liberated from
ardiopulmonary bypass (CPB). Blood from cooled parts of the body will decrease the overall temperature of the overall
rculation, leading to a drift in baseline, which will cause an overestimation of CO. (From Longnecker DE, Brown DL, Newman
Anesthesiology. 2nd ed. McGraw-Hill Companies; 2012, Figure 30.14, P.420.)
(3) Shunts. Intracardiac shunts will cause erroneous values for

thermodilution CO values. This technique should not be used if a
communication exists between the pulmonary and systemic circulations.
A shunt should always be suspected when thermodilution CO values do
not fit the clinical findings.
(4) Timing with the respiratory cycle. As much as a 10% difference in CO
will result, depending on when injection occurs during the respiratory
cycle. These changes are most likely due to actual changes in pulmonary
blood flow during respiration.
(5) Catheter position. The tip of the pulmonary catheter must be in the PA
and must not be “wedged”; otherwise, nonsensical curves are obtained.
3. Minimally invasive CO monitoring. The desire to assess cardiac function and
adequate tissue perfusion in critically ill patients is traditionally accomplished
using the PAC. The controversy about its invasive nature and potential harm
has provoked the development of less invasive CO monitoring devices [14,15].
Just as the PAC has its nuances, these devices have their own sets of limitations
that must be considered.
a. Accuracy and precision. Accuracy refers to the capability of a measurement
to reflect the true CO. This means that a measurement is compared to a “gold
standard” method. Given the widespread use of the PAC, the thermodilution
method is the practical “gold” standard to which new noninvasive CO
monitors are compared. However, it is important to take into account that the
inherent error for thermodilution measurements of CO are in the 10% to 20%
range. Precision indicates the reproducibility of a measurement and refers to
the variability between determinations. For the thermodilution method, studies
of precision have involved probability analyses of large numbers of CO
determinations. Using this approach, it was found that with two injections,
there was only a 50% chance that the numbers obtained were within 5% of the
true CO. If three injections yield results that are within 10% of one another,
there is a 90% probability that the average value is within 10% of the true
CO.
Given that the practical gold standard carries with it some inaccuracies,
new methods based on it will also hold their own similar inherent error.
b. Methods: Minimally invasive CO monitors can be classified into one of the
four main groups: Pulse pressure analysis, pulsed Doppler technologies,
applications of Fick principle using partial CO2 rebreathing, and
bioimpedance/bioreactance.
(1) Pulse pressure analysis: Monitors based on that principle SV can be
tracked continuously by analysis of the arterial waveform. These
monitors require an optimal arterial waveform, thus arrhythmias, IABPs,
LVADs, and even properties of the arterial line monitoring systems (such
as over/underdamping) can alter accuracy of the CO measurement. Three
common pulse contour analysis devices are compared in Table 4.12.
(2) Doppler devices: CO can be measured using the change in frequency of
an ultrasonic beam as it measures blood flow velocity. To achieve
accurate measurements, at least three conditions must be met: (1) The
cross-sectional area of the vessel must be known; (2) the ultrasound
beam must be directed parallel to the flow of blood; and (3) the beam
direction cannot move to any great degree between measurements.
Clinical use of this technique is associated with reduced accuracy and
precision.
Two methods that use ultrasound are as follows:
(a) Transtracheal. Flow in the ascending aorta is determined with a
transducer bonded to the distal portion of the endotracheal tube,
designed to ensure contact of the transducer with the wall of the
trachea. This method is not yet fully validated in humans, and a
study of cardiac patients reported poor correlation when compared
to thermodilution.
(b) Transesophageal. Several esophageal Doppler probes are
available which are smaller than conventional TEE probes. CO is
obtained by multiplying the cross-sectional area of the aorta by the
blood flow velocity. Flow in the aorta is measured using a
transducer placed in the esophagus. Aortic cross-sectional area is
provided from a nomogram or measured by M-mode
echocardiography (Fig. 4.17).
(c) TEE. In addition to the Doppler technique mentioned above, TEE
utilizes Simpson rule in which the LV is divided into a series of
disks to estimate CO without the use of Doppler. End-diastolic and
end-systolic dimensions measured by echocardiography are
converted to volumes, allowing SV and CO to be determined. Given
the size of the monitor and probe, this technique can provide
intermittent CO, but is not ideal for continuous CO measurement
desired in ICU settings.
Summary: The PAC still remains the practical gold standard for
evaluating CO. It also provides true mixed venous saturation and
pulmonary pressures that cannot be obtained from noninvasive
devices. Invasive hemodynamic monitoring remains the standard in
the operating theater. However, select stable cardiac patients may
be candidates in the ICU or stepdown units postoperatively for
minimally invasive device monitoring.
TABLE 4.12 Pulse contour analysis devices
4. Measurements of volume responsiveness. Fluid management is an integral

part of anesthetic care. Fluid administration is regularly administered
intraoperatively to improve CO. However, given frequent comorbidities
associated with conditions that require cardiac surgery, including congestive
heart failure and chronic kidney disease, indiscriminate administration of fluids
may be contraindicated. Because of the complex physiology associated with
both cardiac surgery and general anesthesia, determination of volume
responsiveness can be complex. Studies have shown that static pressure
measurements that have historically been used to assess for volume
responsiveness, specifically, CVP and pulmonary capillary occlusion pressure
(PAOP), are unreliable [ 16,17]. Dynamic parameters (Table 4.13) such as
SPV, PPV, and SVV have shown very promising correlations with volume
responsiveness [18].
FIGURE 4.17 Doppler waveforms of aortic blood flow from esophageal Doppler monitoring. The esophageal Doppler device
derives cardiac output (CO) from the measured peak velocity, mean acceleration, and systolic flow time. As illustrated in the
figure, changes in contractility will affect both peak velocity and mean acceleration, while changes in preload primarily affect
systolic flow time; afterload changes will alter all three variables. (From Longnecker DE, Brown DL, Newman MF, et al.
Anesthesiology. 2nd ed. McGraw-Hill Companies; 2012, Figure 30.15, P. 422.)
Methods
(1) Systolic pressure variation. Increased intrathoracic pressure generated
during a positive pressure breath leads to decreased LV stroke volume,
and subsequently a drop in sBP. The drop in the systolic pressure from
baseline to after delivery of a fixed tidal volume the delta down (Δ down)
has been shown to correlate with volume status. The advantage of this
parameter is that only a standard arterial line is required (Fig. 4.18A).
(2) Pulse pressure variation. A similar concept to SPV, PPV compares
changes in pulse pressure, that is, the difference between systolic and
diastolic pressures throughout the respiratory cycle in a mechanically
ventilated patient. It has been demonstrated that PPV is a more accurate
surrogate of SV, most likely because SPV is influenced by both aortic
transmural pressure (from the LV stroke volume) and extramural pressure
from changes in pleural pressure, whereas PPV eliminates the effects of
pleural pressure as systolic and diastolic pressures would be affected
equally. While this parameter can also be measured by a standard arterial
line, many of the minimally invasive CO measurement devices that rely on
pulse contour analysis will automatically calculate this number (Fig.
4.18B).
TABLE 4.13 Measurements of fluid responsiveness
FIGURE 4.18 A: Arterial waveform tracing demonstrating systolic pressure variation (SPV). The first cycle is recorded
during apnea, giving a baseline from which ΔUp and ΔDown are measured. In this case ΔUp is approximately 7 mm Hg, while
ΔDown is 5 mm Hg, giving an SPV of 22 mm Hg, indicating that this patient would likely respond to a fluid challenge. (From
Pittman JA, Ping JS, Mark JB, et al. Arterial and central venous pressure monitoring. Int Anesthesiol Clin. 2004
Winter;42(1):13–30.) B: An illustration of pulse pressure variation. In this case, the maximal pulse pressure, Δ1, is
approximately 60 mm Hg, and the minimal, Δ2, is 35 mm Hg, giving a pulse pressure difference of Δ1 – Δ2 = 25 mm Hg. The
pulse pressure difference divided by the mean of the two values (47.5 mm Hg) gives a pulse pressure variation of 53%, which
is greater than 12%, indicating that this patient would also likely respond to a fluid challenge. (From Longnecker DE, Brown
DL, Newman MF, et al. Anesthesiology. 2nd ed. McGraw-Hill Companies; 2012, Figure 30.18, P. 425.)
(3) Stroke volume variation. Real-time measurement of variations in SV has

been made possible using the same arterial waveform analysis used for
minimally invasive continuous CO monitoring (see above). These devices
determine SV using an algorithm based on the contour of the arterial
pressure tracing. SVV is also measured, using the formula SVV = (SVmax -
SVmin)/SVmean. SVV has been shown to very accurately predict volume
responsiveness in critical care patients [19].
5. Limitations
CLINICAL PEARL Generally, SPV, PPV, and SVV require a regular heart rhythm to be
accurate.
Further, because all of these parameters rely on cardiopulmonary interaction, it
has been noted that their utility during open heart surgery may be limited. One
study demonstrated good correlation between SVV/PPV and preload surrogates
before sternotomy and after sternal closure, but poor correlation while the chest
was open [20]. However, it should be noted that this study did not look at fluid
responsiveness, only correlation between PPV/SVV and other surrogates for
preload, such as LV end-diastolic area as measured by transthoracic
echocardiography and by RV end-diastolic volume measured by a PAC, both of
which have their own limitations.
6. Conclusions. Determination of volume responsiveness via measurement of PPV
and SVV is a promising newer modality that may be of some use during cardiac
surgery and likely during postoperative management of volume resuscitation.
These measurements are built into several of the minimally invasive CO
measurement modalities, making their use increasingly available as these
devices gain wider acceptance. While there are multiple limitations to
utilization of PPV and SVV during cardiac surgery, these may be mitigated by
future improvements in the arterial waveform analysis algorithms.
H. Echocardiography
TEE. TEE is discussed extensively in Chapter 5.
III. Temperature
Cardiac anesthesia is unique in that therapeutic hypothermia is utilized frequently
and aggressively in many cases. Distribution of thermal energy can be manipulated,
via CPB, more rapidly and extensively than any other anesthetic case. Unique to
cardiac anesthesia are circulatory arrest procedures [21] with cooling to 17°C.
Temperature monitoring for cardiac anesthesia has unique considerations. This
section will introduce these topics without detailed discussion of thermal issues
common to all anesthesiologists [22].
A. Indications: CPB and hypothermia
1. “Warm” CPB: 36° to 37°C; also known as normothermic CPB.
2. “Mild” CPB hypothermia: 32° to 34°C; occasionally termed “tepid.”
3. Moderate hypothermia: 28° to 32°C. Infrequently utilized.
4. DHCA: 17° to 19°C. This unique therapeutic technique is discussed above.
Cardiac surgery utilizes the capabilities of the CPB circuit to rapidly cool or
warm patients. Mild–moderate hypothermia was a common neuroprotective
strategy into the 1990s. Literature comparing normothermic CPB with
hypothermic CPB showed no benefit. Although hypothermic CPB is still
occasionally used, the dysfunction in coagulation pathways and bleeding risk
remains a major consideration. Below 32°C, the myocardium is irritable and
susceptible to arrhythmias, especially during ventricular tachycardia and
fibrillation. The risk of dysrhythmia is particularly high in pediatric patients.
The CPB machine can exceed 37°C and the anesthesiologist should be aware of
the inflow temperatures. Hyperthermia produces significant enzyme
desaturation and cell damage with temperatures ≥41°C.
B. Sites of measurement. Numerous possible sites exist to measure temperature.
These sites can be grouped into the core, brain, or the shell.
1. Core temperature
a. General considerations. The core temperature represents the temperature of
the vital organs. The term core temperature used here is perhaps a misnomer
because gradients exist even within this vessel-rich group during rapid
changes in blood temperature.
b. PAC thermistor. This is the best estimate of the core temperature when
pulmonary blood flow is present (i.e., before and after CPB).
c. Nasopharyngeal temperature. Nasopharyngeal temperature provides an
accurate reflection of brain temperature during CPB. Overinsertion is
common, causing the probe to measure esophageal temperature. The probe
should be inserted into the nasopharynx to a distance equivalent to the
distance from the naris to the tip of the earlobe. Nasopharyngeal temperature
should be monitored in all hypothermic circulatory arrest procedures and CPB
cases with hypothermia requiring rewarming.
d. Tympanic membrane temperature. Temperature at this site reflects brain
temperature, and may provide an alternative to nasopharyngeal temperature.
e. Bladder temperature. This modality has been used to measure core
temperature, although it may be inaccurate in instances when renal blood flow
and urine production are decreased.
f. Esophageal temperature. Because the esophagus is a mediastinal structure,
it will be greatly affected by the temperature of the blood returning from the
extracorporeal pump and should NOT be used routinely for cases involving
CPB.
g. CPB arterial line temperature. This is the temperature of the heat exchanger
(i.e., the lowest temperature during active cooling and the highest temperature
during active rewarming). During either of these phases, a gradient always
exists between the arterial line temperature and any other temperature.
h. CPB venous line temperature. This is the “return” temperature to the
oxygenator and probably best reflects core temperature during CPB when no
active warming or cooling is occurring.
2. Shell temperature
a. General. The shell compartment represents the majority of the body (muscle,
fat, bone), which receives a smaller proportion of the blood flow, thus acting
as an energy sink that can significantly affect temperature fluxes. Shell
temperature lags behind core temperature during cooling and rewarming. At
the point of bypass separation, the core temperature will be significantly
higher than shell temperature. The final equilibrium temperature with thermal
redistribution probably will be closer to the shell temperature than the core
temperature measured initially.
b. Rectal temperature. Although traditionally thought of as a core temperature,
during CPB procedures the rectal temperature most accurately reflects muscle
mass temperature. If the tip of the probe rests in stool, a significant lag will
exist with changing temperatures.
c. Skin temperature. Skin temperature is rarely utilized in cardiac surgery.
C. Risks of temperature monitoring. Epistaxis with nasopharyngeal temperature
monitoring.
D. Recommendations for temperature monitoring. Monitoring temperature at
two sites is 12 recommended: A core site and a shell site. Arterial and venous
line temperatures are available directly from the CPB apparatus. Nasal
temperature monitoring is recommended for circulatory arrest cases to document
brain temperature.
IV. Renal function
A. Indications for monitoring
1. Increased incidence of renal failure after CPB. Acute renal failure is a
recognized complication of CPB, occurring in 2.5% to 31% of cases. Acute
renal failure is related to the preoperative renal function as well as to the
presence of coexisting disease. The nonpulsatile renal blood flow during CPB
has been speculated as a contributing mechanism, although continuous-flow
LVAD has not been associated with excessive renal failure.
2. Use of diuretics in CPB prime. Mannitol is used routinely during CPB for two
reasons:
a. Hemolysis occurs during CPB, and serum hemoglobin levels rise. Urine
output should be maintained to avoid damage to renal tubules.
b. Deliberate hemodilution is induced with the onset of hypothermic CPB.
Maintenance of good urine output during and after CPB allows removal of
excess free water.
B. Urinary catheter. This monitor is the single most important monitor of renal
function during surgical cases involving CPB. Establishing a urinary catheter
should be a priority in emergencies.
CLINICAL PEARL Oliguria or anuria is NOT typical during CPB, as the priming
fluid typically contains mannitol.
Hypothermia can be assessed with a temperature probe/Foley catheter.
C. Electrolytes. Serum electrolytes, especially potassium and magnesium, should
be checked throughout the procedure including at the start of the case, prior to
separation from CPB and 13 after CPB. A therapeutic goal of K + ≥4.0 mEq/L
and Mg++ ≥2.0 mg/dL is commonly utilized. In the vast majority of patients with
adequate renal function, potassium and magnesium concentrations will decline
during CPB secondary to mannitol and improved perfusion. Replacement of
potassium has to account for cardioplegia which contains potassium. A low
serum ionized calcium level may be the cause of diminished pump function. The
timing of the calcium therapy may affect neurologic outcome, Administration of
Ca++ during periods of neural ischemia 14 and/or reperfusion may worsen the
outcome. Many cardiac anesthesiologists will not administer calcium until at
least 15 to 20 minutes following acceptable perfusion (i.e., after aortic cross-
clamp removal).
D. Acute kidney injury (AKI). While AKI is defined by changes in
creatinine/glomerular filtration rate and urine output, novel serum markers such
as neutrophil gelatinase–associated lipocalin (NGAL), may prove useful in the
early detection of AKI.
V. Neurologic function
A. General considerations. Neurocognitive dysfunction is a significant
complication in the cardiac surgical patient. Increased risk of poor outcomes is
multifactorial. Cardiac surgical patients frequently have increased baseline
susceptibility for neurocognitive insults from arterial atherosclerotic disease,
diabetes, and genetic polymorphism(s) coupled. Acute neurologic injury
secondary to CPB and cerebral emboli (air, atheromatous material, thrombus)
are major contributing events to development of postoperative deficits. Advances
in processing capability have made new devices available for neurologic
assessment and risk factor modification during surgery [23–26]. Goals of
monitoring include: diagnose cerebral ischemia, assess the depth of anesthesia
and assess the effectiveness of medications given for brain or spinal cord
protection.
B. Indications for monitoring neurologic function
1. Associated carotid disease
2. Diagnosis of embolic phenomenon
3. Diagnosis of aortic cannula malposition
4. Diagnosis of inadequate arterial flow on CPB
5. Confirmation of adequate cooling
6. Hypothermic circulatory arrest, in an adult or a child
7. Procedures with aortic cross-clamps at T5–L5 which may exclude artery of
Adamkiewicz
C. Physiologic and metabolic monitoring
1. Cerebral perfusion pressure (CPP). Maintaining adequate CPP is the primary
intervention for any neuroprotective strategy. Cerebral blood flow (CBF)
undergoes autoregulation with CPP of 50 to 150 mm Hg. Hypertensive patients
may have a right shift in this curve. A CPP of 60 to 70 mm Hg is a reasonable
goal.
CPP = MAP - CVP
In patients with elevated intracranial pressure (ICP), the highest pressure (CVP
or ICP) should be utilized. There are a number of clinical factors that can
increase the CVP resulting in threatened CBF. Two therapeutic targets which
can be modified are increased CVP and increased mean airway pressure.
CLINICAL PEARL Trendelenburg positioning is an often overlooked cause of
increased CVP. This, along with elevated mean airway pressures, can lead to decreased
cerebral perfusion pressures.
Choice of vasoactive drugs can affect CVP. Increased splanchnic resistance
with low-dose α-adrenergic receptor agonists facilitates blood sequestration (↓
CVP) whereas β2-adrenergic receptor activation, especially in presence of
higher doses of α-adrenergic receptor agonists, results in shift of sequestered
blood into central circulation from venous capacitance sites [27].
2. End-tidal CO2 and mean airway pressure. Hyperventilation to a PaCO2 is a
core anesthesia technique to rapidly reduce CBF resulting in decreased ICP.
The ventilator goal to preserve CPP is maintaining normocapnia. Ventilator
settings should avoid maneuvers that increase mean airway pressure.
PEEP/CPAP are obvious maneuvers that should be evaluated for contribution
to mean airway pressure. A pressure mode of ventilation would seem most
appropriate to achieve these goals.
3. Inspired oxygen concentration (FiO2). Neural tissues are susceptible to
ischemia/reperfusion injury including reactive oxygen species. Mannitol is an
antioxidant as well as an osmotic diuretic. Consider mannitol (0.25 to 1.0 g/kg
IV) administration immediately prior to initiating CPB with a repeat dose when
aortic cross-clamp removed. The lowest safe FiO2 should be employed.
4. Blood glucose monitoring. Hyperglycemia markedly worsens neurologic
outcomes when present during ischemia/reperfusion. An insulin continuous
infusion (CI) should be immediately available in all patients with DM. It is
important to note that the effects of insulin are diminished with hypothermia and
increased catechol states. β-Adrenergic stimulation from the stress response to
CPB increases blood glucose. Insulin CI alters K+ and strong consideration
should be given to administration of KCl and MgSO4 when starting insulin CI.
As a clinically applicable technical note, insulin undergoes nonspecific binding
to the IV tubing. Until these nonspecific binding sites are saturated, very little
insulin actually reaches the patient. The blood glucose goal has engendered
controversy regarding how rigorously it should be controlled. Avoiding
hypoglycemia is a critically important goal. Virtually all cardiac
anesthesiologists will treat hyperglycemia exceeding 200 mg/dL.
5. Cerebral perfusion monitoring. Observation of the face for evenly distributed
blanching and reperfusion when starting CPB is a crude method to assess
cannula position. Some cardiac anesthesiologists advocate bilateral manual
compression of the carotid arteries as CPB is initiated and aortic cross-clamp
applied. The reasoning is that occlusion of the major vascular conduit to the
brain during a high-risk period for cerebral emboli should decrease brain
insult. Obviously cerebral emboli originating from the carotid arteries make
this maneuver controversial.
D. Monitors of CNS electrical activity
1. Electroencephalogram (EEG; see Chapter 26). The EEG measures the
electrical currents generated by the postsynaptic potentials in the pyramidal
cell layer of the cerebral cortex. The basic principle of clinical EEG
monitoring is that cerebral ischemia causes slowing (↑ latency) of the electrical
activity of the brain, as well as a decrease in signal amplitude. EEG requires
additional personnel (↑ cost) for monitoring and alterations of anesthetic
technique. Although intriguing, there is a paucity of literature evaluating EEG in
2. Processed EEG. To increase its intraoperative utility, the EEG data are
processed by fast Fourier analysis into a single power versus time spectral
array that is more easily interpreted. Examples of power spectrum analysis
include compressed spectral array, density spectral array, and bispectral
index (BIS). The BIS monitor analyzes the phase relationships between
different frequency components over time. The result is reduced via a
proprietary method to a single number scaled between 0 (electrical silence)
and 100 (alert wakefulness). The role of BIS monitoring in cardiac surgery is
in evolution [28]. The BIS may be a useful indicator of the depth of anesthesia.
Studies of BIS values as a predictor of anesthetic depth during intravenous
anesthesia (narcotic plus benzodiazepine) are conflicting. One study found a
positive correlation between the BIS and arousal or hemodynamic responses
[29], whereas another study found no such correlation between the BIS value
and plasma concentrations of fentanyl and midazolam [30]. During hypothermic
circulatory arrest, the BIS monitor should be isoelectric (BIS of zero). Many
cardiac anesthesiologists monitor the BIS during cooling and to observe the
effect of supplemental intravenous anesthetic (historically thiopental)
administered for neuroprotection. Evidence supporting BIS data as a monitor of
neurologic function in patients at risk for hypoxic or ischemic brain injury
continues to accumulate [31]. Abnormally low BIS scores and prolonged low
BIS score may be associated with poor neurologic outcomes.
3. Evoked potentials
a. Somatosensory evoked potentials (SSEPs). SSEPs monitor the integrity of
the posterior-lateral spinal cord. It is most useful in operations such as
surgery for a thoracic aneurysm, in which the blood flow to the spinal cord
may be compromised. A stimulus is applied to a peripheral nerve (usually the
tibial nerve), and the resultant brainstem and brain activity is quantified.
b. Visual evoked response and brainstem audio evoked responses. These
techniques do not have routine clinical application in cardiac surgical
procedures.
c. Motor evoked potentials (MEPs). MEPs are useful to monitor the anterior
spinal cord during surgery of the descending aorta and are discussed in more
detail in Chapter 14.
E. Monitors of regional cerebral metabolic function: Jugular bulb venous
oximetry. Measuring the oxygen saturation of the cerebral jugular bulb (SjvVO2)
with a fiberoptic catheter [32] is analogous to measuring the SVO2 in the PA. The
brain is the highest O2-extracting organ in the body. If CBF decreases, oxygen
extraction would increase and the jugular O2 saturation would decrease. SjvVO2
gives reliable real-time data for the ipsilateral cerebral hemisphere. Bilateral
SjvVO2 catheters are required to monitor the entire brain. Significant interpatient
variability exists with SjvVO2, trend monitoring may yield more information than
individual measurements. SjvVO2 catheter placement is an invasive procedure.
Typically a RIJ (retrograde) SjvVO2 catheter is placed as that is most common
site for central line/PAC. Severe desaturation as measured by SjvVO 2 has been
shown to correlate with poor outcome.
F. Near-infrared spectroscopy (NIRS) and cerebral oximetry. NIRS is a
noninvasive method to monitor cerebral metabolic function [31]. A near-infrared
light is emitted from a scalp sensor and penetrates the scalp, skull, cerebrospinal
fluid, and brain. The light is reflected by tissue but differentially absorbed by
hemoglobin-containing moieties. Cerebral oximetry, unlike SjvVO2, conveniently
allows for bilateral data acquisition. It is imperative that baseline cerebral
oximetry measurements are acquired to allow intraoperative interpretation of the
data. The actual value appears to be less important than the trend. A deviation of
20% from baseline values is considered an actionable significant difference.
Currently, the role of NIRS cerebral oximetry application during cardiac surgery
is controversial. Anecdotal reports have not yet transitioned to improved
outcomes and the cost–benefit is unclear. A recent meta-analysis report states:
“Only low-level evidence links low rScO2 during cardiac surgery to
postoperative neurologic complications, and data are insufficient to conclude that
interventions to improve rScO2 desaturation prevent stroke or POCD” [33].
G. Monitors of CNS embolic events
1. Transcranial Doppler ultrasonography (TCD). TCD is very useful in
detecting emboli in the cerebral circulation. Incorporation into clinical practice
has been hindered by difficulty obtaining a reliable signal. TCD has been
utilized primarily as a research tool. TCD assessment of embolic load can
detect up to hundreds (sic) of discreet emboli. Embolic showers are
particularly associated with aortic cross-clamp application and removal.
2. Epiaortic scanning. The importance of aortic atheromas, especially in the
ascending 15 aorta and/or aortic arch, in association with poor neurologic
outcomes has long been recognized. Aortic atheromas with a mobile component
present the greatest risk. The introduction and use of TEE to detect aortic
atheroma was a significant improvement over surgical palpation. However,
TEE had significant limitations particularly in the detection of disease near the
typical aortic cannulation site (distal ascending aorta, proximal aortic arch)
because the airway structures interfere with the TEE signal. Epiaortic scanning
is a highly sensitive and specific monitoring modality to detect atheroma in the
thoracic aorta including regions where TEE evaluation is not possible. In
cardiac surgical patients with identified atheroma, modification of the surgical
technique and neuroprotective strategies has been reported to reduce
neurologic complication from ∼60% to almost 0%.
H. Monitors of splanchnic perfusion and venous function
Gastric tonometry
a. Gastric tonometry as a hypovolemia monitor. The management of
hypovolemia is a fundamental tenet of anesthesiology. There are many
causes of hypovolemia including bleeding and fluid shifts.
Physiologically, the venous capacitance vessels sequester 70% of the total
blood volume, which is returned to the central venous system as the initial
response to hypovolemia [26]. Hypovolemia resulting in hypotension is a
frequent issue in cardiac surgical procedures. Early recognition and
treatment is critical as hypovolemia is a reversible problem. Multiple
routine monitors directly (TEE, PAC/CVP, urine output, physical
examination) or indirectly (certain labs, fluctuations in the arterial catheter
waveform) assess volume status. A major clinical limitation is that loss of
10% to 25% of the total blood volume is undetectable by the typical
cardiac surgery monitors whereas loss of 5% is detectable by gastric
tonometry.
b. Gastric tonometry and splanchnic hypoperfusion. The splanchnic
venous system is the key reservoir for the sequestered blood and is more
responsive to sympathetic activation, especially α- and β2-adrenergic
receptor agonists, than the arterial vasculature [26]. Redistribution of
splanchnic venous blood to the central circulation is the first compensatory
mechanism in response to hypovolemia. Therefore, tissues that are within
the splanchnic perfusion are the first to convert to anaerobic metabolism.
Gastrointestinal mucosal cells produce acidic metabolites under anaerobic
conditions. The tissue lining the gut neutralizes and eliminates the excess
acid load by conversion to CO2 via the HCO3− buffering system. The CO2
freely diffuses across the cellular membrane and into the gut lumen. The
CO2 partial pressure can be readily detectable and quantifiable by gastric
tonometry. Initially, gastric tonometry used the Henderson–Hasselbalch
equation to calculate the gut mucosal intracellular pH (pHi). A pHi ≥7.32
was considered normal. Differences (CO2 gap) between the pCO2 (gut)
versus PaCO2 has supplanted pHi in more recent literature. In healthy
human volunteers, decreased splanchnic perfusion secondary to
experimental bleeding of 25% of estimated total blood volume was
detected by gastric tonometry and SV, but not by other monitors of
hypovolemia. Reinfusion of the blood returned all parameters to baseline
[34].
c. Clinical application of gastric tonometry. Gastric tonometry has been
studied primarily in cardiac surgery and ICU patients, where it proved to
be a very sensitive predictor of poor clinical outcomes. Until recently
there were no studies demonstrating that clinical interventions utilizing
gastric tonometry goal-directed therapy benefitted the clinical outcome.
Cardiac surgical patients receiving colloid volume expansion protocol
(vs. control) had decreased major complications and length of stay (ICU
and hospital) [35]. Interestingly a multicenter randomized clinical trial
comparing gastric tonometry versus cardiac index goal-directed therapy
failed to show a significant difference. However, “normalization of pHi
within 24 hours of resuscitation is a strong signal of therapeutic success”
and a “persistent low pHi despite treatment is associated with a very bad
prognosis” [36]. The lack of evidence-based validation as a monitor with
actionable data coupled with some initial technical issues with the
manufacturer dampened enthusiasm for gastric tonometry. Reports in the
literature generally agreed that a low pHi was a very sensitive marker for
poor outcome but all of the studies were underpowered to determine if
therapeutic normalization improved outcome. Therefore a meta-analysis
was recently published that concluded that goal-directed therapy as
measured by gastric tonometry does improve outcomes in critically ill
patients [37].
d. Advantages of gastric tonometry. The diagnosis and treatment of
hypovolemia is a fundamental component of anesthetic care. Due to the
critically important role that the splanchnic vasculature plays with respect
to hypovolemia, monitoring splanchnic function is potentially a significant
clinical advancement. Gastric tonometry has several advantages compared
to other monitors for hypovolemia:
(1) Monitor at organ/tissue level for regional specific function. The
standard monitors for hypovolemia (art line, CVP, urine output) can
only provide data at the level of the patient.
(2) 16 Splanchnic vasculature sequesters 70% of TBV. The initial
physiologic compensation for hypovolemia is transfer of blood from
splanchnic vasculature to the central venous compartment.
(3) Gastric tonometry detects hypovolemia before other monitors. Loss of
10% to 12% of TBV is detected by gastric tonometry whereas some
monitors (i.e., CVP) are unchanged from baseline. Bleeding of 25%
TBV may not yet be reliably diagnosed by standard monitors.
(4) Minimally invasive. Gastric tonometry is measured via a nasogastric
(NG) tube with a small balloon on the distal end. This is analogous to
using a cuffed versus noncuffed endotracheal tube. In addition to
acquiring gastric tonometry data, the NG tube is functional.
(5) Goal-directed therapy to correct splanchnic hypoperfusion may
improve outcomes in critically ill patients.
(6) Gastric tonometry is a powerful predictor of poor outcome in
nonresponders to goal-directed therapy.
(7) Gastric tonometry data can be collected and measured automatically.
(8) Placement is identical to any other NG tube. Although interference
with acquisition of TEE images is a potential concern, clinical use
without any adjustments or issues with TEE is our experience.
(9) Gastric tonometry may limit endotoxemia. Gut mucosal ischemia
results in intestinal endothelial dysfunction as a barrier of
translocation of bacteria/endotoxins into the systemic circulation.
Gastric tonometry can detect splanchnic hypoperfusion and trigger
intervention prior to endothelial dysfunction.
VI. Cardiac surgical procedures with special monitoring considerations
A. OPCAB. The standard CABG procedure is performed with CPB, which
provides oxygenation and perfusion to the patient while the aortocoronary artery
grafts are anastomosed. Advantageous technical aspects of CPB include a
bloodless and immobile surgical field which facilitates precise placement of
anastomotic sutures. Unfortunately, CPB causes neurocognitive deficits which
may be exacerbated by events such as aortic cross-clamp application resulting in
cerebral embolism (occasionally showering of hundreds of microemboli). This
has motivated development of surgical techniques that allow cardiac
revascularization without requiring CPB. Early experience had similar outcomes
± CPB. A recent meta-analysis suggests that OPCAB may improve outcomes in
high-risk patients [38].
B. OPCAB monitoring
1. Surgical techniques impact monitoring. OPCAB emerged as a surgical
approach that does not require CPB for revascularization. Unique components
of the OPCAB procedure are placement of a myocardial stabilizer and apical
suction device. The myocardial stabilizer adheres to the epicardial surface of
the heart via suction and markedly restricts myocardial movement between the
stabilizer arms. Inherently this results in compression of the heart and an
RWMA. The apical cup attaches to, as its name implies, the apex of the heart.
This allows the surgeon to manipulate the heart and the apical cup suspends the
heart in the desired position. Typically, the apex is displaced anteriorly 60 to
90 degrees. Occasionally the heart is torqued to provide access to posterior
and lateral targets. Additionally, a sterile pack is placed posterior to the heart
to bring apex up into a position that the surgeon can quickly gain a hand grip to
manually displace the heart. A “pericardial sling” is created to cradle the heart
and provides another option to adjust the cardiac position while limiting
manual compression.
2. Hemodynamic monitoring during distal anastomoses. Hemodynamic
monitoring during positioning of the heart and throughout suturing of the distal
anastomosis can be difficult, particularly diagnosing ischemic changes. Some
cardiac anesthesiologists 17 favor SvO2 or ScvO2 monitoring for OPCAB.
Significant reduction of CO accompanied by hypotension and acute heart
failure require immediate action. If prompt resolution of the hemodynamic
instability is not achieved, conversion to (emergent) CPB is required. During
the procedure, alterations commonly observed in hemodynamic monitors are:
a. TEE. The posterior pericardial pack, apical displacement and pericardial
sling may hinder image acquisition. Application of the epicardial stabilizer
creates an obligate RWMA. Distinguishing RWMA secondary to ischemia
versus mechanical impedance may not be possible.
b. ECG. Low-voltage signal and distortion of the ECG tracing are very common
observations. Diagnosing ischemic changes is problematic particularly when
the apex is displaced because the cardiac vectors are altered in an
unpredictable fashion. Dysrhythmia(s) is most likely to occur with coronary
occlusion and with reperfusion. Preconditioning may attenuate
ischemia/reperfusion insult.
c. SpO2. Pulse oximetry may decrease due to low CO. Peripheral
vasoconstriction from low CO may result in loss of SpO2 signal. If access to
the hand is available, digital nerve block with 1 to 2 mL of (plain) local
anesthetic may restore the SpO2 signal.
d. Art line. Arterial waveform may vary with impairment of CO. Systolic
ejection of blood may be obstructed due to mechanical kinking of RV outflow
tract or IVC/SVC. MAP of 60 to 65 mm Hg is typically utilized as a goal for
perfusion pressure. Mechanical problems require mechanical solutions.
Anatomic obstruction(s) due to unfavorable cardiac position can not be
treated pharmacologically. Note that arterial pressure monitoring may indicate
cardiac function without assessment of tissue ḊO2 to the rest of the body.
e. SvO2. Global assessment of adequate ḊO2 can be inferred by determining O2
consumption [V̇O2] from mixed venous oximetry saturation (SvO2) of blood
obtained from the PA. SvO2 corresponds to CO and can be used as a surrogate
CO monitor during OPCAB [39]. Furthermore, SCVO2 has been shown in
OPCAB patients to correspond to jugular bulb saturation (SJO2) [31]. This is
important because SJO2 desaturation to <50 % is frequently noted during
OPCAB procedures. SVO2 has been advocated as the best parameter for
assessment of OPCAB. A normal S VO2 is 75% which corresponds to a PaO2
of 40 mm Hg. SVO2 ≥70% is goal for therapeutic interventions. Oximetric
PACs continuously measure real-time SVO2. VIP PAC can measure SVO2 with
a blood sample obtained from distal port. The sample must be aspirated
slowly to avoid entrainment of oxygenated blood.
f. ScvO2. It is assessed from SVC blood. SCVO2 reflects from brain and upper
extremities and is typically 5% LESS than SVO2. Oximetric CVP catheters are
utilized without need to place a PAC. Normal S CVO2 is 70%. The brain
extracts more oxygen than any other organ; because of this, oxygen saturation
in the IVC will be greater than that in the SVC.
C. Deep hypothermic circulatory arrest (DHCA). DHCA is a neuroprotective
technique utilizing CPB to cool the patient to 17° to 19°C. Therapeutic
hypothermia incorporates modification of some monitors. DHCA is utilized more
frequently in the pediatric population for correction of congenital heart defects;
however there are several specialized procedures where it plays a key role,
including aortic arch endarterectomy, aortic arch aneurysm, aortic dissection,
giant cerebral aneurysm, ascending aortic aneurysm, and renal cell carcinoma
extending into IVC and RA. Modification of anesthetic techniques is required
[21].
1. Temperature. Temperature should be measured in at least two sites. Brain
temperature determined by nasopharyngeal and/or tympanic membrane should
be one of the sites. Core and/or shell temperature should be measured.
Homogeneous hypothermia and normothermia should be achieved prior to
DHCA and CPB separation, respectively.
2. Brainwave electrical activity. The goal of hypothermia is to render the brain
isoelectric in order to reduce cerebral metabolic O2 requirements. Prior to
turning the CPB off, the temperature should be stable and at the temperature
goal at all sites. The head should be packed in ice for topical cooling. The
EEG/BIS should be isoelectric and stable (BIS = 0). It is not clear if
pharmacologic neuroprotection adds any protection on top of hypothermia
during cooling. However during rewarming, administration of pharmacologic
neuroprotection should be considered as the protective effect of hypothermia is
dissipating.
3. Central line site: The cardiovascular pathology may require alternative
cannulation sites for CPB, removing those sites for central line access. For
example, the surgeon may place the patient on fem-fem CPB thus eliminating
the femoral artery/vein from consideration for central access.
4. Arterial line site: The aortic cannula and cross-clamp sites may force the
surgeon to include either the innominate artery or left subclavian within the
nonperfused portion of the aorta. Placement of the arterial line on the
contralateral side allows continued use.
a. Ascending aortic aneurysms require a LEFT radial art line.
b. Descending aortic aneurysm or dissections require a RIGHT radial art line.
c. Aortic arch aneurysm are repaired under DHCA thus can be either right or
left.
5. CPB monitors: Rapid rewarming after DHCA dramatically increases the
incidence and severity of neurocognitive deficits. The temperature gradient
between CPB machine venous/arterial return should be ≤4° to 5°C. Arterial
inflow temperature should probably not exceed 36°C.
D. Thoracoabdominal aortic aneurysm (TAAA). TAAA are complex cases with
some unique monitoring considerations. Decisions regarding which monitors will
be utilized and which sites the monitors will be placed begin with a discussion
with the surgeon. The surgical approach and technique will dictate monitoring
decisions. Topics for discussion include:
1. Will the procedure be performed as an open repair or as an endovascular
aortic repair (EVAR) or thoracic endovascular repair (TEVAR)?
Endovascular repair is minimally invasive, whereas open TAAA could be
considered as maximally invasive. Endovascular repair options for anesthetic
technique and monitors vary widely based on anatomy, experience of the
surgeon/anesthesiologist and patient factors. The minimum monitoring would
include an arterial catheter and two large-bore IVs (i.e., 14 g × 2). Open repair
would prompt placement of an SVO2-CCO PAC and plan for ICU
postoperatively.
2. Which surgical technique is planned? Partial left heart bypass versus CPB
versus CPB/DHCA versus clamp and sew? Partial bypass with a centrifugal
pump is managed with (right) upper and lower extremity arterial lines.
Although all of the blood ejected by the RV passes through the lungs, one-lung
ventilation may result in hypoxia. An S VO2-CCO PAC is indicated for this
paradigm.
3. What incision will be used? A subcostal incision allowing access to both
retroperitoneum and hemithorax may require ECG lead V5 to be placed at
alternative site (see Table 4.1).
4. What is the plan with respect to neuroprotection? Will an intrathecal catheter
be placed to drain CSF? Will full CPB ± DHCA be required with full dose of
heparin? Will evoked potentials be used to monitor spinal cord hypoperfusion?
If EP used which EP? Motor EP? Somatosensory EP?
VII. Additional resources
The World Wide Web provides an abundance of resources (Table 4.14) to gain
further knowledge about monitoring devices.
TABLE 4.14 Internet resources
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5 Transesophageal Echocardiography
Jack S. Shanewise
I. Basic principles of ultrasound imaging

II. Basic principles of Doppler echocardiography
A. Doppler echocardiography
B. The Bernoulli equation
III. Modes of cardiac ultrasound imaging
A. M-mode echocardiography
B. Two-dimensional (2D) echocardiography
C. Pulsed-wave Doppler (PWD)
D. Continuous-wave Doppler (CWD)
E. Color-flow Doppler (CFD)
F. Tissue Doppler
IV. Indications for transesophageal echocardiography (TEE) during cardiac
surgery
V. Safety, contraindications, and risk of TEE
A. Preoperative screening
B. TEE probe insertion and manipulation
C. Complications of TEE
VI. Intraoperative TEE examination
A. Probe insertion
B. Probe manipulation
C. Machine settings
D. TEE views
E. Examination of specific structures
VII. Monitoring applications of TEE
A. Assessing preload
B. Measuring intracardiac pressures
C. Measuring cardiac output
D. Detecting myocardial ischemia
E. Intracardiac air
VIII. TEE for specific types of surgery
A. Coronary artery bypass grafting (CABG)
B. Valve repair surgery
C. Valve replacement surgery
D. Surgery for congenital heart disease
E. Surgery for infective endocarditis
F. Surgery for hypertrophic obstructive cardiomyopathy
G. Thoracic aortic surgery
H. Transplantation surgery
I. Ventricular assist device implantation
J. Minimally invasive cardiac surgery
K. Transcatheter valve interventions
IX. Three-dimensional (3D) echocardiography
A. Fundamental limitations of ultrasound imaging
B. Computed rendering of 2D images into 3D
C. Real-time insonation of a volume of tissue
D. 3D image display and manipulation
KEY POINTS
1. The majority of cardiac surgical transesophageal echocardiography

(TEE) imaging uses two-dimensions, which is accomplished via
phased array transducers consisting of 64 to 128 small crystals
activated sequentially.
2. Pulsed-wave Doppler (PWD) profiles blood flow velocity at a single
point along the ultrasound beam, whereas continuous-wave Doppler
(CWD) detects the maximum velocity profile along the full length of
the ultrasound beam. CWD permits measurement of higher-velocity
blood flows (e.g., aortic stenosis [AS]) than PWD.
3. Color-flow Doppler (CFD) is a form of PWD that superimposes
velocity information onto a two-dimensional (2D) image, which
assesses blood flow direction when it is predominantly moving
either toward or away from the transducer.
4. Before placing a TEE probe, significant esophageal pathology
should be ruled out by asking the patient about swallowing
difficulty and about known esophageal dysfunction.
5. A comprehensive TEE examination typically involves 20 standard
views, which are shown in Figure 5.2.
6. Global and regional left ventricular (LV) systolic and diastolic
function can be assessed qualitatively or quantitatively using TEE,
as can LV preload (end-diastolic volume). Wall motion can be
graded on a scale of 1 (normal) to 5 (dyskinesis).
7. Several TEE modalities can be used to assess mitral regurgitation
(MR), the easiest way being CFD.
8. AS can be assessed using a variety of TEE modalities including
imaging in several planes, planimetry in a short-axis (SAX) view to
trace aortic valve area (AVA), and AVA assessment by continuity
equation.
9. TEE is useful for interrogating the proximal ascending aorta, the
aortic arch, and the descending aorta, but it has a “blind spot” for
the distal ascending aorta that requires epiaortic echocardiography
for diagnostic interrogation. Complete thoracic aortic interrogation
is important in the presence of advanced aortic arteriosclerosis and
aortic dissection.
10. TEE assessment of new LV regional wall-motion abnormalities
(RWMAs) is the most sensitive bedside monitor of myocardial
ischemia.
11. TEE is highly sensitive for detecting intracardiac air.
12. Intraoperative TEE is indispensable during surgery for cardiac valve
repair or replacement, ventricular assist device placement, and
minimally invasive cardiac surgery.
13. Real-time 3D TEE adds information to intraoperative assessment of
operations for mitral valve (MV) disease and congenital heart
disease.
I. Basic principles of ultrasound imaging
Medical ultrasound is produced by a piezoelectric crystal that vibrates in response
to a high-frequency, alternating electrical current. The same crystal is deformed by
returning echoes producing an electrical signal that is detected by the instrument.
Ultrasound transmitted from the transducer into the patient interacts with the tissues
in four ways: (i) Reflection, (ii) refraction, (iii) scattering, and (iv) attenuation.
Ultrasound is reflected when it encounters the interface between tissues of different
acoustic impedance, primarily a function of tissue density, and the timing, intensity,
and phase of these echoes are processed to form the image. The velocity of
transmission of ultrasound through soft tissues is relatively constant (1,540 m/sec),
and the time it takes for the waves to travel to an object, be reflected, and return is
determined by its distance from the transducer. Selecting the frequency of an
ultrasound transducer is a trade-off between image resolution and depth of
penetration. Higher frequencies have better resolution than lower frequencies, but
they do not penetrate as far into tissue. The frequency of the ultrasound used in
transesophageal echocardiography (TEE) typically ranges from 3.5 to 7 million
cycles per second (MHz).
II. Basic principles of Doppler echocardiography
A. Doppler echocardiography uses ultrasound scattered from blood cells to
measure the velocity and direction of blood flow. The Doppler effect increases
the frequency of waves scattered from cells moving toward the transducer and
decreases the frequency of waves from cells moving away. This change in the
transmitted frequency (FT) to the scattered frequency (FS) is called Doppler shift
(FS – FT) and is related to the velocity of blood flow (V) by the Doppler
equation:
where c is the speed of sound in blood (1,540 m/sec) and θ is the angle between
the direction of blood flow and the ultrasound beam. The 2 in the denominator
corrects for the time it takes the ultrasound to travel to and from the blood cells.
In order to get a reasonably accurate (less than 6% error) measurement of blood
velocity with Doppler echocardiography, the angle between the flow and the
ultrasound beam (θ) should be less than 20 degrees.
B. The Bernoulli equation describes the relationship between the flow velocity
through a stenosis and the pressure gradient across the stenosis. It is a complex
relationship that includes factors for convective acceleration, flow acceleration,
and viscous resistance. In certain clinical applications, such as aortic and mitral
stenosis, a simplified form may be used. The simplified Bernoulli equation is:
where ΔP is the pressure gradient in millimeters of mercury (mm Hg) and V is

the velocity in meters per second (m/sec). The simplified Bernoulli equation
should only be used in applications validated against another gold standard.
III. Modes of cardiac ultrasound imaging
A. M-mode echocardiography was the primary imaging mode for
echocardiography for many years before the development of two-dimensional
(2D) imaging in the late 1970s. It directs pulses of a single, linear beam of
ultrasound into the tissues and displays the distance from the transducer of the
returning echoes on the y-axis of a graph with signal strength indicated by
brightness. The x-axis of the graph shows time, and motion of the structures is
seen as curved lines. M-mode is useful for precisely timing events within the
cardiac cycle. Its other advantage is very high temporal resolution, making
thousands of images per second, which allows detection of high-frequency
oscillating motion, such as vibrating vegetations.
B. 2D echocardiography is made by very rapidly moving the ultrasound beam
through a plane, creating multiple scan lines that are displayed simultaneously to
construct a 2D tomographic image. Mechanical transducers accomplish this by
physically rotating or oscillating the crystal. However, TEE probes usually have
phased array transducers, which consist of an array of many 1 (64 to 128) small
crystals that are electrically activated in sequence to move the beam through the
imaging plane. The number of 2D images that can be formed each second is
called frame rate (temporal resolution), which is determined by the width
(number of scan lines per image) and depth (time for each pulse to return) of the
imaging sector. Typical frame rates for 2D echocardiography are 30 to 60 frames
per second, which is fast enough to accurately reflect most motion in the heart.
C. Pulsed-wave Doppler (PWD) measures the velocity and direction of blood flow
in a specific 2 location, called sample volume, which can be placed by the user
in the area of interest of a 2D image. The velocity of flow is displayed with time
on the x-axis and velocity on the y-axis. Velocities going toward the transducer
are above the baseline of the y-axis and velocities away from the transducer
below the baseline. PWD uses one transducer to both send and receive signals,
determining the depth of the sample volume from the transducer by listening at a
predetermined interval after transmission. This limits the maximum rate at which
pulses can be sent (pulse repetition frequency), which in turn limits the maximum
Doppler shift (Nyquist limit) and the blood velocity that can be measured with
PWD. The farther the sample volume is from the transducer, the lower the
maximum velocity that can be measured. Typically, velocities more than 1.5 to 2
m/sec cannot be measured with PWD.
D. Continuous-wave Doppler (CWD) measures the velocity and direction of blood
flow along the line of sight of the ultrasound beam. The information is displayed
with time on the x-axis and velocity on the y-axis, as with PWD. CWD uses two
transducers: One to continuously transmit and the other to continuously receive.
As a result, all returning signals are superimposed on the display, so CWD
cannot determine the depth from the transducer from which a 3 returning signal
originated (range ambiguity), only its direction. But, unlike PWD, CWD has no
limit on the maximum velocity measured. CWD is used to measure blood
velocity too high for PWD, such as aortic stenosis (AS), and to determine the
maximum velocity of a flow profile, such as with mitral stenosis.
E. Color-flow Doppler (CFD) is a form of PWD that superimposes the velocity
information onto the simultaneously created 2D image of the heart, allowing the
location and timing of flow disturbances to be easily seen. Flow toward the
transducer usually is mapped as red and away as blue. Some CFD maps, called
variance maps, add green to indicate turbulence in the flow. Since it is a form of
PWD, CFD cannot accurately measure higher flow velocities, such as mitral
regurgitation (MR) and AS, and these flows appear as a mixture of red and blue,
called mosaic pattern. Also, as the flow velocity passes the limit of the CFD
velocity scale (Nyquist limit), the color will alias, or change from red to blue or
from blue to red, depending on the direction of flow. The aliasing velocity or
Nyquist limit for CFD varies with the depth of the color sector, but typically is
less than 100 cm/sec. Since the instrument must develop both the 2D and Doppler
images, the frame rate is lower with CFD than with 2D imaging alone, typically
in the range from 12 to 24 frames per second. At frame rates below 15 frames
per second, the image becomes noticeably jerky as the eye can discern the
individual images. Decreasing the width and depth of the 2D image and the CFD
sector within it will increase the frame rate.
F. Tissue Doppler is a form of PWD that measures the velocity of tissue motion at
specific points in the myocardium. Its most common application is to measure the
velocity of mitral annular motion to assess systolic function of the left ventricle
(LV). More sophisticated analysis can be performed between two adjacent points
in the myocardium to measure strain (tissue deformation over time) and strain
rate (rate of deformation) to assess systolic and diastolic functions in different
regions of the LV and the right ventricle (RV). Evaluation of synchrony of
ventricular contraction is also possible with tissue Doppler.
IV. Indications for TEE during cardiac surgery
TEE can be used as a diagnostic tool during cardiac surgery to direct the surgical
procedure and diagnose unanticipated problems and complications. TEE also is
useful to the cardiac anesthesiologist as a monitor of cardiac function. Often, TEE
is used for both purposes during heart surgery. The recently revised American
Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists
(ASA/SCA) Practice Guidelines for Perioperative TEE state that “For adult
patients without contraindications, TEE should be used in all open heart (e.g.,
valvular procedures) and thoracic aortic surgical procedures and should be
considered in coronary artery bypass graft surgeries” [1].
V. Safety, contraindications, and risk of TEE
A. Preoperative screening for esophageal disease should be completed before
proceeding with 4 TEE. The patient should be interviewed when possible and
asked about a history of esophageal disease, dysphagia, and hematemesis. The
medical record should be reviewed as well. Relative contraindications to TEE
are listed in Table 5.1. The presence of a relative contraindication requires
balancing the risk with the importance of TEE to the procedure. In patients with
distal esophageal or gastric pathology, it often is possible to obtain the
information needed with TEE without advancing into the distal esophagus.
Preoperative esophagoscopy is another option to consider when the need for
TEE is important and the risk is unclear. Another approach when facing
pathology in the distal esophagus or the stomach is to confine the TEE
examination to mid and upper esophageal (UE) views.
TABLE 5.1 Relative contraindications to transesophageal echocardiography
CLINICAL PEARL ALWAYS think about risk factors and contraindications before
inserting a TEE probe—ESPECIALLY in emergency situations.
B. TEE probe insertion and manipulation should be performed gently. The probe
must never be forced through a resistance, and excessive force must never be
applied to the control wheels.
CLINICAL PEARL During probe insertion, watching or feeling the neck often allows
you to tell whether the probe is going off to one side or another.
C. Complications of TEE are uncommon in properly screened patients, but they
may be serious [2]. Complications of TEE are listed in Table 5.2. Serious
injuries may not be apparent at the time of the procedure [3].
VI. Intraoperative TEE examination
A. Probe insertion is performed after the patient is anesthetized and the
endotracheal tube is secured. An orogastric tube is inserted and the contents of
the stomach and the esophagus are suctioned. As the mandible is displaced
anteriorly, the probe is gently inserted into the posterior pharynx in the midline
and advanced into the esophagus. A laryngoscope may be used to displace the
mandible and better visualize the esophageal opening if necessary. As the probe
is advanced into the thoracic esophagus (approximately 30 cm), the heart should
come into view. On rare occasions, the probe cannot be placed in the esophagus,
in which case the TEE is abandoned.
B. Probe manipulation is accomplished by advancing and withdrawing the probe
within the esophagus, rotating the probe to the patient’s left (counterclockwise)
or right (clockwise). Assuming that the transducer is facing anteriorly (toward
the heart), the tip flexes anteriorly and posteriorly with the large control wheel,
and flexes to the patient’s right and left (can be envisioned as “wagging,” as in a
dog’s tail) with the small control wheel. With a multiplane TEE probe, the angle
of the transducer is rotated axially from 0 degrees (horizontal plane), through 90
degrees (vertical plane), to 180 degrees (mirror image of 0-degree horizontal
plane) (Fig. 5.1).
TABLE 5.2 Complications of transesophageal echocardiography
FIGURE 5.1 Terminology used to describe manipulation of the probe and transducer during image acquisition. (From
Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane
transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for
Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in
Perioperative Transesophageal Echocardiography. Anesth Analg. 1999;89(4):870–884, with permission.)
C. Machine settings are adjusted to optimize the TEE image. These settings are
continuously adjusted by the user as the examination proceeds.
1. Transducer frequency is adjusted to the highest frequency that provides
adequate depth of penetration to the structure being examined.
2. Image depth is adjusted to center the structure being examined in the display.
3. Overall image gain and dynamic range (compression) are adjusted so that the
blood in the chambers appears nearly black and is distinct from the shades of
gray representing tissue.
4. Time gain compensation controls are adjusted so that there is uniform
brightness from the near field to the far field of the image.
5. CFD gain is adjusted to a threshold that just eliminates any background noise
within the color sector.
D. TEE views. The ASE/SCA Guidelines for performing a comprehensive
intraoperative multiplane 5 TEE examination [4] define 20 views that comprise
a comprehensive TEE examination (Table 5.3). These 20 views are shown in
Figure 5.2. An update of these guidelines considered uses of TEE outside the
perioperative arena and described a few additional views [5]. The 20 views are
named for the location of the transducer (echocardiographic window), a
descriptive term of the imaging plane (e.g., short axis [SAX] or long axis
[LAX]), and the major anatomic structure in the view. All of these views can be
developed in most patients. Additional views may be needed to completely
examine a patient with a particular form of pathology. The sequence in which
these views are obtained will vary from examiner to examiner, but it is generally
most efficient to develop the midesophageal (ME) views and then the transgastric
(TG) views.
TABLE 5.3 Recommended transesophageal echocardiographic cross section
CLINICAL PEARL The goal of the TEE examination is NOT to get all 20 views, but
to use the 20 views to discern the structure and function of the heart.
1. ME views are developed with the TEE transducer posterior to the left atrium
(LA). With a multiplane TEE probe, detailed examinations of cardiac chambers
and valves can be completed in most patients from this window alone.
CLINICAL PEARL Pay attention to the position of the transducer—ideally posterior to
the middle of the LA. Small adjustments in or out or flexing the tip to the right can greatly
improve the image.
2. TG views are obtained by passing the transducer into the stomach and directing
the imaging plane superiorly through the diaphragm to the heart. Images of the
LV and RV and the mitral valve (MV) and tricuspid valve (TV) are made from
this window. Views to align the Doppler beam parallel to flow through the left
ventricular outflow tract (LVOT) and aortic valve (AV) can be developed from
the TG window.
FIGURE 5.2 Twenty cross-sectional views (a through t) composing the recommended comprehensive transesophageal
echocardiographic examination. Approximate multiplane angle is indicated by the icon adjacent to each view. asc, ascending;
AV, aortic valve; desc, descending; LAX, long axis; ME, midesophageal; RV, right ventricle; SAX, short axis; TG, transgastric;
UE, upper esophageal. (From Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a
comprehensive intraoperative multiplane transesophageal echocardiography-examination: recommendations of the American
Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists
Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg. 1999;89(4):870–884, with
permission.)
3. Upper esophageal views are made with the transducer at the level of the aortic
arch, which is examined in LAX and SAX. In many patients, images of the main
pulmonary artery (PA) and pulmonic valve (PV) also may be developed,
allowing alignment of the Doppler beam parallel to flow in these structures.
E. Examination of specific structures
CLINICAL PEARL Whenever possible, at the beginning of a case perform a
comprehensive examination and store the images to establish a baseline for later
comparison.
1. Left ventricle. The LV is examined with the ME four-chamber (Video 5.1),
ME two-chamber (Video 5.2), ME LAX (Video 5.3), TG mid-SAX (Video
5.4), and TG two-chamber views.
a. LV size is assessed by measuring the inside diameter at the junction of the
basal and mid-thirds at end diastole using the ME two- or TG two-chamber
view. Normal is less than 5.4 cm for women and less than 6 cm for men.
Normal thickness of the LV wall is 1.2 cm or less at end diastole and is best
measured with TEE from the TG mid-SAX view [6].
b. 6 LV global function may be assessed quantitatively or qualitatively.
Fractional area change (FAC) is a 2D TEE equivalent of ejection fraction
(EF) and is obtained by measuring the LV chamber area in the TG mid-SAX
view by tracing the endocardial border to measure the end-diastolic area
(EDA) and the end-systolic area (ESA) and using the formula: FAC = (EDA −
ESA)/EDA. Normal FAC is greater than 0.50. This method is not as accurate
when wall-motion abnormalities are present in the apex or the base of the LV.
Qualitative assessment of LV function is performed by considering all views
of the LV and estimating the EF (estimated ejection fraction [EEF]) as normal
(EEF greater than 55%), mildly decreased (EEF 45% to 54%), moderately
decreased (EEF 35% to 44%), moderately severely decreased (EEF 25% to
34%), or severely decreased (EEF less than 25%). EEF by experienced
echocardiographers correlates with nonechocardiographic measures of EF as
well or better than quantitative echocardiographic measurements of EF [7].
c. Assessment of regional LV function. The LV is divided into 17 regions or
segments (Fig. 5.3). Each segment is rated qualitatively for thickening during
systole using the following scale: 1 = normal (greater than 30% thickening), 2
= mild hypokinesis (10% to 30% thickening), 3 = severe hypokinesis (less
than 10% thickening), 4 = akinesis (no thickening), and 5 = dyskinesis
(thinning and paradoxical motion during systole). An increase in scale of 2 or
more in a region should be considered significant and suggestive of
myocardial ischemia [8].
IGURE 5.3 Seventeen-segment model of the LV. A: Four-chamber views show the three inferoseptal and three anterolateral
B: Two-chamber views show the three anterior and three inferior segments. C: Long-axis views show the two
nteroseptal and two inferolateral segments. D: Mid–short-axis views show all six segments at the midlevel. E: Basal short-axis
ews show all six segments at the basal level. Basal segments: 1, basal anteroseptal; 2, basal anterior; 3, basal anterolateral; 4,
asal inferolateral; 5, basal inferior; 6, basal inferoseptal. Mid-segments: 7, mid-anteroseptal; 8, mid-anterior; 9, mid-anterolateral;
, mid-inferolateral; 11, mid-inferior; 12, mid-inferoseptal. Apical segments: 13, apical anterior; 14, apical lateral; 15, apical
, apical septal; 17 apical cap or true apex. (Modified from Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA
uidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination:
commendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of
ardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg.
999;89(4):870–884, with permission.)
IGURE 5.4 Transmitral inflow velocity profiles measured with PWD by placing the sample volume between the open tips of the
itral leaflets. A: Normal pattern. The pseudonormal pattern has a similar appearance. B: Impaired relaxation pattern indicative of
ild diastolic dysfunction. The peak E-wave velocity is less than the A wave (E-to-A reversal) and the deceleration time of the E
ave is prolonged. C: Restrictive pattern indicative of advanced diastolic dysfunction. The peak E-wave velocity is increased and
e E-wave deceleration time is decreased. A, atrial filling wave; E, early filling wave.
d. Assessment of diastolic LV function can be made by examining with PWD

the transmitral inflow velocity profile during diastole. The normal pattern has
an E wave corresponding to early passive filling of the LV, followed by a
period of diastasis, and finally an A wave corresponding to atrial contraction
in late diastole (Fig. 5.4A). Milder forms of diastolic dysfunction result in the
impaired relaxation pattern with decreased peak E-to-A velocity ratio and
prolonged E-wave deceleration time (Fig. 5.4B). Advanced diastolic
dysfunction causes the restrictive pattern with increased peak E-to-A
velocity ratio and decreased E-wave deceleration time (Fig. 5.4C). As
diastolic dysfunction progresses from mild to severe over a number of years,
the transmitral flow pattern may pass through a period in which it appears
normal, a condition termed pseudonormal pattern. Normal may be
distinguished from pseudonormal by examination of the pulmonary venous
inflow velocity profile, which normally has positive inflow waves during
systole (S wave) and diastole (D wave) and a small, negative wave
corresponding to atrial contraction (A wave) (Fig. 5.5A). The pseudonormal
pattern has prolongation of the A wave and attenuation of the S wave
compared to the normal pattern (Fig. 5.5B). Age and preload also affect the
transmitral and pulmonary venous inflow velocity patterns.
2. Mitral valve. The MV is examined with the ME four-chamber, ME mitral
commissural, ME LAX, and TG basal SAX views, with and without CFD. It
consists of an anterior leaflet and a posterior leaflet joined at two
commissures, the anterolateral and the posteromedial. There is a papillary
muscle corresponding to each commissure. The posterior leaflet is divided into
three scallops and the anterior leaflet into thirds for purposes of describing the
location of lesions (Fig. 5.6). Prolapse of the MV is present when a portion of
the leaflet moves to the atrial side of the annulus during systole. Flail is said to
be present when a chordae tendineae is ruptured and the corresponding segment
of the valve leaflet is seen oscillating in the LA during systole.
FIGURE 5.5 Pulmonary venous inflow velocity profiles measured with PWD by placing the sample volume in the left upper
pulmonary vein. A: Profile seen with normal diastolic function and transmitral inflow. The S wave is larger than the D wave
and a small A reversal is present. B: Pattern seen with diastolic dysfunction and pseudonormal transmitral inflow. The S wave
is attenuated and smaller than the D wave and an enlarged A wave is present. A, atrial reversal wave; D, diastolic wave; S,
systolic wave.
FIGURE 5.6 Anatomy of the MV. A1, lateral third of the anterior leaflet; A2, middle third of the anterior leaflet; A3, medial
third of the anterior leaflet; P1, lateral scallop of the posterior leaflet; P2, middle scallop of the posterior leaflet; P3, medial
scallop of the posterior leaflet. (From Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a
comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American
Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists
Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg. 1999;89(4):870–884, with
permission.)
a. Mitral regurgitation
7 (1) Judging severity of MR with TEE is based on several factors [9]. The
structure of the valve leaflets is examined with 2D echocardiography,
looking for defects of coaptation. CFD is used to detect retrograde flow
through the valve into the LA. The width of the jet as it passes through the
valve and its size in the LA are noted. Eccentric jets of MR tend to be
more severe than central jets of a similar size. CFD also can detect flow
convergence proximal to the regurgitant orifice, indicating more
significant MR. Pulmonary venous inflow velocity profile is examined
with PWD for systolic flow reversal, a specific but not very sensitive
sign of severe MR. Severity is graded on a semiquantitative scale of 1+
(mild) to 4+ (severe). Most patients have at least trace amounts of MR
detected with TEE.
CLINICAL PEARL Functional MR can look severe in early systole, then lessen or
disappear in mid and late systole as coaptation improves.
(2) Functional MR is due to dilation of the MV annulus or displacement of
the papillary muscles causing a decrease in the surface of coaptation of
the MV leaflets. The structure of the valve leaflets is normal. Functional
MR can be very dynamic and is markedly affected by loading conditions.
The most common causes of functional MR are regional wall-motion
abnormalities (RWMAs) from coronary artery disease and generalized
dilation of the LV.
(3) Myxomatous degeneration of the MV is a common cause of MR
requiring surgery. The leaflets are elongated and redundant, prolapsing
into the LA during systole. Rupture of a chordae is common in this
condition and causes a flail segment of the involved leaflet. TEE can be
used to locate the portion of the MV involved and is helpful in guiding
surgical therapy. Prolapse and flail of the middle scallop of the posterior
leaflet is the most common form and most amenable to repair by
resection of the involved portion and reinforcement of the annulus with
an annuloplasty ring.
(4) Rheumatic MR is caused by thickening and shortening of the MV leaflets
and chordae restricting motion and closure during systole. This type of
MR typically is difficult to repair and usually requires prosthetic valve
replacement.
(5) Proximal isovelocity surface area (PISA) is a method to quantify MR
with echocardiography using CFD and CWD. It is most commonly
applied to central MR and is probably not as accurate for eccentric MR.
The flow velocity of blood increases as it converges toward the
regurgitant orifice and can be seen with CFD. When the velocity reaches
the limit on the CFD scale, aliasing of the signal occurs and the color
mapped onto the 2D image changes from red to blue on the ventricular
side of the valve. This change in color represents a hemispheric shell of
blood converging toward the regurgitant orifice called PISA (Fig. 5.7). If
the surface area of this hemisphere (APISA) is measured and multiplied
by the aliasing velocity toward the transducer (VPISA—taken from the
CFD scale), the instantaneous flow at the PISA in mL/sec is obtained.
APISA is calculated by measuring the radius (r) of the PISA and using the
formula for the area of a hemisphere: (APISA) = 2πr2 = 6.28r2. By the
continuity principle, the instantaneous flow (mL/sec) is the same at the
PISA as at the regurgitant orifice, both of which are the product of an
area and a velocity: APISA × VPISA = ROA × VMR, where ROA is the
regurgitant orifice area. The peak instantaneous velocity of the MR
(VMR) is measured with CWD, allowing the ROA to be calculated.
Rearranging the formula,
IGURE 5.7 Diagram of the PISA method to measure ROA in central MR. The horizontal line represents the MV with a central
gurgitant orifice. As the blood flow converges on the orifice, the velocity increases and causes aliasing of the CFD signal,
hanging the color from red to blue creating the PISA (small arrows) on the ventricular side of the valve. The velocity of the blood
the PISA (VPISA) is taken from the CFD scale. The size of the PISA (APISA) is calculated by measuring its radius (r, large
) and using the formula for the surface area of a hemisphere: A PISA= 2πr2. The peak velocity of the MR (V ) is MR
easured by using CWD aimed through the orifice. FlowPISA = VPISA × APISA and FlowM R = VM R × ROA. By the continuity
inciple, FlowM R = FlowPISA, so ROA = (VPISA × APISA)/VM R.
(6) ROA less than 0.2 cm2 is mild MR and greater than 0.4 cm2 is severe
MR.
(7) If the CFD is adjusted so that the aliasing velocity toward the transducer
is close to 40 cm/sec, and the VMR is assumed to be about 500 cm/sec
(most patients with reasonable hemodynamics) the formula simplifies to:
It is now possible to directly measure ROA with planimetry of three-

dimensional (3D) TEE images of the MV with CFD.
b. Mitral stenosis
Significant mitral stenosis almost always is due to rheumatic heart disease.
Severe mitral annular calcification is a rare cause of significant stenosis. 2D
images show thickening of the leaflets with fusion at the commissures and
restricted opening during diastole. Doppler velocity measurements of the
transmitral inflow show increased peak and mean velocities, which can be
used to calculate peak and mean transvalvular gradients (ΔP = 4V 2).
The best gauge of severity of mitral stenosis is mitral valve area (MVA).
MVA less than 1 cm2 is considered severe, and from 1 to 1.5 cm2 moderate.
TEE can be used to measure valve area in mitral stenosis by the following
methods:
(1) Planimetry. Images of the stenotic orifice may be directly measured from
the TG basal SAX view. The imaging plane is moved above and below
the valve until the minimal orifice is seen, then the image is frozen in
diastole and the orifice traced. Calcification of the annulus or leaflets
may create acoustic shadowing limiting the ability to accurately image
the orifice in many patients. 3D TEE imaging greatly facilitates
planimetry of the stenotic MV orifice.
(2) Pressure half-time. The rate at which the pressure gradient decreases
across a stenotic MV during diastole is directly related to the severity of
the stenosis. A gauge of this rate is the pressure half-time, which can be
measured from the transmitral inflow velocity profile. An empirically
derived formula gives the MVA in square centimeters as:
where PHT is the pressure half-time in milliseconds. This formula has

been validated only for patients with rheumatic mitral stenosis. It cannot
be used if there is more than mild aortic regurgitation (AR) or
immediately after a mitral commissurotomy.
(3) Proximal isovelocity surface area. In mitral stenosis the flow velocity
of blood increases as it converges toward the stenotic orifice and can be
seen with CFD. When the velocity reaches the limit on the CFD scale
going away from the transducer, aliasing of the signal occurs and the
color mapped onto the 2D image changes from blue to red on the atrial
side of the valve. This change in color represents a hemispheric shell of
blood converging toward the stenotic orifice called PISA (Fig. 5.8). If
the surface area of this hemisphere (APISA) is measured and multiplied
by the aliasing velocity going away from the transducer (VPISA—taken
from the CFD scale), the instantaneous flow at the PISA in mL/sec is
obtained. APISA is calculated by measuring the radius of the PISA and
using the formula for the area of a hemisphere and reducing it by the ratio
of the angle formed by the MV leaflets (α angle) and 180 degrees: APISA
= 2πr2 ⋅ (α/180°) = 6.28r2 × (α/180°). The CFD scale is adjusted so that
the radius of the PISA is between 1 and 1.5 cm. By the continuity
principle, the instantaneous flow (mL/sec) is the same at the PISA as at
the stenotic orifice, both of which are the product of an area and a
velocity: APISA × VPISA = MVA × VMV, where MVA is the MV area and
VMV is the peak transmitral inflow velocity measured with CWD.
Rearranging,
IGURE 5.8 Diagram of the PISA method to measure MV area in mitral stenosis. The thick lines represent the MV with a
entral stenotic orifice. As the blood flow converges on the orifice, the velocity increases and causes aliasing of the CFD signal,
hanging the color from blue to red creating the PISA (small arrows) on the atrial side of the valve. The velocity of the blood at the
PISA) is taken from the CFD scale. The size of the PISA (APISA) is calculated by measuring its radius (r, large arrow)
nd using the formula for the surface area of a hemisphere reduced by the ratio of the angle formed by the leaflets (α) and 180
PISA = 2πr2 × α/180°. The peak velocity of the transmitral inflow (V ) is measured by using CWD aimed through the
MV
enotic orifice. FlowPISA = VPISA × APISA and FlowM V = VM V ⋅ MVA. By the continuity principle, Flow M V = FlowPISA, so
PISA × APISA)/VM V.
3. Aortic valve. The AV is examined in the ME AV SAX and ME AV LAX

views, with and without CFD. Doppler measurements of flow velocity through
the AV are made from the TG LAX and deep TG LAX views, which allow the
ultrasound beam to be directed parallel to AV flow. The AV is a semilunar
valve that has three cusps: (i) The right coronary cusp, which is most anterior
and adjacent to the RV outflow tract, (ii) the noncoronary cusp, which is
adjacent to the atrial septum, and (iii) the left coronary cusp.
a. Aortic regurgitation
The severity of AR is assessed with TEE primarily by the size of the
regurgitant jet on CFD and the depth to which it extends into the LV [ 8]. The
valve cusps also should be examined with 2D echocardiography, looking for
perforations and defects in coaptation. Other signs of severe AR include
holodiastolic flow reversal in the descending thoracic aorta measured with
PWD, pressure half-time of AR less than 300 msec as taken from the AR
velocity profile measured with CWD from the TG LAX or deep TG LAX
views, presystolic closure of the MV, and presystolic MR.
b. Aortic stenosis
Evaluation of AS with TEE is based on the appearance of the valve on 2D
images and Doppler velocity measurements of the flow through the stenotic
valve. In AS, the valve leaflets are thickened with markedly restricted
opening during systole. Calcification of 8 the cusps and the annulus may
cause acoustic shadowing. TEE may be used to quantify the severity of AS by
three methods:
(1) Transaortic gradients may be calculated with the simplified Bernoulli
equation (ΔP = 4V 2) by using CWD to measure the flow velocity in
meters per second through a stenotic AV from the TG LAX or deep TG
LAX views. For example, if the peak AV outflow velocity is 5 m/sec, the
peak instantaneous gradient would be 100 mm Hg. Peak velocities
greater than 4 m/sec (peak gradient greater than 64 mm Hg) are
consistent with severe AS, but severe AS may be present with lower
velocities if stroke volume (SV) is low due to poor ventricular function.
(2) AVA by planimetry. AVA is a better means of assessing severity of AS
than gradients and may be measured by planimetry from the ME AV SAX
view. The 2D image is frozen during systole at the level of the free edge
of the leaflets, scrolled to identify the maximum systolic orifice, which is
then traced using the caliper function. Acoustic shadowing from
calcification may obscure the image in many patients and make
planimetry difficult. AVA less than 1 cm2 is considered significant.
(3) AVA by continuity equation. AVA may be calculated using the
continuity equation, which states that the same amount of flow passes
through the AV and the LVOT with each stroke. Flow rate is equal to the
velocity of the flow multiplied by the area through which the flow occurs
(Flow = V ⋅ A) and by the continuity equation is the same at the AV and
the LVOT. Thus,
rearranging, we obtain
The area of the LVOT is obtained from the ME LAX view of the AV by
measuring its diameter during systole and applying the formula for the area
of a circle:
VLVOT is measured with PWD by placing the sample volume just

proximal to the AV in the LVOT and VAV by directing the CWD through
the stenotic valve. It is most convenient to use units of centimeters per
second and centimeters in order to obtain the AVA in units per square
centimeter. Common pitfalls in using the continuity equation to measure
AVA are underestimation of the LVOT diameter, an error that is squared
in the calculation, and underestimating the peak AV velocity due to a
large angle between the direction of the flow and the Doppler beam. It is
also possible to mistake the velocity profile of MR for AS because they
both are systolic and in the same general direction.
4. Right ventricle. The RV is examined in the ME four-chamber, ME RV inflow–
outflow view, and TG RV inflow view, assessing size and global function. The
RV appears to be somewhat smaller than the LV in most views and does not
normally share the apex with the LV. Pressure and/or volume overload will
cause RV enlargement. Global function usually is based on qualitative
assessment of decrease in chamber size during systole. It is rated as normal
function or as mild, moderate, or severe decrease in function.
5. Tricuspid valve. The TV lies between the RV and the right atrium (RA) and
has three leaflets: anterior, posterior, and septal. It is examined with the ME
four-chamber, ME RV inflow–outflow view, and TG RV inflow view, with
and without CFD. Some tricuspid regurgitation (TR) usually is detected.
Severity of TR is graded on a semiquantitative scale of 1+ (mild) to 4+
(severe) based primarily on the size of the regurgitant jet. Significant TR
usually is due to annular dilation secondary to right heart failure. Tricuspid
stenosis is uncommon and usually due to rheumatic heart disease. On TEE it
causes high-velocity, turbulent flow across the TV detected with CFD, PWD,
and CWD.
6. Pulmonic valve. The PV is located anterior and to the left of the AV and is
examined with the ME RV inflow–outflow view and UE aortic arch SAX view,
with and without CFD. PWD and CWD measurements of flow across the PV
are made with the UE aortic arch SAX view because the Doppler beam is
parallel to the flow in this view. Trace pulmonic regurgitation (PR) usually is
seen and normal. Pulmonic stenosis usually is congenital and rare in adults. It
causes high-velocity, turbulent flow across the valve seen with CFD, PWD,
and CWD.
7. Left atrium. The LA is examined in the ME four- and ME two-chamber views
for size and the presence of masses. It normally is less than 5 cm in its
anteroposterior and mediolateral dimensions. Thrombus usually is associated
with atrial fibrillation and LA enlargement and is most commonly in the LA
appendage, seen at the superior lateral aspect of the body of the atrium.
8. Right atrium. The RA is examined in the ME four-chamber and ME bicaval
views for size and masses. A variably sized fold of tissue at the junction of the
inferior vena cava (IVC) and the RA, the Eustachian valve, is seen frequently.
Fine, filamentous mobile strands may be seen in this region as well and are
termed Chiari network. Both are normal structures.
9. Interatrial septum. The interatrial septum (IAS) is examined in the ME four-
chamber, ME LAX, and ME bicaval views. Two portions usually are seen, the
thinner fossa ovalis centrally and a thicker region anteriorly and posteriorly.
Atrial septal defects are seen with 2D echocardiography and interatrial shunts
with CFD. Atrial septal aneurysms cause redundancy and hypermobility of the
IAS. Agitated saline contrast may be injected into the RA following release of
positive airway pressure to look for the appearance of contrast in the LA. This
indicates the presence of a patent foramen ovale (PFO), which may predispose
patients to right-to-left interatrial shunting in the presence of right heart failure
causing hypoxemia and/or paradoxical systemic embolization.
CLINICAL PEARL A saline contrast injection rules out a PFO ONLY if the contrast is
up against the fossa ovalis AND the atrial septum is bowing to the left (i.e., RAP > LAP).
10. Thoracic aorta. Although most of the thoracic aorta lies close to the esophagus
and can be 9 easily seen with TEE, the trachea may come between the
esophagus, the distal ascending aorta, and the proximal aortic arch, obscuring
TEE images of these parts of the aorta.
a. Ascending aorta
The ascending aorta is examined with the ME ascending aortic SAX and ME
ascending aortic LAX views by withdrawing the TEE probe superior to the
LA from the ME AV views to the level of the right PA. The distal third may
be obscured by the trachea and not well seen with TEE. The inside diameter
is normally less than 3.5 cm at the midlevel (anterior to the right PA). A more
complete and detailed examination of the ascending aorta may be performed
after sternotomy with epiaortic echocardiography, in which an
echocardiographic transducer is covered by a sterile sheath and placed
directly on the aorta in the surgical field by the surgeon.
b. Aortic arch
The aortic arch is examined with the UE aortic arch LAX and UE aortic arch
SAX views. The distal arch is easily seen in most patients, but the proximal
arch may be obscured by the trachea. The inside diameter normally is less
than 3 cm. The great vessels often are seen coursing toward the head to the
right of the image in the UE aortic arch SAX view.
c. Descending thoracic aorta
The descending thoracic aorta is examined in SAX (approximately 0-degree
multiplane angle) and LAX (approximately 90-degree angle) from the arch to
the diaphragm. The inside diameter normally is less than 3 cm. The proximal
descending thoracic aorta is lateral to the esophagus and the distal portion is
posterior, so the probe must be rotated as different levels are examined to
keep the aorta centered in the image. It often is possible to see the proximal
abdominal aorta by advancing the probe past the diaphragm.
d. Aortic diseases. Three common abnormalities of the aorta are detected with
TEE:
(1) Atherosclerosis
Atherosclerosis causes thickening and irregularity of the intimal layer of
the aorta that is easily seen with TEE. The normal intima is smooth and
less than 2 mm thick. Severity of atherosclerosis is graded on a five-
point scale: Grade 1 for normal or minimal disease (intima less than 2
mm thick), grade 2 for mild disease (intima 2 to 3 mm thick), grade 3 for
moderate or sessile disease (intima 3 to 5 mm thick), grade 4 for severe
or protruding disease (intima greater than 5 mm thick), and grade 5 for
mobile lesions. The location and extent of the lesions also are noted.
(2) Aneurysm
Aneurysmal dilations of the aorta are classified by their location and
shape as either diffuse (sometimes termed fusiform) or saccular (a sac
coming out the side of the vessel, similar in concept to a bulging hernia).
They often are associated with atherosclerotic changes and/or mural
thrombus, which are easily seen with TEE. Aneurysms with inside
diameter 4 cm or less are considered mild and those greater than 6 cm
are considered severe.
(3) Dissection
An aortic dissection is the separation through the media of the intimal
layer from the rest of the aorta. With TEE, a mobile membrane is seen
within the aorta dividing the vessel into a true and a false lumen. CFD is
applied to the aorta to characterize the flow in the true and false lumens.
Dissections are classified into type A, which involve the ascending aorta
and are a surgical emergency, and type B, which do not involve the
ascending aorta and usually are treated without surgery. TEE findings
that may be associated with type A aortic dissections include aneurysmal
dilation of the aorta, hemopericardium and tamponade, left hemothorax,
AR, and RWMAs due to coronary artery ostial involvement.
VII. Monitoring applications of TEE
A. Assessing preload
The most direct measurement of preload is LV end-diastolic volume. TEE
provides 2D images of the LV, so LV EDA of the TG mid-SAX view has been
used as an estimation of end-diastolic volume. Studies have shown that decreases
in blood volume as little as 1.5% can be detected by this technique [10] and that
correlation between EDA and cardiac output is better than that between PA
occlusion pressure and cardiac output [11].
B. Measuring intracardiac pressures
Measuring flow velocities with Doppler echocardiography and applying the
modified Bernoulli equation allow calculation of gradients between chambers of
the heart at various locations. If the absolute pressure of one of these chambers is
known, the pressure of the other chamber can be calculated. Thus, by measuring
the peak velocity of TR with CWD, one can estimate the peak RV systolic
pressure as the RV to RA gradient (Δ P = 4V2TR) plus the RA pressure. This
equals the PA systolic pressure if there is no pulmonic stenosis. Similar logic
can be used to measure LA, PA diastolic, and LV end-diastolic pressures by
measuring the velocities of MR, PR, and AR jets and knowing the LV systolic
(same as systolic BP), RV diastolic (same as central venous pressure [CVP]),
and aortic diastolic (same as diastolic BP) pressures.
C. Measuring cardiac output
Calculating SV with TEE requires making two measurements: (i) The velocity
profile of flow with PWD or CWD and (ii) the area through which the flow
occurs with 2D echocardiography. These measurements can be made with TEE
in several locations: AV, LVOT, MV, and PA. The accuracy of this technique
depends on both the velocity and area measurements being made in the same
location and at the same time in the cardiac cycle. The velocity profile of the
flow is traced and integrated through time to yield a value called velocity time
integral (VTI), which is in units of length, usually centimeters. Then the area A
through which the flow passes is measured with 2D echocardiography to give a
value in units of length squared, usually square centimeters. The product of VTI
and A yields the SV in units of volume, usually cubic centimeters or milliliters.
SV times the heart rate gives the cardiac output. The best validated technique for
intraoperative TEE uses CWD across the AV from the TG LAX or deep TG LAX
views [12]. The area of the valve then is calculated from the ME AV SAX view
by measuring the intercommissural distance S and applying the formula for the
area of an equilateral triangle: AΔ = 0.433S2. This technique is only applicable if
the AV is normal.
D. Detecting myocardial ischemia
Appearance of a new RWMA on TEE during surgery has been shown to be a
more sensitive 10 indicator of myocardial ischemia than electrocardiographic
changes and a better predictor of progression to myocardial infarction [13]. After
complete baseline examination of all LV segments is recorded for comparison,
the TG mid-SAX view is monitored because it simultaneously shows regions
supplied by all three major coronary arteries. An increase in the wall-motion
score of two or more grades in a segment suggests acute ischemia. Severe
hypovolemia also may produce wall-motion abnormalities without ischemia
[14]. TEE is not a true monitor for ischemia unless it is continuously observed
during surgery and is more often checked at crucial points of the operation, such
as aortic cross-clamping, or when another monitor suggests ischemia, such as
electrocardiographic or hemodynamic changes.
E. Intracardiac air
11 Air in the heart is easily seen with TEE as hyperdense or white areas within
the chambers. In a supine patient, air in the LA accumulates along the IAS and
adjacent to the right upper pulmonary vein. Air in the LV accumulates along the
apical septum. Tiny white spots seen floating within the chambers are
microscopic bubbles and are not of great concern. Large bubbles have air–fluid
levels visible on TEE as straight lines perpendicular to the direction of gravity
tha t wobble as the heart beats. They typically have a shimmering artifact
extending from the air–fluid level away from the transducer. Large bubbles
should be evacuated before discontinuing cardiopulmonary bypass (CPB).
VIII. TEE for specific types of surgery
A. Coronary artery bypass grafting (CABG)
TEE for CABG surgery focuses on global and regional LV functions. Baseline
examination of all segments of the LV is performed and recorded for later
comparison. A baseline RWMA may represent previously infarcted, nonviable
myocardium, chronically ischemic hibernating myocardium, or acutely ischemic
myocardium. Examination of the LV is repeated after grafting. The appearance of
a new RWMA before or after bypass grafting should be considered acute
ischemia. A new RWMA seen immediately after CPB may indicate stunned
myocardium, that is, viable muscle that is perfused but transiently not functioning
due to inadequate myocardial protection during CPB. RV infarction causes
dilation and hypokinesis of the RV on TEE, often associated with significant TR.
Complications of coronary artery disease, such as ischemic MR, LV thrombus,
LV aneurysm, ruptured papillary muscle, and postinfarction ventricular septal
defect, may be detected with TEE. TEE also is important in detecting
atherosclerosis in the aorta, which may increase the risk of stroke during CABG
surgery.
B. Valve repair surgery
12 Intraoperative TEE is very helpful during valve repair surgery. Detailed
baseline examination of the diseased valve can provide the surgeon with
information about the mechanism and etiology of the lesion, indicating the
feasibility of repair and the type of repair needed. Assessment of the repair after
CPB is done so that problems can be detected and immediately addressed. MV
repairs are assessed with TEE for three potential problems:
1. Residual regurgitation. Residual MR is assessed with CFD after MV repair.
Ideally there is no or only trace MR. Mild (1+) MR probably is acceptable.
Moderate (2+) or more MR should lead to consideration of revision of the
repair or valve replacement.
2. Systolic anterior motion (SAM) of the MV. Repair of myxomatous MVs with
redundant leaflets can cause mitral SAM, which is easily diagnosed with TEE.
There is abnormal anterior motion of the excessive leaflet tissue toward the
ventricular septum during systole. This leads to dynamic LVOT obstruction and
MR. SAM can be managed successfully in some cases by increasing
intravascular volume, administering pure vasoconstricting drugs, and stopping
positive inotropic drugs. In severe cases that do not respond to appropriate
treatment, revision of the repair or valve replacement is needed.
3. Stenosis. Excessive narrowing of the mitral orifice by valve repair creating
stenosis is possible but very uncommon. This is seen on TEE by limited
opening of the leaflets and high peak transmitral inflow velocity (greater than 2
m/sec).
C. Valve replacement surgery
After valve replacement surgery, the prosthesis is evaluated with TEE. CFD is
used to examine the valve annulus for paravalvular leaks. Trace paravalvular
leaks often are seen after CPB and are not a cause for concern. Moderate (2+) or
more regurgitation may need to be addressed surgically. Different types of
prosthetic valves have characteristic normal CFD patterns of regurgitation that
should not be confused with pathologic regurgitation. Bileaflet mechanical valve
prostheses may have a leaflet immobilized, usually in the closed position, by
impinging tissue, so TEE evaluation of these valves should document that both
leaflets move freely. An immobile leaflet should be corrected immediately with
surgical intervention. Stentless aortic bioprostheses and aortic homograft
prostheses may develop significant AR if they are not inserted properly. This can
be detected with CFD. Moderate (2+) or more AR usually warrants further
surgical intervention.
D. Surgery for congenital heart disease
TEE can confirm the diagnosis before CPB and occasionally finds previously
undiagnosed lesions in patients with complex congenital heart disease. Septal
defect closure and adequacy of flow through prosthetic conduits and intracardiac
baffles are assessed intraoperatively with TEE using CFD, PWD, and CWD,
allowing immediate correction of inadequate repairs.
E. Surgery for infective endocarditis
TEE is helpful in confirming the location and extent of infection and assessing the
severity of associated lesions such as valvular regurgitation, abscesses, and
fistulae. Intraoperative TEE often detects progression of the infection since the
preoperative studies guiding the surgical intervention. TEE examination after
CPB confirms the adequacy of the resection of infected tissue and repair of
hemodynamic lesions.
F. Surgery for hypertrophic obstructive cardiomyopathy
TEE is used before CPB to measure the thickness of the ventricular septum and
the location of contact of the MV with the septum to guide the surgeon in sizing
the myectomy. The adequacy of the myectomy is assessed with TEE after CPB by
looking for residual SAM, measuring residual gradients across the LVOT, and
assessing severity of residual MR. Moderate (2+) or more MR and a peak LVOT
gradient greater than 50 mm Hg indicate that a more extensive myectomy is
needed. Complications of the repair such as ventricular septal defect and AR are
assessed with TEE after CPB. CFD often reveals a small jet of diastolic flow in
the region of the myectomy from the transected septal perforator artery, which is
inconsequential.
G. Thoracic aortic surgery
TEE is helpful in monitoring cardiac function and providing definition of
thoracic aortic pathology, but it is often difficult to image the distal ascending
aorta and proximal arch with TEE. Caution should be used while performing
TEE in patients with thoracic aortic aneurysms, especially involving the aortic
arch, as the esophagus may be deviated, increasing the risk of injury. A complete
baseline examination of the LV is important to identify changes occurring during
application and removal of the aortic cross-clamp during surgery on the
descending thoracic aorta. When left atrial to aortic or femoral artery partial left
heart bypass is used, TEE LV EDA is used to assess adequacy of LV filling to
balance flow between the proximal and the distal aorta.
H. Transplantation surgery
1. Heart transplantation
Pre-transplant examination of the recipient heart focuses on identifying left
heart thrombus to help prevent dislodgement with surgical manipulation. Right
heart pressures are estimated and aortic cannulation sites are also assessed
before CPB. Adequacy of air evacuation from the donor heart is checked with
TEE before coming off CPB. Evaluation of donor heart function with TEE after
CPB helps direct hemodynamic support. Stenosis of the PA anastomosis is
excluded by measuring the peak velocity across it with CWD. RV dysfunction
after CPB is common and is manifested on TEE by a hypocontractile, dilated
RV with TR secondary to annular dilatation. After CPB, the atrial transplant
suture line often creates a mass visible with TEE along the lateral aspects of
the LA and RA and the midportion of the atrial septum. If the vena cavae are
individually anastomosed, both the superior vena cava (SVC) and IVC
anastomoses should be interrogated using the bicaval view within 1 to 3 cm of
the cavoatrial junction for stenosis and CFD flow acceleration (suggesting or
confirming a stenotic anastomosis).
2. Lung transplantation
A comprehensive baseline examination is recorded for comparison later during
the procedure. For single lung transplants and bilateral sequential lung
transplants, TEE is used to monitor RV function during PA clamping. RV
failure causes increased size and decreased contractility seen with TEE,
usually associated with increasing TR secondary to annular dilatation and may
necessitate going on CPB. Cardiac function is monitored as well during
reperfusion, watching for changes in volume and contractility of the ventricles.
Air embolism with reperfusion is also detected with TEE. After
transplantation, patency of the pulmonary vein-to-LA anastomoses is assessed
using CFD and PWD to measure pulmonary venous inflow velocity.
I. Ventricular assist device implantation
Intraoperative TEE plays a crucial role during VAD implantation surgery. For a
VAD to function properly, the native valve at the outflow of the assisted ventricle
must be reasonably competent (PV for right ventricular assist device [RVAD],
AV for left ventricular assist device [LVAD]). TEE is used to assess these
valves, and if significant regurgitation is present, a prosthetic valve may be
inserted or the native valve sewn shut. TEE is used to detect any intracardiac
shunts with TEE such as PFO, atrial septal defect, or VSD, because a properly
functioning VAD will decompress the assisted side of the heart and can change
the direction of an existing intracardiac shunt. TEE is used to detect thrombus
within the left heart to avoid systemic embolization with manipulation or
insertion of the VAD cannulae into the heart. The aorta is examined for
atherosclerosis to avoid atheroembolism with aortic cannulation, clamping, or
anastomosis of the outflow conduit. Before separating from CPB, TEE is used to
check the orientation of the VAD cannulae to detect and correct obstruction of the
inflow cannula against the wall of the ventricle. Intracardiac air is identified and
removed. While weaning a VAD patient from CPB, TEE helps maintain stable
hemodynamics with its ability to assess the assisted ventricle’s decompression
and the nonassisted ventricle’s volume and function, including the detection of
acute atrioventricular valve incompetence that can accompany acute ventricular
failure. This is especially an issue with LVAD patients, where impaired RV
function may limit LV preload, and hence the VAD’s ability to deliver a normal
cardiac output. Once off CPB but before decannulation, agitated saline contrast is
injected into the RA to rule out right-to-left shunting not detected before CPB
because of elevated left heart filling pressures. With a properly functioning
LVAD, the AV typically will not open after CPB. The function of a VAD
depends on an adequate filling volume, and TEE can be helpful in making
decisions about fluid replacement therapy. Some LVAD patients are expected to
have recovery of ventricular function and eventual explantation of the VAD.
Usually, the timing of the explantation is determined by periodically decreasing
the VAD flow while TEE is used to assess the function of the recovering
ventricle. TEE is also very helpful in the detection of postoperative
complications such as cardiac tamponade and VAD prosthetic valve dysfunction.
J. Minimally invasive cardiac surgery
TEE monitoring is critical to the safe conduct of cardiac surgery with CPB
performed through percutaneous access and limited surgical incisions. It is used
to assure the proper placement of guide wires and to position cannulae and
catheters, as well as detect their displacement during the procedure. Because
there is limited or no direct view of the heart during minimally invasive surgery,
TEE is relied on to detect distention or inappropriate myocardial contraction
during CPB. Likewise, TEE is the best way of judging cardiac volume and
function while weaning from CPB. As with conventional cardiac surgery, TEE is
necessary to follow deairing of the left heart and the adequacy of the surgical
intervention during minimally invasive cardiac surgery.
K. Transcatheter valve interventions
Catheter-based techniques to repair or replace cardiac valves have undergone
great advances in recent years and are being performed more often at more
medical centers. Guidelines for the use of echocardiography during these
procedures have been published [15].
The most widespread of these procedures is transcatheter aortic valve
replacement (TAVR) for AS. TEE may be used to help size the device, but this is
probably best done before the procedure, and other techniques such as CT and
MRI may be more accurate. TEE can be used to help position the device during
TAVR, but fluoroscopy is probably more important in most cases. TAVR
complications, such as annular rupture or RV perforation, may be detected with
TEE, and TEE, as with other types of cardiac interventions, can be a very useful
monitor of cardiac function during the procedure. TEE is probably the best way
to detect and localize AR during TAVR, but it is possible to rule out significant
AR fluoroscopically with an aortic root injection. Many anesthesiologists
believe that general anesthesia with endotracheal intubation is the safest way to
manage the airway during TEE for TAVR, and many centers are forgoing TEE in
favor of sedation techniques. In some cases, transthoracic echocardiography is
employed with moderate conscious sedation, and TEE is used on an as-needed
basis.
Transcatheter repair of the MV for MR is emerging as an effective procedure
in selected cases considered too high risk for conventional surgery. In contrast to
TAVR, where the role of TEE is diminishing, most of the transcatheter mitral
procedures require TEE to properly position and deploy the device, and these
patients are typically anesthetized and intubated. The use of real-time TEE
imaging in three-dimensions has probably contributed to some of the success of
these mitral interventions by clearly showing the position as the device is being
manipulated into position. TEE is also unsurpassed in assessing the severity and
mechanism of MR in real time, often guiding the conduct of the procedure.
IX. 3D echocardiography
3D reconstruction of echocardiographic images from a series of 2D images has
been in clinical use for over 20 years. This technique has been most helpful in
assessing complex congenital heart defects. TEE transducers that acquire
echocardiographic data from a volume of space and create a 3D image in real time
are now commercially available and are being used at many centers for
intraoperative applications. Reports are appearing in the literature describing how
3D echocardiography adds important information to the standard 2D examination.
3D TEE is already providing new and useful information about the anatomical
relationships of complex structures close to the LA, such as the MV. As this
technology continues to evolve and becomes more practical, 13 echocardiography
will be transformed in the same way as was in the 1970s with the development of
2D imaging.
A. Fundamental limitations of ultrasound imaging
The ability to use ultrasound to make medical images is based on a fundamental,
physical fact: The velocity of sound transmission through soft tissue is relatively
constant at about 1,540 m/sec. But this fact also imposes a fundamental limitation
that becomes important in 2D echocardiography and critical in 3D. Since it takes
a fixed amount of time for ultrasound to leave a transducer, travel to and from the
reflector in the tissues, and be detected by the transducer, there is an absolute
limit to the pulses per second of ultrasound (pulse repetition frequency) a system
can transmit without one pulse interfering with the reflection of the previously
sent pulse. Thus, the absolute maximum pulse repetition frequency, when imaging
at 15 cm depth (30 cm travel distance), is about 5,000 pulses/sec. An ultrasound
system constructs the image by synthesizing information from many pulses,
rapidly scanning the ultrasound beam through a plane for 2D or a volume of
space in real-time 3D, and is limited in either the width and depth of the image or
the speed with which it can generate a coherent image (frame rate).
There are two methods of producing 3D images with ultrasound: (i) Off-line
computed rendering of a series of 2D images acquired separately within a short
period of time and (ii) real-time insonation of a volume of tissue.
B. Computed rendering of 2D images into 3D
Off-line rendering has been available for over 20 years and uses the same
computing algorithms developed in radiology for 3D renderings of CT and MRI
images. In the past, these techniques had been limited to the radiology suite, but
as the cost and size of computers dramatically fell, the technology was applied to
portable ultrasound systems and currently is capable of producing a high-quality
3D image with a TEE transducer in about 2 minutes. The process begins with the
positioning of the TEE probe and development of a 2D image of the structure to
be examined. Then, as the probe is held perfectly still, a series of 2D images are
acquired by automatically advancing the multiplane angle through 180 degrees
stepwise in 3- to 5-degree increments. Image acquisition is triggered by the ECG
so that each 2D image starts and ends at the same point in the cardiac cycle, and
translation of the heart (changing of the heart’s position within the thorax)
minimized, usually by gating acquisition to end expiration or by pausing
ventilation, which is easily accomplished in anesthetized patients. With TEE,
acquisition takes about 1 minute. Once image acquisition is completed, the
system then combines the series of 2D images into a 3D image in about 20 or 30
seconds. The main advantages of the off-line rendering are the ability to create
3D images of larger volumes at higher frame rates than real-time 3D and images
that include CFD in much greater detail. Off-line rendering can be done with a
conventional 2D multiplane TEE probe. The disadvantages are the time it takes
to create the image and the requirement to keep the heart from translating during
acquisition. Also, 3D rendering is less accurate in patients with irregular
rhythms.
C. Real-time insonation of a volume of tissue
TEE probes capable of real-time 3D image acquisition have been commercially
available since 2009. The 3D TEE transducer has a rectangular array of over
2,000 elements that systematically scans an ultrasound beam through a pyramidal
volume of tissue with the apex at the probe. This creates a 3D image that
responds to real-time probe manipulation and heart translation and requires no
extended time to acquire or render. But real-time 3D is much more limited than
off-line rendering in its frame rate and its displayed image width and depth, and
real-time CFD is much more limited as well. Newer versions of real-time 3D
systems can increase the size of the volume acquired or the quality of CFD by
acquiring five to seven real-time beats and “stitching” them into a more detailed
or larger image. This requires ECG and respiratory gating, but over a shorter
period than conventional off-line rendering systems. The real-time 3D TEE
probe is a little larger than a 2D multiplane probe, and considerably more
expensive.
FIGURE 5.9 The MV in mid-diastole viewed from the atrial side. * indicates the anterior leaflet and × the posterior leaflet.
An oblique view of the AV is seen, as well. PV, pulmonic valve; AV, aortic valve; RA, right atrium.
FIGURE 5.10 Two-dimensional (2D) views of the heart derived from a three-dimensional (3D) volume of data. Plane A is
a four-chamber view, Plane B is a two-chamber view, and Plane C is an SAX view. The lines show how the 2D planes are
aligned within the 3D volume and can be manipulated with the software to modify the 2D images displayed.
D. 3D image display and manipulation

Once a 3D echo image (dataset) has been acquired, it can be displayed in a
number of ways. It is typically shown as a pyramidal-shaped volume that may be
manipulated using the system software (Fig. 5.9). The volume can be rotated on
each of three axes, allowing it to be seen from any point of view; top or bottom,
front or back, left or right. The volume of data may also be cropped from any
side by using an editing function that removes part of the image with an erasure
plane that is gradually brought into the pyramid until the desired structure is
exposed. Some systems can create a 2D image by orienting a plane through the
3D volume. Another display mode shows two or more 2D images of the
structures simultaneously in synchronized motion (Fig. 5.10). The 3D volumetric
displays are highly processed images that require smoothing and interpolation by
computer algorithms and are thus prone to artifacts, especially dropout. It takes
some time and practice to learn how to properly fine tune the settings of the
system to optimize 3D image quality, but this technology is advancing rapidly,
making it simpler and quicker to get high-quality 3D images. While 3D echo will
provide us with new insights into the structure and function of complex structures
such as the MV, for now significant findings should be confirmed and refined
with 2D imaging.
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6 Induction of Anesthesia and Precardiopulmonary
Bypass Management
Ferenc Puskas, Anand R. Mehta, Michael G. Licina,
and Glenn P. Gravlee
I. Introduction
II. Premedication
III. Preinduction period
A. Basic monitors
B. Invasive monitors
C. Clinical tips
D. Last-minute checks
IV. Induction
A. Attenuation of hemodynamic responses
B. Guiding principles
C. Anticipated difficult intubation
V. Drugs and pharmacology for induction of anesthesia
A. Opioids
B. Other intravenous (IV) anesthetic agents
C. Inhalational agents
D. Muscle relaxants
E. Applications of old drugs in sick patients
F. Inhalational induction in very sick patients
VI. Immediate postinduction period
VII. Management of events between anesthetic induction and
cardiopulmonary bypass (CPB)
A. General principles
B. Preincision
C. Incision
D. Opening the sternum
E. During and after sternal spreading
F. Concerns with cardiac reoperation (“redo heart”)
G. Concerns with urgent or emergent cardiac operation
H. Internal mammary artery (IMA) and radial artery dissection
I. Sympathetic nerve dissection
J. Perioperative stress response
K. Treatment of hemodynamic changes
L. Preparation for cardiopulmonary bypass
KEY POINTS
1. On the day of surgery, most cardiovascular medications should be

administered, with the exceptions of angiotensin-converting enzyme
(ACE) inhibitors, angiotensin receptor blockers, and (selectively)
diuretic agents.
2. Prior to induction of anesthesia, critical emergency drugs should be
prepared for immediate administration. Practices vary, but these
drugs should include a vasopressor, vasodilator, inotrope, β-
adrenergic blocker, and heparin.
3. Induction of anesthesia can be achieved using many different
approaches. The most important underlying principle is avoiding
hypotension while also suppressing the stress response.
4. Hemodynamically tenuous patients likely will not tolerate traditional
induction doses of propofol, but even drugs typically unassociated
with hypotension can cause hypotension in cardiac surgical patients
as a result of anesthetic-induced reduction in sympathetic tone,
synergistic circulatory depression when some induction drugs are
given in combination, and/or initiation of positive pressure
ventilation.
5. Opioids suppress the stress response in a dose-related manner until
a maximum effect is reached at an approximate dose-equivalency of
8 µg/kg of fentanyl.
6. Etomidate offers hemodynamic stability during induction, but also
suppresses adrenal cortical function for approximately 24 hours.
7. Potent inhalational agents induce vasodilation and some
myocardial depression, but can be safely used during induction
especially to complement intravenous (IV) agents such as etomidate
and fentanyl.
8. The reported incidence of ischemia during the precardiopulmonary
bypass (pre-CPB) period ranges from 7% to 56%.
9. The Society of Thoracic Surgeons (STS) recommends a
cephalosporin as the primary prophylactic antibiotic for adult
cardiac surgery. In patients considered high risk for staphylococcus
infection (either presumed or known staphylococcal colonization), it
is reasonable to combine cephalosporins with vancomycin.
10. During a high-dose narcotic-based anesthetic, the reported incidence
of hypertension during sternotomy is as high as 88%.
11. Sinus tachycardia with heart rates (HRs) greater than 100 beats/min
has been associated with a 40% incidence of ischemia. HR greater
than 110 beats/min was associated with a 32% to 63% incidence of
ischemia.
I. Introduction
Induction of anesthesia in a cardiac patient is more than a simple transition from an
awake to a stable anesthetic state. Considering all aspects of the patient’s cardiac
condition allows selection of an anesthetic that best accommodates the patient’s
current cardiac status and medications. No single agent or technique can guarantee
hemodynamic stability. Hemodynamic change with induction can be attributed to
the patient’s pathophysiology and to a reduction in sympathetic tone potentially
causing vasodilation, cardiac depression, and relative hypovolemia. The period
between anesthetic induction and the initiation of cardiopulmonary bypass (CPB)
also poses numerous challenges to the anesthesia and surgical teams.
II. Premedication
A. Just as the patient’s chronic medications can mostly be used to advantage,
so can anesthetic premedication (e.g., intravenous [IV] midazolam,
lorazepam, or fentanyl) become an integral component of the anesthetic
technique.
B. With rare exception, chronic cardiac medications should be administered
orally preoperatively on the day of surgery with as little water as possible.
1. 1 Some clinicians prefer to withhold diuretics on the morning of surgery,
which seems reasonable.
2. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor
blockers have been associated with hypotension following induction of
anesthesia (and perhaps during separation from CPB). Although somewhat
controversial, we prefer to discontinue the patient’s usual dose of these drugs 1
day (24 hours) before surgery in order to reduce the risk for hypotension and
for acute kidney injury that has been associated with ACE inhibitor use in
cardiac surgery [1].
III. Preinduction period
Unstable patients (e.g., critical aortic stenosis, congestive heart failure) probably
should not be premedicated before they reach a preanesthetic holding area that
permits observation by an anesthesia caregiver, and we perceive that few
practitioners currently administer sedatives or opioids prior to the patient’s arrival
in such an area. Some examples of premedication regimens are shown in Table
6.1, but monitoring catheters, such as arterial and central venous “lines,” ideally
should be placed under the influence of premedication, such as IV midazolam (if
not after induction of anesthesia).
A. Basic monitors and supplemental oxygen are important to initiate before
giving supplemental sedation (if needed) and placing invasive monitors.
1. Electrocardiogram
2. Noninvasive blood pressure (BP)
3. Pulse oximeter
TABLE 6.1 Anesthetic premedication for cardiac surgical patients
B. Invasive monitors can be useful during induction [2], so some clinicians

choose to place central “access” catheters, such as a central venous catheter or
pulmonary artery catheter (PAC), before induction of anesthesia. It appears that
most anesthesiologists defer central line placement until after anesthetic
induction, which is an equally acceptable approach that does not appear to affect
patient outcomes. In patients with low cardiac outputs, onset time for anesthetic
induction drugs and for vasoactive drugs can be noticeably delayed when this
approach is chosen. It appears that most anesthesiologists prefer to place the
arterial catheter before inducing anesthesia, as do we, but some prefer to await
induction of anesthesia for this intervention as well.
CLINICAL PEARL Most practitioners place central venous catheters (including
PACs) after induction of anesthesia, although this can also be accomplished before
induction with the aid of judicious sedation.
1. In emergency situations, it may be necessary to proceed with anesthetic
induction before placing invasive monitors. In these situations, if a large-bore
IV catheter is already present, opening the chest is far more important than PAC
or central venous pressure (CVP) catheter measurements. It is highly desirable
to initiate intra-arterial BP monitoring before anesthetic induction in such
cases. If the anesthesiologist is busy stabilizing the patient and preparing for
induction, the surgery team can be asked to assist with radial or femoral
arterial catheter (henceforth termed “line”) placement under local anesthesia.
C. Clinical tips in preparing for cardiac anesthesia
1. Emergency drugs that may be needed can be prepared as dilute bolus doses in
syringes or as IV or syringe infusion pumps attached to a peripheral IV or to the
infusion port or side-port of the introducer of the pulmonary artery (PA) (or
some other central venous) catheter via a manifold.
2. The drugs selected for anesthesia depend on the patient’s condition and
the preferences of the anesthesiologist.
a. Commonly fentanyl or sufentanil, and less commonly remifentanil, are
selected as opioids.
b. Among the potent inhalational agents, isoflurane probably should be selected
for economy, desflurane for rapid titratability, and sevoflurane for
inhalational induction or for an airway that is suspected to be difficult (as a
judgment-based alternative to awake intubation).
c. IV amnestic agents may include benzodiazepines such as midazolam,
lorazepam, or diazepam, or any of the traditional induction agents described
below.
d. For muscle relaxation, succinylcholine (or no muscle relaxant) is suggested
for a suspect airway; pancuronium for low heart rates (HRs); vecuronium,
rocuronium, or cisatracurium for hemodynamic blandness; and cisatracurium
in the case of liver or renal failure. Note that even moderate-to-severe
impairment in renal or hepatic function need not contraindicate any muscle
relaxant per se, but may instead simply merit adjustments in dosing frequency.
3. Specific cardiovascular medications to have available before surgery:
a. 2 Anticholinergic: Atropine (preferred over glycopyrrolate for faster onset)
b. Inotrope: Epinephrine, dobutamine, or dopamine as infusions; epinephrine
also in a syringe for bolus administration
c. Phosphodiesterase III inhibitor: Milrinone
d. Calcium chloride (27.2 mg/mL elemental calcium) or calcium gluconate (9.3
mg/mL elemental calcium)
e. Ephedrine as a bolus (mixed vasopressor/inotrope)
f. Vasopressors
(1) Phenylephrine as a 50- to 100-μg bolus, or as an infusion, or
norepinephrine
(2) Vasopressin (for vascular collapse and resuscitation, especially after left
ventricular (LV) assist device placement and with pulmonary
hypertension)
g. Vasodilators: Nitroglycerin, nicardipine, clevidipine, or nitroprusside
h. Antiarrhythmics and antitachycardic agents
(1) Adenosine
(2) Esmolol, metoprolol
(3) Diltiazem or verapamil
(4) Lidocaine
(5) Amiodarone
(6) Magnesium
i. Anticoagulation and its reversal
(1) Heparin
(2) Protamine
CLINICAL PEARL To be most prepared, at least one inotrope, one vasopressor, and one
vasodilator should be set up and connected in a pump that is preprogrammed and ready to
use. Similarly, syringes should be prepared for bolus administration of at least one
vasopressor, inotrope, vasodilator, and probably a β-adrenergic blocker as well.
j. A custom-built IV pole with a built-in electrical outlet and the capability for
attachment of multiple IV infusion or syringe pumps should be available. In
the case of syringe pumps, battery operation is acceptable if there is a reliable
mechanism for recharging the syringe pumps before each procedure.
D. Last-minute checks. Immediately before anesthetic induction, the following
points should be considered:
1. Reassessment of the patient’s overall cardiopulmonary and airway status
2. Integrity of breathing circuit and immediate availability of suction
3. Availability of blood for transfusion
4. Proximity of a surgeon or a senior resident
5. Any special endotracheal tube (double-lumen, bronchial blocker) or intubation
(video laryngoscope, intubating stylet) needs
6. Immediate availability of emergency cardiac drugs
IV. Induction
The cardiac anesthesiologist must often induce a patient who under normal
circumstances would not receive a general anesthetic. Objectives include:
A. 3 Attenuation of hemodynamic responses to laryngoscopy and surgery
without undue hypotension
1. Conservative drug amounts, as the anesthetic requirement rapidly becomes
relatively minor during surgical skin preparation and draping (exception: high-
dose opioid induction technique, e.g., 50 µg/kg of fentanyl) (Table 6.2)
TABLE 6.2 Recommended induction doses
2. Use drug onset time and interactions to advantage.

3. Adapt induction drug doses to physical status of patient.
B. Guiding principles for anesthetic induction include:
1. Modifications of techniques as new knowledge are gained. For example, trace
the history of sufentanil as used during anesthetic induction.
a. In the 1980s, the recommended induction dose of sufentanil was as high as 25
µg/kg.
b. In the 1990s, recommendations changed to 6 to 10 µg/kg.
c. In the new millennium, as little as 0.1 µg/kg is used.
d. Combinations of sufentanil or fentanyl with etomidate and muscle relaxants
exemplify efficient induction techniques.
2. Physiologic issues
a. Hypovolemia, which is often difficult to assess, is frequently caused by
diuretics and prolonged nothing by mouth (NPO) status.
(1) This is difficult to assess because of the usual absence of preoperative
urine output documentation or LV preload assessment.
(2) Many cardiac surgical patients do not tolerate more than 10% depletion
of intravascular volume without hemodynamic compromise.
(3) Tachycardia and vasoconstriction, which are useful compensatory
mechanisms in normal individuals, may be deleterious in cardiac patients
or may be impaired or even precluded as a result of the patient’s chronic
cardiovascular drug regimen.
(4) Anesthetic drugs may impair appropriate hemodynamic responses [3].
(a) Propofol reduces BP by inducing venodilation with peripheral
pooling of blood, decreasing sympathetic tone to decrease systemic
vascular resistance (SVR), and depressing myocardial contractility.
(b) In decreasing order of circulatory depression, propofol is most
depressant, midazolam is intermediate, and etomidate is the least
depressant.
(5) The most physiologically efficient method of combating hypovolemia is
to augment intravascular volume in the preinduction period using
balanced salt solutions, being careful not to overdo this in patients with
mitral valve lesions or congestive heart failure. The presence or absence
of susceptibility to congestive heart failure may be subtle in patients with
LV diastolic dysfunction. In general, the trend has been toward more
conservative use of fluids in the pre-CPB period in order to minimize
hemodilution and the need for erythrocyte (RBC) transfusion. At times,
this occurs at the expense of circulatory support with vasopressors. This
philosophy is sound as long as sufficient cardiac output is maintained to
perfuse the vital organs and (arguably) is most safely applied if one can
measure cardiac output to ensure an adequate cardiac index (under
anesthesia, probably greater than or equal to 1.8 L/min/m2). The
preinduction initiation of a prophylactic inotropic infusion (e.g., low-
dose epinephrine 0.01 to 0.03 mcg/kg/min or dopamine 1 to 3
mcg/kg/min) in patients with low LV ejection fractions (or with
preserved LV function with documented episodes of diastolic heart
failure) sometimes helps to maintain a stable perfusion pressure and
cardiac output until surgical incision commences.
3. Pharmacodynamic issues. With the exception of ketamine, which can stimulate
the cardiovascular system, all anesthetics decrease BP by some combination of
removing 4 sympathetic tone, directly decreasing SVR, directly depressing the
myocardium, increasing venous pooling (reducing venous return), or inducing
bradycardia.
Important individual drug characteristics to be considered:
a. In critically ill patients, ketamine can decrease BP because depletion of
catecholamines may lead to an inability of indirect central nervous system
(CNS)-mediated sympathomimetic effects to counterbalance its direct
negative inotropic effects. Even in such patients, hypotension appears to be an
uncommon response to ketamine.
b. The conflict between the need to attenuate the hemodynamic response to
intubation and other noxious stimuli without overdosing can be illustrated by
propofol.
(1) Propofol may induce hypotension if used for induction, yet a small dose
may not suppress the hypertensive response to laryngoscopy.
(2) In combination with other drugs: After an induction dose of propofol,
systolic BP fell an average of 28 mm Hg when no fentanyl was
administered, whereas it fell 53 mm Hg when 2 µg/kg of fentanyl was
administered. However, the hemodynamic response to intubation was
decreased in proportion to the preinduction dose of fentanyl [4].
(3) Propofol can be given in small increments (0.5 to 1 mg/kg) judging from
the patient’s physical status and can be used with a small well-timed
dose of opioid (e.g., 1 to 3 µg/kg of fentanyl 2 to 4 minutes preceding
propofol).
CLINICAL PEARL During induction of anesthesia, the dosing and timing of sedative–
hypnotics, inhalational agents, opioids, and muscle relaxants to avoid awake paralysis and
chest wall rigidity while optimizing stress response suppression, mask ventilation, and
intubating conditions epitomize the “art” of cardiac anesthesia.
c. The principle of using the relationship between the plasma drug concentration
and the bioeffector site onset (biophase or Ke0) must be considered, such that
the maximal effects of both the opioid and hypnotic are used to best
advantage.
(1) The mean onset time for peak effect of propofol is 2.9 minutes and for
fentanyl is 6.4 minutes. Ideally, endotracheal intubation should be
performed at the peak concentration of both drugs and after optimal
muscle relaxation has been achieved. This may require a second dose or
a continuous infusion of ultra–short-acting induction agents such as
propofol, because the muscle relaxant onset time may occur after the
peak effect of the bolus dose of the induction agent has dissipated from
rapid redistribution.
CLINICAL PEARL Increasing the opioid dose beyond 8 μg/kg of fentanyl, 0.75 μg/kg
of sufentanil, or 1.2 μg/kg/min of remifentanil does not further attenuate the stress response
(increased BP and HR) to intubation.
d. Depth of anesthesia provided by propofol or other sedative–hypnotic agents
does not determine the degree of stress–response suppression; rather, the CNS
level of opioid analgesia tends to do so.
e. Reducing the doses of anesthetic drugs is often the safest way to induce
critically ill patients.
f. For a hemodynamically stable patient, one might prefer a hemodynamically
bland muscle relaxant. For patients with a baseline HR less than 50 beats/min
or with valvular regurgitation, either pancuronium (if available) or a small
dose of glycopyrrolate (e.g., 0.2 mg) or atropine (e.g., 0.4 mg) might be useful
to increase HR to 70 to 80 beats/min.
g. Induction drugs are administered most efficiently through a central venous
catheter, such as the side-port introducer, or an infusion port in a PAC. This is
one disadvantage to central venous/PA catheter placement after induction of
anesthesia.
h. Muscle relaxants are given early in the sequence. Onset time is important
to consider. This can be defined for most agents in the context of ED95, or the
average dose required to induce 95% suppression of the twitch response. For
most nondepolarizing neuromuscular blockers, the time to achieve maximum
twitch suppression at a dose of 1 × ED95 is 3 to 7 minutes. Use of 2 × or 3 ×
ED95 reduces onset time to 1.5 to 3 minutes, and to as low as 1 to 1.5 minutes
for 3 × ED95 with rocuronium (0.9 mg/kg).
(1) Succinylcholine (1 to 2 mg/kg) can be used to reduce onset time of
neuromuscular blockade to 1 to 1.5 minutes.
CLINICAL PEARL Muscle relaxant timing is important during induction, that is, early
enough to avert opioid-induced chest wall rigidity but late enough to avoid awake paralysis.
i. An example of a drug combination that combines rapid onset (intubating
conditions in 1 to 2 minutes) and good suppression of the stress response to
laryngoscopy is remifentanil 1 µg/kg, etomidate 0.2 mg/kg, and
succinylcholine 1.5 mg/kg, all administered as a simultaneous bolus.
j. High-dose opioid induction techniques:
(1) Achieved popularity in the early 1970s with morphine (1 to 2 mg/kg) and
in the late 1970s with fentanyl (50 to 100 µg/kg) because of the
combination of excellent stress–response suppression and hemodynamic
stability.
(2) Sufentanil (10 to 25 µg/kg) rose to popularity for the same reasons in the
1980s.
(3) This technique lost favor in the 1990s because of long postoperative
intubation times, but it is still potentially useful for high-risk patients
who will require overnight mechanical ventilation regardless of the
anesthetic technique chosen.
(4) Because of the marked vagotonic effects of bolus high-dose opioids,
pancuronium nicely complements this technique, especially if given early
enough in the induction sequence to minimize chest wall rigidity.
(5) These doses of fentanyl and sufentanil can be given as a bolus or over 3
to 5 minutes. Morphine, now seldom used in cardiac anesthesia, must be
given slowly (5 to 10 mg/min) to avoid hypotension. A 2009 study
indicated that morphine may still have a place in cardiac anesthesia, as it
reduced the degree of postoperative pain and the incidence of
postoperative fever [5].
(6) Beware of hypotension if hypnotics are given simultaneously and of
inadequate amnesia if they are not.
C. Anticipated difficult intubation. The cardiac patient with a difficult airway
imposes a conflict between our instincts to preserve and protect the airway
and those to avoid hemodynamic stress. Concerns about loss of airway
control supersede those about hemodynamic stimulation, yet both airway
safety and hemodynamic stability can be achieved with awake intubation.
Suggestions for accomplishing “awake” endotracheal intubation (by any of
several techniques) while still preventing potentially deleterious hemodynamics
follow:
1. Adequate airway anesthesia either greatly attenuates or prevents the
hemodynamic stress of endotracheal intubation. Specific techniques that may
prove helpful include:
a. Nebulized 4% lidocaine for 15 or more minutes prior to airway
instrumentation.
b. Topical sprays such as 2 sec of Cetacaine or 4% lidocaine, although toxicity
can result from either of these agents if used to excess.
c. Nerve blocks: Glossopharyngeal and superior laryngeal blocks can
anesthetize the pharynx down to the level of the vocal cords. They should be
used with caution, as subsequent anticoagulation could lead to hematoma in
case of vascular puncture.
d. Transcricoid or transtracheal injection of 4% lidocaine can suppress the
cough reflex, as can injection of 4% lidocaine via the suction or injection port
of a fiberoptic bronchoscope upon reaching the vocal cords and trachea.
e. A dexmedetomidine bolus and/or infusion offers a useful adjunct to awake
intubation, because it provides some analgesia and stress response
suppression while preserving respiration and responsiveness to verbal
commands. An IV bolus or a continuous infusion of esmolol can also assist in
suppressing hypertension and tachycardia during awake intubation.
CLINICAL PEARL Awake intubation is safe in cardiovascularly unstable patients as
long as adequate airway anesthesia is provided.
2. Low-to-moderate levels of sedation can facilitate patient cooperation and
may induce amnesia:
a. Midazolam titrated to effect.
b. Opioids in low doses (not amnestic), but beware of the combined sedative
and respiratory depressant effects of opioids combined with
sedative/hypnotics, such as midazolam.
c. Conservative infusion doses of propofol (e.g., 10 to 40 µg/kg/min) can be
helpful and may reduce the gag and cough reflex modestly, but can also result
in dysphoria or airway obstruction.
d. Some practitioners select dexmedetomidine for this purpose, whereas others
remain unimpressed with its efficacy or desirability. Favorable aspects
include sedation (without reliable amnesia!), tendency to decrease HR and
BP, and possibly modest airway reflex suppression. For awake intubation,
typically a bolus dose of 1 µg/kg administered is administered intravenously
for awake intubation over approximately 10 minutes, followed by a regular
infusion of 0.2 to 1.0 µg/kg/hr as maintenance.
3. Adjuncts that may help prevent or treat hypertension or tachycardia:
a. β-Adrenergic blockers (e.g., esmolol bolus [0.25 to 1 mg/kg] or infusion
[100 to 300 µg/kg/min])
b. Vasodilators (e.g., nicardipine 500 to 750 µg or nitroglycerin 50- to 100-µg
bolus, or continuous infusion titrated to effect)
c. Mixed adrenergic blocker: IV labetalol titrated to effect (bolus dose typically
10 to 20 mg every 5 to 10 minutes)
d. Be prepared to proceed with a gentle IV induction once endotracheal
intubation has been achieved. If the preparations above have been successful,
the patient will tolerate the presence of the endotracheal tube without
coughing or distress, which reduces the urgency to proceed with induction.
V. Drugs and pharmacology applied to induction of anesthesia
A. Opioids
1. Basic structures and opioid receptors
a. Rigid interlocked molecules of the morphine group known as pentacyclides
and flexible molecules of phenylpiperidine rings, such as fentanyl
b. There are three opioid receptors (µ, κ, and δ) with subgroups.
(1) Opioid receptors are γ-protein–coupled receptors.
2. Properties of opioids. Analgesia is more than the relief of pain or of the
conscious perception of a nociceptive stimulus. A noxious stimulus can affect
an ostensibly unconscious (and unparalyzed) person as demonstrated by
movement in the form of a withdrawal reflex. The stimulus can produce
increased autonomic activity. Narcotics in general are poor hypnotics and
cannot be counted upon to induce amnesia.
3. Induction pharmacokinetics:
a. Pharmacokinetics are similar among three modern synthetic opioids (fentanyl,
sufentanil, and alfentanil) with a few differences [6].
(1) All have a three-compartment model.
(2) Ninety-eight percent of fentanyl is redistributed from the plasma in
the first hour.
(3) Brain levels parallel plasma levels with a lag of 5 minutes.
(4) Fentanyl has a large volume of distribution, which can limit hepatic
access. However, the liver will clear all the fentanyl it gets.
(5) Sufentanil is 7 to 10 times more potent than fentanyl. It has a higher pKa
and only 20% is ionized.
(6) Sufentanil is half as lipid soluble as fentanyl and is more tightly bound to
receptors. It has a lower volume of distribution and a faster recovery
time.
(7) Alfentanil, typically administered as a continuous infusion, is less potent
than fentanyl and shorter acting than sufentanil, but has been largely
superseded by remifentanil (see below).
4. Remifentanil pharmacokinetics:
a. Remifentanil has a unique pharmacokinetic profile, as it is subject to
widespread extrahepatic hydrolysis by nonspecific tissue and blood esterases.
b. It has an onset time of 1 minute and a recovery time of 9 to 20 minutes. These
properties make it very advantageous when there is variation of surgical
stimulus or a desire for early postoperative extubation. The anesthesiologist
can give as much as he or she feels is needed without impeding rapid
recovery.
c. Careful provision of postoperative pain control is essential, as remifentanil-
induced analgesia dissipates rapidly after the infusion is terminated.
B. Other intravenous (IV) anesthetic agents for induction
1. Etomidate
a. Etomidate, a very useful induction agent for cardiac patients, is 10 times
more potent than propofol, with a recommended dose range of 0.15 to 0.3
mg/kg.
b. It is reliable at achieving hypnosis, especially when combined with an opioid.
Administering the primary dose just after giving an opioid may attenuate
myoclonus, which sometimes occurs as a result of subcortical disinhibition.
c. 6 Etomidate reaches the brain in 1 minute.
d. There may be an increased incidence of epileptiform activity in patients with
known epileptic seizure disorders.
e. An induction dose of etomidate typically produces a 10% to 15% decrease in
mean arterial pressure (MAP) and SVR and a 3% to 4% increase in HR and
cardiac output.
f. Importantly, stroke volume, left ventricular end-diastolic volume (LVEDV),
and contractility remain unchanged in normovolemic patients.
g. Etomidate can be used to anesthetize heart transplant patients, because it
preserves myocardial contractility better than any induction technique other
than a high-dose opioid induction.
h. Although traditional induction doses of etomidate and opioids given
individually most often preserve hemodynamics, when they are given together
hypotension may ensue.
i. Since even a single dose of etomidate has been shown to induce significant
adrenal suppression for more than 24 hours (not associated with increased
vasopressor requirement), it should be used with caution in high-risk cardiac
surgical patients or followed by glucocorticoid supplementation for 24 to 48
hours [7].
2. Propofol
a. A normal induction dose of 2 mg/kg will drop BP 15% to 40%.
b. Because propofol resets the baroreceptor reflex, lower BP does not increase
HR.
c. There are significant reductions in SVR, cardiac index, stroke volume, and LV
stroke work index.
d. There is direct myocardial depression at doses above 0.75 mg/kg.
e. Propofol should be titrated according to the patient’s age, weight, and
individual need and ideally injected into a central vein, thereby allowing the
smallest dose to be used effectively and avoiding pain on injection.
f. Propofol’s metabolic clearance is 10 times faster than that of thiopental.
g. There is extensive redistribution and movement from the central compartment
to a peripheral one, which enables rapid recovery.
h. Because it has direct myocardial depressant effects and easily induces
hypotension, propofol should be used with caution (e.g., titrated over 2 to 3
minutes) or reserved for use in hemodynamically stable cardiac patients with
good ventricular function.
3. Thiopental
a. Thiopental is currently not available in the United States, but it is still
used in some other countries.
b. It has a rapid onset and can be used safely in hemodynamically stable
patients.
c. Rapid redistribution to highly perfused tissues causes cessation of thiopental’s
effects.
d. Cardiovascular effects
(1) Predominantly venous pooling and resultant decreased cardiac preload.
(2) Myocardial depressant above 2 mg/kg.
(3) Increases HR by activating baroreceptor reflex.
(4) In patients who have low cardiac output, a greater proportion of the drug
dose goes to the brain and myocardium; thus, a smaller amount of
thiopental has a larger effect.
(5) Overall, there is a dose-related negative inotropic effect from a decrease
in calcium influx.
4. Midazolam
a. Midazolam is a good premedicant but is difficult to titrate to a minimum
effective dose for induction because of a large variation in the hypnotic
dose and a relatively slow onset time to peak CNS effect of 3 to 7
minutes. A typical induction dose is 0.1 to 0.2 mg/kg.
b. It is an effective amnestic, and this constitutes its appeal.
c. The hypotensive effect from an induction dose is similar to or less than that
for thiopental, and it is dose related.
d. In patients who have high cardiac filling pressures, midazolam seems to
mimic low-dose nitroglycerin by reducing filling pressures.
e. The addition of opioids produces a supra-additive hypotensive effect.
CLINICAL PEARL Carefully titrated boluses or infusions of midazolam have become a
mainstay of cardiac anesthesia.
5. Lorazepam and diazepam
a. Lorazepam is a very potent benzodiazepine (approximately 1.5 times as potent
as midazolam), and diazepam is approximately half as potent as midazolam.
b. Because of its potency, lorazepam produces anxiolytic, sedative, and amnestic
effects in lower doses and with fewer side effects than midazolam.
Diazepam’s cardiovascular effects are comparable to those for midazolam,
that is, generally modest preload and afterload reduction that appears to be
enhanced in the presence of potent opioids such as fentanyl, sufentanil, and
remifentanil.
c. Lorazepam is useful in sick cardiac patients when only small amounts of drugs
are desired. Both lorazepam and diazepam can complement high-dose opioid
inductions as long as the slower onset times are understood and
accommodated.
d. If rapid recovery is expected, as in minimally invasive direct coronary artery
bypass surgery, lorazepam is a poor choice because of its relatively long
clinical action (typically several hours). Diazepam in moderate-to-high doses
(greater than 0.15 mg/kg for most patients) can exhibit a prolonged action as
well, and it has an active metabolite. Diazepam’s clinical offset is
disproportionately prolonged in elderly patients when compared to lorazepam
or midazolam.
e. Onset times are relatively slow (lorazepam peaks in 5 to 10 minutes,
diazepam is slightly faster) in the context of induction of anesthesia, but are
acceptable in the context of IV sedation for “line” placement before induction
of anesthesia.
6. Ketamine
a. Ketamine produces a unique cataleptic trance known as dissociative
anesthesia.
b. It is extensively redistributed and eliminated.
c. Bioavailability on IV injection is 97% and 2 mg/kg produces unconsciousness
in 20 to 60 seconds.
d. Ketamine induces significant increases in HR, MAP, and plasma
epinephrine levels. This sympathetic nervous system stimulation is centrally
mediated.
e. Ketamine may be advantageous in hypovolemia, major hemorrhage, or cardiac
tamponade.
f. It allows amnestic obtundation of the hemodynamically unstable patient,
giving the surgeon an opportunity to rapidly intervene and correct a life-
threatening problem (e.g., cardiac tamponade). In these situations, skin
preparation should be performed before induction.
g. The hemodynamic stimulatory effect of ketamine depends on the
presence of a robust myocardium and sympathetic reserve. In the absence
of either, hypotension may ensue from myocardial depression [8].
h. Coronary blood flow may not be sufficient to meet the increased oxygen
demands induced by sympathetic stimulation.
i. Ketamine should be avoided in patients with elevated intracranial pressure.
j. Ketamine is very useful for patients who have experienced severe acute blood
loss.
k. The analgesic effects of ketamine are increasingly recognized and
appreciated, especially in opioid-dependent patients.
l. Ketamine increases salivation and tracheobronchial secretions, so we advise
simultaneous administration of glycopyrrolate in the absence of tachycardia.
C. Inhalational agents
1. Hemodynamic effects. Similar but generally modest levels of myocardial
depression occur with all three popular inhalational agents, isoflurane,
desflurane, and sevoflurane. Serious consequences may occur in patients with
congestive heart failure, however, as a narrow 7 range of anesthetic
concentrations may be tolerated by the compromised myocardium. The
predominant hemodynamic effect of these three agents is dose-dependent
vasodilation, hence reducing BP and SVR [9]. All three agents also induce a
dose-dependent reflex tachycardia that can be attenuated or prevented by β-
adrenergic blockers or opioids.
2. Desflurane is uniquely titratable for induction of anesthesia because of its
rapid onset and offset, which remarkably matches that of a remifentanil
infusion. Because of its pungent aroma, however, desflurane is poorly tolerated
unless it is preceded by an IV induction.
3. Sevoflurane has a much more pleasant aroma, suitable for inhalational
induction, offers hemodynamic stability in most induction situations, and has an
onset time only slightly slower than that of desflurane.
4. Isoflurane, like desflurane, has a pungent aroma, and it is best introduced after
an IV induction.
5. Nitrous oxide is seldom used during anesthetic induction in cardiac surgical
patients, but it is generally safe to use for induction with the probable exception
of patients with markedly increased pulmonary vascular resistance (PVR).
Some find it useful in the hiatus between induction and incision, because one
can achieve a minimum alveolar concentration (MAC) level (see below)
proportionate to its inspired concentration with minimal reduction in BP.
6. Clinical use. Whereas clinically significant brain concentrations (greater than
or equal to 1 × minimal alveolar concentration [MAC]) can be attained with
desflurane and sevoflurane in 2 to 4 minutes, generally lower concentrations
are achieved over the same time frame with isoflurane. Consequently,
desflurane and sevoflurane are more likely to reach concentrations
consistent with stress–response suppression (generally 1.3 to 1.5 times
MAC) during a customary induction period than isoflurane. One potential
drawback to desflurane is sympathetic stimulation when the inspired
concentration is increased rapidly, perhaps owing to its airway irritant effects.
Any of these inhalation agents can be used during induction as a complement to
an IV induction. Desflurane can be useful in cardiac anesthesia not as much
because of its rapid offset as because of its rapid onset.
D. Muscle relaxants
1. A suspected difficult intubation precludes giving the patient a neuromuscular
blocker before achieving intubation unless one is highly confident that mask
ventilation will succeed and that an emergency alternative airway (e.g.,
laryngeal mask) can also succeed.
2. Succinylcholine still has the fastest onset and offset of all muscle relaxants.
3. Significant β-adrenergic blockade and high-dose opioid induction are potential
indications for otherwise obsolescent pancuronium, as its vagolytic effects tend
to counter the vagotonia and bradycardia induced by higher doses of opioids.
4. Intermediate-duration agents: Cisatracurium, rocuronium, and vecuronium
are hemodynamically bland.
a. If hepatic or renal failure exists, cisatracurium appears to be the wisest
choice.
5. Timing of the administration of the muscle relaxant is important.
a. Laryngoscopy should await optimal relaxation (see Section I.B.3.h). Early
administration obviates opioid-induced truncal rigidity, which may impair
mask ventilation and result in systemic oxygen desaturation, yet one should
also ensure amnesia with a sedative–hypnotic agent before administering the
muscle relaxant.
E. Applications of old drugs in sick patients
One busy cardiac surgery center blends the principles of careful patient
assessment, cautious dosing, and fiscal restraint by commonly choosing the
following preinduction sequence:
1. Patient arrives in anesthetic preinduction area or operating room.
a. A large-bore (16-gauge or larger) IV catheter is placed.
b. Light premedication is administered, typically midazolam 1 to 2 mg IV.
c. A 20-gauge radial or brachial arterial catheter is placed using local
anesthesia.
2. IV induction of anesthesia proceeds using the following:
a. Fentanyl 250 to 500 µg in consideration of the patient’s size and hemodynamic
stability.
b. Etomidate 0.15 to 0.2 mg/kg with the same consideration.
c. After ensuring that mask ventilation can be accomplished, succinylcholine 1 to
2 mg/kg is administered.
d. Endotracheal intubation is accomplished.
3. After endotracheal intubation, the next steps are as follows:
a. Placement of central venous access (e.g., double-lumen CVP or 9 French
introducer with single-lumen IV catheter or a PAC placed through the
introducer for hemodynamic monitoring)
b. As hemodynamics permit, careful initiation of isoflurane is administered at
0.5 to 1 MAC with titration to BP and bispectral index (BIS).
c. If needed, IV phenylephrine is titrated to support BP.
d. Upon recovery from succinylcholine, transition to vecuronium (initial dose
approximately 0.03 to 0.05 mg/kg, subsequent doses 0.01 to 0.02 mg/kg) or
rocuronium (initial dose 0.3 to 0.6 mg/kg, subsequently 0.1 to 0.2 mg/kg) for
maintenance of neuromuscular blockade.
F. Inhalational induction in very sick patients
This technique is a good alternative to gently induce very sick patients with low
ejection fraction undergoing left ventricular assist device (LVAD) placement or
heart transplantation. The technique is recommended only in patients who clearly
have empty stomachs to avoid the potential for aspiration, as the induction period
is prolonged:
1. Patient is in the operating room, monitors placed.
2. Large-bore (16-gauge or larger) IV catheter is placed.
3. Light premedication with midazolam 1 to 2 mg IV.
4. Twenty-gauge radial arterial catheter is placed using local anesthetic (1–2%
lidocaine).
5. An inotropic infusion (usually epinephrine or dopamine) is connected to the
peripheral IV, programmed and ready to go.
6. Start preoxygenation and 2% sevoflurane, maintain 2% during entire induction
period, and decrease it only if hemodynamic instability ensues.
7. Administer fentanyl typically 150 to 500 µg in divided doses, depending on
the patient size and age.
8. Consider administering additional midazolam boluses usually up to 5 mg total,
for younger patients (age <65), or increasing the inspired concentration of
sevoflurane to 3% to 4% if hemodynamics remain stable.
9. Upon loss of consciousness, after testing the airway (e.g., oropharyngeal
airway insertion), administer 0.6 to 0.9 mg/kg rocuronium to allow for rapid
intubation.
10. When mask ventilating, hyperventilate with small tidal volumes to decrease
PA pressure, and to avoid intrathoracic overinflation that may increase PVR
and decrease venous return. For similar reasons, avoid positive end-
expiratory pressure (PEEP) and be aware of the possibility of “breath-
stacking” in patients with reactive airways disease or chronic obstructive
pulmonary disease (COPD). The latter patients may require prolonged
expiratory time.
VI. Immediate postinduction period
After induction and intubation, several different techniques may be used for
maintenance of anesthesia. First priorities, however, are to assess the airway
(confirm endotracheal tube location via end-tidal CO2 and auscultation), assess
hemodynamic stability, and respond appropriately to any problems identified.
A. A low-dose continuous infusion of the opioid used for induction or of
remifentanil (e.g., 0.1 µg/kg/min) can be implemented.
B. Consider adding an inhalational agent for maintenance of anesthesia and amnesia.
C. Continuous infusion or intermittent bolus doses of a sedative–hypnotic agent
(e.g., midazolam or ketamine) can be initiated if no potent inhalational agent is
used.
D. A propofol infusion may be useful in hemodynamically robust patients.
E. Some clinicians prefer a dexmedetomidine infusion for its augmentation of
analgesia and tendency to avoid hypertension, although its offset time is
relatively long (15 minutes or more), it can induce hypertension at onset, and
bradycardia and hypotension may occur. Further, it lacks reliable amnestic
effects.
F. The treatment of postinduction hypotension deserves mention. There is a
tendency to administer phenylephrine boluses of 100 to 200 µg as a “knee-jerk”
response to hypotension, when at times either rapid volume infusion, an
alternative vasoactive drug, or both may be more appropriate.
1. If the heart appears empty based on filling pressures, echocardiography
findings, cardiac output measurement, or respiratory variation in systolic
pressure, then rapid administration of crystalloid or colloid is appropriate.
2. If the induction has used drugs most likely to reduce SVR and preload without
affecting myocardial contractility (e.g., midazolam or etomidate with an opioid
and a muscle relaxant), then phenylephrine is appropriate. If the need appears
likely to be sustained because of a lengthy interval to surgical incision, then
consider a continuous phenylephrine infusion of 0.1 to 1 µg/kg/min.
3. If the HR is low or if there is a strong possibility of myocardial depression as
well (e.g., propofol was used for induction or >0.5 MAC of a volatile agent is
in use), then consider using a bolus of ephedrine (5 to 15 mg) or epinephrine
(10 to 25 µg).
A simple technique used frequently and varied in dosage according to the
physical status of the patient probably provides the most consistent results for
most clinicians.
VII. Management of events between anesthetic induction and cardiopulmonary
bypass (CPB)
The time between induction of anesthesia and institution of CPB is
characterized by widely varying surgical stimuli. Anesthetic management during
this high-risk period must strive to:
1. 8 Optimize the myocardial O2 supply/demand ratio and monitor for
myocardial ischemia. The reported incidence of ischemia during this period
varies from as low as 7% to as high as 56% [10].
2. Hemodynamics must be optimized to maintain adequate organ perfusion. This is
best achieved by optimizing the preload, afterload, contractility, HR, and
rhythm depending on underlying cardiac dysfunction and its associated
complications.
3. Manage “fast-track” patients with short-acting anesthetic agents.
4. Adverse hemodynamic changes increase the risk of developing ischemia, heart
failure, hypoxemia, or dysrhythmias. These complications may alter surgical
management and lead to urgent institution of CPB with failure to perform
internal mammary artery (IMA) or radial artery dissection, along with an
increased risk of bleeding.
A few simple rules may assist in the management of cardiac patients before
CPB:
a. “Keep them where they live.”
A review of the preoperative vital signs and tests of cardiac performance
(echocardiography, cardiac catheterization, and other imaging modalities)
helps guide the management of hemodynamics during this period.
b. “The enemy of good is better.”
If the patient’s BP and HR are acceptable, does it matter if the cardiac index
is 1.8 L/min/m2? When a patient is anesthetized, oxygen consumption
decreases, so a lower cardiac index may be adequate. Trying to increase it to
“normal” may lead to other problems, such as dysrhythmias or myocardial
ischemia. Additional parameters such as mixed venous oxygen saturation
(SvO2) and presence of acidosis should be considered prior to treatment.
c. “Do no harm.”
These patients are frequently very ill. If you are having problems managing the
patient, ask for help.
5. Stages of the pre-CPB period. The pre-CPB period can be subdivided into
stages based on the level of surgical stimulation.
a. High levels of stimulation include incision, sternal split, sternal spread,
sympathetic nerve dissection, pericardiotomy, and aortic cannulation.
Inadequate anesthesia or sympathetic activation at these times leads to
increased catecholamine levels, possibly resulting in hypertension,
dysrhythmias, tachycardia, ischemia, or heart failure (Table 6.3).
b. Low-level stimulation occurs during preincision, radial artery or saphenous
vein harvesting, internal mammary (thoracic) artery dissection, and CPB
venous cannulation. Risks during these periods include hypotension,
bradycardia, dysrhythmias, and ischemia (Table 6.3).
TABLE 6.3 Typical hemodynamic responses to surgical stimulation before
cardiopulmonary bypass (CPB)
B. Preincision
This period includes surgical preparation and draping. Several parameters
should be checked during this time:
1. Confirm bilateral breath sounds after final patient positioning.
2. Check pressure points. Ischemia, secondary to compression and compounded
by decreases in temperature and perfusion pressure during CPB, may cause
peripheral neuropathy or damage to soft tissues.
a. Brachial plexus injury can occur if the arms are hyperextended or if chest
retraction is excessive (e.g., occult rib fracture using a sternal retractor) [11].
Excessive chest retraction can occur not only with the sternal spreader but
also during IMA dissection even if the arms are tucked to the sides. If the arms
are placed on arm boards, obtain the proper position by minimizing pectoralis
major muscle tension. Do not extend arms more than 90 degrees from the body
to avoid stretching the brachial plexus.
b. Ulnar nerve injury can occur from compression of the olecranon against the
metal edge of the operating room table. To obtain the proper position, provide
adequate padding under the olecranon. Do not allow the arm to contact the
metal edge of the operating room table.
c. Radial nerve injury can occur from compression of the upper arm against the
“ether screen” or the support post of the chest wall sternal retractors used in
IMA dissection.
d. If the fingers are positioned improperly, finger injury can result from
members of the operating team leaning against the operating table. To obtain
the proper position, hands should be next to the body, with fingers in a neutral
position away from the metal edge of the table. One method to prevent upper
extremity injury is to have the patient position himself or herself. A rolled
surgical towel can be placed in each hand to ensure that the fingers are in a
comfortable and protected position.
e. Occipital alopecia can occur 3 weeks after the operation secondary to
ischemia of the scalp, particularly during hypothermia. To obtain the proper
position, pad and reposition the head frequently during the operation. A
“doughnut” type of pillow protects against this injury as well.
f. Heel skin ischemia and tissue necrosis are possible. Heels should be well
padded in such a way as to redistribute weight away from the heel to the
lower leg.
g. The eyes should be closed, taped, and free from any pressure.
h. Commercial foam dressings may be applied prophylactically to various
pressure points (sacrum and heels) to prevent pressure sores.
3. Adjust fresh gas flow
a. Use of 100% O2 maximizes inspired O2 tension. A lower inspired oxygen
concentration may prevent absorption atelectasis and reduce the risk of O2
toxicity. The inspired oxygen concentration can be titrated based on pulse
oximeter readings and arterial blood gases (ABGs).
b. Nitrous oxide can be used during the pre-CPB period in stable patients. It
will, however,
(1) Decrease the concentration of inspired oxygen (Fio2)
(2) Increase PVR
(3) Increase catecholamine release
(4) Possibly induce ventricular dysfunction
(5) Some evidence suggests that nitrous oxide should not be used in patients
with an evolving myocardial infarct or in patients with ongoing ischemia
because the decrease in Fio2 and potential catecholamine release
theoretically can increase the risk of ischemia and infarct size. This point
remains controversial.
(6) At inspired concentrations of 50% to 60%, nitrous oxide may facilitate
hemodynamic stability while augmenting amnesia in the period between
induction and surgical incision.
4. Check all monitors and lines after final patient position is achieved
a. IV infusions should flow freely, and the arterial pressure waveform should be
assessed for overdamping (flattening of waves) or hyperresonance (typically
seen as exaggeration of systolic peak or “overshoot”).
b. IV injection ports should be accessible.
c. All IV and arterial line connections (stopcocks) should be taped or secured to
prevent their movement and minimize the risk of blood loss from an open
connection.
d. Confirm electrical and patient reference “zero” of all transducers.
e. Nasopharyngeal temperature probes, if required, must be placed prior to
heparinization to avoid excessive nasal bleeding.
5. Check hemodynamic status
a. When available through existing monitors, cardiac index, ventricular filling
pressures, and SvO2 should be evaluated after intubation, in addition to end-
tidal CO2, HR, BP, and SpO2.
b. If transesophageal echocardiography (TEE) is used, check and document the
position of the probe and the presence or absence of dental and oropharyngeal
injury. The TEE probe should be placed before heparinization to avoid
excessive bleeding. Make sure the TEE probe is not in a locked position, as
this may lead to pressure necrosis in the gastrointestinal tract. Bite blocks are
recommended in order to avert expensive probe repairs.
c. A baseline TEE examination should be performed to document the ejection
fraction, wall-motion abnormalities, valve function, and the presence or
absence of intracardiac shunts (see Chapter 5).
6. Check blood chemistry
a. Once a stable anesthetic level is achieved, and ventilation and Fio2 have been
constant for 10 minutes, an ABG measurement should be obtained to confirm
adequate oxygenation and ventilation, and to correlate the ABG with
noninvasive measurements (pulse oximetry and end-tidal CO2 concentration).
Maintain normocapnia, as hypercapnia may increase PVR. Hypocapnia may
promote myocardial ischemia and cardiac dysrhythmias. Hypocapnia and
resulting alkalosis shift the oxyhemoglobin curve to the left, thereby limiting
unloading of oxygen to the cells.
b. Mixed venous hemoglobin O2 saturation can be measured with a mixed
venous blood gas at this time, if necessary, to calibrate a continuous mixed
venous PAC.
c. Electrolytes, calcium, and glucose levels should be determined as clinically
indicated. High glucose levels should be treated to minimize neurologic injury
and to decrease postoperative infection rates. Intraoperative hyperglycemia is
an independent risk factor for other perioperative complications, including
death, after cardiac surgery [12]. Perioperative glucose management of
diabetic patients must be started in the prebypass period. Glucose control may
be achieved by a continuous infusion of insulin with the infusion rate
depending on the patient’s blood glucose level. Boluses of IV insulin may
lead to large swings in blood glucose, thus, an IV infusion is preferred. It is as
important to assess the trends of blood glucose as the absolute blood glucose
levels, especially so to avoid intraoperative hypoglycemia. Hence, glycemic
control should be based on the velocity of glucose change as well as the
absolute value.
d. A blood sample to determine a baseline activated clotting time (ACT) before
heparinization may be drawn at the same time as the sample for ABG. The
blood can be taken from the arterial line after withdrawal of 5 to 10 mL of
blood, depending on the dead space of the arterial line tubing and avoiding
residual heparin, if present, in the flush solution. The perfusionist may require
a blood sample to perform a heparin dose–response curve, which in some
institutions is used to determine the initial heparin dosage.
e. Before any manipulation of the arterial line (zeroing, blood sample
withdrawal), it is important to announce your intentions. This avoids alarming
your colleagues, who may notice the loss of the arterial waveform.
7. Antibiotics
a. Antibiotics are administered before incision and should be timed not to
coincide with the administration of other medications, should an allergic
reaction occur.
b. For cardiac patients, the Surgical Care Improvement Project (SCIP) and the
Society of Thoracic Surgeons (STS) Practice guidelines recommend that
preoperative prophylactic antibiotics be administered within 1 hour prior to
incision (2 hours for vancomycin or fluoroquinolones) and discontinued 48
hours after the end of surgery for cardiac surgical patients.
c. 9 The STS recommends a cephalosporin as the primary prophylactic
antibiotic for adult cardiac surgery. In patients considered high risk for
staphylococcus infection (either presumed or known staphylococcal
colonization), it would be reasonable to combine cephalosporins with
vancomycin. Loading doses of vancomycin are based on total body weight.
Suggested initial dose is 10 to 15 mg/kg with a maximum dose being 1,000
mg. Administration over 1 hour is advised to avoid hypotension.
d. Exclusive vancomycin use for cardiac surgical prophylaxis should be avoided
as it provides no gram-negative coverage.
e. In patients with a history of an immunoglobulin-E–mediated reaction to
penicillin, vancomycin should be administered with additional gram-negative
coverage [13,14].
8. Antifibrinolytics
Excessive fibrinolysis is one of the causes of blood loss following cardiac
surgery. Antifibrinolytic agents are commonly used to minimize bleeding and
thereby reduce the exposure to blood products.
a. Aprotinin (serine protease inhibitor). The FDA suspended the use of
aprotinin after the Blood Conservation using Antifibrinolytics in a
Randomized Trial (BART) trial which demonstrated that aprotinin has a
worse risk–benefit profile than the lysine analogs with a trend toward
increased mortality in patients receiving aprotinin [15].
b. Epsilon-aminocaproic acid (EACA) and tranexamic acid (lysine analogs).
With the suspended use of aprotinin, EACA and tranexamic acid are the only
antifibrinolytics available. Both are effective agents in reducing
postoperative blood loss. However, EACA at equipotent doses to tranexamic
acid is associated with a higher rate of temporary renal dysfunction.
Tranexamic acid is associated with seizures at higher doses [16].
9. Preparation for saphenous vein excision involves lifting the legs above the
level of the heart. Increased venous return increases cardiac preload. This
change is desirable in patients with low filling pressures and normal
ventricular function but may be detrimental in patients with borderline
ventricular reserve and/or pre-existing hypervolemia. Gradual elevation of the
legs may be useful in attenuating the hemodynamic changes. The reverse occurs
when the legs are returned to the neutral position.
10. Endoscopic saphenectomy for harvesting vein grafts for coronary artery
bypass grafting is now common. As in a laparoscopic procedure, carbon
dioxide is the insufflating gas of choice during this procedure. Mechanical
ventilation may have to be adjusted depending on the rise in CO2 as detected by
an end-tidal monitor and ABG analysis. When using carbon dioxide
insufflation, CO2 embolism has been reported. Frail, elderly patients with
fragile tissue are at risk for this complication. Preventive measures include
maintenance of a right atrial pressure to insufflation pressure gradient of greater
than or equal to 5 mm Hg and addition of PEEP. Hemodynamic deterioration
from transmission of gas through a patent foramen ovale into the left heart and
coronary circulation has also been reported [17].
11. Maintenance of body temperature is not a concern during the pre-CPB time
period with the exception of off-pump coronary artery bypass grafting
(OPCAB). It is often preferable to allow the temperature to drift down slowly,
as this allows for more homogeneous hypothermia at institution of CPB, and
modest hypothermia is inconsequential in an anesthetized patient, especially in
the presence of neuromuscular blockade. Before CPB, increasing the room
temperature, humidifying anesthetic gases, warming IV solutions, and using a
warming blanket are not necessary. These measures must be available for post-
CPB management, however. In an anesthetized patient, the physiologic changes
associated with mild hypothermia (34° to 36°C) include the following:
a. Decrease in O2 consumption and CO2 production (8% to 10% for each degree
Celsius)
b. Increase in SVR and PVR
c. Increase in blood viscosity
d. Decrease in CNS function (amnesia, decrease in cerebral metabolic rate or O2
consumption [CMRO2] and decrease in cerebral blood flow)
e. Decrease in anesthetic requirement (MAC decreases 5% for each degree
Celsius)
f. Decrease in renal blood flow and urine output
g. Decrease in hepatic blood flow
h. Minimal increase in plasma catecholamine levels
12. Maintain other organ system function
a. Renal system [18]
(1) Inadequate urine output must be addressed:
(a) Rule out technical problems first (kinked urinary catheter tubing or
disconnected tubing).
(b) Optimize and maintain an adequate intravascular volume and
cardiac output using CVP, PAC, or TEE as a measure of preload
and cardiac performance.
(c) Avoid or treat hypotension.
(d) Maintain adequate oxygenation.
(e) Mannitol (0.25 g/kg IV) may be used to redistribute renal blood
flow to the cortex and to maintain renal tubular flow, although this
has not been proven to improve renal outcomes.
(f) Dopamine (2.5 to 5 μg/kg/min) infusion may be given to increase
renal blood flow by renal vascular dilation. Currently, there is no
evidence that “renal” dose dopamine will prevent perioperative
renal dysfunction. Its use may increase the incidence of atrial
dysrhythmias.
(g) Diuretics (furosemide, 10 to 40 mg; bumetanide, 0.25 to 1 mg) can
be given to maintain renal tubular flow if other measures are
ineffective or if the patient has taken preoperative diuretics.
(2) Patients undergoing emergent surgery may have received a large
radiocontrast dye load at angiography. Avoiding dye-induced acute
tubular necrosis, utilizing the techniques mentioned earlier, is crucial.
b. Central nervous system
(1) Adequate cerebral perfusion pressure must be maintained.
(a) The patient’s preoperative lowest and highest MAPs should be the
limits accepted in the operating room to avoid cerebral ischemia.
Remember, “keep them where they live.”
(b) Elderly patients have a decreased cerebral reserve and are more
sensitive to changes in cerebral perfusion pressure.
(2) Patients at risk for an adverse cerebral event include those with known
carotid artery disease, peripheral vascular disease, or a known embolic
focus.
c. Lungs
(1) Maintain normal pH, Paco2, and adequate Pao2.
(2) Treatment of systemic hypertension with a vasodilator may induce
hypoxemia secondary to inhibition of hypoxic pulmonary
vasoconstriction. Fio2 may have to be increased.
(3) Use of an air–oxygen mixture may prevent absorption atelectasis.
13. Prepare for incision
a. Ensure adequate depth of anesthesia using clinical signs. If available, a
bispectral (BIS) monitor may be helpful. A small dose of a narcotic or
hypnotic or increased concentration of inhaled agent may be necessary.
b. Ensure adequate muscle relaxation to avoid movement with incision and
sternotomy. If movement occurs, make sure the patient is sufficiently
anesthetized, as you are preventing movement with neuromuscular blockade.
C. Incision
1. Adequate depth of anesthesia is necessary but may not be sufficient to avoid
tachycardia and hypertension in response to the stimulus of incision. If
hemodynamic changes occur, they are usually short lived, so medications with
a brief duration of action are recommended.
a. Treatment can include:
(1) Vasodilators
(a) Nitroglycerin (20- to 80-μg bolus) or infusion
(b) Nicardipine infusion
(2) β-Blockers
(a) Esmolol (0.25 to 1 mg/kg)
2. Observe the surgical field for patient movement and blood color. Despite an
abundance of monitors, the presence of bright red blood remains one of the best
ways to assess oxygenation and perfusion.
3. If the patient responds clinically to the incision (tachycardia, hypertension,
other signs of “light” anesthesia, or clinically significant BIS monitor value
changes), then the level of anesthesia must be deepened before sternotomy. Do
not allow sternal split until the patient is anesthetized adequately and
hemodynamics are controlled.
D. Opening the sternum
1. A very high level of stimulation accompanies sternal “split.” The incidence of
hypertension has been reported to be as high as 88% even during a high-dose
narcotic-based anesthetic, 10 for example, a cumulative dose of fentanyl, 50
to 70 μg/kg [19]. Hypertension and tachycardia, if they occur, should be treated
as described for skin incision.
Bradycardia secondary to vagal discharge can occur. It is usually self-
limiting, but if it is persistent and causes hemodynamic compromise, then a
dose of atropine, glycopyrrolate, and/or ephedrine may be necessary.
2. A reciprocating power saw is often used to open the sternum. The lungs should
be “deflated” during opening of the internal table of the sternum to avoid
damage to the lung parenchyma. Forgetting to turn the ventilator back on poses
a potential safety hazard.
3. The patient should have adequate muscle relaxation during sternotomy to avoid
an air embolism. If the patient gasps as the right atrium is cut, air can be
entrained owing to the negative intrapleural pressure.
4. This is the most common time period for awareness and recall due to the
intense stimulation. The risk is greatest with “pure” high-dose opioid
techniques, which are obsolete.
a. Awareness has been reported with fentanyl dosages as large as 150 μg/kg and
with lower fentanyl doses supplemented with amnestic agents. Awareness
usually, but not always, is associated with other symptoms of light anesthesia
(movement, sweating, increased pupil size, hypertension, or tachycardia). A
BIS or other type of anesthesia depth monitor may be helpful, but recall has
occurred in patients with an “adequate” BIS reading.
b. If an amnestic agent has not been administered previously, it should be
considered before sternotomy because these agents decrease the incidence of
recall but will not produce retrograde amnesia. Amnestic supplements do not
always protect against the hypertension and tachycardia associated with
awareness. However, amnestic supplements may cause hypotension. The most
common amnestic agents, their dosages, and side effects include:
(1) Benzodiazepines (midazolam, 2.5 to 10 mg; diazepam, 5 to 15 mg;
lorazepam, 1 to 4 mg) in divided doses usually are well tolerated but can
decrease SVR and contractility in patients with poor ventricular function,
especially when the drugs are added to a narcotic-based anesthetic.
5. Supplementation of opioids (e.g., fentanyl 1 to 3 µg/kg) in anticipation of
sternotomy will attenuate the stress response somewhat.
CLINICAL PEARL Sternotomy is the time of the highest incidence of awareness during
cardiac surgery.
6. At this point, any potential benefit to nitrous oxide becomes questionable, as it
may augment catecholamine release, cause LV dysfunction, and increase PVR
and the risk of hypoxemia. Its use in the noncardiac surgery (ENIGMA) trial
was associated with an increased long-term risk of myocardial infarction.
Nitrous oxide–induced inactivation of methionine synthetase increases plasma
homocysteine levels in the postoperative period. This can lead to endothelial
dysfunction and hypercoagulability [20].
7. Inhalation agents are useful at the time of sternal spread. Primarily they
decrease BP through vasodilation, but can also cause myocardial depression,
bradycardia, tachycardia, or dysrhythmias. They are effective in low
concentrations (e.g., 0.5 MAC) as a component of a “balanced” anesthetic
including other agents such as fentanyl and midazolam, and have become a
standard component of most “fast-track” techniques.
8. Propofol (10- to 50-mg bolus) can rapidly decrease BP if needed.
E. During and after sternal spreading
1. Visually confirm equal inflation of the lungs after the chest is open. Usually the
right lung is visible through its parietal pleura, but the left lung might not be
visible unless left IMA (LIMA) dissection is performed.
2. PAC malfunction with sternal spread has been reported. Most occurrences are
with external jugular or subclavian insertion approaches and involve kinking of
the PAC as it exits the introducer sheath. A reinforced introducer can decrease
the incidence of kinking. If this occurs, the surgeon can often assist by slightly
decreasing the amount of sternal retraction.
Sheath withdrawal may rectify the problem but can lead to the following:
a. Loss of the side-port IV line (distal tip of introducer may become
extravascular)
b. Bleeding
c. Contamination of the access site
3. Innominate (brachiocephalic) vein rupture, as well as brachial plexus injury, is
possible after aggressive sternal spread.
F. Concerns with cardiac reoperation (“redo heart”)
1. The pericardium is usually not closed after heart surgery, and the aorta, RV,
and bypass grafts may adhere to the underside of the sternum. At reoperation,
these structures can be easily injured when the sternum is opened. A clue to this
potential problem may be provided radiologically if there is no space between
the heart and the inner sternal border. Although using an oscillating saw
decreases this risk, it does not eliminate it. As this takes longer than the usual
sternotomy, ventilation should not be held. Knowing the proximity of
mediastinal structures to the sternum is necessary, and if preoperative imaging
suggests that they may be in jeopardy, extra measures before reopening the
sternum, such as peripheral cannulation and CPB (with or without deep
hypothermic circulatory arrest), may be necessary to avoid catastrophe [21]. A
venous cannula may be passed into the right atrium through the femoral vein.
The correct positioning of this cannula may be identified on the mid-esophageal
bicaval view using TEE. Axillary or subclavian cannulation may be the
preferred site for peripheral arterial inflow site as compared to the femoral
artery in patients with concurrent descending, thoracoabdominal, or abdominal
aortic aneurysms. A discussion with the surgeon is necessary to place the
arterial line for monitoring in the contralateral superior extremity in case of
either subclavian or axillary cannulation. Femoral arterial cannulation may be
an alternative.
2. If a pre-existing coronary artery bypass graft is cut, the patient may develop
profound ischemia. Nitroglycerin may be helpful, but if significant myocardial
dysfunction or hypotension occurs, the ultimate treatment is prompt institution
of CPB followed by revascularization of the affected coronary artery.
3. If the right atrium, RV, or great vessels are cut, a surgeon or assistant will put a
“finger in the dike” while the tear is fixed or a decision is made to go
emergently onto CPB. CPB can be initiated using the following:
a. After full heparinization, “sucker bypass” with a femoral artery cannula or
aortic cannula and the cardiotomy suckers are used as the venous return line if
the right atrium cannot be cannulated.
b. Femoral vein–femoral artery bypass
4. Prolonged surgical dissection increases the risk of dysrhythmias.
a. The availability of external defibrillator pads or sterile external paddles
should be considered. Defibrillation may be necessary before complete
exposure of the heart, rendering internal paddles ineffective.
b. Some institutions use a defibrillation pad that adheres to the back and is
placed before induction of anesthesia. This allows for use of an internal
paddle even if the heart is not totally exposed, as current will flow in an
anteroposterior fashion through the heart.
5. Volume replacement (crystalloid, colloid, blood) may be necessary to provide
adequate preload if hemorrhage is brisk during the dissection.
a. Adequate IV access for volume replacement must be available prior to the
start of the surgical procedure. This may be accomplished by securing two
large-bore peripheral IV lines or a large-bore multilumen central venous
access catheter in a central vein.
b. Have at least 2 units of blood available in case it is necessary to transfuse the
patient.
c. After the patient is heparinized, the surgical team should use the CPB suckers
to help salvage blood.
G. Concerns with urgent or emergent cardiac operation
1. Indications include:
a. Cardiac catheterization complications (failed angioplasty with persistent chest
pain, coronary artery dissection) [22]
b. Persistent ischemia with or without chest pain that is refractory to medical
therapy or an intra-aortic balloon pump (IABP)
c. Left main coronary artery disease or left main equivalent
d. Acute aortic dissection
e. Fulminant infective endocarditis
f. Ruptured chordae tendineae
g. Acute ischemic ventricular septal defect
h. Multiple high-grade lesions with significant myocardium at risk
i. Emergent LVAD placement
j. Ruptured or rupturing thoracic aneurysm
k. Cardiac tamponade
l. Ventricular rupture
2. Continue BP, pulse oximeter, and electrocardiographic (ECG) monitoring
during transport and preparation.
3. Aggressively treat ischemia and dysrhythmias that may be present.
4. If a heparin infusion is being given, continue it until sternotomy. This will
increase operative bleeding but will decrease the risk of worsening coronary
thrombosis.
a. Consider heparin resistance and increase the initial heparin dose to avoid
delays in starting CPB because the ACT is too low.
5. Continue antianginal therapy, particularly the nitroglycerin infusion, during an
acute myocardial ischemic event.
6. Maintain coronary perfusion pressure. Phenylephrine or norepinephrine
boluses and/or infusions may be necessary. An IABP may be in use or required.
Maintain IABP timing triggers (ECG or arterial pulse wave).
7. In these cases, time is of the essence. Decisions must be made regarding the
risks and benefits of additional monitoring (arterial line and PAC) relative to
the delay required for catheter insertion. Access to the central circulation and
some form of direct BP monitoring are preferred before beginning surgery.
8. If the patient continues to have significant hemodynamic and ischemic changes,
after induction, that are unresponsive to treatment, proceed to CPB urgently.
9. In a cardiac arrest situation, go directly to CPB. The surgeon can place central
venous and PA lines from the surgical field before weaning the patient from
CPB. TEE is a fast alternative to obtain much of the information derived from a
PAC.
a. Urgency of initiating CPB does not supersede obtaining adequate
heparinization documented by ACT, or adequate anesthetic levels. In a
cardiac arrest situation, consider administering twice the usual dose of
heparin (e.g., 600 USP units/kg) to ensure adequate heparinization. The
surgeon may give the heparin directly into the heart if access is not available.
10. If a “bailout” (coronary perfusion) catheter has been placed across a coronary
dissection, it should not be disturbed. It can be withdrawn from the femoral
arterial sheath just before application of the aortic cross-clamp.
11. Fibrinolytic or antiplatelet agents may have been given in the catheterization
laboratory. These drugs will increase bleeding before and after CPB.
H. Internal mammary artery (IMA) and radial artery dissection
1. This is a period of low-level stimulation.
2. The chest is retracted to one side using the chest wall retractor, and the table is
elevated and rotated away from the surgeon. The LIMA is most commonly
grafted to the left anterior descending artery.
a. This procedure can cause difficulties in BP measurement.
(1) Left-sided radial arterial lines may not function during LIMA dissection
owing to compression of the left subclavian artery with sternal
retraction. The same may be true with a right-sided catheter and a right
IMA (RIMA) dissection.
(2) Transducers must be kept level with the right atrium.
3. Although rare, accidental extubation is possible from thoracic wall movement
during sternal retraction.
4. Radial nerve injury due to compression by the support post of the sternal
retractor is possible.
5. Bleeding may be extensive but hidden from view in the chest cavity (consider
volume replacement to treat hypotension), especially if the ipsilateral pleura
has been opened.
6. Heparin, 5,000 units, may be given during the vessel dissection process.
7. Papaverine may be injected into the IMA for dilation and to prevent spasm.
Systemic effects may include hypotension or anaphylaxis.
8. IMA blood flow usually should be more than 100 mL/min (25 mL collected in
15 seconds) to be considered acceptable for grafting.
9. Mechanical ventilation may need to be adjusted if the motion of the lungs
interferes with the surgical dissection of the IMA. This may be achieved by
reducing the tidal volume and increasing the respiratory rate to achieve
constant minute ventilation.
10. If the radial artery is being harvested as a conduit, the arterial line should be
placed on the other side.
I. Sympathetic nerve dissection
1. After the pericardium is opened, the postganglionic sympathetic nerves are
dissected from the aorta to allow insertion of the aortic cannula.
2. This is the most overlooked period of high-level stimulation because of
sympathetic discharge. Treatment of hemodynamic changes is explained above.
J. Perioperative stress response
The body responds to stress with a catabolic response and an increase in
substrate mobilization. This response is mediated primarily through the
hypothalamic–pituitary–adrenal axis. Stimuli include intubation, surgical
incision, sternotomy, and CPB. Inadequate depth of anesthesia and analgesia
elevates the magnitude of this response.
1. Humoral mediators and the systemic effects of the stress response (see Table
6.4)
2. Modification of the stress response
a. Systemic opioids (high dose)
(1) Techniques using high-dose fentanyl (50 to 150 µg/kg) or sufentanil
(10 to 30 µg/kg) became popular in the 1980s, as they blunt almost all
responses except for prolactin increase and an occasional increase in
myocardial lactate production before CPB. Even in astronomical doses
such as these, opioids alone do not provide sufficient depth of anesthesia
to prevent hypertension and possibly tachycardia for a surgical stimulus
as potent as sternal division (see above under induction techniques).
b. Inhalational anesthetics
(1) Minimum alveolar concentration (MAC) BAR is defined as the
inhalational anesthetic partial pressure that blocks adrenergic response
(BAR) in 50% of patients
(a) MAC BAR is approximately equal to 1.5 MAC.
(b) Cortisol and growth hormone (GH) levels will increase with the
depth of anesthesia.
TABLE 6.4 Stress response—mediators and systemic response
(c) To reduce catecholamine responses in 95% of patients, 2 MAC is

needed.
(d) MAC BAR is associated with decreased BP, myocardial
depression, and increased pulmonary capillary wedge pressure
(PCWP).
c. Systemic medications that decrease catecholamine effects:
(1) β-Adrenergic blockers
(a) β-Blockers attenuate increases in HR and myocardial O2 demand.
(b) Adverse effects include decreased myocardial contractility and
bronchospasm.
d. Centrally acting α2-adrenergic agonists (clonidine, dexmedetomidine) [23]
(1) Both agents decrease peripheral efferent sympathetic activity.
(2) They cause a decrease in all catecholamine levels (reduced
norepinephrine levels are most prominent) and enhance cardiovascular
stability.
(3) They can decrease HR, BP, and SVR in the perioperative period.
(4) Some attenuation of adrenergic response during or after CPB is seen with
preoperative dosing.
(5) They may cause bradycardia and hypotension, especially when combined
with ACE inhibitors or vasodilators. Paradoxically, high doses may
cause increases in PVR, hypertension, and decreases in cardiac index.
(6) Dexmedetomidine will produce analgesia and sedation. Infusions often
are used after CPB for “fast-track” anesthesia.
e. Vasodilators
(1) Vasodilators are used as treatment for increases in BP (usually from
increased SVR), often secondary to elevated norepinephrine levels.
(2) Adverse effects include: reflex increase in catecholamines, reflex
increase in HR, and inhibition of hypoxic pulmonary vasoconstriction.
f. Regional (epidural or subarachnoid) anesthetic techniques [24]
(1) Local anesthetics
(a) These drugs decrease GH, adrenocorticotropic hormone (ACTH),
antidiuretic hormone (ADH), and catecholamine responses to lower
abdominal procedures.
(b) Thoracic epidural anesthesia is inconsistent in blocking the stress
response to thoracic surgery, possibly due to insufficient somatic or
sympathetic blockade or from unblocked afferent fibers.
(c) Adverse effects include decreased SVR, bradycardia, decreased
inotropy from sympathectomy, and risk of epidural hemorrhage after
heparinization.
(d) In elective cardiac surgery, thoracic epidural analgesia combined
with general anesthesia followed by patient-controlled thoracic
epidural analgesia offers no major advantage with respect to
hospital length of stay, quality of recovery, or morbidity when
compared with general anesthesia alone followed by patient-
controlled analgesia with IV morphine [25]. Time to extubation was
shorter and consumption of anesthetics was lower in the patient-
controlled thoracic epidural analgesia group. Pain relief, degree of
sedation, ambulation, and lung volumes were similar in both the
study groups. There was a trend toward lower incidences of
pneumonia and confusion in the patient-controlled thoracic epidural
analgesia group, whereas lung volumes, and cardiac, renal, and
neurologic outcomes were similar between the groups [25].
(2) Narcotics
(a) Peridural narcotics poorly block the stress response to surgery.
(b) They provide postoperative analgesia.
K. Treatment of hemodynamic changes
Vasopressor and vasodilator treatment of any hemodynamic change ideally
should involve the use of agents with a very short half-life, for the following
reasons: (i) The surgical stimuli and the patient response are usually short lived
(after sternotomy, the duration of hemodynamic response is usually limited to 5 to
15 minutes). (ii) Many agents (β-blockers, calcium channel blockers,
vasodilators, ACE inhibitors, and phosphodiesterase inhibitors) will affect
hemodynamic parameters for longer than 15 minutes and have half-lives of
several hours. Their actions could affect weaning from CPB or postoperative
management. For these reasons, the use of short-acting agents (e.g., esmolol,
nitroglycerin, sodium nitroprusside, clevidipine, phenylephrine, and ephedrine)
should be encouraged.
TABLE 6.5 Differential diagnosis of hypotensiona
1. Hypotension
a. Causes
(1) Mechanical causes must first be ruled out before pharmacologic
treatment. Among these are the following:
(a) Surgical compression of the heart
(b) Technical problems with invasive BP measurement (kinked catheter,
wrist position, and air bubbles)
(c) Transient dysrhythmias from surgical manipulation of the heart (see
below)
(2) The most common cause of hypotension is hypovolemia (Table 6.5).
(3) Myocardial ischemia is another potentially treatable cause of
hypotension. Treatment is outlined in Figure 6.1.
2. Hypertension
a. Hypertension is less common in patients with LV dysfunction than in patients
with normal contractility, but it still occurs.
b. The most likely cause of hypertension is sympathetic discharge. This is seen
most often in younger patients and in those with preoperative hypertension
(Table 6.6).
c. Treatment is outlined in Figure 6.2.
3. Sinus bradycardia
a. The most common cause of sinus bradycardia is vagal stimulation, which
often results from the vagotonic effects of narcotics.
b. Treatment
(1) Treatment is indicated for the following:
(a) Any HR decrease associated with a significant decrease in BP.
(b) HR less than 40 beats/min, even without decrease in BP, if it is
associated with a junctional or ventricular escape rhythm.
(2) The underlying cause should be treated.
(3) Atropine, 0.2 to 0.4 mg IV, can cause an unpredictable response.
Emergency bradycardia treatment dose is 0.4 to 1.0 mg.
IGURE 6.1 Treatment of hypotension in the prebypass period. Once hypotension is identified: (i) supply 100% O 2; (ii) check
nd-tidal carbon dioxide level (ETCO2) and blood gas; (iii) decrease inhalation agent concentration; (iv) rule out dysrhythmias and
chnical or mechanical factors, and then treat per algorithm. Algorithm presumes presence of PCWP, for which either pulmonary
tery (PA) diastolic pressure (same values assuming absence of elevated pulmonary vascular resistance [PVR]) or central
enous pressure (CVP) (decrease values 2 to 4 mm Hg). HR, heart rate; MAP, mean arterial pressure; PCWP, pulmonary
apillary wedge pressure (also called pulmonary artery occlusion pressure or PAOP); BPM, beats per minute.
(a) It may cause uncontrolled tachycardia and ischemia.

(b) It can be ineffective, but it is still indicated in the emergency
treatment of bradycardia.
(c) Glycopyrrolate (0.1 to 0.2 mg IV), another vagolytic agent, may
induce less increase in HR, but it is unpredictable and has a longer
half-life than atropine.
(4) Pancuronium, 2 to 4 mg IV, is often effective owing to its
sympathomimetic activity, but it can be unpredictable.
(5) Ephedrine, 2.5 to 25 mg IV, is indicated if bradycardia is associated with
hypotension. The response may be unpredictable.
(6) PACs with pacing capabilities and esophageal atrial pacing may provide
safe and predictable, although expensive, means of increasing the HR.
TABLE 6.6 Differential diagnosis of hypertensiona
IGURE 6.2 Treatment of hypertension in the prebypass period. First, rule out technical problems and airway difficulties. HR,
eart rate; MAP, mean arterial pressure.
TABLE 6.7 Common causes of dysrhythmiasa

(7) Extrathoracic or direct epicardial ventricular pacing can be used for life-
threatening bradycardia. For minimally invasive procedures, placement
of external patches may be needed to provide pacing.
4. Sinus tachycardia
a. Sinus tachycardia appears to be the most significant risk factor for
intraoperative myocardial 11 ischemia. Sinus tachycardia greater than 100
beats/min has been associated with a 40% incidence of ischemia. HR greater
than 110 beats/min was associated with a 32% to 63% incidence of ischemia
[26]. The most likely cause is light anesthesia (sympathetic stimulation).
b. Treatment
(1) Rule out ventilation abnormalities and correct them if present.
(2) Increase anesthetic depth if other signs of light anesthesia or BIS monitor
changes are seen. An empiric small dose of narcotic is often used.
(3) Treat the underlying cause.
(a) Give volume infusion if low preload is evident.
(b) β-Blockade with esmolol can be used, particularly if ischemia is
noted.
5. Dysrhythmias
a. The most likely cause of dysrhythmia in the prebypass period is surgical
manipulation of the heart (Table 6.7).
CLINICAL PEARL Most prebypass dysrhythmias are caused by surgical manipulation of
the heart, and most often the dysrhythmia ceases immediately upon discontinuation of cardiac
manipulation.
b. Treatment
(1) Treatment of the underlying cause. Potassium replacement in the pre-
CPB period should be limited to treatment for symptomatic hypokalemia
because the cardioplegic solution used during CPB may increase the
serum potassium level significantly. Magnesium replacement has been
useful in patients who have dysrhythmias and are hypomagnesemic.
(2) Dysrhythmias causing minor hemodynamic disturbances
(a) Supraventricular tachycardia (including acute atrial fibrillation or
flutter): Stop mechanical irritation or use vagal maneuvers,
adenosine, calcium channel blockers, β-blockers (typically
esmolol), phenylephrine, or edrophonium (often not available in the
United States).
(b) Premature ventricular contractions (PVCs) are mostly benign: Stop
mechanical irritation.
(c) Antiarrhythmics do not reduce PVCs caused by mechanical
irritation.
(d) If not from mechanical irritation, they can be treated with lidocaine,
procainamide, β-blockers, and/or amiodarone, but this is seldom
necessary in the absence of runs of ventricular tachycardia.
(3) Dysrhythmias causing severe hemodynamic compromise
(a) Cardioversion or defibrillation for atrial dysrhythmias, ventricular
tachycardia, or ventricular fibrillation
(i) Internal cardioversion:
(a) Internal paddles are applied directly to the heart when the
chest is open.
(b) Low-energy levels (10 to 25 J) are needed for
cardioversion (skin and chest wall impedance are
bypassed).
(c) Synchronization capabilities are desirable for atrial
dysrhythmias and ventricular tachycardia. This may
require additional cables or equipment to transmit ECG
signal to defibrillator.
(d) Defibrillation requires similar energy levels in a
nonsynchronized mode.
(ii) External cardioversion
(a) Usual paddle size is used with the chest closed.
(b) Energy levels of 50 to 300 J are needed.
(c) Sterile external paddles are desirable if defibrillation pads
were not placed prior to incision and excluded from the
sterile surgical skin preparation area.
L. Preparation for cardiopulmonary bypass
1. Anticoagulation with heparin [27]
Unfractionated heparin is the preferred agent for anticoagulation. It is a water-
soluble mucopolysaccharide with an average molecular weight of 15,000 Da.
a. Mechanism of action: Binds to antithrombin III (AT III), a protease inhibitor,
and increases the speed of the reaction between AT III and several activated
clotting factors (II, IX, X, XI, XII, XIII).
b. Onset time: Less than 1 minute if cardiac output is normal.
c. Half-life: Approximately 2.5 hours at usual cardiac surgery dose.
d. Metabolism: Approximately 50% by liver (heparinase) or reticuloendothelial
system, approximately 50% unchanged by renal elimination.
e. Potency of different preparations may differ markedly.
(1) Potency is measured in units (not milligrams).
(2) Heparin solutions usually contain 100 to 140 units/mg, depending on the
lot or manufacturer.
f. Dosage
(1) The initial dosage of heparin for anticoagulation before CPB is 300 to
400 units/kg. This initial dose has been established by many
investigators. However, some patients may remain inadequately
anticoagulated using this dose, so adequate anticoagulation must be
established on an individual basis according to the ACT (see Chapter
21).
(2) Some institutions use a heparin dose–response titration to establish an
initial dose.
g. Routes of administration. Heparin must be administered directly into a
central vein or into the right atrium, with documentation that heparin is being
administered into the intravascular space (aspiration to confirm blood return,
adequate ACT level).
2. Cannulation (Fig. 6.3)
a. A pericardial sling is created before cannulation to increase working space
and to provide a dam for external cooling fluid and ice slush solution. The
sling may lift the heart, which can decrease venous return and lead to
hypotension.
b. Purse-string sutures are used to keep the aortic and venous cannulae in place
during surgery and to close the incisions after decannulation.
c. If in use, nitrous oxide is discontinued to avoid enlargement of air emboli.
IGURE 6.3 View of an open chest with formation of a pericardial sling (see text). Note arterial and venous cannulation sites.
aval tapes, placed around the superior and inferior vena cava, are tightened to institute complete cardiopulmonary bypass (CPB).
d. Heparin is always given before cannulation.

e. The aortic cannula is ideally inserted first to allow infusion of volume in case
of hemorrhage associated with venous cannulation. Systolic BP should be
decreased to 90 to 100 mm Hg to reduce the risk of aortic dissection and to
facilitate cannulation. If necessary, emergency CPB can be instituted using
cardiotomy suckers to deliver venous return (the so-called “sucker bypass”).
f. The surgical and anesthesia teams both should check the aortic cannula for air
bubbles as it is filled with saline and connected to CPB tubing. A test
transfusion of 100 mL should be performed to ensure proper placement and
functioning of the cannula.
g. If you request an infusion of volume before CPB, make sure the surgical team
or the perfusionist does not have any clamps on the tubing.
h. PEEP may be applied to increase intracardiac pressures to avoid air
entrainment during cannulation of the right atrium.
i. Complications of aortic cannulation
(1) Embolic phenomena from air or atherosclerotic plaque dislodgment can
occur. Epiaortic echocardiography is sometimes used to identify intimal
plaque and to find a “safe” location for the cannula.
(2) Hypotension
(a) Hypotension is usually secondary to hypovolemia (blood loss).
(b) It may result from mechanical compression of the heart.
(c) A partial occlusion clamp used for cannulation may narrow the
aortic lumen (more common in children). Check the aortic pressure
immediately when the clamp is applied.
(3) Dysrhythmias (uncommon) are most likely due to surgical manipulation.
(4) Aortic dissection can occur due to cannula misplacement. A pulsatile
pressure from the aortic cannula that correlates with the radial mean
arterial BP effectively rules out dissection, as can TEE.
(5) Bleeding
(a) Minor bleeding is not uncommon with cannulation.
(b) Major bleeding may occur if the aorta is torn.
(c) Treatment consists of infusion of volume as needed or initiation of
CPB.
(6) Rarely, air entrainment around the cannula occurs, with resultant systemic
embolization.
j. Complications of venous cannulation
(1) Hypotension
(a) Venous cannulation may temporarily impair venous return to cause
reduced cardiac output and hypotension. If a venous cannula is
sufficiently large that it occludes a vena cava, then the most
reasonable option to treat hypotension may be to initiate CPB.
(b) If hypotension is due to hypovolemia, give volume in 100-mL
increments for adults and 10 to 25 mL for pediatric patients through
the aortic line as needed.
(c) Mechanical compression of the heart may cause hypotension,
especially during inferior vena caval cannulation.
(2) Bleeding
(a) Bleeding can occur from a tear of the right atrium or the superior or
inferior vena cava.
(b) Treatment is accomplished by infusing volume or initiating
emergency CPB.
(3) Dysrhythmias
(a) Dysrhythmias usually result from surgical manipulation.
(b) No treatment is required if they do not cause hemodynamic
deterioration.
(c) Cessation or limitation of mechanical stimulation may be all that is
necessary.
(4) Air entrainment from around the cannula with subsequent signs of
pulmonary embolization is possible.
3. Autologous blood removal
a. Sequestration of platelets and clotting factors. Autologous blood may be
removed to sequester platelets and clotting factors from damage during CPB,
with return at the conclusion of CPB. Some practitioners believe this practice
enhances coagulation after CPB and decreases the need for transfusion of
homologous blood and blood products during this period. However, there is
controversy about the benefits of this procedure. Sequestration of platelets and
clotting factors can be accomplished in a variety of ways.
(1) Techniques
(a) Blood, 500 to 1,000 mL, can be withdrawn in the pre-CPB period
and stored in a citrate phosphate dextrose (CPD) solution, similar to
banked blood.
(b) Before initiation of bypass, 500 to 1,000 mL of heparinized blood
can be removed from the venous bypass drainage line and saved for
later infusion.
(c) Plateletpheresis cell salvage equipment can be used in the prebypass
period to remove blood, if necessary, from a central venous
catheter. After centrifugation, the red cells are returned to maintain
hemoglobin levels and O2 transport. The platelet-poor fraction may
be returned to maintain intravascular volume or reserved along with
the platelet-rich fraction for later infusion after bypass.
(2) Risks
(a) Hypotension from hypovolemia. Treat with vasopressors and
decrease the withdrawal rate while increasing the infusion rate.
(b) Decreased O2-carrying capacity, as evidenced by decreased mixed
venous oxygenation saturation. Treat with 100% Fio2, halt blood
removal, return red cells as needed, and begin CPB as soon as
possible.
(c) Infection. Maintain sterile technique for removal and return of
blood.
(3) Relative contraindications
(a) Left main coronary disease or equivalent
(b) LV dysfunction
(c) Anemia with hemoglobin less than 12 g/dL
(d) Emergent surgery
ACKNOWLEDGMENTS
The authors gratefully acknowledge the contributions of Michael Howie, M.B.Ch.B., to
previous versions of this chapter. His vast clinical experience and knowledge of
pharmacology form essential foundations for this chapter.
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7 Management of Cardiopulmonary Bypass
Neville M. Gibbs, Shannon J. Matzelle, and David R.
Larach
I. Preparations for cardiopulmonary bypass (CPB)

A. Assembling and checking the CPB circuit
B. Anesthesiologist’s pre-CPB checklist
C. Management of arterial and venous cannulation
II. Commencement of CPB
A. Establishing “full flow”
B. Initial CPB checklist
C. Cessation of ventilation and lung management
D. Monitoring
E. Adequacy of perfusion
III. Typical CPB sequence
A. Typical coronary artery bypass graft (CABG) operation
B. Typical aortic valve replacement (or repair) operation
C. Typical mitral valve replacement (or repair) operation
D. Typical combined procedures
IV. Maintenance of CPB
A. Anesthesia
B. Hemodynamic management
C. Fluid management and hemodilution
D. Management of anticoagulation
E. Temperature management
F. ECG management
G. Myocardial protection
H. Arterial blood gas and acid–base management
I. Management of serum electrolytes
J. Management of blood glucose
V. Rewarming, aortic cross-clamp release, and preparation for weaning
A. Rewarming
B. Release of aortic cross-clamp
C. Preparation for weaning from CPB
VI. Organ protection during CPB
A. Renal protection
B. Brain protection
C. Myocardial protection
D. Inflammatory response to CPB
E. Lung protection
F. Splanchnic and gastrointestinal protection
VII. Prevention and management of adverse events, complications, and
catastrophes associated with CPB
A. Malposition of arterial cannula
B. Reversed cannulation
C. Obstruction to venous return
D. High pressure in the arterial pump line
E. Massive gas embolism
F. Failure of oxygen supply
G. Pump or oxygenator failure
H. Clotted oxygenator or circuit
I. Dislodgement of cannula or tubing rupture
J. Heater–cooler malfunction
VIII. Minimally invasive surgical techniques requiring CPB
A. Port-access surgery
B. Minithoracotomy
C. Minimally invasive mitral valve surgery
D. Minimally invasive aortic valve surgery
E. Choice of cardioplegia
IX. Management of unusual or rare conditions affecting bypass
A. Sickle cell trait and disease
B. Cold agglutinin disease
C. Cold urticaria
D. Malignant hyperthermia (MH)
E. Hereditary angioedema
F. Pregnancy
G. Jehovah’s Witnesses
KEY POINTS
KEY POINTS
1. Prior to cannulation for cardiopulmonary bypass (CPB), the

anesthesiologist must ensure that adequate anticoagulation has been
achieved. This is typically achieved by heparin administration and
confirmed by an activated clotting time (ACT) >400 seconds.
2. After commencement of CPB, once a target perfusion flow rate has
been confirmed (e.g., full flow) with adequate oxygenation, the
anesthesiologist should discontinue mechanical ventilation and
commence monitoring of CPB variables.
3. Cardioplegic solutions have a variety of “recipes.” In most cases, a
cold hyperkalemic crystalloid solution is used, either alone or in
combination with blood. Cardioplegia can be administered
antegrade (via coronary arteries) or retrograde (via coronary sinus).
4. Anesthesia during CPB can be maintained with various
combinations of volatile agents, opioids, and hypnotic agents.
Anesthetic requirements are reduced during hypothermia.
Maintaining neuromuscular blockade is important in order to avoid
spontaneous breathing and visible or subclinical shivering.
5. Appropriate perfusion flows and pressures during CPB are
controversial, but for most patients, a normothermic perfusion
index (equivalent to a cardiac index) of 2.2 to 2.4 L/min/m2 and
mean arterial pressure (MAP) of 50 to 70 mm Hg suffice.
Continuous monitoring of mixed venous oxygen saturation (MvO2)
is a guide to the adequacy of perfusion but must be supplemented
by other indices, including arterial blood gas measurements to
ensure optimal flows to all organs.
6. Moderate hemodilution is useful during CPB and aided by clear
CPB circuit priming solutions. Minimum safe hemoglobin (Hb)
concentrations during CPB are controversial and must be discussed
pre-CPB. For most patients, a Hb ≥6.5 g/dL (hematocrit [Hct] ≥20%)
is safe in the absence of evidence for inadequate oxygen delivery
(e.g., metabolic acidosis, low MvO2).
7. Hypothermia is commonly used during CPB to reduce oxygen
consumption and metabolism and to confer organ protection. Often
temperatures of 32° to 34°C are used in combination with alpha-stat
arterial blood gas management. Rewarming should be accomplished
slowly and should not proceed beyond a core temperature of 37°C.
8. During cardioplegic arrest, the anesthesiologist monitors the
adequacy of left ventricular (LV) emptying via direct observation of
the heart, the presence of low cardiac filling pressures, and the
absence of all electrical activity on the ECG.
9. Organ protection should be promoted, especially of the brain, but
also of the kidneys, lungs, and gut, by ensuring adequate oxygen
delivery (e.g., flows, Hct) and perfusion pressures (arterial–venous),
as well as by measures to minimize the inflammatory response to
CPB.
10. CPB may be associated with catastrophic events such as aortic
dissection, aortic or venous cannula malposition, venous
obstruction from air lock, massive air embolism, circuit disruption,
pump or oxygenator failure, and blood clots in the extracorporeal
circuit. A high level of expertise and vigilance is required with
mandatory safety precautions and checks.
11. Minimally invasive cardiac procedures typically require additional
instrumentation and monitoring for CPB due to the limited surgical
exposure, with the use of transesophageal echocardiography (TEE)
to guide venous and other cannula placement and lung management
to optimize surgical access.
12. Several rare conditions such as sickle cell disease, cold agglutinin
disease, malignant hyperthermia (MH), and angioedema have
implications for CPB and may require additional interventions or
CPB modifications.
I. Preparations for cardiopulmonary bypass (CPB)

This requires close communication and coordination between surgeon,
perfusionist, and anesthesiologist.
A. Assembling and checking the CPB circuit
The perfusionist assembles the CPB circuit (Fig. 7.1) before commencement of
surgery, so that CPB can be instituted rapidly if necessary. The circuit
components (e.g., pump [roller or centrifugal], tubing [e.g., standard or heparin-
bonded], reservoir [venous and possibly arterial], oxygenator, filters, and safety
monitors) are decided by institutional preference and should comply with
guidelines of professional organizations. Similarly, the type and volume of CPB
prime are decided by the perfusionist, in consultation with surgeon and
anesthesiologist. The perfusionist checks all components using an approved
checklist. See Chapter 20 for details on CPB circuit design and use.
FIGURE 7.1 CPB circuit (example). Blood drains by gravity (or with vacuum assistance) (A) from venae cavae (1)
through venous cannula (2) into venous reservoir (3). Blood from surgical field suction and from vent is pumped (B, C) into
cardiotomy reservoir (not shown) and then drains into venous reservoir (3). Venous blood is oxygenated ( 4), temperature
adjusted (5), raised to arterial pressure (6), filtered (7, 8), and injected into either aorta (10B) or femoral artery (10A).
Arterial line pressure is monitored (9). Note that items 3, 4, and 5 often are single integral units. CPB, cardiopulmonary
bypass. (Modified from Nose Y. The Oxygenator. St. Louis, MO: Mosby; 1973:53.)
B. Anesthesiologist’s pre-CPB checklist (Table 7.1)

1 A separate pre-CPB checklist is undertaken by the anesthesiologist (Table
7.1). This includes ensuring that anticoagulation is sufficient for cannulation and
CPB (e.g., activated clotting time [ACT] >400 seconds), adequate anesthesia
will be provided during CPB, fluid infusions are ceased, and monitors are
withdrawn to safe positions for CPB (e.g., Swan–Ganz catheter, if present, is
withdrawn into the proximal pulmonary artery [PA] and a transesophageal
echocardiography [TEE] probe, if present, is returned to a neutral [unflexed]
position). The urinary catheter drainage bag should be emptied, and the patient’s
face and pupils should be checked so that any changes as a result of CPB can be
recognized. If cerebral oximetry is used, the pre-CPB values should be recorded.
C. Management of arterial and venous cannulation
Prior to cannulation, adequate anticoagulation must be confirmed, and nitrous
oxide, if used, must be ceased (to avoid the expansion of any air bubbles
inadvertently introduced during cannulation). The anesthesiologist typically
reduces the systemic systolic blood pressure to about 80 to 100 mm Hg to reduce
the risk of arterial dissection while the cannula is placed. In most cases, the
arterial cannulation site will be the distal ascending aorta. If so, this site should
be checked for at-risk atherosclerotic plaques (mobile or >3 mm thickness) by
TEE or epiaortic scanning. The perfusionist then checks that the pressure trace
through the arterial cannula matches the systemic blood pressure trace (mean
arterial pressure [MAP] and pulsatility). This ensures that the arterial cannula
has been placed within the aortic lumen. Depending on the type of aortic
cannula, it may be possible to check the correct position of the tip using TEE.
Once the aortic cannula is in place and its correct position has been checked (and
adequate anticoagulation has been confirmed), it is possible to transfuse fluid
from the CPB circuit to treat transient hypotension. If a two-stage venous cannula
is selected, the surgeon then inserts the venous cannula into the right atrium and
guides the distal stage of the cannula into the inferior vena cava (IVC). If
retrograde cardioplegia is planned, a separate smaller cannula is guided via the
right atrium into the coronary sinus, which can also be checked using TEE.
Femoral or arterial cannulation may be used if access to the distal ascending
aorta is limited: The axillary approach avoids retrograde flow in the often
atherosclerotic thoracic and abdominal aorta. The venous cannula can also be
inserted peripherally through a femoral vein, if necessary, but must be advanced
to the right atrium for adequate drainage. In these cases, TEE is required to
confirm satisfactory venous cannula position. Management of arterial and venous
cannulation for minimally invasive procedures is covered in Section VIII.
TABLE 7.1 Prebypass checklist
II. Commencement of CPB

