Coronaries: Considerations

coronary (adj.)Look up coronary at Dictionary.com
c. 1600, “suitable for garlands,” from Latin coronarius “of a crown,” from corona “crown” (see crown (n.)). Anatomical use is 1670s for structure of blood vessels that surround the heart like a crown. Short for coronary thrombosis it dates from 1955. Coronary artery is recorded from 1741.

Anesthetic Considerations for Coronary Artery Disease patients, from Open Anesthesia

General:

  • avoid swings: keep normotensive (20% baseline) and baseline HR
  • Closely watch I/O EKG as 1mm ST change (+/-) for >60s = 10x cardiac event risk
  • 5 mins of hr >105 = 10x death risk p/o

Imaging/Studies

  • Assess echo, stress tests, viability studies, cath for LV fx, valve abnormalities, CAD
  • Quick Guide images: 
    Distribution of Coronary Arteries in relation to Echo Segments
    Distribution of Coronary Arteries in relation to Echo Segments

     

    echo sections
    Echo Segments and 3D View

 

Starting Off: Induce and Intubate

  • Etomidate or low dose propofol, Fentanyl + Midazolam
  • DL < 15s (be quick!)
  • if anticipate difficult intubation, consider spraying lidocaine, blocks, or iv lido prior to DL

Keep it going: Maintenance and Monitoring

  • Debate between Volatiles vs. N20 Opiate, conflicting data, use judgement
  • Volatiles depress but also provide preconditioning that is helpful
  • Short acting BB (Esmolol) not proven to help, but use judgement
  • Paralytics: Pancuronium increases BP and HR, Atracurium and miv can lower BP, Vec/Reoc/Cis neutral (though some concern about histamine with Cis, much lower than Atracurium)
  • Don’t reverse: glyco not well tolerated
  • Standard cardiac setup if high risk surgery (cardiac) or high risk pt (recent MI, CHF, unstable angina)
  • NTG good for ischemia

Finish up: Avoid hypothermia, adequate analgesia and sedation en route to ICU

 

 

 

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The Tricuscupid

 

Indications for Repair of Tricuspid Valve

Notes From https://www.radcliffecardiology.com/articles/indications-surgery-tricuspid-regurgitation

https://www.radcliffecardiology.com/sites/default/files/image-gallery/topilskyfig1.png

 

How does Tricuspid Regurgitation Happen?

80% 2/2 RV enlargement –> annular dilation/leaflet tethering, itself 2/2 LV failure or RV volume/pressure overload

Rheumatic, congenital, endocarditis, traumatic, pacemaker, myxomatous less common

Sx

-decreased exercise tolerance

-RV failure symptoms (edema, ascites, congested liver, decreased appetite), afib

Effective regurgitant orifice (ERO) and proximal isovelocity surface area (PISA) used on echo to evaluate, dependent on volume status with ERO >0.4 cm2 used as criteria

Indications and Timing of Surgery

Performed in isolation or at time of left sided valve surgery

In Isolation

-Severe TR (ERO>0.4CM2) and isolated TR a/w excess m&m

-recent guidelines (class IIa) rec’d Tricuspid repair on its own when patients are symptomatic, including congestive hepatopathy, preferably before significant RV dysfx

-performing isolated Tricuspid repair AFTER left sided heart surgery has typically waited until severe symptoms arise leading to high M&M, however when done before severe symptoms and before significant RV dysfx outcomes are reasonable

-Severe Pulm HTN or significant RV dysfx is considered relative contraindication to surgery

 

TR Surgery at time of Left-sided Valve Surgery

-usually good idea because: TR doesn’t predictably improve after left sided tx, it’s not that risky to add repair of tricuspid to left repair, and reops for isolated Tricuspid repair after left repair is risky

-Risk factors for progression of TR: tricuspid annulus dilatation: ERO >40mm or 21mm/m2 on TTE or >70mm i/o; sig RV dyfx/dilatation, sig tricuspid leaflet tethering, afib, pulm htn, hx of rheumatic mitral disease, hx of RH failure

-rec’d for mild/mod TR at time of left side surgery + Tricuspid annular dilatation or RH failure

 

 

 

Outcomes of coronary artery bypass graft surgery

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994021/#__abstractid201527title

This review article summarizes the major studies that have investigated the outcomes of coronary artery bypass graft surgery (CABG). The article includes a review of the literature in the areas of: history of CABG; indications for CABG; and measurement of quality of life following CABG

But it should be noted…

(recovery from cabg) is a multidimensional phenomenon that is not fully explained by medical factors. Therefore, in addition to studying mortality and morbidity outcomes following CABG, many recent studies have identified that it is important to investigate various physical, psychological, and social variables that have a significant impact on post-operative adjustment to CABG.