Cardiac Anesthesia Update

Charles E. Smith, MD
Professor, CWRU School of Medicine
Director, CT Anesthesia
MetroHealth Medical Center
 Objectives
1. ASE guidelines- IOTEE
2. ACC/AHA guidelines- Valves
3. Diabetes + hyperglycemia
4. Neurocognitive dysfunction
5. Transfusion
 ASE/SCA Guidelines- TEE
Accelerated growth of IOTEE by anesthesia
Complexity of US technology
Conduct of exam
Interpretation of results

Mathews JP et al: ASE / SCA Recommendations and Guidelines for

CQI in Perioperative Echo. JASE + Anesth Analg 2006.
 Training + Credentialing
2 levels of training: basic + advanced
Basic: within usual practice of anesthesia
ventricular fct, gross valve lesions
Advanced: full diagnostic potential of echo
ASE /SCA/NBE:
Testamur status: exam
Board certified: 1 yr TEE/ CT fellowship [vs alternate
training, 2-4 yr, 300 exams]
Credentialing: hospital-specific process
Mathews JP et al: JASE + Anesth Analg 2006.
Standard TEE Exam: Guidelines
Comprehensive: 20 cross-sectional views
UE level: Asc aorta, MPA, L+R atria,
AV+PV
ME level: L+R atria, L+R ventricles,
MV+TV
TG: L+R ventricles
Thoracic Aorta: Desc + distal arch
Mathews JP et al: ASE / SCA Recommendations and Guidelines for CQI in
Perioperative Echo. JASE + Anesth Analg 2006.
Transgastric view: L+R ventricles
ME views: L+R atria, L+R ventricles, MV+TV
UE views: Asc aorta, MPA, L+R atria, AV+PV, pulm veins
Thoracic Aorta: prox asc aorta, distal arch, descending
 ACC/AHA Guidelines
Review of literature by experts
Grade evidence: Level A C [RCTopinion]
Recommendations:
Class I: beneficial
Class IIa: generally in favor
Class IIb: less well established
Class III: not useful, potentially harmful?

AAC/AHA Task Force on Practice Guidelines. Circulation

2006;114(5)e84-231. Endorsed by SCA, STS
 Valvular Heart Disease
Decision to repair/replace valve should be
made before surgery
IOTEE should be used to confirm dx,
evaluate repair + evaluate new findings
(e.g., moderate AS in setting of CABG,
moderate AI if EF or LVEDD, aortic
root reconstruction if dilated > 5 cm)

AAC/AHA Task Force on Practice Guidelines. Circulation

2006;114(5)e84-231. Endorsed by SCA, STS
 IOTEE Indications
Class I: valve repair, valve replacement-
stentless / autograft (Ross), valve surgery in
setting of endocarditis
Level of evidence= B
Class IIa: all valve surgeries
Level of evidence =C

AAC/AHA Task Force on Practice Guidelines. Circulation

2006;114(5)e84-231. Endorsed by SCA, STS
 Aortic Stenosis
Check annulus size
Verify size of aortic root (mismatch?
aneurysmal?)
After bypass: problems w prosthesis:
immobility, leaks

AAC/AHA Task Force on Practice Guidelines. Circulation

2006;114(5)e84-231. Endorsed by SCA, STS
 Severe Aortic Stenosis

2.0 cm

5.7 m/s

1.3 m/s
2.0 2 1.3
AVA = 3.14 ( ------) X ------ = 0.72 cm 2
2 5.7
Severe Aortic Regurgitation
T 1/2 = 84 ms

Vena Contracta = 11 mm
 Mitral Regurgitation
Functional vs structural
After bypass:
Residual MR, MS, SAM
Leaks
Immobility of prosthesis

AAC/AHA Task Force on Practice Guidelines. Circulation

2006;114(5)e84-231. Endorsed by SCA, STS
Severe Mitral Regurgitation

PISA ROA

rn=1.1cm
vn=59 cm
vp=450 cm

= 2(1.1)2(59/450)
= 0.99 cm2
 MR Quantitation
Mild Severe
Jet Area (cm2) <4; <20% LA 40% LA
VC (cm) <0.3 >0.6
RV (cc/beat) <30 60
RF (%) <30 50
ERO (cm2) <0.2 0.4
Pulm vein Blunted systolic Systolic
flow reversal
LA size N or dilated 1+ Dilated +++
SAM
Outflow Tract Obstruction
Cardiac Tamponade
RA Diastolic Collapse
 Type A Dissection: TEE