A. Establishing “full flow”
Once the cannulae are in place and all other checks and observations are
satisfactory, the surgeon indicates that CPB should commence. The perfusionist
gradually increases the flow of oxygenated blood through the arterial cannula into
the systemic circulation. At the same time, the venous clamp is gradually
released, allowing an increasing proportion of systemic venous blood to drain
into the CPB reservoir. Care is taken to match the arterial flow to the venous
drainage. Typically, the arterial inflow is increased over about 30 to 60 seconds
to provide a “normal” cardiac output (CO), based on a cardiac index of about 2.2
to 2.4 L/min/m2. This is known as “full flow.” At this stage, the left ventricle
(LV) should have ceased to eject, and the central venous pressure (CVP) should
be close to zero.
B. Initial CPB checklist (Table 7.2)
As CPB commences, the anesthesiologist should check the patient’s face for
asymmetry of color and the patient’s pupils for asymmetry of size and can repeat
the check of the arterial cannula tip position using TEE. Satisfactory oxygenator
function should be confirmed by checking the color of the arterial blood, oxygen
saturation monitors, and, if available, the in-line PaO2. Adequate venous
drainage is confirmed by the absence of pulsatility in the arterial waveform and
low CVP (typically <5 mm Hg). Transient hypotension (MAP 30 to 50 mm Hg) is
not uncommon following initiation of CPB, but if persistent, aortic dissection
should be ruled out.
TABLE 7.2 Initial cardiopulmonary bypass (CPB) checklist (see also 2-minute drill,
Chapter 20)
CLINICAL PEARL If there is doubt about the ability to achieve full flow or adequate
oxygenation, separation from CPB should be considered, so that the cannula position
and CPB equipment can be rechecked.
C. Cessation of ventilation and lung management
If the observations of the initial CPB checklist are satisfactory and full flow is
established, ventilation 2 of the lungs is ceased. Optimal lung management
during CPB and the relative benefits of continuous positive pressure (5 to 10 cm
H2O) and lower or higher FiO2 are not known, although the use of 100% oxygen
may promote atelectasis. For some minimally invasive procedures, all positive
pressure on the operative side must be avoided.
D. Monitoring
Patient monitoring during CPB includes continuous ECG, MAP, CVP, core
temperature (e.g., nasopharyngeal, tympanic membrane, bladder), blood
temperature, and urine output. Continuous monitoring of venous hemoglobin
(Hb) oxygen saturation (and ideally arterial Hb oxygen saturation) is required
and in-line monitoring of arterial blood gases, pH, electrolytes, and hematocrit
(Hct) are recommended. Measurement errors may lead to inappropriate
management with potentially disastrous consequences, so calibration and
frequent checks confirming accuracy are advised. Depth of anesthesia monitoring
(e.g., bispectral index, entropy) should be continued during CPB. Intermittent
monitoring of coagulation (e.g., ACT), laboratory arterial blood gases,
electrolytes (including calcium, potassium, blood glucose, and lactate), and
Hb are necessary. Estimates of Hb and blood glucose can be obtained rapidly
u s i n g point-of-care devices. Cerebral oximetry using near-infrared
spectroscopy (NIRS) provides an indication of brain tissue oxygenation and is
used in selected patients or for selected procedures [1] (see Sections II.E.4,
IV.E.5, and VI.B).
E. Adequacy of perfusion
1. Oxygen delivery (DO2) is the most important reason for establishing adequate
perfusion (DO2 = CaO2 [blood oxygen content] × effective perfusion flow
rate). The margin of error is often reduced due to hemodilution, but oxygen
utilization may also be decreased by hypothermia. Inadequate DO2 will cause a
reduction in the mixed venous O2 saturation due to increased oxygen extraction.
However, below a critical point, tissue hypoxia and lactic acidosis will also
begin to occur. DO2 can be improved by raising Hct values (by transfusion or
hemoconcentration) or by increasing pump flow rates. Oxygen demand is
reduced by hypothermia and muscle relaxation. Calculation of oxygen
consumption may assist in ensuring that adequate oxygen is being delivered.
2. Mixed venous oxygen saturation (MvO2, SvO2) provides clues to the
adequacy of oxygen delivery (DO2) for any given oxygen demand (VO2).
CLINICAL PEARL The SvO2 provides a valuable guide to the adequacy of global
perfusion, but additional information is required to ensure adequate perfusion to individual
organs and to exclude regional ischemia.
Normally, MvO2 is above 75%, even at normothermia. Below this value,
inadequate VO2 should be suspected, and below 50%, tissue hypoxia is likely.
Unfortunately, satisfactory MvO2 does not exclude regional ischemia. Thus,
although a low venous oxygen saturation should always be remedied, a
normal or high venous saturation does not always imply adequate perfusion
to all organs.
3. Metabolic and lactic acidosis: Tissue hypoxia due to inadequate DO2 will
result in metabolic acidosis, primarily due to increases in lactic acid. The
reduction in pH and bicarbonate and increase in base deficit can be monitored
by in-line or serial arterial blood gas measurement. An increase in lactate level
suggests a metabolic cause for acidosis.
4. Cerebral oximetry (e.g., NIRS). In addition to its role as a monitor of the
adequacy of cerebral oxygen delivery, recent studies have suggested that
cerebral oximetry may be a useful surrogate to assess adequacy of total body
oxygen delivery [2]. As cerebral blood flow is autoregulated more closely than
other organs, decreases in cerebral oxygenation suggest that flow to other
tissues is also impaired.
5. Adequacy of regional perfusion to specific organs: See Section VI.A–F.
III. Typical CPB sequence
A. Typical coronary artery bypass graft (CABG) operation
A typical CABG operation proceeds as follows. Total CPB is initiated and mild-
to-moderate hypothermia is either actively induced (32° to 34°C) or permitted to
occur passively (sometimes called “drifting”). The aorta is cross-clamped and
cardioplegic solution is infused antegrade through the aortic root and/or
retrograde cannula via the coronary sinus to arrest 3 the heart. During antegrade
cardioplegia administration, it is important to monitor for distention of the LV,
and during retrograde cardioplegia infusion, it is important to monitor delivery
pressures. The distal saphenous vein grafts are placed on the most severely
diseased coronary arteries first, to facilitate administration of additional
cardioplegic solution (via the vein graft) distal to the stenosis if necessary. The
internal mammary artery anastomosis (if used) is often undertaken last because of
its fragility and shorter length. Rewarming typically begins when the final distal
anastomosis is started. Once the distal anastomoses are completed, the aorta is
unclamped, and either an aortic side clamp is applied or an internal occlusive
device is used to permit proximal vein graft anastomoses while cardioplegic
solution is being washed out of the heart. In some patients, the proximal
anastomoses are completed with the aortic cross clamp in place, in order to
reduce instrumentation of the aorta (with the risk of dislodging atheroma). Total
CPB continues until the heart is reperfused from its new blood supply. Finally,
when the patient is adequately rewarmed and the coronary artery grafts are
completed, the heart is defibrillated if necessary, epicardial pacing wires are
placed, and separation from CPB commences.
B. Typical aortic valve replacement (or repair) operation
After initiation of CPB and application of the aortic cross-clamp, cardioplegia is
infused as per the CABG procedure, unless the aortic valve is incompetent, in
which case the aortic root is opened and cardioplegic solution is infused into
both coronary artery ostia under direct vision (to prevent the cardioplegic
solution entering the LV through the incompetent aortic valve instead of the
coronary arteries). For this reason, cardioplegia is often administered retrograde
via the coronary sinus, either instead of or in addition to antegrade cardioplegia.
The valve is then either replaced or repaired. Carbon dioxide is often suffused
into the thoracic cavity to displace air from open heart chambers. Rewarming
commences toward the end of valve repair or replacement. The heart is irrigated
to remove residual air or tissue debris, and the aortotomy is closed except for a
vent. The aortic cross-clamp is removed (often with the patient in a head-down
position) and the heart is defibrillated if necessary. Final deairing occurs as
venous drainage to the pump is retarded, the heart fills and begins to eject
(partial CPB), and residual bubbles are aspirated through the aortic vent, an LV
vent, or a needle placed in the apex of the heart. During deairing, the lungs are
inflated to help flush air out of pulmonary veins and the heart chambers, and TEE
is viewed to monitor air evacuation and exclude residual air.
C. Typical mitral valve replacement (or repair) operation
This operation is similar to aortic valve surgery (see Section III.B above), except
that the left atrium (or right atrium for a transatrial septal approach) is opened
instead of the aorta, and the cardioplegia infusion can take place through the
aortic root and the coronary sinus. If a transatrial approach is used, bicaval
venous cannulation is required. The valve is replaced or repaired, and a vent
tube is passed through the mitral valve into the LV to prevent ejection of blood
into the aorta until deairing is completed. Before bicaval cannulation, a PA
catheter, if present, should be withdrawn into the superior vena cava (SVC), and
CVP measurement cephalad to the SVC cannula should be assured. If a PA
catheter introducer is in place, attaching the CVP monitor to the side port of the
introducer is recommended. Carbon dioxide is often suffused into the thoracic
cavity to displace air from open heart chambers. After thorough irrigation of the
field and closure of the atriotomy except for the LV vent, the aortic cross-clamp
is removed, often with the patient in a head-down position. The heart is
defibrillated, if necessary, and deairing occurs as described above. Finally, the
LV vent is removed.
D. Typical combined procedures
For combined valve–CABG procedure, the distal vein graft anastomoses are
created first to permit cardioplegia of the myocardium distal to severe coronary
stenoses. Also, lifting the heart to access the posterior wall vessels can disrupt
myocardium if an artificial valve has been inserted, especially in the case of
mitral valve replacement. Next, the valve repair or replacement is undertaken,
and the operation proceeds as described above. When combined aortic and
mitral valve surgery is performed, usually the mitral valve surgery is performed
first.
IV. Maintenance of CPB
A. Anesthesia
1. Choice of agent and technique. Just as in the pre-CPB period, anesthesia is
typically 4 provided by a potent volatile agent or an infusion of intravenous
(IV) anesthetic (e.g., propofol) on a background of opiates (e.g., fentanyl,
sufentanil) and other sedative drugs (e.g., benzodiazepines). Volatile agents
have a more defined role in myocardial protection than other anesthetics
through ischemic preconditioning and reduction of reperfusion injury [3].
2. Potent volatile agent via pump oxygenator. This requires a vaporizer mount
in the gas inlet line to the oxygenator. A flow- and temperature-compensated
vaporizer, typically containing sevoflurane or isoflurane, is then attached to the
mount. The concentration of agent is typically about 1.0 MAC at normothermia
but depends on the amount of supplementary opiates and sedatives and is
reduced with hypothermia. With most oxygenators, uptake and elimination of
the volatile agent are more rapid than through an anesthesia circuit and a
patient’s lungs. Volatile agent administration can be confirmed by connecting
the gas analysis line from the anesthesia circuit to a side port of the oxygenator
outlet during CPB [4]. If volatile agents are used, appropriate scavenging of the
oxygenator outlet is required. Nitrous oxide is never used because of its
propensity to enlarge gas-filled spaces, including micro and macro gas emboli.
3. Total intravenous anesthesia. Total intravenous anesthesia (TIVA) can be
provided during CPB using a combination of opiates and sedatives, either by
intermittent bolus or by infusion. For propofol, the typical infusion rates are 3
to 6 mg/kg/hr or a target plasma concentration of 2 to 4 μg/mL, depending on
the use of other IV agents and the patient’s temperature. The advantages of
TIVA are simplicity, less myocardial depression, and the absence of a need for
oxygenator scavenging. However, as with all forms of TIVA, ensuring adequate
depth is more difficult, providing greater justification for anesthesia depth
monitoring (e.g., bispectral index, entropy) [5].
4. Muscle relaxation. Movement of the patient during CPB risks cannula
dislodgement. If additional muscle relaxants are not used, adequate depth of
anesthesia to prevent movement must be ensured. Similarly, spontaneous
breathing must be avoided, as this risks the development of negative
intravascular pressures and potential air entrainment. If spontaneous breathing
occurs, adequate depth of anesthesia should be checked, and elevated PaCO2, if
present, should be corrected.
5. Effect of temperature. Anesthetic requirements fall as temperature drops.
However, due to its relatively high blood supply, brain temperature changes
faster than core temperature. For this reason, particular care should be taken to
e ns ur e adequate anesthesia as soon as rewarming commences, and
additional opiates or sedatives may be required. When the patient is
normothermic, anesthetic requirements are the same as the pre-CPB phase,
although the context-sensitive half-time for most anesthetic drugs increases
substantially during and after CPB.
6. Monitoring anesthetic depth. Awareness may be difficult to exclude
clinically due to the use of high-dose opiates, cardiovascular drugs (e.g., β-
adrenergic blockers), and muscle relaxants. Moreover, hemodynamic cues
cannot be used during CPB. The patient should be checked for pupillary
dilation and sweating, but these signs may be affected by opiate medication and
rewarming. Therefore, emphasis should be placed on ensuring delivery of
adequate anesthesia, preferably with the use of depth-of-anesthesia monitors
[5].
7. Altered pharmacokinetics and pharmacodynamics. At the onset of CPB, the
circulating blood volume is increased by the addition of the priming solution
in the extracorporeal circuit, but the percentage change in the total volume of
distribution of most anesthetic agents is minimal. Neuromuscular blockers are
an exception; hence, supplementary doses may be required at the onset of CPB.
Hemodilution reduces the concentration of plasma proteins, increasing the
unbound active proportion of many drugs (e.g., propofol) to offset the reduced
total plasma concentration induced by the increased circulating blood volume.
A small proportion of some agents (e.g., fentanyl, nitroglycerin) may be
absorbed onto the foreign surfaces of the CPB circuit. Hypothermia reduces
the rate of drug metabolism and elimination, as does reduction in blood flow to
the liver and kidneys. Bypassing the lungs reduces pulmonary metabolism
and sequestration of certain drugs and hormones. Reduced blood supply to
vessel-poor tissues such as muscle and fat may result in sequestration of drugs
given pre-CPB. The response to drugs may also be altered by hypothermia and
hemodynamic alterations associated with CPB. The combined effect of these
pharmacologic changes may be difficult to predict, so the principle of titrating
drugs to achieve a certain endpoint is particularly important during CPB.
B. Hemodynamic management. See also Chapter 20.
1. Systemic perfusion flow rate. The most fundamental hemodynamic change
during CPB is the generation of the CO by the CPB pump rather than the
patient’s heart. The 5 perfusionist regulates the CPB pump to deliver the
desired perfusion flow rate for the patient. This is usually based on a
nomogram taking into consideration the patient’s height and weight and the core
temperature. Typically, the perfusion flow rate is set to deliver a perfusion
flow rate of 2.4 L/min/m2 at 37°C and about 1.5 L/min/m2 at 28°C. The
amount delivered by the CPB pump is usually set slightly higher than the target
flow rate to account for any recirculation within the CPB circuit. For example,
a continuous flow of about 200 mL/min from the arterial line filter may be
returned to the reservoir through a purge line to provide a mechanism for
purging trapped microbubbles. The effective perfusion flow rate is the
amount delivered by the CPB pump minus the amount recirculated. An
inadequate effective perfusion flow rate will result in a low venous Hb
oxygen saturation (continuously monitored in the CPB venous return) and the
development of a metabolic acidosis due to anaerobic metabolism and the
accumulation of lactic acid. If other causes for a low venous Hb oxygen
saturation can be excluded (e.g., excessive hemodilution, inadequate
anesthesia, excessive rewarming), the perfusion flow rate should be increased
accordingly. Unfortunately, a normal venous oxygen saturation does not confirm
adequate perfusion of all tissues. Shunting may occur leaving some tissue beds
underperfused. An increased metabolic rate due to shivering, which may be
subclinical during hypothermia (or much more rarely due to thyrotoxicosis or
malignant hyperthermia [MH]), may also reduce venous HbO2 saturations
despite normal flow rates.
2. MAP. The optimum MAP during CPB is not known [6]. Systolic and diastolic
pressures are generally of little concern because the vast majority of CPB is
conducted using nonpulsatile flow. If an adequate perfusion flow rate is
delivered, the actual MAP may be less important, so long as it is above the
lower limit of autoregulation, and there is no critical stenosis in the arterial
supply to individual organs. However, the lower limits of autoregulation vary
widely between patients [7]. Therefore, in adults, a conservative approach is
usually taken, maintaining the MAP between 50 and 70 mm Hg. This assumes a
CVP close to zero and should be adjusted higher if the CVP is raised. Higher
pressures may be required in the presence of pre-existing hypertension or
known cerebrovascular disease. Lower levels may be tolerated in children.
The possibility of measurement error due to inappropriate position of the
pressure transducers or zero drift should be checked frequently and
corrected if necessary.
3. Hypotension. The most important consideration in the management of
hypotension is to ensure that an adequate effective perfusion flow rate is
being delivered. While a transient reduction of perfusion flow rate (such as
may be requested by the surgeon at particular stages of the procedure) is of
little consequence, sustained reductions must be avoided. Once an adequate
perfusion flow rate is confirmed, the MAP may be corrected by increasing the
systemic vascular resistance (SVR) with the use of vasoconstrictors such as
phenylephrine (0.5 to 10 μg/kg/min or norepinephrine 0.03 to 0.3 μg/kg/min),
on the basis of the following relationship:
SVR = (MAP - CVP)/effective perfusion flow rate (L/min)
where MAP is expressed in mm Hg, CVP in mm Hg, and SVR in mm Hg/L/min
(to convert to dyne·s·cm−5, multiply by 80). As there is substantial individual
variability in response to vasoconstrictors, especially during CPB, the dose
should be titrated, commencing with less potent agents (e.g., phenylephrine) or
smaller doses and progressing to higher doses of more potent agents (e.g.,
norepinephrine), if required. Occasionally, vasopressin (e.g., 0.01 to 0.05
units/min) is required. The perfusion flow rate can be increased above normal
to correct hypotension temporarily (e.g., while vasoconstrictors take effect),
but this is not an appropriate strategy to correct persistent hypotension. The
onset of CPB is typically associated with sudden hemodilution, which
decreases SVR. Cardioplegia solution entering the circulation also reduces
SVR and is a common cause of hypotension. Reperfusion of the myocardium
after release of the aortic cross-clamp is another common cause of transient
hypotension. For these reasons, the use of vasoconstrictors during CPB is
common. Continuous infusions are preferable to intermittent boluses to avoid
inadvertent periods of hypertension or “roller coaster” changes in MAP.
4. Hypertension. Hypertension is usually the result of an increase in SVR, which
may be due to endogenous sympathetic stimulation or hypothermia. Before
treating hypertension with direct vasodilators (e.g., nitroglycerin 0.1 to 10
μg/kg/min, sodium nitroprusside 0.1 to 2 μg/kg/min, nicardipine 2 to 5 mg/hr),
adequate anesthesia should be ensured. Artifactual hypertension due to aortic
cannula malposition should also be excluded (see Sections I.C and VII.A). The
perfusion flow rate can be decreased below normal to correct hypertension
temporarily (e.g., while vasodilators take effect), but not to correct persistent
hypertension. Hypertension should be avoided during all aortic cross-clamp
manipulations, including the application and release of side-biting clamps.
Typically, nitroglycerin is the first-line drug with more venous than arterial
vasodilation. Sodium nitroprusside is more potent if nitroglycerin alone is
insufficient. Nicardipine has a longer duration of action and offset.
5. Central venous pressure. With appropriate venous drainage, the CVP should
be low (0 to 5 mm Hg). A persistently high CVP indicates poor venous
drainage, which may require adjustment of the venous cannula or cannulae by
the surgeon. Venous drainage can also be improved slightly by raising the
operating table height, thereby increasing the hydrostatic gradient between the
heart and the venous reservoir. Increasingly, in recent years, suction (vacuum-
assisted venous drainage [VAVD]) is applied to the venous reservoir,
especially for miniaturized circuits (see Chapter 20) or for femoral venous
cannulation (see Section VIII). Excessive suction should be suspected if the
CVP reading falls below −5 mm Hg. As the CVP is a low-range pressure, it is
very sensitive to measurement error (e.g., hydrostatic gradient between
transducer and right atrium). Care should also be taken to ensure that the
catheter measuring the CVP is in a large central vein and is not snared by
surgical tapes.
C. Fluid management and hemodilution
1. CPB prime. The CPB circuit is “primed” with a balanced isotonic crystalloid
solution, to which colloids, mannitol, or buffers may be added, depending on
perfusionist, anesthesiologist, and surgical preference (see Chapter 20). CPB
prime also usually contains a small dose of heparin (e.g., 5,000 to 10,000
units). A dose of the antifibrinolytic agent being used may also be added (e.g.,
aminocaproic acid 5 g or tranexamic acid 1 g). The volume of the prime
depends on the circuit components. It is typically about 1,400 to 2,000 mL for
adults. It is lower for pediatric CPB circuits and for miniaturized CPB systems
(see Chapter 20).
2. Hemodilution. The use of a nonsanguineous prime inevitably results in
hemodilution. The degree of hemodilution on commencement of CPB can be
estimated prior to CPB by multiplying the Hb concentration (or Hct) prior to
CPB by the ratio of the patient’s estimated blood volume to the patient’s
estimated blood volume plus the CPB prime volume. Moderate hemodilution is
usually well tolerated because oxygen delivery remains adequate and oxygen
requirements are often reduced during CPB, especially if hypothermia is used.
Moderate hemodilution may also be beneficial because it reduces blood
viscosity, which counters the increase in blood viscosity induced by
hypothermia that would otherwise impede blood flow.
3. Limits of hemodilution. While the safe limit of hemodilution during CPB in
individual patients is not known, a conservative approach is to avoid Hb levels
<6.5 g/dL (approximately 6 an Hct of 20%). If the estimated degree of
hemodilution on commencement of CPB is too low, allogeneic red blood cells
(RBCs) can be added to the CPB prime. This is particularly important for
smaller patients (due to their lower estimated blood volumes) (e.g., pediatric
patients) and anemic patients. If venous oxygen saturations are low during CPB
despite normal effective perfusion flow rates, excessive hemodilution as a
cause should be considered and additional RBCs added if necessary. Similarly,
inadequate oxygen delivery will result in anaerobic metabolism and the
development of acidosis. Patients with known stenoses of cerebral or renal
arteries may be less tolerant of hemodilution.
CLINICAL PEARL The predicted effect of CPB on the Hct, the safe limit of
hemodilution, and transfusion triggers should be discussed prior to CPB.
4. Time course of hemodilution. During the course of CPB, crystalloid fluid will
diffuse from the vascular to the extracellular space and also will be filtered by
the kidney, gradually reducing the extent of hemodilution. However, crystalloid
cardioplegia returning to the circulation will increase hemodilution, as will the
addition of other crystalloids or colloids used to replace blood loss or
redistribution of fluid into nonvascular compartments.
5. Monitoring hemodilution. The Hb (or Hct) should be measured at least every
30 to 60 minutes and more frequently if there is ongoing blood loss, or low
mixed venous oxygen saturations. If possible, Hct should be monitored
continuously.
6. Acute normovolemic hemodilution. In adult patients with average (or greater)
body size and normal preoperative Hb, acute normovolemic hemodilution prior
to, or at the time of commencement of, CPB should be considered. Typically, 1
to 2 units of anticoagulated blood are collected and replaced with colloids,
crystalloids, or a combination. This blood, containing pre-CPB Hb, platelet,
and clotting factor levels can be reinfused post-CPB.
7. Allogeneic RBC transfusion trigger. The trigger for allogeneic RBC
transfusion varies between institutions and will depend on patient and surgical
factors. It must take into account the balance of harmful effects of allogeneic
RBC transfusion versus the harmful effects of inadequate oxygen carriage.
Ideally, the transfusion trigger for the individual patient should be discussed
between anesthesiologist, perfusionist, and surgeon prior to the commencement
of CPB. Conservative triggers are an Hb <6.5 g/dL during the maintenance
phase of CPB and <8.0 g/dL at the time of separation, although lower levels
may be tolerated in selected patients, and higher levels may be required in
others.
8. Cardiotomy suction. Shed blood may be returned to the CPB circuit using
cardiotomy suction. However, shed blood often contains activated coagulation
and fibrinolytic factors, especially if exposed to the pericardium. Excessive
cardiotomy suction may also be associated with hemolysis, especially if there
is co-aspiration of air. For this reason, some choose to return only brisk blood
loss to the CPB circuit. An alternative is separate cell salvage with washing of
RBCs before returning them to the CPB circuit.
9. Fluid replacement. Fluid may be lost from the circuit through blood loss,
redistribution to other compartments, and filtration by the kidney. A reduction
in the circulating blood volume will manifest as a fall in the CPB reservoir
fluid level. A falling CPB reservoir fluid level is dangerous, as it reduces the
margin of safety for air embolism. In many circuits, an alarm will be activated
if the reservoir volume falls to unsafe levels. The replacement fluid is typically
crystalloid, with colloid added depending on perfusionist, surgeon, and
anesthesiologist preference.
10. Diuresis and ultrafiltration. Occasionally, the return of cardioplegia solution
to the CPB circuit or contraction of the vascular space by vasoconstrictors or
hypothermia will cause the reservoir level to increase. If high levels persist,
diuresis can be encouraged by the use of diuretic agents such as furosemide or
mannitol. Alternatively, an ultrafiltration device can be added to the circuit to
remove water and electrolytes (see Chapter 20).
11. Urine production should be identified and quantified as a sign of adequate
renal perfusion and to assist in appropriate fluid management. Very high urine
flow rates (e.g., >300 mL/hr) may be seen during hemodilution (due to low
plasma oncotic pressure), especially if mannitol is also present in the priming
solution. Oliguria (less than 1 mL/kg/hr) should prompt an investigation
because it may indicate inadequate renal perfusion. However, some
hypothermic patients demonstrate oliguria without an apparent cause. Kinking
of urinary drainage catheters may manifest as apparent oliguria, so this should
be checked before initiating treatment.
D. Management of anticoagulation (see also Chapter 21)
1. Monitoring anticoagulation. The ACT or a similar rapid test of
anticoagulation must periodically confirm adequate anticoagulation (e.g., ACT
>400 seconds; see also Chapter 21). The ACT should be checked before and
after initiating CPB and at least every 30 minutes thereafter. The ACT can be
checked within 2 minutes of administering heparin [8]. As the ACT falls over
time, often a higher target is chosen (e.g., >500 seconds), so that the lowest
ACT remains >400 seconds. During periods of normothermia, heparin
elimination is faster, so a requirement for heparin supplementation is more
likely.
2. Additional heparin is usually given in 5,000- to 10,000-unit increments, and
the ACT is repeated to confirm an adequate response. Use of fully heparin-
coated circuits does not eliminate the need for heparin; an ACT of 400 seconds
or greater is often recommended.
3. Heparin resistance is a term used to describe the inability to achieve adequate
heparinization despite conventional doses of heparin. It may be due to a variety
of causes, but it is most common in patients who have received heparin therapy
for several days preoperatively. Most cases will respond to increased doses
of heparin. However, if an ACT >400 seconds cannot be achieved despite
heparin >600 units/kg, consideration should be given to administering
supplemental antithrombin III (AT-III). A dose of 1,000 units of AT-III
concentrate will increase the AT-III level in an adult by about 30%. Fresh
frozen plasma, 2 to 4 units, is a less expensive alternative, but it is also less
specific and carries a low risk of infectious and other complications. For a
detailed discussion of heparin resistance and AT-III deficiency, see Chapter
21.
E. Temperature management
1. Choice of maintenance temperature. The optimal temperature during the
maintenance phase of CPB is not known. Typically, the patient’s core
temperature at the onset of CPB is 35° to 36°C. Core temperature is usually
measured in the nasopharynx or tympanic membrane, but the bladder or
midesophagus may also be used. The target temperature is chosen on the basis
of the type and length of surgical procedure, patient factors, and surgical
preference. Often the temperature is allowed to drift lower to about 34°C
without active cooling (tepid CPB). Alternatively, the heat exchanger is used to
provide moderate hypothermia, which may be as low as 28°C but is more often
32°C or above. If there is a concern about the adequacy of myocardial
protection, lower temperatures may be used (see also Chapter 23).
2. Hypothermia. Hypothermia during CPB reduces metabolic rate and oxygen
requirements and provides organ protection against ischemia. However, it may
promote coagulation abnormalities and may increase the risk of microbubble
formation during rewarming. Hypothermia shifts the Hb oxygen saturation curve
to the left, reducing peripheral oxygen delivery, but this is countered by the
reduced oxygen requirements. The rewarming phase may prolong CPB duration
and may also risk overheating, particularly the brain.
3. Normothermia. Normothermia (or mild hypothermia, >34°C) has been
reported to be as safe as lower target temperatures and may improve some
outcomes [9].
4. Slow cooling. Lack of response of the nasopharyngeal or tympanic
temperature during the cooling phase may indicate inadequate brain cooling
and should prompt investigation of the cause (e.g., ineffective heat exchanger,
inadequate cerebral perfusion). The position and function of the temperature
monitor should also be checked to exclude artifactual causes.
5. Deep hypothermic circulatory arrest (DHCA). For certain surgical
procedures in which circulatory arrest is required (e.g., repairs of the aortic
arch), deep hypothermia is used as part of a strategy to prevent cerebral
injury. The typical target temperature prior to circulatory arrest is about 15° to
17°C, although if anterograde cerebral perfusion is planned, 22° to 24°C may
suffice. Other strategies to minimize injury include limiting the period of
circulatory arrest to as short a time as possible, anterograde or retrograde
cerebral perfusion during the period of DHCA and pharmacologic protection
us i ng barbiturates (e.g., thiopental 10 mg/kg), corticosteroids (e.g.,
methylprednisolone 30 mg/kg), and mannitol (0.25 to 0.5 g/kg). These must be
given before DHCA is commenced. Ensuring deep neuromuscular blockade
prior to DHCA is advisable. Cerebral oximetry should also be used. For
details of DHCA management, including monitoring, see Chapters 14 and 26.
6. Rewarming. Rewarming should commence early enough to ensure that the
patient’s core temperature has returned to 37°C by the time the surgical
procedure is completed, so that separation from CPB is not delayed. The
surgeon will usually advise the perfusionist when rewarming should
commence, taking into account the patient’s core temperature at the time, how
long the patient has been at this temperature, and the patient’s body size. The
rate of rewarming is limited by the maximum safe temperature gradient
between the water temperature in the heat exchanger and the blood which
should be no greater than 10°C and less as normothermia is approached. Higher
gradients risk the formation of microbubbles. The arterial blood temperature
should also be limited to 37°C to prevent cerebral hyperthermia [10].
Typically, patients’ core temperatures rise about 0.3°C/min. Vasodilators may
facilitate rewarming by improving distribution of blood and permitting higher
pump flow rates.
7. Hypothermia and arterial blood gas analysis. Hypothermia increases the
solubility of oxygen and carbon dioxide, thereby reducing their partial
pressures. However, arterial blood 7 gas measurement is performed at 37°C,
so the values have to be “temperature corrected” to the patient’s blood
temperature if the values at the patient’s blood temperature are required. The
reduced PaO2 is of limited clinical significance, so long as increased fractions
of oxygen are administered (FiO2 >0.5). However, the reduced PaCO2
produces an apparent respiratory alkalosis when temperature-corrected values
are used. To keep the pH normal (pH stat), it would be necessary to add CO2
to the oxygenator. The alternative is to avoid temperature correction of arterial
blood gases on the basis that the degree of dissociation of H+ also varies with
temperature (alpha stat). With this strategy, there is no requirement to add CO 2
to maintain neutrality. These complex biochemical considerations are avoided
by using non–temperature-corrected values and making decisions based on
the values measured at 37°C, irrespective of the patient’s blood temperature.
See Chapter 26 for further discussion of arterial blood gas management.
8. Shivering. Shivering should be avoided by ensuring adequate anesthesia.
Muscle relaxants will also prevent shivering.
F. ECG management
Isolated atrial and ventricular ectopic beats are common during cardiac
manipulation and require no specific intervention. If ventricular fibrillation
occurs before aortic cross-clamp placement, defibrillation may be required.
Ventricular fibrillation once the aortic cross-clamp has been placed is likely to
be short-lived because the delivery of cardioplegia will achieve cardiac
standstill. After aortic cross-clamp, ECG complexes change shape, become less
frequent, and then cease. Absence of an isoelectric ECG indicates insufficient or
ineffective cardioplegia. Return of electrical activity after cardioplegic arrest
suggests washout of cardioplegia solution. 8 The surgeon should be notified, as
additional cardioplegia may be required. Ventricular fibrillation may occur
during the rewarming phase after the release of the aortic cross-clamp. This often
resolves spontaneously but may require defibrillation, especially if the patient
remains hypothermic.
G. Myocardial protection (see also Chapter 23)
1. Cardioplegia. Once the myocardial blood supply is interrupted by the
placement of an aortic cross-clamp, cardioplegic arrest of the myocardium is
required. The antegrade technique is achieved by administering cardioplegia
solution into the aortic root between the aortic valve and aortic clamp. The
interval between the placement of the cross-clamp and the administration of the
cardioplegia is kept to a minimum (no more than a few seconds) to prevent any
warm ischemia. Conventional cardioplegia solutions are high in potassium,
arresting the heart in diastole. The solution is typically administered cold (8° to
12°C) to provide further protection, although warm continuous cardioplegic
techniques are used in some institutions. The solution may be administered
alone (crystalloid cardioplegia) or mixed with blood (blood cardioplegia).
Cardioplegia may also be administered retrograde through a catheter in the
coronary sinus. In patients with aortic regurgitation, administration of
cardioplegia directly into the left and right coronary ostia may be required.
Cardioplegia is typically given intermittently every 20 to 30 minutes but may be
given continuously by infusion. An alternative novel low-sodium crystalloid
cardioplegic solution (Custodiol HTK, Franz Kohler Chemie GmbH, Benshein,
Germany), which lasts up to 3 hours, is often used for minimally invasive and
other complex cardiac procedures because it typically involves less disruption
for repeated intermittent cardioplegia administration [11].
2. Cold. Most myocardial protection techniques involve cold cardioplegia, and
ice may be placed around the heart to provide further protection. Systemic
hypothermia, if used, contributes to keeping the myocardium cold.
3. Venting. During cross-clamping, vents are typically placed in the aortic root to
ensure that the heart does not distend. For open-chamber procedures, vents are
placed also in the left atrium or LV to remove both blood and air. Inadequate
venting may result in the development of tension in the LV, causing potential
subendocardial ischemia. The coronary perfusion pressure for cardioplegia is
also reduced.
4. Avoiding electrical activity. See Section IV.F above.
H. Arterial blood gas and acid–base management
1. Alpha stat or pH stat strategy? (see Section IV.E.7 and Chapter 26)
2. The arterial PO2 is typically maintained between 150 and 300 mm Hg by
adjusting the percentage oxygen in the sweep (analogous to inspired) gas
delivered to the oxygenator. Arterial hypoxemia may indicate inadequate
oxygenator sweep gas flow (or leak) or inadequate oxygen percentage in
the oxygenator sweep gas. Alternatively, it may indicate oxygenator
dysfunction.
3. The arterial PCO2 is maintained at approximately 40 mm Hg by adjusting the
sweep gas flow rate through the oxygenator. There is an inverse relationship
between the sweep gas flow rate and the arterial PCO2. Hypercapnea (PaCO2
>45 mm Hg) should be avoided as it is associated with sympathetic stimulation
and respiratory acidosis. Hypercapnea may be caused by an inadequate sweep
gas flow rate, absorption of CO2 used to flood the chest cavity during open
chamber procedures [12], or increased CO2 production. Administration of
bicarbonate also increases the PaCO2. Hypocapnea (PaCO2 <35 mm Hg)
should also be avoided, as it is associated with respiratory alkalosis and left
shift of the HbO2 dissociation curve (further reducing oxygen delivery) and
cerebral vasoconstriction.
4. Metabolic acidosis (e.g., lactic acidosis) is prevented where possible by
ensuring adequate oxygen delivery and tissue perfusion. Severe metabolic
acidosis should be corrected cautiously with the use of sodium bicarbonate. If
unexplained acidosis occurs with signs of an increased metabolic rate (e.g.,
low mixed venous oxygen saturations, elevated PaCO2), MH should be
considered.
I. Management of serum electrolytes
1. Hyperkalemia may occur when cardioplegia solution (which contains high
potassium concentrations) enters the circulation. This is usually mild or
transient unless large amounts of cardioplegia are used or the patient has
renal dysfunction. Hyperkalemia more often follows the first dose of
cardioplegia than later ones because both the volume and potassium
concentration are typically higher for the initial administration. Hyperkalemia
can cause heart block, negative inotropy, and arrhythmias. Hyperkalemia
can be treated by promoting potassium elimination by loop diuretics (e.g.,
furosemide) or by ultrafiltration. Potassium can also be shifted into cells by
the administration of insulin and glucose or by creating an alkalosis. A normal
ionized calcium level should also be ensured. In rare cases, hemodialysis is
required. If the patient has severe renal dysfunction or the serum potassium
remains above the normal range, the cardioplegia delivery technique should be
modified to ensure that cardioplegia is vented separately and not returned to the
circulation.
2. Hypokalemia. If a patient is hypokalemic, initiating K+ replacement during
CPB is much safer than waiting until after bypass, thus avoiding hypokalemic
dysrhythmias during CPB weaning or potential cardiac arrest during rapid K+
replacement post-CPB.
3. Sodium. Serum sodium should be maintained within the normal range where
possible. Rapid corrections should be avoided due to the risk of acute changes
in intracranial pressure as a result of the changes in plasma osmolality. The
use of low-sodium cardioplegic solutions (e.g., custodial HTK) is associated
with hyponatremia, but hypo-osmolality is avoided by the presence of other
osmotically active particles [11].
4. Ionized calcium levels should be maintained within the normal range.
J. Management of blood glucose
1. Hyperglycemia. Glucose tolerance is often impaired during CPB due to the
stress response associated with CPB, as well as from insulin resistance
induced by hypothermia. Hyperglycemia may exacerbate neuronal injury and
increase the risk of wound infection. Blood glucose should be measured
frequently, especially in patients with diabetes mellitus. Glucose containing
fluids should be avoided. Blood glucose should optimally be maintained below
180 mg/dL, which may require the infusion of insulin.
2. Hypoglycemia. Hypoglycemia should be avoided at all costs during CPB
because severe hypoglycemia is associated with neurologic injury within a
short period, and the signs of hypoglycemia are masked by both the anesthesia
and the hemodynamic changes during CPB. Blood glucose should be measured
more frequently if patients are receiving insulin or have received hypoglycemic
agents preoperatively on the day of surgery.
V. Rewarming, aortic cross-clamp release, and preparation for weaning
A. Rewarming. On commencement of rewarming, additional anesthetics may be
required because the brain rewarms faster than the body core.
CLINICAL PEARL Commencement of rewarming is an appropriate time to reassess
anesthetic depth, anticoagulation, arterial blood gases, and likely requirements for
weaning.
Additional heparin may be required because the rate of metabolism of heparin
returns to normal at normothermia. The extent of hemodilution should be re-assessed
because oxygen requirements increase during rewarming (see also Section IV.E above).
B. Release of aortic cross-clamp
1. Deairing. Air may collect in the pulmonary veins, left atrium, or LV,
particularly during open chamber procedures. This is aspirated through the
aortic root vent prior to cross-clamp release or other vents. Temporarily
raising the CVP and inflating the lungs will fill the LV and permit easier
surgical aspiration of intracavity air. Residual air can be detected using TEE.
Flushing the surgical field with CO2 prior to cardiac chamber closure may
reduce residual air, as CO2 is reabsorbed much faster than air.
2. Blood pressure. Hypertension should be avoided at the time of aortic cross-
clamp release. Transient hypotension may occur after the release of the cross-
clamp, due to residual cardioplegia or metabolites returning to the circulation
as the myocardium is reperfused.
C. Preparation for weaning from CPB. In preparation for weaning from CPB,
cardiac pacing equipment is attached and checked, electrolytes and acid–base
disturbances are corrected if necessary, an adequate Hb is ensured, and
additional inotropic drug infusions (e.g., epinephrine, dobutamine) required for
the weaning process are prepared and attached to the patient. If loading doses of
inodilators (e.g., milrinone) or calcium sensitizers (e.g., levosimendan) are
required, these should be given before completion of CPB. If the negative
inotropic effects of volatile agents are a concern, they should be ceased before
weaning commences, and other agents used to maintain adequate anesthesia.
Anesthetic management of weaning from CPB is covered in Chapter 8.
VI. Organ protection during CPB (see also Chapter 20)
A. Renal protection. The most important renal protective strategy is to ensure
adequate renal 9 perfusion during CPB by optimal fluid loading, appropriate
pump flow rates, close attention to the renal perfusion pressure, and avoidance
of intravascular hemolysis and hemoglobinuria. Numerous strategies have been
proposed to reduce the incidence or severity of acute kidney injury during CPB,
although there is no high-level evidence to support their routine use [13]).
Mannitol, low-dose dopamine, furosemide, prostaglandin E, and fenoldopam (a
selective dopamine-1 receptor agonist) have been advocated for use in high-risk
patients during CPB, particularly if oliguria is present. Fenoldopam 0.05 to 0.10
μg/kg/min showed early promise in some but not all clinical trials [14] . N-
acetylcysteine (a free-radical scavenger), steroids, calcium antagonists, and
urinary alkalinization have also been tried. Hemolysis and hemoglobinuria are
managed by correcting the cause where possible and by promoting diuresis.
B. Brain protection during CPB involves ensuring adequate cerebral perfusion
pressure (MAP – CVP) and oxygen delivery, with measures to prevent
hypotension and increases in either CVP or intracranial pressure (which will
reduce cerebral perfusion pressure). Causes of raised CVP should be identified
and corrected. Mild or moderate hypothermia is often used to provide
additional protection. Deep hypothermia with anterograde or retrograde
cerebral perfusion is used if circulatory arrest is required (see also Section IV.E
above). Care is taken to avoid emboli, both particulate (e.g., atheroma) and
gaseous, by meticulous surgical and perfusion technique. Jugular venous oxygen
saturation and cerebral oximetry using NIRS can be used to guide the efficacy
of interventions. Brain protection is covered in detail in Chapter 26.
C. Myocardial protection. See IV.G above.
D. Inflammatory response to CPB. CPB is one of the main factors contributing to
the inflammatory response associated with cardiac surgery [15]. Reactions are
usually mild or subclinical but may be severe in some cases and contribute to
brain, lung, renal, or myocardial injury. For a detailed discussion of this
inflammatory response to CPB and cardiac surgery, see Chapter 20.
1. Etiology
a. Exposure of blood to circuit components. The extensive contact between
circulating blood and the extracorporeal circuit results in variable amounts of
thrombin generation, activation of complement, release of cytokines, and
expression of immune mediators, all of which may contribute to a systemic
inflammatory response syndrome.
b. Return of shed blood to the CPB circuit via cardiotomy suction. Shed blood
is in contact with mediastinal tissues (e.g., pericardium) and air and is
exposed to shear stress when suction is used. It is a potent source of activated
coagulation factors and proinflammatory mediators. It may also cause
hypotension when returned to the bypass circuit. Unless bleeding is brisk or
stasis is minimal, shed blood should not be returned directly to the CPB
circuit. A cell saver can be used to wash shed blood in order to conserve
RBCs.
c. Ischemia due to inadequate tissue perfusion or organ protection, including
ischemia–
reperfusion injury.
2. Prevention
Severe reactions are difficult to predict or prevent. Adequate anticoagulation,
organ perfusion, and myocardial protection are fundamental. Strategies to
reduce the inflammatory response include the use of biocompatible heparin-
coated circuits, minimization of cardiotomy suction (unless the shed blood is
washed), the use of miniature bypass circuits, centrifugal pumps, steroids, and
leukodepletion filters. Fibrinolysis can be reduced by the use of aminocaproic
or tranexamic acid. Novel anti-inflammatory agents (e.g., pexelizumab)
remain investigational. Although many of these strategies have been effective in
attenuating the inflammatory response to CPB, few have been shown to reduce
major complications in the postoperative period.
3. Management
Low SVR and evidence of capillary leak may be observed during CPB, but
most inflammatory reactions manifest post-CPB. No specific therapy is
available and management is supportive.
E. Lung protection (see also Chapter 20). Numerous strategies have been proposed
to ameliorate lung injury by minimizing the inflammatory response (see Section
VI.D) [13]. These include modification of the circuit (e.g., minimized and
surface-coated circuits, leukofiltration, ultrafiltration, minimizing use of
cardiotomy suction) and administration of anti-inflammatory agents (e.g.,
steroids) and intermittent pulmonary perfusion. While many of these appear to
decrease markers of inflammation and may improve oxygenation (PaO2/FiO2
ratio), none have been shown to significantly improve clinical outcome. As for
other surgery, the use of lung protective ventilation (e.g., low tidal volume,
PEEP, lower FiO 2, and frequent recruitment maneuvers) pre- and post-CPB are
recommended [16,17].
F. Splanchnic and gastrointestinal protection. Although CPB is known to reduce
splanchnic blood flow, there are currently no specific interventions that have
been shown to consistently protect the gastrointestinal system [13,18]. Strategies
include optimizing perfusion and oxygen delivery (see Section II.E) and
minimizing the inflammatory response to CPB (see Section VI.D and also
Chapter 20).
VII. Prevention and management of adverse events, complications, and
catastrophes associated with CPB (see also Chapter 20)
The safe conduct of perfusion requires vigilance on the parts of the perfusionist,
anesthesiologist, 10 and cardiac surgeon to ensure that perfusion-related
problems are prevented where possible and diagnosed early and managed quickly
if they occur [19]. Appropriate training, expertise, and accreditation of all
personnel are required, and adherence to protocols and checklists is encouraged.
The following complications must be actively sought during initiation of CPB.
They may, however, occur at any time during CPB. While they may be rare, the
outcomes are potentially disastrous and prevention is paramount.
A. Malposition of arterial cannula
1. Aortic dissection. If the cannula orifice is situated within the arterial wall, not
in the true lumen, there is a risk of aortic dissection upon commencement of
CPB.
CLINICAL PEARL Adequate expertise and vigilance of all personnel are required to
prevent CPB catastrophes, along with mandatory safety precautions and checks.
Therefore, either arterial cannula pressure or pressure in the arterial tubing proximal to
it should always be monitored, and pressure and pulsatility checked before starting
CPB. If the pressure in the aortic cannula does not match the systemic pressure, CPB must
not commence until the cannula position has been corrected. If the pressure gradient across
the aortic cannula exceeds the recommended range for the flow/cannula combination,
either cannula malposition or aortic dissection should be strongly considered. For femoral
arterial cannulation, TEE can be used to confirm the presence of the guidewire in the distal
aortic lumen prior to advancement of the cannula. If CPB has commenced and a dissection
has occurred or is suspected, CPB must cease, the aortic cannula be repositioned, and the
dissection repaired if necessary.
2. Carotid or innominate artery hyperperfusion (Fig. 7.2) can occur if the
aortic cannula outflow is too close to the innominate artery or left carotid
artery. Deleterious effects include cerebral edema or possibly even arterial
rupture from the high flows and pressures. Prevention is surgical; use of a short
aortic cannula with a flange may help prevent this complication. If a longer
cannula is used, the tip position may be visible in the aortic arch using TEE.
The diagnosis is suggested by facial flushing, pupillary dilation, and
conjunctival chemosis (edema). There is likely to be accompanying low blood
pressure in a left radial or femoral arterial catheter and hypertension in a right
radial arterial catheter due to innominate artery hyperperfusion. The surgeon
must reposition the arterial cannula, and measures to reduce cerebral edema
(e.g., mannitol, head-up position) may be required.
B. Reversed cannulation. Venous drainage connected to the arterial cannula with
arterial inflow into the right atrium or vena cava is very unlikely in adults, due to
different size tubing for arterial and venous drainage. This complication is
avoided also by ensuring that arterial pressures are observed in the arterial
outflow line before commencing CPB. Reversed cannulation will result in very
low systemic pressures and high venous pressures. More importantly, negative
pressure in the aortic cannula risks the entrainment of air, which must be
avoided at all costs. Reverse rotation of roller pumps must also be avoided.
Management requires cessation of CPB, placing the patient in a steep head-down
position, deairing the cannulas, and executing a massive gas embolism protocol if
necessary (Table 7.3).
C. Obstruction to venous return. Sudden reduced venous drainage from the patient
during CPB will lower the reservoir level, increasing the risk of air embolism.
At the same time, the venous pressures in the patient will rise, reducing perfusion
pressure to organs. To avoid emptying the venous reservoir further, the
perfusionist must reduce the perfusion flow rate, further reducing organ
perfusion. Alternatively, large fluid volumes must be added to the reservoir. For
this reason, the cause must be determined immediately and the venous drainage
restored as quickly as possible. Most centers use electronic monitors for low
reservoir volume, which may include automatic feedback to stop roller pump
operation as a safety mechanism (see Section VII.E.1.a).
FIGURE 7.2 Potential aortic cannulation problems. A: Cannula extends into carotid owing to excessive length, causing
excessive carotid flow. B: Angle of cannula insertion is improper, which also causes carotid hypoperfusion. C: Correct
placement. D: Cannula diameter is too small; high-velocity jet of blood may damage intima and occlude a vessel. (Redrawn
from Moores WY. Cardiopulmonary bypass strategies in patients with severe aortic disease. In: Utley JR, ed.
Pathophysiology and Techniques of Cardiopulmonary Bypass. Vol. 2. Baltimore, MD: Williams & Wilkins; 1983:190, with
permission.)
1. Air lock. A sudden reduction in venous blood draining into the venous
reservoir may be caused by the presence of large air bubbles within the venous
drainage cannula. This creates an “air lock” due to the lower pressure gradient
and the surface tension in the air–blood interface. The air lock is overcome by
sequentially elevating the venous tubing allowing the air bubble to rise (float to
the surface), followed by lowering the tubing to allow the weight of the column
of blood to force the bubble distally toward the reservoir.
2. Mechanical. Lifting of the heart within the chest by the surgeon often impedes
venous drainage. The venous cannula may be malpositioned or kinked
inadvertently during surgical manipulations. If reduced venous drainage is
observed, the surgeon must be notified immediately and appropriate venous
drainage restored urgently.
D. High pressure in the arterial pump line. Normally, arterial inflow line pressure
proximal to the aortic cannula is up to three times the patient’s arterial pressure
(or higher for femoral cannulae), due to high resistance in the tubing and arterial
cannula. However, kinking of the inflow line during pump operation will further
increase the pressure, risking disruption of the tubing or connections, especially
if the line is inadvertently clamped. For this reason, a high-pressure alarm is
used, often with automatic feedback to stop roller pump operation.
TABLE 7.3 Massive gas embolism emergency protocola
FIGURE 7.3 Retrograde perfusion in the treatment of massive air embolism. A: Massive arterial gas embolism has
occurred. B: Bubbles in the arterial tree are flushed out by performing retrograde body perfusion into the SVC by
connecting the deaired arterial pump line to the SVC cannula (and tightening caval tapes). Blood and bubbles exit the aorta
from the cannulation wound. SVC, superior vena cava. (Redrawn from Mills NL, Ochsner JL. Massive air embolism during
cardiopulmonary bypass: causes, prevention, and management. J Thorac Cardiovasc Surg. 1980;80:713, with permission.)
E. Massive gas embolism. Most massive (macroscopic) gas emboli [19,20] consist
of air, although oxygen emboli can be generated by a defective or clotted
oxygenator (for further discussion of this and CPB safety devices, see Chapter
20). Use of a vented arterial line filter is an important safety device that can help
prevent gas emboli reaching the patient; its routine use is strongly recommended.
Centrifugal pumps provide an additional level of safety because massive air
entry proximal to the pump will empty the pump chamber and render the
centrifugal force ineffective. Nevertheless, the risk is not removed. Because of
the high risk of stroke, myocardial infarction, or death after massive gas
embolism, prevention is of utmost importance.
1. Etiology
a. Empty or low oxygenator reservoir level. Air may be pumped from an
empty reservoir. Avoiding this scenario is one of the key tasks of the
perfusionist. There are also alarms to alert staff when the oxygenator
reservoir level is reaching an unsafe level. Many such alarms are linked to an
automatic cessation of the arterial roller pump. Vortexing can permit air
entrainment and embolism when the reservoir blood level is very low but not
empty. This is the most important cause of bypass catastrophes when
utilizing a closed reservoir system. A high-risk period for air embolism or
entrainment is at the time of separation from CPB, when the oxygenator
reservoir level is often low.
b. Leaks in the negative pressure part of the CPB circuit (between the
oxygenator reservoir and the arterial pump) may result in air entrainment—for
example, clotted or defective oxygenator, disruption of tubing connections.
c. Entrainment of air around the aortic cannula. This may occur during
cannula insertion. Entrainment can also occur via this route if negative
pressure in the arterial cannula is allowed to develop during periods of no
flow (e.g., before or after the onset of CPB). To prevent negative pressure and
draining blood from the patient, the aortic cannula must be clamped during all
periods when the arterial pump is inactive.
IGURE 7.4 Carotid (A) and vertebral (B) artery deairing during retrograde perfusion. In the management of massive arterial
as embolism, steep head-down position helps to flush bubbles out of the carotid arteries. Application of intermittent pressure to the
arotid arteries increases retrograde vertebral artery flow, which helps to evacuate bubbles. (Redrawn from Mills NL, Ochsner JL.
Massive air embolism during cardiopulmonary bypass: Causes, prevention, and management. J Thorac Cardiovasc Surg.
980;80:713, with permission.)
d. Inadequate deairing prior to aortic cross-clamp release. This is particularly

important for open-chamber procedures.
e. Reversed roller pump flow in vent line or arterial cannula.
f. Pressurized cardiotomy reservoir (causing retrograde flow of air through a
nonocclusive vent line roller head into heart or aorta)
g. Runaway pump head (switch inoperative; must unplug pump and crank by
hand)
h. Other causes not related specifically to CPB include an improper flushing
technique for arterial or left atrial pressure monitoring lines, paradoxical
embolism of venous air across atrial or ventricular septal defects.
Occasionally, a persistent left SVC communicates with the left atrium (IV air
from a left-sided IV may enter the systemic circulation through this SVC).
i. Prevention. Vigilance is required. Safety devices and alarms must be
activated.
j. Diagnosis. Gas embolism is diagnosed mostly by visual inspection. The extent
of gas embolism can be gauged by signs of myocardial or other organ
ischemia.
k. Management. A massive gas embolus emergency protocol should be
available and followed by all staff [20]. See Table 7.3, Figures 7.3 and 7.4.
F. Failure of oxygen supply. Inadequate oxygenator gas flow or a hypoxic mixture
will result in arterial hypoxemia. The blood in the arterial line will appear dark,
and the lower PO2 will register on in-line PO2 or Hb oxygen saturation monitors.
An oxygen analyzer can be incorporated in the oxygenator gas inflow line as an
early alert for hypoxic mixtures, but this will not detect a distal disconnection. A
disconnection of the sweep gas will result in a sudden drop in oxygenator exhaust
CO2 level if this is being monitored (see Section IV.A.2). The O 2 supply should
be restored immediately, connecting a portable O2 cylinder to the oxygenator if
necessary. If a delay is anticipated, either separate from CPB (if still possible)
or cool the patient maximally until O2 supply is restored. Ventilation with room
air is preferable to no ventilation at all, if immediate restoration of O2 supply is
not possible.
G. Pump or oxygenator failure
1. Pump failure may be due to electrical or mechanical failure, tubing rupture or
disconnection, or automatic shut off by a bubble or low reservoir detector. A
runaway pump head may raise the pump flow to its maximum inappropriately,
and the pump control switch will be inoperative. For systems designed to be
used with an electromagnetic or ultrasonic transducer, failure of the sensor can
prevent one from knowing the actual pump flow rate. Miscalibration of the
arterial pump or flowmeter may lead to inadequate (or excessive) blood flow.
An open shunt between the arterial line and the venous reservoir will result in
decreased effective pump flow. If the occlusion of a roller pump is improperly
set, excessive regurgitation occurs (causing hemolysis) and the forward flow is
reduced. In the event of electrical failure, CPB pumps usually have battery
backup and can be hand cranked if necessary until current is restored.
Mechanical failure requires replacement of the pump. In case of a runaway
pump head, the CPB machine must be unplugged and the tubing switched to a
different roller head.
2. Oxygenator failure may be due to a manufacturing defect, mechanical
obstruction from clot or debris, disruption of the oxygenator shell (trauma, spill
of volatile liquid anesthetic), or leakage of water from the heat exchanger into
the blood. The diagnosis is based on arterial blood gas abnormalities, acidosis,
blood leak, excessive hemolysis, or high pre-membrane pressures. For severe
failure, the oxygenator must be replaced. A protocol should be in place for
rapid oxygenator replacement. If body perfusion will be low or absent for
more than 1 or 2 minutes and if the patient cannot be immediately weaned from
CPB, then hypothermia to 18° to 20°C should be induced if possible and
consideration given to brain, myocardial, and renal protection during the
oxygenator replacement. Open cardiac massage may be necessary, depending
on the stage of the operation.
H. Clotted oxygenator or circuit. This serious event can interfere with gas
exchange, prevent CPB flow, or cause massive gas embolus. The main cause is
inadequate anticoagulation, which may result from inadequate dose, heparin
resistance, or the inadvertent administration of protamine during CPB. This
potentially lethal catastrophe should not occur if adequate anticoagulation is
confirmed before initiating CPB and at frequent intervals thereafter. It can be
diagnosed by visual observation of clot in the oxygenator or high arterial line
pressure (evidence of partially clotted arterial line filter). There may also be
clues to inadequate heparinization by the presence of clot in the surgical field.
Management involves cessation of CPB and replacement of the oxygenator and
tubing if necessary. If the patient is not cold, open cardiopulmonary resuscitation
and topical hypothermia may be required. The patient should then be
reheparinized using a different lot of heparin if possible, and satisfactory
anticoagulation confirmed before reinstituting CPB.
I. Dislodgment of cannula or tubing rupture. With appropriate vigilance and
monitoring, this should never occur. Management requires cessation of flow until
the cannula is repositioned or the tubing is replaced and re-priming of the lines if
necessary.
J. Heater–cooler malfunction. If inappropriate water inflow or arterial blood
temperatures are observed, the heater–cooler and its tubing should be checked
and replaced, if necessary. If heater–cooler malfunction can be excluded, the
oxygenator should be checked.
VIII. Minimally invasive surgical techniques requiring CPB
CPB for minimally invasive procedures follows the same principles as
conventional CPB but 11 requires additional instrumentation and monitoring due
to the limited surgical exposure [21]. Irrespective of the technique used, frequent
interaction between surgeon, perfusionist, and anesthesiologist is required for a
successful outcome (see Chapter 13).
CLINICAL PEARL Minimally invasive procedures require additional
instrumentation and monitoring due to the limited surgical access, typically including
TEE guidance for cannula placement.
A. Port-access surgery. Typically the cannulae are inserted peripherally (e.g.,
femoral artery and vein). The venous cannula is advanced into the RA in order to
drain both the SVC and IVC. This is performed using a guidewire technique and
requires TEE guidance. Insertion of a separate SVC cannula via the internal
jugular vein using TEE guidance may also be required. VAVD is often necessary
for peripheral venous cannulation. An aortic occlusion catheter may be used
instead of an aortic cross-clamp. This is placed in the ascending aorta under
fluoroscopic or TEE guidance. An endocoronary sinus catheter is inserted via the
jugular approach under TEE guidance for delivery of retrograde cardioplegia,
and a PA vent catheter is inserted to decompress the heart through the left atrium.
Correct position of the inflated aortic occlusion catheter balloon should be
checked regularly using TEE. Loss of the right radial arterial pressure trace may
indicate cephalad migration of the balloon.
B. Minithoracotomy. If a small incision is used (e.g., hemisternotomy, anterior
thoracotomy), it may be possible to use modified arterial and even venous
cannulas inserted transthoracically and a modified aortic cross-clamp or a
combination of peripheral and central cannulation. An aortic root vent for
anterograde cardioplegia can also be inserted, and a coronary sinus catheter for
retrograde cardioplegia if no other route is possible.
C. Minimally invasive mitral valve surgery. In this procedure, arterial and venous
cannulae are inserted peripherally, and CPB is instituted prior to a right
minithoracotomy [22]. TEE guidance is used to ensure that the venous cannula
enters or crosses the right atrium to drain the SVC as well as the IVC. Due to the
increased length and decreased diameter of the venous cannula, VAVD is
typically required. If the right atrium is opened (e.g., for tricuspid valve surgery),
a separate SVC cannula (often inserted percutaneously) may be required. With
the onset of CPB, ventilation of the lungs is no longer required. Collapse of the
right lung on opening of the chest provides surgical access to the heart and great
vessels. Alternatively, a double lumen endobronchial tube or bronchial blocker
can be used to deflate the right lung earlier while ventilating the left lung. An
aortic root cannula for the administration of cardioplegia can then be placed,
followed by an aortic cross-clamp. Access to the mitral valve is obtained
through the left atrium. CPB management is otherwise unchanged, although before
final separation from CPB, a trial separation is undertaken to ensure satisfactory
mitral valve function (as assessed by TEE). For further details, see Chapter 13.
D. Minimally invasive aortic valve surgery. This can be performed through a
partial (upper) sternotomy with extension of the sternotomy incision into a right
intercostal space (e.g., third intercostal space) [23]. Alternatively, the procedure
can be performed through a right anterior thoracotomy (e.g., second intercostal
space). For the latter, a double-lumen endobronchial tube or bronchial blocker
may be required to collapse the right lung to permit surgical access prior to CPB.
E. Choice of cardioplegia. With minimally invasive procedures, repeated
administration of cardioplegia may be technically more difficult or distracting.
For this reason, the use of a single dose of a longer lasting solution such as
Custodiol is often preferred (see Section IV.G.1). However, ECG monitoring for
return of electrical activity is still required, giving a second dose if necessary.
Care must be taken to ensure that surgical retractors do not impede cardioplegia
distribution to all areas of the heart. Due to the larger volumes required,
ultrafiltration is often used to remove excess water [11,21]. Additional
bicarbonate and calcium are often required prior to separation from CPB.
IX. Management of unusual or rare conditions affecting bypass
A. Sickle cell trait and disease [19,24]. The congenital presence of abnormal HbS
as the trait (heterozygote, Hb-AS) but especially as the disease (homozygote, Hb-
SS) allows RBCs to 12 undergo sickle transformation and occlude the
microvasculature or lyse. RBC sickling may be induced by exposure to
hypoxemia, vascular stasis, hyperosmolarity, or acidosis. Although anesthesia for
noncardiac surgery is well tolerated in sickle trait patients, the risks are higher
for operations requiring CPB. While sickle cell trait patients are at low risk for
RBC sickling, sickle cell disease patients develop RBC sickling at O2
saturations less than 85% and are at risk for developing potentially fatal
thromboses during CPB, unless appropriate measures are taken. Hypoxia,
acidosis, and conditions leading to vascular stasis (e.g., hypovolemia,
dehydration) should be avoided or minimized in all patients with sickle cell trait
or disease. CPB should be avoided if alternative treatment options are available
(e.g., off-pump surgery). If CPB is required, hypothermia and cold cardioplegia
should ideally be avoided. Preoperative transfusion to a Hb >10 g/dL using
donor HbA RBCs will improve oxygen carriage and reduce the percentage of
HbS. For deep hypothermia, exchange transfusion may be required. Expert
preoperative hematologic consultation is advised for sickle cell disease patients
before CPB.
B. Cold agglutinin disease [19,25]. Autoantibodies against RBCs in patients with
cold agglutinin disease are activated by cold exposure below a critical
temperature. Below this temperature, hemagglutination will occur, resulting in
vascular occlusion with organ ischemia or infarction. Low titers of antibodies
with a low critical temperature (e.g., <28°C) are common but of little clinical
relevance. In contrast, patients who have high titers of antibodies with a high
critical temperature are at risk of hemagglutination perioperatively, especially
duri ng hypothermic CPB. The organ at greatest risk of damage is the
myocardium because RBCs are exposed to extreme hypothermia (4° to 8°C)
during the preparation of blood cardioplegia solution. Aggregates thus formed
may be infused into the coronary vasculature, causing severe microcirculatory
occlusion and preventing distribution of cardioplegia. If cold agglutinins are
suspected preoperatively, careful assessment by a hematologist is warranted,
including characterizing the type of antibody, its titer, and its critical temperature.
CPB should be avoided if alternative strategies (e.g., off-pump surgery) are
feasible. If CPB is required, systemic temperatures should be maintained
above the critical temperature. Systemic temperatures of 28°C or higher are
generally safe in asymptomatic patients. DHCA is feasible, provided the coldest
blood temperature is several degrees warmer than the critical temperature.
Cardioplegia management includes avoidance of cold blood cardioplegia. If a
reduction of the patient’s core temperature below their critical temperature for
hemagglutinin formation is unavoidable, preoperative plasmapheresis may be
required.
C. Cold urticaria [26]. Patients with this disorder develop systemic histamine
release and generalized urticaria in response to cold exposure. Cold CPB should
be avoided if possible because marked histamine release occurs during CPB
rewarming and can cause hemodynamic instability. If cold CPB is unavoidable,
the cardiovascular responses to histamine can be prevented by pretreatment with
H1- and H2-receptor blockades; concomitant steroid administration may be
useful.
D. Malignant hyperthermia (MH) [27,28]. An acute MH crisis may occur in
susceptible patients exposed to triggering agents and in rare cases, may manifest
for the first time during CPB. The mainstay of management is prevention, by
avoiding triggering agents. During CPB, the usual early signs of an MH crisis, of
hyperthermia, rigidity, and tachycardia, may be absent due to the use of
hypothermia and cardioplegia. However, the increased skeletal muscle
metabolism associated with the disorder may cause a mixed metabolic and
respiratory acidosis, hyperkalemia, and rhabdomyolysis with myoglobinuria (and
late renal failure) even during CPB. Recognition of MH crisis can be difficult,
particularly during the rewarming phase when temperature is expected to
increase. A high index of suspicion is required for patients with known MH
susceptibility. Management involves ceasing triggering agents, cooling to
reduce hyperthermia, correction of acid–base and electrolyte changes, and the
early administration of dantrolene (1 to 2 mg/kg IV initially, with further doses as
required titrated to effect). Active cooling and treatment of other MH
complications may be necessary in the post-CPB period.
E. Hereditary angioedema [29]. A deficiency or abnormality in function of an
endogenous inhibitor of the C1 esterase complement protein leads to exaggerated
complement pathway activation after even minor stress, resulting in edema of the
airway, face, gastrointestinal tract, and extremities. CPB can cause fatal
complement activation in patients with hereditary angioedema; peak activation
follows protamine administration. In the past, management of acute episodes has
been mainly supportive because epinephrine, steroids, and histamine antagonists
are of little benefit, and fresh frozen plasma may exacerbate the reaction by
providing additional complement substrates. Subacute and chronic therapies
include androgens (stanozolol) and antifibrinolytics. A purified human C1
esterase inhibitor replacement protein (C1-INHRP) concentrate (Cinryze,
ViroPharma, Exton, PA) is now available for prophylaxis against and treatment
of acute episodes, and another purified C1-INH concentrate (Berinert, CSL
Behring, King of Prussia, PA) is available for treatment. Other drugs have been
introduced recently to block bradykinin B2 receptors or inhibitor plasma
kallikrein and reduce the severity of reactions.
F. Pregnancy [30]. Cardiac surgery with CPB during pregnancy involves a high
risk of fetal demise or morbidity. Longer duration of CPB appears to increase the
risk to the fetus. Fetal heart rate monitoring is mandatory in the second and third
trimesters. Uterine contractile activity should be monitored using a
tocodynamometer applied to the maternal abdomen. Maintaining an increased
perfusion pressure (e.g., >70 mm Hg) is advocated because uterine blood flow is
not autoregulated. Using increases in pump flow to elevate the blood pressure
may be preferable to using pressor drugs, due to the risk of uterine artery
vasoconstriction with α-adrenergic stimulation. Toward term, left uterine
displacement is necessary. Fetal bradycardia not related to hypothermia may
indicate placental hypoperfusion and should be treated promptly by increasing
the pump flow and perfusion pressure. Tocolytic drugs such as magnesium
sulfate, ritodrine, or terbutaline may be necessary. Inotropic drugs ideally
should not have unbalanced α-vasoconstrictor or uterine-contracting activity.
G. Jehovah’s Witnesses may accept CPB so long as there is a continuous circuit
and any blood that is not in circulation is not retransfused. Therefore, it is
important to ensure continuous circulation of blood from commencement of CPB
until full separation, with no transfusion of residual blood once CPB has ceased.
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8 The Postcardiopulmonary Bypass Period: Weaning
to ICU Transport
Benjamin N. Morris, Chandrika R. Garner, and Roger
L. Royster
I. Introduction
II. Preparation for termination of bypass: central venous pressure (CVP or
C6V4P6) mnemonic
A. Cold
B. Conduction
C. Calcium
D. Cardiac output (CO)
E. Cells
F. Coagulation
G. Ventilation
H. Vaporizer
I. Volume expanders
J. Visualization of the heart
K. Predictors and factors contributing to adverse cardiovascular outcome
L. Protamine
M. Pressure
N. Pressors and inotropes
O. Pacer
P. Potassium
III. Sequence of events immediately before terminating cardiopulmonary
bypass (CPB)
A. Final checklist before terminating CPB
B. What to look at during weaning
IV. Sequence of events during weaning from CPB
A. Step 1: Impeding venous return to the pump
B. Step 2: Lowering pump flow into the aorta
C. Step 3: Terminating bypass
V. Sequence of events immediately after terminating CPB
A. Preload: Infusing blood from the pump
B. Measuring cardiac function
C. Removing the cannulas
D. Cardiovascular decompensation
E. Inappropriate vasodilation
F. Resumption of CPB
VI. Cardiovascular considerations after successful weaning from CPB
A. Reperfusion injury
B. Decannulation
C. Manipulation of the heart
D. Myocardial ischemia
E. Chest closure
F. Management of hemodynamics in the postbypass period
VII. Noncardiovascular considerations
A. Respiratory system
B. Hematologic system
C. Renal system
D. Central nervous system
E. Metabolic considerations
F. Postbypass temperature regulation
VIII. Preparing for transport
A. Moving the patient to the transport or intensive care unit (ICU) bed in
the operating room (OR)
B. Transport to the ICU
C. Admission to the ICU
KEY POINTS
1. Core temperature (nasopharyngeal or bladder) should be greater

than 36°C before terminating cardiopulmonary bypass (CPB).
Discontinuation of CPB at temperatures less than 36°C increases the
risk of rebound hypothermia in the intensive care unit (ICU).
However, the nasopharyngeal temperature should not exceed 37°C,
as this will increase the risk of postoperative central nervous system
dysfunction. Using nasopharyngeal temperature to avoid
hyperthermia and the rectal/
bladder temperature to assure adequate rewarming may be the safest
technique.
2. Visualization of the heart, directly to assess right ventricular (RV)
function and volume status, as well as with transesophageal
echocardiography (TEE) to rule out air and to assess valve and
ventricular function is important before terminating CPB.
3. The first attempt to terminate CPB is usually the best one. Optimize
all central venous pressure (CVP) mnemonic parameters before
CPB termination. Consider prophylactic inotropes in patients with
markedly reduced ventricular function.
4. Protamine should not be given until the heart has been successfully
weaned from CPB. A struggling heart after CPB discontinuation
could require reinstitution of CPB.
5. Vasoplegic syndrome is a severe form of post-CPB vasodilation
characterized by low arterial pressure, normal to high cardiac output
(CO), normal right-side filling pressures, and low systemic vascular
resistance (SVR) that is refractory to pressor therapy.
6. When evaluating hypoxemia after CPB, the possibility of a right-to-
left shunt through a patent foramen ovale must be considered and
evaluated with TEE.
7. New-onset renal dysfunction requiring dialysis after CPB increases
mortality almost eightfold. Maintenance of a higher mean arterial
pressure (MAP) on pump in patients with pre-existing renal
insufficiency may be protective in some patients.
I. Introduction
Terminating cardiopulmonary bypass (CPB) requires the anesthesiologist to apply
the basic tenets of cardiovascular physiology and pharmacology. The goal is a
smooth transition from the mechanical pump to the heart as the source of blood
flow and pressure. Weaning from the pump involves optimizing cardiovascular
variables including preload, afterload, heart rate (HR) and rhythm, and
contractility as in the pre-CPB period. However, the time period for optimization
is compressed to minutes or seconds, and decisions must be made quickly to avoid
myocardial injury or damage to the other major organ systems.
II. Preparation for termination of bypass: central venous pressure (CVP)
mnemonic
The major objectives in preparing for termination of CPB can be remembered with
the aid of the mnemonic CVP shown in Table 8.1. One can also call this
“C6V4P6” as a reminder of the number of items for each letter.
A. Cold
Core temperature (nasopharyngeal or rectal/bladder) should be greater than 36°C
before terminating CPB. Rectal or bladder temperature should be at least 35° to
36°C [1]. Ending CPB when cold causes prolonged hypothermia from
equilibration of the cooler, vessel-poor group 1 (imperfectly represented by
rectal or bladder temperature) with the warmer and better perfused vessel-rich
group (represented by nasopharyngeal or esophageal temperature).
Nasopharyngeal temperature correlates with brain temperature but may be
artificially elevated during rapid rewarming and should not be used for
determining the temperature at which CPB is discontinued unless it has been
stable for 15 to 20 minutes. Venous return temperature can be used in a similar
manner to help confirm core temperature. The nasopharyngeal temperature should
not exceed 37°C, as this will increase the risk of postoperative central nervous
system dysfunction. Using nasopharyngeal temperature to avoid hyperthermia and
the rectal/bladder temperature to avoid underwarming may be the safest
technique.
TABLE 8.1 The major objectives in preparing for termination of CPB can be remembered
with the aid of the mnemonic CVP
B. Conduction
Cardiac rate and rhythm must be controlled as follows:
1. Rate
a. HR of 80 to 100 beats per minute (bpm) may be needed for adequate cardiac
output (CO) post-CPB because of reduced ventricular compliance and
inability to increase stroke volume. In coronary artery bypass graft (CABG)
procedures, complete revascularization allows a higher rate (80 to 100 bpm)
after CPB, with less risk of ischemia than before CPB. Patients with severely
limited stroke volume (aneurysmectomy or after ventricular remodeling) may
require even higher rates.
b. Sinus bradycardia may be treated with atropine or an inotropic drug, but
epicardial pacing is more reliable and is most commonly employed.
c. Sinus tachycardia of more than 120 bpm should be avoided. Often increasing
preload before termination of CPB will reflexively decrease the HR to an
acceptable level. Other etiologies of sinus tachycardia must be addressed.
Common etiologies include:
(1) Hypoxia
(2) Hypercapnia
(3) Medications (inotropes, anticholinergics)
(4) Light anesthesia, awareness
(a) “Fast track” anesthesia with its lower medication dosing schedule
requires special attention to this complication. An additional dose
of narcotic and benzodiazepine, or hypnotic (propofol infusion)
should be considered during the rewarming period if tachycardia is
present. Bispectral index (BIS) or depth of anesthesia monitors may
be helpful in guiding therapy. A dexmedetomidine infusion can also
be considered.
(5) Anemia
(6) Ischemia: ST and T-wave changes indicative of ischemia should be
treated and the surgeon should be notified. A nitroglycerin (NTG)
infusion and/or an increase in the perfusion pressure often improves the
situation. Refractory causes include residual air or graft occlusions. If
coronary air is suspected, briefly increasing the perfusion pressure to a
mean of 90 mm Hg may improve the situation.
2. Rhythm
a. Normal sinus rhythm is preferable. In patients with poorly compliant, thick-
walled ventricles (associated with aortic stenosis, hypertension, or ischemia),
the atrial “kick” may contribute up to 40% of stroke volume (and thus CO), so
attaining synchronized atrial contraction (sinus rhythm, atrial, or
atrioventricular [AV] sequential pacing) is very important before attempting
CPB termination. Atrial pacing is acceptable if there is no AV block, but often
atrial and ventricular leads are needed. Atrial pacing may not be possible
initially because the atria often require longer to recover from cardioplegia
than the ventricles and have a higher pacing threshold.
b. Supraventricular tachycardias (SVTs, >120 bpm) such as regular narrow-
QRS atrial flutter and atrial fibrillation, should be cardioverted with
synchronized internal cardioversion before terminating CPB. Atrial flutter and
other SVTs from the atrial or AV node may be converted with overdrive
pacing.
c. Esmolol, verapamil, amiodarone, or adenosine may be used to chemically
cardiovert or to control the ventricular response rate. An undesired decrease
in contractility may occur with all of these agents except adenosine.
d. Third-degree AV block requires AV sequential pacing, although atropine
occasionally may be effective.
e. Ventricular dysrhythmias are treated as indicated (see Chapters 2 and 18).
C. Calcium
Calcium should be immediately available to treat hypocalcemia and
hyperkalemia, which commonly occur after CPB. However, the routine
administration of calcium post-CPB is not recommended.
1. Mechanism of action. Most studies suggest that calcium produces an elevation
in systemic vascular resistance (SVR) when the ionized Ca++ level is in the
low–normal range or higher [2]. Despite this increase in afterload, contractility
is maintained. At very low ionized calcium levels (<0.8 mM), contractility is
increased by calcium administration. Elevating calcium levels will also help
counteract the negative physiologic actions of hyperkalemia. The usual and
safest initial dose is 5 mg/kg of calcium chloride (CaCl2).
2. Measurement. Ionized Ca++ levels should be evaluated after rewarming to
help direct therapy. Citrated blood cardioplegia reperfusion solutions can
lower blood Ca++ levels substantially (normal range 1 to 1.3 mmol/dL).
Calcium levels are affected by pH: Low pH will increase Ca++ levels, whereas
elevated pH will decrease Ca++ levels. Correction of pH should be attempted
before treating abnormal values.
3. Risks of calcium administration
a. Arrhythmias: Especially patients taking digoxin (now uncommon) may
experience life-threatening arrhythmias.
b. Inhibition of the hemodynamic action of inotropes (e.g., epinephrine,
dobutamine) has been reported.
c. Coronary artery spasm might occur in rare susceptible patients.
d. Augmentation of reperfusion injury is possible in the already calcium
overloaded myocardium. Calcium administration should be avoided unless
there is hyperkalemia or ionized calcium is less than 0.8 mM.
D. Cardiac output (CO)
Evaluating cardiac function is vital after CPB. CO may be obtained from a
pulmonary artery (PA) catheter or estimated by using transesophageal
echocardiography (TEE). If a continuous CO PA catheter is used, it may take
more than 3 minutes to obtain the first CO after CPB. If the patient is stable,
this is acceptable; if not, the equipment for a manual determination should be
used initially.
E. Cells
1. The hemoglobin concentration should be measured after rewarming. If it is 6.5
g/dL or less before terminating CPB, blood administration should be
considered to maintain O2-carrying capacity after CPB. If the venous reservoir
contains a large amount of blood, this blood may be concentrated by a cell
saver and given back to the patient after CPB, which could preclude the need
for blood transfusion. Patients with residual coronary stenoses, anticipated low
CO, or end-organ damage may benefit from a higher hemoglobin concentration
such as 8 g/dL.
2. Two units of packed red blood cells (PRBCs) should be immediately available
for use once the CPB pump volume is exhausted. If excessive bleeding is
anticipated (see Section F below), then additional units should be on hand.
F. Coagulation
Anticipate possible coagulation abnormalities prior to discontinuation of CPB.
Blood coagulation components (e.g., platelets and fresh frozen plasma [FFP])
should await complete heparin neutralization and be guided by the clinical
situation and laboratory findings (e.g., thromboelastogram, prothrombin time,
partial thromboplastin time, platelet count).
1. Patients at risk include:
a. Patients taking platelet inhibitors (clopidogrel, prasugrel, ticlopidine, aspirin)
[3]
b. Patients having emergency surgery and who have been exposed to:
(1) Thrombolytic agents (alteplase, tenecteplase)
(2) Antiplatelet glycoprotein IIb/IIIa agents (abciximab, eptifibatide,
tirofiban)
(3) Direct thrombin inhibitors (bivalirudin, dabigatran, argatroban)
(4) Warfarin
(5) Factor Xa inhibitors (apixaban, rivaroxaban)
c. Patients with chronic renal failure
d. Long “pump run,” for example, redo or complex operation
e. Low body mass index (BMI)
f. Extreme hypothermia on CPB
g. Excessive bleeding with previous cardiac surgery [4]
CLINICAL PEARL DDAVP can improve clot formation and platelet function in
patients having aortic valve surgery and in patients with LV-assist devices having heart
transplants.
2. Platelets and FFP should be available if indicated (as above).
3. Desmopressin acetate (DDAVP) can be used to increase platelet aggregation in
patients with chronic renal failure and in acquired von Willebrand disease
which occurs with aortic stenosis or left ventricular–assist devices (LVADs).
In patients without pre-existing platelet abnormalities, DDAVP has little effect
on blood loss or replacement in CABG patients but may be effective in open-
chamber surgery.
4. Plasma, fibrinogen concentrates or cryoprecipitate should be available if
indicated for the treatment of appropriate factor deficiencies.
5. Factor concentrates (specifically rVIIA and prothrombin complex concentrates
[PCCs]) have been used in cases of severe refractory bleeding. Possible
complications are related to increased risk of thrombosis (coronary occlusion,
graft occlusion, stroke).
G. Ventilation
1. Adequate oxygenation and ventilation while the patient is on CPB must be
ensured by checking arterial and venous blood gas measurements at routine
intervals. Arterial pH should be between 7.3 and 7.5 at normothermia before
CPB separation.
2. The lungs should be reexpanded with two to three sustained breaths to a peak
pressure of 30 cm H2O with visual confirmation of bilateral lung expansion and
resolution of atelectasis. In patients with internal mammary artery grafts, care
must be taken to prevent lung overdistention, which may cause graft avulsion.
Coordinate this maneuver with the surgical team. An estimate of lung
compliance should be made (see Section VII). The surgeon may need to
evacuate any hemothorax or pneumothorax.
3. Inspired oxygen fraction (FiO2) should be 100%. If air was used during CPB to
prevent atelectasis, it should be discontinued. Nitrous oxide should never be
used during or after cannulation, because it can increase the size of air emboli
[5].
4. Confirm that the pulse oximeter is working once pulsatile flow returns. Pulse
oximeter probes (especially on fingers) may not work, however, despite
pulsatile flow in a patient who is still cold and peripherally vasoconstricted.
5. All respiratory monitors should be on-line (apnea, peak inspiratory pressure
[PIP], FiO2, end-tidal CO2 [ETCO2]).
6. Mechanical ventilation must be started before an attempt to terminate CPB. The
timing for commencement of mechanical ventilation while the patient is still on
CPB remains controversial. Some practitioners believe that ventilation should
begin when arterial or pulmonary pulsatile blood flow resumes in order to
avoid hypoxemia. However, this may not be necessary in normothermic, nearly
full-flow bypass and may cause severe respiratory alkalosis of pulmonary
venous blood. The pulse oximeter or the CPB circuit venous oxygen tension
also can be used to assess the need for ventilation during partial CPB.
7. Auscultation of breath sounds will confirm air movement and may reveal
wheezing, rales, or rhonchi. Visual confirmation of bilateral lung expansion is
important. Appropriate treatment (suctioning, bronchodilators) should be
instituted before terminating CPB. Bronchoscopy may occasionally be needed
for mucus plugging in patients with lung disease.
H. Vaporizer
Inhalation agents used during CPB for blood pressure (BP) control ordinarily
should be turned down or off at least 10 minutes before terminating CPB. These
agents will decrease contractility and confuse the etiology of myocardial
dysfunction postbypass.
I. Volume expanders
Albumin or crystalloid solutions should be available to increase preload if blood
products are not indicated.
J. Visualization of the heart
2 Primarily the right atrium and ventricle are visible from the surgical field.
TEE importantly provides a more detailed examination. It is possible to evaluate
the following parameters:
1. Contractility. An experienced observer can often estimate right ventricle (RV)
contractility by just looking at the heart in the chest, but left ventricle (LV)
visualization is more limited. Both RV and LV wall-motion abnormalities from
ischemia or infarct should be compared to pre-CPB observations.
2. Distention of the chambers can be seen with both methods.
3. Residual air in left-sided structures (e.g., left atrium [LA], LV, pulmonary
veins). TEE imaging during and after ventilation will confirm the location of
residual air. Air evacuation maneuvers should be performed prior to
termination of bypass to prevent a coronary air event.
4. Conduction. Direct observation of the atria and ventricles can often help
differentiate arrhythmias, AV dyssynchrony, or pacemaker malfunction more
easily than using the electrocardiogram (ECG). TEE visualization of the LA
appendage may prove especially helpful in this regard. A four-chamber view is
most helpful.
5. Valvular function or perivalvular leaks should be identified by TEE before
attempting CPB termination so that repair can be accomplished if needed.
K. Predictors and factors contributing to adverse cardiovascular outcome
1. Assess the patient’s risk for difficult weaning from CPB. Risk factors that can
be identified before terminating CPB include [6]:
a. Preoperative left ventricular ejection fraction (LVEF) less than 45% or
diastolic dysfunction
b. Renal disease: Increased morbidity and mortality correlates with preoperative
creatinine concentration.
c. Female patient undergoing CABG (tendency for incomplete revascularization
due to smaller more diseased coronary arteries)
d. Elderly patient
e. Congestive heart failure (usually related to valvular or myocardial
dysfunction)
f. Emergent surgery
(1) Ongoing ischemia or evolving infarct
(2) Failed closed intervention (angioplasty/stent/valvuloplasty)
g. Prolonged CPB duration (≥2 hours)
h. Inadequate surgical repair
(1) Incomplete coronary revascularization
(a) Small vessels (not graftable or poor “runoff”)
(b) Distal disease (especially in diabetic patients)
(2) Valvular disease
(a) Valve replacement with very small valve (high transvalvular
pressure gradient post-CPB)
(b) Suboptimal valve repair (residual regurgitation or stenosis)
i. Incomplete myocardial preservation during cross-clamping
(1) ECG not asystolic (incomplete diastolic arrest)
(2) Prolonged ventricular fibrillation before cross-clamping
(3) Warm myocardium
(a) LV hypertrophy (incomplete cardioplegia)
(b) High-grade coronary stenoses (no cardioplegia to that area of heart)
(c) Choice of grafting order (grafts should ideally be performed first in
an area of the heart served by a high-grade lesion in the absence of
retrograde cardioplegia, so cardioplegia may be infused early)
(d) Noncoronary collateral flow washing out cardioplegia
(e) Poor LV venting causing cardiac distention (aortic insufficiency if
using anterograde cardioplegia)
(f) Inadequate topical cooling
(g) Left-sided superior vena cava with retrograde cardioplegia
j. Prolonged ventricular failure
k. Impaired myocardial perfusion before and after cross-clamping
(1) Sustained low perfusion pressure on CPB (less than 50 mm Hg)
(2) Ventricular distention
(3) Emboli (air, clot, particulate)
(a) From ventriculotomy or improper deairing of coronary grafts
2. Additional preparations for high-risk patients
a. One common practice is to have a syringe of ephedrine (5 mg/mL) or dilute
epinephrine prepared (4 to 10 μg/mL). Boluses can be used until a decision is
made regarding the need for further inotropes.
b. Discuss the need for additional invasive monitoring with the surgeon (i.e., LA
or central aortic catheter).
c. Check for immediate availability of other inotropic or vasoactive
medications: epinephrine, dobutamine, milrinone, norepinephrine,
vasopressin, nitric oxide (NO), or inhaled epoprostenol (Flolan).
d. As appropriate to the anticipated level of difficulty separating from CPB,
check for immediate availability of an intra-aortic balloon pump (IABP).
Consider placement of a femoral arterial catheter prebypass to facilitate its
rapid insertion and possibly for improved BP monitoring.
e. Consider starting an inotropic infusion or an IABP before terminating CPB in
patients with poor contractility. Note that the Frank–Starling law implies that
an empty heart will not beat very forcefully. Often a sluggishly contracting
heart will start to “snap” once it is filled.
f. “The first attempt at terminating CPB is the best one.” Optimizing all
CVP 3 mnemonic parameters before CPB termination is strongly advised. If
in doubt, start an inotrope. Preemptive use of milrinone has been shown to
improve cardiac function during and after cardiac surgery. A milrinone bolus
without an infusion can be sufficient in marginal candidates [7].
g. Ischemic preconditioning/postconditioning. The heart will react to a low
level ischemic stress and subsequent exposure to free radicals by becoming
more “resistant” to further ischemic injury. This can be attempted
intraoperatively [8,9].
(1) Inhalational agents (isoflurane and sevoflurane have been most studied)
can mimic this effect.
(a) This can be accomplished by using the agent at 1 to 2.5 MAC for 5
to 10 minutes after initiating CPB but before aortic cross-clamping
and cardioplegia administration.
(b) Others suggest using sevoflurane pre-CPB, during CPB, and post-
CPB instead of using a propofol infusion [10].
(2) Ketamine, nicorandil, and the “statins” have also been studied with
beneficial results [11].
(3) Postischemic conditioning by brief sequential ischemia and reperfusion
episodes has also been suggested in this setting [12].
L. Protamine
The protamine dose should be calculated and drawn up in a syringe or should be
ready as an 4 infusion. Premature use of protamine is catastrophic. Protamine
should be prominently labeled and should not be placed where routine
medications are stored to avoid accidental use. The surgeon, anesthesiologist,
and perfusionist must all coordinate the use of this medication.
CLINICAL PEARL Given the potential catastrophic consequences of premature
administration of protamine, there should be a team approach such that the surgeon,
anesthesiologist, and perfusionist are all made aware via a “time-out” or similar
approach so that appropriate steps can be taken by all parties.
M. Pressure
Check the zeroing and level of all transducers before terminating CPB.
1. Arterial pressure. Recognize that radial artery catheters may underestimate
central aortic pressure following rewarming [13]. In the absence of aortoiliac
occlusive disease, femoral artery catheters do not share this limitation. An
aortic root vent, if present, may be connected to a transducer also. If the radial
arterial catheter is not functioning, a needle placed in the aorta or aortic
cannula can be transduced during and after termination of CPB until the cannula
is removed.
2. PA pressure. Ensure that the catheter has not migrated distally to a wedge
position. Often the PA catheter must be withdrawn 3 to 5 cm even if this was
done at CPB initiation.
N. Pressors and inotropes
1. Medications that are likely to be used should be readily available, including a
vasodilator (e.g., NTG) and a potent inotropic agent (e.g., dobutamine,
epinephrine, milrinone).
2. NTG and phenylephrine should always be available to infuse after CPB as they
are commonly used. Some practitioners use prophylactic NTG infusion
(approximately 25 to 50 μg/min) for all coronary revascularization procedures
to prevent coronary spasm and to enhance noncoronary collateral flow in cases
of incomplete revascularization. It also can be used as a venodilator to allow
additional CPB pump volume to be infused after CPB.
3. Volumetric infusion pumps deliver vasoactive substances with the highest
accuracy and reproducibility.
O. Pacer
An external pacemaker should be in the room, checked, and set to the initial
settings by the anesthesiologist. A pacemaker often is needed for treatment of
relative bradycardia or asystole. In patients with heart block, AV sequential
pacing is strongly advised to retain a synchronized atrial contraction. Use of a
DDD pacer, when available, is recommended. Temporary biventricular pacing in
patients with reduced EF is used in some centers.
P. Potassium
Blood chemistries should be checked before terminating CPB.
1. Hyperkalemia may induce conduction abnormalities and decreases in
contractility. This is more common after long cross-clamp times when large
amounts of potassium cardioplegia solution are more likely to be used, and the
risk is higher in patients with renal dysfunction.
2. Hypokalemia can cause arrhythmias and should be treated if less than 3.5
mEq/L and there is adequate urine output after CPB.
3. Glucose levels should be checked and treatment undertaken for hyperglycemia
in all patients, not just diabetic patients. Hyperglycemia may contribute to
central nervous system dysfunction, poor wound healing, and cardiac
morbidity. The optimal glucose level is controversial. Some advocate
“aggressive treatment” and suggest a glucose level at or below 110 mg/dL.
Most authors try to maintain a level less than 150 mg/mL due to concerns that
more aggressive control may lead to complications related to hypoglycemia
and possibly higher mortality [14].
4. Ionized Ca++ levels are discussed in Section II.C above.
5. Other electrolytes should be evaluated as needed. In particular, low levels of
magnesium are common after CPB and have been associated with arrhythmias,
coronary vasospasm, and postoperative hypertension. Magnesium (2 to 4 g) can
be administered into the pump prior to emergence from CPB [15].
CLINICAL PEARL Magnesium administered into the CPB circuit can increase serum
magnesium levels and reduce the need for postoperative magnesium administration,
which may cause weakness in a recently extubated patient.
III. Sequence of events immediately before terminating cardiopulmonary bypass
(CPB)
Weaning from bypass describes the transition from total CPB to a final condition in
which the heart provides 100% of the work. The transition should be gradual,
recognizing that cardiac function post-CPB is not usually normal. At times, though,
cardiac function may improve after bypass if ischemia is relieved or valvular
dysfunction repaired.
A. Final checklist before terminating CPB
1. Confirm
a. Ventilation
(1) Lungs are ventilated with 100% O2 with visual confirmation, and ETCO2
is present.
(2) Ventilatory alarms are enabled.
(3) Pulse oximetry is working. Change in monitoring location (e.g., earlobe
or nasal septum) may be necessary.
b. The patient is sufficiently rewarmed.
c. The heart, great vessels, and grafts have been properly deaired.
d. The patient is in optimal metabolic condition.
e. All equipment and medications are ready.
2. Do not proceed until these criteria have been met.
3. Weaning from CPB requires utmost concentration and vigilance by the
anesthesiologist, and all distractions should be eliminated. Turn the music
down and limit extraneous conversations.
B. What to look at during weaning
Key information can be obtained from four sources: the invasive pressure
display, the heart itself, the TEE, and the ECG.
1. Invasive pressure display
a. Pressure waveforms (arterial, central venous pressure [CVP], and PA or LA,
if used) are best displayed using overlapping traces. Advantages of this
display format include the following:
(1) Coronary perfusion pressure is graphically depicted as the vertical height
between the arterial diastolic pressure and the filling pressure (PA
diastolic or LA mean) during diastole.
(2) The vertical separation between the PA mean and CVP waveforms
estimates RV work.
(3) The slope of the rise in central aortic pressure during systole may give
some indication of LV contractility and is most easily appreciated if the
waveform is not compressed.
(4) Valvular regurgitation can be diagnosed by examining CVP, pulmonary
capillary wedge pressure (PCWP), or LA waveforms (e.g., mitral
regurgitation may produce V waves in LA and PCWP tracings) as well
as by TEE.
b. Arterial pressure. The systolic and mean systemic arterial pressures should
be checked continuously.
(1) The systolic pressure describes the pressure generated by the heart’s own
contraction.
(2) Before CPB separation, the mean pressure describes the work performed
by the bypass pump and the vascular tone. After separation, it reflects the
cardiac work and vascular tone. SVR can be easily calculated on pump,
mean arterial pressure (MAP)/flow, prior to separation.
(3) The diastolic pressure reflects vascular tone and gives an indication of
coronary perfusion pressure.
(4) The pulse pressure reflects the mechanical work done by the heart. As the
heart assumes more of the circulatory work, this pressure difference
increases. LV failure is suggested by a decreased pulse pressure.
(5) Difficulty in weaning (poor LV function) may be reflected by a low pulse
pressure or systolic minus mean pressure difference in the presence of
high atrial filling pressures when the venous return line is partially
occluded.
(6) It is important to remember that a radial artery catheter may not be
accurate following CPB. During the first 30 minutes after CPB, the radial
artery tends to underestimate both the systolic and mean central aortic
pressures. The surgeon can often confirm that there is a pressure
difference by palpating the aorta. Clinically significant radial artery
hypotension should be confirmed by a noninvasive BP reading or with a
central aortic or femoral artery pressure measurement before treatment or
resumption of CPB.
c. CVP. This provides an index of right heart filling before and during weaning.
High CVP suggests right heart dysfunction secondary to poor myocardial
protection or pulmonary hypertension.
d. PA pressures. When pulmonary vascular resistance (PVR) is normal, PA
diastolic pressure (PADP) can give a good indication of left heart filling
pressure with volume confirmed by TEE. Pulmonary hypertension usually
indicates elevated PVR and RV afterload. This needs to be treated when the
RV looks sluggish or is failing. NTG and inhaled NO or epoprostenol may be
necessary to treat pulmonary hypertension without decreasing systemic MAP,
which best reflects RV perfusion pressure.
(1) Inspection of the heart visually or by TEE provides valuable
information about contractility, wall-motion abnormalities, conduction,
preload, valvular function, and quality of surgical repair.
(2) ECG changes (e.g., heart block, dysrhythmias, or ischemia occur
frequently, mandating frequent examination).
(3) TEE. The midpapillary transverse view is best for obtaining or
estimating LVEF, preload, and regional wall-motion abnormalities. The
four-chamber view can reveal valvular function and conduction
abnormalities.
(4) Ventilation and oxygenation. Routine airway management issues as
well as problems in the other major organ systems must not be
overlooked. The partial pressure of carbon dioxide (PaCO2) should be
kept at or below 40 mm Hg in the post-CPB period. Minor elevations in
PaCO2 can increase PVR significantly. This is most important when RV
failure is noted.
IV. Sequence of events during weaning from CPB
CLINICAL PEARL TEE is a valuable tool for real-time assessment of LV filling
and function during weaning from CPB.
A. Step 1: Impeding venous return to the pump
1. Consequences of partial venous occlusion. Slowly the venous line is partially
occluded (by the surgeon or perfusionist). This increase in venous line
resistance causes right atrial pressure to rise and diverts blood flow through the
tricuspid valve into the RV instead of draining into the pump circuit. According
to the Frank–Starling law, CO increases as preload rises; as a result, the heart
begins to eject blood more forcefully as the heart fills and enlarges.
2. Preload. The amount of venous line occlusion is adjusted carefully to attain
and maintain optimal LV end-diastolic volume (LVEDV, or LV preload).
a. Estimating preload. With the use of TEE, LV volume can be assessed in real
time. In the absence of TEE, LVEDV can only be estimated from pressures
measured by a central venous or PA catheter. With a PA catheter in place,
both PADP and PCWP estimate LA pressure (LAP). The relationship of
LVEDV to LAP, PCWP, and PADP can be quite variable after bypass
secondary to changes in LV diastolic compliance. PVR also affects PADP.
Decreased LV compliance is caused by myocardial edema and ischemia.
Therefore, PADP, PCWP, and LAP are relatively poor indicators of LVEDV
in the post-CPB period.
b. Optimal preload is the lowest value that provides an adequate CO. Preload
greater than the optimal value may cause:
(1) Ventricular distention and increased wall tension (increased myocardial
oxygen consumption [MVO2])
(2) Decreased coronary perfusion pressure (Coronary perfusion pressure =
diastolic BP – LVEDP)
(3) Excessive or decreased CO, depending on the position on the Starling
curve
(4) Pulmonary edema
c. Typical weaning filling pressures. For patients with good LV function
preoperatively, PCWP of 8 to 12 mm Hg or CVP of 6 to 12 mm Hg often
suffices. Abnormal contractility or diastolic stiffness may necessitate much
higher filling pressures to achieve adequate filling volumes (20 mm Hg or
higher), but in such cases it is imperative to monitor left heart filling by a PA
or LA line, or by TEE. Preoperative PADP and CVP can be useful in
determining appropriate pressures for weaning.
d. CVP/LAP ratio. Normally, the CVP is equal or lower than the LAP, which is
usually estimated by the PADP (CVP/LAP ratio less than or equal to 1). If the
ratio is elevated (greater than 1), this strongly suggests RV dysfunction, and
the intraventricular septum may be forced toward the left in diastole, limiting
LV filling and CO. This “septal shift” often can be diagnosed by TEE as well.
In this situation, termination of CPB may be impossible until the ratio is
normalized by improving RV function [16].
B. Step 2: Lowering pump flow into the aorta
1. Attaining partial bypass. The rise in preload causes the heart to begin to
contribute to the CO. This condition is termed partial bypass because the
venous blood draining into the right atrium divides into two paths: Some goes
into the pump circuit, and some passes through the RV and lungs and is ejected
into the aorta by the LV.
a. Some institutions advocate keeping the patient on partial CPB for several
minutes to wash vasoactive substances from the lungs before terminating CPB
and to provide a gradual transition to normal RV and LV workloads.
2. Reduced pump outflow requirement. Because two sources of blood are now
supplying the aorta, the amount of arterial blood returned from the pump to the
patient can be reduced as native CO increases to maintain total aortic blood
flow. Therefore, the perfusionist is able to lower the pump flow rate in
increments of 0.5 to 1 L/min, resulting in gradual reductions in pump flow rate
while cardiac function and hemodynamics are carefully monitored.
3. Readjusting venous line resistance. Some adjustment in the venous line
resistance may be needed to maintain a constant filling pressure as the heart is
given more work to perform. Also, as arterial pump outflow is reduced, less
venous inflow is needed to keep the venous reservoir from being pumped dry.
Therefore, the venous line clamp can be progressively tightened to achieve the
desired increase in preload.
C. Step 3: Terminating bypass
If the heart is generating an adequate systolic pressure (typically 90 to 100 mm
Hg for an adult) at an acceptable preload with pump flows of 1 L/min or less, the
patient is ready for a trial without CPB, and bypass is terminated. The pump is
stopped and the venous cannula is clamped. If hemodynamics are not satisfactory,
CPB is reinstituted, and management of cardiovascular decompensation is begun.
V. Sequence of events immediately after terminating CPB
A. Preload: Infusing blood from the pump
If cardiac performance is inadequate, small increases in preload may be
beneficial. For adult patients, volume is transferred in 50- to 100-mL increments
from the venous pump reservoir to the patient through the aortic cannula. Before
volume infusion, the aortic cannula should be inspected for air bubbles within its
lumen. Increments of 10 to 50 mL are used in pediatric patients. During volume
infusions from the pump, the BP, filling pressure, and heart should be watched
closely. Continuous infusion is contraindicated because overdistention of the
heart may occur and the oxygenator reservoir may be emptied, thus potentially
infusing air into the patient.
1. The almost instantaneous infusion of volume by the pump allows for evaluation
of LV function. One can assume that during the infusion there is no change in
SVR. According to the formula
BP = CO × SVR
If you make SVR a constant, then:
BP = CO
a. An increase in BP with a small volume infusion must indicate an increase in
CO.
2. If BP and CO do not change with increased preload, the patient probably is at
the top (flat part) of the Frank–Starling curve, and further volume infusion is
unlikely to provide benefit.
3. If BP does rise , the rise is probably due to a rise in CO, and further volume
administration may be beneficial. In this manner, the optimal preload can be
titrated after CPB. TEE can help assess RV size and function with volume
administration.
4. Three factors often contribute to a need to give volume after CPB:
a. Continued rewarming of peripheral vascular beds results in vasodilation.
b. Changes in LV diastolic compliance alter optimal filling pressure.
c. Ongoing bleeding.
B. Measuring cardiac function
1. Before removing the aortic cannula or administering protamine, cardiac
function should be assessed, because an adequate BP can occur in the setting of
low CO and a high SVR. Cardiac function may be assessed by measuring CO
or by TEE. The derived cardiac index (CI) (CO/body surface area) should be
calculated. In general, a CI of more than 2 L/min/m2 should be present to
consider permanent termination of CPB, although an index of greater than 2.2
usually is considered “normal.” If HR is high, a normal CO can exist despite a
low stroke volume. Therefore, a calculation of the stroke volume index
(CI/HR) can be useful (normal is greater than 40 mL/beat/m2).
2. Measuring patient perfusion. Signs of adequate tissue perfusion after CPB
should be sought. Within the first 5 to 10 minutes after terminating CPB, arterial
blood gases and pH should be measured, looking for lactic acidosis or gas
exchange abnormalities. Mixed venous oxygen saturation (SvO2) indicates
global body O2 supply–demand balance. Urine output indicates adequacy of
renal perfusion and normally rises after CPB; lack of such a rise should be
evaluated and treated immediately. The ideal perfusion pressure for adequate
tissue perfusion should be individualized. Patients with renal insufficiency,
cerebrovascular disease, or hypertension may require higher perfusion
pressures, although the increased BP may worsen bleeding.
3. Afterload and aortic impedance. In the presence of good LV function (and the
absence of myocardial ischemia), the anesthesiologist should avoid elevated
afterload (as reflected by systolic BP) to prevent excessive stress on the aortic
suture lines and to reduce surgical bleeding. In adults, the usual desired range
for systolic BP is 100 to 130 mm Hg. With impaired LV function or valvular
regurgitation, SVR should be reduced to the lowest level possible while
maintaining adequate BP for organ perfusion. Reducing the aortic impedance
improves LV ejection and lowers systolic LV wall stress and myocardial O 2
demand. Impedance is related to BP and SVR, and lowering SVR can result in
increased CO with no change in BP.
C. Removing the cannulas
1. Venous cannula(s). The presence of a large cannula(s) in the right atrium or in
the vena cava will impair venous return to the heart, and if cardiac function is
reasonable, the venous cannula should be removed as soon as possible.
Removing the cannula will allow the perfusionist to “reprime” the pump and
allow for further volume infusion through the aortic cannula. Typically, the
venous cannula(s) are removed prior to the initiation of protamine to prevent
contamination of the pump with protamine.
2. Aortic cannula. Removal of the aortic cannula should usually wait until at least
half of the protamine dose has been infused and cardiovascular stability
confirmed.
D. Cardiovascular decompensation
CLINICAL PEARL RV failure can be diagnosed by TEE or by visual assessment of
RV contraction and distention.
1. Refer to Chapter 2 for specific drug pharmacology and doses.
2. Failure of the LV or RV, both of which are recovering from the insult of CPB,
together with low SVR are the most common causes of cardiovascular
insufficiency during the weaning process.
a. LV failure
(1) The differential diagnosis of LV failure after CPB is listed in Table 8.2.
(2) Treatment of LV failure during weaning from CPB includes:
(a) Inotropic drug administration. Most commonly epinephrine or
milrinone is chosen as a first-line agent, although some institutions
advocate the use of dopamine or dobutamine initially. Regardless of
choice, a bolus of epinephrine 4 to 10 μg (or alternatively
ephedrine 5 to 20 mg) can be given to increase contractility and BP
while commencing infusion of an inotrope.
(i) Epinephrine (>3 mcg/min) or dopamine (>3 mcg/kg/min) may
be appropriate if HR is normal and SVR is low or normal.
(ii) Dobutamine or milrinone may be more appropriate if SVR is
increased.
(iii) Low-dose epinephrine or milrinone may be appropriate if HR
is elevated.
(iv) Dobutamine or dopamine may be more appropriate if HR is
low and pacing is not being used.
(v) Norepinephrine or phenylephrine may be appropriate if SVR is
low and CO is normal or elevated.
(vi) Milrinone will significantly reduce SVR, so the use of an
arterial vasoconstrictor (phenylephrine, norepinephrine, or
vasopressin) often is necessary.
(vii) In the setting of post-CPB hypocalcemia, calcium can be an
excellent inotrope (and vasoconstrictor).
(b) Start NTG if ischemia is present (also consider use of short-acting
β-blockers).
b. RV failure
(1) Diagnosis
(a) Active pumping by the RV is mandatory for optimal cardiovascular
function, particularly in the presence of elevated PA pressures.
(b) TEE can be particularly useful in the detection of RV failure. The
RV will appear distended and hypocontractile.
(c) The RV can be directly visualized over the drape when a sternotomy
has been performed. Function and volume of the RV can be
assessed by the surgical and anesthesiology teams in this way.
(d) Patients most at risk include those with
(i) Pulmonary hypertension
(a) Chronic mitral valve disease
(b) Left-to-right shunts (atrial septal defect, ventricular septal
defect)
(c) Massive pulmonary embolism
(d) Air embolism
(e) Primary pulmonary hypertension
(f) Acute or chronic mitral regurgitation
• Valvular dysfunction
• Papillary muscle rupture
(g) Diastolic LV dysfunction
(ii) RV ischemia or infarct or poor myocardial protection
(iii) RV outflow obstruction
(iv) Tricuspid regurgitation
(e) Physiologic findings
(i) Depressed CI.
(ii) Inappropriate elevation in CVP compared to PCWP (unless
biventricular failure exists).
TABLE 8.2 Differential diagnosis of LV failure after CPB
(iii) Increased PVR (more than 2.5 Wood units or greater than 200
dynes sec/cm5; contributes to RV failure, but does not result
from it).
(iv) Pulmonary hypertension; leads to RV failure, but true RV
failure results in high CVP with low PA pressures.
CLINICAL PEARL Pulmonary hypertension can cause RV failure. However, good RV
function and increases in CO can also increase PA pressures.
(v) Increase in CVP relative to PA pressure is a sign of RV failure.
c. Treatment [17]
(1) Treat signs of ischemia (e.g., inferior ST changes, regional RV wall-
motion disturbance).
(a) Start NTG infusion if systemic BP permits.
(b) Increase coronary perfusion pressure by increasing systemic
diastolic pressure with a vasopressor.
(2) Increased preload usually is required but must be judicious in the setting
of RV failure.
(3) Increase inotropic support. Milrinone, dobutamine, and isoproterenol are
often effective because any of these will increase RV contractility and
decrease PVR.
(4) Use adjuncts to decrease PVR [18].
(a) Hyperventilation will induce hypocapnia and decrease PVR. This
should be accomplished by means of a high respiratory rate rather
than an increase in inflation pressure, which may increase PVR.
(b) Avoid hypoxemia, which will induce pulmonary vasoconstriction.
(c) Avoid acidemia.
(d) Maintain normal core temperature.
(e) Use pulmonary vasodilators (NTG, nitroprusside, epoprostenol
[Flolan]) [19].
(5) Administer NO by inhalation (10 to 40 ppm). Prostaglandin E1
prostacyclin (PGE1—epoprostenol) by inhalation. The benefit of inhaled
(rather than intravenous [IV]) pulmonary vasodilators is that well-
ventilated areas will have the most vasodilation, which improves V/Q
matching.
(6) Use an RV-assist device.
E. Inappropriate vasodilation
Inappropriate vasodilation may prevent achievement of an adequate BP despite
an acceptable or elevated CI.
1. Causes include:
a. Pre-existing medications (calcium channel blockers, angiotensin-converting
enzyme [ACE] inhibitors)
b. Electrolyte abnormalities
c. Acid–base disturbances
d. Sepsis
e. Pre-existing diseases (chronic hepatic or renal disease)
f. Hyperthermia
g. Idiopathic condition (poorly characterized factors related to CPB)
2. Excessive hemodilution (e.g., Hgb concentration 7 g/dL or lower) decreases
viscosity and lowers the apparent SVR.
3. Management includes vasoconstrictors (e.g., phenylephrine, vasopressin, or
norepinephrine) and red blood cell (RBC) transfusion when appropriate.
4. Vasoplegic syndrome is a severe form of post-CPB dilation characterized by
low MAP, normal to high CO, normal right-sided filling pressures, and low
SVR which is refractory 5 to pressor therapy. Pre-CPB risk factors include
higher patient EuroSCORE, preoperative use of β-blockers and ACE
inhibitors, pre-CPB hypotension, and pressor use. Unexpected hypotension
after starting CPB may predict this syndrome [20]. The syndrome is associated
with an increased overall mortality. Frequently increasing concentrations of
norepinephrine or norepinephrine combined with vasopressin are used to treat
this syndrome. However, high doses of norepinephrine may compromise organ
perfusion [21]. NO inhibition with methylene blue has been used as salvage
therapy in these cases. A dose of 2 mg/kg can be given over 20 minutes.
Methylene blue is an inhibitor of monoamine oxidase (MAO), and therefore
should not be given to patients who are on MAO inhibitors or selective
serotonin reuptake inhibitors due to the risk of inducing serotonin syndrome
[22].
F. Resumption of CPB
1. The decision to resume CPB after a trial of native circulation should not be
taken lightly, because there are potential dangers to resuming CPB (inadequate
heparinization, hemolysis, worsening coagulopathy, and vasoplegia after a
second bypass run). Nevertheless, CPB must be restarted before permanent
ischemic organ damage occurs (heart, brain, kidneys). TEE can rapidly
facilitate diagnosis and treatment of common problems such as inadequate
preload, thereby potentially preventing resumption of CPB. If severe
cardiovascular derangements continue for a prolonged period, reinstitution of
CPB is indicated. While the patient is on CPB, diagnosis and treatment should
continue but may proceed without markedly increasing the risk of organ failure.
a. A variation on this theme is rapid return to full CPB after an unpromising
weaning effort or a very brief but unreassuring trial of native circulation. This
can enable institution of appropriate pharmacologic or mechanical support
with less immediacy and drama.
2. Heparin should be given as needed based on the last activated clotting time
measurement made while the patient was on CPB. If any protamine was given,
a full dose of heparin, 300 to 400 units/kg, is needed before resuming CPB.
3. During the period that it takes to reestablish CPB, it is important to maintain
coronary and cerebral perfusion with inotropes and vasopressors. In extreme
circumstances, it may be necessary for the surgical assistant to initiate open-
chest massage if the cannulas were already removed.
4. When CPB is reinitiated, consideration should be given to discontinuation of
inotropes and vasopressors, because patients in this situation may become
hypertensive. If BP elevation is marked, the perfusionist can lower pump flow
briefly while appropriate vasodilator therapy is given or until such time as the
effect of these pressors remits (typically less than 5 minutes). Resumption of
extracorporeal circulation importantly lowers myocardial oxygen requirements.
Maintenance of a reasonable perfusion pressure is critical to allow adequate
O2 delivery to potentially ischemic cells. If MAP is inadequate (e.g., <60 mm
Hg), this should be achieved with a pure α-agent such as phenylephrine.
Despite lower O2 requirements and adequate supply, the ischemic cell may not
be able to utilize O2 efficiently. If this is thought to be the case, the use of
secondary cardioplegia should be considered.
5. Additional recovery and reversal of damage can occur if the heart is rearrested
with warm-blood–enriched cardioplegia for a brief period.
6. Any mechanical factors that could compromise cardiac performance must be
sought and surgically corrected.
a. Ongoing ischemia based on ECG changes or TEE wall-motion abnormalities
may indicate graft occlusion and may require surgical reevaluation for graft
patency. A Doppler probe can be used to assess flow.
b. Valvular abnormalities can be assessed by TEE. Perivalvular leaks,
prosthetic valve malfunction, or residual stenosis/regurgitation should be
assessed.
7. Unsuccessful weaning may necessitate the addition of more aggressive
inotropic support. Additional myocardial reperfusion time on CPB may also
circumvent or reduce this need.
8. Additional monitoring. LAP is a better estimate of left ventricular end
diastolic pressure (LVEDP) than PA pressures. Aortic or femoral arterial
pressures may be more accurate than radial arterial pressures. TEE or
epicardial echocardiography can provide valuable data on function and filling.
9. Consideration of separation from bypass should be made only after the surgeon
is assured that technical difficulties did not account for impaired myocardial
performance and that the heart is “adequately rested.” If the second attempt to
wean is unsuccessful, continue to optimize preload and afterload with
vasodilators or volume infusion as needed.
a. IABP will augment diastolic BP, increase coronary perfusion, and decrease
afterload, and should be considered. It is relatively contraindicated in
thoracic aortic surgery or in the presence of mobile atheroma in the aorta seen
on TEE.
b. Chest closure may adversely affect hemodynamics (see Section V.E).
c. If available, ventricular-assist devices or extracorporeal membrane
oxygenation (ECMO) can be life-saving after failed attempts to separate the
patient from CPB. These are generally used either to rest the “stunned
myocardium” or as a bridge to heart transplantation (see Chapter 22).
VI. Cardiovascular considerations after successful weaning from CPB
The post-CPB period represents a time in which the myocardium is recovering
from the insult of surgery, CPB, and its attendant inflammatory effects. During this
period, major physiologic and surgical changes occur that need to be understood in
order to develop proper therapeutic approaches.
A. Reperfusion injury
Reperfusion injury describes a series of functional, structural, and metabolic
alterations that result from reperfusion of myocardium after a period of
temporary ischemia. The potential for this type of injury exists for all cardiac
procedures where the aorta is clamped. The damage is characterized by:
1. Cytosolic accumulation of calcium
2. Marked cell swelling (myocardial edema), which decreases postischemic
blood flow and ventricular compliance
3. Generation of free radicals resulting from reintroduction of O2 during
reperfusion. These oxygen free radicals can cause membrane damage by lipid
peroxidation. Various strategies are used to minimize injury, including
reoxygenation with warm blood to start aerobic metabolism as well as other
evolving strategies [23].
B. Decannulation
When the patient is hemodynamically stable after separation from CPB, the
venous cannula(s) is (are) removed. Blood loss and atrial dysrhythmias are the
most common complications during repair of the atrial cannula site. After
infusion of the appropriate volume of blood from the pump, the aortic cannula is
clamped and removed. To minimize blood loss and prevent possible aortic
disruption, the BP is frequently lowered (systolic pressure usually less than 100
mm Hg) to reduce tension on the aortic wall. If, during aortic cannula removal,
there is significant blood loss resulting in hemodynamic deterioration, a cannula
may quickly be reinserted into the right atrium and the appropriate volume
infused to achieve stability. Protamine administration is usually started prior to
aortic cannula removal in case it adversely affects hemodynamics, but most
surgeons remove it before its completion owing to the risk for intra-aortic clot
and embolism.
C. Manipulation of the heart
The heart often is lifted after bypass to allow examination or repair of the distal
anastomotic sites. The sequelae of this action include impaired venous return,
atrial and ventricular dysrhythmias, and decreased ventricular ejection; all may
result in systemic hypotension. Manipulation such as this should be limited to
brief periods in order to avoid hemodynamic deterioration. If the BP drops
substantially, a good technique is to simply call out the systolic pressure or
MAP, which subtly conveys the need for the surgeon to put the heart back down.
If the heart is slow to recover after such maneuvers, there may be a need to limit
cardiac manipulation. Overtreatment of these hypotensive episodes with the
administration of catecholamine or calcium boluses should be avoided, as it
often results in hypertension once manipulation is stopped. Very high BP at this
stage can lead to graft disruption and increased bleeding.
D. Myocardial ischemia
1. Coronary artery spasm. Ischemia in the postbypass period may derive from
spasm of the native coronary arteries or an internal mammary artery graft. This
typically manifests as regional wall-motion abnormalities on TEE or as ST-
segment elevation, although dysrhythmias, severe hypotension, and cardiac
arrest may also occur as sequelae. Mechanisms that have been proposed
include intense coronary vasoconstriction from hypothermia, local trauma,
respiratory alkalosis, excess sympathetic stimulation of the α-adrenergic
receptors on the coronary vessels, release of vasoconstricting agents from
platelets (thromboxane), and injury to native vascular endothelium with the loss
of endogenous vascular relaxing factors (i.e., endothelium-derived relaxing
factor and prostacyclin). Therapeutic modalities that have been used
successfully to treat coronary spasm include intracoronary administration of
drugs including NTG and papaverine; or systemic administration of NTG,
calcium channel blockers (e.g., nicardipine), and other phosphodiesterase
inhibitors (milrinone).
2. Mechanical obstruction. Compression of vein or internal mammary artery grafts
can produce myocardial ischemia and should be considered. Ventilation with
large tidal volumes can intermittently impair internal mammary artery graft
flow, and overdistended lung can disrupt the graft at the anastomotic site.
3. Air in grafts. Due to improper deairing of grafts or the LV, air bubbles can
impede blood flow through the grafts. Manifestations are typically the same as
with other causes of ischemia, including ST-segment changes, regional wall-
motion abnormalities on TEE, hypotension, or dysrhythmias. Surgeons can
often see air in the coronary arteries to confirm the suspected diagnosis.
Primary treatment is to increase coronary perfusion pressure with increased
aortic diastolic pressure (e.g., administer a vasopressor), but consideration
should also be given to decreasing LVEDP with a vasodilator such as NTG.
Myocardial rest with a return to CPB may be needed.
4. Inadequate revascularization. This may result from poor target coronary
arteries available to the surgeon to graft or planned combination surgical and
percutaneous revascularization (more common with off-pump procedures).
Treatment of inadequate or incomplete revascularization is similar to medical
therapy for coronary artery disease, including maximizing coronary perfusion
pressure and decreasing LVEDP, using vasopressors, vasodilators, and
inotropes as needed.
E. Chest closure
During chest closure, hemodynamic deterioration may ensue. In general, patients
with normal RV and LV function and adequate intravascular volume tolerate
closure without problems. Some patients experience mild hypotension and will
respond promptly to volume administration. In individuals with poor ventricular
function or patients currently receiving inotropic agents, additional volume or
inotropic support may be required to maintain similar hemodynamics. If these
interventions fail, the surgeon may be required to reopen the chest. TEE can be
especially useful to determine the causes of hemodynamic instability, including
myocardial ischemia with new wall-motion abnormalities or hypovolemia. Chest
closure may cause cardiovascular deterioration for the following reasons:
1. In patients who have significant myocardial edema, closure will impair RV
function and venous return.
2. Edematous, overdistended lungs can lead to a tamponade-like effect after
closure in patients with severe chronic obstructive lung disease (COPD).
Ongoing bronchospasm, low pulmonary compliance, and positive end-
expiratory pressure (PEEP) may contribute to this, as may noncompliant chest
walls from obesity or advanced age.
3. A source of bleeding not identified before adaptation of the sternal borders can
lead to cardiac tamponade.
4. Chest closure may kink a vein or internal mammary artery graft to cause
ischemia in the jeopardized area of the myocardium. If these mechanical
problems are eliminated and hemodynamics remain compromised, the chest
may need to be reopened temporarily. If repeated closure efforts fail, a sterile
dressing can be placed to cover the open chest and the patient brought to the
intensive care unit (ICU) in this condition. The chest can then be closed in the
future, typically within 24 to 48 hours.
F. Management of hemodynamics in the postbypass period
Proper management of patients in the postbypass period involves continuous
assessment of five hemodynamic variables as summarized in Figure 8.1. These
are preload, rate, rhythm, contractility, and afterload. Although cardiovascular
collapse after bypass is uncommon, should it occur, it is most likely that a
technical problem (ischemia, valvular dysfunction) or severe metabolic
derangement exists. TEE can help make the correct diagnosis. If cardiovascular
deterioration is unresponsive to maximal inotropic therapy [24] and no
immediately reversible cause can be identified, then reinstitution of CPB will be
necessary.
FIGURE 8.1 Management scheme for cardiovascular dysfunction in the postbypass period. CPB, cardiopulmonary
bypass; IABP, intra-aortic balloon pump.
VII. Noncardiovascular considerations

A. Respiratory system
1. Pulmonary edema
a. Post-CPB pulmonary dysfunction. Originally described in its most severe
form as postperfusion lung syndrome (“pump lung”), pulmonary dysfunction
after CPB is a 6 common event. The alveolar–arterial (A–a) O2 gradient
increases after bypass and becomes greatest at approximately 18 to 48 hours
postoperatively. The etiology of this ventilation–perfusion mismatch is
presumed to be multifactorial, ultimately leading to an increase in
noncardiogenic pulmonary interstitial fluid and resultant hypoxemia and
possibly hypercapnia as well. Etiologic factors include:
(1) Prolonged atelectasis and subsequent loss of surfactant
(2) Hypoxic damage to lung tissue, and pulmonary vasculitis caused by:
(a) Hemolyzed blood
(b) Protein denaturation
(c) Multiple pulmonary microemboli
(d) Ischemic reperfusion injury
(3) Accumulation of activated neutrophils in the lungs. Lysosomal enzymes
produce pulmonary capillary damage and subsequent leakage of plasma.
(4) Transfusion reactions and transfusion-related acute lung injury.
(5) Severe postperfusion lung syndrome has virtually been eliminated today
with the use of membrane oxygenators, which has greatly diminished
blood trauma.
b. LV dysfunction. Reduced systolic and diastolic ventricular function in the
postbypass period will result in elevated pulmonary venous pressures. This,
combined with reduced colloid osmotic pressure from hemodilution, will
result in increased pulmonary interstitial fluid.
c. Pre-existing pulmonary edema. The individuals presenting for surgery with
pulmonary edema represent a significant risk. These patients may be
extremely difficult to oxygenate or ventilate after CPB. Techniques that may
improve oxygenation include ultrafiltration and aggressive diuresis while on
bypass.
d. Treatment options
(1) Decrease preload (NTG infusion)
(2) Decrease afterload (sodium nitroprusside, nicardipine, clevidipine,
decrease vasoconstrictor dose or replace more vasoconstrictive
inotropic drugs like dopamine or norepinephrine with more vasodilatory
ones like dobutamine or milrinone).
(3) Diuresis
(4) Increase contractility
(5) Increase PEEP
(6) Increase tidal volume or FiO2
(7) Inhaled pulmonary vasodilators for refractory hypoxia (NO,
epoprostenol)
(8) In extremely rare and severe cases, ECMO therapy may be necessary.
e. Anaphylactic reactions. Certain drugs (e.g., protamine) and administration of
blood products or colloid volume expanders may rarely increase pulmonary
capillary permeability.
2. Mechanical factors
a. Pneumothorax occurs most commonly when the pleural cavity is entered
during dissection of the internal mammary artery. Other etiologic factors
include barotrauma from excess positive-pressure ventilation, particularly in
patients with low lung or chest wall compliance or emphysematous pulmonary
changes. Entry into the pleural space can result from central venous access.
Pneumothorax may manifest only after chest closure.
b. Hemothorax. Accumulation of blood in the pleural cavity can occur during
bypass, as blood from the mediastinum frequently overfills the pericardial
“sling.” It also may occur with dissection of the internal mammary artery
before administration of heparin, which results in the collection of clot in the
pleural space. The pleural space can be inspected with TEE and visually in
the surgical field, and adequate removal of blood and clot is imperative
before termination of CPB and before chest closure.
c. Movement of the endotracheal tube. Draping the patient for cardiac
procedures often obscures part of the head and the endotracheal tube from our
direct vision. Even when the endotracheal tube is visible from the head of the
operating table, the surgeon may unintentionally push on it in an attempt to
gain better exposure, which may displace it. Therefore, it is important to
intermittently reconfirm proper positioning by checking all connections,
observing bilateral chest movement, and visualizing or auscultating one or
both lung fields if the pleural cavities are exposed. Since partial obstruction
or disconnection can be subtle, ETCO2 and pulse oximeter monitoring may
fail to detect them.
d. Obstruction of the tracheobronchial tree
(1) Mucus plug. Dry inspissated secretions may accumulate in the
tracheobronchial tree or endotracheal tube, and partially or completely
obstruct the airway. In most cases, this can be diagnosed and managed by
suctioning the airway with a small catheter. It may be necessary to use
bronchoscopy to perform guided therapy.
(2) Blood. Injury to the upper airway or trachea due to laryngoscopy,
placement of an endotracheal tube, or an unrecognized pre-existent
airway lesion followed by heparinization may result in aspiration of
blood. If significant, this can result in varying degrees of airway
obstruction. More likely, however, the blood will be aspirated into the
distal airways and alveoli, causing marked ventilation–perfusion
mismatch. Blood also may appear in the airway due to perforation of the
PA from a PA catheter. Risk factors for catheter-induced PA rupture
include surgical manipulation of the heart, advanced patient age,
anticoagulation, hypothermia, and pulmonary hypertension.
3. Increase in dead space
a. The most common cause is air trapping from bronchospasm but may be related
to other factors. The ETCO2 tracing can confirm an obstructive pattern, and
the ETCO2–PaCO2 difference increases. In severe cases the gradient may be
15 to 25 mm Hg.
b. Etiology
(1) Bronchospasm
(a) Pre-existing asthma or COPD
(b) New onset
(i) Mechanical
(a) Endotracheal tube (carinal irritation)
(b) Secretions or blood
(ii) Chemical
(a) Medications
(b) Histamine release
(c) Inflammation
(d) Allergic/anaphylactoid
(2) Adult respiratory distress syndrome (ARDS)
(3) Transfusion related
(4) Decreased CO
(5) Pulmonary embolus
(a) Thrombus unlikely, but possible after protamine administration
(b) Air entrainment
c. Treatment for bronchospasm
(1) Remove the offending agent
(2) Inhaled β2 agonists (albuterol, salmeterol)
(3) Inhaled anticholinergic agents—ipratropium bromide
(4) Epinephrine
(5) Corticosteroids (IV or inhaled)
(6) Consider theophylline in chronic patients
(7) Magnesium
(8) Ventilatory changes (longer expiratory time, lower respiratory rate)
(9) Potent inhalational anesthetic agents if CI is adequate
4. Intrapulmonary shunt
a. Atelectasis. Perhaps the most common cause of decreased arterial
oxygenation postbypass is atelectasis. Although diffuse, chest radiographs
postoperatively frequently reveal a pattern of left lower lobe infiltration and
atelectasis. The likely explanation is that application of ice causes temporary
phrenic nerve injury with subsequent paralysis of the left diaphragm. During
CPB, applying PEEP or even ventilating with low tidal volumes (<200 mL) is
associated with higher PaO2 post-CPB. However, you may be asked to limit
ventilation if it impairs surgical exposure. After CPB, recruitment maneuvers
with addition of PEEP can be utilized to minimize atelectasis while resuming
normal ventilation (6 mL/kg).
b. Inhibition of hypoxic pulmonary vasoconstriction. Hypoxic pulmonary
vasoconstriction is the mechanism believed to be responsible for the increase
in PVR in regions of atelectasis. This protective mechanism can be attenuated
or inhibited by the use of vasodilators (nitroprusside, NTG) and inotropes
used to improve hemodynamic status.
5. Intracardiac shunt. When evaluating hypoxemia after CPB, the possibility of a
right-to-left shunt must always be considered. Decreased RV contractility and
compliance after CPB, in the presence of increased PVR associated with
PEEP, will frequently elevate right atrial pressures above those on the left side.
This equalization or reversal of pressure is the mechanism by which a patent
foramen is opened. TEE should easily facilitate identification of a new
interatrial shunt.
B. Hematologic system
Management of the coagulation system and blood conservation is just below
cardiovascular stability in terms of priority and decision making during this time
period. Blood product management should be a joint decision by the surgical,
intensive care, and anesthesia teams based on individual patient needs and
guided by available coagulation testing to tailor therapy. Institutional algorithms
have been shown to be useful for preventing excessive blood product use in
cardiac surgery. Please see Chapters 9 and 21 for detailed discussion of these
topics.
C. Renal system
1. Effects of CPB on the kidneys. Many of the variables introduced with
initiation of CPB affect the renal system. Hemodilution and/or hemolysis
reduce renal vascular resistance, resulting in increased flow to the outer renal
cortex and subsequent enhanced urine 7 flow. Hemolysis also releases free
hemoglobin, which can cause renal injury. If systemic hypothermia is used as a
form of myocardial protection, renal vascular resistance increases and renal
blood flow, glomerular filtration rate, and free water clearance all decrease.
During CPB, nonpulsatile flow, decreased perfusion pressure, and embolic
phenomena from aortic plaque can also decrease renal blood flow. The
decrease is most likely in patients with renal artery stenosis. CPB-induced
inflammation can also worsen renal outcome. It is important to prevent this
complication, because new-onset renal dysfunction requiring dialysis will
increase mortality almost eightfold [25].
2. Postbypass renal dysfunction. Certain factors have been identified that place
patients at risk for renal dysfunction in the postbypass period. These include
elevated preoperative serum creatinine, combined valve and CABG, advanced
age, and diabetes. Prolonged bypass times and decreased CI post-CPB place
patients at risk.
3. Management. Pharmacologic therapy may have some benefit in patients with
severe pre-existing renal dysfunction or failure. While these therapies may not
prevent acute kidney injury (AKI), they can temporize hypervolemia and
hyperkalemia. A frequent observation is that urine flow is diminished during
bypass compared with the individuals who have normal renal function. Renal
insufficiency may result in significant hyperkalemia and accumulation of
extracellular fluid.
4. Treatment options include:
a. Furosemide (initial dose 10 to 20 mg) or mannitol (0.5 to 1 g/kg).
b. Fenoldopam (0.05 to 0.1 μg/kg/min) will increase renal blood flow and may
provide an important therapeutic option. It may cause unacceptable
hypotension.
c. Ultrafiltration can be performed on CPB to remove excess volume.
d. Despite these interventions, some patients may require dialysis in the early
postoperative period.
D. Central nervous system
1. Anesthetic depth. The modern assessment of anesthetic depth with the BIS or
other monitors may add important information for optimal anesthetic
management. In the postbypass period, there are varying levels of surgical
stimulation, with the highest being the placement of sternal wires and chest
closure. If an increase in depth of anesthesia is needed, the choice of agent(s)
will depend primarily on the patient’s hemodynamic status.
2. Small doses of opioids or benzodiazepines can be titrated incrementally in
patients with stable hemodynamics. Additionally, the judicious use of a volatile
agent may be considered, particularly in patients who are hypertensive with a
reasonable CI.
3. Many anesthesiologists are using a propofol infusion with good results after
CPB. The infusion can be started upon rewarming and continue until and
through the initial ICU stay. An infusion of 25 to 50 μg/kg/min is usually
acceptable but can be titrated as indicated. Another alternative is
dexmedetomidine, starting at doses of 0.2 to 0.5 μg/kg/hr, again titrating as
indicated.
4. It must be remembered that all patients have some degree of postbypass
ventricular dysfunction. Even small doses of narcotics and propofol have the
potential to cause adverse hemodynamic consequences.
5. Neuromuscular blockade. Patients frequently require additional
neuromuscular relaxation in the postbypass period. The main objective is to
prevent shivering, which can increase O2 consumption by as much as 500%.
Frequent monitoring of the train of four is necessary. Renal and hepatic
functions can deteriorate in the face of cardiovascular compromise, which can
be a consideration in the choice or dosing of neuromuscular blocking agent
(e.g., rocuronium vs. cisatracurium). Temperature changes, blood loss, cardiac
function, and adjuvant medications can also affect the pharmacokinetics and
plasma levels of neuromuscular relaxants.
6. Fast-track protocols in some hospitals allow for muscle relaxant reversal in the
operating room (OR) or after admission to the ICU. The cardiovascular side
effects of reversal, such as HR changes, should be anticipated.
E. Metabolic considerations
1. Electrolyte disturbances
a. Hypokalemia is a relatively common electrolyte abnormality in the
postbypass period. Although the etiologic factors are numerous, only those
unique to bypass will be mentioned. The kidney represents a major source of
potassium loss. Both the preoperative and intraoperative use of diuretics,
including mannitol administration, promotes significant potassium wasting.
Glucose may be administered as a myocardial substrate during bypass. If
significant hyperglycemia occurs, an osmotic diuresis with potassium loss
will ensue. Hypokalemia may also result from the shift of potassium to the
intracellular space. Such a shift may occur with alkalemia from either
hyperventilation or excess bicarbonate administration, and with concomitant
administration of insulin in a diabetic patient.
In addition, the use of inotropes capable of stimulating β 2-adrenergic
receptors will promote an intracellular shift of potassium. Treatment will vary
depending on the severity of hypokalemia. Commonly, potassium levels tend
to rise modestly without treatment due to redistribution and blood product
administration. In most instances, IV administration at rates up to 10 mEq/hr
(in adults) will be effective. In life-threatening situations, potassium may be
administered at a rate up to 20 mEq/hr with continuous cardiac monitoring.
Adequate renal function, initially assessed by urine output, should be
confirmed prior to initiating potassium replacement.
TABLE 8.3 Treatment of hyperkalemia
b. Hyperkalemia occurs uncommonly after bypass. In most cases, hyperkalemia

occurs when large doses of cardioplegic agents are administered, particularly
in patients with impaired renal function. Hyperkalemia may persist in the
postbypass period but generally resolves spontaneously without intervention.
Depending on the cardiac rhythm, moderate hyperkalemia (potassium levels
between 6 and 7 mEq/L) may require therapy with one of the treatment
modalities listed in Table 8.3. With severe hyperkalemia (potassium levels
greater than 7 mEq/L), therapeutic interventions will be needed.
c. Hypocalcemia can occur after bypass. Common etiologic factors include
hemodilution from the pump prime, particularly in children; acute alkalemia;
and calcium sequestration from blood product administration. Alkalemia that
occurs with hyperventilation or rapid administration of parenteral bicarbonate
enhances calcium binding to protein. Sequestration of calcium occurs with
administration of a large volume of blood that contains the chelating agent
citrate. Severe hypocalcemia results in myocardial depression and
vasodilation.
(1) Calcium administration after CPB is indicated in the presence of severe
hyperkalemia or in cases of hypotension associated with low serum
ionized calcium. Calcium may be administered as 10% CaCl2 (272 mg of
elemental calcium) in a dose of 5 to 10 mg/kg. The typical adult dose is
500 to 1,000 mg. Calcium gluconate in incremental doses of 10 mg/kg
may also be used.
d. Hypomagnesemia commonly occurs in patients undergoing cardiac surgery.
England et al. suggested that large quantities of magnesium-free fluids with
subsequent hemodilution most likely contribute to this observation [15]. Other
etiologic factors include loss of the cation in the extracorporeal circuit and
redistribution of magnesium to other body stores. In a randomized, controlled
trial (patients in the treatment group receiving 2 g of magnesium chloride after
termination of CPB), magnesium-treated patients had a lower incidence of
postoperative ventricular dysrhythmias and an increased CI in the early
postoperative period [15]. Therefore, many centers will give magnesium prior
to terminating CPB.
2. Hyperglycemia. The stress response places all patients at risk for developing
hyperglycemia during cardiac surgery [26]. Diabetics, particularly those who
are insulin dependent, usually require an intraoperative insulin infusion to
maintain glucose hemostasis. Inotropes, particularly epinephrine, may
contribute to hyperglycemia after bypass by stimulating hepatic glycogenolysis
and gluconeogenesis. The deleterious effects associated with hyperglycemia
include: an osmotic diuresis and its attendant electrolyte abnormalities;
exacerbation of both focal and global ischemic, neurologic and cardiac injury;
and coma (if severe).
F. Postbypass temperature regulation
1. Hypothermia. All patients who undergo hypothermic CPB experience variable
degrees of hypothermia in the postbypass period, with profound effects on the
cardiovascular system, particularly in individuals with borderline cardiac
reserve. As the temperature decreases, arteriolar tone will increase, resulting
in elevated SVR. The hemodynamic consequences include hypertension,
decreased CO, and increased MVO2. If shivering occurs, total body O2
consumption increases. Coagulopathy is also associated with hypothermia.
2. Etiology of postbypass hypothermia. Hypothermic CPB causes a
vasoconstricted state. During rewarming, many of the peripheral vascular beds
(i.e., muscle and subcutaneous fat) may not adequately dilate and therefore can
act as a hypothermic reservoir, which will eventually equilibrate with the
central circulation. Opening and warming these vascular beds with
pharmacologic vasodilation during rewarming may diminish the “after-drop” in
core temperature. The decrease in temperature usually reaches its nadir 80 to
90 minutes after bypass.
3. Prevention and treatment of hypothermia. The most effective way to
attenuate postbypass hypothermia is to be assured that effective rewarming
occurs during CPB. If circulatory arrest was used, rewarming will be
significantly delayed.
The most effective way to maintain temperature postbypass is the forced-air
heater. Underbody techniques are perhaps most useful, because in many cardiac
surgical procedures anterior access is limited to the head and neck due to the
surgical drapes. Covering the head improves warming. A lower body cover
can be used after the vein sites are dressed if necessary. Other techniques that
have been suggested to attenuate hypothermia include heating inspired gases,
use of an IV fluid warmer, increasing ambient temperature, and using warm
irrigation fluids in the chest cavity and warming blankets. The contribution of
these techniques to either postbypass hypothermia prevention or to active
rewarming is likely to be minor, but they may aid in maintaining the patient’s
temperature until he or she leaves the OR.
4. Hyperthermia should be avoided, since it will exacerbate cerebral ischemic
injury, during either aggressive warming on CPB, after CPB, or in the ICU. The
core or nasopharyngeal temperature should not exceed 37°C.
VIII. Preparing for transport
A. Moving the patient to the transport or intensive care unit (ICU) bed in the
operating room (OR)
After the chest is closed and all dressings are applied, the patient must be moved
to the transport bed. This requires a coordinated effort to minimize the risk of
complications. Monitor lines can be lost, inotropic support disconnected, and
ventilation can be interrupted with devastating consequences during this
seemingly easy process. There is a lapse in cardiovascular monitoring during
transfer to a mobile or transport monitor. Disconnect monitoring devices
sequentially, so there is an “active” monitor to assess the patient at all times.
1. Complications of transfer
a. Tracheal extubation
b. Coronary air embolism from bubble dislodgement (after open cardiac
procedures) leading to ischemia or ventricular fibrillation
c. Arterial line or PA catheter removal
d. IABP line disruption
e. Pacemaker wire dislocation or disconnection
f. Loss of IV lines
g. Monitors (pulse oximeter probe, ECG lead) pulled off
h. Patient fall
i. Corneal injury (e.g., from wires, tubing)
j. Loss of vasoactive or inotrope infusions
k. Chest tube or urinary catheter dislodgement
l. Venodilation with resultant hypotension
m. Loss of O2 supply (empty O2 tank)
n. Inadequate manual ventilation (observe for adequate chest wall expansion)
B. Transport to the ICU
Emergency equipment and medications must be collected prior to transport. The
type of equipment necessary is related to the distance traveled. A move 5 floors
away from the OR is much different than one 50 ft away. See Table 8.4 for a
suggested list of equipment/medications. Murphy’s law is in play here. There are
case reports of cardiac arrest and extubation in compromising situations. We
have experienced an IABP failure in an elevator with adverse consequences. The
patient must be monitored and adequate ventilation ensured during transport no
matter the distance transported. Minimum monitoring requirements include: ECG,
arterial line, and pulse oximetry.
Fast-tracking (early extubation) approaches are discussed in Chapter 25. In
highly selected patients, such as patients with atrial septal defect repairs and off-
pump single-vessel bypass grafting which have either short CPB runs or brief
ischemic times, some cardiac surgical teams may choose to extubate the trachea
in the cardiac OR. Patients with long CPB runs and ischemic times are not good
candidates for OR extubation because of potential cardiac and cerebral
complications which may not manifest at this time. Our view is that extubation in
the OR most often unnecessarily complicates the early postoperative period
without patient benefit.
TABLE 8.4 Suggested emergency equipment for transport
CLINICAL PEARL During transport, bring various syringes with a pressor, an

inotrope, and antihypertensive agents, as this can be a time of extreme hemodynamic
lability.
C. Admission to the ICU
Most institutions will call a standardized report to the ICU prior to transport.
This report will document ventilatory settings, inotrope and vasoactive infusions,
and vital signs. This information allows time for preparation. Most ICUs will
continue to use the infusion bags from the OR. If your infusion volumes are
getting low, we recommend replacing them prior to transport, otherwise alert
ICU personnel to have replacement medication infusions available prior to
leaving the OR. The loss of a critical inotrope at this juncture can be
devastating.
After the patient is safely transferred to the ICU, permanent monitoring is
reinstituted sequentially. Document the pertinent vital signs in the anesthesia
record and to whom you gave the report. At this point in time, the anesthesia team
knows the most about the patient’s physiology. If hemodynamic instability is
noted, you are in the best position to provide the treatment of choice. Take
control of the situation.
When giving the report, give those accepting care of the patient any additional
information you feel would help them. For example, you may have seen the CI
fall when the PADP was less than 15 mm Hg because of diastolic dysfunction.
Let the ICU team know, so they won’t have to “reinvent the wheel” and find out
for themselves, putting the patient in harm’s way.
Continued bleeding during transport can induce hypovolemia and increase fluid
requirements. LV dysfunction may improve over time and inotropic support,
which is necessary in the OR, may need to be weaned to avoid hypertensive
complications. Continue care until you are satisfied that the patient’s condition is
stable.
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cardiac operations. J Thorac Cardiovasc Surg. 1987;94(2):286–290.
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Intensive versus conventional glucose control in critically ill patients. N Engl J
Med. 2009;360(13):1283–1297.
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after cardiac surgery. A placebo-controlled, double blind, randomized trial. JAMA.
1992;268(17):2395–2402.
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the termination of cardiopulmonary bypass. Central venous pressure/pulmonary
capillary wedge pressure ratio. J Thorac Cardiovasc Surg. 1985;89(5):706–708.
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9 Blood Management
Nadia B. Hensley, Megan P. Kostibas, Steven M.
Frank, and Colleen G. Koch
I. Background
II. Red blood cell (RBC) transfusion and clinical outcomes
A. Hemoglobin transfusion trigger trials
B. Intraoperative transfusion triggers
C. RBC storage duration
III. Component therapy
A. Restrictive RBC transfusion practices
B. Platelet therapy
C. Fresh-frozen plasma (FFP)
D. Cryoprecipitate
E. Massive transfusion and component ratios
IV. Blood conservation measures
A. Preoperative anemia management
B. Antifibrinolytics
C. Acute normovolemic hemodilution (ANH)
D. Methods used by perfusionists
E. Viscoelastic testing
V. Conclusion
KEY POINTS
1. Blood transfusion is the most common procedure performed in US

hospitals and has been named one of the top five overused
procedures by The Joint Commission.
2. Both anemia and transfusion carry significant risks. Balancing these
risks is the key to appropriate blood transfusion decisions.
3. Despite published guidelines, clinical transfusion practice still varies
substantially among clinicians and centers and often falls outside
recommended guidelines.
4. Transfusion-related acute lung injury (TRALI) is the most frequent
cause of mortality from blood transfusion. The second most
frequent cause of mortality is transfusion-associated circulatory
overload (TACO).
5. Two large hemoglobin trigger trials in cardiac surgery support the
use of a restrictive transfusion strategy with hemoglobin triggers of
7.5 to 8 g/dL; no improvement in primary outcomes was attained
with higher triggers (9 to 10 g/dL).
6. Red blood cell (RBC) storage duration has been associated with
adverse outcomes in retrospective studies; however, recent
prospective clinical trials have not shown better outcomes with
fresh blood than with standard-issue blood. The oldest blood (35 to
42 days) is still untested.
7. Of all blood components, platelets are associated with the highest
risk and cost. Bacterial sepsis is the most common adverse event,
given that platelets are stored at room temperature.
“BLOOD TRANSFUSION IS LIKE MARRIAGE: it should not be entered upon lightly,

unadvisedly or wantonly or more often than is absolutely necessary.”
—R. Beale [1]
I. Background
Blood transfusion is the most common procedure performed in US hospitals
and has been 1 named one of the top five overused procedures by The Joint
Commission. Competing risks form the core of perioperative transfusion.
Patients face tangible complication risks if hemoglobin values fall too low, and
different but equally real risks when exposed to allogeneic 2 blood
transfusion. The risks of both anemia and transfusion vary depending on the
patient’s comorbidities, degree of and ability to tolerate anemia, and surgical
procedure. In the dynamic milieu of the operating rooms, clinicians caring for
cardiovascular surgical patients encounter challenging transfusion decisions daily.
No measures can definitively direct transfusion decisions; rather clinical judgment
based on the balance of perceived risks and benefits must guide individual
transfusion decisions. Given this background, the substantial variability of
transfusion even within a single institution becomes understandable [2,3].
A. Practice patterns vary widely for transfusion of all three major blood
components in cardiac surgery.
1. The wide variation in transfusion practice patterns was highlighted in a
nationwide study in 2010. More than 100,000 patients undergoing isolated
coronary artery 3 bypass graft surgery were included from almost 800
hospitals [3]. Such variability often serves as the impetus for evidence-based
guidelines that are intended to reconcile disparate evidence.
2. The most widely cited guideline for transfusion practice in cardiac surgery is
the guideline for blood transfusion and blood conservation published jointly by
the Society of Thoracic Surgeons (STS) and Society of Cardiovascular
Anesthesiologists, which was last updated in 2011 [4].
B. Patient blood management (PBM) programs
1. PBM programs are somewhat new but are being implemented in many
hospitals with the goal of reducing risks, improving outcomes, and lowering
costs [5].
2. The Society for Advancement of Blood Management defines PBM as “the
timely application of evidence-based medical and surgical concepts designed
to maintain hemoglobin concentration, optimize hemostasis, and minimize
blood loss in an effort to improve patient outcome.”
3. The primary goal of PBM is to reduce unnecessary transfusions. Several
methods of blood conservation discussed in this chapter are being effectively
utilized in PBM programs.
4. The Joint Commission, along with AABB (formerly the American Association
of Blood Banks), introduced a certification for PBM in 2016. Certification
enables hospitals to be recognized for successfully implementing these
valuable methods of care that are considered advancements in patient safety
and quality.
CLINICAL PEARL Anemia, bleeding, and transfusion are all associated with
adverse outcomes. It is therefore important to treat and prevent anemia, to minimize
bleeding, and transfuse blood and blood components according to evidence-based
indications.
C. Complications of transfusion
1. Complications of transfusion have always been a major concern, highlighted by
the threat of transfusion-transmitted viral infections, such as human
immunodeficiency virus (HIV), which peaked in 1983 [6]. Now, with nucleic
acid testing for HIV and hepatitis C, the risk for transmission of these viruses is
similar to that of dying from an airline crash or lightning strike [7].
2. The decrease in infection risk has led some to assume that blood is incredibly
safe; however, transfusion poses much more common and potentially life-
threatening events that should be recognized.
3. The Food and Drug Administration’s (FDA) summary of fatalities related
to transfusion for fiscal year 2015 listed transfusion-related acute lung
injury (TRALI) and transfusion-associated circulatory overload (TACO)
as the first and second 4 most frequent causes of mortality from
transfusion (Fig. 9.1) [8]. Between 2011 and 2015, 38% of deaths were from
TRALI, and 24% were from TACO. Hemolytic transfusion reactions (HTR)
caused by non-ABO (14%) and ABO (7.5%) incompatibilities were also
causes for mortality, followed by microbial contamination and
allergic/anaphylactic reactions.
FIGURE 9.1 In a report from the FDA [8], transfusion-related acute lung injury (TRALI) represented the most frequently
reported cause of transfusion-related mortality, and transfusion-associated circulatory overload (TACO) was the second most
common cause [19]. FDA, Food and Drug Administration; HTR (non-ABO), hemolytic transfusion reactions unrelated to ABO
incompatibility; HTR (ABO), hemolytic transfusion reactions related to ABO incompatibility; FY2015, Fiscal Year 2015.
a. TRALI, which is primarily a clinical diagnosis, can vary from mild to severe.
It is defined by the presence of hypoxemia and pulmonary edema on x-ray
within 6 hours after transfusion. The purported mechanism for TRALI likely
involves human leukocyte antigen (HLA) incompatibility, which triggers a
cytokine-mediated inflammatory response in the lungs that looks clinically
like a number of pulmonary edema–causing conditions; thus some believe that
TRALI is underreported [9,10]. The incidence has been reported as about 1 in
5,000 transfusions; however, recent data from the Mayo Clinic suggest that
TRALI or possible TRALI may occur in as many as 1 in 100 transfusions
[11].
b. TACO, like TRALI, also presents as pulmonary edema; therefore the two
syndromes are often hard to differentiate. TACO is thought to occur in
approximately 1 in 100 transfusions, but it may also be underreported. The
Mayo group has reported a frequency as high as 5 in 100 transfusions [12].
TACO can be difficult to differentiate from heart failure or generalized
intravascular volume overload, all of which can present with the same
clinical picture.
4. A recent investigation noted that TRALI, a diagnosis of exclusion, can be
difficult to diagnose in patients undergoing cardiac surgery. The authors
reported greater pulmonary morbidity in the postoperative period for patients
transfused with RBCs and fresh-frozen plasma (FFP); this pulmonary morbidity
may have been related to TRALI, TACO, both, or neither. Nevertheless,
transfusion of either RBCs or FFP was independently associated with
pulmonary morbidity in the postoperative period [13].
5. Stokes and colleagues [14] recently examined the effect of bleeding-related
complications, blood product use, and costs on a population of inpatient
surgical patients. They documented that inadequate surgical hemostasis leads to
bleeding complications as well as transfusion. The authors were able to rank
incremental cost per hospitalization associated with bleeding-related
complications and adjust for covariates. Their findings support the need for
further implementation of blood conservation strategies.
6. Bleeding complications and the associated need for reoperation correlate
with increased morbidity in cardiac surgical patients. Recent work attempted
to delineate whether increased morbidity risk was related to the reoperation,
blood transfusion, or both. The patients who underwent reoperation had greater
subsequent morbidity, increased resource utilization, and higher in-hospital
mortality even after risk adjustment (Fig. 9.2) [15].
FIGURE 9.2 Predicted probability of operative mortality stratified by reoperation for bleeding and RBC transfusion. RBC
transfusion and reoperation for bleeding were independently associated with increased mortality. RBCs, red blood cells.
(Reprinted with permission from Vivacqua A, Koch CG, Yousuf AM, et al. Morbidity of bleeding after cardiac surgery: is it
blood transfusion, reoperation for bleeding, or both? Ann Thorac Surg. 2011;91:1780–1790.)
7. A recent investigation in patients undergoing noncardiac thoracic surgery

showed that postoperative outcomes were worse in patients transfused with 1
to 2 units of RBCs than in those who received no transfusion. The negative
effect of transfusion was dose dependent and was associated with increased
morbidity and resource utilization. The authors urged clinicians to be cautious
in transfusing patients for mild degrees of anemia [16].
CLINICAL PEARL TRALI and TACO are the leading two causes of transfusion-
related death. HTR and bacterial sepsis are the next most common causes.
II. Red blood cell (RBC) transfusion and clinical outcomes
RBC units contain red cells that have been separated from whole blood by
centrifugation or apheresis (Table 9.1) [17]. Isbister and colleagues reported on
the abundance of data supporting morbidity risk associated with transfusion, yet
noted that transfusion remains “ingrained” in current medical practice almost as a
“default” position [18]. Furthermore, establishing causation between RBC
transfusion and morbidity is difficult because of the potential for confounding in
cohort study designs. Some argue that the etiology of poor outcomes relates to the
fact that “sicker” patients receive a transfusion rather than to the RBC product
itself. Recently, several large studies have examined clinical outcomes related to
transfusion to determine the ideal hemoglobin thresholds for transfusion in
postoperative cardiac surgery patients and whether prolonged RBC storage is
associated with adverse outcomes. In addition, the AABB has recently updated its
red cell transfusion guidelines, which are relevant to cardiac surgery [19].
A. Hemoglobin transfusion trigger trials
1. In the past decade, practice has moved toward transfusing less blood to
patients, 5 including those undergoing cardiac surgery. This change in
practice is supported by large randomized trials showing noninferiority when a
restrictive transfusion strategy is compared to a liberal strategy. The two large
studies carried out in cardiac surgical patients were the Transfusion
Requirements after Cardiac Surgery (TRACS) Trial in 2010 [20], and the
Transfusion Indication Threshold Reduction (TITRe2) in 2015 [21]. Both
studies focused on postoperative transfusion triggers, and neither demonstrated
a difference in the primary outcomes between a liberal and a restrictive
transfusion strategy.
TABLE 9.1 Fast facts: RBCs from American Red Cross compendium [17]
a. TRACS trial
(1) Compared hematocrit of 24% (restrictive) to hematocrit of 30%
(liberal).
(2) Primary outcome was a composite of morbidity and mortality.
(3) The primary outcome occurred with similar frequency in the liberal
(10%) and restrictive (11%) groups (P = 0.85). The various event rates
in the two groups are shown in Figure 9.3.
b. TITRe2 trial
(1) Compared hemoglobin triggers of 7.5 g/dL (restrictive) and 9.0 g/dL
(liberal).
(2) Primary outcome was a serious infection or ischemic event.
IGURE 9.3 Hemoglobin and primary outcome data are shown for the liberal and restrictive transfusion groups in the TRACS
nd the TITRe2 trials [20,21]. In postoperative cardiac surgery patients, adverse event rates for the primary outcome (as defined
y these trials) were similar in the groups assigned to a lower (restrictive) or a higher (liberal) hemoglobin transfusion threshold
). In panel A, the left edge of the red bars represents the hemoglobin trigger (prior to transfusion), and the right edge of
represents the hemoglobin target (after transfusion).
(3) The primary outcome occurred with similar frequency in the liberal
(33.0%) and restrictive (35.1%) groups (P = 0.30). The primary event
rates after 90 days are shown in Figure 9.3.
(4) The fact that outcome event rates were similar in the restrictive and
liberal transfusion groups strongly supports use of a restrictive approach,
as we only add risk and cost by administering more blood than is
necessary. Although the restrictive group had a higher mortality at 90
days postoperatively in the TITRe2 trial (4.2 vs. 2.6%, P = 0.045), this
was a secondary outcome with no statistical adjustment for multiple
comparisons, making the significance questionable. This finding suggests
we may not fully understand tolerable lower levels of hemoglobin in
high-risk patients.
c. A recent meta-analysis [22] of randomized controlled trials (RCTs) involving
transfusion triggers reported that restrictive thresholds may place patients at
risk for adverse postoperative outcomes. The methods differed from those of
other studies in that the authors used a context-specific approach (i.e., they
separated groups for analysis according to patient characteristics and clinical
settings). Risk ratios (RRs) were calculated for the following 30-day
complications: inadequate oxygen supply, mortality, a composite of both, and
infections. Thirty-one trials were regrouped into five context-
specific risk strata. In patients undergoing cardiac/vascular procedures,
restrictive strategies possibly increased the risk of events reflecting
inadequate oxygen supply (RR, 1.09 [95% Confidence Intervals (CI) 0.97 and
1.22]); mortality (RR, 1.39 [CI 0.95, 2.04]); whereas the composite risk of
events did reach statistical significance (RR 1.12, [CI 1.01, 1.24]).
Restrictive transfusion strategies also led to higher RRs among elderly
orthopedic patients. Given the limitations of meta-analyses, this finding does
not clearly support a liberal transfusion strategy in cardiac surgery patients.
2. One caveat is that when patients are actively bleeding, they will need to be
transfused more liberally because whatever hemoglobin threshold is chosen,
transfusion must at least keep pace with the bleeding.
CLINICAL PEARL Two large randomized trials, comparing restrictive transfusion
triggers (hemoglobin 7.5 to 8 g/dL) to liberal transfusion triggers (hemoglobin 9 to 10
g/dL) in postoperative cardiac surgery patients, showed no difference in the primary
outcome that was measured. This supports giving less blood, since we only add risk and
cost when giving more blood than is necessary.
B. Intraoperative transfusion triggers
1. In contrast to the postoperative setting, the ideal intraoperative hemoglobin
transfusion trigger for cardiac surgical patients has not been rigorously studied.
2. The STS and Society of Cardiovascular Anesthesiologists Blood Conservation
Clinical Practice Guidelines [4] suggest a lower limit of 6 g/dL for patients on
cardiopulmonary bypass (CPB) with moderate hypothermia, although they
recognize that high-risk patients may need higher hemoglobin levels. This
recommendation is supported by relatively weak evidence in the guideline.
3. Some centers have begun monitoring cerebral tissue oxygen content with near-
infrared spectroscopy technology; however, no conclusive evidence shows that
this type of monitoring can reliably guide transfusion therapy.
4. By lowering metabolic rate, hypothermic bypass reduces oxygen demands for
all vital organs, meaning that lower hemoglobin levels will be tolerated.
However, some groups now use either very mild or no systemic hypothermia.
Instead they use selective regional cooling of the chest cavity, leaving the brain
and kidneys at normal temperature.
5. Additional studies are needed to determine the ideal hemoglobin levels during
CPB.
C. RBC storage duration
1. As storage duration increases, RBCs undergo alterations in both structural
shape and biochemical properties. Implications of these time-dependent
changes may contribute to adverse clinical outcomes associated with RBC
transfusion. However, findings from clinical and experimental animal studies
have been inconsistent [23–25].
2. Although 6 weeks is the approved shelf life for ADSOL (additive solution)-
preserved RBCs in the United States, according to a recent survey, the mean
storage duration of RBC units has increased from 19.4 days in 2011, to 22.7
days in 2013 [26]. This increase may be due to an overall decrease in blood
utilization nationwide by about 20% over the past decade, resulting in blood
units sitting on the shelf longer before being used. Blood banks still operate on
the “first-in, first-out” inventory management strategy, meaning that the oldest
units get issued preferentially.
3. Survival of red cells after transfusion is an important variable, as it relates to
their functionality. The current FDA-approved 42-day storage duration limit is
based on a requirement that 75% of RBCs remain in circulation for 24 hours
after transfusion, with less than 1% hemolysis. The requirement does not
consider the cells’ functional state. With fresh blood, RBC survival is
approximately 90% at 24 hours posttransfusion. As storage duration increases,
24-hour survival (i.e., circulatory retention) decreases [27,28].
4. Laboratory investigation
a. As storage time increases, RBCs exhibit degradation in structural shape,
membrane deformability, aggregability, and metabolic function. The entire
host of changes is referred to as the “storage lesion,” which contributes to
limited posttransfusion RBC survival and potentially to impaired oxygen
delivery via the microcirculation.
b. A number of biochemical changes occur over time in stored RBCs. Levels of
S-nitrosothiols decrease 2 to 3 hours after collection. After several days of
storage, lactate, potassium, and free hemoglobin progressively increase,
whereas pH decreases [29]. 2,3-Diphosphoglycerate (2,3-DPG) levels
decrease by approximately 95% from baseline by halfway through the
approved shelf life (at 21 days) [30]. This depletion causes a left shift in the
hemoglobin–oxygen saturation curve, which impedes the off-loading of
oxygen from the hemoglobin molecule at the tissue level. It is unclear how
rapidly 2,3-DPG is replenished after transfusion, but studies suggest that a
complete return to baseline requires 24 to 72 hours.
c. Storage-induced reduction in RBC membrane structural integrity (reduced
deformability and increased fragility) is thought to be related to intra-RBC
energy source depletion. RBC membrane deformability is significantly
decreased by about halfway through the shelf life [31]. This loss of
deformability may impede blood flow through small capillaries, which are as
small as 5 microns in diameter, because the RBC itself is 7 microns in
diameter.
d. Release of cell-free hemoglobin and microparticles can lead to increased
consumption of nitric oxide (NO) [32] and unwanted vasoconstriction in
ischemic vascular beds. Some investigators have proposed insufficient NO
bioavailability as an explanation for the increased morbidity and mortality
observed after transfusion [33].
e. Relevy and colleagues [34] showed that not only was RBC membrane
deformability impaired, but RBC endothelial adherence was also increased.
These findings suggest that transfusion of rheologically impaired RBCs might
be detrimental for oxygen delivery, particularly in patients with
cardiovascular disease.
f. In a study of canines with induced sepsis, Solomon et al. [35] showed that
mortality was greater in animals that received RBCs near the end of the 42-
day shelf life than in those that received fresh blood. The mechanism they
proposed was an increase in hemolysis and NO depletion from free
hemoglobin in the circulation.
g. In a recent mouse study, blood stored for ≥35 days was associated with
increased nontransferrin-bound iron (free iron), whereas blood stored <35
days showed no significant increase in free iron [36]. The authors suggested
that this free iron could promote infections, and that consideration should be
given to limiting storage duration to 35 days.
5. Clinical investigation
a. Many clinical studies, including retrospective observational studies and
prospective RCTs, have examined the effect of RBC storage duration on
patient outcomes. 6 Multiple retrospective studies have shown better
outcomes with fresher blood, whereas five recent RCTs have shown no
benefit to fresher blood.
b. In a 2008 retrospective investigation that included over 6,000 cardiac
surgical patients at a single center, patients who received exclusively
older blood exhibited 39% greater in-hospital mortality and 33% greater
1-year mortality than did patients who received exclusively fresher blood
(20 vs. 10 days median storage) [25]. Prolonged intubation, sepsis, and
composite morbidity were also increased. This pivotal study was the
impetus for the large RCTs carried out in a variety of settings, including
adult cardiac surgical patients (the RECESS trial) [37], critically ill adult
ICU patients (the ABLE study) [38], and the largest study to date, which
enrolled all types of hospitalized patients (the INFORM study with over
20,000 patients) [39] . Each of these trials found no difference in any
major clinical outcomes, although few patients were administered blood
near the end of the allowed storage duration limit (35 to 42 days).
c. A recent study with over 23,000 transfused patients, although retrospective,
showed that administering the oldest blood in the bank (35 to 42 days storage)
to the sickest patients in the hospital (those requiring ICU stays) resulted in
higher mortality, but administering “middle age” blood even to high-risk
patients, or the oldest blood to healthier patients did not increase mortality
[40].
d. Most European countries allow a 35-day storage duration limit, whereas the
United States continues to allow 42 days of RBC storage.
CLINICAL PEARL The recent randomized trials showing no difference in
outcomes between blood stored for shorter and longer duration included few patients
receiving blood near the end of the shelf life (35 to 42 days storage). The primary
findings show that very fresh blood and blood stored for a medium duration are
associated with similar outcomes.
III. Component therapy
A. Restrictive RBC transfusion practices have become a standard of care; yet,
evidence-based indications for the use of blood component therapy such as FFP
and platelet concentrate transfusion have been more limited [41]. After donation,
whole blood is separated into components, which are stored at different
temperatures. Though RBCs can be stored for up to 42 days at 1° to 6°C,
platelets are stored at room temperature for a much shorter storage duration of 5
days. Plasma and cryoprecipitate can be stored frozen for 1 year.
1. Use of predetermined ratios of component therapy to RBCs has gained
increased attention as a result of recent research into military and civilian
trauma resuscitation. These investigations focus on earlier and increased use of
component therapy. For example, using a strategy of 1:1:1 RBCs to FFP to
platelets is thought to prevent dilutional coagulopathy.
2. Liumbruno and colleagues [42] provided detailed recommendations for
transfusion of FFP and platelets in a number of clinical settings.
3. Mitra et al. [43] reported increased initial survival in association with higher
FFP:RBC ratios. However, those authors also noted that this association is
difficult to interpret because of an inherent survival bias.
4. Sperry and colleagues [44] associated FFP:RBC ratios ≥1:1.5 with lower
mortality after massive transfusion. In a population of patients who had serious
blunt injury and required ≥8 units of RBCs, survival was better. However, the
risk of acute respiratory distress syndrome was also higher.
5. Though retrospective evidence supports the premise that survival increases
with more aggressive use of plasma and platelets in massive transfusion, only
recently (in 2015) was a large prospective randomized trial [45] published
comparing lower to higher ratios of FFP and platelets to RBCs. The results of
this study are described below in Section III.E.3, under massive transfusion.
TABLE 9.2 Fast facts: platelets from American Red Cross compendium [17]
B. Platelet therapy (Table 9.2)
1. General recommendations for platelet therapy stress that platelet transfusion
cannot be based simply on platelet count. In general, for major surgical
procedures or during massive transfusion (e.g., replacement of one or more
blood volumes), a platelet count of at least 50,000/μL is recommended [46]. A
standard dose of platelets for adults is approximately one unit per 10 kg body
weight. Transfusing six units of platelets harvested from whole blood increases
the platelet count by approximately 30,000/μL (Table 9.2) [17]. This “dose”
corresponds roughly with the number of platelets collected by apheresis from a
single donor. Platelets do not require crossmatching or ABO/Rh compatibility,
but some blood banks preferentially transfuse ABO- and Rh-compatible
platelets when feasible. When patients do not show the expected increase in
platelet counts, they may need HLA-matched units, as HLA antibodies in the
recipient are associated with platelet refractoriness. Since transfusion of
WBCs causes HLA incompatibility, some centers elect to leukoreduce
platelets.
2. Of all the major blood components, platelets are associated with the
highest risk and cost. The foremost major adverse outcome with platelet
transfusion is bacterial sepsis. One in 3,000 platelet concentrates may have
bacterial contamination, with 7 an estimated mortality from sepsis
occurring in between 1 in 17,000 and 1 in 61,000 transfusions [47].
a. Room temperature storage is the primary reason that platelets are more likely
to have bacterial growth than other blood components. Therefore, platelets are
routinely cultured before transfusion is allowed.
b. Newer methods of reducing bacterial contamination include pathogen
reduction technology with either a psoralen compound or riboflavin, followed
by treatment with UV light, which reduces risk for virtually all viral,
bacterial, and other pathogens (e.g., babesiosis, Zika virus). Pathogen
reduction, however, is not yet widespread, given that it was only FDA
approved in late 2014.
c. TRALI has been associated with platelet transfusion more than with other
blood components because TRALI reduction strategies have excluded women
from donating plasma, but not platelets, and women have a higher rate of HLA
antibodies owing to fetal blood exposure during childbirth.
3. As with RBCs, storage leads to changes in platelet structural and biochemical
properties over time. A recent study found no increase in short-term adverse
outcomes with increasing platelet storage time [48]. These authors and others
reviewed current challenges of maintaining adequate platelet inventory with the
limit of 5 days’ storage and also described platelet storage lesion and the
interesting controversy surrounding the proposed extension of platelet storage
to 7 days (e.g., the increased risk for bacterial contamination over time is well
described). Recently the FDA approved 7-day storage for platelets, but only if
a secondary test is used for rapid bacterial detection on the day of transfusion
[46,49].
TABLE 9.3 Fast facts: fresh plasma from American Red Cross compendium [17]
CLINICAL PEARL Platelets impose the highest risk and cost of all the blood
components. The primary risk is bacterial sepsis, which is increased relative to the
other blood components since platelets are stored at room temperature.
C. Fresh-frozen plasma (Table 9.3) [17]
1. FFP refers to human donor plasma that is separated and frozen at −18°C within
8 hours of collection; frozen plasma-24 (FP-24) refers to plasma separated and
frozen at −18°C within 24 hours of collection. FFP from a collection of whole
blood has a volume of approximately 300 mL and can be stored for up to 1
year. Both products contain necessary plasma coagulation factors that are
maintained after thawing and storage at 1° to 6°C for up to 5 days. In general,
the dose of FFP is 10 to 20 mL/kg [50]. FFP should be ABO compatible but
does not require crossmatching.
2. Excessive blood loss, coagulation factor consumption, and specific
deficiencies in coagulation factors are among a number of factors that can
lead to inadequate hemostasis and the need for an FFP transfusion,
particularly when specific factor concentrates are unavailable. In patients
who require massive transfusion, it is well recognized that the use of
crystalloids, colloids, and RBCs can lead to a dilutional coagulopathy, and that
this condition can potentially lead to disseminated intravascular coagulation. A
number of publications address limited adherence to published guidelines and
rational use of FFP transfusion [51]. When surgical bleeding is excessive, it
has been suggested that clinicians guide their FFP use and dosing by point-
of-care testing coagulation studies rather than by preset formulas (see also
Chapter 21).
3. Interestingly, Holland and Brooks [52] reported that FFP transfusion failed to
change the international normalized ratio (INR) in patients with a minimally
prolonged INR (<1.6); INR decreased only with treatment of the disease
causing the elevated INR.
4. Prophylactic use of FFP is not supported by evidence from good-quality RCTs.
Evidence indicates that prophylactic plasma for transfusion is not effective
across a range of clinical settings [51].
5. Although the INR test is routinely used to determine when FFP is given, the
INR was designed to follow anticoagulant dosing with vitamin K antagonist
drugs, and is likely too sensitive and inadequately specific to guide FFP dosing
accurately. For example, in our experience, until the INR is 2.0 or higher, the
thromboelastogram (TEG) will usually be normal, suggesting that coagulation
is unimpaired.
D. Cryoprecipitate (Table 9.4) [17]
1. When FFP is thawed for 24 hours at 1° to 6°C, high–molecular-weight proteins
separate out from the plasma; this precipitate can be frozen at −18°C for up to 1
year.
TABLE 9.4 Fast facts: cryoprecipitate, from American Red Cross compendium [17]
2. One bag of cryoprecipitate contains 10 to 15 mL of insoluble protein.

3. Cryoprecipitate contains Factors I (fibrinogen), VIII, and XIII, von Willebrand
Factor, fibronectin, and platelet microparticles.
4. Cryoprecipitate is most commonly used as a concentrated source of
fibrinogen, except in some European countries where fibrinogen concentrate is
approved (and preferred) to treat acquired fibrinogen deficiency [53]. In the
United States, fibrinogen concentrate is approved by the FDA only for
congenital, not acquired, deficiency.
5. Hypofibrinogenemia occurs in patients undergoing cardiac surgery, most often
in those with hemorrhage. In such patients, even a balanced ratio of RBCs,
FFP, and platelets will eventually result in fibrinogen deficiency, as FFP has
some fibrinogen, but not enough to maintain normal levels during massive
transfusions. Depending upon the weight of the recipient, 10 pooled units of
cryoprecipitate will increase plasma fibrinogen by 70 to 100 mg/dL [50,53].
6. Recent guidelines for treating hemorrhage suggest that fibrinogen levels be
maintained above 150 to 200 mg/dL. Ideally, viscoelastic point-of-care testing
is used to guide such therapies, focusing on clot strength (α-angle and maximum
amplitude).
E. Massive transfusion and component ratios
1. The formal definition of massive transfusion is one entire blood volume
replacement in a 24-hour time period. When a patient undergoes massive
transfusion or experiences any other large, rapid blood loss, it is important to
administer an optimal ratio of blood components to avoid dilutional
coagulopathy.
2. Given the complexity of cardiac surgery and extracorporeal support, the
incidence of massive transfusion is substantial, especially in tertiary referral
centers that perform revision cardiac surgeries, transplants, and extracorporeal
life support (ECMO).
3. Most studies in this area have been retrospective and focused on trauma
patients with active hemorrhage. These studies support using a high ratio of
plasma and platelets to RBCs in order to reconstitute a mixture similar to that
of whole blood. The recently completed PROPPR study showed that in
actively bleeding trauma patients, the primary outcomes of 24-hour and
30-day mortality were similar in the 1:1:1 and the 1:1:2 groups
(platelet:plasma:RBC ratios) [45]. However, early exsanguination, which
was the predominant cause of death, occurred less frequently in the 1:1:1
group. This secondary outcome suggests that a balanced ratio of components,
similar to whole blood, was efficacious in improving outcomes. Whether this
finding applies to massive hemorrhage in cardiac surgical patients is unclear,
as trauma patients may have unique characteristics. Nonetheless, many
providers will use a 1:1:1 ratio when transfusing one or more blood volumes
over a short period. Ideally, the ratio can be tailored based on laboratory
testing, including viscoelastic (TEG or rotational thromboelastometry
[ROTEM]) testing, to avoid coagulopathy.
IV. Blood conservation measures
A. Preoperative anemia management
1. Best practices for PBM include the diagnosis and treatment of
preoperative anemia with the goal of reducing the need for allogeneic
transfusion [54]. This type of care applies primarily to elective surgical
patients because there is insufficient time for medical treatment in urgent or
emergent cases, which are not infrequent in cardiac surgery.
2. For patients undergoing elective surgery, effective and specific treatments, such
as iron replacement for iron deficiency (either oral or intravenous), can make a
difference.
3. Erythropoietic stimulating agents (e.g., erythropoietin or darbepoetin) can also
be used to increase hemoglobin levels preoperatively [55], although the FDA
warnings for thrombotic events and promotion of tumor growth should be
considered when weighing the risks and benefits of such therapies.
4. One must rule out GI malignancy as the underlying cause of iron deficiency in
the anemia workup.
B. Antifibrinolytics
The use of lysine analogs, ε-aminocaproic acid (EACA) and tranexamic acid
(TXA), suppresses pathologic hyperfibrinolysis associated with CPB [56]. In a
2011 Cochrane review, Henry et al. [57] conducted a meta-analysis on
antifibrinolytic use that included 34 studies of TXA, 11 studies of EACA, and
6 trials comparing the two. The findings showed that TXA use was
associated with a 32% reduction in the need for allogeneic blood transfusion.
Those who received EACA had a 30% reduction. On average, patients who
received either TXA or EACA saw reductions in both intraoperative and
postoperative blood loss. Although both drugs are relatively inexpensive, TXA
costs approximately 10 times more for an equivalent dose. Neither drug has been
shown to increase thrombotic events, however TXA in high doses is associated
with increased risk for seizures [58]. These drugs have now replaced aprotinin
as the drugs of choice because aprotinin was removed from the US marketplace
in 2008 for safety concerns (increased mortality) after the BART trial [59].
Although controversial, in 2011 aprotinin was reintroduced and marketed across
Canada and Europe, after debate over the methods used to reclassify the primary
outcomes in the BART study.
CLINICAL PEARL Antifibrinolytic drugs are commonly used intraoperatively to
reduce bleeding and transfusion requirements in cardiac surgery patients. There is no
evidence that they are associated with increased venous thromboembolic events.
C. Acute normovolemic hemodilution (ANH)
1. For ANH, a certain amount of blood is withdrawn from a patient before
heparinization and CPB, and the intravascular volume is replaced to maintain
isovolemia. The autologous whole blood is then readministered, usually after
CPB. The use of ANH reduces requirements for allogeneic transfusion by
preserving RBCs, coagulation factors, and platelets and improving perfusion
during CPB by decreasing blood viscosity [60].
2. Barile et al. [61] conducted a meta-analysis of 29 RCTs that included 2,439
patients to compare the use of ANH with standard intraoperative care.
They assessed the number of allogeneic RBC units transfused, rate of
perioperative transfusion, and estimated total blood loss. They found that
ANH reduced the number of allogeneic RBC units used, the incidence of
transfusion, and the amount of bleeding.
3. ANH is associated with reduced allogeneic transfusion, most notably when
associated with >800 mL of ANH phlebotomy. In a multicenter,
observational study of over 13,000 patients [62], researchers found that at all
volumes of ANH, the number of allogeneic transfusions was reduced. Perhaps
unsurprisingly, this reduction became more pronounced with increased ANH
volume removal. They also noted a lower rate of plasma and platelet
transfusion in those who had ANH, as well as less acute kidney injury and
lower rates of prolonged length of stay.
4. In a retrospective study that included 2,058 patients, Zhou et al. [63] found that
even those who underwent low-volume ANH (5 to 8 mL/kg) required
significantly fewer RBC units intraoperatively. This reduction did not carry
over to a reduction in FFP or platelet transfusions, postoperative or total
perioperative allogeneic transfusions, or significant difference in postoperative
outcomes.
5. Other studies have not demonstrated a reduction in transfusion requirements
with ANH [64,65]. It is also important to note potential confounding variables.
For example, patients who undergo ANH tend to be younger and male, have a
larger body surface area, have less preoperative anemia, and have lower STS
mortality scores.
6. In the 2011 STS guidelines on perioperative blood transfusion and
conservation in cardiac surgery, the evidence supporting ANH was considered
class IIb. Accordingly, the guidelines indicated that ANH could be considered
as part of a multipronged approach to blood conservation [4].
D. Methods used by perfusionists
1. Cell salvage
a. Cell salvage is a technique in which whole blood from a patient is centrifuged
to collect platelets and other clotting factors into the cell-washing supernatant.
b. Dr. Denton Cooley [66] first described salvage of autologous blood during
cardiac surgery in the 1960s.
c. Modern day cell salvage has been used since the early 1980s in cardiac
surgery as a method to reduce transfusion of allogeneic blood products.
d. Numerous RCTs have examined whether cell salvage decreases the risk of
allogeneic blood product transfusion. In one meta-analysis, Wang et al. [ 67]
investigated 31 RCTs and found that the use of cell salvage significantly
reduced the odds of any allogeneic blood product transfusion (OR, 0.63; 95%
CI, 0.43 to 0.94; P = 0.02) compared with no cell salvage. There has been
concern that removal of platelets and clotting factors during cell salvage could
increase the risk of a cardiac surgical patient requiring transfusion of these
products. However, Wang et al. [ 67] discovered that the mean units of FFP (P
= 0.18) and platelets (P = 0.26) transfused did not differ significantly between
those who did and did not receive cell salvage. Similarly, a Cochrane
review in 2010 found that the risk of allogeneic blood transfusion was
reduced by an average of 34% in cardiac surgical patients who received
cell salvage [68]. In addition, the use of cell salvage saved an average of
one RBC unit per patient.
e. Cell salvage has become a standard of care in cardiac surgery owing to the
recent emphasis on blood conservation. In addition, salvaged RBCs may be
higher in quality than stored (banked) RBCs. Compared with banked RBCs,
salvaged blood has normal levels of 2,3-DPG, no left shift in the hemoglobin–
oxygen saturation curve, and better cell membrane deformability [31,69].
2. Modified ultrafiltration
a. Membrane oxygenators activate the coagulation cascade, dilute platelets and
clotting factors, and induce fibrinolysis and systemic inflammatory response
syndrome. Various studies have attempted to mitigate these risks with a
technique known as modified ultrafiltration (MUF), which has been shown to
reduce postoperative blood loss and blood product utilization.
b. MUF involves use of a hydrostatic pressure gradient to remove water and
some low–molecular-weight substances from plasma, producing protein-rich
whole blood to be returned to the patient after the cessation of CPB. When this
technique is used during CPB, it is considered conventional ultrafiltration, or
zero-balance ultrafiltration (Z-BUF). The ultrafiltration occurs on the arterial
side of the pump after blood has been pressurized by the roller pump and gone
through the oxygenator membrane. The outlet is connected to the patient’s
venous line as blood reenters the patient’s right atrium after passing through
the hemofilter.
c. MUF was created by pediatric cardiac surgeons who were attempting to
reduce the hemodilutional effects of CPB, which are particularly pronounced
in children but also occur in adults. In a meta-analysis that compared MUF
to no ultrafiltration, Boodhwani et al. [70] demonstrated that MUF
significantly reduced transfusion requirements. In a prospective
randomized trial of 573 patients, Luciani et al. [71] found not only that the
mean volume of RBCs transfused for each patient was lower but also that the
proportion of patients who did not receive any blood products was higher
with MUF (51.8% vs. 38.1%, P = 0.001).
d. MUF is a blood conservation strategy that is likely underutilized in adults and
has become the standard of care for pediatric cardiac surgical patients.
3. Zero-balance ultrafiltration
a. For Z-BUF, or conventional ultrafiltration, ultrafiltration occurs during CPB,
and the ultrafiltrate is replaced with an equal volume of balanced electrolyte
solution. The Z-BUF filter unit is connected to the CPB pump, takes blood
from a premembrane port, and runs in parallel to the main cardiopulmonary
circuit. To prevent patient blood flow from dropping, the arterial pump rate is
increased to compensate for the blood flow through the hemofilter.
b. The main theoretical advantage is that Z-BUF can be used to reduce the
inflammatory mediators that are activated when blood contacts a foreign
surface. Thus, this technique might decrease lung injury, neurologic
inflammation, bleeding, and acute kidney injury, as well as other indicators of
morbidity. A recent meta-analysis of RCTs showed no significant difference
in ICU length of stay, duration of ventilation, chest tube output, and other
parameters between patients who received Z-BUF and those who received no
hemofiltration [72].
4. Low-volume CPB circuits
a. Smaller-diameter and shorter-length tubing as well as low-volume
oxygenators can reduce the hemodilution that occurs when patients are placed
on CPB.
b. Such low-volume circuits result in blood conservation and can reduce
transfusion requirements.
5. Retrograde autologous prime
a. By using the patient’s own venous blood to prime the CPB circuit by
retrograde flow, a reduction in hemodilution can be achieved, resulting in less
anemia and transfusion requirements.
CLINICAL PEARL Perfusionists play a prominent role in achieving blood
conservation in cardiac surgery patients. There are several methods they can employ to
reduce the incidence of anemia and transfusion.
E. Viscoelastic testing
a. TEG and ROTEM are viscoelastic hemostatic assays that are used to
assess whole blood clot formation: initiation, propagation, strength, and
dissolution. The diagnosis of a specific cause of coagulopathic bleeding
allows for targeted hemostatic correction, and potentially prevents the use
of unwarranted blood products. Early utilization of TEG and ROTEM
(while the patient is still on CPB), allows for prompt decision making
about FFP, platelets, and cryoprecipitate transfusions.
b. Transfusion algorithms that use TEG and ROTEM parameters have
been shown to reduce transfusion requirements in cardiac surgery
[73,74]. One of the first prospective, randomized trials to compare the
algorithmic use of TEG (n = 53) and standard routine laboratory testing (n
= 52) showed that, although intraoperative transfusion rates did not differ
significantly, the TEG group had fewer postoperative and total transfusions
[73]. Early and specific identification of hemostasis abnormalities by TEG
might have enabled physicians to proactively improve hemostasis.
c. More recent studies have continued to show that TEG/ROTEM reduces the
need for transfusion, but also potentially correlates with a reduced
mortality [75]. Conventional viscoelastic testing methods are unable to
detect the effect of antiplatelet medications (P2Y12 inhibitors or aspirin)
on platelet function. Though controversial and arguably lacking sufficient
evidence, the use of point-of-care platelet function tests or platelet
mapping has been suggested as an additional modality to assess platelet
dysfunction caused by antiplatelet agents and CPB [76,77]. Corredor et al.
[78] examined whether the various point-of-care platelet function tests
predicted blood loss and/or blood product utilization after cardiac surgery,
and whether this testing along with blood management algorithms
(TEG/ROTEM) leads to improved patient outcomes. The authors found
that platelet mapping use within a blood transfusion algorithm resulted in a
significant reduction in bleeding at longest follow-up, and reduced
transfusion of RBCs and FFP. Additional large, randomized trials are
needed to confirm these results.
V. Conclusion
Although transfusion is a necessary treatment strategy for selected patients, it is
associated with a number of morbidity risks, as is anemia. Recent work suggests
moving from the current blood banking, “supply-centric” perspective to a “patient-
centric” blood management approach. Implementation of institutional PBM
protocols enhances practitioners’ knowledge base and the consistency of
transfusion practices while encouraging a more restrictive approach to blood
utilization.
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III
Anesthetic Management for Specific
Disorders and Procedures
10 Anesthetic Management of Myocardial
Revascularization
Michael S. Green, Gary Okum, and Jay C. Horrow
I. Introduction
A. Prevalence and economic impact of coronary artery disease
B. Symptoms and progression of coronary artery disease
C. Historical perspective of
coronary artery bypass grafting (CABG)
D. Evaluating risk of morbidity and mortality for CABG surgery
II. Myocardial oxygen supply
A. Introduction
B. Coronary artery anatomy
C. Determinants of myocardial oxygen supply
III. Myocardial oxygen demand
A. Heart rate
B. Contractility
C. Wall stress
D. Summary
IV. Monitoring for myocardial ischemia
A. Introduction
B. Electrocardiogram (ECG) monitoring
C. Pulmonary artery (PA) pressure monitoring
D. Transesophageal echocardiography (TEE)
V. Anesthetic effects on myocardial oxygen supply and demand
A. Intravenous nonopioid agents
B. Volatile agents
C. Nitrous oxide
D. Opioids
E. Muscle relaxants
F. Summary
VI. Anesthetic approach for myocardial revascularization procedures
A. Fast-track cardiac anesthesia
B. Off-bypass revascularization
C. Regional anesthesia adjuncts
D. Special circumstances
VII. Causes and treatment of perioperative myocardial ischemia
A. Causes of ischemia in the prebypass period
B. Causes of ischemia during bypass
C. Causes of ischemia in the postbypass period
D. Treatment of myocardial ischemia
VIII. Anesthesia for hybrid cardiac procedures
A. Impetus for hybrid facilities
B. Hybrid room design considerations
C. Rationale for hybrid procedures
D. Indications for hybrid CABG
E. Anesthetic implications
KEY POINTS
1. Supply of oxygen to the myocardium is determined by arterial

oxygen content of blood and coronary blood flow (CBF).
2. The three main determinants of myocardial oxygen demand are
heart rate, contractility, and wall stress.
3. A doubling of heart rate more than doubles the myocardial oxygen
demand owing to an associated small increase in contractility.
4. Wall stress varies directly with pressure and radius and inversely
with wall thickness.
5. Regional wall-motion abnormalities (RWMAs) occur <1 minute
after onset of ischemia, before electrocardiogram (ECG) changes.
6. Although off-pump, compared to on-pump coronary artery
bypass grafting (CABG), makes no difference in mortality and
quality of life, it associates with shorter durations of mechanical
ventilation and of hospital stay, and with less morbidity.
7. Myocardial ischemia can occur at any time during CABG: before,
during, and after bypass.
8. A brief, intentional period of myocardial ischemia
(“preconditioning”) may protect against the damage caused by
subsequent prolonged ischemia and tissue reperfusion.
9. Hybrid operating rooms (OR) incorporate catheterization facilities;
they allow a surgical approach to the left anterior descending (LAD)
artery combined with a noninvasive approach to other vessels.
I. Introduction
A. Prevalence and economic impact of coronary artery disease
Despite declining rates in the last several decades, coronary heart disease
remains the leading cause of death in the United States, with the prevalence of
16.5 million for an angina pectoris or myocardial infarction diagnosis in 2017
[1].
Cardiovascular disease consumes almost 17% of health care spending on
major illness in the United States, with recently estimated expenditures at $317
billion [2], and nearly a fifth of disability disbursements from the Social Security
Administration [1].
B. Symptoms and progression of coronary artery disease
Unlike valvular heart disease, coronary artery disease presents with symptoms
that are more variable and progress with more sudden, discrete events such as
angina or myocardial infarction. Angina pectoris precedes only 18% of
myocardial infarctions [1]. Many patients who have silent ischemia require
diligence for detection and prompt treatment perioperatively.
C. Historical perspective of coronary artery bypass grafting (CABG)
Early unsuccessful or suboptimal attempts at myocardial revascularization took
place before the 1960s. The first successful attempt at myocardial
revascularization occurred in 1967, when Favalaro and Effler at the Cleveland
Clinic performed reversed saphenous vein bypass grafting procedures. In 1968,
Green anastomosed the internal mammary artery (IMA) directly to a coronary
artery. IMA grafting enjoyed a resurgence of interest in the late 1970s and early
1980s following demonstration of higher graft patency rates and better long-term
survival compared to vein grafts. During these decades, high-dose fentanyl
anesthesia largely supplanted morphine-based and inhalation-based techniques,
allowing operation on more fragile patients at the expense of many hours of
mechanical ventilation after operation.
The 1990s ushered in an interest in enhanced recovery (“fast-track”) cardiac
surgery, accompanied by bypass-sparing myocardial stabilization devices,
“keyhole” surgery, limited sternotomy incisions, and improvements in clinical
outcome [3]. By 2000, transesophageal echocardiography (TEE) had established
a role for monitoring ischemia during coronary revascularization as an adjunct to
the electrocardiogram (ECG) and pulmonary arterial (PA) catheter; by 2015, it
had replaced the PA catheter for many applications.
From 2005 to 2015, refinement of drug-eluting intracoronary stents and
invention of potent antiplatelet drugs reduced the risk of stent thrombosis,
resulting in sharp declines in the number of coronary artery operative
procedures. Only in recent years have operation numbers recovered, now
applied to patients with anatomy too complex for single or multivessel stents.
D. Evaluating risk of morbidity and mortality for CABG surgery
1. Risk factor models. Risk stratification tools differ in the weights assigned to
individual factors, and in the factors considered for inclusion in a model of
increased perioperative morbidity or mortality. Among the reported models,
poor left ventricular (LV) function, including a history of congestive heart
failure or LV ejection fraction less than 30%, advanced age, obesity,
emergency surgery, concomitant valve surgery, prior cardiac surgery, history of
diabetes, and history of renal failure feature prominently [4,5]. Some reports
also link these factors to increased length of stay and increased hospital costs.
Table 10.1 presents several risk stratification tools.
TABLE 10.1 Risk factor inclusion in various risk stratification models for coronary artery
bypass grafting (CABG)
2. Model evaluation. No model can completely capture the risk of caring for
sicker patients. The American College of Cardiology/American Heart
Association (ACC/AHA) assigns a level IIA recommendation (level of
evidence C) to the use of models for prediction of morbidity and mortality [6].
Some models do not allow for adequate flexibility concerning the dynamic
nature of patient physiology during the preoperative period. For example, a
patient’s LV ejection fraction at the time of cardiac catheterization will be used
in the evaluation process instead of that derived from TEE at the time of
surgery.
II. Myocardial oxygen supply
A. Introduction
The viability and function of the heart depend upon the relatively delicate
balance of oxygen supply and demand. The cardiac anesthesiologist can
manipulate these determinants perioperatively to benefit the patient. The
myocardium maximally extracts O2 from arterial blood at rest, with a coronary
sinus blood PO2 of 27 mm Hg, and saturation less than 50%. Upon exertion or
hemodynamic stress, the only way to increase O2 supply acutely to meet the
greater myocardial energy demand is by increasing the coronary blood flow
(CBF). When CBF does not increase sufficiently, anaerobic metabolism and
ischemia ensue. The following approach achieves the clinical goal of ensuring
that O2 supply at least matches demand:
1. Optimize the determinants of myocardial O2 supply and demand.
2. Select anesthetics and adjuvant agents and techniques according to their effects
on O2 supply and demand.
3. Monitor for ischemia to detect its occurrence early and intervene rapidly.
B. Coronary artery anatomy
1. Left main coronary artery. A thorough understanding of the coronary artery
anatomy and the distribution of myocardial blood flow allows an understanding
of the extent and degree of myocardium at risk for ischemia and infarction
during surgery. The blood supply to the myocardium derives from the aorta
through two main coronary arteries (see Fig. 10.1), the left and right coronary
arteries. The left main coronary artery extends for a short distance (0 to 40 mm)
before dividing, between the aorta and PA, into the left anterior descending
(LAD) artery and the circumflex coronary artery.
2. Left anterior descending coronary artery. The LAD coronary artery begins
as a continuation of the left main coronary artery and courses down the
interventricular groove, giving rise to the diagonal and septal branches. The
septal branches vary in number and size, and provide the predominant blood
supply to the interventricular septum. The septal branches also supply the
bundle branches and the Purkinje system. One to three diagonal branches of
variable size distribute blood to the anterolateral aspect of the heart. The LAD
artery usually terminates at the apex of the LV.
FIGURE 10.1 Two examples of possible left main “equivalency.” Two-vessel coronary disease with an occluded left anterior
descending coronary artery (LAD) and myocardium jeopardized by a right coronary artery (RCA) stenosis (A) or an occluded
RCA and myocardium jeopardized by a stenotic LAD (B). Cx, circumflex coronary artery; LCA, left coronary artery. Darker
shading indicates occlusion or severe stenosis. (From Hutter AM Jr. Is there a left main equivalent? Circulation.
1980;62(2):207–211, with permission.)
3. Circumflex coronary artery. The circumflex artery courses through the left
atrioventricular groove giving rise to one to three obtuse marginal branches,
which supply the lateral wall of the LV. In 15% of patients, the circumflex
artery gives rise to the posterior descending coronary artery (“left dominant”).
In 45% of patients, the sinus node artery arises from the circumflex distribution.
4. Right coronary artery (RCA). The RCA traverses the right atrioventricular
groove. It gives rise to acute marginal branches that supply the right anterior
wall of the right ventricle (RV). In approximately 85% of individuals, the RCA
gives rise to the posterior descending artery to supply the posterior inferior
aspect of the LV (right dominant system). Thus, in the majority of the
population, the RCA supplies a significant portion of blood flow to the LV,
while in the other 15% of the population, the posterior-inferior aspect of the LV
is supplied by the circumflex coronary artery (left dominant system) or both
right coronary and circumflex arteries (codominant system). The sinus node
artery arises from the RCA in 55% of patients. The atrioventricular node artery
derives from the dominant coronary artery and is responsible for blood supply
to the node, the bundle of His, and the proximal part of the bundle branches.
C. Determinants of myocardial oxygen supply
In broad terms, the supply of oxygen to the myocardium is determined by the
arterial oxygen 1 content of the blood and the blood flow in the coronary
arteries.
1. O2 content = (hemoglobin) (1.34) (% saturation) + (0.003) (PO2)
Maximal O2 content therefore involves having a high hemoglobin level, highly
saturated blood, and a high PO2, although a high PO2 is quantitatively less
important than a high O2 saturation. Normothermia, normal pH, and high levels
of 2,3-diphosphoglyceric acid all favor tissue release of O2.
2. Determinants of blood flow in normal coronary arteries. CBF varies directly
with the pressure differential across the coronary bed (coronary perfusion
pressure [CPP]) and inversely with coronary vascular resistance (CVR): CBF
= CPP/CVR. However, CBF is autoregulated (i.e., resistance varying directly
with perfusion pressure) so that flow is relatively independent of CPP between
50 and 150 mm Hg but is pressure dependent outside of this range. Metabolic,
autonomic, hormonal, and anatomic parameters alter CVR, and hydraulic
factors influence CPP. Coronary stenoses also increase CVR.
a. Control of CVR. Factors affecting CVR are outlined in Table 10.2.
(1) Metabolic factors. When increased coronary flow is required secondary
to increased myocardial workload, metabolic control factors are
primarily responsible. Hydrogen ion, CO2, lactate, and adenosine all
may play a role in metabolic regulation of CBF by inducing changes in
CVR [7].
TABLE 10.2 Control of coronary vascular resistance
(2) Autonomic nervous system. The coronary arteries and arterioles

possess α- and β-adrenergic receptors. In general, α1-receptors are
responsible for coronary vasoconstriction, whereas β-receptors mediate
a vasodilatory effect. α2-Receptors on endothelial cells and muscarinic
signaling appear to be involved in a nitric oxide–mediated decrease in
coronary vascular tone [8]. An increased population of α-receptors may
cause episodes of coronary spasm in individuals with nonobstructed
coronaries. α1-Mediated constriction of the coronary circulation may
counter some of the metabolic vasodilation, especially in the resting
basal state. However, under most circumstances such as increasing
demand or ischemia, metabolic control factors will override α-mediated
vasoconstriction.
(3) Hormonal factors. Two stress hormones, vasopressin (antidiuretic
hormone) and angiotensin, are potent coronary vasoconstrictors.
However, blood levels of these hormones during major stress may be
insufficient to produce significant coronary vasoconstriction.
Thromboxane participates in thrombosis and coronary vasospasm during
myocardial infarction. Prostaglandin I2 (PGI2) decreases coronary
vascular tone.
(4) Endothelial modulation. Nitric oxide triggers a cyclic guanosine
monophosphate (c-GMP)–mediated vasodilatory effect on vascular
smooth muscle, and may also contribute to vessel patency and blood
flow by inhibiting platelet adhesion. PGI2 and endothelium-derived
hyperpolarizing factor also cause relaxation of vascular smooth muscle.
(5) Anatomic factors
(a) Capillary/myocyte ratio. Only three- to four-fifths of available
myocardial capillaries function during normal conditions. During
exercise, episodes of hypoxia, or extreme myocardial O2 demand,
the additional unopened capillaries are recruited and increase
blood flow, causing a decrease in CVR and in diffusion distance of
O2 to a given myocyte. This adaptation, along with coronary
vasodilation, contributes to coronary vascular reserve.
(b) Coronary collaterals. Coronary collateral channels exist in the
human myocardium. Under most circumstances, they are
nonfunctional. However, in the presence of impeded CBF, these
coronary channels may enlarge over time and become functional.
(6) Other factors affecting CVR. CVR may be partly regulated by
myogenic control of vessel diameter, which dynamically responds to the
distending pressure inside the vessel. CVR increases with the increased
blood viscosity caused by high hematocrit or hypothermia. Thus,
hemodilution should accompany induced hypothermia. There is a
transmural gradient of vascular tone, with vascular resistance being
lower in the subendocardium than in the subepicardium [7].
b. Hydraulic factors and subendocardial blood flow
(1) LV subendocardial blood flow. Unlike CBF in the low-pressure RV
system, LV subendocardial blood flow is intermittent and occurs only
during diastole. Because of the increased intracavitary pressure and
excessive subendocardial myocyte shortening, subendocardial arterioles
are essentially closed during systole. Of the total LV coronary flow,
85% occurs during diastole and 15% occurs in systole (primarily in
the epicardial region). Thus, the majority of blood flow to the
epicardial and middle layers of the LV and all the blood flow to the
endocardium occur during diastole.
(2) Coronary perfusion pressure (CPP). CPP equals the arterial driving
pressure less the back-pressure to flow across the coronary bed. For the
LV, the driving pressure is the aortic blood pressure during diastole. The
back-pressure to flow depends on the area of myocardium under
consideration. Because the endocardium is the area most prone to
ischemia, attention focuses on its flow, and thus the usual formula for
CPP uses left ventricular end-diastolic pressure (LVEDP) as back-
pressure instead of right atrial pressure (RAP), despite the fact that most
coronary venous blood returns to the heart via the coronary sinus:
CPP = Aortic diastolic pressure – LVEDP
Because diastole shortens relative to systole as heart rate increases,
subendocardial blood flow is decreased at extremely rapid heart rates. Figure
10.2 demonstrates the total time per minute spent in diastole as a function of
heart rate. Elevations in LVEDP (e.g., heart failure, ischemia) also will
impede subendocardial blood flow. Thus, to optimize CPP, one should aim
for normal-to-high diastolic blood pressure, low LVEDP, and low heart
rate.
3. Determinants of myocardial blood flow in stenotic coronaries. In addition to
the physiologic determinants of myocardial blood flow in normal coronary
arteries, stenotic vessels add pathologic determinants of myocardial blood
flow. Stenoses locally increase CVR and decrease CBF, although ischemia-
induced arteriolar vasodilation decreases CVR downstream of stenosis in a
compensatory effort to maintain blood flow. Reduction in CBF in stenotic
vessels is a function of the length and degree of stenosis, presence or absence
of collaterals, pattern of stenosis, and presence of certain coexisting disease
states, such as diabetes mellitus and hypertension, which predispose to
microcirculatory pathology and ventricular hypertrophy, respectively.
FIGURE 10.2 Total time spent in diastole each minute is plotted as a function of heart rate in beats per minute. The reduction
in diastolic interval leads to diminished left ventricular (LV) blood flow as heart rate increases.
In particular, some patients present with a vasospastic component, which

may aggravate a fixed lesion or even create anginal symptoms in patients with
angiographically clear vessels.
a. Poiseuille’s law determines the hemodynamic significance of a coronary
obstruction in long (segmental) lesions. Given the same decrease in cross-
sectional area, a longer segmental stenosis of a coronary artery reduces flow
more than a short one.
b. Because CBF is reduced in proportion to the fourth power of the vessel
diameter, a 50% diameter decrease in lumen size decreases flow to 1/16th its
initial value, which is hemodynamically consistent with symptoms of angina
on exertion. A 75% reduction in diameter at angiography corresponds to a
greater than 98% reduction in flow, and corresponds clinically to symptoms
of angina at rest.
c. Sequential lesions in the same coronary artery impact coronary flow in an
additive fashion.
d. With longstanding coronary obstruction, collateral circulation often develops.
For low-grade obstructive lesions, these channels supply enough blood flow
to prevent ischemia. However, as the degree of coronary stenosis increases,
the collateral channels may not be adequate.
e. Certain patterns of stenoses have important clinical implications related to the
amount of myocardium supplied and placed in jeopardy by the stenotic
lesion(s). A left main coronary stenosis limits blood flow to a large amount of
the LV muscle mass. High-grade, very proximal stenotic lesions of both the
circumflex and LAD systems have the same physiologic implications as does
a left main stenosis. Prognostically, however, a left main stenosis is grimmer
because rupture of a single atheroma will compromise a larger amount of
myocardium. In addition, similar “left main equivalent” situations may exist
when a severely stenosed coronary provides collateral blood flow to a region
with a totally occluded vessel (Fig. 10.1). In addition to discrete focal and
segmental coronary lesions in graftable vessels, diffuse distal disease may
lessen the effectiveness of bypassing proximal coronary obstructions.
III. Myocardial oxygen demand
Direct measurement of myocardial oxygen demand is not feasible in the clinical
setting. The three major determinants of myocardial O2 demand are heart rate,
contractility, and wall stress.
A. 2 Heart rate
If a relatively fixed amount of O2 were consumed per heartbeat, one would
expect the O2 demand per minute to increase linearly with heart rate. Thus, a
doubling of heart rate would yield a doubling of O2 demand. In fact, demand
more than doubles with a twofold increase in 3 heart rate. The source of this
additional O2 demand is the staircase phenomenon, in which increased heart rate
causes a small increase in contractility and increases in contractility mean more
O2 consumed (see Section III.B below). As the functional impact of myocardial
ischemia is virtually immediate, the impact of heart rate is best considered in the
context of the balance between oxygen supply and demand per beat rather than
per minute, which underscores the importance of the simultaneous small increase
in O2 demand and substantial decrease in O2 supply associated with even a
modest increase in heart rate.
B. Contractility
More O2 is used by a highly contractile heart compared with a more relaxed
heart.
1. Quantitative assessment. Strictly defined, the contractile state of the heart is a
dynamic intrinsic characteristic that is not influenced by preload or afterload.
Previous attempts to measure contractility using physiologic variables include
the rate of rise of LV pressure, (dP/dt), and its value normalized to chamber
pressure ([dP/dt]/P). Neither succeeds. Clinically it is possible to quantify
dP/dt echocardiographically by measuring the rate of rise in the velocity of the
mitral regurgitant jet using Doppler technology. Unfortunately, loading
conditions and chamber compliance significantly affect the acceleration of the
mitral regurgitant jet. In addition, although mitral regurgitation frequently is
observed echocardiographically, it is not universally present. Contractility can
be approximated in a load-independent fashion using the slope of the end-
systolic pressure–volume relationships of a family of LV pressure–volume
loops. This method usually is not available in clinical settings.
FIGURE 10.3 Relationship of subendocardial O2 supply (represented by myocardial O2 tension) to reductions in coronary
blood flow (CBF). Demonstrated is the increased vulnerability of the subendocardial zone compared to the epicardial zone.
(Modified from Winbury MM, Howe BB. Stenosis: regional myocardial ischemia and reserve. In: Winbury MM, Abiko Y, eds.
Ischemic myocardium and antianginal drugs. New York: Raven; 1979:59.)
2. Qualitative measures. One can easily observe the contractile state of the heart
when the pericardium is open. Remember, though, that the RV is more easily
and most often viewed this way, whereas the LV is more obscured. TEE
provides a means for qualitative estimation of LV contractility. Clinically, we
infer good contractility when the arterial pressure tracing rises briskly.
However, the shape of the radial arterial tracing is heavily influenced by the
system’s resonant frequency, damping by air bubbles in the tubing, compliance
of the arterial tree, reflections of pressure waves from arterioles, and other
confounders.
3. Increased subendocardial myocyte shortening. Myocytes in the
subendocardial region undergo more shortening than those in other areas
because of geometric factors. Because they operate at a higher contractile state,
they have greater oxidative metabolism. Subendocardial vessels, already
maximally dilated, cannot respond to increased demand and intermittent
limitations of blood flow in the subendocardial region. Thus, myocardial O2
tension falls first here (Fig. 10.3), and this region is more susceptible to
ischemia.
C. Wall stress
The stress in the ventricular wall depends on the pressure in the ventricle during
contraction (afterload), the chamber size (preload), and the wall thickness. The
calculation for a sphere (which we shall assume for the shape of the ventricle,
for the sake of simplicity) comes from Laplace’s law:
4 Wall stress = Pressure × radius/(2 × wall thickness)
1. Chamber pressure. Oxygen demand increases with chamber pressure.
Doubling the pressure doubles the O2 demand. Systemic blood pressure usually
reflects the chamber pressure; thus, we equate systemic blood pressure with LV
afterload. The heart’s true afterload is more complex, because elastic and
inertial components also affect ejection. In aortic stenosis, however, the LV
experiences very high chamber pressures despite more modest systemic
pressures. The clinical goal is to keep afterload (and thus wall stress) low.
2. Chamber size. Doubling the ventricular volume increases the radius by only
26% (volume varies with the radius cubed). Thus, increased chamber size is
associated with more modest increases in O2 demand. Nevertheless, because
preload determines ventricular size, we desire a low preload to keep wall
stress (and thus O2 demand) low. Much of the benefit of nitroglycerin stems
from venodilation and its attendant decrease in preload.
TABLE 10.3 Regulation of O2 supply and demand
3. Wall thickness. A thicker wall means less stress over any part of the wall.
Ventricular hypertrophy serves to decrease wall stress, although the additional
tissue requires more O2 overall. Hypertrophy occurs in response to the
elevated afterload that occurs in chronic systemic hypertension or aortic
stenosis. Although wall thickness is essentially uncontrollable clinically, its
effects should be considered. LV aneurysms, seen after transmural infarction,
increase wall stress because of their effect on LV volume (radius) and reduced
wall thickness.
D. Summary
The factors that increase O2 demand are increases in heart rate, chamber size,
chamber pressure, and contractility. Table 10.3 and Figure 10.4 summarize the
myocardial supply and demand relationship. Note that tachycardia and increases
in LVEDP both lead to increased demand and decreased supply of oxygen.
IV. Monitoring for myocardial ischemia
A. Introduction
Typical monitoring for CABG surgery includes the standard American Society of
Anesthesiologists (ASA) monitors and invasive arterial blood pressure
monitoring. The most recent (2010) ASA/SCA practice guidelines recommend
that TEE be considered for all CABG patients unless probe placement is
contraindicated [9]. The use of PA catheters for routine CABG has become
variable. Detection and treatment of intraoperative ischemia is critically
important because intraoperative ischemia is an independent predictor of
postoperative myocardial infarction [10]. Only half of intraoperative ischemic
events can be related to a hemodynamic alteration and none can be detected by
the presence of angina in anesthetized patients. Reduced or negative lactate
extraction in a regional myocardial circulatory bed, while diagnostic of
ischemia, cannot be routinely measured. Thus, we seek clues that ischemia leaves
in its wake: changes on the ECG, PA pressure changes, and myocardial wall-
motion abnormalities.
CLINICAL PEARL Trends in physiologic variables often predict a patient’s status
better than absolute numbers.
B. Electrocardiogram (ECG) monitoring
1. Introduction. TEE detection of wall-motion abnormalities has not replaced
continuous multi-lead ECG monitoring as a standard monitor of intraoperative
ischemia. ECG monitoring is inexpensive, easy to use and read, can be
automated, and is available before and during the induction of anesthesia, when
the TEE probe is not in place, and may be carried through to the intensive care
unit (ICU) setting, where TEE monitoring is impractical. ECG changes are less
sensitive to ischemia: They occur later in the temporal cascade of events that
follow myocardial ischemia, especially with lesser degrees of coronary
supply/demand mismatch.
FIGURE 10.4 Summary of factors that affect myocardial oxygen supply and demand. (Adapted from Crystal GJ.
Cardiovascular physiology. In: Miller RD, ed. Atlas of anesthesia: vol. VIII. Cardiothoracic anesthesia. Philadelphia, PA:
Churchill Livingstone; 1999; 1:1, with permission.)
FIGURE 10.5 A: ST-segment depression, an indicator of subendocardial ischemia. B: Transmural ischemia, one cause of
ST-segment elevation, produces the pattern appearing in the lower tracing.
2. ST-segment analysis. Depression of the ST segment of the ECG denotes

endocardial ischemia, and elevation denotes transmural ischemia. ST-segment
changes occur at least 60 to 120 seconds after the start of ischemia. The
reference for the ST segment usually is taken as 80 ms after the J-point, which
is the end of the QRS wave (Fig. 10.5). Significant changes usually are defined
as 0.1 mV or 1 mm of ST-segment elevation or depression at normal gain. ECG
monitoring systems include automated real-time ST-segment analysis. Although
this feature constitutes a definite advance in the “human engineering” aspects of
ischemia monitoring, the machine is only as smart as the person interpreting its
data. Beware of intraventricular conduction delays, bundle branch blocks, and
ventricular pacing, all of which can render ST-segment analysis invalid. Check
the machine’s determination of where the ST segment occurs: 80 ms after the J-
point is not always appropriate.
a. Differential diagnosis of ST-segment changes. ST-segment elevation ( Fig.
10.5) may arise from the several causes of transmural ischemia
(atherosclerotic disease, coronary vasospasm, intracoronary air), or from
pericarditis or ventricular aneurysm. One also must consider improper lead
placement, particularly reversal of limb and leg leads, and improper selection
of electronic filtering. The diagnostic mode should always be chosen on
machines equipped with a diagnostic–monitor mode selection option.
3. T-wave changes. New T-wave alterations (flipped or flattened) may indicate
ischemia. These may not be detected by viewing the ST segment alone.
Likewise, pseudonormalization of the ST segment or T wave (an ischemic-
looking tracing in a patient without ischemia changing to a more normal-looking
one) may indicate a new onset of ischemia and should be treated appropriately.
4. Multi-lead ECG monitoring. Simultaneous observation of an inferior lead (II,
III, or aVF) and an anterior lead (V5: 5th intercostal space, anterior axillary
line) provides detection superior to single-lead monitoring, together detecting
approximately 90% of ischemic events. Ischemia limited to the posterior
segments of the LV is difficult to detect with standard ECG monitoring.
Modified chest leads may be necessary when the surgical incision precludes
usual placement.
C. Pulmonary artery (PA) pressure monitoring
1. General indications for a PA catheter for revascularization procedures. PA
catheters provide central delivery of infusions (typically via a side port
introducer or a proximal lumen in the catheter), measurement of blood
temperature and chamber pressures, and calculations of cardiac output,
vascular resistance, and RV ejection fraction (with special catheters equipped
with particularly fast thermistors). Some catheters also continuously measure
mixed venous oxygen saturation. Observational studies conclude that PA
catheterization does not affect outcome [11,12]. When clinicians were denied
intraoperative access to PA catheter data unless the situation met strict criteria,
access occurred in only 23% of patients, and management changed in fewer
than 9% of all cases [13]. Even if shown unnecessary for the intraoperative
management of routine coronary bypass surgery, PA catheters achieve utility
postoperatively, when TEE cannot be utilized.
2. Detection of ischemia: PA pressures. The absolute PA pressure is not
diagnostic of ischemia. Pulmonary hypertension, whether primary or secondary
to chronic ischemia, hypertension, or to valvular heart disease, is not
uncommon. PA pressures or pulmonary capillary occlusion pressures (PCWP)
commonly exceed upper levels of normal due to chronic obstructive pulmonary
disease (COPD), dependent catheter locations in the lung, or mitral stenosis,
making elevated PA and PCWP pressures less reliable in the diagnosis of
ischemia [14]. The shape of the transduced pressure waveform, however, is
more predictive. Appearance of a new V wave on the PCWP waveform
indicates functional mitral regurgitation, which is due to “new” ischemic
papillary muscle dysfunction. It may occur before or even in the absence of
ECG changes. However, detection of changes on the pulmonary capillary
occlusion waveform requires frequent balloon inflation (wedging), introducing
additional risk of vessel rupture. Often ischemia may be detected by a change
in the shape of the PA tracing, obviating the need for frequent wedging.
CLINICAL PEARL Look at the waveforms on the monitor first; if believable, then
look at the digital readouts.
D. Transesophageal echocardiography (TEE)
1. General indications for TEE during revascularization procedures. TEE can
assess ventricular preload and contractility, detect myocardial ischemia-
induced regional wall-motion abnormalities (RWMAs), evaluate the aortic
cannulation site, detect concomitant valve pathology, detect the presence and
pathophysiologic effect of pericardial effusion, aid the placement of intra-
aortic balloon catheters and coronary sinus catheters, and detect the presence of
ventricular aneurysms and ventricular septal defects. TEE has become an
invaluable clinical tool and has achieved routine intraoperative use during
CABG at most institutions. New RWMAs after bypass correlate with adverse
outcomes. See Chapter 5 for a detailed discussion of intraoperative TEE.
2. Detection of myocardial ischemia with TEE RWMAs
a. 5 Introduction. The heart develops abnormal motion less than 1 minute
following perfusion defects [15]. RWMAs resulting from myocardial
ischemia temporally precede both ECG and PAP changes. TEE
simultaneously interrogates regions of the heart representative of all three
major coronary arteries, including the posterior wall, which is not easily
monitored with ECG. This is most easily accomplished in the short-axis,
midpapillary muscle view. Some ischemia, confined to regions not visualized
with this view, will escape detection unless one performs a comprehensive
examination in multiple planes.
b. Limitations of monitoring RWMAs
(1) Tethering. Nonischemic tissue adjacent to ischemic tissue may move
abnormally because it is attached to poorly moving tissue, thus
exaggerating an RWMA.
(2) Pacing/bundle branch blocks. Abnormal ventricular depolarization
sequences not only affect ST-segment analysis (see Section IV.B.2), but
also alter wall motion, and can mimic RWMA.
(3) Interventricular septum. Normal septal motion depends on appropriate
ventricular loading conditions, the presence of pericardium, and normal
electrical conduction.
(4) Stunned myocardium. Adequately perfused myocardium may exhibit
RWMA if recovering from recent ischemia, thus prompting inappropriate
therapeutic intervention.
(5) Induction/ICU. TEE use is not practical during induction of anesthesia
or for continuous ICU monitoring.
CLINICAL PEARL Make observation of the surgical field and basic hemodynamics a
priority, especially when performing TEE intraoperatively.
(6) Diastolic LV filling patterns. Unfortunately, ventricular filling patterns
depend on ventricular loading conditions and the site of Doppler
interrogation within the ventricular inflow tract, limiting its utility as a
monitor for ischemia.
c. Intraoperative stress TEE. Low-dose dobutamine (2.5 μg/kg/min), when
administered for 3 to 5 minutes, improves coronary flow without significantly
affecting demand. The resultant myocardial energetics improve existing wall-
motion abnormalities. Demonstration of contractile reserve using
intraoperative stress echo then directs revascularization efforts to regions of
myocardium able to benefit from the additional blood supply.
d. Contrast echocardiography. Intracoronary injection of sonicated albumin
allows imaging of perfused myocardium, providing a tool to identify stunned
myocardium, thus avoiding needless therapeutic intervention. At present,
contrast agents are not approved by the U.S. Food and Drug Administration
for this indication. Routine clinical use awaits resolution of some technical
imaging issues. A microbubble contrast injection technique has also been
described [16].
e. Detection of infarction complications. TEE can detect complications of
ischemia/infarction such as acute mitral insufficiency, ventricular septal
defect, and pericardial effusion.
V. Anesthetic effects on myocardial oxygen supply and demand
Outcome studies in cardiac surgery fail to reveal an effect of particular anesthetic
agents [17,18]. Cardiac anesthesiologists, keenly aware of the impact of anesthetic
agents on myocardial oxygen supply/demand dynamics, effectively monitor for and
treat myocardial ischemia, thus accommodating for any such effects.
A. Intravenous nonopioid agents
1. Propofol. Propofol decreases systemic vascular resistance (SVR) and cardiac
contractility and increases heart rate.
2. Ketamine. Ketamine increases sympathetic tone, leading to increases in SVR,
filling pressures, contractility, and heart rate . Myocardial O2 demand
strongly increases, whereas O2 supply only slightly augments, thus producing
ischemia. However, a patient already maximally sympathetically stimulated
responds with decreased contractility and vasodilation. Ketamine is not
recommended for routine use in patients with ischemic heart disease. However,
it is sometimes used in patients with cardiac tamponade, because of its ability
to preserve heart rate, contractility, and SVR.
3. Etomidate. Induction doses of etomidate (0.2 to 0.3 mg/kg) do not alter heart
rate or cardiac output, although mild peripheral vasodilation may lower
blood pressure slightly. As such, it is an ideal drug for rapid induction of
anesthesia in patients with ischemic heart disease. Etomidate offers little
protection from the increases in heart rate and blood pressure that accompany
intubation. It is usually necessary to supplement etomidate with other agents
(e.g., opioids, benzodiazepines, volatile agents, β-blockers, and nitroglycerin)
in order to control the hemodynamic profile and prevent myocardial oxygen
supply/demand imbalance. An induction dose blocks adrenal steroidogenesis
for at least 6 hours.
4. Benzodiazepines. Midazolam (0.2 mg/kg) or diazepam (0.5 mg/kg) may be
used to induce anesthesia. Although both agents are compatible with the goal of
maintaining hemodynamic stability, blood pressure may decrease more with
midazolam due to more potent peripheral vasodilation. Negative inotropic
effects are inconsequential. Blood pressure and filling pressures decrease with
induction, whereas the heart rate remains essentially unchanged. Addition of
induction doses of a benzodiazepine to a moderate-dose opioid technique,
however, may result in profound peripheral vasodilation and hypotension.
5. α2-Adrenergic agonists. Centrally acting α2-adrenergic agonists result in a
reduction in stress-mediated neurohumoral responses, and therefore are
associated with decreases in heart rate and blood pressure [19]. These agents
typically are used during maintenance of anesthesia or postoperatively.
Preoperative oral clonidine reduces perioperative myocardial ischemia in
patients undergoing CABG surgery, but occasionally results in significant
intraoperative hypotension. Dexmedetomidine possesses greater α2-selectivity
than clonidine. Both agents have sedative and antinociceptive properties. Use
of α2-adrenergic agonists is associated with a reduced opioid requirement. In
addition, α2-adrenergic agonists do not cause respiratory depression.
B. Volatile agents
In general, volatile anesthetics decrease both O2 supply and demand. The net
effect on the myocardial supply/demand balance depends upon the hemodynamic
profile that prevails at the time of administration.
1. Heart rate. Sevoflurane has negligible effect on heart rate. Desflurane and
isoflurane often increase heart rate, although isoflurane decreases heart rate if
its associated decrease in SVR is not profound, if the carotid baroreceptor
function is impaired, or if the patient is fully β-blocked. In the steady state, the
cardiovascular actions of desflurane are similar to those of isoflurane.
However, during rapid desflurane induction without opioids, heart rate and
systemic and PA blood pressures may increase and require therapeutic
intervention.
Desflurane use for inhalation induction is unwise due to a significant increase
in heart rate, particularly with rapid escalation of the inspired concentration.
Junctional rhythms may occur with any volatile agent; they deprive the heart of
an atrial “kick,” leading to decreased stroke volume, cardiac output, and CBF,
offsetting the salubrious effects of low heart rate.
2. Contractility. All volatile anesthetics decrease contractility, lowering O 2
demand. However, isoflurane, desflurane, and sevoflurane cause less
depression than halothane or enflurane. In decompensated hearts, all volatile
anesthetics impair ventricular function.
3. Afterload. Decreases in cardiac output and SVR with volatile anesthesia result
in decreased systemic blood pressure. Venodilation and blunted contractility
account for the decrease in cardiac output. All volatile anesthetics vasodilate,
but SVR decreases least with halothane. Both O2 supply and O2 demand
decrease.
4. Preload. Volatile agents maintain filling pressures. Therefore, CPP (diastolic
aortic pressure minus LVEDP) may decrease during volatile anesthesia.
5. Coronary steal. A coronary “steal” phenomenon has been described in which
dilation of normal vascular beds diverts blood away from other beds that are
ischemic and thus maximally dilated. Steal-prone anatomy may exist in 23% of
the patients undergoing CABG [20]. Coronary steal has been observed in
canine models of steal-prone coronary anatomy with isoflurane administration
under circumstances in which collateral flow is pressure dependent. It is
doubtful that isoflurane-induced coronary steal is clinically significant in
patients undergoing coronary revascularization surgery as long as hypotension
and consequent pressure-dependent coronary artery perfusion are avoided.
Coronary steal has not been reported with halothane, enflurane, or desflurane.
6. Preconditioning. Volatile anesthetics may confer a degree of preconditioning-
like protective effect against ischemia–reperfusion injury in human myocardial
tissue [21] and reduce late cardiac events following cardiac surgery [22] (see
Section VII.D.6).
C. Nitrous oxide
The mild negative inotropic effects of nitrous oxide decrease contractility,
producing a reduction in both O2 supply and demand. Nitrous oxide inhibition of
norepinephrine uptake in the lung may explain the increased plasma
norepinephrine levels and associated increase in pulmonary vascular pressures
and resistance seen with nitrous oxide administration [23]. Adding nitrous oxide
to an opioid-oxygen anesthetic decreases SVR due, in part, to the removal of the
vasoconstrictive effects of 100% O2. The sympathomimetic effects of nitrous
oxide counterbalance any direct depression of contractility except in patients
with poor LV function in whom the myocardium already is highly stimulated
intrinsically.
If nitrous oxide is used in a technique that provides a “light” anesthetic that is
inadequate to cover attendant stimulation, increases in SVR and afterload ensue.
D. Opioids
1. Heart rate. All opioids except meperidine decrease heart rate by centrally
mediated vagotonia; meperidine has an atropine-like effect. The dose of drug
and speed of injection affect the degree of bradycardia. The result is decreased
O2 demand. By releasing histamine, morphine or meperidine may elicit a reflex
tachycardia that decreases O2 supply and increases O2 demand.
2. Contractility. Aside from meperidine, which decreases contractility, the
opioids have little effect on contractility in clinical doses.
3. Afterload. In compromised patients, who often depend on elevated sympathetic
tone to maintain cardiac output and systemic resistance, the loss of sympathetic
tone associated with opioid induction of anesthesia may result in a sudden drop
in blood pressure and consequent decreases in both O2 supply and demand.
Concomitant midazolam use augments the decreased SVR with opioid
induction.
4. Preload. Despite a lack of histamine-releasing properties, fentanyl and
sufentanil reduce preload when administered in either moderate (25 μg/kg for
fentanyl) or larger doses by decreasing intrinsic sympathetic tone. Oxygen
demand is decreased.
5. Hyperdynamic state. Following surgical incision and especially with
sternotomy, elevations of heart rate, blood pressure, and cardiac output with or
without decreased filling pressures are common during pure opioid-oxygen
anesthetic techniques in patients with good ventricular function. This high-
supply/high-demand state may be less preferable than the low-supply/low-
demand state achieved with volatile anesthetic agents. Additional opioid,
which often fails to treat the hypertension associated with a hyperdynamic
cardiac state, may decrease systemic blood pressure excessively when
hypertension originates from increased SVR alone.
E. Muscle relaxants
1. Succinylcholine. This drug may cause a variety of dysrhythmias (bradycardia,
tachycardia, extrasystoles), which negatively affect myocardial O2 balance,
although most often it is hemodynamically benign.
2. Pancuronium. Heart rate increases 20% when pancuronium accompanies a
volatile anesthetic, but effectively neutralizes the bradycardia that accompanies
a high-dose opioid technique. With declining use of high-dose opioid
techniques, many institutions have removed pancuronium from their
formularies, in favor of vecuronium, rocuronium, and cisatracurium.
3. Vecuronium. Vecuronium has a flat cardiovascular profile that is ideal with a
low- or moderate-dose opioid anesthetic supplemented by a volatile agent.
Bradycardia occurs when it accompanies the rapid injection of high doses of
the highly lipid-soluble opioids.
4. Rocuronium. Rocuronium’s mild vagolytic action is typically clinically
insignificant, and rocuronium administration does not cause significant
hemodynamic perturbations.
5. Cisatracurium. Cisatracurium lacks significant cardiovascular effects. The
majority of metabolism is via Hofmann elimination, with ester hydrolysis
making a minor contribution. Evidence supports faster neuromuscular recovery
with cisatracurium versus rocuronium or vecuronium in both adults and
children [24,25], although this difference is likely insignificant in view of the
duration of coronary artery procedures.
F. Summary
Pure volatile anesthesia provides a low-supply/low-demand environment. The
opioid-oxygen technique provides a high-supply/high-demand environment.
Success with either technique depends on maintaining proper balance, with O2
supply exceeding demand. Techniques utilizing modest doses of opioid with
propofol or low doses of volatile anesthetics are commonly used. These
techniques permit rapid recovery from anesthesia while requiring careful
attention to hemodynamic control to avoid intraoperative ischemia, and diligent
monitoring to detect and treat it.
VI. Anesthetic approach for myocardial revascularization procedures
A. Fast-track cardiac anesthesia is defined as techniques leading to early
endotracheal extubation, typically within 6 hours of completion of surgery.
1. Inclusion guidelines. Early fast-track initiatives excluded patients with obesity,
moderate-to-severe pulmonary disease, emergency operations, poor ventricular
function, combined procedures, re-operations, or advanced age—about 40% to
60% of surgical revascularization patients. Application to sicker and riskier
patients has progressed, so that most patients now have an opportunity for early
extubation, the exceptions usually being those with hemodynamic compromise,
intraoperative complications, or difficult airways [26].
2. Anesthetic management (Table 10.4)
a. Premedication. Long-acting agents are preferentially avoided. Same-day
admission patients have inadequate time for sedation with slow-onset agents.
Midazolam (0.03 to 0.07 mg/kg IV) usually suffices to allay anxiety.
b. Intraoperative anesthetic agent management
(1) Induction of anesthesia. Etomidate or propofol accomplishes induction.
Supplementation with a volatile agent or fentanyl (up to 7 µg/kg)
provides more stable hemodynamics for tracheal intubation. Esmolol or
nitroglycerin can prevent or treat a breakthrough hyperdynamic state.
Intrathecal or epidural analgesia, placed preoperatively, facilitates
recovery by decreasing the perioperative opioid requirements [27].
Regarding the potential for neuraxial hematoma formation, current
American Society of Regional Anesthesia and Pain Medicine (ASRA)
guidelines recommend 1 hour between needle insertion and
administration of IV heparin, an interval easily achieved in coronary
artery surgery [28]. Intrathecal lumbar injection of preservative-free
morphine 5 µg/kg via a 25 g or smaller needle is also quick, effective,
and appropriate for these patients already committed to postoperative
intensive care.
(2) Maintenance of anesthesia. Volatile agent supplementation limits the
total opioid dose to 10 to 15 μg/kg fentanyl (or its approximate
equivalent using sufentanil). The ultra–short-acting opioid remifentanil
provides good hemodynamic stability, adequate attenuation of the
neurohumoral stress response, and early awakening. However, a short
half-life and rapid tolerance necessitate substantial opioid administration
postoperatively. Reliance on a volatile agent can lead to a hyperdynamic
state during transport or upon ICU arrival, potentially prompting the use
of long-duration sedatives by the ICU staff.
TABLE 10.4 Typical fast-track cardiac anesthetic
α2-Agonists (e.g., dexmedetomidine and clonidine) are used

adjunctively to reduce the neurohumoral stress response and for their
sedative and antinociceptive properties. These agents reduce the
anesthetic requirement and thus facilitate more rapid emergence.
Further, a dexmedetomidine infusion can be continued postoperatively
without compromising early extubation, thus facilitating both ICU
transition and fast tracking.
c. Intraoperative awareness. Significant intraoperative awareness occurs in
0.3% of fast-track patients, similar to that observed in general surgery [29].
When using moderate doses of opioids, matching the depth of anesthesia to the
operative stimulus at different times will avoid harmful hemodynamic
responses; volatile agents provide this flexibility. A vaporizer attached to the
cardiopulmonary bypass (CPB) circuit facilitates appropriate anesthetic depth
during bypass with moderate hypothermia. The role of continuous processed
EEG monitoring such as bispectral index (BIS, Aspect Medical Systems,
Natick, MA, USA) remains unclear, although many centers have embraced its
use.
d. Temperature homeostasis. Early extubation is unwise in the hypothermic
patient: Arrhythmia, coagulopathy, shivering, and increased oxygen
consumption complicate postoperative care and delay discharge [30]. Fluid-
filled warming blankets and heated-humidified breathing circuits fail to
preserve heat in the face of the huge caloric deficits of cardiac surgical
patients who undergo moderate hypothermia (28° to 32°C) during CPB.
Intravenous (IV) fluid warmers can significantly attenuate core temperature
reduction during cardiac surgery if infused volumes are substantial [31]. The
CPB circuit heat exchanger provides the best means of restoring body
temperature. Prior to separation from CPB, targeting a PA blood temperature
greater than 37°C and a bladder temperature greater than 35°C reduces
hypothermic “rebound.” Forced hot-air convective warming helps during off-
bypass revascularization, despite the minimal body surface available.
Maintaining OR temperature as warm as can be reasonably tolerated by
operative personnel prevents heat loss.
e. Hemostasis. To prevent bleeding after operation, supplement scrupulous
surgical attention to hemostasis with pharmacologic hemostatic agents such as
aminocaproic acid or tranexamic acid (see Chapter 19). Many centers restrict
use of these agents to revascularization that involves CPB.
f. Intraoperative extubation. In the absence of ventricular impairment,
hemodynamic instability, hypothermia, or significant coagulopathy, one can
consider extubation in the OR prior to transport. One nonrandomized,
underpowered study claimed intraoperative extubation did not reduce ICU
length of stay [32]. With careful patient selection, immediate extubation offers
the potential for shorter ICU and hospital stays [33], although the benefit to
using this approach remains debatable. Strategic use of opioids at induction
and judicious use after sternal wiring enables adequate ventilation while
providing satisfactory analgesia. One technique combines intrathecal
morphine (300 to 500 μg) prior to an induction using sufentanil (150 to 250 μg
IV) with morphine (0 to 10 mg IV) at sternal reapposition. Rapid awakening
can be facilitated by substituting nitrous oxide or desflurane for isoflurane or
sevoflurane upon placement of sternal wires. With this technique, ICU
personnel must be willing to tolerate the mild to moderate respiratory
acidosis (PaCO2 up to 50 mm Hg) seen in patients with adequate opioid
analgesia immediately after extubation. Patients remaining intubated need
adequate sedation or anesthesia to last through the transport and for at least 30
minutes beyond in order to avoid hypertension, tachycardia, and coughing in
the semi-controlled environment of tangled access lines and rolling beds.
CLINICAL PEARL Plan ahead for tracheal extubation. When extubating in the OR titrate
analgesics in advance and prepare ICU staff to accept the mild respiratory acidosis
accompanies adequate analgesia.
IGURE 10.6 Early and late immediate postoperative complications seen in patients undergoing coronary revascularization.
ulm, pulmonary; ICU, intensive care unit. (Adapted from Higgins T. Pro: early endotracheal extubation is preferable to late
xtubation in patients following coronary artery surgery. J Cardiothorac Vasc Anesth. 1992;6(4):488–493.)
3. ICU management. A traditional fast-track approach requires sedation with a

relatively short-acting agent until the patient is ready for tracheal extubation,
ideally with an agent devoid of significant hemodynamic effect. For an
uncomplicated patient, tailor the level of sedation for extubation 4 to 6 hours
after arrival, during which time the patient recovers from myocardial stunning,
achieves normothermia, and demonstrates perioperative hemostasis (Fig. 10.6).
Propofol provides a smooth transition from intraoperative anesthesia to
postoperative sedation. It is easy to titrate, with quick onset and offset of
action, and minor hemodynamic effects at sedative doses. Supplemental
nitroglycerin, nitroprusside, or clevidipine infusions can titrate blood pressure
rapidly. Compared to low-dose morphine, sufentanil analgesia in the early ICU
period resulted in fewer and less severe ischemic events [34]. When
administered as a continuous infusion, dexmedetomidine, mimics natural sleep
and significantly reduces use of analgesics, β-blockers, antiemetics,
epinephrine, and diuretics [35]. Studies comparing the safety and efficacy of
dexmedetomidine and propofol for ICU sedation (including endpoints such as
analgesic requirement reduction and hemodynamic changes) fail to substantiate
the superiority of either approach [36,37], and show no difference in ventilator
weaning time [36].
CLINICAL PEARL Monitor hemodynamics continuously during transfer from the OR.
Actively treat important hemodynamic changes and pain during transfer.
4. Clinical and economic benefits
a. Clinical benefits of enhanced recovery. Early extubation may be associated
with reduced postoperative lung atelectasis and improved pulmonary shunt
fraction, and yields greater patient satisfaction as long as appropriate
analgesia is maintained. Positive-
pressure ventilation has deleterious effects on cardiac output and organ
perfusion that may be minimized by early extubation. Early chest tube removal
facilitates patient mobilization.
b. Economic benefits. Early extubation protocols reduce ICU and hospital
lengths of stay, and thus can reduce the cost of hospitalization by as much as
25% [37,38].
B. Off-bypass revascularization
Off-pump coronary artery bypass (OPCAB) utilizes venous or arterial conduits
to the coronary arteries via sternotomy but without CPB. See Section VI.D.2 for a
discussion of port access surgery and Section VI.D.3 for minimally invasive
direct coronary artery bypasses (MIDCAB).
1. Technique. Following sternotomy and anticoagulation, the surgeon places
distal anastomoses using myocardial stabilizers. With the heart continuing to
fill, beat, and contract, a section is immobilized sufficiently to permit vascular
sutures for distal anastomoses. If needed, an aortic side clamp permits
placement of proximal anastomoses. Reapproximation of the sternum and
layered closure complete the surgical procedure.
2. Advantages and Disadvantages
a. Graft patency. Randomized studies comparing OPCAB to conventional
CABG with CPB yield differing results [39,40] with respect to short- and
long-term graft patency. Grafts to the right coronary circulation appear more
likely to lose patency with 6 OPCAB. Outcomes over 6 to 8 years did not
differ between on pump versus OPCAB in an experienced center [41]. Most
available data from randomized controlled studies derive from patients with
expected mortality of 1% to 2%.
b. Level IA evidence-based criteria suggest that mortality and quality-of-life
markers do not differ, whereas the duration of ventilation, hospital length of
stay, and overall morbidity are decreased with OPCAB.
c. Somewhat weaker evidence supports decreased blood loss and transfusion
requirements, decreased myocardial enzyme release up to 24 hours, less renal
dysfunction, fewer coagulation abnormalities, and lower incidences of atrial
fibrillation and cognitive impairment with OPCAB [42].
d. Hemodynamic instability. During performance of circumflex or inferior
anastomoses (i.e., on the posterior surface of the heart), maintaining
hemodynamic stability may prove challenging despite frequent manipulation
of patient position, volume status, and vasopressors. This difficulty derives
from torsion of the heart or geometry incompatible with effective ejection.
Ventricular fibrillation may occur suddenly during this time.
3. Patient selection for OPCAB varies widely among institutions. Examples of
local criteria include:
a. Patients with anterior lesions only, thus limiting the risks of hemodynamic
compromise and potential subsequent graft occlusion associated with inferior
anastomoses.
b. Avoidance of CPB to minimize the risk for stroke and renal failure (i.e., for
those patients with large amounts of aortic plaque, severe vascular disease in
general, or with renal insufficiency).
c. None or all. Some surgeons choose to perform all CABGs as OPCABs, while
others consistently utilize CPB.
4. Preoperative assessment. More so than with conventional CABG, with
OPCAB knowledge of the intended placement of grafts and functional
myocardial reserve prepares the anesthesia team for the extent of physiologic
trespass and its expected impact on homeostasis.
a. Interruption of flow when grafting proximal coronary artery stenoses can
impact a large amount of myocardium.
b. Interruption of flow to vessels with high-grade lesions may have little impact
owing to formation of collateral circulation.
5. Monitoring for a given OPCAB patient should be at least as extensive as for
conventional CABG due to the added stress of cumulative myocardial ischemia
during vessel occlusion and grafting. Twisting or “flipping” the heart changes
its electrical axis, making it difficult to diagnose ischemia via ECG criteria,
and also thwarting acquisition of standard TEE images. Thermodilution will
still accurately measure cardiac output.
6. Fast-track criteria apply. See Section VI.A regarding choice of anesthetic
agents and techniques to facilitate early extubation, awakening, and safe
transfer from intensive care environments. Occasionally, an OPCAB case
converts to one using CPB; for this reason, some caregivers avoid techniques
they would not employ in the presence of full heparinization, such as epidural
anesthesia.
7. Temperature. Without the heat exchanger of the CPB machine to transfer
calories to the patient, temperature management focuses on prevention of heat
loss and use of forced air on available surfaces, even if only head and
shoulders. The so-called “second skin” underbody warming approaches can be
used as well. See Section VI.A.2.d for additional guidance.
8. Heparin management varies among institutions. Some target an ACT twice that
of baseline, as for noncoronary vascular surgery. Others aim for a minimum of
300 seconds, whereas some administer doses as they would for the conduct of
CPB. Protamine doses should aim to neutralize the heparin administered,
because bleeding with OPCAB remains nearly as much a threat to successful
surgery as it does with conventional CABG. However, CPB affects platelet
function adversely and activates the fibrinolytic system more than does
OPCAB.
9. Specific maneuvers to provide adequate hemodynamics.
a. Intravascular volume loading and head down tilt (modified Trendelenburg
position) augment preload to counter obstructed venous return from torqued or
flipped cardiac positioning during performance of distal anastomoses.
b. Vasoconstrictors or vasoconstricting inotropes (e.g., phenylephrine,
norepinephrine, epinephrine) likewise can maintain CPP and collateral flow
during vessel occlusion.
c. Controlled hypotension. When the surgeon sutures proximal anastomoses
using an aortic side clamp, systolic pressures less than 100 mm Hg will help
prevent aortic dissection. Vasodilators and volatile anesthetics plus
normovolemia and head-up tilt can facilitate this.
C. Regional anesthesia adjuncts
1. Intrathecal opioid. Placement of 300 to 500 μg of preservative-free morphine
via lumbar puncture immediately prior to induction of general anesthesia
provides lasting, preemptive analgesia. Larger doses increase the risks of
postoperative pruritus, nausea, and ventilatory depression peaking around 6 to
10 hours after administration. Minimize the possibility of neuraxial bleeding
and compression as follows:
a. Time the administration of heparin to occur at least 1 hour following puncture,
especially if blood returns in the spinal needle [28]. Some centers delay
operation by 24 hours if a large bore needle (e.g., 22 g or larger) has been
used.
b. Use a small gauge spinal needle—25 g or smaller.
c. Do not persist if identification of the intrathecal space proves difficult.
2. Epidural opioid and/or local anesthesia. After identifying the epidural space,
up to 5 mg of preservative-free morphine can provide preemptive analgesia.
Because the larger epidural needle increases the risk of bleeding and of
significant hematoma formation following heparin administration, most
practitioners avoid this approach.
3. Precautions. Potent antiplatelet therapy (e.g., clopidogrel, prasugrel,
ticagrelor) not halted at least 7 days before the day of surgery raises concern in
performing neuraxial procedures, as does a therapeutic INR (greater than 1.5)
from vitamin K antagonist therapy.
4. Neuraxial preemptive analgesia may facilitate early extubation by facilitating
adequate ventilation. Nevertheless, expect a patient breathing spontaneously
immediately after a very-early-extubation technique to have a PaCO2 as high as
50 mm Hg, which is similar to that of noncardiac surgical patients with
adequate opioid-based analgesia in the PACU.
D. Special circumstances
1. Radial artery conduits. Confirm before placing monitoring catheters whether
or not the surgeon intends to utilize this conduit, and if so, mark the operative
upper extremity clearly to avoid placing either intravenous or radial arterial
catheters there. Some protocols call for diltiazem infusions as prophylaxis
against arterial spasm in the radial graft; be aware of the accompanying
systemic vasodilation.
2. Port access surgery. This approach utilizes a small thoracotomy incision,
endoscopic instruments inserted through small ports, and TEE placement of
endovascular devices to facilitate CPB. This technique is more frequently
employed when valvular surgery is performed than coronary revascularization.
3. MIDCAB. An anterior thoracotomy incision permits access for harvesting of
the left IMA and its anastomosis to the LAD coronary artery without CPB.
Although this is technically a variation on OPCAB, typically it is called
MIDCAB.
4. Urgent coronary artery bypass surgery
a. Patient profile. Patients who present for urgent coronary artery bypass
surgery usually have ongoing ischemia, including actively infarcting tissue,
frequently with hemodynamic instability.
b. Induction and monitoring. If the patient’s condition requires rapid
establishment of CPB, utilize existing femoral catheters (from cardiac
catheterization laboratory) for monitoring and intravenous access rather than
delay surgery.
CLINICAL PEARL With active ischemia, time equals myocardium: Be flexible with
sequencing placement of arterial and other catheters with the induction of anesthesia and
surgical incision.
c. Anesthetic management. In the hypotensive patient, consider etomidate for
induction and potent longer-acting amnestics (e.g., lorazepam) as adjuncts.
Make every effort to institute CPB without delay.
5. Patients with poor ventricular function (ejection fraction less than 35%)
receive reduced or no premedication. Severe ventricular compromise may
require inotrope administration before induction. Popular induction techniques
employ etomidate or slow titration of opioids (150 to 250 μg fentanyl every 30
seconds).
6. Left main disease or its equivalent. These patients generally fare better with
a high-supply/high-demand anesthetic technique rather than a low-supply/low-
demand technique (see Section V.F). Maintain diastolic blood pressure during
induction and until revascularization is completed with the aid of phenylephrine
or other vasopressors to ensure adequate oxygen balance.
7. CABG for patients previously treated with antiplatelet medications.
Patients treated with potent antiplatelet agents (platelet glycoprotein receptor
antagonists, clopidogrel, prasugrel, ticagrelor, vorapaxar) are at risk for
significant coagulopathy and consequent bleeding. Empirical platelet infusions
can avoid catastrophic blood loss and high transfusion requirements.
8. CABG for patients with heparin-induced thrombocytopenia. See Chapter
21.
9. Redo CABG procedures. More bleeding, perioperative ischemia, infarction,
and pump failure accompany repeat operations. Adherence of the RV to the
sternum may result in sudden, extensive hemorrhage during surgical dissection.
Table 10.5 summarizes these special concerns, their causes, and appropriate
perioperative anesthetic management.
10. Concomitant acute ischemic mitral regurgitation arises from ischemic papillary
muscle dysfunction or ruptured chordae tendineae, with attendant hemodynamic
instability. Operation is nearly always urgent (see Section VI.D.4). The
accompanying tachycardia, high LVEDP, and increased contractility all worsen
myocardial oxygen supply/demand balance. Intra-aortic balloon
counterpulsation frequently stabilizes these patients sufficiently to permit
survival until the institution of CPB.
VII. Causes and treatment of perioperative myocardial ischemia (Table 10.6).
A. Causes of ischemia in the prebypass period
1. Specific high-risk anesthetic-surgical events. Events precipitating ischemia
in the 7 prebypass period include endotracheal intubation, surgical stress
(skin incision, sternal split), cannulation, and initiation of bypass [10].
Episodes of ischemia may occur during these high-risk events even in the
absence of hemodynamic changes [10].
2. Hemodynamic abnormalities. Some episodes of ischemia during high-risk
periods arise from hemodynamic abnormalities, especially tachycardia (greater
than 100 beats/min). Minimize hemodynamic alterations to prevent myocardial
ischemia. Intraoperative ischemia triples the likelihood of perioperative
infarction.
TABLE 10.5 Perioperative management of the myocardial revascularization reoperation
patient
3. Coronary spasm. Coronary artery spasm in a normal vessel or around an

atherosclerotic lesion causes ischemia. Intense sympathetic stimulation, light
levels of anesthesia, and surgical manipulation may theoretically trigger
coronary vasospasm.
4. Spontaneous thrombus formation. Atherosclerotic plaque rupture with
thrombus formation occludes coronary vessels. Although uncommon, this may
occur at any time, including in the operating room prior to revascularization.
B. Causes of ischemia during bypass
1. Periods without aortic cross-clamp. Hemodynamic alterations rarely lead to
ischemia during CPB. However, mechanical factors and ventricular fibrillation
can sharply decrease oxygen supply or increase its demand, respectively. Air
or microparticles (thrombus, plastic, and other foreign material) present in the
CPB circuit may embolize to the coronary circulation. Whenever the heart or
aorta is opened, air embolism to the native coronary circulation can occur.
TABLE 10.6 Causes of perioperative ischemia in the myocardial revascularization patient
2. During aortic cross-clamp. Ischemia occurs regardless of the myocardial

preservation technique. The potential for ischemic injury and subsequent
infarction increases with cross-clamp time, and varies with the techniques and
protective solutions used for myocardial preservation. Washout of cold
cardioplegic solution owing to excessive noncoronary collateral flow may lead
to ischemia. Electrical and mechanical quiescence during this period precludes
monitoring for ischemia.
3. After cross-clamp removal
a. Surgical and technical complications
(1) Inadvertent incision of the coronary artery back wall, leading to coronary
dissection
(2) Improper handling of the vein graft with endothelial cell loss, leading to
graft thrombus formation
(3) Twisting of vein grafts
(4) Faulty anastomosis of the vein graft to the coronary artery, including
(a) Suturing the artery closed while grafting or poor-quality
anastomoses
(b) Inadequate vein graft length, leading to stretching of the vein when
the heart is filled
(c) Excess length of vein graft, leading to vein kinking
b. Etiology of ST-segment elevation after cross-clamp removal. This arises
from residual electrophysiologic effects of cardioplegia, coronary artery air
or atheromatous debris embolus, or coronary artery spasm. Appearance in the
inferior leads (i.e., right coronary distribution) implicates air embolism,
because air seeks the high (anterior) location of the right coronary ostium.
Ventricular aneurysm and pericarditis also cause persistent ST-segment
elevations.
C. Causes of ischemia in the postbypass period
1. Incomplete revascularization
a. Ungraftable vessels. The region of myocardium supplied by the
unrevascularized stenotic vessel may develop ischemia after CPB because of
the added insult of ischemic arrest.
b. Diffuse distal disease. Revascularization rarely restores effective flow in this
scenario, which often occurs in chronic diabetes. Early vein graft closure
owing to poor runoff in the small distal vessels further complicates care.
c. Stress. Ischemia occurrence depends on attention to oxygen supply and
demand balance, rather than the degree of analgesia or sedation provided
[26,34]. This includes inappropriate inotrope use, including calcium, during
separation from CPB or thereafter.
2. Coronary spasm. Coronary artery spasm can occur in the postbypass period,
most commonly in right coronary arteries that are not diseased. Surgical
manipulation and exogenous and endogenous catecholamines can contribute to
this problem.
3. Mechanical factors. These include vein graft kinking or stretching, or
occlusion of IMA flow from overinflation of the lungs.
4. Thrombus formation. See Section VII.A.4. Postsurgical hypercoagulability
may contribute to clot formation.
D. Treatment of myocardial ischemia (Table 10.7)
1. Treatment of ischemia secondary to hemodynamic abnormalities
a. Increase or decrease anesthetic depth.
b. Administer vasodilators or vasopressors when SVR is either high or low,
respectively, assuming euvolemia.
c. Administer a β-blocker, specifically esmolol (for short half-life), to treat
tachycardia.
d. Use atrioventricular sequential pacing. Specifically in the postbypass period,
this can be extremely beneficial to improve rate, rhythm, and hemodynamic
stability.
TABLE 10.7 Treatment of ischemia
e. Use inotropes for ventricular failure, diagnosed by decreased cardiac output

and increased ventricular filling pressures. Pump failure leads to severe
decreases in CPP because diastolic blood pressure is decreased and LVEDP
is increased. Indiscriminate use of inotropes may aggravate ischemia.
Therefore, preload and heart rate and rhythm should be optimized before using
inotropes.
f. Especially if heparin has not yet been neutralized, consider resuming CPB for
a short period to facilitate myocardial recovery and/or to facilitate initiation
of circulatory support with an inotrope or intra-aortic balloon pump.
2. Correction of surgical complications and mechanical problems
a. Avoid overinflation of the lungs when an IMA graft is present.
b. Increasing systemic blood pressure with a vasoconstrictor such as
phenylephrine can push intracoronary air through the vasculature and restore
blood flow to regions not perfused because of the intravascular air lock.
3. Treatment of coronary spasm. IV nitroglycerin, diltiazem, and nicardipine
can treat coronary spasm. For specific doses of each drug for this indication,
refer to Chapter 2.
4. Specific pharmacologic treatment of ischemia. This treatment includes (a)
nitroglycerin, (b) β-blockers, and (c) calcium channel blockers. Prophylactic
IV nitroglycerin finds use after CPB in incompletely revascularized patients,
patients with severe distal coronary disease, and diabetic patients. Because
ischemia frequently occurs from thrombus formation on an atheroma, many
nonsurgical patients receive heparin as acute therapy and antiplatelet agents
(most commonly aspirin) for long-term prophylaxis. These agents should be
withheld after bypass until the threat of surgical hemorrhage ceases.
5. Mechanical support. Refer to Chapter 22 for a complete discussion of
circulatory assist devices.
a. Intra-aortic balloon pumps. Intra-aortic balloon counterpulsation increases
CPP and decreases LV afterload. Patients with impaired ventricular function
benefit from improved pump performance in addition to relief of ischemia.
b. RV and LV assist devices. These devices may be useful for treating severe
ischemia caused by myocardial failure or ischemia that led to myocardial
failure. Their use as treatment of ischemia is still in question.
6. Ischemic preconditioning is a technique that may be useful in protecting
against myocardial injury or stunning.
a. Myocardial injury. Tissue injury results from ischemia and subsequent tissue
reperfusion may involve a reduction in adenosine triphosphate (ATP) levels,
free oxygen radicals, calcium-mediated injury, nitric oxide, heat shock
proteins, a form of protein kinase C, mitogen-activated protein kinases, and
mitochondrial ATP-dependent potassium channels.
b. Preconditioning. A brief period of tissue ischemia may protect against the
damage 8 caused by subsequent prolonged ischemia and tissue reperfusion.
The benefit of this ischemic preconditioning occurs in both experimental
animals and humans. Endogenously produced adenosine may mediate
ischemic preconditioning via enhanced preservation of ATP, inhibition of
platelet and neutrophil-mediated inflammatory tissue injury, vasodilation, and
decreased basal cellular energy requirements related to intracellular
hyperpolarization [20].
c. Early versus late preconditioning. In experimental models, the early, classic
form of preconditioning lasts 2 to 3 hours after the ischemic event. Typically
the period of ischemia and subsequent period of reperfusion each last about
five minutes. Four such cycles (total 40 minutes) reduce infarct size from a
subsequent 40-minute ischemic period by 75%. The time required to
precondition for each anastomosis to mitigate sequelae from an anticipated 5
to 15 minutes of vessel occlusion creates logistic challenges in clinical
practice.
d. Role of inhalational anesthetics. Halothane, isoflurane, desflurane, and
sevoflurane decrease the deleterious effects of ischemia, in a manner similar
to ischemic preconditioning.
VIII. Anesthesia for hybrid cardiac procedures
A. Impetus for hybrid facilities
The majority of patients requiring coronary revascularization can now be treated
with nonsurgical interventions, thanks to advances in stent design, stent drug
elution, oral antiplatelet drug 9 therapy, and interventional access techniques.
However, anatomic and other technical factors still render complex lesions
better managed surgically. Many cardiac centers have hybrid operating rooms
combining space, lighting, monitoring, and supplies of a cardiac surgical suite
with that of an imaging-equipped interventional laboratory. These facilities
allow combined surgical anastomosis and catheter-based interventions without
moving the patient. Most typically, the LAD artery is revascularized surgically,
based on data indicating better patency, while other grafts may be individualized
either to surgical or catheter approaches based on patient-specific factors. These
hybrid facilities afford excellent anesthetizing conditions for transcatheter valve,
vascular endograft, electrophysiology, neurovascular, and other procedures, thus
justifying their cost to moderately sized institutions.
B. Hybrid room design considerations
1. Stakeholders. Planning a hybrid space requires involvement of all
stakeholders: anesthesiologists, cardiologists, nurses and nurse specialists,
radiologists, surgeons, perfusionists, and administrators.
2. Location. Placement depends on hospital geography. Anesthesiologists usually
prefer the facility in proximity to the main surgical suite, thus providing easy
access to backup equipment and resources, and often near cardiac intensive
care. However, local considerations may supervene.
3. Size. A hybrid room should be at least 1,600 sq ft to accommodate imaging
equipment, scrub area, and control room, as well as the number of people (up
to 20) who may participate in the procedure.
4. Special features. Floor reinforcements and additional lead shielding may be
required. The numerous personnel require many well-positioned auxiliary
monitors to view vital data. Positioning surgical lights amid imaging equipment
and monitors demands considerable design expertise (Fig. 10.7).
C. Rationale for hybrid procedures
1. The problem: Immediate graft failure. Hybrid procedures allow for
immediate correction of graft occlusion. Graft failure prior to discharge from
the hospital occurs in 5% to 20% of patients. These failures arise from vein
valves impeding flow, IMA dissections, vein graft kinking, or incorrect graft
placement. About 6% of grafts imaged immediately after surgery have issues
addressed by interventional techniques, minor adjustments, or surgical
revision.
2. Long-term results. A case-control study compared 141 consecutive hybrid
patients with disease not amenable to CABG alone or percutaneous coronary
intervention (PCI) alone to matched CABG and PCI cohorts. The hybrid
patients underwent LAD surgical grafting using the LIMA followed by PCI of
other lesions. At 3 years’ follow-up, repeat revascularization occurred in 6
hybrid, 3 CABG, and 18 PCI patients; and death in 1, 4, and 5 patients,
respectively [43]. The markedly different anatomic and physiologic states of
the cases relative to the selected controls limit clinical inference from this
study.
FIGURE 10.7 An example of a setup for a hybrid operating room. ARKS, anesthesia information system.
3. Other potential advantages include avoidance of aortic manipulation, fewer

transfusions, and especially compared to OPCAB, less hemodynamic
compromise.
D. Indications for hybrid CABG
The most recent ACC/AHA guidelines [ 44] give a Class IIA recommendation
(level of evidence B) for hybrid CABG in the following situations:
1. Limitations to traditional CABG, such as a heavily calcified proximal aorta or
poor surgical target vessels (but amenable to PCI).
2. Lack of suitable graft conduits.
3. Unfavorable LAD for PCI (excessive tortuosity or chronic occlusion).
E. Anesthetic implications
The working environment may pose a challenge to those accustomed to a
traditional cardiac operating room. This is especially true if the hybrid OR is not
located in proximity to the main cardiac ORs. Routine avoidance of a full median
sternotomy and the brief duration of bypass support early extubation, so the
anesthetic should be designed to allow for that.
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11 Anesthetic Management for the Surgical and
Interventional Treatment of Aortic Valvular Heart
Disease
Benjamin C. Tuck and Matthew M. Townsley
I. Introduction
II. Stenotic versus regurgitant lesions
A. Valvular stenosis
B. Valvular regurgitation
III. Structural and functional response to valvular heart disease
A. Cardiac remodeling
B. Ventricular function
IV. Pressure–volume loops
V. Aortic stenosis (AS)
A. Natural history
B. Pathophysiology
C. Preoperative evaluation and assessment of severity
D. Timing and type of intervention
E. Goals of intraoperative management
F. Postoperative care
VI. Hypertrophic cardiomyopathy (HCM)
A. Natural history
B. Pathophysiology
E. Goals of perioperative management
VII. Aortic regurgitation (AR)
A. Natural history
B. Pathophysiology
VIII. Mixed valvular lesions
A. AS and mitral stenosis
B. AS and mitral regurgitation (MR)
C. AS and AR
D. AR and MR
E. Multivalve surgical procedures
IX. Prosthetic valves
A. Essential characteristics
B. Types of prosthetic valves
C. Echocardiographic evaluation of prosthetic valves in the aortic position
X. Prophylaxis of bacterial endocarditis
KEY POINTS
1. All valvular lesions can potentially lead to changes in cardiac

loading conditions (i.e., volume and/or pressure overload) and a
well-planned anesthetic must compensate for this through the
manipulation of several hemodynamic variables. Most importantly,
these include heart rate and rhythm, preload, afterload, and cardiac
contractility.
2. During transcatheter aortic valve replacement (TAVR), there may be
periods of acute hemodynamic instability as a result of the device
occluding the already narrow valve, the creation of acute aortic
regurgitation (AR) during balloon valvuloplasty, massive bleeding
from dissection of major vasculature, damage to the left ventricle or
mitral valve, or acute occlusion of a coronary ostium.
3. Because atrial contraction contributes up to 40% of left ventricular
filling in patients with aortic stenosis (AS) and hypertrophic
cardiomyopathy (HCM), it is essential to maintain sinus rhythm and
treat arrhythmias aggressively in both of these conditions.
4. In patients with AS, the early use of α-adrenergic agonists, such as
phenylephrine, is indicated to prevent drops in blood pressure that
can quickly lead to severe hemodynamic compromise and cardiac
arrest.
5. The dynamic left ventricular outflow tract (LVOT) obstruction
caused by systolic anterior motion (SAM) of the mitral valve occurs
proximal to the aortic valve (i.e., subaortic) in mid-to-late systole.
The degree of obstruction is directly proportional to LV contractility
and inversely proportional to LV preload (end-diastolic volume)
and afterload. Specifically, decreases in systemic vascular resistance
(SVR) and preload, as well as increases in contractility and heart
rate will precipitate or worsen SAM/LVOT obstruction.
6. Patients with severe, acute AR are not capable of maintaining
sufficient forward stroke volume and often develop sudden and
severe dyspnea, hemodynamic instability, and deteriorate rapidly.
Patients with chronic AR may be asymptomatic for many years.
7. The hemodynamic requirements for combined AS and mitral
regurgitation (MR) are contradictory. Because AS will most
frequently lead to potential cardiovascular collapse, it should be
given priority when managing hemodynamic parameters.
I. Introduction
At most major cardiac centers, the surgical volume for valve procedures has
remained stable, and the management of patients with valvular heart disease
continues to evolve with advances in both catheter-based and surgical
interventions. This is especially true for aortic valve disease, as transcatheter
aortic valve replacement (TAVR) has revolutionized the surgical approach to
aortic stenosis (AS), which is the most common valve lesion in the United States.
The role of the anesthesiologist continues to evolve and expand with these
advancements as well. In particular, the less invasive nature of TAVR, as
compared to surgical aortic valve replacement (AVR), has changed the landscape
of patients presenting for AVR. The growing elderly population and/or those with
significant comorbidities, who would not previously have been operative
candidates, are now presenting for valve replacement at a growing rate. Thus, the
cardiac anesthesiologist is now increasingly called upon to provide care for a
more complicated and challenging patient population with aortic valve disease. In
addition, as experience with TAVR continues to grow, there may eventually be
further expansion of indications for this procedure into a younger and healthier
patient population. In fact, the PARTNER 3 trial is currently underway evaluating
the safety and effectiveness of the SAPIEN 3 (Edwards Lifesciences, Irvine,
California) transcatheter heart valve in low-risk patients with AS. Importantly,
advancements in the technology and experience with these catheter-based
techniques require modifications of the anesthetic technique as well, as many
centers are performing TAVR procedures with moderate anesthesia care or no
sedation at all. Clearly, this introduces a completely new set of considerations for
the safe and effective perioperative management of valve replacement in these
patients. As TAVR continues to evolve, however, open surgical AVR still remains
one of the most common cardiac surgical procedures performed at the present time.
Regardless of the procedural approach, the goal of aortic valve intervention is to
improve symptoms and/or survival, in addition to minimizing the risk of
complications such as irreversible ventricular dysfunction, stroke, pulmonary
hypertension, and dysrhythmias [1]. The anesthetic 1 management of aortic valve
disease is often quite challenging, as both AS and aortic regurgitation (AR)
frequently lead to pathophysiologic changes in the heart with profound
hemodynamic consequences. All valvular lesions can potentially lead to changes in
cardiac loading conditions (i.e., volume and/or pressure overload) and a well-
planned anesthetic must compensate for this through the manipulation of several
hemodynamic variables [2]. Most importantly, these include heart rate and rhythm,
preload, afterload, and cardiac contractility. In addition, it is essential to consider
the time course of the disease, as the clinical presentation and management
considerations will vary dramatically in the setting of acute versus chronic
valvular disorders.
This chapter will review the physiologic implications of both AS and AR and
the practical approach to the management of these patients. Additionally,
hypertrophic cardiomyopathy (HCM) will be discussed, as the hallmark of the
obstructive form of this condition is dynamic subaortic stenosis. A section
addressing prosthetic valves will conclude the chapter with a review of the most
common types of prostheses utilized for AVR.
A. Valvular stenosis. Stenotic lesions lead to pathology associated with pressure
overload. Narrowing of the orifice of a cardiac valve will ultimately lead to
obstruction of blood flow through the valve. This obstruction translates into an
increase in blood flow velocity as it approaches the stenotic valve orifice. The
pattern of blood flow is distinctly different in the regions proximal and distal to a
stenotic valve. The high-velocity flow proximal to the stenosis is laminar and
organized; while distal to the stenosis it becomes turbulent and disorganized. In
addition, the increased blood flow velocities observed in valvular stenosis
translate into an increase in the pressure gradient across the valve. The
simplified Bernoulli equation helps to explain this relationship. In this equation,
the pressure gradient through the stenotic valve can be estimated by multiplying
the peak velocity squared times four:
Pressure gradient (Δ) = 4 . Peak blood flow velocity (v) squared
squared times four:
(ΔP = 4v2)
The simplified Bernoulli equation allows blood flow velocities measured by
Doppler echocardiography to be converted into pressure gradients that can be
used to quantify the severity of valvular stenosis. It is also important to
understand that valvular obstruction can be of two primary types: fixed versus
dynamic. In fixed obstruction (i.e., true valvular AS, subaortic membrane), the
degree of obstruction to blood flow remains constant throughout the cardiac cycle
and is not affected by the loading conditions of the heart. With dynamic
obstruction (i.e., hypertrophic obstructive cardiomyopathy [HOCM] with
dynamic subaortic stenosis), obstruction is only present for part of the cardiac
cycle, primarily occurring in mid-to-late systole. The degree of obstruction is
highly dependent on loading conditions, changing in severity as loading
conditions change.
B. Valvular regurgitation. Regurgitant lesions lead to pathology associated with
volume overload, resulting in chamber dilatation and eccentric hypertrophy (wall
thickness increases in proportion to the increase in LV chamber size). Clinically,
although this chamber remodeling will initially allow the left ventricle (LV) to
compensate for the increased volume load, it will lead to an eventual decline in
LV systolic function that can ultimately lead to irreversible LV failure. Effective
perioperative management of valvular regurgitation is facilitated by
understanding how preload, afterload, and heart rate each affect the contributions
of the forward stroke volume (flow reaching the peripheral circulation) and
regurgitant stroke volume (retrograde flow back across the valve) to the overall
total stroke volume of the ventricle [3]. Hemodynamic management of these
patients should aim to optimize the forward stroke volume, while minimizing the
amount of regurgitant stroke volume.
The anesthetic management of patients undergoing aortic valve surgery requires a
thorough understanding of the hemodynamic changes associated with valvular heart
disease, as well as the cardiac remodeling imposed by an abnormal aortic valve.
A. Cardiac remodeling includes changes in the size, shape, and function of the heart
in response to an acute or chronic cardiac injury. In valvular heart disease,
cardiac injury is usually caused by alterations in ventricular loading conditions.
Depending on the nature of the valvular pathology, the ventricle will be subject
to either pressure or volume overload, or both. This leads to cardiac remodeling
in the form of chamber dilation and ventricular hypertrophy. In addition to
mechanical stress, cardiac remodeling results from the activation of
neurohumoral factors, enzymes such as angiotensin II, ion channels, and oxidative
stress [4]. Intended initially as an adaptive response to maintain cardiac
performance, remodeling eventually leads to decompensation and deterioration
in ventricular function. Ventricular hypertrophy is defined as increased LV mass.
Ventricular hypertrophy can be either concentric or eccentric. Pressure overload
usually results in concentric ventricular hypertrophy, which means that
ventricular mass is increased by myocardial thickening while ventricular volume
is not increased. Concentric versus eccentric hypertrophy can be determined
using echocardiography. LV mass index >95 g/m 2 for women and >115 g/m2 for
men defines hypertrophy. If relative wall thickness is >0.42, the hypertrophy is
concentric. If <0.42, the hypertrophy is eccentric. Concentric hypertrophy
reduces wall stress that results from the chronic pressure overload. Recall the
law of Laplace to understand how this compensatory hypertrophy results in
reduced wall stress, where:
AS is a fixed obstruction at the level of the aortic valve and causes increased
afterload for the LV, which increases the LV intracavitary pressure. The resultant
increase in LV wall stress is mitigated by the increased LV wall thickness as
demonstrated in the equation above. Concentric hypertrophy has the beneficial
effect of reducing LV wall stress and avoiding a significant decline in LV
systolic function. The cost of LV hypertrophy, however, is a reduction in LV
compliance, which leads to diastolic dysfunction with an increase in LV end-
diastolic pressure (LVEDP) and greater risk for subendocardial ischemia.
Volume overload, on the other hand, leads to eccentric hypertrophy, where the
increase in ventricular mass is associated with ventricular cavity dilatation. In
this scenario, myocardial thickness increases in proportion to the increase in
ventricular chamber radius.
B. Ventricular function. To anticipate the effect of valvular lesions on ventricular
function, it is helpful to separate ventricular function into its two distinct
components [2]:
1. Systolic function represents the ventricle’s ability to eject blood into the
systemic circulation.
a. Contractility can be defined as the intrinsic ability of the myocardium to
contract and generate force. Contractility itself is independent of preload and
afterload. Normal contractility means that a ventricle of normal size and
normal preload can generate sufficient stroke volume at rest and during
exercise.
b. Preload can be defined as the load placed on the myocardium before
contraction. This load results from a combination of diastolic volume and
filling pressure and can be expressed as end-diastolic wall stress.
c. Afterload is the load placed on the myocardium during contraction. This load
results from the combination of systolic volume and generated pressure and
can be expressed as end-systolic wall stress.
2. Diastolic function represents the ventricle’s ability to accept inflowing blood.
Diastolic function consists of a combination of relaxation and compliance. In
general, normal diastolic function means that the ventricle accepts normal
diastolic volume at normal filling pressure. When diastolic dysfunction occurs,
maintaining normal ventricular diastolic volume requires elevated ventricular
filling pressure. Both systolic and diastolic function require energy and can be
compromised by ventricular ischemia.
IV. Pressure–volume loops may be utilized to illustrate LV function and performance.
These loops are constructed by plotting ventricular pressure (y axis) versus
ventricular volume (x axis) over the course of a complete cardiac cycle (Fig.
11.1). The presence of valvular heart disease alters the normal pressure–volume
loop tracing, representing changes in ventricular physiology and loading conditions
imposed by valvular pathology. The ventricle adapts differently to each valvular
lesion, and characteristic patterns of the pressure–volume loop help to illustrate
these changes.
V. Aortic stenosis (AS)
A. Natural history
1. Etiology. The normal adult aortic valve has three cusps, with an aortic valve
area of 2.6 to 3.5 cm2, representing a normal aortic valve index of 2 cm2/m2.
AS may result from congenital or acquired valvular heart disease. Congenital
AS is classified as valvular, subvalvular, or supravalvular based on the
anatomic location of the stenotic lesion. Subvalvular and supravalvular aortic
stenoses are usually caused by a membrane or muscular band. Congenital
valvular AS may occur with a unicuspid, bicuspid, or a tricuspid aortic valve
with partial commissural fusion. Aortic valves with supernumerary cusps
(greater than 3 cusps) have also been reported.
FIGURE 11.1 Normal pressure–volume loop. The first segment of the ventricular pressure–volume loop (Phase 1) represents
diastolic filling of the left ventricle. The next two segments represent the two stages of ventricular systole: isovolumic
contraction (Phase 2) and ventricular ejection (Phase 3). The final segment of the loop corresponds to isovolumic relaxation of
the left ventricle, which precedes ventricular filling and the start of the next cardiac cycle. The isovolumic relaxation and
ventricular filling phases constitute the two phases of diastole. Both end-systolic volume at the time of aortic valve closure (AC)
and end-diastolic volume at the time of mitral valve closure (MC) are represented as distinct points on the loop. MO, mitral
valve opening; AO, aortic valve opening; LV, left ventricle. (Modified from Jackson JM, Thomas SJ, Lowenstein E. Anesthetic
management of patients with valvular heart disease. Semin Anesth. 1982;1:240.)
A congenitally bicuspid aortic valve occurs in approximately 1% to 2% of

the general population, making it the most common congenital valvular
malformation. Calcification of a congenitally bicuspid valve results in the early
onset of AS and represents the most common cause of AS among patients
younger than 70 years of age [5]. Estimates suggest that bicuspid aortic valve
disease accounts for approximately 50% of all valve replacements for AS in
the United States and Europe [6]. Commonly associated findings in patients
with bicuspid aortic valves include abnormalities of the aorta, including aortic
coarctation, aortic root dilatation, and an increased risk of aortic dissection.
Of the acquired aortic stenoses, senile degeneration is the most common
cause in the developed world. The fibrotic and calcific change that occurs in
the aortic valve prior to flow obstruction is known as aortic sclerosis, and the
incidence of this may be as high as 25% of individuals over the age of 65 years
and 50% of individuals over the age of 85. Epidemiologic data suggest that the
incidence of severe AS may be as high as 3.4% in individuals over the age of
75 in developed countries [7]. The calcification seen with senile degeneration
of the aortic valve also appears to have an inflammatory component as well,
similar to that observed with coronary artery disease (CAD) [2]. While
rheumatic AS is now rarely seen in the developed world, it remains an
important cause of AS in developing countries. However, senile calcific
disease is the most prevalent etiology of AS worldwide. Additionally,
rheumatic AS is usually associated with some degree of AR and frequently
affects the mitral valve as well. Less frequent causes of AS include
atherosclerosis, end-stage renal disease, and rheumatoid arthritis.
A characteristic finding of senile valvular degeneration is progression of the
calcification from the base of the valve toward the edge, as opposed to
rheumatic degeneration in which calcification spreads from the edge toward the
base.
2. Symptoms. Unicuspid AS often presents in infancy. Patients with rheumatic AS
may be asymptomatic for 40 years or more. Congenital bicuspid aortic valves
in the majority of cases must undergo calcific degeneration to become stenotic.
The time of onset and speed of progression of calcific degeneration vary from
patient to patient. This is why patients with congenitally bicuspid aortic valves
may develop symptomatic AS anytime between the ages of 15 and 65, and even
later in life. Degenerative stenosis of a tricuspid aortic valve usually develops
in the seventh or eighth decade of life. Asymptomatic patients with AS have an
excellent prognosis. Patients with even severe AS may stay asymptomatic for
many years and carry a small risk of sudden death, which does not exceed the
risk of operation. However, the onset of any one of the following triad of
symptoms is an ominous sign and indicates a life expectancy of less than 5
years:
a. Angina pectoris. Angina is the initial symptom in approximately two-thirds of
patients with severe AS. Angina and dyspnea secondary to AS alone initially
occur with exertion [8]. Life expectancy when angina develops is about 5
years.
b. Syncope. Syncope is the first symptom in 15% to 30% of patients. Once
syncope appears, the average life expectancy is 3 to 4 years.
c. Congestive heart failure. Once signs of LV failure occur, the average life
expectancy is only 1 to 2 years.
B. Pathophysiology
1. Heart remodeling. As stenosis progresses, the maintenance of normal stroke
volume is associated with an increasing systolic pressure gradient between the
LV and the aorta. The LV systolic pressure (LVSP) increases to as much as 300
mm Hg, whereas the aortic systolic pressure and stroke volume remain
relatively normal. This pressure gradient results in a compensatory concentric
LV hypertrophy. Occasionally, as stenosis progresses, eccentric LV
hypertrophy may develop and result in impaired LV systolic function.
2. Hemodynamic changes
a. Arterial pressure. In severe AS, the arterial pulse pressure usually is
reduced to less than 50 mm Hg. The systolic pressure rise is delayed with a
late peak and a prominent anacrotic notch. As stenosis increases in severity,
the anacrotic notch occurs lower in the ascending arterial pressure trace. The
dicrotic notch is relatively small or absent.
b. Pulmonary arterial wedge pressure. Because of the elevated LVEDP, which
stretches the mitral valve annulus, a prominent V wave can be observed, but
with progression of the disease and the development of left atrial hypertrophy,
a prominent A wave becomes the dominant feature.
3. Pressure–volume loop in aortic stenosis (Fig. 11.2)
FIGURE 11.2 Pressure–volume loop in aortic stenosis (AS). In comparison to the normal loop, note the elevated peak
systolic pressure necessary to generate a normal stroke volume in the face of the elevated pressure gradient through the aortic
valve. Also, end-diastolic pressure is elevated with a steeper diastolic slope, reflecting diastolic dysfunction with altered left
ventricular compliance. Phase 1, diastolic filling; phase 2, isovolumic contraction; phase 3, ventricular ejection; phase 4,
isovolumic relaxation. MO, mitral valve opening; MC, mitral valve closure; AO, aortic valve opening; AC, aortic valve closure;
LV, left ventricle. (Modified from Jackson JM, Thomas SJ, Lowenstein E. Anesthetic management of patients with valvular
heart disease. Semin Anesth. 1982;1:241.)
TABLE 11.1 Assessment of AS severity with echocardiography

