Cardiothoracic Procedures Flashcards
Lance Carter, C-AA
What are the Surgical Approaches in Cardiac Surgery?
What’s the difference between Invasive vs. Minimally Invasive Cardiac Surgery?
What are considerations when a “minimally invasive” (thoracotomy or Davinci) approach is used?
Which of the following is more commonly done?
What are the Surgical Options For CABG?
What are the three ways they can access the heart during a CABG?
What is a “MICS” CABG?
What is the purpose of using the Davinci in a CABG procedure?
What is Hybrid Coronary Revascularization?
What procedures require a Hybrid Cardiac Operating Room?
What is typical premedication for a CABG?
What are the Surgical Options for Valve Repair/Replacement?
How would the surgeon gain access to the heart during Valve Repair/Replacement?
Are stenotic valves typically repaired or replaced?
Are Regurgitant valves more typically repaired or replaced?
Should Premedication For Valve Repair/Replacement be used?
Endovascular Aortic Valve Replacement can be referred to as? (2)
What is the pathway typically taken with Endovascular Mitral Valve Repair?
What is the pathway for Endovascular Tricuspid & Pulmonic Valve Repair?
What open valve replacement is the only performed “off pump” with an “open” approach?
What are Risks Associated with Endovascular TAVR?
- Stroke and TIA
- Perivalvular leak
- Vascular complications (disection, rupture, etc.)
- Acute kidney injury
- Cardiac conduction abnormalities (i.e., left bundle branch block)
- Postoperative bleeding and atrial fibrillation
What is Anesthetic Management for Endovascular TAVR? (10)
- Renal protection (because of the contrast dye used)
- Adequate perioperative volume loading
- Administration of N-acetylcysteine prior to surgery - Stroke prevention
- Since the risk of stroke is so high, dual antiplatelet therapy (aspirin and clopidogrel) is started before the procedure and continued for 6 months - Lower dose of heparin
- Goal ACT of >250 - Placement of transvenous pacing leads
- Attaching of external defibrillator pads
- Utilization of TEE
- Amicar administration is unnecessary (from what I could read)
- Preparation to “keep the heart still” during valve deployment
- Most commonly, “rapid ventricular pacing (RVP)” will be induced with a rate of 180-220 beats per minute
- It can also be accomplished by virtually stopping the heart with adenosine (12mg) - Hemodynamic goals typical for patients with aortic stenosis
- Preload augmentation
- Low heart rates (50-70 beats/min) are preferred over rapid heart rates (greater than 90 beats/min) to allow adequate diastolic filling time
- Maintenance of sinus rhythm - Continuous postoperative electrocardiogram monitoring for at least 48 hrs
What is the most common technique for aortic anuerysm surgery?
What are Surgical Techniques for Open Ascending Aorta Repair?
What are repair options for Open Descending Aorta Repair?
What do you worry about with clamps on the descending aorta?
Explain Descending Aorta Repair With Partial CPB
Explain Descending Aorta Repair With L Heart Partial Bypass
What are anesthetic considerations for left heart bypass?
- “Left heart bypass with partial CPB requires intensive vigilance to hemodynamics by both the anesthesiologist and the perfusionist. There is a shared circulation in place. It is possible for the perfusionist to divert too much blood from the heart thereby depriving the heart, head, and upper extremities adequate blood supply.”
- Arterial pressure should be measured in the right radial artery and the femoral artery to assess pressure distal to the clamp
- CVP should be compared to PA diastolic or wedge pressure to assess filling of the two ventricles
During L heart bypass, why should arterial pressure be measured in the right radial artery and the femoral artery?
Anesthetic Management For
Open Descending Aorta Repair
What are Possible Spinal Cord Protection Techniques For
Open Descending Aorta Repair?
What is an Aortic Wrapping Procedure?
What is an orthotopic heart transplant?
What is a Heterotopic (“piggyback”) heart transplant?
Biatrial heart transplant?
How many anastomoses does a biatrial heart transplant have?
What is a bicaval heart transplant?
How many anastomoses does a bicaval heart transplant have?
Total heart transplant?
How many anastomoses for a total heart transplant?
What are two advantages to leaving the atria intact during a heart transplant?
What are four risks associated with a biatrial technique?
What are anesthetic considerations regarding denervation of a patient with a previous heart transplant?
