Anaesthesia for adult cardiac surgery requiring repeat sternotomy

Question 1

Why is repeat cardiac surgery associated with increased mortality

Answer 1

Resternotomy = intrathoracic adhesions
- Increased bleeding and coagulopathy
- Risk of damage to pleura, cardiac chambers, previous grafts
- Prolonged surgery therefore prolonged bypass time
Likely older more comorbid patient

Mortality is 2-6x compared to baseline cardiac surgery

Question 2

Indications for repeat cardiac surgery

Answer 2

• Myocardial revascularisation in patients with CABG
• Revision valve surgery due to: thrombosis, endocarditis, restenosis or trans/ paravalvular regurgitation

Question 3

Modifications to cardiac anaesthesia for repeat sternotomy

Answer 3

• Defib pads on prior to GA as sternotomy time may be prolonged
• 2x wide bore IV access- one normally central (PA introducer, vas-cath)
• Some centres advocate for elective peripheral cardio-pulm bypass prior to surgery (fem-fem, axillary- jugular), still empty heart prior to sternotomy
• Consider aprotinin but do not use if used in primary surgery
• Sternotomy is the high-risk time- the patient may need to be trendelenberg and lungs off to “drop” the heart away from the sternum. Be prepared for emergency CPB and massive transfusion