1. Echocardiographic evaluation (Echocardiographic criteria—see Table
11.1)
Echocardiography is now the standard modality for quantifying the severity of
AS. With the exception of rare cases where echocardiography is nondiagnostic
or discrepant with clinical data, cardiac catheterization is no longer
recommended for this purpose. The most commonly utilized methods for
quantifying AS severity with echocardiography include measurement of the
peak blood flow velocity of the AS jet, mean gradient across the aortic valve,
and determination of aortic valve area. In AS, the valve area can be measured
by the direct planimetry and continuity equation methods. The pressure gradient
can be measured using a simplified Bernoulli equation (Fig. 11.3).
Transesophageal echocardiography (TEE) is particularly useful in patients
with poor transthoracic windows or in patients with complex cardiac pathology
(e.g., a combination of subaortic and valvular stenoses). It is also useful when
precise planimetry of the aortic valve area is necessary or when infective
endocarditis is suspected. Supplemental Videos 11.1 and 11.2 demonstrate
TEE images of a severely stenotic aortic valve, with both 2D imaging and
color flow Doppler.
FIGURE 11.3 Severe aortic stenosis (AS), showing determination of the aortic valve (AV) gradient using the Bernoulli
equation. This image displays a deep transgastric long-axis TEE view with a continuous wave Doppler beam aligned through
the left ventricular outflow tract (LVOT) and AV. Tracing 2 on the spectral display (outer traced envelope) represents blood
flow through the severely stenotic AV, with a mean velocity (AV Vmean) of 3.35 m/sec and mean AV pressure gradient (AV
mean PG) of 44.8 mm Hg. A mean PG ≥40 mm Hg is consistent with severe AS. (Reprinted with permission from Perrino AC,
Reeves ST, eds. A Practical Approach to Transesophageal Echocardiography . 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2008:246.)
2. Most patients with severe AS will have a mean transvalvular gradient >40 mm
Hg and peak velocity >4 m/sec. However, up to 30% of patients with an aortic
valve area (AVA) <1 cm 2 may have transvalvular gradients and velocities less
than the cutoffs for severe stenosis [7].
a. Classical low-flow, low-gradient severe AS describes a scenario in which a
patient has a low left ventricular ejection fraction (LVEF) resulting in a low-
flow state (defined as stroke volume index <35 mL/m2) and mean gradient
<40 mm Hg, peak velocity <4 m/sec, and AVA <1 cm 2. In this scenario,
dobutamine stress echocardiography (DSE) should be performed. If the
addition of inotropic support results in a mean gradient >40 mm Hg and the
calculated AVA remains less than 1 cm 2, the diagnosis of true severe AS is
confirmed. If the mean gradient remains less than 40 mm Hg, but the
calculated AVA increases to greater than 1 cm 2, then a diagnosis of
pseudosevere AS is made. Pseudosevere AS is primarily an issue of LV
dysfunction and AVR is not indicated.
b. Paradoxical low-flow, low-gradient severe AS describes a scenario in which
a patient with normal LVEF has an AVA <1 cm 2, mean gradient <40 mm Hg,
and peak velocity <4 m/sec. In this case, the patient has a low-flow state
(stroke volume index <35 mL/m2) because of small stroke volumes secondary
to concentric remodeling and impaired diastolic filling. Low-dose DSE may
be useful in confirming this diagnosis as well.
c. However, if DSE fails to increase the flow across the aortic valve and the
discordant values remain, it is possible to calculate a projected AVA based
on normal flow. For patients that fail to increase the stroke volume by 20%
with dobutamine, the mortality for surgical AVR is high. Additionally,
multidetector computed tomography (CT) can be used to quantitate the
calcification of the aortic valve, and a calcium score can be used to predict
the risk of stenosis progression.
CLINICAL PEARL In the patient with AS and low LV ejection fraction, it is critical to
understand that although the pressure gradients generated with echocardiography may not
suggest criteria for severe AS, these patients with low-flow, low-gradient AS represent a
high-risk patient population.
3. If cardiac catheterization data are utilized, the mean pressure gradient may be
measured from a direct transaortic measurement, and the aortic valve area may
be calculated using the Gorlin formula.
1. The timing of intervention is based upon the stage of the disease, and the stage
of disease takes into account not only the severity determined by
echocardiography but also the presence or absence of symptoms. Table 11.2
summarizes indications for valve replacement.
2. Due to the high risk of sudden death and limited life expectancy, symptomatic
patients should undergo surgery. Asymptomatic patients with severe AS may be
monitored closely until symptoms develop. However, the risk of waiting should
be carefully weighed against the risk of surgery. For example, prior to elective
noncardiac surgery under general or neuraxial anesthesia, asymptomatic
patients with severe AS should be considered for aortic valve surgery.
3. Patients with moderate AS should have aortic valve surgery if they happen to
require another cardiac operation, such as coronary artery bypass grafting
(CABG), because the rate of progression of AS is approximately 0.1 cm2 per
year and the risk of having to redo cardiac surgery is substantially higher than
the risk of the primary operation. Similarly, if a patient undergoing aortic valve
surgery has significant CAD, CABG should be performed simultaneously. In
patients over age 80 years, the risk of AVR alone is approximately the same as
the risk of combined AVR and CABG [9].
4. A commissural incision or balloon aortic valvuloplasty is often the first
procedure performed in young patients with severe noncalcific aortic valve
stenosis, even if they are asymptomatic [8]. This operation frequently results in
some residual AS and AR. Eventually, most patients require a subsequent
prosthetic valve replacement. In older adult patients with calcific AS, valve
replacement is the primary operation. In young adults, a viable alternative to
AVR is the Ross (switch) procedure. In the Ross procedure, the diseased aortic
valve is replaced with the patient’s normal pulmonary valve, and the
pulmonary valve is replaced with a pulmonary homograft. This more complex
procedure avoids the need for systemic anticoagulation and extends the time
until reoperation is required by several decades.
TABLE 11.2 Recommendations for timing of AVR in aortic stenosis (AS)
5. Surgical intervention should not be denied to patients almost no matter how
severe the symptoms because irreversible LV failure occurs only very late in
the disease process.
6. Balloon aortic valvuloplasty in adults with advanced disease often results in
significant AR and early restenosis and is reserved for patients with severe
comorbidity.
7. Transcatheter aortic valve replacement (TAVR). Although surgical
replacement of the aortic valve is the treatment of choice for patients with
severe AS, some patients are at very high risk for mortality or major morbidity
with surgery. TAVR is a less invasive alternative performed without
cardiopulmonary bypass (CPB), in which a bioprosthetic valve is implanted
within the native aortic valve via a catheter introduced through a major artery
or the apex of the LV [ 10]. Both techniques require brief cessation of the
patient’s cardiac output via rapid pacing during positioning of the device.
Hemodynamic instability is not uncommon and necessitates prompt recognition
and treatment. The 30-day mortality is 7%, while at 1-year post-TAVR, the
stroke rate is 4.1% and the overall mortality is 23.7% [11].
a. There are two valves currently available:
(1) Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA):
Transfemoral or transapical deployment. This valve requires rapid
ventricular pacing during deployment and is expanded with a balloon.
Thus, the cardiac output is zero during deployment.
(2) CoreValve ReValving System (Medtronic, Minneapolis, MN):
Transfemoral deployment. This valve is self-expanding and does not
require rapid ventricular pacing to deploy. The LV continues to eject
during deployment.
b. Contraindications. Contraindications used in clinical trials to date include
acute myocardial infarction within 1 month, congenital unicuspid or bicuspid
valve, mixed aortic valve disease (stenosis and regurgitation), HCM, LV
ejection fraction below 20%, native aortic annulus size outside of the
manufacturer’s recommended range, severe vascular disease precluding safe
placement of the introducer sheath (for the transfemoral approach),
cerebrovascular event within 6 months, and need for emergency surgery.
c. Hybrid operating room [12,13]. Cardiovascular hybrid surgery, which
includes TAVR, is a rapidly evolving field where less invasive surgical
approaches are combined with interventional cardiology techniques in the
same setting. Such procedures require a combination of high-quality imaging
modalities found in a cardiac catheterization suite (fluoroscopy, navigation
systems, post-processing capabilities, high-resolution invasive monitoring,
intracardiac and intravascular ultrasound, echocardiography, etc.) in addition
to the ability to perform open surgery under general anesthesia, including the
use of CPB. These procedures require close collaboration and communication
among multidisciplinary teams including interventional cardiologists,
surgeons, anesthesiologists, perfusionists, technicians, and nursing staff, some
of whom may be distant from the operating field. Thus, the presence of
multiple monitor panels in areas visible to all and advanced communication
systems are critical. Large amounts of space and careful planning of room
layout are crucial for all of the equipment to be readily accessible and to
allow unobstructed access to the patient (see Chapter 10). In addition, both the
radiation safety requirements of the cardiac catheterization suite and the
hygienic standards of the operating room must be met. These many demands
have led to the creation of specialized hybrid operating rooms (Fig. 10.7).
d. Surgical approaches (Fig. 11.4) [14–16]
(1) Retrograde or transfemoral approach
(a) The right femoral artery is accessed for device deployment. The left
femoral artery and vein are accessed to provide for hemodynamic
monitoring, transvenous pacing, contrast administration, and
preparation for emergent CPB.
(b) Heparin (100 to 150 units/kg) is given intravenously, titrating
therapy to an activated clotting time (ACT) of about 300 seconds.
(c) A guidewire is advanced across the aortic valve, and the balloon
angioplasty catheter is advanced over the wire.
(d) Ventricular pacing at about 200 beats/min (bpm) creates a low
cardiac output state (Fig. 11.5). In combination with apnea, a
motionless field is obtained during inflation of the balloon, after
which ventilation is resumed and pacing is terminated.
(e) The valve catheter is positioned using fluoroscopy and TEE. Rapid
ventricular pacing and apnea are used during valve deployment.
(f) Fluoroscopy and TEE are used to assess valve position and function
and to check for leak.
(2) Antegrade transapical approach
(a) This more invasive approach is reserved for patients with
peripheral arterial disease which would not accommodate the
introducer and valve deployment systems.
(b) The left femoral artery and vein are accessed as mentioned earlier.
(c) The LV apex is exposed via left anterolateral thoracotomy. TEE may
facilitate identification of the apex.
(d) Heparin is given with the same ACT targets described earlier.
(e) A needle is inserted through the LV apex, through which a guidewire
is passed through the aortic valve under fluoroscopic and TEE
guidance.
(f) A balloon valvuloplasty catheter is introduced over the guidewire
and positioned in the aortic valve. Similar to the retrograde
approach, rapid ventricular pacing and apnea are initiated to create
a motionless field during inflation.
(g) The valvuloplasty sheath is then replaced by the device introducer
sheath through which the prosthetic valve is deployed in a similar
fashion.
IGURE 11.4 Approaches to transcatheter aortic valve replacement (TAVR).
(3) Other approaches

(a) A transaxillary approach has been described as an alternative for
patients with severe iliofemoral arterial disease [17]. Preoperative
CT imaging is obtained to ensure that the vasculature is suitable for
this approach. Access is obtained via surgical cutdown, and the
valve is deployed similar to the retrograde (transfemoral approach).
IGURE 11.5 Hemodynamics during rapid ventricular pacing. The bottom waveform is taken from the arterial catheter. AO,
orta; LV, left ventricle.
(b) Transaortic approach via ministernotomy has also been reported. In

the authors’ institution, this is the most commonly used alternative
approach when peripheral vascular disease prevents a transfemoral
technique.
(c) Recently, a transcarotid approach has been used in patients who are
not candidates for the other approaches.
e. Anesthetic considerations
(1) In addition to standard monitors, large-bore venous access and invasive
blood pressure monitoring are essential. For the ongoing clinical trials, a
pulmonary artery catheter (PAC) is usually placed; however, the catheter
is withdrawn during the procedure itself as it interferes with the
fluoroscopic image. TEE is helpful as a monitor and guide for valve
placement, but transthoracic imaging or fluoroscopy alone may be used
in patients having the procedure done via the retrograde transfemoral
approach, using local anesthesia and sedation.
(2) Blood should be readily available, as massive hemorrhage from arterial
injury can occur acutely.
(3) Radiolucent defibrillation pads should be placed prior to draping the
patient, in case the need arises for cardioversion or defibrillation.
(4) With the transapical and transaortic approaches, general anesthesia is
necessary. Lung isolation may be helpful for surgical exposure but is not
absolutely needed. For the retrograde approach, local or regional
anesthesia with MAC may be adequate, but each patient should be
assessed on an individual basis. The advantages of using local/regional
anesthesia with sedation include the ability to assess neurologic status,
avoidance of airway manipulation, and a more rapid early recovery.
However, general anesthesia may be more comfortable for the patient,
provide immobility during valve deployment, and provide a secure
airway in the event of complications and the need for emergent CPB
[18–20]. General anesthesia is especially helpful when TEE is used, and
some clinicians see this as the “tipping point” for its selection. With
either method of anesthesia, the goal is for the patient to recover rapidly.
Shorter-acting anesthetic agents along with other adjuncts, such as
intercostal nerve blocks performed under direct vision by the surgical
team (transapical approach), will help accomplish this goal.
5 (5) During the procedure, there may be periods of acute hemodynamic
instability as a result of the device occluding the already narrow valve,
the creation of acute AR during valvuloplasty, massive bleeding from
dissection of major vasculature, damage to the LV or mitral valve, or
acute occlusion of a coronary ostium. Arrhythmias are common during
insertion of guidewires and catheters into the LV. Clear communication
with the surgical team is of the utmost importance in order to treat
appropriately and to avoid “overshooting” with vasopressors.
Sometimes the solution is as simple as repositioning the catheter.
CLINICAL PEARL Acute, dramatic hemodynamic changes are common during TAVR, for
both patient-related and procedure-related causes, making it essential to communicate with
the surgical team so that they can contribute to diagnosis and treatment of these changes.
(6) Normothermia should be actively maintained with the use of forced air
warming blankets and fluid warmers as needed.
(7) TEE is used to assess global cardiac function, measure the aortic root for
sizing of the prosthesis, screen for aortic disease, facilitate proper valve
positioning, and identify complications of the procedure such as
paravalvular leak (Supplemental Video 11.3), tamponade, or coronary
occlusion [11,21].
f. Complications [22,23]. Major complications of TAVR include stroke,
vascular damage including dissection, rupture of the aortic root, occlusion of
coronary ostia, cardiac conduction abnormalities, damage to other cardiac
structures such as the mitral valve, embolization of the prosthesis requiring
emergent surgical retrieval, and massive blood loss from vascular damage or
rupture of the LV. Paravalvular leak is more common after TAVR than open
surgery, probably because diseased, calcified tissue that may hinder optimal
valve deployment is not removed. Paravalvular leaks may be treated with
balloon reinflation to better appose the stented prosthesis to the aortic
annulus.
g. Outcomes [9,24]. For nonsurgical candidates, TAVR has been associated
with an improvement of symptoms and mortality at 1 year as compared to
medical management. For patients at too high risk for surgical AVR, TAVR
has transformed the management and led to significant reductions in mortality.
The success of TAVR in this population has led to considerable interest in its
use for lower-risk patients. However, paravalvular regurgitation remains a
limitation with TAVR, and even mild residual postoperative paravalvular
leak may increase mortality. Also, there appears to be a higher incidence of
heart block, stroke, and major vascular complications with TAVR. As the
transcatheter prostheses evolve, it is likely that this technique will eventually
be available for low-risk populations. Currently, only high-risk patients or
intermediate-risk patients who are enrolled in clinical trials are considered
for TAVR. We look forward to more long-term outcome data as the procedure
becomes more common.
8. Surgical (open) aortic valve replacement
a. Patients who require AVR and who do not qualify for (or sometimes who do
not choose) TAVR require a traditional open aortic valve replacement, which
is most often performed using a median sternotomy and cardiopulmonary
bypass. Minimally invasive surgical approaches to aortic valve replacement
are presented in Chapter 13.
TABLE 11.3 Hemodynamic goals for management of AS
b. Anesthetic considerations are as discussed above for TAVR (see Section

V.D.7.e). Goals of perioperative management are generally the same as for
TAVR (see Section V.E).
c. Types of valves are discussed in Section IX.
E. Goals of intraoperative management
1. Hemodynamic profile (Table 11.3)
a. LV preload. Due to the decreased LV compliance as well as the increased
LVEDP and LV end-diastolic volume (LVEDV), preload augmentation is
necessary to maintain a normal stroke volume.
b. Heart rate. Extremes of heart rate are not tolerated well. A high heart rate
can lead to decreased coronary perfusion. A low heart rate can limit cardiac
output in these patients with a fixed stroke volume. If a choice must be made,
however, low heart rates (50 to 70 beats/min) are preferred to rapid heart
rates (greater than 90 beats/min) to allow time for systolic ejection across a
stenotic aortic valve. Because atrial contraction contributes up to 40% of LV
filling, due to decreased LV compliance and impaired early filling during
diastole, it is essential to maintain a sinus rhythm. Supraventricular
dysrhythmias should be treated aggressively, if necessary, with synchronized
DC shock 3 because both tachycardia and the loss of effective atrial
contraction can lead to rapid reduction of cardiac output.
c. Contractility. Stroke volume is maintained through preservation of a
heightened contractile state. β-Blockade is not well tolerated and can lead to
an increase in LVEDV and a decrease in cardiac output significant enough to
induce clinical deterioration.
d. Systemic vascular resistance (SVR). Most of the afterload to LV ejection is
caused by the stenotic aortic valve itself and thus is fixed. Systemic blood
pressure reduction does little to decrease LV afterload. In addition, patients
with hemodynamically significant AS cannot increase cardiac output in
response to a drop in SVR. Thus, arterial hypotension may rapidly develop in
response to the majority of anesthetics. Finally, when hypotension develops,
the hypertrophied myocardium of the patient with AS is at great risk for
subendocardial ischemia because coronary perfusion depends on maintenance
of an adequate systemic diastolic perfusion pressure. Therefore, the early
4 use of α-adrenergic agonists such as phenylephrine is indicated to prevent
drops in blood pressure that can lead quickly to sudden death.
e. Pulmonary vascular resistance. Except for end-stage AS, pulmonary artery
pressures remain relatively normal. Special intervention for stabilizing
pulmonary vascular resistance is not necessary.
2. Anesthetic techniques
3. An experienced cardiac surgeon should be present, and perfusionists should be
prepared before induction of anesthesia, should rapid cardiovascular
deterioration necessitate emergency use of CPB.
4. Placement of external defibrillator pads should be considered to allow for
rapid defibrillation if cardiovascular collapse occurs on induction or prior to
sternotomy.
5. Preinduction arterial line placement is standard practice at most institutions
and is generally well tolerated with light premedication and local anesthetic
infiltration. Invasive blood pressure monitoring facilitates early recognition
and intervention if any hemodynamic instability occurs during induction.
6. During induction of anesthesia, in order to maintain hemodynamic stability,
medications should be carefully titrated to a fine line between a reasonable
depth of anesthesia and hemodynamic stability.
CLINICAL PEARL During induction of general anesthesia for the patient with AS (or
any other valvular lesion), it is less important to focus on the use of specific anesthetic
agents or vasopressor drugs, as it is to proceed with a regimen/plan that aims to achieve
and optimize specific hemodynamic goals (i.e., related to choosing a drug regimen based
on overall optimization of heart rate/rhythm, SVR, inotropy).
7. During the maintenance stage of anesthesia, anesthetic agents causing
myocardial depression, blood pressure reduction, tachycardia, or dysrhythmias
can lead to rapid deterioration. A narcotic-based anesthetic usually is chosen
for this reason. Low concentrations of volatile anesthetics are usually safe.
8. If the patient develops signs or symptoms of ischemia, nitroglycerin should be
used with caution because its effect on preload or arterial pressure may
actually make things worse.
9. Thermodilution cardiac output. PACs are helpful in evaluating the cardiac
output of patients prior to repair/replacement of the aortic valve. The
pulmonary capillary wedge pressure (PCWP), however, may overestimate
preload of a noncompliant LV. Mixed venous oxygen saturation monitoring via
an oximetric PAC may be used to provide a continuous index of cardiac output.
However, because the post-bypass management is not likely to be marked by
myocardial failure or low output states, this technique may be best reserved for
other patients who may be at higher risk of post-bypass hemodynamic
complications.
10. There is also a small risk of life-threatening arrhythmias leading to drug-
resistant hypotension during passage of a PAC through the right atrium and
ventricle. In the absence of pre-existing left bundle branch block or
tachyarrhythmias, a PAC may be placed under continuous rhythm monitoring,
perhaps, after placement of transcutaneous pacing electrodes. In the presence of
pre-existing abnormal rhythms or conduction disturbances, however, the most
conservative approach dictates leaving the catheter tip in a central venous
position until the chest is open, when internal defibrillator pads can be easily
applied and CPB can be initiated within a few minutes, if necessary.
11. TEE is useful for intraoperative monitoring of LV function, preload, and
afterload. TEE can predict prosthetic aortic valve size based on the LV outflow
tract width. It is also very helpful in the detection of air and facilitating
deairing prior to weaning from CPB. TEE is the method of choice for the post-
bypass assessment of a prosthetic valve for paravalvular regurgitation and
prosthetic valve stenosis. It is important to remember that Doppler-derived
blood flow velocities and pressure gradients must be interpreted in light of the
altered loading conditions seen in the dynamic operating room setting.
12. In the presence of myocardial hypertrophy, adequate myocardial preservation
with cardioplegic solution during bypass is a challenging task. A combination
of antegrade cardioplegia administered via coronary ostia and retrograde
cardioplegia via the coronary sinus has an important role in preserving
myocardial integrity.
13. In the absence of preoperative ventricular dysfunction and associated coronary
disease, inotropic support often is not required after CPB because valve
replacement decreases ventricular afterload.
F. Postoperative care. After a sharp drop in the aortic valve gradient, PCWP and
LVEDP immediately decrease and stroke volume rises. Myocardial function
improves rapidly, although the hypertrophied ventricle may still require an
elevated preload to function normally. Over a period of several months, LV
hypertrophy regresses. It must be remembered that a properly sized and
functionally prosthetic aortic valve may cause an elevated mean pressure
gradient (i.e., ∼7 to 19 mm Hg).
1. TAVR patients who receive general anesthesia often are extubated in the
operating room or shortly after arrival in the intensive care unit.
2. Patients undergoing open aortic valve replacements are less often extubated in
the operating room, but may be fast-tracked (see Chapter 10) if conditions
permit.
VI. Hypertrophic cardiomyopathy (HCM)
A. Natural history
1. Etiology and classification. HCM is a relatively common genetic cardiac
disorder, affecting approximately 0.2% of the general population worldwide.
This equates to roughly 1 case in every 500 births, with some estimates now
suggesting an even greater prevalence of HCM, with increased awareness and
screening. Outside of the medical community, its link to the sudden deaths of
young, otherwise healthy athletes has generated mainstream notoriety and
attention for the condition. Nomenclature and classification schemes related to
HCM have historically been somewhat confusing, with several different names
being used to describe this disease state (i.e., idiopathic hypertrophic subaortic
stenosis [IHSS], asymmetric septal hypertrophy, muscular subaortic stenosis).
Since ventricular hypertrophy may occur in a number of different patterns and
not just confined to the ventricular septum, HCM is now recognized as the
preferred term for describing this disorder. Additionally, despite the classic
association of HCM with dynamic obstruction to systolic outflow through the
left ventricular outflow tract (LVOT), only ∼25% of patients with HCM exhibit
this subvalvular obstruction. The term HOCM is used to refer to this subset of
HCM patients.
HCM is a familial disease, inherited in an autosomal dominant fashion with
variable penetrance. Mutations in a number of different genes encoding various
components of cardiac sarcomere proteins have been identified as a cause for
HCM. Most common are mutations involving the β-myosin heavy chain,
myosin-binding protein C, troponin T, troponin I, and tropomyosin α-1 chain.
2. Symptoms. Patients with HCM may present with a wide range of symptoms,
with many having no symptoms at all. The most common presenting symptom is
dyspnea on exertion, with poor exercise tolerance. Patients may also
experience syncope, presyncope, chest pain, fatigue, and palpitations. While
LVOT obstruction may cause symptoms, there is no clear relationship between
the degree of LVOT obstruction and the occurrence or severity of symptoms.
Other equally important causes of symptoms include diastolic dysfunction,
dysrhythmias, mitral regurgitation (MR), and an imbalance of myocardial
oxygen supply and demand. Unfortunately, the initial presenting symptom in
many patients is sudden cardiac death, usually due to ventricular fibrillation.
While all patients with HCM are at risk for sudden death, the highest-risk
groups include those with a family history of HCM and young patients
undergoing significant physical exertion. This has led to increased and
improved measures to screen for HCM in young athletes and patients with a
family history of the disorder.
B. Pathophysiology. By definition, HCM involves an abnormal thickening of the
myocardium without a clearly identifiable cause for the hypertrophy (i.e., chronic
hypertension, AS). There is an absence of chamber dilation and in most cases,
normal-to-hyperdynamic LV systolic function is present. In addition, there are
important histologic derangements, including abnormal cellular architecture and
disarray of the cardiac myocytes, interstitial fibrosis, increased connective
tissue, and patchy myocardial scarring, although this information is rarely
available preoperatively. These cellular abnormalities contribute significantly to
problems with diastolic filling, including decreased chamber compliance and
impaired relaxation. Even more importantly, these histopathologic abnormalities
lead to a derangement in the electrophysiology of the heart capable of inducing
the potentially catastrophic dysrhythmias seen in these patients. HCM patients are
prone to both atrial and ventricular dysrhythmias, with ventricular fibrillation
representing the most common cause of sudden death.
In the subset of patients with outflow tract obstruction, systolic anterior motion
(SAM) of the anterior mitral valve leaflet (AML) is the underlying cause for
dynamic outflow tract obstruction. Severe hypertrophy of the ventricular septum
results in narrowing of the LVOT, whose borders are formed by the septum and
the anterior leaflet of the mitral valve (Fig. 11.6). During systole, further
narrowing of the LVOT occurs due to septal thickening with ventricular
contraction. This leads to an increase in the blood flow velocity and pressure
gradient through the narrowed outflow tract. An important distinction between
this condition and AS is that the pre-existing ventricular hypertrophy leads to the
elevated pressure gradient in HCM, as opposed to the stenotic orifice leading to
ventricular hypertrophy in AS.
Basal septal hypertrophy also leads to a decreased distance between the AML
and the septum. Additionally, patients with HCM tend to have hypertrophied,
anteriorly displaced papillary muscles along with elongated mitral valve leaflets.
This shifts the mitral apparatus toward the septum, causing the posterior mitral
valve leaflet (PML) to coapt closer to the base of the AML, when the two valve
leaflets oppose one another during systole. The result of this altered coaptation is
excess, slack AML tissue extending beyond the coaptation point. Rapid blood
flow creates hydraulic forces (Venturi effect) capable of pulling this slack
anterior mitral leaflet tissue into the LVOT. Although the Venturi effect has long
been hypothesized as the primary mechanism of SAM, it is likely that a drag
force generated by LV contraction pulls the anteriorly displaced, slack leaflet
tissue into the LVOT in early systole. In fact, this drag force (i.e.,
pushing/sweeping of the mitral valve leaflet) into the outflow tract is now
believed to be the predominant cause of SAM. SAM leads to dynamic
obstruction, in which the degree of obstruction varies based upon cardiac loading
conditions and contractility. Specifically, the extent of LVOT obstruction is a
function of the mitral valve leaflet physically contacting the septum in order to
obstruct flow. Therefore, the degree of obstruction correlates directly with the
onset, extent, and duration of mitral–septal contact. The obstruction occurs
proximal to the aortic valve (subaortic) in mid-to-late systole, with the degree of
5 obstruction directly proportional to LV contractility and inversely
proportional to LV preload (end-diastolic volume) and afterload. Specifically,
decreases in SVR and preload, as well as increases in contractility and heart rate
will precipitate or worsen SAM/LVOT obstruction.
FIGURE 11.6 Basal septal hypertrophy in a patient with hypertrophic cardiomyopathy (HCM). Caliper measurement of
the basal septum (dotted white line) demonstrates severe hypertrophy (2.01 cm) visualized in a midesophageal long-axis (ME
LAX) TEE view. LA, left atrium; PML, posterior mitral valve leaflet; AML, anterior mitral valve leaflet; LVOT, left
ventricular outflow tract; LV, left ventricle; IVS, interventricular septum; RV, right ventricle. (Reprinted with permission
from Hymel BJ, Townsley MM. Echocardiographic assessment of systolic anterior motion of the mitral valve. Anesth
Analg. 2014;118(6):1197–1201, Figure 11.1, p. 1198.)
A further consequence of SAM is a posteriorly directed jet of MR that results

from the abnormal mitral valve leaflet motion. During SAM, the distal portion of
the AML remains in the LVOT during systole, as opposed to coapting with the
PML in systole. This essentially creates a funnel, formed by the distal portions of
both mitral valve leaflets, that directs regurgitant flow posteriorly through this
channel. MR in this scenario occurs after the onset of SAM, with its severity
primarily related to the degree of LVOT obstruction. Therefore, maneuvers to
alleviate LVOT obstruction will also lead to improvement or resolution of the
MR. In addition to LVOT obstruction, dynamic mid-cavitary obstruction can also
occur in patients with HCM. This typically occurs in patients with concentric
hypertrophy most pronounced at the mid-LV level. Intracavitary
pressures/obstruction are affected by the same hemodynamic conditions as
SAM/dynamic LVOT obstruction.
While dynamic LVOT obstruction is seen in only a subset of HCM patients,
most will exhibit diastolic dysfunction secondary to ventricular hypertrophy, as
well as hypertrophy and disarray of the myocytes. Early diastolic filling is
impaired secondary to this poor diastolic compliance, making atrial contraction,
and thus maintenance of sinus rhythm, critical for adequate diastolic filling.
Mismatch of oxygen supply and demand is a frequent occurrence in HCM that
predisposes to ischemia. The hypertrophied myocardium represents a large
muscle mass, and there is increased oxygen demand associated with elevated
ventricular pressures and wall tension.
C. Preoperative evaluation and assessment of severity. Echocardiography
allows for assessment of the location and severity of hypertrophy and helps
determine the necessity and feasibility of potential surgical intervention. When
patients with HOCM present for surgical myomectomy, the baseline
intraoperative TEE exam is a critical component of the procedure. The extent of
basal septal hypertrophy is assessed in a midesophageal long-axis (ME LAX)
view at end-diastole (Fig. 11.6). Additionally, a nonstandard ME five-chamber
view may also be used. While normal LV thickness is ≤1 cm, many patients will
often present with severe basal septal hypertrophy in excess of 2 cm. The
diameter of the LVOT, as well as the distance from mitral coaptation point to the
septum (C-sept distance) is also measured. Both a narrow LVOT (≤2.0 cm) and
small C-sept distance (≤2.5 cm) have been identified as risk factors for the
development of hemodynamically significant SAM. Both of the above-mentioned
views can be used to evaluate for the presence of SAM (Supplemental Video
11.4). In the presence of SAM, color flow Doppler will demonstrate high-
velocity, turbulent flow (aliasing) in the LVOT. Additionally, a posteriorly
directed jet of MR is also frequently observed as a consequence of the SAM,
resulting in a characteristic “Y-shaped” color flow Doppler (CFD) pattern
(Supplemental Video 11.5).
CWD measurements of the peak LVOT velocity and pressure gradient, in either
a deep transgastric LAX or transgastric LAX view, quantifies the severity of
subaortic obstruction. With dynamic LVOT obstruction, the Doppler profile
demonstrates a late peaking, “dagger-shaped” envelope of high-velocity flow due
to the onset of obstruction in mid-to-late systole (Fig. 11.7). A mean gradient of
≥30 mm Hg is considered significant. In addition to the mitral coaptation defect
associated with SAM, the mitral apparatus itself may be abnormal in HCM
patients and should be thoroughly examined. LV systolic function is typically
normal or hyperdynamic and diastolic function is almost always abnormal.
FIGURE 11.7 Dynamic left ventricular outflow tract (LVOT) obstruction. Continuous wave Doppler tracing of blood flow
through the LVOT in a patient with hypertrophic cardiomyopathy (HCM), demonstrating a high-velocity Doppler flow profile
with a delayed peak (“dagger shaped”) consistent with dynamic LVOT obstruction peaking in mid-to-late systole. The peak
gradient (max PG) is significantly elevated at 52 mm Hg. (Reprinted with permission from Hymel BJ, Townsley MM.
Echocardiographic assessment of systolic anterior motion of the mitral valve. Anesth Analg. 2014;118(6):1197–1201, Figure
11.2, p. 1199.)
D. Timing and type of intervention. The mainstay of medical therapy for HCM
involves treatment with β-blockers, which help reduce LVOT obstruction due to
their negative inotropic effects and reduction in heart rate. Calcium channel
blockers are also frequently utilized for their favorable effect on diastolic
compliance. The most critical intervention in patients identified as high risk for
malignant dysrhythmias is placement of an automated implantable cardioverter–
defibrillator. Other nonsurgical approaches to decrease outflow obstruction
include dual-chamber pacing and ethanol ablation of the ventricular septum.
Surgical treatment involves removal of septal muscle tissue to widen the LVOT
via septal myomectomy and may occasionally involve modification of the mitral
valve apparatus or mitral valve repair/replacement. Following myomectomy, the
intraoperative TEE exam allows for immediate assessment of the adequacy of
surgical intervention. Expected findings are a significant reduction in the LVOT
gradient by continuous wave Doppler (CWD), as well as thinning of the
septum/widening of the LVOT and resolution of SAM.
1. Hemodynamic profile (Table 11.3)
a. LV preload. Any condition that leads to a decrease in LV cavity size can
potentially exacerbate dynamic LVOT obstruction, as this places the septum
and anterior mitral leaflet in closer proximity, narrowing the outflow tract and
increasing the potential for SAM and obstruction. In this regard, preload
augmentation is essential to help maintain ventricular volume. Additionally,
similar to AS, diastolic dysfunction will lead to decreased LV compliance
with increased LVEDP, which will necessitate adequate preload to maintain a
normal stroke volume. Treatment with nitroglycerin, or other vasodilators,
should be avoided, as it may dangerously reduce cardiac output.
b. Heart rate. It is essential to avoid tachycardia in patients with HCM because
it leads to a reduction in ventricular volume, exacerbation of dynamic LVOT
obstruction, and increased oxygen demand. Decreased heart rates are
beneficial, as this prolongs diastole and allows more time for ventricular
filling. Maintenance of sinus rhythm and the atrial contraction component of
ventricular filling is critical due to reduced early diastolic filling because of
reduced LV compliance.
c. Contractility. Decreases in myocardial contractility help reduce outflow
obstruction. β-Blockade, volatile anesthetics, and avoidance of sympathetic
stimulation are all potentially beneficial. The use of intraoperative inotropic
agents can increase contractility, worsen LVOT obstruction, and lead to
severe hemodynamic instability. Thus, they should be avoided.
CLINICAL PEARL HOCM is one of the few clinical scenarios in which agents with
positive inotropic effects can lead to clinical deterioration.
d. Systemic vascular resistance. Decreases in afterload must be promptly and
aggressively treated with vasopressors, such as phenylephrine or vasopressin.
Hypotension can be especially detrimental in this population because
diastolic dysfunction leads to increased LVEDP, requiring an increased blood
pressure to provide adequate coronary perfusion pressure (CPP):
CPP = Diastolic blood pressure (aorta) - LVEDP
e. Pulmonary vascular resistance. Pulmonary artery pressures remain
relatively normal in most patients. Specific intervention for stabilizing
pulmonary vascular resistance is typically not necessary.
2. Anesthetic technique
a. Premedication. Many of these patients are on maintenance therapy with β-
blockers or calcium channel blockers, which should be given on the day of
surgery and continued throughout the perioperative period.
b. Induction and maintenance of anesthesia. During induction and
laryngoscopy, careful attention is required to avoid decreases in afterload, as
well as sympathetic stimulation leading to increases in heart rate and
contractility. Adequate preload must be maintained and all blood or fluid
losses should be aggressively replaced. The direct myocardial depressant
effect of volatile anesthetics is potentially advantageous.
c. Patients with HCM are at risk for atrial and ventricular tachyarrhythmias
during surgery. Preparation must be in place for immediate cardioversion or
defibrillation.
d. Intraoperative TEE, like preoperative echocardiography, allows visualization
of the location and extent of hypertrophy in the septum, the degree of SAM and
LVOT obstruction, and quantification of the degree of MR. It is customary to
measure the thickness of the septum at the point of contact with the anterior
leaflet, as this information is helpful to the surgeon. Since central venous
pressure (CVP) and PCWP measurements will overestimate true volume
status, TEE is the most reliable means of accurately assessing volume. The
ability to monitor LV systolic function and wall motion is useful, as the
oxygen supply–demand relationship is tenuous in these patients making them
prone to ischemia. The adequacy of surgical repair and any postrepair
complications can also be immediately assessed.
e. Postoperative care. Potential complications in the immediate postoperative
period following septal myomectomy include residual LVOT obstruction,
residual SAM, residual MR, complete heart block, and the creation of a
ventricular septal defect (VSD). Unroofing of septal perforator vessels is an
expected TEE finding after septal myomectomy and should not be confused
with an iatrogenic VSD.
VII. Aortic regurgitation (AR)
A. Natural history
1. Etiology. AR may be caused by abnormalities of either the aortic valve leaflets
or the aorta itself. Problems with the valve leaflets may occur from
degenerative, inflammatory, infectious, traumatic, iatrogenic, or congenital
etiologies. Specific examples include calcific valve disease, rheumatic
disease, endocarditis, a congenitally bicuspid aortic valve, myxomatous valve
disease, and systemic inflammatory disorders. Aortic root dilatation, leading to
separation and incomplete apposition of the aortic valve leaflets in diastole,
can be caused by degenerative aortic dilation, syphilitic aortitis, Marfan
syndrome, and aortic dissection. Acute AR is usually caused by aortic
dissection, trauma, or aortic valve endocarditis.
A helpful approach to understanding the underlying cause of AR has been
described and is based upon a modification of the well-established
classification scheme used to classify mechanisms for MR (Carpentier
classification). With this approach, three types of AR morphology are
described, based upon the motion of the aortic valve leaflets. Type I is
associated with normal aortic valve leaflet motion, type II is associated with
excessive valve leaflet motion (i.e., leaflet prolapse), and type III is associated
with restricted valve leaflet motion (i.e., thickening and/or calcification of
leaflets). Type I AR may be further divided into four additional subtypes based
upon pathology of the aortic root and aortic valve. Type Ia involves sinotubular
junction enlargement and dilatation of the ascending aorta, type Ib involves
dilatation of the sinuses of Valsalva and sinotubular junction, type Ic involves
dilation of the aortic valve annulus, and type Id involves perforation of the
aortic valve leaflet [25].
2. Symptoms. Patients with chronic AR may be asymptomatic for many years.
However, although they remain asymptomatic, many patients will be
undergoing progressive ventricular dilatation with the development of impaired
myocardial contractility. Symptoms such as shortness of breath, palpitations,
fatigue, and angina usually develop only after significant dilatation and
dysfunction of the LV myocardium have occurred. The 10-year mortality for
asymptomatic AR varies between 5% and 15%. Once symptoms develop,
however, patients progressively deteriorate and have an expected survival
around 10 years. Patients with severe acute AR, due to the lack of longstanding
compensation, are not capable of maintaining sufficient forward stroke volume.
These patients are likely to develop sudden and severe dyspnea, significant
pulmonary 6 edema, refractory heart failure, and may deteriorate rapidly due
to cardiovascular collapse.
B. Pathophysiology
1. Pathophysiology and natural progression
a. Acute AR. The sudden occurrence of acute AR places a major volume load
on the LV. The immediate compensatory mechanism for the maintenance of
adequate forward flow is increased sympathetic tone, producing tachycardia
and an increased contractile state. Fluid retention increases preload.
However, the combination of increased LVEDV, along with increased stroke
volume and heart rate may not be sufficient to maintain a normal cardiac
output. Rapid deterioration of LV function can occur, necessitating emergency
CLINICAL PEARL The patient with acute-onset, severe AR represents an especially
high-risk patient population, and the perioperative plan must include preparations to manage
sudden cardiac collapse.
b. Chronic AR. Chronically, AR leads to LV systolic and diastolic volume
overload. LV wall tension also increases, precipitating the replication and
lengthening of cardiac sarcomeres. This causes the wall thickness to increase
in proportion to the increase in LV chamber size in a pattern of eccentric
ventricular hypertrophy. Because the LVEDV increases slowly, the LVEDP
remains relatively normal. Forward flow is aided by the presence of chronic
peripheral vasodilation, which occurs along with a large stroke volume. As
the LV dilatation progresses, coronary perfusion finally decreases leading to
irreversible LV myocardial tissue damage and dysfunction. The onset of LV
dysfunction is followed by an increase in PA pressure with symptoms of
dyspnea and congestive heart failure. As a compensatory mechanism for the
poor cardiac output and poor coronary perfusion, sympathetic constriction of
the periphery occurs to maintain blood pressure, which in turn leads to further
decreases in cardiac output.
2. Pressure wave disturbances
a. Arterial pressure. Incompetence of the aortic valve leads to regurgitant blood
flow from the aorta back into the LV during diastole. This causes a
pronounced decline in aortic diastolic blood pressure, translating into a wide
pulse pressure. Patients with AR, therefore, show a wide pulse pressure with
a rapid rate of rise, a high systolic peak, and a low diastolic pressure. The
pulse pressure may be as great as 80 to 100 mm Hg. The rapid upstroke is due
to the large stroke volume, and the rapid downstroke is due to the rapid flow
of blood from the aorta back into the ventricle and then into the dilated
peripheral vessels. The occurrence of a double peaked, or bisferiens pulse
trace, is not unusual due to the occurrence of a “tidal” or back wave. It is this
wide pulse pressure that leads to the presence of the many eponymous clinical
signs associated with AR.
b. Pulmonary capillary wedge trace. Stretching of the mitral valve annulus may
lead to functional MR, a prominent V wave, and a rapid Y descent. In patients
with acute AR associated with poor ventricular compliance, LV pressure may
increase fast enough to close the mitral valve before end diastole. In this
situation, AR raises the LVEDP above left atrial pressure, and the PCWP can
significantly underestimate the true LVEDP.
3. Pressure–volume loop in aortic regurgitation (Fig. 11.8)
1. Historically, the amount of AR was estimated based on angiographic clearance
of dye injected into the aortic root. Currently, echocardiography is the method
of choice for qualitative, semiquantitative, and quantitative assessment of AR.
a. Echocardiographic assessment of AR (Table 11.4)
Supplemental Videos 11.6 and 11.7 demonstrate the appearance of AR as
seen on TEE. The severity of AR can be assessed with echocardiography by
several techniques (Table 11.5). Qualitative assessment includes the two-
dimensional analysis of the aortic valve anatomy, with particular attention to
any structural abnormalities of the leaflets. The aortic root and LV cavity
should be closely examined for evidence of dilation. CFD allows for
visualization of the regurgitant jet, originating at the aortic valve and
extending back into the LVOT in diastole. An experienced echocardiographer
can often accurately estimate the degree of regurgitation with this initial
observation; however, quantitative measurements are made to more accurately
assess severity. The vena contracta is, perhaps, the most widely utilized
measurement. It represents the narrowest point of the regurgitant jet and
corresponds to the size of the regurgitant orifice. It is a relatively easy
measurement to obtain and is also unaffected by changes in preload or
afterload (Fig. 11.9). Severity of regurgitation can also be estimated by
measuring the extent in which the regurgitant jet occupies the LVOT. The ratio
of jet width to LVOT width, or jet area to LVOT area, has been found to
correlate well with angiographic assessment (Fig. 11.10). CWD can be used
to measure the deceleration rate of the regurgitant jet and the pressure half-
time. These measurements are based on the rate of equilibration between
aortic and LV pressures. As the severity of AR increases (i.e., regurgitant
orifice becomes larger), the more quickly these pressures will equilibrate.
Thus, significant AR corresponds to a steep slope of the jet deceleration rate
and a short pressure half-time. Severe AR may also be associated with
holodiastolic flow reversal in the descending thoracic aorta seen on a pulsed-
wave Doppler (PWD) exam.
IGURE 11.8 Pressure–volume loop in acute and chronic AR. Note the rightward shift of the loop in chronic AR (C), reflecting
evated LV volume without a dramatic elevation in filling pressure. In acute AR (A), LV volumes are also increased; however,
e ventricle has not adapted to accommodate the increased volumes without elevation of filling pressures. AR, aortic regurgitation.
Modified from Jackson JM, Thomas SJ, Lowenstein E. Anesthetic management of patients with valvular heart disease. Semin
. 1982;1:247.)
TABLE 11.4 Hemodynamic goals for management of dynamic subaortic stenosis
TABLE 11.5 Assessment of AR severity with echocardiography
IGURE 11.9 Vena contracta. Caliper measurement of the narrowest portion of the aortic regurgitant jet, which corresponds to
n approximation of the regurgitant orifice area. Ao, aorta; LA, left atrium; LV, left ventricle. (Reprinted with permission from
errino AC, Reeves ST, eds. A Practical Approach to Transesophageal Echocardiography. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2008:232, Figure 11.4.)
IGURE 11.10 Color M-mode assessment of AR. Utilizing a ME aortic long-axis view, the width of the regurgitant jet and the
VOT are measured. The ratio of jet width to LVOT width can be used to estimate the severity of the AR. AR, aortic
gurgitation; ME, midesophageal; LVOT, left ventricular outflow tract. (Reprinted with permission from Perrino AC, Reeves ST,
ds. A Practical Approach to Transesophageal Echocardiography. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2008;
29, Figure 11.2.)
b. Quantitative assessment of AR—calculation of regurgitant volume and

regurgitant fraction. A quantitative estimate of the severity of AR may be
obtained by calculating the regurgitant volume and regurgitant fraction (RF).
The total stroke volume in a patient with AR is the regurgitant volume plus the
forward stroke volume actually ejected into the circulation. The regurgitant
volume is the amount of blood that flows back through the incompetent aortic
valve during each cardiac cycle. It is quantified as the difference between the
total stroke volume flowing through the aortic valve and the total forward
stroke volume through a different valve. This reference valve is most
commonly the mitral valve, with Doppler echocardiography being used to
calculate the transmitral stroke volume. Total LV stroke volume can be
determined with either Doppler echocardiography measurement of flow
through the LV outflow tract or it may be derived from the left ventriculogram
on cardiac catheterization. The RF, or fraction of each stroke volume flowing
back into the LV, equals the ratio of the right ventricle (RV) to the total stroke
volume through the regurgitant aortic valve.
1. Acute aortic regurgitation. Urgent surgical intervention is often indicated in
acute AR due to a high incidence of hemodynamic instability. Inotropic support
is frequently needed to maintain cardiac output.
2. Chronic aortic regurgitation. AVR is recommended for the symptomatic
patient with chronic, severe AR, regardless of LV systolic function.
Asymptomatic patients with chronic AR and LV systolic function (EF <50%)
should also undergo AVR. The asymptomatic patient with normal LV function
should be closely followed for the onset of clinical symptoms and with serial
echocardiographic examination. These patients should have surgical
intervention at the earliest sign of LV dysfunction, as overall outcomes are
significantly improved when surgery is performed prior to deterioration of
ventricular function. Additionally, evidence of ventricular dilatation (left
ventricular end-diastolic diameter >65 mm, left ventricular end-systolic
diameter >50 mm) should prompt consideration for surgery, even in the
presence of normal LV function [1].
3. Surgical intervention. The most frequent approach to surgical treatment of AR
is AVR. Experience with aortic valve repair has been limited to only a few
highly specialized centers, and the durability of aortic valve repair remains
unproven. Although enthusiasm for valve repair in certain patient populations
(i.e., young patients with bicuspid aortic valves) has resulted in advances in the
technique, the AHA/ACC guidelines only recommend aortic valve repair in
specialized centers with proven experience and expertise [1]. In cases in which
AR is secondary to aortic root and/or ascending aortic dilatation, valve-sparing
replacement of the aorta may effectively resolve AR if there is no significant
underlying aortic valve pathology.
1. Hemodynamic management (Table 11.6)
a. LV preload. Due to the increased LV volumes, maintenance of forward flow
depends on preload augmentation. Pharmacologic intervention producing
venous dilation has the potential to impair cardiac output in these patients by
reducing preload.
b. Heart rate. Patients with AR show a significant increase in forward cardiac
output with an increase in heart rate. Decreased time spent in diastole, as
occurs with a faster heart rate, results in a decrease in RF. Actual
improvement in subendocardial blood flow is observed with an increased
heart rate, owing to a higher systemic diastolic pressure and a lower LVEDP.
This explains why a patient who is symptomatic at rest may show an
improvement in symptoms with exercise. A heart rate of around 90 beats/min
seems to be optimal, improving cardiac output while not inducing ischemia.
TABLE 11.6 Hemodynamic goals for management of AR
c. Contractility. LV contractility must be maintained. In patients with impaired

LV function, use of pure β agonists or phosphodiesterase inhibitors can
increase stroke volume through a combination of peripheral dilation and
increased contractility (“inodilation”).
d. Systemic vascular resistance. The forward flow can be improved with
afterload reduction. Increases in LV afterload result in increased stroke work
and can significantly increase the LVEDP.
e. Pulmonary vascular resistance. Pulmonary vascular pressure remains
relatively normal except in patients with end-stage AR associated with severe
LV dysfunction.
a. Premedication. Light premedication is recommended.
b. Induction and maintenance. Serious hemodynamic instability during
induction of general anesthesia is less likely with severe AR than with severe
AS because arterial vasodilation, which is a major effect of most of the
induction drugs, is beneficial in AR and transient hypotension is usually well
tolerated. However, the importance of careful titration of induction agents in
combination with adequate hydration should not be underestimated. Particular
caution is warranted with acute AR, where ventricular decompensation is
more likely to occur. The hemodynamic goals for induction and maintenance
of anesthesia should be directed at preserving the patient’s preload and
contractility, maintaining the peripheral arterial dilation, and avoiding
bradycardia. Careful attention should be paid to avoiding profound
bradycardia/asystole in the period after aortic cannulation and onset of CPB,
since the LV is especially prone to distend due to the presence of the AR.
Until it is vented surgically, the LV must, therefore, vent itself via systolic
ejection.
c. A PAC is helpful in evaluating the cardiac output of patients prior to repair of
the aortic valve and, especially, in the post-bypass period for monitoring and
optimizing preload and myocardial function.
d. Intraoperative TEE is beneficial for monitoring LV function and assessment
of the severity of regurgitation prior to valve surgery. Specific pathology of
the aortic valve leaflets and aortic root can be easily assessed. It is also
useful in predicting the appropriate size of a prosthetic valve based on the
diameters of the aortic annulus and LV outflow tract. If aortic valve repair is
performed, TEE is valuable for providing immediate feedback concerning the
integrity of valvular function. In AVR, TEE allows for immediate assessment
of any perivalvular regurgitation, as well as the pressure gradient across the
newly placed prosthetic valve.
e. Use of an intra-aortic balloon pump is contraindicated in the presence of
significant AR because augmentation of the diastolic pressure will increase
the amount of regurgitant flow.
f. Weaning from cardiopulmonary bypass may be complicated by LV
dysfunction secondary to suboptimal myocardial protection and coronary air
embolism. AVR leads to a mild transvalvular gradient because most
prosthetic valves have a degree of inherent stenosis. An elevated
transvalvular gradient, in combination with a significantly dilated LV, may
result in increased afterload, low cardiac output, and may contribute to LV
dysfunction. Inotropic support may be indicated in order to maintain cardiac
output and avoid further LV dilation and dysfunction. Preload augmentation
must be continued to maintain filling of the dilated LV.
3. Postoperative care. Immediately following AVR, the LVEDP and LVEDV
decrease. However, the LV dilation and eccentric hypertrophy persist. In the
early postoperative period, a decline in LV function may necessitate inotropic
or intra-aortic balloon pump support. If surgical intervention is delayed until
significant LV dysfunction has occurred, the prognosis for long-term survival is
poor. The 5-year survival rate for patients whose hearts do not return to a
relatively normal size within 6 months following surgical repair is only 43%. If
surgery is performed early enough, the heart will return to relatively normal
dimensions, and a long-term survival rate of 85% to 90% after 6 years can be
expected [2].
VIII. Mixed valvular lesions. For all mixed valvular lesions, management decisions
emphasize the most severe or the most hemodynamically significant lesion.
A. AS and mitral stenosis. Pathophysiologically, the progression of the disease
follows a course similar to that seen in patients with pure mitral stenosis with
development of pulmonary hypertension and, eventually, RV failure. Symptoms
are primarily referable to the pulmonary circulation, including dyspnea,
hemoptysis, and atrial fibrillation. This combination of valvular heart disease
may lead to underestimation of the severity of the AS because the aortic valve
gradient may be relatively low owing to low aortic valvular flow. Such a
combination of lesions can be extremely serious because of the limitation of
blood flow at two points. Intraoperative management should focus on maintaining
adequate preload, preserving sinus rhythm, and avoiding tachydysrhythmias in
order to optimize ventricular filling. SVR and systemic blood pressure must be
preserved in order to avoid ventricular ischemia.
B. AS and mitral regurgitation (MR). MR is not an uncommon finding in the
setting of severe AS. With progression of the stenotic lesion, the LVSP increases
to overcome the flow obstruction. MR flows from the LV during systole into the
left atrium (LA). Elevated LVSP results in a larger gradient between the LV and
LA and a subsequent increase in MR. Compensatory ventricular remodeling can
further worsen MR, as the mitral valve annulus is distorted. MR may improve
after the aortic valve is replaced as the LVSP decreases, and this has led to
controversy in the surgical management of moderate, functional MR in the setting
of severe AS. In managing these patients, the hemodynamic requirements for AS
and MR are contradictory. Because 7 AS is more likely to cause cardiovascular
collapse, it should be given priority when managing the hemodynamic variables.
C. AS and AR. The combination of AR and AS is not well tolerated because it
provides the LV with both severe pressure and volume overloading. These
stresses lead to major increases in myocardial oxygen consumption (MVO2) and,
as might be expected, angina pectoris is an early symptom with this combination.
Once symptoms develop, the prognosis is similar to that of pure AS.
D. AR and MR. The combination of AR and MR occurs frequently, and this
combination can cause rapid clinical deterioration. The hemodynamic
requirements of AR and MR are similar. The primary problem is providing
adequate forward flow into the peripheral circulation. The development of
acidosis leading to peripheral vasoconstriction and increased impedance to LV
outflow can lead to rapid clinical deterioration. Therefore, keeping the SVR
relatively low while maintaining an adequate perfusion pressure is the goal until
CPB can be initiated.
E. Multivalve surgical procedures. While the surgical management of multivalve
disease has continued to improve, these patients still represent a significantly
higher-risk group than patients presenting for surgery on a single valve.
IX. Prosthetic valves
The decision regarding which prosthetic valve should be used for a particular
patient is based upon a variety of factors, including the expected longevity of the
patient (mechanical prostheses last longer), the ability of the patient to comply with
anticoagulation therapy (mechanical prostheses require ongoing anticoagulation),
the anatomy and pathology of the existing valvular disease, and the experience of
the operating surgeon [26].
A. Essential characteristics of prosthetic heart valves. An ideal prosthetic heart
valve mimics the characteristics of the native valve and has excellent
hemodynamics, is nonthrombogenic, durable, chemically inert, preserves blood
elements, and allows physiologic blood flow. The large number of different
prosthetic valves that have been developed means that no ideal valve has yet
been found and each valve has its own inherent limitations [27].
1. Mechanical. Current mechanical prosthetic valves are durable but
thrombogenic. At present, all patients with mechanical prosthetic valves
require anticoagulation therapy for the remainder of their lives. Normally,
anticoagulation is provided with warfarin sodium, administered at a dose that
will elevate the prothrombin time to 1.5 to 2 times control. There are four basic
types of mechanical prosthetic valves, the caged ball, caged disc, monocuspid
tilting disc, and bicuspid tilting disc valves. Of these, the bicuspid tilting–disc
valves are in common use today. This valve design is less bulky than its
predecessors and provides improved central laminar blood flow.
FIGURE 11.11 Bileaflet valve prosthesis showing discs in open (A) and closed (B) positions. (Reprinted with permission
from Hensley FA, Martin DE, Gravlee GR. A Practical Approach to Cardiac Anesthesia. 4th ed. Philadelphia, PA: Lippincott
Williams and Wilkins; 2008:344.)
a. Bileaflet tilting–disc valve prosthesis (Fig. 11.11). In 1977, a

bileaflet St. Jude cardiac valve was introduced as a low-profile
device to allow central blood flow around two semicircular discs that
pivot on supporting struts. When the leaflets open, the opening angle
relative to the leaflets ranges from 75 to 90 degrees. Three orifices
are present within the valve when open: a smaller central orifice
between two larger semicircular orifices on the lateral edges [27].
Due to these size differences, higher flow velocities occur within the
smaller central orifice as compared to the two larger outer orifices of
the valve. The valve is designed to have an inherent (but small)
degree of regurgitant flow originating from backflow from the motion
of the occluders and leakage through the components of the prosthesis.
This purposeful regurgitant flow is included in the valve to provide
“washing jets” to minimize blood stasis and thrombus formation on the
valve components [27]. The St. Jude bileaflet tilting–disc valve can
be placed in the aortic, mitral, or tricuspid positions. These valves
produce low resistance to blood flow and have a lower incidence of
thromboembolic complications, though anticoagulation is still
necessary. The most popular bileaflet tilting disc is still the St. Jude
Medical (Saint Paul, MN). Other bileaflet tilting–disc valve
prostheses include the CarboMedics (Sorin Group, Milan, Italy), On-
X (MRCI, Austin, TX), and Advancing the Standard (ATS) Medtronic
valves.
2. Bioprosthetic valves. The Hancock porcine aortic bioprosthesis (now the
Medtronic Hancock II stented porcine bioprosthesis) was introduced in 1970,
followed by the Ionescu–Shiley bovine pericardial prosthesis in 1974, and the
Carpentier–Edwards porcine aortic valve bioprosthesis in 1975. In contrast to
modern mechanical prostheses, current bioprostheses are less durable but also
less thrombogenic. Long-term anticoagulation for a bioprosthetic valve is
usually unnecessary. Bioprosthetic valves in the aortic position last longer than
in the mitral position. Because durability is an issue and because their lifespan
is longer in older patients, bioprosthetic valves are usually used for patients
older than 60 years of age and when anticoagulation is not a desirable option
(e.g., when pregnancy is anticipated).
a. Bioprosthetic valves fall into two types: stented and nonstented. Stented
bioprosthetic valves constructed from porcine aortic valves or bovine
pericardium are placed on a polypropylene stent which is attached to a
silicone sewing ring covered with Dacron. These valves allow for improved
central annular flow and less turbulence, but the stent does cause some
obstruction to forward flow, thereby leading to a residual pressure gradient
across the valve. The effective orifice areas of bioprosthetic valves (for a
given annulus size) are typically smaller than for bileaflet mechanical valves.
A small amount of central regurgitant flow is common in most bioprosthetic
valves. Most valves in current production are treated with glutaraldehyde to
reduce antigenicity and anticalcification agents or processes [27]. Examples
of stented bioprosthetic valves that can be found in clinical use today include
the Carpentier–Edwards Perimount (Fig. 11.12), Magna, and S.A.V. valves
(Edwards Lifesciences, Irvine, CA); Epic (St. Jude Medical); Biocor (St.
Jude Medical); Hancock II (Medtronic); Mitroflow (Sorin Group); Mosaic
(Medtronic); and Trifecta (St. Jude Medical).
IGURE 11.12 Carpentier–Edwards Perimount RSR stented pericardial bioprosthetic aortic valve. (Courtesy of Edwards
ifesciences, Irvine, California.) (Reprinted with permission from Hensley FA, Martin DE, Gravlee GR. A Practical Approach to
ardiac Anesthesia. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:345.)
b. Stentless bioprostheses. Stentless valves were developed in order to

provide improved hemodynamic characteristics and durability as compared to
stented bioprostheses. These valves are constructed from intact porcine aortic
valves or bovine pericardium. Stentless bioprosthetic valves are technically
more difficult to place and are used almost exclusively in the aortic position.
Modern stentless bioprosthetic valves are often used when aortic root
replacement is also necessary. The first generation of stentless bioprostheses
includes Medtronic Freestyle, Toronto SPV (St. Jude Medical), and Prima–
Edwards (Edwards Lifesciences) (Fig. 11.13). Newer generations include the
Shelhigh Super Stentless aortic valve (Shelhigh Inc., Union, NJ) and Sorin
Pericarbon Freedom valve (Sorin Group), which are easier to implant since
they only require one layer of suture for implantation [27].
3. Sutureless bioprosthetic valves. Stent-mounted sutureless valves have
recently been designed for AVR involving sutureless positioning and anchoring
at the site of implantation. These sutureless valves can be used for replacement
of either a diseased native valve or dysfunctional prosthetic valve. A primary
advantage of these valves lies in the fact that they can be implanted more
quickly than other valves, with a significant reduction in aortic cross-clamp and
bypass time. Examples include the Perceval (Sorin Group), 3F Enable valve
(Medtronic), and Intuity (Edwards Lifesciences) [27].
4. Human valves. The first use of a bioprosthesis taken from a cadaver occurred
in 1962. However, techniques such as irradiation or chemical treatment used to
sterilize and preserve the early homografts for implantation led to a shortened
life span. More recently, antibiotic solutions have been used to sterilize human
valves, which then are frozen in liquid nitrogen until implantation. Using these
techniques, weakness of the prosthesis leading to cusp rupture occurs
infrequently, with more than 75% of prostheses lasting for longer than 10 years
regardless of patient age. The incidence of prosthetic valve endocarditis and
hemolysis resulting from blood flow through the homograft is very low.
Anticoagulation is usually not required. Homografts are predominately used in
the aortic position, especially when aortic root replacement is necessary and
for pulmonary valve replacement in the Ross procedure. Homografts may be
most useful in patients younger than 35 and in patients with native valve
endocarditis.
5. Transcatheter valves. Valves utilized in the TAVR procedure have been
introduced and discussed earlier in this chapter. The classification of TAVR
valves falls into two main categories/types: balloon-expandable valves and
self-expanding valves. The Edwards valves initially used for the procedure
were balloon-expandable valves mounted in a steel frame, available in either
23-mm or 26-mm size. The newer generation of valve is the Edwards SAPIEN
XT (Edwards Lifesciences), which is made of bovine pericardium mounted in
a cobalt chromium frame. This valve is available in 20-, 23-, 26-, and 29-mm
sizes and is implanted using either 18-, 19-, or 22-Fr delivery catheter. Of note,
it appears that balloon-expandable valves typically have larger effective
orifice areas and lower gradients compared to surgical bioprosthetic valves.
As previously discussed, however, paravalvular regurgitation is a more
frequent issue with TAVR valves [27].
FIGURE 11.13 Edwards Prima Plus stentless bioprosthetic aortic valve. (Courtesy of Edwards Lifesciences, Irvine,
California.) (Reprinted with permission from Hensley FA, Martin DE, Gravlee GR. A Practical Approach to Cardiac
Anesthesia. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:345.)
CoreValve systems (Medtronic) first introduced for this procedure were self-
expanding valves made from bovine pericardium in a nitinol, self-expanding
frame. Subsequent modifications of this valve have occurred, most notably to
allow for true supra-annular placement of the valve. The current, third-
generation CoreValve is available in 26-, 29-, and 31-mm sizes and is
implanted using an 18-Fr delivery catheter. It appears as though the CoreValve
results in larger effective orifice areas and lower gradients than the SAPIEN
valves but is more likely to demonstrate paravalvular regurgitation following
deployment [27].
C. Echocardiographic evaluation of prosthetic valves in the aortic position
a. Evaluation for aortic prosthetic valve stenosis
(1) The 2D exam should focus on the sewing ring and valve leaflets. Doppler
interrogation should determine the mean transvalvular gradient, peak
velocity, contour of the jet velocity, acceleration time (AT), Doppler
velocity index (DVI), and the effective orifice area of the prosthesis.
FIGURE 11.14 Algorithm for the echocardiographic evaluation of elevated peak velocities in prosthetic valves in the aortic
position. DVI, Doppler velocity index; AT, acceleration time; PrAV, prosthetic aortic valve; LVOT, left ventricular outflow
tract; PPM, patient prosthesis mismatch.
*Pulse wave Doppler sample too close to the valve (particularly when jet velocity by continuous wave Doppler is ≥4 m/s.
**Pulse wave Doppler sample too far (apical) from the valve (particularly when jet velocity is 3–3.9 m/s.
Stenosis further substantiated by effective orifice area derivation compared with reference values if valve type and size are
(Reprinted with permission from Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic
valves with echocardiography and Doppler ultrasound. JASE. 2009;22(9):975–1014, Figure 11.10, p. 990.)
(2) The following findings are suggestive of significant stenosis: mean gradient
>35 mm Hg, peak velocity >4 m/sec, rounded symmetrical contour of the
Doppler velocity profile index (as opposed to early peaking triangular
shape), AT >100 msec, and DVI <25.
(3) Occasionally, there are normal prosthetic valves with elevated peak
velocities. Figure 11.14 presents a useful algorithm for determining if the
conflicting data are due to a high-flow state, measurement error, or
patient–prosthesis mismatch (Fig. 11.14).
b. Evaluation for aortic prosthetic valve regurgitation
(1) The same criteria in determining the severity of native aortic valve
regurgitation can be applied to prosthetic aortic valves.
(2) The 2D evaluation focuses on the sewing ring and valve leaflet motion.
Doppler interrogation allows determination of jet width in the LVOT,
pressure half time, the presence of holodiastolic flow reversal in the
descending thoracic aorta, and calculation of regurgitant volume and RF.
(3) Transthoracic echocardiography has limited ability to evaluate for
posterior paravalvular regurgitation, and TEE may add incremental value
if pathology is suspected in this location.
CLINICAL PEARL When performing TEE for TAVR procedures, it is especially
important to assess for the presence and location of paravalvular regurgitation, as this is
a common complication of the procedure that may need to be immediately addressed
with surgical intervention following initial valve deployment.
TABLE 11.7 Antibiotic recommendations for prophylaxis of bacterial endocarditis
D. Prophylaxis of bacterial endocarditis

When an invasive procedure puts the patient with valvular heart disease at risk of
bacteremia, precautions should be taken to prevent seeding of an abnormal or
artificial valve with bacteria that, once present, are very hard to eradicate.
Practically, this concern translates into (a) a strict aseptic technique for all
procedures performed in patients with valvular heart disease; (b) elimination of
existing sources of infection before implantation of a prosthetic valve; and (c) in
selected cases, antibiotic prophylaxis. Guidelines from the American Heart
Association and American College of Cardiology on prevention of infective
endocarditis limit antibiotic prophylaxis to cardiac conditions associated with
the highest risk of infective endocarditis [28]. These conditions include patients
with prosthetic cardiac valves (including transcatheter-implanted prostheses and
homografts) or material used in heart valve repair (i.e., annuloplasty rings and
chords), previous infective endocarditis, unrepaired cyanotic congenital heart
disease or repaired congenital heart disease with residual shunts or defects in the
proximity of the site of a prosthetic patch or device, and cardiac transplant
recipients with valvular disease. Endocarditis prophylaxis is recommended only
for “dental procedures that involve manipulation of gingival tissue or the
periapical region of teeth or perforation of the oral mucosa.” There is no
evidence to support the administration of antibiotic prophylaxis in
gastrointestinal or genitourinary procedures if there is no known active infection.
Guidelines for antibiotic prophylaxis, to be begun 1 hour prior to a procedure,
are shown in Table 11.7.
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12 Anesthetic Management for the Treatment of
Mitral and Tricuspid Valvular Heart Disease
Rabia Amir, Yanick Baribeau, and Feroze U.
Mahmood
I. Introduction
C. Pressure–volume loops (PV loops)
IV. Valvular heart disease
A. Mitral valve
B. Mitral valve stenosis
C. Mitral valve regurgitation
D. Mitral stenosis (MS) and mitral regurgitation (MR)
E. Tricuspid valve stenosis
F. Tricuspid valve regurgitation
V. Prosthetic valves
KEY POINTS
1. The increasing utilization of intraoperative transesophageal

echocardiography (TEE) has greatly expanded the role of the cardiac
anesthesiologist in operations for valve repair and replacement.
2. In patients with mitral stenosis (MS), particular attention should be
paid to avoiding any increases in pulmonary artery pressure (PAP)
due to inadequate anesthesia or inadvertent acidosis, hypercapnia,
or hypoxemia.
3. Bradycardia is harmful in patients with mitral regurgitation (MR),
leading to an increase in left ventricular (LV) volume, reduction in
forward cardiac output, and an increase in regurgitant fraction (RF).
The heart rate should be kept in the normal to elevated range.
4. The severity of MR can be underestimated under the altered loading
conditions of general anesthesia. Therefore, it is more appropriate to
grade the severity of MR by using the preoperative
echocardiographic examination.
5. In patients with tricuspid regurgitation (TR), high airway pressures
during pulmonary ventilation and agents that can increase PAP
should be avoided. If inotropic support is necessary, dobutamine,
isoproterenol, or milrinone, which dilate the pulmonary vasculature,
should be used.
I. Introduction
A. Despite the decline in open cardiac surgery volume due to advances in
interventional cardiology, valvular heart disease represents 10% to 20% of all
cardiac surgical procedures in the United States.
B. Approximately, 2.5% of the population in industrialized countries is affected by
valvular heart disease with the likelihood of developing valvular heart disease
increasing with age.
C. Valvular heart disease has intraoperative implications in that changes in
hemodynamic variables (heart rate and rhythm, preload, afterload, and
contractility) should be adequately compensated for physiologic optimization.
D. Intraoperative transesophageal echocardiography (TEE) has expanded the role of
the cardiac 1 anesthesiologist during valve repair and replacement surgeries
and provides an enhanced physiologic perspective through the dynamic display
of anatomy.
E. Additionally, intraoperative TEE provides real-time diagnostic interpretation to
guide surgical decision making.
F. Please refer to Chapter 16 for the management of pulmonary valve disease.
1. Stenotic lesions are associated with pathology related to pressure overload in
the upstream cardiac chamber.
2. The narrowed valvular orifice obstructs blood flow across the valve (during
systole in aortic and pulmonary valves; during diastole in mitral and tricuspid
valves) resulting in increased proximal pressure buildup. Flow converges as
blood reaches the stenotic valve with increased velocity and blood is ejected
through the orifice with simultaneous pressure drop and consequent increase in
the pressure gradient across the valve.
3. There are two types of valvular obstruction:
a. Fixed: The degree of obstruction to blood flow is constant throughout the
cardiac cycle.
b. Dynamic: The obstruction is present for only part of the cardiac cycle.
1. Regurgitant lesions cause pathology associated with volume overload that
results in chamber dilatation and eccentric hypertrophy.
2. The ventricles initially compensate for the increased volume load with
increased stroke volume but eventually function declines and irreversible
failure occurs.
3. The hemodynamic management of these patients focuses on maximizing forward
stroke volume (FSV) and minimizing regurgitant stroke volume.
1. Cardiac remodeling includes changes in the size, shape, and function of the
heart in response to an acute or chronic cardiac injury.
2. Cardiac injury in valvular heart disease is caused by alteration in ventricular
loading conditions. The ventricle is subjected to pressure and/or volume
overload, leading to cardiac remodeling in the form of ventricular hypertrophy
and chamber dilation.
3. Neurohumoral factors and enzymes, such as angiotensin II, ion channels, and
oxidative stress, also contribute to cardiac remodeling.
4. Remodeling is initially adaptive but eventually leads to decompensation and
deterioration in ventricular function.
5. Ventricular hypertrophy, defined as increased ventricular mass, can be
concentric or eccentric.
6. Pressure overload results in concentric ventricular hypertrophy where
ventricular mass is increased by myocardial thickening, and ventricular volume
stays constant.
7. Conversely, volume overload causes eccentric ventricular hypertrophy where
increased ventricular volume raises ventricular mass without changing
myocardial wall thickness.
1. Ventricular function is divided into systolic and diastolic functions.
a. Systolic function
(1) Represents the ability of the ventricle to contract and eject blood.
(2) Contractility is the intrinsic ability of the myocardium to contract and
generate force, independent of preload and afterload.
(3) Preload is the stretch placed on myocardium prior to contraction that
results from a combination of diastolic volume and filling pressure. It is
physiologically expressed as end-diastolic stress.
FIGURE 12.1 Normal pressure–volume loop (PV loop). First segment/phase 1 of the PV loop represents diastolic filling of
the left ventricle (LV). Phase 2 represents isovolumetric contraction and phase 3 represents ventricular ejection, and both these
phases constitute ventricular systole. Phase 4 represents the isovolumetric relaxation of the LV and along with phase 1
constitutes ventricular diastole. AC, aortic valve closure at end systole; MC, mitral valve closure at end diastole; MO, mitral
valve opening; AO, aortic valve opening. (Modified from Jackson JM, Thomas SJ, Lowenstein E. Anesthetic management of
patients with valvular heart disease. Semin Anesth. 1982;1:240.)
(4) Afterload is the load placed on the myocardium during contraction that
occurs from a combination of systolic volume and generated pressure. It
is physiologically expressed as end-systolic stress.
b. Diastolic function
(1) Represents the ability of the ventricle to accept inflowing blood.
(2) It consists of a combination of relaxation and compliance.
(3) Diastolic dysfunction is present when the heart requires higher
ventricular filling pressures to maintain normal diastolic ventricular
volume.
(4) Both systolic and diastolic functions require energy and can be
compromised by ventricular ischemia.
C. Pressure–volume loops (PV loops)
PV loops are used to illustrate ventricular function and performance with
ventricular pressure plotted on the y axis and the ventricular volume plotted on
the x axis for one cardiac cycle (Fig. 12.1). Both stenotic and regurgitant valvular
lesions display a characteristic PV loop pattern. Recognizing these patterns can
aid in the identification of lesions and helps to understand the altered ventricular
physiology and function.
IV. Valvular heart disease
A. Mitral valve
1. Anatomy
a. The mitral valve apparatus consists of mitral annulus and the suspension
network that comprises the leaflets, chordae tendineae and papillary muscles
(Fig. 12.2).
b. The anatomical junction between the left atrium (LA) and left ventricle (LV)
is represented by the mitral annulus, which is a three-dimensional (3D),
nonplanar, saddle-shaped, dynamic structure that changes size and shape
during the cardiac cycle.
IGURE 12.2 An illustration of the mitral valve apparatus demonstrating the anterior and posterior leaflets along with the
uspension network which is comprised of chordae tendineae and papillary muscles.
c. The anterior leaflet is attached to one-third of the annulus at its base and the
posterior leaflet is attached to the remaining two-thirds. The posterior leaflet
is divided by two indentations into three scallops that are named from lateral
to medial as P1, P2, and P3, respectively. The anterior leaflet is similarly
divided into three segments, A1, A2, and A3, which correspond to the
posterior scallops.
d. The leaflets meet at the posteromedial and anterolateral commissures with
two groups of papillary muscles situated beneath each commissure. At their
free edges, the leaflets are attached to the papillary muscles by the chordae
tendineae.
e. The chordae are divided into primary, secondary, and tertiary depending on
the location of attachment to the leaflets.
B. Mitral valve stenosis
1. Etiology
a. Mitral stenosis (MS) is the most common valvular sequela of rheumatic heart
disease and accounts for approximately 10% of all cases of MS in Europe.
b. Other causes of MS include degenerative (calcific) and congenital MS.
However, 99% of surgically excised stenotic mitral valves worldwide are
from fibrosis and scarring caused by rheumatic changes [1]. Women are twice
as likely to be affected as compared to men.
c. MS has a high mortality rate. Without surgery, 20% of all diagnosed patients
are likely to die within 1 year of diagnosis, and 50% die within a decade of
being diagnosed with MS.
2. Symptoms
a. Patients with MS from rheumatic heart disease may be asymptomatic for more
than two decades after the initial onset of rheumatic fever. Symptoms appear
with the development of stenosis over years and initially present during
exercise or high cardiac output states.
b. The progression of MS is slow with increasing episodes of fatigue, chest
pain, palpitations, shortness of breath, paroxysmal nocturnal dyspnea,
pulmonary edema, and hemoptysis, as well as hoarseness due to compression
of the left recurrent laryngeal nerve by a distended left atrium (LA) and
enlarged pulmonary artery. LA dilatation may also cause dysphagia through
esophageal compression.
c. Stenotic symptoms become more evident with the onset of atrial fibrillation
that also increases the risk of LA thrombi and subsequent cerebral or systemic
emboli. Chest pain may occur in 10% to 20% of patients with MS but is not a
good predictor of coexisting coronary artery disease (CAD), since it may be
attributed to other causes such as coronary thromboembolism or pulmonary
hypertension.
3. Pathophysiology
a. Natural progression
(1) The normal adult mitral valve area (MVA) is 4.0 to 6.0 cm2 (mitral valve
index: 4 to 4.5 cm2/m2). The symptoms of MS manifest with progressive
decreases in valve area, about 0.1 cm2 annually. Initially dyspnea may
occur with moderate exertion (valve area <2.5 cm2), along with the LA
enlargement and elevated LA volume and pressure that may predispose
to atrial fibrillation and increased blood in the pulmonary vasculature.
The degree of pulmonary hypertension is a marker of the global
hemodynamic consequences of MS, and severe pulmonary hypertension
is associated with a reduction in mean survival of <3 years.
(2) As the valve area further decreases between 1 and 1.5 cm2, symptoms of
MS may be present with mild to moderate exertion. Atrial fibrillation
can herald severe congestive heart failure (CHF) via impaired LA
contraction that normally contributes up to 30% of LV filling in MS. CHF
may also occur secondary to cardiac high-output states with increased
cardiac demand that cause rapid elevations of LA and pulmonary artery
pressures (PAPs).
(3) Severe MS with symptoms at rest manifests when valve areas go below 1
cm2. High LA pressures contribute to increased pulmonary vein
resistance and ensuing chronic pulmonary hypertension, right ventricular
(RV) dilation, and failure. The dilated, high-pressure RV may also cause
left-sided bowing of the interventricular septum, thereby further reducing
LV size, limiting stroke volume, impairing cardiac output, and resulting
in tricuspid regurgitation (TR) with further dilation.
(4) The smallest MVA compatible with life is 0.3 to 0.4 cm2.
b. Intracardiac hemodynamics and cardiac remodeling
(1) Significant MS is characterized by a reduced left ventricular end-
diastolic volume (LVEDV) and left ventricular end-diastolic pressure
(LVEDP) as the blood flow from the LA to the LV is restricted. Reduced
filling of the LV decreases stroke volume and LV contractility may also
decrease due to chronic LV deconditioning.
c. Pressure wave disturbances
(1) In patients with normal sinus rhythm, a large A wave hallmarks MS. If
associated MR is present, a pronounced V wave is also seen. The A
wave becomes small as LA contractility is impaired as a consequence of
severe MS and disappears completely with atrial fibrillation.
(2) PV loop in MS (Fig. 12.3). Stroke volume is reduced due to decreased
LV filling pressures and low end-diastolic and end-systolic volumes.
4. Imaging approach
a. TTE is most commonly used to demonstrate mitral valve morphology and
grade the severity of MS. However, several acquired and congenital
abnormalities of the mitral valve are treated with surgery, and TEE is
uniquely suited to view the mitral valve intraoperatively due to its location. It
is routinely used for preoperative assessment that involves the identification
of the mechanism, extent, and severity of lesions affecting the mitral valve, as
well as for the determination of postoperative success.
b. In recent years, 3D echocardiography has opened another dimension of
imaging by allowing fast acquisition of images, enhanced visualization of the
valvular anatomy, and improved diagnosis of the mechanism of various
pathologies. In particular, leaflet pathology is better appreciated with real-
time 3D TEE.
IGURE 12.3 Pressure–volume loop (PV loop) in mitral stenosis (MS). Due to the reduction in end-diastolic and end-systolic
olumes and LV filling pressure, the stroke volume is decreased in MS. AO, aortic valve opening; MC, mitral valve closure; MO,
itral valve opening; AC, aortic valve closure. Phase 1, ventricular filling; phase 2, isovolumetric contraction; phase 3, ventricular
ection; phase 4, isovolumetric relaxation. (Modified from Jackson JM, Thomas SJ, Lowenstein E. Anesthetic management of
atients with valvular heart disease. Semin Anesth. 1982;1:244.)
c. A stress test may be used when there is a discrepancy between symptoms and
resting Doppler echocardiographic findings.
(1) TEE findings: Traditionally, the mitral valve is examined with the
midesophageal (ME) four-chamber, ME mitral commissural, ME long-
axis (LAX), and transgastric (TG) basal short-axis (SAX) views, with
and without color flow Doppler (CFD) (Fig. 12.4). Patients with MS
secondary to rheumatic fever have distinct echocardiographic features
such as progressive leaflet thickening, calcification, and limited mobility
due to chordal and/or commissural fusion. Restricted motion of the
anterior mitral valve leaflet in diastole presents as “doming” and is
described as a “hockey-stick” appearance. The posterior leaflet may also
be identified as immobile with echocardiography (Video 12.1). LA
enlargement with spontaneous echo contrast is associated with a low-
flow state and should prompt exclusion of thrombi, especially in the LA
appendage. MR may also be present and can be qualitatively and
quantitatively assessed using TEE.
IGURE 12.4 Stenosis of mitral valve seen during ventricular diastole in midesophageal (ME) four-chamber view.
TABLE 12.1 Echocardiographic grouping follows the echocardiographic and fluoroscopic

(calcification) evaluation of the following characteristics: valve mobility,
fusion of the subvalvular apparatus, and the amount of leaflet calcification
(2) Assessment of morphologic features with two-dimensional (2D)

echocardiography such as leaflet thickness, leaflet mobility and
flexibility, leaflet calcification, and commissural and subvalvular fusion
can be used for different scoring systems, including the commonly used
Wilkins score where each feature is graded on a scale of 1 to 4, yielding
a maximal score of 16 [2].
(3) Echocardiographic grouping (Table 12.1) [3] follows the
echocardiographic and fluoroscopic (calcification) evaluation of the
following characteristics: valve mobility, fusion of the subvalvular
apparatus, and the amount of leaflet calcification.
(4) These scores are used to grade mitral valve pathology, determine
suitability for treatment options such as percutaneous mitral balloon
valvuloplasty, and predict successful repair [4].
5. Assessment of severity
a. The severity of MS should not be described by a single value but should be
evaluated using a multimodality approach that establishes pulmonary
pressures, valve areas, and mean Doppler gradients (Table 12.2). These can
be calculated using echocardiography and, sometimes, cardiac catheterization
to measure the MVA or a diastolic pressure gradient across the mitral valve.
The different methods for grading MS severity are summarized in Table 12.2.
b. Routine assessment of the severity of MS involves the combination of mean
gradient using the pressure half-time (PHT) method and planimetry,
respectively. However, the mean gradient and systolic PAP cannot be
considered as surrogate markers of the severity of MS as they are largely
supportive signs.
c. The most commonly used method is the PHT method, utilizing continuous
wave Doppler where prolongation of the PHT corresponds to a decrease in
mitral valve orifice area. A normal PHT is relatively short and correlates to
the rapid early diastolic filling of the LV and the associated rapid fall in the
LA-to-LV pressure gradient during this early filling phase. Since the LA-to-
LV pressure gradient is increased for a longer period in MS, the PHT will
become more prolonged as the degree of stenosis worsens.
d. Planimetry involves the direct tracing of the elliptical mitral valve orifice
area during mid-diastole utilizing the lowest gain setting to visualize the entire
orifice area. The smallest orifice area is determined by scanning the LV from
the apex to the base. Two-dimensional parasternal SAX view is routinely
used and can be augmented with 3D echo to orient the positioning of the
measurement plane.
e. The continuity equation uses the principle of the conservation of mass but
requires a series of measurements that increase the impact of errors of
measurements. It is difficult to use for MS severity since it cannot be used in
the presence of atrial fibrillation or significant mitral or aortic regurgitation.
TABLE 12.2 Quantification of severity of MS
f. The proximal isovelocity surface area (PISA) method allows the estimation of
mitral volume flow by dividing mitral volume flow by the maximum velocity
of diastolic mitral flow as assessed by Continuous Wave Doppler
interrogation (CWD). While it is technically demanding, it is independent of
flow conditions and can be used in the presence of significant regurgitation.
g. The pressure gradient is dependent on transmitral flow and heart rate and,
therefore, may be a less accurate method to evaluate MS severity.
6. Timing and type of intervention
a. Since irreversible ventricular dysfunction may occur, early surgical
intervention is recommended; however, surgery is only recommended for
those patients demonstrating symptoms of MS.
b. For those with mild to moderate MS (MVA 1–1.5 cm 2), conservative
management with regular clinical and echocardiographic examinations every
2 years is recommended. Patients with severe MS (MVA <1.0 cm 2) who are
asymptomatic can be assessed annually.
c. The decision to proceed with surgery depends on the individual and their
unique situation, taking into account preoperative risk factors, the mitral valve
orifice size, indicators of systemic embolization, the presence and severity of
pulmonary hypertension, as well as the lifestyle desired.
d. Once the systolic PAP surpasses 30 mm Hg, surgical intervention will likely
be needed [4]. The four treatment options for rheumatic MS are:
(1) Mitral valve replacement
(2) Open mitral commissurotomy
(3) Closed commissurotomy
(4) Balloon mitral valvuloplasty
e. Closed mitral commissurotomy can only be performed for patients without
atrial thrombosis, significant valvular calcification, or chordal fusion. It can
be performed without cardiopulmonary bypass (CPB); however, this
procedure is rarely done in the United States and has been replaced by mitral
balloon valvuloplasty as the treatment of choice for rheumatic MS.
f. Balloon mitral valvuloplasty is a percutaneous interventional procedure
routinely performed in the cardiac catheterization laboratory under general
anesthesia or conscious sedation. It involves the gradual progression of a
balloon catheter through the interatrial septum that is inflated at the mitral
orifice to split and open fused commissures, increasing MVA. TEE is used in
addition to fluoroscopy to guide the catheter and assess possible thrombi
formation.
g. Contraindications to balloon mitral valvuloplasty in addition to CAD that
requires coronary artery bypass grafting (CABG) and concomitant severe
valvular diseases include MVA >1.5 cm 2, moderate or severe MR, severe
calcification, evidence of LA thrombi, and lack of commissural fusion. It is
relatively contraindicated in MS not due to commissural fusion [5,6].
h. Immediate good results are noted in the majority of patients with the MVA
enlarging to an average of 1.9 to 2.0 cm2, after balloon mitral valvuloplasty.
i. Severe MR, lasting atrial septal defect, and systemic embolism may occur as
possible complications of the procedure.
j. Both commissurotomy and balloon mitral valvuloplasty lower the severity of
stenosis, delaying surgical intervention that is eventually required to relieve
the stenosis. While anticoagulation is rarely required in this time period and
morbidity is lower when compared to an indwelling prosthetic valve, these
procedures still carry a significant risk of restenosis.
k. Mitral valve replacement is required if commissurotomy or balloon mitral
valvuloplasty cannot be performed. In the presence of chronic atrial
fibrillation, the maze procedure or the creation of fibrous scar tissue to disrupt
atrial reentry pathways in the LA can also be performed during surgical
intervention.
7. Goals of perioperative management
a. Hemodynamic management
(1) LV preload
(a) Given the elevated LA pressures and pulmonary vascular congestion
of MS, TEE is the ideal modality used to monitor volume status
intraoperatively and is preferred over more invasive techniques
such as pulmonary artery catheters. Adequate preload is necessary
to facilitate forward flow across the stenotic valve. Aggressive
fluid loading can exacerbate pre-existing CHF into florid pulmonary
edema.
(2) Heart rate
(a) While in theory bradycardia assists hemodynamic stability in MS,
stroke volume generally cannot match excessively low heart rates.
Atrioventricular pacing may be challenging, and a long PR interval
of 0.15 to 0.2 msec will prevent declines in diastolic flow that
could decrease cardiac output. Induction of tachycardia should be
avoided.
(3) Contractility
(a) End-stage MS may be marked by severe CHF due to LV
deconditioning. Atrial filling may also be limited by RV
contractility. Both these factors can lower cardiac output, which
may be hazardous during surgery. Inotropic support is encouraged
prior to initiation and completion of CPB.
(4) Systemic vascular resistance
(a) Decreased cardiac outputs in patients with MS result in elevated
systemic vascular resistance. Afterload reduction in these patients
does not improve the forward flow, and it is critical to maintain
afterload in the normal range.
(5) Pulmonary vascular resistance (PVR)
2 (a) Pulmonary vasoconstriction develops rapidly in these patients in
the setting of hypoxia, inadequate anesthesia, hypercapnia, or
acidosis due to pre-existing elevated PVR.
b. Anesthetic technique
(1) Premedicate with caution in these patients to avoid sudden decreases in
preload or exacerbation of pre-existing pulmonary hypertension via a
slow respiratory drive and concomitant hypoxia and hypercapnia. In the
onset of new atrial fibrillation, cardioversion is suggested.
(2) Proceed cautiously while inserting pulmonary artery catheters for
perioperative management in these patients due to the risk of pulmonary
artery rupture. Note that wedge pressures are often inaccurate and do not
reflect LVEDP. Also monitor PAPs carefully as they may rise suddenly
due to causes stated above.
CLINICAL PEARL With severe MS, pulmonary capillary wedge pressure is usually
elevated, yet LVEDP is reduced.
(3) Mitral valve repair can be assessed using TEE. Complications following
mitral valve repair such as paravalvular leaks and systolic anterior
motion of mitral valve can be recognized early while simultaneously
evaluating ventricular function.
(4) CPB can depress myocardial contractility, including those with normal
preoperative LV function. Therefore, fluids should be initiated with care
to prevent ventricular failure. Cardiac output can be maintained by using
inotropes, vasopressors, and by amiodarone prophylaxis in patients with
chronic atrial fibrillation.
c. Postoperative course
(1) A successful postoperative surgical course is evident as early as
postoperative day 1 by a robust cardiac output accompanied by reduced
pulmonary arterial and LA pressures as well as reduced PVR. While a
mean pressure gradient of 4 to 7 mm Hg usually persists after prosthetic
valve replacement, PVR in most patients continues to decrease. Failure
of the PAP to decrease is usually a sign of irreversible pulmonary
hypertension and/or irreversible LV dysfunction, which are indicators of
poor prognosis.
C. Mitral valve regurgitation
1. Natural history
The spectrum of MR varies from acute forms, in which rapid deterioration of
myocardial function can occur, to chronic forms that have slow indolent
courses. MR may result from mitral valve leaflet abnormalities, mitral annulus
dilation, chordae rupture, papillary muscle disorder, global LV dysfunction, or
disproportionate LV enlargement.
a. Acute MR
(1) Acute MR may result from papillary muscle dysfunction due to
myocardial ischemia or papillary muscle rupture due to myocardial
infarction or blunt chest trauma. Chordae tendineae rupture can be caused
by myxomatous disease of the mitral valve or acute rheumatic fever. A
mitral valve leaflet can acutely deteriorate as a result of infective
endocarditis, balloon valvuloplasty, or a penetrating chest injury.
b. Chronic MR
(1) Mitral annulus dilatation may result from LV dilatation due to dilated or
ischemic cardiomyopathy or aortic insufficiency. It can also develop
from LA enlargement in patients with diastolic dysfunction, for example,
AS or systemic hypertension. Finally, mitral annulus dilatation will
eventually exacerbate MR of any other cause secondary to LA and LV
enlargement and stretching of the annulus.
(2) Disorders of the mitral leaflets include mitral valve prolapse that may be
idiopathic or caused by rheumatic fever or myxomatous degeneration,
mitral leaflet damage by infective endocarditis, and restrictive changes
due to thickening or calcification from any inflammatory or degenerative
process. Restriction can also be caused by disproportionate enlargement
of the LV in relation to papillary muscles and chordae tendineae causing
incomplete mitral valve closure. This occurs in a majority of cases of
ischemic MR.
TABLE 12.3 Classification scheme used to describe differing mechanisms of mitral
regurgitation (MR) based upon the leaflet motion of the valve
(3) Disorders of the subvalvular apparatus. Rupture or elongation of chordae
tendineae may occur in myxomatous degeneration. Rheumatic heart
disease may lead to chordae tendineae rupture, thickening, and calcium
deposition in the subvalvular apparatus. Depending on the type and
number of chordae ruptured, subsequent MR may range from acute to
chronic and from mild to severe.
(4) Functional MR. MR that occurs in the setting of normal leaflets and
chordal structures is frequently due to functional MR. This phenomenon
is not fully understood but is most likely the result of global LV
dysfunction, which results in disruption of the normal geometric
relationship between the mitral valve leaflets, papillary muscles, and
LV. The LV dysfunction results in ventricular and annular dilatation and
a more spherical appearance of the LV, which ultimately disrupts the
normal structure and function of the entire mitral apparatus. Ischemic MR
is a type of functional MR that is caused by ischemic heart disease.
c. Carpentier’s classification
(1) This widely recognized classification scheme is used to describe
differing mechanisms of MR based upon the leaflet motion of the valve
(Table 12.3) [7].
2. Pathophysiology
(1) Acute
(a) Acute MR often presents as biventricular failure. With the loss of
normal LA compliance, rapid rises in LA and PAP lead to
pulmonary congestion, pulmonary edema, and right heart failure.
Heart rate is also increased in an effort to maintain cardiac output
but prevents complete emptying of the LV, raising LV volume and
end-diastolic pressure that cause ischemia and further exacerbate
LV dysfunction.
(2) Chronic
(a) LA dilatation and eccentric hypertrophy mark the gradual
development of chronic MR. Primarily, LV dilation maintains an
adequate LVEDP despite increased volume and preserves forward
cardiac output by an overall increase in the FSV. However, once
LV dilatation and hypertrophy can no longer meet the necessary
FSV to maintain cardiac output, LV dysfunction ensues and
symptoms of heart failure manifest. LA dilatation also causes
widening of the mitral annulus, thereby worsening regurgitation and
contributing to elevated PAPs, pulmonary congestion, and
ultimately, RV dysfunction and failure. It also results in the
development of atrial fibrillation and increases the risk of
thrombosis.
IGURE 12.5 Pressure–volume loop (PV loop) in acute and chronic mitral regurgitation (MR). In chronic MR, there is an
crease in end-diastolic volume without significant increase in LV filling pressures. Whereas in acute MR, the increase in end-
astolic volume is associated with an increase in LV filling pressure. AO, aortic valve opening; MC, mitral valve closure; MO,
itral valve opening; AC, aortic valve closure. Phase 1, ventricular filling; phase 2, isovolumetric contraction; phase 3, ventricular
ection; phase 4, isovolumetric relaxation. (Modified from Jackson JM, Thomas SJ, Lowenstein E. Anesthetic management of
atients with valvular heart disease. Semin Anesth. 1982;1:248.)
b. Intracardiac hemodynamics and cardiac remodeling

(1) In acute MR, maintaining the stroke volume requires dilation of the LA.
This is accomplished by an increase in the LVEDP. In contrast, in
chronic MR, the LVEDP remains normal until the MR has progressed to
a severe stage.
c. Pressure wave disturbances
(1) The compliance of the LA, the compliance of the pulmonary vasculature,
the amount of pulmonary venous return, and the regurgitant volume, all
collectively determine the size of the regurgitant wave (“giant V wave”)
on pulmonary capillary wedge tracing. V waves develop in patients with
acute MR that are absent in patients with chronic disease due to
increased atrial compliance. A PV loop characteristic for MR is
illustrated in Figure 12.5.
d. TEE
(1) The baseline TEE examination should focus on the underlying pathology,
while a more thorough examination should focus on the structure and
function of the valvular apparatus involved as well as the LV function
(Figs. 12.6 and 12.7). The first assessment is necessary for initial
surgical decision making. Once it is decided that mitral repair will
occur, the TEE examination should focus on identifying any predictors of
postrepair systolic anterior motion (SAM), a noted complication of this
procedure that can cause critical postoperative hemodynamic instability.
Several factors can predispose patients to SAM, such as the presence of
a myxomatous mitral valve with redundant leaflets, especially excessive
anterior leaflet tissue in a nondilated, hyperdynamic LV. After repair,
decreased distance between the mitral valve coaptation point and the
ventricular septum (C-sept distance) can also result in SAM [8].
IGURE 12.6 TEE with color flow Doppler (CFD) interrogation demonstrates regurgitation of mitral valve during ventricular
CLINICAL PEARL The severity of MR is often underestimated under the altered loading
conditions of general anesthesia, and so it is more appropriate to grade the severity of MR
using the preoperative echo examination.
3. 3 Assessment of severity
a. Echocardiography has completely replaced the angiocardiographic dye
clearance as the preferred method to assess MR severity.
b. Echocardiographic assessment of MR (Table 12.4)
c. Quantitative assessment of MR
(1) The intraoperative approach to MR begins with quantification of the
regurgitation with PISA or jet area followed by identification of the
mechanism of the lesion based on Carpentier’s classification [9].
IGURE 12.7 Midesophageal (ME) LAX view demonstrating flail of the posterior mitral valve leaflet in severe mitral
gurgitation (MR). Also see Video 12.2.
TABLE 12.4 Echocardiographic assessment of MR
(2) The next step involves geometric quantification with determination of

annular dimensions, length of the leaflets, ventricular dimensions, and
indices of annular leaflet and ventricular remodeling. Before
commencing CPB, predictors of repair failure should be analyzed such
as mitral annular calcification, severity of annular dilatation, and
susceptibility to systolic anterior motion. Once the patient has been
separated from CPB, a postrepair evaluation of surgical success is
conducted by excluding stenosis with planimetry and PHT and excluding
moderate or greater regurgitation [9].
(3) The most conventional methods of MR severity assessment utilize 2D
TEE with CFD (Video 12.3). While it is mostly used for diagnosis of
MR and not MR quantification, the general assumption remains that the
larger the jet area, the more severe the MR. However, this is influenced
by technical factors, loading conditions, and jet eccentricity.
(4) The vena contracta is the narrowest point of the area of the jet as it
leaves the regurgitant orifice. It is measured with an adapted Nyquist
limit for optimal visualization and can be used to grade MR. Vena
contracta width of 3 mm indicates mild MR and ≥7 mm is quantified as
severe [8]. Its utility is limited, however, since it cannot accurately
discriminate mild from moderate or moderate from severe MR. A second
method is required if intermediate values are found. Other limitations of
this method include the assumption that the regurgitant orifice is circular;
its value is unclear in multiple jets.
(5) Flow convergence is the recommended method of quantifying MR, when
possible. The Nyquist limit is reduced for PISA visualization and the
radius is measured at mid-systole. From this, regurgitant volume and
effective regurgitant orifice area (EROA) can be obtained. With these
values, MR can be graded into mild, moderate, or severe. It is also
possible to make subclassifications of mild to moderate or moderate to
severe. This method is especially useful for eccentric jets but also relies
on geometrical assumptions of the orifice form. It is influenced by
hemodynamics and not valid for multiple jets.
4. Surgical intervention
a. Mitral valve repair is the recommended surgical intervention for MR before
mitral valve replacement is attempted. Mitral valve repair is advantageous in
that both chronic anticoagulation (with mechanical valves) and future
reoperation for prosthetic valve failure (with bioprosthetic valves) are
avoided. Most importantly, LV function is better preserved after mitral valve
repair. Disruption of the mitral valve apparatus interferes with LV function,
leading to LV dysfunction. This situation may arise from a mitral valve
replacement and can be avoided by a mitral repair since the apparatus
remains intact. In symptomatic patients with New York Heart Association
(NYHA) class II heart failure and/or chronic or recurrent atrial fibrillation
resulting from MR, surgical intervention is strongly endorsed. In
asymptomatic patients, the decision to wait or go ahead for surgery depends
on the presence of LV enlargement, dysfunction, and pulmonary hypertension,
with the onset of LV dysfunction being the most important indicator for
surgery in these patients. A stress echo can be done to search for latent LV
dysfunction. If chances of repair are good, early surgery is recommended
because good long-term results are likely and anticoagulation is not needed. If
CABG is indicated and at least moderate ischemic MR is present, mitral
valve repair/replacement at the same time as CABG is beneficial. In this
scenario, successful mitral valve repair is often straightforward, requiring
only placement of an annuloplasty ring.
b. The MitraClip transcatheter mitral valve repair procedure reduces MR
severity and symptoms in patients not suitable for surgery.
c. Suitability for repair
(1) Generally, easily reparable mitral valve lesions include leaflet
perforation, mitral valve annulus dilatation, and excessive motion of
mitral valve leaflets. Conditions more difficult to repair include
restricted leaflet motion, severe calcification, and active infection. The
greatest success for mitral valve repairs involves isolated lesions of the
posterior mitral valve leaflet.
(2) Three-dimensional echocardiography allows the generation of dynamic
LA en face surgical views to help in the diagnosis of MR. A similar LV
en face view can be obtained simultaneously among other views. These
views aid in establishing Carpentier’s classification of MR prior to the
initiation of CPB intraoperatively. Accurate diagnosis of valve pathology
is provided with display of mitral valve apparatus in CFD. The
determination of the etiology of degenerative MR can be accomplished
via parameters of mitral valve geometry from real-time 3D
echocardiographic images, particularly using the billowing height and
volume [9].
(3) Degenerative MR. About 70% of the cases of MR result from
degenerative valve disease; these valves are considered the most apt for
repair. However, the decision to repair a regurgitant mitral valve
surgically depends on a number of clinical and echocardiographic
factors. Degenerative MR with multiple (≥3) scallop involvement in both
leaflets, severe mitral annular calcification especially anteriorly,
presence of a large central regurgitant jet, and severe dilatation of the
mitral valve (>5 cm) suggest unsuitability for repair. On the other hand,
relatively longer posterior and chordal lengths and younger age are
encouraging predictors for mitral valve repair surgery [9]. In patients
with large valve perforation who have previously suffered from infective
endocarditis and in patients with rheumatic valve disease, lack of valve
tissue is also a significant predictor of unsuccessful repair.
(4) Ischemic functional MR. Significant MR can occur in the presence of
normal-appearing mitral valve apparatus due to commissural
involvement and posterior leaflet clefts and grooves that appear as >50%
and <50% indentations, respectively. Three-dimensional TEE can
differentiate these findings from ischemic tethering, further clarifying the
etiology of MR. Tethering eventually causes widening of the size of the
regurgitant orifice, shifting the coaptation point below the plane of the
mitral annulus, resulting in a tented appearance of the valve.
Malcoaptation of the leaflets and interscallop regions causes MR, and
the degree of tethering can be used as a surrogate marker for the
chronicity and significance of MR. During a standard 2D TEE, the
distance between the plane of the mitral annulus and the coaptation point
during systole is measured in the ME 4-Ch or ME LAX view and is
called the tenting height. The tenting height is directly related to MR and
a tenting height >0.6 cm is considered abnormal [9]. Three-dimensional
echocardiography provides other tenting indices like mitral valve tenting
area that is a strong marker for MR severity in ischemic cardiomyopathy
patients and tenting volume that correlates well with functional MR
caused by dilated cardiomyopathy.
(5) Around half of the patients with ischemic functional MR undergoing
repair face the probability of repair failure if they have the following
features on intraoperative TEE: systolic tenting area ≥1.6 cm2, severe
functional ischemic MR, and mitral diastolic annulus diameter of 37 mm
[8]. Preoperative TTE can also point to certain indicators of
unsuccessful repair. These include systolic tenting area >2.5 cm2, a
higher posterior leaflet restriction with a posterior leaflet angle >45
degrees, and coaptation distance >1 cm. A large central jet, multiple
central and posteromedial complex jets, and severe LV dilatation also
decrease the likelihood of successful MR repair.
(1) LV preload
CLINICAL PEARL In patients with MR, preload augmentation and maintenance is patient
specific and can be accurately determined by evaluating the patient’s clinical and
hemodynamic response to a fluid load.
(a) Preload augmentation and maintenance is largely patient specific
and can be effectively gauged by assessing the patient’s clinical and
hemodynamic response to a fluid load. However, it is routinely
useful in determining appropriate FSV.
(2) Heart rate
(a) Atrial fibrillation is increasingly common in patients receiving
surgical intervention 4 for MR, particularly in those with chronic
disease. Low heart rates can be extremely deleterious in this
population due to consequent LV volume increase and cardiac
output reduction.
(3) Contractility
(a) The eccentric hypertrophy of MR principally affects the FSV.
Clinical deterioration follows LV dysfunction secondary to loss of
myocardial contractility. Inotropic agents therefore play a key role
in management by augmenting forward flow and diminishing
regurgitation via mitral annular contraction.
(a) Afterload reduction is desired since increased afterload leads to an
increase in regurgitant fraction (RF) and consequently a reduction in
systemic cardiac output.
CLINICAL PEARL PVR is increased in patients with severe MR elevating pulmonary
pressure and raising LA pressure.
(5) Pulmonary vascular resistance (PVR)
(a) The importance of each component in elevating PAP can be
determined by calculating PVR using the following formula:
Avoid situations that may lead to pulmonary constriction such

hypercapnia, hypoxia, nitrous oxide, and inadequate anesthesia in
patients with high PVR.
(1) Premedication
(a) Light medication is usually adequate.
(2) Induction and maintenance of general anesthesia.
(a) The hemodynamic goals for induction and maintenance of anesthesia
center around maintaining a heart rate of 90 beats/min by preserving
ventricular contractility and controlling systemic vascular
resistance. Cautious use of volatile anesthetics, narcotics, and
anxiolytics usually involves titration. Pulmonary edema as a
consequence of rapid rises in PAP can sometimes occur in intubated
patients who have not been appropriately anesthetized.
(3) Pulmonary artery catheters
(a) Rapid increases in PAPs can occur subsequent to LV dysfunction or
pulmonary vasoconstriction. This ventricular dysfunction may be
precipitated by ischemia or vasoconstriction secondary to
inadequate anesthesia. Pulmonary artery catheters in addition to
regulating fluid therapy can also be invaluable in the timely
detection and management of these sudden elevations.
(b) This reversible pulmonary hypertension adequately responds to both
nitric oxide as well as hyperventilation with minimal increase in
intrathoracic pressures while preserving systemic pressures.
Alternatives include inhaled milrinone and prostaglandin E1.
(4) TEE
(a) Post bypass, TEE is invaluable for the assessment of the adequacy
of valvular repair and allows communication with the surgical team
to address any significant complications such as paravalvular leaks
or significant residual regurgitation.
(b) Assessment of the mitral valve after repair involves critical
decision making and is time sensitive. It is performed immediately
post procedure to exclude left ventricular outflow tract obstruction
(LVOT) caused by SAM of redundant leaflets or significant
regurgitation or stenosis. The echocardiographic principles for
postrepair evaluation are the same for both prosthetic and native
valves and include multiple ME and TG views of the repaired
mitral valve to ensure normal function.
(c) Successfully repaired mitral valves when judged by the criteria used
for native valves should have no more than mild MR immediately
after separation from CPB. The most frequent method used for
visual quantification of MR in the immediate post-CPB period is jet
with CFD. Immediate success of repair is shown by lack of
significant stenosis or regurgitation on CFD that also shows
instantaneous adequacy of the valve. Other methods of
quantification such as EROA or vena contracta are challenging and
time consuming due to change in the mitral valve anatomy after
repair. Three-dimensional echocardiography further strengthens the
accuracy of quantitative evaluations and gives evidence for long-
term durability of the valve by providing information on structural
integrity.
(d) Normal leaflet motion and structural stability of the prosthetic
device are shown through LA and LV en face views of the mitral
valve. The ME LAX view also helps exclude and document the
extent of SAM if present. The echocardiographic investigation of
SAM consists of 2D confirmation of anterior leaflet motion and
LVOT velocity of >2 m/sec, CFD evidence of turbulence with an
anteriorly directed eccentric MR jet in LVOT, and early closure of
the aortic valve in M-mode. Three-dimensional imaging can further
provide conclusive proof of complete or partial LVOT obstruction
by SAM over the LVOT in more complex cases.
(e) Reduction in the MVA occurs after mitral valve repair with
annuloplasty. LA/LV compliance and hemodynamic stability
fluctuate in the immediate post-CPB period. Thus, the role of the
PHT method to calculate MVA after repair is controversial. After a
complete physical and CFD examination of the repaired mitral
valve is done, MVA should be calculated by Doppler assessment of
transvalvular flow. Three-dimensional planimetry accounts for the
nonplanar shape of the mitral annulus and has shown promise in
tracing out the mitral valve orifice. However, all of these methods
have certain limitations and must be interpreted contextually with
the given clinical circumstances such as PHT with LVEDV and
gradients with cardiac output (transvalvular flow).
(5) Weaning from CPB
(a) Postoperatively, LV function is compromised more severely in
patients who have received mitral valve replacements due to
extensive resection of the subvalvular apparatus. These patients
therefore require robust inotropic support compared to their
counterparts who have received mitral valve repairs. Postbypass
inotrope use is also determined by several factors including LV
ejection fraction, degree of regurgitation, aortic cross-clamp time,
and presence of pulmonary hypertension. Rarely intra-aortic
balloon pumps may be required to maintain LV structure and
function. Prophylactic treatment with amiodarone may ensure
maintenance of sinus rhythm and is also commonly used if a maze
procedure was performed concurrently.
c. Postoperative course
(1) Cardiac output remains dependent on high LA pressures in patients with
established MR, despite lowering of PAPs and LA pressure following
D. Mitral stenosis (MS) and mitral regurgitation (MR)
1. Rheumatic MS most commonly coexists with MR.
2. The predominant lesion determines which hemodynamic considerations must be
used for decision making in patients with combined MS and MR.
3. Optimal stabilization requires normalization of afterload, heart rate and
contractility, maintenance of adequate preload, and avoidance of agents or
conditions that lead to pulmonary constriction.
4. Patients with multivalve disease are always a higher-risk group than those
patients with single-valve lesions.
E. Tricuspid valve stenosis
1. Natural history
a. Etiology
(1) Tricuspid stenosis can be congenital, carcinoid, or most commonly
caused by rheumatic valvulitis. Rheumatic tricuspid stenosis is rare and
regularly associated with concomitant TR as it almost never exists in
isolation. The mitral valve is involved in most cases. Endocardial
fibroelastosis, right atrial tumor, systemic lupus erythematosus, and
carcinoid syndrome are other causes for tricuspid stenosis.
b. Symptoms
(1) Tricuspid stenosis is apparent in the signs and symptoms of right-sided
heart failure, which includes peripheral edema, hepatic dysfunction,
ascites, hepatomegaly, and jugular venous distention.
2. Pathophysiology
(1) Composed of three leaflets (anterior, posterior, and septal), the tricuspid
valve is the largest cardiac valve with a normal area of 7 to 9 cm2 in the
typical adult. The normal gradient across the tricuspid valve is only 1
mm Hg. By the time the valve opening decreases to less than 1.5 cm2, the
tricuspid valve has endured significant degradation and severely
impaired forward blood flow. As a result, as the stenosis develops, there
is a long asymptomatic period. A mean gradient of 3 mm Hg across the
tricuspid valve typically correlates to a valve area of 1.5 cm2. The right
atrial pressure (RAP) increases, right atrium dilates, and forward blood
flow decreases during progression of the stenosis.
b. Calculation of severity
(1) Cardiac catheterization and echocardiography can be used to grade the
severity of tricuspid stenosis by calculating orifice area and pressure
gradient. A severe stenosis is indicated in a gradient of 5 mm Hg across
the tricuspid valve and tricuspid valve area of 1 cm2.
c. TEE
(1) Patients with rheumatic tricuspid stenosis will demonstrate thickened
leaflets with restricted motion and diastolic doming, often accompanied
by fusion of the commissures. For functional tricuspid stenosis, a right
atrial mass is apparent and responsible for the obstruction of RV inflow.
CWD can be used to assess the pressure gradients for the valve and
subsequently grade the severity of the stenosis.
3. Surgical intervention
a. Salt restriction, diuretics, and digitalization reduce surgical risks in patients
with severe tricuspid stenosis by improving hepatic function, reducing hepatic
congestion, and delaying the surgery. Most patients with tricuspid stenosis
have additional valvular lesions that require operation. If pressure gradients
exceed 5 mm Hg or valvular area is less than 2 cm2, tricuspid valve
intervention is indicated. A low-profile prosthetic valve may be necessary for
extensive calcification. Otherwise, commissurotomy of the tricuspid valve is
usually sufficient.
(1) RV preload
(a) Adequate preload is key to maintaining forward flow across the
stenotic tricuspid valve.
(2) Heart rate
(a) Normal sinus rhythms must be maintained in patients with tricuspid
stenosis. Both supraventricular tachyarrhythmia and bradycardia
can be harmful. The former can cause rapid cardiac deterioration
and should be controlled with immediate cardioversion or
pharmacologic intervention, while the latter can reduce total
forward flow and should be treated pharmacologically or via
pacing.
(3) Contractility
(a) Adequate cardiac output is maintained by an increase in RV
contractility, and tricuspid stenosis impedes initial RV filling. A
sudden drop in ventricular contractility can critically restrict
cardiac output and increase RAP.
(a) In patients with limited blood flow over the tricuspid valve,
systemic vasodilation can exacerbate hypotension.
(5) PVR
(a) Reducing PVR has little benefit in improving forward flow because
forward flow limitation is found at the tricuspid valve. Maintaining
PVR in the normal range is desired.
(1) Minimal premedication is indicated.
(2) In patients with isolated tricuspid stenosis, the anesthetic goals include
maintenance of high preload, high afterload, and adequate contractility.
In patients with coexisting mitral valve disease, the anesthetic technique
usually depends on the type of mitral valve lesion.
(3) Insertion of a pulmonary artery catheter through the stenotic tricuspid
valve can be troublesome and not always warranted. Often, the catheter
can be kept in the superior vena cava (SVC) until after bypass and then
moved ahead by the surgeon upon completion of tricuspid valve
repair/replacement. The catheter can also be floated after weaning from
CPB. Clear communication with the surgeon prior to the beginning of the
operation is recommended.
(4) During CPB, SVC drainage must be carefully tended to in order to avoid
elevated SVC pressure, reduced cerebral perfusion pressure, and
subsequent cerebral injury. Central venous pressure monitoring above
the SVC tie, as well as intermittent assessment of the patient’s head for
any signs of edema and venous stasis, is indicated. The pulmonary artery
is isolated from the blood flow during CPB, so no drug infusions may be
given through associated accessory ports.
CLINICAL PEARL During CPB, the pulmonary artery is isolated from the blood flow
preventing drug infusions from being given through associated accessory ports.
(5) Preload augmentation must be continued during the post-CPB period, and
inotropic support may be warranted if RV dysfunction becomes apparent
[9].
F. Tricuspid valve regurgitation
1. Natural history
a. Isolated TR is uncommon and often seen with drug abuse–related
endocarditis, carcinoid syndrome, Ebstein anomaly, connective tissue
disorders leading to valve prolapse, or chest trauma. Usually functional TR
(FTR) develops secondary to RV failure, pulmonary hypertension, or left-
sided cardiac abnormalities, such as end-stage aortic or MS. Severe aortic or
mitral valve disease that strains the RV can lead to RV failure with TR. This
FTR results either from dilatation of the tricuspid valve annulus or from RV
dilatation that restricts the tricuspid valve leaflets.
2. Pathophysiology
(1) Since RV can compensate for volume overload, isolated TRs are
bearable. Many TR symptoms are from an increased RV afterload. When
TR is associated with pulmonary hypertension, there is decreased
cardiac output due to RV impedance. Atrial fibrillation is also a common
concurrent issue in patients with TR.
b. TEE evaluation and grading of severity of TR
(1) TEE examination of FTR shows dilatation of RV and the tricuspid valve
annulus, along with leaflet restriction due to tethering. Different
accompanying conditions have characteristic appearances. For
endocarditis, vegetations and valvular perforation are common;
rheumatic disease often shows commissural fusion and probable mitral
and/or aortic valve involvement; and carcinoid heart disease results in
diffuse leaflet thickening, leading to both stenosis and regurgitation with
tricuspid and pulmonic valve involvement. In Ebstein anomaly, the
tricuspid leaflets are displaced into the RV cavity, reducing its size and
forcing the leaflets toward the RV apex. CFD is used to assess the
severity of the TR. Similar to MR, however, the severity of the TR is
most likely underestimated because of the changes to the loading
conditions. Pulse wave Doppler can aid in calculating the severity of the
regurgitation via changes in the hepatic vein flow.
c. Pressure wave abnormalities
(1) Although central venous pressure tracings may show the presence of giant
V, other factors, including the compliance of the right atrium, filling of
the right atrium, and regurgitant volume, determine the size of the
regurgitant wave.
(1) RV preload
(a) Since a drop in central venous pressure can severely limit RV stroke
volume, preload augmentation is useful for adequate forward flow.
(2) Heart rate
(a) Normal-to-high heart rates are beneficial in these patients to sustain
forward flow and prevent peripheral congestion.
(3) Contractility
(a) As mentioned previously, TR is usually secondary to RV failure,
and since the RV is equipped to accommodate volume but not
pressure loads, positive-pressure ventilation, elevated PVR, or
suppression of myocardial contractility may all lead to RV failure.
(a) In the absence of aortic or mitral valve lesions, variations in
systemic afterload have little effect on TR.
(5) PVR
(a) Decreases in PVR improve RV function and forward blood flow.
However, high airway pressures and agents that increase PAP
should be avoided, though 5 hyperventilation can be helpful in
reducing PVR by producing hypocapnia. Thus, agents that dilate the
pulmonary vasculature should be used if inotropic support is
necessary. Dobutamine, isoproterenol, or milrinone would be
beneficial for this. In addition, inhalation of nitric oxide or
epoprostenol may also be helpful for these patients.
(1) Minimal premedication is indicated.
(2) In patients with coexisting mitral valve disease, the method of anesthetic
is usually dependent upon the mitral valve lesion, as it is with tricuspid
stenosis.
(3) The regurgitant wave has a tendency to push a pulmonary artery catheter
in the opposite direction of its insertion, making its entry into the
regurgitant tricuspid valve difficult. Cold injectate is ejected retrograde
into the atrium rather than the pulmonary artery, which leads to
inaccuracy in the determination of cardiac output in the presence of TR.
(4) Similar to tricuspid stenosis, during CPB, close attention must be paid to
the SVC drainage.
(5) Residual tricuspid stenosis may occur if a prosthetic valve is placed
because the valve prosthesis is smaller than the native valve and
postbypass preload augmentation may be warranted. In addition, in the
immediate postbypass period, the entire stroke volume will have to be
ejected against the higher PVR with no pop-off pressure lowering back
into the right atrium placing the RV under increased strain. Accordingly,
RV failure requiring inotropic support may occur and should be
anticipated.
V. Prosthetic valves
The decision to use a prosthetic valve is patient specific and depends on various
factors including the expected longevity of the patient (mechanical prostheses last
longer), the ability of the patient to comply with anticoagulation therapy
(mechanical prostheses require ongoing anticoagulation), the anatomy and
pathology of the existing valvular disease, and the experience of the operating
surgeon.
1. An ideal prosthetic valve is nonthrombogenic, chemically inert, preserves
blood elements, and allows physiologic blood flow.
2. There are many different kinds of prosthetic valves available that can replace
tricuspid or mitral valves, but none are without possible complications.
1. Mechanical
a. Although durable, current mechanical valves are thrombogenic. Patients
receiving mechanical valves require anticoagulation therapy indefinitely.
b. Anticoagulation is normally provided with warfarin sodium, administered at a
dose that will elevate the prothrombin time to 1.5 to 2 times control.
c. There are four basic types of mechanical prosthetic valves: the caged ball,
caged disc, monocuspid tilting disc, and bicuspid tilting disc valves. Out of
these, the bicuspid tilting disc valves are the most common because of their
streamlined design as well as improved laminar blood flow.
(1) Bileaflet tilting disc valve prosthesis
(a) In 1977, a bileaflet St. Jude cardiac valve was introduced as a low-
profile device to allow central blood flow through two semicircular
discs that pivot on supporting struts. This valve can be placed in the
aortic, mitral, or tricuspid positions.
(b) These valves produce low resistance to blood flow and have a
lower incidence of thromboembolic complications, though
anticoagulation is still necessary.
(c) A few examples of bileaflet tilting disc valve prostheses include the
CarboMedics, Edwards Tekna, Sorin Bicarbon, and Advancing the
Standard (ATS); the St. Jude Medical remains the most popular.
2. Bioprosthetic valves
a. The Hancock porcine aortic bioprosthesis (now the Medtronic Hancock II
stented porcine bioprosthesis) was introduced in 1970, followed by the
Ionescu–Shiley bovine pericardial prosthesis in 1974 and the Carpentier–
Edwards porcine aortic valve bioprosthesis in 1975.
b. Bioprosthetic valves are beneficial because they usually do not require long-
term anticoagulation therapy and are less thrombogenic; however, they are
less durable as well.
c. Because of lower durability and because these valves last longer in older
patients, they are usually recommended for patients older than 60 years and
when anticoagulation is better avoided.
d. These valves last longer in the aortic position than in the mitral position.
e. These valves fall into two categories: stented and nonstented.
(1) Stented bioprosthetic valves
(a) These valves are constructed from porcine aortic valves or bovine
pericardium and are placed on a polypropylene stent attached to a
silicone sewing ring covered with polyethylene terephthalate
(Dacron).
(b) These valves allow for improved central annular flow and less
turbulence, but the stent does cause some obstruction to forward
flow, thereby leading to a residual pressure gradient across the
valve.
(c) Stented valves that can be found in clinical use today include the
Carpentier–Edwards perimount, Medtronic Mosaic, Carpentier–
Edwards porcine, Hancock porcine, and Medtronic intact porcine.
(2) Stentless bioprostheses
(a) Porcine valves fixed in a pressure-free glutaraldehyde solution and
without the use of a stent make up the category of stentless
bioprostheses.
(b) The primary types of valves clinically encountered in this category
include the St. Jude Medical Toronto SPV stentless porcine,
Edwards Prima Plus stentless bioprosthesis, and Medtronic
Freestyle stentless porcine.
(c) Stentless bioprosthetic valves are used almost exclusively in the
aortic position and often when aortic root replacement is also
necessary. They have excellent hemodynamic characteristics but
technically are more difficult to place.
3. Human valves
a. The first bioprosthesis was from a cadaver in 1962. Early techniques such as
irradiation or chemical treatment used to sterilize and preserve homografts
decreased life span.
b. Antibiotic solutions are used to sterilize human valves that are then frozen in
liquid nitrogen until implantation. This method allows more than 75% of
prostheses to last longer than 10 years, regardless of patient age, as cusp
ruptures from weakness of the prostheses are minimized.
c. Anticoagulation is often unnecessary and the incidence of prosthetic valve
endocarditis and hemolysis from blood flow through the homograft is low.
d. Homografts are primarily used for aortic or pulmonary valve replacement.
e. These are most useful in patients younger than 35 and those with native valve
endocarditis.
ACKNOWLEDGMENTS
The current version of this chapter is based on the one in the previous edition, and the
authors acknowledge with thanks the important contributions of the coauthors in
previous editions as well as Jelliffe Jeganathan, MBBS and Yannis Amador, MD in this
edition.
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13 Alternative Approaches to Cardiothoracic
Surgery with and without Cardiopulmonary Bypass
Anand R. Mehta, Peter Slinger, James G. Ramsay,
Javier H. Campos, and Michael G. Licina
I. Introduction
II. Off-pump coronary artery bypass (OPCAB) and minimally invasive direct
coronary artery bypass (MIDCAB)
A. Historical perspective
B. Rationale for avoiding sternotomy and cardiopulmonary bypass (CPB)
for coronary artery surgery
C. Refinement of surgical approach
D. Patient selection: High risk versus low risk
E. Anesthetic management
F. Anticoagulation
G. Recovery
III. Minimally invasive valve surgery (MIVS)
A. Introduction
B. Surgical approaches
C. Preoperative assessment
D. Monitoring
E. Specific anesthesiology concerns
F. Postoperative management
G. Percutaneous valve repair/replacement
IV. Robotically enhanced cardiac surgery
B. Overview
C. Technologic advances permitting endoscopic surgery
D. Endoscopic robotic-assisted systems
E. Anesthetic considerations related to robotic surgery
F. Conversion to sternotomy
G. Summary
V. Anesthesia for robotic noncardiac thoracic surgery
A. Introduction
B. Anesthetic implications in robotic thoracic surgery
C. Robotic-assisted surgery and anesthesia for mediastinal masses
D. Robotic-assisted pulmonary lobectomy
E. Carbon dioxide (CO2) insufflation during robotic surgery
F. Robotic-assisted esophageal surgery and anesthetic implications
G. Summary
KEY POINTS
1. Off-pump coronary artery bypass grafting (OPCAB) has become a

mainstream technique that accounts for as much as 33% of surgical
coronary revascularization.
2. OPCAB has not produced the expected reductions in neurologic and
renal complications, although it has consistently reduced
perioperative blood loss and transfusion.
3. Adjuncts such as intracoronary shunts, ischemic and/or anesthetic
preconditioning, and intra-aortic balloon pumps (IABPs) may help
to minimize ischemia during OPCAB. Circulatory support with
vasoconstrictors and/or inotropic drugs is often required.
4. Transesophageal echocardiography (TEE) monitoring during
OPCAB can promptly identify acute ischemia, although transgastric
views are often compromised by the cardiac positioning required
for distal coronary anastomoses.
5. Anesthetic techniques compatible with fast-tracking are most often
used for OPCAB, which typically involves a “balanced” technique
utilizing a combination of inhalational anesthetic, modest amounts
of opioid, and intermediate-duration muscle relaxation. Excessive
use of benzodiazepines and long-acting medications is avoided.
6. Adept positioning of the heart during OPCAB minimizes
hemodynamic disturbances from reduced venous return, especially
while performing coronary anastomoses within the right coronary
and left circumflex arterial distributions. Maintaining adequate
intravascular volume is essential.
7. Minimally invasive cardiac valve surgery most often requires CPB,
but the incisions are smaller and sometimes off the midline, and
cannulation for CPB often utilizes port-access technology. Robotic-
assisted techniques can be used for minimally invasive mitral valve
replacement or repair.
8. TEE is critical during minimally invasive valve surgery (MIVS) for
CPB cannulation and assessment of valve structure and function.
9. Percutaneous approaches to mitral regurgitation (MitraClip), mitral
stenosis (balloon mitral valvuloplasty), and aortic stenosis
(transcatheter aortic valve implantation [TAVI]) are rapidly growing
in popularity. Each approach presents unique challenges to the
anesthesiologist; these procedures can be performed either with
sedation or general anesthesia, each with its own benefits and risks.
10. Robotic-assisted minimally invasive techniques can be used for
coronary artery bypass grafting (CABG) performed either on- or
off-cardiopulmonary bypass (CPB).
I. Introduction
The past two decades have witnessed a major evolution in cardiac surgery in
parallel with “minimally invasive” and laparoscopic developments in other
surgical disciplines [1]. Two major objectives have been a reduction in the use of
cardiopulmonary bypass (CPB) for revascularization and a reduction in the
invasiveness of the surgical approach. The overall goals are to preserve and
enhance the quality of the procedure(s) while providing faster recovery, reduced
procedural costs, and reduced morbidity and mortality. The contribution of the
anesthesia care team is to facilitate cost-effective early recovery while providing
safe, excellent operating conditions both for the patient and the surgeon. Anesthetic
techniques and monitoring modalities have needed to evolve with changes in
surgical practice. Anesthesiologists have learned more about how to support the
circulation during cardiac manipulation and periods of coronary occlusion. We
have been charged with monitoring and support while the surgeon operates with
minimal exposure while at the same time facilitating early recovery and discharge.
The surgical techniques and their anesthetic considerations discussed in this
chapter include the following: coronary artery bypass grafting (CABG) without the
use of CPB (off-pump CABG [OPCAB] and minimally invasive direct coronary
artery bypass [MIDCAB]); minimally invasive valve surgery (MIVS, except see
Chapter 11 for transcatheter aortic valve implantation); computer-enhanced,
endoscopic robotic-controlled CABG; and robotic noncardiac thoracic surgical
procedures. Although not mentioned subsequently, we recommend the routine use
of intra-arterial blood pressure monitoring for all of these procedures because of
the rapidity and frequency of significant hemodynamic disturbances and the need
for frequent assessment of labs (e.g., arterial blood gases, activated clotting times
[ACTs], coagulation studies, etc.).
II. Off-pump coronary artery bypass (OPCAB) and minimally invasive direct
coronary artery bypass (MIDCAB)
1. Early revascularization surgery
a. Early attempts at coronary artery surgery without the use of CPB included the
Vineberg procedure in Canada (tunneling the internal mammary artery [IMA]
into the ischemic myocardium) in the 1950s, and internal mammary to
coronary anastomosis in the 1960s by Kolessov in Russia.
b. Sabiston from the United States and Favolaro from South America reported
the use of the saphenous vein for aorta-to-coronary artery bypass grafts,
performed without CPB, in the same period.
c. The introduction of CABG in the late 1960s expanded the indications for
CPB, which had enabled congenital heart repairs and heart valve surgery
since the 1950s. CPB with the use of cardioplegia became the standard of
care in the 1970s, providing a motionless field and myocardial “protection”
with asystole and hypothermia.
2. Reports in the early 1990s
a. South American surgeons with limited resources continued to develop
techniques for surgery without CPB, publishing in North American journals in
the 1980s and early 1990s. In 1991, Benetti et al. [2] reported on 700 CABG
procedures without CPB performed over a 12-year period with very low
morbidity and mortality.
b. North American and European interest grew in the 1990s, fueled by a desire
to make surgery more appealing (vs. angioplasty) as well as the need to
reduce cost and length of stay. Alterative incisions were explored, and
techniques and devices to facilitate surgery on the beating heart were
developed. The terms “OPCAB” and “MIDCAB” were coined.
3. Port-access (or “Heartport”)
a. Simultaneous with attempts to perform CABG without CPB, a group from
Stanford University introduced a technique permitting surgery to be done with
endoscopic instrumentation through small (1 to 2 cm) ports and a small
thoracotomy incision. This was termed port-access surgery or by the trade
name of Heartport (Johnson and Johnson, Inc., New Brunswick, NJ, USA). A
motionless surgical field was required, necessitating CPB. Extensive use of
TEE is required to assist in the placement of and to monitor the position of the
various cannulae and the endoaortic balloon (see below).
b. Port-access cardiac surgery contributed new knowledge in two major areas:
Percutaneous, endovascular instrumentation for CPB and instrumentation for
performing surgery through a small thoracotomy incision. The latter
techniques continue to be developed and modified to permit MIVS through
partial sternotomy or thoracotomy incisions.
4. Minimally invasive direct coronary artery bypass (MIDCAB). A number of
alternative incisions to midline sternotomy have facilitated access to specific
coronary artery distributions to allow CABG without CPB. The most popular
alternative approach is the left anterior thoracotomy, which allows IMA
harvest and grafting to the left anterior descending (LAD) artery
territory. This is the procedure usually referred to as MIDCAB.
5. North American/European experience after 1998
a. 1 Initially viewed by most as experimental, off-pump techniques are now
established as an acceptable alternative to CABG with CPB. The reported use
of OPCAB has been reported to be as high as 33% [3], but the range in
practice is wide. Some surgeons perform virtually all revascularizations as
OPCAB, which typically refers to a multivessel CABG performed through a
median sternotomy without CPB. Most large cardiac surgery practices have at
least one surgeon who performs a significant number of OPCAB procedures.
The physiology and anesthetic management for OPCAB have been recently
reviewed by Chassot et al. [4].
b. MIDCAB procedures are more technically demanding than OPCAB
because they require specialized instrumentation and operating through a
small incision. These procedures are done in a smaller number of institutions
than OPCAB. Some surgeons harvest the IMA endoscopically before making
the small incision to do the coronary anastomosis.
B. Rationale for avoiding sternotomy and cardiopulmonary bypass (CPB) for
coronary artery surgery
1. Reduction in complications
a. Sewing coronary vessels on the beating heart is technically challenging and
not necessarily appropriate for all surgeons [5]. Whether or not there is a
benefit of performing on-pump versus OPCAB is a topic of heated debate.
Several published randomized trials [6–10] confirm reductions in enzyme
release, bleeding, time to extubation, and length of stay. While there are long-
term follow-up studies suggesting similar rates of survival and graft patency
between the two groups [11,12], other studies suggest that graft patency is
lower in off-pump procedures [9,13], with one large randomized controlled
trial finding a higher 1-year mortality rate in the off-pump group [13]. Of note,
the latter studies came from surgeons less experienced in the off-pump
technique. Intraoperative conversion from off-pump to on-pump has been
associated with an increase in mortality [14,15]. Although reduction in stroke
has been one of 2 the proposed benefits of the technique (due to avoidance of
aortic cannulation and cross-clamping), studies do not demonstrate this
benefit. Similarly, reduction in renal dysfunction has been proposed but not
proved in these studies and in one additional recent publication [16]. In
August 2004, an updated guideline for CABG surgery was published by the
American College of Cardiology and American Heart Association; this
guideline recognizes the potential benefits for avoiding CPB but the need for
further data with the lack of proved benefit in randomized controlled trials
[17].
b. Avoidance of aortic manipulation and cannulation might reduce embolic
complications such as stroke, yet a partial or side-biting aortic clamp may be
necessary to perform proximal venous anastomoses in multivessel OPCAB.
This can be avoided by using the IMA as the only proximal vessel with its
origin intact or with the use of devices designed to avoid the use of a cross-
clamp (e.g., the “Heartstring”).
c. The whole body “inflammatory response” induced by extracorporeal
circulation is avoided with MIDCAB and OPCAB. This approach should
result in lower fluid requirements and less coagulopathy and is consistent with
lesser volumes of blood loss and transfusion demonstrated in several
comparisons of OPCAB to CABG with CPB.
2. Competition with angioplasty. Refinements in interventional cardiology and
reductions in postprocedure restenosis have allowed an ever-increasing
population of patients to have coronary lesions treated in the catheterization
laboratory, although long-term outcomes in multivessel coronary disease are
slightly better with CABG than with stents. However, patients will often
choose the less invasive interventional cardiology approach over surgery if
those results are nearly equivalent. Evolution of surgical techniques to provide
excellent results with less physiologic trespass may be necessary for coronary
artery surgery to survive.
3. Progress toward truly “minimally invasive” surgery
a. Avoidance of CPB is more physiologically important than avoidance of
sternotomy, but postoperative recovery from sternotomy is foremost in
patients’ minds. The smaller the surgical scar, the better. The MIDCAB
addresses this issue, but this approach can only access the LAD and its
diagonal branches.
b. Cardiac surgeons have been slow to embrace endoscopic approaches partly
because, until recently, existing technology did not provide the range of
motion and control required for coronary artery anastomoses.
c. The port-access approach introduced endoscopic techniques to cardiac
surgery; surgeons are now working with computer-assisted instruments to
perform surgery on the beating heart (see later). Techniques developed for
off-pump surgery are likely to contribute to the ability to perform such
procedures endoscopically.
C. Refinement of surgical approach
1. Development of modern epicardial stabilizers
a. In early reports, compressive devices (e.g., metal extensions rigidly attached
to the sternal retractor) were used to reduce the motion of the coronary vessel
during the cardiac and respiratory cycles. These devices often interfered with
cardiac function and were impossible to use for left circumflex coronary
artery lesions.
b. Modern devices typically apply gentle pressure or epicardial suction,
reducing the effect on myocardial function while providing better fixation of
the area immediately surrounding the coronary artery anastomotic site. These
devices also allow greater access to arteries on the inferior and posterior
surfaces of the heart (Fig. 13.1).
IGURE 13.1 The Octopus 2 tissue stabilizer (Medtronic Inc., Minneapolis, MN, USA). Through gentle suction the device
evates and pulls the tissue taut, thereby immobilizing the target area. (Courtesy of Medtronic Inc.)
2. Techniques to position the heart (through midline sternotomy)

a. Surgery on the anterior wall of the heart (LAD and diagonal branches) usually
requires only mild repositioning, such as a laparotomy pad under the cardiac
apex. This is associated with minimal effects on cardiac function.
b. Surgery on the right coronary artery (RCA) or the circumflex artery (CX) and
its marginal branches requires turning or twisting of the heart. To do this
manually (i.e., by an assistant) is cumbersome and is associated with
hemodynamic compromise.
c. Use of posterior pericardial traction stitches and a gentle retracting “sock”
(web roll wrapped around the apex in a “sling” to pull the heart to either side)
greatly improves the hemodynamic tolerance of these abnormal positions.
d. For circumflex vessel distribution surgery, dissection of the right pericardium
to prevent the right ventricle (RV) from being compressed as it is being turned
allows preservation of hemodynamic function.
3. Surgical adjuncts to reduce ischemia
a. Performing CABG surgery on the beating heart requires a mandatory period of
coronary occlusion for each distal coronary artery anastomosis.
b. Intracoronary shunts can maintain coronary flow at the possible cost of trauma
to the endothelium.
c. 3 “Ischemic preconditioning” involves a brief (e.g., one to four 5-minute
periods) occlusion and then the same period of reperfusion before performing
the anastomosis. In animal models of myocardial infarction, this technique
reduces the area of necrosis. A nearly equivalent physiologic effect can be
provided by 1 MAC end-tidal isoflurane [18] or other inhaled agents, which
is termed anesthetic or pharmacologic preconditioning. Ischemic
preconditioning for 7- to 10-minute occlusions, such as those required for
OPCAB and MIDCAB, probably does not provide the same benefit as one
might see with longer periods of occlusion, but this technique is employed by
some surgeons.
d. The proximal anastomosis of a vein graft can be performed first in order to
allow immediate perfusion once the distal anastomosis is completed.
e. Regional hypothermia techniques have been described for use during coronary
occlusion.
f. Preoperative insertion of an intra-aortic balloon pump (IABP) has been used
for patients with reduced ventricular function requiring multivessel OPCAB.
D. Patient selection: High risk versus low risk
1. Early reports of OPCAB often described single-vessel or double-vessel bypass
performed on low-risk patients. This was promoted as permitting early
recovery and discharge.
2. OPCAB is now promoted for multivessel bypass in patients with risk
factors for adverse outcomes. Elderly patients at risk for stroke, patients with
severe lung disease, or patients with severe vascular disease and/or renal
dysfunction are often selected. As mentioned earlier, scientific studies have not
yet demonstrated reduced adverse outcomes with OPCAB in these populations.
3. Zenati et al. [19] have described combining MIDCAB (i.e., IMA to LAD) with
angioplasty/stent to other vessels in high-risk patients.
4. As mentioned earlier, a small number of surgeons attempt to perform virtually
all CABG procedures as OPCAB regardless of preoperative risk status.
E. Anesthetic management
1. Preoperative assessment
a. The cardiac catheterization report should be reviewed and the procedure
discussed with the surgeon, including the planned sequence of bypass grafts
and the potential use of specific adjuncts (e.g., shunts or perfusion-assisted
direct coronary artery bypass grafting [PADCAB]). This allows the
anesthesiologist to predict the effect of each coronary occlusion, which
requires knowledge of the coronary anatomy and its usual nomenclature (Fig.
13.2).
IGURE 13.2 Coronary anatomy. The main branches from the circumflex artery (CX) are named “marginal” or “obtuse
arginal” vessels. D1, first diagonal; D2, second diagonal; LAD, left anterior descending artery; LM, left main; PDA, posterior
escending artery; RCA, right coronary artery; LVBr, LV branch; Ra, Ramus intermedius (<40% of individuals).
b. The vessel, location, and degree of stenosis determine the functional response
to intraoperative coronary occlusion. Even with a proximal stenosis, an
important vessel (e.g., LAD) may supply adequate resting flow to a large area
of myocardium. Acute loss of flow to this large area (with surgical occlusion)
may cause ventricular failure. A stenosis further down the vessel may be less
important for overall ventricular performance.
c. High-grade stenosis (e.g., 90%) is likely to be associated with some
collateral blood flow from adjacent regions, as flow through the stenosis may
be inadequate even at rest. A 10-minute occlusion of such a vessel may have
surprisingly little effect on regional function and hemodynamics because of the
collateral flow. A lesser degree of stenosis (e.g., 75% to 80%) may not affect
resting flow, hence there may be little or no collateral blood flow. Occlusion
of such a vessel may cause severe myocardial dysfunction in the distribution
of the vessel.
d. If incisions other than sternotomy are to be employed to access specific
coronary regions, positioning of the arms and the body, the potential need for
one lung anesthesia, and sites for vascular access need to be discuss. Some
surgeons prefer one-lung anesthesia even for a median sternotomy approach to
OPCAB.
2. Measures to avoid hypothermia
a. Unlike on-pump CABG, it is difficult to restore heat to a hypothermic OPCAB
patient. In order to maintain hemostasis and facilitate early recovery,
prevention of heat loss needs to be planned before the patient enters the
room.
b. While in the preoperative area, the patient should be kept warm with blankets.
c. The operating room should be warmed to the greatest degree tolerated by the
operating team (e.g., 75°F or higher). The temperature can be reduced once
warming devices have been placed and the patient is fully draped.
d. The period and degree to which the patient remains uncovered for
preoperative procedures (e.g., urinary catheter placement) and surgical skin
preparation and draping should be minimized. This requires vigilance on the
part of the anesthesiology team and frequent reminders to the surgical team.
e. Various adjuncts to preserve heat include heated mattress cover or insert;
forced-air warming blankets, including sterile “lower body” blankets placed
after vein harvesting; and circumferential heating tubes. A more expensive and
possibly more effective option is the use of disposable surface-gel heating
devices [20].
f. Fluid warmers should be used at least for the principal intravenous volume
infusion “line,” if not for all intravenous lines other than those used for
intravenous drug infusions.
g. Low fresh-gas flows and circle/CO2 reabsorption circuits will help prevent
heat loss.
3. Monitoring (Table 13.1)
a. Preoperative assessment of ventricular function
(1) Preoperative LV function is a major determinant of the need for extensive
monitoring. Patients with normal or near-normal LV function are less
likely to need diagnosis and therapy guided by invasive monitoring.
(2) A patient with an elevated LV end-diastolic pressure (at cardiac
catheterization) may have a “stiff” ventricle, or diastolic dysfunction.
This commonly results from hypertrophy or ischemia. Filling pressures
obtained intraoperatively must be interpreted in this context (i.e., the
filling pressure may overestimate LV preload). Volumetric assessment of
preload (by TEE) can be valuable in this situation.
(3) Patients with poor ventricular function may tolerate coronary occlusions
poorly. Appropriate responses may be best guided by monitors of
cardiac output (CO) and filling pressures, or TEE [21,22].
(4) Repeated occlusions in multiple regions of the myocardium (i.e., for
multivessel OPCAB) are likely to result in a cumulative detrimental
effect on hemodynamics. There may be a period of myocardial
dysfunction requiring inotropic support even in patients with good
underlying LV function. The combination of reduced ventricular function
and the need for multiple bypass grafts is likely to result in a need for
inotropic and/or vasopressor infusions guided by monitoring with a
pulmonary artery catheter (PAC) and/or TEE.
TABLE 13.1 Monitoring approaches for OPCAB and MIDCAB
(5) Preoperative placement of a PAC introducer, but with an obturator of

some kind or a single- or double-lumen central venous catheter placed
through it rather than a PAC may be a reasonable first approach in most
patients. This avoids the use of the PAC in uncomplicated patients while
allowing for rapid PAC placement should this be desired any time in the
perioperative period.
b. Specific monitors
(1) Lead V5 of the electrocardiogram (ECG) detects 75% of the ischemia
found on all 12 leads. This lead should be monitored in all patients
undergoing OPCAB or MIDCAB, as permitted by the surgical incision.
Lead II gives clear P waves, but adds little to the sensitivity of ischemia
detection.
(2) The PAC is variably useful during OPCAB. For single- or double-vessel
bypass in patients with preserved LV function, there can be little
justification for this monitor [23]. The worse the ventricular function
and the greater the number of planned bypass grafts, the more likely
it is that information from the PAC will be useful.
(3) Continuous CO from the PAC or other devices and continuous mixed
venous oximetry may provide incremental benefit in assessing the
adequacy of cardiac function. Use of these devices is often institution-
specific or even surgeon/anesthesiologist-specific.
(4) 4 Monitoring with TEE can provide detailed information about the
effects of coronary occlusion and recovery, and it provides the
earliest, most specific information during acute deterioration and
interventions. Acute ventricular dilatation and mitral regurgitation may
occur when a large region of the myocardium becomes ischemic, and this
is detected immediately with TEE. In addition, distortion of the mitral
annulus due to abnormal positioning may cause mitral regurgitation [24].
Obtaining adequate images may be distracting to clinical care. With the
heart in an unusual position, images may be difficult or impossible to
obtain. A reversible wall-motion abnormality that resolves with
restoration of flow is reassuring; however, this does not guarantee a
good quality graft or anastomosis.
(5) Normal carbon dioxide (CO2) elimination requires adequate CO. If
ventilation is constant, an acute decline in CO will cause an acute
decrease in end-tidal CO2 concentration.
c. Monitoring for specific procedures
(1) For MIDCAB or other reduced-access procedures, provision must be
made for transcutaneous defibrillation and pacing. An important
consideration is the requirement to reinflate the lungs for defibrillation
during closed-chest surgery to provide tissue (rather than air) for the
current to traverse [25].
(2) For port-access surgery (Heartport or related procedures), TEE is
required to guide and monitor cannula placement and function.
a. Early recovery is usually desired. Extubation immediately or shortly after
surgery should be the goal.
b. 5 A vapor-based anesthetic technique facilitates early recovery. Keys to
prevention of delayed awakening are as follows: Minimizing the dose of
benzodiazepine; use of modest doses of opioids; and avoiding residual
paralysis at the end of surgery. Some clinicians use very short-acting opioids
such as remifentanil to facilitate early extubation, but this approach requires
awareness of the need for effective longer-lasting analgesia at the time of
extubation and thereafter. Use of bispectral index (BIS) monitoring can help
guide administration of hypnotic agents.
c. Transfer of the intubated yet awakening patient to the intensive care unit
(ICU), and early ICU care are facilitated by use of short-acting sedative drugs
such as propofol or dexmedetomidine.
d. Thoracic epidural or lumbar spinal anesthetic and analgesic techniques have
been promoted by some as suitable adjuncts to off-pump approaches. There
are reports of OPCAB procedures done without general anesthesia. Most
centers are reluctant to risk major neuraxial techniques immediately before
full heparinization for CPB. Use of such techniques is unlikely to shorten
postoperative length of stay and has not been shown to provide a measurable
benefit.
e. For MIDCAB (thoracotomy), postoperative epidural analgesia [26],
paravertebral block, or intercostal blockade may be useful for pain control.
5. Anticipation and management of ischemia
a. Knowledge of the coronary anatomy and surgical plan is essential. This
allows appropriate timing of pharmacologic and other interventions before
ischemia is induced. Use of isoflurane (or other volatile inhalational agent)
anesthesia can provide pharmacologic “preconditioning,” as mentioned
earlier. The hemodynamic alterations commonly associated with ischemia
such as tachycardia (especially in the presence of hypotension) must be
avoided. Intravenous β-adrenergic blockade may be beneficial; however, this
must be balanced with the possibility of impaired myocardial performance
during coronary occlusion.
b. Maintenance of adequate coronary artery perfusion pressure is of great
importance in allowing collateral blood flow to ischemic regions. Volume
loading and appropriate positioning (see following), alteration of the depth of
anesthesia, and/or use of α-adrenergic agonists may all be indicated.
c. Prophylactic nitrate infusions may interfere with preload (see later).
d. Early experience without modern stabilizers suggested that bradycardia (to
reduce motion) would aid the surgeon. This is no longer an issue. Grafting to
the RCA territory (supplying the sinus and AV nodes) can be associated with
bradycardia. Thus, although β-adrenergic blockade may be useful to prevent
or treat tachycardia, epicardial pacing may be required for ischemia-induced
bradycardia.
e. Anecdotally, patients with compromised ventricular function undergoing
multivessel procedures may benefit from “prophylactic” administration of an
inotropic medication.
6. Intravascular volume loading
a. 6 Positioning of the heart may kink or partially obstruct venous return
and/or compress the RV. Intravascular volume loading and head-down
(Trendelenburg) position can help reduce this effect (Fig. 13.3) [27].
Close observation of the heart, filling pressures, and blood pressure to
provide feedback to the surgeon is essential.
b. Intravenous vasodilators (e.g., nitrates) can exacerbate reductions in cardiac
filling. More commonly, intravenous vasoconstrictors (phenylephrine,
norepinephrine) will be required during abnormal cardiac positions.
7. Surgery-anesthesiology interaction. With all the above considerations, it
should be clear that there must be excellent communication between the surgeon
and the anesthesiologist for OPCAB or MIDCAB. Anticipation and planning
for problems allow the anesthesiologist to intervene in a timely manner. The
surgeon must say in advance what he is planning to do. Similarly, changes in
cardiac performance and the need for intervention must be continuously
communicated to the surgeon. The anesthesiologist must observe the surgical
field, watching the procedure as well as the position, size, and function of the
heart. An observant, communicative team with basic monitoring (ECG, blood
pressure, and central venous pressure) is likely to produce better results than a
team that communicates poorly, but uses extensive monitoring.
F. Anticoagulation
1. Heparin management
a. Heparin anticoagulation protocols are institution-specific. Similar to on-pump
surgery, there are few data to recommend targeting specific ACT values.
b. Some surgeons request full heparinization similar to on-pump procedures
(i.e., ACT target >400 seconds); others request lower doses of heparin such
as would be used for noncardiac vascular procedures (ACT target typically
>200 seconds), or something in between. Outcomes appear to be equivalent
using either approach, which suggests that ACT targets as high as those used
for CPB are unnecessary.
2. Protamine reversal
a. Extracorporeal circulation induces a postoperative multifactorial defect in
coagulation that may reduce early graft thrombosis. When coagulation is
reversed after OPCAB or MIDCAB, no such hypocoagulable state exists;
indeed, there is evidence that the coagulation system is activated by the stress
of surgery, similar to what has been showed for other major procedures [28].
b. In order to gradually return the coagulation to normal leaving perhaps a little
residual heparin effect, reversal may be achieved with incremental doses of
protamine. If “full” heparinization has been employed, administration of 50
mg of protamine may bring the ACT down to near 200 seconds, after which
small increments (10 to 25 mg) can be given to achieve an ACT that is about
25% to 50% above control (i.e., 150 to 180 seconds).
c. If the patient is clinically bleeding with an elevated ACT, then heparin should
be reversed completely. Even in the absence of clinical bleeding, some
cardiac surgeons prefer complete reversal immediately after completion of the
grafts.
d. Prolonged OPCAB procedures may be associated with extensive blood loss
and therefore facilitated by the use of cell-saver devices (i.e., washing of
salvaged blood so it is free of coagulation proteins and platelets). Over time,
this may induce a dilutional coagulopathy similar to what is often seen after
CPB.
IGURE 13.3 Relative changes in hemodynamic parameters during vertical displacement of the beating porcine heart by the
Medtronic Octopus tissue stabilizer and the effect of head-down tilt. BASE, pericardial control position; Cx, circumflex coronary
, displacement of the heart by the Octopus; DIS + TREND, Trendelenburg maneuver (20-degree head-down tilt while
e heart remains retracted 90 degrees); LAD, left anterior descending artery; RCA, right coronary artery; x = mean arterial
essure. Statistical comparison with control values: *p <0.05; **p <0.01; # p <0.001; ^p = 0.046 versus combined relative value of
AD and RCA flows. (From Grundeman PF, Borst C, van Herwaarden JA, et al. Vertical displacement of the beating heart by
e Octopus tissue stabilizer: Influence on coronary flow. Ann Thorac Surg. 1998;65: 1348–1352, with permission.)
3. Antiplatelet therapy
a. Thrombosis at the site of vascular anastomoses is initiated by platelet
aggregation and adhesion. Similar to strategies that are used in
angioplasty/stent procedures, antiplatelet therapy may help reduce early graft
thrombosis in CABG, whether done with or without CPB.
b. A common practice is to administer a dose of aspirin preoperatively. This can
be achieved with a suppository if the patient is already anesthetized.
c. In on-pump CABG, administration of aspirin within 4 hours after the
procedure reduces graft thrombosis. This strategy should also be applied to
OPCAB and MIDCAB.
d. There are no published data about the use of newer antiplatelet drugs in this
setting. As with all such therapies (including aspirin), the concern for
bleeding must be balanced with the desire to prevent graft thrombosis.
4. Antifibrinolytic therapy. Use of lysine analogs to inhibit fibrinolysis has
become common practice with on-pump CABG, as they have been shown to
reduce perioperative blood loss. Recent investigations now support the use of
these agents during OPCAB as well [29].
G. Recovery
1. Extubation in the operating room
a. For uncomplicated procedures, recovery from OPCAB or MIDCAB can be
rapid without the requirement for postoperative ventilation or sedation.
b. Normothermia, hemostasis, and hemodynamic stability must be assured.
c. Residual anesthesia and paralysis from long-acting agents (e.g., pancuronium,
large doses of morphine) must be avoided.
d. The extra time spent in the operating room to achieve extubation may be more
costly than a few hours of postoperative ventilation and sedation.
2. ICU management
a. For most patients, early postoperative management can employ the “fast-
track” technique where mechanical ventilation is withdrawn within a few
hours of surgery, and patients are extubated and possibly mobilized at the
bedside late in the day or during the evening of surgery.
b. ICU stay is driven by institutional practice, but for patients having
straightforward, uncomplicated procedures, there may be no need for more
than a few hours in a high-intensity nursing area (i.e., postanesthetic care unit
or ICU).
c. If length of stay is reduced, cost will almost certainly be reduced. If there is
no significant reduction in stay, the cost of specialized retractor systems may
exceed the cost of the disposables required for CPB.
d. Some surgeons passionately believe that OPCAB is better for their patients;
perhaps with time and additional randomized trials, the hoped-for reductions
in neurologic events, renal dysfunction, and other adverse outcomes will
become apparent.
III. Minimally invasive valve surgery (MIVS)
A. Introduction
The Society of Thoracic Surgeons National Database defines minimally invasive
surgery as “any procedure that has not been performed with a full sternotomy and
CPB support. All other procedures, on- or off-pump with a small incision or off-
pump with a full sternotomy are also considered minimally invasive” [30].
Similar to MIDCAB, the premise of MIVS is that “smaller is better” for valve
surgery as well. A partial sternotomy or small thoracotomy with port incisions
may achieve some benefits when compared to standard median sternotomy.
Similar to OPCAB, alternative approaches were explored in the late 1990s, with
the first publication in 1998. Proposed [31,32] but unproved advantages to these
approaches include the following:
1. Reduced hospital length of stay and costs
2. Quicker return to full activity
3. Less atrial fibrillation (26% vs. 38% in one report [33])
4. Less blood transfusion
5. Same results (mortality, valve function)
6. Less pain
7. Earlier ambulation
In addition, the surgical opinion is that reoperation should be easier after
MIVS, as the pericardium is not opened over the RV outflow tract. These
proposed benefits may be observed with specific surgeons in specific centers;
however, there have been no rigorous or randomized studies. The limited data
that exist suggest that acute postoperative pulmonary function impairment is not
improved by the use of the limited incision. Minimally invasive reoperative
aortic valve surgery is a new and successful technique, especially in patients
who have had previous cardiac operations using a full sternotomy (e.g., prior
CABG). This surgical approach does not disturb the vein grafts or the patent
IMAs [34].
FIGURE 13.4 Incisions for MIVS. The most common approach is the “mini” sternotomy, which extends from the sternal
notch part way to the xiphisternum but is diverted to the right at the level of the third or fourth interspace (for the aortic
valve), leaving the lower sternum intact. The mitral valve can be accessed through the small right thoracotomy. (From
Clements F, Glower DD. Minimally invasive valve surgery. In: Clements F, Shanewise J, eds. Minimally Invasive Cardiac
and Vascular Surgical Techniques. Society of Cardiovascular Anesthesiologists monograph. Philadelphia, PA: Lippincott
Williams & Wilkins; 2001:30.)
B. Surgical approaches (Fig. 13.4)

1. 7 Port-access (Heartport): This approach involves direct surgical
visualization and operation through small openings (ports) and a small right
horizontal thoracotomy incision for access to the mitral valve or atrial septum.
In order to avoid sternotomy, the port-access system uses alternative access
sites and cannulae. The aorta is cannulated through a long femoral arterial
catheter or a shorter transthoracic aortic catheter. These devices are advanced
to the ascending aorta and include an “endo-aortic clamp” or inflatable balloon
to achieve aortic occlusion (“cross-clamp”) from within. They include a
cardioplegia administration port. Venous cannulation is achieved with a long
femoral venous catheter, supplemented as needed with a pulmonary artery vent.
A coronary sinus catheter is used to administer cardioplegia. Placement of
these catheters can be time-consuming and requires imaging with fluoroscopy
and/or TEE. A limited number of institutions still use this approach to MIVS.
Some reports have raised concerns about device-related aortic dissections as
well as endoaortic balloon rupture and dislocation [35].
2. Video-assisted port-assisted (using the port-access cannulae and small
incisions with video equipment to visualize and perform valve surgery). This is
currently performed in a small number of institutions worldwide.
3. Robotic (see below). This is an evolving technique, particularly for mitral
valve repair, with excellent results being reported.
4. Direct-access (small incision—many types: Anterolateral mini-thoracotomy,
partial upper or lower sternotomy, right parasternal incision, and others). The
right parasternal approach is preferred by some surgeons (especially for aortic
valve access) because there is no sternal disruption and it is cosmetically
pleasing. The avoidance of sternotomy bleeding into the pericardial sac with
associated fibrinogen depletion may result in less perioperative bleeding and
less pain that is easier to control, although the need to divide two or more
costochondral cartilages with the parasternal approach does induce
considerable postoperative pain. As mentioned earlier, avoidance of opening
the pericardium over the RV outflow tract may make future cardiac reoperation
easier and safer. One problem with this approach is the sacrifice of the right
IMA.
5. The current standard approach for aortic valve surgery using a minimally
invasive approach is an “inverse L”-shaped partial sternotomy extending to the
third or fourth right intercostal space. In order to bring the entire heart more
anteriorly, three to four retention stitches are passed through the pericardial rim
and fixed to the skin incision. This may be associated with compression of the
right atrium (RA) and a decrease in the venous return to the heart. The arterial
cannula for CPB is placed in the ascending aorta. Venous return is established
by direct cannulation of the right atrial appendage or by percutaneous femoral
vein cannulation of the RA. With the latter cannulation technique, often a two-
stage cannula is used with the distal tip placed at the junction of the superior
vena cava (SVC) and RA as confirmed by TEE (bicaval view) [36].
6. Minimally invasive mitral valve surgery can use a right anterolateral
minithoracotomy for which the patient is positioned supine with slight elevation
of the right chest (often using a folded blanket) and extension of the right arm.
Optimal visualization the heart requires deflation of the right lung, which is
achieved most often by using a double-lumen endobronchial tube. CPB is
established via the femoral vessels. The SVC may also be cannulated
percutaneously via the right internal jugular vein (IJV). A percutaneous
transthoracic aortic cross-clamp is placed through a separate stab incision in
the right posterior axillary line [35], and the mitral valve is accessed through
the left atrium. Another approach is a right parasternal incision with mitral
valve exposure via the RA and interatrial septum.
7. Reduced-size skin/soft tissue incision compared with full median sternotomy
can give a more cosmetically pleasing result.
C. Preoperative assessment
In addition to understanding the valvular and associated cardiac disease, the
anesthesiologist must have a good appreciation for the surgical plan.
Nonsternotomy and port-access approaches require specific positioning,
including having the arms extended or cephalad either suspended in a sling or
resting on an “airplane” type of armrest, and will have implications for
peripheral venous, central venous, and arterial catheter placement. Port-access
procedures will require planning for fluoroscopic and TEE assistance to guide
and monitor placement of catheters.
D. Monitoring
1. Central venous catheter versus PAC. Because of pericardial traction and/or
compression of the RA, pulmonary artery, or RV outflow tract, the relationship
between pressures recorded from central venous or PACs and chamber
volumes may be changed. In addition, due to limited ability to palpate around
the heart, there may be an increased risk of inadvertently including the PAC in
surgical sutures. These considerations must be balanced with the potential need
to guide fluid and inotropic therapy perioperatively.
2. 8 TEE. There can be little doubt that TEE monitoring is an integral part of
MIVS [36]. With such limited access, the surgeon cannot rely on visual cues
about cardiac distension or volume status. Thus, TEE is used in the following
ways:
a. Pre-CPB to determine:
(1) Valve dysfunction
(2) Cardiac volume and function
(3) Arterial cannulation site
(4) Specialized cannula placement, especially for port access
b. During CPB for port-access and robotic surgery, TEE is used to monitor
appropriate placement of the endoaortic “clamp” and to detect intracardiac
air, which can be extensive in MIVS cases.
c. After CPB, TEE is used in the usual manner to assist with identification and
management of new-onset ventricular dysfunction, which may occur in as
much as 20% of MIVS patients. This is more frequent in patients with
significant intracardiac air. TEE is also used to assess valve function and to
look for aortic dissection.
E. Specific anesthesiology concerns
Regardless of the type of surgical access to MIVS, there are several common
problems that require enhanced awareness:
1. Long surgical learning curve: Be prepared for anything during this period.
2. Limited surgical access (small incision)
a. Urgent cardiac pacing and direct current cardioversion may need to be done
transthoracically. Appropriate skin electrodes or patches must be placed
before surgery is started.
b. Big fingers, sponges, or instruments can compress vascular structures, causing
large swings in hemodynamics.
c. “Blind” suture placement can lead to bleeding from posterior sites which can
be very difficult to control. Full median sternotomy is occasionally required
to control the bleeding.
d. Inadequate valve repair or replacement: Paravalvular leaks or valve
dysfunction secondary to suture-induced valve leaflet sticking can occur.
e. Errant suture placement may cause coronary artery compromise leading to
myocardial ischemia, or may affect the conduction system leading to heart
block or dysrhythmias.
f. De-airing is very difficult, even when guided by TEE. Residual air may
embolize to the coronary arteries resulting in acute cardiac decompensation.
CO2 gas is very commonly administered into the operating field to minimize
this complication, with varying success.
g. Tamponade: After chest closure, even a small amount of bleeding can lead to
tamponade physiology in the mini-incision area.
F. Postoperative management
The goal is early recovery and extubation. As in MIDCAB and OPCAB, this is
governed by a number of factors, including patient stability and temperature,
duration of the procedure, and the use of short-acting agents. Extubation in the
operating room is possible but uncommon. Certain incisions (i.e., thoracotomy)
may lend themselves to the use of paravertebral or intercostal nerve blocks for
postoperative pain relief.
G. Percutaneous valve repair/replacement
Percutaneous approaches to mitral regurgitation, mitral stenosis, and aortic
stenosis are rapidly growing in popularity. Each approach presents unique
challenges to the anesthesiologist.
1. 9 MitraClip [37,38]. A clip has been developed for mitral regurgitation
which captures the free edges of both mitral valve leaflets, creating a double
orifice valve similar to the Alfieri surgical repair. Under general anesthesia,
the femoral vein is accessed, and with fluoroscopic and TEE guidance the
device is advanced over a guidewire through the interatrial septum and through
the regurgitant portion of the mitral valve, where it is deployed. Multiple clips
may be used if necessary. Early studies suggest that though the procedure is
safe, it may be most beneficial to high-risk surgical candidates with functional
MR, as conventional surgical methods are more effective in reducing the
severity of MR. Potential complications include hemopericardium leading to
tamponade, damage to the mitral valve, device failure requiring surgical repair,
device embolization, creation of mitral stenosis, and persistent interatrial shunt
from the septal puncture. This procedure continues to be investigated.
2. Percutaneous balloon mitral valvuloplasty [39]. Certain patients with
symptomatic or severe mitral stenosis may be candidates for percutaneous
balloon mitral valvuloplasty as an effective alternative to open surgical mitral
commissurotomy. Prior to the procedure, TEE is performed to interrogate the
left atrium and left atrial appendage for thrombus which may dislodge during
the dilation and lead to systemic embolization. The procedure can be
performed using local anesthesia with sedation or general anesthesia. Under
fluoroscopic guidance, a guidewire is advanced through the femoral vein into
the RA then through the interatrial septum. The balloon catheter is advanced
along the guidewire and positioned in the mitral valve. Once properly
positioned, the balloon is inflated, thereby dilating the valve. Repeated
dilations are performed until there is an improvement of the pressure gradient
between the left atrium and LV, significant mitral regurgitation occurs, or
echocardiographic assessment reveals adequate fracture of the commissures.
Complications include damage to cardiac structures, hemopericardium leading
to tamponade, emboli release, worsening or creation of mitral regurgitation,
damage to the subvalvular apparatus, and persistent interatrial shunt. Acute
success rates and long-term restenosis rates are comparable to those for open
surgical mitral commissurotomy.
3. Transcatheter Aortic Valve Implantation (TAVI) [40]. This technique is
discussed in Chapter 11. That discussion also includes hybrid operating rooms,
which are presented in Chapter 10 as well.
IV. Robotically enhanced cardiac surgery
1. Use of robotics in surgery was initially considered for facilitation of surgical
expertise at a site remote from the surgeon (e.g., battlefield, developing
country).
2. Robotic cardiac surgery has evolved through advances in telemanipulation
technology, endoscopic instruments and visualization tools, and peripheral
cannulation techniques [41].
3. Computer-assisted, robotic cardiac surgery in patients was first reported by
Loulmet et al. [42] and Reichenspurner et al. [43] in 1999. Carpentier and
colleagues performed the first robotically assisted mitral valve surgery in 1997
using a prototype of the da Vinci ® system which was followed by the first
robotic mitral valve surgery by Chitwood et al. in the United States [44]. Since
2002, the Food and Drug Administration (FDA) has approved the use of the da
Vinci system for cardiac surgery [45].
4. 10 Since then, a variety of procedures ranging from multivessel totally
endoscopic coronary artery bypass grafting (TECAB), both on-pump and off-
pump, to hybrid procedures involving robotic revascularization and PCI have
evolved with promising results [46]. Other cardiac surgeries that can be
performed using a robotic system include mitral valve surgeries, tricuspid
valve surgeries, ASD/PFO closure, atrial mass removal (myxoma). Congenital
and catheter-based technologies and surgeries for atrial fibrillation and LV
lead placement have also been performed. Suri et al. have provided proof of
concept for a robotic-assisted aortic valve replacement using a sutureless
bovine pericardial prosthesis (Perceval self-expanding valve) in cadavers
[47].
B. Overview
1. Taylor et al. [48] described the complementary capabilities of surgeon and
machine.
a. Surgeons are dextrous, adaptive, fast, and can execute motions over a large
geometric scale; they develop judgment and experience. Limiting factors
include geometric inaccuracy and inexact exertion of directional force.
Performance is compromised by confined spaces or bad exposure. Surgeons
get tired, and with age can lose skills and vision.
b. Machines are precise and untiring. Computer-controlled instruments can be
moved through an exactly defined trajectory with controlled forces,
facilitating work in confined spaces.
2. Endoscopic surgeries, being minimally invasive, are advantageous by
minimizing stress and pain associated with open procedures. Other advantages
include early recovery, reduced median length of stay, complications,
mortality, cosmetic benefits, decreased bleeding and improved early quality of
life [49,50].
3. Robotic approaches to cardiac surgery avoid sternotomy preserving thoracic
integrity and function and provide a virgin chest for redo operations via a
sternotomy.
C. Technologic advances permitting endoscopic surgery
1. Development of the charge-coupling device (CCD) allows high-resolution
video images to be transmitted through optical scopes to the surgeon. Present
systems utilize 3D (as compared to 2D for endoscopic procedures) 1080i with
10× magnification imaging displays providing better depth perception.
2. High-intensity xenon and halogen light sources improve visualization of the
surgical field.
3. Improved hand instrumentation permits procedures that previously could only
be performed through an open incision to be executed by less invasive methods
[51].
4. The major limitations of endoscopic instruments are the control of fine motor
activity, surgery in a confined space, and a somewhat reduced sensory
feedback of tissue resistance or firmness. This becomes very relevant during
tissue dissection and knot tying and the surgeon depends on visual cues to
ascertain tissue strain [45].
5. Placement of a microprocessor between the surgeon’s hand and the tip of the
surgical instrument dramatically enhances control and fine movement. Table
13.2 lists the ways in which computerized dexterity enhancement addresses
limitations of conventional endoscopy.
6. The addition of a dynamic atrial retractor provides continuous and rapid
retraction providing sustained exposure in a tight space along with true
dexterity provided by the instruments.
7. Other disadvantages include a steep learning curve, increased operative and
CPB times and cost [52]. The technology limits itself to a highly selective
group and is contraindicated in patients with significant aortic, iliofemoral
arterial disease [53], significant mitral annular calcification (MAC) [54],
severe lung disease, chest wall abnormalities with abnormal heart orientation
within the chest cavity, previous thoracic procedures (increased adhesion
leading to poor exposure), severe pulmonary hypertension and severely
reduced ventricular function [55].
TABLE 13.2 Endoscopic versus computer-enhanced instrumentation systems
D. Endoscopic robotic-assisted systems

1. Robotic systems consist of three principal components:
a. A surgeon console. The surgeon sits at the console and grasps specially
designed instrument handles. The surgeon’s motions are relayed to a computer
processor, which digitizes hand motions.
b. A computer control system. The digitized information from the computer
control system is related in real time to robotic manipulators, which are
attached to the operating room table.
c. Robotic manipulators. These manipulators hold the endoscopic instrument
tips, which are inserted into the patient through small ports.
2. Currently, only one robotic system is commercially available: the da Vinci
system (Intuitive Surgical, Mountain View, CA, USA).
3. A number of enhancements are required to move robotic systems toward more
widespread acceptance.
a. Development of endoscopic Doppler ultrasonography may aid in internal
thoracic (mammary) artery harvesting, especially when the vessel is covered
by fat or muscle.
b. Although providing articulation, the endoscopic stabilizers need refinement to
permit easier placement.
c. Multimodal three-dimensional image visualization and manipulation systems
may allow modeling of the range of motion of the robotic arms to individual
patient data sets (computerized tomographic (CT) scan, ECG-gated magnetic
resonance imaging). This may help optimize port placement and minimize the
risk of collisions in the future.
d. “Virtual” cardiac surgical planning platforms will allow the surgeon to
examine the topology of a patient thorax for planning the port placement and
the endoscopic procedure.
E. Anesthetic considerations related to robotic surgery
Robotic surgery requires the anesthesiologist to interact prospectively with the
surgeon and machine to maintain ideal operating conditions, as well as stable
hemodynamics and cardiac rhythm in an environment that may change rapidly
from regional ischemia and cardiac manipulation. When the patient is fully
instrumented and the robotic surgery is under way, direct access to the operative
field is very limited and likely to be delayed. Anticipation and excellent
communication are especially important where rapid surgical interventions are
all but impossible. In general, the less invasive the surgery, the more involved is
the team to compensate for the lack of direct visualization.
CLINICAL PEARL Robotic-assisted cardiac surgery in selected patients offers a
minimally invasive option with equivalent surgical outcomes and faster recovery times.
1. Preoperative preparation
a. Similar to OPCAB or MIDCAB, the anesthesiologist must discuss the
procedure with the surgeon to understand the coronary anatomy, what is
planned, and what special considerations might be involved (see above).
b. Specific to robotic surgery are considerations that may be applicable to the
robot (e.g., site of ports, location of manipulators, electrical interference).
c. Peripheral cannulation and remote access perfusion requires additional
imaging studies such as Doppler US and CT angiography to determine size
and calcification of the peripheral vessels and aorta (atherosclerotic plaques
which may embolize with retrograde perfusion) [53].
2. Monitoring must take into account the patient’s pathology (i.e., underlying
ventricular function), the surgeon’s familiarity with the robotic technique,
anticipated problems, and duration of the procedure.
3. Induction and maintenance of anesthesia
a. Specific anesthetic techniques are similar to other cardiac surgery settings
where rapid emergence from anesthesia is desired (“fast track”).
b. Position is critical for appropriate location of ports and access for robotic
manipulators. For TECAB procedures the left hemithorax is elevated.
Positioning for mitral valve surgery consists of the patient being supine with
the right trunk elevated avoiding excessive stress on neck and shoulders.
c. One-lung ventilation (OLV) may be employed for better visualization and
depends on the surgical procedure. For TECAB the left lung is deflated
whereas for mitral valve surgery the right lung is deflated [55]. This may be
achieved with a double-lumen tube or a bronchial blocker.
d. Lung deflation is critical during exposure, assessment and control of bleeding
and chest closure. Alternatives to lung isolation are intermittent apnea and
establishing CPB prior to exposure [56] (Fig. 13.5).
e. During robotic CABG surgery, CO2 is insufflated into the left hemithorax
during one-lung anesthesia. The insufflation pressure should be 6 to 8 mm Hg.
This sustained positive intrathoracic pressure may mechanically decrease
myocardial contractility and/or impair cardiac filling, which is rapidly
reversible after the release of CO2 from the chest cavity [57]. There may be
sufficient absorption of CO2 to induce respiratory acidosis and its attendant
potential for tachycardia, dysrhythmias, and pulmonary hypertension. These
effects are negated to a certain extent by gradual insufflation, additional fluid
boluses, and use of vasopressors and/or inotropes. Reducing the insufflation
pressure aids in reversing severe hemodynamic compromise almost
immediately [69].
IGURE 13.5 A and B: Peripheral cannulation techniques with use of endoballoon and pulmonary artery vent.
CLINICAL PEARL Lung isolation is essential for better visualization of cardiac

structures and instrumentation inside a closed chest.
f. External defibrillator/pacing pads should be attached to the patient as surgical
access to the heart for either of these functions is very limited and delayed
[55,56].
g. Similar to OPCAB and MIDCAB, a multimodal approach should be taken to
prevent heat loss. Although robotic procedures often reduce the extent of
exposed intrathoracic surfaces as compared to OPCAB or CABG using CPB,
the procedures can be lengthy, so the risk for hypothermia remains significant.
h. Other considerations during robotic cardiac surgery include long operative
times and limited access to the patient. If required, CPR must only be
provided after all robotic instruments are removed to prevent patient injury
[55].
CLINICAL PEARL Access to the patient during the surgical procedure may be limited
making resuscitation difficult.
4. Anticoagulation and reversal. See discussion under “OPCAB and MIDCAB” in
Section II.F.
5. TEE is an essential tool in all robotic cardiac procedures. Limited surgical
exposure makes TEE very important during the procedure [55–57]. It is helpful
in:
a. Confirming the preoperative findings
b. Examination of the visible aorta for severe atheromatous disease which
increases the risk of stroke with retrograde perfusion via femoral artery.
c. Dilatation of the aortic root and or ascending aorta which limits the use of a
percutaneous endoballoon.
d. Presence and quantification of aortic regurgitation necessitating use of a
percutaneous retrograde coronary sinus catheter and a percutaneous PA vent.
Severe aortic regurgitation may potentially limit the approach because of a
lack of adequate ventricular emptying limiting myocardial protection during
CPB.
e. Imaging is critical during remote access perfusion and peripheral cannulation
and its associated complications including aortic dissection and cardiac
tamponade. Positions of guidewires and cannulae need to be confirmed.
Although a peripheral arterial cannula will not be visualized in the descending
aorta visualized by TEE, at our institutions we identify the guidewire in the
aortic lumen prior to cannulation.
f. Ventricular function during capnothorax and volume status.
g. De-airing and weaning from CPB
CLINICAL PEARL TEE is valuable in confirming the surgical diagnosis, monitoring
hemodynamics, confirming placement of peripheral cannulation, percutaneous
cardioplegia devices, and complications.
h. Adequacy of the surgical procedure
6. Cannulation, cross-clamping, cardioplegia delivery, and venting techniques
[41,45,55].
a. Venous drainage
(1) Vacuum-assisted (increases flow by 20% to 40%) venous drainage is
achieved by a percutaneously placed femoral venous catheter (22 to 28F)
with the tip positioned in the SVC.
(2) Additional venous drainage may be supplemented via a percutaneous
SVC cannula (17F) placed via the right IJV.
(3) Alternatively, direct venous cannulation may be achieved through a
larger incision.
b. Arterial cannulation
(1) Arterial cannulation is achieved via the femoral or subclavian artery.
c. Cross-clamping
(1) A percutaneously placed aortic endoballoon via the femoral or
subclavian artery. Aortic root enlargement, inadequate femoral arterial
diameter, and calcium in the ascending aorta may limit its use.
(2) Positioning of the endoballoon in the aortic root is aided by TEE and an
injection of adenosine directly via the device prior to insufflation.
(3) A fine balance between proximal flow from residual cardiac contraction
or infusion of antegrade cardioplegia against the retrograde flow from
the arterial inflow determines the motion of the endoballoon in the aortic
root and ascending aorta. Migration of the device distally may limit
perfusion to the head vessels and inadequate myocardial perfusion. It can
be monitored with the use of TEE (limited utility on CPB with air in the
chest cavity and an empty heart) and monitoring bilateral arterial
pressure tracings. A significant fall in the right arterial pressure tracing
(from innominate artery occlusion) indicates distal migration.
(4) Other complications of endoballoon placement include injury to the
aortic valve while positioning and/or with proximal migration.
(5) Alternatively, a percutaneous transthoracic aortic clamp can be
introduced via the right axilla along with the placement of an aortic root
vent via the incision.
(6) Certain procedures may be performed on a beating heart or with induced
ventricular fibrillation.
CLINICAL PEARL Robotic cardiac surgery has been made possible due to advances in
telemanipulation, peripheral cannulation, and cardioplegia techniques.
d. Cardioplegia delivery
(1) Antegrade
(a) Directly with the use of aortic root cannulation.
(b) Via the endoballoon.
(2) Retrograde [58,59]
(a) Indications for retrograde percutaneous cardioplegia include redo
operations, complex procedures with long operative times, a patent
LIMA, significant aortic regurgitation, and LV hypertrophy.
(b) It is commonly introduced via the right IJV percutaneously under
TEE (modified bicaval view, deep 4-chamber view, midesophageal
2-chamber or mid-esophageal bicommissural view), fluoroscopy
guidance and by transducing the catheter. Ventricularization of the
tracing after balloon inflation suggests it is in the coronary sinus.
(c) It may be difficult to place in patients with a hypoplastic or
thrombosed coronary sinus and a prominent thebesian valve.
Cardioplegia delivery may be ineffective in patients with a dilated
coronary sinus or incorrectly placed (too deep) catheter.
(d) It may be displaced by the venous cannula and or by a dynamic atrial
catheter.
(e) Trauma to the coronary sinus can occur during placement,
overinflation of the catheter balloon, elevated cardioplegia infusion
pressure or aggressive retraction of the heart with the catheter in
place.
e. Venting
(1) Is achieved via the endoballoon, directly via the ascending aorta with a
transthoracic aortic clamp, a percutaneously placed PA vent, or directly
via a vent in the LV across the mitral valve in mitral valve surgeries.
(2) The PA vent is a flimsy non–heparin-coated catheter whose distal tip is
positioned in the main PA with the help of TEE and that drains a rate of
50 mL/min (Figs. 13.6 and 13.7).
f. Postoperative management
(1) Extubation in the operating room may be possible (see above for OPCAB
and MIDCAB).
(2) If postoperative ventilation is anticipated, plan to change the double-
lumen endobronchial tube to a single-lumen endotracheal tube.
(3) Postoperative pain management will depend on the size and number of
port incisions. If a thoracotomy incision was made, intercostal,
paravertebral, epidural analgesia, pectoral nerve (PECS) blocks, and
serratus anterior blocks can be considered.
FIGURE 13.6 Surgical access for robotic mitral valve repair.
FIGURE 13.7 Peripheral cannulation techniques with use of aortic cross-clamp and direct cardioplegia.
F. Conversion to sternotomy
Reasons to abandon the robotic approach for a conventional sternotomy include
inadequate CPB flows, complications with peripheral access and or remote
access perfusion, inadequate exposure, inadequate repair, IMA injury,
anastomosis problems, graft kinking, intraoperative ischemia, ventricular failure,
and inadequate target exposure due to intramyocardial course of the coronary
vessels.
G. Summary
The field of robotically enhanced cardiac surgery will present a wide range of
anesthetic challenges as it continues to develop. Anesthesiologists and surgeons
alike must adapt to rapidly changing techniques in our continuing efforts to
improve clinical outcomes.
V. Anesthesia for robotic noncardiac thoracic surgery
A. Introduction
Robotic surgical procedures are usually performed by two surgeons, the surgeon
at the console and the table-side surgeon, who introduces the trocars and
connects them with the robotic arms and changes the robotic instruments through
the other ports if needed. The size of the robotic trocar is 10 mm for the
binocular robotic camera and 8 mm for the instruments. Some of the potential
advantages of using a robotic surgical system in thoracic surgery include: shorter
hospital length of stay, less pain, less blood loss and transfusion, minimal
scarring, faster recovery, and potentially a faster return to normal activities [60].
Table 13.3 displays the advantages and disadvantages of robotic thoracic
surgery. Table 13.4 displays the surgical procedures performed in thoracic
surgery with the da Vinci robotic surgical system.
TABLE 13.3 Advantages and disadvantages of robotic thoracic surgery
B. Anesthetic implications in robotic thoracic surgery