MHMC #0777095

Type A dissection with flap extending to just superior to RCA ostium

 Aortic Dissection:
TEE Distal Thoracic Aorta

MHMC #0777095

Demonstration of extension of dissection distally

 Diabetes + Hyperglycemia
neuro injury after focal + global ischemia
myocardial infarct size
WBC function
Impaired wound healing
risk infection, especially gluc > 250
 Reasons for Hyperglycemia
insulin requirements w obesity, steroids,
stress response to surgery + CPB
2. Excess glucose in pump prime, cardioplegia
gluconeogenesis + glycogen breakdown (CPB
+ stress response)
glucose utilization: hypothermia
insulin production: pancreatic hypoperfusion

Smith et al: J Cardiothorac Vasc Anesth 2005;19:201

 Diabetes + Deep Sternal Wound Infection

Hyperglycemia - major role in impaired

wound healing + deep sternal wound
infection
Insulin infusion + moderate control
Titrate infusion to gluc 125-175 mg/dl
Start in OR, continue to POD 3
incidence to 0.3%, similar to non-
diabetics
Portland Protocol: Starr Center for Cardiac Surgery. www.starwood.com/
 Van Den Berge Study
RCT, 1548 diabetic + non-diabetic SICU patients
60% had cardiac surgery
Compared tight vs. conventional glucose control
Tight: 80-110 mg/dl
Conventional: insulin only if glucose > 210; endpoint
180-200
mortality in tight group 4.6 v. 8%
infections, dialysis dependent RF, # transfusions
required, need for prolonged mechanical ventilation

N Engl J Med 2001;345:1359-67

 How Tight Should Intraop Control Be?

Furnary- 99: < 200 w insulin infusion mortality

Van den Berghe- 01: 80-110 w insulin infusion
mortality (vs 180-220)
Furnary- 03: < 150 w insulin infusion mortality
(vs > 250)
Finney- 03: < 145
Lazar- 04: < 200 w insulin infusion (vs > 250)
Ouattata- 05: < 200 w insulin infusion
 MHMC Study
Prospective, non-randomized, n=40
Diabetics received continuous infusion regular
insulin, 10 u/m2/h + variable D10W, starting rate
100 ml/h or 9.4 gm gluc/h
Target glucose 101- 140
Standardized anesthetic, bypass, cardioplegia
POC glucose testing + multiple biochemical
measurements

J Cardiothorac Vasc Anesth 2005;19:201

 MHMC Study- Results
53% achieved adequate intraop control + 35% had
control by end of surgery [total =88%]

12% never had control (starting glucose 307-550)

25% had hypoglycemia requiring D50 (mean gluc

57, range 33-74, mostly CRF pts)

J Cardiothorac Vasc Anesth 2005;19:201

Smith et al: J Cardiothorac Vasc Anesth 2005;19:201
 Current Approach- Diabetics

Insulin infusion- mix 250 units regular insulin in

250 ml 0.9% saline
Flush line w 25 ml [insulin binds to tubing]
Starting dose: gluc/100 per hr, continue in ICU
Target glucose 100 - 150
Measure gluc q 1h
Bolus doses can be given IV
Be careful with renal failure +after CPB-
accumulation of insulin + risk hypoglycemia
 Cognitive Dysfunction
Inability to perform normal activities after
surgery
4 major domains of function
1. Verbal memory + language comprehension
2. Abstraction, visuo-spatial orientation
3. Attention, psychomotor processing speed,
concentration
4. Visual memory

Newman MF: SCA Annual Meeting, 2007

 Cognitive Decline, CABG
75

50
%

25

0
Discharge 6 weeks 6 months 5 years

Newman MF: N Engl J Med 2001;344:395. Duke, n=261

 Social + Economic Costs
Cognitive dysfunction
quality of life
return to work
Altered personality, relationships
sexual function
 Implications
Abrupt decline in cognitive function
heralds:
Loss of independence
Withdrawal from society
Death

Seattle Longitudinal Study of Aging

Berlin Aging Study
 Potential Mechanisms
1. High-risk patients
2. High-risk surgical procedures
3. High-risk anesthetic techniques
 Patient Risk Factors
Predictors: baseline cognition, deficit at
discharge, age, yrs of education
Not predictive: EF, HTN, DM, surgical
factors: XC time, CPB time
Etiology: ASVD of proximal aorta,
genetics, anesthetics, pre-existing brain
disease
Newman MF: SCA Annual Meeting, 2007
 Genetic Factors
ApolipoproteinE -4 hyp: APOE allele-
cognitive outcome
Single nucleotide polymorphisms: SNPs-
modulate inflammation, cell matrix
adhesion/interaction, lipid metabolism,
vascular reactivity, PEGASUS study:
minor alleles of CRP 1059G/C + SELP
1087G/A associated w POCD

Newman MF: SCA Annual Meeting, 2007

Surgical Factors: Aortic Manipulation

Emboli detected by TEE after unclamping; Barbut D: 1996

 Microemboli or SCADs
Small capillary +
arteriolar dilations: 10-
70 microns
Footprint of embolic
material during CPB
density correlates with
CPB duration
after CPB, most
gone by 1 wk

