Fawzeya Aboul Fetouh

Professor of Anesthesia Cairo Universityfawziafetouhyahoocom

The last 10 years advances

6th Assiut Anesthesia Conference Hurghada 3-7 Dec 2012

1272012

Discuss lessons learned from SCA annual meeting Bullitin October 2012 ECTAS Cairo Feb 2012

EACTA June Amesterdam 2012 aimed to introduce update in cardiac anesthesia and to Evaluate

controversial issues

Update in biomedical technology

Surgical techniques update

Cardiac anesthesia update

Update in CPB and Perfusion techniques

Post operative strategy update

1272012

Innovative diagnostic and interventional techniques

Coronary angioplasty

Balloon valvoplasty

Hybrid valve surgery mitral and aorta

1272012

UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring

with wide range of accuracy Increase awareness of splanchnic circulation

introduction of gastric tonometry and TEE imaging of the portal circulation

Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient

Bed side monitoring of Hb and Meth Carboxy Hb

Mathews JP et al ASE SCA Recommendations and Guidelines for CQI in Perioperative Echo JASE + Anesth Analg 2009

1272012

Live 3D

Clinically-proven 3D technology

MiniaturizationNext generation micro-beam forming

+ Pure Wave CrystalExceptional image quality

+

Innovative use of 3D TEE minimization More resolution

1272012

MV AV

1272012

Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting

Transmyocardial laser revascularization

Stem cell therapy

Robotic surgery

Ballon valvoplasty

Transcatheter valve surgery

1272012

1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions

such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR

4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required

5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass

1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Innovative diagnostic and interventional techniques

Coronary angioplasty

Balloon valvoplasty

Hybrid valve surgery mitral and aorta

1272012

UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring

with wide range of accuracy Increase awareness of splanchnic circulation

introduction of gastric tonometry and TEE imaging of the portal circulation

Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient

Bed side monitoring of Hb and Meth Carboxy Hb

Mathews JP et al ASE SCA Recommendations and Guidelines for CQI in Perioperative Echo JASE + Anesth Analg 2009

1272012

Live 3D

Clinically-proven 3D technology

MiniaturizationNext generation micro-beam forming

+ Pure Wave CrystalExceptional image quality

+

Innovative use of 3D TEE minimization More resolution

1272012

MV AV

1272012

Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting

Transmyocardial laser revascularization

Stem cell therapy

Robotic surgery

Ballon valvoplasty

Transcatheter valve surgery

1272012

1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions

such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR

4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required

5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass

1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring

with wide range of accuracy Increase awareness of splanchnic circulation

introduction of gastric tonometry and TEE imaging of the portal circulation

Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient

Bed side monitoring of Hb and Meth Carboxy Hb

Mathews JP et al ASE SCA Recommendations and Guidelines for CQI in Perioperative Echo JASE + Anesth Analg 2009

1272012

Live 3D

Clinically-proven 3D technology

MiniaturizationNext generation micro-beam forming

+ Pure Wave CrystalExceptional image quality

+

Innovative use of 3D TEE minimization More resolution

1272012

MV AV

1272012

Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting

Transmyocardial laser revascularization

Stem cell therapy

Robotic surgery

Ballon valvoplasty

Transcatheter valve surgery

1272012

1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions

such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR

4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required

5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass

1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Live 3D

Clinically-proven 3D technology

MiniaturizationNext generation micro-beam forming

+ Pure Wave CrystalExceptional image quality

+

Innovative use of 3D TEE minimization More resolution

1272012

MV AV

1272012

Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting

Transmyocardial laser revascularization

Stem cell therapy

Robotic surgery

Ballon valvoplasty

Transcatheter valve surgery

1272012

1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions

such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR

4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required

5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass

1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

MV AV

1272012

Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting

Transmyocardial laser revascularization

Stem cell therapy

Robotic surgery

Ballon valvoplasty

Transcatheter valve surgery

1272012

1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions

such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR

4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required

5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass

1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting

Transmyocardial laser revascularization

Stem cell therapy

Robotic surgery

Ballon valvoplasty

Transcatheter valve surgery

1272012

1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions

such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR

4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required

5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass

1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions

such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR

4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required

5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass

1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation

interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may

restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for

hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup

1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair

Types local anesthesia + sedation regional combined regionalGA or GA alone

AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE

May need to darr BP during stent deployment SNP NTG adenosine rapid pacing

Michael Andritsos Anesthesia and the endovascular stenting patient 1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques

Further reduction in size of incision

May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient

1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Introduction of TEE in pediatric patient

more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist

Early surgical interference more young age

Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists

1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Warm or tepid cardioplegia

Ultrafiltration as routine use in CPB

Portable modular CPB

1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

(1) Bruckenberger E Herzbericht 2006

(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Introduction of concept of cardioprotection brain protection

Introduction of the concept of ischemic preconditioning

Introduction of newer concept of intropicagents

1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Based on TEE assessment of the cardiac output LV function after separation from CPB

No ldquounnecessaryrdquo Preemptive inotropes

More awareness to afterload reduction and hemodynamic parameters modulation

1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Cardiac glycosides Calcium sensitizers Liothyronine (T3)

1272012

Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation

Effects continue 24 hours after drug stopped in CHF patients active metabolite

Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)

Kivikko Circulation 200310781-86Follath Lancet 2002360196-202

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

bull IABP (Intra-aortic balloon pump)

coronary perfusion with inotropes to

activate oxygen deprived cells

Mortality with 3 inotropes= 80 1

bullMortality with multi-organ failure

two organs = 80 2

bullImpella unloads left ventricle

bullIncreases flow to heart and organs

without inotropes amp reduces

workload 3

1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999

2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash

267 (2005)

IABP

blood outlet

blood inlet

pigtail

9F-Catheter

1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA

Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use

target therapy

1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012

1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors

1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation

Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009

Thank you1272012