The basic principles applied to video-assisted thoracic surgery (VATS) also
apply to robotic-assisted thoracic surgery (see also Chapter 26). The
combination of patient position, management of OLV techniques, and surgical
manipulations alter ventilation and perfusion from the dependent and
nondependent or collapsed lung. The preferred method for lung isolation during
robotic-assisted thoracic surgery is the use of a left-sided double-lumen
endotracheal tube (DLT) because of the greater margin of safety and faster and
more reliable lung collapse. Also, it provides ready access for bronchoscopic
evaluation of the airway during surgical resection.
In general, careful attention must be given to airway devices because changes
in body position may cause tube migration. OLV anesthetic management is more
challenging during robotic thoracic surgery due to the presence of the robot
chassis that is stationed over the patient. The patient’s airway is also usually
located far from the anesthesia field. In some instances access to the airway, if
needed, is not optimal because of the presence of the robotic arms nearby. In
addition, visualization during robotic thoracic surgery may be enhanced by
continuous intrathoracic CO2 insufflation, which may increase airway pressures.
When CO2 is used it should not exceed intrathoracic pressures of 10 to 15 mm
Hg. Increasing the intrathoracic pressure (i.e., >25 mm Hg) can compromise
venous return and cardiac compliance; also the dependent lung develops higher
airway pressures and ventilation can become difficult. During the surgical
procedure, the FiO2 should be maintained at 100% and the peak inspiratory
pressure should be kept <30 cm H2O. The ventilatory parameters should be
adjusted to maintain a PaCO2 at approximately 40 mm Hg.
C. Robotic-assisted surgery and anesthesia for mediastinal masses
One of the commonest thoracic surgical procedures performed to date with the
use of the da Vinci robotic surgical system is thymectomy [61]. Of the patients
scheduled for robotic-assisted thymectomy, some have the diagnosis of
myasthenia gravis because of the presence of a thymoma. Preparation of the
patient for surgery includes neurologic evaluation to assess the patient’s
neurologic status and optimization of neurologic conditions; continuation of
anticholinesterase therapy and plasmapheresis may be indicated in some cases
[62]. Precautions regarding anesthetic management include the proper dosing of
muscle relaxants and the potential consequences of a large mediastinal mass on
oxygenation and ventilation.
TABLE 13.4 Surgical procedures performed in thoracic surgery with the da Vinci
robotic surgical system
Positioning the patient for a thymectomy with the use of the robotic system
requires specific care and attention. In these cases, the patients are placed in an
“incomplete side-up” position at a 30-degree angle right or a left lateral
decubitus position with the use of a beanbag. The arm of the elevated side is
positioned at the patient’s side as far back as possible so the surgeon can gain
enough space for the robotic arms. While the robot is in use it is imperative to
consider strategies to protect all pressure points and to avoid unnecessary
stretching of the elevated arm because this can cause damage to the brachial
plexus. Also, because the arm of the robot is in the chest cavity, a complete lung
collapse must be maintained throughout the procedure. Robotic surgery with the
da Vinci robotic surgical system does not allow for changes in patient position
on the operating room table once the robot has been docked. Robotic thymectomy
requires that the operating room table be rotated 90 degrees away from the
anesthesiologist’s field. For this reason access to the airway to make adjustments
to the DLT during the surgery can be challenging. In some cases, a bilateral
approach may be required. In these cases, the operation is performed in two
stages and requires rotating the table 180 degrees to provide the surgeon access
to the contralateral chest for the second stage of the operation. The
anesthesiologist must be cautious during these changes to avoid problems with
the airway and to ensure that the lines and monitor wires have enough slack to
accommodate changes in position. The anesthesiologist must be aware during
these cases of possible injury to the contralateral pleura, especially if CO2
capnothorax is being used, as the elevated intrathoracic pressure in the
contralateral hemithorax can make ventilation difficult and cause cardiovascular
collapse or tension pneumothorax because of malfunction of the chest tube.
Special attention must be given to the patient’s elevated arm and head to prevent
crushing injuries with the robotic arms. One case report [63] showed a brachial
plexus injury in an 18-year-old male after robotic-assisted thoracoscopic
thymectomy. In this report, the left upper limb was in slight hyperabduction. It is
important to keep in mind that hyperabduction of the elevated arm to give optimal
space to the operating arm of the robot can lead to a neurologic injury. Close
communication between surgeon and anesthesiologist in relation to the
positioning and function of the robot is mandatory, and all proper measures must
be taken, including the use of soft padding and measures to avoid hyperabduction
of the arm. The elevated arm should be protected by using a sling resting device.
Operating room staff should always be vigilant of telescope light sources
because direct contact of these devices with surgical drapes and the patient’s
skin can quickly cause serious burns while telescopes and cameras are being
changed.
An early report by Bodner et al. [64] involving 13 patients with mediastinal
masses resected with the da Vinci robotic surgical system showed no
intraoperative complications or surgical mortality. In this series of patients, a
complete thymectomy with en bloc removal of all mediastinal fat around the
tumor was performed. In this report, cases were restricted to patients with a
tumor size less than 10 cm in diameter.
In a report by Savitt et al. [65] involving 14 patients undergoing robotic-
assisted thymectomy, all patients received a DLT for selective lung ventilation;
in addition, patients were managed with arterial and central venous pressure
catheters. Complete thymectomy was performed on all 14 patients. Right-lung
deflation was accomplished with selective lung ventilation and CO2 insufflation
to a pressure of 10 to 15 mm Hg to maintain the lung away from the operative
area. It is important that the anesthesiologist recognize the effects of CO2
insufflation in the thoracic cavity. The outcome of this report included no
conversion to open thoracotomy, nor any intraoperative complications or deaths;
the median hospital stay was 2 days with a range of 1 to 4 days.
In another report, Rückert et al. [66] had zero mortality and an overall
postoperative morbidity rate of 2% in 106 consecutive robotic-assisted
thymectomies. Therefore, robotic thymectomy appears to be a promising
technique for minimally invasive surgery. Length of stay was shorter with robotic
thymectomy when compared to the conventional approach via sternotomy.
A recent systematic review and meta-analysis comparing robotic-assisted
minimally invasive surgery versus open thymectomy [67] clearly showed that the
patients undergoing robotic thymectomy have a reduced hospital length of stay,
less intraoperative blood loss, fewer chest-in-tube days, and less postoperative
complications when compared to open thymectomy.
In contrast another meta-analysis [68] comparing robotic-assisted thymectomy
versus video-assisted thymectomy showed no statistically significant differences
in surgery outcomes among the two groups (no significant difference on
conversion rates, surgical times or average days or length of stay).
In addition the indications for the use of the robot have been extended for cases
with posterior mediastinal tumor where the access can be challenging and these
have also reported good outcomes [69].
D. Robotic-assisted pulmonary lobectomy
Since the introduction of the da Vinci robotic surgical system, there has been
widespread interest in its use in minimally invasive surgery involving the chest.
Lobectomy with lymph node dissection remains the cornerstone of surgical
treatment of early-stage cancer. However, due to the use of low-dose CT scans,
the number of patients who are diagnosed with early-stage disease each year is
increasing; these patients can be treated via lobectomy or segmentectomy. In
order to offer more minimally invasive resection options to patients with lung
disease, video-assisted lobectomy/segmentectomy and subsequently robotic-
assisted lobectomy/segmentectomy approaches have been developed [70].
The robotic-assisted lobectomy/segmentectomy has attracted the interest of
thoracic surgeons since its introduction in 2002. Proposed advantages of robotic
lobectomy/segmentectomy include: smaller incisions, decreased postoperative
pain, faster recovery time, and superior survival when compared to conventional
open thoracotomy.
A report by Park et al. [71] showed robotic-assisted thoracic surgical
lobectomy to be feasible and safe. In the report, the operation was accomplished
with the robotic system in 30 out of 34 scheduled patients. The remaining four
patients required conversion to open thoracotomy. Anderson et al. [ 72] reported
a series of 21 patients that underwent robotic lung resection for lung cancer. In
this report, the 30-day mortality and conversion rate was 0%. The median
operating room time and blood loss were 3.6 hours and 100 mL. The
complication rate was 27% and included atrial fibrillation and pneumonia.
Gharagozloo et al. [73] reported a series of 100 consecutive robotic-assisted
lobectomies for lung cancer and concluded that robotic surgery is feasible for
mediastinal, hilar, and pulmonary vascular dissection during video-assisted
thoracoscopy lobectomy.
Positioning the patient for a robotic lobectomy includes placing the patient
over a bean bag in a maximally flexed lateral decubitus position with the
elevated arm slightly extended so that the thoracic cavity can be accessed and no
damage to the arm occurs during manipulation of the robotic arms. Patients
undergoing robotic lobectomy must have a lung isolation device to achieve OLV.
In the vast majority of these cases, a left-sided DLT is used and optimal position
is achieved with the flexible fiberoptic bronchoscope. In a few cases in which
the airway is deemed to be difficult, an independent bronchial blocker could be
used and optimal position achieved with the use of a fiberoptic bronchoscope.
Initial thoracic exploration is performed with conventional thoracoscopy to
verify tumor location. During robotic-assisted lobectomy, it is mandatory that
lung collapse is achieved effectively to allow the surgeon the best field of vision
and to avoid unnecessary damage to vessels or lung parenchyma.
All patients undergoing robotic-assisted thoracic lobectomy should have an
arterial line. The anesthesiologist must be ready for potential conversion to an
open thoracotomy. In the Park report [71], three out of four cases that needed to
be converted had minor bleeding; in addition, in one case lung isolation was lost,
requiring an open thoracotomy. It is mandatory that the anesthesiologist involved
in these cases have experience in placing a DLT and can guarantee optimal
position with the aid of flexible fiberoptic bronchoscope. Using intraoperative
fiberoptic bronchoscopy to make adjustments to the DLT during surgery is
challenging because the table is rotated 180 degrees away from the
anesthesiologist’s field. The chassis of the robot is often positioned over the
patients head leaving a very small area for the anesthesiologist to access the
airway.
The report by Gharagozloo et al. [73] reported one nonemergent conversion to
open thoracotomy. In this report, postoperative analgesia was managed with the
infusion of a local anesthetic (0.5% bupivacaine, 4 mL/hr) through catheters
placed in a subpleural tunnel encompassing intercostal spaces 2 through 8. All
patients were extubated in the operating room. Mean operating room time was
216 minutes (range 173 to 369). Overall mortality within 30 days was 4.9%, and
median length of stay was 4 days. Postoperative complications included atrial
fibrillation in four cases, prolonged air leak in two cases, and pleural effusion
requiring drainage in two cases—complications that are not different from those
occurring with video thoracoscopic surgery.
A meta-analysis [74] in 2015 has evaluated the perioperative outcomes of
robotic-assisted thoracoscopic surgery for early-stage lung cancer. This meta-
analysis report showed that the morbidity and perioperative 30-day mortality
was similar in both groups. A more recent meta-analysis [70] comparing robotic-
versus video-assisted lobectomy/segmentectomy for lung cancer showed that
robotic lobectomy is a feasible and safe alternative to a video thoracoscopic
surgery with a low 30-day mortality and similar morbidity; also this study
reported lower open thoracotomy conversion rate, but longer operative time
which increases the cost of surgery. Robotic cases surgical times must be shorter
with a reduced cost and improve morbidity to become an alternative to other
surgical techniques.
Acute and chronic pain after open thoracotomy continues to be a problem.
Minimally invasive thoracic surgery approaches result in less tissue trauma,
shorter recovery, and improved cosmesis [75]. A recent study [76] evaluating the
outcomes of the acute and chronic pain after robotic-, video-assisted
thoracoscopic surgery, or open anatomic pulmonary resection showed that
robotic and video thoracoscopic surgery (VATS) approach resulted in less acute
pain and chronic numbness when compared to open thoracotomy. However, there
was no significant difference between robotic or VATS. This report indicates
that in terms of pain control, there is no difference regardless which minimally
invasive surgery the surgical team chooses and no advantage of one versus the
other technique (robotic vs. VATS).
E. Carbon dioxide (CO2) insufflation during robotic surgery
Continuous low-flow insufflation of CO2 has been demonstrated as an aid for
surgical exposure during minimally invasive thoracic procedures. It has been
used as the only means of providing surgical exposure to the thoracic cavity
(during two-lung ventilation for VATS), or more frequently in conjunction with a
DLT or an independent bronchial blocker and OLV. The compression of the lung
parenchyma by CO2 acts as a retractor.
A study by Ohtsuka et al. [77] involving 38 patients undergoing minimally
invasive internal mammary harvest during cardiac surgery found significant
increases in mean central venous pressure, pulmonary artery pressure, and the
pulmonary artery wedge pressure. They also found that with insufflation of the
right hemithorax, but not the left side, slight decreases were noted in the mean
arterial blood pressure and cardiac index. They concluded that the hemodynamic
effect from continuous insufflation of CO2 at 8 to 10 mm Hg for 30 to 40 minutes
is mild in both hemithoraces, although the impact is greater on the right. This
information was supported by another study [78]. This study involving 20
patients undergoing thoracoscopic sympathectomy and concluded that compared
to the left-sided hemithorax the impact of CO2 insufflation on the vena cava and
the RA during right-sided procedures was associated with reduction of venous
return and low cardiac index and stroke volume. The impact of CO2 insufflation
on the respiratory system has also been studied. El-Dawlatly et al. also reported
a significant pressure-dependent increase in peak airway pressure and a decrease
in dynamic lung compliance but no difference in tidal volume or minute
ventilation during volume-controlled ventilation.
Insufflation of CO2 should only be started after initial thoracoscopic evaluation
has ruled out that the port of insufflation has not compromised a vascular
structure or the lung parenchyma. Communication between the surgeon,
anesthesiologist, and operating room personnel is crucial at this point.
Insufflation is ideally started at low pressures of 4 to 5 mm Hg and is gradually
increased while monitoring the patient’s vital signs. The anesthesiologist should
always be aware of the possibility of gas embolization during these cases. In the
case of sudden cardiac collapse, the CO2 flow should be discontinued
immediately. Ventilation during CO 2 insufflation should be titrated to keep
adequate oxygenation and a normal PaCO2 and pH. Also, damage to the
contralateral pleura may occur resulting in CO2 flow to the contralateral chest,
making ventilation difficult and also causing hemodynamic compromise, along
with the potential development of subcutaneous emphysema. In addition, venous
return compromise or progressive arterial desaturation can occur [79].
F. Robotic-assisted esophageal surgery and anesthetic implications
Transthoracic esophagectomy with extended lymph node dissection is associated
with higher morbidity rates than transhiatal esophagectomy. Esophagectomy is
both a palliative and a potentially curative treatment for esophageal cancer.
Minimally invasive esophagectomy has been performed to lessen the biologic
impact of surgery and potentially reduce pain. The initial esophagectomy
experience with the da Vinci robotic surgical system involved a patient who had
a thoracic esophagectomy with wide celiac axis lymphadenectomy. The case was
reported by Kernstine et al. [80] and had promising results. Thereafter another
report using the da Vinci robotic surgical system has been published of six
patients undergoing esophagectomy without intraoperative complications [81].
The surgical approach in this report was performed from the right side of the
chest. A left-sided DLT was used to selectively collapse the right lung while, at
the same time, ventilation was maintained in the left lung.
In a report by van Hillegersberg et al. [82] involving 21 consecutive patients
with esophageal cancer who underwent robotic-assisted thoracoscopic
esophagolymphadenectomy, 18 were completed thoracoscopically and 3
required open procedures (because of adhesions or intraoperative hemorrhage).
In this case series report, all patients received a left-sided DLT and a thoracic
epidural catheter as part of their anesthetic management. Positioning of these
patients was in a left lateral decubitus position, and the patient was tilted 45
degrees toward the prone position. Once the robotic thoracoscopic phase was
completed, the patient was then put in supine position and a midline laparotomy
was performed. A cervical esophagogastrostomy was performed in the neck for
the completion of surgery. Of interest in this series is the fact that pulmonary
complications occurred in the first 10 cases (60%), caused primarily by left-
sided pneumonia and associated acute respiratory distress syndrome in 3 patients
(33%). These complications were probably related to barotrauma to the left lung
(ventilated lung) attributed to high tidal volumes and high peak inspiratory
pressures. In the 11 patients that followed, the same authors modified their OLV
ventilator settings to administer continuous positive airway pressure ventilation
(5 cm H2O) to the non-ventilated lung and pressure-controlled OLV; with this
approach the respiratory complication rate was reduced to 32%.
A report by Kim et al. [83] described 21 patients who underwent robotic-
assisted thoracoscopic esophagectomy performed in a prone position with the
use of a Univent® bronchial blocker tube (Fuji Systems Corp, Tokyo Japan). All
thoracoscopic procedures were completed with robotic-assisted techniques
followed by a cervical esophagogastrostomy. In Kim’s report, major
complications included anastomotic leakage in four patients, vocal cord
paralysis in six patients, and intra-abdominal bleeding in one patient. The prone
position led to an increase in central venous pressure and mean pulmonary
arterial pressure and a decrease in static lung compliance. The overall
conclusion from this report is that robotic assistance esophagectomy in the prone
position is technically feasible and safe. Others have reported a robotic-assisted
transhiatal esophagectomy technique feasible and safe as well [84].
Another study [85] involved 14 patients who underwent esophagectomy using
the da Vinci robotic surgical system in different surgical stages. It showed that
for a complete robotic esophagectomy including laparoscopic gastric conduit, the
operating room time was an average of 11 hours with a console time by the
surgeon of 5 hours, and an estimated mean blood loss of 400 ± 300 mL. In this
report after the robotic thoracoscopic part of the surgery was accomplished with
the patient in the lateral decubitus position, patients were then placed in supine
position and reintubated, and the DLT was replaced with a single-lumen
endotracheal tube. The head of each patient was turned upward and to the right,
exposing the left neck for the cervical part of the operation. Among the
pulmonary complications in the postoperative period, arterial fibrillation
occurred in 5 out of 14 patients. In this report, among the recommendations to
improve efficiency in these cases is the “use of an experienced anesthesiologist
who can efficiently intubate and manage single-lung ventilation and
hemodynamically support the patient during the procedure.” This follows what
Nifong and Chitwood [86] have reported in their editorial views regarding
anesthesia and robotics: that a team approach with expertise in these procedures
involving nurses, anesthesiologists, and surgeons with an interest in robotic
procedures is required.
The data on robotic-assisted esophagectomy suggest that the procedure is safe,
feasible, and associated with preoperative outcomes similar to open and
minimally invasive esophagectomy. No data, however, demonstrate improved
outcomes in terms of operative morbidity, pain, operative time, or total costs.
Table 13.5 displays the complications of robotic-assisted thoracic surgery
involving the mediastinum lung and esophagus.
TABLE 13.5 Complications of robotic-assisted thoracic surgery
Although the outcome of robotic-assisted minimally invasive esophagectomy

compared to thoracic minimally invasive esophagectomy is comparable, one of
the advantages of using robotic technique is the reduced incidence of vocal cord
paralysis. Three-dimensional images enhance identification of the recurrent
laryngeal nerve; therefore it could reduce the chance of damaging the nerve. One
study [89] reported a reduced incidence of vocal cord paralysis by
approximately 50% when a robotic-assisted technique was used (6/38 vs.
15/20). Other reported complications include anastomotic leakage, bleeding,
dysrhythmia, and acute lung injury [90].
G. Summary
The use of the da Vinci robotic surgical system in thoracic and esophageal
surgery continues to gain acceptance. Although its use has reduced surgical
scarring and decreased length of stay, specific indications for use in these areas
need to be determined. All reports to date describe the use of lung isolation
devices, most often a left-sided DLT, as part of the intraoperative management of
thoracic surgery patients to facilitate surgical exposure. In addition, because the
surgical approach varies depending on the thoracic procedure, optimal
positioning is not standard, and varies among the specific surgical procedures.
Vigilance is required with patients’ elevated arms to avoid nerve injuries or
crush injuries from the robotic arms. Continuous low-flow insufflation of CO2
has been used as an aid for surgical exposure during minimally invasive thoracic
procedures. The potential to convert to an open thoracotomy requires preparation
by the surgical team and anesthesiologist. The use of the da Vinci robotic
surgical system is expected to grow in the years to come. Prospective studies are
needed to define the specific advantages of this robotic system.
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96.
14 Anesthetic Management for Thoracic Aortic
Aneurysm and Dissection
Amanda A. Fox and John R. Cooper, Jr.
I. Classification and natural history

A. Dissection
B. Aneurysm
C. Thoracic aortic rupture (tear)
II. Diagnosis
A. Clinical signs and symptoms
B. Diagnostic tests
C. Indications for surgical correction
III. Preoperative management of patients requiring surgery of the thoracic
aorta
A. Prioritizing: making the diagnosis versus controlling blood pressure
(BP)
B. Achieving hemodynamic stability and control
C. Bleeding and transfusion
D. Assessment of other organ systems
E. Use of pain medications
IV. Surgical and anesthetic considerations
A. Goal of surgical therapy (for aortic dissection, aneurysm, or rupture)
B. Overview of intraoperative anesthetic management (for aortic
dissection, aneurysm, or rupture)
C. Ascending aortic surgery
D. Anesthetic considerations for ascending aortic surgery
E. Aortic arch surgery
F. Anesthetic considerations for aortic arch surgery
G. Descending thoracic and thoracoabdominal aortic surgery
H. Anesthetic considerations in descending thoracic aortic surgery
I. Endovascular (EV) graft repair of the thoracic aorta
J. Anesthetic considerations for patients undergoing EV stent graft repair
of the thoracic aorta
K. Future trends
KEY POINTS
1. An aortic dissection usually occurs when blood penetrates the aortic

intima, forming either an expanding hematoma within the aortic
wall or simply a false channel for blood flow between the medial
layer.
2. An aortic aneurysm involves dilation of all three layers of the aortic
wall.
3. The term dissecting aneurysm, although commonly used, is often a
misnomer because the aorta may not be dilated.
4. Administering a potent arterial vasodilator such as nitroprusside or
nicardipine and a β-blocker to decrease left ventricular (LV) ejection
velocity is critical to preventing further propagation of aortic
dissection, rupture of a torn aorta, or a leaking thoracic aortic
aneurysm.
5. Concomitant aortic valve repair or replacement is often needed with
repair of aortic dissection or aneurysm. Which procedure is used
depends on involvement of the sinus of Valsalva and the aortic
annulus.
6. Managing left heart bypass (LHB) can be challenging for the cardiac
anesthesiologist while descending thoracic aneurysms or aortic tears
are being repaired (see Table 14.11 ). Transesophageal
echocardiography (TEE) is very useful for guiding volume
management, because native cardiac output must be preserved to
provide adequate blood flow to the brain.
7. Cerebral spinal fluid drainage has been shown in randomized
studies to significantly decrease the incidence of postoperative
paraplegia and paraparesis in appropriately selected patients who
undergo descending thoracic aortic surgery.
ANESTHESIOLOGISTS CARING FOR THORACIC AORTIC surgical patients encounter
considerable variation among patients with regard to the cause and location of aortic
disease. It is vital that anesthesiologists understand the implications of and the
challenges related to these variations in providing optimal perioperative care. Members
of both the American Society of Anesthesiologists and the Society of Cardiovascular
Anesthesiologists were involved in the multidisciplinary development of the 2010
ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis
and Management of Patients with Thoracic Aortic Disease [1]. This chapter gives a
concise overview of the pathophysiology of thoracic aortic surgery, a review of its
surgical approaches and results, and a rational approach to managing patients
undergoing thoracic aortic surgery. Surgery on the thoracic aorta, particularly the
descending and thoracoabdominal aorta, can require complex anesthetic management.
Therefore, each team member must have a clear understanding of what is being planned.
Often, all that is required is a brief preoperative conversation among the surgeon,
anesthesiologist, nursing team, and perfusionist as to the exact requirements for a
particular procedure.
CLINICAL PEARL Anesthetic management of thoracic aneurysms requires

knowledge of aortic anatomy, the planned surgical approach, the adjuncts needed,
and excellent communication with the surgeon.
I. Classification and natural history

A. Dissection
1 An aortic dissection usually occurs when blood penetrates the aortic intima,
forming either an expanding hematoma (also called a dissecting hematoma)
within the aortic wall or simply a false channel for flow between the medial
layers. The true lumen of the dissecting aorta is generally not dilated; rather, it is
often compressed by the dissection. Because the dissection does not necessarily
involve the entire circumference of the aorta, branching vessels may be 2
unaffected, they may be occluded, or they may arise from the false lumen. An
aortic aneurysm involves dilation of all three layers of the aortic wall and has
different pathophysiology and management 3 concerns from those of a
dissection. The term dissecting aneurysm, although commonly used, is often a
misnomer because the aorta frequently is not dilated.
1. Incidence and pathophysiology
a. Incidence. The incidence of dissection in the United States is unclear, mainly
because of underreporting; however, European studies have reported an
incidence of 3.2 dissections per 100,000 autopsies, and that the incidence
increased over time. Also, dissection results in more deaths than does
aneurysm rupture [2].
b. Predisposing conditions. The medical conditions predisposing to aortic
dissection are listed in Table 14.1 in general order of importance.
Interestingly, atherosclerosis by itself may not contribute to the risk of
subsequent aortic dissection.
c. Inciting event. The onset of aortic dissection has been associated with
increased physical activity or emotional stress. Dissection also has been
associated with blunt trauma to the chest; however, the temporal relationship
between blunt trauma and subsequent dissection has not been well
established. Dissection can occur without any physical activity. It also can
occur during cannulation for cardiopulmonary bypass (CPB), either antegrade
from the ascending aorta or retrograde from the femoral artery (FA).
TABLE 14.1 Conditions predisposing to aortic dissection
TABLE 14.2 Sites of primary intimal tears in acute dissection of the aorta (398 autopsy
cases)
d. Mechanism of aortic tear. An intimal tear is the initial event in aortic

dissection. The tear usually occurs in a weakened portion of the aortic wall
and typically involves the middle and outer layers of the media. In this area of
weakening, the aortic wall is more susceptible to shear forces produced by
pulsatile blood flow through the aorta. Thus, intimal tears most frequently
arise in the areas subject to the greatest mechanical shear forces (Table 14.2):
the ascending and isthmic (just distal to the left subclavian artery (LSA))
segments of the aorta, which are particularly vulnerable because they are
relatively fixed.
In large autopsy series, however, up to 4% of dissections involved no
identifiable intimal disruption. In these cases, rupture of the vasa vasorum, the
vessels that supply blood to the aortic wall, has been implicated as an
alternative cause of dissection. The thin-walled vasa vasorum are located in
the outer third of the aortic wall, and their rupture would cause the formation
of a medial hematoma and propagation of a dissection in an already diseased
vessel, without formation of an intimal tear.
e. Propagation. An aortic dissection can propagate within seconds. The factors
that contribute to propagation are the hemodynamic forces inherent in pulsatile
flow: pulse pressure and ejection velocity of blood.
f. Exit points. Exit points are found in a relatively small percentage of
dissection cases. Exit-point tears usually occur distal to the intimal tear and
represent points at which blood from the false lumen reenters the true lumen.
The presence or absence of an exit point does not appear to affect the clinical
course.
g. Involvement of arterial branches. Aortic dissection can involve the origins
of the major branches of the aorta, including the coronary arteries. Their
involvement ranges from branch-vessel occlusion due to mechanical
compression by the false lumen to propagation of the dissecting hematoma into
the arterial branch. The incidence of involvement of the various arterial
branches in a large autopsy series is listed in Table 14.3 [3].
2. DeBakey classification of dissections (Fig. 14.1). This classification consists
of three different types based on the location of the intimal tear and the section
of the aorta involved.
a. Type I. The intimal tear is located in the ascending portion, but the dissection
involves all portions of the thoracic aorta (ascending, arch, and descending)
and may extend into the abdominal aorta.
b. Type II. The intimal tear is in the ascending aorta, and the dissection involves
the ascending aorta only, stopping before the takeoff of the innominate artery.
c. Type III. The intimal tear is located in the descending segment. If the
dissection involves the descending portion of the thoracic aorta only, starting
distal to the origin of the LSA and ending above the diaphragm, it is
considered type III A. If the dissection propagates below the diaphragm, it is
considered type III B. By definition, type III dissection can extend proximally
into the arch, but this is rare.
TABLE 14.3 Involvement of major arterial branches in aortic dissections
3. Stanford (Daily) classification of dissections (Fig. 14.2). This classification

is simpler than DeBakey’s and perhaps has more clinical relevance.
a. Type A. Type A dissections are those that have any involvement of the
ascending aorta, regardless of where the intimal tear is located or how far the
dissection propagates. Clinically, type A dissections run a more virulent
course and are generally considered urgent or emergent cases. They are most
often managed with open-chest surgical repair.
b. Type B. Type B dissections involve the aorta distal to the origin of the LSA.
Many cases can be managed medically or with endovascular (EV) therapy.
4. Natural history
a. Mortality—untreated. The survival rate of untreated patients with ascending
aortic dissection is dismal, with a 2-day mortality of up to 50% in some series
and 3-month mortality approaching 90% [3]. The usual cause of death is
rupture of the false lumen into the pleural space or pericardium. Mortality is
lower with DeBakey type III or Stanford type B dissection. Other causes of
death include progressive cardiac failure (aortic valve involvement),
myocardial infarction (coronary artery involvement), stroke (occlusion of
cerebral vessels), and bowel gangrene (mesenteric artery occlusion).
FIGURE 14.1 DeBakey classification of aortic dissections by location: type I, with intimal tear in the ascending portion and
dissection extending to descending aorta; type II, ascending intimal tear and dissection limited to ascending aorta; type III,
intimal tear distal to left subclavian, but dissection extending for a variable distance, either to the diaphragm (a) or to the iliac
artery (b). (From DeBakey ME, Henly WS, Cooley DA, et al. Surgical management of dissecting aneurysms of the aorta. J
Thorac Cardiovasc Surg. 1965;49:131, with permission.)
FIGURE 14.2 Stanford (Daily) classification of aortic dissections. Type A describes a dissection involving the ascending
aorta regardless of site of intimal tear (1, ascending; 2, arch; 3, descending). In type B, both the intimal tear and the extension
are distal to the left subclavian. (From Miller DC, Stinson EB, Oyer PE, et al. Operative treatment of aortic dissections.
Experience with 125 patients over a sixteen-year period. J Thorac Cardiovasc Surg. 1979;78:367, with permission.)
b. Surgical mortality. Overall mortality ranges from 3% to 24% and varies with
the section of aorta that is affected. Dissection involving the aortic arch
carries the highest mortality [2].
B. Aneurysm
1. Incidence. In the European studies cited above, the prevalence of thoracic
aneurysm among autopsied patients was approximately 460 in 100,000. In one
study, 45% of thoracic aneurysms involved the ascending aorta, 10% the arch,
35% the descending aorta, and 10% the thoracoabdominal aorta [4].
2. Classification by location and cause. In general, the causes and
pathophysiology of aortic aneurysm are site dependent (Table 14.4). Most
commonly, ascending aortic aneurysms are due to medial degeneration,
whereas descending and thoracoabdominal aortic aneurysms result from
degenerative conditions associated with atherosclerosis.
3. Classification by shape
a. Fusiform. Fusiform aneurysmal dilation involves the entire circumference of
the aortic wall.
b. Saccular. Saccular aneurysms involve only part of the circumference of the
aortic wall. Isolated aortic arch aneurysms are commonly saccular.
4. Natural history. The natural history of aortic aneurysm is one of progressive
dilation, and more than half of aortic aneurysms eventually rupture. The
untreated, 5-year rate of survival for patients with thoracic aortic aneurysms
ranges from 13% to 39% [2]. Other complications of thoracic aortic aneurysm
include mycotic infection, atheroembolism to peripheral vessels, and
dissection. This last complication is rare, probably occurring in fewer than
10% of cases. Some predictors of poor prognosis are large aneurysm size (i.e.,
maximum transverse diameter >10 cm), symptoms, and associated
cardiovascular disease, especially coronary artery disease, myocardial
infarction, or stroke.
C. Thoracic aortic rupture (tear)
1. Etiology. Most thoracic aortic ruptures occur after trauma—almost always a
deceleration injury from a motor vehicle accident. Sudden deceleration places
great mechanical shear stress on points of the aortic wall that are relatively
immobile. Whereas aortic rupture leads to immediate exsanguination and death
in many patients, approximately 10% to 15% of patients maintain integrity of
the adventitial covering of the aortic lumen and therefore survive to emergency
care. Surgical treatment of these survivors is often successful.
TABLE 14.4 Causes of aneurysm based on location in the aorta
2. Location. Most thoracic aortic ruptures occur just distal to the origin of the
LSA (isthmus), because of the relative fixation of the aorta at this point by the
ligamentum arteriosum (Fig. 14.3). The second most common site of aortic
rupture is in the ascending aorta, just distal to the aortic valve.
II. Diagnosis
A. Clinical signs and symptoms (Table 14.5)
1. Dissection. Aortic dissection usually presents with a dramatic onset and a
fulminant course. Clinical presentations of Stanford types A and B are listed in
Table 14.5.
2. Aneurysm. Aneurysms of the ascending aorta, aortic arch, or descending
thoracic aorta often are asymptomatic until late in their course. In many
circumstances, the aneurysm is not detected until medical evaluation is
conducted for an unrelated problem or for a problem related to a complication
of the aneurysm.
FIGURE 14.3 The heart and great vessels are relatively mobile in the pericardium, whereas the descending aorta is relatively
fixed by its anatomic relations. The attachment of the ligamentum (Lig.) arteriosum enhances this immobility and increases the
risk of aortic tear due to deceleration injury. A., artery. (From Cooley DA, ed. Surgical Treatment of Aortic Aneurysms.
Philadelphia, PA: WB Saunders, 1986:186, with permission.)
TABLE 14.5 Presenting clinical signs and symptoms by location and type of aortic
pathology
3. Traumatic rupture. Rupture most commonly occurs just distal to the LSA. If
the patient survives the initial trauma, signs and symptoms are similar to those
of aneurysms of the descending thoracic aorta.
B. Diagnostic tests
1. Electrocardiogram (ECG). Many patients with aortic disease will have
evidence of left ventricular (LV) hypertrophy on ECG, secondary to the high
incidence of hypertension in these patients. In patients with aortic dissection,
the ECG may show ischemic changes caused by coronary artery involvement,
or evidence of pericarditis from hemopericardium.
2. Chest radiograph. A widened mediastinum is a classic radiographic finding
with thoracic aortic pathology. Widening of the aortic knob is often seen, with
disparate ascending-to-descending aortic diameter. A double shadow has been
described in patients with aortic dissection, secondary to visualization of the
false lumen.
3. Serum laboratory values. There are no laboratory findings specifically
associated with asymptomatic aortic aneurysms. Aortic dissection or rupture
lowers hemoglobin levels. Dissection may raise cardiac enzyme levels by
causing coronary artery occlusion, increase blood urea nitrogen and creatine
levels through renal artery involvement, and lead to metabolic acidosis due to
low cardiac output or ischemic bowel. Fibrinogen levels may decrease in
patients with associated disseminated intravascular coagulation.
4. Computed tomographic scans and magnetic resonance imaging. Computed
tomography using intravenous (IV) contrast is a useful tool for ascertaining
aneurysm size and location and has evolved into the standard modality for
diagnosing and planning the surgical repair of aortic dissections and
aneurysms. It is also useful for following the progression of aortic disease.
Digital images can be manipulated into a three-dimensional form, which can
make it easier to assess the lesion and plan repair. Magnetic resonance imaging
is extremely sensitive and specific in identifying the entry tear location,
presence of false lumen, aortic regurgitation, and pericardial effusion
accompanying aortic dissection [5].
5. Angiography. This technique has been largely replaced by computed
tomography scanning and magnetic resonance imaging but can be useful for
delineating the involvement of the coronary arteries, as well as identifying
significant coronary artery disease in patients with ascending aortic pathology.
Patients with disease of the thoracic aorta often have concurrent coronary
artery disease, and bypassing significant lesions may prevent perioperative
myocardial infarction and improve ventricular function (VF) when patients are
weaned from CPB.
6. Transesophageal echocardiography (TEE). TEE has proved highly sensitive
and specific for diagnosing aortic dissection. In many cases, pulsed-wave and
color flow Doppler imaging can aid in determining the presence, extent, and
type of dissection. Identifying a mobile intimal flap constitutes a prompt
bedside diagnosis that can be lifesaving. In addition, entry and reentry tears can
be located; aortic regurgitation can be identified and quantified, LV function
and wall-motion abnormalities can be assessed, pericardial effusion with
possible associated cardiac tamponade can be identified, and follow-up studies
of the false lumen can be made after therapeutic intervention.
TEE can also be used to assess many thoracic aortic aneurysms. For
ascending or descending thoracic aortic aneurysm in particular, the location,
diameter, and extent of the aneurysm, as well as whether the aneurysm contains
significant atheroma, can often be well described. TEE can also be used to
determine whether the aneurysm is saccular or fusiform in shape. TEE rarely
can be used to definitively identify aneurysmal involvement of the aortic arch
and distal ascending aorta. This is because the trachea obscures the distal
ascending aorta from TEE, and because the entire arch is not usually visible on
TEE. Surgeons who desire detailed preoperative imaging of the aortic arch
should confer with a radiologist about magnetic resonance or computerized
tomographic imaging.
Because traumatic aortic transection generally occurs just distal to the left
subclavian takeoff, it is often easily and rapidly identified by TEE imaging. In
addition, aortic transection operations are usually emergencies, so TEE
imaging is advantageous because it can be conducted quickly and in most
locations in the medical center.
C. Indications for surgical correction
1. Ascending aorta
a. Dissection. Acute type A dissection should be surgically corrected, given its
virulent course and high associated mortality rate if not surgically treated.
b. Aneurysm. Indications for surgical resection include the following:
(1) Persistent pain despite a small aneurysm
(2) Aortic valve involvement producing aortic insufficiency
(3) Angina from LV strain secondary to aneurysmal involvement of the aortic
valve or coronary arteries
(4) Rapidly expanding aneurysm, or an aneurysm larger than 5 to 5.5 cm in
diameter, because the chance of aortic rupture increases with the
aneurysm’s size
2. Aortic arch
a. Dissection. Acute dissection limited to the aortic arch is rare but is an
indication for surgery.
b. Aneurysm. Isolated aneurysm of the aortic arch is rare. However, arch
involvement is often seen together with ascending aneurysm (less so with
descending aneurysm) and is thus dealt with at the time of surgical repair of
the ascending aortic lesion. Indications to operate on the aortic arch include
the following:
(1) Persistent symptoms
(2) Aneurysm larger than 5.5 to 6 cm in transverse diameter
(3) Progressive aneurysmal expansion
3. Descending aorta
a. Dissection. Some controversy remains concerning the best treatment for an
acute type B dissection. Because in-hospital mortality statistics are better for
medical versus surgical interventions and similar for medical versus EV
management [6], type B dissection often is treated medically in the acute
phase, especially if the patient’s comorbidities make the risk of surgical
mortality prohibitively high. However, patients with type B dissection are
treated surgically or with EV repair if they have any of the following
complications:
(1) Failure to control hypertension medically
(2) Continued pain (indicating progression of the dissection)
(3) Aneurysm enlargement on chest radiograph, computed tomographic scan,
or angiogram
(4) Development of a neurologic deficit
(5) Evidence of renal or gastrointestinal ischemia
(6) Development of aortic insufficiency
b. Aneurysm. Indications for surgical or EV repair of descending thoracic
aneurysm include the following:
(1) Aneurysm larger than 5.5 to 6 cm in diameter. In patients with known
connective tissue disorders, the diameter threshold for repair may be
lower [1]
(2) Aneurysm expanding
(3) Aneurysm leaking (causing more fulminant symptoms)
(4) Chronic aneurysm causing persistent pain or other symptoms
III. Preoperative management of patients requiring surgery of the thoracic aorta
Emergency preoperative management of aortic dissection is discussed below.
However, emergency preoperative management is similar for a leaking thoracic
aortic aneurysm or a contained thoracic aortic rupture. Both of these are acute
aortic syndromes.
A. Prioritizing: making the diagnosis versus controlling blood pressure (BP)
1 In patients with suspected aortic dissection, aortic tear, or leaking aortic
aneurysm, the first priority is always to control the BP and ventricular ejection
velocity, because these propagate aortic dissection or rupture. If dissection is
strongly suspected, a definitive diagnosis should be made with radiographic
studies after proper monitoring, IV access, hemodynamic stability, and heart rate
and BP control have been established (if possible). During diagnostic
procedures, the patient should be monitored closely, with a physician present as
clinically indicated. An anesthesiologist, if needed, should become involved as
early as possible to lend expertise in monitoring and in airway and hemodynamic
management in patients whose clinical condition deteriorates before they reach
the operating room. Rapid diagnosis with TEE may save critical minutes in
initiating definitive surgical treatment in patients with suspected thoracic aortic
dissection or rupture.
B. Achieving hemodynamic stability and control
The ideal drug to control BP is administered intravenously, is rapidly acting, has
a short half-life, and causes few, if any, side effects. Systolic and diastolic BPs
and LV ejection velocity should be reduced, because these factors all can
propagate aortic dissection.
1. Monitoring. Patients must have an ECG to detect ischemia and dysrhythmias,
two large-bore IV catheters for volume resuscitation, an arterial line in the
appropriate location (discussed below), and, if time permits, a central venous
catheter or pulmonary artery (PA) catheter for monitoring filling pressures and
for infusing drugs centrally.
2. BP-lowering agents
a. Vasodilators
(1) Nicardipine is a calcium channel blocker that inhibits calcium influx into
vascular smooth muscle and the myocardium. It can be as administered in
a single 0.5- to 2-mg IV “push” or as a 5- to 15-mg/hr infusion titrated to
the desired effect.
(2) Nitroglycerin is a less potent vasodilator than sodium nitroprusside, and
it causes more venous than arterial dilation. It can be useful in patients
whose ascending aortic pathology is coupled with myocardial ischemia,
because nitroglycerin can improve coronary blood flow by inducing
coronary artery vasodilation. Infusion dosage usually ranges from 1 to 4
μg/kg/min.
(3) Nitroprusside is a useful agent for controlling BP in patients with critical
aortic lesions, because its rapid onset and offset make it quickly effective
and easily regulated. A vasodilator that relaxes both arterial and venous
smooth muscles, it is given as an IV infusion, and although central
administration is probably optimal, it can be administered through a
peripheral vein with good effect. The usual starting dose is 0.5 to 1
μg/kg/min, titrated to effect. Doses of 8 to 10 μg/kg/min have been
associated with cyanide toxicity (see also Chapter 2).
b. β1-Antagonists
Decreasing LV ejection velocity is important for decreasing risk of
propagating aortic dissection. Medications to lower heart rate may be
particularly useful for attenuating the reflex tachycardia and increased
ventricular contractility that can occur with use of nicardipine or sodium
nitroprusside. Vasodilation can increase LV ejection velocity by increasing
dP/dt and heart rate. For this reason, β-adrenergic blockade should be used
with vasodilators to decrease both tachycardia and contractility.
(1) Propranolol, a nonselective β-antagonist, has been used for many years
as first-line therapy for reducing LV ejection velocity and can be
administered as an IV bolus of 1 mg, but doses of 4 to 8 mg may be
required for adequate heart rate control. Propranolol has been somewhat
supplanted by selective β1-antagonists.
(2) Labetalol is a combined α- and β-blocker and offers an alternative to the
nitroprusside–propranolol combination. It should be given initially as a
5- to 10-mg loading bolus; once the effect has been assessed, the dose is
doubled, allowing a few minutes for onset of effect. This process should
be repeated until target BP or a total dose of 300 mg is reached. Once
target BP and heart rate are achieved with the loading dose, a continuous
infusion can be started at 1 mg/min, or a small bolus dose can be given
every 10 to 30 minutes to maintain BP control.
(3) Esmolol is a β-blocking agent with a short half-life that can be useful in
these cases. It is administered as a bolus loading dose of 500 μg/kg over
1 minute and then continued as an infusion starting at 50 μg/kg/min and
titrated to effect to a maximum dose of 300 μg/kg/min. Tachyphylaxis is
commonly encountered with esmolol.
(4) Metoprolol, another β1-selective agent, is used in doses of 2.5 to 5 mg
titrated to effect over a few minutes to a maximum dose of 15 to 20 mg. It
provides a longer effect, which may be useful.
3. Desired endpoints. To decrease the chance of propagating aortic dissection or
rupture, systolic BP should usually be lowered to approximately 100 to 120
mm Hg or to a mean pressure of 70 to 90 mm Hg. Heart rate should be 60 to 80
beats/min. If a PA catheter is in place, the cardiac index can be lowered to a
range of 2 to 2.5 L/min/m2 to reduce ejection velocity from a hyperdynamic LV.
C. Bleeding and transfusion
Coagulopathy is frequently encountered in the thoracic aortic surgical patient.
Many of these patients require left heart bypass (LHB) or full CPB during
surgery to help maintain sufficient end-organ perfusion during aortic repair; thus,
they also require heparinization. CPB may cause a consumptive coagulopathy and
enhanced fibrinolysis, thus increasing blood loss. Patients requiring deep
hypothermic circulatory arrest (DHCA) for aortic arch surgery also may have
substantial platelet dysfunction secondary to extreme hypothermia. Platelet
consumption has also been noted in the abdominal aortic surgical population. In
patients undergoing thoracoabdominal aortic aneurysm repairs, “back-bleeding”
through intercostal vessels increases blood loss, and very large losses can occur
that necessitate transfusion of multiple units of blood products.
1. A total of 8 to 10 units of packed red blood cells should be typed and
crossmatched before surgery, and it may be helpful to notify the blood bank that
ongoing blood loss could necessitate transfusing additional blood products
beyond those units that are initially crossmatched.
2. Using blood-scavenging/reprocessing devices decreases the amount of banked
blood transfused, but extensive bleeding and the logistics of effectively
scavenging autologous blood during these operations frequently necessitate
transfusing packed cells and procoagulant blood products. It is also important
to recognize that reprocessed autologous blood is deficient in coagulation
factors, so fresh-frozen plasma or other factor replacement treatment may still
be needed.
3. Antifibrinolytic therapy during aortic surgery is commonly used but
controversial. No adequately powered trials of these drugs have yet been
conducted in aortic surgical patients, so it is not totally clear whether
antifibrinolytics significantly benefit them, particularly those in whom LHB or
no bypass is used and full heparinization is not required [7].
a. Tranexamic acid or ε-aminocaproic acid (EACA). A retrospective study of
72 patients who underwent descending thoracic aortic surgery with LHB and
tranexamic acid or EACA infusion versus no antifibrinolytic therapy found no
difference in incidence of transfusion or chest tube output; however, these
patients also all received intraoperative methylprednisolone and platelet-rich
plasmapheresis before aortic repair [7]. The authors did find that
intraoperative hypothermia independently predicted chest tube output and that
lower preoperative hemoglobin levels, older age, and longer cross-clamp
time independently predicted transfusion. Larger prospective randomized
studies are needed to determine whether tranexamic acid and EACA
effectively reduce bleeding and do not cause thrombotic or other
complications in thoracic aortic operations.
b. On the basis of available data, we can neither recommend nor advise against
using antifibrinolytic therapies in thoracic aortic surgery. Potential thrombotic
risks, including neurocognitive and renal dysfunction, are of concern, and the
clinician should weigh these risks against the benefits of potential decreases
in transfusion.
D. Assessment of other organ systems
1. Neurologic. Preoperatively, the patient should be monitored closely for change
in neurologic status, as this is an indication for immediate surgical intervention.
CLINICAL PEARL Involvement of the artery of Adamkiewicz can lead to lower-
extremity paralysis, whereas propagation of a dissection into a cerebral vessel can result
in a change in mental status or cause stroke symptoms.
2. Renal. Urine output should be monitored, because development of anuria or
oliguria in a euvolemic patient is an indication for immediate surgical
intervention.
3. Gastrointestinal. Serial abdominal examinations should be performed, and
blood gases should be analyzed routinely to assess changes in acid–base status.
Ischemic bowel can cause significant metabolic acidosis.
E. Use of pain medications
Patients with aortic dissection may be anxious and in severe pain. Pain relief is
not only important for patient comfort but also beneficial in controlling BP and
heart rate. Oversedation should be avoided so that ongoing patient assessments
can be made. In addition to neurologic or abdominal symptoms, worsening of
back pain may indicate aneurysm expansion or further aortic dissection and is
regarded by many surgeons as an emergent situation.
IV. Surgical and anesthetic considerations
A. Goal of surgical therapy (for aortic dissection, aneurysm, or rupture)
CLINICAL PEARL The foremost goal in treating acute aortic disruption is
controlling hemorrhage. Once control is achieved, the objectives of managing both acute
and chronic lesions are to repair the diseased aorta and to restore its relations with
major arterial branches.
Thoracic aortic aneurysm is usually treated by replacing the entire diseased
segment of the aorta with a synthetic graft and then reimplanting major arterial
branches into the graft, if necessary. When repairing an aortic dissection, the goal
is to resect the segment of the aorta that contains the intimal tear. When this
segment is removed, it may be possible to obliterate the origin of the false lumen
and interpose graft material.
CLINICAL PEARL It usually is not possible or necessary to replace the entire
dissecting portion of aorta because, if the origin of dissection is controlled, reexpansion
of the true lumen usually compresses and obliterates the false lumen. With contained
aortic rupture, the objective is to resect the area of the aorta that ruptured and either
reanastomose the natural aorta to itself in an end-to-end fashion or interpose graft
material for the repair.
B. Overview of intraoperative anesthetic management (for aortic dissection,
aneurysm, or rupture)
1. Key principles
a. Managing BP. BP control should be sought during the transition from the
preoperative to the intraoperative period. Such control is important in light of
the surgical and anesthetic manipulations that will profoundly affect BP during
the procedure.
b. Monitoring of organ ischemia. If possible, the central nervous system, heart,
kidneys, and lungs should be monitored for adequacy of perfusion. The liver
and gut cannot be monitored continuously, but their metabolic functions can be
checked periodically.
c. Treating coexisting disease. Patients with aortic pathology often have
associated cardiovascular and systemic diseases (Table 14.6).
d. Controlling bleeding. Patients undergoing aortic surgery often have an
inflammatory response to foreign graft material and CPB or LHB. This
inflammation can interact with the coagulation cascade and lead to significant
perioperative coagulopathy. Furthermore, patients with acute dissection and
lower fibrinogen and platelet counts may already have a consumptive process
from the clotting that often occurs in the false lumen. Coagulation
abnormalities and their treatment are discussed in Chapter 21.
2. Induction and anesthetic agents. Many thoracic aortic operations are
emergent procedures that require aspiration precautions while the airway is
being secured. However, the rapid-sequence induction and intubation typically
done for patients with full stomachs may not be appropriate for patients with
thoracic aortic pathology, as wide swings in hemodynamics can occur. A
“modified” rapid-sequence induction may be preferable, titration of anesthetic
induction drugs to better control BP (i.e., avoid hypertension) while
laryngoscopy is being performed. Use of nonparticulate antacids, H2-blockers,
and metoclopramide should be considered before anesthesia is induced. Other
anesthetic considerations and agents are described more fully in Section IV.D.
Despite precautions, marked changes in hemodynamics are common when the
patient’s airway is being secured, and vasoactive drugs (e.g., nitroglycerin,
esmolol) should be available to immediately treat an undesirable hemodynamic
response to intubation.
TABLE 14.6 Incidence of coexisting diseases in patients with aortic pathology presenting
for surgery
TABLE 14.7 Anesthetic and surgical management for thoracic aortic surgery
3. Importance of site of lesion (Table 14.7). Although the principles of

anesthetic induction and maintenance are similar for all aortic lesions, knowing
the location of the thoracic aortic lesion is also important for intraoperative
management.
C. Ascending aortic surgery
1. Surgical approach. Ascending aortic surgery is conducted through a midline
sternotomy.
2. Cardiopulmonary bypass (CPB). CPB is required because of proximal aortic
involvement.
a. If the aneurysm ends in the proximal or middle portion of the ascending aorta,
the arterial cannula for CPB can be placed in the upper ascending aorta or
proximal arch.
CLINICAL PEARL Many ascending aneurysms extend into the proximal aortic arch.
This extension may not be detected until the aorta is exposed, so further management for
arch surgery may be needed.
b. If the entire ascending aorta is involved, the FA can be cannulated, because an
aortic cannula cannot be placed distal to the lesion without jeopardizing
perfusion to the great vessels. Arterial flow on CPB in this case is retrograde
from the FA toward the great vessels. Another, newer approach is to
cannulate the right axillary, innominate, or, occasionally, right carotid artery,
allowing blood to flow retrograde into the innominate artery and then
antegrade into the aorta.
FIGURE 14.4 Circulatory support and clamp placement for surgery of the ascending aorta if femoral arterial cannulation is
used; the distal clamp must be distal to the diseased segment. This may be the only clamp required. CPB, cardiopulmonary
bypass. (From Benumof JL. Intraoperative considerations for special thoracic surgery cases. In: Benumof JL, ed. Anesthesia
for Thoracic Surgery. Philadelphia, PA: WB Saunders, 1987:384, with permission.)
c. Venous cannulation is usually done through the right atrium (RA); however,
femoral venous cannulation may be necessary if the aneurysm is very large
and obscures the atrium.
3. 5 Aortic valve involvement. Aortic valvuloplasty or valve replacement is
often needed with repair of ascending aortic dissection or aneurysm. Which
procedure is used depends on the degree of involvement of the sinuses of
Valsalva and the aortic annulus.
4. Coronary artery involvement. Ascending aortic dissection or aneurysm may
involve the coronary arteries. Aortic dissection can cause coronary occlusion if
an expanding false lumen compresses the coronary ostia; such occlusion
necessitates surgical coronary artery bypass grafting to restore myocardial
blood flow. In cases of proximal aortic aneurysm, displacement of the coronary
arteries from their normal position distal to the aortic annulus usually requires
coronary artery reimplantation into the reconstructed aortic tube graft, or
coronary artery bypass grafting.
5. Surgical techniques. An example of the usual cross-clamp placement used in
surgery of the ascending aorta is shown in Figure 14.4. Note that the distal
clamp is placed more distally than it is in coronary artery bypass surgery, and
the clamped segments might include part of the innominate artery. If aortic
insufficiency is present, a large portion of the cardioplegia solution infused into
the aortic root will flow through the incompetent aortic valve and into the LV
instead of into the coronary arteries. This can cause distention of the LV with
increased myocardial oxygen utilization and diminished myocardial protection
from reduced distribution of cardioplegia. For these reasons, an aortotomy is
often performed immediately after aortic cross-clamping, with direct infusion
of cardioplegia into individual coronary arteries. Many centers also use
retrograde coronary sinus perfusion for cardioplegia administration as an
alternative or in addition to an antegrade technique.
If the aortic valve and annulus are both normal size and unaffected by
concurrent ascending aortic pathology, surgery is limited to replacing the
diseased section of the aorta with graft material. If the annulus is normal size
but the aortic valve is incompetent, the valve may be resuspended or replaced.
If both aortic insufficiency and annular dilation are present, either a composite
graft (i.e., a tube graft with an integral artificial valve) or an aortic valve
replacement with a graft sewn to the native annulus can be used. If the aortic
root is replaced, the coronary arteries must be reimplanted into the wall of a
composite graft. In contrast, if the sinuses of Valsalva are spared by doing a
separate aortic valve replacement and then a supracoronary tube graft, the
coronary arteries may not need to be reimplanted (Fig. 14.5). The posterior
wall of the native aneurysm can be wrapped around the graft material and sewn
in place to help with hemostasis.
FIGURE 14.5 Surgical repair of ascending aortic aneurysm or dissection. A: Aortic valve has been replaced and the aorta is
transected at native annulus, leaving “buttons” of aortic wall around coronary ostia. B: Graft material anastomosed to the
annulus, with left coronary reimplantation. C: Completion of left and beginning of right coronary reimplantation. D: Completion
of distal graft anastomosis. (From Miller DC, Stinson EB, Oyer PE, et al. Concomitant resection of ascending aortic aneurysm
and replacement of the aortic valve—operative results and long-term results with “conventional” techniques in ninety patients. J
Thorac Cardiovasc Surg. 1980;79:394, with permission.)
In patients with ascending dissection, the aortic root is opened and the site of
the intimal tear is located. The section of the aorta that includes the intimal tear
is excised, and the edges of the true and false lumens are sewn together. Graft
is used to replace the excised portion of the aorta.
6. Complications. Complications include any that can occur with an operation
involving CPB and an open ventricle:
a. Air emboli
b. Atheromatous or clot emboli
c. LV dysfunction secondary to inadequate myocardial protection during aortic
cross-clamping. Myocardial dysfunction can, of course, occur despite all
protective efforts.
d. Myocardial infarction or myocardial ischemia secondary to technical
problems with reimplantation of the coronaries
e. Renal or respiratory failure
f. Coagulopathy
g. Hemorrhage, especially from suture lines, which can be especially difficult to
control in certain locations
D. Anesthetic considerations for ascending aortic surgery
1. Monitoring
a. Arterial line placement. The ascending aortic lesion or procedures for its
repair may involve the innominate artery, so a left radial or femoral arterial
line is inserted for direct BP monitoring. Also, if right axillary cannulation is
used, arterial pressure measurement will be falsely elevated because of
increased flow (see below) if the right radial artery is cannulated.
b. ECG. Five-lead, calibrated ECG should be used to monitor both leads II and
V5 for ischemic changes.
c. PA catheter. Because of the advanced age of many of these patients and the
presence of severe systemic disease that may lead to pulmonary hypertension
or low cardiac output, a PA catheter may be useful in selected patients,
particularly in the perioperative period.
d. TEE. In addition to its preoperative diagnostic importance, TEE is a useful
and often necessary adjunct for the intraoperative management of these
patients. Hypovolemia, hypocontractility, myocardial ischemia, intracardiac
air, the location of an intimal tear, and the presence and extent of valvular
dysfunction can all be detected and assessed with TEE. Caution should be
exercised when placing this probe in patients with a large ascending aortic
aneurysm, because of the theoretical risk of rupture.
e. Neuromonitoring
(1) Electroencephalogram (EEG). Either raw or processed
electroencephalographic data may be helpful for judging the adequacy of
cerebral perfusion during CPB. Monitoring the bispectral index might
help to assess the depth of anesthesia during these procedures, but the
benefits of such monitoring are unproven.
(2) Cerebral near-infrared spectroscopy or oximetry is also employed by
many in these cases. See the arch aneurysm section for further discussion.
(3) Temperature. When correctly placed at the back of the oropharynx, a
nasopharyngeal or oropharyngeal temperature probe probably gives the
anesthesiologist the best overall approximation of brain temperature.
f. Renal monitoring. As with all cases involving CPB, urine output should be
monitored.
2. Induction and anesthetic agents. See Table 14.8.
3. Cooling and rewarming. Hypothermic CPB is used in most cases of ascending
aneurysm. If femoral cannulation is to be used and the FA is small, a smaller
cannula may be needed. This may delay cooling and rewarming, because blood
flows on CPB will have to be lower to avoid excessive arterial line pressures
between the roller pump and the arterial cannula.
E. Aortic arch surgery
1. Surgical approach. The arch is exposed through a median sternotomy.
2. Cardiopulmonary bypass (CPB). In most cases, CPB with femoral or right
axillary arterial cannulation and right atrial venous cannulation is required.
3. Technique. Typical aortic clamp placement for this procedure is shown in
Figure 14.6. Note that blood flow to the innominate, left carotid, and LSA will
cease during resection of the aneurysmal or dissected section of the aortic arch,
thus necessitating DHCA.
The attachments of the arch vessels are often excised en bloc so that all three
vessels are located on one “button” of tissue (Fig. 14.7). This facilitates rapid
reimplantation and reestablishment of blood flow through the arch vessels.
Once the distal arch anastomosis is completed, the surgeon sutures the aortic
button containing the arch vessels to the graft that is replacing the diseased
aortic arch. The aortic cross-clamp can then be placed on the graft proximal to
the arch vessels, after which the arch portion of the aortic graft is deaired, and
blood flow is reestablished to the cerebral vessels via the arterial CPB
cannula. The proximal aortic arch anastomosis is then completed.
4. Cerebral protection. As discussed above, resection of the aortic arch requires
interrupting or altering cerebral blood flow, which may contribute to
postoperative stroke and neurocognitive dysfunction—both significant causes
of morbidity and mortality in patients undergoing aortic arch surgery. Although
various surgical approaches are used to reduce cerebral ischemia, all include
lowering patient temperature with CPB to decrease the cerebral metabolic rate,
the corresponding oxygen demand, and the production of toxic metabolites.
TABLE 14.8 Anesthetic considerations and choice of anesthetic agent for surgery of the
aorta
a. DHCA is used for arch surgery, because blood flow through the aorta to the
brain can be stopped and surgical exposure is maximized. DHCA requires
cooling the patient’s core temperature to 15° to 22°C, depending on the
anticipated complexity and duration of the procedure and the adjunctive
technique used (antegrade or retrograde cerebral perfusion [RCP]). Turning
off CPB and partially draining the patient’s blood volume into the venous
reservoir provides a bloodless surgical field while protecting the brain and
other organs, such as the kidneys, for up to 40 minutes [8], or perhaps longer.
DHCA has improved outcomes of aortic arch surgery but is associated with
longer CPB times, which are needed to adequately cool and rewarm the
patient. Animal studies suggest that it is important to rewarm patients
relatively slowly after DHCA, and also not to rewarm the brain above 37°C,
because this increases the risk of cerebral injury [9].
FIGURE 14.6 Representation of cannula and clamp placement for surgery of the aortic arch if femoral bypass is used.
Proximal clamp is placed to arrest the heart. Distal clamp isolates the arch so that the distal anastomosis can be performed.
Middle clamp on major branches isolates the head vessels so that en bloc attachment to graft is possible. The distal and arch
anastomoses may be performed without clamps by using circulatory arrest. CPB, cardiopulmonary bypass. (From Benumof
JL. Intraoperative considerations for special thoracic surgery cases. In: Benumof JL, ed. Anesthesia for Thoracic Surgery.
FIGURE 14.7 Aortic arch replacement. A: The distal suture line is completed first, followed by (B) reattachment of the
arch vessels. C: Flow is reestablished to these vessels by moving the clamp more proximally. D: The proximal suture line is
completed. (From Crawford ES, Saleh SA. Transverse aortic arch aneurysm—improved results of treatment employing new
modifications of aortic reconstruction and hypokalemic cerebral circulatory arrest. Ann Surg. 1981;194:186, with permission.)
CLINICAL PEARL Because patients can undergo DHCA for only a limited time
before suffering cerebral injury, many surgeons use either selective retrograde or
antegrade cerebral perfusion (ACP) as an adjunct to DHCA to prolong the “safe time”
allowed for complicated reconstruction of the aortic arch and its branch vessels while
circulation to the rest of the body is stopped.
b. Retrograde cerebral perfusion (RCP) necessitates individual caval
cannulation. At circulatory arrest, the arterial line of the CPB circuit is
connected to the superior vena caval cannula, through which low flows are
directed to maintain a central venous pressure (CVP) of approximately 20 mm
Hg, although this pressure is not necessarily associated with better outcomes.
Advantages of RCP include relative simplicity, uniform cerebral cooling,
efficient deairing of the cerebral vessels (thus reducing the risk of embolism),
and provision of oxygen and energy substrates. Outcome studies have
identified three risk factors for mortality and morbidity in RCP during DHCA:
time on CPB, urgency of surgery, and patient age [10]. Controversy exists as
to how much flow is actually directed to the brain and how much flow courses
through the extracranial vessels.
FIGURE 14.8 Perfusion circuit for anterograde cerebral perfusion for aortic arch surgery. Venous blood from the right
atrium (RA) drains to the oxygenator (Ox), and is cooled to 28°C by heat exchange (E2) before passing via the main roller
P2) to a femoral artery (FA). A second circuit derived from the oxygenator with a separate heat exchanger ( E1) and
roller pump (P1) provides blood at 6° to 12°C to the brachiocephalic and coronary arteries. (From Bachet J, Guilmet D,
Goudot B, et al. Antegrade cerebral perfusion with cold blood: a 13 year experience. Ann Thorac Surg. 1999;67:1875, with
permission.)
c. Antegrade cerebral perfusion (ACP). With this technique, the brain is

selectively perfused via the innominate or carotid arteries. One method of
administering ACP is to take blood from the CPB circuit’s oxygenator and
deliver it via arterial access to the brain by using a roller pump separate from
the one used for CPB (Fig. 14.8). Many centers use this same technique to
deliver antegrade or retrograde cardioplegia.
Figure 14.8 depicts direct cannulation of both carotid arteries for ACP, but
this technique has been simplified in many practices by cannulating the right
axillary artery or other arteries, as discussed above, instead of the FA for
placement of the arterial line from the CPB circuit. This is usually done by
anastomosing (end to side) a tube graft to the axillary artery and attaching the
arterial line from the pump to the graft. After CPB is initiated and the patient
is cooled, at the time of circulatory arrest the base of the innominate artery is
clamped and ACP is delivered at lower flow rates (e.g., 10 mL/kg/min)
through the axillary artery cannula and thus up the right carotid artery (Fig.
14.9). This allows bilateral cerebral perfusion, assuming that the circle of
Willis is intact. If the integrity of collateral blood flow to the left cerebral
hemisphere is uncertain, the left common carotid also can be cannulated
directly through the surgical field, as shown. Pressure during this method of
ACP can be monitored with a right radial arterial line as noted previously, but
monitoring pressure and maintaining a certain pressure are not known to
improve outcome. Some centers use near-infrared spectroscopy to monitor
unilateral cerebral perfusion during ACP via the right carotid. Results of a
small study suggest that this may be effective [11].
FIGURE 14.9 Antegrade cerebral perfusion (ACP) by right axillary artery cannulation. A: Detail of surgical cutdown and
graft anastomosis to the right axillary artery, showing relationship to the sternal incision. B: Direction of blood flow when the
right axillary artery is used for ACP. The brain is perfused via the right carotid artery and (optionally) via the left carotid
artery from a balloon-tipped catheter inserted through the surgical field into the base of the artery. Venous return to the pump
is via the right atrium (RA). Note occlusion of the base of the innominate artery, allowing opening of the ascending aorta and
aortic arch. (Printed with permission from Baylor College of Medicine.)
Cannulating the right axillary artery instead of the FA to provide CPB

before and after circulatory arrest reduces the risk of systemic
atheroembolism. This is because right axillary artery cannulation provides
antegrade aortic flow, whereas FA cannulation produces retrograde flow
through an often atherosclerotic descending aorta [12].
Additionally, DHCA is required only for completion of the distal and arch
anastomoses. Then the aortic graft can be clamped proximally and full CPB
perfusion reinitiated to the rest of the body while the proximal anastomosis
and any concomitant aortic valve procedure are performed.
Many groups accept ACP as the safest method of brain protection during
arch surgery [13]. ACP may take advantage of autoregulation of cerebral
blood flow, which is thought to remain intact even at low temperatures when
α-stat blood gas management is used. With intact autoregulation, physiologic
protection against complications of hyperperfusion will be active. However,
proponents of pH-stat blood gas management argue that the cerebral
vasodilation that accompanies elevated pCO2 produces more uniform cooling
and perfusion of the brain (see Chapter 26). There is considerable variation
among centers.
5. Complications. Complications of aortic arch surgery include those of any
procedure in which CPB is used. Irreversible cerebral ischemia is a distinct
possibility with this type of surgery. Hemostatic difficulties may be increased
secondary to the multiple suture lines, long CPB times, and prolonged periods
of intraoperative hypothermia.
F. Anesthetic considerations for aortic arch surgery
1. Monitoring
a. Arterial blood pressure (BP). An intra-arterial catheter can be placed in
either the right or left radial artery, depending on which of the head and neck
arteries that extend off of the aortic arch are involved. If both the right- and
left-sided arteries are involved, the FA may need to be catheterized. If the
right axillary artery is cannulated for CPB, right radial arterial line BPs will
not accurately reflect systemic BP during CPB. Conversely, some have
advocated monitoring right radial or brachial pressures to assess flow during
ACP via the right axillary artery or the innominate artery. There is no
consensus on this point. Also, with profound hypothermia, many have found
that the radial artery does not provide accurate pressures for a period during
rewarming, and they electively and preemptively insert a femoral arterial
catheter.
b. Neurologic monitors
(1) Electroencephalography (EEG) is often used to ensure that the patient has
been cooled such that the EEG is isoelectric before DHCA. Propofol is
given by some anesthesiologists to achieve or extend this isoelectric
state.
(2) Nasal or oropharyngeal temperature can be used to monitor brain
cooling; however, nasopharyngeal temperature generally gives the most
accurate estimate of brain temperature [14].
(3) Near-infrared regional spectroscopy (NIRS). This technology measures
frontal cerebral oxygenation through light transmittance. Although the
technology is complex, it is easily applied and seems to be most useful
as a trend monitor during ascending aortic and arch surgery, particularly
when ACP is used. Significant reductions in left-sided sensor values
compared with right-sided ones may indicate an incomplete circle of
Willis. We have found that these values are usually restored when
separate left carotid perfusion begins. Clear outcome data are not yet
available, however. Longer periods of lower cerebral oxygenation
during DHCA, as indicated by NIRS, have been associated with longer
postoperative hospital stays. Large, well-designed prospective studies
are needed to validate the efficacy of these approaches [15,16].
c. Transesophageal echocardiography (TEE). As in ascending aortic surgery
(see Section IV.D.1), TEE provides useful information during arch
procedures.
2. Choice of anesthetic agents. See Table 14.8.
3. Management of hypothermic circulatory arrest. The technique involves core
cooling to a temperature as low as 15° to 20°C. Such low temperatures are
used less often now than in the past; currently, some large centers use a target
temperature of 24°C, pack the head in ice, use pharmacologic adjuncts to aid in
cerebral protection, avoid glucose-containing solutions, and use appropriate
monitoring for selective cerebral perfusion. More details are provided in
Chapter 26.
4. Complications. Complications related directly to anesthesia for aortic arch
surgery are uncommon.
G. Descending thoracic and thoracoabdominal aortic surgery
1. Surgical approach. Aneurysms of the descending thoracic aorta frequently
extend into the abdominal cavity and involve the entire aorta. They are often
grouped according to Crawford classification (Fig. 14.10). The affected
segment of aorta can be exposed through a left thoracotomy incision alone or a
thoracoabdominal incision. Extent IV aneurysms involve the supraceliac
abdominal aorta but still require low thoracic aortic clamping. For aneurysms
of any extent, the patient is placed in a full right lateral decubitus position with
the hips rolled slightly to the left so that the femoral vessels can be cannulated
for LHB or CPB if necessary. When positioning the patient, it is important to
protect pressure points by measures such as using an axillary roll, placing
pillows between the knees, and padding the head and elbows. It is also
important to maintain the occiput in line with the thoracic spine to prevent
traction on the brachial plexus. Various methods can be used to position the left
arm.
FIGURE 14.10 The Crawford classification of repair for thoracoabdominal aortic aneurysm surgery, with a descending
thoracic aortic repair for comparison. The descending aortic repair does not extend beyond the diaphragm, whereas all the
others do. Extent I aneurysms involve an area that begins just distal to the left subclavian artery (LSA) and extends to most or
all of the abdominal visceral vessels but not the infrarenal aorta. Extent II aneurysms also begin distal to the left subclavian and
involve most of the aorta above the abdominal bifurcation. Extent III lesions begin in the midthoracic aorta and involve various
lengths of the abdominal aorta. Finally, Extent IV lesions originate above the celiac axis and end below the renal arteries; these
aneurysms necessitate a thoracoabdominal approach for proximal aortic cross-clamping. DTAA, descending thoracic aortic
aneurysm. (Reproduced with permission from Baylor College of Medicine.)
2. Surgical techniques. Regardless of whether a patient has a descending thoracic

aortic aneurysm, a thoracoabdominal aneurysm, a dissection, or aortic rupture,
surgical repair usually involves placing aortic cross-clamps both above and
below the affected region of the aorta and then opening the aorta and replacing
the diseased segment with a graft.
a. Simple cross-clamping. Some groups report success with cross-clamping the
aorta above and below the lesion without using additional measures to
provide perfusion distal to the aortic lesion. This technique has the advantage
of simplifying the operation and reducing the amount of heparin needed (Fig.
14.11) because more heparin is required when bypass circuits are used. An
obvious disadvantage is potentially compromising flow to the distal aorta and
its perfused organs when the simple cross-clamp technique is used. This
approach is more often used with less extensively diseased segments, such as
aneurysms confined to descending thoracic aorta, and Extent III and IV
thoracoabdominal aneurysms.
Clamping the descending thoracic aorta generally causes marked
hemodynamic changes: profound hypertension in the proximal aorta and
hypotension distal to the cross-clamp. The increase in afterload that occurs
when the majority of the cardiac output goes only to the arteries perfusing the
head and upper extremities can cause acutely elevated LV filling pressures
and a corresponding progressive decline in cardiac output. Presumably, LV
failure can result if afterload remains elevated for a significant length of time.
Furthermore, hypertension in the proximal aorta could precipitate a
catastrophic cerebral event, particularly in patients with unidentified cerebral
aneurysm. Mean arterial pressure (MAP) distal to the aortic cross-clamp may
decrease to less than 10% to 20% of the patient’s baseline BP, causing an
obvious decline in renal perfusion and, perhaps, spinal cord perfusion. The
physiology of aortic cross-clamping can change depending on the actual site
of the clamp and is influenced by many factors, a discussion of which is
beyond the scope of this chapter. Gelman’s review of the subject remains an
excellent reference [17].
FIGURE 14.11 Illustration of simple cross-clamp placement for repair of descending aortic aneurysm or dissection. Distal
clamp placement dictates that flow to the spinal cord and major organs proceeds through collateral vessels. (From Benumof
JL. Intraoperative considerations for special thoracic surgery cases. In: Benumof JL, ed. Anesthesia for Thoracic Surgery.
Aortic coarctation repair is another procedure in which simple cross-

clamping is often used. Chronic obstruction of distal aortic blood flow, such
as that which occurs with aortic coarctation, generally results in well-
developed collateral flow and lessens the hemodynamic changes usually
encountered when a cross-clamp is placed on the descending thoracic aorta.
This is illustrated by BP measurements taken proximal and distal to the aortic
cross-clamp in a series of patients with aortic coarctation versus descending
thoracic aortic aneurysm (Table 14.9) [18].
Another simple method of aortic cross-clamping is an “open” technique, in
which no cross-clamp is placed distal to the aortic pathology. This technique
allows direct inspection of the distal aorta for debris such as thrombus and
atheroma, and graft material can be anastomosed in an oblique fashion that
reincorporates the maximal number of intercostal arteries.
TABLE 14.9 Proximal versus distal blood pressure (BP) in simple aortic clamp
FIGURE 14.12 Placement of a heparin-coated vascular shunt from proximal to distal aorta during repair of descending
aneurysm or dissection. (From Benumof JL. Intraoperative considerations for special thoracic surgery cases. In: Benumof JL,
ed. Anesthesia for Thoracic Surgery. Philadelphia, PA: WB Saunders, 1987:384, with permission.)
b. Shunts. Placing a heparin-bonded (Gott) extracorporeal shunt from the LV,

aortic arch, or LSA to the FA ( Fig. 14.12) provides decompression of the
proximal aorta and perfusion to the distal aorta. Systemic heparinization
usually is not required. However, there may be technical difficulties with
placement and kinking of the shunt, which can result in inadequate distal
flows. Also, relatively small shunt diameters can limit blood flow and,
thereby, limit how much proximal LV decompression and augmentation of
distal aortic perfusion can be accomplished.
c. Extracorporeal circulation (ECC). Historically, the first method used for
distal aortic perfusion and proximal decompression in the repair of
descending thoracic aortic lesions was ECC. There are several ways to
perform ECC, but all involve removal of blood from the patient, passage into
an extracorporeal pump, and reinfusion into the FA or another site to provide
perfusion distal to the aortic cross-clamp (Fig. 14.13). An alternative
technique is perfusing the body of the aneurysm with ECC while the proximal
anastomosis is being performed and then opening the aneurysm and perfusing
the major visceral vessels individually until they can be incorporated into the
anastomosis.
FIGURE 14.13 Partial bypass (PB) (or extracorporeal circulation [ECC]) method for maintaining distal perfusion pressure
and preventing proximal hypertension. Oxygenated blood can be taken directly from the LV or atrium (or aortic arch) and
pumped either by roller head or centrifugal pump into the femoral artery (FA). Alternatively, unoxygenated blood can be taken
from the femoral vein (FV), passed through a separate oxygenator, and pumped into the FA. Use of an oxygenator dictates
the use of a full heparinizing dose. (From Benumof JL. Intraoperative considerations for special thoracic surgery cases. In:
Benumof JL, ed. Anesthesia for Thoracic Surgery. Philadelphia, PA: WB Saunders, 1987:384, with permission.)
FIGURE 14.14 Left heart bypass (LHB). Perfusing the aneurysm allows completion of the proximal anastomosis while
distal perfusion is maintained. After the aneurysm is opened, perfusion of the celiac, superior mesenteric, and renal arteries
may be performed by individual cannulation before these arteries are attached to the graft. (From Coselli JS, LeMaire SA.
Tips for successful outcomes for descending thoracic and thoracoabdominal aortic aneurysm procedures. Semin Vasc Surg.
2008;21:13–20, with permission.)
Blood can be drained from the patient into the extracorporeal pump via the
femoral vein (FV), which is technically the easiest site to access for surgery
on the descending thoracic aorta. However, using a systemic venous drainage
site necessitates placing an oxygenator in the ECC circuit to provide
oxygenated blood for reinfusion. This form of CPB in conjunction with DHCA
may be necessary to repair descending thoracic aortic aneurysms that involve
the distal aortic arch.
Alternatively, LHB can be used. A pulmonary vein or the left atrium (LA),
LV apex, or left axillary artery can be cannulated to carry oxygenated patient
blood to the ECC pump; this blood is then returned via the distal aorta, the
body of the aneurysm, or the FA. This technique does not require an
oxygenator in the LHB circuit (Fig. 14.14).
Both of these ECC techniques have disadvantages. Using an oxygenator
requires complete systemic heparinization, which is associated with increased
risk of hemorrhage, especially into the left lung. Left atrial or ventricular
cannulation for LHB without an oxygenator may allow the use of less heparin,
but this approach increases the risk of systemic air embolism. Also, in the
venous to arterial circulation CPB technique, a heat exchanger is included in
the ECC circuit, which helps to avoid significant perioperative hypothermia
and corresponding coagulopathy, although some degree of hypothermia is
probably advantageous for spinal cord protection. When LHB is used, a heat
exchanger is often not added to the ECC circuit. Table 14.10 summarizes the
possible cannulation sites and the major differences between heparinized
shunts and ECC for perfusion distal to the aortic cross-clamp.
TABLE 14.10 Options for increasing distal perfusion in descending aortic surgery
3. Complications of descending thoracic aortic repairs

a. Cardiac. The rate of major cardiac morbidity and mortality was
approximately 12% in one large series of thoracoabdominal aneurysm repairs
[19].
b. Hemorrhage. Significant perioperative bleeding is a common complication.
c. Renal failure. The incidence of renal failure in large case series ranges from
13% to 18% [19,20]. The mortality rate is substantially higher in patients with
postoperative renal failure [19]. The cause is presumed to be a decrease in
renal blood flow during aortic cross-clamping. However, renal failure can
still occur despite apparently adequate perfusion (heparinized shunt or ECC).
Pre-existing renal dysfunction increases a patient’s risk of postoperative renal
failure.
d. Paraplegia. The reported incidence of paraplegia after open surgical repair
descending thoracic or thoracoabdominal aortic aneurysms ranges from 0.5%
to 38% [19–21]. The cause is either complete interruption of blood supply or
prolonged hypoperfusion (>30 minutes) of the spinal cord via the anterior
spinal artery. The anterior spinal artery is formed by fusion of the vertebral
arteries and is the major blood supply to the anterior spinal cord. As the
anterior spinal artery traverses the spinal cord from cephalad to caudad, it
receives collateral blood supply from radicular branches of the intercostal
arteries (Fig. 14.15). In most patients, one radicular arterial branch, known as
the great radicular artery (of Adamkiewicz), provides a major portion of the
blood supply to the midportion of the spinal cord. It can arise anywhere from
T5 to below L1. Unfortunately, this vessel is difficult to identify by
angiography or by inspection during surgery. Interruption of flow can lead to
paraplegia, depending on the contribution of other collateral arteries to spinal
cord perfusion. With anterior spinal artery hypoperfusion, an anterior spinal
syndrome can result, in which motor function is usually completely lost
(anterior horns) but some sensation may remain intact (posterior columns).
e. Miscellaneous. Other significant complications can arise during surgery of the
descending thoracic aorta. Some of these are specific to the type of aortic
pathology being addressed. For example, death from multiorgan trauma and
failure is a major entity in patients who initially survive traumatic aortic
rupture. Furthermore, thoracic aortic surgical patients are more likely to
succumb to respiratory failure or multiorgan failure than are patients with
isolated abdominal aortic disease. Patients who undergo thoracoabdominal
aortic repair may develop postoperative diaphragmatic dysfunction.
Cerebrovascular accidents are seen in a small number of these patients. Also,
left vocal cord paralysis due to recurrent laryngeal nerve damage commonly
occurs during descending thoracic aortic surgery because of the proximity of
the nerve to the site of the aneurysm.
FIGURE 14.15 Anatomic drawing of the contribution of the radicular arteries to spinal cord blood flow. If the posterior
intercostal artery is involved in a dissection or is sacrificed to facilitate repair of aortic pathology, critical blood supply may be
lost, causing spinal cord ischemia. A., artery. (From Cooley DA, ed. Surgical Treatment of Aortic Aneurysms. Philadelphia,
PA: WB Saunders, 1986:92, with permission.)
CLINICAL PEARL All descending thoracic and thoracoabdominal aneurysms can be

associated with major complications, but Crawford Extent II lesions involve more
potential hazards because more of the aorta is affected.
H. Anesthetic considerations in descending thoracic aortic surgery
1. General considerations. Providing anesthesia for descending thoracic aortic
surgery can be extremely demanding because of profound hemodynamic
changes and compromised perfusion of organs distal to the aortic cross-clamp.
Anesthesia for descending thoracic aortic surgery is summarized in several
good reviews [22,23].
2. Monitoring
a. Arterial blood pressure (BP). A right radial or brachial arterial catheter is
needed to monitor pressures above the proximal clamp because aortic cross-
clamping may occlude the LSA. To assess perfusion distal to the lower aortic
cross-clamp, many centers place a FA catheter in addition to the right radial
or brachial catheter to monitor pressure below the distal clamp. If the LHB
technique of ECC is used, the left FA is typically cannulated for distal
perfusion of the aorta, and the right FA can be used for monitoring BP.
b. 6 Ventricular function (VF). Some operative teams monitor LV function
during proximal aortic cross-clamping. A TEE can be useful for directly
assessing LV function and volume, but occasionally, the TEE probe in the
esophagus can interfere with surgical placement of retractors or clamps. In
those cases, TEE cannot be used. A PA catheter allows indirect assessment of
LV filling and cardiac output, presuming that the right heart and tricuspid
valve function well and the patient does not have pulmonary hypertension.
However, a PA catheter is not as helpful as TEE for intraoperative real-time
patient monitoring.
c. Other monitors. ECG lead V5 cannot be used because of the surgical
approach, which limits the assessment of anterior myocardial ischemia.
However, TEE may allow good assessment of anterior LV wall motion.
3. One-lung anesthesia. To provide good surgical access, double-lumen
endobronchial tubes allow deflation of the left lung during surgery on the
descending thoracic and thoracoabdominal aorta. This not only improves
surgical exposure but also protects the left lung from trauma associated with
surgical manipulation. Furthermore, if trauma to the left lung leads to
hemorrhage into the airway, the double-lumen tube can protect the right lung
from blood spillage. A left-sided double-lumen endotracheal tube is generally
easier for the anesthesiologist to place and is most often used for operations on
the descending thoracic aorta. However, in some patients, the aortic aneurysm
distorts the trachea or left main stem bronchus to the degree that placing a left-
sided double-lumen tube is impossible. Patients with aortic rupture may also
have a distorted left main stem bronchus. Right-sided double-lumen
endobronchial tubes may be used, but proper alignment with the right upper
lobe bronchus should be checked with a fiberoptic bronchoscope.
Alternatively, a single-lumen endotracheal tube with an endobronchial blocker
can be used when a double-lumen tube cannot be placed, or when exchanging a
double-lumen tube for a single-lumen endotracheal tube is anticipated to be
challenging (i.e., the patient has a difficult intubation before undergoing an
operation that involves major transfusion and fluid resuscitation). For a
detailed description of double-lumen and endobronchial blocker tube
placement and single-lung ventilation, see Chapter 15.
4. Anesthetic management before and during aortic cross-clamping. Before
the aorta is cross-clamped, mannitol (0.5 g/kg) is often administered to try to
provide some renal protection during aortic cross-clamping, when kidney
perfusion may be poor. Even when shunting or ECC is used, changes in the
distribution of renal blood flow may make efforts at renal protection prudent.
After the aortic cross-clamp is applied, it is important to closely monitor
acid–base status with serial arterial blood gas measurements, as it is common
for metabolic acidosis to develop because of hypoperfusion of critical organ
beds. Acidosis should be treated aggressively with sodium bicarbonate and
with attempts to increase distal aortic perfusion pressure if LHB or shunting is
used (particularly if the patient is normothermic). If simple aortic cross-
clamping without shunting or ECC is used, proximal hypertension should be
controlled, again with awareness that distal organ flow may be diminished. In
treating proximal hypertension, regional blood flow studies have shown that
infusing nitroprusside may decrease renal and spinal cord blood flow in a
dose-related fashion. Ideally, aortic cross-clamp time (regardless of technique)
should be less than 30 minutes, because the incidence of complications,
especially paraplegia, starts to increase substantially beyond this time.
If a heparinized shunt is used and proximal hypertension cannot be treated
without producing subsequent distal hypotension (<60 mm Hg), the surgeon
should be made aware that there could be a technical problem with the shunt’s
placement. If LHB is used, pump speed can be increased to reduce proximal
hypertension by moving blood volume from the proximal to the distal aorta.
This also increases lower-body perfusion. Usually, little or no pharmacologic
intervention is needed during LHB, because changing the pump speed allows
rapid control of proximal and distal aortic pressures. Table 14.11 lists the
treatment options for several clinical scenarios when using ECC.
Before the surgeon removes the aortic cross-clamp, the patient should be
adequately volume resuscitated, and a vasopressor should be available in case
substantial hypotension occurs after the aorta is unclamped.
CLINICAL PEARL The anesthesiologist must be constantly aware of the stage of the
operation so that major events such as clamping and unclamping of the aorta are
anticipated.
TABLE 14.11 Management of extracorporeal circulation for surgery of the descending

aorta
5. Declamping shock. When simple cross-clamping of the aorta is used,

subsequent unclamping can have serious and even life-threatening
consequences, usually from severe hypotension or myocardial depression.
Declamping syndrome has several theoretical causes, including washout of
acid metabolites, vasodilator substances, sequestration of blood in the gut or
lower extremities, and reactive hyperemia.
CLINICAL PEARL The usual cause, however, is relative or absolute hypovolemia.
Anesthesiologists may be fooled into underresuscitating patients while the
aortic cross-clamp is on because of high proximal arterial pressures. To
attenuate the effects of clamp removal, the patient’s volume should be
optimized, particularly in the 10 to 15 minutes before unclamping. This
includes elevating filling pressures by infusing blood products, colloid, or
crystalloids. Some advocate prophylactic bicarbonate administration just
before clamp removal to minimize myocardial depression from “washout
acidosis.” It is advisable for the surgeon to release the cross-clamp slowly
over a period of 1 to 2 minutes to allow enough time for compensatory
hemodynamic changes to occur and for the anesthesiologist to determine
whether further volume resuscitation is indicated.
Vasopressors may be needed to compensate for hypotension after the aortic
cross-clamp is removed, but the anesthesiologist should take care not to
“overshoot” the target BP, as even transient hypertension can result in
significant bleeding from the aortic suture lines. With a volume-resuscitated
patient and a slow cross-clamp release, any significant postclamp hypotension
usually is short lived and well tolerated. If hypotension is severe, the easiest
intervention is reapplying the clamp and further volume infusion.
If shunts or ECC are used, declamping hypotension is usually mild, as the
vascular bed below the clamp is less “empty,” and there will be less proximal
to distal aortic volume shifting after the aortic cross-clamp is released. If a
volume reservoir is used in the bypass circuit, ECC also provides a means for
rapid volume infusion after the aortic cross-clamp is removed. Some type of
rapid infusion device is most useful in these cases.
6. Fluid therapy and transfusion. Even patients undergoing elective repair of a
descending thoracic aneurysm (vs. aortic rupture or dissection) may be
relatively hypovolemic.
Despite proximal and distal control of portions of the aorta undergoing
surgical repair, blood loss can be considerable in these cases because of
backbleeding from the intercostal arteries, which are often ligated when the
aorta is opened. Use of intraoperative cell-scavenging devices has become
common and has reduced the need for banked blood transfusions. However,
large-volume blood loss can occur rapidly in these operations, and banked
blood transfusions are often needed. As long as liver perfusion is adequate,
even with a large blood loss, citrate toxicity usually is not a problem because
of rapid “first-pass” metabolism in the liver.
CLINICAL PEARL However, thoracic aneurysm repair, particularly with simple
clamping, presents a unique situation because hepatic arterial blood flow to the liver is
compromised, perhaps for an extended period. In this circumstance, transfusing banked
blood may rapidly produce citrate toxicity, resulting in myocardial depression that
requires vigilant calcium chloride infusion.
7. Spinal cord protection. In addition to the use of ECC, shunts, and expeditious
surgery, several other methods have been promoted to protect the spinal cord
during aortic cross-clamping.
a. Maintaining perfusion pressure. Some groups prefer to maintain the
perfusion pressure of the distal aorta in the range of 40 to 60 mm Hg to
increase blood flow to the middle and lower spinal cord. This practice should
be regarded as controversial because at present, few data exist regarding
outcome. No method used to maintain blood flow to the distal aorta (i.e., shunt
or partial bypass [PB]) guarantees that spinal cord blood flow, and therefore
function, will be preserved. Proximal and distal clamp placement to isolate
the diseased aortic segment may include critical intercostal vessels that
provide blood flow to the spinal cord, the loss of which is not compensated
for by distal aortic perfusion. In addition, distal perfusion may be hindered by
atherosclerotic disease in the abdominal aorta, which can also compromise
blood flow to the kidneys and spinal cord. Finally, these crucial arterial
vessels may be disrupted in gaining surgical exposure.
b. Somatosensory-evoked potentials (SEPs). SEPs have been promoted as a
means of assessing functional status of the spinal cord during periods of
possible ischemia. Briefly, SEPs are evoked in the brainstem and cerebral
cortex by stimulating a peripheral nerve. Normal SEPs seem to indicate the
integrity of the posterior (sensory) columns. However, SEPs have several
shortcomings. First, during aortic surgery, the anterior (motor) horns are more
at risk. Perhaps for this reason, patients who reportedly had normal SEPs
during cross-clamping were subsequently found to have paraplegia. Second, it
must be remembered that many anesthetics, including all of the halogenated
drugs, nitrous oxide, and several IV drugs (e.g., thiopental, propofol), alter the
amplitude and latency of the SEP. Ongoing dialogue should therefore occur
between the anesthesiologist and the individual(s) performing and evaluating
the neuromonitoring during the operation to create an anesthetic plan that will
be compatible with effective SEP monitoring (e.g., one-half minimum alveolar
concentration of volatile anesthetic). In addition, if simple cross-clamping is
used, peripheral nerve ischemia will interfere with SEP interpretation.
Although it has been used intraoperatively to help identify intercostal
arteries that should be reimplanted to preserve spinal cord perfusion, SEP
monitoring has not been shown to decrease the incidence of postoperative
paraplegia.
c. Motor-evoked potentials (MEPs). Because of the noted deficiencies in
SEPs monitoring, using MEPs has been advocated as a potentially superior
method of monitoring for spinal cord ischemia, because MEP monitoring can
accurately assess the integrity of the anterior horn of the spinal cord.
However, because the central nerve roots cannot be accessed for direct
stimulation during thoracic surgery, transcranial stimulation over the motor
cortex is used. In addition to being cumbersome, this method has been
reported to trigger seizures in susceptible patients. However, some groups
have successfully used MEPs, particularly as an adjunct to SEPs, to detect
spinal cord injury in patients undergoing thoracic and thoracoabdominal aortic
aneurysm repair. Although studies have shown these neuromonitoring
techniques to be helpful for predicting spinal cord injury during operations on
the thoracic aorta, these monitoring methods cannot definitively rule out
intraoperative spinal cord injury that will result in paraplegia. Therefore,
these methods should be used in addition to, not instead of, intraoperative
spinal cord protection strategies such as cerebrospinal fluid (CSF) drainage
and other efforts to maintain arterial perfusion of the spinal cord [24–26]. As
with SEP monitoring, MEP monitoring requires good communication between
the anesthesiologist and the neuromonitoring personnel, particularly because
neuromuscular blockade cannot be used during intervals when MEP
assessment is needed.
d. Hypothermia. Allowing the core body temperature to passively drift down to
32° to 34°C during surgery lowers the metabolic rate of the spinal cord tissue,
possibly providing some protection from reduced or interrupted blood flow.
Usually, temperature can be reduced adequately by exposing the patient to a
cool operating room. Other methods such as topical cooling (cooling blankets,
bags of crushed ice) and cold saline gastric lavage also may be used.
Controlling temperature precisely is difficult, though. At temperatures below
32°C, the myocardium may become more prone to ventricular arrhythmias,
and hypothermia increases the risk of coagulopathy. Despite these potential
problems, using vigorous methods to rewarm the patient is ill advised because
of the risk of rapidly warming neural tissue that may be ischemic.
e. 7 CSF drainage. Spinal cord damage may also be mediated by the increases
in CSF pressure (CSFP) that often accompany aortic cross-clamping. CSFP
can increase to levels as high as the mean distal aortic pressure. Spinal cord
perfusion pressure (SCPP) is proportional to the patient’s MAP minus the
CSFP or CVP—whichever is highest. SCPP may be reduced to zero during
aortic cross-clamping. One approach to improving perfusion is placing a
lumbar spinal drain, which not only allows measurement of the CSFP, but
also, by removal of CSF, reduces CSFP and increases SCPP, which
apparently reduces the risk of paraplegia [27]. In a randomized controlled
trial, CSF drainage significantly decreased postoperative paraplegia and
paraparesis rates in 145 patients who underwent surgical repair of Extent I or
II thoracoabdominal aneurysm: 13% and 2.6% of patients experienced
postoperative paraplegia or paraparesis in the control group versus the spinal
drain group, respectively [21]. A meta-analysis of 10 clinical trials of CSF
drainage and its effect on spinal cord injury rates after open thoracoabdominal
aortic aneurysm repair suggests a reduction in the short-term spinal cord
injury rate, although the effects on longer-term spinal cord injury in this meta-
analysis (5 studies with long-term data) were not statistically significant [28].
(1) Potential complications of spinal drain placement. Draining CSF in
patients with elevated intraspinal pressure can provide a gradient for
herniation of cerebral structures. Also, CSF drainage, particularly more
rapid CSF drainage to lower CSFPs, can cause intracranial bleeding
from traction of the brain on the meninges, torn bridging veins, and the
formation of subdural hematomas [29,30]. Risk of intracranial bleeding
can be decreased by maintaining CSFP above at least 10 cm H2O (7.4
mm Hg) during CSF drainage [29]. To reduce the incidence of
intracranial hemorrhage and subdural hematoma, some centers have
changed their indications for perioperative CSF drainage in patients with
no indications of spinal cord injury (e.g., changes on intraoperative SEP
or MEP monitoring, postoperative paraplegia). For these patients, CSF
drainage is now targeted to less aggressive minimum CSFP thresholds,
such as 10 to 15 mm Hg, and the rate of drainage is not to exceed 15
mL/hr even if CSFP is above the minimum. If the patients develop
paraplegia postoperatively, CSF drainage is then liberalized to try to
provoke resolution of the paralysis. If a subdural hematoma develops and
CSF is still leaking from the insertion site after drain removal, an
epidural blood patch may be warranted at the site [29]. In addition,
spinal drain placement followed by systemic heparinization could lead to
the formation of an epidural hematoma at the insertion site [30]. This is
of more concern in patients who are undergoing concurrent aortic arch
and descending thoracic aortic repairs that involve CPB with full
heparinization and DHCA and who are, thus, at increased risk of
bleeding. Another risk associated with drain placement is catheter
fracture in the subarachnoid space.
(2) Technique for inserting and monitoring spinal drains. A variety of
spinal drain catheters are commercially available, but the insertion
technique is similar for all. Spinal drain catheters are generally placed
according to anatomic landmarks through a 14G (or smaller) Touhy
needle that has been inserted into the subarachnoid space at a lumbar
interspace (usually L3 to L4 or L4 to L5). Once the catheter is threaded
into the subarachnoid space and the needle is removed, the drain is
attached to a stopcock that allows toggling between CSFP measurement
and drainage collection (Fig. 14.16). Some practitioners drain CSF
intermittently to reduce CSFP, while others prefer to allow continuous
drainage whenever the CSFP exceeds a predetermined set point.
FIGURE 14.16 Intraoperative cerebrospinal fluid (CSF) drainage during thoracoabdominal aortic repair. (From Safi HJ,
Miller CC III, Huynh TT, et al. Distal aortic perfusion and CSF drainage for thoracoabdominal and descending thoracic aortic
repair: ten years of organ protection. Ann Surg. 2003;238:372–380, with permission.)
CLINICAL PEARL Although many try maintaining CSFP at 8 to 10 mm Hg to balance

the benefit of increasing SCPP against the risk of supratentorial bleeding with a lower
CSFP, there is no consensus in the literature regarding what the optimal target CSFP is or
how much CSF should be drained over a set time period.
(3) Postoperative spinal drain management. There is also no consensus
regarding when spinal drains should be removed. This is of concern
because 30% or more of all neurologic deficits have delayed onset [31].
Spinal drains are commonly left in for 48 to 72 hours postoperatively
[21] and are replaced if neurologic deficits occur after the drain is
removed. In addition to maintaining CSFP at 10 to 15 mm Hg in the
postoperative setting, efforts must be made to avoid systemic
hypotension and associated decreased spinal cord perfusion. If delayed-
onset paraparesis or paraplegia evolves, systemic hypotension should be
treated and CSF drained. This combination of measures can result in
some recovery of neurologic function. As with any patient with a dural
puncture, headaches related to residual CSF leaks may be expected, and
some will require therapy with epidural blood patches. Reviewing
experience at the Texas Heart Institute, we found that the incidences of
post–dural puncture headaches and need for an epidural blood patch
were elevated in patients with connective tissue diseases such as Marfan
syndrome [32].
(4) Other methods of spinal cord protection. Additional “protective”
measures, such as IV steroids, pharmacologic suppression of spinal cord
function through IV or intrathecal drug administration, local hypothermia,
and free radical scavengers, are not widely used or are considered
experimental.
8. Pain relief. Thoracic and thoracoabdominal aortic surgical patients can be
given IV opioid and oral analgesics to relieve postoperative pain.
Anesthesiologists may also consider using thoracic epidural anesthesia as an
adjunctive perioperative pain control measure, although, depending on the
length of the surgical incision, analgesic coverage may not be complete.
Whereas thoracic epidural analgesia can potentially enhance perioperative pain
control, the risk of additional significant complications associated with
thoracic epidural placement should also be considered. In a patient who will
undergo partial or even full heparinization and who may have significant
intraoperative and early postoperative coagulopathy, instrumenting the epidural
space can increase the risk of epidural hematoma (just as placing a spinal drain
does). This possibility is particularly worrisome because these patients already
have a primary risk of significant neurologic complications. Additionally, using
a thoracic epidural may mask neurologic complications related to the removal
of a CSF drainage catheter [33]. Thoracic epidural use can delay the diagnosis
and treatment of spinal cord ischemia, such as when a patient cannot move his
or her legs postoperatively, and the possibility of epidural hematoma or motor
blockade related to local anesthesia must also be considered.
9. Preventing renal failure. Many patients who require thoracoabdominal aortic
repair also present with renal dysfunction. It is therefore important to try to
prevent the development of acute or chronic renal failure during the
perioperative period. Renal failure is thought to be caused by ischemia from
interruption of blood flow during clamping, although embolism remains another
possibility. Using CPB or a shunt may be protective, but definitive outcome
data are lacking, and renal failure can still occur despite the use of these
surgical adjuncts. Adequate volume loading is probably important for renal
protection, and some clinicians also use mannitol. In some centers, cold
crystalloid or cold blood renal perfusion is administered during
thoracoabdominal aneurysm repair. If the renal arteries can be surgically
exposed during periods of the operation when renal arterial blood flow is
interrupted, perfusate can be administered with a roller-head pump into
perfusion catheters that are inserted into the renal arteries [34].
I. Endovascular (EV) graft repair of the thoracic aorta
Successful EV graft abdominal aortic aneurysm repair was first reported in 1991
[35]. Since then, EV graft design has improved to allow reliable deployment in
the higher-pulse pressure zones of the thoracic aorta, permitting EV repair of
thoracic aortic aneurysms and dissections that were previously only reparable
with open procedures. This progress has continued to the present with advances
in equipment design, including reduced introducer and graft sizes, and increased
use of percutaneous vessel-closure devices rather than surgical cutdown for
vessel access. There has also been a progressive increase in “hybrid”
procedures combining EV intervention with an adjunctive surgical procedure that
is less extensive than a purely surgical operation would be (e.g., use of an EV
graft to treat a thoracic aneurysm plus a carotid-to-subclavian bypass because the
EV graft occludes the origin of the LSA). This has led to EV therapy of more
complex aortic arch and descending thoracic aortic lesions.
1. Surgical approach. Placing EV grafts in the thoracic aorta generally requires
femoral arterial access through which fluoroscopically guided wires and
catheters can be passed to allow optimal EV graft positioning. The FA can be
accessed percutaneously, or it can be exposed and isolated via a small groin
incision. If the FA is too small or stenotic to accommodate the relatively large
thoracic EV graft delivery system, retroperitoneal dissection may be required
to attain access to the iliac artery. There are reports of EV grafts being placed
in the descending thoracic aorta via alternative arterial access sites such as the
axillary arteries, but the FA remains the typical access site for EV graft
delivery. The delivery system is positioned fluoroscopically at the desired
implantation site, and when the delivery device is withdrawn, the endograft
expands at this final aortic position. After EV graft deployment, fluoroscopy
and TEE are generally used to reassess for blood leakage around the graft.
Patients are positioned supine on the fluoroscopy table throughout the
procedure.
2. Surgical techniques
a. Patients must be systemically anticoagulated, usually with heparin, during the
procedure.
b. It is important that patients do not move during angiography, particularly
during EV graft deployment. Sometimes, the interventionalist will ask the
anesthesiologist to hold respirations during the procedure so that the portion
of the aorta in which the EV graft will be deployed can be more closely
assessed. This is one reason why EV graft placement in the descending
thoracic aorta is usually performed with general anesthesia.
c. EV grafts are designed to withstand the continuous forward and pulsatile
forces of blood flow in the aorta. Advances have led to the development of
self-expanding stents that reliably adhere to the aortic wall after deployment
and do not require temporarily occlusive balloon inflation in the aorta. This
removes the risks of proximal hypertension associated with occluding the
thoracic aorta.
d. EV graft design is evolving rapidly; therefore, the number of patients
ineligible for EV grafts is decreasing. However, limitations remain regarding
who can receive an EV graft in the descending thoracic aorta. The patient’s
aortic pathology must ideally have a proximal “landing zone” at least 10 to 15
mm in length and a diameter no greater than that of the largest available EV
graft. Many descending thoracic aneurysms and dissections involve the distal
aortic arch, including the takeoff of the LSA. EV stent grafts are now placed
that cover the ostia of the LSA, but prophylactic preprocedural LSA
transposition or left subclavian-to-left common carotid artery bypass is
frequently performed as noted above to prevent post–EV graft complications,
including left arm ischemia, stroke, and spinal cord ischemia [36,37]. These
complications can occur because the LSA not only is the main source of blood
flow to the left arm but also branches into the vertebral artery (which
contributes to the blood flow to the posterior portion of the circle of Willis),
the left internal mammary artery, and costocervical trunk [36]. Myocardial
ischemia in patients who have a patent left internal mammary arterial bypass
graft is also possible when the LSA takeoff is covered by an EV graft [36]. It
is important to note that stroke can also occur as a complication of LSA
transposition or left subclavian-to-left common carotid artery bypass, so
patients’ cerebral blood flow anatomy and institutional comfort with the
procedure should be considered before LSA revascularization is performed
[36]. The distal site for EV graft attachment needs to be nonaneurysmal and
also of sufficient length. Furthermore, fenestrated stents can be used to
accommodate aortic side branches [38], but the location of these side
branches still must be carefully evaluated and considered when one is
selecting and placing EV grafts. Aortic tortuosity, calcification, and
atheromatous disease are also considerations in determining whether a patient
is an appropriate candidate for EV graft placement.
3. Advantages of EV graft repair
a. Reduced mortality. Randomized controlled trials have shown significantly
decreased mortality in patients who undergo EV repair of abdominal aortic
aneurysms [39,40]. Nonrandomized studies of descending thoracic aorta
repair have associated EV grafting with significantly lower 30-day mortality
than open surgical repair; however, this mortality benefit may not persist at 1
year after thoracic aortic repair [41]. The randomized controlled
INvestigation of STEnt grafts in Aortic Dissection (INSTEAD) trial reported
no significant 2-year mortality advantage for EV stenting versus medical
therapy alone in patients with uncomplicated type B dissection [42].
However, in a 5-year follow-up study of the INSTEAD patients, rates of
aorta-specific mortality and progression of aortic disease were significantly
lower in those who underwent EV repair rather than optimal medical
management [43].
b. Reduced morbidity. Patients have substantially less blood loss with EV
procedures and are spared the prolonged recovery and pulmonary
complications that are often associated with large thoracoabdominal
incisions. EV procedures also allow greater hemodynamic stability and lower
ischemic risk to the heart and other organs than open repairs do. Patients with
pulmonary and cardiac comorbidities that would eliminate them as candidates
for open repair are often acceptable candidates for thoracic aortic EV graft
placement. A meta-analysis of 42 nonrandomized studies that included 5,888
patients with aneurysm, trauma, or dissection of the descending thoracic aorta
revealed that patients who underwent EV repair versus open surgical repair
had significantly less perioperative paraplegia, cardiac complications,
transfusions, reoperation for bleeding, renal dysfunction, and pneumonia, and
a shorter hospital length of stay [41]. In addition, many patients who undergo
EV repair require substantially shorter intensive care unit stays [44,45].
4. Complications of EV repair
a. Emergency conversion to open repair may be necessary if the aorta is
ruptured or dissected during manipulations to place the EV graft, or if the EV
graft becomes malpositioned such that it poses a substantial risk of visceral
ischemia.
b. Bleeding. Although blood loss during EV repair of the thoracic aorta is
markedly less (by approximately 500 mL) [45] than during open surgery,
bleeding does occur from the FA introducer when it is traversed by wires and
catheters during EV repair. Because many patients with thoracic aortic
disease have comorbidities that make anemia especially undesirable,
significant bleeding warrants periprocedural blood transfusion. Large-volume
blood loss can also occur if the internal iliac artery is damaged during
removal of a large-diameter graft-deployment device. Massive blood loss
should be anticipated in patients with aortic rupture.
c. Endoleak. Endoleak occurs when blood continues to flow into the aneurysmal
sac after EV graft placement. It confers continued risk of aortic rupture and
thus requires early identification and intervention. If identified, responses
range from observation over several months to see whether the leak resolves
spontaneously, to another EV procedure to occlude the source of the leak, to,
in some cases, open surgical repair. The degree of intervention depends on the
type of leak identified. Type I endoleak occurs with an inadequate seal
between the EV graft and the wall of the aorta at either the proximal or distal
attachment sites, such that there is persistent flow into the native aneurysm.
Type II endoleak occurs when the portion of the aorta that was to be excluded
by the graft fills in a retrograde fashion from back-bleeding collateral vessels,
such as the lumbar or inferior mesenteric arteries. No definitive approach
exists for addressing type II endoleak: both observation and side-branch
embolization are used. Type III endoleak results from EV graft failure and
requires conversion to open repair so that the EV graft does not dislodge.
d. Stroke. The incidence of periprocedural stroke is ∼5% [41] and appears to
be highest in patients whose EV graft is placed in the region of the distal arch
that includes the takeoff of the LSA. Among patients who undergo EV graft
placement across the LSA, stroke risk may be lower in those who undergo a
staged carotid-to-subclavian artery bypass procedure first, as this may prevent
vertebrobasilar arterial insufficiency and potential ensuing posterior cerebral
infarction [36]. Stroke risk is elevated in patients who have a history of
stroke, whose computed tomography scans reveal severe atheromatous
disease of the aortic arch, or in whom EV grafting involves the distal aortic
arch [46]. For these reasons, it seems likely that stroke is secondary to
embolic events that result from intra-aortic or carotid arterial manipulation
during positioning and deployment of the EV graft.
e. Paraplegia. Although some data suggest that risk of lower-extremity
paraparesis or paralysis is lower in patients undergoing EV graft versus open
thoracic aortic repair, its incidence is still 3% to 4% [41,45,47]. Many
surgeons and interventional radiologists, therefore, prefer that a lumbar spinal
drain be placed before the procedure and that CSF drainage be conducted in
the same manner described in Section IV.H.7.e for open thoracoabdominal
operations.
f. Contrast nephropathy (CN). Whereas patients who undergo open aortic
surgical repair are susceptible to postoperative acute renal failure from
ischemia during aortic cross-clamping, patients who undergo EV graft repair
are susceptible to CN. Patients with pre-existing renal insufficiency,
especially those with diabetic nephropathy, are particularly susceptible to CN
[48]. Older age, hypertension, repeat contrast exposure within a short time,
use of high-osmolality contrast, and preprocedural medications such as
nonsteroidal anti-inflammatory drugs and angiotensin-converting enzyme
(ACE) inhibitors also increase patients’ risk of CN [48]. Although the
pathogenesis of CN is not completely understood, it appears to be related to
decreased renal medullary perfusion and associated ischemia, as well as a
direct toxic effect of contrast on the renal epithelial cells. We refer the reader
to two excellent reviews of CN for a more detailed discussion [48,49].
J. Anesthetic considerations for patients undergoing EV stent graft repair of
the thoracic aorta
1. General considerations
a. Although thoracic aortic EV graft placement is minimally invasive, the
possibility of aortic rupture, dissection, or malposition of the EV graft should
be considered when the location for the procedure is selected and the
anesthetic approach is chosen, because any of these complications would
necessitate urgent or emergent conversion to an open procedure. If the
procedure must be conducted in an imaging suite because no available
operating room has appropriate angiographic equipment, the entire care team
involved in the procedure must be familiar with plans for resuscitation and for
transport to the operating room. If a cardiac or vascular surgeon is not
performing the EV graft procedure, one should be immediately available if
conversion to open surgery is necessary.
b. Although there are reports of placing thoracic aortic EV grafts under regional
anesthesia, this approach has several disadvantages in comparison to general
anesthesia.
(1) Should emergency conversion to open aortic repair be necessary, this
conversion will be slowed by the need to establish airway control before
positioning the patient for the operation.
(2) If the patient is intubated at the start of the procedure and the surgeon
believes that the patient is at substantial risk for open conversion, the
anesthesiologist can place a bronchial blocker in the left main stem
bronchus without inflating it. The bronchial blocker could then be
quickly inflated during emergency conversion to provide single-lung
ventilation.
(3) Many thoracic aortic EV graft procedures are too lengthy for regional
anesthesia.
(4) General anesthesia with endotracheal intubation allows the
anesthesiologist or cardiologist to conduct TEE evaluation throughout the
procedure. This is particularly useful in assessing for endoleaks and for
differentiating slow leakage associated with the porosity of the EV stent
graft from true high-velocity persistent endoleak [50,51]. In patients
undergoing EV stent graft placement for complicated type B dissection,
TEE can also be helpful for repositioning the guidewire from the false to
the true lumen and for detecting new intimal tears in the thoracic aorta
after EV stent placement [50]. Such new distal aortic tears might require
additional EV stents to be placed.
2. Monitoring. All patients should have standard ASA monitors and a radial
arterial line for BP monitoring to help maintain hemodynamic stability. The
majority of patients presenting for thoracic aortic EV grafts have significant
cardiovascular comorbidities that warrant tight hemodynamic control.
Furthermore, surgeons may request transient, mild hypotension during stent
deployment to help prevent graft migration. In the event that emergent
conversion to open surgery is needed, an arterial line will be extremely useful
in guiding volume resuscitation and possible cardiopulmonary resuscitation.
The site of arterial access for stent delivery should be discussed with the
surgical team because, if the iliofemoral vasculature is not adequate for the
procedure, they may choose to deliver the stent via a brachial artery instead.
Typically, a right radial arterial line is ideal for hemodynamic monitoring
because it allows monitoring of arterial pressure proximal to the distal aortic
arch. Central venous access for monitoring right atrial pressure and effectively
administering vasoactive drugs is reasonable for most patients. Some centers
monitor SEPs and/or MEPs, as well as CSFP, during placement of thoracic
aortic EV grafts. Urine output should be monitored to help assess adequacy of
fluid administration during what can often be long procedures. A fluid warmer
and warming blanket should be used if possible to help prevent hypothermia,
and oropharyngeal temperature should be monitored.
3. Fluid therapy and transfusion
a. Large-bore IV access should be established in case rapid volume
resuscitation is needed.
b. Crossmatched, packed red blood cells should be available.
c. A system for rapidly infusing blood products and other fluids should be
immediately available in cases in which volume resuscitation is needed.
4. Cerebrospinal fluid (CSF) drainage. Risk of paraplegia or paraparesis after
EV graft placement remains approximately 3% to 4%, as noted above,
particularly if long segments of the descending thoracic aorta are involved in
EV graft placement or if the patient has previously undergone abdominal aortic
aneurysm repair [52,53]. Therefore, many surgeons, interventionalists, and
anesthesiologists prefer to place and manage lumbar spinal drains for EV graft
procedures in the manner described above. IV fluids and vasopressor drugs
should be administered to maintain higher MAP. As with patients who undergo
open surgical repair of the descending thoracic aorta, delayed-onset
paraparesis or paraplegia can occur in patients who receive EV stent grafts
[52,53], so patients should undergo frequent postprocedural neurologic
examination; if signs of spinal cord ischemia/injury are detected, aggressive
efforts should be made to increase MAP and to drain more CSF.
5. Contrast nephropathy (CN). Because EV grafting of the thoracic aorta is often
a long procedure that involves a substantial volume of IV contrast, the
anesthesiologist should consider strategies to attenuate the risk of CN,
particularly in patients with renal insufficiency.
a. Hydration. Studies suggest that preprocedural hydration with 0.9% normal
saline mitigates patients’ risk of CN [48]. There is no consensus regarding
duration of IV 0.9% normal saline infusion before or after the procedure, but
avoiding hypovolemia in these patients during the procedure is advisable
[49].
b. N-acetylcysteine (NAC). NAC has antioxidant and vasodilatory effects.
Some studies have shown a benefit of pretreating patients with NAC for 24
hours before procedures requiring IV contrast, while other studies have shown
no such benefit [48,49].
c. Diuretics. Diuretic use does not seem to prevent CN. Some advocate that, if
possible, diuretics be withdrawn for the 24 hours before procedures requiring
contrast [48] because of concern that they may increase the risk of CN.
d. Dopamine and fenoldopam. Neither of these drugs has been found to prevent
CN in human studies [48].
K. Future trends
Just as the past several decades of treatment of aortic diseases have been marked
by innovation and the refinement of surgical and anesthetic techniques, so also
will future years. The most promising developments continue to be made in the
area of EV stenting of aneurysmal, dissected, or traumatically transected
segments of the aorta. EV stent graft technology will probably continue to
advance, with the industry focusing on newer fenestrated grafts that will not
obstruct blood flow to important aortic side branches, and other grafts that are
able to adhere to curved portions of the aorta, such as the aortic arch. There will
also probably be innovations regarding alternate arterial access points for
inserting EV stent–deployment devices. Hopefully, greater strides will also be
made toward even better protection strategies for organs (i.e., spinal cord, gut,
and kidneys), including novel approaches to mitigating end-organ ischemia–
reperfusion injury. Anesthetic developments will focus on refining understanding
of the physiology of organ preservation and the pharmacology needed to achieve
this. Such advances should continue to improve the survival of patients with
thoracic aortic disease.
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15 Anesthetic Management for Surgery of the Lungs
and Mediastinum
Peter Slinger and Erin A. Sullivan
I. Preoperative assessment
A. Overview
B. Risk stratification
II. Intraoperative management
A. Lung separation
B. Positioning
C. Intraoperative monitoring
D. Anesthetic technique
E. Management of one-lung ventilation (OLV)
III. Specific procedures
A. Thoracotomy
B. Video-assisted thoracoscopic surgery (VATS)
C. Bronchopleural fistula
D. Bullae and blebs
E. Abscesses, bronchiectasis, cysts, and empyema
F. Mediastinoscopy
G. Anterior mediastinal mass
H. Tracheal and bronchial stenting
I. Tracheal resection
J. Pulmonary hemorrhage
K. Posttracheostomy hemorrhage
IV. Pulmonary thromboendarterectomy (PTE)
A. Overview
B. Surgical procedure
C. Anesthetic management
D. Post-cardiopulmonary bypass (CPB)
V. Lung volume reduction surgery (LVRS)
A. History of lung volume reduction surgery (LVRS)
B. The National Emphysema Treatment Trial (NETT)
C. Results
D. Conclusions
E. The Cochrane Airways Group
F. Anesthetic management for lung volume reduction surgery (LVRS)
G. Endobronchial valves and blockers for lung volume reduction
H. Conclusions
KEY POINTS
1. Preoperatively, respiratory function should be assessed in three

related but independent areas: respiratory mechanics, gas exchange,
and cardiopulmonary interaction.
2. The most useful preoperative predictor of difficult endobronchial
intubation is the chest film.
3. The most important predictor of PaO2 during one-lung ventilation
(OLV) is the Pa O2 during two-lung ventilation in the lateral position
before OLV.
4. Absolute indications for lung isolation include purulent secretions,
massive pulmonary hemorrhage, bronchopleural fistula, blebs, and
bullae (blood, pus, and air).
5. Iatrogenic injury has been estimated to occur in 0.5 to 2 per 1,000
cases using double-lumen tubes (DLTs).
6. The rapidity of the fall in PaO2 after the onset of OLV is an indicator
of the risk of subsequent desaturation.
7. Because of the risk of increased shunt and pulmonary edema in the
dependent lung, no volume should be given for theoretical third-
space losses during thoracotomy.
8. Desaturation during bilateral lung procedures is particularly a
problem during the second period of OLV.
9. The postoperative mortality following pneumonectomy is 17% in
patients who develop arrhythmias versus 2% in those without this
complication.
10. During induction of general anesthesia in patients with an anterior
mediastinal mass, airway obstruction is the most common and
feared complication.
11. Hemoptysis in a patient with a PA catheter must be assumed to be
caused by perforation of a pulmonary vessel by the catheter until
proven otherwise. The mortality rate may exceed 50%.
12. In a patient with pulmonary hypertension, abrupt cessation of
treatment with a prostacyclin analog can result in potentially
catastrophic rebound pulmonary hypertension.
13. Lung volume reduction surgery (LVRS) is a viable option for a
select group of emphysema patients. Goals of treatment include
improvements in dyspnea, exercise tolerance, quality of life, and
prolonged patient survival.
I. Preoperative assessment
A. Overview
Advances in anesthetic management, surgical techniques, and perioperative care
have expanded the envelope of patients now considered to be operable. The
principles described apply to all types of pulmonary resections and other chest
surgery. In patients with malignancy, the risk/benefit ratio of canceling or
delaying surgery pending other investigation/therapy is always complicated by
the risk of further spread of cancer during any interval before resection.
1. Risk assessment. It is the anesthesiologist’s responsibility to use the
preoperative assessment to identify patients at elevated risk and then to use that
risk assessment to stratify perioperative management and focus resources on the
high-risk patients to improve their outcome. This is the primary function of the
preanesthetic assessment.
2. Initial and final assessments. Commonly, the patient is initially assessed in a
clinic and often not by the member of the anesthesia staff who will administer
the anesthesia. The actual contact with the responsible anesthesiologist may be
only 10 to 15 minutes before induction. It is necessary to organize and
standardize the approach to preoperative evaluation for these patients into two
temporally disconnected phases: the initial (clinic) assessment and the final
(day-of-admission) assessment.
3. “Lung-sparing” surgery. Postoperative preservation of respiratory function
has been shown to be proportional to the amount of functioning lung
parenchyma preserved. To assess patients with limited pulmonary function, the
anesthesiologist must understand these surgical options in addition to
conventional lobectomy and pneumonectomy.
Prethoracotomy assessment involves all aspects of a complete anesthetic
assessment: past history, allergies, medications, and upper airway. Respiratory
complications comprise the major cause of perioperative morbidity and
mortality in thoracic surgery. Atelectasis, pneumonia, and respiratory failure
occur in 15% to 20% of patients, and cardiac complications (e.g., arrhythmia
and ischemia) occur in 10% to 15% of them.
B. Risk stratification
1. Assessment of respiratory function. The best assessment of respiratory
function comes from a history of the patient’s quality of life. An asymptomatic
American Society of Anesthesiologists (ASA) class I or II patient with full
exercise capacity does not need screening cardiorespiratory testing. Assess
respiratory function in three related but independent areas (see Fig. 15.1).
a. 1 Lung mechanics. The most valid single test [1] for postthoracotomy
respiratory complications is the predicted postoperative forced expiratory
volume in 1 second (ppoFEV1%), which is calculated as follows:
ppoFEV1% = preop. FEV1% × (1 - %functional lung tissue removed/100)
Consider the right upper and middle lobes combined as approximately

equivalent to each of the other three lobes and the right lung as 10% larger
than the left lung.
FIGURE 15.1 “Three-legged” stool of prethoracotomy respiratory assessment. pulmon., pulmonary; parench., parenchymal;
ppo, predicted postoperative; FEV 1, forced expiratory volume in 1 second; MVV, maximum voluntary ventilation; RV/TLC,
residual volume/total lung capacity; FVC, forced vital capacity; VO2 max, maximum oxygen consumption; SpO2, oxygen
saturation by pulse oximetry; DLCO, diffusing capacity for carbon monoxide; PaO2, arterial partial pressure of oxygen;
2, arterial partial pressure of carbon dioxide.
Low risk = ppoFEV1 >40% of preoperative predicted FEV1

Moderate risk = ppoFEV1 30% to 40% of preoperative predicted FEV1
High risk = ppoFEV1 <30% of preoperative predicted FEV1
b. Pulmonary parenchymal function. Traditionally, arterial blood gas (ABG)
data such as preoperative PaO2 less than 60 mm Hg or PaCO2 greater than 45
mm Hg have been used as cutoff values for pulmonary resection. Cancer
resections now have been successfully done or even combined with volume
reduction in patients who do not meet these criteria, although they remain
useful as warning indicators of increased risk. The most useful test of the gas
exchange capacity of the lungs is the diffusing capacity for carbon monoxide
(DLCO). DLCO correlates with the total functioning surface area of alveolar–
capillary interface. A ppoDLCO less than 40% correlates with both increased
respiratory and cardiac complications [2].
c. Cardiopulmonary interaction. The traditional test in ambulatory patients is
stair climbing. The ability to climb three flights or more is associated with
decreased mortality. Formal laboratory exercise testing is currently the “gold
standard” for assessment of cardiopulmonary function. The maximal oxygen
consumption (VO2 max) is the most valid exercise predictor of
postthoracotomy outcome. An estimate of VO2 max can be made by dividing
the distance walked in meters in 6 minutes (6MWT) by 30 (i.e., 450 m/30 =
15 mL/kg/min):
Low risk = VO2 max >20 mL/kg/min
Moderate risk = VO2 max = 15 to 20 mL/kg/min
High risk = VO2 max < 15 mL/kg/min
CLINICAL PEARL Patients who can climb at least three flights of stairs without
stopping or who can walk at least 600 m in 6 minutes most often have a low risk of
perioperative mortality following pulmonary resection.
d. Ventilation–perfusion scintigraphy is particularly useful in pneumonectomy
patients and should be considered for any patient who has ppoFEV1 less than
40%. Assessments of ppoFEV1, DLCO, and VO2 max can be upgraded if the
lung region to be resected is nonfunctioning.
FIGURE 15.2 Postthoracotomy anesthetic management. FEV1, forced expiratory volume in 1 second; ppo, predicted
postoperative; DLCO, diffusing capacity for carbon monoxide; TEA, thoracic epidural analgesia; V/Q, ventilation/perfusion;
mech., mechanical.
e. Split-lung function studies. These tests have not shown sufficient predictive
validity for universal adoption in potential lung resection patients.
f. Combination of tests (Fig. 15.2). If a patient has ppoFEV1 greater than 40%,
it should be possible for the patient to be extubated in the operating room at
the conclusion of surgery, assuming the patient is alert, warm, and comfortable
(“AWaC”). If ppoFEV 1 is greater than 30% and exercise tolerance and lung
parenchymal function exceed the increased risk thresholds, then extubation in
the operating room should be possible depending on the status of associated
diseases. Patients with ppoFEV1 20% to 30% and favorable predicted
cardiorespiratory and parenchymal function can be considered for early
extubation if thoracic epidural analgesia (TEA) is used.
2. Intercurrent medical conditions
a. Age. For patients older than 80 years, the rate of respiratory complications
(40%) is double that expected in a younger population, and the rate of cardiac
complications (40%), particularly arrhythmias, nearly triples. The mortality
from pneumonectomy (22% in patients older than 70 years), particularly right
pneumonectomy, is excessive.
CLINICAL PEARL As compared to that for middle-aged patients, the risk of
pulmonary complications in patients over 80 years of age doubles and the risk of cardiac
complications almost triples.
b. Cardiac disease
(1) Ischemia. Pulmonary resection is generally regarded as an intermediate-
risk procedure for perioperative ischemia. Beyond the standard history,
physical examination, and electrocardiogram, routine screening for
cardiac disease does not appear to be cost effective for prethoracotomy
patients. Noninvasive testing is indicated in patients with active cardiac
conditions (unstable ischemia, recent infarction, decompensated heart
failure, severe valvular disease, significant arrhythmia), multiple clinical
predictors of cardiac risk (stable angina, remote infarction, previous
congestive failure, diabetes, renal insufficiency, or cerebrovascular
disease), or in the elderly. Lung resection surgery should ideally be
delayed 4 to 6 weeks after placement of a bare-metal coronary artery
stent and 6 to 12 months after a drug-eluting stent. After a myocardial
infarction, limiting the delay to 4 to 6 weeks in a medically stable and
fully investigated and optimized patient seems acceptable.
(2) Arrhythmia. Atrial fibrillation is a common complication (10% to 15%)
of pulmonary resection surgery. Factors correlating with an increased
incidence of arrhythmia are the amount of lung tissue resected, age,
intraoperative blood loss, esophagectomy, and intrapericardial
dissection. American Association of Thoracic Surgery guidelines
recommend continuation of β-blockers in patients already receiving them
and replacement of magnesium in any patient with low magnesium stores.
For patients at increased risk of arrhythmias, perioperative diltiazem and
postoperative amiodarone prophylaxis should be considered [3].
c. Chronic obstructive pulmonary disease (COPD). Assessment of the severity
of COPD is based on FEV1% predicted, as follows—stage I: greater than
50%; stage II: 35% to 50%; and stage III: less than 35%. The following
factors in COPD need to be considered.
(1) Respiratory drive. Many stage II or III COPD patients have an elevated
PaCO2 at rest. It is not possible to differentiate “CO2 retainers” from
nonretainers on the basis of history, physical examination, or spirometry.
These patients need an ABG preoperatively. Supplemental oxygen
causes the PaCO2 to increase in CO2 retainers by a combination of
decreased respiratory drive and increased dead space.
CLINICAL PEARL In patients with advanced COPD, neither history, physical
examination, nor FEV1 predicts chronic CO2 retention.
(2) Nocturnal hypoxemia. COPD patients desaturate more frequently and

severely than normal patients during sleep. This results from the
rapid/shallow breathing pattern that occurs during rapid eye movement
sleep.
(3) Right ventricular (RV) dysfunction. Cor pulmonale occurs in 40% of
adult COPD patients with FEV1 less than 1 L and in 70% with FEV1 less
than 0.6 L. COPD patients who have resting PaO2 less than 55 mm Hg
and those who desaturate to less than 44 mm Hg with exercise (SpO2
approximately 75%) should receive supplemental home oxygen. The goal
of supplemental oxygen is to maintain PaO2 at 60 to 65 mm Hg.
Pneumonectomy candidates with ppoFEV1 less than 40% should have
transthoracic echocardiography to assess right heart function. Elevation
of right heart pressures places these patients in a very high-risk group.
3. Preoperative therapy of chronic obstructive pulmonary disease (COPD).
The four complications of COPD that must be actively sought and treated at the
initial prethoracotomy assessment are atelectasis, bronchospasm, chest
infection, and pulmonary edema. Patients with COPD have fewer postoperative
pulmonary complications when a perioperative program of chest physiotherapy
is initiated preoperatively. Pulmonary complications decrease in thoracic
surgical patients who are not smoking versus those who continue to smoke up
until the time of surgery.
4. Lung cancer considerations. At the time of initial assessment, cancer patients
should be assessed for the “4 M’s” associated with malignancy: Mass effects,
Metabolic abnormalities, Metastases, and Medications. Prior use of
medications that can exacerbate oxygen-induced pulmonary toxicity, such as
bleomycin, should be considered (Table 15.1).
5. Postoperative analgesia. The risks and benefits of the various forms of
postthoracotomy analgesia should be explained to the patient at the time of
initial preanesthetic assessment. Potential contraindications to specific methods
of analgesia should be determined, such as coagulation problems, sepsis, and
neurologic disorders. If the patient will receive prophylactic anticoagulants and
epidural analgesia is elected, appropriate timing of anticoagulant
administration and neuraxial catheter placement must be arranged. American
Society of Regional Anesthesia guidelines suggest excluding prophylactic
heparin administration during a “window” of 2 to 4 hours before to 1 hour after
epidural catheter placement. Low–molecular-weight heparin precautions are
less clear, but an interval of 24 hours before catheter placement is
recommended.
TABLE 15.1 Anesthetic considerations in lung cancer patients (the “4 M’s”)
TABLE 15.2 Summary of preanesthetic assessment
6. Premedication. Avoid inadvertent withdrawal of drugs that are being taken for
concurrent medical conditions (bronchodilators, antihypertensives, β-
blockers). For esophageal reflux surgery, oral antacid and H2-blockers are
routinely ordered preoperatively. Mild sedation, such as an intravenous (IV)
short-acting benzodiazepine, is often given immediately before placement of
invasive monitoring lines and catheters. In patients with copious secretions, an
antisialagogue (e.g., glycopyrrolate 0.2 mg IV) is useful to facilitate fiberoptic
bronchoscopy (FOB) for positioning of a double-lumen tube (DLT) or
bronchial blocker (BB).
CLINICAL PEARL In patients with copious secretions, prophylactic glycopyrrolate
often facilitates visualization for FOB-assisted DLT positioning.
7. Final preoperative assessment. The final preoperative anesthetic assessment
is made immediately before the patient is brought to the operating room.
Review the data from the initial prethoracotomy assessment (Table 15.2) and
the results of tests ordered at that time. Two other concerns for thoracic
anesthesia need to be assessed: (i) The potential for difficult lung isolation and
(ii) the risk of desaturation during one-lung ventilation (OLV).
a. 2 Assessment of difficult endobronchial intubation. The most useful
predictor of difficult endobronchial intubation is the chest imaging. Clinically
important tracheal or bronchial distortions or compression from tumors or
previous surgery can usually be detected on plain chest radiographs (CXRs).
Distal airway (including distal trachea and proximal bronchi) problems not
detectable on the plain x-ray film may be visualized on chest computed
tomographic (CT) scans. These abnormalities often will not be mentioned in a
written or verbal report from the radiologist or surgeon. The anesthesiologist
must examine the chest image before placing a DLT or BB.
b. 3 Prediction of desaturation during one-lung ventilation (OLV). It is
possible to determine patients at high risk for desaturation during OLV for
thoracic surgery. Factors that correlate with desaturation during OLV are
listed in Table 15.3. The most important predictor of PaO2 during OLV is the
PaO2 during two-lung ventilation in the lateral position before OLV. The
proportion of perfusion or ventilation to the nonoperated lung on preoperative
ventilation/perfusion (V/Q) scans also correlates with the PaO2 during OLV.
The side of the thoracotomy has an effect on PaO2 during OLV. With the left
lung being 10% smaller than the right lung, there is less shunt when the left
lung is collapsed. The degree of obstructive lung disease correlates inversely
with PaO2 during OLV. Patients with more severe airflow limitation on
preoperative spirometry tend to have a better PaO2 during OLV. This is
related to the development of auto positive end-expiratory pressure (PEEP)
during OLV in the obstructed patients.
TABLE 15.3 Factors that correlate with an increased risk of desaturation during OLV
Stratifying the perioperative risks allows the anesthesiologist to develop a

systematic approach to these patients that can be used to guide anesthetic
management (Fig. 15.2).
II. Intraoperative management
A. Lung separation
There are three basic options for lung separation: single-lumen endobronchial
tubes (EBTs), DLTs (left- or right-sided) (see Figs. 15.3 and 15.4), and BBs.
The second half of the 20th century has seen refinements of the DLT from that of
Carlens to a tube specifically designed for intraoperative use (Robertshaw) with
larger, D-shaped lumens and without a carinal hook. Current disposable
polyvinyl chloride DLTs have incorporated high-volume/low-pressure tracheal
and bronchial cuffs. Recently, there has been a revival of interest in BBs due to
several factors: new blocker designs (see Figs. 15.5 and 15.6) [4] and greater
familiarity of anesthesiologists with fiberoptic placement of BBs (see Fig. 15.7).
FIGURE 15.3 The optimal position of a left-sided double-lumen endotracheal tube (ETT). A: Unobstructed view of the
entrance of the right mainstem bronchus as seen from the tracheal lumen. B: Take-off of the right upper lobe bronchus with
the three segments. C: Unobstructed view of the left upper and left lower bronchus as seen from the bronchial lumen.
(Reproduced from Campos J. Lung isolation. In: Slinger P, ed. Principles and Practice of Thoracic Anesthesia. New York:
Springer; 2011, with kind permission of Springer Science + Business Media.)
FIGURE 15.4 Optimal position of a right-sided double-lumen endotracheal tube (ETT) as seen with a fiberoptic
bronchoscope. A: View of the right upper lobe bronchus seen through the ventilating side slot of the bronchial lumen. B:
View of the carina showing the left mainstem bronchus and the bronchial lumen in the right mainstem bronchus seen from
the tracheal lumen. (Reproduced from Campos J. Lung isolation. In: Slinger P, ed. Principles and Practice of Thoracic
Anesthesia. New York: Springer; 2011, with permission of Springer Science + Business Media.)
FIGURE 15.5 Three of the endobronchial blockers currently available in North America. Left: The Cohen® tip-deflecting
endobronchial blocker (Cook Critical Care, Bloomington, IN, USA), which allows anesthesiologists to establish one-lung
ventilation (OLV) by directing its flexible tip left or right into the desired bronchus using a control wheel device on the
proximal end of the blocker in combination with fiberoptic bronchoscopic (FOB) guidance. Middle: The Fuji Uniblocker®
(Fuji Corp., Tokyo, Japan). It has a fixed distal curve that allows it to be rotated for manipulation into position with FOB
guidance. Unlike its predecessor, the Univent blocker, the Uniblocker is used with a standard endotracheal tube (ETT).
Right: The wire-guided endobronchial blocker (Arndt® bronchial blocker; Cook Critical Care) introduced in 1999. It
contains a wire loop in the inner lumen; when used as a snare with a fiberoptic bronchoscope, it allows directed placement.
The snare is then removed, and the 1.4-mm lumen may be used as a suction channel or for oxygen insufflation. (Reproduced
from Campos J. Lung isolation. In: Slinger P, ed. Principles and Practice of Thoracic Anesthesia. New York: Springer; 2011,
with kind permission of Springer Science + Business Media.)
FIGURE 15.6 A, B: The recently introduced EZ Blocker (Teleflex, Wayne, PA, USA). This bronchial blocker (BB) has
two blockers and is placed at the carina with fiberoptic guidance and the corresponding cuff to the operative lung is inflated
when required.
1. 4 Indications for lung separation. Absolute indications for lung isolation

include purulent secretions, massive pulmonary hemorrhage, and
bronchopleural fistula, blebs, and bullae (blood, pus, and air). More
commonly, lung separation is provided intraoperatively to facilitate surgical
exposure.
2. Techniques of lung separation. The optimal methods for lung isolation are
listed in Table 15.4. Because it is impossible to describe one technique as best
in all indications for OLV, the various indications are considered separately.
TABLE 15.4 Selection of airway device for lung isolation
a. Elective pulmonary resection, right-sided. The first choice is a left DLT.

The widest margin of safety in positioning is with left DLTs. With blind
positioning, the incidence of malposition can exceed 20% but is correctable in
virtually all cases by fiberoptic adjustment. During OLV, this technique
maintains continuous access to the nonventilated lung for suctioning,
fiberoptic monitoring of position, and continuous positive airway pressure
(CPAP). There are two possible alternatives: (i) Single-lumen EBT: a
standard 7.5-mm diameter, 32-cm long endotracheal tube (ETT) can be
advanced over an FOB into the left main stem bronchus. (ii) A BB can be
placed external to or intraluminally with an ETT.
FIGURE 15.7 Diagram (top): Placement of an Arndt® blocker through a single-lumen endotracheal tube (ETT) in the right
mainstem bronchus with the fiberoptic bronchoscope. Photographs (bottom): Optimal position of an endobronchial blocker in
the right (A) or left (B) mainstem bronchus as seen through a fiberoptic bronchoscope. Note that the right-sided placement is
deliberately closer to the carina in an effort to avoid overlapping the origin of the right upper lobe bronchus. (Reproduced from
Campos J. Lung isolation. In: Slinger P, ed. Principles and Practice of Thoracic Anesthesia. New York: Springer; 2011, with
kind permission of Springer Science + Business Media.)
b. Elective pulmonary resection, left-sided

(1) Not pneumonectomy. There is no obvious best choice between a BB
and a left DLT. Use of a left DLT for a left thoracotomy can be
associated with obstruction of the tracheal lumen by the lateral tracheal
wall and subsequent problems with gas exchange in the ventilated lung.
A right DLT is an alternate choice.
(2) Left pneumonectomy. When a pneumonectomy is foreseen, a right DLT
is the best choice. A right DLT will permit the surgeon to palpate the left
hilum during OLV without interference from a tube or blocker in the left
main stem bronchus. The disposable right DLTs currently available in
North America vary greatly in design, depending on the manufacturer
(Mallinckrodt, Rusch, Kendall). The Mallinckrodt design currently is the
most reliable. All three designs include a ventilating side slot
(fenestration) in the distal bronchial lumen for right upper lobe
ventilation. Optimal positioning technique includes bronchoscopically
confirming that this fenestration aligns with the right upper lobe orifice
as shown in Figure 15.4. If left lung isolation is impossible despite
extremely high pressures in the right DLT bronchial cuff, a Fogarty
catheter can be passed into the left main bronchus as a BB. As an
alternative, there is no clear preference between a left DLT or BB. These
all require repositioning before clamping the left main stem bronchus.
c. Thoracoscopy. Lung biopsies, wedge resection, bleb/bullae resections, and
some lobectomies can be done using video-assisted thoracoscopic surgery
(VATS). During open thoracotomy, the lung can be compressed by the surgeon
to facilitate collapse before inflation of a BB. A left DLT is generally
preferred for thoracoscopy.
d. Pulmonary hemorrhage. Life-threatening pulmonary hemorrhage can result
from a wide variety of causes, such as aspergillosis, tuberculosis, and
pulmonary artery (PA) catheter trauma. The primary risk for these patients is
asphyxiation, and first-line treatment is lung isolation and suctioning the lower
airways. Lung isolation can be with a DLT, BB, or single-lumen EBT,
depending on availability and the clinical circumstances. Tracheobronchial
hemorrhage from blunt chest trauma usually resolves with suctioning; only
rarely is lung isolation necessary.
e. Bronchopleural fistula. The anesthesiologist is faced with the triple problem
of avoiding tension pneumothorax, ensuring adequate ventilation, and
protecting the healthy lung from any fluid collection in the involved
hemithorax. Management depends on the site of the fistula and the urgency of
the clinical situation. For a peripheral bronchopleural fistula in a stable
patient, a BB may be acceptable. For a large central fistula and in urgent
situations, the most rapid and reliable method of securing one-lung isolation
and ventilation is a DLT. In life-threatening situations, a DLT can be placed in
awake patients with direct FOB guidance.
CLINICAL PEARL Because positive pressure ventilation risks tension pneumothorax
in patients with bronchopleural fistula (and massive air leak in the presence of a chest
tube), either preservation of spontaneous ventilation until lung isolation is achieved or
rapid attainment of lung isolation is highly recommended.
f. Purulent secretions (lung abscess, hydatid cysts). Lobar or segmental
blockade is ideal. Loss of lung isolation in these cases is not merely a surgical
inconvenience but may be life threatening. A left DLT is usually preferred.
g. Nonpulmonary thoracic surgery. Thoracic aortic and esophageal surgeries
require OLV. Because there is no risk of ventilated-lung contamination, a left
DLT and a BB are equivalent choices.
h. Bronchial surgery. An intrabronchial tumor, bronchial trauma, or bronchial
sleeve resection during a lobectomy requires that the surgeon have
intraluminal access to the ipsilateral main stem bronchus. Either a single-
lumen EBT or a DLT in the ventilated lung is preferred.
i. Unilateral lung lavage, independent lung ventilation, and lung transplantation
are all best accomplished with a left DLT.
3. Upper airway abnormalities. It is occasionally necessary to provide OLV in
patients who have abnormal upper airways due to previous surgery or trauma
or in patients who are known for difficult intubations. There are four basic
options for these patients: (i) Fiberoptic-guided intubation with a DLT, (ii)
secure the airway with an ETT and then use a “tube exchanger” to place a DLT,
(iii) use a BB, and (iv) use an uncut single-lumen tube as an EBT.
The optimal choice will depend on the patient and the operation. At all times,
it is best to maintain spontaneous ventilation and to do nothing blindly in the
presence of blood or pus. Awake FOB intubation with a DLT requires thorough
topical anesthesia of the airway. It is important when using a tube exchanger to
have a second person perform a direct laryngoscopy to expose as much of the
glottis as possible during the tube change. Direct laryngoscopy decreases the
angles between the oropharynx and trachea and reduces the chance of trauma to
the airway from the DLT. Videolaryngoscopes are very useful for this.
BBs are often the best choice for these patients. If the ET tube is too narrow
to easily accommodate both a bronchoscope and a BB, the BB can be
introduced through the glottis independently external to the ET tube with
fiberoptic guidance. Bilateral BBs can be used for bilateral resections or the
same blocker can be manipulated from side to side. Bilateral single-lumen
EBTs or BBs can be used for lung isolation in patients with tracheal fistulas,
trauma, or other abnormalities in the region of the carina. Smaller DLTs (32,
28, and 26 Fr) are available, but they will not permit passage of an FOB of the
diameter commonly available to monitor positioning (3.5 to 4.0 mm). An ETT
designed for microlaryngoscopy (5- to 6-mm inner diameter [ID] and greater
than 30 cm long) can be used as an EBT, with FOB positioning, but beware of
right upper lobe obstruction if placed in the right mainstem bronchus. If the
patient’s trachea can accept a 7-mm ETT, a Fogarty catheter (8-Fr venous
thrombectomy catheter with a 10-mL balloon) can be passed through the ETT
via an FOB adapter for use as a BB.
4. Chest trauma. It is common in both open and closed chest trauma to have some
hemoptysis from alveolar hemorrhage. The majority of these cases can be
managed without lung isolation after bronchoscopy and suction. The majority of
the deaths in these patients are due to their other injuries and not from airway
hemorrhage or air embolus. Lung isolation may be helpful in some cases, but if
resources and time are limited, the priority must be the resuscitation of the
patient.
5. 5 Avoiding iatrogenic airway injury. Iatrogenic injury has been estimated to
occur in 0.5 to 2 per 1,000 cases with DLTs [5].
a. Examine the chest x-ray film or computed tomography (CT) scan, which
can help predict the majority of difficult endobronchial intubations.
b. Use an appropriate size tube. Too small a tube will make lung isolation
difficult. Too large a tube is more likely to cause trauma. Useful guidelines for
DLT sizes in adults are as follows:
(1) Females’ height <1.6 m (63 in): 35 Fr (possibly 32 Fr if <1.5 m)
(2) Females >1.6 m: 37 Fr
(3) Males <1.7 m (67 in): 39 Fr (possibly 37 Fr if <1.6 m)
(4) Males >1.7 m: 41 Fr
CLINICAL PEARL Avoid the natural tendency to place a DLT that is too small
because this often complicates tube positioning, successful lung isolation, and suctioning.
c. Depth of insertion of DLT. Tracheobronchial dimensions correlate with
height. The average depth at insertion, from the teeth, for a left DLT is 29 cm
in an adult and varies ±1 cm for each 10 cm of patient height above/below
170 cm.
d. Avoid nitrous oxide. Nitrous oxide 70% can increase the bronchial cuff
volume by 5 to 16 mL intraoperatively.
e. Inflate the bronchial cuff/blocker only to the minimal volume required for
lung isolation and for the minimal time. This volume is usually less than 3
mL for a DLT bronchial cuff and <7 mL for a BB. Inflating the bronchial cuff
does not stabilize the DLT position when the patient is turned to the lateral
position.
(1) Endobronchial intubation must be done gently and with fiberoptic
guidance if resistance is met. A significant number of case reports of
airway injury are from cases of esophageal surgery, where the elastic
supporting tissue may be weakened (e.g., by preoperative radiation
treatments) and predisposed to rupture from DLT placement.
FIGURE 15.8 The free online bronchoscopy simulator at www.pie.med.utoronto.ca. The user can navigate the
tracheobronchial tree using real-time video by clicking on the lighted directional arrows under the “Bronchoscopic view”
). Clicking on the labels on the “Bronchoscopic view” gives details of the anatomy seen. The process is aided by the
“Bronchial Tree Navigational Map” (left), which shows the simultaneous location of the bronchoscope as the orange line in
the airway. (Reproduced from Campos J. Lung isolation. In: Slinger P, ed. Principles and Practice of Thoracic Anesthesia.
New York: Springer; 2011, with kind permission of Springer Science + Business Media.)
6. Other complications of lung separation

a. Malpositioning. Initial malpositioning of DLTs with blind placement can
occur in greater than 30% of cases. Verification and adjustment with FOB
immediately before initiating OLV is mandatory because these tubes will
migrate during patient positioning. Malpositioning after the start of OLV due
to dislodgment is more of a problem with BBs than DLTs.
b. Airway resistance. The resistance from a 37-Fr DLT during two-lung
ventilation is less than that of an 8-mm ID ETT but exceeds that of a 9-mm
ETT. For short periods of postoperative ventilation and weaning, airflow
resistance is not a problem with a DLT.
7. The ABCs of lung separation will always apply:
a. Know the tracheobronchial anatomy [6].
b. Use the fiberoptic bronchoscope (see Fig. 15.8) [7].
c. Look at the chest x-ray film and CT scan in advance.
B. Positioning
The majority of thoracic procedures are performed with the patient in the lateral
position, but, depending on the surgical technique, a semisupine or semiprone
lateral position may be used. It is awkward to induce anesthesia in the lateral
position; thus, monitors will be placed and anesthesia will be usually induced in
the supine position and the anesthetized patient will then be repositioned for
surgery. It is possible to induce anesthesia in the lateral position, but semilateral
positioning is preferable if tolerated. This may rarely be indicated with unilateral
lung diseases, such as bronchiectasis or hemoptysis, until lung isolation can be
achieved. However, even these patients will have to be repositioned and the
diseased lung turned to the nondependent side. Due to the loss of venous vascular
tone in the anesthetized patient, it is not uncommon to see hypotension from
redistribution of systemic venous blood when the patient is turned to or from the
lateral position.
All lines and monitors will have to be secured during position change and their
function reassessed after repositioning. The anesthesiologist should take
responsibility for the head, neck, and airway during position change and must be
in charge of the operating team to direct repositioning. It is useful to make an
initial “head-to-toe” survey of the patient after induction and intubation, checking
oxygenation, ventilation, hemodynamics, lines, monitors, and potential nerve
injuries. This survey must be repeated after repositioning. It is nearly impossible
to avoid some movement of a DLT or BB during repositioning. The patient’s
head, neck, and EBT should be turned en bloc with the patient’s thoracolumbar
spine. The margin of error in positioning EBTs or blockers is often so narrow
that even small movements can have significant clinical implications.
EBT/blocker position and adequacy of ventilation must be rechecked by
auscultation and FOB after patient repositioning.
1. Neurovascular complications. The brachial plexus is the site of the majority of
intraoperative nerve injuries related to the lateral position. The brachial plexus
is fixed at two points: proximally by the transverse process of the cervical
vertebrae and distally by the axillary fascia. This two-point fixation plus the
extreme mobility of neighboring skeletal and muscular structures make the
brachial plexus extremely liable to injury. The patient should be positioned
with padding under the dependent thorax to keep the weight of the upper body
off the dependent arm brachial plexus. This padding will exacerbate the
pressure on the brachial plexus if it migrates superiorly into the axilla. It is
useful to survey the patient from the side of the table immediately after the
patient is turned to ensure that the entire vertebral column is aligned properly.
The dependent leg should be slightly flexed with padding under the knee to
protect the peroneal nerve lateral to the proximal head of the fibula. The
nondependent leg is placed in a neutral straight position and padding placed
between it and the dependent leg. The dependent leg must be observed for
vascular compression. Excessively tight strapping at the hip level can compress
the sciatic nerve of the nondependent leg. A “head-to-toe” protocol to monitor
for possible neurovascular injuries related to the lateral decubitus position is
given in Table 15.5. In general, the goal for this exercise is to avoid stretching
or compressing nerves and compressing arteries or veins.
2. Physiologic changes in the lateral position
a. Ventilation. Significant changes in ventilation develop between the lungs
when the patient is placed in the lateral position. The compliance curves of
the two lungs are different because of their difference in size. The lateral
position, anesthesia, paralysis, and opening the thorax all combine to magnify
these differences between the lungs.
In a spontaneously breathing patient, ventilation of the dependent lung will
increase approximately 10% when the patient is turned to the lateral position.
Once the patient is anesthetized and paralyzed, ventilation of the dependent
lung will decrease 15%. The compliance of the entire respiratory system will
increase once the nondependent hemithorax is open, yet will decrease from
interpleural insufflation in a VATS.
TABLE 15.5 Avoiding neurovascular injuries specific to the lateral position
TABLE 15.6 Intraoperative complications that occur with increased frequency during
thoracotomy
Applying PEEP to both lungs in the lateral position, PEEP preferentially

goes to the most compliant lung regions and hyperinflates the nondependent
lung without causing any improvement in gas exchange. In the lateral position,
atelectasis will develop in a mean of 5% of total lung volume, all in the
dependent lung.
b. Perfusion. Turning the patient to the lateral position decreases the blood flow
of the nondependent lung due to gravity by approximately 10% of the total
pulmonary blood flow.
The matching of ventilation and perfusion will usually decrease in the
lateral position compared to the supine position. Pulmonary arteriovenous
shunt usually increases from approximately 5% in the supine position to 10%
to 15% in the lateral position.
C. Intraoperative monitoring
1. General to all pulmonary resections. The majority are major operative
procedures of moderate duration (2 to 4 hours) and performed in the lateral
position either with induced pneumothorax (VATS) or open. Consideration for
monitoring and maintenance of body temperature and fluid volume should be
given to all of these cases. All cases should have standard ASA monitoring.
Additional monitoring is guided by a knowledge of which complications are
likely to occur (Table 15.6).
2. Specific to certain types of resection. There are complications that are more
prone to occur with certain resections, such as hemorrhage from an extrapleural
pneumonectomy, contralateral lung soiling with resection of a cyst or
bronchiectasis, air leak hypoventilation, or tension pneumothorax with a
bronchopleural fistula.
3. 6 Oxygenation. Significant arterial oxygen desaturation (less than 90%)
during OLV occurs in approximately 1% of the surgical population with a high
inspired oxygen concentration (FiO2) of 1. Pulse oximetry (SpO2) has not
negated the need for direct measurement of arterial PaO2 via intermittent blood
gases in the majority of thoracotomy patients. PaO2 offers a more useful
estimate of the margin of safety above desaturation than SpO2. The rapidity of
the fall in PaO2 after the onset of OLV is an indicator of the risk of subsequent
desaturation. Consequently, we recommend measuring Pa O2 by ABG before
OLV and 20 minutes after the start of OLV.
4. Capnometry. End-tidal CO2 (PetCO2) is a less reliable indicator of the PaCO2
during OLV than during two-lung ventilation, and the P a-etCO2 gradient
increases during OLV. As the patient is turned to the lateral position, the P etCO2
of the nondependent lung falls relative to the dependent lung because of
increased perfusion of the dependent lung and increased dead space of the
nondependent lung. At the onset of OLV, the P etCO2 of the dependent lung
usually falls transiently, as all the minute ventilation is transferred to this lung.
The PetCO2 then rises as the fractional perfusion is increased to this dependent
lung by collapse and pulmonary vasoconstriction of the nonventilated lung. If
there is no correction of minute ventilation, the net result will be increased
baseline PaCO2 and PetCO2, with an increased gradient. Severe (greater than 5
mm Hg) or prolonged falls in PetCO2 indicate a maldistribution of perfusion
between ventilated and nonventilated lungs and may be an early warning of a
patient who will desaturate during OLV.
5. Invasive hemodynamic monitoring
a. Arterial catheter. There is a significant incidence of transient severe
hypotension from surgical compression of the heart or great vessels during
intrathoracic procedures. For this reason, plus the utility of intermittent ABG
sampling, it is useful to have beat-to-beat assessment of systemic blood
pressure during many thoracic surgery cases. Exceptions are limited
procedures such as “wedge” segmental resections and/or thoracoscopic
resections in younger/healthier patients. For most thoracotomies, placement of
a radial artery catheter can be in either the dependent or nondependent arm.
b. Central venous pressures (CVPs). CVP readings obtained intraoperatively
with the chest open are not reliable indicators of right atrial pressure or RV
preload. It is our practice to routinely place CVP lines in pneumonectomy
patients, but not for lesser resections unless there is significant other
concurrent illness or risk of bleeding. Our choice is to use the right internal
jugular vein with ultrasound guidance to minimize the risk of pneumothorax
(as compared to subclavian vein CVP placement) for CVP access unless there
is a contraindication.
c. Pulmonary artery (PA) catheters. The risk/benefit ratio for the routine use
of PA catheters for pulmonary resection surgery favors their infrequent use,
such as patients with life-threatening coexisting cardiac disease or possibly
active septicemia. Several recently developed systems of noninvasive cardiac
output monitoring may prove equally useful for this purpose (e.g., FloTrac®,
Edwards Lifesciences, Irvine, CA, USA).
6. Fiberoptic bronchoscopy (FOB). Significant malpositions of left-sided or
right-sided DLTs that can lead to desaturation during OLV are often not
detected by auscultation or other traditional methods of confirming placement.
Positioning of DLTs or BBs should be confirmed after placing the patient in the
surgical position because a substantial percentage of tubes/blockers migrate
during repositioning of the patient.
CLINICAL PEARL Head and neck extension or rotation during patient repositioning
risks displacement of a previously perfectly positioned DLT.
7. Continuous spirometry. Side-stream spirometry monitors inspiratory and
expiratory pressures, volume, and flow interactions during anesthesia. The
adequacy of lung isolation can be monitored by breath-to-breath comparison of
inspiratory and expiratory tidal volumes. This also gives a sense of the
magnitude of air leaks from the ventilated lung. Changes in the position of a
DLT can be detected by changes in the pressure–volume loops.
D. Anesthetic technique
Any anesthetic technique that provides safe and stable general anesthesia for
major surgery can and has been used for lung resection. Many centers use
combined regional (e.g., TEA or paravertebral blocks) and general anesthesia
for thoracic surgery. Commonly, neuromuscular blockers are used, but they are
not essential to the safe conduct of thoracotomies or to DLT management.
1. 7 Intravenous (IV) fluids. Because of hydrostatic effects, excessive
administration of IV fluids can cause increased shunt and lead to pulmonary
edema of the dependent lung. Because the dependent lung is the lung that must
carry on gas exchange during OLV, it is best to be as judicious as possible with
fluid administration. IV fluids are administered to replace volume deficits and
for maintenance only during lung resection anesthesia. No volume is given for
theoretical third-space losses during thoracotomy (Table 15.7).
2. Nitrous oxide. Nitrous oxide/oxygen mixtures are more prone to cause
atelectasis in poorly ventilated lung regions than oxygen by itself. The optimal
method to prevent dependent lung atelectasis is the use of air/oxygen mixtures
during both two-lung ventilation and OLV, titrating the Fi O2 to avoid
hypoxemia. Nitrous oxide also tends to increase PA pressures in patients who
have pulmonary hypertension.
TABLE 15.7 Fluid management for pulmonary resection surgery
3. Temperature. Maintenance of body temperature can be a problem during

thoracic surgery because of heat loss from the open hemithorax. This is
particularly a problem at the extremes of the age spectrum. Most of the body’s
physiologic functions, including hypoxic pulmonary vasoconstriction (HPV),
are inhibited during hypothermia. Increasing the ambient room temperature and
using lower and upper body forced-air patient warmers are the best methods to
prevent inadvertent intraoperative hypothermia.
4. Prevention of bronchospasm. Due to the high incidence of coexisting reactive
airways disease in the thoracic surgical population, it is generally advisable to
use an anesthetic technique that decreases bronchial irritability. This is
particularly important because the added airway manipulation caused by
placement of a DLT or BB potently triggers bronchoconstriction. Avoid
manipulation of the airway in a lightly anesthetized patient, use bronchodilating
anesthetics, and avoid drugs which release histamine.
For IV induction of anesthesia, either propofol or ketamine diminishes
bronchospasm. For maintenance of anesthesia, propofol and/or any of the
volatile anesthetics will diminish bronchial reactivity. Sevoflurane may be the
most potent bronchodilator of the volatile anesthetics.
5. Coronary artery disease. Since a large proportion of lung resection
population is composed of elderly patients and smokers, there is a high
coincidence of coronary artery disease. This will be a major factor in the
choice of the anesthetic technique for many thoracic surgery patients. The
anesthetic technique should optimize the myocardial oxygen supply/demand
ratio by maintaining arterial oxygenation and diastolic blood pressure while
avoiding unnecessary increases in myocardial contractility and heart rate.
TEA/analgesia may help to achieve these goals.
E. Management of one-lung ventilation (OLV)
1. Hypoxemia. There is an incidence of <4% of hypoxemia (arterial saturation
<90%) during OLV for thoracic surgery. Hypoxemia is more likely to occur
when OLV is in the supine position.
2. Hypoxic pulmonary vasoconstriction (HPV). HPV is thought to decrease the
blood flow to the nonventilated lung by 50%. The stimulus for HPV is
primarily the alveolar oxygen tension (PA O2), which stimulates precapillary
vasoconstriction to redistribute pulmonary blood flow away from hypoxemic
lung regions via a pathway involving nitric oxide (NO) and/or cyclooxygenase
synthesis inhibition. All of the volatile anesthetics inhibit HPV. This inhibition
is dose dependent. Isoflurane, sevoflurane, and desflurane cause less inhibition
than older volatile agents such as halothane [8]. No clinical benefit has been
shown for total IV anesthesia beyond that seen with isoflurane 1 MAC
(minimum alveolar concentration) or less. HPV is decreased by all
vasodilators such as nitroglycerin and nitroprusside. In general, vasodilators
can be expected to cause a deterioration in PaO2 during OLV.
3. Cardiac output. The net effects of an increase in cardiac output during OLV
tend to favor an increase in PaO2. However, elevation of cardiac output beyond
physiologic needs tends to oppose HPV and may cause PaO2 to fall.
4. Ventilation during one-lung anesthesia. It is possible to improve gas
exchange for selected individual patients by altering the ventilatory variables
that are under the control of the anesthesiologist: tidal volume, rate,
inspiratory/expiratory ratio, PaCO2, peak and plateau airway pressures, and
PEEP (Table 15.8).
TABLE 15.8 Recommended ventilation parameters for OLV
a. Respiratory acid–base status. The overall efficacy of HPV is optimal with

normal pH and PaCO2.
b. Tidal volume. A 5 to 6 mL/kg ideal body weight for OLV is a reasonable
starting point. The tidal volume should be adjusted during OLV to keep the
airway peak pressure less than 35 cm H2O and the plateau airway pressure
less than 25 cm H2O.
CLINICAL PEARL A common misconception is that tidal volume should be

substantially reduced when converting from two-lung ventilation to OLV.
c. Positive end-expiratory pressure (PEEP). Most patients with either normal
or supranormal (restrictive lung disease) lung elastic recoil will benefit from
low levels (5 cm H2O) of PEEP during OLV. A recruitment maneuver (e.g.,
static inflation to 20 cm H2O for 20 seconds, observing for hypotension) to the
ventilated lung is useful at the start of OLV. Auto-PEEP is prone to occur in
patients with decreased lung elastic recoil, such as those with emphysema.
Auto-PEEP is difficult to detect using currently available anesthetic
ventilators but can be estimated with a manually applied prolonged expiratory
phase with zero end-expiratory pressure. Applied PEEP combines with auto-
PEEP in an unpredictable fashion.
d. Volume control versus pressure control. Pressure-control OLV is useful in
patients with severe obstructive disease and to limit airway pressure in
patients with blebs, bullae, or fresh resections in the lung, and also in patients
at risk of acute lung injury (pneumonectomies, lung transplantation). When
using pressure-control OLV without setting a guaranteed minimum tidal
volume, it is important to set an alarm for minimum tidal volume (e.g., 3
mL/kg ideal body weight).
e. Inspired oxygen concentration (FiO2). The FiO2 should be increased at the
start of OLV to 0.8 to 1.0 and then can be decreased as tolerated over the next
20 minutes.
5. Treatment of hypoxemia during one-lung ventilation (OLV) (see Table
15.9)
In cases of severe and/or acute desaturation, resume two-lung ventilation
immediately, deflate the bronchial cuff or blocker, and then check the position
of the DLT or BB with FOB. In cases of desaturation that have not become life-
threatening:
a. Increase inspired oxygen concentration (FiO2). The first-line therapy is to
increase the FiO2, which is an option in essentially all patients except those
who received bleomycin or similar therapy that potentiates pulmonary oxygen
toxicity.
b. Positive end-expiratory pressure (PEEP). PEEP to the ventilated dependent
lung will improve oxygenation in patients with normal lung mechanics and
those with increased elastic recoil due to restrictive lung diseases. Apply a
recruitment maneuver to the ventilated lung before application of PEEP.
TABLE 15.9 Treatment options for hypoxemia during OLV
c. Pharmacologic manipulations. Increasing cardiac output will result in a

small but clinically useful increase in both PvO2 and PaO2 if cardiac output
has decreased. Eliminating potent vasodilators, such as nitroglycerin and
halothane, will improve oxygenation during OLV. Selective pulmonary
vasodilators such as NO have not yet proven to be reliable.
d. Continuous positive airway pressure (CPAP) must be applied to a fully
inflated or reinflated lung for optimal effect. When CPAP is applied to a fully
inflated lung, as little as 2 to 3 cm H2O can be used. All that is required is a
CPAP valve and an oxygen source. Ideally, the circuit should permit variation
of the CPAP level and should include a reservoir bag to allow easy
reinflation of the nonventilated lung and a manometer to measure the actual
CPAP supplied. Such circuits are commercially available or can be readily
constructed. When the bronchus of the operative lung is obstructed or open to
atmosphere, CPAP will not improve oxygenation. During thoracoscopic
surgery, CPAP can significantly interfere with surgery.
CLINICAL PEARL When CPAP is applied to the nondependent, surgical lung to treat
hypoxemia, the lung must first be reinflated.
e. Alternative ventilation methods. Several alternative methods of OLV, all of
which involve partial ventilation of the nonventilated lung, have been
described. All improve oxygenation during OLV. These techniques are useful
in patients who are particularly at risk for desaturation, such as those with
previous pulmonary resections of the contralateral lung.
(1) Oxygen insufflation (5 L/min) for brief periods via the suction channel of
an FOB to partially recruit a segment of the nonventilated lung remote
from the site of surgery (e.g., a basilar segment of the lower lobe for
upper lobe surgery). This is particularly useful in VATS [9]. Surgeon’s
direct observation is useful to prevent over-reinflation.
(2) Selective lobar collapse of only the operative lobe in the open
hemithorax by placement of a blocker in the appropriate lobar bronchus
of the ipsilateral operative lung.
(3) Differential lung ventilation by only partially occluding the lumen of the
DLT to the operative lung.
(4) Intermittent reinflation of the nonventilated lung by regular reexpansion of
the operative lung via an attached CPAP circuit.
(5) Conventional OLV of the nonoperative lung and high-frequency jet
ventilation of the operative lung.
f. Mechanical restriction of pulmonary blood flow. It is possible for the
surgeon to directly compress or clamp the blood flow to the nonventilated
lung. This can be done temporarily in emergency desaturation situations or
definitively in cases of pneumonectomy or lung transplantation. Another
technique is inflation of a PA catheter balloon in the main PA of the operative
lung.
6. 8 Prevention of hypoxemia. The treatments outlined as therapy for
hypoxemia can be used prophylactically to prevent hypoxemia in patients who
are at high risk for desaturation during OLV. Desaturation during bilateral lung
procedures is particularly a problem during a second period of OLV (e.g.,
bilateral thoracotomy). It is advisable to operate first on the lung that has better
gas exchange. For the majority of patients, this means operating on the right
side first.
III. Specific procedures
A. Thoracotomy
1. Operations
a. Lobectomy. Lobectomy is the most common pulmonary resection for lung
cancer. Early functional loss exceeds the amount of lung tissue resected, but
function recovers over a period of 6 weeks so that the final net loss of
respiratory function is equivalent to the amount of functioning lung tissue
excised. The recovery of pulmonary function after thoracotomy is unique
because it shows a plateau with no early recovery during the first 72 hours
postoperatively. This period coincides with the occurrence of the majority of
postthoracotomy respiratory complications (atelectasis, pneumonia), which
are the major causes of mortality after pulmonary resection. These
complications are particularly associated with lobectomy and its variations,
probably due to the transient dysfunction that occurs in the remaining lobe(s).
The right middle lobe is particularly at risk for these complications after a
right upper lobectomy and can develop torsion about its bronchovascular
pedicle or lobar bronchial kinking as it expands into the apex of the right
hemithorax.
b. Sleeve lobectomy. A sleeve lobectomy is the excision of a lobe plus the
adjacent segment of mainstem bronchus with bronchoplastic repair of the
bronchus by end-to-end anastomosis to preserve the distal functioning
pulmonary parenchyma. It is done to preserve functioning lung tissue when the
tumor encroaches to less than 2 cm from the lobar bronchial orifices,
precluding simple lobectomy. This procedure is usually done for right upper
lobe tumors but can be used for other lobes. The anesthetic implications of
this procedure are that, most often, no airway catheter (single lumen or DLT)
or BB can be placed in the ipsilateral main stem bronchus, although some
surgeons prefer to use a carefully positioned left-sided DLT during left upper
lobe sleeve lobectomies. Mucus clearance across the bronchial anastomosis
may be impaired after sleeve resection, and local tumor recurrence is a
problem.
c. Bilobectomy. In the right lung, a bilobectomy may be used to conserve either
a functioning upper or lower lobe when the tumor extends across the lobar
fissure or for malignancies involving the bronchus intermedius (the portion of
the right main stem bronchus distal to the right upper lobe orifice). The
complication rate is slightly higher than for a simple lobectomy but is less
than for a pneumonectomy. The incidence of cardiac dysrhythmias increases
postoperatively versus lobectomy, whereas the incidence of respiratory
complications remains the same. The residual lobe cannot completely fill the
hemithorax, and all patients will have a degree of pneumothorax that can be
expected to resolve gradually.
d. Pneumonectomy. Complete removal of the lung is required when a
lobectomy or its modifications is not adequate to remove the local disease
and/or ipsilateral lymph node metastases. Atelectasis and pneumonia occur
after pneumonectomy, as they do after lobectomy, but may be less of a
problem because of the absence of residual parenchymal dysfunction on the
operative side. The mortality rate after pneumonectomy exceeds that for
lobectomy because of complications that are more likely with
pneumonectomy.
TABLE 15.10 Postpneumonectomy pulmonary edema
(1) Postpneumonectomy pulmonary edema. This syndrome presents

clinically with dyspnea and an increased alveolar–arterial oxygen
gradient on the second or third postoperative day [10] and has a high
fatality rate. Radiologic changes precede clinical symptoms by
approximately 24 hours. The factors that are known about this syndrome
are listed in Table 15.10. Excessive perioperative administration of IV
crystalloids or colloids can exacerbate it. However, there is no evidence
that judicious amounts of fluids cause this problem. The residual
nonoperated lung has an increased pulmonary capillary permeability
after pneumonectomy that is not seen in the nonoperated lung after
lobectomy. The cause of this increased permeability may be related to
surgical lymphatic damage, capillary stress injury from increased flow,
or increased airway pressure and hyperinflation of the ventilated lung
during OLV. The majority of lobectomies have the potential to become a
pneumonectomy, so caution is needed with fluids in most thoracic cases.
(2) 9 Atrial fibrillation. Up to 50% of postpneumonectomy patients will
develop supraventricular arrhythmias in the first week postoperatively,
the majority of which are atrial fibrillation. The perioperative mortality
is 17% in patients who develop arrhythmias versus 2% in those without
them. The etiology seems to depend on two factors: RV strain and
increased sympathetic nervous activity. Similar arrhythmias occur with a
lesser incidence after lesser pulmonary resections. Prophylactic digoxin
is not effective in preventing them [11].
(3) Mechanical effects. A variety of potentially lethal intrathoracic
mechanical derangements of cardiorespiratory function can occur after
pneumonectomy. The most important of these is cardiac herniation
through an incompletely closed pericardium. This is particularly a risk
after right pneumonectomy and presents with acute severe hypotension in
the immediate postoperative period. The only useful therapy is
immediate reoperation to return the heart into the pericardium. A
subacute form of cardiac herniation can occur after a left pneumonectomy
and presents with a picture of myocardial ischemia as the apex of the
heart herniates through the pericardial defect and compresses the
coronary arteries. Less acute presentations of cardiovascular or
respiratory symptoms may develop related to shifts of the mediastinum
that can compress the great vessels or airways after pneumonectomy.
CLINICAL PEARL If sudden, severe hypotension occurs in the early postoperative
period after pneumonectomy, a diagnosis of cardiac herniation should be assumed unless
proven otherwise.
e. Sleeve pneumonectomy. Tumors involving the most proximal portions of the
main stem bronchus and the carina may require a sleeve pneumonectomy.
These are performed most commonly for right-sided tumors and usually can
be performed without cardiopulmonary bypass (CPB) via a right thoracotomy.
A long single-lumen EBT can be advanced into the left main stem bronchus
during the period of anastomosis, or the lung can be ventilated via a separate
sterile ETT and circuit that is passed into the operating field and used for
temporary intubation of the open distal bronchus. High-frequency positive
pressure ventilation (HFPPV) also has been used for this procedure.
Because the carina is surgically more accessible from the right side, left
sleeve pneumonectomies are commonly performed as a two-stage operation,
first a left thoracotomy and pneumonectomy, and then a right thoracotomy for
the carinal excision. The complication rate and mortality are higher and the 5-
year survival significantly lower than for nonsleeve pneumonectomies.
f. Lesser resections (segmentectomy, wedge). These procedures are
commonly performed in the elderly or in patients with limited
cardiopulmonary reserves to preserve functioning pulmonary parenchyma.
These lesser resections are associated with a lower 5-year survival rate
compared to lobectomy due to locoregional recurrence of cancer. The
decrease of pulmonary function (FEV1) for lesser resections is in proportion
to the amount of lung tissue removed. Lesser resections are acceptable therapy
for nonmalignant lung lesions.
g. Extended resections. Portions of the chest wall, diaphragm, pericardium, left
atrium, vena cava, brachial plexus, or vertebral body may be excised with
adjacent lung tumor. Resection of any of these structures has important
anesthetic implications for choice and placement of intraoperative monitors
and lines and for postoperative management.
h. Subsequent pulmonary resections. Lung resection surgery after previous
lung resection is increasingly frequent. These operations can be performed for
either benign or malignant disease. Ten percent of lung cancer patients can be
expected to develop a second primary tumor. Prediction of postoperative lung
function for these patients is accurate based on the assessment of preoperative
function (lung mechanics, gas exchange, and cardiopulmonary reserve) and
estimation of the amount of functional lung tissue removed at surgery (Fig.
15.1). Lobectomy after pneumonectomy can be performed safely if the patient
meets minimal standards for predicted postoperative pulmonary function.
Intraoperative collapse of the ipsilateral lung is not possible, but surgery can
be facilitated by selective lobar or segment bronchial blockade or the use of
HFPPV.
Completion pneumonectomy after a previous ipsilateral resection for cancer
has a greater than 40% 5-year survival rate. Intraoperative hemorrhage is the
specific anesthetic concern with this procedure, as more than 50% of patients
experience blood loss of greater than 1,000 mL. Hemorrhage is particularly a
problem in completion pneumonectomy for nonmalignant lung disease (lung
abscess, bronchiectasis, tuberculosis). Inflammatory lung disease tends to
destroy the tissue planes around the hilum and makes the surgical dissection
more difficult, with an attendant increase in perioperative mortality.
i. Incomplete resections. In general, a lung cancer patient’s prognosis is not
improved from an incomplete resection. There are several exceptions.
Incompletely resected tumors with direct mediastinal invasion or tumors of
the superior sulcus may benefit if the resection is combined with adjuvant
brachytherapy or external irradiation. Also, if the residual tumor is limited to
microscopic involvement of the cut mucosal margin of the bronchus, 5-year
survival is increased beyond that seen without surgery. Incomplete resections
may be indicated for palliation in cases of airway obstruction or hemoptysis if
these are not amenable to endoscopic or radiologic procedures.
j. Adjuvant and neoadjuvant therapy. The benefits of pre- and/or
postoperative prophylactic chemotherapy and/or radiotherapy are unclear for
lung cancer patients who have undergone complete resections. Thoracic
irradiation is usually given to patients with resected N2 node involvement
disease. Chemotherapy may be of some benefit after resection of advanced
adenocarcinoma. Neoadjuvant cisplatin-based regimens for marginally
resectable stage IIIa or IIIb disease are currently under investigation.
Preoperative radiotherapy does not appear to offer any survival benefits and
makes the surgery technically more difficult.
TABLE 15.11 Surgical approaches for pulmonary resections
2. Surgical approaches. Any given pulmonary resection can be accomplished by

a variety of different surgical approaches. The approach used in an individual
case depends on the interaction of several factors, which include the site and
pathology of the lesion(s) and the training and experience of the surgical team.
Each approach has specific anesthetic implications. Common thoracic surgical
approaches and their generally accepted advantages and disadvantages are
listed in Table 15.11.
a. Posterolateral thoracotomy. For decades, this was the traditional incision in
thoracic surgery. The patient is placed in the lateral decubitus position. Chest
access is usually via the fifth or sixth intercostal space. The left seventh or
eighth space may be used for access to the esophageal hiatus. The serratus
anterior, latissimus dorsi, and trapezius muscles all are partially divided
during incision, with subsequent postoperative pain and disability. Chest
access may be obtained directly through an intercostal space or by excision of
a rib. Exposure to all ipsilateral intrathoracic structures is excellent.
b. Muscle-sparing lateral thoracotomy. The lateral muscle-sparing
thoracotomy has been advocated to reduce the pain and disability associated
with a standard posterolateral thoracotomy. The skin incision may or may not
be smaller, but an extensive subcutaneous dissection is required to mobilize
the latissimus and serratus muscles.
c. Anterolateral thoracotomy. This is a particularly useful incision in trauma
because it allows complete access to the patient for ongoing resuscitation and
does not require repositioning for laparotomy or exploration of the
contralateral chest. Exposure to the posterior hemithorax is limited in
comparison to a posterolateral incision. Because this approach requires
incision of only the pectoralis muscles, pain and shoulder disability may be
less than with a standard thoracotomy.
d. Axillary thoracotomy. The transaxillary approach provides access only to
the apical areas of the hemithorax. The ipsilateral arm must be draped free or
suspended, and access to this arm will be limited intraoperatively. Thus, it is
preferable for vascular access and monitoring to use the contralateral arm.
Postoperative pain and disability are less than with a standard thoracotomy.
This is an adequate incision for first rib resection, resection of apical
bullae/blebs, or thoracic sympathectomy.
e. Median sternotomy. This incision, which is the standard for cardiac surgery,
has potential benefits for certain thoracic procedures. Bilateral excisions for
metastases and bullae are best performed via this incision. It has been
demonstrated that postoperative spirometry is superior and pain is less after
median sternotomy than thoracotomy. Most pulmonary resections can be
performed via a median sternotomy, which obviates the need for a separate
incision in cases of combined cardiac and thoracic surgery (see Section III.J).
Certain procedures are more difficult via a median sternotomy, including
procedures performed for superior sulcus tumors, tumors with posterior chest
wall extension, and left lower lobe tumors. OLV is more of a necessity for
surgical exposure than for lateral thoracotomies because of the limited
surgical access, and oxygen desaturation is more common with OLV in the
supine than the lateral position.
f. Transsternal bilateral thoracotomy (the “clamshell” incision). This is the
common incision for bilateral lung transplantation. Because of increased pain
and postoperative chest wall dysfunction, it is not commonly used for other
intrathoracic procedures. It has been used for resection of bilateral
metastases, pericardiectomy, resection of a posterior ventricular aneurysm,
and cardiac surgery in a patient with a tracheotomy.
B. Video-assisted thoracoscopic surgery (VATS)
Essentially any surgical procedure that is performed via thoracotomy has been
attempted by VATS. VATS has been advocated for pulmonary resection of lung
cancer in patients with limited respiratory reserves because of decreased
postoperative pain and loss of early postoperative spirometric respiratory
function that is only approximately half of that seen when the same operation is
performed by thoracotomy. VATS is the procedure of choice for resection of
nonmalignant pulmonary lesions (blebs, bullae, granulomas). VATS will
probably become the commonest procedure for the majority of cancer resections.
Also, VATS is used for sympathectomy for palmar hyperhidrosis and for the
intrathoracic portion of esophagogastrectomy. Bilateral VATS can be performed
in the supine position for apical lesions, but for most operations, bilateral VATS
requires change from one lateral position to the other intraoperatively. Robotic
thoracic surgery is being used increasingly for minimally invasive procedures
due to better visualization (see also Chapter 13 for further discussion of robotic
thoracic surgery).
Some procedures are attempted by VATS initially with conversion to
thoracotomy if the surgery proves impractical. OLV with complete collapse of
the operative lung is more of a priority than for open thoracotomy, and
application of CPAP to the nonventilated lung is more detrimental to surgery than
in open thoracotomy. To aid collapse of the lung, particularly in patients with
COPD and poor lung elastic recoil, it is best to ventilate with oxygen instead of
air/oxygen mixtures during the period of two-lung ventilation before lung
collapse and to apply suction (−20 cm H2O) to the nonventilated lung after the
start of OLV until collapse is complete. Postoperative management is essentially
the same as for thoracotomy, and most patients initially will have chest drains.
The amount of postoperative pain after VATS varies greatly depending on the
surgical procedure performed. Simple wedge excisions will have only the pain
of several small intercostal incisions and the chest drain(s), and this can usually
be easily managed with oral medications. Pleural abrasions or instillation of
pleural sclerosing agents, which are often done for recurrent pneumothoraces or
effusions, are extremely painful and may require full postoperative analgesic
management, up to and including TEA, in patients with limited pulmonary
function.
CLINICAL PEARL Complete collapse of the operative lung is more critical to VATS
than to open thoracotomies, and the application of CPAP to that lung is relatively
contraindicated because it severely compromises surgical exposure.
C. Bronchopleural fistula
A persistent communication between the airway and the interpleural space can
develop after medical conditions, such as rupture of a bleb or bulla, infection, or
malignancy. Bronchopleural fistula can develop as a postoperative complication
after lung surgery. The large majority of persistent lung air leaks will heal with
drainage and conservative management.
Surgical intervention is indicated when conservative therapy is unable to
permit adequate gas exchange (this is more likely to occur in the immediate
postoperative period, particularly after pneumonectomy) or when conventional
chest tube drainage and suction are unable to reexpand the ipsilateral lung, or for
a second ipsilateral or first contralateral pneumothorax.
There are three specific anesthetic goals in all patients with a bronchopleural
fistula:
1. Healthy lung regions must be protected from soiling by extrapleural fluid from
the affected hemithorax (e.g., coexisting empyema).
2. The ventilation technique must avoid development of a tension pneumothorax in
the affected hemithorax.
3. The anesthetic technique must ensure adequate alveolar gas exchange in the
presence of a low-resistance air leak.
To achieve these goals, there are two management principles that should be
used in essentially all cases:
1. A functioning chest drain should be placed before the induction of anesthesia
and connected to an underwater seal without suction.
2. A method of lung separation should be placed so that the fistula can be isolated
as necessary intraoperatively.
After placement of a chest drain, there are three options for induction of
anesthesia [12]:
1. A single-lumen or double-lumen EBT or blocker can be placed in an awake
patient with topical anesthesia and its position checked fiberoptically before
induction. This is often not the best choice in a patient with severely
compromised gas exchange because maintaining adequate oxygenation in an
already hypoxemic patient can be a problem during awake intubation.
2. Induction of anesthesia, maintaining spontaneous ventilation until lung isolation
is secured. A spontaneous ventilation induction may not be desirable if there is
a risk of aspiration and in patients with compromised hemodynamics.
3. IV induction of general anesthesia and muscle relaxation after meticulous
preoxygenation and manual ventilation using small tidal volumes and low
airway pressures until the lung isolation is confirmed. The efficiency of this
technique can be improved by using a bronchoscope to guide DLT placement
during intubation.
The air leak through a bronchopleural fistula is dependent on the pressure
gradient between the mean airway pressure at the site of the fistula and the
interpleural space. High-frequency ventilation, with and without lung or lobar
blockade, has been used in certain cases. High-frequency techniques may permit
relatively lower proximal mean airway pressures than conventional mechanical
ventilation and may be more useful in large central air leaks.
D. Bullae and blebs
Whenever positive-pressure ventilation is applied to the airway of a patient with
a bulla or bleb, there is the risk of lesion rupture and development of a tension
pneumothorax that will require drainage and may progress to a bronchopleural
fistula. The anesthetic considerations are similar to those for a patient with a
bronchopleural fistula, except that it is best not to place a chest drain
prophylactically because the chest tube may enter the bulla and create a fistula
and there is not the risk of soiling healthy lung regions from extrapleural fluid that
exists with fistulas. For induction of anesthesia, it is usually optimal to maintain
spontaneous ventilation until the lung or lobe with the bulla or bleb is isolated.
When there is a risk of aspiration or it is believed that the patient’s gas exchange
or hemodynamics may not permit spontaneous ventilation for induction, the
anesthesiologist will need to use small tidal volumes and low airway pressures
during positive-pressure ventilation until the airway is isolated. Nitrous oxide
will diffuse into a bleb or bulla, causing it to enlarge, and must be avoided.
E. Abscesses, bronchiectasis, cysts, and empyema
As with bronchopleural fistulas, there is the risk of soiling healthy lung regions
by uncontrolled spillage from these lesions. Lung isolation is a primary
requirement for anesthesia, and the anesthetic principles and management are
similar to those described for fistulas. When an intrathoracic space-occupying
lesion is removed, there is the potential for reexpansion pulmonary edema to
develop after reinflation of the ipsilateral lung. A slow and gradual reinflation
may decrease the severity of this complication.
F. Mediastinoscopy
Cervical mediastinoscopy is a diagnostic sampling of the mediastinal nodes to
assess if a pulmonary resection will improve outcome. Basically, it is an attempt
to differentiate between stage I or II and stage III lung cancer because the benefits
of surgery vary tremendously between these stages. Mediastinoscopy can avoid
some but not all unnecessary exploratory thoracotomies. Mediastinoscopy is
often omitted from the cancer staging if the CT scan of the mediastinum is
negative (mediastinal nodes less than 1 cm in the short axis). Because there are a
significant number of false-positive results on cancer staging with CT scan, all
patients with positive mediastinal nodes on CT should have a mediastinoscopy.
Mediastinoscopy can be done during a separate anesthetic before pulmonary
resection, often as an outpatient, or after induction of anesthesia preceding
pulmonary resection. Apart from the specific anesthetic considerations of
mediastinoscopy itself, the anesthetic implication of starting the case with these
diagnostic procedures is that the resection may be aborted based on the initial
mediastinoscopy findings. The likelihood of not proceeding to thoracotomy must
enter into each individual assessment of risk/benefit when considering placing an
epidural catheter before induction.
Mediastinoscopy is most commonly done via a cervical approach with an
incision in the suprasternal notch. Any structure in the upper chest can be injured
during the procedure, including great vessels, pleura (pneumothorax), nerves
(recurrent laryngeal), and airways.
Hemorrhage is the most frequent major complication, particularly due to
inadvertent PA biopsy, and this must always be considered with respect to
vascular access, monitoring, and the availability of means for resuscitation.
Fortunately, significant hemorrhage during mediastinoscopy can usually be
tamponaded temporarily by the surgeon when resuscitation is required. In only a
minority of mediastinoscopy hemorrhages is it necessary to proceed to
thoracotomy for surgical control of bleeding.
A frequent complication of cervical mediastinoscopy is transient compression
of the brachiocephalic (innominate) artery by the mediastinoscope. The surgeon
is usually unaware that this is occurring, so it is essential to incorporate
continuous pulse monitoring in the right arm (pulse oximetry, arterial line, or
palpation) into the anesthetic plan. The surgeon can then be immediately notified
and avoid the risk of cerebral ischemia in patients who may not have good
collateral cerebral circulation.
CLINICAL PEARL During mediastinoscopy, continuous pulse monitoring in the right
arm is essential to early recognition of innominate artery compression.
Because of the different pattern of lymphatic drainage of the left upper lobe,
patients with left upper lobe tumors often will have an anterior left parasternal
mediastinoscopy or median sternotomy instead of or in addition to a cervical
mediastinoscopy. The serious complications associated with cervical
mediastinoscopy are not as frequent with parasternal mediastinoscopy.
Endobronchial ultrasound (EBUS)-guided mediastinal nodal biopsies via an
FOB are increasingly used as an alternative to traditional mediastinoscopy as a
lung cancer–staging procedure. These can be performed awake with topical
anesthesia of the airway or under general anesthesia.
G. Anterior mediastinal mass
10 Patients with anterior mediastinal masses present unique problems to the
anesthesiologist. A large number of such patients require anesthesia for biopsy of
these masses by mediastinoscopy or VATS, or they may require definitive
resection via sternotomy or thoracotomy. Tumors of the anterior mediastinum
include thymoma, teratoma, lymphoma, cystic hygroma, bronchogenic cyst, and
thyroid tumors. Anterior mediastinal masses may cause obstruction of major
airways, main pulmonary arteries, atria, and the superior vena cava. Any one of
these complications can be life threatening. During induction of general
anesthesia in patients with an anterior mediastinal mass, airway obstruction is the
most common and feared complication.
It is important to note that the point of tracheal compression usually
occurs distal to the ETT. A history of supine dyspnea or cough should alert the
clinician to the possibility of airway obstruction upon induction of anesthesia.
Life-threatening complications may occur in the absence of symptoms. The other
major complication is cardiovascular collapse secondary to compression of the
heart or major vessels. Symptoms of supine syncope suggest vascular
compression. Death upon induction of general anesthesia in patients with an
anterior mediastinal mass is always a risk. Anesthetic deaths have mainly been
reported in children. These deaths may be the result of the more compressible
cartilaginous structure of the airway in children or because of the difficulty in
obtaining a history of positional symptoms in children.
The most important diagnostic test in the patient with an anterior mediastinal
mass is the CT scan of the trachea and chest. Children with tracheobronchial
compression greater than 50% on CT cannot be safely given general anesthesia
[13]. Flow–volume loops, specifically exacerbation of a variable intrathoracic
obstruction pattern (expiratory plateau) when supine, are unreliable for
predicting which patients will have intraoperative airway complications.
Echocardiography is indicated for patients with vascular compressive symptoms.
Management. General anesthesia will exacerbate extrinsic intrathoracic
airway compression in at least three ways. First, reduced lung volume occurs
during general anesthesia; second, bronchial smooth muscle relaxes during
general anesthesia allowing greater compressibility of large airways; and third,
paralysis eliminates the caudal movement of the diaphragm seen during
spontaneous ventilation. This reduces or eliminates the normal transpleural
pressure gradient that dilates the airways during inspiration and minimizes the
effects of extrinsic intrathoracic airway compression.
Management of these patients is guided by their symptoms (Tables 15.12 to
15.14) and the CT scan. All of these patients need a step-by-step induction of
anesthesia with continuous monitoring of gas exchange and hemodynamics. This
“NPIC” (Noli Pontes Ignii Consumere, i.e., don’t burn your bridges)
anesthetic induction can be an inhalation induction with a volatile agent such as
sevoflurane or IV titration of propofol with or without ketamine, which maintains
spontaneous ventilation until either the airway is definitively secured or the
procedure is completed [14]. Awake intubation of the trachea before induction is
a possibility in some adult patients if the CT scan shows an area of
noncompressed distal trachea to which the ETT can be advanced before
induction. If muscle relaxants are required, ventilation should first be gradually
taken over manually to assure that positive-pressure ventilation is possible and
only then can a muscle relaxant be administered. Development of airway or
vascular compression requires that the patient be awakened as rapidly as
possible and then other options for the surgery to be explored. Intraoperative
life-threatening airway compression has usually responded to one of two
therapies: either repositioning of the patient (which should be determined before
induction if there is one side or position that causes less compression) or rigid
bronchoscopy and ventilation distal to the obstruction. This means that an
experienced bronchoscopist and equipment must always be immediately
available in the operating room with these cases.
CLINICAL PEARL Loss of airway during induction of a patient with an anterior
mediastinal mass requires rapid rescue by repositioning the patient or by rigid
bronchoscopy.
TABLE 15.12 Grading scale for symptoms in patients with an anterior mediastinal mass
TABLE 15.13 Anterior mediastinal mass patient safety stratification for “NPIC” general
anesthesia
Femorofemoral CPB before induction of anesthesia is a possibility for some

patients who are considered “unsafe” for “NPIC” general anesthesia. The
concept of CPB “standby” during attempted induction of anesthesia is fraught
with danger because there is not enough time after a sudden airway collapse to
establish CPB before hypoxic cerebral injury occurs [15]. Other options for
“unsafe” patients include local anesthetic biopsy of the mediastinal mass or
biopsy of another node (e.g., supraclavicular), preoperative radiotherapy with a
nonradiated “window” for subsequent biopsy, preoperative chemotherapy or
short-course steroids, and CT-guided biopsy of mass or drainage of a cyst.
H. Tracheal and bronchial stenting
Regional narrowing of the trachea or bronchi can be treated temporarily or
definitively by placement of tracheal or bronchial stents [16]. The only previous
options for these lesions were dilation, laser excision, or surgical excision.
Airway stenting is an option for palliation of patients with mediastinal masses
pending other therapy. There are two major varieties of stent: metallic and
silastic (Dumon). Both are commonly placed during rigid bronchoscopy, although
there is an option to place the self-expanding metallic stents with flexible FOB.
The metallic stents are more stable and more resistant to dislocation in the
airway but are difficult (often impossible) to remove once placed. Thus, metallic
stents are commonly only used for palliation in malignant airway obstructions.
Anesthetic management for tracheal stenting is similar to management of
patients with mediastinal masses. General anesthesia with muscle relaxation is
optimal, but in patients with severe symptoms of airway obstruction, induction of
anesthesia should follow a step-by-step “NPIC” protocol as discussed above.
I. Tracheal resection
Anatomically, the trachea has a necessary structural rigidity and a segmental
blood supply that complicate its resection and repair. Many different prosthetic
designs and materials have been evaluated as tracheal substitutes. Because of
unresolved problems with anatomic disruption, poor healing, and infection, end-
to-end anastomosis of the trachea remains the ideal method of repair.
Endotracheal intubation and resulting strictures were once the primary cause of
the need for tracheal resection, but using less irritating ETT materials and
limiting the duration of prolonged endotracheal intubation have decreased this
complication. Benign and malignant tumors (e.g., adenocarcinomas and
cylindromas) constitute the remaining indications for tracheal resection.
TABLE 15.14 Anterior mediastinal mass management for all “uncertain” patients for
“NPIC” general anesthesia
For a controlled and methodical operation on the trachea, full control of the
airway must be maintained at all times. Cooperation between the surgeon and
anesthesiologist is of utmost importance. Both should visualize the lesion
preoperatively (CT and bronchoscopy). With preoperative planning and
discussions, they can avoid unnecessary hasty procedures that might compromise
the end result or worse. Benign lesions can be dilated preoperatively to allow
the passage of a small ETT through the lesion. Operatively, the area below the
lesion is addressed first. If the degree of obstruction increases, a sterile ETT can
be placed directly from the surgical field. The patient should be spontaneously
ventilating at the end of the case to allow for extubation. Some surgeons will
temporarily place a Montgomery “T” tube distal to the anastomosis with the side
arm of the “T” brought out anteriorly through the neck incision to ensure gas
exchange in case of proximal tracheoglottic obstruction or edema. Some surgeons
will leave a temporary “chin retention” suture for several days postoperatively.
This heavy suture between the chin and the sternum restricts head extension and
limits traction on the fresh tracheal anastomosis. CPB greatly complicates the
conduct of the operation and has largely been unnecessary.
J. Pulmonary hemorrhage
Massive hemoptysis is defined as expectoration of >200 mL of blood in 24 to 48
hours. The commonest causes are carcinoma, bronchiectasis, and trauma (blunt,
penetrating, or secondary to a PA catheter). Death can occur quickly due to
asphyxia. Management requires four sequential steps: lung isolation,
resuscitation, diagnosis, and definitive treatment. The anesthesiologist is often
called to deal with these cases outside of the operating room. There is no
consensus on the best method of lung isolation. The initial method for lung
isolation will depend on the availability of appropriate equipment and an
assessment of the patient’s airway. All three basic methods of lung isolation have
been used: DLTs, single-lumen EBTs, and BBs. FOB is usually not helpful to
position EBTs or blockers in the presence of torrential pulmonary hemorrhage,
and lung isolation must be guided by clinical signs (primarily auscultation).
DLTs will achieve rapid and secure lung isolation. Even if a left-sided tube
enters the right mainstem bronchus, only the right upper lobe will be obstructed.
However, suctioning large amounts of blood or clots is difficult through the
narrow lumens of a DLT. An option is initial placement of a single-lumen tube
for oxygenation and suctioning and then replacement with a DLT either by
laryngoscopy or with an appropriate tube exchanger. An uncut single-lumen ETT
can be advanced directly into the right mainstem bronchus or rotated 90 degrees
counterclockwise for advancement into the left mainstem bronchus (less reliable
than right-mainstem intubation). A BB will normally pass easily into the right
mainstem bronchus and is useful for right-sided hemorrhage (90% of PA
catheter–induced hemorrhages are right sided). After lung isolation and
resuscitation have been achieved, both diagnosis and definitive therapy are now
most commonly performed by radiologists [17] (except for blunt and penetrating
trauma).
1. 11 Pulmonary artery (PA) catheter–induced hemorrhage. Hemoptysis in a
patient with a PA catheter must be assumed to be caused by perforation of a
pulmonary vessel by the catheter until proven otherwise. The mortality rate may
exceed 50%. This complication seems to be occurring less than previously,
possibly related to stricter indications for the use of PA catheters and more
appropriate management of PA catheters with less reliance on wedge pressure
measurements. Therapy for PA catheter–induced hemorrhage should follow an
organized protocol with some variation depending on the severity of the
hemorrhage (see Table 15.15).
2. During weaning from cardiopulmonary bypass(CPB): Weaning from CPB is
one of the times when PA catheter–induced hemorrhage is most likely to occur.
Management of the PA catheter during CPB by routinely withdrawing the
catheter 2 to 3 cm to avoid wedging during CPB may decrease the risk of this
complication. When hemoptysis does occur in this situation, there are several
management options available (see Fig. 15.9). The anesthesiologist should
resist the temptation to rapidly reverse the anticoagulation in order to quickly
get off CPB since this can lead to disaster. Resumption of full CPB ensures
oxygenation while the tracheobronchial tree is suctioned and then visualized
with FOB. The use of a PA vent or full-flow CPB may be required to decrease
the pulmonary blood flow sufficiently to define the bleeding site (usually the
right lower lobe). The pleural cavity should be opened to assess the lung
parenchymal damage. When possible, conservative management with lung
isolation constitutes optimal therapy. In patients with persistent hemorrhage
who are not candidates for lung resection, temporary lobar PA occlusion with a
vascular loop may be an option.
TABLE 15.15 Management of the patient with a PA catheter–induced pulmonary
hemorrhage
K. Posttracheostomy hemorrhage
Hemorrhage in the immediate postoperative period following a tracheostomy is
usually from local vessels such as the anterior jugular or inferior thyroid veins.
Massive hemorrhage 1 to 6 weeks postoperatively is most commonly due to
tracheo-innominate artery fistula [18]. A small sentinel bleed occurs in most
patients before a massive bleed. The management protocol for tracheo-
innominate artery fistula is outlined in Table 15.16.
IV. Pulmonary thromboendarterectomy (PTE)
A. Overview
PTE, a complete endarterectomy of the pulmonary vascular tree, is the definitive
treatment for chronic thromboembolic pulmonary hypertension (CTEPH).
Pulmonary embolism (PE) is a relatively common cardiovascular event, and in a
small percentage of cases it leads to a chronic condition in which repeated
microemboli lead to accumulation of connective and elastic tissue on the surface
of the pulmonary vessels with resultant end-stage lung disease due to pulmonary
hypertension [19]. The only potentially curative options are lung transplantation
and PTE, with PTE preferred because of its favorable long-term morbidity and
mortality profile. Surgical mortality rates vary in the range of 3% to 6% [20].
The most common symptom of CTEPH is exertional dyspnea. Other symptoms
may include chest tightness, hemoptysis, and peripheral edema.
FIGURE 15.9 Management of pulmonary hemorrhage during weaning from cardiopulmonary bypass. BB, bronchial
blocker; CPB, cardiopulmonary bypass; DLT, double-lumen tube; ETT, endotracheal tube; PA, pulmonary artery; FOB,
fiberoptic bronchoscopy; PEEP, positive end-expiratory pressure; parench., lung parenchyma; p.r.n. (pro re nata), as
needed.
TABLE 15.16 Management of tracheo-innominate artery fistula hemorrhage
Preoperative evaluation includes CXR, pulmonary function testing, right heart

catheterization with pulmonary angiography, high-resolution magnetic resonance
imaging, ABG analysis, V/Q scanning, and echocardiography. Diffusing capacity
(DLCO) is often reduced and may be the only abnormality on pulmonary function
testing. Pulmonary arterial pressures are elevated (mean >25 mm Hg) and
sometimes are suprasystemic. Resting cardiac output is often low. Many patients
exhibit hypoxia, particularly with exercise. PaCO2 is often slightly reduced,
although dead space ventilation is increased. With transthoracic
echocardiography, an estimate of PA systolic pressure is provided by Doppler
interrogation of the tricuspid regurgitant envelope. Echocardiographic findings
include RV enlargement, leftward displacement of the interventricular septum,
and encroachment of the enlarged right ventricle (RV) on the left ventricle (LV).
12 Pulmonary angiography is the gold standard to confirm the diagnosis and
to determine the surgical accessibility of thromboembolic disease. Many CTEPH
patients receive medical pulmonary vasodilator therapy. This therapy may
consist of phosphodiesterase 5 inhibition (e.g., sildenafil), endothelin-1
inhibition (e.g., bosentan), and prostacyclin analogs (e.g., iloprost, epoprostenol,
treprostinil). It is prudent to continue these medications preoperatively and to
consider their use postoperatively if the surgical result is suboptimal. Abrupt
cessation of a prostacyclin analog can result in potentially catastrophic rebound
pulmonary hypertension.
B. Surgical procedure
PTE is performed through a midline sternotomy and requires CPB with deep
hypothermic circulatory arrest (DHCA) in most centers. (Details of anesthetic
and CPB management at the Toronto General Hospital are presented in Tables
15.17 and 15.18.) CPB is established with cannulation of the ascending aorta and
the inferior and superior vena cava. Circulatory arrest is limited to 20-minute
epochs. If additional arrest time is necessary, reperfusion is carried out at 18°C
core temperature for a minimum of 10 minutes.
CLINICAL PEARL In chronic pulmonary thromboembolic disease, the development
of prominent bronchial arterial collaterals requires the use of circulatory arrest during
pulmonary thromboembolectomy.
C. Anesthetic management
The majority of lines and monitors are placed preinduction due to the risk of
hemodynamic collapse on induction. Because of the high right-sided pressures,
the coronary blood supply to the RV is at risk. Maintenance of adequate mean
systemic arterial pressure, systemic vascular resistance (SVR), inotropic state,
and normal sinus rhythm is critical. Markedly elevated PA systolic pressures
(>2/3 systemic), RVEDP (>14 mm Hg), severe tricuspid regurgitation, and
preoperative pulmonary vascular resistance (PVR) >1,000 dyne sec cm−5 are
signs of impending decompensation. In order to ensure adequate RV coronary
perfusion, a combined vasopressor/inotrope (e.g., norepinephrine) is begun prior
to induction with additional inotropic support (e.g., dobutamine or epinephrine)
as indicated. Generally, patients with CTEPH have fixed PVR because of
mechanical obstruction. However, high PVR can still be exacerbated by factors
that increase PVR (e.g., hypoxia, hypercarbia, acidosis, pain, and anxiety). Thus,
these stressors should be minimized during induction and the pre-CPB period.
Attempts to lower the PVR pharmacologically (e.g., nitroglycerin, nitroprusside)
should generally be avoided as they have minimal efficacy in treating CTEPH
and can dangerously jeopardize the coronary perfusion pressure to the RV
myocardium. Direct pulmonary vasodilators such as NO and prostaglandins,
which may be useful in the medical management of patients with other types of
pulmonary hypertension, generally show limited benefit for pulmonary
endarterectomy patients in the perioperative period.
TABLE 15.17 Pulmonary thromboendarterectomy anesthesia, key points (Toronto
General Hospital protocol)
TABLE 15.18 Pulmonary thromboendarterectomy CPB, Toronto General Hospital

protocol
End-tidal carbon dioxide (ETCO2) is a poor measure of ventilation adequacy

in these patients both pre- and post-CPB, since dead space ventilation is an
integral part of the disease process. Transesophageal echocardiography (TEE) is
valuable in monitoring and assessing cardiac function and filling during PTE.
The process of separation from CPB is similar to other surgeries involving
CPB. Modest vasopressor/inotropic support (e.g., norepinephrine 0.01 to 0.05
μg/kg/min and/or epinephrine 0.02 to 0.05 μg/kg/min) is often necessary initially
because of the long hypothermic period and long aortic cross-clamp time. If the
surgery has only been partially successful because of small-vessel disease,
pulmonary vasodilators such as inhaled prostacyclin or NO should be
considered. Most often, improvement in the cardiac index is seen with a dramatic
decrease in PA pressures and a drop in the PVR.
D. Post-cardiopulmonary bypass (CPB)
Frothy sputum, if present, likely indicates the onset of reperfusion pulmonary
edema. In this case, the ETT is suctioned, FOB is used to evaluate any
intrapulmonary source of bleeding, and increasing amounts of PEEP are applied
beginning with 5 cm H2O. If bleeding is minor and peripheral, a BB can be
placed in the appropriate lobar bronchus. If severe bleeding persists and is
predominantly unilateral, lung isolation (double-lumen EBT) and independent
lung ventilation are considered, as well as other interventions such as topical
vasopressors.
V. Lung volume reduction surgery (LVRS)
13 According to the National Heart, Blood, and Lung Institute, approximately
13.5 million persons in the United States are afflicted with COPD, and 3.1 million
of these patients have emphysema (Cure Researchtm.com,
http://www.cureresearch.com) as the primary manifestation. Airflow obstruction
associated with chronic bronchitis or emphysema occurs due to a loss of the elastic
recoil properties of the lung and chest wall. As the disease progresses, patients
become increasingly debilitated. They exhibit symptoms of severe dyspnea,
require supplemental oxygen, and display poor exercise tolerance. LVRS offers a
select group of patients the possibility of improved exercise tolerance, reduction in
dyspnea, improved quality of life, and extended life span. It has been suggested that
LVRS may provide these patients with a benefit that otherwise cannot be achieved
by any means other than lung transplantation.
A. History of lung volume reduction surgery (LVRS)
1. In 1957, Otto Brantigan, MD, described a surgical technique for patients with
end-stage emphysema that was designed to alleviate symptoms of severe
dyspnea and exercise intolerance. He reasoned that by excising the
nonfunctional lung tissue, the compressive effects exerted on normal lung tissue
could be relieved to improve V/Q matching. Unfortunately, the operative
mortality was significant and no objective measures of benefit could be
documented. Thus, early LVRS was abandoned as a viable therapy for patients
with end-stage emphysema until 1993.
2. In 1996, Joel Cooper, MD, authored an editorial advocating the technique of
LVRS as a “logical, physiologically sound procedure of demonstrable benefit
for a selected group of patients with no alternative therapy” [21,22]. He further
stated that the successful application of LVRS was “made possible through an
improved understanding of pulmonary physiology, improved anesthetic and
surgical techniques, and lessons learned from experience with lung
transplantation.” Although Dr. Cooper touted the benefits of LVRS for certain
patients, he did not minimize the surgical risk and suggested that this was not a
procedure to be performed in all healthcare centers across the country.
Additionally, he advocated that COPD patients who would otherwise qualify
for lung transplantation should be simultaneously evaluated for LVRS so that
they would receive the procedure proving to be most appropriate. Dr. Cooper’s
proposals led to the design and implementation of the National Emphysema
Treatment Trial (NETT).
B. The National Emphysema Treatment Trial (NETT)
The NETT was conducted from January 1998 to July 2002; 3,777 patients were
evaluated and 1,218 patients were ultimately randomized to receive either LVRS
or medical therapy.
1. The primary objective of the NETT was to determine if the addition of LVRS
to medical therapy improves patient survival and increases exercise capacity.
2. Secondary objectives included defining the profile of patients likely to benefit
from LVRS and determining if LVRS improves quality of life, reduces
debilitating symptoms, and improves overall pulmonary function.
3. A successful procedure was defined as a 60% to 70% increase in FEV1 by 3
months postoperatively that is sustained for at least 1 year; decreased
total lung capacity (TLC) and residual volume; improved exercise
tolerance; and significant reduction in supplemental oxygen requirement.
C. Results. Of the 608 patients assigned to LVRS, 580 underwent surgery (406 via
median sternotomy; 174 VATS). Among the 610 patients assigned to medical
therapy alone, 33 underwent LVRS outside the study and 15 received lung
transplantation [23]. Overall mortality was 0.11 deaths per person-year in both
treatment groups. After 24 months, exercise capacity improved more than 10 W
in 15% of patients in the surgery group compared with 3% in the medical
therapy–alone group. After exclusion of 140 patients at high risk for death from
surgery [21], overall mortality in the surgery group was 0.09 deaths per person-
year versus 0.10 in the medical group. Among patients with predominantly upper
lobe emphysema and low baseline exercise capacity, mortality was lower in the
surgery group than in the medical therapy–alone group.
D. Conclusions. The data from the trial suggested that, overall, LVRS increased the
chance of improved exercise capacity but did not demonstrate a survival
advantage as compared with medical therapy alone. There was a survival
advantage demonstrated for those patients with both predominantly upper lobe
emphysema and low baseline exercise capacity. Patients with non–upper lobe
emphysema and high baseline exercise capacity were found to be poor
candidates for LVRS because of the increase in mortality and negligible
functional gain [24].
E. The Cochrane Airways Group recently published a review of all available
randomized clinical trials comparing the effectiveness of LVRS versus
nonsurgical standard therapy to improve outcomes in patients with severe diffuse
emphysema [25]. This review includes 11 studies and 1,760 participants. This
review concluded that LVRS may be effective for selected patients with severe
emphysema and may lead to better health status and lung function outcomes,
specifically for patients with upper lobe–predominant emphysema with low
exercise capacity. The procedure is associated with risks of early mortality and
adverse events (persistent air leaks, pulmonary morbidity [e.g., pneumonia] and
cardiovascular morbidity). Although LVRS increases quality-associated life
years, it is relatively costly.
F. Anesthetic management for lung volume reduction surgery (LVRS).
Anesthesiology expertise is essential to successful outcomes for patients
undergoing LVRS. Our expertise in cardiopulmonary physiology, pharmacology,
and pain management allows us to minimize postoperative complications.
1. Preoperative assessment. All patients scheduled for LVRS receive the
following preoperative physiologic studies: (a) Standard pulmonary function
studies; (b) plethysmographic measurement of lung volumes; (c) standardized
6-minute walk test; (d) ABG values; (e) quantitative nuclear lung perfusion
scans; and (f) radionuclide cardiac ventriculogram and/or dobutamine stress
echocardiogram.
2. Preoperative pulmonary rehabilitation program. After the initial
preoperative evaluation, all patients are enrolled in a pulmonary rehabilitation
program for a minimum of 6 weeks before surgical intervention.
3. Monitors. In addition to the standard monitors, large-bore IV access and an
arterial catheter are recommended. The use of central venous catheters and PA
catheters should be considered on an individual patient basis.
4. The judicious use of TEA, both intraoperatively and postoperatively, affords
advantages as follows: (a) Preserved ability to cough and clear secretions, thus
decreasing atelectasis and possibly reducing pulmonary infection; (b)
decreased airway resistance; (c) improved phrenic nerve function; (d)
stabilization of coronary endothelial function; (e) improved myocardial
perfusion; (f) earlier return of bowel function; (g) preservation of
immunocompetence; and (h) decreased cost of perioperative care through
reduction of perioperative complications. Best results are obtained with
catheters placed in the T4–T5 or T5–T6 spinal interspaces.
a. Intraoperative TEA. TEA can be used as an adjunct to general anesthesia.
Local anesthetics, such as 2% lidocaine, 0.5% ropivacaine, or 0.25%
bupivacaine, provide optimal surgical conditions. The local anesthetics can
be delivered via intermittent bolus or as a continuous infusion.
(1) Because persistent air leaks may be a problem in the postoperative
period and may be exacerbated by positive-pressure ventilation, it is
optimal to extubate the patients either at the conclusion of surgery or as
soon as possible thereafter.
(2) Caution must be exercised if opioids are added to the infusate because
they have the potential to severely depress the patient’s respiratory
efforts.
b. Postoperative TEA. TEA provides superior postoperative analgesia for both
median sternotomy and bilateral thoracoscopic surgical procedures. A
reduced concentration of local anesthetic plus a small dose of opioids
delivered by continuous infusion is suggested (e.g., 0.2% ropivacaine plus
0.01 mg/mL hydromorphone).
c. Paravertebral nerve blocks (PVNB) may be used as an alternative to TEA.
They may be performed either by multiple injections or by inserting a catheter
into the paravertebral space for use with a continuous infusion of local
anesthetic. This technique requires the use of a multimodal analgesic regimen
including IV opioids and nonsteroidal anti-inflammatory agents. The effect of
PVN on morbidity and mortality following thoracic surgery, in particular
LVRS, has yet to be determined.
5. A left-sided double-lumen EBT should be used to secure the patient’s airway.
6. General anesthesia. Induction of general anesthesia can be conducted with
agents that promote hemodynamic homeostasis. An example is etomidate 0.2
mg/kg plus an easily reversible nondepolarizing neuromuscular blocking agent
such as rocuronium. Maintenance anesthesia may consist of low doses of a
volatile agent (e.g., 0.2–0.4% end-tidal isoflurane) and oxygen in addition to
TEA. The anesthetic plan for each patient should be individualized
appropriately.
7. Postoperative management. Problems that should be anticipated in the
postoperative period include (a) oversedation, (b) accumulation of airway
secretions, (c) pneumothorax, (d) bronchospasm, (e) PE, (f) pneumonia, (g)
persistent air leaks, (h) arrhythmias, (i) myocardial infarction, and (j) PE.
Reintubation and mechanical ventilation are associated with high morbidity and
mortality. Several measures can be taken to minimize these adverse side
effects:
a. Judicious pulmonary toilet
b. Bronchodilators
c. Effective analgesia with TEA or PVNB/multimodal analgesia
d. Avoidance of systemic corticosteroids
G. Endobronchial valves and blockers for lung volume reduction. Although LVRS
has been shown to benefit patients with a heterogeneous pattern of emphysema,
this constitutes only about 20% of patients who are eligible candidates for this
treatment. Procedures for bronchoscopic LVRS have been developed to treat
patients with heterogeneous and homogeneous patterns of emphysema.
Endobronchial treatment has been studied for more than a decade and has been
approved in several countries throughout the world; however, it still remains an
investigational therapy in the United States. The rationale for this minimally
invasive approach is that, by endobronchially obstructing the emphysematous
segments of the lung, collapse of these areas should occur. This should reduce
hyperinflation and alleviate symptoms without the need for surgery. Currently
available bronchoscopic techniques include endobronchial blockers/valves,
biologic glues, and airway bypass. Although significant improvements can be
achieved with endobronchial valves/blockers, the results have not been as
substantial as those obtained with surgical LVRS.
H. Conclusions. LVRS is a viable option for a select group of emphysema patients,
and endobronchial valves and blockers that are undergoing clinical trials hold
much promise as a treatment alternative for all emphysema patients. Regardless
of the selection of treatment modality, the goals remain the same: improvements
in dyspnea, exercise tolerance, quality of life, and prolonged survival.
The anesthesiologist must be actively engaged in the perioperative management
of these patients. Patient history and preoperative status as well as the results
obtained from the evaluation of CXRs, high-resolution CT scans, and right heart
catheterizations should be carefully weighed when planning these procedures.
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16 Anesthetic Management for Adult Patients with
Congenital Heart Disease
Laurie K. Davies, S. Adil Husain, and Nathaen S.
Weitzel
I. Introduction
II. Epidemiology
A. Defining adult congenital heart disease (ACHD)
B. Classification
C. Prevalence
D. Healthcare system considerations
III. What are the key anesthetic considerations in ACHD?
A. History
B. Signs and symptoms of ACHD
C. How can you assess the perioperative risk for ACHD patients?
IV. What common sequelae are associated with ACHD?
A. Arrhythmias
B. Pulmonary arterial hypertension (PAH)
C. What are some general hemodynamic goals for patients with PAH?
V. What laboratory and imaging studies are needed?
A. Preoperative laboratory and imaging testing
B. Cardiac catheterization and/or echocardiography
C. Electrocardiogram (ECG)
D. Chest radiography
VI. What monitors should be used in ACHD surgery?
A. Standard American Society of Anesthesiologists (ASA) monitors
VII. What are some general intraoperative anesthetic considerations for
patients with ACHD?
A. Complete surgical correction
B. Partial surgical correction or palliation
C. Uncorrected lesions
D. General approach
VIII. What is the ideal approach to postoperative management for ACHD
patients?
A. Pain management
B. Arrhythmias
C. Volume considerations
IX. What is the approach for patients presenting for repeat sternotomy?
A. What are the key surgical considerations in preparation for repeat
sternotomy?
B. What are the key anesthetic considerations in preparation for repeat
sternotomy?
C. What is the role of antifibrinolytic therapy?
X. What is the role of heart transplantation?
A. Heart transplantation or combined heart and lung transplantation can
be a life-saving measure for the patient who has developed severe heart
failure
B. What are the outcomes of transplant?
XI. What are the specific details for managing patients with partially
corrected or palliative repairs?
A. Fontan repair
B. Tetralogy of Fallot (ToF)—“Blue baby syndrome”
C. Right (pulmonary) ventricle to pulmonary artery conduits
D. Pulmonary valve abnormalities
E. Transposition of great vessels (TGV)
XII. What are the key details for patients with uncorrected CHD?
A. Adult atrial septal defect (ASD)
B. Ventricular septal defects (VSD)
XIII. What are the antibiotic prophylactic considerations for patients with
ACHD?
XIV. Conclusions
KEY POINTS
1. In adult congenital heart disease (ACHD), a clinically relevant

classification of lesions into three categories is useful: (1)
“Complete” surgical correction; (2) partial surgical correction or
palliation; and (3) uncorrected congenital heart disease (CHD).
2. Over one million patients with CHD have reached adulthood in the
United States. Adults with CHD now clearly outnumber the
population of children with CHD.
3. Improvements in surgical techniques have allowed 90% of children
with CHD to survive to adulthood with relatively normal
functionality.
4. Ventricular and atrial arrhythmias are extremely common in adult
CHD, accounting for nearly 50% of emergency hospitalizations.
5. Adult CHD patients have an incidence of pulmonary artery
hypertension (PAH) as high as 10%.
6. Patients with PAH have a high surgical mortality rate (4% to 24%).
7. For both cyanotic (right-to-left shunts) and left-to-right shunts, there
are general principles that impact anesthetic management.
8. Patients with complicated residual lesions requiring medium- to
high-risk surgery should be managed at centers of excellence with
physicians and staff trained in adult congenital disease.
I. Introduction
In 1938, Robert Gross performed the first ligation of a patent ductus arteriosus
(PDA), thus initiating a major advance in congenital heart surgery and paving the
way for development of modern surgical techniques [1]. Major improvements
followed, which manifested as continuous reductions in mortality between that
time and the 1980s. In 2000, the 32nd Bethesda Conference report generated from
the American College of Cardiology indicated that approximately 85% of patients
operated on with congenital heart disease (CHD) survived to adulthood [2]. That
report estimated that 800,000 patients with adult congenital heart disease (ACHD)
were living in the United States in 2000. More recent data suggest that the number
of adults living with CHD in the United States now approaches 1.5 million [3]
(Fig. 16.1). These reports highlight the importance of an emerging problem in our
healthcare system, which is developing a seamless model for transition of CHD
patient care from pediatric to adult heart centers. There has been a widespread call
for an increased number of physicians capable of providing continuity of care for
these patients in an outpatient setting, as well as during the perioperative period.
This chapter will focus on anesthesia-specific issues facing ACHD patients in the
perioperative period.
II. Epidemiology
A. Defining ACHD
Attempts to establish prevalence and even mortality data for ACHD depend on
defining which patients to include. A strict definition of ACHD was proposed by
Mitchell et al., “a gross structural abnormality of the heart or intrathoracic great
vessels that is actually or possibly of functional significance” [4]. This definition
excludes persistent left-sided vena cava, abnormalities of major arteries,
bicuspid aortic valve (AV) disease, mitral valve prolapse, and the like [5].
B. Classification
1 A pathologic categorization scheme divides CHD patients into categories of
great, moderate, and simple complexity [6,7] (Table 16.1). These categories are
particularly helpful in neonatal disease. In ACHD, a different categorization may
be more clinically relevant. These three categories are listed below [8]:
1. “Complete” Repair
a. Examples include repaired atrial septal defect (ASD), ventricular septal
defect (VSD), and PDA without hemodynamic sequelae.
b. It must be kept in mind, however, that it is rare that any cardiac surgical repair
is considered curative, as there are long-term sequelae in most of these
ACHD patients.
2. Partial surgical correction or palliation
a. Examples include palliative repairs such as Fontan, tetralogy of Fallot (ToF),
and transposition of great arteries (TGA) (e.g., Mustard or Senning repair),
leaving hemodynamic or physiologic compromise.
IGURE 16.1 Estimated numbers of adults and children living with CHD in the United States between 2000 and 2010. There has
een a substantial increase in the number of adults living with CHD compared to a smaller increase in children. Numbers were
xtrapolated from estimated population prevalence from the province of Quebec, Canada, and the USA population in 2000 and
010. CHD, congenital heart disease. (From Alshawabkeh LI, Opotowsky AR. Burden of heart failure in adults with congenital
eart disease. Curr Heart Fail Rep. 2016;13:247–254.)
3. Uncorrected CHD
a. Examples include minor ASD, minor VSD, Ebstein anomaly, or undiagnosed
ACHD due to limited healthcare access as child.
C. Prevalence
1. 2 Almost 1 in 100 babies is born with CHD. The actual number of adult
patients with congenital heart defects is difficult to obtain; however, recent
estimates suggest that the ACHD population of patients in Europe is estimated
at 2.3 million. A longitudinal study in Canada reported a near 70% increase in
the number of adults alive with CHD over the period from 2000 to 2010.
Extrapolating their findings suggests that the adult population of CHD patients
in the United states is approximately 1.5 million [3,5,9]. Significant
improvements in surgical techniques have allowed many patients (up to 90% of
children with CHD) to survive to adulthood, and maintain relatively normal
function [3,5,9].
2. Select populations
a. A recent estimate from Canada [3] reported a CHD prevalence of 13.11 cases
per 1,000 children and 6.12 cases per 1,000 adults. Selecting out patients with
complex CHD (Table 16.1) reduces these estimates to 1.76 per 1,000 children
and 0.62 per 1,000 adults. From 2000 to 2010, they noted an increase in
prevalence of all CHD and severe CHD in both children and adults; however,
a much larger increase was documented in adults than in children. The
proportion of subjects with CHD who were adults increased from 54% in
2000 to 66% in 2010.
b. ACHD becomes a significant issue in certain populations such as obstetrics
where patients with CHD now represent the majority (60% to 80%) of
obstetric patients with cardiac disease. Since the obstetric population is
predominantly young and healthy, it makes sense that CHD patients who reach
childbearing age would represent a high proportion of obstetric patients with
cardiac disease.
TABLE 16.1 ACHD classification [7]
3. 3 Survival data
a. It is estimated that 96% of newborns who survive the first year will reach the
age of 16 [5].
b. Median expected survival has increased significantly since 2000, with current
estimates placing the median age of death for ACHD at 57 years [5].
c. Although the outcome of these patients has improved, more patients with
complex disease are surviving into adulthood. Their care remains challenging,
as death rates in the population from 20 to >70 years of age may be two to
seven times higher for the ACHD population than for their peers who lack
ACHD [10].
D. Healthcare system considerations
The ACC/AHA 2008 guidelines for ACHD highlight the fact that pediatric
cardiology centers have significant infrastructure to support patients with CHD,
but that this is largely lacking in adult healthcare system. This includes access to
physicians with training in ACHD, as well as advanced practice nursing, case
management, and social workers familiar with the needs of these patients [11].
These guidelines echo the recommendations made by the Bethesda conference, as
well as the Canadian Cardiovascular Society Consensus Conference statements
from 2010 [2,12–17]. Also, adult patients with CHD report difficulties in several
areas of daily life, including employment and insurability [18]. Currently, the
Affordable Care Act stipulates that no person may be denied coverage based on
a pre-existing condition (including heart disease). However, it is critical that
patients ensure that a qualified physician with expertise in CHD be covered by
whatever insurance plan they choose.
TABLE 16.2 Summary of qualifications for regional centers of excellence in adult
congenital heart disease (ACHD)
1. Overall recommendations taken from these reports suggest a focus on

improvement in ACHD healthcare delivery through the following:
a. Improved transition clinics for adolescents approaching adulthood
b. Outreach programs to educate patients and families about key issues related to
their disease
c. Enhanced education of adult caregivers trained in ACHD management
d. Coordination of healthcare delivery through regional centers of excellence
e. Development of ready referral pathways from primary care physicians to
these regional centers of excellence
2. Centers of excellence
a. The services and provider requirements for such centers are summarized in
Table 16.2, taken from the 2008 ACC/AHA guidelines. Key areas with
physicians specializing in ACHD are indicated.
CLINICAL PEARL Patients with either moderate or great complexity lesions should be
managed at centers of excellence for surgical interventions.
III. What are the key anesthetic considerations in ACHD?
To evaluate the ACHD patient prior to surgery, the anesthesiologist must gain an
understanding of the patient’s medical history, current functional status, state of
surgical repair, and overall health. Key items are discussed below.
A. History
Obtaining a thorough and accurate surgical and medical history is critical,
however challenging, as only half of patients with ACHD are able to correctly
describe their diagnosis [19]. Patients with ACHD have varying functional
capacities which may make evaluation of true cardiac capacity more challenging.
Remember that an adult with CHD has always lived with this disease and does
not know anything different. That makes self-reporting of ACHD inaccurate,
because the patients routinely underestimate their degree of compromise. Another
fact that must be taken into consideration is that the ACHD population is
extremely heterogeneous. There are patients who are diagnosed for the first time
in adulthood, patients who have had prior palliative repair with recurrent
symptomatology, as well as patients who were thought to have “complete”
repairs who now have delayed presentation of pathology. Also, the surgical
strategies have markedly changed over the last 50 years, necessitating an
understanding of the particular (possibly now obsolete) operation the patient has
undergone with its associated consequences.
B. Signs and symptoms of ACHD
Some generalized examination findings that may indicate ACHD include the
following [20]:
1. Continuous heart murmurs: There are relatively few acquired cardiac diseases
producing a continuous type of murmur.
2. Right bundle branch block (RBBB): This can occur in the general population;
however, if found in conjunction with a continuous murmur, this may indicate a
congenital defect.
3. Evidence of cyanosis without existing pulmonary disease
4. The above findings should trigger an echocardiographic study prior to surgical
care.
C. How can you assess the perioperative risk for ACHD patients?
Anesthetic evaluation should focus on predicting risk of surgery in this patient
population. Some key prognostic indicators for outcomes in ACHD surgery (both
cardiac and noncardiac) include the presence of the factors listed below
[8,11,19,21] (Table 16.3):
1. Pulmonary arterial hypertension (PAH)
2. Cyanosis or residual VSD
3. Need for reoperation (cardiac surgery)
4. Arrhythmias
5. Ventricular dysfunction
6. Single ventricle physiology or a systemic right ventricle
TABLE 16.3 Common medical concerns in patients with ACHD [16]
TABLE 16.4 Tachyarrhythmias associated with ACHD [4,7,20]
IV. What common sequelae are associated with ACHD?

