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 [RCT→opinion]
• 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 cm2
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

= 2Π(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
1. ↑ insulin requirements w obesity, steroids,
stress response to surgery + CPB
2. Excess glucose in pump prime, cardioplegia
3. ↑ gluconeogenesis + glycogen breakdown (CPB
+ stress response)
4. ↓ glucose utilization: hypothermia
5. ↓ 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/research/insulin.html
 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
2. High-risk patients
3. High-risk surgical procedures
4. 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 ε-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, cont’d
• 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?
– Rosengart, 98: ↑ Hct, ↓ RBC trx
– Shapira, 98: ↑ Hct, ↓ RBC trx
– Balachandran, 02: ↑ Hct, ↓ RBC trx
– Eising, 03: ↑ COP, ↓ extravascular lung
water+ earlier time to mobilization
– 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