Moody DM: AnnThorac Surg 1995;59:1304

 Anesthetic Factors
May interact w peptides- oligomerization,
amyloid deposition + protein folding
Low BIS levels were associated w risk in
elderly [cumulative hr BIS < 45]
Longitudinal studies in progress to assess
POCD, delirium + effect of anesthetics

Monk TG: Anesthesiology 2004;A62

Newman MF: SCA Annual Meeting, 2007
Hyperthermia + POCD
 Anesthetic Risk Factors
Anesthetic agents affect release of CNS
neurotransmitters
acetylcholine, dopamine, norepinephrine
Effects of anesthetics on cholinergic neurons in
the basal forebrain [memory regulation]?
Effects of aging on choline reserves
Difficult to evaluate effects of anesthesia on long
term memory + cognition
Blood Trx + Blood Conservation
Cardiac surgery consumes >80% blood products
transfused at operation
Blood products may be assoc w major morbidity +
mortality: TRIM, TRALI, infection, death
Trx practices vary greatly
High risk pts: Elderly, Preop anemia / coagulation
defect, Preop antiplatelet drugs, Redo or complex
procedure, Emergency, co-morbidities
 Optimal hematocrit-1
Therapeutic dilemma: Anemia is bad, but so
is transfusion
Anemia
mortality
quality of life
Jeopardizes organ viability, especially in
presence of limited vasodilator reserve
Gravlee GP. SCA Annual Meeting, 2007
 Optimal hematocrit- 2
Therapeutic dilemma, contd
Transfusion is bad
mortality + morbidity
immediate O2 transport is limited
TRIM, inflammation [role of leukoreduction],
TRALI
Viral/bacteria/parasites
Gravlee GP. SCA Annual Meeting, 2007
 Transfusion Avoidance Techniques
High yield:
preop Hct
CPB priming volume
RAP: retrograde autologous priming
Effective intraop cell saver
Ultrafiltration
Lower yield:
Antifibrinolytics
Protamine dosing

Gravlee GP. SCA Annual Meeting, 2007

 Retrograde Autologous Priming
Replace crystalloid prime w pts own blood
Limits degree of HD
Fewer pts reach critical trx trigger

Murphy GS. SCA Annual Meeting, 2007

 Retrograde Autologous Priming- 2
How to do this?
Heparinize, place arterial cannula, allow pts
blood to flow backwards + displace crystalloid
[perfusionist: rapping]
Maintain SBP > 100 using small doses of PHE
(80-400 ug). Turn off vasodilators
Primary risk- hypotension

Murphy GS. SCA Annual Meeting, 2007

 Retrograde Autologous Priming-3
What is the data?
1. Rosengart, 98: Hct, RBC trx
2. Shapira, 98: Hct, RBC trx
3. Balachandran, 02: Hct, RBC trx
4. Eising, 03: COP, extravascular lung
water+ earlier time to mobilization
5. Murphy, 04 + 06: Hct, trend to mortality,
delirium, afib, + vent > 24 hr
 Cell Salvage- 1
After bypass: transfer blood from prime to cell
saver bowl for washing
Can also collect shed blood for washing
Hct of processed blood: 60%, 2-3 DPG but
processing eliminates platelets +factors
Savings: ~ 1-2 units allogeneic blood
 Cell Salvage- 2
Requirements: CPB
Anticoagulated blood
Centrifuge bowl +
tubing
Shed Blood
Aspiration assembly
Reservoir
Tubing
 Cell Salvage- 3
Few disadvantages in heart room because have:
Dedicated perfusionist + heparinized pump
prime and
Wound is clean
Risks:
Air embolism w infusion under pressure
DIC if use cell saver suction for
thrombogenic material
 Ultrafiltration
Remove water + low MW substances under
a hydrostatic pressure gradient
Induces hemoconcentration: total body
water accumulation + inflammatory
mediators
bleeding, blood trx, morbidity + mortality
Initially validated in peds, but also adults

Tassani 99; Kiziltepe 01; Leyh 01; Luciani 01;

Reasons Why Trx Avoidance Techniques Fail

Had PVCs, PACS

Had to start vasopressors/ inotropes
Looked a little oozy
BP a little low
CI was a little low
Pt was old
Pt was high risk
Gravlee GP. SCA Annual Meeting, 2007
 Summary
1. IOTEE: routinely use for valves, often helpful
for CABG
2. Hyperglycemia: treated w insulin infusion, target
glucose < 150, especially if diabetic
3. Cognitive dysfunction: high risk pts + surgery;
genetics + anesthetic factors play a role
4. Multimodal blood conservation techniques work
well: RAP, cell saver, ultrafiltration, amicar,
protamine dosing