In contrast to the neonate with CHD, ACHD patients begin to acquire additional
medical comorbidities that should be considered in management planning.
Common comorbidities in this patient population are listed in Table 16.3, and
preoperative evaluation should take these into account. Cardiac arrhythmias,
pulmonary hypertension, ventricular dysfunction, cyanosis (or residual VSD),
valve abnormalities, and aneurysms represent some of the key comorbid conditions
commonly associated with ACHD that have serious management considerations
and result in overall increased perioperative risk [4]. Obtaining a detailed history
on the degree of involvement of these issues will enable adequate planning in
management. Two of the most common and critical areas (arrhythmias and
pulmonary hypertension) will be addressed here.
A. Arrhythmias
4 Ventricular and atrial arrhythmias are extremely common in ACHD
patients, accounting for nearly 50% of emergency hospitalizations [8]. The
type of rhythm disturbance depends primarily on the lesion and method of
surgical repair. Tables 16.4 and 16.5 divide the bradyarrhythmias from
tachyarrhythmias by lesion type.
CLINICAL PEARL ACHD patients are at high risk for cardiac arrhythmias,
especially patients with moderate or highly complex repairs.
TABLE 16.5 Bradyarrhythmias associated with ACHD [4,7,20]
FIGURE 16.2 Macro-reentrant VT in tetralogy of Fallot. A: An autopsy specimen of repaired tetralogy with the anterior
RV surface opened to reveal the VSD patch and the patch-augmented RVOT (the outflow patch in this case is
transannular). A hypothetical re-entry circuit is traced onto this image ( black arrows), with the superior portion of the loop
traveling through the conal septum (upper rim of the VSD). B: Actual electroanatomic map of sustained VT from an adult
tetralogy patient, showing a nearly identical circuit. The propagation pattern is shown by the black arrows and is reflected by
the color scheme (red > yellow > green > blue > purple). A narrow conduction channel was found between the rightward
edge of the outflow patch scar (gray area) and the superior rim of the tricuspid valve. A cluster of radiofrequency
applications at this site (pink dots) closed off the channel and permanently eliminated this VT circuit. LV, left ventricle;
MPA, main pulmonary artery; RV, right ventricle; RVOT, right ventricular outflow tract; TV, tricuspid valve; VSD,
ventricular septal disease; VT, ventricular tachycardia. (Reprinted with permission from Walsh EP, Cecchin F. Congenital
heart disease for the adult cardiologist: arrhythmias in adult patients with congenital heart disease. Circulation.
2007;115(4):534–545.)
1. In general, patients who fall in the moderate to complex categories are at higher
risk for arrhythmias. ToF (Fig. 16.2) and Fontan lesions carry an extremely
high arrhythmia burden [22,23]. In addition, any patient with a ventricular
repair or patch is at high risk for ventricular rhythm disturbances, while
those patients with atrial repairs, atrial baffles, etc., are likely to develop
atrial arrhythmias [23].
2. Patients with right-sided lesions have a higher likelihood of developing
arrhythmias, although the long-term morbidity/mortality outcomes are similar
between right- and left-sided lesions [24].
3. Older patient age at the time of surgical repair seems to be associated with an
increased incidence of arrhythmias.
4. Patients with either ASD or VSD can have interruption in the normal
conduction pathways or abnormal variants such as duplicate AV nodes ( Fig.
16.3), leading to reentrant arrhythmias [23]. The most common arrhythmia seen
in older ACHD patients is intra-atrial reentrant tachycardia (IART), a macro-
reentrant circuit within atrial tissue, often occurring because of disruption by
patches, atriotomy incisions, and scars.
5. Management
a. Antiarrhythmic medical therapy remains the mainstay for many patients,
although results are often suboptimal in some cases such as IART, despite the
use of potent agents such as amiodarone [23].
b. Ablative procedures. Recent advances in electrophysiology have allowed
significant improvements in management of these rhythm disturbances.
Electrophysiologists are able to map out the conduction pathways in the heart,
and ablate malignant tracts (Figs. 16.2 and 16.4). This is most useful for atrial
arrhythmias, with short-term success rates nearing 90% [23]. Long-term
outcomes following ablation are less promising and not widely reported. de
Groot et al. reported a 59% recurrence after the initial ablation, with the
location of the recurrent pathway being different for all but one patient. At 5
years, 58% of patients were in sinus rhythm and 33% of the initial population
were maintained on antiarrhythmic drug therapy [25]. Electrophysiologic
testing and ablative procedures are considered a Class I recommendation for
patients with known rhythm disturbances [11].
IGURE 16.3 Representation of twin AV nodes with a Mönckeberg sling. The cardiac anatomy in this sketch includes a large
eptal defect in the AV canal region, shown in a right anterior oblique projection. Both an anterior and a posterior AV node are
epicted (each with its own His bundle) along with a connecting “sling” between the two systems. This conduction arrangement
an produce two distinct non–pre-excited QRS morphologies (depending on which AV node is engaged earliest by the atrial
ctivation wave front), and a variety of reentrant tachycardias. AV, atrioventricular. (Redrawn from Walsh EP, Cecchin F.
ongenital heart disease for the adult cardiologist: arrhythmias in adult patients with congenital heart disease. Circulation.
007;115(4):534–545.)
IGURE 16.4 Electroanatomic map of an IART circuit involving the anterolateral surface of the right atrium in a patient with a
evious Fontan operation (cavopulmonary connection). A detailed anatomic shell was generated for the ablation procedure by
erging high-resolution computed tomography data with real-time data gathered from the 3D mapping catheter. The propagation
attern for the IART circuit is shown by black arrows and is also reflected by the color scheme (red > yellow > green > blue >
urple). The critical component of the circuit appeared to be a narrow conduction channel through a region of scar (central gray
). A cluster of radiofrequency applications ( maroon dots) was placed at the entrance zone to this narrow channel and
ermanently eliminated this IART circuit. IART, intra-atrial reentrant tachycardia; IVC, inferior vena cava; JXN, junction; LAT,
teral; LPA, left pulmonary artery; RA, right atrium; RPA, right pulmonary artery; SVC, superior vena cava. (Reprinted with
ermission from Walsh EP, Cecchin F. Congenital heart disease for the adult cardiologist: arrhythmias in adult patients with
ongenital heart disease. Circulation. 2007;115(4):534–545.)
c. Implantable devices. For patients at risk for ventricular arrhythmias,

automatic implantable cardiac defibrillators (AICDs) can offer a life-saving
modality and are a class II recommendation for ACHD patients [11] . While
ventricular tachycardia (VT) is rare in the first and second decades, it
becomes increasingly prevalent as the patient ages, with those patients
with a history of ventricular intervention being at highest risk [23]. VT
circuits can develop a macro-reentrant characteristic similar to the atrial
IART (Fig. 16.4). ToF patients have a high risk, and a careful history should
be obtained, inquiring about symptoms and any outpatient studies. Patients at
risk for bradyarrhythmias often will have a pacemaker in place, which should
be interrogated and sensitivity limits adjusted for the surgical procedure [21].
1. Anesthetic management. A recent practice advisory (2011) for patients
with implanted cardiac devices recommends that AICDs be disabled prior
to surgery to prevent inadvertent defibrillation due to electrocautery;
however, this is specific to procedures where electromagnetic interference
is likely [21]. If the AICD is disabled, it is imperative that the patient be
placed on continuous monitoring, with external defibrillation pads in place,
and that the device be enabled again in the PACU.
2. Complex patients. Actual placement of AICD leads into the heart in
patients with complex lesions is often difficult, if not impossible [23].
Presence of abnormal venous return, surgically created shunts or baffles, as
well as scarring from previous surgery can make adequate placement
challenging. Occasionally, patients will require an open surgical approach
to place epicardial pacing/defibrillation leads, although this procedure
carries risk as well due to scarring and reoperative concerns (see Section
IX below).
B. Pulmonary arterial hypertension (PAH)
5 PAH is defined as a mean pulmonary pressure greater than 25 mm Hg at
rest or 30 mm Hg with exercise [26]. ACHD patients have a PAH incidence of
up to 10%, with Eisenmenger syndrome (ES) being present in approximately 1%
[5]. The etiology of the PAH typically falls in the World Health Organization
Group I or II. Group I is PAH due to primary PAH but includes congenital shunts,
and group II is due to pulmonary venous hypertension (i.e., disease due to valve
disorders, volume excess, and LV dysfunction).
1. 6 Surgical risk. PAH patients are high-risk surgical candidates. Published
series demonstrate a range of surgical mortalities from a low of 4% to a
high of 24% depending on disease severity and surgical procedure [27].
Surgical and anesthetic risk should be clearly stated to the patient, especially
for an elective case. Patients with ES should be considered higher-risk
candidates and extreme care should be taken in managing these cases. See
Section XII.B.2.
CLINICAL PEARL ACHD patients with concomitant PAH should be considered high
risk, and management at a center of excellence is recommended.
a. Hemodynamic spiral. Acute deterioration is possible as RV failure causes
reduced pulmonary blood flow, leading to hypoxia which subsequently
increases the pulmonary vascular resistance (PVR). The elevated PVR
ultimately leads to increased strain on the RV. This initiates a catastrophic
hemodynamic chain of events in which the decreased RV stroke volume
decreases LV preload and output, and coronary blood flow to both the LV and
RV decreases. The already failing RV may not be able to recover from this
insult, resulting in cardiac arrest. This “death spiral” is always possible in
PAH patients; the anesthesia provider should be aware of it and take
steps to prevent it [26].
CLINICAL PEARL Right coronary perfusion occurs throughout the cardiac cycle, making
maintenance of systemic blood pressure important in optimizing right ventricular function.
2. How do you treat RV failure in the setting of PAH? Treatment of acute RV
failure should focus on reducing PVR (see Section IV.B.3 below), while
utilizing β-adrenergic agonist inotropic agents such as dobutamine and/or
phosphodiesterase-inhibiting agents such as milrinone, as these provide
inotropic support with moderate reductions in PVR (and systemic vascular
resistance [SVR]). Consider using a vasopressor such as norepinephrine in the
setting of systemic hypotension to increase the coronary perfusion pressure. In
severe scenarios, an intra-aortic balloon pump can also be used to increase
coronary perfusion pressure, thus supporting the RV [9].
3. What are some treatment modalities during surgery to reduce PVR acutely
[8,9]?
a. Consider moderate hyperventilation (PaCO2 low 30s) while administering
100% oxygen.
b. Use low-pressure ventilation if possible as high-intrathoracic pressure can
mechanically compress extra-alveolar vessels and reduce CO.
c. Utilize nitric oxide for acute reductions in PVR and/or consider inhaled
prostanoid (iloprost) if available.
d. Intravenous (IV) magnesium sulfate may provide temporary reductions in
PVR.
CLINICAL PEARL PVR is powerfully influenced by ventilation, so strict attention must
be paid to oxygenation, ventilation, and intra-thoracic pressure.
C. What are some general hemodynamic goals for patients with PAH [26]?
Anesthetic and hemodynamic goals for pulmonary hypertension
1. Avoid elevations in PVR. Prevent hypoxemia, acidosis, hypercarbia, and pain.
Provide supplemental oxygen at all times. Consider inhaled nitric oxide (iNO)
to acutely decrease PVR.
2. Maintain SVR. Decreased SVR can reduce CO dramatically due to the “fixed”
PVR. This fixed PVR limits the RV’s ability to accommodate the usual increase
in CO that ensues from reduced LV afterload. LV and RV ischemia from
reduced coronary artery perfusion pressure from the decreased systemic
diastolic pressure can also contribute to the decrease in CO and “death spiral.”
Keep in mind also that right ventricular coronary perfusion occurs during both
systole and diastole, which may help explain the right ventricle’s dependence
on adequate systemic blood pressure.
3. Avoid myocardial depressants and maintain myocardial contractility.
4. Maintain chronic prostaglandin therapy without altering dosage.
5. Utilize low-pressure mechanical ventilation (or spontaneous ventilation
with normal PaCO2) when possible.
V. What laboratory and imaging studies are needed?
The overall goal in preoperative laboratory and imaging studies is to assist the
physicians in understanding the degree of involvement of any comorbid disease.
A. Preoperative laboratory and imaging testing should be guided by degree of
severity of disease. Patients with normal functional status can be treated as any
adult presenting for surgery, whereas the patient with severe functional limitation
due to cardiac disease warrants additional evaluation. Laboratory evaluation
may include complete blood count, coagulation studies, and basic metabolic
studies.
B. Cardiac catheterization and/or echocardiography studies are particularly
helpful in symptomatic patients by providing information on structural status of
the heart, functional status of the ventricles, and degree of PAH. Many patients
will also have either magnetic resonance imaging (MRI) or computed
tomography (CT) reconstructive imaging as part of standard surveillance, and
these can add tremendously to the understanding of the current pathophysiologic
state.
C. An electrocardiogram (ECG) should be obtained at baseline as there are often
abnormalities present. This can also alert the practitioner to the presence of a
pacemaker or other abnormal cardiac rhythms.
D. Chest radiography. This can be helpful to determine the degree of heart and lung
disease at baseline.
VI. What monitors should be used in ACHD surgery?
A. Standard American Society of Anesthesiologists (ASA) monitors should be
employed for every case. In addition, most cases involving moderate to complex
ACHD patients will utilize some degree of invasive monitoring. Some key
considerations include the following [28]:
1. Location of an arterial line, if needed, should consider previous surgical
procedures such as Blalock–Taussig shunts using the subclavian artery, which
compromise blood flow to the ipsilateral upper extremity.
2. Central venous catheters (CVCs) should be reserved for the most symptomatic
patients, as risk of thrombus and stroke is higher.
3. Pulmonary artery (PA) catheters are often anatomically difficult or impossible
to place and are seldom helpful in patients with cyanotic cardiac lesions.
4. Transesophageal echocardiography (TEE) may be the most useful real-time
monitor of cardiovascular status, especially when using general anesthesia, and
should strongly be considered for patients with reduced functional status for all
medium- and high-risk procedures.
5. Near-infrared spectroscopy (NIRS) has been suggested as a tool to monitor
both cerebral and peripheral oxygenation. The concept is that this technology
helps identify changes in oxygen delivery and may be more sensitive to changes
in cardiac output. Central nervous system insults associated with cardiac
surgery remain an unsolved problem. Brain damage can occur as a result of
global hypoxia–ischemia or focal emboli. NIRS may provide data on cerebral
oxygenation, and enthusiasm for this technology has increased with hopes of
reducing neurologic dysfunction. Many centers have adopted NIRS as a
standard of care. Available data suggest that multimodality monitoring,
including NIRS, may be a useful adjunct. However, the current literature on the
use of NIRS alone does not conclusively demonstrate improvement in
neurologic outcome. Data correlating NIRS findings with indirect measures of
neurologic outcome or mortality are limited. Although NIRS has promise for
measuring regional tissue oxygen saturation, the lack of data demonstrating
improved outcomes limits the support for widespread implementation [29].
VII. What are some general intraoperative anesthetic considerations for patients
with ACHD?
While the pathologic categorization (simple, moderate, and complex) of CHD is
useful, a more clinically based approach may be more useful in intraoperative
planning. One such scheme, as introduced earlier, is to consider patients based on
surgical correction such as the following:
A. Complete surgical correction (i.e., repaired ASD, VSD, and PDA). Patients
with surgically corrected lesions, as well as palliated lesions with good
functional results, typically demonstrate hemodynamic stability and normal
physiology. As such, these can be assumed to be very low-risk patients and
managed as an otherwise healthy adult patient.
B. Partial surgical correction or palliation (i.e., Fontan, ToF, and TGA [Mustard
or Senning repair]). Palliated patients with complex disease and reduced
functional capacity due to the type of lesion should be managed with more
concern and will be the main focus below.
C. Uncorrected lesions (i.e., minor ASD, minor VSD, and Ebstein anomaly).
Uncorrected patients warrant thorough examination into type of lesion and current
functional state, as often these are minor lesions if they have not caused any
medical or functional issues into adulthood.
D. 7 General approach. For both cyanotic lesions (right-to-left shunts) and left-to-
right shunts, there are general concepts that will aid in careful anesthetic
planning.
1. Cyanotic lesions [28]
a. Cyanotic lesions have some element of right-to-left shunt, often even after
surgical repair. The degree of this shunt determines the level of cyanosis
present. Caution should be taken with sedative medicines, as lowering
ventilation can increase PVR and exacerbate cyanosis by increasing right-to-
left shunt.
b. Right-to-left shunting reduces the uptake of inhalational anesthetics and can
prolong inhalation induction. Conversely, the onset of IV induction may be
hastened.
c. Nitrous oxide may elevate PA pressure and should be either avoided or used
cautiously.
d. Air embolus. Take extreme care to avoid an air embolus. All IV lines should
be thoroughly deaired and monitored during medication administration.
Epidural catheter placement should use saline for loss of resistance, not air,
because air into an epidural vein can cross into the systemic circulation.
e. SVR. Changes in SVR disrupt the balance between pulmonary and systemic
circulations to change the shunt. All anesthetic medications should be slowly
titrated to prevent rapid changes. This holds true for both regional and general
anesthetics.
f. Single-shot spinal anesthetic techniques are generally contraindicated, as
quick onset of spinal sympathectomy is poorly tolerated.
g. Administration of antibiotics (vancomycin), if given quickly, may reduce SVR
and become clinically detrimental.
h. Choice of anesthetic induction drug is not as important as the manner and
vigilance used by the anesthesiologist in managing hemodynamics.
i. Clinical endpoints that might decrease PVR, such as increases in mixed
venous O2 (typically via high FiO2) and modest degrees of respiratory
alkalosis, are encouraged.
CLINICAL PEARL Patients with shunt lesions—either cyanotic or left to right, have
adapted their physiology to account for this, so anesthetic agents should be titrated carefully
to avoid massively disrupting this delicate balance.
2. Chronic left-to-right shunting. Balance between SVR and PVR determines the
shunt fraction and the direction of shunting. Chronic left-to-right shunting causes
the following:
a. Excessive pulmonary blood flow leading to pulmonary edema or pulmonary
hypertension. The increased pulmonary flow causes PVR to increase over
time, reducing left-to-right shunting, leading to eventual equilibration of left
and right ventricular pressures. Eventually, this process results in conversion
of the left-to-right shunt into a right-to-left shunt, the so-called Eisenmenger
physiology or syndrome (ES).
b. Once ES develops, cyanosis ensues along with variable degrees of heart
failure which places patients in the highest-risk category for surgical
procedures.
c. Even without Eisenmenger syndrome, these patients may experience heart
failure as a result of the high RV and pulmonary blood flow, which may be as
much as four times systemic blood flow.
d. SVR. Acute changes in SVR from anesthetic administration or pain can result
in alteration or reversal of the shunt, leading to heart failure or cyanosis,
depending upon where the patient is in the evolution from large left-to-right
shunting into the right-to-left shunting of Eisenmenger physiology. Overall
anesthetic goals should be to maintain the balance that the patient has and
avoid abrupt alterations.
e. High levels of supplemental oxygen may allow for reduced PVR and
worsening of the left-to-right shunt. On the other hand, hypoxemia should be
prevented, as this may shift the shunt to right-to-left and result in cyanosis. A
fine balance must be struck when managing oxygenation for these patients.
f. Air embolus. As in cyanotic lesions, take extreme care to avoid an air
embolus. Even predominant left-to-right shunts can become bidirectional,
putting the patient at risk for a systemic air embolus.
g. Single-shot spinal anesthesia is contraindicated for patients who have or are
approaching Eisenmenger physiology. Spinal anesthesia is theoretically
beneficial for patients with large left-to-right shunts and normal or only
slightly elevated PVR that remains far below SVR.
h. Inhalational agents. Uptake should not be affected by left-to-right shunting.
Right-to-left shunting prolongs inhalation inductions, but this is rarely
clinically relevant if cardiac output is maintained.
VIII. What is the ideal approach to postoperative management for ACHD patients?
Postoperative management should take into account all the risk factors described
above in the anesthetic planning, and one should attempt to maintain the patient in
the hemodynamic state to which he/she has adapted.
A. Pain management
Patients with palliated lesions often have some degree of residual shunt, or even
single ventricle physiology. As such, overall cardiac performance depends to a
large degree on the PVR. Attempts should be made to minimize impairment of
ventilation in these patients as hypercarbia will increase PVR and potentially
worsen cyanosis or increase ventricular failure in susceptible patients.
1. Regional anesthesia may be ideal for patients with significant anticipated
postoperative pain as this can greatly reduce the level of systemic opioid use,
thus reducing the risk of respiratory complications. Prior to neuraxial
interventions and major plexus blocks, laboratory evaluation of coagulation
status should be obtained in any patient with a history of anticoagulant therapy
or significant liver dysfunction.
B. Arrhythmias
For patients at elevated risk (Tables 16.4 and 16.5), perioperative monitoring in
a telemetry bed may be indicated if there is not an AICD in place. For patients
with AICDs or pacemakers, consider postoperative interrogation of the device if
there was significant electrical interference during the surgery, or if the device
had a magnet applied. Additionally, if the AICD was disabled for the procedure,
it is imperative that defibrillation equipment be immediately available until the
device is turned back on.
C. Volume considerations
Many ACHD patients with palliated lesions have a narrow margin of error in
fluid management. They can easily be pushed into heart failure with overly
aggressive fluid management, and conversely may develop significant reductions
in cardiac output with a minimalist approach. There is not an ideal volume
strategy that fits all patients, but management must be closely tailored to each
patient’s physiologic status. As discussed above, invasive monitoring may not be
possible in many of these patients or may not accurately reflect actual volume
status, so management can be complicated. TEE use intraoperatively along with
close monitoring of urine output may be the best approach in complex patients.
IX. What is the approach for patients presenting for repeat sternotomy?
A. What are the key surgical considerations in preparation for repeat
sternotomy?
For patients with ACHD, repeat sternotomy is often the initial surgical
intervention. Often these patients have had multiple previous chest surgeries,
increasing the degree of scarring in the pericardial space and thus making the
surgical approach more demanding. Overall mortality increases with repeat
sternotomy and is reported to be in the range of 3% to 6%. Reentrant injury has
been reported to greatly increase the risk in certain series and may approach
18% to 25%. However, other reports indicate no increase in mortality but a
significant increase in duration of surgery [30–33]. The perioperative mortality
risk appears to correlate with increased number of sternotomies, presence
of single ventricle physiology, and presence of an RV-to-PA conduit.
1. Preoperative preparation. Several preoperative variables are important and
can prove valuable in planning a repeat sternotomy. A PA and lateral chest
radiograph can be helpful, and should always be examined prior to operative
intervention. These radiographs can supply important information such as the
number of sternal wires in place and their condition, and the lateral film
provides clues about the distance between the posterior sternal table (border)
and the heart itself. In addition, many patients have had preoperative cardiac
catheterization studies. It is always helpful to the surgeon to assess this study
and lateral radiographic images to obtain an anatomic assessment of the level
of concern about repeat sternotomy. These pictures can provide much data
about what portion of the sternum may be adherent to cardiac structures and
which sternal wires are closest to these areas of concern.
2. Cannulation options. Should there be any significant concern regarding repeat
sternotomy and a high index of suspicion for injury, femoral cannulation should
be considered. Preoperative discussions with the perfusion and anesthesia
teams are critical to planning alternative strategies for cannulation and the
decision to initiate cardiopulmonary bypass (CPB) using extrathoracic
cannulation techniques before initiating or completing repeat sternotomy.
3. Specifics of repeat sternotomy. Several techniques are important when
pursuing a repeat sternotomy. Positional manipulation of the operating table can
be critical to visualization of the posterior table of the sternum as the surgeon
pursues repeat sternotomy from below (inferiorly). In addition, use of specific
retractors (e.g., internal mammary retractor) can also greatly facilitate slow,
sequential separation and elevation of the sternum. The goal of this portion of
reentry should be to obtain safe removal of previously placed sternal wires
while separating the sternum from the heart.
4. Lysis of adhesions. Once repeat sternotomy is accomplished, significant lysis
of adhesions is undertaken. Good communication with the surgical team is
critical during this process. The primary initial surgical goal should be to
define and separate areas of cannulation from scar tissue (assuming the patient
was not cannulated via femoral or other access before initiating the repeat
sternotomy). These areas include the ascending aorta, right atrium (in single
venous cannulation), and/or the superior vena cava (SVC) and inferior vena
cava (IVC) (in cases of bicaval cannulation). Further dissection of the heart and
possible previously placed shunts may be more safely accomplished once
cannulae are in place for initiation of CPB.
5. Initiation of CPB. It is important to have all systemic-to-PA conduits/shunts
adequately isolated and secured prior to initiation of CPB. Once bypass is
begun, these connections must be ligated (or clamped) so that the circuit will
not induce pulmonary overcirculation and systemic undercirculation.
B. What are the key anesthetic considerations in preparation for repeat
sternotomy?
The majority of ACHD patients undergoing cardiac surgery will require repeat
sternotomy. Often these patients have had multiple prior chest surgeries,
increasing the degree of scarring in the pericardial space, thus making the
surgical approach more demanding. Key anesthetic considerations for repeat
sternotomy revolve around preparation for possible reentrant injury as well as
increased transfusion requirements.
1. Large-bore IV access is critical in the event of reentrant injury. Consider the
patient’s vascular anatomy and evaluate any possible central venous clots or
strictures, as these patients may have had multiple central lines in the past or
unusual anatomic venous connections to the heart. Ultrasound guidance is
recommended during central (and possibly peripheral) venous line placement
to help evaluate vascular anatomy and patency. A large-bore CVC (8.5-Fr
introducer) in addition to one to two large-bore peripheral IV catheters
attached to a high-flow fluid warmer may be prudent.
2. Placement of external defibrillator patches because access to an open
chest for internal defibrillation may be delayed.
3. Crossmatched packed red blood cells (PRBCs) should be available and double
checked in a cooler in the OR at incision. Many patients will have had multiple
transfusions in the past, and thus may have unique antibody profiles, which can
delay the type and cross process. Typically, one should have 2 to 4 units of
PRBCs available.
4. Ventilation management during reentry should be discussed with the surgical
team. Asghar et al. suggest that slight hyperinflation of the lungs, using a
recruitment maneuver during sternal spreading, can actually minimize reentrant
injury by reducing venous return through increased intrathoracic pressure, thus
decreasing the size of the RV [34].
5. Full discussion of risk should be undertaken with the surgical team before
surgery. On the basis of this discussion, the surgical team may elect to
cannulate the femoral vessels or perform axillary arterial cannulation to enable
emergent institution of cardiopulmonary bypass in the event of reentrant injury.
C. What is the role of antifibrinolytic therapy?
Fibrinolysis is known to occur during cardiopulmonary bypass and is associated
with increased blood loss and transfusion in cardiac surgery. As a result,
antifibrinolytic drugs have been recommended in the 2011 Society of Thoracic
Surgeons and Society of Cardiovascular Anesthesiologists (STS/SCA)
guidelines [35]. Aprotinin was withdrawn from the market in 2008 due to
concerns for increased mortality despite reduction in blood loss which was
demonstrated in various trials [35,36]. The STS/SCA recommendations include
routine use of either an aminocaproic acid or tranexamic acid infusion for all
cardiac surgeries, for which a typical regimen initiates the infusion prior to skin
incision and continues it throughout the operation [36–40].
X. What is the role of heart tranplantation?
A. Heart transplantation or combined heart and lung transplantation can be a
life-saving measure for the patient who has developed severe heart failure.
ACHD patients most commonly listed for transplant include patients with
uncorrectable or partially palliated lesions such as those listed below [11]:
1. Single ventricle physiology with pulmonary vascular disease (heart/lung
transplant)
2. Lesions associated with ventricular dysfunction due to pulmonary vascular
disease (heart/lung or isolated lung transplant)
3. Isolated heart failure without significant pulmonary vascular disease (more
common in single ventricle physiology, or TGV patients treated by atrial switch
procedures) (heart transplant).
4. Patients who clinically meet the metrics for transplant should have a thorough
pretransplant evaluation assessing the anatomy of the patient, as well as PVR.
Longstanding elevations in PVR can easily lead to right heart failure in the
donor heart and must be anticipated in these patients. Sometimes this may tip
the scales to a combined heart/lung transplant.
a. For isolated heart transplant cases in patients with elevated PVR, it is
recommended to take steps to avoid acute right heart failure in the
transplanted donor heart. This often involves a combination of iNO and
vasoactive infusions (dobutamine, milrinone) to provide inotropic support
along with pulmonary vasodilation. See Chapter 17 for full discussion.
B. What are the outcomes of transplant?
ACHD patients make up nearly 3% of the total number of patients listed for
cardiac transplantation [41]. Davies et al. investigated patients listed for
transplant from 1995 to 2009. This study indicated that the ACHD patients who
went on to heart transplant had a higher early mortality, possibly due to increased
repeat sternotomy incidence in this group. They had equivalent long-term
mortality to non-CHD heart transplant patients (53% 10-year survival in both
groups).
XI. What are the specific details for managing patients with partially corrected or
palliative repairs?
A. Fontan repair
Fontan palliation has been the primary surgical approach for complex lesions
such as tricuspid atresia (TA), hypoplastic left heart, double-inlet LV, double-
outlet RV, severe AV defects, and heterotaxy syndrome [ 42]. Management of
these lesions in both the neonate and the adult patient present one of the biggest
challenges in anesthetic practice [43]. Patient selection is extremely important in
determining the success of the Fontan procedure. Ideally, PVR should be low
(less than 4 Wood units) and the mean PA pressure less than 15 mm Hg.
Adequately sized PAs, the absence of systemic atrioventricular valve
dysfunction, reliable sinus rhythm, and preserved LV function are also important.
Appropriate patient selection has resulted in survival rates approaching 90% at
10 years following this palliative surgery; thus, more and more Fontan patients
may present for adult surgery [44]. Key aspects pertaining to adult management
are presented below.
1. Pathophysiology. TA creates a situation where blood must pass from the right
atrium to the left atrium via an ASD, where it mixes with pulmonary venous
return. Blood flow is then directed to both the PA and the aorta by various
routes. Regardless of type of repair, blood flow depends entirely on the left
ventricle (LV) for cardiac output [ 28,42]. For a more detailed review, please
see the extensive discussion of adult Fontan physiology provided by Dr. Eagle
and Dr. Daves in 2011 [42].
FIGURE 16.5 Fontan surgical techniques: Classical atriopulmonary connection (includes SVC to RPA anastomosis that is not
shown) (A), lateral tunnel (B), and extracardiac conduit (C). ASD, atrial septal defect; RPA, right pulmonary artery; SVC,
superior vena cava; IVC, inferior vena cava; RA, right atrium. (Redrawn from d’Udekem Y, Iyengar AJ, Cochrane AD, et al.
The Fontan procedure: contemporary techniques have improved long-term outcomes. Circulation. 2007;116(Suppl I):I157–
2. Surgical correction. The Fontan procedure, which is the definitive palliative

surgical approach, creates a univentricular circulation via a cavopulmonary
anastomosis. The procedure creates a classical or bidirectional Glenn shunt
(SVC to PA connection), closure of the ASD, ligation of the proximal PA, and
creation of a right atrial-to-PA or IVC-to-PA connection. Multiple variations of
the Fontan procedure exist (Fig. 16.5); however, the same general physiologic
principles most often apply [28].
3. What are the key physiologic and anesthetic management considerations?
a. Blood flow to the PAs is passive. Elevations in PVR will therefore reduce
pulmonary flow, and hence decrease cardiac output, by reducing the gradient
between the vena cava and the PA.
IGURE 16.6 Transesophageal echocardiographic image of the VSD patch repair typically visualized in adult patients with
evious ToF repair. This is the midesophageal long-axis view demonstrating the over-riding aorta with the in situ patch. AV,
rioventricular (mitral) valve; LVOT, left ventricular outflow tract; RV, right ventricle; ToF, tetralogy of Fallot; VSD, ventricular
eptal defect. (Image courtesy of Bryan Ahlgren DO, University of Colorado Denver.)
b. Hemodynamic stability is highly dependent upon maintaining

appropriately high systemic venous pressures and right atrial preload.
Decreased right atrial preload causes dramatic declines in pulmonary blood
flow and cardiac output. Peripheral edema often results from the high systemic
venous pressures, hence the margin of error differentiating adequate and
excessive systemic venous preload can be perilously small.
c. Spontaneous respiration assists forward flow by keeping PVR low. Any
compromise in pulmonary function can be detrimental by increasing PVR.
Preoperative sedation should be used carefully due to risk of hypercapnia and
resultant elevation in PVR. If positive pressure ventilation is necessary, use
the lowest pressure possible to achieve adequate ventilation.
d. The single ventricle is prone to failure leading to pulmonary edema. The atrial
contribution to flow is significant, yet arrhythmias that compromise its
contribution are common. As expected, such arrhythmias are poorly tolerated.
e. Progressive hepatic failure is widely prevalent due to altered hepatic
circulation from increased systemic venous pressures. This can present as a
bleeding tendency, a clotting tendency, or as a mixed picture. Pulmonary
embolism and stroke are common late complications.
f. Invasive monitoring can be problematic and may be unnecessary except for
hemodynamically unstable patients.
(1) CVC placement probably carries a higher risk of thromboembolic events
but may nevertheless be appropriate for short-term use. The decision to
place a CVC should not be taken lightly, as thrombosis of the SVC in this
setting would be deadly. CVPs as high as 25 to 30 mm Hg are not
unexpected and may be essential to drive blood through the pulmonary
circulation. A PA catheter is unnecessary as the CVP reflects PA
pressures.
(2) Arterial line monitoring is advised, but its location must take surgical
shunts into account.
(3) TEE should be strongly considered for intraoperative monitoring during
general anesthesia.
g. General anesthesia. A careful selection of induction agents that will provide
a smooth hemodynamic profile is preferred.
(1) Etomidate and ketamine are excellent induction agents, and moderate
doses of an opioid such as fentanyl, sufentanil, or remifentanil will
reduce the stress response.
(2) A muscle relaxant with minimal hemodynamic effects (e.g.,
succinylcholine or rocuronium) is desirable.
(3) The particular choice of anesthetic agent is not as important as
understanding the hemodynamic goals and administering the agents
carefully.
h. Regional anesthesia may be employed for appropriate surgical cases.
However, titrated epidural anesthesia may be preferable to single-injection
spinal anesthesia, as abrupt reductions in sympathetic tone may precipitously
reduce SVR, which will not be well tolerated.
CLINICAL PEARL During anesthesia, patients with Fontan physiology require extreme
emphasis on appropriate preload, minimizing PVR via adequate ventilation strategies, and
inotropic support of the single ventricle.
4. Anesthetic and hemodynamic goals for patients with Fontan physiology
a. Maintain preload. Avoid aortocaval compression.
b. Avoid elevation in PVR by preventing acidosis, hypoxemia, and hypercarbia.
c. Maintain sinus rhythm.
d. Maintain spontaneous respiration when possible, which can pose a major
challenge in the context of providing adequate anesthesia and analgesia.
e. Avoid myocardial depressants.
B. Tetralogy of Fallot (ToF)—“Blue baby syndrome”
ToF is characterized by existence of a VSD, pulmonic stenosis/right ventricular
outflow tract obstruction (RVOTO), overriding aorta, and right ventricular
hypertrophy. There is great variability in the extent of these defects ranging from
small VSD and overriding aorta with minimal pulmonary stenosis (PS) to severe
PS and large VSD. Outcomes with current surgical repair techniques are
excellent, and there is a 36-year survival of nearly 86% [45].
1. Palliative shunts (Blalock–Taussig, Waterston, or Potts), which involve
systemic arterial (aorta or subclavian artery) to PA anastomoses, were the
initial solution. These palliative shunts provided temporary relief of symptoms,
but often at the expense of significant long-term sequelae [28].
2. Definitive surgical repair involves closure of the VSD and relief of RVOTO
using resection and reconstruction with Gore-Tex patch grafting across the
RVOTO or conduits to bypass the RVOTO (Fig. 16.6).
3. Common reasons for reoperation include residual VSD or recurrence of the
VSD (10% to 20%), residual RVOTO or stenosis (10%) leading to right heart
failure, and progressive RV dilation/dysfunction caused by pulmonic
insufficiency (PI) from the RVOT patch.
4. Additional concerns include a higher risk of sudden cardiac death compared
with age-matched controls, elevated risk of arrhythmias (especially atrial
fibrillation), RBBB, pulmonary regurgitation, and right ventricular aneurysms.
5. Patients with either PS or significant pulmonic valvular regurgitation are more
likely to develop right heart failure. Avoidance of elevated PVR and
maintenance of high-normal filling pressures are critical in patients with
pulmonic valvular regurgitation [43]. See discussion for RV–PA conduits
below.
6. General anesthesia. Choice of induction agents should be tailored to achieve
the hemodynamic goals below and based on underlying cardiac function.
a. If an arterial catheter is placed, patients with Blalock–Taussig shunts will
require cannulation in the contralateral arm or in either leg.
b. TEE should be considered during general anesthesia.
7. Regional anesthesia may be employed for appropriate surgical cases.
However, titrated epidural anesthesia may be preferable to single-shot spinal
anesthesia for certain ToF patients depending on the degree of palliation and
current symptoms.
8. Anesthetic and hemodynamic goals in ToF
a. Avoid changes (especially decreases) in SVR to prevent altering any
existing shunt.
b. Avoid increases in PVR by preventing hypoxia, hypercarbia, acidosis, and
providing supplemental oxygen.
c. Maintain normal to elevated cardiac filling pressures, especially in patients
with right ventricular impairment. Avoid aortocaval compression.
d. Continuous ECG monitoring is particularly important due to the high incidence
of both atrial and ventricular arrhythmias.
e. Tachycardia and increases in myocardial contractility should be avoided in
situations where there is residual RVOTO, as this may exacerbate the
obstruction and cause right-to-left shunting.
C. Right (pulmonary) ventricle to pulmonary artery conduits
The RV–PA conduit is a surgical technique used in the palliation of multiple
lesions including pulmonary atresia, ToF, truncus arteriosus, TGA with VSD, PS,
and forms of double-outlet RV [ 46]. Various types of conduits have been
employed for initial repair ranging from aortic homografts (Ross procedure),
pulmonary homografts, pericardial patches/reconstructions, to a variety of valved
or nonvalved artificial conduits (Dacron, Gore-Tex, etc.). For this section, it is
useful to discuss the ventricle as either the pulmonary ventricle (i.e., the ventricle
supplying the PA) or the systemic ventricle (i.e., the ventricle supplying the
aorta).
1. Risk factors leading to reoperation: Conduit failure is thought to occur in
roughly 50% of patients at 10 years and 70% of patients at 20 years after
placement. Conduit failure, typically, is due to patient growth, thus resulting in
a functionally “small” conduit, development of pulmonary valve (PV)
insufficiency, and/or various degrees of calcification. Conduit failure is
defined by a variety of methods depending on the type of conduit, but in general
include the following [45–48]:
a. Symptomatic patients (dyspnea, fatigue, chest pain, palpitations, presyncope,
and decreased exercise tolerance) demonstrating signs of RV failure with
elevated pulmonic valve (PV) peak gradients >40 mm Hg.
b. Asymptomatic patients with pulmonary ventricular pressures approaching
systemic pressures, increasing pulmonary ventricular size with increasing PV
insufficiency and/or tricuspid insufficiency.
c. Patients with severe PI and NYHA functional class II or III symptoms should
be considered for PV replacement with or without conduit repair [48].
d. Deterioration in exercise testing or functional capacity.
e. Patients who are very young at the time of conduit placement, those with
small-diameter conduits, those with diagnosis of truncus arteriosus or TGA,
and those receiving homografts are at elevated risk of conduit failure.
2. What are the key anesthetic concerns for pulmonary ventricle–PA conduit
replacements?
a. These are repeat sternotomy procedures, so all the considerations outlined in
Section IX should be followed. The pulmonary ventricle–PA conduit is an
anterior structure, so has high risk of injury on reentry sternotomy.
b. Hemodynamic considerations should take into account the current physiologic
and functional status of the patient. The majority of these patients will be
suffering from some degree of right heart failure, so careful control of the PVR
should be of utmost concern. In addition, PI is common and often in the
moderate to severe range. This leads to overdistention of the right (or
pulmonary) ventricle with the potential to worsen RV failure.
c. Patients with residual VSD are at risk for alterations in the shunt fraction if
there are significant changes to either PVR or SVR, which can worsen right
heart function or create cyanosis.
d. As with PAH, the right (or pulmonary) ventricle is susceptible to failure,
which leads to reduced pulmonary blood flow, hypoxia, and subsequent
increases in PVR. This in turn initiates a catastrophic hemodynamic chain of
events where the decreased RV (or pulmonary) stroke volume decreases LV
output and coronary blood flow to both the LV and RV decreases.
CLINICAL PEARL Repeat sternotomy on patients with failed RV–PA conduits are
especially high risk for injury during sternotomy.
3. What are the hemodynamic goals for patients with pulmonary ventricle–
PA conduit failure?
Management should be based on the etiology of the conduit failure, which
usually falls into two basic categories: stenosis or insufficiency. Stenotic
lesions are discussed in Section XI.D on PV stenosis. PI is frequently caused
by balloon valvuloplasty to treat pulmonic stenosis. It is also common after
successful repair of the RVOTO associated with ToF [ 49]. For patients with
PI, there are some basic hemodynamic suggestions that will assist in
developing the anesthetic plan.
a. Overall management goals include to maintain a relative tachycardia (heart
rate 80 to 90) and to minimize PVR. This approach will help reduce the
regurgitant fraction and promote increased forward flow across the conduit.
b. In patients with elements of RV (or pulmonary) failure, be careful using agents
with direct myocardial depressant effects such as propofol. Etomidate may be
an ideal choice.
c. Consider early inotropic support for patients with RV (or pulmonary) failure.
Dobutamine is a good option given the relative tachycardia coupled with
reduction in PVR/SVR associated with this β-adrenergic agent. Guidelines
provided for PAH also apply to these patients (see Section IV.C).
D. Pulmonary valve abnormalities
PV abnormalities are associated with approximately 12% of ACHD lesions [47].
The causes of PS range from valve-specific abnormalities to problems with the
development of the RV itself (see Table 16.6), and derive almost exclusively
from congenital lesions. PS may be found in patients with palliated disease (i.e.,
ToF following repair), or may represent an unrepaired lesion, but is discussed
here due to its association with RV–PA conduit abnormalities.
1. How is PS diagnosed and what are typical symptoms? Patients with severe
PS generally have exertional dyspnea. The diagnosis is often made via
echocardiographic examination. With isolated PV disease, cardiac
catheterization is rarely needed.
2. How is PS categorized?
a. Trivial PS = peak gradient <25 mm Hg.
b. Mild PS = peak gradient of 25 to 49 mm Hg.
c. Moderate PS = peak gradient of 50 to 79 mm Hg.
d. Severe PS = peak gradient >80 mm Hg.
3. What are the available therapeutic options for PS? Patients with trivial or
mild PS can expect a 96% and 77% 10-year surgery-free survival,
respectively, based on existing outcome studies. These patients are typically
followed by echocardiography every 5 to 10 years for progression, or more
frequently based on symptom development [48].
a. Balloon valvuloplasty is the treatment of choice (Class I recommendation) for
patients with symptomatic PS with gradients >50 mm Hg and <2+ PI, or any
patient with exertional dyspnea and gradients in the 30 to 40 mm Hg range. It
is not recommended for most patients with dysplastic valve disease
(characterized by poorly mobile valve without commissural fusion), for
patients with gradients <30 mm Hg or in patients with moderate to severe PI.
Both short- and long-term results are quite good with balloon valvuloplasty
with restenosis rates <5% [50,51]; results that are essentially equivalent to
surgical management with commissurotomy.
b. Surgical intervention is also effective and carried out under direct
visualization for patients deemed poor candidates for balloon valvuloplasty.
There is typically some residual PI following surgical commissurotomy, and
depending on the valve morphology, occasionally PV replacement is required.
Bioprosthetic valves carry a long life span in the pulmonic position and are
the replacement valve of choice [48,49].
TABLE 16.6 Causes of RVOTO in adult patients
4. What are the key anesthetic management concerns for patients with PS?
The right ventricle in a patient with PS develops a characteristic
pathophysiology in a similar fashion to that of the LV in a patient with aortic
stenosis, although the resultant symptomatology is different. Over time, the
increased RV systolic pressure required to overcome the obstructive lesion
leads to RV hypertrophy, and, if left untreated, to RV failure. Ideally, these
lesions should be treated before the onset of RV failure for best outcomes.
5. Hemodynamic considerations during anesthetic management should follow the
guidelines for any stenotic lesion.
a. Relative bradycardia (heart rate in the 60 to 80 range) is preferred to allow
time for complete ventricular ejection. Slower heart rates will also allow for
increased coronary perfusion time.
b. PS represents a fixed obstruction to outflow, so alterations in PVR will not
change the obstruction. Preload should be maintained to promote forward
flow.
c. SVR should be maintained in the patient’s normal range, as reductions in
diastolic pressure will decrease coronary perfusion pressure, leading to RV
ischemia. Normally, the RV receives blood flow during both diastole and
systole; however, with RV hypertrophy this is shifted primarily to the
diastolic phase.
E. Transposition of great vessels (TGV)
TGV is relatively rare, representing 1% to 5% of congenital heart defects. The
two main types are congenitally corrected TGV (L-TGV) and complete TGV (D-
TGV). Without surgical intervention, survival to 6 months in D-TGV is less than
10% [8,11,28]. L-TGV allows survival, albeit typically at the cost of early adult
heart failure.
1. How is D-TGV palliated and what are the physiologic sequelae?
D-TGV is described as blood flow in a parallel system, such that systemic
venous return flows to the right atrium and right ventricle, which then ejects
blood into the aorta [9,28]. Pulmonary venous blood flow proceeds to the left
atrium (LA), LV, and then into the PA. Without additional communication from
septal defects or a PDA, there is no connection between blood oxygenated in
the lungs and systemic arteries, and therefore survival is impossible.
a. Atrial switch operations such as the Mustard or Senning procedure create an
atrial baffle that causes venous blood to cross at the atrial level into the
appropriate ventricle. Since the morphologic right ventricle then continues to
eject blood into the aorta, these patients experience a higher risk of heart
failure as a result of that ventricle’s impaired capacity to chronically pump
against systemic arterial pressures [8].
b. The arterial switch, known as the Jatene procedure, switches the PA and aorta
with reimplantation of the coronary vessels. This requires that the LV be
sufficiently large to provide systemic flows. These patients often have
relatively normal physiology following surgical repair and should be
considered in the surgically corrected category [8]. There are two long-term
complications to be aware of, which include development of aortic
insufficiency on the neoaortic valve (occurring in 25% of patients), and
coronary ostial lesions leading to myocardial ischemia [8].
2. What are the key anesthetic considerations for patients with TGV?
a. Patients with D-TGV who have been treated with the arterial switch (Jatene)
will typically have normal cardiac function, so management should focus on
any coexisting medical issues. Contrary to this, those patients managed with
the Mustard or Senning approach (atrial switch) are at higher risk of
developing heart failure due to the systemic right ventricle, as well as the
atrial baffle, which occasionally obstructs flow.
b. As mentioned above, L-TGV patients are also at increased risk of heart
failure, so evaluation should focus on determining functional status and
symptoms of heart failure.
c. Arrhythmias are very common in patients treated with Mustard or Senning
repairs. VT and IART are the most common (Table 16.4).
d. Invasive monitors should be used selectively. CVCs may be useful for
vascular access and monitoring in patients with heart failure, but PA catheters
are probably ill-advised in patients who have undergone atrial switch
procedures. Preoperative information from recent echocardiograms can be
invaluable for symptomatic patients.
3. How should induction of general anesthesia be managed?
Induction should focus on the degree of heart failure present in the patient.
Choose induction agents with minimal myocardial depressant effects;
etomidate, ketamine, midazolam, or fentanyl may be ideal choices. Additional
effects of inhaled agents in moderate doses are generally well tolerated as the
afterload reduction improves forward flow.
4. Anesthetic and hemodynamic goals for TGV
a. Consider an arterial catheter and/or CVC and avoid excessive fluids in
patients with evidence of heart failure.
b. Avoid negative inotropic agents.
c. Monitor for arrhythmias and treat as indicated.
5. Should regional anesthesia be utilized in patients with TGV? As with
general anesthesia, the afterload reduction following the sympathetic blockade
from neuraxial anesthesia will improve forward flow in patients with mild to
moderate degrees of heart failure. Care should be taken in patients with severe
heart failure symptoms. Single-shot spinal anesthetic techniques may not be
tolerated due to the rapid reduction in preload and SVR. Instead, consider using
an epidural catheter with a slow titration of local anesthetic agents.
XII. What are the key details for patients with uncorrected CHD?
Uncorrected lesions presenting in the adult patient represent a group of diagnoses
that are typically on the mild end of the spectrum, given that these patients remain
largely symptom-free into adulthood. Examples include ASD, VSD, Ebstein
anomaly, or undiagnosed ACHD due to limited healthcare access as child. Patients
with more complex disease states that are unrepaired due to limited healthcare
access should be managed according to the existing lesion’s pathophysiology, and
will represent a more complex situation. This section will focus primarily on
septal defects presenting in the adult patient.
FIGURE 16.7 Location of atrial septal defects (ASDs). IVC, inferior vena cava; RA, right atrium; RV, right ventricle;
SVC, superior vena cava. (Reprinted with permission from Rouine-Rapp K, Miller-Hance WC. Transesophageal
echocardiography for congenital heart disease in the adult. In: Perrino AC Jr, Reeves ST, eds. A Practical Approach to
Transesophageal Echocardiography. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:372.)
A. Adult atrial septal defect (ASD)

ASDs account for nearly one-third of adult congenital heart defects and are found
in women more commonly than in men [52]. Small defects (less than 5 mm) are
hemodynamically insignificant, but large defects (greater than 20 mm) can lead to
significant shunting and eventual RV overload or failure [ 28,53]. ASDs do not
typically close spontaneously and are commonly associated with additional
cardiac defects. The anatomy of septal defects in the adult is typically the same
as that described for the child (Fig. 16.7). Common defects include ostium
primum, ostium secundum, sinus venosus, and patent foramen ovale. These
defects are often linked to more complex CHD, which should be considered
during initial workup. Ostium primum defects are frequently associated with a
mitral cleft or other atrioventricular valve abnormalities, while sinus venosus
defects are associated with partial anomalous pulmonary venous return.
Hemodynamic consequences of ASD follow that of a left-to-right shunt as
described above, the severity of which depends on the shunt fraction
(pulmonary:systemic or Qp:Qs ratio).
1. What are the clinical symptoms for adult ASDs?
The natural course of unrepaired ASD is that as the patient ages and LV
diastolic dysfunction develops, the increased LV end-diastolic pressure tends
to worsen the left-to-right shunt. This leads to increased shunt fraction, RV
dilation, and development of clinical symptoms, often in the fourth or fifth
decade of life [53]. Typical clinical symptoms include the following:
a. Dyspnea with exertion, possibly due to chronic preload reduction of the LV
along with overloaded pulmonary system. This symptom typically is improved
with ASD closure.
b. Cardiac arrhythmias (atrial fibrillation) due to atrial enlargement and
stretching of conduction system. Atrial volumes tend to remain elevated in the
adult following repair, and thus arrhythmias tend to persist after repair.
c. Embolic stroke—typically due to paradoxical embolism.
d. Exercise-induced cyanosis can occur (see below).
2. What are the indications for repair [52,53]? A combination of
echocardiographic and catheterization-based diagnostic testing is generally
used to determine eligibility for repair. Outcomes with repair (either surgical
or transcatheter) seem to indicate a benefit in overall survival, as 10-year
survival rates for adult patients following repair exceed 95%, while medical
management alone has a 10-year 84% survival [54]. Outcomes appear to be
better for patients repaired at earlier ages (before the fourth decade), whereas
medical management may be better later in life [54,55]. Indications for repair
include the following:
a. Adult patients with a pulmonary-to-systemic shunt (Qp:Qs) ratio >1.5:1.0
b. Echocardiographic evidence of RV volume overload
c. Development of arrhythmia due to atrial enlargement
d. Exercise-induced cyanosis without existing pulmonary hypertension
e. Embolic stroke
3. How does pulmonary hypertension relate to ASD? PAH is rarely caused by
an ASD, is found in less than 10% of patients with ASD, and if PAH is not
diagnosed by adulthood in the presence of an ASD, it rarely develops. In
addition, Eisenmenger physiology rarely develops due to ASD. There is debate
regarding the mechanism of PAH associated with ASD, but many consider
ASD a marker of PAH, and not a causative agent [ 53,54]. Regardless, there are
important considerations for patients with ASD and moderate to severe PAH.
The presence of an ASD allows for blood to flow from right to left, bypassing
the high-resistance pulmonary bed in PAH, and thus decompressing the RV.
This reduces the classic heart failure symptoms, at the cost of cyanosis, and
these patients should not have the ASD closed. Occasionally, creation of an
ASD is a temporary measure used to bridge patients with severe PAH to
transplant. In fact, presence of PAH with PVR >4 Wood units may be a
contraindication for ASD closure.
4. Should surgical repair or transcatheter closure be used to repair the ASD?
Surgical closure of ASD is a safe and effective operation, with mortality rates
below 1.5 % and long-term survival >95% as mentioned above [51]. Recent
advances in transcatheter approaches have shown excellent outcomes,
equivalent to surgical repair, with the obvious avoidance of the morbidity
associated with sternotomy [54–58]. Typically, transcatheter closure is
associated with shorter hospital stays, less overall complications, and reduced
cost.
5. What characteristics of the lesion increase difficulty with transcatheter
repair? Once the indications for closure listed previously are established,
certain anatomic characteristics must be considered for adequate transcatheter
closure. Key anatomic features include the following:
a. Size of defect. ASD <26 mm is considered normal size, with >26 mm
considered a large defect. Large ASD is not a contraindication for device
closure, but there is an elevated risk of dislodgement or erosion when using
large devices [54].
b. Central lesions, that is, ostium secundum defects, are the most amenable to
treatment. Ostium primum and sinus venosus lesions are often not
anatomically suited to transcatheter techniques, so surgical repair is
recommended [11].
(1) Lesions with deficient anterior-superior rim. This deficiency is
common in large ASDs, and makes placement of the device more
technically challenging. Despite this, complications such as dislodgement
or erosion are well below 1% in multiple studies [54], and seem to be
most related to oversizing of devices. As such, device sizing should be
limited to 1.5 times the diameter of the ASD by TEE.
(2) Lesions with deficient posterior-inferior rim. This lesion is even more
technically challenging than deficient anterior-superior rim. However,
the incidence is also lower and thus there are insufficient data to
determine overall complications in these lesions.
c. Multiple lesions/fenestrated defects. This type of abnormality also poses a
technical challenge. Approaches vary between balloon atrial septostomy to
create a single ASD versus placement of multiple smaller occlusion devices.
IGURE 16.8 Three-dimensional (3D) TEE view of an Amplatzer device placed in a large centrally located ASD. ASD, atrial
eptal defect; TEE, transesophageal echocardiography. (Image by Nathaen Weitzel, MD, University of Colorado Denver.)
d. Atrial septal aneurysms. The aneurysmal septal wall creates difficulty with
device closure using standard devices that rely to some degree on the septal
structure. Patch or double disc devices are more appropriate, which are more
technically challenging.
6. What are the typical devices used in the catheterization laboratory?
Currently, two main devices have become the standard following multiple
studies using many different devices. In the United States, Amplatzer (St. Jude
Medical) and Helex (W.L. Gore) are the two devices with current FDA
approval. Three-dimensional (3D) TEE imaging of an Amplatzer device in
place is seen in Figure 16.8.
7. What are the anesthetic considerations for surgical or device closure in
ASD? General considerations for patients with shunts are discussed in Section
VII.D, all of which apply to these patients. Typically, adult patients presenting
for ASD closure are hemodynamically stable even in the setting of the clinical
symptoms discussed above. On the basis of preoperative evaluation,
specifically current functional status, the anesthesiologist can anticipate a
relatively normal induction plan aiming for overall smooth hemodynamics.
Some key aspects of this procedure to anticipate in anesthetic planning are
listed below:
a. Discuss the device procedure plans with the cardiology team, as many times
the interventional cardiologist will want to place right heart catheters while
the patient is spontaneously ventilating to obtain catheter-based measurements
of RA, RV, and PA pressures. Typically, this portion of the procedure will be
carried out under light sedation and on room air to avoid any changes to the
PVR due to oxygen supplementation.
b. Device closure is typically carried out using both echocardiography and x-ray
imaging in the catheterization suite. Total procedural time can vary in
duration, but typically ranges from 1 to 4 hours. Due to the length of the
procedure and the need for prolonged TEE evaluation, general anesthesia is
typically employed. Standard ASA monitors are usually all that is needed.
However, for patients with severe hemodynamic compromise, invasive blood
pressure monitoring may be utilized.
c. General anesthesia can be safely induced with various approaches in nearly
all patients and agents such as propofol or etomidate are acceptable. Heparin
is typically given during the device procedure to maintain an Activated
Clotting Time (ACT) >250 seconds. Surgical repairs are performed on CPB
and require higher ACTs.
d. Patients with septal defects are at risk for embolic events to the brain. All
IV lines should be thoroughly deaired, and extreme care should be taken
to avoid any injection of air through IV lines.
FIGURE 16.9 Common locations for ventricular septal defects (VSDs). (Reprinted with permission from Rouine-Rapp K,
Miller-Hance WC. Transesophageal echocardiography for congenital heart disease in the adult. In: Perrino AC Jr, Reeves
ST, eds. A Practical Approach to Transesophageal Echocardiography. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2008: 377.)
B. Ventricular septal defects (VSDs)

VSD is the most common congenital heart lesion in children, although nearly
90% close spontaneously by age 10 [52,53]. Those patients with large lesions
who are symptomatic at birth will usually be surgically corrected, while
asymptomatic patients will often be closely monitored for evidence of
spontaneous closure. Surgical closure often involves a right atriotomy or
ventricular incision, and this carries a significant risk of interventricular and
even atrioventricular conduction abnormalities. VSDs can present in multiple
areas of the septum, with 80% being in the perimembranous region (Fig. 16.9),
the muscular septum the next highest frequency, and the subarterial or double-
committed outlet being rather rare. In contrast to ASD, unrepaired VSDs can
have significant consequences and may lead to development of Eisenmenger
physiology if left untreated.
1. Can transcatheter closure be utilized to treat VSD? This question is not as
clearly answered as for ASD closure. However, advances over the past decade
have led to significant improvements in device closure for VSD. Outcome data
seem to favor this approach, with the most common associated complication
being arrhythmias. Placement success is more than 95% in multiple studies, and
6-year follow-up demonstrates more than 85% freedom from event rates
[59–64]. The considerations for device closure in ASD apply here as well.
Establishing good communication with the cardiology team before the
procedure to discuss specific diagnostic and therapeutic plans that may impact
anesthetic planning is critical.
2. What if ES is present? ES represents the most common cyanotic cardiac
defect in adults [65]. Chronic left-to-right shunting results in right ventricular
hypertrophy, elevated PVR, and significant ventricular and arterial remodeling
on the right side. In pregnancy, ES carries a maternal mortality ranging from
30% to 70% along with a high incidence of fetal demise, so patients are usually
counseled against pregnancy [65], and are considered extremely high risk for
surgery. Sudden death is common and may be due to stroke, arrhythmia,
abscess, or heart failure. In the absence of pregnancy, 25-year survival after
diagnosis of ES is reported to be 42% [52].
a. Pathophysiology. ES is defined by a PVR greater than 800 dynes · sec/cm5
along with right-to-left or bidirectional shunt flow. Correction of the shunt
may resolve the pulmonary hypertension, but once pulmonary arteriolar
remodeling (i.e., medial hypertrophy) develops, the elevated PVR is
irreversible, differentiating ES from primary pulmonary hypertension.
b. Symptoms. Fatigue, dyspnea, cyanosis, edema, clubbing, and polycythemia.
c. The underlying right-to-left shunt, hyperviscosity from polycythemia, and the
development of heart failure promote thrombus formation and may elevate
stroke risk.
3. Anesthetic management in ES. Historically, regional anesthesia was thought
to be contraindicated and general anesthesia was the standard. A review of
cases of noncardiac surgery including labor and cesarean section in ES
indicates that regional anesthesia is indeed safe for these patients [66]. Martin
et al. state that mortality is related to a type of surgical procedure, independent
of choice of anesthetic. Despite this, anesthetic delivery requires utmost
vigilance to maintain hemodynamic goals (see below) with any type of
anesthesia.
a. Regional anesthesia. Slow titration of local anesthetic. Aggressive treatment
of any reduction in SVR (i.e., systemic hypotension) with phenylephrine is
effective. Maintenance of intravascular volume status with careful fluid
boluses and phenylephrine for decreased SVR should be used to prevent onset
or exacerbation of cyanosis. Single-shot spinal anesthesia is considered
contraindicated. Avoidance of elevations in PVR is critical; thus, additional
sedative medications should be used cautiously, as reductions in ventilation
will lead to hypercarbia and elevation of PVR.
b. For general anesthesia, slow titration of induction agents is preferred, as
rapid sequence inductions carry a high risk of SVR alterations and subsequent
hemodynamic collapse. This places the patient at increased risk of aspiration,
so strict NPO guidelines, use of pharmacologic prophylaxis against aspiration
(sodium citrate, H2 blockade, etc.), and mask ventilation using cricoid
pressure should be considered. Ketamine and etomidate are probably the best
options for induction agents, whereas propofol and thiopental should be
avoided due to marked reductions in SVR or cardiac output. Inhalational
agents should be used with caution because of their propensity to decrease
SVR. Nitrous oxide should be avoided or used with great caution because of
its propensity to increase PVR. Maintenance of anesthesia may be
accomplished using careful titration of IV agents such as nondepolarizing
neuromuscular blockers, opioids, and sedative–hypnotic agents such as
midazolam or ketamine, “topping off” with potent inhalational agents at
concentrations of less than 0.5 MAC.
c. Monitors. Pulse oximetry may be the most important monitor, as changes in
saturation directly correlate with alterations in shunt flow [28]. Intra-arterial
monitoring is generally employed to closely follow blood pressure. CVCs
are controversial. CVC placement carries a risk of air embolus, thrombus, and
pneumothorax, which can be devastating in these patients, although
information about cardiac filling pressures can be useful. PA catheters are
relatively contraindicated in patients with ES for a number of reasons [28].
The anatomic abnormality causing ES typically renders flow-directed
flotation of PA catheters difficult or impossible, and the risks for arrhythmia,
PA rupture, and thromboembolism are elevated. Cardiac output measurements
will be inaccurate due to the large shunt. TEE may provide the best real-time
monitor of cardiac preload and the status of right-to-left shunting.
4. Anesthetic and hemodynamic goals for ES
a. Avoid elevations in PVR. Prevent hypoxemia, acidosis, hypercarbia, and
pain. Provide supplemental oxygen at all times.
b. Maintain SVR. Reductions in SVR will increase right-to-left shunting.
c. Avoid myocardial depressants and maintain myocardial contractility.
d. Maintain preload and sinus rhythm.
TABLE 16.7 Cardiac conditions associated with highest risk of adverse outcomes from
endocarditis for which prophylaxis with dental procedures is reasonable
5. Can iNO be employed in ES? iNO is a direct-acting pulmonary vasodilator

that avoids systemic vasodilation, thus reducing shunt flow and hypoxia. In
general, it is thought that patients with ES are not responsive to most pulmonary
vasodilators, including iNO. However, there is some evidence for the use of
iNO for labor in Eisenmenger patients, with several case reports indicating
improvement in oxygenation and reduced pulmonary pressures [67]. Patients
are arriving to the OR on chronic oral pulmonary vasodilators. Therapy with IV
pulmonary vasodilators may be required postoperatively to prevent rebound
elevation in pulmonary pressures.
XIII. What are the antibiotic prophylactic considerations for patients with ACHD?
Infective endocarditis carries high morbidity and mortality, and as such has led to
previous recommendations about antibiotic prophylaxis regimens for patients with
heart defects. Current recommendations center around the concept that most
exposures to infectious agents occur during daily activities, and suggest
maintaining a high index of suspicion for signs of endocarditis in susceptible
patients [68]. Good oral hygiene is critical to prevent infection in these patients,
and antibiotic prophylaxis is recommended only in select lesions listed in Table
16.7.
XIV. Conclusions
ACHD encompasses a wide range of patients with variable presentations,
symptoms, and degree of illness. Some of the most common and critical
presentations have been addressed in this chapter; however, due to the huge range
of presentations, variations in all of these lesions are likely to be found, and many
other diagnoses have not been covered. The underlying concept found throughout
management of ACHD is to obtain as much information as possible about the
patient’s medical and surgical history, along with current functional capacity. This
will give the greatest information about the current level of heart function. On the
basis of this information, consider the lesion based on the classifications discussed
above, and develop an anesthetic management plan based on individualized
physiology for your patient. Consultation with congenital cardiologists or
cardiothoracic surgeons can be invaluable. Patients with complicated residual
lesions requiring medium- to high-risk surgery should be handled at centers of
excellence with physicians and nursing staff trained in adult congenital disease.
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17 Anesthetic Management of Cardiac and
Pulmonary Transplantation
James M. Anton, Anne L. Rother, Charles D. Collard,
and Erin A. Sullivan
Part I: Cardiac Transplantation

I. Heart failure (HF)
A. Etiology
B. Pathophysiology
C. Medical management of HF
D. Mechanical circulatory support (MCS) devices
II. Cardiac transplant recipient characteristics
A. Cardiac transplantation indications
B. Cardiac transplantation contraindications
III. The cardiac transplant donor
A. Donor selection
B. Determination of brain death
C. Pathophysiology of brain death
D. Management of the cardiac transplant donor
E. Anesthetic management of the donor
F. Organ harvest technique
IV. Surgical techniques for cardiac transplantation
A. Orthotopic cardiac transplantation
B. Heterotopic cardiac transplantation
V. Preoperative management of the cardiac transplant patient
A. Timing and coordination
B. Preoperative evaluation
VI. Anesthetic management of the cardiac transplant recipient
A. Premedication
B. Importance of aseptic technique
C. Monitoring
D. Considerations for repeat sternotomy
E. Anesthetic induction
F. Anesthetic maintenance
G. Cardiopulmonary bypass (CPB)
VII. Postcardiopulmonary bypass (Post-CPB)
A. Autonomic denervation of the transplanted heart
B. Right ventricular (RV) dysfunction
C. Left ventricular (LV) dysfunction
D. Coagulation
E. Renal dysfunction
F. Pulmonary dysfunction
G. Hyperacute allograft rejection
VIII. The role of intraoperative transesophageal echocardiography (TEE)
IX. Cardiac transplantation survival and complications
A. Infection
B. Acute rejection
C. Graft failure and cardiac allograft vasculopathy (CAV)
D. Renal insufficiency (RI)
E. Malignancy
F. Immunosuppressive drug side effects
X. Pediatric cardiac transplantation
XI. Combined heart–lung transplantation (HLT)
XII. Anesthesia for the previously transplanted patient
A. Physiology of the previously transplanted patient
B. Pharmacology of the previously transplanted patient
C. Preoperative evaluation
D. Anesthesia management
E. Pregnancy following cardiac transplantation
XIII. Future directions
Part II: Lung Transplantation
XIV. Lung transplantation
A. Epidemiology
B. Pathophysiology of end-stage pulmonary disease (ESPD)
C. Recipient selection criteria: Indications and contraindications
D. Medical evaluation of lung transplant candidates
E. Choice of lung transplant procedure
F. Selection criteria for donor lungs
G. Preanesthetic considerations
H. Induction and maintenance of anesthesia
I. Surgical procedures and anesthesia-related interventions
J. Postoperative management and complications
K. Outcome
L. Special considerations for pediatric lung transplantation
M. Anesthesia for the post–lung-transplant patient
N. The future of lung transplantation
PART I: CARDIAC TRANSPLANTATION
KEY POINTS
1. Nonischemic cardiomyopathy (49%) is the most common

pretransplant diagnosis worldwide.
2. Nearly 85% of recipients in the United States (US) require some
form of life support prior to cardiac transplantation. For example,
the number of pretransplant patients with ventricular assist devices
(VADs) has risen dramatically (29% in 2008 vs. 45% in 2015).
3. Increased preoperative pulmonary vascular resistance (PVR) in the
recipient predicts early graft dysfunction and an increased incidence
of right heart dysfunction. Right ventricular (RV) failure accounts
for nearly 20% of early mortality after transplantation.
4. During orthotopic cardiac transplantation, the cardiac autonomic
plexus is transected leaving the transplanted heart without
autonomic innervation. The denervated heart responds to direct-
acting agents such as catecholamines, which are utilized frequently
in the post-bypass period.
5. In contrast to the nontransplanted patient, where increases in cardiac
output (CO) can be quickly achieved through a sympathetically
mediated increase in heart rate, the cardiac transplanted patient,
whose sympathetic innervation to the heart will be interrupted, tends
to require an increase in preload in order to increase CO.
ALTHOUGH “DESTINATION THERAPY” USING MECHANICAL CIRCULATORY SUPPORT
(MCS) devices has increasingly become a viable option, and advances in MCS devices
have resulted in a significant survival benefit, cardiac transplantation remains the gold
standard for the treatment of heart failure (HF) refractory to medical therapy [1]. Since
the first human cardiac transplant by Christiaan Barnard in 1967, over 118,000 cardiac
transplants have been performed worldwide [2]. Currently, approximately 4,500
cardiac transplants are performed per year, with approximately 2,700 occurring in the
United States (US) [2]. Despite an increasingly high-risk patient population, survival
rates continue to improve due to advances in immunosuppression, surgical technique,
perioperative management, and the diagnosis and treatment of allograft rejection and
allograft vasculopathy [3]. In the US, cardiac transplantation is limited to member
centers of the United Network for Organ Sharing (UNOS). UNOS, in turn, administers
the Organ Procurement and Transplantation Network (OPTN) which maintains the only
national patient waiting list in US.
I. Heart failure (HF)

More than 6.5 million American adults carry a diagnosis of HF, with an incidence
of 960,000 new cases per year [4]. The American College of Cardiology (ACC)
and the American Heart Association (AHA) define HF as a clinical syndrome that
can result from any structural or functional cardiac disorder that impairs the ability
of the ventricle to fill with or eject blood. The majority of patients with HF owe
their symptoms to impairment of left ventricular (LV) myocardial function [ 5].
Because volume overload is not necessarily present, the term “HF” is now
preferred to the older term “congestive HF.”
FIGURE 17.1 Stages in the development of heart failure (HF) and recommended therapy. HTN, hypertension; DM,
diabetes mellitus; LV, left ventricle; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;
MI, myocardial infarction; LVH, left ventricular hypertrophy; EF, ejection fraction; HF, heart failure; HFpEF, heart
failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HRQOL, health-related
quality of life; ICD, implantable cardioverter defibrillator; AF, atrial fibrillation; GDMT, goal-directed medical therapy;
MCS, mechanical circulatory support. (From Yancy CW, Jessup M, Bozkurt B, et al. ACCF/AHA guideline for the
management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American
Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):1810–1852.)
The New York Heart Association (NYHA) scale is used to quantify the degree
of functional limitation imposed by HF. Most patients with HF, however, do not
show an uninterrupted and inexorable progression along the NYHA scale [5]. In
2005, the ACC/AHA created a staging scheme reflective of the fact that HF has
established risk factors, a clear progression, and specific treatments at each stage
that can reduce morbidity and mortality (Fig. 17.1). Patients presenting for heart
transplantation invariably present in stage D, refractory HF.
A. Etiology
1 Nonischemic cardiomyopathy (49%) is the most common pretransplant
diagnosis worldwide [2]. Ischemic cardiomyopathy accounts for 35%, with
valvular cardiomyopathy, restrictive cardiomyopathy, hypertrophic
cardiomyopathy, viral cardiomyopathy, retransplantation, and congenital heart
disease accounting for the remaining percentage of adult heart transplant
recipients.
B. Pathophysiology
The neurohormonal model portrays HF as a progressive disorder initiated by an
index event, which either damages the myocardium directly or disrupts the ability
of the myocardium to generate force [6]. HF progression is characterized by
declining ventricular function and activation of compensatory adrenergic, and
salt and water retention pathways. Ejection fraction (EF) is initially maintained
by increases in LV end-diastolic volume, myocardial fiber length, and
adrenergically mediated increases in myocardial contractility. LV remodeling
takes place during this time, and while initially adaptive, may independently
contribute to HF progression [6]. The chronic overexpression of molecular
mediators of compensation (e.g., norepinephrine, angiotensin II, endothelin,
natriuretic peptides, aldosterone, and tumor necrosis factor) may lead to
deleterious effects on cardiac myocytes and their extracellular matrix [6,7]. The
result is progressive LV dilation, as well as decreasing EF and cardiac output
(CO). Fatigue, dyspnea, and signs of fluid retention develop. Other organ systems
such as the liver and kidneys become compromised by persistent decreases in
CO and elevated venous pressures. With continued progression of HF, stroke
volume (SV) becomes unresponsive to increases in preload, and increases in
afterload are poorly tolerated (Fig. 17.2). Chronic exposure to circulating
catecholamines may result in downregulation of myocardial β1-adrenergic
receptors, making the heart less responsive to inotropic therapy.
FIGURE 17.2 Pressure–volume (P–V) relationships in a normal heart and a heart with end-stage, dilated cardiomyopathy
(DCM). Shown are the left ventricular (LV) P–V loops (dotted lines) obtained from a normal heart and a heart with end-
stage DCM following an increase in afterload. The slope depicts the LV end-systolic P–V relationship. Note that the
myopathic heart stroke volume (SV) is markedly decreased by increases in afterload. (From Clark NJ, Martin RD.
Anesthetic considerations for patients undergoing cardiac transplantation. J Cardiothorac Anesth. 1988;2:519–542, with
permission.)
CLINICAL PEARL Patients with end-stage HF are chronically exposed to high

circulating catecholamine levels and, as a result, are less responsive to inotropic
therapy.
C. Medical management of HF
1. Therapeutic goals
The therapeutic goal for HF management is to slow or halt the progression from
stages A to D. Lifestyle modifications and selected pharmacotherapy are the
mainstays of therapy for stages A and B. When stage C is reached, combination
pharmacotherapy includes diuresis, interruption of the renin–angiotensin axis,
and β-blockade. Selective use of direct vasodilators and inotropes is also
indicated. Utilization of cardiac resynchronization therapy (CRT) and/or an
implantable defibrillator may be recommended. Despite optimum medical
management, some patients will progress to stage D, refractory HF. Chronic
intravenous (IV) inotropes, MCS devices, and heart transplantation are the only
measures available for palliation or treatment.
a. Inotropes
Inotropic agents commonly used to treat cardiac failure include digitalis,
catecholamines, and phosphodiesterase-III inhibitors. Digitalis, in
combination with β-blockers, is effective in treating HF complicated by atrial
fibrillation, but does not confer increased survival [8]. Similarly, recent
evidence indicates that digitalis may have a role in the treatment of HF in
patients with normal sinus rhythm, but this remains without documented
mortality benefit [9]. Administered orally, digitalis exerts a positive inotropic
effect by inhibiting the myocardial cell sodium pump and increasing cytosolic
calcium concentrations. Digitalis also prolongs atrioventricular conduction
time, leading to PR interval prolongation and possible heart block. Digitalis
blood levels should be monitored as significant side effects, including atrial
and ventricular arrhythmias, can occur particularly in the presence of
hypokalemia.
Myocardial β1-adrenergic receptor stimulation by IV administration of
catecholamines, such as epinephrine, norepinephrine, dobutamine, or
dopamine, is often used to improve cardiac performance, diuresis, and
clinical stability. Phosphodiesterase-III (PDE) inhibitors, such as milrinone
and enoximone, may also be used. PDE inhibitors combine both positive
inotropic and vasodilatory activity by inhibiting cyclic AMP (cAMP)
metabolism. Occasionally, patients may not be weaned from IV inotropic
support despite repeated attempts. At such times, an indwelling IV catheter
may be placed to allow for the continuous infusion of an inotrope for patients
awaiting transplantation, or to facilitate home palliation. However, chronic
inotrope use has not been shown to increase survival [10].
b. Diuretics
Diuretics provide symptomatic relief to HF patients more quickly than any
other class of drug, and are the only class of drug used in HF that can
adequately control fluid retention. Classes of diuretics used include the loop
diuretics (e.g., furosemide, bumetanide, torsemide), the thiazide diuretics
(e.g., hydrochlorothiazide), and the thiazide-like drug metolazone. Adverse
diuretic effects include electrolyte disturbances (particularly of potassium and
magnesium), hypotension, intravascular volume depletion, and azotemia.
c. Renin–angiotensin–aldosterone system inhibitors
Inhibition of the renin–angiotensin–aldosterone system may occur at the level
of the angiotensin-converting enzyme inhibitors (ACEIs), the angiotensin
receptor blockers (ARBs), or the aldosterone receptor. In combination with
β1-antagonists, ACEIs have been shown to reduce HF progression by
interfering with the neurohormonal pathways that modulate LV remodeling.
ACEIs alleviate symptoms, enhance the overall sense of well-being, and
reduce the risk of hospitalization and death in patients with HF [11,12].
Adverse effects of ACEIs include hypotension, worsening renal function, and
hyperkalemia. If the adverse effects of ACEIs cannot be tolerated, ARBs may
be considered as an alternative. ARBs have been shown to reduce morbidity
and mortality in HF patients [12]. The propensity of ARBs to increase serum
potassium levels limits their usage in patients with impaired renal function. A
new class of medication, combined angiotensin receptor blocker neprilysin
inhibitors (ARNIs), has been associated with significant reductions in hospital
admissions and mortality as compared to ACEIs. Guidelines now recommend
substituting ARNIs for ACEIs or ARBs in appropriate patients [ 11,12].
Aldosterone exerts an adverse effect on heart structure and function
independent of angiotensin II [13]. Spironolactone is the most widely used
aldosterone antagonist in HF patients, although eplerenone has been studied in
HF after myocardial infarction.
d. Vasodilators
Vasodilators are used in the acute treatment of HF to reduce myocardial
preload and afterload, thereby reducing myocardial work and oxygen demand.
By preferentially reducing preload via venodilation, nitroglycerin may be
useful for relieving the symptoms of pulmonary edema. β-Type natriuretic
peptide (nesiritide) is used effectively for the medical management of
decompensated HF [10]. Nesiritide, an arterial and venous dilator, acts by
increasing cyclic GMP (cGMP) [10]. In hospitalized patients, a dose-
dependent reduction of pulmonary capillary wedge pressure, right atrial
pressure, and mean pulmonary artery (PA) pressure was demonstrated, along
with improvements in cardiac index and clinical outcome [14]. A recent meta-
analysis found reduced readmission rates and in-hospital mortality rates with
nesiritide therapy as compared to dobutamine therapy for patients with acute
decompensated HF [14].
e. β-Adrenergic receptor blockade
In combination with interruption of the renin–angiotensin–aldosterone axis
and diuresis, β-adrenergic receptor blockade is now standard treatment for
HF. Carvedilol, bisoprolol, and sustained release metoprolol have been
demonstrated to be effective in reducing mortality in patients with chronic HF
[11]. Chronic adrenergic stimulation initially supports the failing heart, but
may lead to progression of HF through neurohormonal-mediated LV
remodeling. β-Blockers likely exert their benefit through attenuation of this
influence. Adverse reactions to β-blockers in patients with HF include fluid
retention, fatigue, bradycardia, heart block, and hypotension.
f. Anticoagulants
Patients with HF are at increased risk of thromboembolism as a result of low
CO and a high incidence of coexistent atrial fibrillation. Long-term
prophylactic anticoagulation with agents such as warfarin is common and may
contribute to perioperative bleeding at the time of cardiac transplantation.
g. Cardiac implantable electronic devices (CIEDs)
CIEDs broadly consist of devices that seek to manage bradyarrhythmias
(pacemakers), tachyarrhythmias (implantable cardiac defibrillators), and
ventricular dyssynchrony (biventricular pacing/CRT). These devices are used
to reduce the incidence of sudden cardiac death, and to slow HF progression
[15]. Their presence may complicate the placement of central venous
catheters and require the involvement of the electrophysiology team for
interrogation and reprogramming [16].
D. Mechanical circulatory support (MCS) devices
Nearly 85% of recipients in the US require some form of life support prior to
he a r t 2 transplantation [17]. These include IV medications, mechanical
ventilation, intra-aortic balloon pump (IABP), extracorporeal life support (ELS),
total artificial hearts (TAHs), and ventricular assist devices (VADs). IV
medications, IABPs, ELS, and extracorporeal VADs are useful in temporizing a
hospitalized patient with cardiogenic shock. Intracorporeal MCS devices offer
the potential for discharge to home and may yield the greatest potential
improvement in quality of life for patients with class D HF who are awaiting
heart transplant surgery.
In the US, the number of patients undergoing heart transplantation with a pre-
existent VAD has risen dramatically (29% in 2008 vs. 45% in 2015) [ 17]. The
increased use of VADs has contributed to a decline in the heart transplant waiting
list mortality despite increased waiting times secondary to their use as a bridge-
to-transplantation [17,18]. One-year survival while being supported on a VAD
has risen to 85% [19]. However, the influence of VADs on post–heart-transplant
survival remains controversial, with some studies suggesting an increased 6-
month mortality after transplant, while others suggest no increase in mortality
[19,20].
CLINICAL PEARL The increased use of VADs has resulted in a decline in heart
transplant waiting list mortality, however, the influence of VADs on post-heart-
transplant survival remains controversial.
II. Cardiac transplant recipient characteristics
The number of active transplant candidates in US has increased by 90% between
2004 and 2015 [17]. In 1999, UNOS modified its listing system to be two-tiered
(Table 17.1), and in 2006, UNOS modified the allocation of donor hearts to
expand organ sharing within geographic regions. In 2014–2015, the median time to
transplantation was 12.4 months. Among adults, there was an increase in the
number of candidates >65 years (14% in 2008 vs. 18% in 2015) [17]. Among all
age groups, there was an increase in cardiomyopathy as a primary diagnosis
(44.7% in 2005 vs. 57.5% in 2015) and a decrease in both congenital heart disease
as a primary diagnosis (5.6% in 2005 vs. 3.7% in 2015), and coronary artery
disease (CAD) as a primary diagnosis (41% in 2005 vs. 33% in 2015) [17].
Finally, the percentage of patients classified as 1A or 1B has increased
dramatically (13.2% in 2005 vs. 53.8% in 2015) [17]. The reduction in waiting
list mortality and increases in category 1A and 1B candidates may be in part due to
the impact of VADs.
TABLE 17.1 United Network for Organ Sharing (UNOS) listing criteria for heart
transplantation
A. Cardiac transplantation indications

Indications for heart transplantation are listed in Table 17.2 [21]. Potential
cardiac transplant candidates must have all reversible causes of HF excluded,
and their medical management optimized.
B. Cardiac transplantation contraindications
3 There has been a gradual relaxation in the cardiac transplantation exclusion
criteria as experience with increasingly complex cases has grown [2]. Absolute
exclusion criteria have been simplified (Table 17.3) [21].
Increased preoperative pulmonary vascular resistance (PVR) predicts early
graft dysfunction and increased mortality, due to an increased incidence of right
heart dysfunction [21–23]. Methods used to quantify the severity of pulmonary
hypertension (HTN) include calculation of PVR and the transpulmonary gradient
(mean PA pressure − pulmonary capillary wedge pressure [PCWP]). At most
centers, patients are not considered orthotopic cardiac transplant candidates if
they demonstrate a PVR >5 Wood units or transpulmonary gradient >15 mm Hg
without evidence of pharmacologic reversibility [23]. The reversibility of
pulmonary HTN can be evaluated by vasodilator administration, including IV
sodium nitroprusside, inhaled nitric oxide (iNO), and inhaled epoprostenol
(PGI2). In patients who receive VADs, “fixed” elevated PVR may be reduced
and thus improve posttransplant outcome, or qualify a previously excluded
patient for heart transplant [21–23]. The only transplant options for patients with
severe irreversible pulmonary HTN include heterotopic cardiac or combined
heart–lung transplantation (HLT).
TABLE 17.2 Indications for heart transplantation
TABLE 17.3 Contraindications to heart transplantation
III. The cardiac transplant donor

A. Donor selection
The primary factor limiting cardiac transplantation is a shortage of donors.
Standard criteria for donors, first outlined in the 1980s, resulted in a paucity of
donor organs relative to the number of patients who could benefit from heart
transplantation. In an attempt to increase donor numbers, the criteria for cardiac
organ donation have been relaxed. So-called “marginal donor” hearts may be
transplanted into borderline heart transplant candidates with good results when
compared to their expected prognosis without transplantation [24].
Characteristics of marginal donors include older age (>55 years), the presence of
CAD, donor/recipient size mismatch, history of donor drug abuse, increased
ischemic times, and donor seropositivity for viral hepatitis [24–26].
Nonetheless, the risk of failed transplantation has been shown to increase with
increased donor age, LV hypertrophy, and the presence of concomitant disease
[26]. In an effort to further expand the donor pool, donation after circulatory
death (DCD) for heart transplantation has been described recently using ex vivo
perfusion. Early evidence suggests that with strict limitations and the use of ex
vivo perfusion systems, DCD donation for heart transplantation may be feasible
[25,27]. Contraindications to heart donation are listed in Table 17.4.
TABLE 17.4 Contraindications to heart donation
Before a donor heart may be harvested, permission for donation must be

obtained, the suitability of the heart for donation must be ascertained, and the
diagnosis of brain death must be made. Initial functional and structural evaluation
of the potential heart donor ought to be done with electrocardiography and
transthoracic echocardiography. Normal LV function predicts suitability for heart
transplantation, and subsequent management of the donor may be guided by other
invasive monitors such as PA catheters or serial echocardiography [ 24].
Coronary angiography may be performed on patients ≥40 years old [24]. Donor–
recipient factors such as size, ABO compatibility, and antihuman leukocyte
antigen (HLA)–antibody compatibility are also being assessed. Logistic factors,
including ischemic organ time must be considered. Finally, the harvesting
surgeon will directly inspect the donor heart [24].
B. Determination of brain death
In the US, The Uniform Determination of Death Act defines death as either (1) the
irreversible cessation of circulatory and respiratory functions, or (2) irreversible
cessation of all functions of the entire brain, including the brain stem. A
determination of death must be made in accordance with accepted medical
standards. For the diagnosis of brain death to be made, the patient’s core body
temperature must be >32.5°C, and no drug with the potential to alter neurologic
or neuromuscular function must be present.
C. Pathophysiology of brain death
When brain death results from severe brain injury, increased intracranial
pressure results in progressive herniation and ischemia of the brain stem.
Subsequent hemodynamic instability, endocrine, and metabolic disturbances
disrupt homeostasis, and may render organs unsuitable for transplantation (Table
17.5).
1. Cardiovascular function
In an attempt to maintain cerebral blood flow to the increasingly ischemic brain
stem, blood pressure (BP) and heart rate rise. While usually transient, this
adrenergically mediated “sympathetic storm” may precipitate
electrocardiographic and echocardiographic findings consistent with
myocardial ischemia [28,29]. Occasionally, severe systemic hypertension may
persist and require management [28,29]. Hypotension will affect most brain-
dead patients and may be refractory to pressors [28,29]. Hypotension may
result from hypovolemia caused by traumatic blood loss, central diabetes
insipidus (DI), or osmotic therapy for management of elevated intracranial
pressure. Loss of sympathetic tone resulting in blunted vasomotor reflexes,
vasodilatation, and impaired myocardial contractility also contributes to
hypotension [28,29]. Noxious stimuli may induce exaggerated hypertensive
responses mediated by intact spinal sympathetic reflexes that are no longer
inhibited by descending pathways. Despite optimal donor support, terminal
cardiac arrhythmias may occur within 48 to 72 hours of brain death.
TABLE 17.5 Incidence of pathophysiologic changes after brain stem death
2. Endocrine dysfunction
Dysfunction of the posterior pituitary gland occurs in a majority of brain-dead
organ donors. The loss of antidiuretic hormone (ADH) results in DI, which is
manifested by polyuria, hypovolemia, and hypernatremia [28,29].
Derangements in other electrolytes including potassium, magnesium, and
calcium may also occur as a result of DI. Dysfunction of the anterior pituitary
gland has been inconsistently described, with hemodynamic and electrolyte
disturbances attributable in part to loss of thyroid-stimulating hormone (TSH),
growth hormone (GH), and adrenocorticotropic hormone (ACTH) [28–30].
Plasma concentrations of glucose may become variable (most often elevated),
due to changes in serum cortisol levels, the use of catecholamine therapy,
progressive insulin resistance, and the administration of glucose-containing
fluids [29].
3. Pulmonary function
Hypoxemia resulting from lung trauma, infection, or pulmonary edema may
occur following brain death. Pulmonary edema in this setting may be
neurogenic, cardiogenic, or inflammatory in origin [29].
4. Temperature regulation
Thermoregulation by the hypothalamus is lost after brain death. Increased heat
loss occurs because of an inability to vasoconstrict, along with a reduction in
metabolic activity, which puts brain-dead organ donors at risk for hypothermia.
Adverse consequences of hypothermia include cardiac dysfunction,
arrhythmias, decreased tissue oxygen delivery, coagulopathy, and cold-induced
diuresis [28].
5. Coagulation
Coagulopathy may result from hypothermia and from dilution of clotting factors
following massive transfusion and fluid resuscitation. Disseminated
intravascular coagulation occurs in 28% to 55% of brain-dead organ donors
due to the release of tissue thromboplastin and activation of the coagulation
cascade by the ischemic brain [29].
D. Management of the cardiac transplant donor
Posttransplant graft function is in part dependent on optimal donor management
prior to organ harvesting. Strategies for the management of brain-dead organ
donors seek to stabilize their physiology through active resuscitation so that the
functional integrity of potentially transplantable organs is maintained [28,29].
1. Cardiovascular function
Donor systemic BP and central venous pressure (CVP) should be monitored
continuously using arterial and central venous catheters [26]. Goals include a
mean arterial pressure >60 to 70 mm Hg, a CVP of 6 to 10 mm Hg, urinary
output >1 mL/kg/hr, and an LV ejection fraction (LVEF) >45% [ 28,29]. The
initial treatment step in maintaining hemodynamic stability is maintenance of
euvolemia using aggressive replacement of intravascular volume with
crystalloids, colloids, and packed red blood cells (pRBCs) if the hemoglobin
(Hgb) concentration is <10 g/dL or the hematocrit is <30% [26,28].
If hemodynamic stability is not restored with fluid resuscitation, placement of
a PA catheter, use of echocardiography, or continuous CO monitoring should be
used to assess right and left-sided intracardiac pressures, CO, and systemic
vascular resistance (SVR) [28,29]. Use of inotropes and pressors should be
guided by these additional diagnostics. Dopamine and vasopressin are
recommended as first-line agents, with epinephrine, norepinephrine,
phenylephrine, and dobutamine utilized for severe shock [29]. However,
prolonged use of catecholamines at high doses should be avoided due to
potential downregulation of β-receptors on the donor heart, and the negative
impact this may have on graft function after cardiac transplant [28]. High-dose
α-adrenergic receptor agonists should be used cautiously, as peripheral and
splanchnic vasoconstriction may result in decreased perfusion of other
potential donor organs and metabolic acidosis. Vasopressin has catecholamine-
sparing effects without impairing graft function [26,28].
Hormonal replacement is indicated in brain-dead donors with hemodynamic
instability refractory to fluids, catecholamines, and vasopressin; however, its
efficacy has not been completely validated [29]. Regimens vary widely, but a
combination of thyroid hormone, corticosteroid, ADH, and insulin seem to
maximize organ yield [29]. All are part of the UNOS standard donor
management protocol.
2. Fluid and electrolytes
Hypernatremia (sodium >155 mEq/L) in the donor has been associated with
higher rates of primary graft failure, particularly in liver transplantation
[28,29]. Aggressive treatment of DI with 1-desamino-8-D-arginine vasopressin
(ddAVP) is indicated. IV fluids should be given to replace urinary losses and
to maintain urine output [29]. Normoglycemia (120 to 180 mg/dL) should be
achieved through the use of dextrose-containing fluids, and/or an insulin
infusion [29]. Metabolic acidosis and respiratory alkalosis should be
corrected, with a goal pH of 7.40 to 7.45 [29].
3. Pulmonary function
If lung procurement is also being considered, a lung protective management
protocol consisting of lower tidal volumes (6 to 8 mL/kg) and higher positive
end-expiratory pressure (PEEP) of 8 to 10 cm H2O and optimal positioning of
the patient (head of bed >30 degrees) should be initiated. Optimal volume
management with goal CVP of 6 to 8 mm Hg and PCWP of 6 to 10 mm Hg has
been shown to improve donor lung function without increasing other organ
(heart/liver/kidney) dysfunction [29].
Efforts to prevent pulmonary aspiration, atelectasis, and infection are
warranted. Neurogenic pulmonary edema should be managed with PEEP,
careful diuresis, and iNO in appropriate donors [29].
4. Temperature
Monitoring of core temperature is mandatory, as hypothermia adversely affects
coagulation, cardiac rhythm, and oxygen delivery. Use of heated IV fluids,
blankets, and humidifiers may prevent hypothermia.
5. Coagulation
Different transplant centers have individual guidelines for blood component
therapy for management of coagulopathy. In general, component therapy should
be guided by repeated donor platelet and clotting factor measurements.
Generally accepted goals include an international normalized ratio (INR) of
<1.5 and a platelet count of >100,000/mm3 [29]. Antifibrinolytics to control
donor bleeding are not recommended due to the risk of microvascular
thrombosis.
E. Anesthetic management of the donor
Anesthetic management of the donor during organ harvesting is an extension of
preoperative management. If the lungs are to be harvested, a lung protective
ventilation strategy should be employed as well as judicious fluid management to
keep the CVP <10 cm H2O [31]. Vasopressors to maintain adequate BP, hormone
replacement, and transfusion per institutional protocol to keep Hgb >8 g/dL and
to manage coagulopathy should be continued through the intraoperative period
[31]. Although intact spinal reflexes may result in hypertension, tachycardia, and
muscle movement, these signs do not indicate cerebral function or pain
perception. Nondepolarizing muscle relaxants may be used to prevent spinal
reflex-mediated muscle contraction.
CLINICAL PEARL Anesthetic management of the organ donor includes the use of
vasopressors to maintain adequate BP, lung protective ventilatory strategies, and
transfusion per institutional protocol to keep Hgb >8 g/dL.
F. Organ harvest technique
After initial dissection, the patient is fully heparinized. The perfusion-sensitive
organs (i.e., kidneys and liver) are removed prior to cardiectomy. The donor
heart is excised en bloc via median sternotomy after dissection of the pericardial
attachments. The superior and inferior venae cavae are ligated first, allowing
exsanguination. The aorta is cross-clamped and cold cardioplegia administered.
The aorta and pulmonary arteries are transected, leaving the native donor arterial
segments as long as possible. Finally, the pulmonary veins are individually
divided after lifting the donor organ out of the thoracic cavity. Most donor hearts
are currently preserved with specialized cold colloid solutions (e.g., University
of Wisconsin [UW], histidine-tryptophan-ketoglutarate [HTK], or Celsior
solution) and placed in cold storage at 4°C [32]. When this technique is used,
optimal myocardial function after transplantation is achieved when the donor
heart ischemic time is <4 hours [32].
IV. Surgical techniques for cardiac transplantation
A. Orthotopic cardiac transplantation
Over 98% of cardiac transplants performed are orthotopic. The recipient is
placed on standard cardiopulmonary bypass (CPB) and, if present, the PA
catheter withdrawn into the superior vena cava. The femoral vessels are often
selected for arterial and venous CPB cannulation in patients undergoing repeat
sternotomy. Otherwise, the distal ascending aorta is cannulated and bicaval
cannulae with snares placed, completely excluding the heart from the native
circulation. The aorta and pulmonary arteries are then clamped and divided.
Depending on the implantation technique (Fig. 17.3), either both native atria or a
single left atrial cuff containing the pulmonary veins is preserved. The native
atrial appendages are discarded because of the risk of postoperative thrombus
formation.
FIGURE 17.3 Surgical techniques for cardiac transplantation. A: Biatrial technique. The donor heart is anastomosed to
the main bulk of the recipient’s native right and left atria. B: Bicaval technique. The donor heart left atrium is anastomosed
to a single left atrial cuff, including the pulmonary veins, in the recipient. (From Aziz TM, Burgess MI, El Gamel A, et al.
Orthotopic cardiac transplantation technique: a survey of current practice. Ann Thorac Surg. 1999;68:1242–1246, with
permission.)
The donor heart is inspected for the presence of a patent foramen ovale. If
patent, it is surgically closed, as right-to-left interatrial shunting and hypoxemia
may occur in the presence of elevated right-sided pressures following
transplantation. The donor and recipient left atria are anastomosed first, followed
by the right atria, or cavae when a bicaval anastomotic technique is chosen. The
subsequent order of anastomoses varies depending on the donor heart ischemic
time and the experience of the surgeon. The donor and recipient aortas are joined
and the aortic cross-clamp removed with the patient in Trendelenburg position to
decrease air embolism. After completion of the PA anastomosis and placement of
temporary epicardial pacing wires, the heart is de-aired and the patient weaned
from CPB.
1. Biatrial implantation
Biatrial implantation is the technique originally described by Barnard. It
preserves portions of the recipient’s native atria to create two atrial
anastomoses (Fig. 17.3A). Biatrial orthotopic heart transplantation has been
performed successfully for over four decades and has the advantage of being
relatively simple and possibly faster to perform [33]. It is, however, falling out
of favor. The biatrial technique puts the sinoatrial node at risk of injury,
redundant atrial tissue may contribute to atrial dysrhythmias, and distortion of
the right atrium may contribute to a higher risk for tricuspid regurgitation [33].
Although patients receiving biatrial transplant experience a higher incidence of
permanent pacemakers (2.0% vs. 9.1%) and tricuspid regurgitation, no
definitive difference in long-term survival has been demonstrated [33–35].
2. Bicaval implantation
The bicaval implantation technique is a modification of the biatrial technique.
Only a single, small left atrial cuff containing the pulmonary veins is preserved
in the recipient. Bicaval and left atrial anastomoses are performed (Fig.
17.3B). The bicaval technique is growing in popularity, particularly at higher
volume transplant centers [33]. Demonstrated advantages of the bicaval
technique include a higher incidence of postoperative sinus rhythm, lower right
atrial pressures, a reduced need for permanent pacemaker, and lower incidence
of tricuspid regurgitation [33–35]. A decreased risk of perioperative mortality
may exist [33].
B. Heterotopic cardiac transplantation
Heterotopic transplantation accounts for less than 1% of cardiac transplantation
procedures per annum. In this technique, the recipient’s heart is not excised.
Instead, the donor heart is placed within the right anterior thorax, and
anastomosed to the recipient’s native heart such that a parallel circulation is
established. The recipient and donor atria are anastomosed, followed by the
aortas. An artificial conduit usually joins the pulmonary arteries, with the native
and donor right ventricles ejecting into the native PA. Similarly, both the native
and donor left ventricles eject into the native aorta. Thus, the recipient’s RV,
which is conditioned to eject against elevated PA pressures, will provide most
of the right-sided ventricular output, whereas the healthy donor LV will make the
major contribution to left-sided ventricular output. Situations in which
heterotopic cardiac transplantation may be advantageous include recipients with
severe pulmonary HTN, a small donor-to-recipient size ratio, and a marginal
donor heart [36]. Disadvantages of heterotopic cardiac transplantation include
relatively high operative mortality, a requirement for continued medical treatment
of the failing native heart, the potential for the native heart to be a
thromboembolism source, compromised pulmonary function due to placement of
donor heart in the right chest, and possible increased incidence of
tachyarrhythmias in both the native and heterotopic hearts [36].
V. Preoperative management of the cardiac transplant patient
A. Timing and coordination
When planning cardiac transplantation, important considerations include the time
required for donor organ transport and potential for failure to complete recipient
cannulation in a timely fashion (e.g., repeat sternotomy). Since the timing of heart
transplants is dictated by donor availability, transplantation can take place at any
hour of the day. Ideally, to minimize ischemic time, anesthetic induction of the
recipient should be timed so that the recipient is already on CPB when the donor
heart arrives. However, since the attendant risks of general anesthesia are
magnified in the recipient, who by definition has advanced HF, induction of
anesthesia ought to be delayed until a definitive “go” is received from the
harvesting team.
B. Preoperative evaluation
The anesthesiologist usually has limited time for preoperative assessment of the
cardiac transplant recipient. The presentation of this patient population varies
widely, from a stable outpatient requiring no inotropic or mechanical support to a
critically ill inpatient requiring cardiac support ranging from inotropes to IABP
to extracorporeal membrane oxygenation (ECMO) [37]. These recipients will
have been under the care of a medical team experienced in the management of
HF, and their medical therapy is likely to have already been optimized. When the
recipient is already admitted to the intensive care unit (ICU), all aspects of their
ongoing care should be reviewed, including pulmonary status and ventilation
settings, presence of invasive monitors and existing venous access, use of
inotropes and/or pressors, and the use of MCS devices. In any case, the
preoperative anesthetic evaluation should include a thorough history, physical
examination, review of the patient’s medical record, and assessment of the
patient’s functional status [37]. The electrocardiogram (ECG), echocardiogram,
chest x-ray, and cardiac catheterization results should be noted, and all
hematologic, renal, and liver function tests reviewed.
1. Concomitant organ dysfunction
Chronic systemic hypoperfusion and venous congestion in the recipient may
produce reversible hepatic and renal dysfunction. Mild to moderate elevations
of hepatic enzymes, bilirubin, and prolongation of prothrombin time are
common. Preoperative hepatic dysfunction and anticoagulant medication may
also contribute to the abnormal coagulation profile frequently observed in
cardiac transplant recipients. Blood urea nitrogen is commonly elevated in
patients with end-stage heart disease due to chronic hypoperfusion and the
concomitant prerenal effects of high-dose diuretics.
2. Preoperative medications
Preoperative inotropic support should be continued throughout the pre-CPB
period. Patients receiving digitalis and diuretics have an increased risk of
dysrhythmias in the presence of hypokalemia. Anticoagulants such as warfarin,
heparin, and aspirin may increase the need for perioperative blood product
administration.
3. Preoperative monitoring
The position, function, and duration of invasive monitoring catheters should be
noted. The function and settings of IABPs and VADs should be reviewed. If a
CIED is present, it should be interrogated and the antitachyarrhythmia/rate
responsiveness functions suspended in the operating room after external
defibrillation pads have been applied [37]. Patients with invasive monitoring
and/or MCS require extra personnel and vigilance to ensure safe transport from
the ICU to the operating room.
4. The combined heart–lung recipient
The combined heart–lung transplant recipient often requires special
preoperative evaluation. Cystic fibrosis recipients should first have an
otolaryngologic evaluation before being placed on a waiting list. Many of these
patients will require endoscopic maxillary antrostomies for sinus access and
monthly antibiotic irrigation. This measure has decreased the incidence of
serious posttransplant bacterial infections in that patient population. Previous
smokers must undergo screening to exclude malignancy. A negative sputum
cytology, thoracic CT scan, bronchoscopy, and otolaryngologic evaluation are
required. In addition, left heart catheterization, coronary angiography, and a
carotid duplex scan may be performed in previous smokers.
VI. Anesthetic management of the cardiac transplant recipient
A. Premedication
The HF patient has elevated levels of circulating catecholamines and is preload
dependent. Even a small dose of sedative medication may result in vasodilatation
and hemodynamic decompensation. Therefore, sedatives should be avoided or
carefully titrated, along with supplemental oxygen.
CLINICAL PEARL The HF patient presenting for heart transplant has high circulating
catecholamine levels and is preload dependent, and small doses of sedative medications
may cause vasodilatation and hemodynamic decompensation.
Patients presenting for cardiac transplantation should be considered “full
stomach,” as most present with short notice. If oral cyclosporine or azathioprine
is started preoperatively, gastric emptying is slowed. Oral sodium citrate and/or
IV metoclopramide may be useful in raising gastric pH and reducing gastric
volumes.
B. Importance of aseptic technique
Perioperative immunosuppressive therapy places the cardiac transplant recipient
at increased risk of infection. All invasive procedures should be done under
aseptic or sterile conditions.
C. Monitoring
Noninvasive monitoring should include a standard 5-lead ECG, BP measurement,
pulse oximetry, capnography, and nasopharyngeal temperature. If not already in
situ, large-bore peripheral and central venous access should be obtained.
Invasive monitoring should include systemic arterial as well as central venous
and/or PA pressures and a urinary catheter. Intraoperative transesophageal
echocardiography (TEE) is standard practice [37]. A PA catheter may be helpful
in the post-CPB period, allowing monitoring of CO, ventricular filling pressures,
and calculation of SVR and PVR. Additional monitors (e.g., cerebral oximetry)
may be indicated in selected patients [37]. Traditionally, catheterization of the
right internal jugular vein is avoided to preserve this route for the
endomyocardial biopsies (EMBs) routinely performed to screen for myocardial
rejection. Nonetheless, difficulty with EMB by alternative routes has not been
reported in circumstances where the right internal jugular vein was used for
central access.
D. Considerations for repeat sternotomy
Many cardiac transplant recipients will have undergone previous cardiac surgery
and are at increased risk of inadvertent trauma to the great vessels or pre-existing
coronary artery bypass grafts during sternotomy. Patients having repeat
sternotomy should have external defibrillation pads placed before induction and
cross-matched, irradiated pRBCs available in the operating room prior to
sternotomy. The potential for a prolonged surgical dissection time in patients
with a “redo chest” may necessitate anesthetic induction earlier than usual in
order to coordinate with donor heart arrival. Other considerations for repeat
sternotomy include the potential for bleeding and the need for femoral or axillary
CPB cannulation.
E. Anesthetic induction
1. Hemodynamic goals
Cardiac transplant recipients typically have hypokinetic, noncompliant
ventricles sensitive to alterations in myocardial preload and afterload.
Hemodynamic priorities for anesthetic induction are to maintain heart rate (HR)
and contractility, avoid acute changes in preload and afterload, and prevent
increases in PVR. Inotropic support is very often required during anesthetic
induction and throughout the pre-CPB period. Owing to afterload sensitivity,
epinephrine or norepinephrine infusions are probably preferable to
phenylephrine or vasopressin infusions for BP support.
2. Aspiration precautions
Rapid sequence induction with maintenance of cricoid pressure should be
considered.
3. Anesthetic agents
Due to the slow circulation time in patients with end-stage HF, a delayed
response to administered anesthetic agents is common. IV anesthetics
commonly used for anesthetic induction of the cardiac transplant recipient
include etomidate (0.1 to 0.3 mg/kg) in combination with fentanyl (2.5 to 10
μg/kg) or sufentanil (5 to 8 μg/kg). High-dose narcotic regimens (e.g., fentanyl
25-50 ug/kg) have also been used successfully. Bradycardia occurring in
response to high-dose narcotics should be treated promptly, as CO in patients
with end-stage heart disease is HR dependent. Small doses of midazolam,
ketamine, or scopolamine help ensure amnesia, but should be used cautiously
as they may synergistically lower SVR and induce hypotension.
4. Muscle relaxants
Muscle relaxants with minimal cardiovascular effects (e.g., rocuronium,
cisatracurium, or vecuronium) are most commonly utilized. As an added
advantage, their relatively rapid onset facilitates rapid sequence induction in
patients at risk for aspiration [37].
F. Anesthetic maintenance
During the pre-CPB period, anesthetic goals include maintenance of
hemodynamic stability and end-organ perfusion. Most anesthetic maintenance
regimens are narcotic-based with supplemental inhalational agents and
benzodiazepines. Although most inhalational agents have negative inotropic
effects, low concentrations of these agents are usually well tolerated and
decrease the risk of awareness. Anesthetic depth can be difficult to assess in this
patient population, as the sympathetic response to light planes of anesthesia is
often blunted. The use of narcotic-based anesthetic regimens may also increase
the risk of awareness during anesthesia.
Antifibrinolytics such as tranexamic acid or epsilon-aminocaproic acid may be
administered following anesthetic induction to reduce bleeding.
G. Cardiopulmonary bypass (CPB)
CPB for cardiac transplantation is similar to that employed for routine cardiac
surgical procedures. Femoral venous and arterial cannulation sites are frequently
chosen in patients undergoing repeat sternotomy. Moderate hypothermia (28° to
30°C) is commonly used during CPB to improve myocardial protection.
Hemofiltration and/or mannitol administration is common during CPB, as
patients with HF often have a large intravascular blood volume and coexistent
renal impairment. Although immunosuppressive regimens vary among
transplantation centers, high-dose IV glucocorticoids such as methylprednisolone
are frequently administered prior to aortic cross-clamp release to reduce the
likelihood of hyperacute rejection. Immunosuppressive induction therapy with an
interleukin-2 receptor (IL2R) antagonist, or a polyclonal antilymphocyte
antibody, has been employed in over 50% of patients between 2009 and 2014 in
order to reduce the risk of T-cell rejection. [ 2]. However, no consensus on the
safety and efficacy of induction therapy exists [37,38]. The availability and
timing of immunosuppressive medications should be discussed with the
transplant team ahead of time.
VII. Postcardiopulmonary bypass (Post-CPB)
Prior to CPB termination, the patient should be normothermic and all electrolyte
and acid–base abnormalities corrected. Complete de-airing of the heart prior to
aortic cross-clamp removal is essential. TEE may be particularly useful for
assessing the efficacy of cardiac de-airing maneuvers. Inotropic agents may be
commenced prior to CPB termination. A HR of 90 to 110 beats/min, a mean
systemic arterial BP >65 mm Hg, and ventricular filling pressures of
approximately 12 to 16 mm Hg (CVP) and 14 to 18 mm Hg (PCWP) are often
required in the immediate post-CPB period. Although inotropic support is usually
required for several days, patients are often extubated within 24 hours and
discharged from the ICU by the third postoperative day. Clinical considerations in
the immediate postoperative period include:
A. Autonomic denervation of the transplanted heart
During orthotopic cardiac transplantation, the cardiac autonomic plexus is
transected, leaving the transplanted heart without autonomic innervation. The
transplanted heart thus does not 4 respond to direct autonomic nervous system
stimulation or to drugs that act indirectly through the autonomic nervous system
(e.g., atropine). The denervated, transplanted heart responds to direct-acting
agents such as catecholamines. Transient bradycardia and slow nodal rhythms
are common following aortic cross-clamp release. An infusion of a direct-acting
β-adrenergic receptor agonist such as isoproterenol or dobutamine is frequently
started prior to CPB termination, and titrated to achieve a HR around 100
beats/min. Newly transplanted hearts unresponsive to pharmacologic stimulation
may require temporary epicardial pacing. Although most initial dysrhythmias
resolve, some cardiac transplant recipients require placement of a permanent
pacemaker.
B. Right ventricular (RV) dysfunction
RV failure is a significant cause of early morbidity and mortality, and is one of
the most common causes of failure to wean from CPB [37]. Acute RV failure
following cardiac transplantation may be due to prolonged donor heart ischemic
time, mechanical obstruction at the level of the PA anastomosis, pulmonary
hypertension (both pre-existing and protamine induced), donor-recipient size
mismatch, and acute rejection [37]. RV distension and hypokinesis may be
diagnosed by TEE or direct observation of the surgical field. Other findings
suggesting RV failure include elevations in the CVP, PA pressure, or the
transpulmonary gradient (>15 mm Hg).
Goals for managing RV dysfunction include maintaining systemic BP, lowering
PVR, and minimizing RV dilation. Maintaining atrioventricular synchrony is
especially important in optimizing RV preload. Correction of electrolyte and
acid–base disturbances and the use of inotropic support may improve RV
function. Optimizing ventilator settings and the use of inhaled pulmonary
vasodilators may reduce RV afterload. Useful inotropes include epinephrine,
dobutamine, isoproterenol, and milrinone; the latter three agents may also reduce
pulmonary vascular resistance [37]. Inhaled pulmonary vasodilators include
prostacyclin (PGI2), prostaglandin E1 (PGE1), and nitric oxide (NO) [37]. Nitric
oxide selectively reduces PVR by activating guanylate cyclase in vascular
smooth muscle cells, producing an increase in cGMP and smooth muscle
relaxation. Little systemic effect is seen as it is inactivated by Hgb and has a 6-
second half-life. NO administration results in the formation of the toxic
metabolites nitrogen dioxide and methemoglobin. In the presence of severe LV
dysfunction, selective dilation of the pulmonary vasculature by NO may lead to
an increase in PCWP and pulmonary edema. PGI2 is an arachidonic acid
derivative with a half-life of 3 to 6 minutes. It binds to a prostanoid receptor and
causes an increase in intracellular cAMP, and consequently vasodilation. PGI 2
has been shown to be efficacious for over 20 years in heart transplant patients
[37]. Relative to NO, PGI2 is less costly, easier to administer and does not create
toxic metabolites. It may, however, cause a degree of systemic hypotension due
to its longer half-life, and may be implicated in increased bleeding due to
inhibition of platelet function [39]. RV failure refractory to medical treatment
may require insertion of a right VAD or institution of extracorporeal circulation.
CLINICAL PEARL RV dysfunction is a significant cause of early morbidity and
mortality following heart transplant, and managing RV dysfunction includes maintaining
systemic BP, lowering PVR, and minimizing RV dysfunction.
C. Left ventricular (LV) dysfunction
Post-CPB LV dysfunction may result from prolonged donor heart ischemic time,
inadequate myocardial perfusion, intracoronary embolization of intracavitary air,
or surgical manipulation. The incidence of post-CPB LV dysfunction is greater in
donors requiring prolonged, high-dose inotropic support prior to organ harvest.
Continued postoperative inotropic support with dobutamine, epinephrine, or
norepinephrine may be required.
D. Coagulation
Coagulopathy following cardiac transplantation is common, and perioperative
bleeding should be treated early and aggressively. Potential etiologies include
hepatic dysfunction secondary to chronic hepatic venous congestion,
preoperative anticoagulation, CPB-induced platelet dysfunction, hypothermia,
and hemodilution of clotting factors. After ruling out surgical bleeding, blood
product administration should be guided by repeated measurements of platelet
count and plasma coagulation. Due to an increased risk of infection and graft
versus host disease, all administered blood products should be cytomegalovirus
(CMV)-negative and irradiated or leukocyte-depleted. RBCs and platelets should
be administered through leukocyte filters. Desmopressin (DDAVP) has been
shown to reduce postoperative blood loss in selected surgical patients, but has
not been shown to reliably decrease transfusion requirements post-CPB [40].
E. Renal dysfunction
Renal dysfunction, as evidenced by increased serum creatinine and oliguria, is
common in the immediate postoperative period. Contributing factors include pre-
existing renal impairment, cyclosporine-associated renal toxicity, perioperative
hypotension, and CPB. Treatment of renal dysfunction includes optimization of
CO and systemic BP, as well as judicious use of diuretics to avoid volume
overload.
F. Pulmonary dysfunction
Postoperative pulmonary complications such as atelectasis, pleural effusion, and
pneumonia are common and may be reduced by ventilation using PEEP, regular
endobronchial suctioning, and chest physiotherapy. Bronchoscopy to clear
pulmonary secretions is often useful. Pulmonary infection in the
immunosuppressed recipient should be treated early and aggressively.
G. Hyperacute allograft rejection
Cardiac allograft hyperacute rejection is caused by preformed HLA antibodies
present in the recipient. There are several explanations for the pre-existing
antibodies that initiate hyperacute rejection. First, prior recipients of blood
transfusions may develop antibodies to major histocompatibility complex (MHC)
antigens in the transfused blood. Multiple pregnancies may also expose females
to fetal paternal antigens, resulting in antibody formation. Finally, prior
transplant recipients may have already formed antibodies to other MHC antigens,
so that they may be present at the time of a second transplant. Collectively, these
antibodies are formulated into a panel reactive antibody (PRA) score that
represents the percentage of the population to which the recipient will likely
react. Higher scores are thus associated with longer wait times because it takes
longer to find a donor without antibodies. Although extremely rare, hyperacute
rejection results in severe cardiac dysfunction and death within hours of
transplantation. Assisted MCS until cardiac retransplantation is the only
therapeutic option.
VIII. The role of intraoperative transesophageal echocardiography (TEE)
Intraoperative TEE is a valuable tool for the evaluation and management of the
cardiac transplant recipient. In addition to monitoring ventricular function, TEE in
the pre-CPB period may be used to identify intracavitary thrombus, estimate
recipient PA pressures, and evaluate the aortic cannulation and cross-clamp sites
for the presence of atherosclerotic disease. TEE may also be used in the post-CPB
period to evaluate the efficacy of cardiac de-airing, cardiac function, and surgical
anastomoses. The caval veins, left atrium, and pulmonary vein anastomoses should
be evaluated for any evidence of obstruction or distortion [41]. Stenosis of the
main PA should also be excluded by continuous-wave Doppler measurement of the
pressure gradient across the anastomosis. After orthotopic cardiac transplantation,
the long axis of the left atrium often appears larger than usual because of joining of
the donor and recipient left atria. Occasionally, excess donor atrial tissue may
obstruct the mitral valve orifice resulting in pulmonary HTN and RV failure. TEE
findings in the immediate post-CPB period frequently include impaired ventricular
contractility, decreased diastolic compliance, septal dyskinesis, and acute mild to
moderate tricuspid, pulmonic, and mitral valve regurgitation. Although LV size and
function is typically normal on long-term echocardiographic follow-up of healthy
cardiac transplant recipients, RV enlargement and tricuspid valve regurgitation
persist in up to 33% of patients. Persistent tricuspid valve regurgitation may result
from geometrical alterations of the right atrium or ventricle, asynchronous
contraction of the donor and recipient atria, or valvular damage occurring during
EMB.
IX. Cardiac transplantation survival and complications
Survival following cardiac transplantation in the US in 2008–2010 was 89.6%,
82.9%, and 77% at 1, 3, and 5 years, respectively [17]. These figures are
consistent across the adult range of ages, except for recipients aged 65 or older (1-
year survival of 85%) [17]. Beyond the first-year posttransplant, lower survival
was seen in recipients aged 18 to 35, African Americans and in retransplant
recipients (5-year survival of 73.8%, 72.2%, and 74.5%, respectively) [17].
Overall, 6-month, 1-, 3-, and 5-year survival after heart transplantation has
improved since 2004 (Fig. 17.4). Important causes of morbidity and mortality are
infection, acute rejection, graft failure and cardiac allograft vasculopathy (CAV),
renal insufficiency (RI) and malignancy. Other causes of long-term morbidity after
transplantation include hypertension, diabetes mellitus, and hyperlipidemia.
A. Infection
Infections in the early period (<30 days) are mainly nosocomial and bacterial in
nature, and account for 14% of deaths [2]. With the routine use of bacterial and
viral prophylaxis, there has been a significant reduction in pneumocystis
pneumonia infection and herpesviridae (including CMV) [42]. Beyond 30 days,
infection remains an important cause of mortality, reaching its peak as a primary
cause of death (32%) from 31 days to 1 year posttransplant [2].
FIGURE 17.4 Survival for adult heart transplants performed between January 1982 and June 2014, stratified by era of
transplant. (From Lund LH, Edwards LB, Dipchand AI, et al; International Society for Heart and Lung Transplantation. The
registry of the International Society for Heart and Lung Transplantation: thirty-third adult heart transplantation report—2016.
J Heart Lung Transplant. 2016;35(10):1158–1169.)
B. Acute rejection
Improvements in management have rendered acute rejection of the transplanted
heart a less common cause of death (9%) between 2009 and 2015 [2]. However,
up to 30% of recipients may experience rejection within the first year [17].
Female recipients are at higher risk than males, and the risk of rejection
decreases with increasing age of the recipient [17]. EMB remains the gold
standard for confirming acute allograft rejection. Repeated EMB is associated
with an increased incidence of tricuspid valve regurgitation.
C. Graft failure and cardiac allograft vasculopathy (CAV)
Graft failure is the leading cause of death in the first 30 days after transplant
(40%), presumably due to primary graft failure [2]. After 30 days, chronic
processes such as antibody-mediated rejection and CAV are more likely causes
of graft failure. Graft failure continues to be a significant cause of death after 1
year, accounting for 17% of deaths [2]. Graft failure confirmed due to CAV
becomes prominent between 1 to 3 years posttransplant, and accounts for 26% of
deaths [2]. The prevalence of CAV is 27% at 5 years and 47% at 10 years [ 2].
Significant CAV is defined angiographically by a stenosis of at least 50%. Unlike
atherosclerotic CAD, CAV is characterized by a diffuse intimal hyperplasia [42].
Nonimmune risk factors for CAV include hypertension, hyperlipidemia, diabetes
mellitus, explosive etiology of donor brain death, hyperhomocysteinemia, and
older donor age. Immune risk factors include HLA donor/recipient mismatch,
recurrent cellular rejection, and antibody-mediated rejection (high PRA score).
Aggressive management of risk factors is the primary strategy for preventing
CAV. The diffuse nature of the vasculopathy defies percutaneous or surgical
revascularization strategies.
D. Renal insufficiency (RI)
RI is a strong predictor of reduced survival after transplant. Defined as a serum
creatinine >2.5 mg/dL, or necessitating dialysis or kidney transplant, severe RI is
identified as the primary cause of death in a significant number of patients [43].
Risks for early RI, developing within 1 year of transplant, are increased donor
and recipient age, increased recipient serum creatinine at time of transplant,
presence of a VAD, female recipient, rapamycin use at discharge, and IL2R-
antagonist induction [43]. Fortunately, the incidence of impaired renal function
after heart transplant is decreasing, with 86% of patients transplanted between
1994 and 2005 being free of severe renal dysfunction at 5 years [2].
TABLE 17.6 Immunosuppressive agents
E. Malignancy
Presumably as a consequence of long-term immunosuppression, solid-organ
transplant recipients experience a higher risk for malignancy than does the
general population. Skin cancer is the most common malignancy in heart
transplant recipients, with incidence at 1, 5, and 10 years of 1.7%, 9.3%, and
18.1%, respectively [2]. Lymphoproliferative malignancies occur less frequently
than do malignancies of the skin, but their treatments are much less likely to be
curative. Incidence at 1, 5, and 10 years is 0.5%, 1.1%, and 1.9%, respectively
[2]. Mortality attributed to malignancy depends on time after transplant, and is as
high as 21% after 10 years [2].
F. Immunosuppressive drug side effects
Cardiac transplant recipients require lifelong immunosuppression. Protocols
vary among transplant centers; however, most regimens include triple therapy
with corticosteroids, a calcineurin inhibitor, and an antiproliferative agent [3].
Immunosuppressants increase the risk of infection and are associated with
numerous side effects (Table 17.6) [44]. Furthermore, chronic
immunosuppression increases the risk of malignancies including skin cancers;
lymphoproliferative malignancies; various adenocarcinomas; cancers of the lung,
bladder, kidney, breast, and colon; and Kaposi sarcoma.
X. Pediatric cardiac transplantation
In the US in 2015, children accounted for 13% of cardiac transplant recipients [2].
The primary indications for pediatric cardiac transplantation are complex
congenital heart disease and idiopathic dilated cardiomyopathy (DCM) [17]. At
present, the majority of pediatric heart transplants take place in children >1 year of
age at highly specialized pediatric centers [17]. Five-year survival rates for
transplant recipients younger than 1 year, ages 1 to 5 years, ages 6 to 10 years, and
ages 11 to 17 years are 71.2%, 78.4%, 87.5%, and 77.4%, respectively [17]. Like
adult programs, pediatric cardiac transplant programs face a severe donor heart
shortage. The use of implantable VADs for bridge-to-transplantation is limited by
the small body size of most pediatric transplant candidates, with only 21% of
pediatric heart transplant recipients being supported by a VAD [17].
XI. Combined heart–lung transplantation (HLT)
In 2014, only 27 HLTs were done in the US [ 2]. Donor procurement is of critical
importance to the success of the operation, especially with respect to lung
preservation. However, current techniques have led to safe procurement with
ischemic times up to 6 hours.
The operation is performed using a double- or single-lumen endotracheal tube
with the patient in the supine position. The surgical approach is generally through a
median sternotomy, with particular emphasis on preservation of the phrenic, vagal,
and recurrent laryngeal nerves [45]. After fully heparinizing the recipient, the
ascending aorta is cannulated near the base of the innominate artery, and the venae
cavae are individually cannulated laterally and snared. CPB with systemic cooling
to 28° to 30°C is instituted, and the heart is excised at the midatrial level. The
aorta is divided just above the aortic valve, and the PA is divided at its
bifurcation. The left atrial remnant is then divided vertically at a point halfway
between the right and left pulmonary veins. Following division of the pulmonary
ligament, the left lung is moved into the field, allowing full dissection of the
posterior aspect of the left hilum, being careful to avoid the vagus nerve
posteriorly. After this is completed, the left main PA is divided, and the left main
bronchus is stapled and divided. The same technique of hilar dissection and
division is repeated on the right side, and both lungs removed from the chest.
Meticulous hemostasis of the bronchial vessels is necessary, as this area of
dissection is obscured once graft implantation is completed. Once hemostasis is
achieved, the trachea is divided at the carina.
The donor heart–lung bloc is removed from its transport container, prepared, and
then lowered into the chest, passing the right lung beneath the right phrenic nerve
pedicle. The left lung is then gently manipulated under the left phrenic nerve
pedicle. The tracheal anastomosis is then performed, and the lungs ventilated with
room air at half-normal tidal volumes to inflate the lungs and reduce atelectasis.
The heart is then anastomosed as previously described. After separation from
CPB, the patient is usually ventilated with a FiO2 of 40% and PEEP at 3 to 5 cm
H2O, being very careful to avoid high inspiratory pressures that may disrupt the
tracheal anastomoses.
XII. Anesthesia for the previously transplanted patient
Many heart transplant recipients will undergo additional surgical procedures in
their lifetime. Common surgical procedures following cardiac transplantation are
listed in Table 17.7. Many of these subsequent surgical procedures are attributable
to sequelae of the transplant surgery itself, atherosclerosis, and
immunosuppression. Optimal anesthetic management of the previous transplant
recipient requires full understanding of the patient’s ongoing physiology and
pharmacology.
TABLE 17.7 Common surgical procedures following cardiac transplantation
A. Physiology of the previously transplanted patient

During orthotopic cardiac transplantation, the cardiac autonomic plexus is
transected, leaving the transplanted heart without autonomic innervation [46].
Due to the absence of parasympathetic innervation of the sinoatrial node, the
transplanted heart will exhibit a resting HR of 90 to 110 beats/min. In addition,
reflex bradycardia does not occur. Increases in HR and SV 5 in response to
stress are blunted, as they depend on circulating adrenal hormones. Although
most transplanted hearts have near-normal contractility at rest, stress may reveal
a reduction in functional reserve. The Starling volume–CO relationship,
however, tends to remain intact.
A higher rate of dysrhythmia is seen due to the absence of parasympathetic tone
coupled with conduction abnormalities. First-degree atrioventricular block is
common, and 30% of patients will have right bundle branch block [46].
B. Pharmacology of the previously transplanted patient
Autonomic denervation of the transplanted heart alters the pharmacodynamic
activity of many drugs (Table 17.8). Drugs that mediate their actions through the
autonomic nervous system are ineffective in altering HR and contractility. In
contrast, drugs that act directly on the heart are effective. The β-adrenergic
response of the transplanted heart to direct-acting catecholamines such as
epinephrine is often increased. Reflex bradycardia or tachycardia in response to
changes in systemic arterial BP is absent. Narcotic-induced decreases in HR are
frequently diminished in the transplanted heart. Drugs with mixed activity (e.g.,
dopamine and ephedrine) will mediate an effect only through their direct actions.
Vagolytic drugs such as atropine and glycopyrrolate will not alter HR, although
their peripheral anticholinergic activity remains unaffected. Anticholinergic
coadministration with reversal of neuromuscular blockade is still warranted to
counteract the noncardiac muscarinic effects of neostigmine or edrophonium.
C. Preoperative evaluation
A thorough medical history, physical examination, and review of the medical
record should be undertaken. Current medications should be noted. Particular
attention should be paid to determining cardiac allograft function, evidence of
rejection or infection, complications of immunosuppression, and end-organ
disease. Systemic HTN is common and a significant proportion of patients will
have CAV within 1 year of cardiac transplantation. The absence of angina
pectoris does not exclude significant CAD, because the transplanted heart is
denervated. The patient’s activity level and exercise tolerance are good
indicators of allograft function. Symptoms of dyspnea and HF suggest significant
CAD or myocardial rejection. The presentation of infection may be atypical in
immunosuppressed patients, with fever and leukocytosis often absent. Soft tissue
changes in the patient’s airway may occur due to lymphoproliferative disease and
corticosteroid administration. Cyclosporine may cause gingival hyperplasia and
friability. Hematocrit, coagulation profile, electrolytes, and creatinine should be
checked, because immunosuppressive therapy is commonly associated with
anemia, thrombocytopenia, electrolyte disturbances, and renal dysfunction.
Recent chest x-rays, ECGs, and coronary angiograms should be reviewed. More
than one P wave may be seen on the ECG in patients in whom cardiac
transplantation was performed using a biatrial technique (Fig. 17.5). Although
seen on the ECG, the P wave originating in the native atria does not conduct
impulses across the anastomotic line.
TABLE 17.8 Drug effects on the denervated heart
FIGURE 17.5 Transplanted heart electrocardiogram (ECG). The transplanted heart ECG is commonly characterized by
two sets of P waves, right-axis deviation, and incomplete right bundle branch block (with biatrial technique). The donor heart
P waves are small and precede the QRS complex, whereas P waves originating from the recipient’s atria (labeled as p) are
unrelated to the QRS complex. (From Fowler NO. Clinical Electrocardiographic Diagnosis. Philadelphia, PA: Lippincott
Williams & Wilkins; 2000:225, with permission.)
D. Anesthesia management
1. Clinical implications of immunosuppressive therapy
All cardiac transplant patients are immunosuppressed and consequently at
higher risk of infection. All vascular access procedures should be carried out
using aseptic or sterile technique. Antibiotic prophylaxis should be considered
for any procedure with the potential to produce bacteremia. Oral
immunosuppressive medication should be continued without interruption or
given IV to maintain blood levels within the therapeutic range. IV and oral
doses of azathioprine are approximately equivalent. Administration of large
volumes of IV fluids will decrease blood levels of immunosuppressants, and
therefore levels should be checked daily. Immunosuppressant nephrotoxicity
may be exacerbated by coadministration of other potentially renal toxic
medications such as nonsteroidal anti-inflammatory agents or gentamicin.
Chronic corticosteroid therapy to prevent allograft rejection may result in
adrenal suppression. Supplemental “stress” steroids should thus be
administered to critically ill patients or patients undergoing major surgical
procedures.
2. Monitoring
Standard anesthetic monitors should be used, including 5-lead ECG to detect
ischemia and dysrhythmias. Cardiac transplant patients frequently have fragile
skin and osteoporotic bones secondary to chronic corticosteroid administration.
Care with tape, automated BP cuffs, and patient positioning is essential to
avoid skin and musculoskeletal trauma. As for all patients undergoing
anesthesia, invasive monitoring should only be considered for situations in
which the benefits outweigh the risks. Importantly, cardiac transplant patients
have an increased risk of developing catheter-related infections with a high
associated morbidity and mortality. Intraoperative TEE permits rapid
evaluation of volume status, cardiac function and ischemia, and may be a useful
substitute for invasive monitoring. Should central venous access be required,
alternatives to the right internal jugular vein should be considered to preserve
its use for EMB. Careful monitoring of neuromuscular blockade with a
peripheral nerve stimulator is recommended in the previously transplanted
patient, as cyclosporine may prolong neuromuscular blockade following
administration of nondepolarizing neuromuscular blocking agents. In contrast,
an attenuated response to nondepolarizing muscle relaxants may be seen in
patients receiving azathioprine.
3. Anesthesia techniques
Both general and regional anesthesia techniques have been used safely in
cardiac transplant patients. In the absence of significant cardiorespiratory,
renal, or hepatic dysfunction, there is no absolute contraindication to any
anesthetic technique. For any selected anesthetic technique, maintenance of
ventricular filling pressures is essential, as the transplanted heart increases CO
primarily by increasing SV.
a. General anesthesia
General anesthesia is frequently preferred over regional anesthesia for
cardiac transplant patients, as alterations in myocardial preload and afterload
may be more predictable. Cyclosporine and tacrolimus decrease renal blood
flow and glomerular filtration via thromboxane-mediated renal
vasoconstriction. Thus, renally excreted anesthetics and muscle relaxants
should be used with caution in patients receiving these medications.
Cyclosporine and tacrolimus also lower the seizure threshold, hence
hyperventilation should be avoided. Elevations in the resting HR and a
delayed sympathetic response to noxious stimuli in cardiac transplant
recipients may make anesthetic depth difficult to assess.
b. Regional anesthesia
Many immunosuppressants cause thrombocytopenia and alter the coagulation
profile. Both the platelet count and coagulation profile should be within
normal limits if spinal or epidural regional anesthesia is planned. Ventricular
filling pressures should be maintained following induction of central neural
axis blockade to prevent hypotension caused by the delayed response of the
denervated, transplanted heart to a rapid decrease in sympathetic tone.
Volume loading, ventricular filling pressure monitoring, and careful titration
of local anesthetic agents may avoid hemodynamic instability. Hypotension
should be treated with vasopressors that directly stimulate their target
receptors.
4. Blood transfusion
The cardiac transplant recipient is at increased risk for blood product
transfusion complications. Adverse reactions include infection, graft-versus-
host disease, and immunomodulation. Use of irradiated, leukocyte-depleted,
CMV-negative blood products and white blood cell filters for blood product
administration reduces the incidence of adverse transfusion reactions. The
blood bank should receive early notification if the use of blood products is
anticipated, because the presence of reactive antibodies delaying cross-match
is not infrequent.
E. Pregnancy following cardiac transplantation
Despite an increased incidence of preeclampsia and preterm labor, increasing
numbers of cardiac transplant recipients are successfully carrying pregnancies to
term. In general, the transplanted heart is able to adapt to the physiologic changes
of pregnancy. Due to an increased sensitivity to the β-adrenergic effects of
tocolytics such as terbutaline and ritodrine, use of alternative drugs such as
magnesium and nifedipine may be considered. Although pregnancy does not
adversely affect cardiac allografts, the risk of acute cardiac allograft rejection
may be increased postpartum. All immunosuppressive drugs used to prevent
cardiac allograft rejection cross the placenta, though most are not thought to be
teratogenic.
XIII. Future directions
As medical management of HF continues to improve, a patient’s need for definitive
therapy with heart transplantation may become delayed or diminished. Based on
trends over the previous decade, it is to be expected that patients who do present
for heart transplant will have an increasing number and severity of comorbidities
[3]. The emerging role of MCS devices for destination therapy will also affect
future developments in heart transplantation [1]. Intensive investigation into the use
of stem cells and bioengineered organs may someday obviate the current organ
shortage. Continuing advances in our understanding of mechanisms of rejection are
likely to improve immunomodulation and delay graft failure. Improvements in
surveillance, such as intravascular ultrasound, may eliminate the need for routine
EMB. For the immediate future, however, heart transplantation continues to offer
patients with advanced HF their best opportunity for a better quality and length of
life.
PART II: LUNG TRANSPLANTATION
KEY POINTS
6. End-stage pulmonary disease (ESPD) is one of the five leading

causes of mortality and morbidity in adults in the US. ESPD results
from destruction of the pulmonary parenchyma and vasculature.
Lung transplantation is the definitive treatment for these patients.
7. Due to a severe shortage of suitable donor lungs, other therapeutic
options were developed that may offer alternatives to those patients
who otherwise might succumb to their disease while awaiting lung
transplantation.
8. For those patients with ESPD who develop cardiogenic shock due
to right ventricular (RV) failure or worsening respiratory failure
(hypoxia, hypercarbia, and acidosis), bridging to transplantation
may be a consideration (e.g., extracorporeal membrane oxygenation
[ECMO], Novalung, or Decap).
9. Because the number of lung transplant recipients far exceeds the
number of suitable lung donors, up to one-third of recipients die
while awaiting transplantation. Recently, improvements to the
method for allocation of lungs have served to decrease recipient
waiting time for transplantation.
10. Depending on the patient’s pathophysiology, there are several
surgical options: single-lung transplantation (SLT), bilateral
sequential lung transplantation (BSLT), en bloc double-lung
transplantation (DbLT), heart–lung transplantation (HLT), and
living-related lobar transplantation (LRT).
6 End-stage pulmonary disease (ESPD) is one of the five leading causes of mortality
and morbidity in adults in US. ESPD results from destruction of the pulmonary
parenchyma and vasculature. Lung transplantation is the definitive treatment for these
patients. Depending on the patient’s pathophysiology, there are several surgical options:
single-lung transplantation (SLT), bilateral sequential lung transplantation (BSLT), en
bloc double-lung transplantation (DbLT), heart–lung transplantation (HLT), and living-
related lobar transplantation (LRT). Prior to 1989, the most common type of lung
transplant was combined HLT. Currently BSLT has become the most common approach.
Due to a severe shortage of suitable donor lungs, other therapeutic 7 options were
developed that may offer alternatives to those patients who otherwise might succumb to
their disease while awaiting lung transplantation. Several improvements in the
management of a highly selected group of patients with emphysema via lung volume
reduction surgery (LVRS), patients with cystic fibrosis (CF) via newer antibiotic
agents, and patients with pulmonary hypertension via long-term prostacyclin therapy
have been reported as viable options. Likewise, for those patients with ESPD who
develop cardiogenic shock due to right ventricular (RV) failure or worsening
respiratory failure (hypoxia, hypercarbia, and 8 acidosis), bridging to transplantation
may be a consideration (e.g., extracorporeal membrane oxygenation [ECMO],
Novalung, or Decap).
XIV. Lung transplantation

A. Epidemiology
1. Total candidates. In the US, there are in excess of one million potential lung
transplant recipients among those suffering from ESPD.
2. Survival of candidates. Because the number of lung transplant recipients far
exceeds the number of suitable lung donors, up to one-third of recipients die
while awaiting 9 transplantation. Recently, improvements to the method for
allocation of lungs have decreased recipient waiting time for transplantation. In
May 2005, the lung allocation score (LAS) was adopted in the US [47]. This
system is based on the severity of the recipient’s disease coupled with medical
urgency for transplantation. The LAS attempts to balance the risk of death while
awaiting transplantation with posttransplant survival. Since the LAS has been
implemented, the total number of recipients on the waiting list has decreased by
50% and the total waiting time has also decreased from a median of 792 days
in 2004 to 200 days or less during the time period of 2005 to 2008 [48].
Statistics from August 2017 indicate that there are 1,763 lung recipients and 40
heart–lung recipients awaiting transplantation (Organ Procurement and
Transplantation Network, https://optn.transplant.hrsa.gov/data).
3. Total procedures. According to the most recent data supplied by the
International Society of Heart and Lung Transplant (ISHLT) Registry, a total of
55,795 lung transplants and 3,879 HLT have been performed through June 30,
2015 [49].
B. Pathophysiology of end-stage pulmonary disease (ESPD)
1. Parenchymal ESPD is classified as obstructive, restrictive, or infectious.
a. Obstructive diseases are characterized by elevation of airway resistance,
diminished expiratory flow rates, severe V/Q mismatching, and pronounced
air trapping. The most common cause is smoking-induced emphysema;
however, other causes include asthma and several comparatively rare
congenital disorders. Among these, α1-antitrypsin deficiency is associated
with severe bullous emphysema that manifests in the fourth or fifth decade of
life.
b. Restrictive diseases are characterized by interstitial fibrosis that results in a
loss of lung elasticity and compliance. Most fibrotic processes are idiopathic
in nature but they may also be caused by an immune mechanism or inhalation
injury. Interstitial lung diseases may affect the pulmonary vasculature as well;
therefore, pulmonary hypertension is frequently present. Functionally,
diseases in this category are associated with diminished lung volumes and
diffusion capacities, albeit with preserved airflow rates. Respiratory muscle
strength is usually adequate because of the increased work of breathing
experienced by this patient population.
c. The common infectious etiologic factors are associated with CF and
bronchiectasis.
(1) CF produces mucous plugging of peripheral airways leading to the
development of pneumonia, chronic bronchitis, and bronchiectasis. The
incidence of CF is 0.2% of live births in US.
(2) Smoking, α1-antitrypsin deficiency, and environmental exposures may
lead to the development of bronchiectasis.
2. Etiologic factors of end-stage pulmonary vascular diseases are (a) diffuse
arteriovenous malformations, (b) congenital heart disease with Eisenmenger
syndrome, or (c) pulmonary arterial hypertension (PAH). PAH is rare and most
frequently idiopathic. It is characterized by marked elevation of pulmonary
vascular resistance (PVR) secondary to hyperplasia of the muscular pulmonary
arteries combined with fibrosis and obliteration of the smallest arterioles.
C. Recipient selection criteria: Indications and contraindications
1. Recipient selection criteria and indications for lung transplantation are listed
in Table 17.9 [50]. Referral and listing of potential candidates are based on the
progression of the patient’s disease along with their risk of death on the waiting
list balanced with the likelihood of survival after transplantation; however,
each patient must be considered on an individual basis and subjected to
standardized selection criteria.
TABLE 17.9 Indications and contraindications for lung transplantationa
2. Relative and absolute contraindications to lung transplantation are listed in

Table 17.9. Although candidates for organ transplantation frequently have
abnormal physical or laboratory findings, such information must be
distinguished from concurrent primary organ failure or a systemic disease that
otherwise might disqualify candidacy. The relative contraindications to lung
transplant have changed as improvements in the medical management of
potential recipients have evolved. For example, coronary artery disease
(CAD), previous CABG and corticosteroid usage, once absolute
contraindications, are now not prohibitive, particularly if left ventricular (LV)
function is preserved and corticosteroid doses are moderate [51,52]. Another
highly controversial and debated issue is the transplantation of patients with
multiple or pan-resistant bacteria, in particular, patients with CF who
concurrently have been diagnosed with Burkholderia cepacia [53]. Although
the international guidelines do not regard the presence of B. cepacia as an
absolute contraindication to lung transplantation, there are multiple transplant
centers that limit organ allocation and treatment in these patients. It has been
reported in the literature that triple antimicrobial therapy can be bactericidal
toward multiresistant B. cepacia [54,55]. Ultimately, the decision to transplant
CF patients with this microbe rests with each transplant center, because the
previous data indicate a much higher incidence of preoperative and
postoperative morbidity and mortality in this population.
D. Medical evaluation of lung transplant candidates
All candidates are systematically evaluated by history, physical examination, and
laboratory studies. Additionally, pretransplant evaluation includes chest
radiographs, computerized tomography (CT) scans, arterial blood gas (ABG)
values, spirometric and respiratory flow studies, ventilation and perfusion
scanning, 6-minute walk test, right heart catheterization, and echocardiography.
On the basis of studies of the natural history of ESPD, specific laboratory criteria
for referral to most lung transplantation programs that depend on the specific
underlying disease have been developed (e.g., cardiac index less than 2 L/min/m2
in patients with PAH and FEV1 less than 30% predicted in patients with COPD
or CF). Most centers provide documentation of the evaluation results on a
summary sheet that is readily available to the anesthesiology team on short
notice.
E. Choice of lung transplant procedure
Choice of lung transplant procedure is based upon (a) the consequences of
leaving a native lung in situ; (b) the procedure most likely to yield the best
functional outcome for a given 10 pathophysiologic process; and (c) the relative
incidence of perioperative complications associated with a particular procedure.
Currently, the vast majority of lung transplants are performed using the BSLT
technique.
1. SLT
a. SLT can be selected for transplant recipients with noninfectious lung
pathophysiology. SLT is a frequent option for older patients with end-stage
pulmonary fibrosis or emphysema, as it poses a lower perioperative risk [56];
however, in patients with severe bullous emphysema, SLT may exacerbate
native lung hyperinflation and result in severe acute and/or chronic allograft
compromise secondary to compression atelectasis. Preoperative measurement
of the recipient static lung compliance has been suggested as a screening
technique to determine whether SLT alone, SLT plus LVRS, or BSLT is most
beneficial.
b. SLT offers several advantages over the less frequently used en bloc DbLT:
(a) SLT may extend the limited supply of donor organs to more patients but
has less functional reserve as a buffer for complications. It is also associated
with a worse outcome [49]; (b) SLT is feasible in many patients without the
use of cardiopulmonary bypass (CPB), so complications arising from
coagulopathic states are less frequent; and (c) bronchial anastomoses used in
SLT show a decreased rate of dehiscence compared to tracheal anastomosis
used for en bloc DbLT.
c. SLT involves pneumonectomy and implantation of the lung allograft. The
choice of the native lung to be extracted is determined preoperatively. The
lung with the poorest pulmonary function as delineated by V/Q scanning is
generally chosen for replacement by the allograft. If the native lungs are
equally impaired and pleural scarring is absent, the left lung is chosen for
relative technical simplicity:
(1) The native left pulmonary veins are more accessible than those on the
right.
(2) The left hemithorax can more easily accommodate an oversized donor
lung.
(3) The recipient’s left main stem bronchus is longer.
2. BSLT
a. Since 1996, there has been a proportional increase in adult BSLT for every
major indication for lung transplantation except for CF (which remains
essentially a 100% indication for BSLT) and in 2015 it accounted for 78% of
lung transplant procedures [49].
b. While SLT is still performed frequently for end-stage IPF and emphysema in
older recipients (>65 years of age), BSLT is also increasingly utilized for
these conditions. Between 1996 and 2015, the share of BSLT for these
conditions almost doubled [50].
c. BSLT is the procedure of choice for septic lung disease (e.g., generalized
bronchiectasis), CF, young patients with COPD, and PAH. In contrast to en
bloc DbLT, the BSLT procedure offers several advantages: (a) it permits two
lungs to be implanted without CPB; (b) it decreases the incidence of bronchial
anastomotic complications; and (c) it is less technically difficult.
d. In some instances, BSLT may lead to better functional outcomes in the
treatment of end-stage pulmonary hypertension.
3. HLT
a. The indications for HLT are diminishing as experience with isolated lung
transplantation evolves. The latter operation will suffice in most cases when it
is performed before irreversible heart failure (HF) occurs or in concert with
intracardiac repair of simple congenital defects. The total number of centers
performing HLT has increased from 37 in 2003 to 177 in 2015 due to the
addition of reporting centers to the ISHLT Registry. Participating centers
reported a total of 58 adult and pediatric HLT for calendar year 2015 [49].
b. HLT is indicated for patients with ESPD complicated by irreversible HF or
end-stage congenital heart disease with secondary pulmonary vascular
involvement (Eisenmenger syndrome). Specific pathologic diagnoses in
recipients include idiopathic PAH, COPD/emphysema with right heart failure,
acquired heart disease, CF, and fibrotic and granulomatous diseases of the
lung. Congenital heart disease and PAH remain the main indications for adult
HLT [49].
4. Living-related donor lobar transplantation
a. As of May 2006, 243 living-donor lobar transplants have been performed in
US. Although outcomes in adult recipients are similar to cadaveric
transplants, results in the pediatric recipient population are reported to be
superior to those who receive cadaveric allografts [57,58]. Improved function
and a decrease in the incidence of bronchiolitis obliterans have been noted.
Despite these findings, LRT is rarely performed.
b. Although lobar donation is considered to be a relatively safe procedure, one
group noted a 61% postoperative complication rate in the living donors.
Complications included pleural effusions, bronchial stump fistulas, phrenic
nerve injury, and bronchial strictures.
F. Selection criteria for donor lungs
1. Suitable lung allografts are characterized by PaO2 greater than 300 mm Hg
during mechanical ventilation with FiO2 of 1.0 and positive end-expiratory
pressure (PEEP) of 5 cm H2O; ABO compatibility; no chest trauma or
cardiopulmonary surgery; no aspiration sepsis; negative Gram stain
sputum; no purulent secretions.
2. The donor ideally should be younger than 55 years old with either no
smoking history or one of 20 pack-years or less [59].
3. Extended donor criteria: age >55 years; compatible nonidentical ABO group;
chest x-ray with focal or unilateral abnormality; PaO2 <300 mm Hg during
mechanical ventilation with FiO2 1.0 and PEEP of 5 cm H2O; smoking history
>20 pack-years; absence of extensive chest trauma; prior cardiopulmonary
surgery; secretions in upper airways; positive serology (e.g., hepatitis B or C)
[60].
4. In an attempt to provide a larger pool of suitable lung donors, the lungs from
non–heart-beating donors (donation after cardiac death) have been
transplanted and reported to produce a successful recipient outcome [61].
5. As experience in the field of genetic therapy continues to grow, cytokine
profiling has become an important method to identify organs suitable for
donation and transplantation. Fisher et al. [62] reported that elevated levels of
interleukin-8 in donor lungs were associated with early graft failure and
decreased recipient survival. These data suggest that cytokine profiles could be
an early indicator of recipient outcome.
6. Procurement procedure. Because both the heart and lungs are often harvested
from the same donor for different recipients, a method has been developed to
perform cardiectomy and reduce the risk of lung injury. During cardiectomy, a
residual atrial cuff is left attached to the donor lungs. The trachea is stapled and
divided at its midpoint, and the lungs are removed en bloc. Subsequently, the
pulmonary vasculature is flushed and immersed in a hypothermic preservative
(most commonly Euro-Collins or University of Wisconsin solution ±
prostaglandin E1 [PGE1]).
7. Lung allograft preservation
a. There are several relevant issues surrounding donor lung preservation;
however, all focus on methods to provide ready sources of energy and
cryoprotection and to prevent vasospasm, cellular swelling, and accumulation
of toxic metabolites. For example, free radical scavengers such as superoxide
dismutase and catalase can be added to prevent oxygen-derived free radicals
from damaging key intracellular constituents after reperfusion, and PGE1 can
be added to promote uniform cooling and distribution of preservative
solutions.
b. Standard preservation techniques allow a reported maximum allograft
ischemic time of 6 to 8 hours; however, ischemic times of 10 to 12 hours
may be tolerated depending on the preservative solution.
c. Normothermic ex vivo lung perfusion (EVLP) is a newer preservation
technique aimed at reconditioning and improving the function of marginal
donor lungs. The harvested donor lung is perfused in an ex vivo circuit using
an acellular normothermic perfusate while they are ventilated at body
temperature to mimic physiologic conditions. Cypel et al. [63] demonstrated
that transplantation of high-risk donor lungs that were physiologically stable
during 4 hours of EVLP had a lower incidence of primary graft dysfunction 72
hours posttransplant compared with controls.
8. Clinical immunology of organ matching. ABO matching is essential before
transplantation, because the donor-specific major blood group isoagglutinins
have been implicated as a cause of allograft hyperacute rejection. Once
procured, the practical matter of a 6- to 8-hour donor lung ischemic time limit
severely restricts prospective matching of histocompatibility antigens, panel
reactive antibody (PRA) screens, and the geography of organ donation. One
study suggests that the total ischemic time alone does not predict a poor
outcome after transplantation. Rather, the additive effect of increased donor age
(older than 55 years) plus increased ischemic allograft time (more than 6 to 7
hours) is a more reliable indicator of poor posttransplant survival [64].
G. Preanesthetic considerations
1. Because of a chronic shortage of suitable lungs available for transplantation,
many patients experience long waiting periods ranging from several months to
several years. Interval changes may occur since completion of the initial
medical evaluation. Specifically, reduction in exercise tolerance; new drug
regimens or requirements for oxygen and steroids; appearance of purulent
sputum; signs or symptoms indicative of right HF (e.g., hepatomegaly,
peripheral edema); or presence of fever are among the most common
occurrences that should be explored in the immediate preoperative period.
2. Lung transplants are always performed as emergency procedures because of the
relatively short safe ischemic time for allografts. As is customary for any
emergent surgical procedure, the time of last oral intake should be ascertained
before induction of general anesthesia.
3. Patients undergoing lung transplantation may exhibit signs and symptoms of
anxiety. They usually have not received the benefit of anxiolytic premedication
before their arrival in the operating room. One should be vigilant when
administering anxiolytic agents to these patients so that their impaired
respiratory drive is not further compromised.
CLINICAL PEARL One should be vigilant when administering anxiolytic agents to lung
transplant recipients so that their impaired respiratory drive is not further compromised.
4. Insertion of a thoracic epidural catheter for both intraoperative and
postoperative analgesia may be performed before induction of general
anesthesia. The catheter should be inserted at a spinal level that provides
appropriate anesthesia and analgesia in concordance with the surgical incision
site (e.g., T-4 to T-5 or T-5 to T-6) [ 65]. Alternatively, bilateral paravertebral
catheters may be inserted. Placement of a thoracic epidural catheter or bilateral
paravertebral catheters when anticoagulation is anticipated for CPB remains
controversial.
CLINICAL PEARL Regional anesthesia is an option for perioperative analgesia that
may be performed prior to induction of general anesthesia. A thoracic epidural catheter or
bilateral paravertebral catheters may be used for this purpose. Placement of these
catheters remains controversial when anticoagulation is anticipated for the use of CPB in
lung transplantation.
5. Chronically cyanotic patients are frequently severely polycythemic (hematocrit
greater than 60%) and may manifest clotting abnormalities. In these instances,
phlebotomy and hemodilution may be beneficial in minimizing the occurrence
of end-organ infarction.
6. Size matching between donor and recipient is facilitated by comparing the
vertical and transverse radiologic chest dimensions of the donor and recipient.
Organs are also matched on the basis of ABO compatibility, because the value
of histocompatibility matching is still unknown and requires time in excess of
the tolerable ischemic time for the lung allograft.
7. Some transfusion practices are specific for transplantation. For example,
CMV seronegative blood products must be available for seronegative
recipients if CMV sepsis is to be avoided. When transplantation of CMV-
negative donors and recipients occurs, leukocyte filters are used to reduce
exposure to CMV during transfusion of blood and blood products. Likewise, if
human leukocyte antigen alloimmunization is to be avoided, leukocyte-reduced
blood is necessary for transplant candidates, particularly if they require
transfusion before organ transplantation.
8. Close coordination and effective communication between the transplant team
and the organ harvesting team is vital so that excess allograft ischemic time is
avoided.
9. Arrangements should be made for intraoperative availability of a multimodality
ventilator for patients with the most severe forms of lung disease. Useful
ventilator settings include the ability to deliver minute volumes greater than
15 L/min (especially helpful if airway leaks are present); adjustable inflation
pressure “pop-offs” (to allow high inflation pressures to be delivered to
noncompliant lungs); adjustable respiratory cycle waveforms; and availability
of high levels of PEEP (e.g., 15 to 20 cm H2O during reperfusion pulmonary
edema).
10. iNO and inhaled nebulized prostacyclin have been proven effective for
treatment of pulmonary hypertension and early reperfusion injury in some
patients.
CLINICAL PEARL iNO and inhaled nebulized prostacyclin have been proven
effective for treatment of pulmonary hypertension and early reperfusion injury in some
patients.
H. Induction and maintenance of anesthesia
1. Preoperative laboratory studies. These studies are useful to predict
difficulties during the induction of general anesthesia. For example, air trapping
and diminished expiratory flow rates may exacerbate hypercapnia and lead to
hemodynamic instability during mask ventilation and after endotracheal
intubation. Elevated pulmonary artery (PA) pressures may indicate the
likelihood that CPB may be necessary.
2. Intraoperative monitoring
a. Bo th systemic and PA pressure monitoring are essential during lung
transplant procedures. Dyspnea, arrhythmias, RV dilation, and pulmonary
hypertension may complicate PA catheter insertion before induction of general
anesthesia. Oximetric PA catheters are useful in this setting to evaluate tissue
oxygen delivery in patients who are subject to sudden cardiac instability.
Some suggest that RV ejection fraction catheters may be useful for the
diagnosis of right HF. Radial arterial cannulation with or without femoral
artery cannulation is appropriate for monitoring of systemic arterial blood
pressure. Femoral arterial catheters may interfere with groin cannulation for
CPB; however, they can also serve as a means of quick access should VA
ECMO be required.
b. Pulse oximetry is especially useful for continuous monitoring of SpO2 during
stressful intervals, such as the onset of one lung ventilation (OLV) or cross-
clamping of the PA.
c. Near infrared reflectance spectroscopy (NIRS) monitoring has proven very
useful in monitoring the adequacy of cerebral oxygenation during both ECMO
and CPB as well as in detecting lower limb ischemia related to femoral
cannulation.
d. Transesophageal echocardiography (TEE) is perhaps the most useful monitor
available. TEE allows for (a) direct visualization of RV and LV wall motion
and function as well as assessment of intracardiac valvular function; (b)
assessment of PA and pulmonary vein anastomoses and blood flow; (c)
assessment of the elimination of intracardiac air that occurs during pulmonary
venous anastomosis; and (d) calculation of PA pressure as measured by color
Doppler flow velocity.
CLINICAL PEARL TEE is perhaps the most useful monitor available. TEE allows for
(a) direct visualization of RV and LV wall motion and function as well as assessment of
intracardiac valvular function; (b) assessment of PA and pulmonary vein anastomoses and
blood flow; (c) assessment of the elimination of intracardiac air that occurs during
pulmonary venous anastomosis; and (d) calculation of PA pressure as measured by color
Doppler flow velocity.
3. Intravenous (IV) access. Large-caliber IV catheters inserted peripherally and
centrally (e.g., 14-gauge peripheral IV; 8.5- to 9.0-Fr central venous
introducer), supplemented by a rapid infusion device, are essential for lung
transplant operations in which massive transfusion requirements are anticipated
(e.g., HLT for congenital heart disease with Eisenmenger syndrome; BSLT for
CF with pleural scarring). For patients with significant PAH and RV
dysfunction, preinduction femoral vascular access for rapid cannulation for
ECMO or CPB should be considered.
4. Positioning. Full lateral decubitus position is typically used during SLT, even
when CPB is anticipated (e.g., SLT for PPH). One groin is usually prepped into
the field to allow for the option of femoral cannula insertion for CPB. The
supine position is used for BSLT, facilitating either median sternotomy,
clamshell incision, or bilateral anterior thoracotomy incision.
5. “Pump standby.” This safeguard is prudent for patients with pulmonary
hypertension or borderline ABG values, even when SLT is planned.
6. Selection of anesthetic agents
a. Agents that promote hemodynamic homeostasis are preferred for induction of
general anesthesia. One example is etomidate and a nondepolarizing
neuromuscular blocking agent such as rocuronium, which may be used during
a modified rapid sequence induction technique. Modest amounts of fentanyl (5
to 10 μg/kg) administered IV may be used if indicated to control
cardiovascular responses to endotracheal intubation.
b. If early postoperative extubation is not planned, we recommend maintenance
of anesthesia using high doses of opioids (e.g., fentanyl 20 to 75 μg/kg)
supplemented with low doses of a potent inhaled agent (e.g., isoflurane 0.2%
to 0.6%) and a neuromuscular blocking agent. Thoracic Epidural Anesthesia,
in addition to providing excellent postoperative analgesia, may be used to
enhance general anesthesia intraoperatively. Continuous infusion of a local
anesthetic, such as 0.2% to 0.5% ropivacaine, provides ideal surgical
anesthesia and analgesia and allows for reduced doses of both IV opioids and
inhaled agents.
c. Nitrous oxide is generally avoided for the following reasons: (a) 100%
oxygen is almost always required to maintain an acceptable arterial saturation
during OLV; (b) bullae may expand and compress the residual normal lung
parenchyma, thus exacerbating V/Q mismatching; and (c) occult
pneumothoraces may occur.
7. Securing the airway. Lung isolation is required for optimal surgical exposure.
Both double-lumen endobronchial tubes (EBTs) and bronchial blockers are
useful for this purpose. A general discussion of these choices is provided in
Chapter 15.
a. Advantages of double-lumen EBTs in the setting of lung transplantation
include the following:
(1) Facilitation of lung isolation
(2) Ability to suction the nonventilated lung
(3) Ability to apply CPAP to the nonventilated lung
(4) Provision for postoperative independent lung ventilation
b. Left-sided EBTs (e.g., Broncho-Cath) are recommended for both right and left
SLTs as well as for BSLT (right-sided DLTs are still used for left SLT in
some centers). There is a higher incidence of right upper lobe obstruction
when right-sided double-lumen EBTs are used, because the right upper lobe
orifice is relatively close to the right main stem bronchus.
c. Selecting the correct size of EBT. In general, the largest-sized EBT that can
be placed without causing airway trauma is preferred to facilitate therapeutic
flexible bronchoscopy both intraoperatively and postoperatively. This is
typically 39 Fr for a male and 37 Fr for a female recipient. CF patients are
generally of lesser build and may require a 35-Fr EBT.
d. Many lung transplant recipients have limited pulmonary reserve, and
desaturation during intubation may occur rapidly. Therefore, initial EBT
positioning can be accomplished quickly and accurately with the aid of a
flexible FOB.
CLINICAL PEARL Many lung transplant recipients have limited pulmonary reserve, and
desaturation during intubation may occur rapidly. Therefore, initial EBT positioning can be
accomplished quickly and accurately with the aid of a flexible FOB.
8. Management of ventilation
a. Lateral decubitus positioning may be associated with significant alterations
in oxygenation and ventilation, depending on the underlying pulmonary
pathophysiology. Positional improvement or deterioration in blood gas values
is sometimes predictable on the basis of the patient’s preoperative V/Q scan.
b. General strategies for supporting oxygenation during OLV (i.e., during SLT
and BSLT) are discussed in Chapter 15.
c. Alteration of the inspired to expired ratios during mechanical ventilation may
be useful during SLT in patients with emphysema. Increasing the expiratory
time during each respiratory cycle allows for adequate exhalation, thus
reducing the possibility of overinflation of the native lung (breath stacking)
and subsequent compromise of the allograft.
d. Similarly, independent or differential ventilation is often used during SLT
for emphysema recipients, particularly those with gross V/Q mismatching.
e. After allograft implantation, the lowest possible FiO2 to maintain adequate
oxygenation is used in concert with 10 cm H2O PEEP. In patients with
emphysema, independent lung ventilation allows PEEP to be selectively
delivered to the allograft and avoid air trapping and overinflation of the native
lung.
f. Frequent suctioning and lavage via flexible FOB is helpful to maintain
airway patency during BSLT for CF or whenever airway bleeding and
secretions are sufficient to cause obstruction and impair gas exchange.
I. Surgical procedures and anesthesia-related interventions
1. Surgical dissection may be complicated by extensive pleural adhesions,
vascular anomalies, vascular collaterals, or previous cardiac or thoracic
surgery.
2. OLV is almost always used during lung transplantation to facilitate dissection.
With the onset of OLV, acute deterioration in gas exchange and hemodynamics
must be anticipated. Strategies for improving oxygenation under these
circumstances include the following:
a. PEEP applied to the nonoperative (ventilated) lung provided that bullous
disease or emphysema is absent
b. CPAP or high-frequency jet ventilation in the operative (nonventilated) lung
c. Ligation of the branch PA of the operative lung
d. Initiation of mechanical circulatory support
3. Clamping the branch PA when PA pressures are low is usually well tolerated
and improves V/Q matching and ABG values. If elevated PA pressures
exacerbate right HF, vasodilators and inotropes may improve systemic
hemodynamics; however, gas exchange may be further impaired, depending on
the agents that are selected (e.g., sodium nitroprusside may worsen V/Q
mismatching). Should the patient’s condition deteriorate despite pharmacologic
intervention, implementation of CPB or ECMO should be considered.
4. Immediately before implantation of the donor lung, the donor hilar structures
are trimmed to match the size of the recipient bronchus, branch PA, and atrial
cuff containing the pulmonary venous orifices. While the allograft is kept
scrupulously cold, the bronchial anastomoses, atrial cuff, and PA anastomoses
are completed in sequence.
5. The ischemic interval ends with the removal of vascular clamps, but until
ventilation is restored, systemic arterial saturation remains unchanged.
Immediately before vascular unclamping, methylprednisolone (250 to 500 mg)
is administered IV to minimize the potential for hyperacute allograft rejection.
Reperfusion may be associated with systemic hypotension due to circulation of
vasoactive substances requiring preemptive adjustment of hemodynamic
support.
6. Reinflation of the allograft follows, sometimes with the aid of a flexible FOB
to clear airway secretions. This procedure allows for direct viewing of the
airway anastomosis to ensure patency.
7. After SLT for emphysema, independent lung ventilation can be instituted if
indicated using the anesthesia ventilator for the native lung (increased
expiratory time, low tidal volume, no PEEP) and an intensive care unit–quality
ventilator for the allograft (increased respiratory rates, low tidal volumes of 5
to 7 mL/kg, 10 cm H2O PEEP, and FiO2 ≤0.3).
8. Reperfusion injury, characterized by increasing alveolar–arterial gradients,
deteriorating compliance, and gross pulmonary edema, may follow allograft
reperfusion within minutes to hours. The most effective treatments are PEEP
and strict limitation of volume infusion, both crystalloid and colloid. Rarely,
reperfusion injury may be accompanied by pulmonary hypertension. Inhaled
NO (40 to 80 ppm) has been the agent of choice in this instance; however,
inhaled prostacyclin has also been effective in decreasing PA pressure [ 39]. If
evidence of right HF occurs, continuous IV infusion of norepinephrine (0.05 to
0.2 μg/kg/min), milrinone (0.375 to 0.5 μg/kg/min), or a combination of the two
may prove efficacious.
CLINICAL PEARL The most effective treatments for reperfusion injury are PEEP and
strict limitation of volume infusion, both crystalloid and colloid. Rarely, reperfusion injury
may be accompanied by pulmonary hypertension. Inhaled NO (40 to 80 ppm) has been the
agent of choice in this instance; however, inhaled prostacyclin has also been effective in
decreasing PA pressure.
9. At the conclusion of surgery, the EBT can be exchanged for a standard single-
lumen ETT or retained for independent lung ventilation in the intensive care
unit (ICU).
10. BSLT is used to treat the same spectrum of patients as those previously treated
by the en bloc DbLT procedure. BSLT is the preferred technique in many
centers. BSLT can often be accomplished without the use of CPB. Its major
disadvantage is that serial implantation prolongs the ischemic time for the
second allograft lung.
J. Postoperative management and complications
1. The immediate priorities are acute, intensive respiratory and cardiovascular
support.
a. Early respiratory insufficiency is usually due to reperfusion injury, which is
characterized by large alveolar–arterial O2 gradients, poor pulmonary
compliance, and parenchymal infiltrates despite low cardiac filling pressures.
Mechanical ventilation with PEEP is essential, but inflation pressures are kept
to a minimum in consideration of the new airway anastomoses.
b. FiO2 is maintained at the lowest levels compatible with an acceptable arterial
oxygen saturation.
c. Fifteen percent of lung transplant recipients may develop severe lung injury
secondary to reperfusion injury and lymphatic disruption during the surgical
procedure. This pattern of lung injury can be treated with ECMO, NO, or
selective lung ventilation if indicated.
d. Acute allograft dysfunction can occur and is associated with a mortality rate
of up to 60%.
e. Cardiovascular deterioration may be secondary to hemorrhage, PA or
pulmonary venous anastomotic obstruction, tension pneumothorax, or
pneumopericardium. TEE may be a useful diagnostic tool in the setting of
vascular obstructive lesions. Hemorrhage most frequently occurs in patients
with pleural disease and Eisenmenger syndrome. Tension pneumothorax
occurs more frequently in patients with concomitant end-stage emphysema.
2. Immunosuppressive drug regimens (Table 17.6) have been developed to
control the recipient’s immune response and prevent allograft rejection [66].
Clinical immunosuppression for lung transplant can be considered in several
different contexts: (1) induction therapy, (2) maintenance therapy, and (3)
antirejection therapy. Most centers use a triple-drug maintenance regimen that
includes corticosteroids, a calcineurin inhibitor (e.g., cyclosporine or
tacrolimus), and an antiproliferative agent (e.g., azathioprine). Although these
regimens may adequately control acute rejection, chronic rejection still
accounts for a majority of long-term morbidity and mortality.
a. Cyclosporine is a cyclic polypeptide derived from a soil fungus. Its major
actions are to inhibit macrophage and T-cell production of interleukins and to
block activation of helper T cells.
b. Azathioprine blocks de novo purine biosynthesis, which is important to both
DNA and RNA production, thus inhibiting both T- and B-cell proliferation.
c. Prednisone is an anti-inflammatory drug that suppresses helper T-cell
proliferation and interleukin production by T cells.
d. Tacrolimus is a macrolide antibiotic with immunosuppressant properties that
blocks interleukin production and proliferation of T lymphocytes. It is used as
a substitute for cyclosporine in the setting of acute allograft rejection.
Tacrolimus, in comparison to cyclosporine, has been associated with a lower
rate of rejection, similar infection rates, and increased incidence of new-onset
diabetes mellitus. It is effective in slowing progression of bronchiolitis
obliterans. Some suggest using tacrolimus as a primary immunosuppressive
agent for these reasons.
e. Approximately 50% of lung transplant centers also utilize induction therapy
with polyclonal antibody (antithymocyte globulin), interleukin-2 receptor
antagonists (daclizumab or basiliximab), or alemtuzumab.
3. The rate of postoperative infectious complications is higher in lung transplant
patients compared with other solid organ transplant recipients. Therefore, one
must be able to differentiate infection versus allograft rejection.
a. Several factors increase the susceptibility of transplanted lungs to infection:
(a) exposure to the external environment; (b) pulmonary lymphatic disruption;
(c) impairment of mucociliary function; (d) prolonged mechanical ventilation
predisposing the patient to nosocomial infection and airway colonization; and
(e) presence of airway foreign bodies (e.g., sutures).
b. Proper diagnosis is crucial to successful outcome and is usually performed
via a transbronchial biopsy using flexible FOB. Occasionally, open lung
biopsy is necessary.
c. During the initial 2 postoperative months, nosocomial gram-negative
bacteria are the most frequent causes of pneumonia. Thereafter, CMV
pneumonitis becomes more common and is associated with progression to a
state of chronic allograft rejection.
4. The vagus, phrenic, and recurrent laryngeal nerves are jeopardized during
lung transplantation. Their injury complicates weaning from mechanical
ventilation.
5. Postoperative airways complications include bronchial anastamotic
dehiscence, bronchial stenosis (most common), obstructive granulomas,
bronchomalacia, and bronchial fistula formation [67].
K. Outcome
1. Survival. Recent reports from the ISHLT Registry indicate that the median
survival is 5.8 years. The unadjusted benchmark survival rate was 89% at 3
months, 80% at 1 year, 65% at 3 years, 54% at 5 years, and 32% at 10 years
for the time period of January 1990 through June 2014 [49]. These rates are
slightly higher than previously reported.
a. Categorical risk factors significantly associated with mortality during the first
posttransplant year include recipient male gender, type of underlying lung
disease (e.g., COPD), pretransplant long-term steroid use, retransplantation,
earlier era of transplantation, increased severity of illness at the time of
transplantation (mechanical ventilation or dialysis), donor cause of death
other than anoxia, CVA or stroke or head trauma, higher mismatching of donor
and recipient HLA type, CMV mismatch and nonidentical donor and recipient
blood groups.
b. Continuous risk factors significantly associated with mortality include older
recipient and donor age at transplantation, lower transplant center volume,
shorter donor height, extremes of donor height minus recipient height
difference, lower donor–recipient BMI ratio, higher pretransplantation
bilirubin, higher amount of supplemental O2 at rest, lower percentage
predicted value of FVC, increased serum creatinine.
c. Post–lung-transplant morbidity factors include (a) hypertension, (b) renal
dysfunction, (c) hyperlipidemia, (d) diabetes mellitus, (e) bronchiolitis
obliterans, and (f) coronary artery vasculopathy.
2. Exercise tolerance has been shown to improve after lung transplantation, as
have the quality-of-life factors for survivors.
L. Special considerations for pediatric lung transplantation
1. Epidemiology
a. Since 1986, there have been 2,229 lung transplant procedures reported in
children 17 years old and younger [68].
b. CF, idiopathic PAH, interstitial lung disease, and proliferative bronchiolitis
obliterans account for almost all diagnoses in pediatric lung recipients. BSLT
is the most frequent procedure.
2. Outcome. One-year survival is currently comparable with that reported for
adults [68].
3. Pathophysiology. In children with severe developmental anomalies of the lung
(e.g., congenital diaphragmatic hernia with pulmonary hypoplasia,
cystadenomatous malformations), isolated lung transplantation may offer the
only chance for survival. Rarely, HLT may be indicated during childhood for
PPH, CF, or Eisenmenger syndrome.
4. Donor lungs. Size considerations place additional limitations on organ
matching for pediatric recipients and thereby exacerbate shortages. The
scarcity of suitable donor organs has propagated living-related lung lobe
donation; however, the success of this approach is somewhat uncertain. In
addition, donor and recipient morbidity and mortality inherent to this operation
have sparked considerable controversy.
5. Intubation. In smaller children, using DLTs is not feasible; instead, selective
endobronchial intubation with a conventional cuffed single-lumen tube is the
most frequent choice.
M. Anesthesia for the post–lung-transplant patient
In addition to certain specific considerations, several general principles apply to
all patients who have undergone successful lung transplantation, including the
toxicity of immunosuppressants, potential for infectious and malignant
complications, and interactions between immunosuppressants and other
pharmacologic agents (including anesthetics).
1. Cardiac denervation may result after en bloc DbLT because extensive
retrocardiac dissection is often necessary.
2. Airway anastomoses may be associated with chronic strictures and inadequate
clearance of secretions.
3. Toxic systemic effects of immunosuppressants
a. Cyclosporine is a potent nephrotoxin. Blood urea nitrogen and creatinine
levels increase and most patients develop systemic hypertension.
Cyclosporine can produce hepatocellular injury, hyperuricemia, gingival
hypertrophy, hirsutism, and tremors or seizures (at high serum levels).
b. Azathioprine suppresses all formed elements in the bone marrow. Anemia,
thrombocytopenia, and occasionally aplastic anemia may result. Azathioprine
is associated with hepatocellular and pancreatic impairment, alopecia, and
gastrointestinal distress. There may be an increased requirement in the dosage
of nondepolarizing neuromuscular blocking agents in this patient population.
c. Prednisone produces adrenal suppression, glucose intolerance, peptic
ulceration, aseptic osteonecrosis, and integument fragility. Controversy
surrounds the need to administer intraoperative “stress doses” of
glucocorticoids to patients with chronic adrenal suppression.
d. Tacrolimus exhibits a spectrum of toxicities (including nephrotoxicity)
similar to those for cyclosporine.
4. Infections
a. Early posttransplant bacterial infections are typically related to pneumonia
(Streptococcus pneumoniae; gram-negative bacilli), wound infection
(Staphylococcus aureus), and use of urinary catheters (Escherichia coli).
Because of the particular susceptibility of pneumonia, early extubation of the
trachea after general anesthesia is highly recommended.
b. CMV is the most frequent viral pathogen in lung transplant recipients and
results either from primary infection (after contaminated allograft implantation
or blood transfusion in seronegative recipients) or secondary to reactivated
infection in a seropositive patient.
c. After the first few months of immunosuppression, vulnerability to
opportunistic pathogens increases (CMV, Pneumocystis carinii, herpes
zoster). If diagnosis is rapid and treatment decisive, survival prevails.
Prophylactic antibiotic regimens are available and have been successful in
reducing the prevalence of some of these infections (e.g., trimethoprim-
sulfamethoxazole for P. carinii).
5. Posttransplant lymphoproliferative disorders are more likely to develop in
immunosuppressed patients. Posttransplant lymphoproliferative disorder is the
third leading cause of death outside the perioperative period, with an incidence
ranging from 1.8% to 20%. Other neoplasms have been associated with
immunosuppression, including (a) non-Hodgkin lymphoma; (b) squamous cell
carcinoma of the skin and lip; (c) Kaposi sarcoma; and (d) carcinoma of the
vulva, perineum, kidney, and hepatobiliary tree.
6. Drug interactions
a. Both cyclosporine and prednisone are metabolized by the cytochrome P450
enzyme system in hepatocytes. Drugs that inhibit those enzymes (e.g., calcium
channel blockers) may increase their serum concentrations and promote toxic
side effects.
b. Other drugs (e.g., barbiturates and phenytoin) may induce the P450 enzymes
and decrease cyclosporine levels below therapeutic range.
N. The future of lung transplantation
Lung transplantation is a viable therapeutic option for many patients with ESPD.
Although advances in surgical techniques, organ preservation, and perioperative
care have led to improved recipient survival and quality of life, a limited
availability of suitable donor organs remains an obstacle. Efforts to expand the
donor organ pool through the use of allografts from older donors and nonbeating
heart donation are continuing. These efforts, coupled with refinement of the organ
allocation and prioritization criteria, should ideally expedite transplantation for
the most critically ill patients. Development of perioperative optimization
protocols and a more widespread use of mechanical life support such as ECMO
have been instrumental in improving patient survival in both the pre- and
posttransplantation periods. Ongoing research about mechanisms, prevention, and
treatment of bronchiolitis obliterans offers hope that this devastating
complication can be reduced or eliminated.
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18 Arrhythmia, Rhythm Management Devices, and
Catheter and Surgical Ablation
Soraya M. Samii and Jerry C. Luck, Jr.
I. Introduction
II. Concepts of arrhythmogenesis
A. Basic electrophysiology
B. Mechanism of arrhythmia
C. Anatomical substrates and triggers
D. Neural control of arrhythmias
E. Clinical approach to arrhythmias
III. Treatment modalities
A. Pharmacologic treatment
B. Nonpharmacologic treatments
IV. Device function, malfunction, and interference
A. Pacemakers
B. Internal cardioverter–defibrillator (ICD)
V. Perioperative considerations for a patient with a cardiac implantable
electrical device (CIED)
A. Preoperative patient evaluation
B. CIED team evaluation
C. Device management
D. Precautions: Surgery unrelated to device
E. Management for system implantation or revision
VI. Catheter or surgical modification of arrhythmia substrates
A. Radiofrequency catheter ablation
B. Arrhythmia surgery
KEY POINTS
1. Patients with moderate-to-severe left ventricular dysfunction are at a
higher risk for sustained monomorphic ventricular tachycardia (VT)
than those with preserved left ventricular function.
2. VT commonly causes syncope, and when it is associated with
structural heart disease, it is also associated with a high risk of
sudden cardiac death.
3. Symptomatic patients with sinus node dysfunction (SND) or
evidence of other conduction disease such as second- or third-
degree atrioventricular (AV) block almost always need a permanent
pacemaker preoperatively.
4. For VT, intravenous (IV) amiodarone is the initial drug of choice,
but lidocaine may also be considered, especially if there is concern
for ongoing ischemia. For torsades de pointes, management
includes eliminating offending drugs in the setting of the long QT
syndromes.
5. Bifascicular block with periodic third-degree AV block and syncope
is associated with an increased incidence of sudden death.
Prophylactic permanent pacing is indicated in this circumstance.
6. The requirement for temporary pacing with acute MI by itself does
not constitute an indication for permanent pacing.
7. Sensor-driven tachycardia may occur with adaptive-rate devices that
sense vibration and impedance changes. Thus, we advise disabling
rate responsiveness in the perioperative period. Placing a magnet on
the pacemaker will usually deactivate the rate–responsiveness
feature and program the device to asynchronous pacing.
8. Most contemporary pacemaker devices respond to magnet
application by a device-specific single- or dual-chamber
asynchronous pacing mode. Adaptive-rate response is generally
suspended with magnet mode as well. With asynchronous pacing,
the pacemaker will no longer be inhibited by sensed activity and
will instead pace at a fixed rate regardless of underlying rhythm.
9. Some manufacturers, e.g., Biotronik, St. Jude Medical, and Boston
Scientific devices, have a programmable magnet mode that may
make response to magnet application different than anticipated.
Although rarely used, this feature may be programmed to save
patient-activated rhythm recordings with magnet application, rather
than revert the pacemaker to asynchronous pacing.
10. Electromagnetic interference (EMI) signals between 5 and 100 Hz
are not filtered because these overlap the frequency range of
intracardiac signals. Therefore, EMI in this frequency range may be
interpreted as intracardiac signals, giving rise to abnormal behavior.
Possible responses include (i) inappropriate inhibition or triggering
of stimulation, (ii) asynchronous pacing (Fig. 18.5), (iii) mode
resetting, (iv) direct damage to the pulse generator circuitry, and (v)
triggering of unnecessary ICD shocks.
11. Treatment options for VT include antitachycardia pacing,
cardioversion, or defibrillation. Up to 90% of monomorphic VTs
can be terminated by a critical pacing sequence, reducing the need
for painful shocks and conserving battery life. With antitachycardia
pacing, trains of stimuli are delivered at a fixed percentage of the
VT cycle length.
12. Acute MI, severe acute acid–base or electrolyte imbalance, or
hypoxia may increase defibrillation thresholds, leading to ineffective
shocks. Any of these also could affect the rate or morphology of VT
and the ability to diagnose VT.
13. Magnet application does not interfere with bradycardia pacing and
does not trigger asynchronous pacing in an ICD. Magnet application
in contemporary ICDs causes inhibition of tachycardia sensing and
delivery of shock only. All current ICDs remain inhibited as long as
the magnet remains in stable contact with the ICD. Once the magnet
is removed, the ICD reverts to the programmed tachyarrhythmia
settings.
14. Baseline information about the surgery is needed by the CIED team
(cardiologist, electrophysiologist, and pacemaker clinic staff
managing the device) such as (i) type and location of the procedure,
(ii) body position at surgery, (iii) electrosurgery needed and site of
use, (iv) potential need for DC cardioversion or defibrillation, and
(v) other EMI sources.
15. Pacemaker-dependent patients are at particular risk of asystole in the
presence of EMI. If EMI is likely (e.g., unipolar cautery in the
vicinity of the pulse generator or leads and surgery above the
umbilicus), then the device should be programmed to an
asynchronous mode. In most situations, this can be done with
magnet application, which will also inactivate the rate-responsive
pacing.
16. In cases where the pacemaker-dependent patient has an ICD or the
location of surgery precludes placement of a magnet, programming
the device to an asynchronous mode is recommended.
17. Use of a magnet eliminates the complexity of reprogramming the
CIED in the operating room. The magnet can be easily removed
when an underlying rhythm competes with asynchronous pacing.
I. Introduction
Any disturbance of rhythm or conduction or arrhythmia that destabilizes
hemodynamics perioperatively will need to be addressed. Treatment with
antiarrhythmic agents has been the standard approach to manage symptomatic
arrhythmias acutely. Device therapy indications have expanded for long-term
rhythm management. The emphasis in this chapter is on perioperative management
of patients with implanted devices. Concepts of arrhythmogenesis, antiarrhythmic
action, and drug selection are discussed only briefly.
II. Concepts of arrhythmogenesis
A. Basic electrophysiology
1. Action potential (AP). A ventricular muscle cell’s AP has five phases caused
by changes in the cell membrane’s permeability to sodium, potassium, and
calcium (Fig. 18.1). Phase 0 represents depolarization and is characterized by
a rapid upstroke, as sodium rapidly enters the cell. There is a rapid drop in the
cell’s impedance from a resting state at –80 to –85 mV. Phase 1 is an early
rapid repolarization period caused by potassium egress from the cell. Phase 2
is a plateau phase representing a slow recovery phase: The slow inward
calcium current is counterbalanced by outward potassium current. Phase 3 is a
rapid repolarization phase as a result of accelerated potassium efflux. The
diastolic interval between APs is termed phase 4 and is a cell’s resting
membrane state in atrial and ventricular muscle.
2. Ion channels. Electrical activation of cardiac cells is the result of membrane
currents crossing the hydrophobic lipid membranes through their specific
protein channel. Opening and closing of gates in these channels are determined
by the membrane potential (voltage dependence) and by the time elapsed after
changes in potential (time dependence). Membrane channels cycle through the
“activated,” “inactivated,” and “recovery” stages with each AP. Inward
currents of sodium and calcium ions enter the cell using this gating mechanism.
On the surface electrocardiogram (ECG), rapid-acting sodium currents
contribute to the “P” and the “QRS” complexes. Depolarization of the
sinoatrial (SA) node and the atrioventricular (AV) node, in contrast, occurs as
a result of the slower-opening calcium-dependent channels. The slowly
conducting calcium channel in the AV node creates the delay in the node and is
responsible for nearly two-thirds of the PR interval during normal conduction.
A group of potassium channels are responsible for repolarization and the “T”
wave on the ECG.
Cardiac arrhythmias occur when abnormal channel proteins are substituted
for the normal protein and the ion channel is altered. For example, QT
prolongation may be inherited as a result of encoding an altered gene or it may
be acquired as a consequence of an antiarrhythmic agent inhibiting a specific
ion channel [1].
3. Excitability. Reducing the cell’s transmembrane potential to a critical level
will initiate a propagated response, and this level is termed the threshold
potential. There are two mechanisms by which a propagated AP is developed:
(i) a natural electrical stimulus and (ii) an applied electrical current. For an
applied stimulus, threshold of a tissue is defined as the minimum amount of
energy that will elicit a response. When external electrodes are used, only that
part of the stimulus which penetrates the cell membrane contributes to
excitation. The size of the stimulating electrode is critical to threshold.
Reducing the size of the stimulating electrode (from 3 to 0.5 mm) will increase
the current density over a smaller area and decrease the amount of energy
needed to achieve threshold. It is common practice in pacing to use a small
stimulating electrode and a larger indifferent electrode to reduce threshold and
facilitate excitation.
4. Conduction. There are regions of cells with specialized conduction
characteristics within the heart that propagate conduction in a preferential
direction, spreading to adjacent areas faster though the preferential sites. This
allows for a more organized direction of conduction so that, for example, both
atria are depolarized prior to the stimulus reaching the AV node to depolarize
the ventricles. In the sinus and AV nodes, L- and T-type calcium channels are
the source of the propagated current [2]. In the Purkinje fiber, the sodium
channel is the source of the conducted current. Conduction velocity is much
slower at about 0.2 m/sec in the node versus 2 m/sec in the Purkinje cells.
These different characteristics explain the effects of certain antiarrhythmic
medications. For instance, blocking the sodium channel with a class I
antiarrhythmic agent will preferentially reduce the conduction velocity in the
Purkinje cells compared to the AV node because of this agent’s primary effect
on sodium channels.
B. Mechanism of arrhythmia (Table 18.1)
1. Automaticity. Automaticity is a unique property of an excitable cell allowing
spontaneous depolarization and initiation of electrical impulse in the absence
of external electrical stimulation. The SA node serves as the primary automatic
pacemaker for the heart. Subsidiary pacemakers exhibiting automaticity are
also found along the crista terminalis, the coronary sinus ostium, within the AV
junction, and in the ventricular His–Purkinje system. They may assume control
of the heart if the SA node falters. Automaticity is either normal or abnormal.
Alterations in automaticity due to changes in the ionic currents normally
involved in impulse initiation are considered normal. Examples of normal
automaticity include sinus tachycardia and junctional tachycardia during
catecholamine states that increase current through the T-type calcium channels
in the nodal cells. Abnormal automaticity occurs when ionic currents not
normally involved in impulse initiation cause spontaneous depolarizations in
atrial and ventricular muscle cells that normally do not have pacemaker
activity. An example of abnormal automaticity occurs during ischemic injury,
causing muscle cells to shift their maximum diastolic potential to a more
positive resting level and thus facilitate spontaneous depolarization [3].
FIGURE 18.1 Action potential (AP) and resting membrane potential (RMP) of a quiescent Purkinje fiber. Extracellular and
intracellular ion concentrations during phase 4 and the active and passive ion exchangers that restore intracellular ion
concentrations during phase 4 are shown to the right of the AP. Inward depolarizing and outward repolarizing currents are
shown below the AP. The adenosine triphosphate (ATP)-dependent Na/K pump maintains steep outwardly and inwardly
directed gradients (arrows) for K+ and Na+, respectively, and generates small net outward current. The passive Na/Ca
exchanger generates small net inward current. A small, inward “leak” of Na + keeps the RMP slightly positive to the K
equilibrium potential (−96 mV). AP phase 0 is the upstroke, phase 1 is initial rapid repolarization, phase 2 is the plateau, and
phase 3 is final repolarization. The cell is unresponsive to propagating AP or external stimuli during the absolute refractory
period. A small electronic potential ( A) occurs in response to a propagating AP or external stimulus during the relative
refractory period (RRP). It is incapable of self-propagation. A normal AP is generated at the end of the RRP (B), when the Na
channels have fully recovered from inactivation. It is capable of propagation. Note that threshold potential (TP) for excitation is
more positive during the RRP.
TABLE 18.1 Confirmed or postulated electrophysiologic mechanisms for clinical

arrhythmias
2. Triggered activity. Triggered activity is the result of abnormal oscillations in

membrane potential reaching the threshold to induce another AP, following a
normal AP depolarization. These afterdepolarizations can occur before full
repolarization has occurred, known as early afterdepolarizations (EADs), or
late after repolarization has occurred, known as delayed afterdepolarization
(DAD). Oscillations of either type of afterdepolarizations that exceed the
threshold potential may trigger an abnormal tachycardia.
EADs occur most frequently with delays in repolarization and prolongation
of the QT interval. Acquired and congenital QT prolongation syndromes are
predisposed to EADs and can result in torsades de pointes, sometimes known
as polymorphic ventricular tachycardia (VT) and sudden death. The torsades de
pointes, triggered in prolonged QT syndromes, is facilitated by bradycardia
and adrenaline. Examples of inherited predisposition to triggered initiation
include defects in genes encoding Na and K ion channels that produce a net
reduction in outward positive current during repolarization, resulting in
prolongation of the QT interval. Acquired prolongation of the QT interval from
hypokalemia, pharmacologic agents including class IA and III antiarrhythmics,
antibiotics such as erythromycin and antifungal agents, antihistamines, and the
phenothiazine piperidine class can cause EADs.
DAD potentials cause arrhythmias related to calcium overload. Digoxin
toxicity is the most common agent causing DAD, and triggered activity is the
common mechanism for digitalis-induced accelerated junctional rhythm and
bidirectional VT. Catecholamines facilitate calcium loading and the
development of DADs.
3. Reentry. For either anatomical or functional reentrant excitation to occur, the
electrical wave front must circle around a core of inexcitable tissue at a rate
that preserves an excitable gap. For initiation, there must be (i) an area of
unidirectional conduction block, (ii) two conduction pathways that are
connected at each end, and (iii) an area of slow conduction. Anatomical
reentrant circuits are common to several supraventricular tachycardias (SVTs),
including Wolff–Parkinson–White syndrome, with an accessory AV pathway
and typical and atypical AV nodal reentrant tachycardia. Classic atrial flutter
has an anatomical right atrial loop classically involving the area of slow
conduction known as the cavotricuspid isthmus. Pathologic sustained
monomorphic VT is commonly due to scar or fibrosis. This creates a
mechanism for anatomic reeentry.
A functional reentrant loop involves a small circuit around an area of tissue
with an inexcitable core. Functional reentry may occur with some forms of
atrial tachycardia and is a mechanism for the multiple wavelet theory of atrial
fibrillation.
C. Anatomical substrates and triggers
1. Supraventricular. The highly complex atria have a heterogeneous branching
network of subendocardial muscle bundles that create functional areas of block
as well as preferential planes of excitation. Longitudinal connected myocardial
fibers conduct faster than fibers connected along transverse or parallel lines
(the so-called anisotropic conduction). In the right atrium, the crista terminalis
and eustachian ridge tend to act as anatomical barriers that help to facilitate a
single reentrant loop during atrial flutter. An area of slow conduction can
usually be found in the isthmus of atrial tissue between the tricuspid annulus
and the inferior vena cava. This is a frequent anatomical area for ablation of
both clockwise and counterclockwise atrial flutter. The ostia of the pulmonary
veins are frequently the sites of the initiation of atrial fibrillation. This chaotic
atrial rhythm can be triggered by a single focus, frequently localized to a
pulmonary vein. Once initiated by a premature depolarization, the multiple
wavelets are facilitated by the complex nature of the atria.
2. 1 Ventricular. Myocardial ischemia and infarction can create both acute and
chronic substrates for VT and fibrillation. As discussed above, scar from
previous infarction can create an anatomic reentrant circuit, providing the
substrate for reentrant VT. In the acute events such as acute coronary occlusion,
metabolic derangements occur including local hyperkalemia, hypoxia, acidosis,
and an increase in adrenergic tone, increasing the likelihood for automaticity,
triggered activity, and functional reentry. With acute coronary occlusion,
ventricular fibrillation (VF) is common and is directly related to an increase in
sympathetic tone. Accelerated idiopathic ventricular rhythm is frequently seen
with acute myocardial infarction and is attributed to abnormal automaticity. In
the chronic phase, the infarct becomes mottled, and over several weeks, islands
of viable muscle cells are surrounded by electrically inert barriers of scar
tissue. Slow conduction is present and allows for unidirectional block. These
factors are conducive to reentry, which is the mechanism for sustained
monomorphic VT in about 6% to 8% of survivors of myocardial infarction.
Myocardial remodeling as a consequence of infarction provides a classic
substrate for arrhythmias. Patients with moderate-to-severe left ventricular
dysfunction are at a higher risk for sustained monomorphic VT than those with
preserved left ventricular function.
D. Neural control of arrhythmias
1. β-Adrenergic modulation. Increased sympathetic tone increases the
susceptibility to VF in the early stage of myocardial infarction. In the chronic
phase, it facilitates initiation of sustained monomorphic VT. β-Adrenergic
blocking drugs, propranolol, metoprolol, and nadolol significantly reduce the
incidence of VF during acute infarction and reduce the risk of sudden death
later. Also, β-Blockers do not prevent reperfusion arrhythmias.
2. Parasympathetic activation. During acute infarction, vagal activation exerts a
protective effect against VF. Bradycardia appears necessary for this protective
effect. Increasing heart rate by pacing will negate this protective effect. Vagal
stimulation does little to protect against reperfusion arrhythmias.
E. Clinical approach to arrhythmias
1. Syncope is defined as the loss of consciousness and muscle tone with
spontaneous resolution. It may occur in up to 40% of the general population.
The most common is vasovagal or neurally mediated syncope, which is quite
common in the young. This type of syncope is not associated with increased
risk of death. Syncope occurs at an annual rate of 6% in patients 75 years or
older but in only 0.7% of those below age 45. The goal is to determine if
syncope is of the benign vasovagal variety or of the more dangerous cardiac
type [4]. The 1-year mortality from syncope of a cardiac cause can range from
18% to 33%, while the noncardiac group has 0% to 6% mortality. Patients with
vasovagal-mediated syncope do not die from syncope. The anatomical cardiac
causes of syncope result in obstruction to cardiac output, such as aortic stenosis
and outflow obstruction in hypertrophic cardiomyopathy. Arrhythmias that
suddenly reduce cardiac output and profoundly affect blood pressure can cause
syncope. Sinus node dysfunction (SND) and AV block are common causes of
bradyarrhythmias that can cause syncope. SVT causes syncope less often. VT
more commonly causes syncope, and when it is associated with structural heart
disease, it is also associated with a high risk of sudden cardiac death. In
patients with syncope, check the ECG for arrhythmias such as atrial fibrillation,
evidence of myocardial infarction, or conduction disease such as bundle branch
block. Other important features to evaluate include preexcitation (delta waves),
the QT interval, and ectopy. Any of these abnormalities may predict a greater
risk of mortality and a need for further evaluation.
2. 2 Bradycardia. Heart rates less than 60 bpm are considered bradycardic.
Slow heart rhythms become an issue generally in older patients who may be
asymptomatic. Resting slow heart rates in young patients are most likely a
result of high vagal tone and are not pathologic. Heart rates greater than 50 bpm
tend to be hemodynamically stable, while those less than 40 bpm while the
patient is awake often are not. If the asymptomatic bradycardic patient has no
evidence of conduction disease (normal QRS morphology) and a chronotropic
response to exercise, atropine, or isoproterenol, a pacemaker is rarely
indicated. On the other hand, symptomatic patients with SND or evidence of
conduction disease such as second- or third-degree AV block almost always
need a permanent pacemaker preoperatively. Bradycardia secondary to
neurocardiogenic syncope, medications, or increased vagal tone will not
generally require a pacemaker. Simply removing the offending medicine or
treating the inciting condition will be sufficient.
3. 3 Tachycardia. Heart rates above 100 bpm are termed “tachycardia.” These
can be sinus, a pathologic SVT, or VT. Sinus tachycardia rarely exceeds 140
bpm at rest, unless the patient is in distress, shock, acute respiratory failure, or
thyroid storm. In adults not in distress, a narrow, regular QRS tachycardia at
rates above 150 bpm is rarely sinus. Regular and narrow QRS tachycardia at
these rapid rates is frequently paroxysmal supraventricular tachycardia (PSVT)
or atrial flutter with 2:1 conduction. Irregular SVTs are either the more
common atrial fibrillation or multifocal atrial tachycardia. The latter is seen in
elderly patients with severe chronic pulmonary disease.
Wide QRS tachycardia may be ventricular or supraventricular in origin. In
general, if the patient has underlying heart disease, the mechanism of the wide
complex tachycardia is VT, until proven otherwise. However, there are several
conditions in which the mechanism may be SVT, including (i) SVT with an
underlying or functional bundle branch block, (ii) SVT with nonspecific
intraventricular conduction delay, or (iii) preexcitation syndrome. The ECG
diagnosis of VT hinges on seeing AV dissociation or fusion or capture beats.
Intraventricular conduction delay can occur with the use of class I
antiarrhythmic agents or in the setting of extreme hyperkalemia. Wolff–
Parkinson–White syndrome should be considered in a young healthy individual
presenting with atrial fibrillation and a wide QRS rhythm. Functional bundle
branch block is seen in the young and rarely in the elderly.
III. Treatment modalities
A. Pharmacologic treatment
Algorithms are in place for acute treatment of SVTs. SVT is usually treated with
intravenous (IV) adenosine acutely in the symptomatic patient. For atrial
fibrillation, the initial focus is on rate control. Agents that are effective acutely
include IV diltiazem and the β-blockers metoprolol and esmolol. Esmolol has an
extremely short half-life. Digoxin is of little use acutely and is very
unpredictable. IV amiodarone is now being used more frequently in the acute
management of patients with poor ventricular function and atrial fibrillation with
rapid ventricular rates. This medication should ideally be infused through a
central line, given the risk for tissue necrosis with extravasation. The
pharmacologic treatment of ventricular arrhythmias in the hemodynamically
stable patient involves treating the underlying causes. For VT, IV amiodarone is
the initial drug of choice, but lidocaine is also considered, especially if there is
concern for ongoing ischemia. For torsades de pointes, management includes
eliminating offending drugs in the setting of the long QT syndromes. Correcting
electrolyte deficiencies with IV magnesium and potassium are particularly
helpful in correcting the prolonged QT interval, as possibly stopping medications
contributing to bradycardia. Amiodarone in the setting of torsades de pointes can
prolong the QT interval and make the problem worse. For the hemodynamically
unstable patient with sustained ventricular arrhythmias, pharmacologic
management would follow the current advanced cardiac life support (ACLS)
protocols.
4 Proarrhythmia. Although drugs have proved safe and effective in the
normal heart, their safety and efficacy have proved worrisome in the structurally
abnormal heart. Chronic drug therapy for arrhythmias in patients with structural
heart disease is associated with increased mortality due to proarrhythmic effects.
Class IA antiarrhythmic agents are contraindicated in individuals with congestive
heart failure and poor left ventricular function (ejection fraction below 0.30).
Class IC agents should be avoided in individuals with a prior myocardial
infarction because of the increased risk of sudden death [5]. Class III agents will
prolong the QT interval and increase the risk of torsades de pointes.
B. Nonpharmacologic treatments
The emphasis on the chronic treatment for arrhythmias, especially ventricular
arrhythmias in patients with structural heart disease, has moved from drugs to
electricity. Because of technologic advances, cardiac implantable electrical
devices (CIEDs) have become smaller and increasingly complex. This
complexity has greatly expanded therapeutic options, but it has greatly increased
the potential for unexpected medical device interference and, in rare cases,
malfunction in the perioperative setting. Except in infants and small children, a
formal thoracotomy is no longer used for implantation of a CIED.
1. External cardioversion and defibrillation. External direct-current (DC)
cardioversion differs from defibrillation, only in that the former incorporates a
time delay circuit for shock synchronization to the QRS complex of the surface
ECG. Current devices employ universal use of biphasic shocks, which lower
shock current requirements for DC cardioversion and defibrillation. Automated
external defibrillators self-analyze and give instructions for defibrillation.
a. Indications. Synchronized shocks are used for most pathologic
hemodynamically unstable tachycardias, except VF or VT when the QRS
complex cannot be distinguished from T waves. Automatic rhythm
disturbances (e.g., accelerated AV junctional or accelerated idioventricular
rhythms) are not amenable to DC cardioversion.
b. Procedure. Synchronized cardioversion with the largest R or S wave on the
ECG will prevent inadvertent triggering of VF. Improper synchronization may
occur when there is bundle branch block with a wide R wave, when the T
wave is highly peaked, and with pacing artifacts from a malfunctioning
pacemaker (i.e., failure to capture). Synchronization should be checked after
each discharge. Electrodes are placed in an anterior–lateral, posterior–
lateral, or an anteroposterior (AP) position. Current should pass though the
heart’s long axis, depolarize the bulk of myocardium, and minimize flow
through high-impedance bony tissue. Standard electrode pads with adhesive
gel are usually used to ensure effective skin contact and electrode stability.
The electrode paste or gel is used to reduce transthoracic impedance.
Bridging of the electrodes by conductive paste or gel should be avoided
because this will reduce the amount of energy delivered to the heart. Present-
day units automatically boot to an energy setting of 200 J. This is the starting
energy dosage for defibrillating adults. For cardioversion, energy titration
(initially use only the lowest possible energies) reduces both energy use and
complications. Initial settings of 20 to 50 J may be successful for terminating
typical atrial flutter or stable monomorphic VT. DC cardioversion is
extremely painful. Patients must be deeply sedated for DC cardioversion at
any power setting. In general, an anesthesiologist or nurse anesthetist will
administer a short-acting sedative such as IV propofol or etomidate. The
combination of midazolam and fentanyl can be an alternative but is not ideal
due to the prolonged duration of action.
c. CIEDs and cardioversion. External cardioversion has been shown to be safe
in the presence of CIEDs with proper electrode positioning [6]. Using the
anterior–posterior pads position and the anterior pad location at least 8 cm
from the CIED will prevent malfunction or damage to the device. Directly
applied currents on the CIED could cause a power-on-reset phenomenon.
Directly applied currents to the ventricles during open cardiac surgery on
occasion can also cause reset of the pulse generator. In general, interrogation
of the CIED system is recommended after cardioversion to confirm no
circuitry has been damaged.
2. Temporary pacing. Compared to drugs for treating cardiac rhythm
disturbances, temporary pacing has several advantages. The effect is
immediate, control is precise, and there is reduced risk of untoward effects and
proarrhythmia. The risks of temporary pacing involve placement of the
pacemaker electrode and ensuring pacemaker position stability.
a. Indications. Temporary pacing is indicated for rate support in patients with
symptomatic bradycardia or escape rhythms, usually with heart rates less than
40 bpm. Prophylactic or stand-by pacing is indicated for patients at increased
risk for sudden high-degree AV heart block. Temporary pacing can be used to
overdrive or terminate atrial flutter and some sustained monomorphic VT.
More specific established and emerging indications for temporary pacing are
shown in Table 18.2. The endpoint for temporary pacing is resolution of the
indication or implantation of a permanent pacemaker for a continuing
indication.
b. Technology. Transvenous endocardial or epicardial leads are usually used
for temporary pacing. Transvenous (endocardial) leads are passed from
above using the internal jugular or subclavian approaches or from below
using a femoral vein. Epicardial leads are routinely used in patients having
cardiac surgery. The noninvasive transcutaneous and transesophageal routes
are also available. Transcutaneous pacing is uncomfortable and used in
emergency situations, and capture is sometimes difficult to obtain. In the
operating room, it is for transient backup pacing only. It produces ventricular
capture and does not preserve optimal hemodynamics in patients with intact
AV conduction. With available technology for transesophageal pacing, only
atrial pacing is reliable. Thus, the method is not suitable for patients with
advanced AV block or atrial fibrillation.
3. Permanent pacing. Permanent pacemakers are no longer prescribed simply for
rate support. They have become an integral part of treatment, along with drugs
and other measures, to prevent arrhythmias and improve quality of life in
patients with conduction disease and heart failure [7].
TABLE 18.2 Usual and less-established indications for temporary cardiac pacing
a. Indications. The presence or absence of symptoms directly attributable to

bradycardia has an important influence on the decision to implant a permanent
pacemaker. There is increasing interest in multisite pacing as part of the
management for patients with structural heart disease and heart failure. In the
past, pacemakers were also prescribed to treat reentrant tachyarrhythmias.
Today, this capability can be programmed for either the atrium or ventricle as
part of “tiered therapies” with an internal cardioverter–defibrillator (ICD)
and in only a few pacemakers.
(1) AV block. Patients may be asymptomatic or have symptoms related to
bradycardia, ventricular arrhythmias, or both. There is little evidence
that pacing improves survival with isolated first-degree AV block. With
type I second-degree AV block due to AV nodal conduction delay,
progression to higher-degree block is unlikely. Pacing is usually not
indicated unless the patient has symptoms. With type II second-degree
AV block within or below the His bundle, symptoms are frequent,
prognosis is poor, and progression to third-degree AV block is common.
Pacing is recommended for chronic type II second-degree AV block. It is
recommended for type I second-degree AV block in the presence of
symptoms such as syncope. Pacing improves survival in both types of
second-degree AV blocks. Nonrandomized studies strongly suggest that
pacing improves survival in patients with third-degree AV block [7].
5 (2) Bifascicular and trifascicular block. Although third-degree AV block
is commonly preceded by bifascicular block, the rate of progression is
slow (years) [8]. Further, there is no credible evidence for acute
progression to third-degree AV block during anesthesia and surgery.
Bifascicular block with periodic third-degree AV block and syncope is
associated with an increased incidence of sudden death. Prophylactic
permanent pacing is indicated in this circumstance.
6 (3) AV block after acute MI. The requirement for temporary pacing with
acute MI by itself does not constitute an indication for permanent pacing.
The long-term prognosis for survivors of acute MI is related primarily to
the extent of myocardial injury and nature of intraventricular conduction
defects, rather than to AV block itself. Acute MI patients with
intraventricular conduction disturbances have unfavorable short- and
long-term prognoses, with increased risk of sudden death. This prognosis
is not necessarily due to the development of high-grade AV block,
although the incidence of such block is higher in these patients.
(4) SND. SND may manifest as sinus bradycardia, pause or arrest, or SA
block, with or without escape rhythms. It often occurs in association with
atrial fibrillation or atrial flutter (tachycardia–bradycardia syndrome).
Patients with SND may have symptoms due to bradycardia, tachycardia,
or both. Correlation of symptoms with arrhythmias is essential and is
established by ambulatory monitoring. SND also presents as
chronotropic incompetence (inability to increase rate appropriately). An
adaptive-rate pacemaker may benefit these patients by restoring more
physiologic heart rates. Although symptomatic SND is the primary
indication for a pacemaker, pacing does not necessarily improve
survival, but it can improve the quality of life.
(5) Hypersensitive carotid sinus syndrome or neurally mediated
syndrome. Hypersensitive carotid sinus syndrome is manifest by
syncope due to an exaggerated response to carotid sinus stimulation. It is
an uncommon cause of syncope. If purely cardioinhibitory (asystole,
heart block) and without vasodepressor components (vasodilatation),
then a pacemaker can be prescribed. A hyperactive response is defined
as asystole for longer than 3 seconds due to sinus arrest or heart block
and an abrupt decrease in blood pressure. With the more common
neurally mediated mixed response, attention to both components is
essential for effective therapy. Neurally mediated (vasovagal) syncope
accounts for nearly 25% of all syncope. The role of permanent pacing is
controversial but probably limited.
(6) Pacing in children and adolescents. Indications for pacing are similar in
children and adults, but there are additional considerations. For example,
what is the optimal heart rate for the patient’s age? Further, what is
optimal given ventricular dysfunction or altered circulatory physiology?
Hence, pacing indications are based more on correlation of symptoms
with bradycardia, rather than arbitrary rate criteria, and include the
following:
(a) Bradycardia only after other causes (e.g., seizures, breath holding,
apnea, or neurally mediated mechanisms) are excluded.
(b) Symptomatic congenital third-degree AV block
(c) Persistent, advanced second- or third-degree AV block after cardiac
surgery. However, for patients with residual bifascicular block and
intermittent AV block, the need is less certain.
(d) Use along with β-blockers in patients with congenital long QT
syndrome, especially with pause-dependent VT.
(7) Miscellaneous pacing indications
(a) A dual-chamber pacemaker with short AV delay reduces left
ventricular outflow tract obstruction, alleviates symptoms in
obstructive hypertrophic cardiomyopathy in some cases, and may
improve functional status. Permanent pacing does not reduce
mortality or prevent sudden death in this disease.
(b) Bradyarrhythmias after cardiac transplantation are mostly due to
SND. Cardiac transplantation today preserves the sinus node, so
SND is much less likely. Most patients with bradycardia show
improvement by 1 year, so that long-term pacing is unnecessary.
(c) A combination of pacing and β-blockers may be used for
prophylaxis for tachyarrhythmias in congenital long QT
syndrome. Pacing therapy alone is not recommended. Backup dual-
chamber defibrillator therapy is now preferred.
b. Technology. Current single- and dual-chamber and cardiac resynchronization
therapy (CRT) pacemakers are sophisticated devices with multiple
programmable features, including automatic mode switching, rate-adaptive
pacing, automatic threshold pacing, and programmable lead configuration.
Current pacemakers also allow for remote monitoring technology, so that
regular device follow-up can be done from home via a dedicated cellular line.
Older pacemaker systems may not have this updated technology and still
requires in-office and from-home magnet checks for routine follow-up of these
devices. Pacemakers are powered by lithium iodide batteries, with an
expected service life of 5 to 12 years, depending on device capabilities, need
for pacing, and programmed stimulus parameters. Most systems use
transvenous leads. Lead configuration is programmable. With the unipolar
configuration, the pacemaker housing (can) serves as anode (+) and the distal
electrode of the bipolar pacing lead as cathode (–). With the bipolar
configuration, proximal and distal lead electrodes serve as anode and
cathode, respectively. The ability to program unipolar pacing is necessary if
lead insulation or conductor failure occurs in a bipolar lead system. Also, it
permits exploitation of either configuration while minimizing its
disadvantages (e.g., oversensing with unipolar leads). A dual-chamber
pacemaker with automatic mode switching is optimal for patients with AV
block and susceptibility to paroxysmal atrial fibrillation. Algorithms detect
fast, nonphysiologic atrial rates and automatically switch the pacing mode to
one that excludes atrial tracking and the associated risk of upper-rate
ventricular pacing. There is also the recently Food and Drug Administration
(FDA)-approved leadless intracardiac pacing technology that currently is only
available for single-chamber ventricular pacing but does provide rate-
response therapy [9]. This is a rapidly expanding technology that will likely
grow with expanding indications and sophistication in the next few years.
4. Implantable cardioverter–defibrillator. Current ICDs are multiprogrammable,
mainly involving transvenous leads, and may incorporate all capabilities of a
modern dual-chamber pacemaker and CRT pacemakers. ICDs are powered by
a combination of both batteries and capacitors. All current models also have
remote monitoring technology that allows patients to have remote follow-up via
dedicated cellular lines for routine ICD evaluations. This limits the required
in-person visits to the device clinic or doctor’s office to annual or biannual
evaluations. In addition, ICDs have multiple tachycardia detection zones, with
programmable detection criteria and “tiered therapy” for each (antitachycardia
pacing → cardioversion shocks → defibrillatory shocks, if necessary). ICDs
also store arrhythmia event records and treatment results. In addition, ICDs
have undergone significant downsizing (50 mL or smaller) and nearly all are
prepectoral implants. The exception to this location is now the completely
subcutaneous ICD with essentially no pacing function [10]. The subcutaneous
positioning of this device generator is the left lateral chest, with the lead
positioned subcutaneously to the lower sternum and just lateral and parallel to
the sternum.
a. Indications. ICDs are used for secondary or primary prevention of sudden
death.
(1) Secondary prevention. ICDs are used for secondary prevention in
patients who have survived a cardiac arrest from sustained ventricular
arrhythmias. Most commonly, these are patients with heart failure and
reduced left ventricular systolic function. Of this population, coronary
artery disease and ischemic cardiomyopathy are the most common
etiologies of the heart failure. Secondary prevention indications for ICDs
also include individuals with structural heart disease, who have
documented sustained ventricular tachyarrhythmias or inducible
sustained ventricular tachyarrhythmias by electrophysiologic testing.
ICDs are widely accepted for improving outcomes in these patients by
preventing sudden cardiac death. Other indications for secondary
prevention include patients with long QT syndrome and recurrent
syncope, sustained ventricular arrhythmias, or sudden cardiac arrest
despite drug therapy. ICD plus class IA drugs are prescribed for patients
with idiopathic VF and Brugada syndrome with recurrent ventricular
arrhythmias. Other indications are (i) sudden death survivors with
hypertrophic cardiomyopathy; (ii) prophylaxis for syncope and sudden
death with arrhythmogenic right ventricular dysplasia; and (iii) children
with malignant tachyarrhythmias or sudden death and congenital heart
disease, cardiomyopathies, or primary electrical disease (e.g., long QT
syndrome) [7].
(2) Primary prevention. ICDs are used for primary prevention of sudden
death in patients who are at high risk for sudden cardiac death. This
population mainly includes those with systolic heart failure with ejection
fractions ≤35% that has not improved despite medical therapy. The cause
of heart failure may be from coronary artery disease or of nonischemic
origin. Other indications for primary prevention ICDs include patients
with high-risk features with inherited or acquired conditions that place
them at increased risk for life-threatening ventricular arrhythmias,
including long QT syndrome, hypertrophic cardiomyopathy,
arrhythmogenic right ventricular dysplasia, cardiac sarcoid, Brugada
syndrome, and congenital heart disease [7].
b. Technology. The ICD pulse generator is a self-powered minicomputer with
one or two (in series) batteries that power the pulse generator, circuitry, and
aluminum electrolytic capacitors. The batteries may be lithium–silver
vanadium oxide or evolving hybrid technology and vary between the
manufacturers. A major challenge in ICD design is the large range of voltages
within a very small package. Intracardiac signals may be as low as 100 μV,
and therapeutic shocks approach 750 V. Further, ICD batteries contain up to
20,000 J, and a potential hazard exists if the charging and firing circuits were
to electrically or thermally unload all this energy into the patient in a brief
time period. The number of shocks delivered during treatment is usually
limited to five or six per arrhythmia. The expected service life is 5 to 12
years.
IV. Device function, malfunction, and interference [11]
A. Pacemakers
A single-chamber pacemaker stimulates the atria or ventricles at programmed
timing intervals. Sensing spontaneous atrial or ventricular depolarizations inhibit
the device from delivering unnecessary or inappropriate stimuli. Dual-chamber
devices time the delivery of ventricular stimuli relative to sensed atrial
depolarizations to maintain proper AV synchrony. Figure 18.2 illustrates how a
pacemaker might be configured to pace in patients with SND or AV heart block
(AVHB).
FIGURE 18.2 Bradycardia pacing modes. A dysfunctional sinoatrial node (SAN), atrium, or atrioventricular node (AVN)
is indicated by white circles or rectangles. Normal impulse transmission between these structures and the ventricles (Vent)
is indicated by solid lines, with blocked or ineffective conduction indicated by hashed lines. An arrow pointing toward the
pulse generator (blue) indicates sensing, whereas one pointing toward the atrium or ventricle indicates pacing in that
chamber. Top left: AAI pacing for sinus arrest or bradycardia. There is a single atrial lead for both sensing and pacing.
Atrial pacing occurs unless inhibited by a sensed spontaneous atrial depolarization. Top right: VVI pacing for AV heart
block with atrial fibrillation. There is a single ventricular lead for both sensing and pacing. Ventricular pacing occurs unless
inhibited by a sensed spontaneous ventricular depolarization. Bottom left: VDD pacing for AV heart block with normal
SAN and atrial function. The atrial lead is for sensing only, and the ventricular lead is for both pacing and sensing. After a
sensed atrial depolarization, the ventricle is paced after the programmed AV interval (i.e., atrial-triggered ventricular pacing
[VAT]), unless first inhibited by a sensed ventricular depolarization (i.e., the VVI component of the VDD mode). Bottom
right: Dual-chamber sequential or AV universal (DDD) pacing for sinus bradycardia with AV heart block. Both atrial and
ventricular leads are for sensing and pacing. This mode incorporates all of the preceding pacing capabilities (AAI, VVI, and
VAT).
TABLE 18.3 NASPE/BPEG (NBG) pacemaker code used as shorthand to designate

pacing modes
I n Figure 18.2 and throughout this chapter, the North American Society for
Pacing and Electrophysiology–British Pacing and Electrophysiology Group
(NASPE/BPEG) pacemaker code (also known as the NBG code) is used as a
short-hand to describe pacing modes (Table 18.3).
1. Function. Today, most US pacemakers are dual-chamber (DDD or DDDR)
devices with rate-adaptive features (rate response) that can be activated if
clinically indicated. Single-chamber pacemakers may pace either the atrium or
ventricle depending on lead placement and also may have rate-adaptive
features turned on. Dual-chamber pacemakers may also be programmed to act
like a single-chamber pacer, activating either the atrial or ventricular lead
through the use of the proprietary programmer. For example, in individuals
with normal conduction and sinus node function, dual-chamber pacemakers may
operate as a single-chamber device in the AAI (AAIR, AAI) or VVI (VVIR)
modes (Fig. 18.2). There are also expanding indications for CRT pacing
systems to improve cardiac resynchronizations in both heart failure and pacer-
dependent patients [12].
a. Single-chamber pacemaker. These devices have a single timing interval, the
atrial or ventricular escape interval, between successive stimuli in the
absence of sensed depolarization. In the AAI or VVI mode (Fig. 18.3), pacing
occurs at the end of the programmed atrial or ventricular escape interval,
unless a spontaneous atrial or ventricular depolarization is sensed first,
resetting these intervals. If the device has rate hysteresis as a programmable
option, then the atrial or ventricular escape interval after a sensed
depolarization is programmed longer than that after a paced depolarization to
encourage emergence of intrinsic rhythm and prolong battery life.
b. Dual-chamber pacemaker. A DDD (“AV universal”) pacemaker can pace
and sense in both the atrium and the ventricle. It has two basic timing intervals
whose sum is the pacing cycle duration (Fig. 18.4). The first is the AV
interval, which is the programmed interval from a paced or sensed atrial
depolarization to ensuing ventricular stimulation. Some devices offer the
option of programmable AV interval hysteresis. If so, the AV interval after
paced atrial depolarization is longer than that after sensed depolarization to
maintain greater uniformity between atrial and ventricular depolarizations.
The second interval is the VA interval, the interval between sensed or paced
ventricular depolarization and the next atrial stimulus. During atrial and
ventricular refractory periods (Fig. 18.4), sensed events do not reset the
device escape timing. During the ventricular channel blanking period (Fig.
18.4), ventricular sensing is disabled to avoid overloading of the ventricular
sense amplifier by voltage generated by the atrial stimulus, thereby
inappropriately resetting the VA interval. Sensing during the alert periods
outside the ventricular blanking and postventricular atrial and ventricular
refractory periods initiates new AV or VA intervals ( Fig. 18.4).
Operationally, depending on sensing patterns, a DDD pacemaker can provide
atrial, ventricular, dual-chamber sequential, or no pacing (Fig. 18.4). There is
also proprietary software in most dual-chamber pacemakers that promotes
intrinsic ventricular conduction (if appropriate) or minimizes unnecessary
right ventricular pacing. This programming can appear abnormal and may be
misinterpreted as pacemaker malfunction [13]. On rhythm strips or ECGs, this
pacemaker programming may result in variable and prolonged AV delays with
resumption of ventricular pacing and shortening of paced AV delay when the
intrinsic AV delay becomes too long.
IGURE 18.3 Top: AAI pacing, as for a patient with sinus bradycardia and intact AV conduction. The atrium is paced (beats 1
arrow pointing toward the electrocardiogram (ECG) in the atrial channel (AC) timing diagram—unless inhibited by sensed
pontaneous atrial depolarization (beat 2)—arrow pointing away from the ECG in the AC timing diagram. The atrial refractory
eriod (AtRP) prevents R and T waves from being sensed by the AC and inappropriately resetting the atrial escape timing (AA
terval). Note that spontaneous atrial depolarization (beat 2) occurs before the AA interval times out, resetting the AA interval.
short vertical line in the AC timing diagram above beat 2 shows where the stimulus would have occurred had the previous AA
terval timed out. In the absence of subsequent spontaneous atrial depolarization (beat 3), the AA interval times out with delivery
a stimulus. Bottom: VVI pacing, as for a patient with atrial fibrillation and AV heart block. Beats 1 and 3 are paced and beat 2
spontaneous. The latter resets the ventricular escape interval (VV), which otherwise would have timed out with delivery of a
imulus, indicated by the short vertical line in the ventricular channel (VC) timing diagram above beat 2. The new VV interval
mes out with stimulus delivery (beat 3) because there is no sensed ventricular depolarization to reset the timing. VRP, ventricular
fractory period.
IGURE 18.4 AV universal (DDD) pacing, as for a patient with sinus node dysfunction (SND) and atrioventricular (AV) heart
ock. The atrium is paced (beat 1)—arrow pointing toward the electrocardiogram (ECG) in the atrial channel (AC) timing diagram
bove beat 1—unless inhibited by sensed atrial depolarization (beats 2 and 3)—arrows pointing away from the ECG in the AC
ming diagram. The AC is refractory during the AV interval and from delivery of the ventricular stimulus until the end of the
ostventricular atrial refractory period (PVARP). This prevents atrial sensing from resetting the escape timing (i.e., AV interval).
he ventricular channel (VC) blanking period (BP) prevents sensing of the atrial pacing stimulus, thereby resetting the AV interval
nd delaying ventricular stimulus delivery. However, sensed ventricular depolarization or noise (e.g., electrocautery) in the alert
eriod (VC) after the blanking period also could inhibit ventricular stimulation. As shown, this does not occur, so the AV interval
mes out with delivery of a ventricular stimulus. The ventricular refractory period (VRP) prevents sensed T waves from
appropriately resetting the ventriculoatrial (VA) interval. However, sensing during the alert periods after the PVARP or VRP will
set basic timing, initiating new AV and VA intervals, respectively. Since the first beat is fully paced, it is an example of
synchronous AV sequential pacing (i.e., DOO). With the second beat, a sensed spontaneous atrial depolarization initiates a new
V interval, inhibiting the atrial stimulus that would have occurred, indicated by the short vertical line in the AC timing diagram.
ubsequently, there is spontaneous ventricular depolarization before the AV interval times out. The ventricular stimulus that
herwise would have occurred at the end of the AV interval is indicated by the short vertical line in the VC timing diagram below
eat 2. The third beat begins with a sensed atrial depolarization. As with beat 2, this also occurs before the VA interval times out.
n the absence of sensed ventricular depolarization (beat 3), the new AV interval times out with ventricular stimulus delivery. Beat
is an example of atrial-inhibited, ventricular-triggered pacing (i.e., VDD).
c. CRT pacemakers. CRT pacemakers are indicated in patients with systolic

heart failure and conduction disease. These devices have an additional lead
pacing the left ventricle. They may be programmed to AV sequentially pace in
the case of sinus rhythm or just pace the ventricle in the case of permanent
atrial fibrillation. With CRT pacing, there is simultaneous pacing of both the
right and left ventricles to improve the intraventricular depolarization time.
Multipoint pacing, pacing at multiple sites in the left ventricle, has proved to
further enhance the heart failure response to this therapy [14].
d. Adaptive-rate pacing (ARP). ARP is a programmable feature in nearly all
implanted devices (both pacemakers and ICDs) in service today. In patients
with chronotropic incompetence, ARP has been shown to improve exercise
capacity and quality of life. Activity-based sensors are used most commonly
to determine the paced heart rate. These are piezoelectric crystals that sense
vibration (up-and-down motion) or acceleration (forward–backward
movement) as an index of physical activity. Minute ventilation sensors
measure changes in transthoracic impedance with respiration (i.e., increase
with inspiration and decrease with expiration) and provide an estimate of
metabolic need that is more proportional to exercise. Some pacemaker
algorithms detect changes in contractility in determining the ARP response.
ARP sensors may have a disproportionate response time at the beginning of
exercise versus steady-state exercise; a dual-sensor ARP or physiologic
sensor device may provide a more proportional response. Obviously, such
complexity and the use of multiple physiologic sensors increase the potential
for unexpected device interactions in the perioperative setting. For example,
simple manipulation of the generator may inappropriately activate the ARP
sensor, resulting in increased pacing heart rate. In addition, changes in
breathing may result in changes in ARP if minute ventilation sensors are
activated.
TABLE 18.4 Categories of pacemaker malfunction, electrocardiogram (ECG) appearance,
and likely cause for malfunction
2. Malfunction. Primary pacemaker malfunction is rare (less than 2% of all

device-related problems). Pacing malfunction can occur with ICDs because all
ICDs today include a pacing function which can pace at least the ventricle.
Some devices have programmed behavior that simulates malfunction, termed
pseudomalfunction. For example, failure to pace may be misdiagnosed with
programmed rate hysteresis. Also, apparent device malfunction in response to
electromagnetic interference (EMI) may be normal device operation, as
described later in this chapter.
Pacemaker malfunction is classified as failure to pace, failure to capture,
pacing at abnormal rates, failure to sense, oversensing, and malfunction unique
to dual-chamber devices (Table 18.4). Among the causes for failure to capture
are drugs or conditions that affect pacing thresholds (Table 18.5). To diagnose
malfunction, it is necessary to obtain a 12-lead ECG and chest x-ray film and to
interrogate the device for pacing and sensing thresholds, lead impedances,
battery voltage, and magnet rate.
Malfunctions unique to dual-chamber devices are crosstalk inhibition and
pacemaker-mediated tachycardia (PMT).
a. Crosstalk inhibition. Crosstalk refers to the oversensing of atrial signals from
atrial stimulation on the ventricular sense channel or circuit of a dual-chamber
pacemaker. This oversensing has the potential of inhibiting ventricular output.
Crosstalk is prevented by increasing the ventricular sensing threshold,
decreasing atrial stimulus output, or programming a longer ventricular
blanking period (Fig. 18.4), so long as these provide adequate safety margins
for atrial capture and ventricular sensing. If crosstalk cannot be prevented,
many dual-chamber devices have a feature referred to as nonphysiologic AV
delay or ventricular safety pacing. Whenever the ventricular channel senses
anything early during the AV interval, a ventricular stimulus is triggered after
an abbreviated AV interval. This either will depolarize ventricular
myocardium or will fail to do so if myocardium is refractory due to
spontaneous depolarization. The premature timing of the triggered ventricular
stimulus prevents it from occurring during the vulnerable period of the T
wave.
TABLE 18.5 Drugs and conditions that affect or have no proven effect on pacing thresholds
b. Pacemaker-mediated tachycardia (PMT). PMT is undesired rapid pacing

caused by the device or its interaction with the patient. PMT includes sensor-
driven tachycardia, tachycardia due to tracking of myopotentials or atrial
tachyarrhythmias, pacemaker reentrant tachycardia, and runaway pacemaker.
7 Sensor-driven tachycardia may occur with adaptive-rate devices that
sense vibration, impedance changes, or the QT interval if they sense
mechanical or physiologic interference, which leads to inappropriate high-
rate pacing. Thus, it is advised that ARP be disabled in perioperative settings.
Pacemaker reentrant tachycardia can occur in a device programmed to
an atrial tracking mode. Up to 50% of patients with dual-chamber devices are
susceptible to PRT because they have retrograde (VA) conduction via the
AVN. PRT occurs when spontaneous or paced ventricular beats are conducted
back to the atria to trigger ventricular pacing. To prevent PRT, a longer
postventricular atrial refractory period is programmed (Fig. 18.4). Also,
placing a magnet over the pulse generator will terminate PRT in most devices
by disabling sensing. However, PRT may recur after the magnet is removed.
3. 8 Response of pacemaker to magnet application. Most contemporary
pacemaker devices respond to magnet application by a device-specific single-
or dual-chamber asynchronous pacing mode. Adaptive-rate response is
generally suspended with magnet mode as well. With asynchronous pacing, the
pacemaker will no longer be inhibited by sensed activity and instead pace at a
fixed rate regardless of underlying rhythm. The first few magnet-triggered beats
may occur at a rate and output other than that seen later. Pacing amplitudes
remain constant at the programmed output in Biotronik, Boston Scientific, and
Medtronic pacemakers. The pacing amplitude with magnet application in
ELA/Sorin and St. Jude pacemakers may be higher than the programmed output
settings. The response to a magnet should be determined prior to an anticipated
surgical procedure and is predicted by the brand of the pacemaker in most
circumstances. However, some manufacturers, Biotronik, St. Jude Medical, and
Boston Scientific devices, have a programmable magnet mode that may make
response to magnet application different than anticipated. Although rarely used,
this feature may be programmed to save patient-activated rhythm recordings
with magnet application, rather than revert the pacemaker to asynchronous
pacing. Discussion or documentation with the providers that follow the device
can confirm that the typical magnet response is “on.” Alternatively, if this
communication is not possible, a magnet can be placed on the device to
evaluate if there is a change to asynchronous pacing on telemetry. The magnet-
triggered rate and the duration of pacing do vary based on manufacturer and
battery status. For example, Biotronik pacemakers have a magnet rate at 90
bpm for 10 beats only, while all other manufacturers pace asynchronously as
long as the magnet is in contact with the pacemaker. The fixed magnet rate for
Boston Scientific pacemakers is 100 bpm; St. Jude is 98.6 bpm; ELA/Sorin is
96 bpm. Medtronic pacemakers are triggered for three beats at 100 bpm, then
default to 85 bpm. However, with impending power source depletion, the
magnet rate will approach the programmed rate of the end-of-life (EOL) or
elective replacement indicator (ERI) and is usually a slower pacing interval
than the standard magnet rate (Table 18.6). 9
TABLE 18.6 Elective replacement indicators (ERI) that may affect the nominal rate of
pacing
In a patient whose intrinsic rhythm inhibits the device, magnet application

may serve to identify the programmed mode when the correct programmer is
not available for telemetry. Also, with device malfunction due to improper
sensing, magnet-initiated asynchronous pacing may temporarily correct the
problem, confirming the presence of far-field sensing, crosstalk inhibition, T-
wave sensing, or PMT. Finally, in pacemaker-dependent patients, magnet
application may ensure pacing if EMI inhibits output (e.g., surgical
electrocautery).
4. Interference. CIEDs are subject to interference from nonbiologic
electromagnetic sources. In general, devices in service today are effectively
shielded against many forms of EMI. However, with the continued advances
and changes in technology with medical procedures as well as CIEDs, it is
recommended that a CIED management plan be established for the patient
based on both the planned medical procedure and type and indication for the
CIED [11]. This process is recommended for elective procedures. The
following describes some scenarios where the programming may not be
predictable, supporting the practice of establishing a perioperative CIED
management plan. EMI frequencies above 109 Hz (i.e., infrared, visible light,
ultraviolet, x-rays, and gamma rays) do not typically interfere with pacemakers
or ICDs because the wavelengths are much shorter than the device or lead
dimensions. High-intensity therapeutic x-rays and irradiation can directly
damage circuitry. A management plan is often required in individuals who
require therapeutic radiation near their CIED. In general, EMI enters a device
by conduction (direct contact) or radiation (leads acting as an antenna).
Devices are protected from EMI by (i) shielding the circuitry, (ii) using a
bipolar versus unipolar lead configuration for sensing to minimize the antenna,
and (iii) filtering incoming signals to exclude noncardiac signals. If EMI does
enter the pulse generator, noise protection algorithms in the timing circuit help
reduce its effect on the patient. However, EMI signals between 5 and 100 Hz
are not filtered because these overlap the frequency range of intracardiac
signals. Therefore, EMI in this frequency range may be interpreted as
intracardiac signals, giving rise to abnormal behavior. Possible responses
include, (i) inappropriate inhibition or triggering of stimulation, (ii)
asynchronous pacing (Fig. 18.5), (iii) mode resetting, (iv) direct damage to the
pulse generator circuitry, and (v) triggering of unnecessary ICD shocks (Table
18.7).
10 Finally, with EMI and inappropriate device behavior, it is widely
assumed that placing a magnet over a pulse generator invariably will cause
asynchronous pacing as long as the magnet remains in place. However, this is
not always the case. Although used rarely, some devices (see Section III.A.3)
may have programmed magnet response off. In contrast to pacemakers, magnet
application on ICDs will not alter the pacing mode and will not change the
mode to asynchronous pacing (see below). Thus, if possible, one should
determine before EMI exposure what pulse generator is present and what must
be done to provide protection. If this is not possible preoperatively, then one
must observe the magnet response during EMI to ascertain whether there is
protection from EMI sensing. For example, if a pacemaker-dependent patient
has inappropriate inhibition or triggering of output during electrosurgery even
with magnet application, then electrosurgery must be limited to short bursts.
FIGURE 18.5 VVI pacemaker to continuous electromagnetic interference (EMI). Temporary asynchronous pacing
stimulation (Stim) occurs at the programmed basic rate interval. The ventricular refractory period (rectangles) begins with the
noise (N) sampling period (blue rectangles), during which time there is no sensing. During the remainder of this refractory
period, repeated noise (N) sensing above a specified minimal frequency (e.g., 7 Hz) is interpreted as EMI. This restarts the
ventricular refractory period. Portions of the previous refractory period preempted by the newly initiated ventricular refractory
period are indicated by hashed rectangles. Therefore, so long as interference persists, the pacemaker remains refractory and
escape timing is determined entirely by the programmed basic rate interval. In this example, the second paced R wave falls in
the noise sampling period. It is not sensed, but it initiates a new ventricular refractory period. The spontaneous R wave is not
sensed and does not affect escape timing.
B. Internal cardioverter–defibrillator (ICD)