What effects does neostigmine have on a patient with a previous heart transplant?
Does atropine/robinul prevent bradycardia in a heart transplant patient when reversed with neostigmine?
What is the Problem With Pulmonary Hypertension & Heart Transplants?
Heart Transplant Option For
Patients With Pulmonary Hypertension
When is a heterotrophic heart transplant indicated?
What Implications Of “Denervation”? (9)
- The loss of vagal tone means that the resting heart rate for these patients is usually faster(usually >90 beats/min)
- Atropine & Robinul (when administered alone) have little to no effect on heart rate
- Neostigmine causes bradycardia, which can be treated with anticholinergics
- Bradycardia must be treated with pacing or with beta 1 agonists
- Isoproterenol (Isuprel), Dobutamine, Epi, Norepi - The patient cannot experience angina
- The baroreceptor reflex doesn’t really work, so the heart rate might not change in response to changes in blood pressure (as occurs with hypovolemia, etc)
- Reflex bradycardia (from phenylephrine, Valsalva, carotid massage, etc) is nonexistent - Sympathetic “reinnervation” can occur in some patients within 12 months of the cardiac operation
- The increase in cardiac output following exertion is primarily due to an increase in stroke volume
- If a biatrial technique was used, the SA node of the recipient remains intact, which means the patient will have 2 SA nodes (the original and the donor), and may produce 2 P waves on their ECG
Does the donor/old SA node affect heart rate more in a dually innervated heart transplant with two SA nodes?
Anesthetic management for a patient with a heart transplant?
- PA pressures should be kept low to prevent right heart failure
- Inotropic support is more likely to be needed than for other cardiac operations
- Immunosuppressive therapy should be implemented
- Beware of hyperkalemia post transplant, since the preservative solution is rich in potassium
Possible strategies to reduce pulmonary artery pressure?
When is Methylprednisolone indicated?
What way to lower plasma K+ concentration prior to anastomosis?
Hyperventilation
What is Transmyocardial Revascularization (TMR)?
What are the Two Theories For TMR’s Efficacy?
What are Anesthetic Considerations for Transmyocardial Revascularization (TMR)?
What should you be thinking about?
Difference between Pericardial Effusion/Cardiac Tamponade?
What are hemodynamic effects of cardiac tamponade?
What is Beck’s triad?
What are Treatment Options for Cardiac Tamponade?
Anesthetic management for a pericardial window?
- General vs. MAC anesthesia
- Impending tamponade or not? In other words, is this an emergency?
- Induction of anesthesia (in unstable patients)
- Bradycardia should be avoided
- Spontaneous ventilation should be maintained if possible
During induction in unstable patients with a pericardial window operation, what are things to consider?
Why should bradycardia be avoided in a pericardial window operation?
What does positive pressure ventilation do to cardiac output and venous return?
What is an Mediastinoscopy, and what is our anesthetic concern during the surgery?
Significance Of Innominate Artery Compression
Airway Management For Mediastinoscopy
This is NOT a thoracotomy, and neither lung needs to be down, so a single lumen endotracheal tube is fine
Arterial Line Placement For Mediastinoscopy
When is it acceptable to place the arterial line in the LEFT arm during a mediastinoscopy?
Primary concern with a mediastinal mass is compression of what?
What can obstructed venous return lead too?
What is Pemberton’s Sign?
What is another Potential Sign & Symptom of a Mediastinal Mass?
Anesthetic Management For A Mediastinal Mass? (10)
- Maintain spontaneous ventilation if possible
- Perform an awake fiberoptic intubation in the sitting position if possible if the patient is symptomatic
- Consider using an “armored” (reinforced) endotracheal tube
- If not doing an awake intubation, know the risks/benefits of an inhalational induction vs. a routine induction
- Have a plan for ventilation, based on where the obstruction is and how significant it is
- Use a semi-upright position for induction & maintenance of anesthesia
- “The head-up position is helpful in reducing airway edema” - Avoid hypotension in order to maintain cerebral perfusion pressure
- Place IVs in the lower extremities if there is evidence of SVC syndrome, and consider preload augmentations
- Consider the need for immediate available surgical intervention
What is the Plan for Ventilation With a Mediastinal Mass?
What is jet ventilation?
How do you use the jet ventilator?
Considerations for Laser Lead Extraction