An ICD consists of a pulse generator and leads for tachyarrhythmia detection and
therapy. Modern ICDs use transvenous lead systems for sensing, pacing, and
biphasic shock delivery. Epicardial leads are still used in infants and small
children and occasionally in adult patients. Use of biphasic compared to
monophasic shocks has greatly lowered defibrillation energy requirements and
has led to development of smaller ICDs.
TABLE 18.7 Perioperative EMI sources and their potential effects on implanted
pacemakers or implantable cardioverter–defibrillators
1. Sensing ventricular depolarizations. Reliable sensing is essential. The sense

amplifier must respond quickly and accurately to rates of 30 to 360 bpm or
greater and to the varying amplitude and morphology of intracardiac signals
during VT or VF. Unfiltered intracardiac electrograms are sent to the sense
amplifier. This has a band-pass filter to reject low-frequency T waves and
high-frequency noise. There is automatic gain control (auto-gain), a rectifier to
eliminate polarity dependency, and a fixed or auto-adjusting threshold event
detector. The sense amplifier produces a set of R–R intervals for the VT/VF
detection algorithms to use.
2. VF detection. ICDs use rate criteria as the sole method for detecting VF. Due
to the circumstances of VF, the detection algorithms must have high sensitivity
and low specificity. If criteria for detection are too aggressive, the ICD likely
will oversense T waves during sinus rhythm, leading to spurious shocks. If too
conservative, it likely will undersense some VF but work very well during
sinus rhythm. An ICD X/Y detector triggers when X of the previous Y-sensed
ventricular intervals are shorter than the VF detection interval. Typically, this
is 70% to 80% of intervals in a sliding window of 10 to 24. This approach is
very good at ignoring the effect of a small number of undersensed events due to
the small amplitude of VF intracardiac signals. Any tachycardia with a cycle
length less than the VF detection interval will initiate VF therapy. After
capacitor charging but before shock delivery, an algorithm confirms the
presence of VF. After shock delivery, redetection and episode termination
algorithms determine whether VF has terminated, continued, or changed.
3. Tachycardia detection and discrimination (single-chamber ICD). Most VT
algorithms require a programmable number of consecutive R–R intervals
shorter than the VT detection interval. A longer R–R interval, as might occur
during atrial fibrillation, would reset the VT counters. In patients with both
supraventricular and ventricular tachyarrhythmias, up to 45% of ICD
discharges may be inappropriate if rate is used as the sole criterion for VT
therapy.
To increase specificity, VT detection algorithm enhancements are
programmed for one or more VT zones in single-chamber ICDs, including
criteria for stability of rate, suddenness of onset, and intracardiac QRS
morphology.
a. The rate-stability criterion is used to distinguish sustained monomorphic VT
with little cycle length variation from atrial fibrillation with much greater
cycle length variation. Such enhancement criteria are not available in the VF
zone, where maximum sensitivity is required. Also, they are programmed only
in rate zones that correspond to VT hemodynamically tolerated by the patient.
b. The suddenness of onset criterion is used to distinguish sinus tachycardia
from VT because VT has a more sudden rate increase.
c. Finally, morphology algorithms discriminate VT from SVT based on
morphology of intracardiac electrograms.
4. Tachycardia detection and discrimination (dual-chamber ICD). Inadequate
specificity of VT detection algorithms, despite enhancements, has been a
significant problem with single-chamber ICDs. Dual-chamber ICDs use an
atrial lead, which is used for bradycardia pacing and sensing for tachycardia
discrimination. Detection algorithms use atrial and ventricular timing data to
discriminate SVT from VT. For example, the algorithm in devices of one
manufacturer has several key elements: (i) the pattern of atrial and ventricular
events; (ii) atrial and ventricular rates; (iii) regularity of R–R intervals; (iv)
presence or absence of AV dissociation; and (v) atrial and ventricular pattern
analysis.
5. 11 Tiered therapy. Treatment options for VT include antitachycardia pacing,
cardioversion, or defibrillation. More than 80% of monomorphic VTs can be
terminated by a critical pacing sequence, reducing the need for painful shocks
and improving quality of life [15]. With antitachycardia pacing, trains of
stimuli are delivered at a fixed percentage of the VT cycle length. Repeated and
more aggressive trains result either in termination of VT or progression to
cardioversion or defibrillation.
6. ICD malfunction. Malfunctions specific to ICD include inappropriate shock
delivery, failure to deliver therapy, ineffective shocks, and interactions with
drugs or devices affecting the efficacy of therapy. There is potential for pacing
malfunction as well, since all ICDs have a pacemaker function.
a. Inappropriate delivery of shocks. Artifacts created by lead-related
malfunction may be interpreted as tachycardia, with inappropriate shock
delivery. Electrocautery artifact may be similarly misinterpreted. Rapid SVT
or nonsustained VT may be misdiagnosed as sustained VT or VF, especially if
rate-only criteria are used for diagnosis. R- and T-wave oversensing, causing
double counting during bradycardia pacing, has led to inappropriate shocks.
b. Failure to deliver therapy or ineffective shocks.
CLINICAL PEARL Having a magnet placed over the ICD generator will usually turn off
detections and will result in no delivery of shocks regardless of the arrhythmia. For this
reason, it is recommended that patients be on monitored cardiac telemetry prior to magnet
placement.
ICDs can stop delivering therapies after about six shocks for a single episode.
If a patient requires repeated shocks for VF, therapy may be exhausted or the
tachyarrhythmias may be undersensed, with failure to deliver therapy.
Exposure to diagnostic x-rays or computed tomographic scans does not
adversely affect shock delivery. Acute MI, severe acute acid–base or
electrolyte imbalance, or hypoxia may increase defibrillation thresholds,
leading to ineffective shocks. Any of these also could affect the rate or
morphology of VT and the ability to diagnose VT. Finally, isoflurane and
propofol do not affect defibrillation thresholds. The effect of other anesthetics
or drugs used to supplement anesthesia is unknown.
c. 12 Drug–device interactions affecting efficacy of ICD therapy.
Antiarrhythmic drugs may be used along with an ICD to suppress (i) recurrent
sustained VT and the need for shocks, (ii) nonsustained VT that triggers
unnecessary shocks, and (iii) atrial fibrillation with inappropriate shocks to
excessive ventricular heart rates. Also, they may be used to slow VT to make
it better tolerated or more amenable to termination by antitachycardia pacing
and to slow AV nodal conduction with atrial fibrillation.
Possible adverse effects of combined drug and ICD therapy are, (i) slowing
of VT to below the programmed rate-detection threshold; (ii) proarrhythmia,
increasing the need for shocks; (iii) increased defibrillation thresholds; (iv)
reduced hemodynamic tolerance of VT; (v) increase in PR, QRS, or QT
intervals, causing multiple counting and spurious shocks; and (vi) altered
morphology or reduced amplitude of intracardiac electrograms and failure to
detect VT/VF. Lidocaine, chronic amiodarone, class IC drugs (e.g.,
flecainide), and phenytoin can increase defibrillation thresholds. Class IA
drugs (e.g., quinidine) generally do not affect defibrillation thresholds.
d. Device–device interactions affecting efficacy of therapy. In the past,
pacemakers were used for bradycardia and antitachycardia pacing in ICD
patients. Today, ICDs incorporate both pacing capabilities, but still there may
be occasional patients with an ICD and a pacemaker. More common today
may be the consideration of brain or nerve stimulators in a patient with an
ICD or pacemaker. Regardless of the type of pulse stimulators, possible
adverse interactions between two devices include, (i) sensed pacing artifacts
or depolarizations that may lead to multiple counting, misdiagnosis as VT/VF,
and spurious shocks and (ii) ICD shocks that may reprogram a pacemaker or
cause failure to capture or sense. The use of only bipolar pacing from the
other device will minimize such interference but must be fully evaluated prior
to permanent implantation.
7. 13 Response of an ICD to magnet application [8]. Magnet application does
not interfere with bradycardia pacing and does not trigger asynchronous pacing
in an ICD. Magnet application in current ICDs causes inhibition of tachycardia
sensing and delivery of shock only. All current ICDs remain inhibited as long
as the magnet remains in stable contact with the ICD. Once the magnet is
removed, the ICD reverts to the programmed tachyarrhythmia settings. One
deviation from this is in some Biotronik ICD platforms where a magnet placed
in direct contact with the ICD will inhibit continuously up to 8 hours. After 8
hours, the programmed tachycardia therapy will be reactivated, even if the
magnet is still in contact. This universal response to magnet across all
manufacturers has not always been the case and has caused confusion on how to
deal with ICDs in the operative setting. Older platforms manufactured by
Boston Scientific/Guidant Corp. had a programmable response to magnet
application, most commonly programmed to Magnet Use Enable, but there were
exceptions. Most of these device platforms are no longer in service.
With an appropriately placed magnet, Boston Scientific (Guidant) ICDs have
R-synchronous beeping followed by a continuous sound that indicates
inactivation of tachyarrhythmia function. Medtronic devices emit a continuous
sound for 20 to 30 seconds to indicate inactivation of tachyarrhythmia sensing.
ICDs by St. Jude Medical, Biotronik, and ELA/Sorin do not emit sounds in the
presence of a magnet. These different audible responses to magnets may
continue to be a source of confusion. Regardless of the audible response, all
ICDs turn off tachycardia sensing and therapy when a magnet remains applied
to the generator.
8. Interference and ICD. Reports of inappropriate ICD shocks due to EMI
oversensing are infrequent. EMI initially might be misinterpreted as VF, but
spurious shocks will not occur unless it continues beyond the capacitor
charging period (see Section III.B.2 and Table 18.7). Magnet application does
not interfere with bradycardia pacing and does not trigger asynchronous
pacing in an ICD.
V. Perioperative considerations for a patient with a cardiac implantable electrical
device (CIED) [11]
A. Preoperative patient evaluation
Patients with pacemakers or ICDs, especially the latter, often have serious
cardiac functional impairment. Many have debilitating coexisting systemic
disease as well. Special attention is paid to progression of disease and functional
status, current medications, and compliance with treatment. No special testing is
required just because the patient has an implanted device. However, identifying
whether the device is an ICD versus pacemaker and documenting compliance
with device follow-up is important in the perioperative management. It is now
recommended that a plan of perioperative CIED management be developed prior
to elective procedures [11]. This plan is usually scripted by the CIED team after
they have been advised about the nature of the planned procedure. Baseline
information about the surgery is needed by the CIED team (cardiologist,
electrophysiologist, and pacemaker clinic staff managing the device) such as (i)
type and location of the procedure, (ii) body position at surgery, (iii)
electrosurgery needed and site of use, (iv) potential need for DC cardioversion
or defibrillation, and (v) other EMI sources.
B. 14 Cardiac implantable electrical device team evaluation
Patients are usually regularly followed by a CIED team. Frequently, the
management plan for perioperative procedures can be determined by the team
that follows the patient’s device regularly. If that information or approach is not
available, most surgical facilities today have an onsite CIED clinic or service
(or access to one) that should be consulted to provide preoperative consultation
on the management of the device. All patients should carry a card that identifies
the model and serial numbers of the device, the date of implantation, and the
implanting physician or clinic. Unless the planned surgery is truly emergent or
poses little risk of EMI-related device malfunction (e.g., bipolar cautery will be
used; the surgical field is far removed from the device, leads, and grounding
plate), it is imperative to (i) identify the device (manufacturer, model, leads,
battery status), (ii) determine the date and indication(s) for its implantation, and
(iii) to check its function. If a recent device check (for pacemakers <12 months
and for ICDs <6 months) is not available, then the CIED team should perform a
check. The data to be provided by this interrogation are, (i) type of device
(single, dual, biventricular); (ii) programmed mode; (iii) programmed rates,
energy, sensing, tachyarrhythmia settings for an ICD; (iv) pacemaker-dependent
status; (v) underlying rhythm; (vi) specifics about magnet response; and (vii)
pacing safety margin and battery longevity. If the CIED has no recent device
check data and it cannot be interrogated, then obtain (i) a 12-lead ECG (for
pacemakers, with and without a magnet) and (ii) an x-ray film of the pulse
generator area which may reveal a unique radiopaque code (“signature”) that
identifies the manufacturer and model of the device (Table 18.8). If the surgery is
truly emergent and it is not possible to identify the device, then placing the
patient on cardiac telemetry and then placing a magnet on the device to deactivate
VT/VF detections in case the device is a defibrillator would be recommended.
This may result in asynchronous pacing if the device is a pacemaker.
C. Device management
A qualified physician with device expertise must supervise the recommended
preoperative prescription for device management. The prescription should not be
provided by industry-employed representatives.
TABLE 18.8 North American manufacturers of pacemakers and implantable
cardioverter–defibrillators
CLINICAL PEARL For pacemaker-dependent patients: These patients are at

particular risk of asystole in the presence of EMI. If EMI is likely (e.g., unipolar cautery
in the vicinity of the pulse generator or leads and surgery above the umbilicus) and short
bursts of electrocautery cannot be guaranteed, then the device should be programmed to
an asynchronous mode. In the case of pacemakers, this can be done with magnet
application in most situations, which will also inactivate the rate-responsive pacing.
However, it is best to confirm the magnet response prior to the surgical procedure.
CLINICAL PEARL In cases where the pacemaker-dependent patient has an ICD

or the location of surgery precludes placement of a magnet, consideration of
programming the device to an asynchronous mode with the proprietary programmer is
recommended. The other alternative if reprogramming is not an option is to limit the
EMI to short bursts, while watching the response of pacing, and minimize episodes of
asystole.
For patients with adaptive-rate pacemakers (including some ICDs), this
capability should be programmed off if EMI causes inappropriate rate response.
As stated above, for pacemakers, magnet application will inactivate this feature,
but ICDs will need to be reprogrammed (Table 18.7). In ICDs, tachycardia
sensing and therapy should be turned off. This can be accomplished with magnet
application or with reprogramming. If any reprogramming is planned, then
patients must stay on monitored telemetry until the CIED is reprogrammed back
to baseline settings. If the magnet is applied, then the patient must remain on
monitored telemetry until the magnet is removed.
In an emergency, obtain a rhythm strip or ECG to determine if there is pacing.
If the device is determined to be a pacemaker and the patient is pacing, then the
assumption is that the patient is pacemaker dependent. In this situation, there
needs to be continuous hemodynamic monitoring that will not be distorted with
EMI, such as a pulse waveform from an arterial line or plethysmography. A form
of backup pacing should also be considered such as anterior–posterior
transcutaneous pacing pads. A magnet should be placed on the device to force
asynchronous pacing if the surgery is above the umbilicus or use of extensive
electrosurgery is likely. If the procedure is performed below the umbilicus, then
have the magnet available if pacing inhibition is seen. Use of short
electrosurgical bursts will reduce the likelihood of pacemaker inhibition.
If intrinsic conduction (i.e., no pacing) is seen on the 12-lead ECG and the
device is found to be a pacemaker, then proceed with surgery and have a magnet
available. Please note that if the patient has an ICD rather than a pacemaker in
either the situation of pacing or not pacing, deactivation of VT/VF detections
with a magnet is recommended. In the case of an ICD, the magnet will not affect
the pacing programming, and the electrosurgery could result in pacing inhibition.
Short bursts of electrocautery are recommended to reduce the risk of pacing
inhibition.
CLINICAL PEARL Magnet versus reprogramming: If the CIED is
reprogrammed, then continuous monitoring is mandated. In the operating room, it is
difficult to reverse reprogramming. If spontaneous heart rates exceed the asynchronous
programmed pacing rate, then both deleterious hemodynamic and arrhythmia events may
develop. Likewise, post procedure, the ICD antitachyarrhythmia therapies must be
reactivated. This does not always occur and is a possible source of medical error. Use
of a magnet eliminates the complexity of reprogramming the CIED in the operating room.
The magnet can be easily removed when competing rhythms develop with asynchronous
pacing. However, the magnet behavior of the specific CIED needs to be known
preoperatively.
D. Precautions: Surgery unrelated to device
The chief concern is to reduce risk of hemodynamic instability due to
inappropriate inhibition or triggering of output (pacing stimuli or shocks) or
upper-rate pacing behavior (adaptive-rate devices). If EMI is likely to cause
device malfunction and the patient does not have an adequate intrinsic rhythm, the
pacemaker should be programmed to an asynchronous mode and tachycardia
sensing disabled for ICD. If the device features ARP, this should be programmed
off. If ICD sensing is disabled, continuous cardiac monitoring must be maintained
and an external cardioverter–defibrillator must be available.
1. Surgical sources for EMI. Technology has provided a variety of new surgical
tools to assist in a variety of procedures. Many of these new technologies
create EMI. It is this EMI that can cause erratic behavior in pacemakers and
ICDs. Any tool that uses electricity or uses a magnetic field can emit interfering
signals when close to the device or heart. Locating the grounding plate as far as
possible from the cautery tool reduces EMI from unipolar cautery. The pulse
generator and leads should not be between the Bovie tool and grounding plate
(i.e., in the current pathway). Pacing function is confirmed by monitoring heart
sounds or the pulse waveform. Only the lowest possible energies and brief
bursts of electrocautery or other sources of EMI such as RF should be used,
especially with instability due to device malfunction. If cautery must be used in
the vicinity (less than 15 cm) of the pulse generator or leads and there is
significant hemodynamic instability due to EMI, then it is reasonable to place a
magnet directly over the pulse generator of a pacemaker. This will cause most
devices to pace asynchronously until the magnet is removed, unless the magnet
mode has been programmed off. In a situation with an ICD and no device
information, a magnet should not be placed over the ICD pulse generator unless
EMI is unavoidable. If EMI is unavoidable, then the patient needs to be placed
on cardiac monitor, and a magnet will need to be placed on (and kept on) the
ICD generator during cautery or RF therapy. In this case, EMI has a potential to
trigger antitachycardia pacing or shocks that may destabilize the patient. By
placing the magnet over the generator, the device will no longer sense or treat
tachyarrhythmias. It will not react to EMI or to a real tachyarrhythmia.
However, as discussed above, the magnet will not affect the pacing
programming, including rate response of the ICD.
2. External cardioversion or defibrillation. Shocks probably will not cause
temporary inhibition or transient loss of capture. Today’s devices are better
shielded, and nearly all have a backup bradycardia pacing capability and a
reset mode. Pulse generator damage is related to the distance of the external
paddles or electrode pads from the pulse generator. All device manufacturers
recommend the AP paddle configuration, with the paddles located at least 8 cm
from the pulse generator. Further, it is advised that the lowest possible energies
be used for cardioversion or defibrillation. After cardioversion or
defibrillation, the device must be interrogated to assure proper function.
E. Management for system implantation or revision
Except in infants and small children, in whom epicardial leads are widely used,
most CIED systems use transvenous leads. The pulse generator and leads are
often implanted using local anesthesia and sedation. For epicardial lead
placement with a thoracotomy, general anesthesia is needed. General anesthesia
or monitored anesthesia care with heavy sedation may be requested for some
pacer and ICD system implants, especially if the patient has significant advanced
comorbidities.
1. Lead extraction [16]—general anesthesia is often recommended for cases
involving lead extractions, especially in leads that are more than 10 years old.
Cases involving lead extraction are often more prolonged procedures and carry
additional procedural risk, the most concerning being catastrophic bleeding.
Indications for lead extraction have expanded with recent updates in the HRS
Guidelines. Class I indications for lead extraction mainly involve infected
pacemaker and ICD systems and symptomatic occlusion of central veins. Other
important indications involve removing nonfunctional leads to avoid future
complications of superior vena cava syndrome, especially in young patients. In
the case of device infection, these patients may have sepsis and are certainly at
risk of becoming septic during the lead extraction. The potential bleeding sites
include tearing of the superior vena cava and intracardiac perforation or
avulsion. This type of procedure also involves the use of large-bore central
venous sheaths up to 18 Fr in size that may be used from both the subclavian
and femoral venous sites. The prolonged procedure time involving large
sheaths also places the patients at risk for pulmonary embolism or stroke
caused by either air or clot. Fortunately, enhanced tools have been devised that
improve patient safety and ease of extraction, including Excimer laser tools and
cutting sheaths. Even with these enhanced tools, the risk of life-threatening
bleeding is real and requires immediate recognition and action. Cardiothoracic
surgeons and facilities need to be available within minutes if there are
complications. In these situations, there is an emergent need for thoracotomy
and surgical repair. Tools for pericardiocentesis and chest tube insertion must
be in arms reach. In addition, these cases may be further complicated by the
patient being pacemaker dependent. This situation will require the use of
temporary pacing that may become dislodged during the intracardiac
manipulation of the leads. Because of the potential complications that can occur
in lead extraction, it is imperative to have continuous hemodynamic monitoring.
A sudden drop in blood pressure may be the only warning sign to alert
clinicians of pending circulatory collapse due to a complication from lead
extraction.
2. For all procedures requiring general anesthesia or monitored anesthesia care,
consider the following:
a. Most patients with symptomatic bradycardia will have temporary pacing.
Otherwise, chronotropic drugs with backup external pacing should be
available. Sedation may make an escape rhythm due to conduction disease
worse.
b. Have reliable plethysmography waveform or direct arterial blood pressure
monitoring.
c. Select the best surface ECG leads for P waves (II, V1) and for ischemia
diagnosis (V5).
d. Pulmonary artery catheters are seldom used or needed today. They may
interfere with ICD lead positioning.
e. An external cardioverter–defibrillator must be available and functioning.
Defibrillator patches should be applied to the patient in the anterior–posterior
configuration and more than 8 cm away from the CIED.
f. With an ICD, tachycardia sensing should be disabled by a magnet or with
reprogramming when unipolar electrosurgery is used.
g. Contemporary inhalation and IV anesthetics are not known to increase
defibrillation thresholds and are selected more with a view to hemodynamic
tolerance. Inhalation agents and propofol may affect the morphology of sensed
intracardiac electrograms and inducibility of tachyarrhythmias, which is a
consideration during EP testing. Contemporary inhalation anesthetics
(sevoflurane, desflurane) and small amounts of lidocaine for vascular access
are not known to affect defibrillation thresholds.
h. Paralytic agents must be used with caution during lead implant procedures. It
is customary to assure that lead placement does not cause diaphragmatic or
chest wall stimulation during pacing. This avoidable extracardiac stimulation
will be inhibited by paralytic agents. If extracardiac stimulation occurs, the
pacemaker lead usually requires repositioning.
VI. Catheter or surgical modification of arrhythmia substrates
RF catheter ablation has replaced antiarrhythmic drug therapy for the treatment of
many types of chronic or recurring cardiac tachyarrhythmias. Tachyarrhythmias
amenable to this form of treatment include those shown at EP study to have a focal
origin (triggered or automatic) or are sustained by fixed, defined reentry circuits.
Surgical ablation may be performed for these same arrhythmias if catheter ablation
has failed or is not feasible. In addition, a catheter or surgical maze procedure may
be used to interrupt multiple reentry circuits associated with atrial fibrillation [17].
A. Radiofrequency catheter ablation [18]
RF catheter ablation procedures are performed in an EP laboratory using
conscious sedation (generally with midazolam, fentanyl, and/or propofol).
Usually, both tachyarrhythmia diagnosis and RF ablation can be performed in a
single session. Three to five electrode catheters are inserted percutaneously into
the femoral, internal jugular, or subclavian vein, or via a retrograde aortic or
transseptal approach, and positioned within the heart to allow pacing and
recording at key sites. The efficacy of RF catheter ablation depends on accurate
identification of the site of origin of the arrhythmia. Once this site has been
identified and the electrode catheter is positioned in direct contact with the site,
RF energy is delivered through the catheter to eliminate the source or circuit of
the arrhythmia. After AV nodal ablation, all patients require a permanent
pacemaker because of AV block. Pulmonary vein isolation with RF energy or
cryoablation with transvenous catheters is used generally for symptomatic
patients with recurrent paroxysmal and persistent atrial fibrillation [19].
For CIED patients undergoing RF catheter ablation, RF energy may cause
electrical reset, reprogramming, over- or undersensing, and inappropriate
inhibition. Rarely does RF energy lead to reset or damage at the lead–tissue
interface.
B. Arrhythmia surgery [20]
The potential morbidity of open chest surgery, as well as associated high costs,
length of hospitalization, and delayed functional recovery, fostered the
development of percutaneous catheter ablation. Nonetheless, direct surgical
approaches and hybrid approaches continue to have an important role for patients
with arrhythmogenic conditions refractory to catheter ablation or with associated
surgical abnormalities. Surgical procedures have been designed for almost all
supraventricular tachyarrhythmias but today have application primarily to the
treatment of atrial fibrillation [21].
ACKNOWLEDGMENTS
Jerry Luck, Jr., MD, has been a contributing author to this book since the first edition.
His passion for education and his wealth of knowledge has been legendary. Dr. Luck
was my mentor, colleague, and friend. Following his passing in 2015, I am honored to
continue the updates in this chapter.
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19 Anesthetic Considerations for Patients with
Pericardial Disease
Matthew S. Hull and Matthew M. Townsley
I. Introduction
II. Pericardial anatomy and physiology
III. Causes of pericardial disease
IV. Pericardial tamponade
A. Natural history
B. Pathophysiology
C. Diagnostic evaluation and assessment
D. Treatment
V. Constrictive pericarditis (CP)
A. Natural history
B. Pathophysiology
D. Treatment
KEY POINTS
1. Although the etiology of pericardial disorders is quite variable, the

manifestations of pericardial disease are primarily expressed as
pericardial effusion, inflammation, and constriction. The common
theme is impaired cardiac filling, with the severity of symptoms
dependent upon the degree to which filling is impaired.
2. A relatively small amount of fluid (50 to 100 mL) that accumulates
rapidly within the closed pericardial space is sufficient to
dramatically increase intrapericardial pressure and interfere with
cardiac filling. Conversely, a chronic increase in pericardial fluid
will result in hemodynamic instability only after a large volume of
fluid accumulation, perhaps as great as a liter.
3. The right heart is most vulnerable to pericardial compression due to
its thinner walls and lower chamber pressures as compared to the
left heart.
4. Cardiac tamponade is often described with Beck triad: muffled heart
sounds, jugular venous distention (JVD), and hypotension.
5. Pulsus paradoxus (an abnormally high drop in systolic pressure >20
mm Hg during inspiration) occurs secondary to ventricular septal
shift crowding the left ventricle (LV) during right ventricular (RV)
filling. The opposite occurs during expiration. This phenomenon is
described as enhanced ventricular interdependence.
6. Electrical alternans is due to swinging of the heart within the fluid of
the pericardial sac, leading to beat-to-beat changes in the electrical
axis as seen on electrocardiogram (ECG).
7. Diastolic collapse lasting more than one-third of diastole, as
demonstrated with echocardiography, is fairly specific for
tamponade.
8. Cardiovascular collapse may quickly ensue with induction of
general anesthesia in a patient with cardiac tamponade. If
pericardiocentesis cannot be performed in a hemodynamically
compromised patient prior to surgical intervention, the patient
should be prepped and draped prior to anesthetic induction so that
surgery may proceed immediately following intubation. Volume
loading prior to general anesthetic induction, as well as inotropic
and vasopressor support, is often required. Expect further
deterioration after positive pressure ventilation is initiated.
9. Constrictive pericarditis (CP) is a diagnosis that encompasses a wide
spectrum of disease, from acute and subacute cases that may resolve
spontaneously, or with medical therapy, to the classic chronically
progressive form of CP.
10. Although manifestations of hemodynamic instability are less with
chronic pericarditis than with tamponade, induction and
maintenance of anesthesia must encompass the same concerns and
principles for hemodynamic management.
I. Introduction
Pericardial disease is common throughout the world and is frequently encountered
in the cardiac operating room. Clinical significance varies from asymptomatic
incidental findings to life-threatening emergencies. Associated morbidity and
mortality can be significant and the altered physiology of these disease states
presents numerous challenges to safe perioperative management. Although the
etiology of pericardial disorders is quite variable—including infectious,
inflammatory, autoimmune, and malignant states—common themes arise allowing
the anesthesiologist to safely approach the patient presenting with pericardial
disease. Regardless of the underlying cause, the effects of pericardial disease on
cardiac function most often present as impaired cardiac filling, with the severity of
symptoms dependent upon the degree to which filling is impaired. This filling
impairment is usually represented by pericardial effusion or constriction.
1 Although imaging modalities such as computed tomography (CT) and cardiac
magnetic resonance imaging (MRI) are increasingly used to characterize
pericardial disease, echocardiography has become the first-line diagnostic tool
given its noninvasive and relatively inexpensive nature [1]. In addition,
echocardiography allows for rapid recognition of life-threatening pericardial
tamponade in the perioperative setting.
This chapter will review the normal structure and function of the pericardium, as
well as the most common causes of pericardial disease. The two most clinically
relevant pericardial disorders—cardiac tamponade and constrictive pericarditis
(CP)—will be discussed in detail, focusing on pertinent anesthetic management
considerations. Additionally, online supplemental content provides specific
echocardiographic examples of tamponade, chronic pericardial effusion, and CP.
II. Pericardial anatomy and physiology
A. The normal pericardium is a dual-enveloped sac surrounding the heart and great
vessels. It is comprised of two layers: the parietal pericardium and the visceral
pericardium. The parietal pericardium is a thick, fibrous outer layer comprised
primarily of collagen and elastin. It attaches to the adventitia of the great vessels,
diaphragm, sternum, and the vertebral bodies. The inner visceral pericardium
rests on the surface of the heart. It is composed of a single layer of mesothelial
cells, which adhere to the pericardium. Normal pericardial thickness is 1 to 2
mm.
B. Two distinct sinuses are formed at points where the pericardium appears to fold
onto itself (Fig. 19.1). The oblique sinus forms posteriorly, between the left
atrium and pulmonary veins, and is a common location for blood to collect after
cardiac surgery (Supplemental Video 19.1). The transverse sinus also forms
posteriorly behind the left atrium, situated behind the aorta and pulmonary artery
(Supplemental Video 19.2).
C. Normal cardiac function can still occur in the absence of the pericardium, making
it nonessential for survival. However, it does provide several useful physiologic
functions. It aids in the reducing friction between the heart and surrounding
structures, limits acute dilatation of cardiac chambers, provides a barrier to
infection, optimizes coupling of left and right ventricular (RV) filling and
function, and limits excessive motion of the heart within the chest cavity. The
pericardium is also metabolically active, secreting prostaglandins that affect
coronary artery tone and cardiac reflexes [2].
D. The pericardium is a highly innervated structure. Pericardial inflammation or
manipulation may produce severe pain or vagally mediated reflexes.
III. Causes of pericardial disease
The etiologies of pericardial disease are numerous and can lead to pericardial
inflammation, effusion, or both. Often, the care of these patients must not only
consider the underlying pericardial pathology, but the manifestations and
complications of the underlying condition as well. Pericardial disease can be
caused by infection (i.e., viral, bacterial, fungal, tuberculosis), connective tissue
disorders (i.e., systemic lupus erythematosus, sarcoidosis, rheumatoid arthritis),
trauma, uremia, malignancy, postmyocardial infarction (Dressler syndrome), or
following cardiac surgery and other invasive cardiac procedures.
FIGURE 19.1 Anatomy of the pericardium and pericardial sinuses. The left image (A) demonstrates the heart in situ
with a section of the parietal pericardium cut away. The right image (B), with the heart cut away, demonstrates the
oblique sinus (arrow at ∼6 o’clock) and the transverse sinus (arrow at ∼3 o’clock). (Reprinted with permission from
Lachman N, Syed FF, Habib A, et al. Correlative anatomy for the electrophysiologist, part I: The pericardial space, oblique
sinus, transverse sinus. J Cardiovasc Electrophysiol. 2010;21(12):1421–1426.)
IV. Pericardial tamponade

A. Natural history
1. Etiology. The visceral pericardium is responsible for the production of
pericardial fluid, which is an ultrafiltrate of plasma. This fluid provides
lubrication to decrease friction between the pericardial layers. The pericardial
space normally contains 10 to 50 mL of fluid, which is drained by the
lymphatic system. As previously discussed, many conditions can cause fluid
(serous, serosanguineous, and purulent) and/or blood to accumulate within the
pericardial space. The majority of pericardial effusions are not
hemodynamically significant and do not progress to tamponade. Tamponade
occurs when extrinsic pericardial compression of the heart leads to diminished
venous filling and, ultimately, reduced cardiac output. In addition to fluid
collection within the pericardium, tamponade may also be caused by the
accumulation of clot or air in the pericardial space. Acute, life-threatening
tamponade most frequently results from bleeding into the pericardial space
after cardiac surgery or other invasive cardiac procedures, following blunt
chest trauma, or due to a ruptured ascending aortic aneurysm or aortic
dissection [3] (Fig. 19.2). Tamponade may occur in as many as 8.8% of
patients presenting for cardiac surgery, although it is more commonly seen after
valve surgery than coronary artery bypass grafting (CABG). The onset is
typically in the immediate postoperative period, but may potentially occur
several days following surgery. Frequently there is localized clot or effusion,
which causes nonuniform compression of the cardiac chambers and manifests
without the classical clinical features of tamponade (Supplemental Video
19.3). The diagnosis of postcardiac surgery tamponade can therefore be
challenging, especially when considering the many potential causes of
hemodynamic instability during this time period. Unfortunately, morbidity and
mortality increases significantly the longer the diagnosis is delayed [4].
FIGURE 19.2 Critical tamponade with right atrial (RA) and ventricular (RV) collapse. A: Midesophageal four-chamber
transesophageal echocardiography (TEE) view demonstrating collapse of RA and RV following RA perforation by J-wire
during cannulation for venoarterial extracorporeal membrane oxygenation (VA ECMO) support. B: Midesophageal four-
chamber view from same patient following evacuation of hemopericardium, relief of tamponade, and repair of RA.
2. 2 Symptomatology. Symptoms of cardiac tamponade are usually rapid in

onset, but depend upon the rate at which pericardial fluid accumulates. A
relatively small amount of fluid (50 to 100 mL) that rapidly accumulates within
the closed pericardial space is sufficient to dramatically increase
intrapericardial pressure and interfere with cardiac filling. However, a chronic
increase in pericardial fluid will produce tamponade only after a large volume
(>1 L) is present. A gradual accumulation of fluid stretches the parietal
pericardium, allowing larger volumes to be tolerated before symptoms occur
(Supplemental Videos 19.4 and 19.5). Lack of this pericardial stretch explains
the abrupt onset of symptoms and clinical deterioration in the setting of acute
tamponade. The primary symptoms of cardiac tamponade include dyspnea,
orthopnea, diaphoresis, and chest pain. Dyspnea is often the first and most
sensitive symptom [5].
B. Pathophysiology
3 The primary abnormality in cardiac tamponade is impaired diastolic filling of
the heart, caused by elevated intrapericardial pressure that leads to compression
of the atria and ventricles. The right heart is most vulnerable to the compression
due to its thinner walls and lower chamber pressures as compared to the left
heart (Supplemental Video 19.6). Diastolic filling pressures (i.e., central venous
pressure [CVP], left atrial pressure, pulmonary capillary wedge pressure, left
and right ventricular end-diastolic pressures [LVEDP and RVEDP]) become
elevated and began to equilibrate with one another, as well as the
intrapericardial pressure. Physiologic manifestations of pericardial fluid, as
previously discussed, are contingent upon the rate and amount of fluid
accumulation, with a continuum ranging from clinical insignificance to severe
hemodynamic collapse (Fig. 19.3). Cardiac filling is critically reduced, which
translates into decreased stroke volume, cardiac output, and systemic blood
pressure. Compensatory sympathetic responses attempt to offset this reduction in
stroke volume, with elevated levels of plasma catecholamines resulting in
systemic vasoconstriction and tachycardia. This may temporarily maintain
cardiac output and systemic perfusion; however, sudden hemodynamic collapse
may rapidly occur with depletion of catecholamines and/or continued elevation
of intrapericardial pressure.
FIGURE 19.3 Pressure–volume relationship in acute versus chronic pericardial effusions. Intrapericardial pressure is
contingent upon the change in intrapericardial volume. Pressure is relatively stable until a critical volume occurs. At this
point, minimal increases in volume will lead to significant changes in intrapericardial pressure. With chronic effusions,
pericardial stretch allows for a greater amount of volume to accumulate before critical increases in pressure occur. The lack
of pericardial stretch explains the significant elevations in pressures seen with only small amounts of rapidly accumulating
intrapericardial fluid. (Reprinted with permission from Avery EG, Shernan SK. Echocardiographic evaluation of pericardial
disease. In: Savage RM, Aronson SA, Shernan SK, eds. Comprehensive Textbook of Perioperative Transesophageal
Echocardiography. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:726—this figure is originally from Spodick
DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684–690.)

1. Clinical evaluation
a. 4 Acute tamponade is often described by Beck triad: muffled heart sounds,
jugular venous distention (JVD) (due to increased venous pressure), and
hypotension. Other common findings include tachypnea and tachycardia.
b. 5 Pulsus paradoxus, although not specific for tamponade, may be present.
While a modest decrease of systolic arterial blood pressure during inspiration
is physiologic, and exaggerated decrease in blood pressure is pathologic.
Pulsus paradoxus is defined as a decrease of more than 10 mm Hg in systolic
arterial pressure that occurs with inspiration. Tamponade physiology leads to
respiratory variability in ventricular diastolic filling, in which the negative
intrathoracic pressure accompanying inspiration leads to enhanced right-sided
filling. Since total intracardiac volume is fixed by the pericardial
compression, as the RV fills it will lead to a shift of the interventricular
septum toward the left ventricle (LV). This crowding of the LV impedes its
filling, decreasing LV stroke volume and resulting in an exaggerated decline
in systolic blood pressure seen with inspiration. The opposite is true during
expiration, with diminished RV and enhanced LV filling. Pulsus paradoxus is
also seen in patients with chronic lung disease, large pleural effusions, RV
dysfunction, and CP.
c. The chest x-ray may show an enlarged, globular, and bottle-shaped cardiac
silhouette. The right costophrenic angle is reduced to less than 90 degrees and
the lung fields are typically clear. Pericardial fat lines in a lateral film are an
uncommon, but highly specific, finding.
d. 6 The ECG is nonspecific, but may demonstrate sinus tachycardia, low-
voltage QRS, nonspecific ST-T wave abnormalities, and electrical alternans.
Electrical alternans (Fig. 19.4) is due to swinging of the heart within the
fluid of the pericardial sac, leading to beat-to-beat changes in the electrical
axis.
IGURE 19.4 Electrical alternans with cardiac tamponade. Note that this phenomenon is not seen in all electrocardiographic
ads. (Reprinted with permission from Badescu GC, Sherman BM, Zaidan JR, Barash PB. Appendix 2: Atlas of
lectrocardiography. In: Barash PB, Cullen BF, Stoelting RK, et al, eds. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer,
e. Table 19.1 summarizes the classic clinical manifestations most commonly

described in cardiac tamponade.
2. Catheterization data. Cardiac tamponade is a clinical diagnosis that cannot
be made with catheterization data alone; however, common patterns of
intracardiac pressures are usually seen. There is elevation and near
equalization of the CVP, RVEDP, pulmonary capillary wedge pressure, left
atrial pressure, and LVEDP. Increased CVP and right atrial (RA) pressures are
seen with a prominent x-descent and a diminished or absent y-descent (Fig.
19.5).
CLINICAL PEARL When hemodynamic instability occurs within the setting of elevated
filling pressures (as demonstrated by CVP and/or pulmonary artery pressure
measurements), cardiac tamponade must be immediately included in the differential
diagnosis (especially in the postcardiac surgery patient).
TABLE 19.1 Cardiac tamponade—clinical manifestations
3. Echocardiography. Echocardiography is the diagnostic modality of choice in

evaluating cardiac tamponade. It is the most sensitive tool for making the
diagnosis of pericardial effusion. Initial evaluation should focus on the
presence, size, and extent (circumferential vs. localized/loculated) of the
pericardial effusion, which is seen as an echo-free space surrounding the heart.
The effusion should be measured to estimate its severity (Table 19.2; Fig.
19.6).
FIGURE 19.5 Right atrial (RA) and pericardial pressures in cardiac tamponade. A: Note equal RA and pericardial pressures
and the diminished y-descent of the RA waveform. B: After removal of 100 mL of fluid, the pericardial pressure is lower than
RA pressure, and the normal large descent has returned. (Reprinted with permission from Hensley FA, Martin DE, Gravlee
GP. A Practical Approach to Cardiac Anesthesia. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:475.)
7 Although echocardiography alone cannot definitively diagnose

tamponade, in the presence of a pericardial effusion there are several
echocardiographic features consistently associated with tamponade physiology
(Figs. 19.7 and 19.8). With tamponade, RA collapse is a sensitive sign,
typically beginning in end diastole and continuing through systole
(Supplemental Video 19.7). Systolic RA collapse persisting for more than one-
third of the cardiac cycle is specific for tamponade. Diastolic RV collapse is
also observed and, when lasting for more than one-third of diastole, is even
more specific than systolic RA collapse for the identification of tamponade.
End-diastolic dimensions of the RV will be reduced, reflective of diminished
ventricular filling. Paradoxical motion of the interventricular septum is a
frequent finding, reflecting the reciprocal respiratory variability in diastolic
filling. These changes are also reflected with Doppler transmitral and
transtricuspid inflow velocity profiles.
CLINICAL PEARL If tamponade is suspected, bedside echocardiography can
provide immediate information to assist/confirm clinical suspicion by allowing for
visualization of pericardial effusion and/or compression leading to cardiac chamber
collapse.
D. Treatment
Definitive treatment of cardiac tamponade is emergent drainage and/or relief of
pericardial compression, which may be accomplished through either
pericardiocentesis or surgical decompression.
TABLE 19.2 Estimation of effusion severity
1. Pericardiocentesis. Pericardiocentesis may be performed with or without

imaging guidance (i.e., echocardiography, fluoroscopy). Imaging is often
preferred to assist in safely guiding the needle tip through the pericardium to
the most optimal location for drainage, as well as assessing the adequacy of
fluid removal. Without imaging there is a significantly higher risk of
complications, such as cardiac perforation, puncture of coronary or internal
mammary arteries, and pneumothorax. In the setting of severe hemodynamic
instability, however, it may be necessary to proceed without imaging due to the
significant risk of rapid and profound clinical deterioration. A catheter is
frequently left in the pericardial space to allow for continuous drainage (Fig.
19.9).
FIGURE 19.6 Measurement of pericardial effusion volume with echocardiography. Transgastric transesophageal
echocardiography (TEE) view showing caliper measurement to estimate the size of pericardial effusion. As shown in Table
, caliper measurement of 1.86 cm is indicative of a 250- to 500-mL pericardial effusion volume.
FIGURE 19.7 Right atrial (RA) systolic collapse in a patient with cardiac tamponade. Transthoracic subcostal four-chamber
view demonstrating RA bowing and collapse during systole. Pericardial effusion can be seen surrounding the RA right ventricle.
ECG monitoring is helpful in identifying systolic RA collapse in tamponade.
FIGURE 19.8 The pericardial space is occupied by a large amount of clot (marked by the white arrows), seen posterior to
the inferior wall of the left ventricle (LV) in a transgastric short-axis midpapillary transesophageal echocardiography (TEE)
FIGURE 19.9 The most common needle insertion points for pericardiocentesis, including the paraxiphoid and apical
approaches. When using the paraxiphoid approach, the needle tip should be directed toward the left shoulder. With the apical
approach, the needle tip is aimed internally. (Reprinted with permission from Spodick DH. Acute cardiac tamponade. N Engl J
. 2003;349(7):684–690.)
2. Surgical drainage. Indications for surgical drainage include unsuccessful

pericardiocentesis, localized/loculated effusions, removal of clot, and ongoing
intrapericardial bleeding (i.e., acute aortic dissection, trauma, following
cardiac surgery or percutaneous cardiac procedures). The surgical approach is
primarily via subxyphoid pericardial window or a small anterior thoracotomy.
The subxyphoid approach is easier to perform but offers a limited exposure,
while a thoracotomy provides excellent exposure and is indicated if a larger
surgical field is required. Both approaches allow for open exploration,
facilitating the removal of clot and fibrinous debris. With hemorrhagic
tamponade following cardiac surgery, full mediastinal exploration is often
needed to localize the source of bleeding and stabilize the patient. In the setting
of malignant effusions, diagnostic pericardial biopsies can be obtained with a
surgical approach to drainage [3]. Some patients may continue to experience
recurrent pericardial effusions, requiring consideration of pericardiectomy.
This is most commonly seen in patients with malignant effusions or uremia [6].
8 The hemodynamic state of the patient will dictate the sequence of anesthesia
and surgery. While general anesthesia is frequently used, it may likely contribute
to clinical decompensation in the severely compromised patient. Direct
myocardial depression, systemic vasodilation, and diminished preload
accompanying the induction of general anesthesia can lead to a profound
decrease in cardiac output. Potentially life-threatening cardiac collapse may
ensue. In this scenario, pericardiocentesis or subxyphoid pericardial window can
be performed under local anesthesia to avoid these complications. Frequently,
hemodynamic instability is dramatically improved with the removal of only a
small amount of fluid. This is due to the steep curve of the pressure–volume
relationship of the pericardial contents [3]. Following initial drainage, the patient
may become stable enough to tolerate the institution of general anesthesia for the
remainder of the procedure.
CLINICAL PEARL In a patient with tamponade, it is important to discuss with the
surgeon the feasibility of draining at least a portion of the pericardial effusion prior to
induction in order to relieve cardiac compression and minimize the risk of severe
cardiac compromise.
1. Premedication with anxiolytics or opioids should be avoided in patients with
true cardiac tamponade, as even small doses of these medications can
precipitate acute cardiac collapse.
2. To facilitate ventricular filling, preload should be optimized with intravenous
fluids prior to induction. Any manipulations that decrease venous return should
be avoided or minimized as much as possible.
3. In addition to standard noninvasive monitors, an arterial line should be strongly
considered prior to induction to allow for preoperative quantification of pulsus
paradoxus and beat-to-beat monitoring of systemic blood pressure. Adequate
intravenous access is needed for volume replacement and drug administration.
Central venous access may be beneficial, but is not always essential. In a
severely unstable patient, surgical intervention should not be delayed for the
placement of lines or monitors.
4. Before proceeding with induction the patient should be fully prepped and
draped, with the surgical team immediately available to make incision in the
event of hemodynamic collapse upon induction.
CLINICAL PEARL Many describe parallels between the conduct of general anesthetic
induction for cardiac tamponade with that of induction for emergency cesarean section, in
which it is critical to have close coordination between the surgical and anesthesia teams
that allows for surgical incision to occur immediately after the airway has been secured.
5. The perioperative anesthetic plan should have the following hemodynamic
goals (Table 19.3): Reductions in heart rate should be avoided and contractility
optimized to preserve cardiac output, as these patients have both a fixed and
reduced stroke volume. Adequate preload is essential to promote RV filling.
Decreases in systemic vascular resistance are particularly detrimental, as this
will reduce RV filling and systemic perfusion pressure.
TABLE 19.3 Hemodynamic goals in cardiac tamponade
6. Positive pressure ventilation can cause a dramatic decline in preload and

cardiac output. It is therefore suggested that patients with tamponade be
allowed to breathe spontaneously until the pericardial sac is opened and
drained. If spontaneous ventilation is not possible, ventilation with high
respiratory rates and low tidal volumes should be considered to minimize
elevation in mean airway pressures.
CLINICAL PEARL Airway management in a patient with tamponade is complicated by
the presence of surgical drapes above the patients head, so in the setting of a potentially
difficult airway it is crucial to have all preparations and equipment in place prior to
induction (i.e., video laryngoscope, additional anesthesia providers to provide help).
7. Careful consideration should be given to the selection of induction drugs, with
particular attention aimed at minimizing myocardial depression and peripheral
vasodilation. Etomidate is a reasonable induction agent, as it produces minimal
decreases in contractility and systemic vascular resistance, although
hemodynamic instability may still occur in the setting of tamponade physiology.
Benzodiazepines are also a reasonable choice. Many advocate the use of
ketamine in this setting, relying on the sympathetic stimulation it provides to
minimize hemodynamic compromise. It is important to note, however, that in a
catecholamine-depleted state many patients will have a diminished ability to
increase their own sympathetic nervous system activity. In these patients, the
myocardial depressant properties of ketamine will be unmasked and significant
hypotension is likely to occur. Opioids should be given with caution, as vagally
mediated bradycardia can significantly diminish cardiac output.
CLINICAL PEARL Vasopressor and inotropic drugs should be immediately available
to administer with general anesthetic induction and, in many cases, it is prudent to begin
infusions of vasoactive medications (if not already started prior to arrival in the operating
room) to support the patient’s hemodynamics during and following induction.
8. Inotropes (i.e., epinephrine, norepinephrine) and vasoconstrictors (i.e.,
phenylephrine, vasopressin) are often needed to maintain cardiac output and
peripheral vascular resistance, but serve only as a temporizing measure until
tamponade can be definitively treated with drainage.
9. Tamponade is rarely seen in patients presenting for surgical drainage of
chronic, recurrent pericardial effusions. In this scenario, however, it is still
essential to obtain as much information as possible regarding the clinical
significance and severity of the effusion. This should include a review of the
preoperative echocardiogram, a thorough discussion with the surgeon, and a
detailed history and physical focusing, in particular, on any vital sign
abnormalities. A high index of suspicion should be maintained for the potential
of perioperative hemodynamic instability.
CLINICAL PEARL While tamponade is not commonly seen in the setting of a chronic
pericardial effusion, it is still important to remain vigilant and prepared for the occurrence
of hemodynamic instability.
V. Constrictive pericarditis (CP)
A. Natural history
1. 9 Etiology. CP is a diagnosis that encompasses a wide spectrum of disease,
from acute or subacute cases that may resolve spontaneously (or with medical
therapy) to the classic chronic, progressive CP, which will be the focus of this
section. Other entities noted in the literature include effusive CP, in which
patients present with cardiac effusion or tamponade but retain characteristics of
CP following drainage of the effusion; localized CP, involving only parts of the
pericardium with variable hemodynamic sequelae; and occult CP, in which
rapid infusion of intravenous fluids can provoke the signs and symptoms of the
disease [7]. While many etiologies have been documented, the most common
are idiopathic, viral, postcardiac surgery, mediastinal radiation, and, in
developing countries, tuberculosis.
2. Symptomatology. CP presents most commonly as chronic and progressive
fatigue, orthopnea, dyspnea on exertion, peripheral edema, and abdominal
distention. Given the nonspecific nature of these findings, care must be taken to
differentiate this disease process from other entities such as hepatic failure, RV
failure, tricuspid valve disease, and, in particular, restrictive cardiomyopathy.
As the pathophysiology underlying these conditions is markedly different, the
medical and surgical management varies considerably as well.
B. Pathophysiology
The hallmark of CP is a thickened, calcified, and adherent pericardium. This
effectively confines the heart inside a rigid shell. From a pathophysiologic
perspective, this has three major consequences [8]:
1. Impaired diastolic filling. The noncompliant pericardium limits filling of all
cardiac chambers, with elevation and near equalization of end-diastolic
pressures. Ventricular filling occurs rapidly during early diastole, but ceases
abruptly as the volume, and thus pressure, in the ventricle reaches a critical
point. This results in the characteristic “dip and plateau,” or “square root sign,”
noted in ventricular pressure tracings. Atrial systole does little to augment LV
filling, and cardiac output is maintained by a compensatory increase in heart
rate.
2. Dissociation of intrathoracic pressures. The rigid pericardium isolates the
cardiac chambers from the negative pressure generated during inspiration,
resulting in a decreased gradient between the pulmonary veins and the left
atrium. Consequently, left heart filling, and thus cardiac output, are decreased.
3. Ventricular interdependence. As discussed previously, left and right heart
filling are not independent events. Increases in right heart filling may cause a
leftward shift in the interventricular septum at the expense of left heart filling.
Expiration, as would be expected, reverses this pattern. This phenomenon is
known as ventricular interdependence and is exaggerated in CP.
4. One of the most important consequences of pericardial constriction is
significant respiratory variation in left and RV filling patterns. This is an
important consideration in the diagnosis of CP and provides the foundation for
the diagnostic workup to be discussed later. Of note, this respiratory variation
is maintained, but reversed, in patients on mechanical ventilation [9].
1. Clinical evaluation
a. The diagnosis of CP is difficult to make on history and physical examination
alone, but must be considered in patients presenting with the signs and
symptoms of venous congestion mentioned previously. On examination, JVD
with Kussmaul sign (an increase in JVD on inspiration) and Friedreich sign (a
rapid decrease in JVD during early diastole) may be present. Pulsus
paradoxus is variably present. On cardiac auscultation, a “pericardial knock”
may be noted. This is a high-pitched sound in early diastole that is caused by
the sudden cessation of ventricular filling and is a highly specific, but
insensitive, clue to the diagnosis. Pulmonary edema is often absent and
pulsatile hepatomegaly may be noted on abdominal examination.
b. Laboratory investigation may reveal organ dysfunction secondary to the
disease process (i.e., kidney injury, elevated liver enzymes). Natriuretic
peptide levels, which are released in response to myocardial stretch and are
increased in many cases of heart failure, are usually normal or only slightly
elevated. This is attributed to the rigid pericardium limiting the amount of
potential chamber dilatation.
c. ECG findings are nonspecific and may include sinus tachycardia, atrial
fibrillation, conduction delays, p mitrale, and ST-segment and T-wave
changes.
d. While calcification of the pericardium is not universal, its presence on the
lateral chest x-ray may suggest CP. A thickened pericardium (>2 mm) may be
appreciated on CT or MRI and other imaging techniques may demonstrate the
pericardium being adherent to the myocardium.
FIGURE 19.10 Waveform characteristics commonly seen during catheterization of patients with CP before ( A) and after
) pericardiectomy. Note the “square root sign” in the right ventricular (RV) pressure tracing, and the “M” waveform in the
central venous pressure (CVP) tracing prior to pericardiectomy. ECG, electrocardiogram; PA, pulmonary artery. (Reprinted
with permission from Skubas NJ, Beardslee M, Barzilai B, et al. Constrictive pericarditis: intraoperative hemodynamic and
echocardiographic evaluation of cardiac filling dynamics. Anesth Analg. 2001;92(6):1424–1426.)
2. Catheterization data. As in tamponade, cardiac catheterization is not always

necessary for the diagnosis of CP. However, it may be helpful in the diagnosis
of effusive CP, with some suggesting its routine use during the drainage of
pericardial effusions. Certain waveform characteristics may be seen during
placement of invasive monitors in the operating room (Fig. 19.10). RA
pressure tracings may show “M” or “W” waveforms with a prominent y-
descent, the diagnostic equivalent of Friedreich sign. Ventricular pressure
tracings may show the characteristic “dip and plateau,” or “square root sign,”
as previously described. The end-diastolic pressures in all chambers are
elevated and nearly equal (≤5 mm Hg difference). RV systolic pressures are
usually <50 mm Hg, with an RV end-diastolic to RV systolic ratio of ≥1:3.
FIGURE 19.11 Transesophageal pulsed wave transmitral Doppler profile in a patient with CP during positive pressure
ventilation. Note the preserved, but reversed, respiratory variation as opposed to that which would be seen in a spontaneously
ventilating patient. Insp, inspiration; exp, expiration. (Reprinted with permission from Avery EG, Shernan SK.
Echocardiographic evaluation of pericardial disease. In: Savage RM, Aronson SA, Shernan SK, eds. Comprehensive Textbook
of Perioperative Transesophageal Echocardiography. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:737.)
3. Echocardiography. Echocardiography is essential to the diagnosis of CP and

more advanced techniques have become useful in its differentiation from other
disease processes. Two-dimensional and M-mode examination may show a
thickened, hyperechoic pericardium; diastolic flattening of the LV posterior
wall, reflective of the abrupt cessation of ventricular filling; a ventricular
septal “bounce,” caused by the sudden changes in the transseptal pressure
gradient (Supplemental Video 19.8); atrial tethering (Supplemental Video
19.9); premature closure of the mitral valve and opening of the pulmonic valve,
indicative of high chamber pressures; enlarged hepatic veins; and IVC plethora,
where the vessel remains dilated and lacks the normal change in diameter
during the respiratory cycle. Doppler evaluation of transmitral, transtricuspid,
and pulmonary vein flow shows characteristic tracings with profound
respiratory variation (often >25%) (Fig. 19.11). Newer techniques, such as
tissue Doppler imaging (TDI) of the mitral annulus (Fig. 19.12) and color
Doppler M-mode of transmitral flow propagation velocity (Fig. 19.13) allow
further characterization and differentiation from restrictive cardiomyopathy
[10] (Table 19.4).
D. Treatment
As previously mentioned, some cases of acute constriction may resolve
spontaneously or with medical management. The definitive management of
chronic CP, however, is usually surgical. Pericardiectomy, or pericardial
decortication, is often performed via left thoracotomy or midline sternotomy,
depending on the extent of resection necessary. The goal of treatment is total
resection of both the visceral and parietal pericardium, and while this can often
be performed without the use of cardiopulmonary bypass (CPB), its use may be
indicated in more difficult dissections. Despite improvements in surgical
technique, operative mortality remains as high as 10%, with poor prognostic
predictors including prior cardiac surgery, radiation, malignancy, and advanced
heart failure on presentation. As opposed to patients with tamponade, where
surgical drainage may provide immediate improvement in hemodynamic and
clinical status, an immediate improvement in symptoms is not generally
observed.
FIGURE 19.12 Lateral Wall Tissue Doppler Imaging (TDI) in a patient with constrictive pericarditis (CP). Note lateral
TDI E′ velocity (arrow) is greater than 8 cm/s, distinguishing CP from restrictive cardiomyopathy (as outlined in Table 19.3).
FIGURE 19.13 Transesophageal image of the transmitral color M-mode (propagation velocity, Vp ) profile of a patient
with CP. The slope of the first aliasing velocity is used in this determination and is depicted by the pink line. (Reprinted with
permission from Avery EG, Shernan SK. Echocardiographic evaluation of pericardial disease. In: Savage RM, Aronson SA,
Shernan SK, eds. Comprehensive Textbook of Perioperative Transesophageal Echocardiography. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2011:738.)
TABLE 19.4 Clues to the differentiation of CP and restrictive cardiomyopathy

10 As the pathophysiologic manifestations of CP generally parallel that of
tamponade, the anesthetic management of a patient presenting for
pericardiectomy is similar to those mentioned for tamponade.
1. Premedication with benzodiazepines or opioids must be titrated judiciously and
according to the patient’s preoperative hemodynamic status. The sympathetic
nervous system plays an important role in maintaining cardiac output and any
inhibition may lead to clinical and hemodynamic deterioration.
2. In addition to standard noninvasive monitors, the intraoperative and
postoperative management of patients with CP often requires invasive
monitors. An arterial line is beneficial for frequent blood gas analysis (most
importantly for cases involving thoracotomy), as well as continuous blood
pressure monitoring (especially during cardiac manipulation and when CPB is
utilized). The decision to place an arterial line either preoperatively or after
induction of anesthesia must take into account the patient’s clinical status and
the possibility of hemodynamic instability on induction. Adequate intravenous
access must be obtained given the possibility of marked and precipitous blood
loss (cardiac chamber or coronary artery perforation, myocardial injury due to
stripping of the pericardium), with central venous access allowing the rapid
infusion of IV fluids/blood products and vasoactive drugs, as well as the
monitoring of CVP. Perioperative cardiac output monitoring via a pulmonary
artery catheter may be beneficial, especially as low cardiac output syndrome
may persist into the postoperative period [4]. Intraoperative transesophageal
echocardiography (TEE) provides useful information for both the surgeon and
the anesthesiologist, in particular with regard to ventricular filling and function.
3. Pericardiectomy requires general anesthesia and care must be taken to avoid
hemodynamic deterioration during induction and maintenance of anesthesia.
Preload must be maintained, and often augmented, to ensure cardiac filling, and
reductions in either preload or afterload are usually poorly tolerated. An
elevated heart rate plays an important role in maintenance of cardiac output and
bradycardia can be particularly detrimental. While the atrial “kick” does little
to enhance ventricular filling in patients with CP, extreme tachycardia, such as
atrial fibrillation with a rapid ventricular rate, may be poorly tolerated.
Contractility should be maintained, as significant myocardial depression will
adversely impact cardiac output and systemic flow.
4. Based on these hemodynamic goals, induction and maintenance of anesthesia
involve similar considerations as previously described for patients presenting
with tamponade. Vasoactive medications must be readily available to offset
any perturbations caused by the anesthetic agents or surgical manipulations,
most notably decreased preload, afterload, contractility, and heart rate.
Surgical blood loss and coagulopathy may be significant, necessitating
aggressive resuscitation and correction of the underlying coagulopathy.
CLINICAL PEARL Depending on the extent of surgical dissection, severe surgical
bleeding and coagulopathy are common with pericardiectomy.
REFERENCES
1. Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography
clinical recommendations for multimodality cardiovascular imaging of patients
with pericardial disease: endorsed by the Society for Cardiovascular Magnetic
Resonance and Society of Cardiovascular Computed Tomography. J Am Soc
Echocardiogr. 2013;26(9):965–1012.e15.
2. Little WC, Freeman GL. Contemporary reviews in cardiovascular medicine:
pericardial disease. Circulation. 2006;113:1622–1632.
3. O’Connor CJ, Tuman KJ. The intraoperative management of patients with
cardiac tamponade. Anesthesiol Clin. 2010;28(1):87–96.
4. Oliver WC, Mauermann WJ, Nuttall GA. Uncommon cardiac diseases. In: Kaplan JA,
Reich DL, Savino JS, eds. Kaplan’s Cardiac Anesthesia: The Echo Era. 6th ed. St.
Louis, MO: Elsevier Saunders; 2011:706–713.
5. Gandhi S, Schneider A, Mohiuddin S, et al. Has the clinical presentation and
clinician’s index of suspicion of cardiac tamponade changed over the past decade?
Echocardiography. 2008;25(3):237–241.
6. Dinardo JA, Zvara DA. Anesthesia for Cardiac Surgery. 3rd ed. Malden, MA:
Blackwell Publishing; 2008.
7. Sagrista-Salueda J. Pericardial constriction: uncommon patterns. Heart.
2004;90(3):257–258.
8. Myers RB, Spodick DH. Constrictive pericarditis: clinical and pathophysiologic
characteristics. Am Heart J. 1999;138(2 Pt 1):219–232.
9. Abdalla IA, Murray RD, Awad HE, et al. Reversal of the pattern of respiratory
variation of Doppler inflow velocities in constrictive pericarditis during mechanical
ventilation. J Am Soc Echocardiogr. 2000;13(9):827–831.
10. Rajagopalan N, Garcia MJ, Rodriguez L, et al. Comparison of new Doppler
echocardiographic methods to differentiate constrictive pericardial heart disease and
restrictive cardiomyopathy. Am J Cardiol. 2001;87(1):86–94.
IV
Circulatory Support
20 Cardiopulmonary Bypass: Equipment, Circuits,
and Pathophysiology
Eugene A. Hessel, II
Part I. The Cardiopulmonary Bypass Circuit

I. Introduction
II. Components of the circuit
A. Overview
B. Venous cannulation and drainage
C. Arterial cannulation
D. Venous reservoir
E. Systemic (arterial) pump
F. The oxygenator (artificial lung or gas-exchanging device)
G. Heat exchanger
H. Cardioplegia delivery system or circuit
I. Cardiotomy, field suction, cell salvage processors, and cell (red blood
cell [RBC]) savers
J. Venting
K. Ultrafiltration/hemoconcentrators
L. Filters and bubble traps
M. Safety devices and monitors on the heart–lung (H–L) machine
III. Special topics
A. Surface coating
B. Miniaturized or minimized circuits
C. Pediatric circuits
D. Cerebral perfusion during circulatory arrest
E. Less common cannulation
IV. Priming
A. Overview
B. Consequence of asanguineous primes
C. Retrograde autologous priming (RAP)
D. Composition of the prime
E. Priming of the circuit
F. Final disposition of prime at the end of cardiopulmonary bypass (CPB)
V. Complications, safety, and risk containment
A. Incidence of adverse events
B. Specific complications and their diagnosis and management
C. Risk containment
D. Key role of the anesthesiologist in the conduct of CPB
Part II. Pathophysiology of Cardiopulmonary Bypass

I. Introduction
II. CPB as a perfusion system
A. Circulatory control during CPB
B. Circulatory changes during CPB
III. Adequacy of perfusion
A. How to define
B. Monitoring
IV. Hypothermia and CPB
A. Effects of hypothermia on biochemical reactions
B. Effects of hypothermia on blood viscosity
C. Changes in blood gases associated with hypothermia
V. Systemic effects of CPB
A. Causes and contributors of adverse systemic effects of CPB
B. Blood
C. Fluid balance and interstitial fluid accumulation (“capillary leak
syndrome”) during CPB
D. Inflammation
E. Stress response
VI. Effect of CPB on various organs
A. Heart
B. Central nervous system (CNS)
C. Kidneys
D. Splanchnic, gastrointestinal (GI), and hepatic effects
E. Lungs
VII. Role of CPB on adverse effects of cardiac surgery
VIII. Summary
KEY POINTS
KEY POINTS
1. All anesthesiologists who care for patients undergoing

cardiopulmonary bypass (CPB) should be intimately familiar with
the details and function of the heart–lung (H–L) machine (also
referred to as the extracorporeal circuit [ECC]) and be involved in
the establishment of protocols and the conduct of CPB during
cardiac surgery.
2. The goal of CPB is to provide adequate gas exchange, oxygen
delivery, and systemic blood flow with adequate perfusion pressure
while minimizing the detrimental effects of bypass.
3. Roller pumps may cause more damage to blood elements than
centrifugal pumps and can result in massive air embolism if the
venous reservoir becomes empty.
4. Although centrifugal pumps pose less risk for massive air emboli,
they can pump potentially lethal quantities of smaller bubbles. When
a centrifugal pump is connected to the patient’s arterial system but is
not rotating, blood will flow backward through the pump and out of
the patient unless the CPB systemic arterial line is clamped or a one-
way valve is incorporated into the arterial line.
5. Membrane oxygenators (MOs) function similarly to natural lungs,
imposing a membrane between the ventilating gas and the flowing
blood, thereby eliminating direct contact between blood and gas.
6. An important limitation of polymethyl pentene (PMP) diffusion
MOs is that they do not appear to allow transfer of volatile
anesthetics and therefore intravenous anesthetics must be employed
during CPB.
7. During bypass, excessive and rapid warming of blood with the
bypass heat exchanger must be avoided (1) to prevent gas coming
out of solution risking embolism and (2) excessive heating of the
brain with potential neurologic damage.
8. Cardiotomy suction should be minimized or cell salvage techniques
used to process the aspirated cardiotomy blood, as it contains
microaggregates and is thought to be a major source of hemolysis
and microemboli during CPB.
9. Adequate venting of the left ventricle (LV) requires constant
monitoring, and several methods of venting the LV are available.
10. Adverse events during CPB are not uncommon. Risk containment
requires the attention of anesthesiologists in addition to
perfusionists and surgeons.
11. CPB introduces major physiologic abnormalities and contributes to
the systemic inflammatory response (SIR) and organ dysfunction
associated with cardiac surgery. However, CPB is not the only nor
necessarily even the major cause of these adverse events.
PART I. THE CARDIOPULMONARY BYPASS CIRCUIT
I. Introduction
A. 1 Cardiopulmonary bypass (CPB), introduced in 1953 to facilitate open heart
surgery, is considered one of the major advances in medicine. All
anesthesiologists who care for these patients should be intimately familiar
with the details and function of the heart–lung (H–L) machine (also referred
to as the extracorporeal circuit [ECC]) and be involved in the establishment
of protocols and the conduct of CPB during cardiac surgery. In this chapter,
the components of the H–L machine, the physiologic principles and
pathophysiologic consequences of CPB, and the important role the
anesthesiologist should play in its optimal and safe conduct are described. In
Chapter 7, the medical management of patients during CPB is described.
B. The primary goal and function of CPB is to divert blood away from the heart and
lungs and return it to the systemic arterial system, thereby permitting surgery on
the nonfunctioning heart. In doing so, it must replace the function of both the heart
and the lungs. The CPB circuit must provide adequate gas exchange, oxygen
delivery, systemic blood flow, and arterial pressure while minimizing adverse
effects. This is accomplished by the two principal components of the H–L
machine: The artificial lung (blood gas–exchanging device or “oxygenator”) and
the arterial pump. The “oxygenator” removes carbon dioxide and adds oxygen to
provide the desired PaCO2 and PaO2, while the arterial pump returns the blood
to the patient’s arterial system to maintain adequate systemic arterial pressure
and organ perfusion.
FIGURE 20.1 Detailed schematic diagram of arrangement of a typical cardiopulmonary bypass (CPB) circuit using a
membrane oxygenator (MO) with integral hardshell venous reservoir and heat exchanger (HE) (lower center) and
external cardiotomy reservoir. Venous cannulation is by a cavoatrial cannula and arterial cannulation is in the
ascending aorta. Some circuits do not incorporate an MO recirculation line; in these cases the cardioplegia blood source is
a separate outlet connector built-in to the oxygenator near the arterial outlet. The systemic blood pump may be either a roller
or centrifugal type. The cardioplegia delivery system (right) is a one-pass combination blood/crystalloid type. The
heater–cooler water source may be operated to supply water separately to both the oxygenator heat exchanger and
cardioplegia delivery system. The air bubble detector sensor may be placed on the line between the venous reservoir and
systemic pump, between the pump and MO inlet or between the oxygenator outlet and arterial filter (neither shown) or on
the line after the arterial filter (optional position on drawing). One-way valves prevent retrograde flow (some circuits with a
centrifugal pump also incorporate a one-way valve after the pump and within the systemic flow line). Other safety devices
include an oxygen analyzer placed between the anesthetic vaporizer (if used) and the oxygenator gas inlet and a venous
reservoir-level sensor attached to the housing of the hardshell venous reservoir (on the left). Arrows, directions of flow;
, placement of tubing clamps; P and T, pressure and temperature sensors, respectively. Hemoconcentrator (described in
text) not shown. (From Figure 2.2 in Hessel EA, Shann KG. Blood pumps, circuitry and cannulation techniques in
cardiopulmonary bypass. In: Gravlee GP, Davis RF, Hammon J, eds. Cardiopulmonary Bypass and Mechanical Support:
Principles and Practice. 4th ed. Philadelphia, PA: Wolters Kluwer; 2016:21, with permission.)
C. 2 Because the proximal ascending aorta is often cross-clamped to arrest the

heart to facilitate surgery, a cardioplegia delivery system is added to minimize
myocardial ischemia. Other components of the ECC include cannulae that
connect to the systemic venous and arterial systems, a venous reservoir, a heat
exchanger to control body temperature, surgical field and cardiotomy suction,
and various safety and monitoring devices.
D. The components listed above will all be described in this chapter. The interested
reader may find further details on CPB components in other texts [1–4].
II. Components of the circuit
A. Overview
The essential components of the H–L machine include the CPB console,
oxygenator, venous reservoir, arterial pump, cardioplegia circuit, ventilating
circuit, monitoring and safety systems, and various filters. These components can
be assembled in myriad configurations depending on perfusionist/surgeon
preference and patient need. Figure 20.1 shows a detailed schematic of a typical
CPB circuit. Desaturated blood exits the patient through a right atrium
(RA)/inferior vena cava (IVC) venous (“cavoatrial” or “two-stage”) cannula
and is diverted to the venous reservoir by gravity siphon drainage through
large-bore polyvinyl chloride (PVC) tubing. Blood is then drawn from the
venous reservoir by the systemic blood pump, which can be either roller or
centrifugal (kinetic), and pumped through a heat exchanger (integral to the
membrane oxygenator [MO]). Blood then passes through the oxygenator, through
an arterial filter, and back into the patient through the arterial cannula inserted
into the ascending aorta. Additional parts of the circuit include a recirculation
line between the arterial side of the oxygenator and the venous reservoir that is
used to facilitate priming the system and as a blood source for cardioplegia. A
purge line is located on the housing of the arterial filter and is kept open during
CPB to vent any air from the circuit back to either the venous reservoir or a
second reservoir called cardiotomy reservoir.
Other roller pumps on the H–L machine are used for various functions
including delivery of cardioplegia solution, return of shed blood in the surgical
field via aspiration, venting of blood from intracardiac sources, or the removal
of air from the venous reservoir when collapsible venous reservoir “bag”
systems are used. Additional components of the CPB system include
microprocessors for console control and electronic data recording, a
cooler/heater which serves as an adjustable temperature water source used in
conjunction with the circuit heat exchangers, an anesthetic vaporizer for the
administration of volatile anesthetic agents, cardioplegia delivery system,
various sensors for monitoring arterial and venous blood parameters as well as
oxygen concentrations in the ventilating circuit, and various safety devices. Most
of the components through which the blood passes are disposable and
commercially custom-prepared to meet the specific requirements of individual
cardiac teams.
FIGURE 20.2 Venous cannulation (central, intrathoracic). Methods of venous cannulation: A: Single cannulation of right
atrium (RA) with a “two-stage” cavoatrial cannula. This is typically inserted through the RA appendage. Note that the
narrower tip of the cannula is in the inferior vena cava (IVC), where it drains this vein. The wider portion, with additional
drainage holes, resides in the RA, where blood is received from the coronary sinus and superior vena cava (SVC). The SVC
must drain via the RA when a cavoatrial cannula is used. B: Separate cannulation of the SVC and IVC. Note that there are
loops placed around the cavae and venous cannulae and passed through tubing to act as tourniquets or snares. The
tourniquet on the SVC has been tightened to divert all SVC flow into the SVC cannula and prevent communication with the
RA. (From Figure 2.5 in Hessel EA, Shann KG. Blood pumps, circuitry and cannulation techniques in cardiopulmonary
bypass. In: Gravlee GP, Davis RF, Hammon J, eds. Cardiopulmonary Bypass and Mechanical Support: Principles and
Practice. 4th ed. Philadelphia, PA: Wolters Kluwer; 2016:25, with permission.)
B. Venous cannulation and drainage

1. Overview. Blood must be diverted into the H–L machine to keep it from
passing through the heart and lungs, which permits access to the heart by the
surgeon.
2. Central venous cannulation (Fig. 20.2)
a. Single simple cannula in RA. Inserted through a purse-string suture in the RA
free wall or atrial appendage. This type of cannulation tends to be unstable,
does not reliably divert flow away from the right ventricle (RV), and is rarely
used in adult CPB.
b. Cavoatrial or “two-stage” single cannula. A single-lumen cannula with a
wide proximal portion with drainage slits situated in the RA, and a narrower
distal end placed into the IVC. The tip in the IVC makes this cannula more
stable. It is usually inserted through a purse-string suture in the atrial
appendage. Insertion may be difficult in the presence of RA masses,
hardware, or a prominent Eustachian valve or Chiari network, and tears of the
IVC in this region are difficult to manage. This is the most common type of
cannulation for coronary artery and aortic valve surgery. It may not reliably
prevent blood from entering the RV, and may not provide optimal myocardial
cooling (especially the RA and RV). Superior vena cava (SVC) drainage and
hence venous return to the H–L machine can be compromised if the junction of
the SVC to the RA is kinked, which can occur when the heart is lifted up for
grafting of vessels on the back of the heart.
c. Bicaval cannulation. Separate cannulae are placed into the SVC and IVC
either directly or indirectly through the RA through purse-string sutures.
Bicaval cannulation is most effective at totally diverting blood away from
the heart. When the right heart must be opened, additional large ligatures or
tapes are placed around the SVC and the IVC surrounding the indwelling
venous cannulae to prevent any caval blood from entering the atrium (and any
air getting from the atrium into the venous drainage). When the caval tapes are
tightened, this is termed “complete bypass.” When these tapes are tightened, it
is critical to avoid obstruction of the cannulae to avoid venous hypertension
(congestion). This is of particular concern in the SVC because of the potential
adverse impact on cerebral perfusion; pressure in the SVC cephalad to the tip
of the SVC cannula should be monitored. Bicaval cannulation is necessary
whenever the surgeon plans to open the right heart (for surgery involving the
tricuspid valve, RA masses, transatrial septal approaches to left heart, and for
some congenital heart surgery) and for mitral valve (MV) surgery. Viewing
the MV requires either RA retraction (which may kink the cavoatrial junction)
or direct (transseptal) access via the RA. Bicaval cannulation, by diverting
blood away from the right heart, minimizes cardiac warming, especially of the
RA and RV during cold cardioplegia. However, when the caval tapes are
tightened and the RA remains closed, there is no place for coronary sinus
blood to drain both prior to aortic cross-clamping and when giving antegrade
cardioplegia, so the RA and RV will distend. In that case, either one of the
caval tapes must be released or the RA opened or vented.
CLINICAL PEARL When bicaval venous drainage cannulation is employed during CPB,
it is important to monitor central venous pressure cephalad to the tip of the venous drainage
cannula.
d. Impact of persistent left superior vena cava (LSVC) on venous
cannulation: About 0.3% to 0.5% of the general population and about 3% to
10% of patients with congenital heart disease have a persistent LSVC. This
remnant of fetal development drains blood from the junction of the left internal
jugular (IJ) and left subclavian veins into the coronary sinus, and thence into
the RA. A dilated coronary sinus (≥∼11 mm) seen on echocardiography may
be a clue to its presence. In the presence an LSVC, placing cannulae in the
right SVC and IVC will not divert all systemic venous drainage away from the
RA. One solution is for the surgeon to temporarily occlude (snare) the LSVC.
However, in about two-thirds of these patients, the left innominate vein is
absent or small, so this maneuver may result in cerebral venous hypertension.
In these cases, the surgeon may place a third venous cannula in the LSVC
either retrograde via the coronary sinus or directly into the LSVC through a
purse-string suture.
CLINICAL PEARL A dilated coronary sinus may suggest the presence of a persistent
LSVC, which can adversely impact the conduct of CPB and administration of retrograde
cardioplegia.
3. Peripheral venous cannulation is used for minimally invasive “port-access”
approaches, heart surgery via left thoracotomy, or for cannulation before
entering the chest (electively or emergently when bleeding is anticipated or
encountered). Most commonly, these venous cannulae are placed via the
femoral vein (and rarely the IJ vein). If the femoral vein is used, the cannula is
usually positioned with the tip at the SVC–RA junction. Positioning the cannula
is often guided by transesophageal echocardiography (TEE). Bicaval
cannulation is possible with a special IVC cannula designed for this purpose. If
a separate IJ venous cannula is placed, it is often inserted by the
anesthesiologist shortly after induction. As peripheral venous cannulae are
smaller and longer than directly placed cannulae, resistance to drainage is
greater, which may require use of augmented venous drainage (see Section
II.B.5.b).
FIGURE 20.3 Venous cannulae. Drawings of commonly used venous cannulae. A: Tapered, “two-stage” right atrium (RA)–
inferior vena cava (IVC) cannula. B: Straight, wire-reinforced “lighthouse”-tipped cannula for RA or separate cannulation of
the superior vena cava (SVC) or IVC. C: Right-angled, metal-tipped cannula for cannulation of the SVC or IVC. (From Figure
2.3 in Hessel EA, Shann KG. Blood pumps, circuitry and cannulation techniques in cardiopulmonary bypass. In: Gravlee GP,
Davis RF, Hammon J, eds. Cardiopulmonary Bypass and Mechanical Support: Principles and Practice. 4th ed. Philadelphia,
PA: Wolters Kluwer; 2016:22, with permission.)
4. Venous cannulae are plastic (Fig. 20.3). Some are wire-reinforced to

minimize kinking. Others designed for direct caval cannulation have curved thin
metal or plastic tips for a favorable internal diameter to external diameter
(ID:OD) ratio.
5. Types of venous drainage
a. Gravity. Venous drainage is usually accomplished by gravity (siphon effect).
This requires that the venous drainage tubing is full of fluid (blood). Drainage
is based upon the pressure difference of the column of fluid between the level
of the patient and that of the H–L machine (venous reservoir). Flow is
influenced by central venous pressure (intravascular volume and venous tone),
height differential between the patient and the H–L machine, and resistance in
the venous cannula and tubing (length, ID, mechanical obstruction, or
malposition of cannulae). “Chattering” of the venous lines suggest excessive
drainage or inadequate venous return. Since drainage depends on a siphon,
this will be interrupted if the venous line becomes filled with air.
b. Augmented venous drainage is used when long or smaller venous cannulae
are employed and to permit elevation of the H–L machine to the level of the
patients (all designed to decrease the prime volume or for peripheral or port-
access cannulation). Two classes of systems are utilized: vacuum-assisted and
kinetic.
(1) Vacuum-assisted drainage is accomplished by attaching the venous line
to a closed “hardshell” venous reservoir (see Section II.D.1.a) to which
vacuum (usually negative 20 to 50 mm Hg) is applied. Whenever
augmented venous drainage is employed, there is increased risk of
aspirating air from around the venous cannulae, and application of a
second purse-string suture around them is recommended. There is also
additional risk of developing positive pressure in the closed reservoir,
which can lead to retrograde venous air embolism. This requires
inclusion of a positive pressure release valve and heightened
perfusionist attention.
(2) Kinetic-assisted drainage is accomplished by inserting a pump, which is
usually a centrifugal pump and rarely a roller pump). Centrifugal pumps
are easier to control and minimize collapse of the cavae or atrium around
the tip of the cannulae. As with vacuum-assisted drainage, this technique
requires close perfusionist attention to avoid air aspiration into the ECC.
(3) Studies have not found that use of augmented venous return
increases blood trauma or aggravates the inflammatory response to
CPB.
FIGURE 20.4 Arterial cannulae. Drawings of commonly used arterial cannulae. A: Thin metal–tipped, right-angled
cannula with a plastic molded flange for securing cannula to the aorta. B: Similar design to (A) but with plastic right-angled
C: Angled, diffusion-tipped cannula designed to direct systemic flow in four directions (right) to avoid a “jetting effect”
that may occur with conventional single-lumen arterial cannulae. D: Integral cannula/tubing connector and luer port (for
deairing) incorporated onto some newer arterial cannulae. (From Figure 2.8 in Hessel EA, Shann KG. Blood pumps, circuitry
and cannulation techniques in cardiopulmonary bypass. In: Gravlee GP, Davis RF, Hammon J, eds. Cardiopulmonary Bypass
and Mechanical Support: Principles and Practice. 4th ed. Philadelphia, PA: Wolters Kluwer; 2016:30, with permission.)
C. Arterial cannulation
1. Overview. The blood from the H–L machine must be returned to the systemic
arterial system through an arterial cannula. These cannulae must carry the entire
systemic blood flow (“cardiac output”) through the narrowest part of the
circuit. Cannula size selection balances the desired blood flow (mainly
influenced by patient size) and a desire to keep blood velocity below 200
cm/sec and pressure gradients below 100 mm Hg. Higher flows and pressures
may traumatize blood elements and the arterial wall (via “sandblasting” to
potentially induce intimal dissection and/or atheroembolism) and reduce flow
into critical side branches (e.g., right brachiocephalic artery) via high-velocity
streaming effects. To maximize the ID:OD ratio, cannula tips are often
constructed of metal or hard plastic. To minimize both pressure gradient and
the size of the aortic incision, this narrowest part of the arterial line is kept as
short as possible. Some special tips have been designed to minimize the exit
velocities and jet effects (Fig. 20.4). Most commonly the arterial cannula is
inserted into the distal ascending aorta, but other sites are also used. Special
arterial cannulae (e.g., Soft-FlowTM [Medtronic, Minneapolis, Minnesota],
OptiflowTM [LivaNova, London, England] Embol-XTM [Edwards Lifesciences,
Irvine, CA], and CardiogardTM [Cardiogard Medical ltd, Hertzliya Pituach,
Israel]) have been developed to minimize risk of embolization, but are not
widely used.
TABLE 20.1 Arterial cannulation sites
2. Cannulation site options (Table 20.1)
a. Ascending aorta. The surgeon inserts the cannula through one or two
concentric purse-string sutures in the distal ascending aorta and directs it
toward the transverse arch to avoid preferential streaming to any of the three
arch branches. Some surgeons place a long cannula directed into the proximal
descending aorta to minimize jet effects in the arch, while others use very
short cannulae inserted only 1 to 2 cm into the aorta. Dislodgement of
atheromatous material from the cannulation site is a primary concern. Because
palpation of the aorta may not detect atheroma and this site is hidden from
TEE imaging, many advocate imaging of the intended cannulation site using
epiaortic ultrasound. Dissection associated with ascending aortic cannulation
occurs in about 0.08% (1 per 1,250 cases, range 0.02% to 0.2%). The
ascending aorta may not be a suitable cannulation site for various reasons
including severe atherosclerotic disease, aortic dissection, use of minimal-
access surgery, and risk of hemorrhage during repeat sternotomy.
b. Femoral or external iliac artery. This is the second most common approach
and is used when ascending aortic cannulation is not desirable or feasible.
However, this approach has a number of limitations, including risk of
dissection (0.3% to 0.8% or ∼1/200 cases), atheroembolism (especially into
brain and heart), malperfusion of the brain and other organs in the presence of
aortic dissection or atherosclerosis, and ischemia of the cannulated limb.
Upon initiation of CPB and intermittently throughout it, TEE surveillance of
the descending aorta is recommended to detect retrograde dissection.
Prolonged femoral cannulation times may release emboli and acid metabolites
from the limb upon reperfusion and cause subsequent compartment syndrome
in the limb. To minimize leg ischemia, some groups sew a graft onto the side
of the femoral artery and insert the arterial cannula into this graft so that blood
flows both retrograde and antegrade, while others insert a supplemental
arterial cannula into the distal femoral artery.
CLINICAL PEARL Cannulation of the femoral artery for arterial inflow carries
substantial risk of iatrogenic retrograde aortic dissection, which should be monitored via
TEE intermittently during CPB.
c. Axillary/subclavian artery cannulation is often advocated in the presence of
aortic dissection or severe atherosclerosis. These vessels are usually free of
significant atherosclerosis, and may pose less risk of malperfusion, but risk of
iatrogenic dissection is similar (∼0.7% or ∼1/140 cases) to that with femoral
cannulation. The artery is approached through an infraclavicular incision, and
the cannula can be placed either directly into the vessel or via a graft sewn
onto the side of the artery. The right side is favored since it permits selective
cerebral perfusion (SCP) if circulatory arrest is required (see Section
III.D.3). If the vessel is cannulated directly (i.e., not through a side-arm graft),
then the artery in the contralateral upper extremity (radial or brachial) must be
used for systemic arterial pressure monitoring during CPB.
d. Innominate (brachiocephalic) artery cannulation is uncommonly used,
because the presence of the cannula (flow directed toward the aortic arch)
may restrict flow around it into the right carotid artery and hence the brain.
D. Venous reservoir
1. Overview. Venous drainage from the patient flows into a reservoir placed
immediately before the systemic arterial pump to serve as a “holding tank” and
act as a buffer for imbalances between venous return and arterial flow. As a
high capacitance (i.e., low pressure) receiving chamber for venous return, it
facilitates gravity drainage of venous blood. As much as 3 L of blood may need
to be translocated from the patient to the ECC when full CPB begins. This
reservoir may also serve as a gross bubble trap for air that enters the venous
line and as a site for adding blood, fluids, or drugs to the circulation. One of its
most important functions is to provide a source (reservoir) of blood if venous
drainage is sharply reduced or stopped, hence providing the perfusionist with a
reaction time in order to avoid “pumping the CPB system dry” and risking
massive air embolism. These reservoirs usually include various filtering
devices. There are two classes of reservoirs:
a. Rigid hardshell plastic, “open” venous canisters. Advantages include ability
to handle venous air more effectively, simplicity of priming, larger capacity,
and ease of applying suction for vacuum-assisted venous return. Most
hardshell venous reservoirs incorporate macro- and microfilters (usually
coated with defoaming agents), and can also serve as the cardiotomy reservoir
(see Section II.I.1) by directly receiving suctioned and vented blood. Their
ability to remove gaseous microemboli (GME) varies.
b. Softshell, collapsible plastic bag, “closed” venous reservoirs. These
reservoirs eliminate the gas–blood interface and reduce the risk of massive
air embolism because they will collapse when emptied and do not permit air
to enter the systemic pump. Closed collapsible reservoirs also make the
aspiration of air by the venous cannulae more obvious to the perfusionist, but
require a way of emptying the air out of the reservoir. When softshell
reservoirs are used, a separate cardiotomy reservoir is required (see Section
II.I.1). Because of reduction of the gas–blood interface, their use may be
associated with less inflammatory activation. Data comparing clinical
outcome with use of the two types of venous reservoirs are conflicting and
inconclusive [5].
E. Systemic (arterial) pump
There are currently two types of blood pumps used in the CPB circuit: roller and
kinetic (most commonly called centrifugal) (Table 20.2). In the United States,
kinetic pumps are used in approximately 50% of all procedures.
1. Roller pump (Fig. 20.5)
a. Principles of operation. Blood is moved through this pump by sequential
compression of tubing by a roller against a horseshoe-shaped backing plate or
raceway. A typical pump has two roller heads configured 180 degrees apart
to maintain continuous roller head contact with the tubing. The output is
determined by the stroke volume of each revolution (the volume within the
tubing, which is dependent upon the tubing size and the length of the
compressed pathway) times the revolutions per minute (rpm). Flow from a
systemic roller pump increases or decreases linearly with rpm. With larger ID
tubing (e.g., 1/2-in ID), lower rpm are required to achieve the same output
compared to smaller ID tubing. The total pump output is displayed in
milliliters or liters per minute on the pump control panel. Roller pumps are
also used to deliver cardioplegia solution, remove blood and air from heart
chambers or great vessels, and suction shed blood from the operative field.
TABLE 20.2 Comparison of roller versus centrifugal pumps
b. Adjustment of occlusion. To minimize hemolysis, the occlusion must be

properly set. Occlusion describes the degree to which the tubing is
compressed between the rollers and the backing plate. An underocclusive
pump will allow retrograde movement of fluid when the pressure in the
downstream location exceeds that generated by the pump, thereby reducing
forward flow. Conversely, an overocclusive pump will create cellular
damage (red blood cell [RBC] hemolysis, white blood cell [WBC], and
platelet activation) and excessive wear on the tubing with release of
microparticles (“spallation”). Occlusion is set by the perfusionist by adjusting
the distance between the raceway and each of the roller heads. Typically,
occlusion is adjusted to be barely nonocclusive.
c. 3 Advantages and disadvantages. Roller pumps offer the advantages of
being simple, effective, inexpensive, having a low priming volume, and
producing a reliable output that is afterload independent. The drawback to
afterload independence is that, in the presence of downstream obstruction,
high pressure will develop which may cause rupture of connections in the
arterial line. If upstream inflow is obstructed, roller pumps can generate high
negative pressures creating microbubbles (“cavitation”) and RBC damage.
Roller pumps may cause more damage to blood components and can result
in massive air embolism if the venous reservoir becomes empty. They do
not adjust to changes in venous return and require more careful attention by the
perfusionist.
2. Centrifugal pumps (Fig. 20.6)
a. Principles of operation. Centrifugal pumps consist of a nest of smooth plastic
cones or a vaned impeller located inside a plastic housing. When rotated
rapidly (2,000 to 3,000 rpm), these pumps generate a pressure differential that
causes fluid movement. Vaned, impeller-type rotary (centrifugal) pumps are
predominantly being used rather than the traditional cone-type centrifugal
pumps, because they have smaller prime volumes and may cause less
hemolysis.
b. Advantages and disadvantages. Unlike roller pumps, these devices are
totally nonocclusive and afterload dependent (an increase in downstream
resistance or pressure decreases forward flow). Flow is not determined by
rotational rate alone, and therefore a flowmeter must be incorporated in the
outflow line to quantify pump flow. Furthermore, when the pump is
connected to the patient’s arterial system but is not rotating, blood will
flow backward through the pump and out of the patient unless the CPB
systemic arterial line is clamped or a one-way valve is incorporated into
the arterial line. This can cause exsanguination of the patient or aspiration of
air into the arterial line around the purse-string sutures. On the other hand, if
the arterial line becomes occluded, these pumps will not generate excessive
pressure and will not rupture the systemic flow line. Likewise, they will not
generate as much negative pressure and hence as much cavitation and
microembolus production as a roller pump if inflow becomes occluded. 4
FIGURE 20.5 Roller pump. Drawing of a dual roller pump and tubing. The principle of the roller pump is demonstrated by the
hand roller in the lower drawing moving along a section of tubing pushing fluid ahead of it and suctioning fluid behind it. The
upper four drawings in sequence (A–D) show how roller B first moves fluid ahead of it and suctions fluid behind it (A). As the
pump rotates clockwise, the second roller A begins to engage the tubing (B). As the rotation continues there is a very brief
period with volume trapped between the two rollers (C) and no forward flow, which imparts some pulsatility. In position ( D),
leaves the tubing, while the second roller A continues to move fluid in the same direction. Not shown are the roller
pump backing plate, tubing holders, and tube guides for maintaining the tubing within the raceway. Large arrows in and out of
tubing indicate direction of fluid flow, and small arrows near roller B indicate direction of roller arm rotation. (From Stofer RC.
A Technic for Extracorporeal Circulation. Springfield, IL: Charles C. Thomas; 1968:22, with permission.)
FIGURE 20.6 Centrifugal pumps. Drawings of centrifugal pump heads. A cross-sectional view of a smooth, cone-type pump
is shown on the top. Blood enters at A and is expelled on the right (B) due to kinetic forces created by the three rapidly spinning
cones. Impeller-type pumps with vanes are shown in the bottom drawings. (Modified from Trocchio CR, Sketel JO. Mechanical
pumps for extracorporeal circulation. In: Mora CT, ed. Cardiopulmonary Bypass: Principles and Techniques of Extracorporeal
Circulation. New York: Springer-Verlag; 1995:222, 223, with permission.)
A reputed advantage of centrifugal pumps over roller pumps is less risk of

pumping massive air emboli into the arterial line; centrifugal pumps will
become deprimed and stop pumping if more than approximately 50 mL of air
is introduced into the circuit. However, they will pass smaller but still
potentially lethal quantities of smaller bubbles. A number of studies have
demonstrated that centrifugal pumps cause less trauma to blood elements, less
activation of coagulation, produce fewer microemboli, and may be associated
with better clinical outcomes than roller pumps [5].
3. Pulsatile flow and pulsatile pumps
a. Overview. Most roller pumps produce only a low-amplitude, high-frequency
pulsatile flow of little physiologic relevance, while centrifugal pumps
produce a nonpulsatile flow. The necessity and importance of pulsatile flow
has long been debated [5].
b. How pulsatile flow is generated during CPB. Several methods are
commonly used to achieve arterial pulsations during CPB:
(1) If partial CPB is being used, venous drainage can be reduced to permit
some cardiac ejection.
(2) If an intra-aortic balloon is in place, it can be used to impart pulsatility to
the flow.
(3) Pulsations can be produced by roller pumps, and to a lesser degree by
centrifugal pumps, designed to rotate at varying speeds.
c. Damping effects of the aortic cannula. The first two methods of producing
pulsations are more effective because they generate the pulse in the aorta
itself. Although many pumps can generate a pulsatile outflow, the amount of
pulsatile energy transmitted into the aorta is limited by the damping effects
caused by the narrow aortic cannula, MOs, and arterial microfilters.
Calculations show that very little of the pulsatile energy generated is actually
delivered into the patient’s arterial system [6].
d. Liabilities of attempting to generate pulsatile flow inside the ECC
(1) Increased cost and complexity
(2) Requires use of larger arterial cannulae
(3) Associated with higher peak nozzle velocities out of the arterial cannula
(risking vascular injury and atheroembolism)
F. The oxygenator (artificial lung or gas-exchanging device)
1. Although numerous types of oxygenators have been used in the past, currently
only MOs are used in most parts of the world. These produce less blood trauma
and microemboli, permit more precise control of arterial blood gases, and
likely improve patient outcomes as compared with bubble oxygenators.
Virtually all current MOs are positioned after the arterial pump because the
resistance in the blood path requires blood to be pumped through them, and to
minimize the risk of pulling air through the membrane and producing GME.
Most oxygenators also include an integral heat exchanger (see Section II.G.1).
5 MOs function similarly to natural lungs, imposing a membrane between
the ventilating gas and the flowing blood and eliminating direct contact
between the blood and the gas. At least three types of membranes are used:
a. Silicone membranes. Rarely used today, these true membranes usually consist
of thin sheets of silicone rubber wrapped circumferentially over a spool.
b. Microporous polypropylene (PPL) membranes. Usually configured in
longitudinal bundles of narrow hollow fibers, but occasionally as folded
sheets of membrane. The pores fill with autologous plasma which serves as
the “membrane” through which gas exchange occurs. With excessive pressure
in the blood path or over prolonged time, plasma may leak through the
membrane (which degrades gas transfer), while excessive negative pressure
can lead to entrainment of air emboli. In hollow fiber MOs, the blood
typically flows outside the hollow fibers, while ventilating gases flow through
the hollow fibers (in a countercurrent direction).
c. 6 Polymethyl pentene (PMP) diffusion membranes. Hollow fiber MOs
made of a nonporous plastic, PMP, are true membranes. This has the
advantage of minimizing the risk of plasma leak and microair aspiration and
permits prolonged oxygenation (days). Gas exchange occurs by diffusion
across this true membrane. An important limitation is that PMP does not
appear to allow adequate transfer of volatile anesthetics, therefore
intravenous anesthetics must be employed during CPB. Because of this
limitation and because they are more expensive, PMP “diffusion” MOs are not
commonly used for conventional CPB, at least in the United States. Because of
their reduced risk of plasma leak (“oxygenator pulmonary edema”), they are
commonly used for long-term extracorporeal support (e.g., extracorporeal
membrane oxygenation [ECMO]).
2. Membrane oxygenators (MOs) were thought to serve as bubble filters and to
prevent venous GME from passing into the arterial system, but it is now
recognized that the majority of microscopic venous gas emboli do transit
through MOs. The effectiveness of GME removal varies among MOs [5].
Because of this limitation, teams must make every effort to minimize the
entrainment and administration of air into the venous drainage system.
3. Control of gas exchange and gas supply to the MO. Gas exchange by MO is
controlled similarly to that in normal lungs. Arterial carbon dioxide levels are
controlled by flow of fresh gas (commonly called “sweep gas flow”) through
the oxygenator (analogous to alveolar minute ventilation), and arterial PO2 is
controlled by varying fractional inspired oxygen (FiO2). Oxygenators require a
gas supply system. This typically includes a source of oxygen and air (and
occasionally carbon dioxide), which passes through a blender. An oxygen
analyzer should be incorporated in the MO gas supply line after the blender.
An anesthetic vaporizer may also be placed in the gas supply line near the
oxygenator. Volatile anesthetic liquids may destroy plastic components of
ECCs; therefore, care must be taken when filling them with volatile agents. A
method of scavenging waste gas from the oxygenator outlet should be provided
(American Society of ExtraCorporeal Technology [AmSECT] standard 6.8.)
[7].
4. MOs can fail during CPB. Groom et al. [8] have advocated inserting a shunt
(3/8-in tubing) between the inlet and outlet of the MO to facilitate exchange of
the defective oxygenator with a new oxygenator using a parallel replacement
(PRONTO) procedure.
G. Heat exchanger
1. Overview. The passage of blood through the ECC results in heat loss and
patient cooling. To maintain normothermia, heat must be added to the circuit.
This is accomplished with a heat exchanger, which may also be used to
intentionally cool and rewarm the patient. Heat exchangers consist of heat-
exchanging tubes (often metal) through which the blood flows. These tubes are
surrounded by water of varying temperatures. As mentioned earlier, heat
exchangers are often incorporated in the oxygenator, which is called an integral
heat exchanger.
2. Heater–cooler. To control the temperature of the water flowing through the
heat exchanger, a heater–cooler device adjusts the water temperature and
pumps it through the heat exchanger (countercurrent with the blood flow, which
is more efficient).
3. Recently sporadic and relatively rare outbreaks of mycobacterium chimaera
surgical site and prosthetic device infections have been traced to bioaerosols
of this agent emanating from contamination of one model of heater–cooler units.
4. 7 Excessive gradients between the blood and water temperature should be
avoided. Excessive warming can lead to gases coming out of solution and
causing GME as well as excessive heating of the brain to induce or
aggravate injury. As a result, guidelines for temperature management during
CPB have been promulgated [9].
a. Oxygenator arterial outlet temperature is the recommended surrogate for
cerebral temperature (class I recommendation, level C evidence)
b. Oxygenator arterial outlet temperature is assumed to underestimate cerebral
temperature (class I, level C)
c. Nasopharyngeal or pulmonary arterial (PA) temperatures are reasonable
estimates of core temperature after weaning from CPB (class IIa, level C)
d. Arterial outlet temperature should be no higher than 37°C during CPB to
prevent cerebral hyperthermia (class I, level C)
e. Peak cooling temperature gradient between the oxygenator arterial outlet and
venous inlet should not exceed 10°C to prevent the generation of gaseous
emboli (class I, level C)
f. Peak warming temperature gradient between the oxygenator arterial outlet and
venous inlet should not exceed 10°C to prevent outgassing (microemboli
formation) (class I, level C)
g. During warming, when oxygenator arterial outlet temperature ≥30oC, the
warming gradient between the oxygenator arterial outlet and venous inlet
should be ≤4oC and/or warming rate ≤0.5°C/min
5. Separate heat exchangers are also used in the cardioplegia circuits (see Section
II.H.3).
H. Cardioplegia delivery system or circuit
1. Overview. When the aorta is cross-clamped (distal to the aortic valve but
proximal to the arterial inflow cannula) to provide a quiet operative field or
access to the aortic valve, the heart is deprived of coronary perfusion and
becomes ischemic. This is usually managed by perfusing the heart with
cardioplegia solutions. See also Chapter 23 for further discussion on
myocardial protection.
2. Routes of delivery of cardioplegia solutions
a. Aortic root. A cannula is inserted in the aortic root (proximal to the cross-
clamp). Typically this has a “Y” configuration: one limb is connected to the
cardioplegia delivery system and the other to suction (to vent the left ventricle
[LV] or aspirate air). The cardioplegia solution is delivered into the aortic
root and thence into the coronary arteries. This is not effective in the
presence of severe aortic regurgitation or when the aortic root is open; it
is also less effective in the presence of severe proximal coronary artery
stenosis. Ideally, pressure in the aortic root should be measured during
administration of the cardioplegia to assure adequate coronary flow and
maintained at about 70 to 100 mm Hg.
b. Directly into the coronary ostia. Special handheld cannulae are placed
directly into the right and left main coronary arteries after the aortic root is
opened for delivery of the cardioplegia solutions. This is commonly done in
the presence of aortic regurgitation and during open aortic valve procedures.
c. Retrograde into the coronary sinus. Balloon-tipped cannulae are inserted
blindly (or under direct vision if the RA is opened) into the coronary sinus
through a purse-string suture in the low lateral wall of the RA. TEE may be
helpful in guiding and assessing placement. Many of these cannulae have a
pressure port near the tip so that the pressure in the coronary sinus can be
monitored during perfusion (ideally maintained between 30 and 50 mm Hg).
Retrograde administration of cardioplegia may be advantageous in the
presence of severe coronary artery stenosis or aortic regurgitation and during
aortic valve surgery. However, it may provide inferior protection of the
RV, because the cannula may exclude some veins draining RV myocardium
into the coronary sinus or directly into the RA (Thebesian veins). The
presence of a persistent LSVC compromises retrograde cardioplegia efficacy.
3. Delivery systems. These vary in their complexity. If blood cardioplegia is
being used, blood is taken out of the arterial perfusion line following
oxygenation and mixed with the crystalloid cardioplegia solution (at various
blood–crystalloid ratios). This may be accomplished by using two separate
roller pumps, or with a single roller pump which drives two tubes of different
sizes (to produce the proper flow ratio). The mixture is then passed through a
dedicated heat exchanger. Microfiltration may be added and pressures and
temperatures are monitored. Some use more complex delivery systems which
permit rapid change of the concentration of various components in the
cardioplegia solution.
I. Cardiotomy, field suction, cell salvage processors, and cell (RBC) savers
1. Overview. During CPB there is often considerable bleeding into the surgical
field due to systemic heparinization and persistent pulmonary and coronary
venous drainage. It is usually not desirable to discard this large volume of
blood via conventional discard suction. Traditionally, this blood is removed
from the field by roller pumps on the H–L machine (“cardiotomy suckers”)
and returned to the H–L machine via the cardiotomy reservoir (which includes
filters and, as noted above, is commonly incorporated into the hardshell venous
reservoir, but must be added separately when a softshell reservoir is used).
The cardiotomy suction should not be used until the patient is adequately
anticoagulated and should be discontinued as soon as heparin neutralization
with protamine commences (to avoid clotting of blood in the ECC).
2. 8 Hazards of cardiotomy blood. Cardiotomy blood contains microaggregates
of cells, fat, foreign debris, and thrombogenic and fibrinolytic factors, and is
thought to be a major source of microemboli and hemolysis during CPB. For
these reasons cardiotomy suction should be used sparingly.
3. An alternative strategy is to suction the field blood into a cell salvage
washer/processor/saver system (or to process the blood that has been
suctioned into a standalone cardiotomy reservoir with this cell salvage system
before returning it to the H–L machine). These devices wash the blood with
saline, and separate the red cells from the plasma and saline by centrifugation
with the intent of reducing the microemboli, fat, etc. They also remove plasma
proteins, platelets, heparin, and some of the WBCs while retaining
concentrated RBCs (hematocrit about 70%). Not all processors are equally
effective at removing fat, and the salvaged blood may have to be specially
filtered before administration. Some of the problems associated with the use of
cell processors include delayed availability and turnover time (not adequate in
the face of rapid hemorrhage) and loss of platelets and coagulation factors
(resulting in a consumptive coagulopathy if >6 bowls or 1,500 mL of blood is
processed). Comparative studies of cardiotomy suction versus cell processors
have produced conflicting results [5].
J. Venting
1. Overview. Both the RV and LV must be decompressed during CPB to improve
surgical exposure, reduce myocardial oxygen demand, and attenuate mechanical
damage to the heart from overdistention.
2. The RV is readily visible to the surgeon, and decompression depends on
adequacy of venous drainage. The LV is more difficult to observe, has more
adverse consequences if distended, and requires various strategies for venting.
3. Consequences of distention of the left heart:
a. Stretches myocardium causing ventricular dysfunction
b. Myocardial ischemia: impairs subendocardial perfusion and increases
myocardial oxygen needs
c. Increases left atrial pressure, leading to pulmonary edema and hemorrhage
d. Interferes with surgical exposure
4. Distention of the left heart is likely to occur when the LV is unable to empty
(e.g., on initiation of CPB, especially in the presence of aortic regurgitation;
during cardiac arrest, aortic cross-clamping, and administration of antegrade
cardioplegia; during ventricular fibrillation; and following aortic cross-clamp
release).
5. Sources of blood coming into the left heart during CPB:
a. Bronchial venous drainage (normal ∼100 mL/min)
b. Systemic venous blood that bypasses venous cannulae and passes through
right heart and lungs
c. Aortic regurgitation
d. Thebesian veins draining into the left heart (but these are not common)
e. Patent ductus arteriosus (PDA) (∼1/3,500 adults)
f. Atrial septal defect (ASD), ventricular septal defect (VSD)
6. Assessment of adequacy of decompression of the left heart by inspection or
palpation is difficult because of its position and thick walls of the LV.
Elevation of the pulmonary artery pressure if a pulmonary artery catheter
(PAC) is in place may suggest distention of the left heart, but the best method of
evaluating the adequacy of LV decompression is TEE.
CLINICAL PEARL Distention of the LV can be difficult to detect clinically during
CPB, and is best diagnosed by use of TEE.
7. 9 Methods of venting or decompressing the left heart (see Fig. 20.7 and
Table 20.3): Cannulae are inserted in various locations and attached to tubing
connected to roller pumps which transmits the blood to the venous or
cardiotomy reservoirs. The end of the suction tubing from the H–L machine
should first be placed into fluid to assure that it is sucking and not emitting
air before it is connected to any intracardiac or aorta venting cannula. The
amount of suction must be constantly adjusted by the perfusionist to avoid
excessive (risk of damage to heart or aspirating air) or inadequate (over
distention) venting.
a. Aortic root vent (one limb of the antegrade cardioplegia cannula): This is the
most common technique used during coronary artery bypass graft (CABG)
surgery. Suction is applied to the antegrade cardioplegia cannula (directly or
via a side limb). Aortic root venting of the LV is only effective when the aorta
is cross-clamped, when antegrade cardioplegia is not being administered, and
when the aortic root is not opened.
b. LV vent placed via the right superior pulmonary vein. A cannula is inserted
at the junction of the right superior pulmonary vein with the left atrium and
then threaded through the left atrium and MV into the LV. This method is used
during aortic valve and MV surgery (especially in the presence of aortic
regurgitation) and for patients with poor LV function undergoing CABG.
FIGURE 20.7 Sites for venting the left heart. A: Aortic root cannula; one limb of the “Y” is connected to the cardioplegia
delivery system and the other limb to suction (siphon or roller pump) for venting the aortic root and hence the left ventricle
B: Cannula inserted at the junction of the right superior pulmonary vein (RSPV) with the left atrium and then threaded
through the left atrium and mitral valve (MV) and into the LV. C: Cannula inserted directly into the apex of the LV. D:
Cannula is inserted into the pulmonary artery. AO, aorta; PA pulmonary artery; LA, left atrium; RV, right ventricle. (From
Figure 2.25 in Hessel EA, Shann KG. Blood pumps, circuitry and cannulation techniques in cardiopulmonary bypass. In: Gravlee
GP, Davis RF, Hammon J, eds. Cardiopulmonary Bypass and Mechanical Support: Principles and Practice. 4th ed. Philadelphia,
PA: Wolters Kluwer; 2016:69, with permission.)
c. LV vent placed directly through the LV apex. This is rarely used today
because of difficulty in positioning, control of bleeding after removal, and the
possibility of forming late apical LV aneurysms.
d. Vent placed through the left atrial appendage or the top of the left atrium
(into either the left atrium or LV). This is rarely used.
e. Vent placed in the main pulmonary artery. This method minimizes the risk
of air entry into the left heart (although it can still occur). It does not provide
reliable decompression of the LV in the presence of aortic regurgitation, and
closure of the incision in the pulmonary artery can be problematic in patients
with pulmonary hypertension.
8. Complications of venting the left heart include systemic air embolism,
bleeding, damage to cardiac structures, dislodgement of thrombi, calcium,
tumor, etc., and MV incompetence. A critical complication is inadvertent
pumping of air into the heart via these vent lines. This occurs if tubing is
misaligned in the roller pump-head or if the pump is in reverse mode. Air can
also enter the left heart when these lines are inserted or removed; therefore, the
volume and pressure in the left heart should be elevated at these times and
ventilation interrupted.
TABLE 20.3 Methods of venting the left heart
9. Any time the heart is opened, even by simply placing a catheter in a chamber,
air may collect in the heart. If not removed, this air will embolize with
resumption of cardiac contractions. Even right-heart air has the potential to
pass into the left heart via septal defects or through the lungs. In addition to
vigorous attempts at removal of all air before closing the left heart, the use of
venting at the highest point of the aorta is considered the final safety
maneuver against systemic air embolism. This is most commonly
accomplished using the antegrade cardioplegia cannula (see Section II.H.2.a)
which is placed on suction. TEE is particularly useful in assessing the
adequacy of deairing. Because of carbon dioxide’s increased solubility and its
potential for reducing the size of microemboli, some surgical teams flood the
surgical field with carbon dioxide during open cardiac procedures.
K. Ultrafiltration/hemoconcentrators
A hemofiltration device (also referred to as an ultrafilter) consists of a
semipermeable membrane which separates blood flowing on one side (under
pressure) and air (sometimes under vacuum) on the other side. Water and small
molecules (sodium, potassium, water-soluble non–protein-bound anesthetic
agents) can pass through it and be removed from the blood, but protein and
cellular blood components do not. Hemoconcentrators are used to eliminate
excess crystalloid and potassium, and to raise hematocrit (hemoconcentrate).
They may also remove inflammatory mediators and hence reduce the systemic
inflammatory response syndrome (SIRS). The device is usually placed distal to
the arterial pump with drainage into the venous limb or reservoir. It can also be
placed in the venous limb of the circuit, which requires a separate pump. Five
hundred to 2,000 mL or more of fluid may be removed during an adult case.
When used postbypass (but before reversing heparin) it is referred to as
“modified ultrafiltration” or “MUF.” MUF is commonly used in pediatric
cases but less so in adult cases [3,10].
L. Filters and bubble traps
1. Overview. CPB generates macro- and microemboli of gas, lipids, and other
particles (WBCs, platelets, foreign debris) which must be filtered out.
2. Types and location. Many different types of filters (screen and packed fibers
[“in-depth”], made of various materials) with various pore sizes are employed
in multiple locations in the ECC. These sites include the venous and
cardiotomy reservoirs, “built” into the MO, in the arterial and cardioplegia
lines, blood administration sets such as the cell processor, and the gas line
supplying the oxygenator. The “in-depth filters” mainly work by adsorption.
The clinical importance of the various types of filters remains controversial
[5].
3. Arterial line filter/bubble trap. Most centers employ a microfilter/bubble trap
on the arterial line, especially to reduce air embolization [5]. If used, often a
clamped bypass line is placed around the filter in case the filter becomes
obstructed and a vent line with a one-way valve runs from the filter/bubble trap
to the venous reservoir to vent any trapped air. The inclusion of a microfilter in
some commercial MOs may eliminate the need for a separate arterial line
microfilter.
4. Some advocate the employment of leukocyte-depleting filters in various ECC
locations, but their benefit remains to be proven.
M. Safety devices and monitors on the heart–lung (H–L) machine
S e e Table 20.4 and the 2017 American Society of Extracorporeal
Technology standards and guidelines for perfusion practice [7].
III. Special topics
A. Surface coating
Many commercial circuits coat all of the surfaces that come in contact with blood
(tubing, reservoirs, oxygenators) with various proprietary substances designed to
minimize activation of blood components. Many of these coatings include
heparin, which should be avoided in patients with heparin-induced
thrombocytopenia (HIT). The clinical benefits of any or of one type of coating
over another remain controversial [5].
B. Miniaturized or minimized circuits
By reducing the surface area and prime volume, miniaturized circuits reduce the
amount of hemodilution (resulting in less blood transfusions) and are purported
to reduce the inflammatory response to CPB and contribute to improved clinical
outcomes [11]. They often feature a closed venoarterial circuit (i.e., no venous
reservoir or cardiotomy suction) and kinetic-assisted venous drainage. A
sophisticated air detection and elimination system is required, as well as
stringent avoidance of air entrance into the venous line. Concerns about safety
(especially air embolization), inability to handle fluctuations in venous return
(especially if the patient has a large blood volume or experiences
exsanguination), and lack of cardiotomy and field suction require careful
consideration. These systems require close communication among all team
members. Miniaturized circuits are less commonly used in the United States
compared with Europe. Their use is usually limited to uncomplicated CABG and
aortic valve surgery and cases associated with minimal intravascular volume
shifts or need to scavenge blood from the surgical field.
TABLE 20.4 Monitors and safety devices
C. Pediatric circuits
The major challenges of pediatric CPB are (1) the small blood volume of the
patient compared with the prime volume of the ECC, and (2) the small venous
and arterial cannulae required. Pediatric cardiac surgery groups and industry
have made great strides in miniaturization and reduction of priming volumes
(some as little at 100 to 200 mL) by including augmented venous return to allow
narrower tubing and elevation of the H–L machine to keep it closer to the patient
and shorten the tubing. Most pediatric cardiac surgery centers in North America
include albumin in the priming fluids; packed RBCs and fresh-frozen plasma or
whole blood are often used for infants [10]. Some groups exclude arterial
microfilters and others use an oxygenator which has an integrated arterial-side
microfilter. In contradistinction to adult CPB, inline arterial blood gas
monitoring is employed by the vast majority of North American pediatric centers.
See additional discussion in Chapter 16.
D. Cerebral perfusion during circulatory arrest
1. Overview. Circulatory arrest is often required for conduct of surgery involving
the aortic arch and in congenital heart surgery. Deep hypothermia (<18°C) can
be used to minimize cerebral injury. For periods of circulatory arrest exceeding
30 minutes, two strategies for cerebral perfusion listed below are commonly
employed. The benefits and preference of one over the other remain
controversial.
2. Retrograde cerebral perfusion (RCP). The arterial line from the H–L
machine is connected to the SVC cannula (in the case of bicaval cannulation),
or to a separate cannula inserted through a purse-string suture in the SVC. The
SVC is occluded between the entrance of the catheter and the junction with the
RA. Cold blood (15° to 18°C) is then pumped at flow rates of 250 to 500
mL/min and pressures maintained between 20 and 40 mm Hg. It may be
desirable to measure the pressure via a catheter placed directly into the right IJ
vein, since valves may reduce the amount of delivered flow and pressure. If
pressure is measured in this location, it is probably prudent to keep the
pressure <25 mm Hg to minimize cerebral edema. Although RCP provides
minimal nutritional flow to the brain, it helps limit rewarming and likely
washes out atheroemboli and air in the cerebral arteries.
3. Antegrade cerebral perfusion (ACP) or selective cerebral perfusion (SCP).
Catheter(s) (sometimes with balloon cuffs) connected to the arterial line are
inserted into the right innominate or carotid arteries or the left carotid and
subclavian arteries. Cold blood is then infused at a rate of about 10 mL/kg/min
at a pressure of 30 to 70 mm Hg. This technique provides more cerebral blood
flow than RCP but adds a risk of arterial trauma and embolization. If the
systemic arterial cannula has been inserted into the right subclavian artery (see
Section II.C.2.c), then selective perfusion of the right carotid artery can be
accomplished by occluding the proximal innominate artery. If a subclavian
arterial cannula has been placed via a graft sewn onto the side of the artery, the
pressure in the right radial or brachial artery also represents the right carotid
cerebral arterial perfusion pressure. Obviously this provides only unilateral
perfusion and relies on an adequate circle of Willis to perfuse the left side of
the brain. Monitoring hemispheric oxygenation with bilateral cerebral oximetry
may identify the need to add left-sided arterial perfusion.
E. Less common cannulation
1. Minimally invasive or port access CPB involves use of smaller incision and
often smaller or specially designed venous and arterial cannulae for
transthoracic placement or peripheral cannulation. This may require augmented
venous drainage and increase the risk of aortic dissection (e.g., femoral artery
cannulation). Peripherally placed retrograde coronary sinus catheters (placed
via the right IJ vein often by the anesthesiologist), and aortic balloon occlusion
catheters and antegrade cardioplegia cannulae (passed via the femoral artery)
are used. These require TEE and/or fluoroscopic guidance for proper
placement.
2. Right thoracotomy. This approach gives excellent views of the MV and RA,
but aortic cannulation, occlusion of the ascending aorta, administration of
antegrade cardioplegia, and deairing of the LV are problematic. Often some of
the minimally invasive cannulation techniques mentioned above are employed.
3. Left thoracotomy. This approach is used for surgery on the descending
thoracic aorta and occasionally for reoperative MV surgery and CABG surgery
for revascularization of the lateral or posterior heart. Venous cannulation is
problematic. Peripheral RA cannulation via the femoral vein is commonly
employed (see Section II.B.3). For descending thoracic aortic surgery, isolated
partial left heart bypass (LHB) can be accomplished by cannulating the left
atrium or ventricle directly or via purse-string guarded incisions in the left
superior pulmonary vein or left atrial appendage for venous outflow and into
the distal aorta or femoral artery for arterial return. Partial LHB presumes
adequate RV output and pulmonary perfusion, hence it does not require an
oxygenator or venous reservoir and may not include a heat exchanger. LHB
typically employs a centrifugal pump and use heparin-coated tubing, permitting
minimal systemic heparinization. This technique only supplies oxygenated
blood to the lower half of the body, as the LV supplies the upper half via the
intact ascending aorta and transverse aortic arch. LHB flows are typically 1 to
1.5 L/min/m2 and are adjusted to adequately decompress the left heart and
maintain adequate pressures in the lower (via LHB) and upper (via native
circulation) parts of the body. Management of partial LHB is quite challenging
and requires excellent communication between the anesthesiologist and
perfusionist. TEE assessment of LV filling is extremely valuable [12].
IV. Priming
A. Overview
The ECC (including venous and arterial lines) must be filled with fluid
(“primed”) before use and all air in the circuit eliminated. Circuits are usually
primed with asanguinous (clear) fluids. To minimize hemodilution, much effort
has recently been directed at reducing the priming volume of ECCs to as low as
1,000 to 1,250 mL for adults.
B. Consequence of asanguinous primes
Priming results in hemodilution with reduction of hematocrit, plasma proteins,
and coagulation factors. Controversy surrounds the acceptable lower level of
hematocrit [5]. However, prior to initiation of CPB, the predicted hematocrit
should be estimated to determine if the team wishes to add RBCs to the prime.
Predicted hematocrit = (Baseline hematocrit × estimated blood volume
[EBV])/(EBV + prime volume + first dose of crystalloid in the cardioplegia
solution)
Baseline hematocrit used for this calculation should be obtained immediately
prior to CPB to account for any crystalloids administered prior to CPB and is
expressed as a fraction (e.g., hematocrit of 33 = 0.33) in this formula.
C. Retrograde autologous priming (RAP)
RAP is a method of reducing hemodilution. Before commencing CPB, arterial
blood is drained retrograde to displace asanguineous prime in the arterial line
(which is sequestered in a collection bag). Immediately before going onto CPB,
venous blood may also be allowed to drain out of the patient through the venous
line into the collection bag (“antegrade autologous priming”). With this method
500 to 1,000 mL of asanguineous prime may be eliminated. However, it is
associated with a reduction of the patient’s blood volume and may result in
hypotension. Placing the patient in Trendelenburg position and administering a
vasopressor are often required. The majority of randomized trials have
demonstrated that RAP reduces perioperative packed RBC transfusions and is
usually safe. However, this technique can be dangerous in certain high-risk
patients, leading to hypotension and immediate initiation of CPB because of loss
of cardiac preload. Further studies are needed to determine the effect of
retrograde priming on major morbidity and mortality. Another method of
reducing asanguineous prime is to remove fluid from the venous line and initiate
CPB with a “dry” venous line. The use of this technique presumes the presence
of sufficient pre-CPB intravascular blood volume to sustain adequate CPB
perfusion flows once CPB commences.
D. Composition of the prime
Many formulations are used. Most comprise a balanced electrolyte solution
without glucose. Much controversy surrounds the need to add colloid, and the use
of albumin has been recommended. Many add mannitol to the prime and most
include heparin (about 5,000 to 10,000 units).
E. Priming of the circuit
The perfusionist fills the circuit with the priming fluid and circulates it
employing various maneuvers to remove all air. Often before introducing the
prime the circuit is flushed with carbon dioxide, which is more easily removed
from the prime than air bubbles. Usually, a prebypass microfilter is temporarily
included in the circuit during this recirculation process to remove any foreign
particles.
F. Final disposition of prime at the end of cardiopulmonary bypass (CPB)
Usually, as much of this volume as possible is returned to the patient before
removing the arterial line. That which is left may either be pumped directly
(sometimes through a hemoconcentrator) via a pre-existing IV line into the patient
or placed into an IV bag for administration by the anesthesiologist (preserving
platelets and protein but also containing heparin which may require
neutralization), or first processed by a cell-washing device and
hemoconcentrated, which eliminates heparin.
V. Complications, safety, and risk containment
A. Incidence of adverse events
Four surveys covering practice between 1994 and 2007 have reported CPB-
associated rates of adverse events of 1/16, 1/35, 1/138, and 1/199 (average
2.6%), with severe injury or death rates of 1/1,236, 1/1,288, 1/1,453, and
1/3,220 (average 0.065%) [13–16].
B. 10 Specific complications and their diagnosis and management
These are discussed in Chapter 7.
CLINICAL PEARL Cardiac anesthesiologists should be prepared to diagnose and
help manage serious complications that can occur during CPB.
C. Risk containment
This requires the active and continuing participation of all members of the team
(surgeons, perfusionists, anesthesiologists, and nurses).
1. Vigilance on the part of all members of the team is required.
2. Special monitoring of the adequacy of global and specific organ perfusion is
discussed in Chapter 7 and by Murphy et al. [5]. Two issues deserve special
attention:
a. Central nervous system (CNS). Many advocate the use of cerebral near-
infrared spectroscopy (NIRS) (i.e., cerebral oximetry) or other monitors of
cerebral perfusion/function (e.g., transcranial Doppler, processed
electroencephalography) to detect problems with venous drainage and arterial
cannulation and malperfusion (e.g., dissection) [17].
b. TEE is useful not only to diagnose cardiac abnormalities pre-CPB and
evaluate surgical repairs, but also to assist with the conduct of CPB. Some
of these applications include the following:
(1) Evaluating atherosclerosis in the aorta (typically requiring epiaortic
scanning) as it relates to cannulation and placement of clamps
(2) Detect abnormal-size coronary sinus or presence of patent foramen ovale
(3) Evaluating placement of cannulae, especially retrograde coronary sinus
cannula, LV vents, and transfemorally placed IVC cannulae, and intra-
aortic balloon pump (IABP)
(4) Detect devices, masses (thrombi and tumors), and anatomic
abnormalities that could affect cannulation
(5) Assess adequacy of decompression of the LV
(6) Detect and evaluate deairing of left heart
(7) Detect aortic dissection and malperfusion of arch vessels
CLINICAL PEARL TEE and epiaortic scanning contribute to the safe conduct and
monitoring of CPB.
3. Education, practice, experience, retraining, certification, and recertification of
perfusionists and other team members.
4. Communication between surgeon, perfusionist, and anesthesiologist. Each must
warn team members of actions that could impact all the others, and of any
variance with normal course of CPB or deviations in expected parameters.
Commands must be positively and verbally acknowledged.
5. The “two-minute drill”: Although serious complications are uncommon, it is
prudent to wait about 2 minutes after going on “full bypass” before
arresting the heart, to assure that all is going well and to rule out serious
complications which can be most easily managed by discontinuing CPB and
resuming normal circulation. One should confirm the following endpoints:
a. Able to achieve targeted systemic (“pump”) flow
b. Adequate venous return and not losing volume
c. Adequate oxygenation of arterial blood (i.e., function of the MO)
d. Acceptable arterial pressure and exclusion of arterial dissection as a cause of
hypotension
e. RV and LV are decompressed
f. Acceptable systemic venous pressure
g. Acceptable arterial line pressure
h. Acceptable venous oxygen saturation
CLINICAL PEARL The aorta should not be cross-clamped nor cardioplegia administered
until sufficient time (about 2 minutes) has elapsed to assure satisfactory and stable function of
the H–L machine and conduct of CPB.
6. Planning, development of, and adherence to protocols for routine as well as
unusual types of CPB and of complications
7. Use of prebypass checklists and for other key times during CPB and for
adverse events
8. Use of safety equipment and alarms
9. Appropriate preventive maintenance program, replacement of old equipment,
and familiarity and testing of new equipment
10. Team practice at diagnosing and management of major complications
11. Periodic audit, team meetings, quality assurance, and quality improvement. Use
of a registry to measure variation and for benchmarking
12. Automated control and regulation of the H–L machine
D. Key role of the anesthesiologist in the conduct of CPB
Anesthesiologists are in a unique position to assist with the conduct and
management of CPB. Their detailed knowledge about the patient’s medical
history and the patient’s course prior to arrival in the operation room and prior to
CPB gives them a unique perspective. They are able to observe both the surgical
field and the H–L machine, and can facilitate communication between the
perfusionist and surgeon. Anesthesiologists should oversee the anesthetic and
vasoactive drug management and patient monitoring during CPB and make
recommendations concerning the safe and appropriate conduct of CPB. They
should be vigilant for any adverse events and assist with the management of the
complications discussed in Chapter 7. Finally, anesthesiologists should
collaborate with surgeons and perfusionists in the development of protocols for
the conduct of safe CPB, participate in practice sessions for handling emergency
situations and complications, and be involved in education, and quality
assessment and improvement activities related to perfusion.
CLINICAL PEARL Cardiac anesthesiologists should participate in the conduct and
monitoring of CPB and manage anesthesia during CPB.
CLINICAL PEARL Cardiac anesthesiologists should participate with surgeons and

perfusionists in developing protocols for conduct of CPB and in the quality assessment
and improvement activities associated with it.
PART II. PATHOPHYSIOLOGY OF CARDIOPULMONARY BYPASS
I. Introduction
Improvements in the design of the CPB circuit and greater understanding of the
physiologic insult of CPB have contributed to the relative safety of modern cardiac
surgery [18]. Despite advancements in technology and knowledge during the past
several decades, a variety of minor and major complications are observed
following CPB.
Major physiologic trespasses introduced by CPB include:
A. Alterations of pulsatility, blood flow patterns, and pressure
B. Exposure of blood to nonphysiologic surfaces and shear stresses
C. Hemodilution
D. Systemic stress response and inflammation
E. Varying degrees of hypothermia (or hyperthermia during rewarming).
Improving the safety of CPB depends on greater understanding of these
aberrations [19].
II. CPB as a perfusion system
A. Circulatory control during CPB
“Cardiac output” during CPB is the pump flow rate, which can be set at any level
desired, but is limited by the amount of venous return. Systemic and venous
blood pressures are partially dependent on the patient’s autonomic tone, but can
be manipulated by increasing or decreasing venous drainage and by
administering various fluids, vasopressors or vasodilators. Thus, the circulation
during CPB is controlled in large part by the perfusionist and the
anesthesiologist. The management of systemic blood flow, systemic arterial
pressure, and venous pressure are discussed in Chapter 7.
Distribution of blood flow. In addition to total blood flow, one must be
concerned about flow in each organ. Studies have noted a hierarchy of
distribution of blood flow during normothermia and hypothermia as total flow is
reduced [20]. Even at “normal flow” (i.e., 2.4 L/min/m2), muscle blood flow is
significantly reduced during CPB. As flow is progressively reduced, first
splanchnic, then renal, and eventually (only at extremely low flows) cerebral
flows are reduced.
B. Circulatory changes during CPB
1. Changes at onset of CPB. At commencement of CPB, there is usually a fall in
systemic blood pressure due to reduced intravascular blood volume or to a
decrease in systemic vascular resistance (SVR). The latter may result from the
following:
a. Decreased blood viscosity secondary to hemodilution by the pump-priming
fluid
b. Decreased vascular tone secondary to:
(1) Dilution of circulating catecholamines
(2) Temporary hypoxemia. Hypoxemia from initial circulation of pump
asanguineous priming fluid may lead to decreased vascular tone
(3) Low pH, calcium, and magnesium levels in the priming fluid
2. Circulatory changes during hypothermic CPB
a. Increased SVR. There is considerable patient-to-patient variation in SVR
during CPB. However, as CPB progresses, there will generally be a steady
increase in systemic pressure due to increasing SVR if flow rates are kept
constant. The observed increase in SVR during the course of CPB is due to
several factors:
(1) Decreased vascular cross-sectional area from closure of portions of the
microvasculature
(2) Vasoconstriction brought on by the following factors:
(a) Hypothermia
(b) Increasing levels of circulating catecholamines, arginine
vasopressin (AVP), endothelin, and angiotensin II
(3) Increase in blood viscosity secondary to hypothermia and rising
hematocrit (due to urine output or translocation of fluid into the
interstitial compartment or hemoconcentrator)
b. Decreased SVR. Transient decreases in SVR and systemic pressure may be
observed shortly after infusion of cardioplegic solutions, especially if the
solutions contain nitroglycerin
3. Circulatory changes during the rewarming phase of CPB
a. As the perfusate temperature is increased to rewarm the patient, variable
circulatory responses are observed depending on the anesthetics used, patient
hematocrit, underlying disease, and other factors. SVR and mean arterial
pressure (MAP) increase frequently during initial rewarming from 25° to
32°C, but then usually decrease as temperature increases above 32°C.
b. A more consistent decrease in SVR and MAP usually occurs with release of
the aortic cross-clamp and reperfusion of the heart. Despite cardioplegia and
hypothermia, there is some degree of ongoing metabolic activity and
utilization of myocardial energy stores during the ischemic period. This
results in coronary vasodilation and a marked increase in coronary blood
flow and decrease in arterial pressure. In addition, when the heart is
reperfused, accumulated metabolites are washed out of the heart into the
general circulation. Some of these metabolites, most notably adenosine, are
potent vasodilators which decrease SVR.
4. Changes in the microcirculation and adequacy of tissue perfusion during
CPB
a. During CPB, cardiac output and arterial pressure can be easily maintained at
“normal” values. However, decreases in oxygen consumption and increases in
serum lactate concentrations during CPB as well as evidence of organ
dysfunction post-CPB suggest that tissue perfusion may be impaired.
b. Factors contributing to this may include:
(1) Constriction of precapillary arteriolar sphincters caused by
catecholamines, angiotensin, vasopressin, thromboxane, endothelin, and
decreased release of nitric oxide (NO)
(2) Increased interstitial fluid volume (edema)
(3) Decreased lymphatic drainage
(4) Loss of pulsatile flow
(5) “Sludging” in the capillaries due to hypothermia
(6) Altered deformability of RBCs
(7) Microaggregation and adhesion of white cells, platelets, and fibrin onto
the endothelium related to the SIR
(8) Microemboli (gas, lipids, cellular aggregates), primarily from the
cardiotomy suction
c. Suggested ways to optimize microcirculatory function during CPB include
administration of vasodilators, use of pulsatile perfusion techniques,
hemodilution to a hematocrit between 20% and 30%, use of microfiltration,
minimizing return of unprocessed cardiotomy suction blood directly into the
H–L machine, and anti-inflammatory strategies.
5. Pulsatile versus nonpulsatile flow during CPB. One of the major physiologic
derangements introduced by CPB is loss of pulsatile arterial blood flow.
Intuitively, it seems desirable to reproduce normal flow patterns as closely as
possible during CPB. Ways of generating pulsatile flow and their limitations
were presented earlier (see Section II.E.3). There is considerable controversy
about the merits of and need for pulsatile perfusion as compared to
conventional nonpulsatile perfusion [5,21].
a. Putative benefits of pulsatile flow
(1) Transmission of more energy to the microcirculation, which improves
tissue perfusion, lymphatic flow, and cellular metabolism
(2) Reduction of adverse neuroendocrine responses (mainly
vasoconstrictive) to nonpulsatile flow that emanate from baroreceptors,
the kidneys, and the endothelium
b. Clinical outcome. Clinical outcome data have been conflicting. A recent
evidence-based review concluded that existing data were insufficient to
support recommendations for or against pulsatile perfusion to reduce the
incidence of complications following CPB [5].
III. Adequacy of perfusion
A. How to define
No widely accepted definition of optimal perfusion during CPB exists. Perfusion
can be considered acceptable if the patient survives without evidence of organ
dysfunction. However, optimal CPB perfusion should be followed by a healthy,
productive, and long life after cardiac surgery. To support this goal, perfusion
during CPB should ideally achieve the following goals:
1. Maintain adequate oxygen delivery, blood flow, and perfusion pressure to
all organs
2. Avoid activation of undesirable reactions, for example, neuroendocrine
stress response and inflammation
3. Minimize microembolization and disturbance of the coagulation system
B. Monitoring
Monitoring adequacy of perfusion is discussed in Chapter 7.
IV. Hypothermia and CPB
A. Effects of hypothermia on biochemical reactions
The Q10 for chemical reactions is a measure of changes in rate of reaction for
each 10°C increase in temperature. For human tissues, Q10 is approximately 2.
As a result, for each 10°C decrease in body temperature, the rate of reaction (i.e.,
metabolic rate or oxygen consumption) is roughly halved.
B. Effects of hypothermia on blood viscosity
Hypothermia increases blood viscosity. In contemporary CPB practice, patients
are typically hemodiluted to hematocrits of 20% to 30% during CPB due to
asanguineous pump-priming. Although oxygen-carrying capacity is decreased
from hemodilution, oxygen delivery may paradoxically increase as a result of
decreased viscosity and enhanced microcirculatory flow. Experimental data
suggest that viscosity remains stable if hematocrit (%) matches temperature (in
°C) during hypothermia. The optimal degree of hemodilution during hypothermic
CPB has not been determined. Recent studies have demonstrated an association
between substantial CPB hemodilution (hematocrits below 20% to 24%,
depending upon the study) and morbidity and mortality. Clinicians should avoid
both excessively high (increased blood viscosity and decreased microcirculatory
flow) and low (inadequate oxygen content) hematocrits during CPB.
C. Changes in blood gases associated with hypothermia
1. Changes in oxygen–hemoglobin dissociation curve. As temperature
decreases, the affinity of oxygen for hemoglobin increases, that is, the oxygen–
hemoglobin dissociation curve shifts to the left. Consequently, a lower partial
pressure of oxygen in the tissues is required to remove the same amount of
oxygen from the hemoglobin molecule.
2. Changes in solubility of O2 and CO2. As temperature decreases, gases
become more soluble in liquid. For a given partial pressure, more gas will be
dissolved in the plasma. This is more significant for CO2 due to a higher
solubility in plasma at any given temperature. The higher solubility of oxygen
partially offsets the left shift in the oxygen–hemoglobin dissociation curve.
3. Neutrality of water. Neutral water is water in which the [H+] is equal to the
[OH−]. At 37°C, the pH of neutral water is 6.8. At 25°C the pH of neutral
water is 7. The neutral pH of water increases linearly 0.017 units for each
degree Celsius decrease in temperature. This impacts optimal management of
pH and PaCO2 during CPB.
4. Differing strategies for measuring and managing blood gases during CPB
are discussed in Chapters 7 and 26.
V. Systemic effects of the CPB
CPB triggers an “explosion” of highly unphysiologic events that may cause or
contribute to complications (Fig. 20.8) [21,22].
A. Causes and contributors of adverse systemic effects of CPB
1. Microemboli (gas and particulate matter)
2. Activation of the inflammatory and coagulation systems
3. Altered temperature with active or passive cooling followed by active
warming
4. Exposure of blood to foreign surfaces
5. Reinfusion of shed blood and transfusion of blood products
6. Hemodynamic alterations (abnormal flow rate and pattern, abnormal arterial
and venous pressures)
7. Ischemia and reperfusion (especially of heart, lungs, and gut)
8. Hyperoxia
9. Hemodilution (with anemia and reduced oncotic pressure)
B. Blood
1. Coagulation and fibrinolytic systems and tissue factor (TF). Changes in the
coagulation cascade, platelets, and the fibrinolytic cascade are discussed in
Chapter 21.
2. Changes in formed elements
a. RBCs
(1) RBCs become stiffer and less deformable during CPB, which may
interfere with microcirculatory blood flow and increase susceptibility to
hemolysis.
(2) During CPB, RBCs are exposed to foreign surfaces and shear stresses
which may cause their destruction. The degree of hemolysis is increased
by both higher flow rates and the accompanying increase in rate of shear,
and by gas–fluid interfaces in the ECC. As red cells are lysed, the free
hemoglobin produced binds to haptoglobin. When the amount of free
hemoglobin generated exceeds the binding capacity of haptoglobin,
serum-free hemoglobin concentrations increase and hemoglobin is then
filtered by the kidney, resulting in hemoglobinuria. Cardiotomy suction
contributes importantly to hemolysis during CPB.
b. Leukocytes. CPB affects primarily neutrophils (polymorphonuclear
leukocytes [PMNs]) and, to a lesser degree, monocytes. Shortly after the onset
of CPB, circulating PMNs decrease markedly. This results from sequestration
in various vascular beds. Blockage of vessels by PMN clumping or
microcirculatory derangements induced by substances released from PMNs
may contribute to organ dysfunction after CPB. Circulating PMN levels
increase dramatically with rewarming. Neutrophils released from the
pulmonary circulation and younger cells released from the bone marrow
contribute to this neutrophilia.
FIGURE 20.8 The “explosion” of adverse events triggered by cardiopulmonary bypass. (From Elefteriades JA. Mini-
CABG. A step forward or backward? The “pro” point of view. J Cardiothorac Vasc Anesth. 1997;11:661, with permission.)
Effects of CPB on the host defense functions of PMNs remain controversial.
Studies demonstrating decreased responsiveness of PMNs to chemotactic and
aggregating stimuli indicate impaired defense mechanisms. However, other
studies show that the bactericidal activity of PMNs increases for up to 3 days
after CPB.
3. Changes in plasma proteins
a. Denaturation. Exposure of proteins to gas–liquid interfaces causes
denaturation. Protein denaturation leads to altered enzymatic function, altered
solubility, lipid release into the blood stream, and RBC membrane alteration
that promotes capillary sludging and microcirculatory dysfunction.
b. Reduced colloid osmotic (oncotic) pressure (COP). Because of
hemodilution, plasma protein concentration and hence COP fall with onset of
CPB if no colloids are added to the CPB circuit. There is controversy about
the need for and benefits of avoiding the fall in COP by using albumin or
artificial colloids (e.g., dextrans, starches) in the priming solution.
4. Activation of humoral cascade systems, for example, complement,
coagulation, and fibrinolytic systems (see Sections V.D.1 and V.D.2).
C. Fluid balance and interstitial fluid accumulation (“capillary leak syndrome”)
during CPB
Increased interstitial fluid in many tissues and organs is common during and
following CPB. If extreme, this can cause pathologic capillary leak syndrome
(e.g., adult respiratory distress syndrome [ARDS], cerebral edema). Until
recently, fluid fluxes at the microcirculatory level were attributed mainly to the
factors described by Starling:
Tissue fluid accumulation = K[(Pc - Pis ) - δ (πc - πis c)] - Qlymph
where K is the filtration coefficient (“permeability”) of capillary membrane, Pc

the mean intracapillary hydrostatic pressure, Pis the mean interstitial hydrostatic
pressure, δ the reflection coefficient to macromolecules, πc the intracapillary
oncotic pressure, π is the interstitial oncotic pressure, Qlymph the lymph flow out
of interstitium.
CPB shifts this balance toward accumulation of interstitial fluid by affecting
several of these variables. Membrane permeability is increased by activation of
a systemic inflammatory response (SIR) and intermittent ischemia/reperfusion
potentially leading to organ injury. Plasma oncotic pressure falls from the use of
asanguineous priming fluids. Inadequate venous drainage may increase mean
capillary hydrostatic pressure, whereas immobility, lack of pulsatile flow, and
loss of negative intrathoracic pressure impede lymphatic flow. The endothelial
glycocalyx (EG) is now recognized as playing an important role in modifying the
effect of these Starling factors [23]. Shredding of the EG has been demonstrated
during CPB in infants and adults, and even following off-pump CABG [24]. This
likely increases capillary permeability and perhaps induces capillary leak
syndrome.
D. Inflammation
All patients undergoing cardiac surgery will experience a systemic inflammatory
response (SIR) to the procedure [25]. Although the trauma of major surgery per
se induces inflammation, CPB accentuates this response.
SIR represents unphysiologic activation of the innate immune system resulting
in a whole-body response resembling that associated with sepsis and trauma.
This presents as a spectrum of responses ranging from near-universal evidence of
mild inflammation (fever, leukocytosis), to more significant clinical signs
(tachycardia, increased cardiac output, decreased SVR, increased oxygen
consumption, increased capillary permeability) to frank organ dysfunction
(cardiac, renal, pulmonary, GI, hepatic, CNS) and potentially to the multiple
organ dysfunction syndrome (MODS) and death.
Normal inflammation is a localized protective response composed of cellular
and humoral components. When the localized inflammatory response becomes
excessive, it may spill over to the rest of the body. The same response occurs
when the injury is systemically widespread (e.g., CPB), in which case a
generalized inflammatory response leads to diffuse end-organ damage [25].
1. Activation. Nonspecific activators of the inflammatory response include
surgical trauma and tissue injury, blood loss or transfusion, and hypothermia.
However, CPB may independently activate the inflammatory response by
several unique mechanisms:
a. Contact activation occurs when blood comes into contact with the foreign
surface of the ECC. This activates the complement, coagulation, kallikrein–
bradykinin and fibrinolytic systems as well as WBCs and platelets. The use
of cardiotomy suction contributes importantly to this response. Blood
aspirated via cardiotomy suction becomes contaminated with TF, TF
activator, and fibrin degradation products.
b. Ischemia–reperfusion. Reperfusion injury refers to damage to tissue caused
when blood supply returns to the tissue after a period of ischemia. The
absence of oxygen and nutrients from blood creates a condition in which the
restoration of circulation results in inflammation and oxidative damage from
the oxygen rather than reestablishment of normal function. The reintroduction
of oxygen via restored blood flow promotes the formation of oxygen-free
radicals, which damage cellular proteins, DNA, and plasma membranes.
WBCs carried to the area also release a host of inflammatory substances such
as interleukins (IL). As noted above, these activated leukocytes can build up
in small capillaries to cause obstruction and more ischemia.
c. Endotoxemia related to splanchnic hypoperfusion/ischemia. Transient
splanchnic hypoperfusion (see below) during CPB damages GI mucosa to
induce endotoxemia. Endotoxin, which is a lipopolysaccharide in the cell
wall of gram-negative bacteria, binds with lipopolysaccharide-binding
protein to stimulate the release of tumor necrosis factor (TNF) from
macrophages, thus potentially triggering SIR (see below).
d. Gaseous and particulate microemboli also induce an inflammatory response.
2. Propagation. Once the inflammatory response is triggered, components of the
immune and coagulation systems and various cells are activated which
propagate the SIR. These components include the following:
a. Complement. The complement system is activated by exposure of blood to
foreign surfaces, endotoxin released from the GI tract, and heparin–protamine
complexes. Its activation leads to the release of various substances (e.g., C3a,
C3b, and C5a) which increase production of cytokines and leukotrienes as
well as capillary permeability and leukocyte–endothelial adhesion.
b. Cytokines are released from activated monocytes, macrophages,
lymphocytes, and the endothelium leading to both pro- and antiinflammatory
effects.
c. Nitric oxide production is upregulated, contributing to vasodilation, increased
vascular permeability, and potential end-organ dysfunction.
d. Leukotrienes are potent vasoconstrictors.
e. Platelet-activating factor (PAF) contributes to activation of clotting as well
as inflammation (see “Platelets” below).
f. TF is expressed by many cells and initiates coagulation and release of
cytokines.
g. The kallikrein–bradykinin system amplifies the inflammatory response and
increases vascular permeability.
h. Metalloproteinases (collagenases, gelatinases) rise following CPB. They
are released from activated neutrophils and degrade collagen in basement
membrane. They facilitate migration of neutrophils into tissues and may
contribute to the inflammatory response and organ injury.
i. Endothelins are released by endothelial cell and are potent vasoconstrictors.
j. Coagulation and fibrinolysis. The coagulation–fibrinolysis cascade is closely
intertwined with the inflammatory response and are activated by cardiac
surgery and CPB. These lead to both bleeding and thrombotic–embolic
complications.
k. The endothelium. The endothelium is an active participant in a variety of
physiologic and pathologic processes. It plays a major role in regulating
vascular tone, membrane permeability, coagulation and thrombosis,
fibrinolysis, and inflammation. It attracts and directs the passage of leukocytes
into areas of inflammation through the expression of adhesion molecules. CPB
causes extensive activation and dysfunction of the endothelium due to
ischemia/reperfusion, exposure to inflammatory mediators, surgical
manipulation, and hemodynamic shear stresses. Expression of adhesion
molecules mediates the binding of neutrophils to the endothelium and
translocation into the interstitium. Resultant neutrophil degranulation attacks
the endothelial barrier function to induce capillary leak and edema.
l. Neutrophils, monocytes, macrophages, and lymphocytes. Interaction of
activated endothelium and neutrophils with the endothelium leads to tissue
damage and end-organ dysfunction via microvascular occlusion or release of
toxic metabolites and enzymes. B and T lymphocytes decrease in number and
function following CPB, which may cause immunosuppression and increase
the risk for infections.
m. Platelets. Through the production and release of leukotrienes, serotonin,
chemokines, PF4, and other substances, platelets contribute to the
inflammatory response.
3. Although some studies have found that modifying the ECC and practice of CPB
(e.g., surface coating, minimizing circuit size, leukofiltration, eliminating or
reducing cardiotomy suction, and shortening duration) and even elimination of
CPB (e.g., off-pump CABG) reduce inflammatory markers, they do not
eliminate the SIR to cardiac surgery and may not improve clinical outcomes.
4. Consequences of the inflammatory response to CPB. The inflammatory
response to major surgery per se and to CPB likely contributes to multiple
organ injuries, coagulopathy and disseminated intravascular coagulation (DIC),
infection risk, and death. In most patients, the early SIR resolves without
significant injury as a result of discontinuation of the stimulus, dissipation of
mediators, or the action of naturally occurring antagonists (e.g., IL-10). The
variability in the expression, consequences, and outcome of the inflammatory
response to CPB is the subject of much speculation. Factors likely to influence
this variability include the preoperative condition of the patient, type and
complexity of the surgery, and, perhaps most importantly, underlying genetic
polymorphism.
5. Strategies to minimize the inflammatory response to CPB are discussed in
Chapter 7.
E. Stress response
1. Endocrine, metabolic, and electrolyte effects. CPB is associated with a
marked exaggeration of the stress response associated with all types of
surgery. This is manifested by large increases in epinephrine, norepinephrine,
AVP, adrenocorticotropic hormone, cortisol, growth hormone, and glucagon.
Elevated catecholamines may adversely affect regional and organ blood flow
patterns. Catecholamines also increase myocardial oxygen consumption, which
may adversely affect the balance of myocardial oxygen supply and demand at
the time of reperfusion. Other stress hormones also increase catabolic reactions
to increase energy consumption and potentially cause tissue breakdown and
impaired wound healing.
2. Hyperglycemia is invariably encountered during CPB, especially in patients
with diabetes mellitus. Contributors to hyperglycemia include decreased
insulin production, insulin resistance (enhanced by stress hormones and
hypothermia), decreased consumption (related to insulin resistance and
hypothermia), increased glycogenolysis and gluconeogenesis (related to stress
hormones), increased reabsorption of glucose by the kidney, and administration
of glucose in cardioplegia solutions. Observational studies have demonstrated
an association between post-CPB hyperglycemia and increased morbidity and
mortality. Although measurement and control of blood glucose values during
and following CPB is strongly recommended, the optimal “target range” for
serum glucose concentrations remains controversial.
3. Renin, angiotensin II, and aldosterone levels all tend to rise during CPB.
Some patients display the so-called sick euthyroid syndrome with reduced tri-
iodothyronine (T3), thyroxine (T4), and free thyroxin levels but normal thyroid-
stimulating hormone levels. The etiology of this phenomenon is unclear, but it
provides the rationale for administration of thyroid hormone in some patients
with low cardiac output syndrome postoperatively.
4. Calcium, magnesium, and potassium. Both ionized calcium and total and
unfilterable fractions of magnesium commonly fall, whereas potassium levels
may fluctuate widely during CPB. The latter may be related to diuretics,
catecholamines, preoperative spironolactone (aldactone) and β-blockers,
potassium-containing cardioplegia, and renal dysfunction. The importance of
maintaining normal levels of these ions to preserve normal muscle and cardiac
function and prevent dysrhythmias is apparent.
VI. Effect of CPB on various organs
A. Heart
Some degree of myocardial injury and cell necrosis, as evidenced by release of
troponin, occurs during CPB, which may result in myocardial stunning and
dysfunction. However, frank myocardial infarction is relatively uncommon,
although the ECG and cardiac enzyme changes which identify myocardial
infarction have not been precisely defined. The effects of cardiac surgery on the
heart and myocardial protection are reviewed in Chapter 23.
B. Central nervous system (CNS)
Cerebral dysfunction (ranging from subtle neurocognitive dysfunction to frank
stroke or coma) is not infrequent following CPB. Its etiology is multifactorial and
includes hypoperfusion, macroemboli, microemboli, and the inflammatory
response to CPB. For further discussion, see Chapters 7 and 26.
C. Kidneys
1. Renal dysfunction or acute kidney injury (AKI), which ranges from a rise in
creatinine and release of renal tubular proteins to severe renal failure requiring
renal replacement therapy (RRT), remains a persistent and prevalent problem
following cardiac surgery involving CPB (15% to 30%) and is associated with
increased morbidity and short- and long-term mortality [21,26,27]. Even mild
elevations of serum creatinine are associated with increased morbidity and
mortality, and RRT is associated with a mortality of as high as 60%. Features
of CPB thought to contribute to AKI include the inflammatory response,
ischemia/reperfusion, and embolization (microparticles, air, and atheroma).
2. An increase in renal vasoconstriction (∼20%), decrease in percent of systemic
flow to the kidney (∼28%) and renal oxygen delivery (∼20%), an increase in
renal oxygen extraction (∼40%), and release of a protein marker of tubular
injury were found in humans undergoing CPB [28]. All of these changes suggest
impaired renal oxygenation (ischemia) during conventional CPB [28].
3. AKI has been associated with the severity of atherosclerosis of the ascending
aorta [29], the magnitude duration of MAP below the lower limit of
autoregulation in the brain [30], and a critically low systemic oxygen delivery
(<272 mL/min/m2) during CPB [31]. Intravascular hemolysis and
hemoglobinuria can also cause acute tubular necrosis.
4. Urine output is a crude indicator of renal function, but there is no correlation
between the amount of urine output during CPB and the incidence of
postoperative renal failure. Urine output is greater when MAP is higher, when
pulsatile perfusion is used, and when mannitol is added to pump-priming fluids.
5. Although CPB per se may contribute to AKI after cardiac surgery, other
preoperative and intraoperative surgical factors (e.g., low hematocrit and
transfusion of RBCs) and postoperative course and care contribute to it
[21,26]. Some studies comparing off-pump with on-pump CABG have found
less renal dysfunction but most have not observed less renal failure or RRT by
avoiding the use of CPB [32]. Thus the development of renal failure appears to
depend more on the preoperative renal function and postoperative
hemodynamic status than on various manipulations during CPB.
6. Methods of renal protection during CPB are discussed in Chapter 7.
D. Splanchnic, gastrointestinal (GI), and hepatic effects
1. GI complications are relatively uncommon (∼1.2%, range 0.3% to 6.1%)
following cardiac surgery but are associated with morbidity and high mortality
(∼34%, range 9% to 87%) [33,34]. These complications include GI bleeding
(∼31% of GI complications and ∼0.4% of all cardiac surgery cases),
mesenteric ischemia (18% and 0.2%), pancreatitis (11% and 0.1%),
cholecystitis (11% and 0.1%), peptic ulcer (4% and 0.05%), diverticulitis (3%
and 0.03%), liver failure (4% and 0.05%), and others (18%) [33].
2. Multiple risk factors have been identified, but the most prominent preoperative
factors include age >70, low cardiac output, peripheral vascular disease
(PVD), chronic renal failure, reoperative procedures, and CABG plus valve
procedures. The most prominent intraoperative factors include duration of
CPB, transfusion and administration of vasopressors. A complicated
postoperative course (e.g., sepsis, mediastinitis, bleeding, and prolonged
mechanical ventilation [>24 to 48 hours]) is frequently associated with GI
complications.
3. The presumed cause of these complications is splanchnic ischemia, which may
be related to abnormal systemic hemodynamics (low flow, low MAP, lack of
pulsatility), SIR, and athero- and other microemboli.
4. Clinical and animal studies suggest that, although global splanchnic blood flow
appears to be preserved during high-flow CPB, splanchnic flow will be
compromised early in the hierarchy of regional blood flow whenever systemic
flow is reduced [20]. Administration of vasoconstrictors, such as
phenylephrine, norepinephrine, and AVP likely further reduce splanchnic blood
flow. Furthermore, many subjects exhibit increased intestinal permeability,
decreased gastric or intestinal mucosal pH and increased mucosal PCO2,
decreased mucosal blood flow, and endotoxemia, all of which suggest that
mucosal ischemia occurs frequently during CPB. Although SIR likely
contributes to GI ischemia, conversely GI ischemia may play a primary role in
the development of SIR syndrome and injury of other organs. Thus, the GI
tract is both the cause and a target of SIR in cardiac surgery.
5. Hyperbilirubinemia (>2.50 to 3.0 mg/dL) is encountered in ∼25% (range 9% to
40%) of cardiac surgery patients, with an associated mortality of ∼4%. Liver
failure occurs in 0.03% to 0.1% of cardiac surgery patients with an extremely
high associated mortality of 56% to 78%. As with renal failure, hepatic
dysfunction appears to be more dependent on hemodynamic status before and
after CPB than on any direct effect of CPB. The risk of postoperative jaundice
increases in the setting of high RA pressures, persistent hypotension after CPB,
or significant transfusion.
6. As with other adverse effects attributed to CPB following cardiac surgery,
most studies have not found a reduced incidence of GI complications when
CABG is done off-pump (OPCAB) nor that use of CPB was an independent
risk factor for GI complications in studies comparing on- and off-pump CABG.
7. Strategies to prevent GI complications are discussed in Chapter 7.
E. Lungs
1. Since the dawn of CPB, the lungs have been the unfortunate target of post-CPB
organ injury. Although less frequent (at ∼25% of patients) than in the past,
postoperative pulmonary complications remain a leading cause of morbidity
and mortality [35,36]. Manifestations range from the nearly ubiquitous decline
in PaO2/FiO2 ratio to ARDS (incidence 0.4% to 3%, mortality 15% to 70%).
Other pulmonary complications include pulmonary effusions, pulmonary
edema, pneumonia (incidence 2% to 10%, mortality up to 43%), diaphragmatic
dysfunction, and phrenic nerve paralysis. The pathophysiology is likely
multifactorial [21,36] and is thought to include the aforementioned
inflammatory response as well as activation of coagulation, pulmonary
ischemia and reperfusion (I/R) (as well as I/R in other organs), left heart
failure, atelectasis from absent ventilation during CPB, mechanical injury from
entering the pleural cavities, blood transfusion, and perioperative lung
management. Preoperative lung disease, poor LV function, age, and probably
genetic makeup comprise some of risk factors. Lung ischemia during CPB is
likely an important cause. This probably derives from loss of pulmonary artery
flow as well as marked reduction in bronchial artery flow during CPB, leading
in turn to inflammation, increased capillary permeability, increased pulmonary
vascular resistance, reduced pulmonary compliance and gas exchange, and
perhaps vulnerability to infection.
2. Methods to reduce lung injury associated with CPB are discussed in Chapter
7.
VII. Role of CPB on adverse effects of cardiac surgery
11 A popular hypothesis has been that CPB principally causes the adverse
consequences of cardiac surgery as a result of amplification of the inflammatory
response, embolization, ischemia/reperfusion, and lack of pulsatility, among other
things. This hypothesis has largely been dispelled based upon multiple studies
comparing CABG surgery with versus without CPB. Although often more evidence
of inflammation has been found with CPB, recent large randomized controlled
trials (RCTs) and meta-analyses incorporating over 50 RCT studies including over
16,000 patients have found no difference in the usual composite endpoints of 30-
day mortality plus major complications. These comparisons have found conflicting
results for the individual complications of renal dysfunction, lung dysfunction, and
strokes. Nevertheless, avoiding CPB was associated with reductions in RBC
transfusion along with small reductions in duration of mechanical ventilation (∼3 to
4 hours), intensive care unit (ICU) stay (∼0.35 day), and hospital stay (∼1 day).
The most recent and largest meta-analysis also detected a decrease in strokes
(1.34% vs. 2.0%, odds ratio 0.72) [37].
VIII. Summary
CPB is performed safely and effectively in most patients throughout the world.
This results from a combination of sophisticated equipment and well-trained and
educated perfusionists. The responsibility for safe CPB is shared by surgeons,
anesthesiologists, and perfusionists in order to manage cardiac surgery with the
lowest possible patient risk. Despite technologic advances in circuit design over
the past several decades, CPB imposes physiologic aberrations that may cause
postoperative organ dysfunction. Post-CPB organ dysfunction comprises a
spectrum ranging from mild dysfunction in one organ system to death from
multiorgan failure. One should remember that, despite myriad improvements to
CPB over many decades, placing a patient on CPB still constitutes a
physiologic trespass. Absence of significant damage caused by CPB depends
primarily on a particular patient’s ability to compensate for the derangements
introduced by that trespass.
ACKNOWLEDGMENT
The author gratefully acknowledges the contributions of other authors to a previous
version of this chapter which appeared in the 4th edition of this text: Glenn S. Murphy,
Robert C. Groom, and Joseph N. Ghansah.
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21 Coagulation Management During and After
Cardiopulmonary Bypass
Jacob Raphael, Alan Finley, S. Nini Malayaman, Jay
C. Horrow, Glenn P. Gravlee, and Linda Shore-
Lesserson
I. Introduction
II. Physiology of coagulation
A. Mechanisms of hemostasis
B. Tests of hemostatic function
III. Anticoagulation for cardiopulmonary bypass (CPB)
A. Heparin pharmacology
B. Dosing and monitoring
C. Heparin resistance
D. Heparin-induced thrombocytopenia (HIT)
E. Alternatives to unfractionated heparin (UFH)
IV. Neutralization of heparin
A. Proof of concept
B. Protamine dose
C. Protamine administration
D. Monitoring heparin neutralization
E. Adverse effects
F. Alternatives to protamine administration
V. Hemostatic abnormalities in the cardiac surgical patient
A. Management of the patient taking preoperative antithrombotic drugs
B. Abnormalities acquired during cardiac surgery
C. Pharmacologic and protective prophylaxis
VI. Management of postbypass bleeding
A. Evaluation of hemostasis
B. Treatment of postbypass hemostatic disorders
C. Transfusion medicine and the use of point-of-care–based algorithms
KEY POINTS
1. Previous concepts of independent intrinsic and extrinsic plasma

coagulation pathways, a cell-free final common pathway, and
platelet clotting have given way to an integrated concept of cell-
based coagulation occurring on the platelet surface as depicted in
Figure 21.2.
2. In the absence of a history suggesting a preoperative bleeding
disorder (e.g., von Willebrand disease, warfarin therapy), routine
hemostatic screening for patients undergoing cardiac surgery is not
cost-effective at predicting excessive perioperative bleeding.
3. Unfractionated heparin (UFH) is a hydrophilic macromolecular
glycosaminoglycan of varying chain lengths which anticoagulates
principally by potentiating antithrombin III (ATIII)–induced
inactivation of factors IIa (thrombin) and Xa.
4. Intravenously administered heparin typically peaks within 1 minute,
redistributes only slightly, and has a dose-related half-life that
reaches approximately 2 hours in the large doses used for
cardiopulmonary bypass (CPB). Heparin bolus administration
decreases systemic vascular resistance by 10% to 20%.
5. The usual initial heparin dose is 300 to 400 units/kg to achieve an
activated clotting time (ACT) exceeding 400 seconds for safe
initiation and maintenance of CPB. Heparin 5,000 to 10,000 units
should be added to the CPB priming solution.
6. Heparin is most often monitored using ACT, but ACT precision is
suboptimal at the heparin concentrations required for CPB, and it is
also subject to prolongation from hemodilution and hypothermia.
As a result, some practitioners choose to monitor and maintain a
target whole blood heparin concentration (typically 3 to 4 units/mL),
in addition to exceeding a target ACT during CPB.
7. Resistance to heparin-induced anticoagulation is multifactorial.
Treatment most commonly consists of either administration of
additional heparin or ATIII supplementation with ATIII
concentrates or FFP.
8. Heparin-induced thrombocytopenia (HIT) produces a severe
procoagulant state that may occur after 5 or more continuous days
of heparin administration. Diagnosis requires the combination of an
appropriate clinical context and a complex variety of laboratory
tests.
9. Documented presence of HIT in a patient who must urgently
undergo cardiac surgery requiring CPB is possibly best managed by
using bivalirudin for anticoagulation.
10. Protamine neutralizes heparin stoichiometrically as a result of a
strong cation (protamine)-to-anion (heparin) interaction.
11. A variety of protamine dosing methods are used clinically. Most
often 60 to 80 mg of protamine per 100 units of heparin
administered prior to CPB (including heparin placed in the CPB
priming solution if residual CPB volume is to be reinfused unaltered
by hemoconcentration or cell washing) suffices to neutralize
heparin. Excessive protamine administration impairs blood clotting.
12. In order to avoid hypotension, protamine should be administered
slowly, ideally by a continuous intravenous infusion over 5 to 10
minutes.
13. Protamine can induce severe anaphylactic or anaphylactoid
reactions.
14. Post-CPB clotting abnormalities are best managed using a systematic
approach. Post-CPB bleeding algorithms reduce bleeding and
transfusion.
I. Introduction
In essence, CPB creates a blood “detour” to permit surgery on the heart. This
detour must route the blood through an artificial heart and lung while maintaining
its fluidity. Historically, fluidity represented the final frontier in the development
of cardiac surgery because effective mechanisms for blood gas exchange and for
propelling the blood had been established more than a decade before surmounting
the fluidity challenge. The challenge was to find a therapeutic approach that would
inhibit blood’s natural propensity to clot when it contacts foreign surfaces. Since
the restoration of normal coagulation was desirable at the end of the surgical
procedure, this clotting inhibition needed to be reversible, like turning a spigot on
and off. The long-awaited solution was monumental: anticoagulation with heparin
followed by neutralization with protamine. This fundamental approach to
establishing and reversing blood fluidity remains unchanged after over 60
years, although much fine-tuning has occurred. This chapter reviews
anticoagulation and the restoration of coagulation in the patients undergoing CPB.
II. Physiology of coagulation
A. Mechanisms of hemostasis
1. Plasma coagulation. Figure 21.1 depicts the plasma coagulation pathway.
Blood contact with foreign surfaces classically was thought to activate the
intrinsic pathway, whereas vascular injury or disruption was thought to activate
the extrinsic pathway. These definitions seem counterintuitive because vascular
disruption should be intrinsic and foreign bodies extrinsic, but logic has held
little sway in coagulation pathway nomenclature. Thankfully, distinctions
between the intrinsic and extrinsic pathways have become less important
because both the activators and the pathways overlap (e.g., connection between
VIIa and IXa).
a. Intrinsic pathway. Contact activation involves binding of factor XII to
negatively charged surfaces, which leads to the common pathway through
factors XI, IX, platelet factor 3, cofactor VIII, and calcium. Kallikrein is also
formed in this reaction and serves as a positive feedback mechanism and as an
initiator of fibrinolysis (a negative feedback mechanism) and inflammation.
For cardiac surgery, this pathway’s clinical importance lies more in the
access it provides for heparin monitoring and neutralization than in its role in
normal hemostasis.
b. Extrinsic pathway. Tissue factor (TF) initiates the extrinsic pathway, which
proceeds to activate factor IX and rapidly stimulates the common pathway
with the aid of factor VII and calcium.
c. 1 Common pathway. Beginning with the assisted activation of factor X, this
pathway proceeds to convert prothrombin (factor II) to thrombin and
fibrinogen (factor I) to fibrin monomer, which initiates the actual substance of
the clot. Fibrin monomer then crosslinks to form a more stable clot with the
aid of calcium and factor XIII. Rather than thinking of the common
pathway as the result of activation of two independent paths, the concept
of cell-based coagulation has been adopted to better explain the
hemostatic mechanisms that occur simultaneously in the body (Fig. 21.2).
IGURE 21.1 Schematic representation of the hemostatic system depicting the vascular, platelet, and coagulation components. F,
ctor; HMWK, high–molecular-weight kininogen; vWF, von Willebrand factor; Ca ++; ionized calcium; VIII:C, factor VIII
oagulation component; TxA2, thromboxane A2; ADP, adenosine diphosphate.
When tissue injury occurs, TF is expressed on the surface of TF-bearing

cells. Presentation of TF to its ligand factor VII causes the activation of
factors IX and X on the TF-bearing cell. This is called “initiation.” The
activation of factor X causes thrombin formation, which then incites further
protease activation. These reactions occur on the phospholipid surface of the
platelet and are called “amplification.” The final stage of clot formation is
known as “propagation.”
Activated factor X also initiates platelet-surface clotting activity, as
depicted in Figure 21.2. This platelet-surface activity greatly speeds the
overall formation of clot and should be considered as a vital component of the
clotting cascade.
d. Thrombin is the most important enzyme in the pathway because (in
addition to activating fibrinogen) it
(1) Provides positive feedback by activating cofactors V and VIII
(2) Accelerates crosslinking of fibrinogen by activating factor XIII
(3) Strongly stimulates platelet adhesion and aggregation
IGURE 21.2 Cell-based model of hemostasis. Cellular hemostasis is thought to occur in three stages: initiation, amplification,
nd propagation. The initiation stage (1) takes place on tissue factor (TF)-bearing cells (cells such as monocytes that can bind TF
nd present it to a ligand), which come into play when endothelial injury occurs and TF is exposed. The initiation stage is
haracterized by presentation of TF to its ligand factor VII and the subsequent activation of factors IX and X on the TF-bearing
ell. The activation of factor X to Xa causes thrombin production and activation. Once generated, thrombin feeds back to activate
ctors VIII, V, and platelets (Plt, plts). The amplification stage (2) then occurs on the surface of the activated platelet, which
xposes surface phospholipids that act as receptors for the activated factors VIIIa and IXa. The platelet surface allows for further
rombin formation and hence the amplification of coagulation. Continued generation and activation of thrombin causes further
ositive feedback mechanisms (3) to occur that ultimately ensure the formation of a stable clot, including cleavage of fibrinogen to
brin, release and activation of factor XIII for fibrin cross-linkage, and the release of a thrombin-activatable fibrinolysis inhibitor.
(4) Facilitates clot resorption by releasing tissue plasminogen activator
(tPA) from endothelial cells
(5) Activates protein C, which provides negative feedback by inactivating
factors Va and VIIIa
2. Platelet activation. As shown in Figure 21.1, a variety of stimuli initiate
platelet activation, and thrombin is an especially potent one. This sets off a
cascade of events that initiates platelet adhesion to endogenous or
extracorporeal surfaces, followed by platelet aggregation and formation of a
primary platelet plug. Fibrin clots and platelet plugs form simultaneously and
mesh together, yielding a product more tenacious and difficult to dissolve than
either alone. Whereas formerly plasma-based and platelet-based clotting were
often thought to represent independent pathways, more recent accounts show
that the plasma coagulation pathway evolves mainly on the platelet surface,
such that the plasma and platelet clotting processes are more interdependent
than independent.
a. von Willebrand factor (vWF) is an important ligand for platelet adhesion at
low shear stress and for aggregation at higher shear rates. Fibrinogen is the
major ligand for platelet aggregation.
b. Products released from platelet storage granules (adenosine diphosphate
[ADP], epinephrine, calcium, thromboxane A2, factor V, and vWF) serve to
perpetuate platelet activation and the plasma coagulation cascade.
3. Nature’s system of checks and balances demands counterbalancing forces to
discourage runaway clot formation and to dissolve clots. These
counterbalances include the following:
a. Proteins C and S, which inactivate factors Va and VIIIa
b. Antithrombin III (ATIII), antithrombin, or AT, which inhibits thrombin as well
as factors XIa, IXa, XIIa, and Xa
c. TF inhibitor, which inhibits the initiation of the extrinsic pathway
d. tPA, which is released from endothelium and converts plasminogen to
plasmin, which in turn breaks down fibrin. Plasminogen activator inhibitor 1
in turn inhibits tPA to prevent uncontrolled fibrinolysis.
TABLE 21.1 Common clinical tests of hemostatic function
B. Tests of hemostatic function

1. Table 21.1 lists commonly used laboratory tests of hemostatic function [1].
These tests may be used to detect hemostatic abnormalities preoperatively or
after CPB. With the exception of the ACT, typically they are not commonly
used during CPB except under extenuating circumstances, because most of them
will be abnormal as a result of hemodilution, anticoagulation, and sometimes
hypothermia.
CLINICAL PEARL Even in cardiac surgery, neither routine preoperative nor
postbypass routine hemostatic laboratory testing has proven helpful in predicting patients
who will bleed excessively.
a. 2 Most studies suggest that routine preoperative hemostatic screening is
not helpful in predicting patients who will bleed excessively during
surgery. If the patient’s clinical history (e.g., nosebleeds; prolonged bleeding
with small cuts, dental work, or surgery; easy bruising; strong family history
of pathologic bleeding) suggests the need for hemostatic screening, selective
use of these and other tests is appropriate. Similarly, when the patient is
taking medications that alter hemostatic function, specific hemostatic function
tests may be indicated. Examples include the following:
(1) Heparin: Activated partial thromboplastin time (aPTT) or ACT
(2) Low–molecular-weight heparin (LMWH), including the pentasaccharide
fondaparinux: No test or anti-Xa plasma activity
(3) Warfarin: Prothrombin time (PT) and/or international normalized ratio
(INR)
(4) Platelet inhibitors including aspirin: No testing, bleeding time, or
specific platelet function tests. Preliminary data suggest that specific
platelet function tests in patients taking thienopyridine agents may
correlate with postoperative bleeding risk.
III. Anticoagulation for cardiopulmonary bypass (CPB)
Heparin is the drug of choice for anticoagulation, unless there is a contraindication
such as ongoing HIT.
A. Heparin pharmacology [2]
Structure. As drugs go, unfractionated heparin (UFH) might be described as
impure. Heparin resides physiologically in mast cells, and it is commercially
derived most often from the lungs of cattle (bovine lung heparin) or the intestines
of pigs (porcine mucosal heparin). Commercial preparations used for CPB
typically include a range of molecular weights from 3,000 to 40,000 Da, with a
mean molecular weight of approximately 15,000 Da. Each molecule is a heavily
sulfated glycosaminoglycan polymer, so heparin is a strong biologic acid that is
negatively charged at physiologic pH. Porcine mucosal and bovine lung heparin
historically provided satisfactory conditions for CPB but currently only porcine
UFH is commercially available.
1. 3 Action. A specific pentasaccharide sequence that binds to ATIII is present
on approximately 30% of heparin molecules. This binding potentiates the
action of ATIII more than 1,000-fold, thereby allowing heparin to inhibit
thrombin and factor Xa most importantly, but also factors IXa, XIa, and XIIa.
a. Inhibition of thrombin requires simultaneous binding of heparin to both
ATIII and thrombin, whereas inhibition of factor Xa requires only that
heparin binds to ATIII. The former reaction limits thrombin inhibition to
longer saccharide chains (18 or more saccharide units); hence, shorter chains
can selectively inhibit Xa. This is the primary principle underlying therapy
with LMWH and with the “ultimate” LMWH fondaparinux, which contains
just the critical pentasaccharide sequence needed for binding ATIII; hence, it
induces virtually exclusive Xa inhibition.
(1) Because thrombin inhibition appears pivotal for CPB anticoagulation and
also because LMWH and heparinoids have a long half-life and are
poorly neutralized by protamine, LMWH (including fondaparinux) is
inadvisable as a CPB anticoagulant.
b. Heparin binds and activates cofactor II, a non–ATIII-dependent thrombin
inhibitor. This may explain why heparin-induced anticoagulation can be
effective even in the presence of marked ATIII deficiency, although the
primary mechanism of anticoagulant action is potentiation of the ATIII-
mediated inhibition of thrombin.
2. Potency. Heparin potency is tested by measuring the anticoagulation effect in
animal plasma. The United States Pharmacopoeia (USP) defines 1 unit of
activity as the amount of heparin that maintains the fluidity of 1 mL of citrated
sheep plasma for 1 hour after recalcification.
a. Heparin dosing is best recorded in USP units because commercial
preparations vary in the number of USP units per milligram. The most
common concentration is 100 units/mg (1,000 units/mL) and is standardized to
have a variation in potency of no more than 10% [3].
3. 4 Pharmacokinetics. After central venous administration, heparin’s effect
peaks within 1 minute, and there is a small rapid redistribution that most
often is clinically insignificant [4,5].
a. Heparin’s large molecular size and its polarity restrict its distribution mainly
to the intravascular space and endothelial cells.
b. The onset of CPB increases circulating blood volume by approximately 1,000
to 1,500 mL; hence, plasma heparin concentration drops proportionately with
the onset of CPB, unless heparin is added to the CPB priming solution.
c. Heparin is eliminated by the kidneys or by metabolism in the
reticuloendothelial system.
d. Elimination half-life has been determined only by bioassay—that is, by the
time course of clotting time prolongation. By this standard, heparin’s
elimination time is dose dependent [6]. At lower doses, such as 100 to 150
USP units/kg, elimination half-time is approximately 1 hour. At CPB doses of
300 to 400 USP units/kg, elimination half-time is 2 or more hours; hence,
clinically significant anticoagulation might persist for 4 to 6 hours in the
absence of neutralization by protamine. Hypothermia and probably CPB itself
prolong elimination.
CLINICAL PEARL The half-life of heparin is dose dependent.
4. Side effects. Heparin’s actions on the hemostatic system extend beyond its
primary anticoagulant mechanism to include activation of tPA, platelet
activation, and enhancement of TF pathway inhibitor.
a. Lipoprotein lipase activation influences plasma lipid concentrations, which
indirectly affects the plasma concentrations of lipid-soluble drugs.
b. Heparin boluses decrease systemic vascular resistance. Typically this
effect is small (10% to 20%), but rarely it can be more impressive and may
merit treatment with a vasopressor or calcium chloride.
c. Anaphylaxis rarely occurs.
d. HIT is covered elsewhere in this chapter.
B. Dosing and monitoring
1. 5 Dosing. The initial loading dose of heparin varies among centers and most
commonly ranges from 300 to 400 USP U/kg. Still other centers base the initial
dose on a bedside ex vivo heparin dose–response titration.
a. Since heparin distributes primarily into the plasma compartment, increasing
the dose with increasing body weight assumes that plasma volume increases
in direct proportion to body weight. This is not the case because fat does not
increase blood volume in proportion to weight. Consequently, there is seldom
reason to exceed an initial dose of 35,000 to 40,000 units, even in patients
weighing more than 100 kg, as lean body mass tends to peak at 90 kg for
females and 110 kg for males.
b. Heparin dosing for coronary revascularization procedures performed without
CPB is controversial. Published doses range from 100 to 300 U/kg, but most
centers use 100 to 150 units/kg and set minimum acceptable ACT values at
200 to 300 seconds.
c. The CPB priming solution should contain heparin at approximately the
same concentration as that of the patient’s bloodstream at the onset of
CPB. Since this most often would be 3 to 4 U/mL, a priming volume of 1,500
mL should contain at least 5,000 units of heparin. CPB priming solutions
commonly contain 5,000 to 10,000 units of heparin.
d. Supplemental heparin doses typically are guided by monitoring of
anticoagulation.
2. Monitoring. Until the late 1970s, heparin dosing was guided by experiential
practices and varied a great deal from hospital to hospital. Using ACT, a
variation on the Lee–White clotting time, Bull et al. identified rather
staggering variations in the approach to heparin dosing and in both the
initial anticoagulant response and the time course of anticoagulation in
response to a fixed dose of heparin. This landmark work rapidly led to the
realization that the anticoagulant response to heparin should be monitored.
3. Approaches to anticoagulation monitoring for CPB. The ACT is the most
widely used test, although some centers monitor blood heparin concentration
as well.
a. 6 ACT uses an activant such as celite or kaolin to activate clotting, then
measures the clotting time in a test tube. Heparin prolongs ACT with a roughly
linear dose–response pattern (Fig. 21.3). Normal ACT depends upon such
factors as the specific activant and device, prewarming (vs. room
temperature) of test tubes, and operator technique but generally falls between
110 and 140 seconds.
IGURE 21.3 Graph of a heparin (and protamine) dosing algorithm. In the graph, the control activated clotting time (ACT) is
hown as point A, and the ACT resulting from an initial heparin bolus of 200 units/kg is shown in point B. The line connecting A
nd B then is extrapolated and a desired ACT is selected. Point C represents the intersection between this line and a target ACT
400 seconds, theoretically requiring an additional heparin dose represented by the difference between points C and B on the
orizontal axis (arrow C). Similarly, to achieve an ACT of 480 seconds ( higher horizontal dotted line intersecting the ACT vs.
eparin dose line at point D), one would administer the additional heparin dose represented by arrow D. To estimate heparin
oncentration and calculate protamine dose at the time of heparin neutralization, the most recently measured ACT value is plotted
n the dose–response line (point E in the example). The whole blood heparin concentration present theoretically is represented by
e difference between point E and point A on the horizontal axis ( arrow E). The protamine dose required to neutralize the
maining heparin then may be calculated. Protamine 1 mg/kg is administered for every 100 units/kg of heparin present. (Modified
om Bull BS, Huse WM, Brauer FS, et al. Heparin therapy during extracorporeal circulation: II. The use of a dose-response curve
individualize heparin and protamine dosage. J Thorac Cardiovasc Surg. 1975;69:686 by Gravlee GP. Anticoagulation for
ardiopulmonary bypass. In: Gravlee GP, Davis RF, Kurusz M, et al., eds. Cardiopulmonary Bypass: Principles and Practice. 2nd
d. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:435–472, with permission.)
Although originally described as a manual test, most centers use one of the
two automated approaches to ACT (International Technidyne, Edison, NJ,
USA or Medtronic HemoTec, Fridley, MN, USA). These two automated
approaches yield slightly different values, both at baseline and with
anticoagulation, because of different activators and endpoint detection
techniques.
ACT is prolonged by hypothermia and hemodilution; hence, conditions
often imposed by CPB alter the ACT–heparin dose–response relationship [8].
Some see this as risking underanticoagulation, although hemodilution and
hypothermia legitimately enhance anticoagulation. Overreliance on
hypothermic enhancement of ACT prolongation risks underanticoagulation
upon rewarming. Also, at temperatures below 25°C, ACT prolongation
becomes so profound that alternative tests such as whole blood heparin
concentration measurement may be advisable.
The minimum ACT acceptable for CPB is the level below which
anticoagulation is not optimized. Accepting an ACT below this value will
result in activation of the coagulation system and potentially the development
of a consumptive coagulopathy or catastrophic thrombus. Although the concept
of the minimum ACT is clear, the actual minimum ACT remains controversial.
Furthermore, clinicians often choose a target ACT value much higher than the
minimum ACT to provide a margin of safety. There are studies supporting the
safety of ACT values as low as 300 seconds, with or without extracorporeal
surfaces coated with heparin or other anticoagulants, yet most centers accept
only values exceeding 400 or 480 seconds. In addition, different devices and
tests yield different dose–response relationships for heparin concentration
versus ACT, as well as different sensitivities to hypothermia and
hemodilution.
(1) As a clotting test, ACT is somewhat crude and may vary as much as
10% on repeated testing at heparin concentrations used for CPB [9],
so it seems reasonable to build in a safety margin by accepting 400
seconds as a minimum safe threshold for sustained CPB.
(2) Aprotinin, which is now used rarely in clinical practice, complicates the
use of ACT monitoring, as a result of marked prolongation of celite
ACTs in the presence of heparin and aprotinin. This may represent
enhanced anticoagulation to some degree, but in the presence of
aprotinin, it is probably wise to titrate heparin to a celite ACT level
exceeding 750 seconds or to use a kaolin ACT instead. Kaolin ACT
minimum levels do not have to be adjusted in the presence of aprotinin.
b. Whole blood heparin concentrations can be measured during CPB. The most
commonly used technique is automated protamine titration (Medtronic
HemoTec, Fridley, MN). Advocates of this monitoring technique argue that
CPB-induced distortion of the ACT–heparin dose–response relationship
mandates maintenance of the heparin concentration originally needed before
CPB to achieve the target ACT level [10] . Heparin dosing based upon
concentration alone substantially increases the amount of heparin given
during CPB, which enhances suppression of thrombin formation. This benefit
may accrue at the expense of heparin rebound, if not monitored, and more
profound platelet activation that may aggravate and prolong platelet
dysfunction after CPB. The distortion of the ACT–heparin sensitivity
relationship can be partly overcome using plasma-modified ACT testing [11]
or by maximal activation of the ACT test sample, as is done in a
thromboelastograph (TEG) modification of the ACT [12]. Whole blood point-
of-care measurement of heparin concentration can also be performed with the
HepTest POC-Hi (Americana Diagnostica, Stamford, CT). This test
correlates well with heparin concentrations during CPB and more closely
approximates the trend in plasma anti-Xa levels than does the standard ACT
[13].
(1) Whole blood heparin concentrations of 3 to 4 U/mL most often are
sufficient for CPB. Plasma heparin concentrations (typically anti-Xa
concentrations) are higher because circulating heparin only resides in the
plasma compartment.
(2) Patients can vary widely in their sensitivity to heparin-induced
anticoagulation; therefore, isolated use of heparin concentration could
lead to dangerous underanticoagulation. If this technique is chosen,
simultaneous use of ACT or another clotting time is strongly advised.
(3) Heparin concentration monitoring may be a useful adjunct to ACT
monitoring both in the presence of aprotinin and during periods of
hypothermia below 25°C.
(4) Heparin concentration monitoring may be advantageous in selecting a
protamine dose because the dose will be chosen in relation to
approximate actual blood heparin concentration. The weakness of this
technique is its dependence on a calculated blood volume determination
at a time when blood volume may vary substantially.
c. Other monitors of anticoagulation. Neither ACT nor heparin concentration
is perfect, so other tests have been evaluated or are under investigation. The
aPTT and traditional thrombin time are typically so sensitive to heparin that
those tests are not useful at the heparin concentrations needed for CPB. The
high-dose thrombin time (HiTT, International Technidyne) offers a linear
dose–response in the usual heparin concentration range used for CPB. The
heparin management test (HMT, Helena, Beaumont, TX) offers another
platform for ACT monitoring and can be used to monitor heparin at high
(cardiac surgery) and low (vascular surgery) concentration ranges. Clotting
times have also been successfully monitored using viscoelastic tests—the
Sonoclot (SkACT, Sienco, Arvada, CO) [14] and the TEG.
CLINICAL PEARL Despite its many limitations, activated clotting time (ACT) rapidly
and reliably diagnoses the adequacy of heparin-induced anticoagulation.
C. Heparin resistance
7 No universal definition of heparin resistance exists, but it can be loosely
defined as the need for greater-than-expected heparin doses to achieve the target
ACT for CPB. As noted earlier, ACT prolongation in response to heparin varies
greatly. A number of factors that may decrease the ACT response to heparin are
listed in Table 21.2 [2]. ATIII deficiency is cited most often for heparin
resistance, but overall, the correlation between ATIII concentrations and
anticoagulant response to a bolus of heparin has been weak and inconsistent,
perhaps because heparin resistance often is multifactorial [15].
Clinical approach. When faced with heparin resistance, four treatment options
exist: (1) Administer additional heparin, (2) ATIII supplementation with fresh
frozen plasma (FFP), (3) ATIII supplementation with ATIII concentrate, and (4)
proceed with CPB with the current ACT.
1. Most often heparin resistance can be managed by simply giving more
heparin to account for the potential that an adequate heparin
concentration has not been achieved. If heparin concentrations are being
monitored, then achieving a heparin concentration of 4 U/mL should be
adequate, as there is likely no improvement in anticoagulation at higher heparin
concentrations. When using higher-than-normal doses of heparin, clinicians
should consider monitoring and potentially treating heparin rebound, as the risk
of its development increases with higher heparin doses.
2. When higher doses of heparin have failed to increase the ACT sufficiently (i.e.,
>600 USP units/kg), ATIII supplementation should be considered, as it has
been shown to increase the ACT. Traditionally, this was achieved with FFP.
The concentration of ATIII in FFP is ∼1 U/mL, which translates to a standard
dose of 2 units of FFP to achieve 500 units of ATIII. Although FFP is known to
increase the ACT by providing ATIII supplementation, it is no longer
considered a first-line therapy due to the risk of allogeneic transfusion and
limited data supporting its use. Furthermore, FFP is only recommended for
single-factor deficiencies when a concentrate is not available for that factor.
TABLE 21.2 Potential causes of heparin resistance
3. Because of these issues, ATIII supplementation with ATIII concentrate has

become standard therapy. In addition to limiting the negative sequelae of
transfusing FFP, multiple studies exist showing a consistent increase in the
ACT after ATIII supplementation. The Society of Thoracic Surgeons/Society of
Cardiovascular Anesthesiologists (STS/SCA) blood conservation guidelines
recommend ATIII concentrate as a class I recommendation for use in patients
with ATIII-mediated heparin resistance immediately before cardiopulmonary
bypass [16]. The increase in ACT abates concerns about subtherapeutic
anticoagulation, although evidence showing an improvement in clinical
outcomes is lacking.
4. Occasionally, a fourth option can be chosen, which is to accept the achieved
ACT and commence CPB. Although the minimum ACT value for safely
commencing CPB remains unclear, the wide variation in target ACT values
across institutions indicates that the acceptable safe range for target ACT may
be very large.
a. Prediction of heparin resistance. Medtronic HemoTec’s HMS Plus
Hemostasis Management System and International Technidyne’s Hemochron
RxDx system each provide an in vitro opportunity to titrate the patient’s whole
blood to predetermined heparin concentrations and hence predict the initial
heparin dose required to achieve a particular target ACT. Some centers use
one of these devices to predict heparin resistance prior to heparin
administration. This approach allows “customization” of initial heparin
dosing as well as advance preparation for anticipated heparin resistance—for
example, ordering ATIII concentrate or FFP.
D. Heparin-induced thrombocytopenia (HIT)
1. Benign thrombocytopenia from heparin’s proaggregatory effect on platelets
develops in 5% to 28% of patients.
a. This mild decrease in platelet count typically occurs within 1 to 2 days of
heparin administration without thrombosis or immune response. This response
was formerly called HIT type I, and it is not considered pathologic. However,
thrombocytopenia occurring within 1 to 2 days of heparin administration can
be pathologic immune-mediated HIT if the patient’s plasma retains heparin
antibodies from a previous exposure. This latter situation is most likely to
occur in a patient who has experienced clinical HIT within the past several
weeks.
b. 8 HIT is a severe condition that most often occurs after 5 continuous
days of heparin administration (average onset time, 9 days) and is immune
mediated. Antibody binding to the complex formed between heparin and
platelet factor 4 (PF4) is responsible for the syndrome. Antibody binding to
platelets and endothelial cells causes platelet activation, endothelial injury,
and complement activation. This syndrome is highly morbid and can be fatal
as a result of thromboembolic phenomena.
(1) Among patients who develop HIT, the incidence of thrombosis
approximates 20%, the mortality of which can be as high as 40%.
(2) Diagnosis. Thrombocytopenia (usually defined as platelet count
<100,000/uL, but this is complicated for several days by post-CPB
hemodilution), demonstration of heparin/PF4 antibody plus (ideally)
documentation of heparin-induced aggregation of platelets.
(a) Heparin-induced serotonin release assay: A functional test, often
considered the gold standard.
(b) Heparin-induced platelet activation assay (HIPAA): A functional
test, may be nonspecific.
(c) Enzyme-linked immunosorbent assay (ELISA) specific for the
heparin/PF4 complex or for PF4 alone: Patients with a positive
antibody test do not always develop thrombosis. Antibodies to the
heparin/PF4 complex are associated with adverse outcomes after
cardiac surgery [17]. Whether the antibody causes these outcomes
or merely serves as a marker for a more critically ill patient has not
been determined. Antibodies associated with HIT often become
undetectable 50 to 85 days after discontinuing heparin. After 100
days of heparin discontinuation, one can be confident that short-term
reexposure to heparin (as for CPB) will not result in antibody
formation [18]. Continued heparin reexposure is not recommended,
even though the clinical syndrome does not always recur upon
reexposure to the drug. Sometimes the syndrome resolves despite
continued heparin therapy. HIT can be associated with heparin
resistance and thus should be part of the differential diagnosis.
CLINICAL PEARL The antibodies that cause HIT typically disappear from plasma 50 to
85 days after the most recent exposure to heparin. Once that occurs, it is safe to administer
heparin for short periods such as those required for surgical cardiopulmonary bypass.
(3) Treatments for HIT and alternative anticoagulant sources:
(a) In HIT, changing the heparin formulation or using LMWH or
heparinoids is no longer recommended, because cross-reactivity
with other heparins exists (see Section III.E).
(b) Plasmapheresis can be used to remove the antibody but may be
insufficient therapy by itself.
(c) Heparin can be combined with platelet inhibitors (e.g., iloprost) to
reduce the aggregability of platelets.
(d) Hirudin, bivalirudin, and argatroban are direct thrombin inhibitors.
E. Alternatives to unfractionated heparin (UFH)
1. LMWH (shorter-chain heparin molecules, including fondaparinux).
Intravenously administered LMWH has a half-life at least twice as long as that
of UFH and possibly several times as long for some LMWH compounds.
Problems in CPB arise from the fact that protamine neutralization only reverses
the factor IIa inhibition and leaves the predominant factor Xa inhibition intact.
LMWH therapy also complicates heparin monitoring because aPTT (and
presumably ACT) is much less sensitive to Xa inhibition and will not
accurately measure the full anticoagulant effect. Factor Xa inhibition can be
measured directly in plasma and with a plasma-modified whole blood test, but
there is no simple point-of-care test available. LMWHs are not recommended
for use in HIT patients because of cross-reactivity of the antibody, although
some reports suggest that fondaparinux may be safe because it is too small to
bind to antibodies.
2. Bivalirudin
a. 9 Synthetic polypeptide that directly inhibits thrombin by binding
simultaneously to its active catalytic site and its substrate recognition site.
Shown to be a safe and effective alternative to heparin anticoagulation in
patients undergoing cardiac surgery requiring CPB [19].
b. Half-life is 24 minutes. Elimination is primarily by proteolysis and, to a
smaller degree, renal elimination. Even though this half-life is shorter than
heparin’s, the absence of a reversal agent and the profound degree of
anticoagulation used for CPB may cause coagulopathy for 2 or more
hours following CPB.
c. Dose during interventional procedures: 0.75 mg/kg bolus followed by a 1.75
mg/kg/hr infusion, yielding a median ACT of 346 seconds [20].
d. Dose for CPB: 1 mg/kg bolus followed by a 2.5 mg/kg/hr infusion. A
recirculation limb and avoidance of circuit (and saphenous vein graft)
stasis is necessary.
e. Studies in interventional procedures suggest lower bleeding rates than UFH
and similar efficacy.
f. Argatroban. A direct thrombin inhibitor that is approved by the U.S. Food and
Drug Administration (FDA) for anticoagulation in HIT patients but not yet
approved for use in CPB. Argatroban undergoes hepatic metabolism with a
half-life of 39 to 51 minutes.
CLINICAL PEARL Although drugs such as bivalirudin may be theoretically superior to
heparin for anticoagulation for cardiopulmonary bypass, the absence of effective reversal
agents makes them impractical for routine use.
IV. Neutralization of heparin
A. Proof of concept
Protamine, commercially prepared from fish sperm, first found clinical utility in
its combination with insulin to delay insulin’s absorption and prolong its effect.
Combination of protamine with heparin, intended to achieve a similar
prolongation of heparin’s effect, resulted instead in inactivation of heparin.
Combining the strongly cationic protamine with strongly anionic heparin
produces a stable complex devoid of anticoagulant activity.
1. 10 Heparin and protamine combine in proportion to weight. One milligram
of protamine neutralizes 1 mg (typically 100 U) of heparin [21].
B. Protamine dose
Since protamine appears to distribute within the circulatory system as heparin
does, the protamine dose required to neutralize a given dose of heparin equals
the number of milligrams of heparin remaining in the patient’s circulation at the
time of neutralization. Thus, clinical protocols to determine the initial dose of
protamine first estimate the blood heparin concentration and blood volume.
Direct assay of heparin concentration is difficult and unnecessary. Indirect assay
using protamine effect in vitro is more accurate than ratio-based estimates and is
easily performed. Three different methods of choosing an initial protamine dose
are commonly used:
1. 11 Empiric ratio. Most clinicians choose a dose of protamine based on the
total number of units of heparin administered, giving between 0.6 and 1.3 mg of
protamine for every 100 units of heparin administered.
2. Clinical efficacy has been documented using a ratio as low as 0.6 mg of
protamine to 100 units of heparin administered. Initial doses using this ratio
result in a mild-to-moderate protamine excess relative to heparin that ensures
total neutralization and minimizes the likelihood of subsequent heparin
rebound. Ratios exceeding 1 mg/100 units tend to be excessive.
Example: A patient receives 25,000 units of heparin before CPB, with no
subsequent heparin required, and 5,000 units in the bypass pump prime. A ratio
of 1 mg:100 units yields a 300-mg protamine neutralizing dose. A ratio of 0.6
mg:100 units would result in 180 mg of protamine as the neutralizing dose. The
former dose applies best when the patient receives all residual extracorporeal
circuit blood, unwashed, prior to protamine administration; the latter dose
makes most sense for CPB durations of 1 to 2 hours, during which heparin has
ample opportunity for metabolism and excretion.
3. Estimated from a heparin dose–response curve. This method depends upon
construction of a heparin dose–response curve prior to or during bypass (see
Fig. 21.3). The technique then estimates the blood concentration of heparin at
the time of neutralization (see Fig. 21.3 legend for details). Assumptions
include (i) linearity of the heparin dose–ACT response relationship, (ii)
potential extrapolation beyond actual data collected, and (iii) constancy of the
volume of distribution of heparin and protamine. Most often, clinicians choose
the arbitrary ratio of 1 mg of protamine to 100 units of heparin to calculate the
protamine dose.
4. Calculated from in vitro protamine effect, by measuring ACT both with and
without protamine added to blood at the time of neutralization. The HMS
system from Medtronic HemoTec automates this technique to calculate
protamine dose. These curves assume a linear dose–response and extrapolate
to a baseline ACT in calculating the initial protamine dose. These devices also
calculate blood volume based on patient’s height and weight rather than on any
definitive measurement, which can be a source of error. The same protamine
titration curve can be performed using the TEG, but this assay has not become
fully automated.
C. Protamine administration. Always administer protamine slowly
12 The rate of administration is more important than the route of administration
in preventing adverse hemodynamic effects (see Section IV.E.1). One can either
use a syringe or dilute the drug in a small volume of intravenous fluid and infuse
by gravity or calibrated pump. Because the syringe technique results in multiple
boluses, restricting its use to doses less than 1 mg/kg, or 20 mg in any 60-second
period, appears advisable. We recommend a continuous infusion technique
rather than hand-operated syringe administration, because this reduces the
natural tendency to administer the protamine too quickly and it frees our hands
for other important patient care activities (e.g., vasoactive drug titration,
echocardiography examination) that coincide with protamine administration.
1. The injected dose of protamine cannot neutralize heparin bound to plasma
proteins or within endothelial cells. Release of heparin from these stored areas
after initial protamine administration may result in reappearance of heparin
anticoagulant effect (heparin rebound). Small additional doses of protamine
will provide neutralization when repeat testing (e.g., ACT initially normalizes
to 110 seconds but 30 minutes later is 140 seconds) shows a heparin effect in a
bleeding patient.
2. Protamine does not remain long in the vascular system following
administration. Therefore, administration of heparinized blood, such as that
remaining in the CPB machine without washing, following completion of the
neutralizing protamine infusion, will likely result in renewed anticoagulation to
a small extent. An additional small dose of protamine, about 1 mg/20 mL of
transfused pump blood, should address this contingency.
D. Monitoring heparin neutralization
1. ACT. After protamine administration, the ACT test should return a value no
more than 10% above the value before heparin administration. If more
prolonged, residual heparin activity is likely. An ACT value that remains
prolonged despite additional protamine suggests a technical error or, less
commonly, some other hemostatic abnormality.
2. Protamine titration. This test utilizes a series of tubes with increasing amounts
of added protamine, beginning with none. One adds patient blood to each tube
and determines which tube clots first. Because protamine has anticoagulant
properties in vitro, it prolongs the coagulation time of normal blood in test
tubes. Knowing which tube clots first allows identification of unneutralized
heparin as well as estimation of the additional amount of protamine needed to
achieve complete neutralization. This test can be performed manually or by
using an automated device (Medtronic HemoTec).
E. Adverse effects [22]
1. Hypotension from rapid administration. Administration of a neutralizing
dose of protamine (about 3 mg/kg) over 3 or fewer minutes decreases both
systemic and pulmonary arterial pressures as well as venous return. This
predictable response may be blunted, but not predictably avoided, by volume
loading. Release of vasoactive compounds from mast cells or other sites may
be responsible for this adverse response.
2. 12 Anaphylactoid reactions. Although protamine is a foreign protein, immune
responses occur infrequently following exposure so that true allergy to
protamine is uncommon. Table 21.3 lists those patients at potential risk.
3. Pulmonary vasoconstriction. Occasionally protamine increases pulmonary
arterial pressure, resulting in right ventricular failure, decreased cardiac
output, and systemic hypotension. Formation of large heparin–protamine
complexes may stimulate production of thromboxane by pulmonary
macrophages, causing vasoconstriction. In some animal models, the probability
of experiencing this response is increased by faster rates of protamine
administration.
TABLE 21.3 Patients at potential risk for true allergy to protamine
4. Antihemostatic effects. Protamine activates thrombin receptors on platelets,

causing partial activation and subsequent impairment of platelet aggregation.
Transient thrombocytopenia also occurs in the first hour after a full neutralizing
dose of protamine. Inhibition of plasma coagulation can also occur.
5. Treatment of adverse protamine reactions. Systemic hypotension during or
within 10 minutes after protamine administration suggests protamine as the
cause but other causes such as hypovolemia and left ventricular dysfunction
should be considered. Specific treatment depends on other hemodynamic
events.
a. Normal or low pulmonary artery pressures suggest either rapid administration
or an anaphylactoid reaction. Rapid fluid administration alone often suffices
to treat the former, whereas the latter cause usually requires aggressive
volume resuscitation, large doses of epinephrine, and possibly other
vasoactive compounds and inhaled bronchodilators. Refer to other sources for
the treatment of acute anaphylaxis, including use of systemic corticosteroids.
b. High pulmonary artery pressures suggest a pulmonary vasoconstriction
reaction. Inotropes with pulmonary dilating properties, such as isoproterenol
or milrinone, will support the failing heart while facilitating movement of
blood across the pulmonary circulation. Inhaled nitric oxide may also be
useful. With extreme hemodynamic deterioration, reinstitution of CPB may be
necessary. In this case, give a full heparin dose (at least 300 U/kg).
Occasionally, heparin alone will correct the pulmonary hypertension
(presumably by breaking up large heparin–protamine complexes, the putative
stimulant to thromboxane production) such that reinstitution of CPB no longer
becomes necessary, although neutralization of heparin becomes an even bigger
problem.
c. Prevention of adverse responses
a. Rate of administration. Always administer fully neutralizing doses of
protamine slowly (minimum duration 3 minutes, with a target of 10
minutes recommended). Rather than depend on volume loading to prevent
hypotension, simply dilute the drug and give it slowly. Place the calculated
dose in 50 mL or more of clear fluid and connect a small-drop
(approximately 60 drops/mL) administration set to limit the infusion rate or
use an infusion pump connected either to a 50-mL syringe or a 50-mL (or
greater) fluid bag containing protamine. Some clinicians advocate a
protamine “test dose,” such as 1 mg intravenously, prior to protamine
administration. Our view is that slow initiation of a continuous protamine
infusion accomplishes the same end, after which the infusion rate can be
increased as tolerated down to a minimum infusion time as above.
CLINICAL PEARL The most common cause of hypotension during protamine
administration is overly rapid administration.
b. Route of administration. The preponderance of evidence suggests that
peripheral vein infusion offers no benefit over central venous infusion as
long as the infusion is dilute and not rapid. Injection directly into the aorta
provides no reliable protection and risks introduction of embolic material,
such as small bubbles, pieces of rubber stopper, or glass.
c. High-risk subgroups. Patients without previous exposure to protamine,
including those with diabetes or prior vasectomy, require no special
measures before initial exposure. Even patients who have received
protamine-containing insulin preparations rarely develop an adverse
response; however, the presence of antibodies to the heparin/protamine
complex has been demonstrated [23]. Only patients with a prior history of
an adverse response to protamine warrant special treatment. See Table 21.3
for the relative risks of protamine administration to these subgroups.
d. Prior protamine reaction. Prepare a special, dilute protamine solution of
about 1 mg in 100 mL and administer over 10 minutes. If no adverse
response occurs, administer the fully neutralizing dose as described earlier.
Skin tests taken before giving protamine provide little predictive value and
frequently are falsely positive. Special immunologic tests for protamine
allergy, such as radioallergosorbent test (RAST) and ELISA, also
demonstrate many false-positive results.
F. Alternatives to protamine administration
1. Allow heparin’s effect to dissipate. This approach results in continued
hemorrhage with substantial transfusion requirements, bouts of hypovolemia,
and the potential for consumptive coagulopathy. Although this may be the only
option available, ideally it should be avoided.
2. Platelet concentrates. PF4 is released from activated platelets. It combines with
and neutralizes heparin. However, platelet concentrates do not effectively
restore coagulation following CPB. A recombinant form of PF4 failed in
clinical trials as a protamine alternative.
3. Hexadimethrine. This synthetic polycation, no longer readily available in the
United States because of renal toxicity, can avoid true allergic reactions to
protamine. However, like protamine, it forms complexes with heparin that can
incite pulmonary vasoconstriction if administered quickly.
4. Methylene blue. Even large doses do not effectively restore the ACT.
However, inhibition of nitric oxide synthetase can incite pulmonary
hypertension, making this approach potentially hazardous.
5. Investigational substances. Heparinase I, an enzyme produced by harmless soil
bacteria, failed in clinical trials as a protamine alternative. Virus-like
particles, engineered from bacteriophage Qβ coat protein, have shown
consistent neutralization of heparin with less variability than protamine in
plasma from heparin-treated patients [24]. Cationically modified chitosan
binds to heparin to form complexes similar to those formed by protamine [25].
6. With no alternative to protamine immediately available, or even under active
clinical investigation, alternatives to heparin (see Section III.E) assume greater
importance in the management of patients with demonstrated severe adverse
responses to protamine.
V. Hemostatic abnormalities in the cardiac surgical patient [1,26]
A. Management of the patient taking preoperative antithrombotic drugs
Table 21.4 lists commonly used antithrombotic drugs and their mechanisms of
action.
1. Anticoagulant therapy. Patients receiving warfarin anticoagulant medications
should be advised to discontinue the medication 3 to 5 days before the
anticipated cardiac surgery. In general, an INR value less than 2 reflects an
acceptable recovery of vitamin K–dependent clotting factors. In fact, some
residual inhibition of the extrinsic coagulation pathway advantageously
accentuates anticoagulation for CPB. If anticoagulation is so vitally important
that it must be maintained until the time of surgery, an intravenous infusion of
heparin may be started preoperatively. Heparin may be discontinued a few
hours before surgery or continued into the operative period.
a. In urgent or semi-urgent surgery, the effects of warfarin may need rapid
reversal, which can be accomplished by giving FFP until INR correction
occurs [30]. Concomitant administration of vitamin K may accelerate warfarin
reversal.
b. In clinical studies, prothrombin complex concentrate (PCC) was found more
effective with quicker time to INR correction and no volume overload
observed compared to FFP [27].
CLINICAL PEARL When available, PCC, and not FFP, should be used for the
emergency reversal of warfarin effect.
2. The use of novel direct oral anticoagulants (DOACs) (dabigatran and the Xa
inhibitors, apixaban, rivaroxaban, and edoxaban) for treatment of venous
thromboembolism and prevention of thromboembolic complications in patients
with nonvalvular atrial fibrillation has increased over the last several years. In
patients with atrial fibrillation, when compared with warfarin, DOACs have a
similar efficacy in preventing stroke but a lower risk for intracranial bleeding
[28,29].
a. Recommendations are to discontinue dabigatran 24 hours prior to cardiac
surgery and the factor Xa inhibitors 3 to 5 days prior to surgery. Patients with
renal failure (dabigatran) or liver failure (factor Xa inhibitors) metabolize
and clear these drugs more slowly.
TABLE 21.4 Common antithrombotic drugs
b. DOACs present special management challenges when rapid reversal in

bleeding patients or prior to emergency surgery is required. Routine
laboratory coagulation tests (PT and aPTT) are unreliable in assessing
residual anticoagulant effect, and specific quantitative assays may not be
widely available in every medical center.
c. For patients treated with dabigatran, the humanized monoclonal antibody
idarucizumab was approved in 2015 for reversal in cases of serious bleeding
or prior to emergency surgery [30].
d. Currently, there is no approved specific reversal agent for factor Xa
inhibitors. Case reports and human volunteer studies suggest that PCC can be
used to reverse the effect of factor Xa inhibitors. Andexanet alfa, a specific
reversal agent for factor Xa inhibitors and LMWH, is currently undergoing
clinical trials for emergency reversal of these agents.
3. Antiplatelet therapy
a. Aspirin. Many studies support the use of aspirin in the prevention of
thrombosis in coronary and cerebral vascular disease. Patients taking aspirin
who undergo cardiac surgery have a propensity for increased bleeding
postoperatively; however, the benefits of aspirin therapy, weighed against a
potential for bleeding, often lead to preoperative continuation of aspirin
therapy. Most patients do not bleed excessively with this approach. An
increase in bleeding, if it exists, is not necessarily accompanied by an
increase in transfusion requirements due to blood conservation strategies in
use.
b. Glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors. The GPIIb/IIIa receptor is the
platelet fibrinogen receptor, which causes fibrinogen bridging of adjacent
platelets and subsequent platelet aggregation. GPIIb/IIIa inhibitors inhibit
platelet aggregation and have been increasingly used during interventional
cardiology procedures. Their beneficial effects include reductions in mortality
and cardiac events after angioplasty and stent procedures. However, there is
strong potential for hemorrhagic complications if these patients present for
emergent cardiac surgery. Currently, the three intravenous GPIIb/IIIa
inhibitors in clinical use are abciximab, tirofiban, and eptifibatide. Abciximab
is a monoclonal antibody to the GPIIb/IIIa receptor that inhibits fibrinogen
binding and covalently alters the GPIIb/IIIa receptor. Tirofiban and
eptifibatide are smaller competitive receptor blockers whose effects are
reversible after discontinuation of therapy. Their short duration of action may
mitigate some perioperative bleeding complications [31] and may actually
provide some platelet protection during CPB.
c. ADP receptor inhibitors. The thienopyridine derivatives ticlopidine,
clopidogrel, and prasugrel noncompetitively antagonize at a platelet ADP
receptor known as the P2Y12 receptor. Blockade of this receptor by one of
these agents elevates cyclic adenosine monophosphate levels to induce
profound and rapid platelet disaggregation. Clopidogrel use in conjunction
with percutaneous coronary intervention or in acute coronary syndromes
reduces the occurrence of adverse ischemic events [32]. Antiplatelet activity
is permanent for the life span of the platelet because the P2Y12 receptor is
permanently altered. Clopidogrel is a prodrug that is metabolized by
cytochrome P450 (2C19 and 3A4) to its active metabolite. The combination
of clopidogrel and aspirin is synergistic. Meta-analyses demonstrate that
clopidogrel pretreatment before cardiac surgery is associated with more
bleeding than that observed in nonexposed patients [33].
B. Abnormalities acquired during cardiac surgery
1. Endothelial dysfunction. Contact of blood with extracorporeal surfaces initiates
a “total body inflammatory response” characterized by activation of
coagulation, fibrinolysis, and inflammation. This leads to an abnormal cellular–
endothelial interaction.
2. Persistent heparin effect. This is uncommon because most clinicians fully
neutralize the administered heparin, although heparin rebound (resumption of
heparin effect after complete neutralization) is relatively common within
the first 2 hours following CPB and usually responds well to small (e.g., 25
mg), incremental doses of protamine.
3. Platelet abnormalities (Table 21.5)
a. Thrombocytopenia occurs frequently after CPB due to dilution of the blood
volume with extracorporeal circuit volume and platelet consumption or
sequestration. This thrombocytopenia can be severe (<50,000/μL) but, in the
absence of other hemostasis abnormalities, often does not lead to excessive
bleeding. With modern techniques, platelet counts after CPB most often
exceed 100,000/μL.
b. Platelet dysfunction. The most prevalent yet elusive cause of hemostatic
abnormalities after CPB is platelet dysfunction. Platelets are rendered
inactive by contact activation from the extracorporeal surfaces, hypothermia,
receptor downregulation, and by heparin and protamine. Heparin activates
platelets to render them less functional after CPB, and protamine also
depresses platelet function. The use of antithrombotic drugs preoperatively
leads to an even greater degree of platelet dysfunction after CPB.
4. Coagulopathy. Hemodilution and consumption of coagulation factors by
microvascular coagulation combine to cause the deficiencies of coagulation
seen after CPB. Despite the use of large doses of heparin, contact activation
causes microvascular activation of factor XII and initiates the intrinsic pathway
of coagulation.
TABLE 21.5 Causes of platelet dysfunction in cardiac surgery
5. Fibrinolysis. Fibrinolysis can be primary or secondary during CPB (Fig. 21.4).

Primary fibrinolysis occurs from release of endothelial plasminogen activators.
Secondary fibrinolysis describes activation of plasmin as a result of a feedback
response to fibrin formation. Circulating plasmin degradation products
adversely affect platelet function.
6. Pharmacology. As noted earlier, heparin and protamine impair platelet
function. Other drugs commonly used during CPB (milrinone, nitroglycerin,
nitroprusside) adversely affect platelet function in vitro, but in vivo their
effects appear to be clinically undetectable.
7. Hypothermia. Hypothermia impairs the enzymatic cascades of the coagulation
pathway. Platelets are activated during mild hypothermia and are depressed
during moderate to severe hypothermia.
C. Pharmacologic and protective prophylaxis
1. Platelet protection
a. Antifibrinolytic agents. See Section V.C.2.
b. Coated surfaces. Heparin-bonded circuits attenuate the inflammatory response
to CPB and may confer some platelet protective properties.
c. Antiplatelet agents that are active during CPB may confer platelet protection
so long as they are short acting. Patients who have emergency surgery after
having been exposed to tirofiban or eptifibatide do not experience excessive
postoperative bleeding and receive equivalent or reduced transfusion
volumes.
2. Antifibrinolytic agents [34]
a. Synthetic antifibrinolytic agents: ε-aminocaproic acid (EACA) and tranexamic
acid (TA). EACA and TA act as lysine analogs that bind to the lysine-binding
sites of plasmin and plasminogen (Fig. 21.4). TA is a more potent analog of
EACA that has a higher affinity for plasminogen than does EACA. Fibrin
degradation products inhibit platelet function. Thus, plasmin inhibition may
protect platelets. The benefits of EACA and TA have been demonstrated
in multiple meta-analyses to reduce bleeding in cardiac surgery, when
these agents are used prophylactically (i.e., initiated before CPB and
maintained throughout CPB) rather than as rescue agents [35] . Dosing:
EACA: 100 to 150 mg/kg bolus, 10 to 15 mg/kg/hr or 4- to 10-g bolus, 1 g/hr.
Reports suggest constant plasma activity may be best achieved with smaller
initial boluses (approximately 50 mg/kg) followed by higher maintenance
doses (20 to 25 mg/kg/hr). TA: Low dose: 10 to 20 mg/kg bolus, 1 to 2
mg/kg/hr; moderate dose: 30 to 50 mg/kg bolus, 15 to 30 mg/kg/hr; or high
dose: 5-g bolus, repeat bolus to total 15 g. The latter dosing scheme probably
is much higher than necessary, and there is concern that high-dose TA may be
associated with seizures and other central nervous system adverse events
[36,37].
IGURE 21.4 Schematic diagram of the fibrinolytic system displaying endogenous and exogenous activators and inhibitors of
brinolysis. The antihemostatic actions of plasmin and fibrin(ogen) split products (FSPs) are illustrated. aPC, activated protein C;
ACA, ε-aminocaproic acid; TA, tranexamic acid; tPA, tissue plasminogen activator; UK, urokinase.
b. Aprotinin, a high–molecular-weight proteinase inhibitor of bovine origin,

inhibits plasmin, kallikrein, and other serine proteases. Aprotinin decreases
activation of the hematologic system during CPB and subsequent fibrinolysis,
resulting in significant decrease in postoperative bleeding. It is the only agent
found to be successful in reducing the rate of reoperation for bleeding in meta-
analyses. However, an increased rate of mortality and renal morbidity has
been reported with aprotinin that caused the drug to be removed from
commercial use [38–40]. Recently, the drug has been reapproved for use in
cardiac surgery patients in Canada and several European countries, but it is
still not available in the United States. Newer protease inhibitors are currently
under investigation for use in cardiac surgery.
c. Investigational substances: Carbon monoxide–releasing molecule-2 (CORM-
2) significantly improved velocity of clot formation and clot strength in
plasma in patients, both before and following CPB. Pending further trials,
CORM-2 may be of use in improving coagulation and decreasing fibrinolysis
in patients with persistent bleeding after CPB [41].
3. Accurate heparin and protamine dosing. Attempts to individualize heparin and
protamine doses in order to minimize bleeding rely on patient-specific doses of
each drug based on patient sensitivity. A number of different heparin and
protamine management strategies have been reported to result in reduced
perioperative bleeding.
a. Higher heparin concentrations during CPB have been associated with
increased mediastinal tube bleeding postoperatively. Higher doses might
predispose to greater bleeding as a result of heparin rebound or platelet
dysfunction. This leads to the practice of giving just enough heparin to
maintain a “threshold” minimum acceptable ACT.
b. Some investigators postulate that higher heparin levels allow for reduced
activation of the coagulation cascade and may blunt the consumptive
coagulopathy that occurs with microvascular coagulation. This leads to the
practice of maintaining heparin at a specific concentration in the blood, which
leads to large doses of heparin and higher ACTs. Heparin management
strategies are still highly variable and institution specific.
c. Lower protamine doses have been used successfully to neutralize heparin
after CPB and have been associated with reduced bleeding and transfusion
requirements. This relationship between higher heparin and lower protamine
doses has been suggested to result in less postoperative bleeding.
4. Inhibition of inflammation
a. Coated surfaces. Heparin-bonded CPB circuits make the extracorporeal
circuit more biocompatible and thus effectively attenuate the inflammatory
response to CPB. Despite this benefit, use of these circuits has not uniformly
reduced morbidity. Use of a reduced heparin dose, in conjunction with
heparin-bonded circuits, has shown reductions in postoperative chest tube
drainage and transfusion requirements, but reduced heparin dosing in this
scenario is not yet fully endorsed, as the overall effect on safety for CPB is
unclear.
b. Steroids. Methylprednisolone and dexamethasone have been used to reduce
the inflammatory response, but improved clinical outcomes have not been
demonstrated. The use of steroids has also fallen out of favor due to risks of
hyperglycemia and immune suppression [42,43].
c. Aprotinin acts by kallikrein inhibition to reduce the inflammatory response;
however, it is not in common clinical use at this time.
d. Modified ultrafiltration has a beneficial effect of reducing postoperative
morbidity and improving organ function after CPB in pediatric patients.
e. Complement inhibitors are mostly experimental agents. They act to prevent
activation of complement by kallikrein inhibition or direct complement
antagonism. Reduction of the inflammatory response theoretically should
reduce morbidity. Clinical trials have demonstrated marginal effects that did
not reach clinical endpoints; thus, these agents have not become mainstream
therapy in CPB.
VI. Management of postbypass bleeding [1]
CLINICAL PEARL Treatment of any abnormal laboratory value should not take
place unless warranted by the clinical situation—that is, observation of clinical
coagulopathy. Treat the patient, not the number!
A. Evaluation of hemostasis
1. Achieve surgical hemostasis.
2. Confirm adequate heparin neutralization. Tests of heparin neutralization:
heparinase ACT, protamine titration test, heparinase TEG/rotational
thromboelastometry (ROTEM).
Note: The standard ACT is not a specific test for complete heparin
neutralization—that is, it is possible to have ACT return to normal while some
residual heparin effect remains. If the ACT has returned to baseline and
residual heparin effect is either suspected or identified using a protamine
titration technique, treat this by titrating in additional protamine. Most
often protamine, 25 mg, completes the neutralization.
CLINICAL PEARL Even if ACT has returned to baseline, its insensitivity to low
concentrations of heparin makes it reasonable to administer a small additional dose of
protamine if coagulopathic bleeding continues.
3. Point-of-care testing to diagnose and treat bleeding. Point-of-care tests,
preferably viscoelastic tests (TEG/ROTEM), should be used appropriately in
order to accurately and rapidly pinpoint the cause of a hemostasis defect.
Etiologies of post-CPB bleeding should be prioritized by the clinician and
should be tested in logical order. These tests should include heparin
neutralization (see Section VI.A.2), platelet function, platelet number,
coagulation, fibrinogen, and fibrinolysis (Table 21.6).
a. Tests of platelet function: TEG/ROTEM, Sonoclot, Plateletworks, Platelet
Function Analyzer-100, VerifyNow, and whole blood aggregometry to name a
few. Treatment of platelet dysfunction may include administration of
desmopressin acetate (DDAVP) 0.3 µg/kg slowly (over approximately 15
to 20 minutes, as vasodilation may occur). If platelet number is less than
50,000/µL or platelet dysfunction persists after DDAVP, a transfusion of
platelet concentrates is recommended. Since some platelet dysfunction
routinely exists after CPB, some clinicians transfuse platelets in the presence
of coagulopathic bleeding if platelet count is below 100,000/µL. This
approach appears reasonable if tests of platelet function are not readily
available.
b. Coagulation tests. Standard coagulation tests are usually not helpful in
directing treatment for the bleeding surgical patient, as they have a prolonged
turnaround time, do not correlate with surgical bleeding, and do not measure
indices such as platelet function and fibrinolysis. Yet, if viscoelastic
coagulation tests are unavailable, standard coagulation tests (PT, aPTT,
thrombin time) should be used. Treating abnormalities in coagulation factors
usually includes transfusion of FFP. Recent clinical studies have reported that
administration of 3- or 4-factor PCC is as effective as FFP transfusion,
especially in the context of preoperative warfarin therapy [44–46] and avoids
FFP-related complications such as transfusion-related acute lung injury
(TRALI) and transfusion-associated circulatory overload (TACO). For
massive bleeding when hemostasis cannot be achieved with conventional
therapies, administration of recombinant factor VIIa (rVIIa) has been used as
rescue therapy [47]. Administration of rVIIa will also treat CPB- or drug-
induced platelet dysfunction by creating a thrombin burst; however, its safety
has not been fully established, and risks of thromboembolic complications
need to be considered [48].
TABLE 21.6 Point-of-care tests of platelet function
c. Tests of hypofibrinogenemia and fibrinolysis. TEG/ROTEM, euglobulin lysis

time, fibrin degradation products, D-dimers. Low fibrinogen levels are
common after CPB and may need to be replaced with cryoprecipitate or
fibrinogen concentrate (where available). The FIBTEM assay of ROTEM or
functional fibrinogen of TEG are the primary assays performed to assess
fibrinogen-related clot firmness. Quantification of fibrinogen levels is also
reasonable, but this takes more time. Treatment of primary increased
fibrinolysis includes administration of an antifibrinolytic agent. If an
antifibrinolytic agent has already been administered and discontinued, the
same agent should be restarted. Starting a different class of antifibrinolytic
drug in the same patient is not recommended. Secondary fibrinolysis should
be treated by replacement of consumed coagulation factors (FFP or
cryoprecipitate).
B. Treatment of postbypass hemostatic disorders
Follow the steps below in order. They reflect the causes of postoperative
bleeding in decreasing frequency of occurrence. Remember to maintain
intravascular volume to avoid generating or exacerbating a consumptive
coagulopathy. These steps are designed to address the situation where urgency
dictates that one must treat a presumed cause before obtaining laboratory results.
Do not embrace any one presumed cause; rather, constantly reevaluate and
question your assumptions. Instead of bedside empiricism, however, we
encourage the development and use of transfusion algorithms based on
evaluation of multiple possible etiologies for bleeding, preferably using
viscoelastic-based point-of-care coagulation testing (see Section VI.C).
1. 14 Rule out a surgical cause. Excessive intraoperative bleeding or
postoperative chest tube drainage usually results from surgical bleeding. A
generalized slower ooze suggests a nonsurgical cause. Keep the blood pressure
in the low normal range to facilitate surgical repair and optimally for some
time thereafter to maximize the potential for clot formation.
2. Maintain normothermia. Surface warming devices or raising the operating room
temperature may be appropriate. In the effort to restore intravascular volume
rapidly, clinicians must infuse refrigerated blood products only with adequate
warming, lest they cause or accentuate hypothermia, thereby decreasing platelet
function and enzymatic activity of clotting proteins.
3. Heparin reversal. Confirm complete heparin neutralization with an ACT or by
viscoelastic testing. If viscoelastic tests are unavailable, aPTT should be
evaluated.
4. Administer more protamine if the ACT exceeds its baseline (pre-heparin) value
by >10 seconds (or other tests suggest residual heparin effect). A dose of 25 to
50 mg usually suffices. Remember that transfusion of large volumes of
unwashed RBCs directly from the CPB machine (“pump blood”) may expose
the patients to additional heparin and thus may require administration of
additional protamine.
5. In the absence of hypovolemia, consider application of 5 cm of positive end-
expiratory pressure (PEEP) to help tamponade open blood vessels in the chest.
This maneuver may be most effective after the sternum is closed because of
limitations in the ability of PEEP to effectively increase mediastinal end-
expiratory pressure while the chest remains open.
6. Platelet transfusion and/or DDAVP. If testing uncovers platelet dysfunction, or
if it is highly suspected, give platelet concentrates for platelet count below
100,000/μL. While awaiting platelet concentrates from the blood bank,
consider administration of DDAVP 0.3 μg/kg, especially if there is laboratory
evidence of platelet dysfunction (e.g., decreased maximum amplitude on TEG
or ROTEM). This may resolve the coagulopathy and avoid the need for platelet
concentrates.
7. FFP. Administer 15 mL/kg of FFP for evidence of clotting factors deficiency on
TEG or ROTEM (prolonged R time or CT index, respectively), PT in excess of
1.5 times control, or an INR in excess of 2. Administration of PCC may be an
alternative to FFP, especially when volume overload is of concern [49].
8. Administer an antifibrinolytic agent. Although these agents work best when
administered prophylactically before and during CPB, about half of their
benefit occurs if given (or continued) in the post-CPB period. An increased D-
dimer value or the TEG/ROTEM tracings and assays may indicate active
fibrinolysis that would warrant antifibrinolytic agent administration or higher
doses if antifibrinolytic agents are already being administered.
9. Consider measuring fibrinogen concentration, D-dimer, and thrombin time, the
last of which is prolonged only by residual heparin, inadequate amount or
functionality of fibrinogen, and fibrin degradation products. Cryoprecipitate or
fibrinogen concentrate: Cryoprecipitate 1 unit/4 kg body weight (generally 15
to 20 units in adults) will correct fibrinogen deficiency (<100 mg/dL). Its use is
best reserved for situations where hypofibrinogenemia has been documented
(by viscoelastic testing or direct quantification of fibrinogen level). Fibrinogen
concentrate is an alternative for cryoprecipitate and is in wide use in Europe.
Initial clinical studies demonstrated favorable outcomes of reduced bleeding
and less transfusions in high-risk patients treated with fibrinogen concentrate
[50]; however, recent prospective randomized trials have failed to demonstrate
a similar result [51,52].
10. Administration of rVIIa. rVIIa has been frequently used as “off-label” rescue
medication for massive bleeding situations when conventional hemostatic
therapy failed. In cardiac surgery, reductions in bleeding have clearly been
documented; however, a dose of 80 μg/kg has been associated with
thromboembolic complications [48,53]. Administration of rVIIa probably
makes the most sense when given as a secondary intervention when two
“rounds” of FFP 10 to 15 mL/kg and platelet concentrates 1 unit/10 kg have not
resolved the coagulopathy. Overwhelming coagulopathy may at times call for
earlier use of this potentially lifesaving agent, for which an initial dose of 30 to
40 μg/kg is recommended. Remember that optimization of fibrinogen level
prior to administration of rVIIa is crucial for an optimal hemostatic effect.
C. Transfusion medicine and the use of point-of-care (POC)–based algorithms
Allogeneic transfusions after CPB are common because of the wide range of
hemostatic insults incurred. The lack of adequate testing of hemostasis and the
subjectivity of a diagnosis of microvascular bleeding lead to indiscriminate
transfusion practices.
1. Excessive bleeding leading to massive transfusion of red blood cells, platelets,
cryoprecipitate, and plasma is associated with increased morbidity and
mortality [54]. Numerous clinical trials and meta-analyses demonstrate that the
use of point-of-care–based transfusion algorithms is associated with less
bleeding and transfusion requirements in cardiac surgery patients [55];
therefore, the rational use of transfusion algorithms should create an approach
to transfusion medicine that is stepwise, logical, and based on the hemostatic
defects that are most common and easily treated [56–58].
This usually starts with a specific test of heparin neutralization. After
residual heparin is ruled out, other point-of-care coagulation tests (preferably
viscoelastic assays) are measured.
CLINICAL PEARL Standardized point-of-care algorithms for diagnosis and
management of postbypass coagulopathy reduce both bleeding and transfusion, and the
specific diagnostic device(s) used are likely less important than local accessibility and
rapid results.
2. One of the most critical tests that should be measured “early” in a
transfusion algorithm is an accurate point-of-care test of platelet function.
3. Aside from confirming neutralization of heparin, the routine use of coagulation
tests after CPB has not proven beneficial in the absence of a clinical
coagulopathy. In patients who are suspected to have microvascular
coagulopathic bleeding, an individualized goal-directed hemostatic approach
that is based on POC-guided algorithms has been associated with improved
patient outcomes when compared to standard laboratory-based or empiric
transfusion therapy.
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22 Devices for Cardiac Support and Replacement
Jordan R. H. Hoffman, Jay D. Pal, and Joseph C.
Cleveland, Jr.
I. Introduction
II. History
III. Indications
A. Bridge to recovery
B. Bridge to transplantation
C. Destination therapy
IV. Classification and attachment sites of ventricular assist devices (VADs)
A. Left ventricular assist device (LVAD)
B. Right ventricular assist device (RVAD)
C. Biventricular assist device (BIVAD)
D. Total artificial heart (TAH)
V. Mechanical assistance systems
A. Pulsatile
B. Continuous flow
VI. Intraoperative considerations
A. Anesthetic considerations
B. Surgical techniques
C. Initiation of support for LVAD
D. Initiation of support for BIVAD
E. Initiation of support for RVAD
VII. Postoperative management and complications
A. Right-sided circulatory failure
B. Hemorrhage
C. Thromboembolism
D. Infection
E. Device malfunction
VIII. Weaning from VAD support
IX. Management of the VAD patient for noncardiac surgery
X. Future considerations
A. Totally implantable LVAD
B. Miniaturization of LVADs
C. TAH
XI. Intra-aortic balloon pump (IABP) circulatory assistance
A. Indications for placement
B. Contraindications to placement
C. Functional design
D. IABP placement
E. IABP control
F. IABP weaning
G. Management of anticoagulation during IABP assistance
H. Complications
I. Limitations
KEY POINTS
1. Mechanical circulatory support (MCS) devices most often are

ventricular assist devices (VADs), which are indicated for bridging
to myocardial recovery, cardiac transplantation, or as a permanent
assist device (destination therapy).
2. The principal growth area for VADs in recent years has been
destination therapy. The predominant device used for this indication
is the Abbott HeartMate II, although the HeartMate 3 and HeartWare
HVAD are likely to receive this indication in the near future.
3. In New York Heart Association class IV heart failure (minimal
activity–induced symptoms), VADs provide better survival and
quality of life than medical therapy.
4. A variety of nonpulsatile right ventricular assist devices (RVADs)
and a pulsatile total artificial heart (TAH) are Food and Drug
Administration (FDA) approved for bridging to recovery or to
transplantation. RVADs are sometimes needed as a bridge to right
ventricle (RV) recovery for patients undergoing destination left
ventricular assist device (LVAD) placement.
5. Newer short-term bridging VADs include the CentriMag, Tandem
Heart, and Impella pumps, all of which are continuous-flow pumps
that implant and operate in separate and distinct ways.
6. Separation from cardiopulmonary bypass (CPB) after LVAD
placement may be complicated by RV failure, which may require
various combinations of pulmonary arterial vasodilators (e.g.,
milrinone, nitric oxide), inotropes (e.g., dobutamine, epinephrine),
and systemic arterial vasoconstrictors (e.g., vasopressin).
7. Common early postoperative problems include bleeding and RV
dysfunction. Late postoperative problems include device thrombosis
and infection.
8. Continuous-flow VAD patients presenting for noncardiac surgery
pose a variety of clinical problems, which include obtaining
accurate measurements of blood pressure (BP) and pulse oximetry,
maintaining VAD blood flow, as well as challenges with hemostasis.
9. Intra-aortic balloon pumps (IABPs) are most often used to provide
temporary left ventricle (LV) support to patients undergoing
interventional cardiology or cardiac surgical procedures. IABPs
augment diastolic blood flow to increase coronary artery blood flow
and reduce LV afterload.
10. IABP inflation and deflation must be synchronized to the cardiac
cycle, which can be done using either electrocardiography (ECG) or
an intra-arterial waveform. Inflation should commence just after
systole ends, and deflation should end just before systole begins.
I. Introduction
The use of mechanical circulatory support (MCS) devices, most commonly left
ventricular assist devices (LVADs) have grown significantly in recent years. As
the population ages and the incidence of heart failure rises, the supply of donor
hearts for transplantation remains constant. Therefore, a larger percentage of
patients are undergoing LVAD surgery as a bridge to heart transplantation. In
addition, a significant number of patients who are not eligible for transplantation
are undergoing LVAD implantation as permanent, or destination, therapy. This
group of patients is the fastest growing group of MCS patients, and are living
longer with durable LVADs. In addition, the development of newer, short-term
MCS devices has led increased growth of patients being supported for
interventional cardiology and cardiac surgery procedures, as well as for bridging
strategies for myocardial recovery after infarction or myocarditis.
CLINICAL PEARL Relatively small intracardiac shunts can enlarge when the left-
sided filling pressures are reduced after LVAD implantation.
CLINICAL PEARL Right ventricular (RV) function will typically deteriorate after
LVAD implantation and will often require significant inotropic support.
Devices are getting smaller, easier to implant, and more durable. This chapter
will discuss the current state of MCS, including available devices and therapies.
II. History
Dr. Michael DeBakey performed the first successful clinical implant of a
ventricular assist device (VAD) for postcardiotomy cardiac failure in 1966 [ 1].
The patient was mechanically supported for 4 days. The first successful use of
MCS as a “bridge” to transplantation occurred by Dr. Denton Cooley in 1978 at
the Texas Heart Institute [2]. That patient was supported for 5 days by a
pneumatically actuated paracorporeal device. The first implant of a total artificial
heart (TAH) was performed on Dr. Barney Clarke, a retired dentist, by Dr.
William DeVries in 1982 at the University of Utah [ 3]. The pump was a Jarvik-7
TAH designed by Dr. Robert Jarvik. Dr. Clarke lived for 112 days; unfortunately,
the world watched him slowly and courageously die over the ensuing months from
sepsis and embolic events. As with the pioneering experience with cardiac
transplantation in the 1960s, there was public criticism of TAH as an
“advancement” that was not worthwhile. Nevertheless, development of more
sophisticated devices for short- and long-term use quietly persisted. Successful
recovery of patients in acute cardiogenic shock using short-term VADs occurred
and the data improved. The first pump to receive Food and Drug Administration
(FDA) approval in the United States was the Abiomed BVS 5000 (Abiomed,
Danvers, MA, USA) in November, 1992. Two implantable pumps were then
approved for inpatient long-term use, the HeartMate IP system (Thoratec Corp.,
Pleasanton, CA, USA) and the Novacor system (Worldheart, Ontario, Canada). In
1995, both the HeartMate vented electric (VE) system and the Novacor system
were subsequently approved for outpatient use. This was followed by the Thoratec
VAD system (Thoratec Corp., Pleasanton, CA, USA), which was approved as a
long-term support system in 1996. In 2001, the landmark REMATCH (Randomized
Evaluation of Mechanical Assistance for the Treatment of Congestive Heart
Failure) trial led to the approval of the Thoratec VE for destination therapy [4].
FIGURE 22.1 Diagram of a patient with an implanted HM II continuous-flow LVAD including driveline and portable
power source. (Reproduced with permission from Thoratec, Inc., Pleasanton, CA, USA.)
The TAH also evolved during this time. The SynCardia Systems Inc.
CardioWest TAH represented the evolution of the Jarvik TAH and has had over
1,700 implants worldwide. It is currently the only TAH system approved for
bridge to transplantation, and is in a clinical study for the use as destination
therapy.
The period of 2007 to 2012 has marked an exciting and exponential rise in the
use of newer, smaller rotary and centrifugal LVADs. The HeartMate II (HM II)
LVAD (Abbott, Abbott Park, USA) received FDA approval for bridge to
transplantation in 2008 and destination therapy in 2010 (Fig. 22.1). The HeartMate
3 (HM 3) (Fig. 22.2), the successor to the HM II, is currently only available for
use in clinical trials in the United States for bridge to transplantation and
destination therapy. Its touted benefits include less blood trauma, a frictionless
magnetically suspended rotor, and fully intrapericardial implantation. The
Heartware HVAD (Medtronic, Minneapolis, USA) is a centrifugal pump which
also has the advantage of implantation directly into the left ventricle (LV) apex
without requiring an additional extrapericardial pocket (Fig. 22.3). Since an
additional pump pocket is not required, alternate approaches for implantation are
possible, reserving sternotomy for future cardiac procedures. The Heartware
HVAD is currently approved for bridge to transplantation and likely to be
approved for destination shortly.
FIGURE 22.2 HeartMate 3 magnetically levitated centrifugal LVAD. (Reprinted with permission from SJMedical.)
Concurrent with the development of long-term, implantable LVADs, a number of

short-term devices have been brought to market and are seeing increasing use. The
Centrimag (Abbott, Abbott Park, USA) and TandemHeart (CardiacAssist
Technologies, Pittsburgh, USA) both use centrifugal, paracorporeal pumps to
provide short-term mechanical support in a variety of configurations. The Impella
temporary VAD (Abiomed, Danvers, USA) is a system of catheter-based pumps
which can be inserted percutaneously or via a surgical cutdown, and is approved
for use in protected percutaneous coronary interventions (Impella 2.5, CP), as well
as for circulatory support (Impella 5.0) (Fig. 22.4). An RV support device
(Impella RP) is currently in trials in the United States.
III. Indications
There are three commonly described indications for the use of mechanical
circulatory support devices (MCSDs): bridge to myocardial recovery, bridge to
cardiac transplantation, and destination therapy.
A. 1 Bridge to recovery
The use of an MCSD as a recovery system has focused on short-term use.
Traditionally, this has been thought of as support for days to weeks. Clinical
indications for this use include cardiogenic shock in the following settings:
1. Postcardiotomy
2. Acute myocardial infarction (MI)
3. Viral cardiomyopathies
4. Primary graft failure after cardiac transplantation
The postcardiotomy use of these pumps has declined over the past several
years. This likely derives from improved perfusion and preservation
techniques. Nevertheless, in this patient population the anticipated recovery
time was 3 to 5 days. Animal data for support to recovery supported this
timeline, as recovery was seen quite early [5]. We now recognize that there
may be substantial variability in the time it may take for patients’ hearts to
recover while on support, dependent on the etiology of cardiac failure. Data
from the Abiomed voluntary registry showed that mean support time to
successful recovery may exceed 30 days. Several devices are now employed
as short-term bridge-to-recovery devices: the Abiomed Impella 2.5, CP, 5.0,
and RP (for right heart dysfunction), the Centrimag system, and the
TandemHeart systems. The goal of a short-term bridge-to-recovery device is to
provide end-organ perfusion while the heart is recovering. These short-term
devices are especially useful in catastrophic, sudden presentations of
cardiogenic shock (e.g., prolonged cardiac arrest during high-risk percutaneous
coronary interventions) situations in which the likelihood of intact neurologic
recovery remains unknown. These devices allow time to determine whether an
irreversible neurologic injury would determine the patient’s ultimate outcome.
FIGURE 22.3 HeartWare HVAD intrapericardial centrifugal LVAD. (Reprinted with permission from Rogers JG, Pagani
FD, Tatooles AJ, et al. Intrapericardial left ventricular assist device for advanced heart failure. N Engl J Med. 2017;376:451–
FIGURE 22.4 Impella catheter-based LVAD. (Reprinted with permission from Abiomed.)
B. Bridge to transplantation
The use of MCSDs as a bridge to cardiac transplantation constituted the early
human laboratory to understand the long-term effects of support on many
physiologic parameters as well as on quality-of-life measures. The therapy was
instituted in individuals who were listed for cardiac transplantation, but failing
conventional or inotropic therapy. The MCSD would be employed to support
the patient and improve the physiologic condition until a donor heart became
available. The MCSD would then be explanted at the time of cardiac
transplantation.
The most commonly used VADs in the United States are the Thoratec Corp.
HM II and the HeartWare Inc. HVAD. The SynCardia Systems TAH is also
approved for this indication but is used much less commonly. The Thoratec HM
II pump has become the mainstay of pumps implanted for a bridge-to-
transplantation indication. The Thoratec Corp. HM 3 is the successor to the HM
II and remains limited to use in clinical trial. Both the HM II and HVAD are
approved for use as bridge-to-transplant due to randomized clinical trials
demonstrating survival benefit relative to other bridging strategies [6,7].
C. 2 Destination therapy
As experience with long-term use of MCSD led to successful outpatient use of
this therapy, the concept of using MCSD as another option for patients with end-
stage heart failure who were not transplant candidates emerged.
A landmark study called REMATCH concluded that end-stage heart failure
patients who received a Thoratec Heartmate VE LVAD experienced
improved survival and quality of life when compared to optimal medical
therapy. The use of MCSD as permanent support for end-stage heart failure is
now an accepted and viable therapy that is also supported by the Center for
Medicare Services (CMS). The Heartmate XVE was the first LVAD approved
for this indication. In a subsequent randomized trial comparing the Heartmate
XVE with the HM II LVAD (continuous-flow pump), the HM II LVAD proved
superior to the Heartmate XVE, with 2-year survival in the HM II cohort of 58%
versus 25% in the XVE group. The HM II received FDA approval for destination
therapy in 2009. While the HeartWare HVAD has not yet received FDA
approval for use as destination therapy, the HeartWare ENDURANCE clinical
trial has recently concluded demonstrating noninferior 2-year outcomes when
compared to the HM II LVAD in patients ineligible for cardiac transplant and
will likely result in FDA approval for this indication [8]. 3
FIGURE 22.5 TAH implant requires resection of both ventricles. (Courtesy of syncardia.com.)
IV. Classification and attachment sites of ventricular assist devices (VADs)

VADs can be used as an isolated LVAD, an isolated right ventricular assist device
(RVAD), or as a biventricular assist device (BIVAD). These devices can be
surgically implanted, or inserted percutaneously. TAHs differ from VADs in that a
TAH is inserted by resecting both ventricles, and anastomosing the sewing cuffs of
the TAH to the mitral and tricuspid annuli ( Fig. 22.5). In contrast, if a BIVAD is
implanted, the LV and RV remain in place, but the pulmonary and systemic
circulations are redirected through the VADs.
A. Left ventricular assist device (LVAD)
For left-sided circulatory support, the inflow for all of the approved devices
resides in the LV, with the exception of TandemHeart, which has a cannula in the
left atrium. The LV apex is the preferred site of LVAD attachment for most
of the long-term devices. The Impella platform is placed across the aortic
valve, with the inflow in the LV. The left atrium is not the ideal cannulation site
for long-term support as the LV may then form large thrombi as a result of blood
stasis. In addition, flows through the LVAD are generally higher with LV versus
LA cannulation for VAD inflow. For cardiogenic shock where short-term LVAD
support is anticipated, left atrial cannulation is a reasonable option. The LVAD
outflow graft is routinely anastomosed to the aorta, usually the ascending
aorta. The Impella outflow is immediately distal to the aortic valve and the
TandemHeart outflow is in the femoral artery for retrograde flow into the aorta.
B. 4 Right ventricular assist device (RVAD)
For right-sided support, either right atrial or RV cannulation can be used
successfully. Substantial thrombus formation in the RV does not appear to result
from right atrial cannulation even in long-term support, although this experience
is limited. The RVAD outflow graft is anastomosed to the pulmonary artery.
VADs can be implanted without the support of cardiopulmonary bypass (CPB),
but CPB is generally used to maintain patient stability [8].
C. Biventricular assist device (BIVAD)
A BIVAD ( Fig. 22.6) consists of the simultaneous use of RVAD and LVAD with
connections as noted earlier for the individual assist devices. A combination of
short- and long-term devices can be used in a BIVAD configuration if required.
FIGURE 22.6 Illustration of the Centrimag continuous-flow VAD positioned as an RVAD with inflow from the right
atrium and outflow into the pulmonary artery. Also pictured is an HM II LVAD with inflow from the LV apex and outflow
into the ascending aorta. (Reproduced with permission from Thoratec, Inc., Pleasanton, CA, USA.)
D. Total artificial heart (TAH)

Placement of a TAH requires excision of the native ventricle. The SynCardia
TAH requires removal of the ventricles, preserving the tricuspid and mitral
annulus for securing the device. Valves are located in both the inlet
(atrioventricular) and the outlet (aortic or pulmonary) positions. Separate graft
conduits connect the two pumping chambers to the aorta and main pulmonary
artery.
V. Mechanical assistance systems
A variety of mechanical support systems are used to treat patients with end-stage
heart failure. While early-generation pumps were pulsatile, all currently available
devices (with the exception of the Syncardia TAH) are continuous-flow devices.
The current technologies include axial flow (HM II, Impella) and centrifugal
designs (HeartMate3, HVAD, TandemHeart).
A. Pulsatile
Pulsatile pumps are generally volume displacement pumps that work like the
native heart. These are often called first-generation pumps. The pumping
chamber fills for a set duration of time, and this volume of blood is ejected into
the aorta. Pulsatile pumps all have inflow and outflow valves mimicking the
native mitral and aortic valves. The Syncardia TAH is pneumatically driven to
generate pulsatile flow similar to the native heart. The device rate and percent
systole (ejection time) is set to achieve normal values for cardiac output.
B. Continuous flow
Axial flow devices with bearings are considered “second-generation”
devices, whereas the centrifugal pumps are considered “third-generation”
devices.
1. Short-term support. Three continuous-flow pumps are currently being utilized
in the United States as short-term support devices: CentriMag (Thoratec Corp.,
Pleasanton, CA, USA), the TandemHeart (TandemLife, Inc., Pittsburgh, PA,
USA), and Impella (Abiomed, Danvers, MA, USA). The CentriMag pump (Fig.
22.5) is most commonly utilized with an open chest implantation with left atrial
or LV inflow cannulation for the LVAD, and ascending aortic cannulation for
outflow. The right atrium or RV can be cannulated for inflow and the
pulmonary artery as outflow for an RVAD. The TandemHeart pump is
attractive as a percutaneous LVAD. The inflow is placed via the right common
femoral vein, across the intra-atrial septum into the left atrium. The outflow is
in the descending thoracic aorta via a cannula placed in the femoral artery. The
Impella system comes in a variety of sizes and can be placed percutaneously or
via cutdown through a graft, depending on the goals of treatment. When placed
percutaneously, typically it is placed via the common femoral artery, retrograde
across the aortic valve into the LV. Inflow is through the LV and outflow is into
the ascending aorta—the VAD is placed across the aortic valve. A larger
Impella 5.0 is placed surgically through a cutdown and vascular graft in the
femoral or axillary arteries, and can provide up to 5 L/min of flow.
2. Long-term support. The two most commonly used continuous-flow LVADs
are the Thoratec HM II LVAD and the Heartware HVAD. The HM II was FDA
approved as a bridge to transplantation in 2008 and received FDA approval for
use as destination therapy in January 2010. While the HeartWare HVAD has
received FDA approval for the indication of bridge-to-transplant, its use as a
destination therapy is not yet approved in the United States. The ENDURANCE
trial is a randomized controlled trial comparing Heartware HVAD to the HM II
LVAD for destination therapy [ 8]. The authors found that the HVAD was
noninferior to the HM II at 2 years with respect to stroke-free survival, and
device malfunction or removal. The HM3 has completed enrollment and is
currently available only via the continued access protocol. Early results have
been favorable relative to the HM II [9].
3. Advantages and disadvantages. Continuous-flow devices offer the
advantage of being much smaller than their pulsatile counterparts, as no
“blood chamber” is needed. Their smaller size often leads to easier
implantation with less intraoperative dissection. This can reduce blood loss,
shorten operative times, reduce infection rates, and provide the potential for
more rapid patient recovery. The data generated from the outcomes with
utilization of continuous-flow devices as a bridge-to-transplant indication show
excellent 1-year survival, approaching 90%. The 2-year survival for the cohort
that received the HM II for destination therapy was 58%, and continues to
improve with recent experience [10–12].
4. Continuous-flow devices pose inherent challenges. These devices do not have
valves and need to flow a minimum rate to prevent stasis and thrombus
formation. In addition, as patients are managed with long-term devices, certain
complications that are device related have emerged. The HM II LVAD
universally cleaves von Willebrand factor (vWF). Nearly all patients with an
HM II LVAD acquire a deficiency in vWF and are prone to mucosal bleeding
events—particularly in the gastrointestinal tract [13]. The recently available
HeartMate3 is a magnetically levitated centrifugal pump, and recent studies
have demonstrated a decrease in the rate of pump thrombus, while providing
full circulatory support [9]. The mag-lev design allows for a bearingless
design, which reduces friction, heat, and wear, which are responsible for
thrombus formation and device malfunction. Many patients have minimal
arterial pulsatility when on full support. This is not generally problematic
when arterial pressure is monitored with an indwelling arterial catheter, but
may become so when the patient leaves the intensive care unit (ICU) or leaves
the hospital for home or an extended care facility. In most cases, an automated
blood pressure (BP) cuff is inaccurate, and manual Doppler monitoring of BP
is required.
VI. Intraoperative considerations
A. Anesthetic considerations
1. Monitoring: Standard American Society of Anesthesiologists monitors
(electrocardiography [ECG], pulse oximetry, temperature) are used with the
possible exception of a noninvasive BP cuff. As noted earlier, an arterial
catheter is essential and consideration might be given to its placement in a
larger central artery such as the femoral artery, in order to minimize the
potential problem of central-to-peripheral BP discrepancies at separation from
CPB or thereafter. Monitoring cerebral oxygenation using near-infrared
spectroscopy (NIRS) technology is recommended, especially since the absence
of pulsatile blood flow will render conventional pulse oximetry unreliable.
Pulmonary artery catheters can be very helpful for the assessment of RV
function and pulmonary vascular resistance (PVR), but they may be
mechanically infeasible after initiation of therapy with RVAD, BIVAD, or
TAH. Intraoperative transesophageal echocardiography is essential for the
assessment of aortic valve competency, patent foramen ovale (PFO), LV
thrombus, adequacy of VAD inflow and outflow, cardiac preload assessment,
and RV function (for isolated LVADs).
CLINICAL PEARL Intraoperative transesophageal echocardiography should focus on
aortic valve competence, intracardiac shunts, LV thrombus, positioning of LVAD inflow
cannula, cardiac preload, and RV function.
2. Cardiac rhythm management device: Many of these patients will have an
implanted cardiac rhythm management device (automatic implantable
cardioverter-defibrillator and/or pacemaker) that requires a management plan
prior to proceeding with induction of anesthesia. The antiarrhythmia functions
will need to be turned off so they are not triggered by electrocautery during
surgery. As soon as such deactivation occurs, patients require continuous ECG
monitoring and external cardioversion capability needs to be immediately
available. Management of the pacemaker function is dependent on the patient’s
underlying rhythm, the device’s current settings, and its pacing activity. Please
see Chapter 18 for these considerations. Once the surgery is completed, it is
critical to reinstate antiarrhythmia functions and interrogate the device.
CLINICAL PEARL Dysrhythmias can be particularly detrimental in the setting of
depressed ventricular function. External defibrillator pads should be placed on the patient
prior to induction of anesthesia.
3. Vascular access: Large-bore vascular access is required because blood loss
and coagulopathy can be substantial. This can be achieved with one large-bore
(16 gauge or larger) peripheral intravenous catheter and a large-lumen (e.g., 9-
Fr) central-access introducer or with its equivalent via central venous access
(e.g., a pulmonary artery catheter introducer with additional double-lumen
large-bore integral ports).
4. Anesthetic techniques. General endotracheal anesthesia is used, and most
practitioners probably place emphasis on use of drugs that minimize
hemodynamic impact. Anesthetic drugs should be titrated carefully, accounting
for slower circulation time and a lower volume of distribution for drugs in
heart failure patients. Hypoxia and hypercarbia can further impair myocardial
function and increase PVR. Hence, periods of apnea should be avoided and
ventilation continued even when performing a rapid sequence induction.
Pre-existing inotropic and vasoactive drugs should be continued. Patients
often present with high levels of intrinsic sympathetic tone to the operating
room and induction of anesthesia frequently is followed by marked
hypotension. In addition to careful titration of anesthetic drugs, starting a low-
dose vasoactive infusion, such as norepinephrine, prior to induction may
preempt such effects.
Secondary organ dysfunction should be considered in the choice of anesthetic
drugs, for example, cisatracurium would be appropriate as a muscle relaxant in
a patient with impaired liver function. Nitrous oxide probably should be
avoided because of its potential to increase PVR and the high risk of
intravascular air.
CLINICAL PEARL Arrhythmia can be detrimental to an already marginal cardiac
output and the anesthesiologist should be prepared for immediate cardioversion if needed.
Therefore, external pacing pads should be placed on the patient and connected to a
defibrillator prior to induction.
B. Surgical techniques
1. Cannulation techniques
a. VADs: VAD implantation is most commonly performed using CPB without
myocardial arrest. Atrial cannulation is the most common approach to gain
inflow for short-term support when using either a right- or left-sided VAD
system. The atria are easily accessed and the low pressures in these chambers
facilitate hemostasis upon decannulation when the heart has recovered. The
right atrial appendage is used for right-sided support. For left-sided support,
the interatrial groove at the junction of the right superior pulmonary vein or
the left atrial appendage are the most common sites for cannulation. Other
cannulation options for left-sided support include the dome of the left atrium
(between the aorta and superior vena cava), or through the apex of the LV.
Cannulation of the LV apex for inflow minimizes blood stasis in the ventricle
and provides the best decompression of the heart, which may aid in
myocardial recovery in short-term usage. However, decannulation and repair
of this high-pressure chamber can be difficult and often requires placement
back onto CPB. LV apex cannulation is highly recommended when a
prosthetic mitral valve is present to maintain blood flow through the valve and
prevent thrombus formation. The LV apex is the sole acceptable inflow
cannulation site for most long-term LVADs.
b. TAH. For implantation of a TAH, excision of the native ventricles must be
performed while preserving the atria. After initiation of CPB with bicaval
cannulation, the surgeon attaches sewing cuffs that will connect the atria to the
TAH pumping chambers, after which the surgeon sews grafts to both the aorta
and the main pulmonary artery. After these grafts and cuffs are sewn, leak
testing with pressurized saline (tinged with methylene blue) is used. Leak
testing is imperative as the suture lines are often inaccessible if bleeding
occurs once the TAH is in place. The TAH is then attached to the atrial cuffs
followed by the arterial grafts.
C. Initiation of support for LVAD
1. 6 Initial considerations. Techniques for the initiation of support are similar in
all of the pulsatile systems. Ventilation is reestablished and the heart is
gradually filled. The assist device is started at a slow rate until adequate
preload and afterload are established. If the ventricle(s) are not
decompressed with the initiation of support, inflow obstruction (into the
VAD) must be considered. Pulmonary edema may also develop as the blood
backs up into the pulmonary vasculature. If appropriate inflow and outflow
cannula placement and decompression of the LV are achieved, transesophageal
echocardiography (TEE) should be utilized to identify interventricular septal
position. Displacement toward the LV may compromise right heart function by
impairing the septal component of RV contraction, and the physical distortion
may also induce tricuspid regurgitation. Treatment is by reducing LVAD speed,
and increasing medical therapy for RV function, such as inotropes and inhaled
pulmonary vasodilators. Right-sided function may be further compromised
by increased PVR caused by thromboxane A2 and transfusion-induced
cytokine activation as a result of CPB [14].
2. Role of TEE. Use of TEE to separate from CPB is essential. TEE is used to
assess the presence of air in the ventricle or ejecting from the LVAD into the
ascending aorta. The chamber that has been cannulated for the inflow of the
MCSD should be decompressed. If the chamber is full, and there is poor
device flow, there is a technical issue that needs to be identified and
corrected. If the LV is empty and there is poor flow through the VAD, then
there is either inadequate RV preload or right heart failure (which may be
primary or secondary to high PVR). As the LV is decompressed and global
cardiac output increases, there may be some tolerable physiologic right heart
dilation, which may at times be difficult to distinguish from right heart failure.
The apical interventricular septum can occasionally deflect leftward and
obstruct inflow into the LVAD. This phenomenon is known as a suction event,
and results in decreased pump speed and output. When this occurs, it is easily
identified by TEE. TEE is also used to identify aortic insufficiency and the
presence of intracardiac shunts, either of which may arise at the time of VAD
support even if absent before that time.
3. Aortic insufficiency. Aortic valve insufficiency (AI) can be challenging, and
TEE is essential to identify its presence or absence and severity. Even mild
preoperative AI can be problematic since patients in cardiogenic shock will
have a low mean arterial pressure (MAP) and a high LV end-diastolic pressure
(LVEDP) to produce a relatively low aortic transvalvular diastolic gradient.
With implementation of LVAD support, the LVEDP will become very low and
the MAP will be higher, so the aortic transvalvular gradient (MAP–LVEDP)
will be much greater. Mild preoperative AI, therefore, can become severe AI
with LVAD support. This induces high LVAD flows as the insufficient valve
fills the LV and subsequently the VAD. The resulting high LVAD flow rates are
deceptive, because much of the flow is “circular” from LV to LVAD to
ascending aorta and back via the incompetent aortic valve to the LV, so the net
forward flow will be low. The aortic valve incompetence must be eliminated
in this situation, but the approach is controversial depending on the indications
for device implant and expected duration of support (valve replacement vs.
permanent valve closure) [15–19].
CLINICAL PEARL Aortic insufficiency in a patient being supported with a continuous-
flow LVAD will typically be underestimated due to the continuous nature of the regurgitant
4. Intracardiac shunts. Quiescent intracardiac shunts may become clinically

apparent and significant as a result of changes in chamber pressures when
VAD support is initiated. A PFO is present in up to 20% of the population, but
is clinically quiescent in the vast majority of these patients. Upon unloading the
LV and left atrium with LVAD support, right atrial pressure will become higher
than left atrial pressure. Under these circumstances, even a small PFO can
produce a large right-to-left shunt manifested by arterial desaturation and
potential paradoxical air embolism. These shunts should be closed when
identified and should be assessed by TEE both before and after initiation of
VAD support. If identified preoperatively, cannulation techniques for CPB may
be altered to facilitate repair.
5. Pharmacologic support. Inotropic agents (e.g., dobutamine, milrinone,
epinephrine) are important to support the right heart when only left-sided
support is used. Inhaled nitric oxide or epoprostenol may be invaluable in
the early management of these patients because of its capacity to
vasodilate the pulmonary vasculature without the systemic hypotensive
effects seen with other pulmonary artery vasodilators. Alternative
approaches include the use of a phosphodiesterase inhibitor (e.g., milrinone,
which decreases pulmonary and systemic vascular resistances) in combination
with a systemic vasoconstrictor such as vasopressin. Vasopressin offers an
advantage over α-adrenergic agonists because it possesses minimal
vasoconstrictive effects on the pulmonary arterial vasculature.
For a variety of reasons, systemic arterial vasodilation commonly occurs
after initiation of LVAD support, so need for a systemic vasoconstrictor is
common. Antiarrhythmics are initiated as required before weaning from bypass
onto device support.
D. Initiation of support for BIVAD
1. Initial considerations. When initiating biventricular support, the left system
should be actuated first to prevent LV overdistention and resultant pulmonary
edema. Inotropic support can be totally discontinued, but vasopressor support
is often required. Biventricular support allows more complete resting of the
heart and usually allows total decompression of the venous system as well.
This minimizes hepatic and other end-organ congestion. The PA catheter should
not be withdrawn as it will be difficult to reinsert it. Thermodilution cardiac
outputs are not calculable when an RVAD is functioning. All available
temporary RVADs have accurate flow measurement tools that can replace the
need for Swan–Ganz cardiac output monitoring.
2. Flow rates. The RVAD and LVAD should both have similar flow rates. The
LVAD often has higher flow rates due to physiologic shunts (bronchial arterial
return). RVAD flow that exceeds LVAD flow early after initiating BIVAD
support is worrisome. This can occur with two common scenarios:
One or both left-sided cannulae are malpositioned to impede inflow to or
from the device. If the obstruction is not corrected, the lungs can become
flooded with the increased blood flow from the RVAD.
The LV is beginning to recover and is ejecting some blood over and above
the LVAD flow. This can be identified by the appearance of an arterial
pressure waveform corresponding to the QRS complex of the ECG (see
weaning from device support).
E. Initiation of support for RVAD
1. Initial considerations. Isolated RVAD support is less common than LVAD or
BIVAD support, but when used, the essential considerations are similar to
LVAD. CPB is weaned rapidly as RVAD support is increased. All currently
available devices can overcome elevated PVR, however, significantly elevated
pulmonary artery pressures may lead to pulmonary edema.
2. Pharmacologic support. In many instances, some inotropic support of the LV
will be necessary to handle the increased RV output.
VII. Postoperative management and complications
A. 7 Right-sided circulatory failure
Right-sided circulatory management is the key to perioperative care for LVAD
patients. Attention to right heart management and PVR is critical. Strategies
include pacing (chronotropy), inotropes, and pulmonary vasodilators to increase
flow through the pulmonary vascular bed. For additional considerations, see
LVAD initiation.
B. Hemorrhage
Postoperative hemorrhage is common in this patient population. Heart failure
often leads to hepatic congestion and renal insufficiency. Both of these processes
lead to imbalances in platelet function and the coagulation cascade. The addition
of CPB and the consumptive coagulopathy that can be initiated can exacerbate
postoperative bleeding. In addition, exposing the blood to the foreign surfaces of
the extracorporeal circuit and of the conduit cannulae can also lead to a
consumptive coagulopathy. It should not be a surprise that postoperative
hemorrhage and reexploration for bleeding is a common occurrence.
Reexploration for bleeding/tamponade can then be performed when the patient is
adequately resuscitated. Use of a thromboelastogram (TEG) and
thromboelastometry to help target the deficiency in the clotting process is gaining
popularity. Transfused platelets and red blood cells (packed cells or whole
blood) in transplant candidates should ideally be leukoreduced, because
exogenous leukocytes induce alloimmunization that can develop antibodies
against future potential donated organs. High levels of these preformed
antibodies reduce the pool of otherwise-suitable donor organs for these patients.
Fresh frozen plasma and cryoprecipitate do not have high leukocyte content and
do not need filtration.
C. Thromboembolism
Thromboembolism is associated with all current assist systems. The unique
design characteristics of each system as well as the patient’s underlying
pathology establish the overall risk. Anticoagulation with heparin is required for
short-term devices and warfarin and aspirin are required with all long-term
assist devices.
D. Infection
Device-related infection is the most common cause of morbidity in the
chronically supported patient. Driveline and device “pocket” infections occur in
up to 40% of these patients. The vast majority of these infections may be
managed with chronic antibiotic therapy until transplantation. Device exchange
for infection has not been demonstrated to be universally effective due to
necessary replacement of the new pump into an infected field.
E. Device malfunction
Catastrophic device malfunctions occur infrequently but can be life threatening.
These include mechanical device failure, device separation or fracture, graft or
valve rupture, and console failure. Minor device malfunctions occur more
frequently and are usually addressed at the bedside. These include driveline
damage and controller malfunctions. All of these malfunctions are becoming
increasingly rare as yearly device modifications and software upgrades are
introduced.
VIII. Weaning from VAD support
A minority of patients will experience myocardia recovery sufficient for device
explantation [20]. For patients in whom the heart recovers, the heart will be able to
eject and the arterial waveform will begin to display pulses corresponding to the
QRS complex [21]. When the device flows are weaned downward and cardiac
preload conditions move toward normal, these ejections will become more
prominent. If the device can be weaned to 1 L/min flow and the patient can
maintain adequate perfusion with reasonable inotropic support, explantation
can be considered. This evaluation can be performed in the ICU. TEE can once
again be very helpful in assessing cardiac function as the heart is loaded. Final
weaning from the device is accomplished in the operating room, as CPB or
surgical cutdown on the access site needed for device explantation.
IX. Management of the VAD patient for noncardiac surgery
8 These patients can be very ill if surgery is contemplated early after MCSD
implantation. However, patients will often recover physiologically over the
ensuing weeks and months. Patients who are stable on support may safely undergo
noncardiac surgical procedures [22,23]. The optimal approach involves asking
some basic questions:
A. What chamber(s) are being assisted (LVAD, RVAD, BIVAD, or TAH)?
B. What type of pump is being used? All continuous-flow pumps are preload
dependent and afterload sensitive, with centrifugal designs in particular impacted
by systemic hypertension. Percutaneous and peripherally inserted pumps are also
positional and patient movement may impact device functionality.
C. Is technical support personnel available to help manage and troubleshoot the
pump? This is critical for transport as well as intraoperative management.
D. How does one determine flow through the pump? This can be quantitative or
qualitative, depending upon the pump, but knowledge of pump flow clearly
assists in determining systemic vascular resistance and PVR, which in turn guide
anesthetic drug selection, pharmacologic support, and volume management.
E. Will TEE be helpful? If major volume shifts are anticipated, use of TEE can be
very helpful in assessing preload, valvular function, and intracardiac shunts.
F. What is the patient’s clotting status? For most pumps, anticoagulation and
antiplatelet medications are required. This has major implications for reversal of
anticoagulation (if safely possible) and blood component use. Reversal of
warfarin and conversion to intravenous heparin may be indicated. In general, be
prepared for transfusion of RBCs and other components.
G. What is the patient’s intravenous access? Central venous access is desirable in
most situations, but large-bore peripheral access is acceptable for minor surgical
procedures.
H. What pharmacologic support is the patient receiving? This will vary from no
support to multiple inotropes, antiarrhythmics, vasoconstrictors, and pulmonary
vasodilators. If nitric oxide is in use, this will require planning for transport and
operating room use.
I. Will electrocautery affect the assist device? For most devices, this will not be a
problem, but excessive electrocautery can intermittently interfere with the
function of coexisting pacemakers or defibrillators. If electrocautery poses a
problem, either short bursts may suffice or the use of an ultrasonic scalpel can be
considered.
J. Does the patient have a cardiac rhythm management device? If yes, what is the
management plan?
K. If defibrillation or electrical cardioversion is needed, how will it be most safely
applied?
L. If the patient does not have pulsatile blood flow, consider the use of NIRS
technology to monitor cerebral oxygenation as conventional pulse oximetry relies
on pulsatile blood flow.
X. Future considerations
A. Totally implantable LVAD
The totally implantable LVAD will need to employ a replenishable source of
power with an internal battery reserve. A transcutaneous energy transfer system
(TETS) has been employed in the now discontinued AbioCor device as well as
LionHeart (Arrow International, Inc., Reading, PA, USA). This has the potential
advantage of improved infection risk, as it obviates the percutaneous driveline.
This technology is currently limited by the size of the internal battery and skin
injury from transcutaneous charging.
B. Miniaturization of LVADs
Continuous evolution of LVAD therapy will result in smaller devices more
amenable to minimally invasive surgical approaches, resulting in less
physiologic stress to patients and faster recovery.
C. TAH
Use of a TAH has gained traction in the field of MCSD, however, the vast
majority of patients can be managed with isolated LV devices. Many patients
with biventricular failure can be managed with a long-term LVAD and short-term
RVAD. For those patients not suitable for this strategy, TAH therapy is the only
option. Outcomes have not yet approached those of isolated LVAD therapy in
general use.
XI. Intra-aortic balloon pump (IABP) circulatory assistance
A. 9 Indications for placement
Thought by some to be reserved for placement after one or more failed attempts
at separation from CPB, the number of IABPs placed in the cardiac
catheterization laboratory approaches or exceeds the number placed
intraoperatively. Interventional cardiologists often place IABPs when high-grade
lesions of proximal coronary vessels supplying large regions of myocardium are
diagnosed, or when myocardial ischemia persists or MI occurs after an
intervention such as coronary stent placement. Retrospective outcome studies for
preoperative versus intraoperative placement of IABP for coronary artery bypass
graft (CABG) patients suggest that preoperative IABP placement improves
outcome and shortens hospital stay, especially for patients with low ejection
fractions or those undergoing urgent or emergent CABG [24]. Indications for
intraoperative IABP placement vary widely among centers and even among or
within surgical teams. LV failure despite moderate- to high-dose inotropic
support and/or evidence of ongoing regional myocardial ischemia that is not
amenable to surgical revascularization constitutes the primary intraoperative
indications. Moderately severe LV failure despite reasonable inotropic support
that is thought to derive from an injury that will resolve (or greatly improve)
within 24 to 48 hours (e.g., LV stunning) constitutes the most common
intraoperative indication. The definitions of “LV failure,” “maximal inotropic
support,” and “ongoing regional myocardial ischemia” may vary widely among
surgeons and anesthesiologists. Independent predictors of death among patients
with intraoperative IABP insertion include New York Heart Association class III
or IV symptom level, mitral valve replacement or repair, prolonged CPB, urgent
or emergent operation, emergent reinstitution of CPB, preoperative renal
dysfunction, diabetes mellitus, RV failure, complex ventricular ectopy, pacer
dependence, and IABP placement via the ascending aorta. IABP assistance can
be used during high-risk off-pump CABG as well, where the support of coronary
perfusion pressure may be especially helpful while the heart is placed in
positions that compromise cardiac filling or emptying. Rarely, prophylactic
IABP placement may be appropriate for high-risk urgent noncardiac surgery.
B. Contraindications to placement
1. Aortic insufficiency. Use of the IABP is relatively contraindicated in patients
with AI. As the IABP inflates in the descending aorta during diastole to
promote retrograde flow into the ascending aorta, this potentially increases
aortic valvular regurgitation, further distending the LV at the expense of
coronary perfusion.
2. Sepsis. As with any prosthetic intravascular device, bacteremic infections are
difficult to treat if the prosthetic surfaces become seeded with bacteria.
3. Severe vascular disease. Placement of an IABP may be technically difficult in
patients with atherosclerosis or other vascular pathologies. Such patients are
more prone to arterial thrombosis during use of an IABP. Patients with
abdominal aortic aneurysms are at increased risk for aortic rupture, although
balloons have been successfully passed and used in such patients. For patients
with severe aortoiliac or femoral arterial disease, another option is to place the
balloon directly into the descending thoracic aorta. Alternatively, placement
may be performed through a small vascular graft sewn to the subclavian artery.
These options require a subsequent trip to the operating room to remove the
device when such support becomes unnecessary.
C. Functional design
The IABP consists of an inflatable balloon at the end of a catheter that is
typically advanced into the descending thoracic aorta percutaneously from the
groin (Fig. 22.4). The balloon inflates during diastole, displacing blood from the
thoracic aorta and increasing aortic diastolic pressure. Balloon inflation
improves coronary perfusion pressure, increasing coronary blood flow to both
the LV and the RV. During early systole, rapid balloon deflation reduces LV
afterload and wall tension. IABP can improve myocardial energy balance at most
by 15%. The IABP drive console consists of a pressurized gas reservoir that is
connected to the balloon supply line through an electronically controlled
solenoid valve. The gas used to inflate the balloon is either CO2 or helium. The
advantage of CO2 is its high blood solubility, which reduces the consequences of
balloon rupture with potential gas embolization. The advantage of helium is its
low density, which thereby decreases the Reynolds number and allows the same
flow through a smaller driveline. A tube with a smaller diameter decreases the
potential for injury to the artery.
D. IABP placement
Insertion of the IABP is usually accomplished either percutaneously or by
surgical cutdown into the femoral artery using the Seldinger technique for
placement of a large-diameter introducer. Accurate placement of the Seldinger
wire is often confirmed intraoperatively using TEE.
The balloon is passed through the introducer.
The balloon is ideally positioned so that its tip is at the junction of the
descending aorta and the aortic arch, just distal to the origin of the subclavian
artery, as shown in Figure 22.6. This positioning minimizes the risk of subclavian
or renal artery injury or occlusion. Radiographically, the tip should lie between
the anterior portion of the second intercostal space and the first lumbar vertebra.
When the IABP is placed intraoperatively, transesophageal echocardiography
can confirm proper tip location before initiation of balloon assistance.
Fluoroscopy, if available, can also facilitate positioning.
CLINICAL PEARL Intraoperative placement of an IABP will typically require TEE
guidance for positioning: the tip of the catheter should be approximately 2 cm from the
subclavian artery.
E. 10 IABP control
Several parameters are important during the setup and operation of an IABP.
1. Synchronization of the IABP. Synchronization of the IABP with the cardiac
rhythm is accomplished by using either the electrocardiographic QRS complex
or the arterial pressure waveform. If there is a natural pulse pressure greater
than 40 mm Hg, use of the arterial waveform for synchronization is often
preferred in the operating room because the electrical artifact produced by
electrocautery inhibits ECG-triggered IABP control units. Recent monitoring
systems have advanced suppression circuitry designed to reduce electrical
noise from electrocautery. Most current consoles can differentiate pacer spikes
from a QRS complex, allowing proper timing of IABP inflation even when
atrial or atrioventricular pacing is in use, but pacer interference should be
considered in the differential diagnosis of faulty IABP timing.
FIGURE 22.7 Manipulation of the timing of inflation and deflation of IABP. Tracings illustrate 1:2 support for the sake of
A: Normal tracing. Augmentation commences after the dicrotic notch (1) augments diastolic pressure (2), and reaches
its nadir just before the next contraction (3). Peak systolic pressure in the next (nonaugmented) beat is decreased (4). B: Early
inflation. Augmentation commences before aortic valve closure (1), thereby increasing afterload and possibly inducing aortic
regurgitation. C: Late inflation. Diastolic augmentation is inadequate, and end-diastolic pressure is not different from that in the
unassisted cycle (3). D: Early deflation. Diastolic augmentation and afterload reduction are impaired. E: Inadequate filling time.
Timing is satisfactory, but diastolic augmentation is impaired. (From Sladen RN. Management of the adult cardiac patient in the
intensive care unit. In: Ream AK, Fogdall RP, eds. Acute Cardiovascular Management in Anesthesia and Intensive Care.
Philadelphia, PA: Lippincott; 1982:509.)
2. Timing of balloon inflation and deflation. When setting the timing of IABP
inflation (Fig. 22.7), it is important to time the onset of the pressure rise caused
by balloon inflation with the dicrotic notch of the arterial waveform, which
signifies aortic valve closure and the start of diastole. If inflation begins
sooner, the IABP will impede ventricular ejection. If it begins later, the
effectiveness of the balloon in augmenting coronary perfusion and reducing
afterload will be limited. Deflation should be timed so that the arterial pressure
just reaches its minimum level at the onset of the next ventricular pulse. If it
deflates too soon, the aorta will not be maximally evacuated before ventricular
contraction, and coronary perfusion will not be optimized. If the balloon
deflates too late, it will impede LV ejection. Most modern balloon devices use
an intra-aortic arterial waveform obtained from the tip of the balloon catheter.
If this mechanism should fail and synchronization should be monitored from
another site, subtle differences in optimal timing may occur (e.g., balloon
inflation and deflation as judged by a femoral arterial waveform are delayed in
comparison to an intra-aortic or radial arterial waveform) (Fig. 22.8).
FIGURE 22.8 Placement of the IABP in the aorta. The IABP is shown in the descending aorta, with the tip at the distal
aortic arch. During systole the balloon is deflated to enhance ventricular ejection. During diastole the balloon inflates, forcing
blood from the proximal aorta into the coronary and peripheral vessels.
3. Ratio of native ventricle pulsations to IABP pulsation. Pumping is frequently

initiated at a ratio of 1:2 (one IABP beat for every two cardiac beats), so the
natural ventricular beats and augmented beats can be compared to determine
IABP timing and efficacy. Depending on the patient’s condition, the ratio will
often be increased to 1:1 to obtain maximal benefit.
4. Stroke volume of the balloon. The volume of gas used to inflate the balloon is
determined by the balloon used and the patient’s size. Exceeding the volume for
which the balloon was designed risks rupture with arterial gas embolization.
Typically, balloon volume is set to 50% to 60% of the patient’s ideal stroke
volume [25].
5. Balloon filling. The time required for the balloon to fill and empty is
determined by the density of the gas used, gas pressure, the length and diameter
of the gas line, and balloon volume. These values are usually constant for any
particular balloon. At high heart rates, the time required for balloon filling may
limit balloon stroke volume.
F. IABP weaning
Weaning the patient from IABP circulatory assistance should be considered when
inotropic support has been reduced substantially, allowing “room” to increase
inotropic support as IABP support is reduced. Weaning is done primarily by
gradually (over 6 to 12 hours) decreasing the ratio of augmented to native
heartbeats (from 1:1 to 1:2 to 1:4 or less) and/or decreasing balloon inflation
volume while maintaining acceptable hemodynamics, which often necessitates a
concomitant increase in inotropic support. The balloon is never turned off while
it remains in the aorta except when the patient is anticoagulated, as during CPB,
because of the risk of thrombus formation on the balloon or balloon catheter.
Comparison of intra-arterial pressure tracings of augmented ventricular
pulsations to native pulsations can serve as an indicator of ventricular
performance. As ventricular performance improves, the amplitude of the native
pressure tracing will increase relative to the augmented pressure tracing. By
comparing the magnitude of these two pulses over time, one can obtain a
qualitative assessment of ventricular performance. Once the IABP is removed, it
is important to continue close examination of the distal ipsilateral leg because
partial or total femoral arterial occlusion may occur.
G. Management of anticoagulation during IABP assistance
During extended IABP use, anticoagulation is generally indicated. In the
immediate post-CPB period, anticoagulants are not to be required for the first
few hours or until drainage from the chest tubes is acceptable (less than 100 to
150 mL/hr). Heparin can prevent IABP-related thrombosis and its ready
reversibility offers appeal. Evidence suggests a no-heparin IABP protocol
provides acceptable low rates of thrombus formation with less bleeding
complications than when anticoagulation is used. The surgeon should weigh the
risks of thrombus formation with prolonged heparin-free IABP use against the
risk of excessive bleeding when using anticoagulation [24]. If heparin is used,
adequate anticoagulation should be confirmed every 4 to 6 hours with activated
clotting time (ACT) or activated partial thromboplastin time (aPTT) maintained
at 1.5 to 2 times normal values.
H. Complications
The incidence of IABP complications has decreased significantly from its early
use, but significant morbidities persist. The most frequent complications are
vascular in nature, with a reported incidence of 6% to 33% [25]. These
complications include events such as limb ischemia, compartment syndrome,
mesenteric infarction, aortic perforation, and aortic dissection. Risk factors for
these complications include a history of peripheral vascular disease, female
gender, tobacco smoking, diabetes mellitus, and postoperative IABP placement.
Because of small femoral artery size and the likelihood of concurrent peripheral
vascular disease, a common expression among cardiac surgeons is “little old
ladies and balloon pumps don’t mix.” Other complications include infection,
primarily at the groin site of a transcutaneous introducer, and coagulopathies
(especially thrombocytopenia). Neurologic complications include paresthesia,
ischemic neuritis, neuralgia, footdrop, and rarely paraplegia [26]. Balloon
rupture with gas embolus can occur presumably as a result of severe aortic
atherosclerotic calcifications. When this occurs, blood is usually seen in the gas
driveline and the arterial pressure deflection caused by the IABP is lost. Most
pumps have an alarm that indicates low balloon pressure. Air embolism from the
pressure monitoring line to the brain is a larger risk from the IABP than from a
radial artery catheter, because the monitoring port is located at the tip of the
balloon catheter, which is close to the origin of the carotid arteries. Arterial
blood gases should be drawn through the IABP pressure monitoring line only if
no other locations are available, paying meticulous attention to ensure that no air
bubbles or other debris are flushed through the tubing.
I. Limitations
The ability of the IABP to augment cardiac output and unload the LV is limited,
because the IABP does not directly affect LV function. With severe LV failure, an
IABP will not provide sufficient flow to sustain the circulation. When the LV
cannot eject blood into the aorta, the IABP will simply cause pulsations in the
arterial waveform without increasing blood flow. In this situation, a VAD must
be considered, although readily correctable technical problems with the IABP,
such as malpositioning, kinking of the gas line, or improper inflation–deflation
timing, should be considered. Early IABPs were not effective during rapid
cardiac rhythms. Improvements in the pneumatic circuitry and compressor
response time now permit some IABP models to provide hemodynamic
improvement at rates up to 190 beats/min. Irregular heart rhythms persist as a
limitation to IABP efficacy, because optimal timing of inflation and deflation
cannot be achieved with large variations in the R–R interval.
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23 Intraoperative Myocardial Protection
Pedro Catarino, David Philip Jenkins, and Kamen
Valchanov
I. Introduction
II. History
III. Myocardial energetics
IV. Ischemia–reperfusion injury
V. Interventions before aortic cross-clamping
VI. Interventions after aortic cross-clamping
A. Forms of cardioplegia
B. Temperature of cardioplegia
C. Route of delivery
VII. Interventions around cross-clamp removal
VIII. Alternatives to cardioplegia
A. Cross-clamp fibrillation
B. Off-pump coronary artery bypass
C. Beating heart on cardiopulmonary bypass (CPB)
IX. Conclusion
KEY POINTS
1. Aortic cross-clamping is a key step in the vast majority of cardiac

surgical procedures, initiating a period of global ischemia of the
myocardium.
2. Inadequate myocardial protection remains one of the main causes of
postoperative low cardiac output syndrome.
3. Removal of the aortic cross-clamp results in reperfusion of the
myocardium and resumption of electromechanical activity but
produces a variable ischemia–reperfusion injury, attenuation of
which remains the subject of research.
4. Cardioplegia is the predominant technique of intraoperative
5. The key components of most forms of cardioplegia are
hyperkalemia and hypothermia. The hyperkalemia produces
electromechanical arrest of the myocardium in diastole, and the
hypothermia lengthens the arrest time and further reduces
myocardial metabolic activity.
6. Cardioplegia exists in numerous different recipes and various forms
of delivery are possible, with little hard evidence to favor any
particular strategy.
7. With appropriate intraoperative myocardial protection, the heart will
generally comfortably tolerate 120 minutes of ischemia time, after
which additional time will come at a cost of increased risk of low
cardiac output syndrome.
I. Introduction
Operations on the heart are best performed in a still and bloodless field. This
necessitates interruption of blood flow to the heart, at least intermittently.
Minimization of injury resulting from this ischemic challenge is the objective of
intraoperative myocardial protection. Since the interruption of blood flow is a
deliberate sequenced event, there exists the opportunity to set up optimal
conditions in which this can occur.
Optimal intraoperative myocardial protection results from a collaboration
between surgeon, anesthesiologist, and perfusionist. However, with the surgeon
focused on the technical aspect of the procedure and the perfusionist on the conduct
of cardiopulmonary bypass (CPB), the anesthesiologist has a particular
responsibility to pick up subtle changes in monitoring which might herald
inadequate protection.
CLINICAL PEARL Teamwork, the hallmark of high-functioning cardiac surgery
teams, is especially important during cardioplegia administration, as this is perhaps
the most important determinant of post-bypass cardiac function.
The context of the myocardial protection is important; for example, the setting of
acute myocardial infarction might represent a different challenge to that of the
chronically hypertrophied left ventricle. Integration of general anesthetic
principles, conduct of CPB, type of cardioplegia, and nature of delivery are keys to
a successful outcome to the procedure.
II. History
A. 1 The field of intraoperative myocardial protection has evolved from and with
the development of CPB in 1953. Although CPB kept the patient’s organs
perfused while the heart was arrested and decompressed, the requirement for a
bloodless field almost invariably necessitated cross-clamping of the aorta with
consequent global ischemia of the myocardium.
B. The early years of cardiac surgery involved little attention to myocardial
ischemia with surgeons attempting to operate expeditiously during periods of
normothermic ischemia. In 1955, Melrose introduced hyperkalemic arrest
primarily to provide a still heart for surgery rather than to provide protection
from ischemia. This approach frequently proved inadequate with increasingly
recognized low cardiac output syndrome and occasionally the development of
“stone heart.”1 However, the idea that cessation of electromechanical activity
was important to myocardial protection had been established, and Lam first used
the term cardioplegia (Greek cardio, heart; plegia, paralysis) in 1957.
C. In 1956, Lillehei maintained perfusion of the heart during cross-clamping with
retrograde perfusion via a catheter in the coronary sinus.
D. Topical cooling was used for myocardial protection in the form of iced slush by
Hufnagel in 1961 and iced saline by Shumway in 1964.
E. Continuous coronary perfusion by cannulae placed in the coronary ostia was
championed by McGoon in 1965 and remains in use today. In practice it is
cumbersome, with leaking cannulae and the risk of coronary ostial damage
limiting its use.
F. The first pharmacologic interventions to deliberately address intraoperative
myocardial protection did not come until later in the 1960s. There were two
relatively distinct forms of cardioplegia, which both used hyperkalemia to
produce a depolarization of the myocyte resting potential, arresting the heart in
diastole.
1. Bretschneider (1964) solution was a sodium-poor, calcium-free, procaine-
containing solution which, apart from potassium of 10 mmol/L, resembled the
intracellular electrolyte milieu.
2. Hearse and Braimbridge (1975) developed St. Thomas solution, which was
hyperkalemic (initially 20 mmol/L, now 16 mmol/L) with an otherwise
extracellular electrolyte milieu.
G. Buckberg (1970s) introduced the use of blood as a vehicle for cardioplegia, and
this has become the most widely used format worldwide.
H. Substrate enhancement, variation in the temperature of administration, and mode
and route of delivery together have produced an enormous variety of options for
hyperkalemic depolarizing intraoperative myocardial protection.
I. Alternative forms of pharmacologic cardioplegia seeking to avoid hyperkalemia
and depolarization remain under investigation and are largely the preserve of
special interest groups.
CLINICAL PEARL Over the past 75 years, the field of myocardial protection has
evolved to the point where it is now used routinely, safely, and effectively.
III. Myocardial energetics
A. The heart has a very high basal oxygen consumption (8 to 10 mL O2/min/100 g)
and the highest oxygen extraction of a major organ (10 to 13 mL O2/100 mL or
70% of the oxygen content). Basal coronary blood flow is 1 mL/min/100 g or
about 250 mL/min—5% of the cardiac output. In normal coronary arteries,
autoregulation between a mean systemic pressure of 60 mm Hg and 140 mm Hg
matches coronary blood flow to oxygen demand with up to fivefold increases in
coronary blood flow—25% of the cardiac output.
FIGURE 23.1 Oxygen consumption under different conditions in the canine heart. (From Buckberg GD, Brazier JR,
Nelson RL, et al. Studies of the effects of hypothermia on regional myocardial blood flow and metabolism during
cardiopulmonary bypass. I. The adequately perfused beating, fibrillating, and arrested heart. J Thorac Cardiovasc Surg.
1977;73:87–94, with permission.)
B. In the aerobic state, the heart can use a variety of energy substrates. In the fasting
state, 70% is from free fatty acids with the remainder from glucose, but after a
meal, this can change to 100% glucose and other carbohydrates. During exercise,
lactate can be utilized. Ketone bodies, acetate, pyruvate, and amino acids are
other potential sources.
C. Despite this variety of energy substrates, oxidative phosphorylation is
responsible for nearly all the production of adenosine triphosphate (ATP),
making the heart highly dependent on a continuous supply of oxygen. Thirty-eight
moles of ATP will be produced by aerobic metabolism of 1 mole of glucose.
Anaerobic enzymes are not present in sufficient concentration to make a
significant contribution and under anaerobic conditions ATP production is just 2
moles per mole of glucose.
D. The rate of myocardial oxygen consumption (MvO2) is therefore indicative of the
metabolic demand of the heart and has been commonly used to estimate the
energy requirement of the heart under different conditions. The well-known
results from Buckberg’s work shown in Figure 23.1 [1] demonstrate the
reduction in energy requirement by one-third when work is not performed, such
as on CPB (i.e., 5.6 mL O2/min/100 g) and by 90% when the heart is
electromechanically arrested (1.1 mL O2/min/100 g). Further stepwise reductions
in energy expenditure result from cooling, with 50% reduction for every 10°C.
CLINICAL PEARL Electromechanical cardioplegic arrest brings a 90% reduction in
myocardial energy requirements.
E. Under ischemic conditions, the ATP reserves in the heart diminish markedly
within 5 to 10 minutes as shown in Figure 23.2 [2]. The three main reactions
requiring ATP are myosin ATPase responsible for actomyosin contraction,
Ca2+/Mg2+-ATPase responsible for removal of Ca 2+ from the myocyte cytosol,
and Na+/K+-ATPase responsible for removal of Na + from the myocyte cytosol.
Therefore, ischemia results in a rapid cessation of contractile function and loss
of the membrane potential with accumulation of Ca2+ and Na+. Anaerobic
glycolysis produces intracellular acidosis, further depressing cellular function. It
is likely that increased mitochondrial membrane permeability occurs early.
Eventually, loss of cellular membrane integrity results in irreversible necrosis.
Complement activation occurs with this injury and there is a wider damaging
inflammatory response.
F. 2 The objective of intraoperative myocardial protection is therefore the
avoidance of this sequence of events, which can lead to low cardiac output
syndrome after CPB, and has focused on the rapid induction and maintenance of
cardiac arrest with or without hypothermia as the best strategies to prevent ATP
depletion and so to preserve cellular integrity.
FIGURE 23.2 Effect of 60 minutes of warm global ischemia on myocardial ATP in dogs. Prior to ischemia, one group
received a nucleoside transport blocker (NBMPR) and an adenosine deaminase inhibitor (EHNA). (From Anwar S, Ding
M, Wechsler AS. Intermittent aortic cross clamping prevents cumulative adenosine triphosphate depletion, ventricular
fibrillation, and dysfunction (stunning): is it preconditioning? J Thorac Cardiovasc Surg. 1995;110(2):328–339, with
permission.)
CLINICAL PEARL The fundamental goal of any cardioplegia solution is to prevent

myocyte ATP depletion and preserve cellular well-being.
IV. Ischemia–reperfusion injury
A. While physiologic reperfusion of myocytes is key to restarting oxidative
phosphorylation, replenishment of ATP, and restoration of ion balance within the
cells, it has long been recognized that there is an initial paradoxical
reoxygenation-dependent enhancement of tissue injury on reperfusion, known as
the ischemia–reperfusion injury [3].
B. Two main molecular mechanisms are thought to be involved:
1. Reactive oxygen species [4], particularly superoxide (•O2−) and hydrogen
peroxide (H2O2), are generated in the first few minutes of reperfusion by a
combination of mitochondrial electron transport chain dysfunction, xanthine
oxidase effect, and activated neutrophils. These reactive oxygen species then
cause peroxidation of cellular phospholipid layers leading to loss of cellular
integrity and function.
2. Calcium accumulation [5] in the myocyte and within mitochondria during
ischemia is exacerbated on reperfusion by activation of the mitochondrial Ca2+
uniporter and the sarcolemmal Ca2+ channel. Calcium-dependent
phospholipases and proteases are activated and induce membrane and other
injuries.
3. 3 Despite substantial research into the field of ischemia–reperfusion injury,
almost none of the experimental strategies have been translated into clinical
practice. Many units do practice “controlled reperfusion” which usually
indicates a period of reduced pressure of reperfusion during the first few
minutes. The practice of “terminal hot shot” is more commonly used (see
Section VII).
V. Interventions before aortic cross-clamping
A. Avoidance of ischemia prior to institution of CPB by proper attention to
anesthetic technique is recommended, particularly at induction, with avoidance
of either hypotension or hypertension. This may include appropriate use of
preoperative intra-aortic balloon pump placement.
B. Inhalational anesthetics and myocardial protection
Extensive evidence from experimental studies has shown that inhalational
anesthetics protect the heart from ischemic injury in animal models and in vitro
human myocardium, an effect demonstrated on both myocytes and endothelial
cells [6]. While the use of inhalational anesthetics in the clinical setting has been
linked to reductions in various markers of myocardial injury, the totality of the
evidence falls short of supporting their use as specific cardioprotective agents. It
is a likely useful by-product of these agents, however.
C. Systemic cooling is used to varying degrees by different centers and surgeons
and, indeed, may be individualized to the procedure and the patient. Cooling is
not invariable, with some surgeons preferring to operate at normothermia, but
temperatures between 28°C and 33°C are widely used for standard surgeries.
Systemic cooling may be primarily a strategy for neurologic protection, and it is
known that each reduction of 10°C (Q10) reduces the MvO2 by 50% in myocytes
as in other tissues (Fig. 23.1). Furthermore, the degree of systemic hypothermia
will affect rewarming of the cardioplegia-cooled heart, both via direct contact
and through the return of systemic blood to the heart via noncoronary collateral
channels [7].
D. Institution of CPB results in immediate unloading of the heart and, therefore,
reduction in energy requirement, so long as significant aortic regurgitation is not
present. This can be achieved within a couple of minutes if a bypass circuit is
ready and primed.
E. Avoidance of ventricular distention is critical. Ventricular distention produces
increased wall tension with greater energy consumption and decreased
subendocardial perfusion. Aortic regurgitation is usually an issue in regard to
this during delivery of cardioplegia (i.e., after cross-clamping). However, there
are instances where CPB is continued without aortic cross-
clamping—for example, profound systemic cooling or technical difficulties in
isolating the aorta (e.g., revision surgery, where aortic regurgitation requires
additional precautions). Furthermore, aortic regurgitation may be produced by
ventricular fibrillation (VF) or manipulation of the heart. In these circumstances,
adequate venting of the left ventricle, typically by a right superior pulmonary
vein vent or a left ventricular apical vent, is essential for adequate intraoperative
CLINICAL PEARL With severe aortic regurgitation is important to prevent the heart
from slowing down and distending. It should be allowed to vent itself (by contracting)
until deliberately stopped by the surgeon via administration of cardioplegia.
F. Myocardial ischemic preconditioning
Ischemic preconditioning [8] is a phenomenon whereby the heart can be
“conditioned” by brief cycles (3 to 5 minutes) of nonlethal myocardial ischemia
and reperfusion, such that infarct size is reduced after a subsequent period of
sustained ischemia. Other parameters such as ATP levels, intracellular pH, and
ultrastructural features are also preserved. This effect has been replicated in a
large variety of animal species including humans, and indeed in in vitro cultures
of human myocytes. The protective effect has two windows. The first (classical
or early preconditioning) lasts between 4 hours and 6 hours with a second
window beginning at 24 hours and lasting up to 72 hours. No single pathway
explains the ischemic preconditioning, leaving a variety of potential mediators
such as adenosine, bradykinin, protein kinase C, and the mitochondrial
permeability transition pore. Numerous pharmacologic interventions aiming to
replicate the preconditioning effect have been assessed but as yet there is
insufficient evidence to support the use of any agent clinically.
G. The discovery that a “conditioning” stimulus could be applied to an organ or
tissue away from the heart is termed remote ischemic preconditioning. This
phenomenon is more easily translatable into the clinical setting, and indeed has
been applied noninvasively using a standard blood pressure cuff placed on the
upper or lower limb but without demonstrating a significant clinical effect [9].
VI. Interventions after aortic cross-clamping
A. Forms of cardioplegia
1. 4 The primary strategy for intraoperative myocardial protection is through the
delivery of cardioplegia solutions to the myocardium to produce a diastolic
electromechanical arrest. Although a recent study showed that over 160
different recipes of cardioplegia were in use in the United States, these
solutions all share some basic principles.
TABLE 23.1 Composition of various forms of cardioplegia
2. 5 The most common method for rapid induction of diastolic arrest is through
elevation of myocardial extracellular potassium resulting in depolarization of
the resting membrane potential. At a K+ concentration of around 10 mmol/L,
this reaches around –65 mV and the voltage-dependent fast Na+ channel crucial
for initiation of the action potential is inactivated, arresting the heart in
diastole. Of course, given the numerous ion channels and pumps, this does not
occur in isolation, and there is a concomitant increase in intracellular Na+ and
Ca2+. Also, the abnormal ion gradients leave ion pumps functioning and thus
consuming ATP.
3. The simplest forms of cardioplegia are crystalloid solutions, of which there are
two types that produce depolarization: extracellular and intracellular.
Extracellular types contain relatively higher concentration of Na+, Ca2+, and
Mg2+, whereas intracellular types contain no or low concentrations of Na+ and
Ca2+. All contain K+ in ranges from 10 to 40 mmol/L (Table 23.1).
4. 6 The prototype of an extracellular cardioplegia is St. Thomas solution [10]
(also Plegisol [Pfizer, Inc.]).
5. The characteristic intracellular cardioplegia is Bretschneider solution (also
HTK or Custodiol HTK Solution [Essential Pharmaceuticals, LLC]) [11]. The
low Na+ concentration reduces intracellular Na+ buildup and also intracellular
Ca2+ levels. Thus at least theoretically, there is a reduced tendency to
intracellular edema and reperfusion injury due to Ca2+. The hypocalcemia
within the myocardium prolongs the arrest period and reduces the need for
maintenance dosing. Bretschneider’s and St. Thomas’s solutions also have
different volumes of administration and induction times.
6. Since the late 1970s, crystalloid solutions have been increasingly replaced by
blood cardioplegia [12]. There are several advantages of using blood as the
main vehicle for delivery of the active elements of cardioplegia—that is,
replacing crystalloid. Blood has a much higher oxygen-carrying potential,
better rheologic properties potentially improving microcirculatory perfusion,
contains substrates for metabolism (fatty acids and glucose), has strong acid-
buffering capacity, contains endogenous antioxidants, and has a natural oncotic
force, thereby reducing the tendency for myocardial edema.
7. Blood cardioplegia is primarily produced in a 4:1 ratio of blood to
cardioplegia (extracellular type) aimed at producing the same final
concentration of K+ as would be present in the crystalloid infusate. In practical
terms, higher concentration (say 84 mmol/L K+) solutions in commercially
produced bags of crystalloid are used to spike blood diverted from the CPB
circuit, which passes through a dedicated heat exchanger to determine the
cardioplegia temperature.
8. Efforts to reduce hemodilution further have produced a strategy of microplegia
[13], where the volume of crystalloid is even further reduced using even more
concentrated solutions delivered via syringe drivers. These are probably only
really advantageous for strategies of continuous and warm cardioplegia
delivery.
9. A more recently developed depolarizing formulation is del Nido cardioplegia
which was initially developed for pediatric and infant patients but is
increasingly widely used in adults, particularly in the United States. It is a four-
part crystalloid to one-part whole blood formulation. The main components are
potassium and lidocaine (Table 23.1), but emphasis is given to the presence of
bicarbonate, mannitol, and magnesium. It is typically used as a single shot of
1,000 mL in adults and provides arrest maintenance of around 90 minutes [14].
10. Some centers use different solutions, temperatures, and routes of delivery for
induction of cardioplegia, for maintenance of cardioplegia, and for reperfusion
before cross-clamp removal (“hot shot”) [15] (see Table 23.1). This is by no
means as widespread as the dominance of blood cardioplegia for reasons of
simplicity and the very good results already achieved with a single formulation.
11. There are other forms of cardioplegia which seek to avoid depolarization of the
myocyte resting potential in order to avoid intracellular Na+ and Ca2+ loading
with consequent maintained energy utilization [16]. There are also concerns
over the effect of relatively high K+ causing endothelial injury, local
inflammation, arrhythmias, and coronary vasoconstriction [17]. A number of
methods of inducing a so-called “polarized” arrest (in which the membrane
potential is maintained close to the resting potential) have been put forward
including local anesthetics like lidocaine, adenosine, esmolol, and K+ channel
openers such as pinacidil. These forms of cardioplegia are delivered as one-
shot crystalloid solutions.
12. Lidocaine blocks fast-acting Na+ channels to prevent depolarization.
Adenosine opens K+ channels, which increases the outward K+ current
resulting in hyperpolarization via A1 receptor stimulation [18]. Esmolol is an
ultra–short-acting cardioselective β-blocker which has been shown to arrest the
heart in diastole due mainly to its negatively inotropic effect, but also blocks
Ca2+ and Na+ channels [19]. K+ ATP channel openers produce
hyperpolarization, although they have not been widely adopted in the clinical
setting. Two commercially available solutions are adenocaine, combining
adenosine and lidocaine, and St. Thomas polarizing cardioplegia, combining
esmolol, adenosine, and magnesium (Table 23.1).
CLINICAL PEARL The majority of adult surgical teams use multiple doses of
depolarizing blood cardioplegia solution based on the principle of hyperkalemic
diastolic arrest supplemented by hypothermia (local and/or systemic).
B. Temperature of cardioplegia
1. The myocardium may have been cooled by systemic cooling in the 30–33°C
range achieved through CPB. However, most intraoperative myocardial
protection historically (and indeed in clinical practice) involves cooling the
myocardium to a temperature of around 15°C. Although a degree of topical
cooling can be achieved through iced slush or saline or a cooling jacket, this is
primarily effective for the thin-walled right ventricle. Adequate cooling of the
left ventricle is achieved by delivery of cardioplegia at 4° to 10°C.
2. The increasing use of blood cardioplegia combined with the realization that
leftward shift of the oxygen dissociation curve at low temperatures might
reduce oxygen uptake in the cooled myocardium stimulated the use of warm
blood cardioplegia.
3. The use of warm (37°C) oxygenated blood cardioplegia for induction is thought
to allow for induction of electromechanical arrest while maximizing oxygen
and other substrate uptake during the delivery period and therefore minimizing
ATP depletion [ 20]. It has been particularly proposed in cases where there
might be evolving myocardial infarction as a technique to rescue these areas at
the time of induction.
4. Warm blood cardioplegia may also be used for maintenance, especially if CPB
is being conducted at normothermia. Numerous studies have compared it to
cold blood cardioplegia, and several studies report lower incidence of
perioperative myocardial infarction and a lower incidence of low cardiac
output syndromes [21].
5. Infusion of terminal warm blood cardioplegia (“hot shot”) may be used as an
adjunct to cold cardioplegia to replenish substrates (see Section VII).
6. Tepid cardioplegia (29°C) has also been described [22] and appears to be safe
and effective, although it remains to be determined whether it confers better
myocardial protection than other temperatures.
C. Route of delivery
1. Just as there are many solutions of cardioplegia, there are multiple forms of
delivery: antegrade into the aortic root, antegrade down individual coronary
ostia, antegrade down vein grafts, and retrograde; and each can be continuous
or intermittent.
2. Antegrade cardioplegia may be delivered by a cannula placed in the ascending
aorta proximal to the aortic cross-clamp. The cardioplegia is delivered at 200
to 300 mL/min at a pressure of 70 to 100 mm Hg while observing pressure in
the aortic root and the myocardium for evenness of cooling, absence of
distention, and electromechanical arrest. A 1,000-mL (14 mL/kg) induction
dose of blood cardioplegia is typically supplemented at 20-minute intervals
with 200- to 400-mL doses. For extracellular crystalloid cardioplegia, 1,000
mL is given at induction and then supplemented at 40-minute intervals with
500-mL doses. Intracellular crystalloid is often one shot with a 2,000-mL
induction dose lasting around 120 minutes, when it can then be supplemented if
necessary. This makes it quite suitable for minimally invasive procedures,
where the ease of supplementation is less.
3. Maintenance of cardioplegic arrest may require supplementation of
cardioplegia. This becomes necessary due to rewarming and reperfusion of the
myocardium by direct contact with systemically perfused tissues such as the
diaphragm, varying amounts of blood returned to the heart from the pulmonary
veins, and noncoronary collateral flow—small pericardial and mediastinal
vessels communicating with the coronary circulation. All of these vary from
case to case and can be difficult to predict. The principle behind maintenance
dosing of cardioplegia is that electromechanical quiescence should be
maintained and both the ECG and myocardium should be observed. Some
centers place a temperature probe in the left ventricular myocardium and use
this measurement to determine the adequacy of cardioplegia and thus the need
for supplementation. The composition of the cardioplegia will also influence
the need for supplementation. Blood cardioplegia typically requires more
frequent supplementation than crystalloid as do extracellular formulations
compared to intracellular. Temperature is important with warmer systemic
temperature and warmer cardioplegia both necessitating more frequent dosage.
4. In the setting of aortic regurgitation, delivery of cardioplegia into the aortic
root can produce left ventricular distention. Even where the left ventricle is
vented, the cardioplegia may not adequately pressurize the aortic root and it is
unclear how much cardioplegia is actually delivered down the coronary
arteries. Therefore, it is preferable to open the aorta and deliver the
cardioplegia directly down the coronary ostia using cannulae specifically
designed for this purpose. The cannulae can be in a Y to perfuse both ostia
simultaneously, or each ostium can be perfused sequentially with a volume
proportionate to the amount of myocardium it perfuses. Some ostial cannulae
can be fixed in place and used for continuous perfusion of cardioplegia.
5. In the setting of a precarious coronary anatomy, severe coronary artery disease
may result in uneven distribution of cardioplegia by an antegrade route. A free
conduit grafted to a diseased coronary artery can be used for delivery of
cardioplegia. Some surgeons use this more generally as a method of checking
adequacy of flow in each graft. Supplementary cardioplegia may also be
administered retrogradely. This is particularly indicated in redo coronary
artery bypass procedures [23].
6. Retrograde cardioplegia [24] is delivered by a purpose-made balloon-tipped
cannula placed in the coronary sinus. This is mostly placed blind, via the right
atrial free wall, but can also be placed directly with the right atrium opened.
The perfusion passes via the coronary venous system into the capillary bed and
subsequently into the arterial tree and comes out of both coronary ostia.
Pressure is limited to <40 mm Hg to avoid edema and this typically produces a
flow of 150 to 200 mL/min. Correct placement of the cannula should be
confirmed by one or more of: visualization on TEE, digital palpation of the
cannula tip, ventricularization of the pressure trace of the cannula, observation
of an increase in pressure with flow down the cannula, and observation of
perfusate coming out of the coronary ostia when the aorta is open.
FIGURE 23.3 Placement of the retrograde cannula in the coronary sinus beyond the veins draining the right ventricle.
7. The right ventricle is drained by the Thebesian veins, which empty directly into
the right ventricle. Furthermore, those epicardial veins which do drain the right
ventricle enter the coronary sinus near the ostium, near the site of a retrograde
cannula balloon (Fig. 23.3). Therefore, there are some concerns that there can
be relatively less perfusion of the right ventricle by the retrograde route.
CLINICAL PEARL Do not rely on retrograde cardioplegia alone to protect the right
heart because its venous drainage is predominantly via Thebesian veins; those cardiac
veins which do drain to the coronary sinus often do so proximal to the typical location of a
retrograde cannula balloon.
8. In valvular surgery, the use of retrograde cardioplegia facilitates the surgical
steps. In aortic valve surgery, repeat doses of cardioplegia can be given
without interrupting the procedure to cannulate the coronary ostia in antegrade
fashion (but note Clinical Pearl above). In mitral valve surgery, retraction of
the heart can distort the aortic root and produce aortic regurgitation if
cardioplegia is administered antegradely without letting down the retraction.
Retrograde cardioplegia may be administered without changing the exposure.
9. Antegrade and retrograde cardioplegia may be used together [25] either
simultaneously or alternatingly. Most commonly, the antegrade route used to
arrest the heart (induction) and the retrograde route is used for repeat dosing
(maintenance). Retrograde cardioplegia used for induction takes much longer to
achieve arrest, which may exacerbate ATP depletion. On the other hand, the
use of retrograde cardioplegia for reperfusion prior to cross-clamp removal
(hot shot) permits substrate replenishment at a warm temperature and low
pressure, achieving several of the principles of controlled reperfusion.
VII. Interventions around cross-clamp removal
A. The term “hot shot” refers to the delivery of warm blood [26], frequently with
hyperkalemia prior to the removal of the cross-clamp. This is thought to enhance
substrate replenishment while maintaining electromechanical arrest—that is,
during a period of low substrate utilization.
B. In the 1980s, Buckberg performed a series of experimental studies investigating
how altering the conditions of reperfusion affected myocardial recovery. The
description “gentle” reperfusion as a cardioprotective strategy arose from this
work and is currently practiced as “controlled reperfusion.” This involves
reducing the systemic pressure when the cross-clamp is removed for a period of
a couple of minutes, maintaining a mean pressure of around 40 mm Hg.
C. In this early period of reperfusion, the contractile function of the heart is
depressed and the myocardium is particularly susceptible to distention. Due
attention is necessary to avoid ventricular distention and to address it by venting
if required. The importance of VF in the decompressed heart at this stage is less
clear, but the presence of VF certainly makes assessment of distention difficult
and usually stimulates the clinicians to reverse it by electrical and/or
pharmacologic measures.
D. Immediately prior to removal of the aortic cross-clamp, the left side of the heart
should be thoroughly de-aired. This typically involves pushing blood flow
through the right side of the heart and then lungs to push air out through the left
side, either through an LV or aortic vent. To do this, the perfusionist partially
occludes the venous return, filling the right atrium and right ventricle and pushing
blood into the lungs. The anesthesiologist ventilates the lungs which helps to push
blood and air from the pulmonary circulation into the left heart. Only when this
air has been expelled can the cross-clamp be removed to avoid left ventricular
ejection of air into the systemic circulation. Even with these measures, it is likely
that some pockets of air remain in the most uppermost areas of the circulation.
Since the right coronary artery is anterior in the aortic root, any air is most likely
to embolize here and could cause malperfusion at this delicate time. Attention to
this possibility should be maintained until all this air has been eliminated, which
may be several minutes after cross-clamp removal. Some surgeons use
insufflation of CO2 into the operative field which, being denser than air,
displaces this during the procedure. Any gaseous emboli at the end are, therefore,
composed of highly soluble CO2 rather than relatively insoluble air.
E. Many years after the description of controlled reperfusion and ischemic
preconditioning, the phenomenon of ischemic postconditioning was
demonstrated. This is the reduction of ischemic injury by interrupting periods of
reperfusion with brief periods of reocclusion. Although initially described in a
canine model, this technique has been reported as beneficial in the clinical
setting, although its clinical merit remains to be determined [27].
VIII. Alternatives to cardioplegia
A. Cross-clamp fibrillation
1. This is essentially a historical technique for coronary artery bypass [28]. The
heart was deliberately fibrillated and the aortic cross-clamp applied. The
specific coronary artery was exposed and grafted. The cross-clamp was then
removed and the heart defibrillated. For free grafts, the proximal anastomosis
was completed with the heart perfused and beating, using a side-biting clamp
on the ascending aorta, allowing immediate reperfusion of that coronary
territory. Then the next graft was performed under a further period of cross-
clamp fibrillation and so on, until all the grafts were completed. Usually,
systemic hypothermia of 28° to 30°C and a pulmonary artery vent were used to
provide some protection and avoid distention.
B. Off-pump coronary artery bypass
1. Off-pump coronary revascularization accounts for around 20% of all cases,
varying according to institutional and surgeon preferences. As far as
intraoperative myocardial protection, attention to general anesthetic principles
is all the more critical and this is addressed in Chapter 10. Coronary perfusion
must remain adequate and various maneuvers are employed to optimize this
including operative table positioning, cardiac positioning, pacing, and
judicious use of vasopressors [29].
2. The left internal mammary artery to left anterior descending artery anastomosis
is performed first to provide the greatest territory of revascularization with a
minimum of cardiac displacement. As in cross-clamp fibrillation, proximal
anastomoses may be performed immediately after the distal anastomosis in
order to achieve immediate revascularization. Although some surgeons place
intracoronary shunts while performing distal anastomoses, these introduce a
degree of stenosis and distal flow is reduced compared to a patent vessel.
C. Beating heart on cardiopulmonary bypass (CPB)
1. In the presence of a competent aortic valve, the myocardium can be perfused
from the bypass circuit allowing the heart to beat throughout the procedure.
2. This is a very common approach for operations on the right side of the heart,
particularly tricuspid or pulmonary valve operations, since the right side is
bypassed. Attention to entraining air to the left side of the heart is critical.
3. In mitral valve surgery, this technique is also used with venting of the left
ventricle via the mitral valve, both to facilitate exposure and to prevent air
embolism, since in this case the left ventricle is full of air [30]. A resurgence in
this strategy coincides with an interest in minimal access and transcatheter
approaches to the mitral valve.
4. Aortic arch procedures are typically prolonged and require long periods of
cooling and rewarming. If the aortic valve is competent, the ascending aorta
can be cross-clamped and the heart perfused by normothermic blood flow at
500 to 700 mL/min proximal to the clamp, essentially separating cardiac and
systemic perfusion circuits [31]. Adequacy of cardiac perfusion is assessed by
observation of a pressurized aortic root alongside a comfortable and flaccid
beating heart with a normal electrocardiogram. Of course, in most cases of
aortic arch surgery, concomitant procedures are required on the heart itself and
the aortic root. These can be performed with standard cardioplegia techniques
during systemic cooling, and then the heart restarted and maintained beating
with this normothermic perfusion technique, while the surgeon tackles the
aortic arch.
IX. Conclusion
A. An enormous array of formulations and strategies exist for intraoperative
myocardial protection. Contemporary results of cardiac surgery produce
mortality rates of less than 2% and myocardial infarction rates of less than 4%.
The evidence for any particular strategy is usually based on laboratory
experiments, which have proved difficult to translate into significant clinical
differences in the clinical arena. For this reason, many units and surgeons choose
to simplify their approach to provide a practiced and reproducible technique
with as universal an application as possible.
B. 7 With appropriate intraoperative myocardial protection, the heart will
generally comfortably tolerate 120 minutes of ischemia time, after which
additional time will come at a cost of increased risk of low cardiac output
syndrome.
C. As our understanding of the mechanisms underlying global ischemia–reperfusion
injury in the heart improves, so no doubt will our techniques for tolerating and
reversing longer and longer periods of myocardial ischemia.
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24 Extracorporeal Membrane Oxygenation for
Pulmonary or Cardiac Support
Darryl Abrams, Jonathan Hastie, and Daniel Brodie
I. History of extracorporeal membrane oxygenation (ECMO)

II. ECMO physiology
III. Cannulation strategies
A. Venovenous
B. Venoarterial
IV. Indications and evidence for ECMO in respiratory failure
B. Bridge to transplant
V. Indications and evidence for ECMO in cardiac failure
B. Bridge to left ventricular assist device (LVAD) or transplant
VI. ECMO management
A. Invasive mechanical ventilation practices
B. Anticoagulation strategies
C. Early mobilization
D. Weaning ECMO
VII. ECMO transport
VIII. Complications
IX. Economic considerations
X. Ethical considerations
KEY POINTS
1. Venovenous extracorporeal membrane oxygenation (ECMO)

provides for gas exchange without cardiac support, whereas
venoarterial ECMO provides support for both impaired gas
exchange and impaired cardiac function.
2. Because carbon dioxide can be removed efficiently at low blood
flow rates, extracorporeal carbon dioxide removal (ECCO2R) has
the potential to alter the paradigm of the management of respiratory
failure through the use of minimization and avoidance of
mechanical ventilation.
3. In femoral–femoral venoarterial ECMO, delivery of oxygenated
blood to the aortic arch and great vessels may be compromised
when native gas exchange is impaired and there is residual native
cardiac output. Hybrid, upper-body, or central cannulation strategies
may mitigate this problem.
4. Temporary venoarterial ECMO is used in cardiac failure patients as
part of several potential strategies or bridges; the endpoints of these
bridges may include recovery, heart transplantation, long-term
mechanical circulatory support, or, when outcomes are uncertain, a
decision. However, ECMO for respiratory failure can only be used
as bridge to recovery or transplantation because no other bridge or
destination device is currently in existence.
5. Extracorporeal cardiopulmonary resuscitation (ECPR) has the
potential to significantly improve neurologically intact survival from
cardiac arrest. However, appropriate patient selection is essential in
optimizing outcomes and avoiding the widespread application of
this resource-intensive strategy.
THE USE OF EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) for severe

respiratory and cardiac failure has grown rapidly over the last several years in the
context of both technologic advances in extracorporeal circuitry and a growing body of
literature demonstrating favorable outcomes. As cannulation techniques and management
strategies evolve, ECMO has the potential to transform the approach to severe
cardiopulmonary failure. This chapter addresses the rationale for ECMO use, its
potential indications and contraindications, management approaches to the circuit and
patient, and common complications. Lastly, because ECMO is a resource-intensive
technology that profoundly affects the ability to support critically ill patients, economic
impact and ethically challenging situations are discussed.
I. History of ECMO
A. ECMO was first devised as an extension of cardiopulmonary bypass, with the
idea that respiratory and cardiac function could be supported through
extracorporeal circuitry beyond the operating room setting.
B. The first successful application of ECMO for acute severe respiratory failure
was in 1971.
C. Although such success held great promise for the future development of the field
and expanding use in severe respiratory failure, prospective randomized trials in
1979 and 1994 failed to demonstrate a survival benefit from ECMO compared to
conventional management. Much of the failure of ECMO was attributed to high
complication rates, particularly bleeding and thrombosis. These complications
fundamentally relate to the circuitry components available at the time and limited
practitioner experience with the technology.
D. Over the last 20 years, substantial advances in extracorporeal technology include
the following components:
1. Novel cannula designs that optimize drainage and reinfusion of blood
2. Biocompatible circuits which decrease the risk of thrombus formation and
reduce the requirement for anticoagulation
3. Oxygenators that improve efficiency through the use of semipermeable
membranes to selectively allow for diffusion of gas
4. Centrifugal pumps that reduce trauma to blood components and decrease the
risk of damage to the circuit
E. The combination of improved technology, with a more favorable risk profile, and
concurrent advances in the overall critical care management of patients with
severe cardiopulmonary failure have led to a growing body of literature that
suggests improving survival in patients supported with ECMO. However, this
literature largely comprises nonrandomized observational trials with their
inherent limitations in study design.
II. ECMO physiology
A. ECMO provides for gas exchange during severe respiratory failure by directly
oxygenating and removing carbon dioxide from blood [1].
B. Deoxygenated blood is drained from a central vein and pumped through a gas
exchange device called a membrane oxygenator. The blood passes along one side
of a semipermeable membrane, while gas, referred to as sweep gas, passes along
the other side. The gas is typically a mixture of oxygen and air, the proportions of
which (i.e., the fraction of delivered oxygen, FDO2) are controlled by a blender.
C. The membrane allows for diffusion of oxygen down a gradient from high
concentration in the sweep gas to low concentration in the blood compartment.
Carbon dioxide also diffuses from high to low concentration (from the blood
compartment to the gas compartment).
D. Well-oxygenated blood leaving the membrane oxygenator is then reinfused back
to the patient. The carbon dioxide removed by the membrane oxygenator is
vented to the environment.
E. 1 When blood is drained from a vein and reinfused into a vein, the configuration
is called venovenous ECMO. This configuration provides only gas exchange and
relies upon the native cardiac function to circulate the reinfused, oxygenated
blood.
CLINICAL PEARL Venovenous ECMO provides gas exchange support, whereas
venoarterial ECMO provides both gas exchange and hemodynamic support.
F. Venoarterial ECMO describes the configuration in which blood is drained from a
vein and reinfused into an artery. This provides both gas exchange and
hemodynamic support by reinfusing blood under pressure directly into the
systemic arterial circulation.
CLINICAL PEARL In cases of acute right ventricular failure due to severe
hypoxemia or hypercapnia, venovenous ECMO may be sufficient to improve right heart
function without the need for venoarterial support.
G. 2 Extracorporeal oxygen delivery is proportional to extracorporeal blood flow;
large cannulae are often required to achieve adequate flow rates. Extracorporeal
carbon dioxide removal (ECCO2R) is predominantly determined by the sweep
gas flow rate and can be achieved at much lower blood flow rates. This allows
for the use of smaller cannulae which may be associated with fewer
complications.
CLINICAL PEARL The main determinant of oxygenation through the ECMO
circuit is blood flow rate. The main determinant of carbon dioxide removal through
the ECMO circuit, during full-flow ECMO, is the sweep gas flow rate.
III. Cannulation strategies
A. Venovenous
ECMO traditionally involves the insertion of two separate cannulae, one for
drainage and one for reinfusion. Venous drainage commonly occurs from the
inferior vena cava (IVC), which is accessed through a femoral vein, while
reinfused blood is delivered to the superior vena cava (SVC) through an internal
jugular vein (Fig. 24.1).
1. A two-site venovenous configuration has the advantage of ease of bedside
insertion without the need for advanced imaging techniques (although
ultrasound guidance is recommended). However, the orientation of the drainage
and reinfusion cannulae may result in drainage of reinfused, well-oxygenated
blood back into the circuit without first having passed through the systemic
circulation. This phenomenon, known as recirculation, limits the efficiency of
the circuit’s gas exchange.
2. An alternative single-site configuration may minimize recirculation through the
use of a bicaval, dual-lumen cannula.
a. This cannula is inserted into an internal jugular vein with its tip in the IVC. It
is positioned so that SVC and IVC drainage ports drain blood into one lumen.
After passing through the membrane oxygenator, reinfused blood passes
through a second lumen whose port is directed toward the tricuspid valve
(Fig. 24.2).
b. Recirculation is minimized both by separating drainage and reinfusion ports
and directing the reinfusion jet toward the tricuspid valve.
c. By avoiding the cannulation of a femoral vein, this configuration may
minimize infectious risks and allow for increased mobility.
d. In order to ensure correct placement and orientation, this cannula should
ideally be placed with guidance from both transesophageal echocardiography
and fluoroscopy.
CLINICAL PEARL Two-site venovenous ECMO is the most common configuration
when ECMO is used for respiratory failure; its downsides include femoral cannulation
and tendency for recirculation. Single-site cannulation with a dual-lumen cannula avoids
femoral cannulation and minimizes recirculation; however, such an approach requires
advanced imaging techniques to ensure satisfactory placement.
B. Venoarterial
ECMO is most commonly performed with peripheral insertion of cannulae into
the femoral vein and artery. This approach, much like two-site venovenous
ECMO, can be performed rapidly at the bedside, which is particularly useful for
supporting hemodynamically unstable patients. Such an approach is usually
adequate to provide sufficient circulatory support to maintain adequate end-organ
perfusion.
1. 3 Hybrid configurations. Femoral venoarterial ECMO creates retrograde
flow of reinfused blood in the aorta. In patients receiving venoarterial ECMO
for cardiac failure, who have concomitant severe respiratory failure, residual
native cardiac function may pump deoxygenated blood into the ascending aorta.
These competing blood flows can lead to the delivery of poorly oxygenated
blood to the coronary and cerebral circulations (Fig. 24.3). One remedy to this
problem involves the addition of a second reinfusion limb into the internal
jugular vein, which will improve the oxygenation of blood passing through the
native cardiac circulation. This configuration is referred to as venoarterial
venous ECMO (Fig. 24.4).
FIGURE 24.1 Two-site venovenous extracorporeal membrane oxygenation (ECMO). Venous blood is drained from a central
vein via a drainage cannula, pumped through an oxygenator, and returned to a central vein through a separate reinfusion
cannula. Inset: Some reinfused blood may be taken back up by the drainage cannula (purple arrow) without passing through the
systemic circulation, which is referred to as recirculation. (Reprinted with permission from Clinics in Chest Medicine. Abrams
D, Brodie D. Extracorporeal circulatory approaches to treat ARDS. Clin Chest Med. 2014;35(4):765–779. Figure 2, also
reprinted with permission from www.collectedmed.com)
2. In circumstances in which sufficient circulatory support cannot be provided by

the cannulation of peripheral vessels, central cannulation may be necessary,
with the use of shorter, larger-bore cannulae. This configuration, which is
analogous to typical cardiopulmonary bypass cannulation for open heart
surgery, varies based on the patient’s needs and may include, for example, right
atrial drainage with either aortic or pulmonary venous reinfusion.
FIGURE 24.2 Single-site venovenous extracorporeal membrane oxygenation (ECMO). Dual-lumen cannula insertion allows
for venovenous ECMO through a single venous access point and may minimize recirculation when properly positioned.
(Reprinted with permission from Clinics in Chest Medicine. Abrams D, Brodie D. Extracorporeal circulatory approaches to
treat ARDS. Clin Chest Med. 2014;35(4):765–779. Figure 4, also reprinted with permission from www.collectedmed.com)
3. Left ventricular venting. The retrograde flow of reinfused blood in the aorta
in femoral venoarterial ECMO may result in several adverse physiologic
consequences related to an increase in left ventricular afterload. Increased left
ventricular afterload increases wall stress, which both increases myocardial
oxygen demand and decreases coronary artery perfusion. Increased left
ventricular afterload also leads to an increase in the end-diastolic volume,
which is associated with stasis and intracardiac thrombus formation,
particularly when the aortic valve is not opening. Left ventricular venting,
performed either percutaneously or surgically, mitigates each of these effects
by decompressing the ventricle. Left ventricular venting (drainage) into the
ECMO circuit also reduces the likelihood of upper-body hypoxemia in patients
with impaired lung function.
FIGURE 24.3 Femoral venoarterial extracorporeal membrane oxygenation (ECMO) in the setting of impaired gas
exchange. Reinfused oxygenated blood flows retrograde up the aorta (red arrow) and may meet resistance from
antegrade flow from the native cardiac output (purple arrow), which, in the context of impaired native gas exchange, may
lead to poor upper body oxygenation. (Reprinted with permission from Clinics in Chest Medicine. Abrams D, Brodie D.
Novel uses of extracorporeal membrane oxygenation in adults. Clin Chest Med. 2015;36(3):373–384. Figure 4, also
CLINICAL PEARL The most common approach for venoarterial ECMO utilizes
femoral venous drainage and femoral arterial reinfusion. However, this configuration
may be associated with upper-body hypoxia in the setting of impaired native gas
exchange and residual native left ventricular function.
IV. Indications and evidence for ECMO in respiratory failure
1. Severe acute respiratory distress syndrome (ARDS). The most common
indication for venovenous ECMO is severe ARDS, defined by the acute onset
of severe hypoxemia with bilateral infiltrates on chest imaging that cannot be
fully explained by elevated left atrial pressure.
FIGURE 24.4 Venoarterial venous extracorporeal membrane oxygenation (ECMO). Inadequate upper body oxygenation due
to a combination of femoral venoarterial ECMO and impaired native gas exchange may be partially overcome by the addition of
a second reinfusion limb into an internal jugular vein. (Reprinted with permission from Clinics in Chest Medicine. Abrams D,
Brodie D. Novel uses of extracorporeal membrane oxygenation in adults. Clin Chest Med. 2015;36(3):373–384. Figure 5, also
a. A volume- and pressure-limited ventilation strategy is standard of care in

ARDS, with a proven mortality benefit over conventional higher volumes and
plateau airway pressures [2]. Other strategies that confer a mortality benefit in
ARDS include prone positioning and possibly the early use of neuromuscular
blockade or high levels of positive end-expiratory pressure (PEEP).
b. Propensity analyses of patients with and without ECMO support for severe
ARDS in the context of the influenza A (H1N1) pandemic in 2009 showed
conflicting results as to the effect of ECMO on survival. One observational
study in the United Kingdom demonstrated a significant reduction in mortality
(24% vs. 47%, relative risk 0.51; 95% CI 0.31–0.84, p = 0.008), whereas a
comparable study in a French cohort demonstrated no survival benefit from
ECMO.
c. The only prospective randomized trial in which ECMO was performed with
relatively modern technology and in the era of standard-of-care low–tidal-
volume ventilation for severe acute respiratory failure was the Conventional
Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial,
which demonstrated an improved rate of 6-month survival without severe
disability when a strategy of referral to an ECMO-capable center was
compared with usual care management (relative risk 0.69; 95% CI 0.05–0.97,
p = 0.03) [3]. Of note:
(1) Only 76% of subjects referred for ECMO ever received ECMO. The
other 24% either improved with standard of care conventional
mechanical ventilation, worsened prior to being able to receive ECMO,
or died prior to arrival at the ECMO center.
(2) Only 70% of subjects in the control arm were managed with standard-of-
care lung-protective mechanical ventilation at any time during the study.
(3) These methodologic flaws limit the conclusions that can be drawn
regarding the effect of ECMO itself on survival in severe acute
respiratory failure and rather suggest the benefits associated with
adherence to standard of care and referral to a center with the capacity to
initiate ECMO. Additional randomized controlled studies are needed to
elucidate the role of ECMO in this patient population.
d. A prospective randomized controlled trial of ECMO versus standard-of-care
conventional management in severe refractory ARDS is currently ongoing and
may help elucidate the role of ECMO in these patients (ClinicalTrials.gov
Identifier: NCT01470703).
e. Proposed thresholds to initiate ECMO in ARDS [1]:
(1) Ratio of partial pressure of oxygen in arterial blood (PaO2) to fraction of
inspired oxygen (FiO2) less than 80 mm Hg with the use of high FiO2 and
PEEP
(2) Respiratory acidosis with pH less than 7.15 despite optimal ventilator
management
(3) Excessively high plateau airway pressures (>35 to 45 cm H2O,
depending on patient’s body habitus) despite optimal ventilator
management
2. Primary graft dysfunction (PGD) after lung transplantation. Clinically
similar to ARDS, though etiologically thought to be a consequence of
ischemia–reperfusion injury, PGD manifests as acute hypoxemic respiratory
failure and radiographic infiltrates in the allograft within 72 hours of lung
transplantation. ECMO should be considered early in PGD to support severe
gas exchange impairment and minimize harm from aggressive ventilator
settings. In select patients, particularly those with pretransplantation pulmonary
hypertension or right ventricular dysfunction, venoarterial ECMO may be
considered intraoperatively as a means of accomplishing two ends: providing
intraoperative hemodynamic support and controlling reperfusion to the allograft
to minimize the risk of PGD. In some patients with severe pulmonary
hypertension, venoarterial ECMO may be instituted preoperatively for
respiratory failure associated with hemodynamic instability.
3. Acute hypercapnic respiratory failure. ECCO2R may be used in the
management of hypercapnic respiratory failure with a favorable risk–benefit
profile while minimizing or eliminating the need for invasive mechanical
ventilation. The relatively low risk is rooted in the ability to achieve carbon
dioxide removal at low blood flow rates with smaller cannulae as compared to
cannulae used for hypoxemic respiratory failure.
a. Potential benefits of this strategy include:
(1) Minimization of dynamic hyperinflation and auto-PEEP
(2) Minimization of ventilator-associated lung injury (VALI)
(3) Avoidance of ventilator-associated pneumonia
(4) Improved delivery of aerosolized medications
(5) Facilitation of early mobilization through better control of dyspnea and
work of breathing
b. The feasibility of such a strategy has been demonstrated in small studies of
subjects with acute exacerbations of chronic obstructive pulmonary disease
[4]. Prospective randomized studies comparing ECCO2R to conventional
management are needed before this approach can be recommended for clinical
use.
c. A similar approach may be considered in severe cases of status asthmaticus in
which patients have marked ventilatory impairment, often as a consequence of
positive pressure ventilation and dynamic hyperinflation.
B. Bridge to transplant
1. ECMO support for end-stage respiratory failure as a bridging therapy to lung
transplantation has traditionally been associated with poor posttransplant
outcomes, mostly due to poor patient selection and device-associated
complications. However, there have recently been improvements in
posttransplant outcomes for patients supported with ECMO pretransplant.
These improvements are at least in part attributable to:
a. Careful patient selection and earlier initiation, thereby avoiding patients too
moribund to successfully undergo lung transplantation
b. Increased experience at high-volume centers with an associated reduction in
complications
c. Strategies that optimize physical conditioning and minimize ICU
complications. These strategies include avoidance of sedation, endotracheal
extubation, and early mobilization
d. 4 Because there is no destination device for respiratory failure equivalent to
the left ventricular assist device (LVAD) in advanced cardiac failure, patients
with end-stage respiratory failure should be selected for ECMO support only
when they are candidates for lung transplantation.
CLINICAL PEARL Indications for venovenous ECMO include bridge to recovery
for severe ARDS and bridge to lung transplantation for end-stage respiratory failure.
The use of ECCO2R for acute hypercapnic respiratory failure is a promising area of
ongoing research.
V. Indications and evidence for ECMO in cardiac failure
1. Cardiogenic shock. Venoarterial ECMO is one of several mechanical
circulatory support systems that have the ability to support severe cardiogenic
shock, with the advantages that it can be initiated rapidly at the bedside and
offers gas exchange support. The success of ECMO support as a bridge to
recovery largely depends on the etiology, with cardiac failure due to acute
myocardial infarction and fulminant myocarditis having the most favorable
outcomes. The data for ECMO in cardiogenic shock are largely limited to case
series, small cohort studies, and retrospective propensity analyses [5]. Pre-
ECMO prognostication scores have been proposed to help maximize patient
outcomes by identifying those most likely to benefit from ECMO support.
a. Postcardiotomy cardiogenic shock is an uncommon complication of cardiac
surgery that is associated with significant mortality. ECMO may be
considered as temporary postoperative support when a patient cannot be
weaned from cardiopulmonary bypass in the operating room.
b. Primary graft failure (PGF), a rare complication of heart transplantation that is
associated with a high rate of mortality, may be supported with venoarterial
ECMO. Patients with PGF who are supported on ECMO and who survive
beyond the early posttransplant period have comparable long-term survival to
transplant recipients who never developed PGF.
2. 5 Extracorporeal cardiopulmonary resuscitation (ECPR). ECPR (the use of
ECMO in refractory cardiac arrest) is a rapidly expanding indication for
venoarterial ECMO. There are no prospective randomized controlled trials of
ECPR compared to conventional CPR; however, propensity analyses suggest
significantly higher neurologically intact survival with ECPR compared to
conventional CPR in both in-hospital and out-of-hospital cardiac arrests.
Younger age, shorter duration of CPR prior to ECMO initiation, and subsequent
cardiac interventions have all been associated with more favorable outcomes.
3. Pulmonary vascular disease
a. Decompensated pulmonary hypertension with right ventricular failure, a
condition associated with high mortality, is emerging as a potential target for
ECMO support [6]. Traditionally a venoarterial configuration is needed to
decompress the right ventricle and bypass the high resistance of the pulmonary
vasculature. However, such an approach may be inadequate to oxygenate the
upper body when femoral vessels are used for venoarterial ECMO.
Alternative strategies include the following approaches:
(1) Upper-body venoarterial ECMO with right internal jugular venous
drainage and subclavian or innominate arterial reinfusion via an end-to-
side graft
(2) Single-site, dual-lumen cannulation (with bicaval drainage) via the
internal jugular vein with reinfusion directed across a pre-existing atrial
septal defect or intentionally created septostomy
(3) Pumpless arteriovenous ECMO between the main pulmonary artery and
the left atrium
(4) Right atrial to left atrial ECMO. This configuration provides right
ventricular support and gas exchange but uses the native left ventricle for
the systemic circulation. Like venoarterial ECMO, it is associated with
increased risk of stroke.
b. Pulmonary embolism, when associated with severe right ventricular
dysfunction with or without hemodynamic collapse, may be appropriate for
venoarterial ECMO support. Nonrandomized studies have demonstrated
favorable survival rates when this strategy has been employed with
concomitant consideration of systemic thrombolysis, catheter-directed
therapies, or surgical embolectomy.
B. Bridge to left ventricular assist device (LVAD) or transplantation
1. ECMO has been reported as a viable bridging strategy for both LVAD and
heart transplantation. LVAD themselves are used as either a longer-term bridge
to transplantation or as destination therapy for patients who are not eligible for
transplantation. Because venoarterial ECMO is associated with significant
morbidity, the duration of support is typically limited to 1 to 2 weeks. During
this time, assessment of neurologic function and organ system recovery are
significant factors in determining the timing of LVAD insertion. Pre-ECMO
patient characteristics that have been associated with poor outcomes for ECMO
as bridge to VAD or transplant include age greater than 50, CPR prior to
ECMO initiation, and high pre-ECMO severity of illness scores.
2. In cases where it is unclear whether cardiac function will recover (e.g., post-
acute myocardial infarction complicated by cardiogenic shock), ECMO may be
considered as a bridge to decision, where serial assessments of myocardial
recovery are needed to determine whether a patient will proceed to recovery,
VAD, or transplantation. Preservation of noncardiac end-organ function is of
particular importance if destination device therapy or transplantation is being
considered.
CLINICAL PEARL Indications for venoarterial ECMO include bridge to recovery
for potentially reversible cardiogenic shock or cardiac arrest and bridge to VAD or
heart transplantation for irreversible cardiac failure. An emerging strategy is the use
of venoarterial ECMO in patients with decompensated pulmonary hypertension as a
bridge to either transplant or recovery.
VI. ECMO management
A. Invasive mechanical ventilation practices
1. VALI is believed to be the main determinant of poor outcomes in ARDS,
explaining why a volume- and pressure-limited ventilation strategy has such a
significant impact on survival.
2. Several studies have demonstrated that tidal volumes and plateau pressures
below the current standard of care could further reduce VALI. However,
reductions in tidal volumes, airway pressures, and respiratory rates with
conventional invasive mechanical ventilation are often limited by intolerable
levels of respiratory acidosis that come with marked reductions in minute
ventilation.
3. The presence of extracorporeal ventilation can facilitate even lower tidal
volumes and airway pressures by managing the concomitant hypercapnia and
acidemia, to the point where in select cases mechanical ventilation may be
discontinued and patients could be extubated while on ECMO.
4. In cases of severe ARDS in which ECMO is initiated for refractory gas
exchange abnormalities or excess plateau airway pressures, many ECMO
centers utilize a strategy of very low tidal volumes and respiratory rates while
maintaining a moderate amount of PEEP to minimize alveolar collapse.
Occasionally, in select patients, mechanical ventilation can be discontinued
altogether.
5. A very lung-protective ventilation strategy may ultimately prove beneficial in
less severe forms of ARDS, where oxygenation is better preserved and an
approach targeting CO2 removal alone with lower blood flows and smaller
cannulae (i.e., ECCO2R) is sufficient. Prospective randomized controlled trials
are in progress, seeking to determine if there is a clinical benefit that outweighs
the potential risks of extracorporeal support.
CLINICAL PEARL The use of ECMO for respiratory failure in mechanically ventilated
patients can reduce the incidence of VALI by permitting the use of very low tidal volumes
and plateau airway pressures.
B. Anticoagulation strategies
1. Continuous systemic anticoagulation is generally needed to maintain ECMO
circuit patency and minimize thrombotic risk to the patient. The degree of
anticoagulation has to be balanced with the risk of hemorrhagic complications.
There are no universally accepted anticoagulation standards for ECMO nor is
there a consensus on how anticoagulation should be monitored, with activated
clotting time, activated partial thromboplastin time (aPTT), and
thromboelastography, among others, having been reported.
2. For VV ECMO, a strategy that combines lower-level anticoagulation,
restrictive transfusion thresholds, and reinfusion of circuit blood at the time of
decannulation has been shown to be associated with favorable outcomes with
minimal transfusion requirements [7].
3. Prolonged heparin infusions may reduce available antithrombin III and thereby
impair the efficacy of heparin. Antithrombin III is available in the recombinant
form and may be considered to restore the efficacy of heparin in the context of
low antithrombin III levels.
4. If heparin cannot be used, for example, in the setting of heparin-induced
thrombocytopenia (HIT), alternative anticoagulants include argatroban and
bivalirudin.
CLINICAL PEARL Low levels of systemic anticoagulation appear to be effective at
maintaining ECMO circuit patency while minimizing the risk of significant bleeding.
C. Early mobilization
1. Early mobilization of critically ill patients has repeatedly been demonstrated to
be not only safe but also effective in reducing ICU-associated complications.
2. Extubation and cessation of mechanical ventilation, if feasible while receiving
ECMO therapy, may aid in early patient mobilization.
3. Through the use of more compact circuitry and the avoidance of femoral
cannulation, it has become feasible for patient supported with ECMO to
undergo early mobilization, including ambulation [8].
4. Physical rehabilitation, including early mobilization, is of critical importance
in the bridge-to-transplant population in order to maintain transplant candidacy.
Whether there is a benefit in the bridge-to-recovery population comparable to
that seen in other critically ill patients has yet to be determined and is an area
of active research.
D. Weaning ECMO
1. Venovenous. Patients should be evaluated for their readiness to wean from
ECMO support after the underlying cause of respiratory failure is treated and
the patient’s native gas exchange and respiratory system mechanics improve.
There are several approaches to weaning venovenous ECMO. An approach of
incremental reductions in sweep gas flow rate and FDO2 while monitoring the
ability to maintain adequate gas exchange with native lung function is most
commonly employed. Blood flow rate may also be reduced as a means of
weaning (although very low blood flow rates should be avoided, as the risk of
circuit thrombosis increases). A trial with sweep gas flow turned off for a
prespecified period of time (e.g., 30 minutes) with acceptable gas exchange, no
excess work of breathing, and acceptable ventilator settings (if applicable)
should be performed in most patients prior to consideration of decannulation
and may be used as the sole determinant of weaning readiness.
2. Venoarterial. Weaning from venoarterial ECMO differs significantly from
venovenous ECMO. Because venoarterial ECMO provides hemodynamic
support, weaning can be performed with incremental reductions in
extracorporeal blood flow with serial assessments of vasopressor and inotrope
requirements, cardiac function, and end-organ perfusion. Ideally, vasopressors
will be able to be minimized or discontinued entirely prior to decannulation
from venoarterial ECMO, while it is more common to maintain some
pharmacologic inotropic support. During weaning trials, a minimum
extracorporeal blood flow rate of 2 L/min should be maintained through the
circuit to avoid circuit thrombosis. Sweep gas FDO2 is typically not weaned in
order to avoid the creation of a right-to-left shunt. If a patient appears ready for
decannulation from a hemodynamic perspective but continues to require
extracorporeal gas exchange support, conversion from venoarterial to
venovenous ECMO (with its lower risk of systemic embolization) should be
considered.
CLINICAL PEARL When weaning venovenous ECMO, sweep gas flow is
typically discontinued to assess adequacy of native gas exchange and readiness for
decannulation. In venoarterial ECMO, extracorporeal blood flow is typically
reduced to assess hemodynamic readiness for decannulation. In venoarterial ECMO,
sweep gas flow should always be maintained; discontinuation of sweep gas flow
would lead to hypoxemia from a right-to-left shunt.
VII. ECMO transport
A. Patients with severe refractory respiratory or cardiac failure who would
otherwise benefit from ECMO support may be at facilities without ECMO
capabilities and yet be too unstable to transport to an ECMO-capable center.
Under such circumstances, mobile ECMO transport teams may improve these
patients’ outcomes by performing ECMO cannulation at the origin hospital and
transporting them to specialized centers capable of providing ongoing ECMO
management.
B. ECMO transport has been demonstrated to be safe and feasible. This highlights
the potential role of regionalization of ECMO in order to maximize outcomes by
referring patients to high-volume centers with greater experience [9].
VIII. Complications
A. Potential complications are inherent with any invasive intervention, especially
among patients with severe underlying critical illness, and must be weighed
against the potential benefit of the intervention. Complication rates for ECMO
vary greatly based on center experience, management strategies, devices used,
and patient characteristics.
1. Commonly encountered hematologic complications include hemorrhage and
thrombotic/thromboembolic events, the severities of which are heavily
influenced by center-specific anticoagulation practices and patient-specific
factors. Less common hematologic complications include hemolysis,
thrombocytopenia, disseminated intravascular coagulation, acquired von
Willebrand disease, and HIT.
a. The diagnosis of HIT during ECMO should be made based on appropriate
clinical criteria (e.g., 4T score). If HIT is suspected, a heparin antibody test
should be performed as an initial screening test, followed by a serotonin
release assay if the heparin antibody test is positive. Alternate anticoagulants
(e.g., direct thrombin inhibitors) may be used for anticoagulation while
awaiting the results of serologic testing.
2. Infectious complication rates vary substantially by center and by the manner in
which ECMO-related infections are defined. Standardized infection control
practices should be used for ECMO insertion, maintenance, and removal.
3. Other complications such as limb ischemia, limb engorgement, and vascular
perforation may be a consequence of certain ECMO cannulation approaches
and techniques and will be influenced by the experience of the provider
performing the procedure and the use of radiographic guidance. Prompt
Doppler examination in the ICU will guide interventions.
IX. Economic considerations
A. The implementation across a health system of any novel technology, particularly
for commonly encountered diseases, has to take into consideration the resources
it may require, including financial resources that will vary greatly by region.
There are limited data on the economic impact of ECMO use in ARDS and even
less in ECMO for cardiac failure. The CESAR trial, conducted within the United
Kingdom’s National Health Service, estimated that referral for consideration of
ECMO led to a gain of 0.03 quality-adjusted life-years (QALYs) at 6-month
follow-up, with the predicted cost per QALY of ECMO to be £19,252 (95% CI
£7,622–59,200).
B. Any prospective randomized studies assessing the role of ECMO in
cardiopulmonary failure would benefit from describing the economic impact in
addition to the clinical outcomes, so that hospitals and healthcare systems can
best decide how to allocate the resources appropriately.
X. Ethical considerations
With the advent of technology that is able to entirely support the respiratory or
cardiac system, and to do so for prolonged periods of time, the creation of
ethically challenging situations is inevitable [10].
A. The ability of ECPR to improve survival beyond conventional CPR opens up the
potential for ECPR to be used indiscriminately among patients suffering cardiac
arrest, a practice that has the capacity to prolong suffering for many patients
without changing the ultimate outcome. Whenever possible, evidence-based
criteria ought to be used to identify patients most likely to benefit from ECPR.
B. The lack of destination device therapy in end-stage respiratory failure creates its
own unique dilemma. Patients supported with ECMO as bridge to transplant who
are no longer deemed transplant candidates and yet are dependent on ECMO for
respiratory function have no viable long-term solution, often referred to as a
“bridge to nowhere.” Whether to continue supporting these patients and for how
long, particularly those patients who are sentient, is a fraught situation that often
requires ethics and palliative care consultations and extensive discussions with
the patient and family. Potential bridge-to-transplant candidates ought to be
carefully selected so as to avoid the “bridge-to-nowhere” scenario whenever
possible.
C. Because venoarterial ECMO may adequately support end-organ perfusion in the
absence of native cardiac function, the relevance of CPR, and thus a “Do Not
Resuscitate” (DNR) order, may be murky. This highlights the need to understand
goals of care and not only the procedures to be performed. Even in the absence of
a physiologic benefit of CPR, a DNR order may still help convey the overall
goals of care for the patient, particularly if it is deemed that meaningful recovery
cannot be achieved. At that point, the conversation should focus on limiting or
withdrawing life-sustaining treatments.
REFERENCES
1. Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in
adults. N Engl J Med. 2011;365(20): 1905–1914.
2. Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, Morris A,
et al. Ventilation with lower tidal volumes as compared with traditional tidal
volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J
Med. 2000;342(18):1301–1308.
3. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of
conventional ventilatory support versus extracorporeal membrane oxygenation for
severe adult respiratory failure (CESAR): a multicentre randomised controlled trial.
Lancet. 2009;374(9698):1351–1363.
4. Abrams DC, Brenner K, Burkart KM, et al. Pilot study of extracorporeal carbon
dioxide removal to facilitate extubation and ambulation in exacerbations of chronic
obstructive pulmonary disease. Ann Am Thorac Soc. 2013;10(4):307–314.
5. Abrams D, Combes A, Brodie D. Extracorporeal membrane oxygenation in
cardiopulmonary disease in adults. J Am Coll Cardiol. 2014;63(25 Pt A):2769–
2778.
6. Abrams DC, Brodie D, Rosenzweig EB, et al. Upper-body extracorporeal
membrane oxygenation as a strategy in decompensated pulmonary arterial
hypertension. Pulm Circ. 2013;3(2):432–435.
7. Agerstrand CL, Burkart KM, Abrams DC, et al. Blood conservation in extracorporeal
membrane oxygenation for acute respiratory distress syndrome. Ann Thorac Surg.
2015;99(2):590–595.
8. Abrams D, Javidfar J, Farrand E, et al. Early mobilization of patients receiving
extracorporeal membrane oxygenation: a retrospective cohort study. Crit Care.
2014;18(1):R38.
9. Combes A, Brodie D, Bartlett R, et al. Position paper for the organization of
extracorporeal membrane oxygenation programs for acute respiratory failure in adult
patients. Am J Respir Crit Care Med. 2014;190(5):488–496.
10. Abrams DC, Prager K, Blinderman CD, et al. Ethical dilemmas encountered with the
use of extracorporeal membrane oxygenation in adults. Chest. 2014;145(4):876–882.
V
Perioperative Management
25 Postoperative Care of the Cardiac Surgical
Patient
Breandan L. Sullivan and Michael H. Wall
I. Transition from operating room (OR) to intensive care unit (ICU)

B. The transport process
II. Transfer of care to the ICU team
A. Importance of handoffs
B. Logistics
C. Transition to ICU monitors
D. Initial ventilator settings
E. The actual handoff
F. Laboratory tests/electrocardiogram (ECG)/chest radiograph (CXR)
III. Mechanical ventilation after cardiac surgery
A. Hemodynamic response to positive-pressure ventilation (PPV)
B. Pulmonary changes after sternotomy and thoracotomy
C. Choosing modes of ventilation
D. Liberation from mechanical ventilation
E. Incentive spirometry, deep breathing, and coughing maneuvers
IV. Principles of fast tracking
A. Goals of fast tracking
B. Methods of fast tracking
C. Fast tracking in the postanesthesia care unit (PACU)
D. Utilizing protocols
V. Enhanced recovery after cardiac surgery
A. Goals of enhanced recovery after cardiac surgery
B. Team approach
C. Engaged, empowered team
VI. Hemodynamic management in the postoperative period
A. Monitoring for ischemia
B. Ventricular dysfunction after cardiac surgery
C. Fluid management
D. Managing hypotension
E. Dysrhythmia management
F. Perioperative hypertension
G. Pulmonary hypertension
VII. Postoperative pain and sedation management techniques
A. Systemic opioids
B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
C. Intrathecal opioids
D. Nerve blocks
E. Sedation
VIII. Metabolic abnormalities
A. Electrolyte abnormalities
B. Shivering
C. Acidosis
D. Glucose management
IX. Complications in the first 24 hours postoperatively
A. Respiratory failure
B. Bleeding
C. Cardiac tamponade
D. Pneumothorax
E. Hemothorax
F. Acute graft closure
G. Prosthetic valve failure
H. Postoperative neurologic dysfunction
X. Discharge from the ICU
XI. The transplant patient
XII. Patients with mechanical assist devices
A. Intra-aortic balloon pump (IABP)
B. Ventricular assist device (VAD)
C. Extracorporeal membrane oxygenator (ECMO)
XIII. Family issues in the postoperative period
A. The preoperative discussion
B. Family visitation
C. The role of family support
KEY POINTS
KEY POINTS
1. Transport from the operating room (OR) to the intensive care unit
(ICU) is a critical period for patient monitoring or vigilance.
Emergency drugs and airway equipment should be present, and
adequate transportation personnel (typically three people) should
accompany the patient during transport.
2. Patient “handoff” to the ICU should be consistent, careful, and
structured and should not distract caregivers from continuous
assessment of hemodynamics, oxygenation, and ventilation.
3. Early postoperative respiratory support ranges from full mechanical
ventilation to immediate extubation in the OR, depending upon
institutional practice patterns, anesthetic techniques, and patient
stability. There is no “best” ventilation mode for cardiac surgery
patients.
4. Weaning from mechanical ventilation involves assessment of
oxygenation adequacy (typically PaO2/FiO2 >100 on positive end-
expiratory pressure [PEEP] 5 cm H2O or less), hemodynamic
stability, patient responsiveness to commands, and measured
ventilatory parameters such as vital capacity and the rapid shallow
breathing index (RSBI).
5. Fast-tracking protocols designed to extubate cardiac surgery patients
within several hours of completion of surgery are common. With
such protocols, early postoperative continuous infusions of
propofol or dexmedetomidine may be helpful.
6. Enhanced recovery after cardiac surgery involves a multidisciplinary
approach with physical therapists, occupational therapists,
dieticians, and pharmacists, with the combined goal of shortening
the convalescent time after cardiac surgery.
7. Early postoperative differential diagnosis of hypotension is often
challenging and includes hypovolemia, heart valve dysfunction, left
ventricular (LV) and/or right ventricular (RV) dysfunction, cardiac
tamponade, cardiac dysrhythmia, and vasodilation. Once a diagnosis
has been made, optimal therapy usually becomes clear.
8. Hypertension is not uncommon and must be acutely and effectively
managed to minimize bleeding and other complications such as LV
failure and aortic dissection. The differential diagnoses include pain,
hypothermia, hypercarbia, hypoxemia, intravascular volume excess,
anxiety, and pre-existing essential hypertension, among others.
9. Acute poststernotomy pain most often is managed by administering
intravenous (IV) opioids, but other potentially helpful modalities
include nonsteroidal anti-inflammatory drugs (NSAIDs), intrathecal
opioids, and central neuraxial or peripheral nerve blocks.
10. Early postoperative acid–base, electrolyte, and glucose disturbances
are common. They should be diagnosed and treated promptly.
11. Postoperative bleeding may be surgical, coagulopathic, or both.
Aggressive diagnosis and treatment of coagulation disturbances
facilitates early diagnosis and treatment of surgical bleeding (i.e.,
return to OR for reexploration) and avoidance of cardiac
tamponade.
12. Discharge from the ICU typically occurs in 1 to 2 days. Criteria vary
with cardiac surgical procedures and with institutional capabilities
for post-ICU patient care (e.g., stepdown ICU beds vs. traditional
floor nursing care).
13. Adequate communication with patients’ family members and
adequate family visitation and support greatly facilitate
postoperative recovery.
THE PURPOSE OF THIS CHAPTER is to briefly discuss the transport of the cardiac surgery
patient from the OR to the ICU, the handoff of care from the OR team to the ICU team,
and an approach to common problems that occur in the first 24 hours in the ICU. The
reader is referred to standard critical care text books for discussion of more chronic
ICU problems such as nutrition, infectious disease, sepsis, and multiple organ failure.
I. Transition from operating room (OR) to intensive care unit (ICU)

1. Movement of a critically ill patient in the immediate postoperative period to
the ICU or to an intermediate-level postcardiac surgical recovery area is a
risky business. Inter- or intrahospital transport of critically ill patients is
associated with increased morbidity and mortality [1].
2. The American College of Critical Care Medicine (ACCM) guidelines state that
“during transport, there is no hiatus in the monitoring or maintenance of a
patient’s vital signs” [2].
3. The ACCM guidelines state that there are four major areas to optimize
efficiency and safety of patient transport: communication (or handoffs),
personnel, equipment, and monitoring. Each of these areas will be discussed.
B. The transport process
1. Prior to movement of the patient from OR table to ICU bed
a. Airway/breathing. If patients are suitable candidates for rapid extubation
(see Section IV) and meet standard extubation criteria, they can be extubated
in the OR, or within 6 to 8 hours of arrival in the ICU. If the patient is to
remain intubated, the endotracheal tube should be checked for position and
patency and should be securely attached to the patient. In addition, all chest
tubes and drains should be checked for ongoing bleeding to ensure that
immediate transport from the OR is appropriate and for proper functioning to
avoid hemothorax or pneumothorax during transport.
b. Circulation. The patient should be hemodynamically stable prior to transport.
In general, if the patient requires frequent bolus doses or increasing doses of
vasoactive drugs, it is better to stabilize prior to transport.
(1) Pacemaker. Proper settings and functioning of the pacemaker should be
checked at this point.
c. Coagulation. Bleeding should be controlled, and a plan for correction of
ongoing coagulopathy should be made prior to transport.
d. Metabolic. Metabolic abnormalities (glucose, electrolyte, and acid–base)
should be identified and corrected as much as possible prior to the transport.
e. Brief telephone report. A brief verbal report to the ICU team should be
provided prior to transport (see Section IV).
f. Special bed. Patients at high risk for development of pressure ulcers (pre-
existing pressure ulcers, poor nutritional status, elderly, poor ventricular
function, etc.) should be placed on special beds/mattresses in the OR.
2. Patient movement from the OR table to the transport bed. Movement can
cause hemodynamic instability, fluid shifts, and arrhythmias. Movement can
also cause inadvertent loss of airway, vascular access, and interruption of
intravenous (IV) infusions. Residual intracardiac air is a complication of many
procedures (e.g., valve replacement) and this air may be easily dislodged when
moving the patient. In addition, the position of a pulmonary artery catheter
(PAC) can be altered during patient movement. Confirmation of the PAC
position (i.e., pulmonary artery waveform rather than pulmonary artery
occluded or right ventricular [RV] waveform) before and after patient
movement should be done. Sudden onset of dysrhythmia should trigger
examination of the PAC. Ready access to a large-bore IV infusion port and to
any ongoing or continuous infusions of medications is critical to managing this
period safely and being able to respond promptly.
CLINICAL PEARL Although it is difficult to stop a “moving train,” if hemodynamic
deterioration occurs in the OR even after transfer from the OR table to the ICU bed, it is
better to stop, reassess, and stabilize the patient than to proceed with transport.
3. Transport from the OR to the ICU
a. Personnel. Generally, at least three members of the operative team should
transport the patient from the OR to the ICU. This should include a member of
the anesthesia care team, surgical team, and a nurse or technician. Additional
team members (perfusionists, respiratory therapists, etc.) may be needed for
patients on mechanical assist devices, inhaled pulmonary vasodilators, or
those with acute lung injury (ALI) who require a transport ventilator.
b. Equipment. ACCM guidelines recommend a minimum of a blood pressure
monitor, pulse oximeter, and cardiac monitor/defibrillator for all transports of
critically ill patients [1]. An additional monitor to consider is continuous end-
tidal CO2 for intubated patients. Equipment and drugs for emergency airway
management should be immediately available. An oxygen (O2) source with
enough O2 for the duration of transport plus 30 minutes must be available.
Basic emergency advanced cardiac life support (ACLS) drugs should be
immediately available. All infusions should be checked and all pumps should
be fully charged prior to transport. Supplemental O2 should be provided to all
extubated patients. Ambu bag ventilation (with or without positive end-
expiratory pressure [PEEP] valves) can be used for most patients. Transport
ventilators may be needed for patients with ALI or acute respiratory distress
syndrome (ARDS). Mechanical support device batteries should be
immediately available.
c. 1 Monitoring. ACCM guidelines state that critically ill patients should “. . .
receive the same level of basic physiologic monitoring and transport as they
had in the ICU . . . .” The same concept applies to patients leaving the OR [1].
d. IV access. Every effort must be made to avoid a “tangle” of IV tubing. In
general, it is best to have one large-bore IV identified for rapid administration
of fluids or emergency medications. This line should be easily identified and
immediately accessible. Bolus medications should ideally be given via a
central venous site for faster onset. Finally, all IV fluid bags should be full
enough to give fluid boluses as needed.
e. Sedation/analgesia. In extubated patients, it is best not to give boluses of
narcotics during transport. It is probably better and safer to give analgesics
prior to transport and then give additional medications after arrival in the
ICU. In intubated patients, it is best to start the postoperative sedation and
analgesia plan prior to transport to minimize the need to give bolus
medications during transport.
II. Transfer of care to the ICU team
A. Importance of handoffs
The handoff of care from the OR team to the ICU team is a surprisingly
hazardous and dangerous event. The Joint Commission identified that
communication failure was the root cause of 65% of sentinel events in 2006 [2].
Numerous studies have shown that the best handoffs occur when they are
structured, standardized, and use checklists [3–6]. Recently, many centers are
developing handoff tools from the electronic medical record (EMR) [7].
B. Logistics
Ideally, each member of the OR and ICU teams should have specific tasks and the
handoff should occur in a standardized sequence [3,4]. One simple sequence
would be transition from transport to ICU monitor, then initial ventilator settings,
and then formal structured handoff.
C. 2 Transition to ICU monitors
The patient must be continuously monitored during this process. Ideally, each
parameter (ECG, O2 saturation, etc.) should be transferred from the transport
monitor to the ICU monitor in series, as opposed to unhooking all of them at once
and then hooking them up one at a time. Some systems allow for all the monitors
to be almost instantly switched over by removing the entire “brick” at once. In
any event, based on local monitors, there should be an orderly transition between
both sets of monitors.
CLINICAL PEARL Amidst the flurry of activity upon arrival in the ICU, the
anesthesiologist must keep a “10,000-feet” oversight perspective and intervene as
needed to ensure optimal patient management during this transition.
D. Initial ventilator settings
Intubated patients must have their endotracheal tube evaluated for patency,
security, and position. This can be accomplished with a chest x-ray or with a
bedside bronchoscopy. Ventilator parameters including ventilator mode, rate,
fraction of inspired oxygen (FiO2), PEEP, and pressure support must be selected.
The patients who have no respiratory effort can be placed on assist-control (AC)
or synchronized intermittent mandatory ventilation (SIMV) with an adequate rate,
tidal volume, and PEEP. The patients who have regained spontaneous respiratory
effort can be placed on SIMV or pressure support ventilation (PSV). PSV and
SIMV modes can be combined. Excessive use of PEEP impedes venous return
and may impair RV performance. The application of PEEP may decrease
mediastinal bleeding, although the literature on this topic is inconsistent and this
technique must be used with caution, as PEEP’s adverse effects on
hemodynamics are well established.
E. The actual handoff
Once the monitors have been transferred to the ICU bedside monitor and
oxygenation and ventilation have been confirmed, a structured handoff should
occur. This should include the patient’s name, age, allergies, medical history, all
significant intraoperative events, and the immediate postoperative plan. One
structured handoff form generated from the EMR is shown (see Fig. 25.1). Time
should be allowed for questions and answers from all members of OR and ICU
teams.
1. The initial review of the patient upon his or her arrival to the recovery area
includes the patient’s history, age, height, weight, pre-existing medical
conditions, any allergies, a list of preoperative medications, and review of the
most current laboratory findings (with special emphasis on potassium and
hematocrit [Hct]). The report should include a detailed review of the patient’s
cardiac status, including ventricular dysfunction, valvular disease, coronary
anatomy, and details of the surgical procedure.
2. An anesthetic review should be presented, which includes types and location
of IV catheters and invasive monitors, along with any complications that
occurred during their placement. A brief description of the anesthetic technique
should be discussed to help plan for a smooth emergence. Any difficulties with
airway management should be emphasized, particularly when weaning and
extubation protocols are utilized. The presence or absence of obstructive sleep
apnea should be discussed and the need for continuing patient’s home
continuous positive airway pressure (CPAP) or bilevel positive airway
pressure (BiPAP) should be addressed. A post-cardiopulmonary bypass (CPB)
synopsis should be reported, including the use of vasoactive, inotropic, and
antiarrhythmic drugs, as well as any untoward events such as arrhythmias and
presumed drug reactions. This should also include an update on the presence or
absence of bleeding prior to chest closure.
3. Early upon arrival to the ICU, the patient’s heart rate, rhythm, and blood
pressure should be determined. If the heart is being paced, the settings should
be reviewed and all electrodes identified and secured, as the patient may be
dependent on the device.
a. If the patient has a permanent pacemaker or defibrillator, the settings should
also be reviewed. The devices should be interrogated in the ICU and
antitachycardia treatment should be activated. While waiting for the device to
be activated, external defibrillator pads should be placed on the patient and a
defibrillator should be immediately available [8].
b. If the patient has a ventricular assist device (VAD), the monitor should be
attached to a wall-based energy supply and the output of the device should be
attached to the display module. The settings of the device and the position and
location of the cannula should be reviewed.
c. For patients on extracorporal membrane oxygenation (ECMO), the O2 and air
supplies should be attached to the wall outlet supplies, and backup tanks
should be available (see Chapter 24).
F. Laboratory tests/electrocardiogram (ECG)/chest radiograph (CXR)
After the handoff is complete and questions are answered, baseline ECG, CXR,
and laboratory tests should be obtained. An initial arterial blood gas (ABG)
should be drawn to ensure the adequacy of oxygenation and ventilation, whether
the patient is on a mechanical ventilator or breathing spontaneously. Potassium,
blood glucose, and Hct levels should be obtained. Acid–base status should be
reviewed from ABGs. Baseline coagulation parameters, including prothrombin
time (PT), activated partial thromboplastin time (aPTT), and platelet count
should be acquired if the patient is bleeding excessively.
FIGURE 25.1 Structured handoff form generated from electronic medical records (EMRs).
FIGURE 25.2 The effect of increasing and decreasing intrathoracic pressure (ITP) on the pressure–volume loop of the
cardiac cycle. The slope of the left ventricular (LV) end-systolic pressure–volume relationship (ESPVR) is proportional to
contractility. The slope of the diastolic LV pressure–volume relationship defines diastolic compliance [10].
III. Mechanical ventilation after cardiac surgery

A. Hemodynamic response to positive-pressure ventilation (PPV)
Heart–lung interactions with PPV are complex [9,10]. In patients with normal left
ventricular (LV) function, PPV increases intrathoracic pressure (ITP), which
reduces venous return, afterload, and stroke volume (SV) and cardiac output
(CO) (see Fig. 25.2). On the other hand, in patients with LV dysfunction,
decreased preload and afterload actually can improve LV performance and CO
(see Fig. 25.3). PEEP further increases ITP and decreases venous return.
FIGURE 25.3 The effect of increasing and decreasing intrathoracic pressure (ITP) on the left ventricular (LV) pressure–
volume loop of the cardiac cycle in congestive heart failure when LV contractility is reduced and intravascular volume is
expanded. The slope of the left ventricular end-systolic pressure–volume relationship (LV ESPVR) is proportional to
contractility. The slope of the diastolic LV pressure–volume relationship defines diastolic compliance [10].
CLINICAL PEARL During transport and transition from OR to ICU, always consider
acute changes in ventilation (e.g., tidal volume, mean airway pressure, PEEP) as the
explanation for new-onset hypotension.
B. Pulmonary changes after sternotomy and thoracotomy
Cardiac surgery requires either a midline sternotomy or a thoracotomy. Both of
these approaches temporarily compromise the function of the thoracic cage,
which acts as a respiratory pump. One week after cardiac surgery, there is a
significant reduction in total lung capacity, inspiratory vital capacity, forced
expiratory volumes, and functional residual capacity compared to preoperative
values [11]. Even at 6 weeks postoperatively, total lung capacity, inspiratory
vital capacity, and forced expiratory volume remained significantly below
preoperative values. These findings suggest a marked tendency toward
postoperative atelectasis and the possibility of hypoxemia from increased
physiologic shunting. These changes in chest wall function can increase
physiologic shunt to as much as 13% (compared to a baseline normal value of
5%).
In addition to these changes in mechanics and volumes, there are also
abnormalities in gas exchange, compliance, and work of breathing [12]. The
cause of these abnormalities is multifactorial and may include inflammation,
reperfusion, and other mechanisms.
C. Choosing modes of ventilation
1. Extubated patient. If the patient was extubated in the OR, supplemental
oxygen may be all that is necessary postoperatively. Following a general
anesthetic, patients will exhibit a mild increase in the PaCO2. Aggressive
pulmonary toilet and frequent incentive spirometry must be performed to
prevent the atelectasis and hypoxemia that may develop from changes in chest
wall function.
2. Noninvasive ventilation (NIV). NIV can be used to treat or prevent
postoperative respiratory failure and has been shown to prevent reintubation,
decrease ventilator-associated pneumonia, and improve outcomes [13,14]. A
sample protocol for the use of NIV is shown in Figure 25.4. Contraindications
are shown in Table 25.1. Two types of NIV are commonly used:
a. Continuous positive airway pressure (CPAP), where constant airway
pressure is applied during both inspiration and expiration.
b. Bilevel positive airway pressure (BiPAP), where PSV is applied during
inspiration and PEEP is applied during expiration.
3. Intubated patient
a. 3 If a patient returns from the OR with an endotracheal tube in place, an
individualized plan of care should be developed for that patient. The choice
of mechanical ventilation mode is based on the patient’s inherent respiratory
effort. If a patient demonstrates an inspiratory effort, PSV or SIMV can be
used.
If a patient is not demonstrating spontaneous respiratory effort, AC or SIMV
should be selected. In AC, a set respiratory rate (RR) is delivered regardless
of the patient’s respiratory effort. If a spontaneous breath is initiated, the
ventilator detects the trigger and delivers a set tidal volume (or pressure if on
pressure control ventilation). In SIMV, a set RR is also delivered, but
spontaneous breaths over the set rate are not fully supported (like they are in
AC) but are dependent on the patient’s effort.
b. Patients with severe hypoxemia, respiratory failure, or (mild, moderate, or
severe) ARDS will need to be ventilated in a way that minimizes or avoids
further “ventilator-induced lung injury” [15]. There have been several recent
reviews on the ICU management of ARDS [16–20]. In the early stages of
ARDS, complete control over a patient’s oxygenation and ventilation is
needed. This often involves deep sedation with aggressive titration of PEEP
and often neuromuscular blockade as well.
Initial ventilator settings in patients with ARDS would include
(ardsnet.org):
(1) Any ventilator mode
(2) Tidal volume (VT) 6 mL/kg of predicted (i.e., ideal) body weight
(3) Set RR, so minute ventilation is adequate, 18 to 22 breaths/min
(4) Adjust VT and RR to achieve a goal pH of 7.30 to 7.40 and plateau
pressure <30 cm H2O.
IGURE 25.4 Protocol for initiation of curative postoperative noninvasive ventilation (NIV). PSV, pressure support ventilation;
EEP, positive end-expiratory pressure; FiO2, fraction of inspired oxygen; SpO2, pulse oximetry saturation [13].
4. Weaning from mechanical ventilation is multifactorial. In many

postoperative environments, this can best be accomplished by using an
algorithm so that weaning can proceed methodically and without interruption.
Figure 25.5 shows an algorithm that could facilitate efficient weaning. Prior to
attempts at weaning, the following parameters must be met:
a. Normothermia
b. Hemodynamically stable
TABLE 25.1 Contraindications to noninvasive positive-pressure ventilation
IGURE 25.5 Protocolized flow chart for ventilator discontinuation [22]. SBT, spontaneous breathing trial.
(1) Stable vasoactive drug requirements

(2) Not requiring increasing doses (infusion rates) or boluses of inotropes or
vasopressors
c. Stable heart rate and rhythm
d. Normal acid–base and metabolic state
e. Not bleeding excessively (criteria vary, but generally <150 mL/hr chest tube
drainage)
If these criteria are met, the patient is ready to be liberated from mechanical
ventilation.
D. Liberation from mechanical ventilation
1. Current recommendations are that patients should be liberated from mechanical
ventilation as quickly as possible, and an attempt should be made at least daily
[21,22].
2. The first step is to assess the following to determine “readiness to wean”:
a. PaO2/FiO2 >200 mm Hg with PEEP ≤5 cm H2O
b. Hemodynamically stable
c. Awake, alert, and following commands
d. Able to cough effectively
e. Adequate reversal of neuromuscular blockade (negative inspiratory force
[NIF] of 30 cm H2O or more, able to lift head off bed >5 seconds, no fade on
train-of-four, vital capacity >15 mL/kg, etc.)
f. A rapid shallow breathing index (RSBI), defined as RR divided by tidal
volume in liters (RR/VT) <80 to 100 breaths/min/L after a 2- to 3-minute
spontaneous breathing trial (SBT)
3. If the patient passes the readiness to wean screen, a trial of spontaneous
ventilation via T-piece or with low levels of PSV (5 to 7 cm H 2O) and PEEP
(≤5 cm H2O) for 30 to 120 minutes is done. At the end of the trial, if the RSBI
is <80 to 100, the patient should be considered for extubation if they meet the
following final criteria:
a. Awake and alert
b. Able to cough and clear secretions
(1) Patients who require suctioning more often than every 2 hours are at a
higher risk for reintubation.
c. No airway edema (as judged crudely by edema of tongue and presence of leak
when endotracheal tube cuff is deflated)
d. Hemodynamically stable
(1) Less than 20% change in HR, BP, pulmonary artery pressures, cardiac
index, etc., during the trial.
e. Normal oxygenation and ventilation
4. If the patient meets the criteria, extubation can be performed.
5. If the patient does not meet the criteria, correctable causes need to be identified
and optimized prior to another attempt.
6. Patients who repeatedly fail SBTs may require more long-term weaning from
mechanical ventilation [21].
CLINICAL PEARL Although specific protocols for weaning and extubation can vary, it
is critical to establish a checklist for this process and to routinely apply it to every patient.
E. Incentive spirometry, deep breathing, and coughing maneuvers
Patients must be encouraged to use incentive spirometry and to do deep
breathing and coughing maneuvers after extubation to reduce atelectasis. There
are numerous physiologic causes of hypoxemia. Diffusion abnormality, low FiO2,
hypoventilation, and V/Q mismatch along with shunt comprise the list of
possibilities, with atelectasis (causing shunt) being the most common. If
hypoxemia persists and atelectasis is the presumed cause, NIV can be used to
improve oxygenation and decrease shunt.
IV. Principles of fast tracking
A. Goals of fast tracking
Fast-track (FT) cardiac surgery was introduced to speed recovery and increase
efficiency of limited resources (ICUs). Early extubation, ambulation, cardiac
rehabilitation, and discharge are key goals of an FT program. Numerous
randomized controlled trials have shown that FT cardiac surgery is safe and less
expensive than conventional cardiac anesthesia [23]. Initially, FT protocols were
limited to young, low-risk patients; however, it can be used safely in older and
higher-risk patients as well [24].
B. 5 Methods of fast tracking
A variety of anesthetic techniques can be used to facilitate fast tracking. Shorter-
acting IV narcotics can be combined with intrathecal opioids to enhance
postoperative analgesia [25,26]. Propofol infusions are often used because of a
predictable and rapid recovery profile that is almost independent of the duration
of infusion, assuming use of targeted propofol infusions or a processed EEG
endpoint. This property makes propofol a very good sedative agent in the early
postoperative management of FT cardiac surgery patients, assuming that
hemodynamic stability is not compromised by its use. Caution is needed when
short-acting agents are used intraoperatively to set the stage for early extubation,
as the incidence of intraoperative awareness may be as high as 0.3% [27].
Dexmedetomidine is an IV α2-adrenergic agonist that may facilitate fast tracking
in cardiac surgical patients. Dexmedetomidine possesses both sedative and
analgesic properties and allows patients to follow commands despite adequate
sedation, and it most often does not require weaning prior to extubation.
Dexmedetomidine does not possess reliable amnestic properties.
Dexmedetomidine has been evaluated in a number of trials in the ICU in both
cardiac surgery and noncardiac surgery patients. When compared to propofol,
midazolam, and morphine in separate trials, dexmedetomidine has been shown to
provide adjunctive analgesia, induce less delirium, and decrease the duration of
mechanical ventilation [28–31].
C. Fast tracking in the postanesthesia care unit (PACU)
Many institutions prepare for the postoperative management of cardiac surgery
patients by developing enhanced stepdown or PACUs, where postoperative
management can occur safely and efficiently. These units require nurses who
understand fast-tracking techniques, so that patients who have undergone cardiac
surgery can move smoothly through early extubation in preparation for early
transfer to a regular nursing unit. These specialized PACUs can be very effective
in providing FT techniques because of their focused effort in caring for FT
cardiac surgery patients [32]. Some investigators have even implemented
ambulatory cardiac surgery programs [33]!
D. Utilizing protocols
Developing and utilizing institution-specific FT protocols revolves around
systematic plans for weaning patients from ventilators and managing routine
postoperative issues to facilitate the progression toward early ICU and hospital
discharge. Protocols ideally address most issues before they occur. Fast-tracking
protocol development should involve all members of the perioperative care team
before implementation.
V. Enhanced recovery after cardiac surgery
A. 6 Goals of enhanced recovery after cardiac surgery
Abdominal surgery protocols have successfully adopted enhanced recovery
protocols with the goals of decreasing surgical stress response, decreasing length
of stay and minimizing iatrogenic injury, and ultimately improving patient
outcomes [34]. In the United States, cardiac surgical practice has been slower to
adopt enhanced recovery practices. Many cardiac surgery patients undergo
similar recovery and monitoring protocols regardless of their degree of illness
and complexity of surgery [35].
B. Team approach
Modern ICUs treat patients with an intensivist-based, multidisciplinary approach
that incorporates the proven benefits of having patients that are awake and are
able to participate in early mobilization and rehabilitation. Along with early
mobilization, multidisciplinary teams strive for early postoperative enteral
nutrition and rapid deescalation of invasive monitors in order to prevent
hospital-acquired infections. This is in sharp contrast to previous models of
patients on mechanical ventilation that were frequently heavily sedated and often
paralyzed until their critical illness resolved.
C. Engaged, empowered team
This approach involves an engaged and empowered team of physicians, intensive
care nurses, physical therapists, dieticians, and pharmacists. Survival at
discharge is no longer the main focus of critical care physicians. Retrospective
data have suggested that patients who survive critical illness suffer from
problems that may be preventable in the ICU. A transition in critical care
research in the past 15 years has challenged previous beliefs. Recent research
addresses morbidities associated with bed rest, oversedation, iatrogenically
induced delirium, posttraumatic stress disorder, and weakness associated with
critical illness. In this evolving practice, patients are awake despite mechanical
ventilation, ambulated despite advanced therapies like ECMO, and are
participating in family meetings and major clinical decisions [36].
VI. Hemodynamic management in the postoperative period
A. Monitoring for ischemia
Ischemia can be detected by utilizing a continuous ECG with ST-segment
analysis, although there is a slight delay in diagnosis of ischemia using this
method. Many bedside ECG monitoring systems have ST-segment analysis built
into their software algorithms, which is a cost-effective method of monitoring for
ischemic events. It is important to ensure that the ECG is in diagnostic mode
when evaluating potentially ischemic ECG changes. In monitor mode, the ECG
filters out some electrical input (to decrease artifact) and may not accurately
reflect ischemic changes. If continuous ST-segment analysis is chosen, leads II
and V4 or V5 should be monitored, and sensitivity improves if three leads are
used (leads I, II, and V4 or V5; or leads II, V4, and V5). When in doubt, proceed
to a 12-lead ECG, which, despite limitations, is always more definitive than an
electronic monitor. Other indicators of myocardial ischemia include pulmonary
artery pressures and CO, which tend to be less reliable (and oftentimes late)
markers of myocardial ischemia. Transesophageal echocardiogram (TEE)
segmental wall-motion abnormalities represent the most sensitive early detector
of myocardial ischemia, but continuous monitoring usually is not done because
the TEE probe (if used) typically is removed at the end of surgery. It is important
for the intensivist to recognize the changes in ECG and hemodynamics that can
result from temporary epicardial ventricular pacing. Epicardial ventricular
pacing can mimic septal wall dyskinesis that actually represents a pacemaker-
induced change in the ventricular depolarization sequence.
Intraoperative and ongoing postoperative ischemia can be detected as soon as
6 hours after the event begins by examining some specific cardiac markers. The
earliest and most useful marker is cardiac troponin I (cTnI). The ability to
measure cTnI is particularly useful in cases where ECG monitoring is difficult to
interpret, such as with left bundle branch block or LV hypertrophy. Elevated
plasma levels of this biologic marker provide clear evidence of ischemia and
may suggest a diagnosis of myocardial infarction.
In postoperative cardiac surgical patients, all of the above methods have
significant problems. Most often, myocardial ischemia is suspected by ECG
changes or unexpected increases in vasoactive drug requirements. The diagnosis
is best confirmed by transthoracic echocardiography (TTE) or TEE. Diagnosis
may require cardiac catheterization. Treatment options include returning to the
OR or medical management.
CLINICAL PEARL Since traditional diagnostic markers for myocardial ischemia
often lack sensitivity or specificity after cardiac surgery, TTE or TEE should be used
liberally to assess for new wall-motion disturbances when ischemia is suspected.
B. Ventricular dysfunction after cardiac surgery
1. Causes. In addition to pre-existing ventricular dysfunction, postoperative
causes of ventricular dysfunction include inadequate myocardial protection,
myocardial stunning, incomplete revascularization, and reperfusion injury.
Preoperative predictors of postoperative ventricular dysfunction include
cardiac enlargement, advanced age, diabetes mellitus, female gender, high LV
end-diastolic pressures at cardiac catheterization, small coronary arteries (for
coronary revascularization procedures), and LV ejection fraction less than 0.4.
Intraoperative predictors include longer CPB and aortic cross-clamp times.
These factors increase the likelihood of needing inotropic support in the
postoperative period. The patients who have normal preoperative cardiac
performance and short periods of CPB have a much lower likelihood of
requiring postoperative inotropic support. The patients who fail to achieve
adequate hemodynamics even with pharmacologic support will require
mechanical cardiac assistance such as an intra-aortic balloon pump (IABP) or
VAD. Recently, Hollenberg has written an excellent review article on
vasoactive drugs in circulatory shock [34].
The myocardium has both β1- and β2-adrenergic receptors, which contribute
to inotropy and lusitropy (enhanced diastolic relaxation). β-Adrenergic
agonists (β-agonists) are often the first-line agents used when there is a need to
improve ventricular function after CPB. Depletion of endogenous
catecholamines and the resulting β-receptor downregulation can blunt the
response to β-agonists. Increased G-inhibitory proteins, reperfusion injury,
tachycardia, incomplete revascularization, nonviable myocardium,
preoperative use of β-agonists, and acute or chronic heart failure also may
attenuate the response to β-agonists.
2. Treatment
a. Catecholamines. The inotropic response to β1/β2-adrenergic receptor
stimulation occurs via activation of the Gs protein and adenylyl cyclase
leading to increased intracellular cyclic adenosine monophosphate (cAMP). It
is important to recognize that lusitropy is an active, energy-consuming
process; impaired ventricular relaxation (diastolic dysfunction) can cause
heart failure alone or in combination with systolic dysfunction. Until recently,
there have been no head-to-head clinical trials comparing the clinical
outcomes of inotropes and vasopressors. In a trial of 30 patients with
dopamine-resistant cardiogenic shock, the patients were randomized to
receive either epinephrine alone or dobutamine in combination with
norepinephrine. Both groups experienced an increase in cardiac index and a
decrease in their plasma creatinine concentrations. The group receiving
epinephrine experienced more arrhythmias, transient lactic acidosis, and a
decrease in splanchnic perfusion [37].
b. Phosphodiesterase type III inhibitors (amrinone and milrinone) augment β-
adrenergic–mediated stimulation by inhibiting the breakdown of cAMP.
Phosphodiesterase inhibitors (PDEIs) act either additively or synergistically
with β-adrenergic agonists. PDEIs appear to have anti-ischemic effects and
may favorably alter myocardial oxygen consumption [38]. PDEIs can be
added to β-agonist therapy or employed as a first-line inotrope. Because
PDEIs also induce systemic and pulmonary vasodilation (sometimes they are
termed inodilators), clinical paradigms that favor their use include pulmonary
hypertension, RV failure, aortic or mitral valvular regurgitation, and
acute/chronic β1/β2-adrenergic receptor desensitization (long-standing
congestive heart failure [CHF], use of β-agonist therapy preoperatively).
c. Levosimendan is a novel inotrope that, at this time, is neither FDA-approved
nor available in North America. Levosimendan is a myofilament “calcium
sensitizer,” which results in increased inotropy by improving the efficiency of
the coupling of force-generating myocyte proteins in response to a given level
of calcium [39]. Like PDEIs, levosimendan may augment inotropy without
significantly increasing myocardial oxygen consumption, thus improving the
myocardial oxygen supply/demand balance. In a recent meta-analysis in
postoperative coronary artery bypass grafting (CABG), levosimendan was
associated with improved mortality and morbidity [40].
d. B-type natriuretic peptide (nesiritide) has been favored by some for the
medical management of CHF [41–45], although some work also associates the
use of this agent with increased mortality in that setting. The role of nesiritide
in the cardiac surgical population remains ill-defined.
In patients with severely impaired cardiac performance, additional
monitoring may be required to ascertain if the patient has optimal myocardial
function. Oximetric PACs can provide real-time determinations of mixed
venous oxygen saturation (SvO2). A normal SvO 2 value of 75% corresponds
to a PaO2 of approximately 40 mm Hg. Reductions in SvO2 result from either
decreased oxygen delivery (decreased CO, decreased hemoglobin
concentration, or decreased arterial oxygen saturation) or increased oxygen
consumption. A sustained SvO 2 below 40% is associated with increased
morbidity and mortality. Similarly, some practitioners choose to use PACs
with continuous cardiac output (CCO) determination in such patients or with
both SvO2 and CCO.
C. Fluid management
Managing postoperative fluids after cardiac surgery can be challenging [41]. The
effects of hypothermia (vasoconstriction) and hyperthermia (vasodilation)
commonly complicate fluid management, especially in the first few hours after
cardiac surgery. Central venous pressure (CVP) and PAC are frequently utilized
in the cardiac surgical population; however, it is imperative to recognize that
these monitors measure pressure as a surrogate estimate of volume and/or
cardiac performance. Filling pressures (CVP, pulmonary artery occlusion
pressure [PAOP], and pulmonary artery diastolic pressure [PADP]) poorly
assess total blood volume and volume responsiveness [46]. Volume
responsiveness is defined by an increase in cardiac index of >15%, in response
to a fluid challenge. For mechanically ventilated patients who have a regular
respiratory pattern, the pulse pressure variation on an arterial pressure waveform
can be a highly useful tool in predicting a hypotensive patient’s response to a
fluid challenge [47–49].
Cardiac surgical procedures, especially those involving CPB, typically result
in fluid sequestration into the interstitial compartment. In addition to the changes
in circulating blood volume from blood loss and other factors, fluid shifts into or
out of the interstitial or the intracellular compartments can be anticipated in the
hours following cardiac surgery. Most cardiac surgery patients reach the
recovery area with excess total-body fluids present that must eventually be
mobilized. Healthy patients who have adequate cardiac and renal function
typically diurese these fluids over the first two postoperative days without
assistance. Other cardiac surgery patients, such as the elderly or those with renal
or cardiac dysfunction, may require diuretic drugs (or possibly dialysis or
hemofiltration) to remove excess body water.
Management of blood components, particularly packed red blood cells
(PRBCs), in the cardiac surgical population is controversial [50,51]. Both
transfusion of blood products and anemia are associated with increased
perioperative morbidity and mortality. Even though cardiac surgical patients
frequently require allogeneic blood products, establishing a transfusion trigger is
difficult. Most patients probably require transfusion of PRBC at an Hct less than
or equal to 21% (hemoglobin concentration [Hgb] less than or equal to 7 g/dL),
and few or none require transfusion when Hct is greater than or equal to 30%
(Hgb greater than or equal to 10 g/dL).
CLINICAL PEARL Hemodynamic measurements such as cardiac output, stroke
volume, and pulse pressure variation more reliably assess the potential need for
additional IV fluids than measurement of cardiac filling pressures.
D. Managing hypotension
Systematic evaluation of preload, afterload, contractility, and heart rate and
rhythm should be performed in the hypotensive patient. If preload is adequate and
an acceptable heart rate and a normal cardiac rhythm are present, hypotension
represents either inadequate myocardial function or vasodilation. Inadequate
cardiac function is managed with inotropes. Vasodilation is managed with
vasoconstrictors.
1. Vasodilatory shock. Eight percent of cardiac surgery patients experience
refractory vasodilatory shock after CPB. This refractory shock is associated
with increased mortality (as high as 25%). These patients do not respond to
traditional treatments, vasopressors, or volume expansion. The causes of the
problem are usually multifactorial: long CPB duration, preoperative use of
angiotensin-converting enzyme inhibitors (or angiotensin-receptor blockers) or
calcium channel blockers, heart transplantation, VAD placement, and
myocardial dysfunction. Small clinical trials have shown improved morbidity
and mortality in this patient population with the use of an IV bolus of methylene
blue followed by a continuous infusion [52]. Arginine vasopressin and high-
dose hydroxocobalamin [53] may also be useful.
2. 7 Two other causes of hypotension that are difficult to diagnose without the
aid of transesophageal echocardiography are systolic anterior motion (SAM) of
the mitral valve and cardiac tamponade.
3. SAM of the mitral valve should be assessed in the OR in patients undergoing
mitral valve repair or septal myectomy. A c-sept distance (see Fig. 25.6) of 2.5
cm or less is associated with a high risk of SAM [54].
FIGURE 25.6 Schematic demonstrating the transesophageal echocardiographic measurements performed prior to and after
mitral valve repair. The biplane image, obtained from the esophageal location at zero degrees, includes the left atrium (LA), left
ventricle (LV), mitral valve, and the LV outflow tract. Lengths of the anterior and posterior leaflets were obtained using the
middle scallops. AL, anterior leaflet length; Coapt Ann, distance from the mitral coaptation point to the annular plane; C Sept,
distance from the mitral coaptation point to the septum; LVIDs, LV internal diameter in systole; PL, posterior leaflet length
4. Tamponade. Postcardiac surgery tamponade should be considered, especially
if the patient is demonstrating signs of shock from low CO. A large series of
patients diagnosed with postcardiac surgery tamponade demonstrated that the
classical diagnostic signs such as equalizing filling pressures, increased jugular
venous pressure, and pulsus paradoxus are frequently not present.
Echocardiography can aid in the diagnosis; however, tamponade is a
constellation of symptoms rather than a single echocardiographic finding [55].
CLINICAL PEARL After cardiac surgery, cardiac tamponade can be localized and is
best diagnosed by careful echocardiographic interrogation.
E. Dysrhythmia management
Managing postoperative dysrhythmias constitutes an important part of ICU care in
cardiac surgery patients. A variety of atrial or ventricular dysrhythmias can
occur. Patients with ongoing myocardial ischemia, possibly from incomplete
revascularization or myocardial stunning, are predisposed to dysrhythmias.
Atrial fibrillation is the most common dysrhythmia to occur after cardiac surgery,
and it may occur in as many as half of the patients who undergo myocardial
revascularization using CPB. Useful drugs for treating atrial fibrillation include
magnesium, digoxin, diltiazem, esmolol, and amiodarone [56].
It has been shown that various preoperative or postoperative
pharmacologic prophylactic strategies may reduce the incidence of
postoperative atrial fibrillation or other atrial dysrhythmias [57–59]. It is
important to identify the patients who are at increased risk for developing
perioperative atrial fibrillation. These include patients who have a previous
history of atrial fibrillation; have undergone a combination valve and CABG
procedure; are receiving inotropic support; or have pre-existing mitral valve
disease, lung disease, or congenital heart disease. Prophylaxis against atrial
fibrillation may decrease both the number of days spent in the ICU and the total
length of stay in the hospital. Administration of a long-acting β-adrenergic
receptor antagonist (i.e., atenolol or metoprolol) is frequently initiated on the
first postoperative day following cardiac surgery.
The prophylactic use of corticosteroids, and particularly hydrocortisone, has
been shown in a recent meta-analysis of randomized controlled trials to be
effective in decreasing the incidence of atrial fibrillation in a high-risk patient
population [60,61]. It appears that a single dose of steroids during induction of
anesthesia is sufficient to provide this benefit.
In the context of arrhythmia prevention, it is particularly important to maintain
normal magnesium and potassium concentrations perioperatively [62,63].
F. Perioperative hypertension
Perioperative hypertension can result from a number of causes:
1. 8 Etiologies of acute postoperative hypertension include emergence from
anesthesia, hypothermia, hypercarbia, hypoxemia, hypoglycemia,
intravascular volume excess, pain, and anxiety. One must consider iatrogenic
causes such as administration of the wrong medication or use of a
vasoconstrictor when it is not necessary.
2. Another cause of postoperative hypertension is withdrawal from preoperative
antihypertensive medications. The β-blockers and centrally acting α2-agonists
(clonidine) are known to elicit rebound hypertension upon withdrawal.
3. Unusual causes include intracranial hypertension (from cerebral edema or
massive stroke), bladder distention, hypoglycemia, and withdrawal syndromes
(e.g., alcohol withdrawal syndrome, withdrawing from chronic opioid use).
4. Rare causes to consider include endocrine or metabolic disorders such as
hyperthyroidism, pheochromocytoma, renin–angiotensin disorders, and
malignant hyperthermia.
G. Pulmonary hypertension
Pulmonary hypertension may occur after cardiac surgery, the causes of which can
be divided into new-onset acute pulmonary hypertension and continuation of a
more chronic pulmonary hypertensive state. A primary consideration in the
evaluation of pulmonary hypertension is the effect on RV performance.
Echocardiography is critically important in diagnosing right heart failure.
Pulmonary artery pressures may decrease, and CVP may increase in the presence
of worsening right heart failure. Because of the unique geometry of the RV,
traditional echocardiography measurements of LV function cannot be applied to
RV performance. Specific validated measurements such as tricuspid annular
plane systolic excursion index [64] or Tei index [65,66] should be used to assess
the RV function. Pulmonary hypertension and RV failure are particularly
problematic following heart or lung transplantation and VAD placement [67].
1. Chronic pulmonary hypertension is less responsive than systemic
hypertension to traditional therapeutic interventions. Chronic elevation in the
pulmonary vascular resistance (PVR) stresses the RV and can lead to RV
dysfunction. In addition, the RV hypertrophy associated with chronic pulmonary
hypertension enhances susceptibility to inadequate RV oxygen delivery.
Chronic pulmonary hypertension is managed by continuing any ongoing
medications that the patient has been taking, such as calcium channel blockers,
along with utilizing therapeutic agents mentioned below for management of
acute pulmonary hypertension.
2. Acute postoperative pulmonary hypertension must be managed aggressively
to avoid RV failure [ 68–70]. Parameters that influence pulmonary hypertension
(see Table 25.2) should be optimized. There are four major categories of focus
in addressing right heart failure associated with acute pulmonary hypertension
[71] (Fig. 25.7).
a. Volume status of the right ventricle (RV) (echocardiography).
Echocardiography will provide a good understanding of the primary problem:
volume versus pressure overload. Chronic pressure overload causes RV
hypertrophy, often with normal RV contractility and volume.
b. Right ventricular function. Address the need for inotropic support
(dobutamine, PDEIs, epinephrine). In addition, optimize the heart rate and
rhythm.
TABLE 25.2 Factors that contribute to pulmonary hypertension
c. Decrease pulmonary vascular resistance (PVR) (and hence RV afterload)

by correcting any existing acidosis, hypercarbia, or hypoxemia. Consider
adding a pulmonary artery vasodilator (inhaled nitric oxide, inhaled
prostacyclin, IV PDEIs, and IV nitroglycerin) and minimize any harmful
effects of PPV (high peak airway pressures, excessive tidal volumes, and
ventilator-induced lung injury).
d. Maintain an adequate right coronary artery perfusion pressure by adding
a vasopressor (norepinephrine, vasopressin, phenylephrine) or mechanical
diastolic pressure support via an IABP [72].
FIGURE 25.7 Pathophysiology of RV failure in the setting of high PVR. CO, cardiac output; LV, left ventricle; PVR,
pulmonary vascular resistance; RCA, right coronary artery; RV, right ventricle [68].
VII. Postoperative pain and sedation management techniques

Managing postoperative pain and agitation are paramount in caring for the
postoperative cardiac surgery patient. Pain represents a response to nociceptor
stimulation from the surgical intervention. Patients may be agitated after cardiac
surgery for a variety of reasons. Table 25.3 lists some possible causes of agitation
that must be considered because they might be “masked” by the administration of a
sedative drug or by residual neuromuscular blockade.
TABLE 25.3 Causes of postoperative agitation
A. Systemic opioids
9 A variety of techniques can be used to manage postoperative pain. It is very
useful to initially discern the type, quality, and location of pain before
administering an analgesic agent. Commonly used opioids include fentanyl,
morphine, and hydromorphone.
NSAIDs can be helpful when managing postoperative pain in cardiac surgery. A
small amount of drug can provide analgesia without excessive sedation and other
complications (e.g., respiratory depression) associated with opioid use. A
concern with NSAIDs is their inhibition of platelet function and the potential for
increased bleeding. NSAIDs also have been considered a poor choice after
cardiac surgery because of their tendency to induce gastric ulcer formation and
impair renal function. Renal insufficiency, active peptic ulcer disease, history of
gastrointestinal bleeding, and bleeding diathesis should exclude the use of
NSAIDs in the postoperative cardiac surgery patient [73].
C. Intrathecal opioids
In the era of fast tracking, several regional analgesic techniques have been
pursued to improve patient comfort. Systemic (IV, intramuscular, transcutaneous,
or oral) opioids can cause respiratory depression and somnolence, making them
potentially undesirable for fast tracking. Intrathecal opioids (e.g., morphine 5 to 8
µg/kg up to 1 mg) constitute an alternative to systemic opioids for cardiac
surgery [74]. This route has been explored in an attempt to improve patient
comfort while minimizing respiratory depression and other side effects.
Intrathecal or epidural opioids can facilitate early extubation and discharge from
an ICU without compromising pain control or increasing the likelihood of
myocardial ischemia [75]. Intrathecal morphine may be useful in attenuating the
postsurgical stress response in CABG surgery patients as measured by plasma
cortisol and epinephrine concentrations [76]. This evidence suggests that
intrathecal opioids may be an excellent pain management choice in preparing the
cardiac surgical patient for early extubation and fast tracking in the ICU.
However, this approach has not gained widespread support, perhaps, because the
principal proved advantage is decreased systemic opioid use.
D. Nerve blocks
A variety of systemic and intrathecal analgesic techniques have been suggested.
Although these techniques are useful, each has inherent risks and complications.
Nerve blocks constitute a potential alternative to these methods. Intercostal nerve
blocks can be performed with ease during thoracic surgery procedures, as the
intercostal nerves are easily accessible through the surgical field. These blocks
can also be performed percutaneously by the anesthesia provider preoperatively
or postoperatively. Intercostal nerve blocks do not provide satisfactory analgesia
for a median sternotomy. Thoracic epidural analgesia (TEA) for cardiac surgical
procedures [74] requiring CPB is considered acceptable by some practitioners
and appears to be more accepted in Europe and Asia than in North America. Off-
pump coronary artery bypass (OPCAB) procedures may be especially well
suited to TEA. TEA decreases the risk of ischemia during cardiac surgery.
However, many cardiac anesthesiologists consider the risk of epidural
hematoma, however small, to be a deterrent in the face of the hypocoagulable
state present during and after CPB. Paravertebral nerve blocks (PVBs) may be an
alternative to TEA, which may be associated with less risk of epidural
hematoma. PVB and bilateral PVB catheters have been utilized with success in
cardiac surgical procedures [77–79]. Recently, parasternal nerve blockade has
been described and may prove to be useful [80].
TABLE 25.4 ICU sedation
E. Sedation
It is essential to understand the goals of sedation in a critically ill patient. In the
ICU, one should titrate sedatives to the desired effect as precisely as one would
titrate vasopressors, inotropes, and oxygen. Light sedation with aggressive
analgesic techniques shortens ICU stay, decreases delirium, decreases
posttraumatic stress disorder, and probably improves mortality. Sedation should
be goal directed. The majority of patients in the ICU should be awake and
interactive even if they require mechanical ventilation [81]. Not all postoperative
cardiac surgery patients require sedation (see Table 25.4).
1. Benzodiazepines, when used as sedatives, have been associated with
prolonged mechanical ventilation, delirium, and possibly increased mortality
when used as continuous infusions [82,83].
2. Propofol is commonly administered as a continuous infusion in the ICU for
sedation. It is easily titrated to effect but can produce significant vasodilation
or myocardial depression with resultant hypotension. Propofol causes a burning
pain during peripheral administration, so central venous administration is
advisable if possible. In addition, propofol can be a source for sepsis since the
lipid mixture can act as a medium for bacterial growth; strict aseptic technique
must be used.
3. Dexmedetomidine is a potent α2-adrenergic agonist that provides sedation,
hemodynamic stability, decreased cardiac ischemia, improved pulmonary
function, and analgesia and can, therefore, be a good choice in cardiac surgical
patients [84–86]. Hypotension and bradycardia are occasionally attributed to
its use. Dexmedetomidine is unique among sedatives, in that patients remain
cooperative yet calm, and it does not require weaning to permit extubation.
Dexmedetomidine activates endogenous sleep pathways, which may decrease
agitation and confusion. Dexmedetomidine is administered as a continuous IV
infusion (0.2 to 0.7 mcg/kg/hr) and is approved for use up to 24 hours. Clinical
trials for extended infusion of dexmedetomidine at higher doses (up to 1.5
mcg/kg/hr) in a diverse ICU population have resulted in more ventilator-free
days and more delirium-free days when compared to similar sedation end
points with lorazepam or midazolam. Withdrawal syndromes (ethanol, chronic
pain narcotic use, illicit drugs) can also be managed with the administration of
α2-adrenergic agonists.
CLINICAL PEARL Postoperative sedation using dexmedetomidine offers several

advantages over both propofol and benzodiazepines.
VIII. Metabolic abnormalities
Many metabolic abnormalities can occur in the perioperative period. These
irregularities result from the physiologic stress response or from the large fluid and
electrolyte shifts that can be derived from IV infusions or from CPB priming or
myocardial protectant solutions.
A. Electrolyte abnormalities
1. Hyperkalemia can present from cardioplegia, overaggressive replacement, or
secondary extracellular shifts associated with respiratory or metabolic
acidosis. Hypokalemia increases the risk for dysrhythmia following cardiac
surgery. Inclusion of mannitol in the CPB priming solution, improved renal
perfusion, and aggressive treatment of blood glucose with insulin infusion all
contribute to hypokalemia. Hypokalemia is more common than hyperkalemia.
Potassium supplementation can be infused at a maximum rate of 20 mEq/hr via
a central venous catheter. Rapid potassium infusion can induce lethal
arrhythmias. The target serum potassium concentration should be >3.5 mEq/L
but not higher than 5 mEq/L.
2. 10 Hypomagnesemia is a common perioperative electrolyte abnormality and
is associated with postoperative dysrhythmia, myocardial ischemia, and
ventricular dysfunction [62,87]. Hypomagnesemia may result from dilution by
large CPB priming volumes and from urinary excretion. Renal potassium
retention requires adequate magnesium concentration, and thus magnesium
administration should always be considered in hypokalemic patients. If
magnesium supplementation is required, it can be given in amounts of 2 to 4 g
IV over 30 to 45 minutes. An infusion of 1 g/hr of magnesium sulfate can be
used as well to assure a slow, steady infusion of this substance. If given too
fast, it may cause hypotension or muscle weakness. In refractory dysrhythmias,
particularly of the ventricular type, a normal serum magnesium concentration
may not exclude the possibility of decreased total-body stores of magnesium.
The target serum magnesium concentration should be 2 to 2.5 mEq/L.
3. Hypocalcemia may be present and may be related to rapid transfusion of large
amounts of citrate-preserved bank blood. Hypocalcemia can be treated with
250- to 1,000-mg IV doses of calcium chloride (or 500 to 2,000 mg of calcium
gluconate), while paying careful attention to the potential for development of
dysrhythmias. When following the calcium status, it is important to measure
ionized calcium and not total calcium because low albumin levels may
decrease total calcium levels, whereas ionized calcium remains normal.
4. Hypophosphatemia is a common problem encountered in the ICU.
Hypophosphatemia can contribute to weakness and poor myocardial function,
can change the ability of red blood cells to change shape, and can affect
oxyhemoglobin dissociation [88,89].
B. Shivering. The exact mechanism of shivering is difficult to discern, but it is
thought to be associated with inadequate rewarming and the resulting
hypothermic temperature “afterdrop.” Many patients are hypothermic when they
arrive in the ICU and develop shivering as they emerge from anesthesia.
Shivering can result in a 300% to 600% increase in oxygen demand, which
potentially places unachievable oxygen delivery demand upon a compromised
myocardium. The associated increase in CO2 production may cause respiratory
acidosis. In patients with inadequate end-organ oxygen delivery, sustained
shivering frequently will require mechanical ventilation, and consideration
should be given to administration of neuromuscular blockers to abolish the
increased metabolic demand of shivering. Effective first-line treatments include
active rewarming with forced air blankets and prevention of further temperature
loss. Pharmacologic interventions that reduce shivering include IV meperidine
(12.5 to 25 mg) or dexmedetomidine.
CLINICAL PEARL Patients with tenuous cardiac compensation poorly tolerate the
additional oxygen consumption induced by shivering.
C. Acidosis can be described as respiratory, metabolic, or mixed. Metabolic
acidosis is divided into anion gap and non–anion gap acidosis. A complete
discussion of acid–base disorders is beyond the scope of this chapter and can be
found in standard critical care textbooks. We will briefly discuss the most
common causes of acidosis in the early postoperative period.
1. Respiratory acidosis results from hypoventilation or increased CO2
production. Residual anesthetics or an awakening patient with inadequate
analgesia combined with impaired respiratory mechanics may lead to
hypoventilation. Treatment consists of support of ventilation while treating the
underlying cause.
2. Metabolic acidosis, when present, is associated frequently with inadequate
systemic perfusion because of compromised cardiac function. Treatment is
directed at correcting the underlying cause of the acidosis. Metabolic acidosis
in a cardiac surgery patient may require administration of sodium bicarbonate
as a temporizing measure, especially in patients who are hemodynamically
unstable.
3. Lactic acidosis, a frequent finding in cardiac surgery patients, needs to be
managed by assuring adequate CO and intravascular volume and avoidance of
shivering. There is some evidence that the use of sodium bicarbonate to treat
lactic acidosis should be avoided; however, most of the critical care data
assessing the effects of buffers in treating acidosis do not include patients with
acute pulmonary hypertension or right heart failure. Epinephrine can produce a
transient lactic acidosis that does not appear to reflect inadequate perfusion.
D. Glucose management. Glycemic control in the critically ill is a highly
controversial topic. Data from 2001 indicated that tight glycemic control in
cardiac surgery patients (80 to 110 mg/dL) induced a remarkable improvement in
mortality [90]; however, subsequent trials have failed to reproduce this dramatic
effect. The most recent multicenter, multinational interventional trial of tight
glycemic control demonstrated an increase in mortality when hyperglycemia was
aggressively managed to maintain a glucose range of 81 to 108 mg/dL [91].
Control of blood glucose levels at less than 150 mg/dL (or some would say less
than 180 to 200 mg/dL, as there is no consensus standard) and avoiding
hypoglycemia with frequent monitoring is a reasonable goal in cardiac surgical
patients. Unrecognized hyperglycemia can result in excessive diuresis and the
potential for a hyperosmolar or ketoacidotic state. Elevated serum glucose can be
managed by using a continuous infusion of regular insulin, often starting at a dose
of 0.1 units/kg/hr or less with titration to the desired serum blood glucose level.
CLINICAL PEARL Overly ambitious glucose control increases mortality.
IX. Complications in the first 24 hours postoperatively
A number of life-threatening complications can occur in the first 24 hours after
cardiac or thoracic surgery.
A. Respiratory failure
Respiratory failure may be the most common postoperative complication of
cardiac or thoracic surgery. Pulmonary dysfunction develops from the surgical
incision and its attendant disruption of the thoracic cage. Postoperative pain
exacerbates this effect. Respiratory failure can present as hypoxemia,
hypercarbia, or both. Prompt identification and appropriate treatment is essential.
Atelectasis, the most common pulmonary complication following cardiac
surgery, can usually be managed with the application of PEEP, BiPAP, or CPAP.
B. Bleeding
Postoperative hemorrhage from ongoing surgical bleeding or coagulopathy
increases a patient’s length of stay and mortality [92]. Bleeding typically is
monitored by the amount of blood that drains into the chest tubes after surgery. It
is critical to differentiate a bleeding diathesis from a surgical bleeding situation
requiring reoperation. Consequently, in bleeding patients, it becomes essential to
determine the status of the coagulation system, which is traditionally done by
acquiring (at a minimum) PT, aPTT, fibrinogen concentration, and platelet count,
in addition to a chest x-ray. This panel of tests does not provide any indication of
the functional status of the platelets. A thromboelastogram (TEG) or other
platelet functional assays provide useful information about platelet functional
status, and the TEG also provides information about plasma clotting function and
fibrinolysis. Assessment of platelet function is particularly important in managing
the cardiac patients who have received aspirin or other platelet inhibitors (e.g.,
clopidogrel, glycoprotein IIb/IIIa inhibitors) preoperatively. Transfusion of
platelet concentrates may be appropriate when one suspects that the bleeding
results from platelet dysfunction.
1. Fresh frozen plasma (FFP) should most often be used to correct abnormalities
in PT, international normalized ratio (INR), or aPTT, although modest
elevations in these tests are often clinically insignificant. When associated with
clinical bleeding, elevations of PT or aPTT in excess of 1.3 times the upper
limit of normal or of INR in excess of 1.5 should probably be treated. Elevated
aPTT may occur from deficiencies of plasma coagulation factors or from
residual heparin.
2. 11 Fibrinogen deficiency (typically less than 75 mg/dL) is treated with
cryoprecipitate. Fibrinogen concentrates are available in some countries.
3. The role of activated factor VII in the cardiac surgical population is
controversial. A meta-analysis of 35 randomized clinical trials that included
both cardiac surgery and noncardiac surgery trials showed no statistically
significant difference in venous thrombosis after administration of activated
factor VII, including doses up to 80 mcg/kg. However, there was a statistically
significant increase in coronary arterial thromboembolic events when
compared to placebo [93].
4. Surgical bleeding is often considered once coagulopathy has been ruled out,
and it may require a return to the OR for mediastinal or thoracic reexploration
to identify and control a bleeding site. Surgical reexploration commonly fails to
identify a specific source for the bleeding. However, plasminogen (from
dissolved blood clots) is removed by irrigation of the pericardium and
mediastinum, which may markedly decrease bleeding. In general, chest tube
drainage greater than 500 mL/hr (even once), sustained drainage exceeding 200
mL/hr, or increasing chest tube drainage justifies surgical reexploration.
Sudden hemorrhage from a suture line or cannulation site can cause profound
hypotension from hypovolemia or tamponade. Rapid infusion of blood
products, colloids, or crystalloids is then necessary to maintain intravascular
volume. Patients who can be quickly stabilized are transferred to the OR. In
some instances, emergency resternotomy must be performed in the ICU to
control life-threatening hemorrhage or tamponade.
CLINICAL PEARL Life-threatening hemorrhage or tamponade requires emergency
reopening of the sternum at the bedside in the ICU.
C. Cardiac tamponade
Excessive mediastinal bleeding with inadequate drainage or sudden massive
bleeding can result in cardiac tamponade. Cardiac tamponade after cardiac
surgery may seem impossible if the pericardium has been left open, suggesting to
the inexperienced observer that tamponade cannot occur. However, this is not
true because tamponade may occur in localized areas, affecting an area as
circumscribed as the right atrium. As discussed above, it is important to
recognize that traditionally described equalization of filling pressures is an
unreliable sign of postcardiac surgery tamponade. The differential diagnosis
includes biventricular failure. TEE or TTE may be important to making the
correct diagnosis. At times, cardiac tamponade requires emergent surgical
intervention.
D. Pneumothorax
Pneumothorax can occur in patients who have undergone sternotomy,
thoracotomy, or are undergoing PPV. Most cardiac surgical patients arrive in the
recovery or ICU area with one or more chest (intrapleural) tubes in place, in
addition to mediastinal tubes. These patients should have a baseline
postoperative chest x-ray upon ICU arrival to confirm the adequacy of chest tube
placement and the absence of a pneumothorax. Patients who have had a redo
sternotomy or who have had an internal mammary artery used for CABG are at
particular high risk for pneumothorax and hemothorax. There is increasing
evidence that bedside ultrasound is valuable in diagnosing pneumothorax,
hemothorax, and lung consolidation. In some studies, it has higher accuracy than
portable chest x-ray when compared to CT scan [94]. An intensivist who is
skilled in performing the exam can obtain immediate data and perform repeat
exams if needed. Pneumothorax can convert to tension pneumothorax when chest
tubes function improperly. The resulting shift of mediastinal structures can
obstruct the vena cava or distort the heart to cause a low CO state and
hypotension.
E. Hemothorax
Hemothorax can occur after coronary artery bypass surgery and must be
considered in all patients who have undergone internal mammary artery
dissection, which most often involves opening the left intrapleural space. These
patients may need to be returned to the OR for surgical management.
F. Acute graft closure
Acute coronary graft closure, while uncommon, can result in myocardial
ischemia or infarction. If cardiac decompensation occurs and graft closure is the
suspected cause, reexploration should be performed to evaluate graft patency.
However, this may be a diagnosis of exclusion, and reexploration for this reason
is uncommon. These patients may need to be taken to the cardiac catheterization
laboratory, where emergent cardiac catheterization can be performed to discern
the presence of an occluded graft. Controversy continues about whether graft
patency is similar or different in off-pump (OPCAB) versus on-pump CABG
procedures either acutely or long term [95–97].
G. Prosthetic valve failure
Acute prosthetic valve failure should be suspected when sudden hemodynamic
changes occur following open heart surgery, particularly if the rhythm is
unchanged and intermittent loss of the arterial waveform is noted on the monitor
screen. Immediate surgical correction is necessary. Valve dehiscence with a
perivalvular leak usually does not present in the early postoperative period. TEE
is the diagnostic modality of choice to evaluate prosthetic valve function in this
setting. There is increasing experience and success with closing or reducing
perivalvular leaks in the interventional cardiology laboratory using percutaneous
atrial septal defect (ASD) and ventricular septal defect (VSD) closure devices.
H. Postoperative neurologic dysfunction
Neurologic complications are frequently recognized in the postoperative period
and remain one of the most important complications following cardiac surgery
[98,99], so an early postoperative neurologic examination is very important.
Neurologic complications can be divided into three groups: (1) focal ischemic
injury (stroke), (2) neurocognitive dysfunction (including diffuse
encephalopathy), and (3) peripheral nervous system injury. Central nervous
system dysfunction after cardiac surgery is discussed in detail in Chapter 26.
Brachial plexus injury resulting from sternal retraction can occur, particularly on
the left side during internal mammary arterial dissection. A thorough motor
examination of the legs is crucial after descending thoracic aortic or
thoracoabdominal aneurysm repairs. A delirium assessment, such as the
confusion assessment method for ICU Patients (CAM-ICU), can identify patients
with hypoactive delirium [100]. Hypoactive delirium in the ICU carries with it
an increased morbidity and mortality. Vanderbilt University ICU physicians have
developed an excellent resource about delirium for families and clinicians,
which can be found at www.icudelirium.org.
X. Discharge from the ICU
Discharge from the ICU historically has occurred 1 to 3 days after cardiothoracic
surgery. Reducing the amount of time spent in the ICU after cardiac surgery
recently has become a priority. Many patients are now discharged from the ICU on
the morning after routine CABG operations without compromise in patient care or
safety. Complications such as those noted earlier often delay ICU discharge. Some
centers place routine CABG patients in an ICU-level recovery area for several
hours before discharging them to a “stepdown” or intermediate care area, or even
to a “monitored bed” postoperative nursing unit.
12 The criteria for ICU discharge vary depending upon the type of surgery.
Predicting which patients can leave the ICU in an early FT style can be
accomplished by reviewing a variety of preoperative risk factors. Reduced LV
ejection fraction is a valid predictor of higher mortality, morbidity, and resource
utilization [101]. Other preoperative predictors of prolonged ICU stays include
cardiogenic shock, age greater than 80 years, dialysis-dependent renal failure, and
surgery performed emergently [102]. These factors and others can be used to
predict a patient’s length of stay and to plan for resource utilization.
XI. The transplant patient (see Chapter 17)
The care of cardiac transplant patients is similar to other cardiac patients with
several notable exceptions [103]. Pulmonary hypertension and RV failure are the
primary challenges in the early postoperative period following heart or lung
transplantation [67]. Heart transplant recipients may have varying degrees of end-
organ dysfunction secondary to chronic low CO. Finally, these patients require
meticulous attention to medications used to attenuate graft rejection.
XII. Patients with mechanical assist devices (see also Chapter 22)
Recent technologic advances have facilitated the development of mechanical assist
devices for cardiac surgery patients with severely impaired RV or LV function.
The number of assist devices available continues to grow, resulting in options for
LV, RV, or biventricular mechanical assistance [ 104,105]. Postoperative
management of patients with mechanical assist devices requires a thorough
understanding of the technology underlying any device that may be chosen. The
primary risks with mechanical assistance include thrombosis, bleeding from
anticoagulation, infection from percutaneous catheters, and failure to wean from
assist devices intended for temporary cardiac support.
A. Intra-aortic balloon pump (IABP)
An IABP is typically the first mechanical assist device utilized for cardiogenic
shock in cardiac surgical patients [106] (see Chapter 22). The goals of IABP
therapy are to acutely decrease the LV afterload, thereby improving forward
blood flow, and to augment the LV coronary artery perfusion during diastole.
Coronary blood flow is only augmented in patients with hypotension associated
with their cardiogenic shock [107]. The IABP is most often placed
percutaneously via the femoral artery into the descending thoracic aorta. There
are two management strategies for weaning IABP support. Some clinicians wean
pharmacologic support prior to weaning IABP support; this allows them to
resume inotropic support should the patient decompensate after IABP removal.
Other clinicians wean IABP support first, due to concerns about lower extremity
ischemia from arterial occlusion of the femoral and/or iliac arteries. Despite the
clear risk of lower extremity ischemia from arterial occlusion, there is no
decrease in embolic or thrombotic complications when the patient undergoes
systemic anticoagulation [108]. In either strategy, the IABP is weaned from a 1:1
setting (each cardiac contraction triggers an IABP deflation/inflation cycle) to
1:2, then a brief trial at 1:3 precedes IABP removal.
B. Ventricular assist device (VAD) (see Chapter 22)
VAD can be utilized for support of the left (LVAD), right (RVAD), or both
(BiVAD) ventricles [104,105]. There are three indications for VAD therapy:
1. Temporary support (less than 14 days) in patients who fail to wean from CPB
but are expected to recover sufficient cardiac function for removal of the VAD.
2. Bridge to cardiac transplantation.
3. Destination VAD therapy; patients who require long-term or permanent VAD
support with the expectation that they will be discharged from the hospital with
the VAD.
In patients with LVADs, the possibility that LV decompression will result in
geometric alterations and precipitation of right heart failure must be
considered. Other considerations that must be addressed during the ICU period
include adequate oxygenation and ventilation using a mechanical ventilator,
along with maintenance of temperature, nutrition, acid–base balance, and
electrolyte balance. The patients with mechanical assist devices can be weaned
from the ventilator using standard weaning protocols depending upon their
hemodynamic status, blood gas exchange, and neurologic stability. If a VAD
has been implanted as short-term support with an anticipated return to the OR
within a few days to remove the device, this tends to discourage endotracheal
extubation.
C. Extracorporeal membrane oxygenator (ECMO) (see Chapter 24)
In some circumstances, notably when ARDS coexists with heart failure,
temporary support with ECMO is chosen in situations that would otherwise call
for LVAD, RVAD, or BiVAD.
XIII. Family issues in the postoperative period
Interaction with families is important in communicating any patient’s status and in
giving appropriate expectations about recovery.
A. The preoperative discussion
In the preoperative discussion, it is important for the surgeon and
anesthesiologist to give a detailed description of what to anticipate in the
postoperative period. This information can be relayed either through
preoperative visits or through video or website access describing typical
postoperative events. Detailed discussions about planned extubation in the OR or
in the ICU may prevent patients from misinterpreting early postoperative
intubation as being awake during surgery. It is also important to discuss the goals
of general anesthesia versus sedation in the ICU. Caution should be used when
assuring the patient that they will have complete amnesia of the OR or being
intubated. Family members should be told to expect that the cardiac surgical
patient will have invasive monitors and may have significant edema, which alters
their appearance. Reassurance that these are temporary cosmetic changes will
provide comfort. Preoperative visits allow patients and their families the
opportunity to ask questions and to understand the plan of movement through the
postoperative course in a more relaxed setting than the preanesthesia holding
area. Often anesthesiology preoperative visits may be compromised or precluded
by admission day surgery patterns whereby cardiac surgery patients arrive at the
hospital on the day of surgery. In these circumstances, opportunities for
discussions with anesthesia care providers can be limited and should be
anticipated at the preoperative visit with the surgeon, when information can be
disseminated and questions can be answered. Some centers compensate for this
practice pattern with anesthesia-specific pamphlets or web-based videos, often
with a Frequently Asked Questions section.
B. Family visitation
Family visitation occurs in the ICU or recovery room for many postoperative
cardiac and thoracic surgery patients. This provides reassurance about the
patient’s clinical course progression as well as encouragement toward
subsequent postoperative care. Family members can be very important in
encouraging adequate pulmonary toilet, coughing, deep breathing, and early
ambulation to improve postoperative outcomes. Most cardiac surgery programs
have designated personnel for the liaison between the professional staff caring
for postoperative cardiac surgery patients and the family members who need
education, encouragement, and the opportunity to assist in postoperative care.
C. The role of family support
13 Family support is a vital link toward the early success of a fast-tracking
program. Family members need adequate education by surgical and anesthesia
staff, who can outline the expected early postoperative events. The role of family
support is heightened when patients spend very short periods in postoperative
areas such as the recovery room or ICU. Family members who are educated
about the expected postoperative course can facilitate postoperative care and
smooth the transition from the ICU to a regular nursing floor and finally to the
patient’s home.
CLINICAL PEARL Throughout the perioperative period, close communication with
family members enhances patient outcomes.
ACKNOWLEDGMENTS
The authors would like to thank Mark Gerhardt, MD, the author of the previous edition
of this chapter, and Jennifer Olin for her editorial assistance.
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26 Protection of the Brain During Cardiopulmonary
Bypass
Satoru Fujii and John M. Murkin
I. Central nervous system (CNS) dysfunction associated with cardiac

surgery
A. Overview
B. Stroke incidence
C. Transcatheter aortic valve replacement (TAVR) versus surgical aortic
valve replacement (SAVR)
D. Early versus delayed stroke
E. Cognitive dysfunction
F. Comparison groups
G. Risk factors
H. Delirium
II. Cerebral physiology
A. Cerebral autoregulation (CA)
B. Lower limit of cerebral autoregulation
C. pH management
III. Etiology of central nervous system (CNS) damage
A. Embolization
B. Hypoperfusion
C. Inflammation
IV. Intraoperative cerebral monitoring
A. Brain temperature
B. Electroencephalogram (EEG)
C. Transcranial Doppler (TCD)
D. Jugular oximetry
E. Near-infrared spectroscopy (NIRS)
F. Cerebral perfusion pressure (CPP)
G. Lower limit of cerebral autoregulation
V. Prevention of central nervous system (CNS) injury
A. Embolic load
B. Off-pump coronary artery bypass (OPCAB), coronary artery bypass
(CAB), and minimally invasive extracorporeal circulation (MiECC)
C. Perfusion equipment and techniques
D. Open-chamber de-airing techniques
E. Cerebral perfusion
F. Euglycemia
G. Mild hypothermia
H. Best practice cardiopulmonary bypass (CPB)
VI. Pharmacologic cerebral protection
A. Metabolic suppression
B. Calcium channel blockers
C. Glutamate antagonists
D. Lidocaine
E. Statins
VII. Deep hypothermic circulatory arrest (DHCA)
A. Clinical indications
B. Technique
C. Brain protection
VIII. Cardiac surgery in patients with cerebrovascular disease
A. Incidence
B. Morbidity
C. Combined carotid and cardiac procedures
IX. Summary
KEY POINTS
1. The incidence of overt stroke is 1.5% to 2.5% for closed-chamber

cardiac procedures. For open-chamber, combined and aortic arch
procedures, the incidence of stroke ranges from 4.2% to 13%.
2. Risk factors for early stroke include advanced age, duration of
cardiopulmonary bypass (CPB), high postoperative creatinine, and
extensive aortic atherosclerosis, while delayed stroke was associated
with female gender, postoperative atrial fibrillation, cerebrovascular
disease, and requirement for inotropic support.
3. Within the first postoperative week, a majority of patients
undergoing bypass surgery using CPB demonstrate a degree of
cognitive dysfunction. This appears to be largely due to underlying
patient factors interacting with emboli, inflammation, and blood–
brain barrier (BBB) alterations.
4. The incidence of late postoperative cognitive dysfunction appears to
be similar to an age- and gender-matched nonsurgical cohort having
similar comorbidities, implying progression of underlying disease.
5. A wide variety of autoregulation thresholds occur even with α-stat
blood gas management and are likely a consequence of increased
age and cerebrovascular disease.
6. α-Stat blood gas management, which maintains a normal
transmembrane pH gradient and maintains cerebral autoregulation
(CA) of blood flow, should be used in adult patients undergoing
bypass. This modality may help reduce cerebral embolization.
7. Cerebral emboli may come from multiple sources that are patient
related, procedure related, and equipment related.
8. Watershed lesions are commonly due to profound hypotensive
episodes but may also be the result of cerebral embolism.
Embolization and hypotension acting together magnify central
nervous system (CNS) injury.
9. Leukocytosis is associated with a higher risk for ischemic stroke.
The results strongly implicate inflammation and white cell activation
as etiologic factors in both the extent and severity of perioperative
cerebral events.
I. Central nervous system (CNS) dysfunction associated with cardiac surgery

A. Overview
Despite continuing improvements in surgical and cardiopulmonary bypass (CPB)
techniques, stroke remains a devastating postoperative complication for patients
and their families. In a randomized study in which 1,800 patients with three-
vessel or left mainstem coronary artery disease were assigned to percutaneous
coronary intervention (PCI) or conventional coronary artery bypass (CAB)
surgery, there was no difference in mortality at 1 year and a significantly lower
incidence of primary composite endpoint of major adverse cardiac or
cerebrovascular event (MACCE) in CAB versus PCI (12.4% vs. 17.8%; p
<0.00) groups [1]. However, while the overall outcome should argue strongly in
favor of CAB surgery, the stroke rate was significantly higher in CAB than PCI
(2.2% vs. 0.6%; p = 0.003). Given the relatively equivalent risk factors between
PCI and CAB patients in this study, the mechanism of perioperative stroke must
be better understood if we are to further reduce the risk of CNS morbidity related
to cardiac surgery. This chapter will review the current incidence and risk
factors for brain damage in cardiac surgery and will outline strategies aimed
at protection of the brain during cardiac surgical procedures.
B. Stroke incidence
1 In most series reported to date, the incidence of clinically apparent neurologic
injury or overt stroke is 1.5% to 2.5% for closed-chamber cardiac procedures
(e.g., CAB surgery). Up to 25% to 65% of strokes after CAB surgeries are
bilateral or multiple, suggestive of an embolic etiology [2]. For open-chamber
procedures (e.g., valve surgery), the reported incidence of stroke varies from
4.2% to 13%, which could be related to increased risk of particulate
embolization, increased hemodynamic instability, or prolonged CPB time [3].
C. Transcatheter aortic valve replacement (TAVR) versus surgical aortic valve
replacement (SAVR)
Transcatheter aortic valve replacement (TAVR) is a novel technique and has
been available as an alternative to surgical aortic valve replacement (SAVR) for
more than a decade. Various types of valves have been commercially available,
and their use is dependent on the type of procedure and patients’ vascular size
and anatomy. Although the initial studies showed increased incidences of stroke
post-TAVR compared to medical management, subsequent studies show
noninferiority or superiority of TAVR compared with SAVR in terms of
neurologic complications. In 2016, 2,032 intermediate-risk patients were
recruited and randomly assigned to transfemoral (TF) or transthoracic (TT)
TAVR or SAVR. The rate of disabling stroke was 6.2% after TAVR and 6.4%
after SAVR at 2 years, while the incidence of new-onset atrial fibrillation was
significantly lower in TAVR compared with SAVR (9.1% vs. 26.4%) which may
affect the long-term incidence of stroke [4]. While TF approach was formerly
associated with higher stroke rates compared with TT—possibly as a
consequence of passage through the aortic arch—a recent meta-analysis
encompassing seven European national TAVR registries found stroke rates were
lower at 3% regardless of TT- or TF-TAVR strategy [ 5]. Ever improving TAVR
devices, improved patient management and expanding indication of TAVR for
intermediate-risk patients are thought attributable for the reduced stroke rates.
CLINICAL PEARL Current stroke rates of TAVR are comparable to SAVR.
D. Early versus delayed stroke
2 Distinguishing stroke as early (i.e., persistent neurologic deficit apparent
within 24 hours of emergence from anesthesia) from delayed (i.e., persistent
neurologic deficit developing days after anesthesia recovery) is important to
better discriminate etiology and assess potential risk-reduction strategies. Only
approximately 50% of perioperative strokes present during the first 24 hours post
surgery tend to be more severe with a higher permanent deficit and early stroke
has a higher impact on perioperative mortality [6,7]. The higher mortality
could be related to sicker patients or to stroke being just one manifestation of
other concomitant embolic/hypoperfusion-mediated complications. Stroke can
also have a long-term effect on mortality (Fig. 26.1). In a prospective study on
CAB patients, the adjusted survival rates at 1, 5, and 10 years were 94.1%,
83.3%, and 61.9% among patients free from stroke versus 83%, 58.7%, and
26.9% for those suffering perioperative stroke [8]. Risk factors for early stroke
include advanced age, duration of CPB, high preoperative creatinine, and
extensive aortic atherosclerosis, while delayed stroke was associated with
female gender, postoperative atrial fibrillation, cerebrovascular disease, and
requirements for inotropic support [7] . Delayed but not early stroke was
associated with long-term mortality.
CLINICAL PEARL Early stroke (persistent neurologic deficit apparent within 24
hours of emergence from anesthesia) has a higher impact on perioperative mortality than
late stroke.
FIGURE 26.1 Effect of stroke on 10-year survival after coronary artery bypass grafting. The crude annual incidence of
death was 18.1/100 person-years among patients with strokes and 3.7/100 person-years among patients without strokes (p
<0.001). (From Dacey LJ, Likosky DS, Leavitt BJ, et al. Perioperative stroke and long-term survival after coronary bypass
graft surgery. Ann Thorac Surg. 2005;79(2):532–536, with permission.)
E. Cognitive dysfunction
3 Within the first postoperative week, up to 83% of all patients undergoing
CAB surgery using CPB demonstrate a degree of cognitive dysfunction. Of these
patients, 38% have symptoms of intellectual impairment and 10% are considered
to be overtly disabled. Concentration, retention, and processing of new
information and visuospatial organization are the most frequently affected
domains [9], and at 5-year follow-up, more than 35% of CAB patients exhibit
some degree of neuropsychological dysfunction. Variable definitions, different
measurement techniques, and different intervals of postoperative cognitive testing
confound this issue, however, giving rise to reported incidences of perioperative
cognitive decline that vary from 4% to 90%. Additional confounders include the
variability in performance to repeated neuropsychometric testing, even in healthy
subjects, and an innate decline in cognitive function associated with both aging
and the various comorbidities found in cardiac surgical patients. The challenge
lies in discerning whether a specific event—for example, cardiac surgery—is
causal or coincidental to deterioration in cognitive function. 4
CLINICAL PEARL Longer-term cognitive dysfunction has a similar incidence
whether patients undergo cardiac surgery with or without the use of CPB, or instead
undergo PCI or are managed medically, with the implication that aging and progression
of underlying atherosclerosis and related comorbidities are primary risk factors [10].
F. Comparison groups
The incidence of new postoperative CNS dysfunction in CAB patients has been
compared with that of patients undergoing major abdominal vascular or thoracic
surgical procedures. Most of these patients usually have concomitant disease
including hypertension, diabetes mellitus, diffuse atherosclerosis, and chronic
lung disease. After adjusting for identified risk factors, patients undergoing any
surgical procedure have been found more likely to suffer a cerebrovascular
accident (CVA) than nonoperated controls, with an odds ratio of 3.9. Even after
excluding high-risk surgery (cardiac, vascular, and neurologic), the odds ratio is
2.9, which suggests the perioperative period itself predisposes patients to
stroke. This observation is of particular relevance in considering the role of
inflammatory processes and the salutary effect of statins as discussed below.
Studies on patients undergoing CAB surgery have demonstrated minimal
difference in long-term cognitive function between patients undergoing on-pump
versus off-pump procedures [11]. However, in general, it does appear that,
compared with other noncardiac surgical groups, the incidence of early
postoperative cognitive dysfunction is higher in CAB patients. Since new
ischemic lesions on magnetic resonance imaging (MRI) studies in valve surgery
patients correlate with early postoperative cognitive dysfunction [12], as do
intraoperative cerebral oxygen desaturation and early postoperative cognitive
dysfunction in CAB patients, it appears that efforts to mitigate early
postoperative cognitive dysfunction are warranted, since early postoperative
cognitive dysfunction partly reflects subclinical brain injury.
G. Risk factors
Table 26.1 shows risk factors for both stroke and cognitive dysfunction. Risk
factors have been pooled into various risk prediction models, which, while
useful to compare patient groups, are still not predictive of a particular
individual’s outcome, although the presence of key risk factors may help in
deciding the best procedure for a particular high-risk patient (i.e., surgery vs.
angioplasty or valvuloplasty). Specific risk factors (i.e., aortic atherosclerosis,
recent stroke) should prompt further preoperative investigations (e.g., carotid
scanning, modification of intraoperative management) and may even suggest a
change in surgical approach (i.e., off-pump CAB [OPCAB] with no
instrumentation of the aorta—anaortic) to minimize the potential for neurologic
complications.
H. Delirium
The incidence of delirium in cardiac surgery has been reported as 17.5% to 30%,
and is associated with increased mortality, pulmonary dysfunction, and longer
duration of hospitalization [13,14]. Although the exact mechanisms have not been
fully elucidated, systemic inflammation, chemokines, cytokines, endothelial
dysfunction, and disruption of blood–brain barrier (BBB) have been recognized
as potential factors thought to cause neurotransmitter interference, global
cognitive disorder, and neuroinflammation [15].
TABLE 26.1 Risk factors for neurologic complications in cardiac surgery
Multiple risk factors have been implicated, including duration of CPB, lowest
mean arterial pressure (MAP), hemoglobin level, lowest body temperature, RBC
transfusion, and platelet transfusion; however, in multivariate analysis, only
platelet transfusion remained as an independent risk factor [16]. Various
standardized assessment tools have been employed for detection of delirium,
including Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)
or Intensive Care Delirium Screening Checklist (ICDSC), which assess level of
consciousness, inattention, disorientation, hallucinations/delusions/psychosis,
psychomotor agitation or retardation, inappropriate speech or mood, sleep/wake
cycle disturbances, and symptom fluctuation [17]. Several studies have compared
CAB with OPCAB, but results have been inconclusive, with one study indicating
OPCAB was associated with lower incidences of delirium compared to on-pump
CAB (7.9% vs. 2.3%) [18]. The incidences of delirium reported by these authors
were much lower than those from other reports, and another study found no
difference in the incidence of delirium between on-pump and OPCAB [19]. A
recent study demonstrated that SAVR-treated patients had a higher incidence of
postoperative delirium than TF TAVR (51% vs. 29%) [ 20]. Also, they
demonstrated that delirium was associated with increased mortality at 30 days
and 1 year and longer Intensive Care Unit (ICU) and hospital lengths of stay.
Delirium is highest with TT compared with TF TAVR, likely reflecting the fact
that primarily higher-risk patients with small vascular size or severe aortic
tortuosity undergo TT TAVR and that pain from minithoracotomy may play a role
in triggering delirium [21].
II. Cerebral physiology
A. Cerebral autoregulation (CA)
In normal subjects, cerebral blood flow (CBF) remains relatively constant at 50
mL/100 g/min over a wide range of MAP from 50 to 150 mm Hg. This
autoregulatory plateau reflects the tight matching between regional cerebral
metabolic rate for O 2 (CMRO 2) and CBF. With decreased metabolic activity
resulting from certain anesthetics or hypothermia, lowered CMRO2 produces a
resultant reduction in CBF and establishment of a lower autoregulatory plateau.
Rather than a single cerebral autoregulatory curve, there are instead a series of
autoregulatory curves, each representing a differing set of metabolic conditions
of the brain (e.g., normal metabolic activity at 37°C vs. lowered metabolic
activity at 28°C). The autoregulatory plateau reflects intact cerebral flow and
metabolism coupling, and it varies with metabolic rate (Fig. 26.2).
FIGURE 26.2 Cerebral autoregulatory curves during normothermia and hypothermia. The upper curve demonstrates a
higher cerebral blood flow (CBF) autoregulatory plateau that is appropriate for the higher cerebral metabolic rate for O2
(CMRO2) in the awake state versus a lower CBF plateau during hypothermia. With maximal cerebral vasodilation, lower
cerebral perfusion pressure (CPP) results in lower CBF that is appropriate at a lower CMRO2 (hypothermia) but not at a
higher CMRO2. (From Murkin JM. The pathophysiology of cardiopulmonary bypass. Can J Anesth. 1989;36:S41–S44, with
permission.)
With intact autoregulation, lowered substrate requirement during conditions of

lowered metabolic rate (e.g., anesthesia, hypothermia) requires less blood flow
and can be delivered at a lower perfusion pressure—in the absence of direct
cerebral vasodilators, such as CO2. CA is impaired in patients with diabetes
mellitus and appears to be lost during deep hypothermia (e.g., less than 20°C)
and for several hours after deep hypothermic circulatory arrest (DHCA). This
results in pressure-passive CBF; in these instances, hypotension may entail
increased risk for cerebral hypoperfusion. Similarly, in patients with chronic
hypertension, CA has been reset and higher perfusion pressures are needed
during CPB.
B. Lower limit of cerebral autoregulation
5 An important new area of investigation is detection and monitoring of the
lower limit of cerebral autoregulation (LLA). It is relevant that most of the initial
studies on CBF and CMRO2 during CPB specifically excluded patients with
overt cerebrovascular disease [22], while more recent studies have included
both elderly patients and those with previous CVA, and have indicated a striking
variability in the LLA threshold (Fig. 26.3) [23,24]. Using transcranial Doppler
(TCD) or cerebral near-infrared spectroscopy (NIRS), absent or high LLA
ranging from 45 to 80 mm Hg has been demonstrated [23,24]. Several large
single-center studies have demonstrated post hoc correlations between duration
of MAP below LLA and various adverse outcomes including stroke and renal
failure [25,26], while MAP above upper limit autoregulation (ULA) has been
associated with a higher risk of delirium [27].
CLINICAL PEARL During CPB, cerebral venous pressure should be monitored by a
catheter placed proximally in the SVC (usually via introducer sheath of CVC or PA
catheter) and by visual inspection of the face.
C. pH management
There is an inverse relationship between solubility of respiratory gases and
blood temperature. With cooling of blood in the tissue, CO2 partial pressure
(PaCO2) decreases and arterial pH (pHa) increases, producing an apparent
respiratory alkalosis.
FIGURE 26.3 Example of patients with intact and nonintact CA. CA, cerebral autoregulation; nCA, absent cerebral
autoregulation; Mx, mean velocity index; CFIx, cerebral flow index correlation index; LLA, lower limit of CA as shown by
vertical arrow (A); MAP, mean arterial pressure. Dotted line is Mx/CFIx >0.35 indicates pressure passive cerebral blood
flow (B). (From Murkin JM, Kamar M, Silman Z, et al. Intraoperative cerebral autoregulation assessment using ultrasound-
tagged nearinfrared-based cerebral blood flow in comparison to transcranial Doppler cerebral flow velocity: a pilot study. J
Cardiothorac Vasc Anesth. 2015;29(5):1187–1193 with permission)
1. α-Stat maintains pHa 7.4 and PaCO 2 40 mm Hg at 37°C without addition

of exogenous CO 2. Intracellular pH is primarily determined by the neutral pH
(pHN) of water. Since pHN becomes progressively more alkaline with
decreasing temperature, intracellular pH becomes correspondingly more
alkaline during hypothermia. Since this intracellular alkalosis occurs in
parallel with the hypothermia-induced increased solubility of CO2 and
increased blood pH, the normal transmembrane pH gradient of approximately
0.6 units remains unchanged, thus preserving optimal function of various
intracellular enzyme systems. The preservation of normal transmembrane
pH gradient is the crux of α-stat pH theory, and, in fact, we function in vivo
according to α-stat principles. Since different tissues have differing
temperatures (e.g., exercising muscle at 41°C vs. skin at 25°C), they also will
have correspondingly different pHa values (e.g., 7.34 vs. 7.6, respectively),
although the net pHa at 37°C will be 7.4. α-Stat management acknowledges the
temperature dependence of normal pHa and strives to maintain a constant
transmembrane pH gradient by maintaining PaCO2 at 40 mm Hg (or at the
patient’s baseline physiologic PaCO2) and pHa at 7.4, as measured in vitro at
37°C. For this strategy during CPB, total CO2 is kept constant by not adding
exogenous CO2 and thus not compensating for increased solubility of CO2.
Blood samples measured at 37°C will show pHa 7.4 and PaCO2 40 mm Hg, but
those same samples measured at 28°C would have pHa 7.56 and PaCO2 26 mm
Hg (Fig. 26.4). In recent studies, even with the use of α-stat, a wide variability
or absence of LLA autoregulatory threshold has been found, likely as a
consequence of the increased age and presence of overt cerebrovascular
disease in current surgical populations [23,24]. 6
FIGURE 26.4 Contrasting arterial blood gas values as seen in vitro at 37°C or in vivo at 28°C when using α-stat or pH-stat
management. Using pH-stat, laboratory values in vitro would be pHa 7.26 and PaCO2 56 mm Hg, whereas temperature-
corrected values in vivo would be pHa 7.4 and PaCO2 40 mm Hg. If α-stat were used, laboratory values in vitro would be pHa
7.4 and PaCO2 40 mm Hg, whereas temperature-corrected values in vivo would be pHa 7.56 and PaCO2 26 mm Hg.
2. pH-stat management involves the addition of exogenous CO 2 to maintain

PaCO 2 40 mm Hg and pHa 7.4 when corrected for the patient’s body
temperature in vivo. Until the mid-1980s, pH-stat management was generally
the most common mode of pH management during moderate hypothermic CPB.
Since CO2 is a potent cerebral vasodilator, such increases in total PaCO2
associated with pH-stat have been shown to produce cerebral vasodilation,
impairing cerebral flow and metabolism coupling and producing loss of CA
(Fig. 26.5). There is evidence that pH-stat management can increase the
incidence of postoperative cognitive dysfunction when CPB duration exceeds
90 minutes [9]. This likely reflects both increased delivery of microemboli into
the brain resulting from CO2-induced vasodilation and impairment of regional
CA.
III. Etiology of central nervous system (CNS) damage
A. Embolization
7 In the context of CPB, focal ischemia is most often a consequence of isolated
cerebral arteriolar obstruction by particulate or gaseous emboli. Emboli vary in
size, nature (particulate vs. gaseous), and origin (patient vs. equipment). Embolic
characteristics influencing tissue distribution include size, solubility, viscosity,
and buoyancy relative to blood. Vessel diameter, anatomical location, and
inflammatory responsivity influence tissue vulnerability. Open-chamber
procedures generally entail greater risk of microgaseous embolizations, which
increase BBB permeability and may engender heightened drug toxicity [28].
Calcific or atheromatous macroembolic debris from the ascending aorta or aortic
arch appears to be a prime factor in the production of clinical stroke syndromes.
FIGURE 26.5 Linear regression analysis of CBF and CMRO2, or cerebral perfusion pressure (CPP), for patients
managed using α-stat (non–temperature-corrected) or pH-stat (temperature-corrected) management during moderate
hypothermia (28°C). With pH-stat (A), there is no correlation between CBF and CMRO2, demonstrating loss of cerebral
flow and metabolism coupling, whereas with α-stat (C), there is a highly significant (p <0.005) correlation. CBF significantly
<0.002) correlates with CPP using pH-stat (B) reflecting pressure-passive CBF and loss of autoregulation, whereas with
α-stat (D), CBF is independent of CPP. (From Murkin JM, Farrar JK, Tweed WA, et al. Cerebral autoregulation and
flow/metabolism coupling during cardiopulmonary bypass: the influence of PaCO2. Anesth Analg. 1987;66(9):825–832, with
permission.)
1. Microgaseous emboli. It was formerly thought that cerebral microgaseous

emboli produced cognitive dysfunction. Studies of OPCAB, in which CPB is
avoided, appear to have a relatively similar incidence of cognitive dysfunction
when compared to CAB. The greatest numbers of microgaseous emboli are
found in open-chamber surgery but again this paradoxically does not appear to
result in greater incidences of cognitive impairment. Microgaseous emboli thus
appear to be relatively less injurious than otherwise predicted, which may
reflect a salutary effect of systemic heparinization [29]. However,
microgaseous emboli do increase BBB permeability, which has been
correlated with cerebral edema, enhanced neurotoxicity and postoperative
seizures following high-dose tranexamic acid administration [28].
2. Detection of emboli
a. Brain histology. Isolated areas of perivascular and focal subarachnoid
hemorrhage, neuronal swelling, and axonal degeneration are seen with higher
frequency in the brains of patients dying after cardiac surgery than after non-
CPB major vascular surgery. After surgery using unfiltered CPB circuits,
fibrin and platelet emboli and calcific and atheromatous debris were seen
frequently in small arterioles and capillary beds. Small cerebral capillary
and arterial dilatations (SCADs) have been demonstrated histologically,
occurring in nonsurvivors after proximal aortic instrumentation after either
CPB or coronary angiography. These SCADs are increasingly believed to be
due in part to lipid microemboli from the usage of unprocessed cardiotomy
suction blood.
b. Intraoperative emboli detection. Intraoperative fluorescein retinal
angiography has demonstrated that extensive retinal microvascular
embolization occurs during CPB. The incidence and extent of retinal
obstruction are much greater with bubble than with membrane oxygenators,
despite the use of 40-μm arterial line filters. Use of TCD insonation enables
assessment of blood flow perfusion characteristics through the middle
cerebral artery (MCA). TCD insonation permits measurement of blood flow
velocity and detection and quantification of emboli, though discrimination of
gaseous from particulate emboli remains unreliable. Proximal aortic
instrumentation and initiation of CPB have been identified as particularly
embologenic events. After open-chamber surgery, cerebral emboli are
detected as the heart fills and begins to eject, underscoring the importance of
meticulous de-airing techniques.
3. Sources of emboli
a. Patient-related sources
(1) Aortic atheroma. Atheromatous debris can be embolized during aortic
clamping or cannulation. Intraoperative aortic ultrasonography using
either transesophageal echocardiography (TEE; high sensitivity, low
specificity) or epiaortic scanning (EAS; high sensitivity, high specificity)
enables visualization of the aortic wall and can be used to guide
cannulation sites. Ultrasonography has demonstrated that plaque may
fracture or shear off and embolize during CPB as a consequence of
trauma from aortic clamping and cannulation or from blood “jetting”
from the aortic cannula, or may result in intimal flap formation with
potential for delayed postoperative embolization [30]. Using EAS, Ura et
al. compared images before and after CPB in 472 patients undergoing
cardiac surgery and noted new lesions in the ascending aortic intima in
16 patients (3.4%) following decannulation [30]. In 10 patients, 3 of
whom suffered postoperative CVA, the new lesions were severe with
mobile lesions or disruption of the intima, of which 6 were related to
aortic clamping and the other 4 to aortic cannulation. Only the maximal
thickness of the atheroma near the aortic manipulation site was a
predictor of new lesions. As such, embolization of plaque or thrombus
from such intimal fractures may explain one mechanism of delayed stroke
cited above. Proximal aortic atherosclerosis is thus a significant risk
factor for neurologic injury.
(2) Intraventricular thrombi. During closed-chamber procedures in patients
with recent mural thrombi, manipulation of the heart can dislodge atrial
or ventricular thrombi that embolize once the heart begins to fill and
eject.
(3) Valvular calcifications. Valve surgery, particularly valve replacement
surgery, is associated with increased risk of CVA resulting from
embolization of intracavitary valve debris.
(4) Postoperative atrial fibrillation. Early-onset atrial fibrillation is
associated with a variety of adverse outcomes, has been strongly linked
to increased perioperative stroke risk, and is particularly associated with
an increased risk of delayed-onset postoperative stroke [6]. Even
transient new-onset atrial fibrillation is associated with an increased risk
of 30-day and 1-year major cardiovascular events comprising stroke,
cardiac death, and myocardial infarction (MI). In cardiac surgical
patients, a decreased incidence of atrial fibrillation has been associated
with perioperative statin therapy as discussed below. Increased efforts
should be aimed at reducing even transient new-onset postoperative
atrial fibrillation.
CLINICAL PEARL Anaortic OPCAB for patients at increased risk of stroke appears to be
an effective strategy to minimize early stroke risk.
b. Procedure-related sources
(1) While open-chamber procedures (e.g., septal repair, ventricular
aneurysmectomy, valve surgery) expose the arterial circulation to air or
particulate debris, closed-chamber procedures also can be associated
with ventricular air. Use of a ventricular vent, particularly if active
suction is applied and the heart is empty, produces localized
subatmospheric pressure at the vent tip within the left ventricle (LV) and
causes air to be entrained retrograde from the vent insertion site (usually
through the superior pulmonary vein) into the LV (Fig. 26.6). In patients
with a left ventricular assist device (LVAD), wherein blood is drawn
from the ventricular cavity causing a low-pressure gradient, even
surgical microtears in fibrotic myocardial tissue can become a rapidly-
accruing source of intraventricular air. Inadvertent opening of the left
atrium (LA) or LV while the heart is beating also causes rapid air
entrainment and increased potential for massive cerebral air
embolization, necessitating emergency de-airing techniques [31].
Immediate flooding of the pericardial site is recommended. TEE can
assist in visualization and guide the removal of residual intracavitary air.
(2) Aortic cannulation and clamping are associated with cerebral
embolization, particularly in the presence of extensive aortic
atherosclerosis.
(3) After 90 minutes of CPB, the incidence of cognitive dysfunction
increases compared to CPB of shorter duration [9]. It is important to note
that duration of CPB may be increased by factors (e.g., extensive
atherosclerotic disease) that may independently contribute to neurologic
injury [2,3]. Duration of CPB is an independent risk factor for
postoperative brain dysfunction.
c. Equipment-related sources
(1) Incorporation of a 25-μm filter into the aortic inflow line effectively
reduces cerebral embolic load and has been shown to decrease the
incidence of postoperative cognitive dysfunction.
IGURE 26.6 Diagram of vent air entrainment.
(2) Membrane oxygenators give rise to markedly fewer gaseous microemboli

than bubble oxygenators, but do not entirely eliminate the risk of air
emboli. Similarly, air entrained into the venous side of a membrane
oxygenator (or gaseous emboli resulting from drug administration via
injection directly into the CPB circuitry) can transit the membrane and
appear in the arterial inflow line despite the use of arterial line filters.
(3) Use of 20- to 40-μm filters in the cardiotomy return line prevents
particulate debris from the operative site from entering the CPB circuit.
Use of cardiotomy blood washing techniques (Cell Saver) is associated
with reduced amounts of cerebral lipid microemboli, but has not been
consistently shown to improve CNS outcomes.
(4) Use of nitrous oxide (N2O) before commencement of CPB has been
associated with increased evidence of ischemic damage, likely because
residual N2O increases the size of any microgaseous emboli in the
cerebral circulation. This especially applies to the first few hours after
CPB, when high fractional inspired oxygen (FiO2) should be used to
minimize the size of residual gaseous microemboli.
B. Hypoperfusion
1. 8 Watershed areas. Areas of brain localized at the boundary limits of major
cerebral arteries (e.g., anterior and middle, middle and posterior cerebral
arteries, or superior and posteroinferior cerebellar arteries) are known as
arterial boundary zones or watershed zones. Rapid severe hypoperfusion
can produce ischemic lesions within these boundary zones found at the
territorial limits of the major cerebral arteries. The most frequently affected
area is the parieto-occipital sulcus located at the limits of the anterior, middle,
and posterior cerebral arteries. Despite global ischemic stress, these watershed
lesions may be focal and asymmetrical. Although commonly due to profoundly
hypotensive episodes, watershed lesions are not pathognomonic of a
hypotensive episode, and may result from cerebral emboli.
CLINICAL PEARL Hyperthermia during CPB must be avoided, especially during
rewarming, because rewarming is associated with exacerbation of ischemic neurologic
injury.
2. Cerebral perfusion pressure (CPP). During moderate hypothermia (28° to
30°C) using α-stat pH management, autoregulation is preserved in certain
patients over CPP ranging from 20 to 100 mm Hg. However, studies in older
cardiac surgical patients and those with cerebrovascular disease indicate a
wide variability of LLA between 45 and 80 mm Hg, including some in whom
autoregulation could not be shown [23,24]. Additionally, there are several
conditions in which autoregulation may be lost (Table 26.2), including during
profound hypothermia (15° to 20°C), where there is evidence of hypothermia-
induced vasoparesis. Diabetic patients have impaired CA even at moderate
hypothermia.
TABLE 26.2 Factors associated with loss of cerebral autoregulation (CA)
During CPB, there may be dissociation between MAP and CPP as a result of
unrecognized cerebral venous hypertension. Particularly with the use of a
single two-stage venous cannula, cerebral venous drainage may be impaired,
especially during cardiac dislocation for performing posterior distal
anastomoses. Consequently, jugular venous pressure (JVP) should be measured
proximally within the superior vena cava (SVC) (e.g., via introducer port of
pulmonary artery [PA] or a central venous pressure [CVP]) catheter. CPP can
also be compromised during OPCAB surgery, especially while performing
multiple-graft procedures. During these operations, the patient is often placed
in steep head-down tilt and the heart is lifted to expose the distal targets, two
factors which can increase CVP and thus decrease CPP. Concurrent systemic
arterial hypotension and low cardiac output may often occur, thereby
compounding cerebral hypoperfusion.
3. Circulatory arrest. During circulatory arrest under normothermic conditions,
O2 levels are depleted within a few seconds of onset of ischemia, EEG activity
is lost (isoelectric EEG) within 30 seconds, high-energy phosphates are
exhausted within 1 minute, and ischemic neuronal damage is found after
periods of anoxia as brief as 5 minutes. During surgical circulatory arrest,
profound hypothermia (16° to 18°C) is used to minimize CMRO2 and increase
the tolerance for ischemia.
For certain cardiac electrophysiologic (EP) procedures (e.g., mapping and
ablation of certain refractory arrhythmias and deployment of implantable
defibrillators), transient ventricular fibrillation (VF) is often induced at
normothermia and without circulatory support. Duration of VF must be limited
to less than 1 minute, and prompt hemodynamic resuscitation with at least 5
minutes of reperfusion should be maintained between episodes of VF to
minimize cognitive injury [32].
4. Intracerebral and extracerebral atherosclerosis. Patient-related factors
including intracerebral and extracerebral atherosclerosis compound the impact
of perioperative hypotension. The incidence of neurologic injury after cardiac
surgery is higher in patients with previous stroke, hypertension, advanced age,
diabetes, and carotid bruit [3], all of which are factors related to more
extensive cerebrovascular disease. In one series of 206 perioperative CAB
patients, over 50% of patients exhibited concomitant cerebrovascular disease
[33] . Such patients are more prone to cerebral ischemia secondary to
atheroemboli and perioperative hemodynamic instability.
C. Inflammation
Ischemia can be defined as a critical decrease in tissue energy substrate (e.g.,
glucose, O2), whether resulting from impaired bioavailability and/or decreased
substrate delivery (perfusion/microcirculation), below which ion-pump failure
triggers cytotoxic cascades and tissue necrosis. Whether precipitated by emboli
or hypoperfusion, inflammatory cascades exacerbate and trigger various
cytotoxic cascades, leading to cerebral damage and neuronal necrosis.
1. Ischemic penumbra. A potentially viable brain region of unpredictable
extent, variably responsive to resuscitative measures. The ultimate size and
histologic extent of the ischemic penumbra, which any of a diversity of
ischemic insults will produce, is influenced by the duration of the ischemic
insult, the affected vascular territory, the presence of collateral circulation, and
factors that either ameliorate (e.g., hypothermia) or increase (e.g.,
proinflammatory mediators) the impact of ischemia on neuronal tissue [34].
This is the concept of the “ischemic penumbra,” and salvage of the ischemic
penumbra is the goal of neuroresuscitative efforts.
9 The correlations between markers of active systemic inflammation and
perioperative stroke are manifold. These include perioperative elevations in C-
reactive protein (and other biomarkers) and white blood cell count, which
correlate with both the extent and incidence of end-organ injury in cardiac
surgery and in nonoperated patients [35,36].
2. “Panvascular inflammation” is a term that has been used in patients presenting
with unstable angina in reference to the correlation between markers of
inflammation and the extent and magnitude of a generalized heightened
activity of systemic plaque, as demonstrated in carotid and other major vessel
groups [37], and which has been proposed as a mechanism for the significantly
greater incidence of stroke in the SYNTAX trial of CAB versus PCI [ 37],
despite other major cardiovascular and composite outcomes favoring CAB [1].
3. Pathophysiology of neuronal ischemia
a. Apoptosis, necrosis, and inflammation. Two distinct phases of cellular death
have been described after cerebral ischemia: apoptosis and necrosis. These
are related to the intensity and duration of the ischemic insult. Apoptosis is
programmed cerebral cell death. Its main features include cell shrinkage
with preservation of cell membrane and mitochondrial integrity and lack of
inflammation and injury to the surrounding tissue. There is some evidence that
CPB may exacerbate apoptotic processes, thereby accelerating neuronal loss
to manifest as delayed postoperative CNS injury. Necrosis is a
nonprogrammed event leading to cellular swelling, disruption of cell
membrane, and mitochondrial damage with inflammatory reaction, vascular
damage, and edema formation [34]. The core of the ischemic tissue will show
predominantly necrosis, and apoptosis will be found mostly in the periphery
of the ischemic area. The sensitivity of neurons to ischemic insult varies by
region, with hippocampal areas exhibiting marked vulnerability.
b. Lactic acidosis. Glucose is essentially the sole substrate for energy
production by the brain, being metabolized to produce 36 moles of adenosine
triphosphate (ATP) per mole of glucose. Oxygen is essential for oxidative
phosphorylation, and in the presence of ischemia, anaerobic glucose
metabolism yields only 2 moles of ATP and results in lactate production with
accumulation of hydrogen ion (H+) . Anaerobic glycolysis is the primary
cause of acidosis during ischemia, and the severity of lactic acidosis is
directly related to preischemic glucose concentrations. Hyperglycemia is
associated with worsening of neurologic injury after cerebral ischemia and
should be avoided in the perioperative period.
c. Ion gradients and role of calcium. Neuronal function and structural integrity
are dependent on ionic gradients, such that up to 75% of ATP produced by
resting neurons is utilized for extrusion of calcium by calcium-dependent
ATPase. With ischemia, decreased ATP production and evolving lactic
acidosis impair transmembrane ionic pumps and consequently diminish
cellular electrochemical gradients, leading to cell depolarization.
Extraneuronal leakage of K+ depolarizes adjacent neurons, thereby decreasing
synaptic transmission and, along with extracellular calcium, promoting
vasospasm in the adjacent vasculature.
d. Leukocytosis. In a subanalysis of a trial randomizing 18,558 patients with
symptomatic vascular disease to receive aspirin or clopidogrel, it was
observed that in the week prior to a second vascular event, the quartile with
highest leukocyte counts had higher risks for ischemic stroke, MI, and
vascular death after adjustment for other risk factors [35]. In the week before
a recurrent event, but not at earlier time points, the leukocyte count was
significantly increased over baseline levels, suggesting that leukocyte counts
(and mainly neutrophil counts) are independently associated with ischemic
events in these high-risk populations. Consistent with this, in a prospective
study of 7,483 patients who underwent CAB or valvular surgery or both,
leukocyte count was compared with the occurrence of postoperative stroke
[36]. There were a total of 125 postoperative strokes; leukocyte count was
significantly higher preoperatively and immediately postoperatively in
patients with stroke, and the magnitude of leukocyte count elevation correlated
with stroke magnitude and extent. These results strongly implicate
inflammation and white cell activation as etiologic in both the extent and
severity of perioperative cerebrovascular events.
e. Excitotoxicity. Glutamate is the most abundant excitatory amino acid (EAA)
in the brain. It serves metabolic, neurotransmitter, and neurotropic functions
and is normally compartmentalized in the neuron. Under normal conditions,
brain cells quickly take up extracellular glutamate. Glutamate stimulates two
kinds of receptors: ionophore-linked receptors and metabotropic receptors;
the latter ones acting only as modifiers of the excitotoxic injury. The main
excitotoxic role lies in the ionophore-linked receptors, and these include
NMDA (N-methyl-D-aspartate), AMPA (alpha-amino-methylisoxazole-
propionic acid), and kainate, responsible for mediating transmembrane Ca2+
and Na+/K+ passage. Ischemia produces enhanced presynaptic EAA release
and decreased reuptake, which causes activation of postsynaptic NMDA and
AMPA receptors and produces massive efflux of K + and influx of Na+ and
Ca+ and resultant osmolysis and calcium-related damage. EAAs also are
increasingly implicated in free radical formation. Administration of
ketamine, an NMDA-receptor antagonist, has shown variable efficacy to
decrease neuronal ischemic injuy.
f. Calcium. With ischemia, ATP depletion causes loss of ionic gradients,
resulting in cell membrane depolarization and influx of calcium ion (Ca2+)
through voltage-sensitive channels. Intracellular accumulation of Ca2+ is
likely the final common pathway leading to neuronal death through enhanced
protein and lipid catabolism. Elevated intracellular calcium activates both
phospholipases, which leads to membrane cell breakdown and arachidonic
acid and free radical formation, and endonucleases, which induces
fragmentation of genomic DNA, mitochondrial dysfunction, and energy failure.
The intensity of intracellular calcium overload is the key factor leading to
irreversible cellular damage. Influx of Ca2+ can be minimized by calcium
antagonists. Nimodipine has shown clinical benefit in decreasing vasospasm
after subarachnoid hemorrhage, but has been associated with increased
bleeding and mortality in cardiac surgical patients.
g. Free fatty acids (FFAs). Some of the earliest cell membrane changes with
ischemia involve production of FFAs from membrane phospholipids.
Intracellular Ca2+ activates calcium-dependent phospholipases C and A2,
transforming membrane phospholipids into FFAs, which themselves are
neurotoxic. FFAs are powerful uncouplers of oxidative phosphorylation and
can undergo further oxidation from arachidonic acid, with resultant free
radical formation. During cerebral ischemia, FFA production is decreased
by administration of calcium antagonists and 21-aminosteroids (lazaroids),
which are potent inhibitors of lipid peroxidation. Despite laboratory
promise, clinical trials have so far been disappointing.
h. Nitric oxide (NO). NO is a free radical gas synthesized from L-arginine by
NO synthase (NOS). NO functions as a neurotransmitter and has a role in
regulating CBF and inflammation. In brain ischemia, the elevation of
intracellular calcium markedly increases the activity of NOS. Increased NO
combined with superoxide anion leads to the formation of other reactive
oxygen species, hydroxyl free radicals, and nitrogen dioxide to produce
proteolysis and cell damage. NO also mediates activation of ADP-
polymerase leading to ATP and nicotinamide consumption and cell death
[34]. Experimentally, lazaroids ameliorate neuronal ischemic damage when
administered for ischemic stress, but results of clinical trials have not been
positive.
IV. Intraoperative cerebral monitoring
A. Brain temperature
Accurate monitoring of brain temperature is essential, as temperature profoundly
influences CMRO2 and thus tolerance for ischemia. Mild hypothermia (less than
35°C) is disproportionately effective in decreasing ischemia-related injury due
to inhibition of EAA release. During CPB, thermal gradients exist between
various tissues; thus, brain temperature must be measured independent of other
sites. Because of the small risk of trauma associated with placement of a
tympanic thermistor, nasopharyngeal temperature (NPT) is the preferred site for
clinical monitoring of brain temperature. Thermistor insertion should be through
the nares to the level of the midpoint of the zygoma, a depth of 7 to 10 cm in an
adult. Insertion of the thermistor before heparinization, using lubrication and
exerting gentle pressure parallel to the floor of the nose, will minimize epistaxis
—which can be problematic in a heparinized patient—and trauma to mucosa and
turbinates. Esophageal temperature is a poor substitute for NPT because it
variously reflects aortic inflow temperature, temperature of surrounding tissue,
and the influence of residual ice or cooled fluid within the pericardial sac. For
DHCA and high-risk patients, a thermistor/oximetric catheter can be placed
retrograde into the jugular bulb, thus providing a sensitive clinical measure of
global brain temperature and oxygenation. However, the invasivity, potential for
wall artifact and other confounders have largely led to the use of cerebral NIRS
in lieu of jugular oximetry.
TABLE 26.3 EEG confounders
B. Electroencephalogram (EEG)
EEG represents the amplified, summated, and spontaneous electrical activity of
the superficial cerebral cortex. Each electrode reflects microcurrent (10 to 200
μV) generated by electrical gradients across layers of neurons aligned at right
angles to the monitored cortical surface in a 2- to 3-cm radius. EEG activity is
commonly divided into four bands according to frequency: δ less than 4 Hz; θ 4
to 8 Hz; α 9 to 12 Hz; and β greater than 13 Hz. In general, slower frequencies
indicate a deeper level of anesthesia. Several factors can confound
interpretation of intraoperative EEG including the presence of various anesthetic
agents, profound changes in body temperature, and the electrically hostile
environment of an operating room (Table 26.3) which, along with its technical
complexity, have limited its primary clinical use to postoperative monitoring for
nonconvulsive seizures after suspected brain injury [28,38]. Although subtle
EEG changes may be difficult to interpret, development of asymmetric EEG
activity should be considered to represent hemispheric compromise (Table
26.4).
1. Processed electroencephalogram (EEG). Increasingly, processed EEG is
employed intraoperatively (e.g., bispectral index [BIS] and others) for
monitoring depth of anesthesia. Additionally, electrocortical “silence” or burst
suppression can be readily identified with such devices and should be sought
during cooling for DHCA to ensure adequacy of brain metabolic suppression.
Most commercially available processed EEG monitors employ single- or two-
channel adhesive pads that are fixed to frontotemporal areas. After initial
electronic filtering, analog EEG voltages are rapidly digitized (150/sec) and
analyzed over “epochs” (generally 2 to 4 seconds in duration) using analyses
based on either frequency-domain or time-domain processing.
TABLE 26.4 Causes of electroencephalographic asymmetry
a. Compressed spectral array (CSA) and density-modulated display of

power spectrum analysis (density spectral array, DSA). For frequency-
domain processing, some EEG applications use power spectral analysis. In
this application, each EEG epoch is converted into a series of sine-wave
components using Fourier transformation that treats the digitized EEG as a
sum of sine waves of variable frequency and power. The amplitude (power)
of each of the sine-wave components is indicated as a function of its
frequency, and in the CSA, each EEG epoch is shown over time in a three-
dimensional representation (frequency vs. power vs. time), with the most
current epoch in the foreground. However, the vertical displacement,
representing both power and time, hinders recognition of low-
amplitude activity followed by high-amplitude activity in the same frequency
band, reducing its efficacy. DSA is a representation in which each epoch is
displayed using color-scale intensity or dot size proportional to the power of
the individual frequency band. It can be difficult to recognize small changes in
frequency using this display, but both CSA and DSA also calculate the
spectral edge frequency below which 95% of EEG power is located.
b. Spectral edge frequency (aperiodic analysis). Aperiodic analysis is a time-
domain-based processing and does not use Fourier transformation. Instead, it
is based on assessing voltage versus time of the raw EEG. Fast- and slow-
wave components are analyzed separately and then combined for display.
This model of analysis is also used to calculate the burst suppression ratio,
which can be an indicator of anesthetic depth and cerebral metabolism
depression. Epileptiform activity and artifact have been reported to be most
readily identified by time-domain processing. EEG frequency carrying the
median power (median frequency power) correlates with plasma levels of
several narcotics. The spectral edge frequency correlates with clinical
assessment of anesthetic depth achieved with barbiturates or volatile
anesthetics.
2. Bispectral index (BIS). Most frequency-domain processing (CSA, DSA) treats
those component waveforms resulting from Fourier transformation as
independent. BIS analysis measures potential interactions between the waves to
determine the presence of interactive components (harmonics) indicative of
phase coupling (biocoherence)—information that is not present in power
spectral analysis. EEG slowing and synchrony often occur in relation to
increasing depth of anesthesia. BIS measurement devices are the first ones
specifically designed for the measurement of the hypnotic effects of drugs
approved by the U.S. Food and Drug Administration (FDA).
3. Evoked potentials (EPs). Metabolic and hemodynamic homeostasis
determines the state of cerebral functional integrity. The latter can be inferred
from EEG changes in response to repeated stimulation of intact afferent
pathways. Separated from raw EEG and averaged, these EPs are described in
terms of latency (time between the stimulus and respective EEG change) and
amplitude (cortical microcurrent 1 to 5 μV). Reduction in CBF below 18
mL/100 g/min causes progressive decrease of the latter, which disappears at
CBF below 15 mL/100 g/min. In clinical practice, only the response of sensory
neurons of gray matter can be tested in this way. More commonly, EPs serve to
monitor the function of sensory tracts as somatosensory-evoked potentials
(SSEPs). Certain anesthetic agents complicate the recognition of specific
effects of changing metabolic environment on cortical SSEPs (e.g., isoflurane
increases latency and decreases amplitude of SSEPs) and have variable effects
on different EPs (e.g., visual, somatosensory). Subcortical SSEP, which avoids
anesthetic confounding, has recently been successfully introduced clinically
[39]. Temperature alterations also affect the latency and amplitude of SSEP,
confounding a primary use of SSEP for monitoring integrity of spinal cord
during elephant trunk and other thoracic aortic procedures.
C. Transcranial Doppler (TCD)
Insonation of blood moving within a vessel produces a characteristic shift in
signal frequency (Doppler shift) that is proportional to the flow velocity. Use of
low-frequency sound waves (2 to 4 MHz) from depth-gated, direction-sensitive
probes allows transmission through thin areas of skull (e.g., the temporal
window located above the zygomatic arch between the ear and orbit). This
transmission enables continuous assessment of blood flow velocity within the
major intracerebral arteries (e.g., proximal MCA). Cerebral perfusion
characteristics also can be assessed using TCD insonation for demonstration of
laminar versus pulsatile flow or for detection of emboli. Because dissimilar
acoustic echoes reflect inhomogeneities in the insonated substrate,
microaggregate or microgaseous emboli can be detected within the bloodstream.
Because TCD essentially functions as a microphone, artifactual noise transients
can register as emboli. However, certain criteria have been employed to
distinguish embolic signals from noise artifact (Table 26.5). Much greater
acoustic resonance of gas emboli relative to formed elements creates limits of
TCD detection for formed elements greater than 100 lm wherein the
amplitude of signal is proportional to the size of the embolus, whereas for
bubble emboli, limits of resolution are 50 lm and the amplitude of the
reflected signal is unrelated to the bubble size.
TABLE 26.5 Transcranial Doppler (TCD) characteristics of emboli versus noise
Because of the ability to focus a pulsed ultrasound beam, however, by using a

dual gating technique in which the vessel is insonated at two discrete sites,
emboli can be discriminated from artifacts. This reflects the fact that emboli
propagate with blood motion and artifact does not, and thus emboli (but not
artifact) will be detected sequentially at different depths along the insonated
cerebral artery.
One of the major goals in intraoperative TCD monitoring is discriminating
solid versus gaseous cerebral emboli. Solid and gaseous microemboli may be
differentiated with a new generation of multifrequency transducers, using both 2-
and 2.5-MHz crystals, based on the principle that solid microemboli reflect
more ultrasound at the higher than at the lower frequency, whereas the
opposite is the case for gaseous microemboli. How robust this will prove in
clinical practice remains to be seen and the results to date remain unconvincing.
D. Jugular oximetry
The characteristic attenuation of 650 to 1,100 nm of infrared light by a few
specific light-absorbing chromophores (primarily oxyhemoglobin,
deoxyhemoglobin, and oxidized cytochrome c oxidase) imparts wavelength
(color) shift on the incident light. This spectral shift is proportionate to the
degree of oxygenation, thereby enabling quantification of tissue oxygenation using
optical spectroscopic devices. Placement of a fiberoptic oximetric catheter into
the jugular bulb provides continuous monitoring of the hemoglobin saturation of
effluent cerebral venous blood and reflects global cerebral O2 supply and
demand balance. Jugular oximetry may provide an appropriate endpoint for
termination of cooling before DHCA. After jugular saturation has increased
maximally and stabilized, CMRO2 is at its lowest. Such monitoring has identified
an association between rewarming after hypothermic CPB and significant
cerebral venous blood desaturation. This indicates mismatching between
cerebral O2 supply and metabolic rate. Assuming adequate arterial oxygen
saturation, increasing either hemoglobin concentration or depth of anesthesia
(greater metabolic suppression) may be appropriate. However, the invasive
nature and other confounders have led to cerebral NIRS largely supplanting
jugular oximetry.
E. Near-infrared spectroscopy (NIRS)
Similar principles of light absorbance are used during noninvasive cerebral
optical spectroscopy using scalp-attached probes. Most of the currently available
commercial devices employ two-channel monitoring using adhesive pads, with
one or more transmitting and two or more separately spaced receiving optodes.
Differential spacing of the receiving optodes enables correction for extracerebral
tissues to be made, allowing an assessment of regional oxygen saturation (rSO2)
of the cerebral cortex (Fig. 26.7). Current studies estimate that there is between
5% and 15% influence of extracerebral tissue on cerebral oximetry values as
measured. Advantages and limitations of NIRS cerebral oximetry monitoring are
shown in Table 26.6. This device enables indices of cerebral oxygenation to be
determined in a continuous manner in a variety of clinical circumstances. There
is no requirement for pulsatile blood flow, thus enabling continuous monitoring
during CPB, and there are no temperature-related artifacts. A potential limitation
is the fact that the cerebral sample volumes are on the order of 1 mL of frontal
cortical tissue, thus rendering them highly localized. Since NIRS measures total
tissue oxygenation, various factors including patient age, hemoglobin
concentration at the measurement site, and sensor location can affect rSO2 values.
A prospective study demonstrated that avoidance of low intraoperative cerebral
oximetry values decreases major organ morbidity and death in patients
undergoing CABG surgery [40], and a recent multicenter study [41] has
confirmed the successful treatment of cerebral desaturations using the original
algorithm proposed [40]. While there is increasing clinical consensus that
cerebral oximetry is beneficial in patients undergoing hypothermic circulatory
arrest with direct cerebral perfusion [42], some clinicians remain skeptical [43].
Large-scale multicenter clinical outcomes studies will be required in order to
make a solid recommendation for the widespread use of cerebral oximetry in
FIGURE 26.7 Schematic representation of tissue layers through which light must propagate to reach the brain. Light
propagating from source to receiver 1 has a mean tissue path length such that it predominantly samples superficial tissue
(scalp and skull), whereas light propagating to receiver 2 has a deeper mean path length into the brain. The signal from
receiver 1 is used to correct the signal from receiver 2 for superficial tissue contamination. (From McCormick PW, Stewart
M, Goetting MG, et al. Noninvasive cerebral optical spectroscopy for monitoring cerebral oxygen delivery and
hemodynamics. Crit Care Med. 1991;19:89–97, with permission.)
F. Cerebral perfusion pressure (CPP)

CPP represents the difference between driving pressure, or MAP, and
downstream pressure, or intracranial pressure (ICP). During CPB, direct
measure of ICP is not available; thus, CVP may be used as a surrogate. In the
presence of impaired drainage from the SVC, which may occur during
dislocation of the heart (particularly with use of a single two-stage cannula),
cerebral venous hypertension may occur. Because atrial drainage is unimpaired,
CVP measured from the atrium will be low; hence, this condition may be
unrecognized unless proximal pressure is measured. If sustained, cerebral venous
hypertension can lead to cerebral edema and substantially decreased CPP,
despite apparently adequate MAP (Fig. 26.8). NIRS cerebral oximetry has been
demonstrated to rapidly detect such events when cerebral desaturation occurs.
TABLE 26.6 Advantages and limitations of NIRS cerebral oximetry
FIGURE 26.8 A: Systolic, mean, and diastolic arterial blood pressures (BPs), with commencement of cardiopulmonary
bypass (CPB) indicated at 3:15 PM, after which mean arterial pressure (MAP) is shown. B: Pulmonary artery systolic,
mean, and diastolic pressures with proximal jugular venous pressure (JVP) recorded at 3:15 PM, with commencement of
CPB. A single two-stage venous cannula was used for CPB. With rotation of the heart, venous return to the oxygenator
decreased and JVP approached MAP values. (Modified from Murkin JM. Intraoperative management. In: Estafanous FG,
Barash PG, Reves JG, eds. Cardiac Anesthesia: Principles and Clinical Practice. Philadelphia, PA: J.B. Lippincott Company;
1994:326, with permission.)
CLINICAL PEARL One primary indication for pH-stat is during cooling for DHCA.
G. Lower limit of cerebral autoregulation
One of the most dynamic new developments in brain monitoring is the potential
detection of individualized LLA intraoperatively. Based on studies initially
conducted in head-injured patients, correlations were made between spontaneous
fluctuations in MAP and corresponding changes in cerebral perfusion [44]. It has
recently been determined that both TCD-monitored flow and cerebral NIRS
velocity alterations correlate inconsistently with changes in MAP [44]. LLA is
estimated by determining correlation coefficient (CC) between MAP and NIRS,
which is taken to indicate pressure dependency of cerebral perfusion if greater
than 0.35, or independence of pressure and flow (e.g., intact CA) if less than
0.35. The lowest MAP at which the CC exceeds 0.35 corresponds to the LLA as
shown in Figure 26.3. Given its ease of use for data collection, cerebral NIRS is
now utilized in clinical studies to detect LLA and has correlated with a variety of
adverse outcomes [25–27,40]. Although individualized LLA currently is only
used clinically as a research tool, ultimately it will become clinically available.
V. Prevention of central nervous system (CNS) injury
As discussed in detail below, Table 26.7 shows a series of evidence-based
recommendations designed to limit the risk of perioperative cerebral injury in
cardiac surgical patients [45]. Table 26.8 outlines specific interventions designed
to limit or avoid particular risk factors.
TABLE 26.7 Evidence-based guidelines for best practice bypass
TABLE 26.8 Perioperative strategies to minimize CNS brain injury
A. Embolic load
1. Aortic instrumentation
a. Direct EAS of ascending aorta is the most sensitive technique for
intraoperative assessment of atherosclerotic burden. Alternatively, initial TEE
screening of descending aorta, followed by EAS if TEE detects descending
aortic atherosclerosis, represents an acceptable screening strategy. Although it
remains a standard of care, palpation of the aorta has not proven sensitive to
detect noncalcific aortic atherosclerosis or to decrease stroke risk. Routine
EAS is becoming standard of care in certain institutions [46]. With the
identification of extensive aortic atherosclerosis, distal aortic arch or axillary
artery cannulation and “no touch” anaortic techniques should be considered.
b. Minimize the number of aortic clampings. Exclusive use of arterial grafts
(e.g., mammary, gastroepiploic) or sutureless proximal anastomotic devices
can avoid aortic partial clamping for proximal anastomoses. In cases of
severe atheroscleroses, anaortic-
technique OPCAB with zero manipulation of the ascending aorta significantly
decreases stroke rate.
B. Off-pump coronary artery bypass (OPCAB), coronary artery bypass (CAB),
and minimally invasive extracorporeal circulation (MiECC)
In a 2012 meta-analysis of risk of stroke in OPCAB versus conventional on-
pump CAB surgery, analysis of 59 randomized clinical trials involving 8,961
randomly assigned patients, of whom 4,461 patients were assigned to OPCAB
and 4,500 to CAB, found a composite stroke incidence of 1.4% in OPCAB
versus 2.1% in CAB groups [47]. All studies to date have reported either no
difference or a trend toward lower stroke incidence with OPCAB. A more recent
meta-analysis of 13 studies with 37,720 patients compared outcomes between
CAB and OPCAB both with and without aortic clamping, and found that anaortic
OPCAB had the lowest rate of perioperative stroke. Avoidance of CPB reduced
risk of short-term mortality, renal failure, atrial fibrillation, and bleeding [48].
CLINICAL PEARL Recent studies have demonstrated a striking interindividual
variability in the LLA during CPB.
1. Current minimally invasive extracorporeal circulation (MiECC) systems have
improved biocompatibility of CPB components. A meta-analysis including
22,778 patients favored CAB using MiECC over both OPCAB and non-
MiECC-CAB for both morbidity (including renal failure and stroke) and
mortality outcomes [49].
C. Perfusion equipment and techniques
1. Precirculation of CPB circuit for a minimum of 30 minutes with a 5-μm filter is
recommended to remove plasticizers and other potential manufacturing
microdebris.
2. Incorporation of a micropore (20 to 40 μm) filter into the cardiotomy return
line keeps tissue and a variety of other particulate debris from the surgical field
out of the CPB circuit, although lipid microemboli are not well removed.
3. Cell salvage processing prior to retransfusion of cardiotomy suction blood has
been proposed to decrease lipid embolic load, but has not been shown to
consistently improve early postoperative cognitive outcomes.
4. Use of a 40-μm filter on the arterial inflow line decreases delivery of emboli
into the arterial circulation.
5. To minimize gas bubble formation due to decreased solubility with rewarming,
the temperature gradient between the arterial inflow blood and the patient must
be less than 10°C.
6. During rewarming, arterial blood inflow temperature must not exceed 37°C.
7. There is a possibility of air entrainment from cardiac vents in the surgical field.
Meticulous de-airing of CPB venous cannulae and all syringes used for
injection into the CPB circuitry are essential to minimize arterial gas
embolization.
D. Open-chamber de-airing techniques
1. Before commencing ventricular ejection, needle aspiration of the LV and LA,
combined with manual agitation of the heart, is required to dislodge air
entrapped in the trabeculae. This process should be combined with concomitant
manual ventilation of the lungs to mobilize residual air within the pulmonary
veins.
2. TEE is used to detect residual intracavitary air and assist needle aspirations.
3. Steep Trendelenburg tilt is thought to divert cerebral emboli, though diffuse
flow vortices within the atherosclerotic aorta can confound attempts at emboli
diversion.
4. Transient bilateral carotid compression during defibrillation and initial filling
and commencement of heart ejection should be reserved for instances where the
risk of intracavitary air remains high and there is no suspicion of carotid
atherosclerosis.
5. Insufflation of CO2 into the surgical field decreases cerebral embolic load in
open-chamber procedures, but to date has not been associated with improved
neurologic or cognitive outcomes [29].
E. Cerebral perfusion
During moderate (28°C) hypothermic CPB, relative hypotension may be
tolerated, as CA can be preserved to CPP 20 mm Hg during α-stat blood gas
management [22]. However, in elderly patients or those with cerebrovascular
disease, higher pressure should be maintained, because the lower autoregulatory
threshold has been shown to vary markedly in such patients [23,24]. As assessed
by NPT, the brain rewarms rapidly; therefore, hypotension (MAP less than 50
mm Hg) should be avoided after commencement of rewarming. Inadvertent
compromise of CPP should also be avoided by monitoring proximal SVC
pressure to detect cerebral venous hypertension. Diabetics and patients with
previous CVA have impaired CA, and CBF is directly dependent on MAP. Such
patients, as well as those with chronic hypertension, may benefit from close CNS
monitoring and maintenance of higher perfusion pressures.
F. Euglycemia
There is considerable evidence from experimental models and from patients with
CVA that hyperglycemia increases the magnitude and extent of neurologic injury
during ischemia. Hyperglycemia should be avoided as a basic approach.
Glucose-free infusions and a glucose-free prime should be used for CPB
circuits because insulin resistance develops during CPB (partially as a result of
increased endogenous catecholamines), producing glucose intolerance and
increasing the tendency for refractory hyperglycemia. A structured approach to
maintain normal values of blood glucose is considered favorable to patients’
outcomes and is a recognized element of best practice CPB guidelines as shown
i n Table 26.7 [45]. However, the deleterious impact of hypoglycemia on
mortality has tempered strict glycemic protocols in favor of permitting mild
hyperglycemia, e.g., CPB glucose levels as high as 150–180 mg/dL.
G. Mild hypothermia
Increasing evidence shows EAAs as pivotal to the genesis of ischemic
neurologic injury. Since EAA synthesis and release are critically temperature
dependent and are significantly inhibited below 35°C [34], brain temperature
(NPT) should be monitored continuously during rewarming, hyperthermia (NPT
greater than 37°C) must be avoided, and brain temperature should be
maintained less than 37°C after separating from CPB and up to 24 hours
postoperatively [45].
H. Best practice cardiopulmonary bypass (CPB)
Recommendations from an evidence-based review for conducting safe, patient-
centered CPB as based on a structured MEDLINE search coupled with a critical
review of scientific literature and debates stemming from presentations at
regional and national conferences are shown in Table 26.7 [45].
CLINICAL PEARL Even transient postoperative atrial fibrillation is associated
with an increased risk of 1-year cardiovascular events (stroke, MI, and cardiac
death).
FIGURE 26.9 Nomogram of probability of “safe” total circulatory arrest according to duration of total arrest time at
nasopharyngeal temperature (NPTs) of 37°C, 28°C, and 18°C, defined as the duration of total arrest after which no
structural or functional damage has occurred. (From Kirklin JK, Kirklin JW, Pacifico AD. Deep hypothermia and total
circulatory arrest. In: Arciniegas E, ed. Pediatric Cardiac Surgery. Chicago, IL: Year Book; 1985:79–85, with permission.)
VI. Pharmacologic cerebral protection

Despite a profound and ongoing increase in the understanding of the mechanisms
involved in ischemic neuronal injury and the development of new subselective
classes of drugs, currently none represent a standard of practice, but these or
related compounds may become part of the therapeutic armamentarium.
A. Metabolic suppression
1. Rationale and limitations. Metabolic activity is temperature dependent, and
hypothermia produces an exponential decrease in CMR. Unlike pharmacologic
metabolic suppressants, hypothermia decreases metabolic activity related both
to functional activity (e.g., EEG activity) and basal activity (e.g., ion pumps).
Hypothermia prolongs the tolerance for global ischemia (Fig. 26.9) and is
undertaken particularly for circulatory arrest. During cardiac surgery, however,
the greatest risk for cerebral emboli occurs during normothermia with
cannulation and decannulation; hence, pharmacologic metabolic suppressants
have been investigated. While there was previously some interest in high-dose
thiopental or propofol-induced burst suppression [50], no consistent clinical
benefit was demonstrated.
2. Agents. As shown in Figure 26.10, various anesthetics have the ability to
produce EEG burst suppression and decreases in CMR to approximately 70%
of awake CMRO2, averaging 2 to 2.5 mL/100 g/min.
a. Propofol. Transient EEG burst suppression is obtained at dosages of 2 to 3
mg/kg with proportional decreases in CBF and CMRO2. Infusion at 0.1 to 0.3
mg/kg/min produces sustained EEG suppression and is rapidly metabolized;
therefore, it does not typically prolong recovery and extubation times.
Hypotension from systemic vasodilation may require administration of
phenylephrine or other such vasoconstrictors. Prolonged administration of
propofol (>48 hours) has been associated with the rare occurrence of a severe
metabolic syndrome characterized by metabolic acidosis, rhabdomyolysis of
skeletal and cardiac muscle, renal failure, hepatomegaly, and death [51].
b. Isoflurane, sevoflurane, and desflurane. At inspired concentrations of 1.5 to
2 MAC, burst suppression is produced. Unlike the intravenous agents, EEG
suppression with inhalational agents is not accompanied by any decrease in
CBF, although CMR O2 is reduced. Rapid elimination occurs upon
discontinuation of volatile anesthetics. Of particular interest is the evidence of
ischemic preconditioning and neuroprotection associated with administration
of volatile anesthetics, which have been variously demonstrated to decrease
glutamate release, modulate calcium flux, and inhibit generation of free
radicals as well as modulate apoptosis [52]. Large-scale clinical studies are
currently lacking but it does appear that volatile anesthetics do not
increase and may decrease postoperative CNS dysfunction.
FIGURE 26.10 EEG tracings from three patients during normothermic cardiopulmonary bypass (CPB). The top tracing
demonstrates characteristic low-voltage activity occurring during high-dose fentanyl anesthesia. The middle tracing shows
the burst suppression pattern resulting from thiopental administration. The lower pattern demonstrates burst suppression
occurring during isoflurane administration. (From Woodcock TE, Murkin JM, Farrar JK, et al. Pharmacologic EEG
suppression during cardiopulmonary bypass: cerebral hemodynamic and metabolic effects of thiopental or isoflurane during
hypothermia and normothermia. Anesthesiology. 1987;67:218–224, with permission.)
B. Calcium channel blockers

Massive calcium influx is the final common pathway of ischemic neuronal injury.
In clinical trials, calcium channel antagonists (nimodipine) have demonstrated
efficacy in decreasing vasospasm after subarachnoid hemorrhage; however,
nimodipine also has been associated with increased bleeding and higher
mortality in cardiac surgical patients.
C. Glutamate antagonists
Since excitotoxicity is recognized as central to ischemic neuronal injury, EAA-
receptor antagonists remain investigational. NMDA (e.g., ketamine) and AMPA-
receptor antagonists have been found to be neuroprotective following cardiac
arrest, but clinical studies in cardiac surgical patients remain inconclusive [53].
D. Lidocaine
Given its ability to decrease ischemia-mediated neuronal membrane
depolarization and attendant excitotoxic cascades, two small clinical trials of
lidocaine versus placebo have demonstrated lowered incidences of cognitive
dysfunction in cardiac surgical patients. However, preliminary results from a
larger clinical trial do not confirm these results.
E. Statins
An increasingly promising line of investigation is the role of perioperative statin
therapy, either alone or in combination with other medications. Evidence is
accruing that, when administered prior to CAB surgery, statins reduce the risk of
perioperative mortality, stroke, and atrial fibrillation. When combined with
chronic β-blocker usage, preliminary evidence suggests that statins may decrease
risk for perioperative stroke in CAB patients [54].
VII. Deep hypothermic circulatory arrest (DHCA)
A. Clinical indications
DHCA sometimes is used for major surgical procedures because it provides a
motionless, cannula-free, bloodless field. By allowing unobstructed surgical
access, DHCA facilitates repair of complex congenital anomalies in neonates
and infants. In adults, DHCA allows temporary interruption of cerebral
perfusion, primarily for aortic arch reconstruction or for resection of giant
cerebral aneurysms.
B. Technique
1. Core and external cooling. In most North American centers, active external
cooling (e.g., ice baths) has been largely eliminated, but packing the head in ice
is still recommended to inhibit secondary rewarming prior to onset of
reperfusion. Core cooling using CPB allows efficient and controlled onset of
hypothermia, and cooling persists until core temperature (bladder, rectal) is
stable at 15° to 20°C in the absence of selective cerebral perfusion (SCP).
Cooling must be continued until stable brain temperature (e.g., NPT, jugular
thermistry) has been achieved. Some centers use development of isoelectric
EEG, or plateau in cerebral NIRS (>90% saturation), as the endpoint for
cooling.
2. Decannulation. Before circulatory arrest, administration of long-acting muscle
relaxants is required to ensure profound motor block in order to minimize
systemic O2 consumption. With cessation of perfusion, venous cannulas are
unclamped, allowing passive exsanguination into the CPB circuit and
decreasing distention of the heart and bleeding into the surgical site. For
pediatric surgery, venous cannulas are usually removed to facilitate surgical
exposure. Often passive circulation of blood within the CPB circuit is
continued ex vivo to avoid stasis.
C. Brain protection
1. Temperature. Hypothermia is the primary component of brain protection
during circulatory arrest. The temperature coefficient (Q10), which is the ratio
of metabolic rates at temperatures 10°C apart, has been shown to be 2.3 for
human brain such that CMR is still 17% of baseline at 15°C. A 20°C (37° to
17°C) decrease in brain temperature enhances cerebral tolerance for ischemia
(see Fig. 26.9). Cooling the patient to a temperature of 10° to 15°C seems to
offer the best protection to the brain. Minimizing rewarming of the brain is
essential; therefore, external heat sources (e.g., overhead lights, ambient room
temperature) should be minimized. Application of external ice packs to the
head has been shown experimentally to delay brain rewarming and increase
ischemic tolerance. Propofol and/or steroids are sometimes administered
before circulatory arrest, although a beneficial effect is unproven.
2. Anterograde and retrograde perfusion. Because of CA with preferential
shunting of blood to the brain, even low systemic perfusion rates (e.g., 10 to 25
mL/kg/min) during deep hypothermia have been shown to significantly improve
cerebral ischemic tolerance in comparison to total circulatory arrest. A
prospective randomized study has shown that continuous low-flow perfusion
(0.71/min · m2) at 18°C for pediatric patients younger than 3 months old
undergoing arterial switch operations results in significantly lower incidences
of clinical seizures and brain creatinine kinase isoenzyme versus DHCA, and is
now the standard of care.
For aortic arch procedures in which arterial inflow is restricted, SCP via
brachiocephalic or carotid perfusion is employed. Since these techniques
assume adequacy of circle of Willis, there is increasing clinical interest in
bihemispheric NIRS cerebral (and preoperative cerebral angiography) to
assess adequacy of unilateral SCP. NIRS cerebral oximetry has been reported
to detect catheter kinking or inadequacy of flow in a number of cases.
Retrograde cerebral (CRP) perfusion does not provide sufficient substrate
supply to continuously maintain brain metabolic demand, but may prevent
rewarming and decrease cerebral embolization. In a recent case report, RCP
with pressure-augmented perfusion guided by NIRS was felt to provide
enhanced cerebral perfusion and was not associated with neurologic deficit
despite prolonged duration of perfusion [55]. Consensus has emerged that
cerebral oximetry monitoring is beneficial when SCP or retrograde cerebral
perfusion (RCP) is employed.
TABLE 26.9 Summary of deep hypothermic circulatory arrest (DHCA)
3. pH management. In a large randomized clinical trial, use of either α-stat or

pH-stat acid–base management strategy during reparative infant cardiac
operations with DHCA was not consistently related to early
neurodevelopmental outcomes, yet experimental and clinical studies have
demonstrated more homogeneous brain cooling with pH-stat. Conversely, pH-
stat impairs CA and potentially increases cerebral embolization; therefore, a
reasonable approach is to employ pH-stat during cooling and α-stat during
SCP perfusion and rewarming (Table 26.9).
CLINICAL PEARL Embolization and hypoperfusion acting together can play a
synergistic role and either cause or magnify CNS injury in cardiac surgical patients.
VIII. Cardiac surgery in patients with cerebrovascular disease
A. Incidence
Coronary atherosclerosis increases the likelihood of coexisting carotid
arteriopathy. Presence or absence of carotid bruits is a poor predictor of carotid
stenosis or the risk for perioperative stroke. In a survey of patients undergoing
CABG, 5.5% showed significant unilateral carotid stenosis, 2.2% had bilateral
stenoses, and 1.5% of patients had unilateral or bilateral carotid occlusion.
Another study of over 200 CABG patients demonstrated a 54% incidence of
significant cerebrovascular (carotid or intracranial) atherosclerosis
preoperatively [33]. In general, however, noninvasive (ultrasonography) and
invasive (contrast arteriography) investigations are usually reserved for patients
who have had overt symptoms of cerebrovascular insufficiency (e.g., transient
ischemic attacks or stroke) during the previous 3 to 6 months. In part, this reflects
the clinical recognition that carotid endarterectomy (CEA) does not appreciably
reduce risk of perioperative CVA in cardiac surgical patients [55].
B. Morbidity
Neurologic injury associated with cardiovascular surgery is a consequence of
both cerebral emboli and hypoperfusion. Carotid disease is an important
etiologic factor in the pathophysiology of post-CAB stroke but is probably only
responsible for, at most, about 50% of all strokes [55,56]. Paradoxically,
perioperative stroke is more frequent on the side contralateral to the stenosis and
may reflect a relative diversion of flow and emboli to the nonstenotic side.
Carotid stenosis is associated with a greater incidence of aortic atherosclerosis
and concomitant intracerebral arterial disease. The presence of combined carotid
and cardiac disease suggests more advanced and severe atherosclerosis and a
higher risk of embolization and/or hypoperfusion during cardiac surgery, and
emphasizes the necessity for optimal intraoperative management (e.g., NIRS,
EAS, and related best practices) [45].
C. Combined carotid and cardiac procedures
1. Rationale. Indications for CEA and CAB should be considered independently.
There is no compelling evidence that, in the absence of significant
symptomatology, CEA decreases perioperative stroke risk [ 55]. The role of
carotid stenting is promising and is increasingly employed perioperatively for
patients with symptomatic disease [56].
2. Morbidity. In asymptomatic patients, CEA does not decrease perioperative
stroke risk. The reported combined risk of death, CVA, and MI for synchronous
procedures (CEA + CAB) is 11.5%, and for staged procedures (CEA, then
CAB), it is 10.2%, suggesting that institutional experience is of primary
importance. Because of the paucity of natural history data, there is no
systematic evidence that staged or synchronous operations confer any benefit
over isolated CAB surgery [55].
As such, while there is a strong correlation between risk of perioperative
stroke and presence of carotid stenosis, it is not clear that CEA mitigates this
risk. In a meta-analysis of 11 studies in which 760 CAB patients underwent
either staged or synchronous CAB plus CEA, it was noted that 87% of the
patients were neurologically asymptomatic and 82% had unilateral carotid
disease. Overall, the 30-day risk of death or stroke was 9.1%, and while it was
observed that staged CAB and then CEA was considered less invasive, the
authors concluded that “it remains questionable whether the observed 9%
risk of CEA can be justified in any asymptomatic patient with unilateral
carotid disease” [57].
IX. Summary
Strong evidence supports a number of procedural and technical modifications that
have been shown to decrease perioperative CNS complications [45]. Avoidance
of instrumentation of ascending aortic atheroma by enhanced screening techniques
(e.g., preoperative MRI, intraoperative EAS) and selective use of OPCAB and
anaortic techniques for patients with significant aortic atherosclerosis, more
judicious use of NIRS for assessing adequacy of cerebral perfusion during CPB,
avoidance of cerebral hyperthermia during rewarming on CPB and
postoperatively, attenuation of perioperative and CPB-related inflammatory
responses, enhanced usage of techniques to decrease postoperative atrial
fibrillation, as well as administration of statins throughout the perioperative period
have all been shown efficacious in decreasing perioperative CNS complications.
The challenge is not only to better understand which patients are at increased
risk but to encourage more widespread assessment and adoption of
cerebroprotective strategies.
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27 Pain Management for Cardiothoracic Procedures
Brandi A. Bottiger, Rebecca Y. Klinger, Thomas M.
McLoughlin, Jr., and Mark Stafford-Smith
I. Introduction
A. Incidence and severity of pain after cardiothoracic procedures
B. Transmission pathways for nociception
C. Analgesia considerations: the procedure, patient, and process
D. Adverse consequences of pain
E. Outcome benefits of good analgesia for cardiothoracic procedures
II. Pain management pharmacology
A. Opioid analgesics
C. Acetaminophen (paracetamol)
D. Local anesthetics
E. α2-Adrenergic agonists
F. Ketamine
G. Gabapentinoids
H. Biologics
I. Nonpharmacologic analgesia
III. Pain management strategies
A. Enteral
B. Subcutaneous (SC)/intramuscular (IM)
C. Intravenous (IV)
D. Interpleural
E. Intercostal
F. Fascial plane blocks
G. Paravertebral blocks (PVBs)
H. Intrathecal (IT)
I. Epidural
IV. Pain management regimens for specific cardiothoracic procedures
A. Conventional coronary artery bypass and open-chamber procedures
B. Off-pump (sternotomy) cardiac procedures
C. Transcatheter and percutaneous procedures (transcatheter aortic valve
replacement, mitral clip, electrophysiology procedures)
D. Minimally invasive (minithoracotomy/para- or partial
sternotomy/robotic) cardiac procedures
E. Thoracotomy/thoracoscopy procedures (noncardiac)
F. Open and closed (total endovascular aortic repair [TEVAR])
descending thoracic aortic procedures
V. Approach to specific complications and side effects of analgesic
strategies
A. Complications of nonsteroidal anti-inflammatory drugs (NSAIDs)
B. Nausea and vomiting
C. Pruritus
D. Respiratory depression
E. Neurologic complications
F. Infectious complications
VI. Risk versus benefit: epidural/intrathecal (IT) analgesia for cardiac
surgical procedures requiring systemic anticoagulation
VII. Considerations in facilitating transitions of care
A. Enhanced recovery after surgery (ERAS)
B. Quality and safety considerations
C. Intrathecal (IT) morphine
KEY POINTS
1. Chronic pain due to intercostal nerve injury develops in

approximately 50% of postthoracotomy patients, and in 5% this pain
becomes severe and disabling.
2. Often overlooked, chronic pain after median sternotomy occurs in
up to 30% of patients, with pain rated as severe in 4%.
3. For neuraxial anesthesia, highly lipophilic drugs, such as fentanyl,
are best used with catheters placed near the involved dermatomes.
Hydrophilic drugs, such as morphine, are most useful for remote
catheters such as those positioned in the lumbar region.
4. Epidural opioids should generally not be administered unless
postoperative observation and monitoring for delayed respiratory
depression are planned.
5. Patients with severe lung disease may have the most to gain in terms
of improved outcome from optimal postoperative analgesia such as
continuous thoracic epidural and paravertebral techniques.
6. The risk of important nephrotoxicity appears to be low (1:1,000 to
1:10,000) with perioperative ketorolac administration.
7. Respiratory depression requiring naloxone administration is
reported to occur in 0.2% to 1% of patients receiving epidural
narcotics.
8. Pending additional contributions to our understanding of the risk of
peridural bleeding, the trend in expert opinion has recently shifted
to argue for caution, particularly regarding thoracic epidural catheter
placement prior to “full” heparinization for cardiac surgery. Fascial
plane blocks are a promising approach to analgesia for some
procedures that limits such risks.
I. Introduction
A. Incidence and severity of pain after cardiothoracic procedures
1 Pain is an unpleasant sensation occurring in varying degrees of severity as a
consequence of injury or disease. Chest surgery, via sternotomy and especially
via thoracotomy, is among the most debilitating for patients due to pain and
consequent respiratory dysfunction. Important sources of postoperative
discomfort after cardiothoracic surgery, in addition to incisional pain, include
indwelling thoracostomy tubes, rib or sternal fractures, and costovertebral joint
pain due to sternal retraction. Chronic pain due to intercostal nerve injury during
thoracic surgery and persisting for >2 months, develops in approximately 50% of
postthoracotomy patients, and in 5% this pain becomes severe and disabling.
Persistent pain after cardiac surgery affects approximately 37% of patients in the
first 6 months after cardiac surgery and remains present for more than 2 years in
17% [1]. Acute pain specifically attributed to median sternotomy is a frequent
occurrence and is rated as severe by more patients [2] than expected.
Poststernotomy pain also becomes chronic in up to 30% of patients [3], being
rated as severe in 4% [4]. Furthermore, despite the hope that minimally invasive
thoracic and cardiac surgical procedures involving smaller incisions would
reduce the incidence and severity of postoperative pain compared to traditional
approaches, clinical experience has not borne out this assumption for most
patients. Recent trials demonstrate similar chronic pain incidences between open
and minimally invasive approaches to thoracic surgery [5]. No single
thoracotomy technique has been shown to reduce the incidence of chronic
postthoracotomy pain, and patients should be warned in advance of this potential
postoperative complication. Similarly, acute postoperative pain has been
reported to be subjectively equivalent between conventional sternotomy and
minimally invasive approaches to cardiac surgical procedures [6]. 2
Psychosocial and genetic risk factors are associated with persistent pain states
in various settings [7–9] including surgical populations [10]. However, this has
yet to be proven in prospective trials involving thoracic surgical patients [5].
Notably, some evidence supports a protective effect from regional anesthesia
techniques in the prevention of persistent postthoracotomy pain states [11].
B. Transmission pathways for nociception
An understanding of the anatomy and physiology of pain pathways underpins the
logical choice of analgesic strategies during and after cardiothoracic surgery.
Multimodal approaches take advantage of numerous therapeutic targets in the
signaling chain to optimize pain control while minimizing side effects [12].
In the thoracic region, pain signals are relayed through myelinated Aδ and
unmyelinated C fibers in peripheral intercostal nerves. The ventral, posterior,
and visceral branches of each intercostal nerve innervate the anterior chest wall,
posterior chest wall, and visceral aspects of the chest, respectively. These
branches join together just before entering the paravertebral space and then pass
through the intervertebral foramina in the spinal canal. Sensory intercostal nerve
fibers form a dorsal root that fuses with the spinal cord dorsal horn to enter the
central nervous system (CNS). Somatic pain is mediated predominantly through
myelinated Aδ fibers in the ventral and posterior branches. Sympathetic
(visceral) pain is mediated by unmyelinated C fibers in all three branches.
Sympathetic afferent pain signals are directed from intercostal nerve branches
through the sympathetic trunk (a paravertebral structure found just beneath the
parietal pleura in the thorax) and then pass back into the peripheral nerves to
enter the CNS from T1 to L2. In addition, the vagus nerve provides
parasympathetic visceral innervation of the thorax. This cranial nerve enters the
CNS through the medulla oblongata and, therefore, is not normally affected by
epidural or intrathecal (IT) methods of pain control.
Spinal cord dermatomal segments typically lie cephalad to their respective
vertebrae, since the spinal cord and spinal canal are different in length. Thus,
knowledge of spinal anatomy is essential if regional analgesia techniques are to
be successful. This is particularly important to remember when using lipid-
soluble epidural opioids because the targeted dorsal horn often is significantly
cephalad relative to the associated intervertebral foramen and nerve.
CLINICAL PEARL When using lipid-soluble epidural opioids in the neuraxial space,
the targeted dorsal horn is often significantly cephalad relative to the associated
intervertebral foramen and nerve.
Most spinal pain signals are transmitted to the brain after crossing from the
dorsal horn to contralateral spinal cord structures (e.g., spinothalamic tract).
Distribution of nociceptive messages occurs to numerous locations in the brain,
resulting in cognitive, affective, and autonomic responses to noxious stimuli.
Regional and neuraxial techniques involving local anesthetics target and block
the afferent pathways from the peripheral nerve to the spinal cord.
Endogenous modification of pain signals begins at the site of tissue trauma and
includes hyperalgesia related to inflammation and other CNS-mediated
phenomena, such as “windup.” The substantia gelatinosa of the dorsal horn is an
important location for pain signal modulation, including effects that are mediated
through opioid, adrenergic, and N-methyl-D-aspartate (NMDA) receptor systems.
C. Analgesia considerations: the procedure, patient, and process
The degree and location of surgical trauma, particularly in relation to the site of
skin incision and route of bony access to the chest, are particularly important in
anticipating analgesic requirements after cardiothoracic surgery. Notably,
minimally invasive procedures that reduce total surgical tissue disruption but
relocate it to more pain-sensitive regions may not translate into reduced
postoperative pain or risk of chronic pain (e.g., minithoracotomy vs. sternotomy).
Limited evidence in thoracic surgery suggests that enhanced recovery programs
and decision support tools that guide therapies are important to consider in
reducing length of stay and improving economic outcomes for select groups of
patients [13,14]. However, specific analgesic choices should be reviewed for
individual patients, in particular for high-risk patients in whom outcome benefits
may be the greatest. This includes not only offering appropriate postoperative
analgesia delivery but also preoperative education regarding pain reporting,
procedures, devices to provide analgesia, and expectations for postoperative
transition to oral medications and home administration.
CLINICAL PEARL Risks and benefits of specific analgesic choices should be
reviewed for individual patients, in particular for high-risk patients in whom outcome
benefits may be the greatest. Patient education and setting expectations prior to surgery
are key elements for success.
D. Adverse consequences of pain
In addition to the unpleasant emotional aspects of pain, nociceptive signals have
several other effects that can be harmful and delay patient recovery. These
include activation of neuroendocrine reflexes constituting the surgical stress
response (including inflammation and elevated circulating catecholamines), a
catabolic state associated with high levels of several humoral substances (e.g.,
cortisol, vasopressin, renin, angiotensin), decreased vagal tone, and increased
oxygen consumption. Spinal reflex responses to pain include localized muscle
spasm and activation of the sympathetic nervous system.
Pathophysiologic consequences of the neuroendocrine local and systemic
responses to pain include respiratory complications related to diaphragmatic
dysfunction, myocardial ischemia, ileus, urinary retention and oliguria,
thromboembolism, and immune impairment [15].
E. Outcome benefits of good analgesia for cardiothoracic procedures
A primary benefit of effective pain control is patient satisfaction and an
improved recovery profile. Studies have documented additional advantages of
optimizing analgesia, especially in recovery from thoracotomy. Belief that the
pain of median sternotomy is less severe and inconsequential to outcomes leads
many institutions to employ conventional analgesia protocols involving fixed
dosing of analgesics on a timed schedule. However, after coronary bypass graft
surgery, attention to profound analgesia in the early postoperative period may
decrease the incidence and severity of myocardial ischemia.
Evidence supporting reductions in perioperative complications related to pain
relief are reported for many different analgesic techniques and may be related to
their effectiveness in blocking the surgical stress response and nociceptive spinal
reflexes. In this regard, neuraxial and regional analgesia are most often reported
as being effective. Nonetheless, beyond reduced pain, any outcome benefits
related to the incidence of major morbidities and mortality of specific analgesia
techniques remain difficult to prove, possibly due to the insufficient numbers of
patients studied and the low frequency of these events, as is well summarized in
a review by Liu et al. [16]. In general, reported benefits of good analgesia rely
on reporting of surrogate markers that correlate with major adverse outcomes
(e.g., arterial oxygen saturation) that imply attenuation of the adverse
consequences of pain outlined in Section I.D. For example, in the setting of
thoracic surgery, thoracic epidural analgesia provides superior pain relief
compared to systemic opioids and decreases the incidence of atelectasis,
pulmonary infections, hypoxemia, and other pulmonary complications [16]. In
addition, effective analgesia established before surgery in some circumstances
may provide preemptive protection against the development of chronic pain
syndromes. Aggressive pain control in the early postoperative period was
associated with a greater than 50% reduction in the number of patients continuing
to experience chronic pain 1 year after thoracotomy in one study [17,18].
Unfortunately, in cardiac surgery, reports of neuraxial techniques generally
involve small numbers and fail to demonstrate clinical outcome benefits,
although benefits in hospital length of stay and cost avoidance have been
commonly shown [19]. An outcome benefit following cardiac surgery with
central neuraxial analgesia was not demonstrated in a meta-analysis published in
2004 or in a randomized trial published in 2011 [20,21].
II. Pain management pharmacology
Multimodal analgesia and regional techniques that spare opioids in the
perioperative period are desirable, particularly in the context of the Centers for
Disease Control and the World Health Organization’s efforts to improve the
communication between patients and providers regarding safety, efficacy, and the
risks associated with long-term opioid therapy [22,23].
A. Opioid analgesics
1. Mechanisms. Opioid analgesics are a broad group of compounds that include
naturally occurring extracts of opium (e.g., morphine, codeine), synthetic
substances (e.g., fentanyl, hydromorphone), and endogenous peptides (e.g.,
endorphins, enkephalins). The analgesic effects of these drugs are all linked to
their interaction with opioid receptors; however, individual agents may
function as agonists, antagonists, or partial agonists at different receptor
subtype populations. Opioid receptors are widely distributed throughout the
body, but they are particularly concentrated within the substantia gelatinosa of
the dorsal horn of the spinal cord and in regions of the brain including the
rostral ventral medulla, locus coeruleus, and midbrain periaqueductal gray
area. Stimulation of opioid receptors inhibits the enzyme adenyl cyclase, closes
voltage-dependent calcium channels, and opens calcium-dependent inwardly
rectifying potassium channels, resulting in inhibitory effects characterized by
neuronal hyperpolarization and decreased excitability. Opioid receptor
subtypes have been sequenced and cloned, and they belong to the growing list
of G-protein–coupled receptors. The effects of agonist binding at different
opioid receptor subtypes are summarized in Table 27.1.
TABLE 27.1 Opioid receptors
2. Perioperative use. Opioids are commonly administered throughout the

perioperative period for cardiothoracic procedures. Preoperatively, they can
be given orally, intramuscularly (IM), or intravenously (IV) alone or as part of
a sedative cocktail to provide anxiolysis and analgesia for transport and
placement of intravascular catheters. Intraoperatively, they are given IV most
commonly as part of a balanced anesthetic technique that includes potent
inhaled anesthetics, benzodiazepines, and other agents. Finally, they can be
injected directly into the thecal sac or included as a component of epidural
infusions to provide intraoperative and postoperative analgesia. Opioids
administered via the epidural route have varying spread and analgesic potency
based in part on their water solubility. Matching analgesic requirements with
knowledge of the position of the epidural catheter relative to the dermatomes
affected requires understanding of the relative lipophilicity of the drug. Highly
lipophilic drugs, such as fentanyl, may be best used with catheters placed near
the involved dermatomes. Hydrophilic drugs, such as morphine, are generally
useful even for remote catheters, such as those positioned in the lumbar region.
Drugs with intermediate lipophilicity, such as hydromorphone, are considered
ideal by most and can be used for more balanced dermatomal spread.
3. 3 Side effects and cautions
a. Respiratory depression (increased risk with higher dosing, coadministration
of other sedatives, opioid-naïve patients, advanced age, central neuraxial
administration of hydrophilic opioid agents)
b. Sedation
c. Pruritus
d. Nausea
e. Urinary retention, especially common in the elderly and in males receiving
spinal opioids
f. Inhibition of intestinal peristalsis/constipation
g. CNS excitation/hypertonia, much more notable with rapid IV administration of
lipophilic agents
h. Miosis
i. Biliary spasm
All of the above effects can be reversed with the administration of opioid
antagonist drugs (e.g., naloxone). Opioid rotation, or changing the narcotic
drug that a patient is receiving, may also be useful in reducing the incidence or
severity of complicating side effects and also in enhancing the patient’s
experience of analgesia [24]. Notably, a new area of interest surrounds
emerging evidence that choices as simple as the postoperative opioid
analgesic selected (e.g., morphine vs. hydromorphone) may be associated
with hospital lengths of stay and 30-day readmission rates [25].
1. Mechanisms. NSAIDs act principally through both central and peripheral
inhibition of cyclooxygenase, resulting in decreased synthesis of prostaglandins
from arachidonic acid, including prostacyclin and thromboxane. Prostaglandins
are involved in the physiology of numerous signaling pathways, including those
influencing renal perfusion, bronchial smooth muscle tone, hemostasis, gastric
mucosal secretions, and the inflammatory response. Prostaglandin E2 is the
eicosanoid produced in the greatest quantity at sites of trauma and inflammation
and is an important mediator of pain. The full therapeutic effects of NSAIDs
are complex and likely involve mechanisms that are independent of
prostaglandin effects. For example, prostaglandin synthesis is effectively
inhibited with low doses of most NSAIDs; however, much higher doses are
required to produce anti-inflammatory effects.
2. Perioperative use. NSAIDs are useful for postoperative analgesia. They are
most commonly administered in cardiothoracic surgical patients as a
complement to neuraxial techniques. Their principal advantage is the absence
of respiratory depression and other opioid side effects. Many NSAIDs are
available for oral or rectal administration. Ketorolac is a nonselective NSAID
intended for short-term use (5 days or less) with preparations available for IV
or IM injection, in addition to oral forms.
3. Side effects and cautions
a. Decreased renal blood flow/parenchymal ischemia
b. Gastrointestinal mucosal irritation
c. Impaired primary hemostasis
d. Differential risk of myocardial and other ischemic events (in nonsurgical
populations), of unknown importance in the perioperative period [26]
4. COX-2 inhibitors
The effects of cyclooxygenase are mediated by two distinct isoenzymes termed
COX-1 and COX-2. COX-1 is the constitutive form responsible for the
production of prostaglandins involved in homeostatic processes of the kidney,
gut, endothelium, and platelets. COX-2 is predominantly an inducible isoform
responsible for the production of prostaglandins during inflammation. Highly
selective COX-2 inhibitors have potent analgesic properties and were
previously popular for treating perioperative pain. Data from large randomized
double-blind trials [27] revealed an increased incidence of cardiovascular
complications, including myocardial infarction, with agents in this drug class.
Celecoxib is the remaining COX-2 inhibitor widely available for prescription
in the United States. The difference between celecoxib and the other agents may
be due to its relatively modest COX-2 versus COX-1 subtype selectivity
compared to the other agents (30:1 vs. >300:1). However, celecoxib is
primarily recommended for the treatment of severe arthritis, rheumatoid
arthritis, and ankylosing spondylitis in circumstances where treatment of these
conditions with several other NSAIDs has failed.
C. Acetaminophen (paracetamol)
1. Mechanism
Acetaminophen is a synthetic, nonopiate, analgesic drug that is distinct from
most other NSAIDs in that it is a weak inhibitor of the synthesis of
prostaglandins and of COX-1 and COX-2. Its mechanisms appear to be
primarily central, resulting in analgesia and antipyresis, with only minimal anti-
inflammation. COX-3, a splice variant of COX-1, has been suggested to be the
site of action. Other proposed mechanisms include the activation of descending
serotonergic pathways and the inhibition of the nitric oxide pathway mediated
by a variety of neurotransmitter receptors including NMDA and substance P.
Although the exact site and mechanism of analgesic action is not clearly
defined, acetaminophen appears to produce analgesia by elevation of the pain
threshold.
2. Perioperative use and cautions
Although acetaminophen is primarily used for oral and rectal administration, in
2010, the FDA approved an IV form of the drug for relieving pain or fever in
surgical patients in adults and children aged two and older. It is useful in the
treatment of moderate to severe postsurgical pain, demonstrating an opioid-
sparing effect with good patient acceptance and few adverse effects, especially
in orthopedic surgical populations [28]. A modest opioid-sparing effect, with
no reduction in the incidence of nausea and vomiting, was found when IV was
compared to oral acetaminophen in a postoperative population of coronary
artery bypass surgical patients [29].
The primary risk of acetaminophen is hepatotoxicity secondary to overdose.
Acetaminophen toxicity is the leading cause of acute liver failure in the United
States. A typical IV adult dosing schedule involves the administration of 650 to
1,000 mg every 6 hours, with infusion of the drug timed to occur over at least
15 minutes.
D. Local anesthetics
1. Mechanisms. Local anesthetics interrupt neural conduction, thus disrupting
transmission of pain and other nerve impulses through the blockade of neuronal
voltage-gated sodium channels. This blockade does not change the resting
potential of the nerve. However, altered sodium ion channel permeability
slows depolarization such that, in the presence of a sufficient concentration of
local anesthetic, the threshold for the propagation of an action potential cannot
be reached.
2. Perioperative use. Local anesthetics are used throughout the perioperative
period for topical infiltration, for infiltration near peripheral nerves, or in the
central neuraxial space. Their advantage lies in their capacity to provide
profound analgesia without the undesired side effects seen with opioids or
NSAIDs. Effective regional anesthesia is the best technique to most completely
attenuate the neurohumoral stress response to pain. Thoracic epidural analgesia
is particularly useful in treating pain, both somatic and visceral, for patients
with occlusive coronary artery disease. Limited data support the use of
systemic lidocaine to attenuate early postoperative pain after noncardiac
surgery [30], but this has not yet been demonstrated in cardiac surgery [31].
3. Liposomal preparations. Liposomal technology now allows for the extended-
release delivery of local anesthetic medications using a single-injection
technique. The purported advantage of liposomal delivery of local anesthetic is
its prolonged analgesic effect.
Currently the only commercially available preparation in the United States is
liposomal bupivacaine (Exparel™; Pacira Pharmaceuticals, Inc., Parsippany,
New Jersey), which demonstrates analgesic effects for up to 72 hours.
However, infiltration of liposomal bupivacaine at the surgical site is not
superior to bupivacaine hydrochloride [32]. There has been no international
standard for the perioperative use of these preparations, and variability in
practice exists as to whether liposomal bupivacaine is diluted with standard
bupivacaine, or normal saline prior to injection. In some countries, legislative
bodies have approved for use for subcutaneous (SC) infiltration, fascial plane
blocks, and peripheral nerve blocks, but there has been no extensively studied
or approved use for the neuraxial space [33–36]. Current cost/benefit
assessment seems not in favor of the use of available liposomal preparations
for cardiothoracic surgery patients.
4. Side effects and cautions
a. Not surprisingly, side effects from sodium channel blockade due to local
anesthetic toxicity resemble those observed with severe extracellular
hyponatremia. Excessive local anesthetic blood concentrations, achieved
through absorption or inadvertent intravascular injection, predictably result in
toxic effects on the CNS (seizures, coma) and the heart (negative inotropy,
conduction disturbances, arrhythmias). Table 27.2 lists commonly accepted
maximum local anesthetic dosing for infiltration anesthesia.
TABLE 27.2 Maximum recommended dosing of local anesthetic agents for local infiltration
b. Caution must be exercised in the performance of any invasive regional

anesthesia procedure in the setting of ongoing or proposed anticoagulation or
thrombolysis.
c. Although regional anesthesia can be initiated without an apparent increase in
the risk of bleeding in patients taking only aspirin or NSAIDs, the American
Society of Regional Anesthesia and Pain Medicine (ASRA;
www.ASRA.com) last published their consensus recommendations in 2010
for regional anesthesia in patients receiving antithrombotic therapy [37].
Recommendations include withholding antiplatelet agents clopidogrel
(Plavix) for 7 days, ticlopidine (Ticlid) for 14 days, and GP IIb/IIIa
antagonists for 4 to 48 hours prior to placement of a neuraxial block. ASRA
also recommends holding warfarin for 4 to 5 days, low–molecular-weight
heparins for 12 to 24 hours (depending on drug and dose), and unfractionated
heparin for 8 to 12 hours (depending on dosing interval) before neuraxial
block placement. Practice advisories regarding recommendations for time
intervals for the new oral anticoagulants are being drafted in the United States,
with some interim recommendations including holding dabigatran for 5 days,
apixaban for 3 days, rivaroxaban for 3 days, prasugrel for 7 to 10 days, and
ticagrelor for 5 to 7 days [37]. These guidelines recommend consideration of
deep plexus or peripheral nerve blockade in the setting of drug-altered
hemostasis.
d. Allergic reactions are not uncommon, particularly to the para-aminobenzoic
acid metabolites of ester local anesthetics or to the preservative materials
found in commercial local anesthetic preparations. True allergic reactions to
preservative-free amide local anesthetics (e.g., lidocaine) are rare, and
suspected cases are often attributed in retrospect to inadvertent intravascular
injection of epinephrine-containing solutions.
e. Concentration-dependent neurotoxicity of local anesthetics (e.g., cauda
equina syndrome following IT local anesthetic injection) is now well
described [38].
f. The liposomal bupivacaine (Exparel™) has specific cautions regarding its
administration. The manufacturer (Pacira Pharmaceuticals, Inc., Parsippany,
New Jersey) recommends that liposomal bupivacaine be administered 20
minutes after lidocaine. Furthermore, other formulations of bupivacaine
should not be administered until 96 hours following the administration of
liposomal bupivacaine. An additional caution is that liposomal bupivacaine
should not be allowed to come into contact with antiseptic solutions (e.g.,
chlorhexidine, povidone iodine) as these solutions may cause disruption of the
liposomes, leading to a sudden release of toxic amounts of bupivacaine into
the plasma [39].
E. α2-Adrenergic agonists
Clonidine is the prototypical drug in this class, although dexmedetomidine is also
approved for clinical use. Both drugs produce analgesia through agonism at
central α2-receptors in the substantia gelatinosa of the spinal cord and sedation
through receptors in the locus coeruleus in the brainstem. They may also act at
peripheral α2-receptors located on sympathetic nerve terminals to decrease
norepinephrine output in sympathetically mediated pain. The analgesic effect of
these drugs is distinct and complementary to that of opioids when used in
combination. Clonidine may be administered orally to provide sedation and
analgesia as a premedication. Preservative-free clonidine may be included as a
component of epidural infusions or IT injections. Although these agents have
limited respiratory depressant properties, hypotension, sedation, and dry mouth
are common side effects from analgesic doses. Loss of standard cues for
analgesia administration in unconscious patients (e.g., tachycardia, hypertension)
due to the autonomic effects of α2-adrenergic agonists may result in
overestimation of the analgesic benefits of such agents.
F. Ketamine
Ketamine has complex interactions with a variety of receptors but is thought to
act primarily through blockade of the excitatory effects of the neurotransmitter,
glutamic acid, at the NMDA receptor in the CNS. It can be administered orally or
parenterally to provide sedation, potent analgesia, and “dissociative anesthesia.”
The principal advantages of ketamine stem from its sympathomimetic properties
and lack of respiratory depression. Cautions include increased secretions and
dysphoric reactions. Ketamine administered by low-dose IV infusion as an
adjunct to a poststernotomy and postthoracotomy analgesic regimen may increase
patient satisfaction and provide an opioid-sparing effect [40]. Ketamine may also
be added as an adjunctive medication to epidural infusions, including thoracic
epidural infusions for acute postthoracotomy pain [41].
G. Gabapentinoids
Designed as analogs of GABA, the mechanism by which gabapentinoids affect
neuropathy is through binding to the α2δ-1 and α2δ-2 subunits of calcium
channels. Despite a meta-analysis of acute postoperative pain studies not finding
a reduction of early perioperative pain scores or opioid consumption with a
single dose of gabapentin or pregabalin, many general acute pain multimodal
analgesic algorithms include gabapentinoid agents. Of importance are the known
sedative and respiratory depressant side effects of these agents in a population
such as cardiothoracic patients who are at high risk of serious postoperative
respiratory complications. Although the short-term benefits of these agents are
questionable in cardiothoracic patients, there may be longer-term value as an
adjuvant analgesic strategy against chronic pain (e.g., postthoracotomy) [42,43].
H. Biologics
Presently, the genetic and molecular mechanism that may predict acute and
chronic pain are being further elucidated [42]. This makes biologics (i.e., agents
extracted or synthesized from biologic sources) an attractive potential future
therapy. At the current time there are no biologics recommended for pain
management in the cardiothoracic surgery setting; however, these agents may
have promise as therapeutics for further research.
I. Nonpharmacologic analgesia
1. Cryoablation. A cryoprobe can be introduced into the intercostal space and
used to produce transient (1 to 4 days) numbness in the distribution of the
intercostal nerve. A cryoprobe circulates cold gas (approximately −80°C).
When applied for two to three treatments of approximately 2 minutes each, this
temporarily disrupts neural function. Cryoablation has been shown to reduce
pain and the need for systemic analgesics after lateral thoracotomy for cardiac
surgery [44].
2. Nursing care. Empathic nursing care and nursing-guided relaxation techniques
are important components to patient comfort throughout the perioperative
period and should not be overlooked [44].
III. Pain management strategies
A. Enteral
Gastrointestinal ileus is rarely a concern after routine cardiothoracic surgical
procedures; therefore, transition to oral administration of analgesics should be
considered as soon as pain management goals are likely to be effectively
achieved by this route. This is particularly important because oral agents are
currently the simplest, cheapest, and the most reliable way to continue effective
analgesia after hospital discharge, and they should be used as the mainstay of any
“fast-track” analgesia protocol.
B. Subcutaneous (SC)/intramuscular (IM)
SC and IM injections remain effective and inexpensive alternate parenteral
routes to IV administration for the delivery of potent systemic analgesia using
opioids (e.g., morphine, hydromorphone, meperidine). SC or IM injection results
in slower onset of analgesia than the IV route and, therefore, is more suitable for
scheduled dosing (e.g., every 3 to 6 hours) rather than “as needed.” A notable
disadvantage of the SC route is injection-related discomfort, which can largely
be avoided by slow injection through an indwelling SC butterfly needle.
C. Intravenous
In the absence of neuraxial analgesia, IV opioid analgesia is generally the
primary tool to provide effective pain relief for the early postoperative patient.
The advantages of this route include rapid onset and ease of titration to effect. In
addition, for the awake patient, patient-controlled IV delivery of opioids (i.e.,
patient-controlled analgesia [PCA]) has become widely available. PCA units
combine options for baseline continuous infusion of drug with patient-
administered bolus doses after programmed lockout periods to minimize the risk
of overdose and maximize the patient’s sense of “control” over their pain.
Patient satisfaction using PCA analgesia rivals that with neuraxial analgesia.
Analgesic agents that have traditionally been available only for oral
administration are becoming available for parenteral usage. IV ketorolac and
acetaminophen have gained widespread acceptance as analgesic alternatives for
thoracic surgical patients that are devoid of respiratory depressant effects.
D. Interpleural
Interpleural analgesia involves the placement of a catheter between the visceral
and parietal pleura for the subsequent instillation of local anesthetic solution.
The ensuing pain relief is believed to be the result of the blockade of intercostal
nerves in addition to local actions on the pleura. Disadvantages of this technique
include the requirement for relatively high doses of local anesthetic with
relatively enhanced vascular uptake, poor effectiveness, and possible impairment
of ipsilateral diaphragmatic function. For these reasons, interpleural analgesia
has been largely abandoned as a strategy for pain control in cardiothoracic
surgery patients.
E. Intercostal
Sequential intercostal blocks (e.g., T4 to T10) can contribute to unilateral
postoperative chest wall analgesia for thoracic surgery. Bilateral intercostal
nerve blocks (ICBs) may be used for pain relief after median sternotomy [45].
ICBs require depositing local anesthetic (e.g., 4 mL of 0.5% bupivacaine per
nerve) at the inferior border of the associated rib near the proximal intercostal
nerve. ICBs are generally performed through the skin before surgery or by the
surgeon under direct vision within the chest. ICBs typically contribute to
analgesia for up to 12 hours. However, they do not include blockade of the
posterior and visceral rami of the intercostal nerve, thus they often require
additional NSAID or parenteral analgesia to be effective.
F. Fascial plane blocks
The availability of ultrasound guidance to identify various thoracic fascial planes
has facilitated the injection of local anesthetic to achieve ipsilateral chest wall
analgesia with avoidance of the more invasive neuraxial and paravertebral
approaches. Given the typically distant location from the neuraxis, fascial plane
blocks are appealing since they may provide adequate analgesia for
cardiothoracic surgical procedures while avoiding unwanted hypotension,
urinary retention, and bleeding risk associated with neuraxial blockade. Single
injection and catheter-based strategies in these fascial planes that may be applied
to cardiac and thoracic surgery are described below.
1. Pecs 1 and 2. The so-called “Pecs” blocks are interfascial plane blocks of the
anterior chest wall. Originally described [46] and primarily studied for use in
breast surgery, when used in combination, these provide analgesia to the
anterior and anterolateral chest wall. Pecs 1 is aimed to block the ipsilateral,
lateral, and medial pectoral nerves, while Pecs 2 is aimed to block the lateral
rami of the intercostal nerves and the long thoracic nerve. These blocks may be
useful as part of a multimodal analgesia strategy for minimally invasive cardiac
surgical procedures involving small anterior thoracotomies; such an approach
has been described following minimally invasive mitral valve replacement
[47].
2. Serratus anterior plane block. This chest wall block targets the thoracic
intercostal nerves as well as the thoracodorsal and long thoracic nerves to
provide analgesia to the anterolateral and a portion of the posterior hemithorax
with a distribution from approximately T2 to T9 [48]. There are a few clinical
reports of its efficacy for providing analgesia for rib fractures and for thoracic
surgical procedures [49,50].
3. Erector spinae plane block. The erector spinae plane block involves
depositing local anesthetic in the plane between the erector spinae musculature
and the transverse process of the T5 vertebra [51]. Given its proximity to the
midline relative to other fascial plane blocks, this approach may be more likely
to achieve blockade of both the dorsal and ventral rami of the thoracic spinal
nerves in a dermatomal distribution spanning approximately T2 to T9. Several
case reports of this block have described its utility in thoracic surgery [51–53].
G. Paravertebral blocks (PVBs)
PVBs can provide unilateral chest wall analgesia for thoracic surgery. Sequential
thoracic PVB injections (e.g., T4 to T10, 4 mL of 0.5% ropivacaine per level)
may be combined with “light” general anesthesia for thoracotomy procedures and
provide analgesia for several hours postoperatively. At some institutions,
continuous PVB catheters are used interchangeably with epidural analgesia to
provide pain relief with an apparent superior side-effect profile [54].
Anticipated chest tube insertion sites typically dictate the lowest PVB level
required. Although the use of PVBs reduces intraoperative opioid requirement,
NSAID and/or opioid supplementation is often required after thoracotomy to
achieve adequate comfort. “Emergence” from PVB-mediated analgesia may
occur on the day after surgery, often after transfer from an intensive care
environment; therefore, it is important that other analgesia alternatives be
immediately available at this time. Potential advantages of PVBs and ICBs
relative to neuraxial techniques include the avoidance of opioid-related side
effects, epidural hematoma, and hypotension related to bilateral sympathetic
block. Nonetheless, ICB and PVB analgesia have the disadvantages that they may
be less reliable than thoracic epidural analgesia and can themselves be
complicated by epidural spread of local anesthetic. Notably, compared to PVBs,
ICBs do not affect the posterior and visceral rami of the intercostal nerves and
tend to recede more rapidly. The paravertebral space, where peripheral nerves
exit from the spinal canal, is limited superiorly and inferiorly by the heads of
associated ribs, anteriorly by the parietal pleura, and posteriorly by the superior
costotransverse ligament.
H. Intrathecal (IT)
IT opioid analgesia is a suitable strategy for major pain after median sternotomy
or thoracotomy [55]. The benefits and risks of a spinal procedure should always
be carefully weighed before using this technique, particularly with regard to the
risk of spinal hematoma in patients receiving anticoagulation or with abnormal
hemostasis. Small-caliber noncutting spinal needles (e.g., 27-gauge Whitacre
needle) are often selected for lumbar spinal injection of preservative-free
morphine. Age rather than weight predicts proper IT opioid dosing in adults; 10
μg/kg IT morphine dosing is effective for cardiothoracic surgery in most adults
and is usually administered before the induction of general anesthesia. Smaller
doses (e.g., 0.3 to 0.5 mg, total dose) are required to reduce the likelihood of
respiratory depression in elderly patients (older than 75 years of age). It is
prudent to avoid the use of IT morphine in patients aged 85 years or older. Since
rare patients will develop significant delayed respiratory depression, hourly
monitoring of respiratory rate and consciousness for 18 to 24 hours is advisable
with this technique. Reduced doses of sedative and hypnotic agents during
general anesthesia may lower the likelihood of excessive postoperative
somnolence. The onset of thoracic analgesia is approximately 1 to 2 hours after
injection, lasting up to 24 hours. Postoperative NSAID therapy complements IT
morphine analgesia without sedative effects. IT clonidine (1 μg/kg) combined
with IT morphine produces superior analgesia compared to either drug
administered alone [56]. IV or oral analgesia must be immediately available in
anticipation of the resolution of IT morphine analgesia approximately 24 hours
after injection because significant pain may develop rapidly. IT administration of
other drugs for cardiac and thoracic surgeries, such as local anesthetic agents or
short-acting opioids (e.g., sufentanil), is mainly limited to the intraoperative
period.
I. Epidural
Epidural anesthesia is ideal for thoracic surgery and is the most widely studied
and used form of regional analgesia for this purpose [18]. Although epidural
catheter placement for use during and after cardiac surgery is reported to have
benefits [57], this approach has not gained a similar level of acceptance. Of note,
while many agree that thoracic epidural analgesia is the gold standard for pain
control after open thoracotomy, no regional anesthetic technique has yet emerged
as superior for pain control after less-invasive video-assisted thoracoscopic
surgical (VATS) approaches to lung resection [ 58]. The role of truncal and
fascial plane blocks, some of which are described above, as viable options for
pain relief following VATS procedures involving brief hospital stays has yet to
be fully explored.
Thoracic epidural catheter placement (T4 to T10) is often preferred over
lumbar for thoracic surgery. Proponents of thoracic catheter placement cite the
reduced local anesthetic dosing requirements, closer proximity to the thoracic
segment dorsal horns, and reduced likelihood of dislodgement postoperatively.
Concern regarding increased risk of spinal cord injury using a thoracic compared
to a lumbar approach for epidural catheter placement has not been borne out;
however, some practitioners prefer that thoracic epidural catheter placement
occur while the patient is sufficiently alert to reliably report paresthesias or other
problems during the procedure. Selection of the thoracic interspace should be
dictated by the surgical incision. The epidural catheter should be placed 4 to 6
cm into the epidural space and securely taped.
4 Intraoperative use of an epidural catheter enhances the value of regional
anesthesia for thoracotomy surgery by permitting a “light general” anesthetic
technique with reduced residual respiratory depressant effects. Epidural local
anesthetic block should be preceded by a “test dose” of an epinephrine-
containing local anesthetic to rule out intravascular or IT catheter placement.
Epidural opioids should generally not be administered unless postoperative
observation and monitoring for delayed respiratory depression is planned. To
minimize postoperative somnolence and the risk of respiratory depression, the
administration of potent IV sedatives and opioids should be reduced or avoided
during surgery, and the agents used to maintain general anesthesia should be
easily reversible (e.g., volatile anesthetic agents). A popular mixture for
postoperative epidural analgesia is dilute local anesthetic (e.g., 0.125%
bupivacaine) containing an opioid with intermediate lipid solubility (e.g.,
hydromorphone, 10 μg/mL); this is administered by continuous infusion at a
starting rate of 4 to 7 mL/hr, ideally starting at least 15 minutes before the end of
surgery and titrated to clinical effect. Since early titration of epidural analgesic
infusions is often required, and pain is not effectively reported by the awakening
patient, an initial analgesic dose of hydromorphone and local anesthetic agent
should be administered (e.g., 200-μg hydromorphone bolus, 3-mL preservative-
free 2% lidocaine) before emergence. IV ketorolac or acetaminophen can also be
administered at this time when indicated. Ketorolac is often especially effective
in helping to manage shoulder discomfort secondary to indwelling thoracostomy
tubes, since this complaint often persists in the setting of good incisional pain
control with epidural analgesia. Titration of epidural analgesia to comfort should
be completed in the postoperative recovery area where transfer of care to the
acute pain care team should occur.
CLINICAL PEARL A primary benefit of effective pain control is patient
satisfaction and improved recovery profile with avoidance of the negative
consequences of pain; various analgesic strategies with or without neuraxial and
regional techniques, can be considered. There is no “gold standard” recipe, as it is
difficult to prove an outcome benefit with any single technique.
IV. Pain management regimens for specific cardiothoracic procedures
A. Conventional coronary artery bypass grafting and open-chamber procedures
The move away from standard high-dose opioid anesthesia and prolonged
durations of postoperative ventilation has increased interest in different
approaches to analgesia after cardiac surgery. Many procedures are suitable for
early tracheal extubation and therefore require analgesia regimens compatible
with a rapid recovery. Standard regimens for cardiac surgery now commonly
involve modest intraoperative opioid dosing and the postoperative bedside
availability of parenteral opioids as required in the first 12 to 24 hours, either
patient controlled or administered by a nurse. Transition to oral agents is
encouraged as soon as food is tolerated.
Routine NSAID therapy for uncomplicated patients is a safe and cost-effective
way to complement opioid analgesia. Preoperative IT morphine has gained
popularity in some centers. In experienced hands, imaginative combinations, such
as preoperative IT morphine and intraoperative IV remifentanil infusion, provide
reproducible excellent analgesia with tracheal extubation often possible in the
operating room [45].
B. Off-pump (sternotomy) cardiac procedures
One interpretation of “minimally invasive” cardiac surgery involves the
avoidance of cardiopulmonary bypass (CPB). The more limited systemic
inflammatory response–associated CPB avoidance oddly may increase the
perception of pain. Additionally, off-pump cardiac surgery is often accompanied
by a “fast-track” approach to pain relief, which further challenges traditional
opioid-based analgesia regimens. Inadequate pain relief is an important
addressable cause for delayed hospital discharge. Thus, interest in analgesic
approaches other than parenteral opioids for off pump CABGs parallels the trend
in traditional cardiac surgery on CPB, as outlined above (see Section IV.A).
C. Transcatheter and percutaneous procedures (transcatheter aortic valve
replacement, mitral clip, electrophysiology procedures)
Percutaneous and transcatheter approaches to valvular disease and dysrythmias
generally involve peripheral (e.g., groin) access and avoid the need for thoracic
incisions. This can often be managed with local anesthetic infiltration at the site
along with the use of nonopioid adjunct medications. Many European and
American centers have moved to performing these procedures with sedation or
local anesthesia only.
D. Minimally invasive (minithoracotomy/para- or partial sternotomy/robotic)
cardiac procedures
In contrast to off-pump procedures, a second interpretation of “minimally
invasive” cardiac surgery involves port-access catheter-based CPB employing
very small incisions to achieve surgical goals. Although there were hopes that
port-access procedures would be associated with less pain, this has not been
proven to be true, most likely because of the relocation of the smaller incisions to
more pain-sensitive areas (e.g., minithoracotomy). In addition to the alternate
analgesic approaches outlined for patients undergoing traditional cardiac surgery
with CPB (see Section IV.A), the possibility of using novel approaches to
minithoracotomy analgesia, including ICBs, one-shot PVBs, continuous PVBs,
and fascial plane blocks, exist but have not been sufficiently explored to
recommend their routine use.
E. Thoracotomy/thoracoscopy procedures (noncardiac)
5 An increasing number of the patients presenting for lung surgery have end-
stage lung disease and may not have been considered eligible for an operative
procedure several years ago [59]. In part, these changes in eligibility for lung
resection are due in part to the availability of less-invasive techniques, including
minimally invasive VATS procedures. Patients with severe lung disease may
have the most to gain from any improvements in outcome related to optimal
postoperative analgesia (e.g., continuous thoracic epidural) [59]. Most
physiologically invasive procedures (e.g., lobectomy) are now routinely
performed using VATS approaches, although some procedures (e.g.,
pneumonectomy) typically still require the traditional and more painful
thoracotomy incision. “Light” general anesthesia with regional blockade of the
chest wall is a particularly suitable anesthetic approach for lung and other chest
surgery. Sedatives (e.g., midazolam) should be used sparingly or completely
avoided; often even a small dose of midazolam (e.g., 0.5 mg) will extend the
action of shorter-acting agents, such as propofol (e.g., 10 mg), if sedation is
absolutely necessary for line placement. Using this approach, residual
sedative/hypnotic effects can be minimized, early tracheal extubation is more
reliably achieved, and the transition to postoperative pain management is
facilitated.
Analgesia for VATS and thoracotomy procedures in the intraoperative and
postoperative period is often achieved through a multimodal approach including
parenteral opioids, NSAIDs, and regional anesthesia; however, there is a large
amount of variability between hospitals as to whether patients receive
perioperative multimodal analgesia [60]. A spectrum of regional anesthesia
procedures are available, including thoracic epidural, spinal, PVBs, intercostal
blocks, interpleural blocks, and several potentially applicable thoracic fascial
plane blocks. These can be performed transcutaneously under ultrasound needle
guidance by the anesthesiologist or in some cases from within the rib cage during
surgery by the surgeon. Selection of a regional analgesia approach should include
a plan for transition to oral medication and match the anticipated hospital
discharge timing; notably, neuraxial opioids may delay discharge if used
inappropriately. Finally, many patients with normal pulmonary function having a
minor surgical procedure will have good analgesia with IV PCA morphine or
fentanyl alone.
Selection of a regional blockade technique is best made after evaluation of
both the patient status and the demands of the surgery. American Society of
Anesthesiologists class I to II patients anticipating postoperative hospital stays
up to 48 hours may benefit from regional anesthetic blocks; however, anxious
patients in this group should not be overly pressured to undergo a regional
procedure. In contrast, patients who are deconditioned or undergoing more
extensive procedures are more likely to benefit from regional anesthesia. Routine
postoperative NSAID or acetaminophen therapy should be considered, since
these agents are devoid of sedation and are particularly effective analgesics in
combination with regional analgesia. Local anesthetic/opioid mixtures are
popular analgesic regimens for use as continuous epidural infusions (see Section
III.H). However, in high-risk cases (e.g., lung volume reduction or lung
transplant surgery), where avoidance of all respiratory depressants is desirable,
analgesia may be achieved using a dilute local anesthetic agent alone.
Tachyphylaxis is a common problem with any local anesthetic–alone technique,
requiring frequent rate readjustments. Removal of an epidural catheter subjects a
patient to all the same risks as insertion. When transfer from epidural to oral
analgesia is being considered, thromboprophylaxis protocols should be
coordinated with epidural catheter removal to minimize the risk of epidural
hematoma. If the patient is taking warfarin, the international normalized ratio at
the time of catheter removal should be <1.5 to minimize the risk of bleeding.
F. Open and closed (total endovascular aortic repair [TEVAR]) descending
thoracic aortic procedures
Major surgical procedures to treat diseases of the descending thoracic aorta often
require both an extensive left thoracotomy incision and a long midline abdominal
incision. Unfortunately, serious complications are common with these procedures
and include high incidences of bleeding/
coagulopathy due to the extensive surgery, paraplegia from spinal cord ischemia,
and acute kidney injury. Despite the significant pain associated with these
incisions, analgesia is often relegated to a secondary concern. In addition,
increased risks of renal and spinal cord injury are relative contraindications to
some of the most useful agents of a multimodal approach to severe postoperative
pain. However, some creative approaches to analgesia are being considered. In
addition to standard IV opioid techniques, a tunneled catheter under the left
parietal pleura can be placed to extend cephalad over several dermatomes of the
chest wall and deliver dilute local anesthetic. Unfortunately, there is little
research in this area to guide clinicians. Some anesthesiologists and surgical
teams even feel that the benefits of thoracic epidural analgesia merit placement of
a thoracic epidural catheter either preoperatively or after surgery.
V. Approach to specific complications and side effects of analgesic strategies
A. Complications of nonsteroidal anti-inflammatory drugs (NSAIDs)
1. Renal toxicity. Normal patients exhibit a low rate of prostaglandin synthesis in
the renal vasculature, such that cyclooxygenase inhibition has little effect.
However, vasodilatory prostaglandins may play an important role in the
preservation of renal perfusion in disease states. Nephrotoxicity, secondary to
vasoconstriction of both afferent and efferent renal arterioles leading to
reduced glomerular filtration rate, is commonly seen with NSAID
administration in patients with dehydration, sepsis, congestive heart failure, or
other causes of renal hypoperfusion. Avoiding NSAID-induced renal toxicity is
best accomplished by limiting or avoiding their use in patients with decreased
renal reserve and in those at risk for hypoperfusion. Risk appears to be low
with perioperative ketorolac administration (1:1,000 to 1:10,000) [61].
NSAID-induced nephrotoxicity is usually reversible with discontinuation of the
drug.
2. 6 Gastrointestinal mucosal irritation. Gastrointestinal mucosal irritation is
the most common NSAID side effect and can occur regardless of the route of
administration. It may result in erosion and severe gastrointestinal bleeding.
Prostaglandins are involved in multiple aspects of gastric mucosal protection,
including mucosal blood flow, epithelial cell growth, and surface mucus and
bicarbonate production. Prophylaxis may involve administration of histamine
(H2)-receptor antagonists, proton pump inhibitors (e.g., omeprazole),
protective agents (e.g., sucralfate), or prostaglandin analogs (e.g., misoprostol).
Each of these treatments appears to be effective in decreasing ulceration with
NSAID treatment.
3. Impaired primary hemostasis. Nonspecific cyclooxygenase inhibition leads to
impaired platelet aggregation that may increase intraoperative or postoperative
bleeding. The duration of effect is highly variable depending on the individual
drug (reversible vs. irreversible enzymatic inhibition). The only effective
prophylaxis or treatment is to discontinue NSAIDs for a sufficient duration
preoperatively (e.g., ibuprofen more than 3 days, aspirin more than 7 to 10
days).
B. Nausea and vomiting
Nausea and vomiting as a consequence of analgesia is most commonly associated
with opioids. Opioids cause nausea primarily through activation of the
chemoreceptor trigger zone of the brainstem in the floor of the fourth ventricle. A
vestibular component is also postulated because it is clear that motion increases
the incidence of nausea. Finally, the inhibitory effects of opioids on
gastrointestinal motility may contribute. Nausea can accompany opioid therapy
regardless of the route of administration. It occurs in roughly 25% to 35% of
patients treated with spinal opioids and is more frequent with the spinal use of
hydrophilic drugs (e.g., morphine) secondary to enhanced rostral spread of these
agents [62]. The optimal pharmacologic treatment of nausea and vomiting
involves such agents as ondansetron, prochlorperazine, chlorpromazine,
promethazine, metoclopramide, and dexamethasone.
C. Pruritus
Pruritus is a common side effect of opioids administered by any route, but it can
be particularly problematic after neuraxial administration. The mechanism is
unclear and likely complex, but pruritus is not likely caused solely by either
preservatives within the opioid preparation or histamine release. Pruritus often
improves as the duration of opioid treatment lengthens. Pruritus is most
effectively treated with antihistamines, mixed agonist–antagonist opioids (e.g.,
nalbuphine), or by naloxone infusion.
D. Respiratory depression
7 Hypoventilation is a potentially life-threatening complication of opioids. It
can occur early after administration by any route, but it is particularly feared as a
delayed complication of neuraxial opioid administration. Whatever the method of
administration, opioid-related hypoventilation occurs secondary to elevated
cerebrospinal fluid drug levels, either from systemic absorption or rostral spread
of neuraxially administered drug, which then produce depression of the
medullary respiratory center. Respiratory depression requiring naloxone
administration is reported to occur in 0.2% to 1% of patients receiving epidural
opioids [63], but the incidence is likely higher in opioid-naïve patients being
treated for acute pain. Other factors that may increase the risk include advanced
age, poor overall medical condition, higher opioid dosing (particularly of
hydrophilic drugs), increased intrathoracic or intra-abdominal pressure (as may
occur during mechanical ventilation), and coincident administration of other CNS
depressants. Patients who have received spinal opioids in the prior 18 to 24
hours or in whom continuous infusions are being administered should have their
ventilatory rate and level of alertness confirmed at least hourly. Caretakers
should be aware that deteriorating levels of consciousness might portend severe
respiratory depression even if ventilatory rates appear preserved. Arterial blood
gas analysis should be used early in the investigation of decreased alertness.
Modest doses of naloxone (0.04 to 0.1 mg IV) are usually sufficient to
temporarily reverse respiratory depression if discovered before it has become
severe.
E. Neurologic complications
Although neurologic complications from analgesic procedures are extremely
rare, when these occur they can be catastrophic and appropriate management is
key to minimizing adverse consequences. Nerve injury may be heralded by an
acute discomfort with nerve trauma during a procedure but may only be apparent
when local anesthetic effects recede. Therefore, it is essential that this diagnosis
is not overlooked in the evaluation of a prolonged block. In particular, if a spinal
cord hematoma is being considered, it should be remembered that the promptness
of surgical decompression is the most important predictor of recovery of
neurologic function [64] . Eighty-eight percent of neurologic deficits related to
spinal hematoma will resolve if surgical decompression occurs within 12 hours
of symptom onset, whereas only 40% will have improvement when surgery
occurs beyond 24 hours. A key aspect in the evaluation of a possible nerve injury
is the involvement of a neurologist in consultation. Most nerve injuries are
transient and recover over several days, but the opinion of a specialist in this
area will assure that effective acute treatments are not delayed.
F. Infectious complications
Infectious complications associated with neuraxial techniques are rare but
potentially catastrophic, potentially requiring surgical intervention and drainage.
Most recent practice advisories recommend looking for risk factors for infection
and considering alternatives to neuraxial techniques for high-risk patients. A
known epidural abscess is a contraindication to neuraxial blockade. According
to this consensus document [65], if bacteremia is present, preprocedural
antibiotics should be considered. Aseptic technique, with antiseptic skin
preparation and use of sterile barriers and occlusive dressings, should be
employed for placement of all neuraxial needles and catheters. Use of bacterial
filters and avoidance of excessive catheter manipulation post placement is useful
in preventing infection. Teams managing neuraxial or regional catheters should
consider removal of accidentally disconnected or unnecessary catheters daily in
the context of each patient’s medical status, while balancing the benefits of good
pain control.
VI. Risk versus benefit: epidural/intrathecal (IT) analgesia for cardiac surgical
procedures requiring systemic anticoagulation
Controversy has surrounded the relative risks and benefits of neuraxial blockade
for patients undergoing cardiac surgery requiring systemic anticoagulation.
Clearly, extensive clinical experience and literature support the safety of neuraxial
procedures in the setting of heparin anticoagulation accompanying major vascular
surgery; but, in such cases, heparin dosing is generally lower than for cardiac
surgery and is not accompanied by the added effects of CPB on impaired
hemostasis. Established guidelines have been available to support decision making
in this regard, including the avoidance of neuraxial interventions when patients
have pre-existing hemostatic disorders, postponing surgery for 24 hours in the
event of a traumatic (“bloody”) tap at the time of needle or catheter insertion, and
delaying heparin administration for at least 60 minutes after performance of an
uncomplicated neuraxial procedure. These guidelines are largely based on the
analysis of retrospective cohorts [66]. Current ASRA consensus guidelines
indicate that “insufficient data and experience are available to determine if the risk
of neuraxial hematoma is increased when combining neuraxial techniques with the
full anticoagulation of cardiac surgery” [37].
8 Despite widespread belief in the salutatory effects of excellent analgesia, the
principal patient-related benefit of central neuraxial analgesia for cardiac surgery
is patient satisfaction. Importantly, a body of literature has assembled that does not
support the belief that central neuraxial analgesia improves major clinical
outcomes [20]. Epidural hematoma can complicate thoracic epidural placement for
cardiac surgery, although to date there are no reports of spinal bleeding
complicating single-shot IT drug placement prior to cardiac surgery, and the risk
for epidural catheter insertion prior to cardiac surgery has been assessed to be
equivalent to that for obstetric anesthesia [67,68]. Pending additional contributions
to our understanding, the trend in expert opinion argues for caution, particularly
regarding thoracic epidural catheter placement prior to “full” heparin
anticoagulation for cardiac surgery.
CLINICAL PEARL Expert opinion leans toward caution in the setting of neuraxial
blockade for cardiac surgery, with cognizance of holding systemic anticoagulation as
appropriate per available practice guidelines.
VII. Considerations in facilitating transitions of care
A. Enhanced recovery after surgery (ERAS)
ERAS programs for thoracic surgery evolved from historical “fast-tracking”
protocols to now include preoptimization, minimizing fasting time,
thromboembolic prophylaxis, anesthetic and analgesic techniques, surgical
approach, postoperative rehabilitation, and chest tube management. Such
protocols demonstrate improvements in morbidity and length of stay for selected
patient groups.
B. Quality and safety considerations
Reliable postoperative analgesia is a key component in facilitating prompt
tracheal extubation (within 6 hours) after cardiac surgery. Such “fast tracking” of
low-risk cardiac surgery patients appears to be safe and has been adopted by
many centers as a process to shorten intensive care unit and hospital lengths of
stay. Patients may receive additional benefits, such as improved cardiac function
and reduced rates of respiratory infections and complications. Attention to
reducing risk and to institutional resource utilization has expanded the focus on
accelerating and improving transitions of care for all cardiothoracic surgical
patients, not just those deemed “low risk” in advance. Similarly, the role of the
anesthesiologist in care pathway design has expanded well beyond facilitating
early extubation and early postoperative analgesia toward greater preoperative
and postoperative integration as a key perioperative physician [69].
C. Intrathecal (IT) morphine
IT morphine is used in many centers for eligible cardiac surgery patients to
provide analgesia and mild sedation in the early postoperative period. However,
some studies have failed to demonstrate a beneficial effect of IT morphine either
in improving early analgesia or in facilitating early extubation. NSAIDs
complement opioid analgesia regardless of how the opioid is administered.
Indomethacin, administered rectally as 100-mg suppositories, is a common
component of fast-tracking protocols for cardiac surgery aimed at reducing pain
and early postoperative narcotic use. Some NSAIDs may antagonize opioid-
induced respiratory depression [70]. Intraoperative and postoperative continuous
infusions of remifentanil or alfentanil (with or without supplemental propofol
infusion) are used in some centers to allow for controlled analgesia and
“scheduled extubation.” Both a high-dose narcotic technique using the ultra–
short-acting narcotic remifentanil [45] or an anesthetic incorporating high
thoracic epidural conduction block [57] have been suggested as methods that may
improve outcomes by inhibiting perioperative stress responses while facilitating
early extubation and fast tracking.
Postoperative analgesia strategy for thoracic surgery patients often influences
disposition when continuous epidural infusions are used, since the care team
must be equipped and trained to intervene when potentially serious
complications of postoperative analgesia occur, such as hypotension from local
anesthetic–mediated reductions in sympathetic tone and delayed respiratory
depression due to cephalad spread of neuraxial opioids. In formulating an
analgesia plan for thoracic surgery, considerable respect must be paid to the
failure to achieve tracheal extubation—a serious complication of emergence
whose occurrence is partly under the influence of the anesthesiologist. This is
particularly important since major pulmonary complications of lung resection
surgery are more than twice as likely in the setting of postoperative respiratory
failure and are highly associated with other markers of adverse outcome,
including postoperative mortality. Contributors to the heightened risk of
respiratory failure after lung resection include “variable” factors amenable to
optimization, such as inadequate respiratory mechanics from pain-related chest
wall splinting, poor positioning, and residual paralysis.
Since pain at emergence from anesthesia for lung resection is extremely
difficult to treat without increasing the risk of acute respiratory depression and
interfering with efforts to extubate the patient, the anesthesiologist must be
confident that analgesia is established pre-emergence. If a thoracic epidural
catheter has been placed, a common practice 10 to 15 minutes prior to emergence
is to supplement existing analgesia with an additional 2-mL bolus of 2%
preservative-free lidocaine for an average adult male; this represents a modest
investment in protection from emergence pain that rarely causes block-mediated
hypotension but allows for tracheal extubation before more pain management
interventions are needed. Fortunately, difficult emergence sequences are
relatively infrequent, but the patient with limited respiratory reserve likely has
the most to gain from an experienced anesthesia team to avoid a prolonged
episode of postoperative mechanical ventilation. Rarely, sequential blood gas
determinations immediately following tracheal extubation (e.g., every 3 minutes)
identify the marginal patient whose CO2 levels are rising despite optimal
analgesia, a concerning finding that requires further prompt intervention and
optimization to avert respiratory failure and tracheal reintubation.
CLINICAL PEARL Pain at emergence from anesthesia for lung resection is extremely
difficult to treat without increasing the risk of acute respiratory depression in a patient
with limited respiratory reserve, and can be optimized prior to extubation by modest
dosing of neuraxial or regional catheters with local anesthetic prior to emergence.
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Index
Note: Page number followed by f and t indicates figure and table only.
A
Abciximab, 646t
Acetaminophen (paracetamol), 768–769
Acetylsalicylic acid. See Aspirin
ACHD. See Adult congenital heart disease
Acidosis, 724–725
Actin, 5–6
Action potential (AP), 548, 549f
Activated clotting time (ACT), 223, 634t, 636–638, 650–651
blood chemistry and, 197
heparin dose–response curve, 197
Activated factor VII, 726
Activated partial thromboplastin time (aPTT), 634t
Acute coronary syndrome (ACS)
medical management for, 89
presentation, 88, 89t
Acute kidney injury (AKI), 147, 260, 626
Acute normovolemic hemodilution (ANH), 277–278
Adaptive-rate pacing (ARP), 561–562
Adenoscan. See Adenosine therapy
Adenosine therapy, 74, 74t, 96, 184, 619
ADP receptor inhibitors, 647
Adrenaline. See Epinephrine
ADSOL (additive solution)-preserved RBCs, 272
Adult congenital heart disease (ACHD), 477, 478f
anesthetic considerations, 481
antibiotic prophylactic considerations, 504
arrhythmias with, 482–485
classification, 477, 479t
complete repair, 477
partial surgical correction or palliation, 477
uncorrected CHD, 478
definition of, 477
Fontan repair, 491–494, 492f
healthcare system considerations, 479–480
regional centers of excellence, 480t
and heart transplantation, 491
intraoperative anesthetic considerations, 487
chronic left-to-right shunting, 488–489
cyanotic lesions, 487–488
laboratory and imaging studies, 486
cardiac catheterization/echocardiography, 486
chest radiography, 487
electrocardiogram, 487
preoperative testing, 486
medical concerns in patients with, 481t
monitors used in surgery, 487
perioperative risk for, 481
postoperative management, 489
arrhythmias, 489
pain management, 489
volume considerations, 489
prevalence, 478–479
pulmonary arterial hypertension and, 485–486
pulmonary valve abnormalities, 496–497
repeat sternotomy, anesthetic considerations in, 490
repeat sternotomy, surgical considerations in, 489
cannulation options, 490
initiation of CPB, 490
lysis of adhesions, 490
preoperative preparation, 489–490
specifics of repeat sternotomy, 490
RV–PA conduit, 495–496
signs and symptoms of, 481
surgical and medical history, 481
tachyarrhythmias associated with, 482t
tetralogy of Fallot, 494–495
transposition of great vessels, 497–498
uncorrected lesions, 478, 498–499
atrial septal defect, 499–501, 499f, 501f
ventricular septal defects, 502–504, 502f
Afterload, 315
Air embolus, 488
Air lock, 230
Airway management, in cardiac tamponade, 585
Airway stenting, 466
AKI. See Acute kidney injury
Aldactone. See Spironolactone
Aldosterone, 511
α2-Adrenergic agonists, 297
Alpha (a)-adrenergic receptors, 28, 29–34, 29f
Alprostadil, 66
American Society of Anesthesiologists (ASA), 110
Amiloride, 79
Aminocaproic acid, in cardiac surgery, 491
Amiodarone, 71–72, 92, 184
for arrhythmia, 552, 553
Amplitude ratio, 114, 116
Anaerobic glycolysis, 678, 746
Anesthesia
during CPB, 219–220
induction of, 181–193
last-minute checks, 184
Anesthetic level, blood chemistry and, 196–197
Anesthetic/pharmacologic preconditioning, 372, 376
Aneurysm, 172, 403. See also Thoracic aortic aneurysm and dissections
causes, 403, 404t
classification, 403
clinical signs and symptoms, 404, 405t–406t
incidence, 403
natural history, 403
Angiotensin-converting enzyme (ACE) inhibitors, 52–53, 62–67, 182
for heart failure, 511
for SIHD, 88
Angiotensin II
action, 35
dose, 35
side effects, 36
Angiotensin receptor blocker neprilysin inhibitors (ARNIs), 511
Angiotensin receptor blockers (ARB), 64, 182
ANH. See Acute normovolemic hemodilution
Antegrade cardioplegia, 685
Antiarrhythmics agents, 70–72, 184
Antibiotic prophylaxis, for bacterial endocarditis, 343, 343t
Anticholinergic medication, 184
Antidepressants, 30
Antidysrhythmics, 107
Antifibrinolytic therapy, 197
in aortic surgery, 410
in cardiac surgery, 491
Antihypertensives, 94t, 106, 106t
Anti-ischemic therapy, 89, 90t
Antilymphocyte globulin, 526t
Antitachycardic agents, 184
Antithrombin III (ATIII) deficiency, 639, 639t
Antithrombotic and antiplatelet therapy, for cardiovascular diseases, 105–106
Antithrombotic drugs, 646t
Aortic aneurysm, 400
Aortic arch, 172
Aortic arch surgery, 415–419
cardiopulmonary bypass, 415
cerebral protection, 415–416
antegrade cerebral perfusion (ACP), 418–419, 418f, 419f
DHCA, 416–417
retrograde cerebral perfusion (RCP), 417–418
complications, 419
surgical approach, 415
technique, 415, 416f, 417f
Aortic atheroma, 149, 742
Aortic coarctation repair, 422
Aortic cross-clamp manipulations, 221
Aortic cross-clamp release, 227
Aortic dissection, 172–173, 400. See also Thoracic aortic aneurysm and dissections
arterial branches, involvement of, 401, 402t
clinical signs and symptoms, 404, 405t–406t
DeBakey classification, 401–402, 402f
exit points, 401
incidence, 400
mechanism of aortic tear, 401, 401t
natural history, 402–403
onset of, 400–401
predisposing conditions, 400, 400t
propagation, 401
Stanford (Daily) classification, 402, 403f
Aortic regurgitation (AR), 170
acute, 332–333, 336
anesthetic technique
induction and maintenance, 337
intraoperative TEE, 337
premedication, 337
weaning from cardiopulmonary bypass, 337
and aortic stenosis, 338
chronic, 333, 336
echocardiographic assessment, 333–335
color M-mode assessment, 335f
severity of AR, 333, 334t, 335
vena contracta, 335f
etiology, 332
and mitral regurgitation, 338
pathophysiology, 332–333
perioperative management
contractility, 337
heart rate, 336
hemodynamic management, 336–337, 336t
LV preload, 336
pulmonary vascular resistance, 337
systemic vascular resistance, 337
postoperative care, 337
pressure–volume loop in, 334f
pressure wave disturbances, 333
quantitative assessment, 336
surgical treatment, 336
symptoms, 332
vasodilator drugs for, 52
Aortic stenosis (AS), 170–171
and aortic regurgitation, 338
balloon aortic valvuloplasty, 319–320
echocardiographic evaluation, 318–319, 318f, 318t
etiology, 315–316
heart remodeling in, 317
hemodynamic changes in
arterial pressure, 317
pulmonary arterial wedge pressure, 317
and mitral stenosis, 338
perioperative management, 325–326
contractility, 325
external defibrillator pads placement, 325
heart rate, 325
hemodynamic profile, 325, 325t
induction of anesthesia and hemodynamic goals, 326
LV preload, 325
maintenance stage of anesthesia, 326
preinduction arterial line placement, 325–326
systemic vascular resistance (SVR), 325
thermodilution cardiac output, 326
transesophageal echocardiography, 326
postoperative care, 326–327
pressure–volume loop in, 317f
Ross (switch) procedure, 320
severity of, 318–319
surgical (open) aortic valve replacement, 324–325
symptoms, 316–317
timing of intervention, 319–320, 320t
transcatheter aortic valve replacement, 320–324
anesthetic considerations, 323–324
antegrade transapical approach, 321, 322f
complications, 324
contraindications, 320–321
hybrid operating room, 321
outcomes, 324
retrograde/transfemoral approach, 321, 322f
transaortic approach, 323
transaxillary approach, 322
transcarotid approach, 323
Aortic valve (AV), 170–171
Apixaban, 645, 646t
Apresoline. See Hydralazine
Aprotinin, 638, 649
CPB period and, 197
AR. See Aortic regurgitation
ARB. See Angiotensin receptor blockers
Argatroban, 641
Arndt® bronchial blocker, 446f
Arrhythmia
anatomical substrates and triggers
supraventricular, 551
ventricular, 551
clinical approach
bradycardia, 552
syncope, 551–552
tachycardia, 552
mechanism of, 550t
automaticity, 548–550
reentry, 550–551
triggered activity, 550
neural control
β-adrenergic modulation, 551
parasympathetic activation, 551
risk of, 442–443
surgery, 573
treatment
nonpharmacologic, 553–557
external cardioversion and defibrillation, 553–554
implantable cardioverter–defibrillator, 556–557
permanent pacing, 554–556
temporary pacing, 554, 554t
pharmacologic, 552–553
Arrhythmogenesis, basic electrophysiology, 548
action potential, 548, 549f
conduction, 548
excitability, 548
ion channels, 548
Arterial baroreceptors, 16–18, 17f
Arterial blood gas (ABG), 441
Arterial cannulae, 601, 601f
Arterial cannulation, CPB, 601–602, 601f
cannulation sites, 602, 602t
ascending aorta, 602
axillary/subclavian artery cannulation, 603
femoral or external iliac artery, 602
innominate (brachiocephalic) artery, 603
Arterial catheter, for thoracic surgery, 454
Arterial catheterization
abnormal arterial waveform morphology, 123, 124f
arterial tracings, interpretation of, 121–123, 121f–123f
cannulation, sites of, 119–120
complications of, 123
indications, 119, 119t
Arterial line filter, 613
Arterial pump, 597
Arterial waveform, abnormal, 123, 124f
Artery of Adamkiewicz, 410
Artificial lung, 595, 597, 607–608
AS. See Aortic stenosis
ASA. See American Society of Anesthesiologists
Ascending aorta, 172
Ascending aortic surgery, 412–414
cooling and rewarming, 415
induction and anesthetic agents, 416t
monitoring, 415
aortic valve involvement, 413
cardiopulmonary bypass, 412–413
complications, 414
coronary artery involvement, 413
surgical approach, 412
surgical techniques, 413–414, 413f, 414f
Aspirin, 103, 103t, 646t, 647
for ACS, 90t
for SIHD, 88
Atelectasis, 260
Atherosclerosis, 172
ATPase, 6
ATP reserves, under ischemic conditions, 678
Atria, 9
Atrial baroreceptors, 14–16, 15f, 16f
Atrial fibrillation, pulmonary resection surgery and, 442
Atrial septal defect (ASD), adult, 499–501, 499f, 501f
Atropine, 73, 184, 187
Augmented venous drainage, 600
Automated protamine titration, 638
Automaticity, 548–550
AV. See Aortic valve
AV block, 552, 555
Azathioprine, 526t, 541, 542
B
Bacterial endocarditis, prophylaxis of, 343, 343t
Balloon aortic valvuloplasty, aortic stenosis, 319–320
Balloon mitral valvuloplasty, 353
Balloon valvuloplasty, 496
Bare metal stents (BMS), 102
Baroreceptors, 13
arterial, 16–18, 17f
atrial, 14–16, 15f, 16f
Basiliximab, 526t
BB. See Bronchial blocker
Beck triad, 579
Benzodiazepines, 297, 722
Bernoulli equation, 158
Beta-adrenergic blockade
for cardiovascular diseases, 105
for SIHD, 88
Beta (β)-adrenergic receptors, 28, 36–37, 288
actions, 50
advantages, 50
clinical use, 51–52
disadvantages, 50
features, 51
Beta (β)-agonists, 36–37, 51
β1-antagonists, for BP control, 409
Bicaval cannulation, 599
Bifascicular block, 555
Bileaflet tilting–disc valve prosthesis, 339, 339f, 366
Bilobectomy, 458
Bioprosthetic valves, 339, 366
stented, 339–340, 340f
stentless, 340, 341f
Biotronik pacemakers, 563–564
Biphasic shock delivery, 565
BIS. See Bispectral index
Bispectral index (BIS), 148, 376
Bivalirudin, 641, 646t
Biventricular assist device (BIVAD), 662, 663f
Blalock–Taussig shunts, 487
Bleeding, 123
Blood chemistry, CPB period and, 196–197
Blood conservation measures
acute normovolemic hemodilution, 277–278
antifibrinolytics, 277
cell salvage, 278
low-volume CPB circuits, 279
modified ultrafiltration, 278–279
preoperative anemia management, 276–277
retrograde autologous prime, 279
viscoelastic testing, 279–280
zero-balance ultrafiltration, 279
Blood pressures (BPs), 11, 14
Blood pumps, in CPB circuit, 603
centrifugal pumps, 604–606, 606f
pulsatile flow and pulsatile pumps, 606–607
roller pump, 603–604, 605f
Blood transfusion, 266–267
complications of, 267–269
cryoprecipitate, 275–276, 276t
fresh-frozen plasma, 275, 275t
massive transfusion and component ratios, 276
PBM programs, 267
platelet therapy, 274, 274t
red blood cell, 269–273
restrictive RBC transfusion practices, 273
transfusion practice in cardiac surgery, 267
Blue baby syndrome, 494–495
BMS. See Bare metal stents
Body temperature
during pre-CPB time period, 198
during thoracic surgery, 455
Boston Scientific ICDs, 568
BPs. See Blood pressures
Brachial plexus, 452
Brachial plexus injury, CPB period and, 195
Bradyarrhythmias, drugs for, 73
Bradycardia, 92, 552
Brain, 13, 21
Breath sounds, CPB period and, 195
Bretschneider solution, 681
Bronchial blocker (BB), 444, 445, 447f, 450, 538
Bronchopleural fistula, 449, 462–463
air leak through, 463
anesthetic goals in, 463
management principles, 463
options for induction of anesthesia, 463
Bronchospasm, prevention of, 455
B-type natriuretic peptide (nesiritide), 717
Bubble trap, 613
Bullae and blebs, 463
Bumetanide, 78
Bumex. See Bumetanide
Bupivacaine (Exparel™), 770
Burkholderia cepacia, 533
C
CABG. See Coronary artery bypass grafting
Calan. See Verapamil
Calcium, 45–46, 67
actions, 46
administration, 46
advantages, 46
clinical use, 47
disadvantages, 46
ions, 67
myocardial effects of, 67
offset, 46
use, indications for, 46
Calcium channel blockers (CCBs), 92. See also specific agents
clinical effects, 67–68
general considerations, 67
versus nitrates, 67
Calcium chloride, 184
Calcium flux, 4, 5
Calcium gluconate, 184
Cannulation strategies
left ventricular venting, 692
use of a bicaval, dual-lumen cannula, 690, 691f
venoarterial, 690–692
venovenous, 690
Capillary leak syndrome, 623
Capnometry, 453
Capoten. See Captopril
Captopril
actions, 62
administration, 63
advantages, 62
clinical use, 63
disadvantages, 62–63
indications, 63
offset, 62
Carbon dioxide (CO2) insufflation, during robotic surgery, 393
Carbon monoxide–releasing molecule-2 (CORM-2), 649–650
Cardene. See Nicardipine
Cardiac allograft hyperacute rejection, 524
Cardiac allograft vasculopathy (CAV), 525
Cardiac anesthesia, 145
Cardiac arrhythmias, 548. See also Arrhythmia
Cardiac catheterization
coronary anatomy, representation of, 99, 99f
left ventricular function, assessment of, 99–100, 101f
normal hemodynamic values at, 98t
overview, 98
valvular function, assessment of, 100–102
Cardiac implantable electronic devices (CIEDs), 512
and cardioversion, 554
CIED team evaluation, 569
device management, 569–570
precautions, 570–571
preoperative patient evaluation, 568–569
and RF catheter ablation, 572–573
system implantation or revision, management for, 571–572
Cardiac myocyte
length–tension relationship, 6–7, 7f
compliance, 7
contractility, 8
intracellular Ca2+ concentration, 8
oxygen consumption, 8
organization of, 6
sarcomere, 5–6, 6f
Cardiac output (CO)
assumptions and errors, 139–140, 140f
during CPB, 618
measurement of, 173
methods, 139
minimally invasive monitoring, 140–141, 142t
volume responsiveness, measurements of, 142–145, 143t, 144f
Cardiac resynchronization therapy (CRT), 510
Cardiac risk evaluation (CARE) score, 85
Cardiac surgery
abnormalities acquired during, 647–648
in patients with cerebrovascular disease, 759–760
platelet dysfunction in, 647, 648t
Cardiac surgical patient
clinical perioperative risk assessment, 85–86, 86t
functional status of, 86–87
genomic contributions to cardiac risk assessment, 87
hemostatic abnormalities in, 645–650, 646t
monitoring, 109–153
surgical problems and procedures, risk with, 87
Cardiac tamponade, 576, 577–585
catheterization data, 580
clinical evaluation, 579–580, 580t
echocardiography, 580–581, 582f, 583f
electrical alternans with, 579, 580f
etiology, 577–578
pathophysiology, 578, 579f
perioperative management, goal of, 584–585
with right atrial (RA) and ventricular (RV) collapse, 578f
symptoms, 578
treatment of, 581
pericardiocentesis, 581–582, 583f
surgical drainage, 583–584
Cardiac transplantation, 508
anesthetic management
of cardiac transplant recipient, 520–522
of donor, 517–518
bradyarrhythmias after, 556
brain death and, 515
determination of, 515
pathophysiology of, 515–516, 515t
cardiac transplant donor, management of, 516
cardiovascular function, 516–517
coagulation, 517
fluid and electrolytes, 517
pulmonary function, 517
temperature, 517
cardiac transplant recipient, anesthetic management of, 520–522
anesthetic induction, 521–522
anesthetic maintenance, 522
aseptic technique, importance of, 521
cardiopulmonary bypass, 522
monitoring, 521
premedication, 520–521
repeat sternotomy, considerations for, 521
in children, 526–527
contraindications to, 513, 514t
donor selection, 514–515
contraindications to heart donation, 515t
marginal donors, 514
future directions, 531
heart failure and, 508–512
heterotopic, 519
indications for, 513, 513t
intraoperative TEE, role of, 524
organ harvest technique, 518
orthotopic, 518–519, 518f
postoperative period, considerations in, 522
autonomic denervation of transplanted heart, 522
coagulation, 523
hyperacute allograft rejection, 524
LV dysfunction, 523
pulmonary dysfunction, 524
renal dysfunction, 523
RV dysfunction, 522–523
pregnancy following, 530–531
preoperative management
combined heart–lung recipient, 520
concomitant organ dysfunction, 520
medications, 520
monitoring, 520
preoperative assessment, 520
timing and coordination, 519–520
previously transplanted patient, anesthesia for, 527–531
recipient characteristics, 512–514
surgical techniques for, 518f
survival and complications, 524, 525f
acute rejection, 525
cardiac allograft vasculopathy, 525
graft failure, 525
immunosuppressive drug side effects, 526, 526t
infection, 524
malignancy, 526
renal insufficiency, 525–526
Cardiac ultrasound imaging, modes of, 158–159
Cardioplegia, 225, 680–682, 681–683, 681t
delivery of, 387, 597, 608–609, 683–685, 684f
temperature of, 682–683
Cardiopulmonary bypass (CPB), 110, 194–212, 320, 369, 595, 596f, 618, 631
adequacy of perfusion during, 620
anesthesiologist in, role of, 618
anesthetic induction and, 194–212
cardiac reoperation, 200–201
general principles, 194
hemodynamic changes, treatment of, 204–209
hemodynamic responses, 195t
incision, 199
internal mammary artery, 202–203
perioperative stress response, 203–204, 203t
preincision, 195–199
radial artery dissection, 202–203
sternal spreading, during and after, 200
sternum opening, 199–200
sympathetic nerve dissection, 203
urgent/emergent cardiac operation, 201–202
anticoagulation for (see Heparin)
aortic cross-clamp release, 227
avoidance of, 370–371
for cardiac transplantation, 522
cerebral perfusion during circulatory arrest, 614–615
antegrade cerebral perfusion (ACP), 615
retrograde cerebral perfusion (RCP), 614–615
circulatory changes during, 619–620
circulatory control during, 618–619
commencement of
adequacy of perfusion, 217–218
cessation of ventilation and lung management, 217
establishing full flow, 216
initial CPB checklist, 216–217, 217t
monitoring, 217
complications, prevention and management of, 229, 616
clotted oxygenator or circuit, 234
dislodgment of cannula/tubing rupture, 234
failure of oxygen supply, 233–234
heater–cooler malfunction, 234
high pressure in arterial pump line, 230, 232
malposition of arterial cannula, 229
massive gas embolism, 232–233
obstruction to venous return, 229–230
oxygenator failure, 234
pump failure, 234
reversed cannulation, 229
components of circuit
arterial cannulation, 601–603, 602t
cardioplegia delivery system, 608–609
cardiotomy, field suction, cell salvage processors, and cell savers, 609–610
filters and bubble traps, 613
heat exchanger, 608
monitors and safety devices, 614t
overview, 597–598
oxygenator, 607–608
systemic (arterial) pump, 603–607
ultrafiltration/hemoconcentrators, 613
venous cannulation and drainage, 598–601, 598f
venous reservoir, 603
venting, 610–612, 612t
conditions affecting
cold agglutinin disease, 236
cold urticaria, 236
hereditary angioedema, 236–237
Jehovah’s Witnesses, 237
malignant hyperthermia, 236
pregnancy, 237
sickle cell trait and disease, 235–236
conduct of, 676–677
effect of, on organs, 227–229
central nervous system, 626
heart, 626
kidneys, 626
lungs, 627
splanchnic, gastrointestinal, and hepatic effects, 626–627
goal and function of, 595
hypothermia and, 620–621
Cardiopulmonary bypass (CPB) (continued)
less common cannulation
left thoracotomy, 615
minimally invasive or port access CPB, 615
right thoracotomy, 615
maintenance of
acid–base management, 226
anesthesia, 219–220
anticoagulation management, 223–224
arterial blood gas, 226
blood glucose management, 226–227
ECG management, 225
fluid management and hemodilution, 222–223
hemodynamic management, 220–222
myocardial protection, 225–226
serum electrolytes management, 226
temperature management, 224–225
miniaturized or minimized circuits, 613
for minimally invasive procedures, 234
aortic valve surgery, 235
cardioplegia, choice of, 235
minithoracotomy, 235
mitral valve surgery, 235
port-access surgery, 235
pediatric circuits, 613–614
postbypass bleeding, management of, 650–653
preparations for, 209–212, 210f, 214
arterial and venous cannulation, 215–216
assembling and checking CPB circuit, 214–215, 215f
pre-CPB checklist, 215, 216t
priming, 615
asanguinous primes, consequence of, 615–616
of circuit, 616
composition of prime, 616
final disposition of prime, 616
retrograde autologous priming (RAP), 616
rewarming, 227
risk containment, 616–618
role of, on adverse effects of cardiac surgery, 627–628
sequence
aortic valve replacement operation, 218–219
combined valve–CABG procedure, 219
mitral valve replacement operation, 219
typical CABG operation, 218
surface coating, 613
systemic effects of, 621, 622f
adverse effects, causes of, 621
blood, 621, 623
fluid balance and interstitial fluid accumulation, 623
inflammation, 623–625
stress response, 625–626
termination of (see Termination of bypass)
weaning from, 467–468
preparation for, 227
Cardiotomy reservoir, 609
Cardiotomy suckers, 609
Cardiovascular control system, 13–14
Cardiovascular diseases, 85
cardiac catheterization for, 98–102
drugs for, 28–29
interventional cardiac catheterization, 102–105
noninvasive cardiac imaging of, 95–98
patient presentation, 85–87
preoperative medical management of, 87–95, 105–107
Cardiovascular hybrid surgery, 321
Cardiovascular system
effect of anesthesia on, 23–24
integration, 21–23
Cardizem. See Diltiazem
Carotid stenosis, 95, 759–760
Carpentier–Edwards Perimount bioprosthetic valve, 339, 340f
Catapres. See Clonidine
Catecholamines, for heart failure, 511
Catecholamine vasoconstrictors, 37
Catheter whip, 118
Cavoatrial cannula, 598, 598f
CCBs. See Calcium channel blockers
Cell-based model of hemostasis, 632, 633f
Cell, ionic content, 4f
Cell salvage, 278
Cell salvage processors, 609
Central nervous system (CNS), 198–199
effect of CPB on, 626
Central nervous system (CNS) damage
embolizations, 740–744
detection of, 742
equipment-related, 743–744
microgaseous emboli, 741
patient-related, 742–743
procedure-related, 743, 743f
hypoperfusion, 744–745
inflammation, 745–747
Central nervous system (CNS) dysfunction with cardiac surgery, 734–737
in CAB patients, 736
cognitive dysfunction, 736
incidence of perioperative stroke, 735
perioperative strategies to manage, 753t
risk factors, 736, 737t
stroke incidence, 734, 735f
Central nervous system (CNS) injury, prevention of
best practice cardiopulmonary bypass (CPB), 755
cerebral perfusion, 755
embolic load, 754
euglycemia, 755
mild hypothermia, 755
minimally invasive extracorporeal circulation (MiECC), 754
open-chamber de-airing techniques, 755
perfusion equipment and techniques, 754
Central venous catheters (CVCs), in ACHD surgery, 487
Central venous pressure (CVP), 123, 222, 454
complications, 127
indications, 123–124, 124f
interpretation, 127–129, 129f
RA-RV hemodynamic abnormalities, differential diagnosis of, 128t
renal system and, 198
techniques, 125–127, 125t, 126f
waveform, components of, 127t
Centrifugal pumps, 600–601
Cerebral autoregulation (CA), 737–738
factors associated with loss of, 745t
lower limit and upper limit, 738
during normothermia and hypothermia, 738f
Cerebral monitoring, intraoperative. See Intraoperative cerebral monitoring
Cerebral oximetry, 149, 218
Cerebral perfusion pressure (CPP), 744–745
Cerebrovascular disease
genetic factors, 95
perioperative neurologic dysfunction, 94–95
surgical procedure, effect of, 95
Cervical mediastinoscopy, 464
CFD. See Color-flow Doppler
CFD gain, TEE and, 161
Chamber wall, 8–9
Charge-coupling device (CCD), 383
Chest imaging
in aortic dissection, 406
for difficult endobronchial intubation, 444
CHF. See Chronic heart failure
Chronic cardiac medications, administration of, 182
Chronic heart failure (CHF), vasodilator drugs for, 52
Chronic obstructive pulmonary disease (COPD), 443
preoperative therapy of, 443
severity of, assessment of, 443
Chronic stable angina. See Stable ischemic heart disease (SIHD)
Chronic thromboembolic pulmonary hypertension (CTEPH), 468–469
CIEDs. See Cardiac implantable electronic devices
Cilostazol (Pletal), 105–106
Circulatory arrest, 745
Circumflex coronary artery, 287
Cisatracurium, 183, 192, 298
Clamshell incision, 462
Clevidipine, 69–70, 184
CLLS. See Constant light-level system
Clonidine, 64–65
Clopidogrel, 103, 103t, 105–106, 646t, 647
Closed mitral commissurotomy, 353
Coagulation, physiology of
hemostasis, mechanisms of, 631–633, 632f, 633f
hemostatic function, tests of, 634–635, 634t
Coagulation tests, 651
Cochrane Airways Group, 473
Cohen® tip-deflecting endobronchial blocker, 446f
Cold agglutinin disease, 236
Cold urticaria, 236
Color-flow Doppler (CFD), 158–159
Combined heart–lung transplantation (HLT), 527
Comparator, 13
Complement system, 624
Computed rendering of 2D images into 3D, 177
Computed tomography, 98
aortic aneurysm, 407
Computer control system, 384
Congenital heart disease (CHD), 477, 478f
TEE for, 174
Congestive heart failure
clinical assessment and medical management of, 90–92
perioperative morbidity, 92
treatment of, 91f
Constant light-level system (CLLS), 12–13
Constrictive pericarditis (CP), 576, 586–591
catheterization data, 587–588, 587f
clinical evaluation, 586–587
echocardiography, 588, 588f, 589f
etiology, 586
pathophysiology, 586
perioperative management, 590–591
and restrictive cardiomyopathy, 590t
symptoms, 586
treatment, 588
Continuous CO, 136, 136t
Continuous-flow devices, 664–665
Continuous noninvasive blood pressure monitors, 114
Continuous positive airway pressure (CPAP), during one-lung ventilation, 457
Continuous spirometry, 454
Continuous-wave Doppler (CWD), 158
Contractility, 18–19, 315
Contrast nephropathy (CN), 435
Controller, 12, 13
Control systems, 12–13, 14f
Cordarone. See Amiodarone
Core temperature, 145–146
CoreValve ReValving System, 320
CoreValve systems, 341
Coronary anatomy, 286–287, 373, 373f
Coronary artery bypass grafting (CABG), 85, 102, 218, 285
risk of morbidity and mortality for, 285–286, 286t
TEE for, 174
Coronary artery disease
prevalence and economic impact of, 285
symptoms and progression of, 285
Coronary artery spasm, 256
Coronary artery stent thrombosis, 103
antiplatelet agents, 103t
perioperative antiplatelet therapy in patients with, 104–105
prevention of, 104
risk factors for, 104t
Coronary perfusion pressure (CPP), 289, 331
Coronary vascular resistance (CVR)
control of, 287–288, 288t
anatomic factors, 288
autonomic nervous system, 288
endothelium-derived hyperpolarizing factor, 288
hormonal factors, 288
hydraulic factors, 289
metabolic, 287–288
factors affecting, 288
Cor pulmonale, 443
Corticosteroids, for immunosuppression, 526t
Coumadin, for heart failure, 512
CPB. See Cardiopulmonary bypass
Cryoablation, 771
Cryoprecipitate, 275–276, 276t
CSF pressure (CSFP), 430
CVP. See Central venous pressure
CWD. See Continuous-wave Doppler
Cyclosporine, 526t, 541, 542
Cystic fibrosis (CF), 531, 532
Cytokine profiling, 535
Cytokines, 624
D
Dabigatran, 645, 646t
Daclizumab, 526t
Damping coefficient, 115f, 116–118, 116f, 117f
DAPT. See Dual antiplatelet therapy
The da Vinci system, 384. See also Robotically enhanced cardiac surgery
D-dimer, 634t
Dead space, 259–260
Declamping syndrome, 427–428
Deep hypothermic circulatory arrest (DHCA), 152–153, 224, 409, 469, 759t
brain protection, 758–759
clinical indications, 758
technique, 758
Delayed afterdepolarization (DAD), 550
Delirium, incidence in cardiac surgery, 736–737
del Nido cardioplegia, 382
DES. See Drug-eluting stents
Descending thoracic and thoracoabdominal aortic surgery, 420–425
aortic cross-clamping and, 427
declamping shock, 427–428
fluid therapy and transfusion, 428
monitoring, 426
one-lung anesthesia, 427
pain relief, 432
renal failure prevention, 432
spinal cord protection, 429–432
surgical approach, 420, 421f
surgical techniques, 421
cross-clamping, 421–422, 422f, 422t
extracorporeal circulation, 423–425, 423f, 424f
shunts, 423, 423f
Descending thoracic aorta, 172
Desflurane, 183, 191–192, 297, 756
Desmopressin acetate (DDAVP), 243, 523, 651
Dexmedetomidine, 722
DHCA. See Deep hypothermic circulatory arrest
Diastolic function, 315
Diastolic left ventricle examination, TEE and, 163–165, 164f, 165f
Diastolic ventricular dysfunction, 36
Diazepam, 183, 191, 297
Dibenzyline. See Phenoxybenzamine
Diffusing capacity for carbon monoxide (DLCO), 441
Digitalis, for heart failure, 510–511
Digoxin, 47
actions, 47
administration, 48
advantages, 47
disadvantages, 48
hemodynamics, 47
offset, 47
pediatric, 48
Diltiazem, 69, 76, 92, 184
Dipyridamole, 96, 646t
Direct oral anticoagulants (DOACs), 645, 646
Diuretics
actions, 77
adverse effects, 77–78
loop, 78–79
osmotic, 80
potassium-sparing, 79–80
thiazide, 79
Dobutamine, 37, 184
actions, 37
administration, 38
advantages, 37
clinical use, 38
disadvantages, 38
indications, 38
offset, 37
Dobutamine stress echocardiography (DSE), 96, 319
Dobutrex. See Dobutamine
Dopamine, 31, 38, 184
actions, 38
administration, 39
advantages, 38–39
clinical use, 39
disadvantages, 39
indications, 39
offset, 38
Dopaminergic receptors, 36
Dopexamine
actions, 39–40
administration, 40
advantages, 40
clinical use, 40
disadvantages, 40
indications, 40
offset, 40
Doppler echocardiography, principles of, 157–158
Doppler equation, 157
Double-lumen tube (DLT), 444, 445, 445f, 446f, 447, 449–451, 450
Doxazosin, 62
Droperidol, 28
Drug-eluting stents (DES), 104
Drugs
antiarrhythmic, 70–72
for bradyarrhythmias, 73
for cardiovascular diseases treatment, 28–29
dosage calculations, 27
genomics, 28
pharmacogenetics, 28
receptor interactions, 27–28
pharmacodynamics, 27–28
pharmacokinetics, 27
vasodilators, 52–67
DSE. See Dobutamine stress echocardiogram
Dual antiplatelet therapy (DAPT), 89, 90
Duke risk score, 96
Dynamic range, TEE and, 161
Dysrhythmias, 92, 208–209, 208t
E
ε-aminocaproic acid (EACA), 197, 277, 410, 648
Early afterdepolarizations (EADs), 550
Echocardiography, 95
in cardiac tamponade, 580–581, 582f, 583f
in constrictive pericarditis, 588, 588f, 589f
Edecrin. See Ethacrynic acid
Edoxaban, 645, 646t
Edwards Prima Plus stentless bioprosthetic aortic valve, 340, 341f
Edwards SAPIEN valve, 320
EEF. See Estimated ejection fraction
EES. See Everolimus-eluting stents
Effectors, 13
for healthy individual, 18–21
Eisenmenger syndrome (ES), 485, 502–504
Ejection fraction (EF), 509–510
Ejection fraction catheter, 135–136
Elective replacement indicator (ERI), 564, 564t
Electrical conduction, 3–5, 4f, 5f
Electrocardiogram (ECG), 111–114
computer-assisted interpretation, 113
filters, 113
indications, 111
lead placement, 112t
myocardial ischemia detection, 113–114, 113f
recommendations for, 114
techniques, 111–112
Electrocardiography, in aortic dissection, 406
Electrolyte abnormalities
hyperkalemia, 724
hypocalcemia, 724
hypokalemia, 724
hypomagnesemia, 724
hypophosphatemia, 724
Electrolytes, 146–147
Electromagnetic interference (EMI), 564–565, 565f
Embryologic development of heart, 3
Enalapril, 63
Enalaprilat, 63–64
En bloc double-lung transplantation (DbLT), 531
Endobronchial blockers, 446f
Endobronchial ultrasound (EBUS)-guided mediastinal nodal biopsy, 464
Endocardial leads, 554
Endoleak, 434
Endoscopic saphenectomy, 197–198
Endothelial glycocalyx (EG), 623
Endothelins, 624
Endothelium, 624–625
Endotracheal tube, movement of, 259
Endovascular (EV) graft repair of thoracic aorta, 432–435
advantages of, 433–434
cerebrospinal fluid (CSF) drainage, 436
contrast nephropathy, 436
fluid therapy and transfusion, 436
complications, 434–435
bleeding, 434
contrast nephropathy, 435
emergency conversion to open repair, 434
endoleak, 434
paraplegia, 434–435
stroke, 434
surgical approach, 432–433
techniques, 433
End-stage pulmonary disease (ESPD), 531, 532. See also Lung transplantation
bronchiectasis and, 532
CF and, 532
parenchymal, 532
End-tidal carbon dioxide (ETCO2), 471
Enhanced recovery after cardiac surgery
engaged and empowered team of physicians for, 715–716
goals of, 715
team approach, 715
Enhanced recovery after surgery (ERAS), 778–779
Enoximone, for heart failure, 511
Enzyme-linked immunosorbent assay (ELISA), 640
Ephedrine, 31, 184
actions, 31
administration, 32
advantages, 32
clinical use, 32
disadvantages, 32
indications, 32
offset, 32
Epiaortic echocardiography, 172
Epiaortic scanning, 149
Epicardial leads, 565
Epinephrine, 32, 33, 40, 184
actions, 40
administration, 41
advantages, 40–41
disadvantages, 41
indications, 41
offset, 40
Eplerenone, 79, 511
Epoprostenol (PGI2), 66–67
Eptifibatide, 646t
Erector spinae plane block, 773
Esmolol, 51, 75, 184
for arrhythmia, 552
for BP control, 409
Esophageal surgery, robotic-assisted, 393–395
Estimated ejection fraction (EEF), 164
Ethacrynic acid, 79
Etomidate, 186, 187, 189–190, 296, 538
in cardiac tamponade, 585
ETT. See Exercise tolerance test
EuroSCORE, 85
Eustachian valve, 171
Everolimus-eluting stents (EES), 104
Excitation–contraction coupling, in heart, 4
Excitotoxicity, 746–747
Exercise tolerance test (ETT), 95–96
External cardioversion and defibrillation, 553–554
Extracellular crystalloid cardioplegia, 683
Extracorporeal carbon dioxide removal (ECCO2R), 690
in management of hypercapnic respiratory failure, 695
Extracorporeal circulation (ECC), 423–425, 423f, 424f
Extracorporeal membrane oxygenation (ECMO)
as a bridging therapy, 696
in cardiac failure, indications and evidence
bridging strategy for LVAD and heart transplantation, 697
extracorporeal cardiopulmonary resuscitation (ECPR), 696
pulmonary vascular disease, 696–697
severe cardiogenic shock, 696
economic considerations, 700
ethical considerations, 700
femoral venoarterial, 690, 693f
history of, 689
management
against anticoagulation, 698
early mobilization of critically ill patients, 698
invasive mechanical ventilation practices, 697–698
weaning from venoarterial ECMO, approaches to, 698–699
weaning from venovenous ECMO, approaches to, 698–699
physiology, 689–690
potential complications, 699–700
in respiratory failure, indications and evidence
in management of hypercapnic respiratory failure, 695
in primary graft dysfunction (PGD) after lung transplantation, 695
in severe acute respiratory distress syndrome (ARDS), 693–695
transport, 699
two-site venovenous, 690, 691f
use of, 688
venoarterial, 689
venoarterial venous, 691, 694f
venovenous, 689
Eyes, CPB period and, 195
EZ Blocker, 447f
F
Factor Xa inhibitors, 645, 646
Fast-track (FT) cardiac surgery
goals of, 714–715
methods of, 715
in postanesthesia care unit (PACU), 715
protocols, 715
Feedback loop, 12
Fenoldopam, 65–66
Fentanyl, 183, 188, 203
Fiberoptic bronchoscopy (FOB), 444, 451, 451f, 454
Fibrinogen, 634t
Fibrinogen deficiency, 726
Fibrinolysis, during CPB, 648, 649f
Finger injury, CPB period and, 195
Five-electrode system, ECG, 112
Fluid management, for pulmonary resection surgery, 454, 455t
Fluid warmers, 374
Fontan repair, 491–494, 492f
Free fatty acids (FFAs), during cerebral ischemia, 747
Fresh-frozen plasma (FFA), 275, 275t, 726
Fresh gas flow, CPB period and, 195–196
Friedreich sign, 586
Fuji Uniblocker®, 446f
Furosemide, 78
G
Gastric tonometry
advantages of, 150–151
clinical application of, 150
as hypovolemia monitor, 149–150
and splanchnic hypoperfusion, 150
Genetic testing, 87
Glucagon, 45
Glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, 647
Glycopyrrolate, 73, 187, 444
Guanabenz, 65
Guanfacine, 65
H
HCM. See Hypertrophic cardiomyopathy
Heart
atria, 9
chamber wall, 8–9
electrical conduction of, 3–5, 4f, 5f
embryologic development of, 3
excitation–contraction coupling in, 4
fibrous skeleton of, 3
myocardial oxygen consumption, 11–12
preload and compliance, 9
ventricle, 9
ventricular work, 9–11, 10f
Heart failure (HF), 508–509
defined, 509
end-stage, 510
etiology, 509
mechanical circulatory support devices, 512
medical management, 510
anticoagulants, 512
β-adrenergic receptor blockade, 512
CIEDs, 512
diuretics, 511
inotropes, 510–511
renin–angiotensin–aldosterone system inhibitors, 511
therapeutic goals, 510
vasodilators, 511–512
New York Heart Association (NYHA) scale, 509
Heart–lung (H–L) machine, 595, 597. See also Cardiopulmonary bypass (CPB)
Heart–lung transplantation (HLT), 531, 535
HeartMate II (HM II) LVAD, 658, 658f
HeartMate 3 (HM 3) LVAD, 658, 659f
Heartport, 370
Heart rate, 121, 122f
Heart rhythm, 121, 122f
Heart transplantation, 491. See also Cardiac transplantation
TEE for, 175
Heartware HVAD, 658–659, 660f
Heat exchanger, 608
Heel skin ischemia, CPB period and, 195
Hemodilution, 221, 222
limits of, 222
monitoring, 223
time course of, 222
Hemodynamic management during postoperative period
dysrhythmia management, 719–720
fluid management, 717–718
hypotension management, 718–719
monioring of ischemia, 716
perioperative hypertension, 720
postcardiac surgery tamponade, 719
of pre-existing ventricular dysfunction, 716–717
pulmonary hypertension, 720–721, 721t
of refractory vasodilatory shock after CPB, 718
Hemolytic transfusion reactions (HTR), 267
Hemorrhage, 20, 21
Hemostasis, mechanisms of, 631–633
Hemothorax, 258–259
Heparin, 184, 202, 223, 635, 646t, 650
action, 635
dosing and monitoring, 636–638
elimination half-life, 636
neutralization of
alternatives to protamine administration, 645
monitoring of, 643
proof of concept, 642
protamine administration, 642–643
protamine dose, 642
treatment of adverse protamine reactions, 644
pharmacology, 635–636
potency, 635
resistance, 224, 639–640, 639t
side effects, 636
Heparinase I, 645
Heparin-coated vascular shunt, 423, 423f
Heparin-induced platelet activation assay (HIPAA), 640
Heparin-induced serotonin release assay, 640
Heparin-induced thrombocytopenia (HIT), 640–641
Heparin management test (HMT), 638
Heparin rebound, 647
Hereditary angioedema, 236–237
Heterotopic cardiac transplantation, 519. See also Cardiac transplantation
Hexadimethrine, 645
HF. See Heart failure
High-dose thrombin time (HiTT), 638
Highfrequency positive pressure ventilation (HFPPV), 460
HIT. See Heparin-induced thrombocytopenia
Homografts, 340
Human valves, 340, 366
Hybrid cardiac procedures, anesthesia for
anesthetic implications, 309
hybrid facilities, 308
hybrid room design considerations, 308, 309f
indications for, 309
rationale for, 308–309
Hybrid operating room, 321
Hydralazine
actions, 53
advantages, 53
clinical use, 54
disadvantages, 54
offset, 53
Hypercapnea, 226
Hyperdynamic reflexes, 53
Hyperglycemia, during CPB, 226–227, 262, 625
Hyperkalemia, 226, 246, 262, 724
Hypersensitive carotid sinus syndrome, 555
Hypertension, 23, 92, 205, 207f, 207t
antihypertensive drug classes, 94t
antihypertensive therapy, 93–94
blood pressure level, 92–93
causes of, 94t
during CPB, 221–222
etiology, 93
risk factors for, 93t
sequelae of, 93
Hypertrophic cardiomyopathy (HCM), 327
induction and maintenance of anesthesia, 331
premedication, 331
basal septal hypertrophy in, 328, 328f
dynamic LVOT obstruction in, 329–330, 330f
etiology and classification, 327
intraoperative TEE, 331–332
perioperative management
contractility, 331
heart rate, 331
hemodynamic profile, 331
LV preload, 331
postoperative care, 332
preoperative evaluation, 329–330
symptoms, 327
timing and type of intervention, 330
Hypocalcemia, 262
Hypocapnea, 226
Hypoglycemia, 227
Hypokalemia, 226, 246, 261, 724
Hypomagnesemia, 262, 724
Hypotension, 21–22, 205, 205t, 206f
during CPB, 221
Hypothermia
and arterial blood gas analysis, 225
and CPB, 224, 620–621
OPCAB patient and, 374
postbypass, 262–263
Hypovolemia, 37, 122
induction and, 185–186
Hypoxemia, during one-lung ventilation, 456–458, 457t
Hypoxic pulmonary vasoconstriction (HPV), 260, 455
I
IABP. See Intra-aortic balloon pump
IAS. See Interatrial septum
ICD. See Implantable cardioverter-defibrillator
ICP. See Intracranial pressure
IMA. See Internal mammary artery
Image depth, TEE and, 161
Immediate postinduction period, 193–194
Immunosuppressive agents, for cardiac transplant recipients, 526, 526t
Impaired relaxation pattern, diastolic LV examination, 165, 165f
Impella catheter-based LVAD, 659, 661f
Implantable cardioverter–defibrillator (ICD), 510, 556–557, 565–568
dual-chamber, 567
indications
primary prevention, 557
secondary prevention, 557
interference and, 568
magnet application, response to, 568
malfunction, 567–568
sensing ventricular depolarizations, 566
single-chamber, 566
tachycardia detection and discrimination, 566–567
technology, 557
tiered therapy, 567
VF detection, 566
Inamrinone, 43–44
Incision, CPB period and, 199
Induction
applications of old drugs in sick patients, 192–193
and cardiopulmonary bypass, 194–212
drug doses, recommended, 184–185, 185t
guiding principles for, 185–186
hemodynamic responses, 184–185
inhalational, 193
intravenous (IV) anesthetic agents for, 189–191
last-minute checks, 184
pharmacodynamic issues, 186–188
Infection, 123
Infective endocarditis, TEE for, 175
Inhalational agents, 191–192
Inocor. See Inamrinone
Inotropes
in heart failure, 510–511
Inspra. See Eplerenone
INSTEAD trial, 433
Interatrial septum (IAS), 171–172
Intermittent noninvasive blood pressure monitors, 114
Internal mammary artery (IMA), 202–203
Internet resources, monitoring devices, 153t
Interventional cardiac catheterization
coronary artery stent thrombosis, 103
PCI, 102–103
Intra-aortic balloon pump (IABP), 119, 255, 373
balloon filling, 673
complications, 674
contraindications to placement, 671
control, 671–673
functional design, 671
indications for placement, 670
limitations, 674
management of anticoagulation during, 674
placement, 671
stroke volume of balloon, 673
synchronization of, 671–672
timing of IABP inflation and deflation, 672–673, 672f
ventricle pulsations to IABP pulsation, 673
weaning, 673–674
Intracardiac air, 173–174
Intracardiac pressures, measurement of, 173
Intracardiac shunts, vasodilator drugs for, 53
Intracerebral and extracerebral atherosclerosis, 745
Intracoronary shunts, 372
Intracranial pressure (ICP), 53
Intraoperative cerebral monitoring
aperiodic analysis, 749
bispectral index (BIS), 749
brain temperature, 747
cerebral perfusion pressure (CPP), 751
compressed spectral array (CSA), 748–749
density-modulated display of power spectrum analysis (DSA), 748–749
electroencephalogram (EEG), 748, 748t
evoked potentials (EPs), 749
jugular oximetry measures, 750
of lower limit of autoregulation, 752
near-infrared spectroscopy (NIRS) measures, 750–751, 751t
processed electroencephalogram (EEG), 748
transcranial Doppler (TCD) detection, 749–750, 750t
Intraoperative myocardial protection
beating heart on cardiopulmonary bypass (CPB), 686
cross-clamp fibrillation, 685
history, 677
early pharmacologic interventions, 677
use of blood as a vehicle for cardioplegia, 677
inhalational anesthetics for, 679–680
interventions after aortic cross-clamping
cardioplegia solutions, 680–682, 681t
routes of delivery of cardioplegia, 683–685
temperature of cardioplegia, 682–683
interventions around cross-clamp removal, 685
interventions before aortic cross-clamping, 679–680
avoidance of ventricular distention, 680
systemic cooling, 680, 682
LIMA to LAD anastomosis, 686
myocardial energetics for, 677–678
objective of, 678, 679f
off-pump coronary revascularization, 686
optimal, 676
Intrathecal opioids, 722
Intravascular pressure measurements, 114–119, 115f–117f
Intraventricular thrombi, 743
Intrinsic sympathomimetic activity (ISA), 51
Intropin. See Dopamine
Invasive oximetric monitors, 135t
Ion channels, 548
ISA. See Intrinsic sympathomimetic activity
Ischemia, 123
during coronary revascularization, 285
definition, 745
OPCAB and, 372–373, 376–377
Ischemia–reperfusion injury
“controlled reperfusion,” practice of, 679
molecular mechanisms, 679
“terminal hot shot,” practice of, 679
Ischemic penumbra, 745
Ischemic preconditioning, 245, 372, 680
Isoflurane, 183, 192, 297
and pharmacologic preconditioning, 376
Isoproterenol, 42, 73
actions, 42
administration, 43
advantages, 42
clinical use, 43
disadvantages, 42
dose, 43
indications, 42–43
offset, 42
Isoptin. See Verapamil
Isuprel. See Isoproterenol
IV fentanyl, 182
IV lorazepam, 182
IV midazolam, 182
J
Jehovah’s Witnesses, 237
Jugular bulb venous oximetry, 149
K
Kallikrein–bradykinin system, 624
Ketamine, 191, 296
Kidneys, effect of CPB on, 626
Kinetic-assisted drainage, 600–601
Kussmaul sign, 586
L
LA. See Left atrium
Labetalol, 51, 60
for BP control, 409
Lactic acidosis, 725, 746
Lasix. See Furosemide
Law of Laplace, 315
Lead placement, ECG, 112t
Left anterior descending (LAD) artery, 286, 370
Left atrium (LA), 171
Left heart bypass (LHB), 424, 424f
Left main coronary artery, 286, 287f
Left superior vena cava (LSVC), persistent, 599
Left ventricle (LV)
diastolic function of, 164–165, 164f, 165, 165f
examination, TEE and, 163–165, 164f, 165f
global function, 164
Left ventricular assist devices (LVADs), 657, 662. See also Mechanical circulatory
support (MCS) devices
Left ventricular EF (LVEF), 100
Left ventricular end-diastolic pressure (LVEDP), 9, 99–100
Left ventricular end-diastolic volume (LVEDV), 111
Leukocyte-depleting filters, 613
Leukocytosis, 746
Leukotrienes, 624
Levophed, 32
actions, 32
administration, 33
advantages, 33
clinical use, 33
disadvantages, 33
offset, 32
Levosimendan, 717
actions, 49
administration, 49
advantages, 49
disadvantages, 49
indications for, 49
Lexiscan. See Regadenoson
Lidocaine, 72, 184, 682
for ventricular arrhythmias, 553
Lignocaine. See Lidocaine
Living-related lobar transplantation (LRT), 531, 535
Lobectomy, 458
Loop diuretics, 78–79
Lorazepam, 183, 191
Low–molecular-weight heparin (LMWH), 634, 635, 641, 646t
Lung allocation score (LAS), 532
Lung allograft preservation, 535–536
Lung cancer, 443
anesthetic considerations (4 M’s), 443t
initial assessment, 443
Lungs, 199
Lungs and mediastinum, surgery of, 439–440
intraoperative management
anesthetic technique, 454–455
lung separation, 445–451
one-lung ventilation, 455–458
positioning, 451–453
lung volume reduction surgery, 471–474
COPD therapy, 443
final anesthetic assessment, 444–445, 444t
initial and final assessments, 440
lung cancer considerations, 443, 443t
lung-sparing surgery, 440
medical conditions, intercurrent, 442–443
postoperative analgesia, 443–444
premedication, 444
respiratory function, 440–442
risk assessment, 440
risk stratification, 440–445
procedures
abscesses, bronchiectasis, cysts, and empyema, 463–464
anterior mediastinal mass, 464–466
bronchopleural fistula, 462–463
bullae and blebs, 463
mediastinoscopy, 464
posttracheostomy hemorrhage, 468
pulmonary hemorrhage, 467–468
thoracotomy, 458–462
tracheal and bronchial stenting, 466
tracheal resection, 466–467
video-assisted thoracoscopic surgery, 462
pulmonary thromboendarterectomy, 468–471
Lung separation, 445–451, 467
ABCs of, 451
airway resistance, 451
chest trauma, 450
iatrogenic airway injury, avoidance of, 450
indications, 447
malpositioning of DLTs, 451
options for, 445, 445f–447f
selection of airway device for, 447t
techniques of, 447, 447t
bronchial surgery, 449
bronchopleural fistula, 449
elective pulmonary resection, left-sided, 448–449
elective pulmonary resection, right-sided, 447–448
nonpulmonary thoracic surgery, 449
pulmonary hemorrhage, 449
purulent secretions, 449
thoracoscopy, 449
upper airway abnormalities, 449–450
Lung-sparing surgery, 440
Lung transplantation, 531
contraindications, 533–534, 533t
donor lungs, selection criteria for, 535–536
end-stage pulmonary disease and, 532
epidemiology, 532
future of, 543
immunosuppression therapy, 541
indications, 532–533, 533t
induction and maintenance of anesthesia, 537–539
medical evaluation of candidate, 534
outcome, 541–542
pediatric, 542
post–lung-transplant patient, anesthesia for, 542–543
postoperative management and complications, 540–541
preanesthetic considerations, 536–537
procedure, choice of, 534
bilateral sequential lung transplantation (BSLT), 534–535
heart–lung transplantation (HLT), 535
living-related donor lobar transplantation, 535
single-lung transplantation (SLT), 534
surgical procedures and anesthesia-related interventions, 539–540
TEE for, 175
Lung volume reduction surgery (LVRS), 471–474
anesthetic management for, 473–474
endobronchial valves and blockers, 474
history of, 472
National Emphysema Treatment Trial (NETT), 472
results, 472
LV. See Left ventricle
LVEDP. See Left ventricular end-diastolic pressure
LVEDV. See Left ventricular end-diastolic volume
LVEF. See Left ventricular EF
LV end-diastolic pressure (LVEDP), 315
LV subendocardial blood flow, 289
Lymphatic circulation, 20–21
Lysine analogs, during OPCAB, 379
M
Machine settings, TEE and, 161
Magnesium sulfate, 76
Magnetic resonance imaging (MRI), 97–98
in aortic dissection, 407
Malignant hyperthermia, 236
Mannitol, 80
MAP. See Mean arterial pressure
Masking hypovolemia with vasopressors, 21–23
Massive gas embolism, 232–233
Massive hemoptysis, 467
MCS. See Mechanical circulatory support
Mean arterial pressure (MAP), 110
during CPB, 221
Mechanical assistance systems, 663
continuous flow, 664–665
pulsatile, 663–664
Mechanical circulatory support (MCS), 508, 512, 657
anesthetic considerations
anesthetic techniques, 665–666
cardiac rhythm management device, 665
monitoring, 665
vascular access, 665
future considerations
miniaturization of LVADs, 670
TAH, 670
totally implantable LVAD, 670
historical perspective, 657–659
indications for use of, 659
bridge to myocardial recovery, 659, 661
bridge to transplantation, 661
destination therapy, 661–662
and noncardiac surgery, 669–670
postoperative management and complications
device malfunction, 669
hemorrhage, 668
infection, 669
right-sided circulatory failure, 668
thromboembolism, 668–669
surgical techniques
BIVAD, initiation of support for, 668
cannulation techniques, 666
LVAD, initiation of support for, 666–668
RVAD, initiation of support for, 668
total artificial heart (TAH), 663
ventricular assist devices, 657
biventricular assist device (BIVAD), 662, 663f
left VAD (LVAD), 662
right VAD (RVAD), 662
weaning from VAD support, 669
Mechanical prosthetic valves, 338–339, 339f, 365–366
Mechanical ventilation, 243
Mediastinal masses, anterior, 464–466, 465t, 466t
Mediastinoscopy, 464
Medtronic devices, 568
Membrane oxygenators (MOs), 607, 689
MEPs. See Motor evoked potentials
Metabolic acidosis, 226, 725
Metalloproteinases, 624
Methylene blue, 645
Methylprednisolone, 540
Metoprolol, 184
for BP control, 409
Microgaseous emboli, 742
Midamor. See Amiloride
Midazolam, 183, 186, 190, 297
Midesophageal (ME) views, TEE and, 162
Milrinone, 44, 184
actions, 44
advantages, 44
disadvantages, 44
indications, 45
onset and offset, 44
Minimally invasive cardiac surgery, TEE for, 176
Minimally invasive direct coronary artery bypass (MIDCAB), 369
Minimally invasive mitral valve surgery, 381
Minimally invasive valve surgery (MIVS), 379–383
advantages of, 379
anesthesiology concerns, 382
incisions for, 380f
monitoring, 381
percutaneous valve repair/replacement, 382–383
surgical approaches, 380–381, 380f
direct-access, 380–381
inverse L-shaped partial sternotomy, 381
port-access, 380
robotic, 380
video-assisted port-assisted, 380
Minimum alveolar concentration (MAC), 203–204
Minithoracotomy, 235
MitraClip, 382
Mitral regurgitation (MR), 354
acute, 354
induction and maintenance of anesthesia, 361
premedication, 360
pulmonary artery catheters, 361
TEE examination, 361–362
weaning from CPB, 362
Carpentier’s classification, 355, 355t
chronic, 354–355
functional, 355
hemodynamic management
contractility, 360
heart rate, 360
LV preload, 360
intracardiac hemodynamics and cardiac remodeling, 356
mitral stenosis and, 362
postoperative course, 362
pressure wave disturbances, 356, 356f
progression of, 355
severity of, assessment of, 357–358
echocardiographic assessment, 357, 358t
flow convergence, 358
vena contracta, 358
subvalvular apparatus disorders and, 355
surgical intervention, 358–360
TEE examination, 356, 357f
Mitral stenosis (MS), 168–170, 169f
anesthetic technique, 354
etiology, 348
hemodynamic management
contractility, 353
heart rate, 353
LV preload, 353
imaging studies, 349–351, 350f, 351t
intracardiac hemodynamics and cardiac remodeling, 349
postoperative surgical course, 354
pressure wave disturbances, 349, 350f
progression, 349
severity of, assessment of, 351–352, 352t
symptoms, 348–349
timing and type of intervention, 352–353
Mitral valve (MV), 165–170, 347–348, 348f
anatomy of, 166f
myxomatous degeneration of, 167
regurgitation, 167–168, 168f
replacement, 353
stenosis, 168–170, 169f
Mitral valve area (MVA), 168, 349
MIVS. See Minimally invasive valve surgery
Mixed venous oxygen saturation (SvO2), 135, 135t
M-mode echocardiography, 158
Modified ultrafiltration (MUF), 278–279, 613
Monitoring applications, of TEE, 173–174
Monoamine oxidase (MAO) inhibitors, 30
interactions with, 33–34
Monogenetic disorders, 87
Morphine, 188
Motor-evoked potentials (MEPs), 149, 429–430
MPI. See Myocardial perfusion imaging
MRI. See Magnetic resonance imaging
Mucus plug, 259
Muscle relaxants, 185–187, 192
MV. See Mitral valve
MVA. See Mitral valve area
Mycophenolate mofetil, 526t
Myocardial ischemia, 37
acute coronary syndrome, 88–89
CCBs and, 68
detection, 173
electrocardiogram for detection, 113–114, 113f
preoperative risk factors, 87
preoperative testing for, 95–98
prior infarction and surgery, interval between, 89–90
stable ischemic heart disease, 87–88
with unstable angina, risk factors for death, 89t
without angina, 89
Myocardial ischemia, monitoring of
ECG monitoring, 292
ICU monitoring, 296
of infarction complications, 296
multi-lead ECG monitoring, 294
pulmonary artery (PA) pressure monitoring, 295
ST-segment analysis, 294, 294f
transesophageal echocardiography (TEE) measures, 295–296
T-wave changes, 294
Myocardial ischemia, treatment of, 307t
of coronary spasm, 307
correction of surgical complications and mechanical problems, 307
ischemic preconditioning, 307–308
mechanical support for, 307
secondary to hemodynamic abnormalities, 306–307
Myocardial oxygen consumption, 11–12
Myocardial oxygen supply
coronary artery anatomy, 286–287
determinants of, 287–290
blood flow in normal coronary arteries, 287
O2 content, 287
in stenotic coronaries, 289–290
Myocardial oxygen supply and demand
anesthetic effects on, 296–299
intravenous nonopioid agents, 296–297
muscle relaxants, 298
nitrous oxide, 297–298
opioids, 298
volatile anesthetics, 297
determinants of, 293f
contractility, 290–291, 291f
heart rate, 290
wall stress, 291–292
Myocardial perfusion imaging (MPI), 96
Myocardial protection, 225
Myocardial revascularization procedures, anesthetic approach for
anesthetic agent management, 299–300
clinical and economic benefits, 301
fast-track cardiac anesthesia, 299–301, 299t, 301f
ICU management, 301
Myosin, 5–6
N
N-acetylcysteine (NAC), 436
National Emphysema Treatment Trial (NETT), 472
Natural frequency, 115f, 116
Near-infrared spectroscopy (NIRS), 149, 420, 487
Negative feedback loop, 12
Neo-synephrine. See Phenylephrine
Nerve blocks, 722–723
Nesiritide
actions, 59
clinical use, 60
Neurocognitive dysfunction, 147
Neurologic complications in cardiac surgery, 736, 737t
Neurologic function, 147–151
CNS electrical activity, monitors of, 148–149
indications for monitoring, 147
physiologic and metabolic monitoring, 147–148
Neuronal ischemia, 746
Nicardipine, 69, 184
for BP control, 408
Nimodipine, 747
Nipride. See Nitroprusside
NIRS. See Near-infrared spectroscopy
Nitric oxide (NO), 288, 297–298, 624, 747
actions, 58
advantages, 59
clinical use, 59
disadvantages, 59
offset, 58
Nitroglycerin, 56, 184
actions, 54–55
advantages, 55
for BP control, 409
disadvantages, 55
offset, 55
Nitroprusside, 184
actions, 56
advantages, 56
for BP control, 409
clinical use, 58
disadvantages, 56
toxicity, 57–58
Nitrous oxide, 192, 454, 538
NO. See Nitric oxide
Nocturnal hypoxemia, 443
Noninvasive cardiac imaging
echocardiography, 95
myocardial ischemia, preoperative testing for, 95–98
Nonsteroidal anti-inflammatory drugs (NSAIDs), 722
Noradrenaline, 32
actions, 32
administration, 33
advantages, 33
clinical use, 33
disadvantages, 33
offset, 32
Norepinephrine, 184
Normodyne. See Labetalol
Normothermia, 224
North American Society for Pacing and Electrophysiology–British Pacing and
Electrophysiology Group, 559, 559t
Nothing by mouth (NPO) status, 185
“NPIC” general anesthesia, 465–466, 466t
Nyquist limit, 158
O
Occipital alopecia, CPB period and, 195
Octopus 2 tissue stabilizer, 372f
Off-pump CABG and MIDCAB, 369
anticoagulation
antifibrinolytic therapy, 379
antiplatelet therapy, 378–379
heparin management, 377
protamine reversal, 377
extubation in operating room, 379
historical perspective, 369–370
hypothermia, avoidance of, 374
ICU management, 379
intravascular volume loading, 377
ischemia, management of, 376–377
monitoring approaches, 374–376, 375t
patient selection, 373
preoperative assessment, 373–374
sternotomy and CPB, avoidance of, 370–371
surgery-anesthesiology interaction, 377
surgical approach, refinement of, 371–372
heart positioning, 372
modern epicardial stabilizers, 371, 372f
surgical adjuncts to reduce ischemia, 372–373
Off-pump coronary artery bypass (OPCAB), 151, 198, 301–303, 369. See also Off-
pump CABG and MIDCAB
advantages and disadvantages, 302
fast-track criteria, 302
heparin management, 303
monitoring, 151–152, 302
patient selection for, 302
perioperative anesthetic management, 305t
regional anesthesia adjuncts, 303
technique, 302
OKT3, 526t
OLV. See One-lung ventilation
One-lung ventilation (OLV), 385
desaturation during, 444–445, 444t
management of, 455–458
cardiac output, 455
hypoxemia, 455, 456–458, 457t
hypoxic pulmonary vasoconstriction, 455
pressure-control OLV, 456
ventilation parameters, 455–456, 456t
OPCAB. See Off-pump coronary artery bypass
Opioids
and induction, 185t, 187, 188
properties of, 189
receptors, 189
Organ Procurement and Transplantation Network (OPTN), 508
Orthotopic cardiac transplantation, 518–519, 518f. See also Cardiac transplantation
biatrial implantation, 519
bicaval implantation, 519
Osmotic diuretics, 80
Oxygenators, 595, 597, 607–608
Oxygen delivery variables, 136t
P
PAC. See Pulmonary artery catheter
Pacemaker-mediated tachycardia (PMT), 563
Pacemaker reentrant tachycardia, 563
Pacemakers, 557–565
adaptive-rate pacing (ARP), 561–562
bradycardia pacing modes, 558f
cardiac resynchronization therapy, 561
dual-chamber, 557, 559–560, 561f, 562
function, 559–562
interference, 564–565, 565f
malfunction, 562–563, 562t, 563t
crosstalk inhibition, 562–563
pacemaker-mediated tachycardia, 563
NASPE/BPEG (NBG) pacemaker code, 559, 559t
response to magnet application, 563–564, 564t
single-chamber, 557, 559, 560f
Pacing PACs, 134–135
Paclitaxel-eluting stents (PES), 104
Pain after cardiothoracic procedures
adverse consequences of, 766
analgesia considerations, 765
outcome benefits, 766
incidence and severity, 764
transmission pathways for nociception, 765
Pain management pharmacology
acetaminophen (paracetamol), 768–769
α2-Adrenergic agonists, 770–771
biologics, 771
complications and side effects of analgesic strategies
infectious complications, 778
nausea and vomiting, 777
neurologic complications, 777–778
nonsteroidal anti-inflammatory drugs (NSAIDs), 776–777
pruritus, 777
respiratory depression, 777
COX-2 inhibitors, 768
gabapentinoids, 771
intrathecal (IT) morphine, 779
ketamine, 771
local anesthetics, 769, 770t
nonpharmacologic analgesia, 771
nonsteroidal anti-inflammatory drugs (NSAIDs), 768
opioid analgesics, 766–768
Pain management strategies
enteral administration of, 771
epidural anesthesia, 773–774, 778
fascial plane blocks, 772
intercostal blocks, 772
interpleural analgesia, 772
intrathecal (IT) analgesia, 773, 778
intravenous administration of, 772
paravertebral blocks (PVBs), 773
for specific cardiothoracic procedures
conventional coronary artery bypass grafting and open-chamber procedures,
774–775
minimally invasive (minithoracotomy/para- or partial sternotomy/robotic)
cardiac procedures, 775
off-pump (sternotomy) cardiac procedures, 775
open and closed descending thoracic aortic procedures, 776
thoracotomy/thoracoscopy procedures, 775–776
transcatheter and percutaneous procedures, 775
subcutaneous (SC)/intramuscular (IM) administration of, 771–772
Pancuronium, 183, 298
Panvascular inflammation, 745
Paravertebral nerve blocks (PVNB), 473
Paroxysmal supraventricular tachycardia (PSVT), 552
PARTNER 3 trial, 313
Patent ductus arteriosus (PDA), 477
Patent foramen ovale (PFO), 171–172
Patient blood management (PBM) programs, 267
“Pecs” blocks, 772
Pediatric cardiac transplantation, 526–527
Pediatric digoxin, 48
Pediatric lung transplantation, 542
Percutaneous balloon mitral valvuloplasty, 382–383
Percutaneous transluminal coronary angioplasty (PTCA), 102
Perfusion-assisted direct coronary artery bypass grafting (PADCAB), 373
Pericardial disease, 576
anatomy and physiology related to, 576
causes of, 576–577
constrictive pericarditis, 586–591
pericardial tamponade, 577–585 (see also Cardiac tamponade)
Pericardial knock, 586
Pericardial sinuses, 576, 577f
Pericardiocentesis, 581–582, 583f
Pericardium, 576, 577f
parietal, 576
visceral, 576
Perioperative myocardial ischemia
causes, 304–306, 305t
treatment, 306–308
Perioperative stress response, cardiopulmonary bypass, 203–204, 203t
Peripheral venous cannulation, 599–600
Permanent pacing, 554–556
PES. See Paclitaxel-eluting stents
PET. See Positron emission tomography
PFO. See Patent foramen ovale
Pharmacologic cerebral protection
calcium channel blockers for, 757
glutamate antagonists, 757
lidocaine, 757
metabolic suppression, 756–757, 756f, 757f
statins, 757–8
Phenoxybenzamine, 61
Phentolamine, 60–61
Phenylephrine, 30, 184
actions, 30
administration, 31
advantages, 30
clinical use, 31
disadvantages, 30–31
offset, 30
pH management in cardiac surgery, 738–740, 742f
Phosphodiesterase III inhibitor, 184
Phosphodiesterase-III (PDE) inhibitors, for heart failure, 511
Phosphodiesterase type III inhibitors, 717
Physiologic reserves, 14
for healthy individual, 18–21
Piezoelectric crystals, ultrasound imaging and, 157
PISA. See Proximal isovelocity surface area
Planimetry, 168, 351
Plasma coagulation pathway, 631–633, 632f
Platelet-activating factor (PAF), 624
Platelet therapy, 274, 274t
Plavix. See Clopidogrel
Pneumonectomy, 458–459
and atrial fibrillation, 459
lobectomy after, 460
mechanical effects, 459
and postpneumonectomy pulmonary edema, 459, 459t
Pneumothorax, 258
Point-of-care tests, of platelet function, 651, 651t
Polymorphic ventricular tachycardia (VT), 550
Port-access surgery, 235, 370
Positive end-expiratory pressure (PEEP), during one-lung ventilation, 456
Positive feedback system, 12, 13
Positive inotropic drugs
cAMP-dependent agents, 36–45
cAMP-independent agents, 45–50
for low co, 36
Positron emission tomography (PET) scan, 97
Postbypass bleeding, management of, 650–653
Postoperative atrial fibrillation, 742–743
Postoperative care of cardiac surgical patient
care of cardiac transplant patients, 727–728
complications in first 24 hours
acute coronary graft closure, 727
acute prosthetic valve failure, 727
bleeding, 725–726
cardiac tamponade, 726
hemothorax, 727
pneumothorax, 726
postoperative neurologic dysfunction, 727
respiratory failure, 725
discharge from ICU, 727
family issues in, 728–729
glucose management, 725
mechanical ventilation after cardiac surgery, 710–714
choosing modes of ventilation, 711
heart–lung interactions with PPV, analysis of, 710, 710f
liberation from, 714
noninvasive ventilation (NIV), 711, 712f, 713t
pulmonary changes, checking of, 711
settings for patients with ARDS, 711
use of incentive spirometry, 714
weaning from, 712–714, 713f
metabolic abnormalities, management of, 724–725
patients with mechanical assist devices, 728
extracorporeal membrane oxygenator (ECMO), 728
intra-aortic balloon pump (IABP), 728
ventricular assist device (VAD), 728
postoperative pain and sedation management techniques, 721–723, 722t
ICU sedation, 723, 723t
nerve blocks, 722–723
transfer of care to ICU team, 707–708
anesthetic review, 708
baseline ECG, CXR, and laboratory tests reports, 708
handoff of care, 707, 709f
initial review, 708
ventilator settings, 707–708
transition to intensive care unit (ICU), 705–707
transport process, 705–706, 705–707
Postpneumonectomy pulmonary edema, 459, 459t
Posttracheostomy hemorrhage, 468
Posttransplant lymphoproliferative disorder, 543
Potassium-sparing diuretics, 79–80
PPV. See Pulse pressure variation
Prasugrel, 103, 103t, 646t
Prazosin, 62
Prednisone, 541, 543
Pregnancy, CPB during, 237
Preincision, CPB period and, 195–199
Preinduction period, 182–184
Preload, 9, 315
measurement of, 173
Pressure half-time, 168–169, 351
Pressure points, CPB period and, 195
Pressure sensors, 14
Pressure–volume loops, 315, 316f, 347, 347f
in aortic regurgitation, 334f
in aortic stenosis, 317f
in mitral stenosis, 349, 350f
Prethoracotomy assessment, 440
Primacor. See Milrinone
Priming, 615
asanguinous primes, consequence of, 615–616
of circuit, 616
composition of prime, 616
final disposition of prime, 616
retrograde autologous priming (RAP), 616
Proarrhythmia, 553
Probe insertion, TEE, 160
Probe manipulation, TEE, 160, 161f
Procainamide, 70–71
Procan-SR. See Procainamide
Pronestyl. See Procainamide
Propofol, 186, 190, 296, 722, 756
PROPPR study, 276
Propranolol, for BP control, 409
Prosthetic valves, 338, 365–366
in aortic position, echocardiographic evaluation of, 341–342, 342f
bioprosthetic valves, 339–340, 340f
characteristics of, 338
human valves, 340
mechanical, 338–339, 339f
sutureless valves, 340
transcatheter valves, 340–341
Protamine, 184, 245
administration, 642–643
prevention of, 644
treatment of, 644
alternatives to, 645
dose, 642
Prothrombin complex concentrate (PCC), 645
Prothrombin time (PT), 634t
Proximal isovelocity surface area (PISA), 167, 168f, 169, 169f, 352
Pseudonormal pattern, diastolic LV examination, 165, 166f
PTCA. See Percutaneous transluminal coronary angioplasty
PTE. See Pulmonary thromboendarterectomy
Pulmonary angiography, 469
Pulmonary artery catheter (PAC), 24, 110–111, 138–139, 323
in ACHD surgery, 487
complications, 138
hemorrhage induced by, 467, 468t
indications, 130–132, 130t, 131t, 132t
insertion, techniques of, 137–138
LA pressure, 133
parameters measured, 129
placement, contraindications for, 132
pressure data, interpretation of, 133
pressure waveforms from, 134f
for pulmonary resection surgery, 454
timing of placement, 133
types of, 133–136
Pulmonary capillary wedge trace, aortic regurgitation, 333
Pulmonary edema, 258
Pulmonary hemorrhage, 449, 467–468
Pulmonary hypertension, 80
treatment of, 34t
Pulmonary lobectomy, robotic-assisted, 392–393
Pulmonary thromboendarterectomy (PTE), 468–471
anesthetic management, 469–471
post-cardiopulmonary bypass, 471
preoperative evaluation, 469
surgical procedure, 469, 470t, 471t
Pulmonary valve abnormalities, 496–497
Pulmonary vascular resistance (PVR), 248, 513
Pulmonic valve (PV), 171
Pulsatile pumps, 663–664
Pulsed-wave Doppler (PWD), 158
Pulse oximetry, 503, 537
Pulse pressure, 121–122
Pulse pressure variation (PPV), 110
Pulsus paradoxus, 579
Purkinje fibers, 3
PV. See Pulmonic valve
PWD. See Pulsed-wave Doppler
P2Y12 receptor, 647
Q
QT syndrome, 28
R
RA. See Right atrium
Radial artery dissection, 202–203
Radial nerve injury, CPB period and, 195
Radiofrequency catheter ablation, 572–573
Radionuclide stress imaging, 96–97
Rapamycin, 526t
Real-time insonation, of volume of tissue, 177, 179
Red blood cell (RBC) transfusion, 269–273, 270t
hemoglobin transfusion trigger trials, 269–271
intraoperative transfusion triggers, 271
RBC storage duration, 271–273
Regadenoson, 96
Regional anesthesia, for postoperative pain, 489
Regional wall-motion abnormalities (RWMAs), 167, 295
TEE monitoring, 295
limitations, 295–296
Regitine. See Phentolamine
Regulated variable, 12
Regulation of variable, 13
Regurgitant lesions, 100, 102f, 314
REMATCH study, 661
Remifentanil, 183, 187, 189
Renal function
acute kidney injury, 147
electrolytes, 146–147
indications for monitoring, 146
urinary catheter, 146
Reperfusion injury, 540
Reserpine, 30
Resonant frequency, 115f, 116
Respiratory acidosis, 725
Respiratory function, preoperative assessment of, 440–442, 441f
cardiopulmonary interaction, 441
combination of tests, 442, 442f
lung mechanics, 440–441
pulmonary parenchymal function, 441
split-lung function studies, 442
ventilation–perfusion scintigraphy, 441
Restrictive pattern, diastolic LV examination, 165, 165f
Retrograde cardioplegia, 683–685
Rewarming, 224–225
Right atrium (RA), 171
Right coronary artery (RCA), 287
Right ventricle (RV), 171
failure, treatment of, 34t
Right (pulmonary) ventricle to pulmonary artery conduits, 495–496
Right ventricular assist device (RVAD), 662
Right ventricular (RV) dysfunction, 443
Rivaroxaban, 645, 646t
Robotically enhanced cardiac surgery, 383–389
induction and maintenance of anesthesia, 385–386, 386f
monitoring, 385
preoperative preparation, 385
arterial cannulation, 387
cardioplegia delivery, 388
conversion to sternotomy, 388
cross-clamping, 387
endoscopic robotic-assisted systems, 384–385
historical perspective, 383
overview, 383
technologic advances and, 383–384
TEE evaluation, 386–387
venous drainage, 387
venting, 388, 388f, 389f
Robotic manipulators, 384
Robotic noncardiac thoracic surgery, anesthesia for, 389, 390t
esophageal surgery, 393–395
insufflation of CO2, 393
mediastinal masses, 390–392
pulmonary lobectomy, 392–393
robotic thoracic surgery, 390
Rocuronium, 183, 192, 298, 538
RV. See Right ventricle
RWMAs. See Regional wall-motion abnormalities
S
Saphenous vein excision, 197
Sarcomere, 5–6, 6f
Sensor, 12
Sensor-driven tachycardia, 563
Serratus anterior plane block, 772–773
SES. See Sirolimus-eluting stents
Sevoflurane, 183, 192, 297, 756
Shell temperature, 146
Shivering, 724
Sick euthyroid syndrome, 625
Sickle cell trait and disease, 235–236
SIHD. See Stable ischemic heart disease
Simplified Bernoulli equation, 158
Single-lung transplantation (SLT), 531, 534
Single-photon emission computed tomography (SPECT), 97
Single-shot spinal anesthesia, 488
Sinus bradycardia, 205–208
Sinus node dysfunction (SND), 552, 555
Sinus tachycardia, 208, 552
Sirolimus-eluting stents (SES), 104
Sleeve lobectomy, 458
Sleeve pneumonectomy, 459–460
Society of Thoracic Surgeons (STS) Practice guidelines, 197
Sodium, serum, 226
Somatosensory evoked potentials (SSEPs), 148, 429
Sotalol, 92
SPECT. See Single-photon emission computed tomography
Spinal anesthesia, 488
Spinal cord perfusion pressure (SCPP), 430
Spinal cord protection, during aortic cross-clamping, 429–432
CSF drainage, 430–431
hypothermia, 430
motor-evoked potentials, 429–430
perfusion pressure, 429
somatosensory-evoked potentials, 429
Spinal drain catheters, 430–431
Spironolactone, 79–80, 511
SPV. See Systolic pressure variation
Square root sign, 586, 587f, 588
SSEPs. See Somatosensory evoked potentials
Stable ischemic heart disease (SIHD), 87–88
Stair climbing, 441
Starling curve, 10f, 11
Statins, for cardiovascular diseases, 105
Stenotic lesions, 100–101, 314
versus regurgitant lesions, 314
Stented bioprosthetic valves, 339–340, 340f
Stentless bioprostheses, 340, 341f
Stent-mounted sutureless valves, 340
Sternotomy, repeat
anesthetic considerations in, 490
antifibrinolytic therapy in, role of, 491
surgical considerations in, 489–490
Stimulation levels, CPB period and, 194, 195t
Stone heart, 677
Strain gauges, 118
Stress echocardiography, 96
Stress response, CPB and, 625
Stretch receptors, 14, 16f
Stroke volume index (SVI), 11
Stroke volume variation (SVV), 110
St. Thomas solution, 681
Succinylcholine, 183, 187, 192, 298
Sucker bypass, 210f
Sufentanil, 183, 187, 188, 203
Supraventricular arrhythmias
classification, therapy-based, 73–74
rate control therapy, 73–77
Supraventricular tachycardia (SVT), 31, 48, 73–77, 92
Surface-gel heating devices, disposable, 374
Surgeon console, 384
Surgical aortic valve replacement (SAVR), 734
Surgical bleeding, 726
Surgical Care Improvement Project (SCIP), 197
Surgical drainage, cardiac tamponade, 583–584
Sutureless bioprosthetic valves, 340
SVI. See Stroke volume index
SVR. See Systemic vascular resistance
SVT. See Supraventricular tachycardia
SVV. See Stroke volume variation
Sympathetic nerve dissection, 203
Syncope, 551–552
Systemic inflammatory response (SIR), 623
Systemic vascular resistance (SVR), 12, 18, 221
Systolic anterior motion (SAM) of mitral valve, 718, 719f
Systolic function, 315
Systolic pressure variation (SPV), 110
Systolic ventricular dysfunction, 36
T
Tachycardia, 185, 552
Tacrolimus, 526t, 541, 543
TCD. See Transcranial Doppler ultrasonography
TEE. See Transesophageal echocardiography
Temperature, 145
indications, 145
monitoring, risks of, 146
recommendations for monitoring, 146
sites of measurement, 145–146
Temporary pacing, 554, 554t
Tepid cardioplegia, 683
Terazosin, 62
Termination of bypass, 240
and cardiovascular considerations, 255
chest closure, 256–257
decannulation, 255
hemodynamics, management of, 257, 257f
manipulation of heart, 255
myocardial ischemia, 256
reperfusion injury, 255
noncardiovascular considerations
central nervous system, 261
electrolyte disturbances, 261–262
hematologic system, 260
hyperglycemia, 262
renal system, 260–261
respiratory system, 258–260
temperature regulation, 262–263
preparation for, 240
calcium, 241–242
cardiac output, 242
cells, 242
coagulation, 242–243
cold, 240–241
conduction, 241
CVP mnemonic, 240t
heart, visualization of, 244
incomplete myocardial preservation during cross-clamping, 244–245
pacer, 246
potassium, 246
pressors and inotropes, 246
pressure, 246
protamine, 245
risk factors for adverse cardiovascular outcome, 244
vaporizer, 243
ventilation, 243
volume expanders, 243
sequence of events
immediately after terminating CPB, 249–255
during weaning from CPB, 248–249
sequence of events before, 246–247
final checklist, 247
inspection of heart, 248
invasive pressure display, 247
TEE examination, 248
ventilation and oxygenation, 248
transport, preparation for, 263–264
Tetralogy of Fallot (ToF), 494–495
Thermoregulation, vasodilator drugs for, 52
Thiazide diuretics, 79
Thin filament, 5–6
Thiopental, 190
“Third space” volume, 20
Thoracic aorta, 172–173
Thoracic aortic aneurysm and dissections, 400
anesthetic management, intraoperative, 411
bleeding control, 411
BP control, 411
coexisting disease treatment, 411, 411t
induction and anesthetic agents, 411–412
location of lesion, 412, 412t
aortic arch surgery, 415–419
ascending aortic surgery, 412–414
classification and natural history
aneurysm, 403, 404t
dissection, 400–403
thoracic aortic ruptures, 403–404
Thoracic aortic aneurysm and dissections (continued)
clinical signs and symptoms, 404–406, 405t–406t
descending thoracic and thoracoabdominal aortic surgery, 420–425
diagnostic tests
angiography, 407
chest radiograph, 406
CT scan, 407
electrocardiogram, 406
magnetic resonance imaging, 407
serum laboratory values, 406–407
transesophageal echocardiography, 407
EV graft repair of thoracic aorta, 432–435
future trends, 436–437
preoperative management, 408
bleeding and transfusion, 409–410
diagnosis and control of BP, 408
hemodynamic stability and control, 408–409
organ systems assessment, 410
pain medications, 410
surgical correction, indications for
aortic arch, 407–408
ascending aorta, 407
descending aorta, 408
surgical therapy, goal of, 410–411
Thoracic aortic rupture, 403–404, 404f
Thoracic aortic surgery, TEE for, 175
Thoracic epidural analgesia (TEA), 432, 442, 473
for cardiac surgical procedures, 722
Thoracic epidural anesthesia, 538
Thoracic epidural catheter, 536
Thoracotomy, 458–462
operations
adjuvant and neoadjuvant therapy, 460–461
bilobectomy, 458
extended resections, 460
incomplete resection, 460
lesser resections, 460
lobectomy, 458
pneumonectomy, 458–459
sleeve lobectomy, 458
sleeve pneumonectomy, 459–460
subsequent pulmonary resections, 460
surgical approaches, 461, 461t
anterolateral thoracotomy, 461
axillary thoracotomy, 461
median sternotomy, 462
muscle-sparing lateral thoracotomy, 461
posterolateral thoracotomy, 461
transsternal bilateral thoracotomy, 462
Three-dimensional (3D) image display and manipulation, 178f, 179
Three-electrode system, ECG, 111
Thrombin, 632
Thrombin time, 634t
Thrombocytopenia, after CPB, 647
Thromboembolism, preoperative risk stratification for perioperative, 106t
Thrombosis, 123
Thymectomy, robotic-assisted, 390–392
Ticagrelor, 103, 103t, 646t
Ticlopidine, 103, 103t, 646t
Time-gain compensation, TEE and, 161
Tirofiban, 646t
Tissue Doppler imaging (TDI), 588
Tissue factor (TF), 631
Tissue necrosis, CPB period and, 195
Topical cooling for myocardial protection, 677
Torsades de pointes, 28, 550
Total artificial heart (TAH), 663
Total intravenous anesthesia (TIVA), during CPB, 219–220
Totally endoscopic coronary artery bypass grafting (TECAB), 383
Tracheal resection, 466–467
Tracheal stenting, 466
Tracheobronchial tree, obstruction of, 259
Tracheo-innominate artery fistula hemorrhage, management of, 468, 469t
Trandate. See Labetalol
Tranexamic acid (TA), 197, 277, 410, 648
in cardiac surgery, 491
Transcatheter aortic valve implantation (TAVI), 383
Transcatheter aortic valve replacement (TAVR), 313, 734–735
aortic stenosis, 320–324
Transcatheter valve interventions, TEE for, 176–177
Transcatheter valves, 340–341
Transcranial Doppler ultrasonography (TCD), 149
Transducer, 118, 119
Transducer frequency, TEE and, 161
Transesophageal echocardiography (TEE), 24, 111, 156–179, 318
in ACHD surgery, 487
aortic dissection, 407
in cardiac transplantation, 524
complications of, 160, 160t
contraindications for, 159t
cross section, 162t
3D, 177–179, 178f
esophageal disease, preoperative screening for, 159
indications for, 159
intraoperative examination, 160–163
in lung transplantation, 537, 538
machine settings, 161
mitral regurgitation, 356, 357f
in MIVS patients, 381
monitoring applications of, 173–174
probe insertion and manipulation, 160
in robotic cardiac procedures, 386–387
safety/contraindications/risk of, 159–160
for surgery, 174–177
tricuspid valve stenosis, 363
views, 161–163, 162t, 163f
Transfusion-associated circulatory overload (TACO), 267, 268
Transfusion Indication Threshold Reduction (TITRe2) trial, 270–271
Transfusion-related acute lung injury (TRALI), 267, 268
Transfusion Requirements after Cardiac Surgery (TRACS) trial, 270
Transgastric (TG) views, TEE and, 162
Transposition of great vessels (TGV), 497–498
Transthoracic echocardiography (TTE), 24, 716, 726
mitral stenosis, 349
Transvenous endocardial leads, 554
Triamterene, 80
Tricuspid valve (TV), 162, 171
Tricuspid valve regurgitation
natural history, 364
pressure wave abnormalities, 364
progression, 364
TEE evaluation and grading of severity, 364
Tricuspid valve stenosis, 362–364
anesthetic technique, 363–364
etiology, 362
hemodynamic management, 363
progression, 362
severity of, 362–363
surgical intervention, 363
symptoms, 362
TEE examination, 363
Tropomyosin, 5–6
Troponin, 5–6
T-tubule system, 4, 4f
Tu score, 85
TV. See Tricuspid valve
Two-dimensional echocardiography, 158
U
Ulnar nerve injury, CPB period and, 195
Ultrasound imaging, 110
limitations of, 177
piezoelectric crystals and, 157
Unfractionated heparin (UFH), 635. See also Heparin
United Network for Organ Sharing (UNOS), 508
listing criteria for heart transplantation, 512, 513t
Upper esophageal (UE) views, TEE and, 163
USN. See Ultrasound
V
Vacuum-assisted drainage, 600
VADs. See Ventricular assist devices
Vagal activation, 551
Valve repair surgery, TEE for, 174
Valve replacement surgery, TEE for, 174
Valvular calcifications, 742
Valvular heart disease, structural and functional response to
ventricular function, 315, 346
diastolic function, 315, 347
systolic function, 315, 346–347
Valvular stenosis, 314, 346
versus valvular regurgitation, 314, 346
Vapor-based anesthetic technique, 376
Vaporizer, 243
Variance maps, 159
Vasa vasorum, rupture of, 401
Vasoactive inotrope scoring, 27
Vasoconstriction, 185
Vasodilation, 182
Vasodilators
for BP control, 408–409
cautions, 53
for heart failure, 511–512
indications for use, 52–53
mechanisms of action, 52
sites of action, 52
specific agents, 53–67
Vasoplegic syndrome, 253
Vasopressin, 184
actions, 34
advantages, 34–35
clinical use, 35
disadvantages, 35
Vasopressors, 29–36
α-adrenergic receptor pharmacology, 29–34, 29f
Vasotec. See Enalapril
Vasotec-IV. See Enalaprilat
Vecuronium, 183, 192, 298
Venous cannulae, 600, 600f
Venous cannulation and drainage, CPB, 598–601, 598f
Venous capacitance, 19
Venous infusion port (VIP), 133
Venous reservoir, 603
Ventilation–perfusion scintigraphy, 441–442
Venting, 387, 610–612, 612t
Ventricle, 9
Ventricular arrhythmias, 92
Ventricular assist device implantation surgery, TEE for, 175–176
Ventricular assist devices (VADs), 657. See also Mechanical circulatory support
(MCS) devices
biventricular assist device (BIVAD), 662, 663f
left VAD (LVAD), 662
right VAD (RVAD), 662
Ventricular ejection rate, 53
Ventricular fibrillation (VF), 551
Ventricular hypertrophy, 314
concentric, 314–315
eccentric, 315
Ventricular septal defects (VSDs), 502–504, 502f
Ventricular tachycardias (VTs), 92
Venturi effect, 328
Verapamil, 69, 75–76, 92, 184
Video-assisted thoracoscopic surgery (VATS), 462
VIP. See Venous infusion port
Viscoelastic testing, 279–280, 651
Volume expanders, 243
von Willebrand factor (vWF), 633
VSDs. See Ventricular septal defects
VTs. See Ventricular tachycardias
W
Wall stress, 291–292
Warfarin, 646t
reversal of, 645
Warfarin sodium, 338
Warm blood cardioplegia, 683
Watershed zones, 744
Whole blood clotting time (WBCT), 634t
Wire-guided endobronchial blocker, 446f
Wolff–Parkinson–White syndrome, 552
X
Xylocaine. See Lidocaine
Z
Z disc, 6
Zero-balance ultrafiltration (Z-BUF), 279
ZES. See Zotarolimus-eluting stents
Zotarolimus-eluting stents (ZES), 104

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https://t.

ANDREW D. SHAW, MB, FRCA

K ARSTEN B ARTELS, MD, MS

6th edition https://t.me/Anesthesia_Books

Given continuous, rapid advances in medical science and health information,

Frederick Allen Hensley, Jr., MD

Chronology of Frederick A. Hensley’s postdoctoral education and primary career

1984–1995: Penn State University College of Medicine, Assistant Professor, Associate

1995–2000: Sinai Hospital of Baltimore, Anesthesiologist-in-Chief and Medical

2001–2009: Imogene Bassett Healthcare (Cooperstown, New York), Anesthesiologist

2009–2013: University of Alabama at Birmingham, Benjamin Monroe Carraway

John F. Butterworth, IV, MD

Joseph C. Cleveland, Jr., MD

John R. Cooper, Jr., MD

Amanda A. Fox, MD, MPH

Chandrika R. Garner, MD, FASE

Thomas E. J. Gayeski, MD, PhD

Mark A. Gerhardt, MD, PhD

Neville M. Gibbs, MBBS, MD, FANZCA

Michael S. Green, DO, MBA

Eugene A. Hessel, II, MD

Jordan R. H. Hoffman, MD, MPH

Jay C. Horrow, MD, MS, FACC

David Philip Jenkins, MB, BS

Rebecca Y. Klinger, MD, MS

Colleen G. Koch, MD, MS, MBA, FACC

David R. Larach, MD, PhD

Jerry C. Luck, Jr., MD✝

Shannon J. Matzelle, MBBS, FANZCA

Thomas M. McLoughlin, Jr., MD

Anand R. Mehta, MBBS

John M. Murkin, MD, FRCPC

Jay D. Pal, MD, PhD

Nirvik Pal, MBBS, MD

Ferenc Puskas, MD, PhD

Anne L. Rother, MBBS, FANZCA

Soraya M. Samii, MD, PhD

Jack S. Shanewise, MD, FASE

Linda Shore-Lesserson, MD, FAHA, FASE

Peter Slinger, MD, FRCPC

Mark Stafford-Smith, MD, CM, FRCP, FASE

Erin A. Sullivan, MD, FASA

Matthew M. Townsley, MD, FASE

Kamen Valchanov, MD, BSc

Michael H. Wall, MD, FCCM

SECTION I: CARDIOVASCULAR PHYSIOLOGY AND PHARMACOLOGY

1. Cardiovascular Physiology: A Primer

SECTION II: GENERAL APPROACH TO CARDIOTHORACIC ANESTHESIA

3. The Cardiac Surgical Patient

4. Monitoring the Cardiac Surgical Patient

6. Induction of Anesthesia and Precardiopulmonary Bypass Management

7. Management of Cardiopulmonary Bypass

8. The Postcardiopulmonary Bypass Period: Weaning to ICU Transport

10. Anesthetic Management of Myocardial Revascularization

13. Alternative Approaches to Cardiothoracic Surgery with and without

14. Anesthetic Management for Thoracic Aortic Aneurysm and Dissection

15. Anesthetic Management for Surgery of the Lungs and Mediastinum

17. Anesthetic Management of Cardiac and Pulmonary Transplantation

19. Anesthetic Considerations for Patients with Pericardial Disease