opcab

ANESTHESIA FOR OFF PUMP CORONARY ARTERY BYPASS

GRAFTING (OPCAB)

DR GEETANJALI S VERMA

REGISTRAR (CARDIAC ANESTHESIA)

MANIPAL HOSPITAL, BLORE

DEFINITION

• Off-pump coronary artery bypass or "beating heart"

surgery is a form of CABG surgery performed

without CPB (heart-lung machine) as a treatment

for coronary heart disease.

• During most bypass surgeries, the heart is stopped and a

heart-lung machine takes over the work of the heart and

lungs.

• When a cardiac surgeon chooses to perform the CABG

procedure off-pump, also known as OPCAB (Off-pump

Coronary Artery Bypass), the heart is still beating while

the graft attachments are made to bypass a blockage.


THE BEGINNING

• First open heart surgery - performed by John Gibbon in

1952 using cardiopulmonary bypass

• First successful OPCAB was performed in 1961 and

Kolesov in 1964 performed the first successful

anastomosis of left internal mammary artery (LIMA) to

left anterior descending artery (LAD)

• In 1967, Favalaro and Effler performed reversed

saphenous vein grafting.

• In 1968, Green performed anastomosis of the internal

mammary artery to the coronary artery .


Development of modern epicardialstabilizers

• In early reports, compressive devices (e.g., metalextensions rigidly attached to the sternal retractor) wereused to reduce the motion of the coronary vessel duringthe cardiac and respiratory cycles. These devices ofteninterfered with cardiac function and were impossible to usefor left circumflex coronary artery lesions.

• Modern devices typically apply gentle pressure orepicardial suction, reducing the effect on myocardialfunction while providing better fixation of the areaimmediately surrounding the coronary artery anastomoticsite. These devices also allow greater access to arteries onthe inferior and posterior surfaces of the heart


OPCAB tissue stabilization and heart positioning devices.

Verma S et al. Circulation. 2004;109:1206-1211

Copyright © American Heart Association, Inc. All rights reserved.

Genzyme Immobilizerutilizes a stabilization platform and silastic vessel loops

the Medtronic Octopus4 tissue stabilizer and Starfish2 heart positionerutilize vacuum suction to stabilize and position the heart.

Coro-Vasc System (CoroNeo Inc)illustrates silastic snares that are looped around the target coronary vessel and then fixed to a small immobile plate, thus directly immobilizing the target vessel.

PATIENT SELECTION

• a. Early reports of OPCAB often described single-vessel or double-vessel bypass performed on low-risk patients - promoted for early recovery and discharge.

• b. OPCAB is now promoted for multivessel bypass in patients with risk factors for adverse outcomes. Elderly patients at risk for stroke, patients with severe lung disease, or patients with severe vascular disease and/or renal dysfunction are often selected.

• Zenati et al. and others have described combining MIDCAB (i.e. IMA to LAD) with angioplasty/stent to other vessels in high-risk patients.


OPCAB Demands

Exposure of post, Lat wall of the heart.

Stabilization of target area.

Visualization Occlusion of the Coronary Ar.

or Shunt.

Stable Hemodynamics.


CONTRAINDICATIONS

- Very small arteries ( <1mm)

- Calcified arteries.

- Poor conduits.

- Huge hearts.

- Hemodynamic Instability/Ischemia.

- Cardiogenic shock.


GOALS OF ANESTHETIC MGMT• Provision of safe anaesthesia using a technique that offers

maximum cardiac protection and stability

• Maintaining haemodynamics in the intraoperative period

by physical and pharmacological methods

• Allowing early emergence, ambulation

• Providing adequate pain relief in the postoperative

period.


PRE OP ASSESSMENT

• For optimization of diabetes, hypertension, reactive

airway and other coexisting morbidities

• To alley anxiety related to the procedure

• Preoperative assessment of the carotid arteries

• Essential investigations done: CBC, coagulation profile,

lipid profile, electrolytes, Blood grouping and serology,

renal and liver function tests, CXR, ECG, Echo, USG

abdomen (elderly males), PFT


PRE MEDICATION- Anti aspiration prophylaxis: Ranitidine (150mg) /

Pantoprazole (40mg) + prokinetic (Metochlopramide 10 mg)

- Anti anxiety: tab Alprazolam 0.5-1mg oral

- 0.05mg.kg -1 of midazolam + 1µg.kg -1 of fentanyl IV30minutes prior to surgery with supplemental oxygen.

- Regular medn:

- Beta blockers should be continued in same dosage

- Anti platelet medications - stopped atleast 1 week prior tosurgery

- ACE inhibitors may be stopped 24 to 36 hours prior tosurgery (substituted with calcium channel blockers)

- For DM patients – conversion to short acting Insulin


INTRA OP MONITORING

- ECG – lead II and V5

- well visualized 'P' wave and QRS complex prior to commencing

the surgery

- SpO2, ETCO2

- Temperature monitoring

- Urinary output monitoring

- Invasive blood pressure (IBP) monitoring - By radial or

femoral artery

- The cannulation of the femoral artery not only permits access to

the central arterial tree but provides access to quick insertion of

an intra aortic balloon pump.

- If radial artery cannulation is planned the Allen's test must be

performed prior to performing cannulation.DR GEETANJALI S VERMA

Pulmonary artery catheter (PAC)

Usually placed via the right internal jugular vein.

Indications:

Ejection fraction <0.4

Significant abnormality of the left ventricular wall

motion.

LVEDP > 18 mm Hg at rest.

Recent MI and unstable angina.


Transesophageal echocardiography (TEE)

Advantages:- Identify myocardial ischaemia early by detecting regional wall motion

abnormalities.

- Assess left ventricular dysfunction intra operatively.

- Assessing the improvement in myocardial function after the completion of revascularization.

DisadvantageInability to image the required part of the heart during grafting .


INDUCTION

• Induction should be slow

• By intravenous (Propofol/ Etomidate/ Thiopentone + Opioids

(fentanyl / morphine) +BZD) or inhalational method (Sevo/Iso in 1-

2 MAC)

• Neuromuscular blockade - 0.7 mg/kg Rocuronium IV or

Vecuronium 0.08-0.1 mg/kg IV (Pan/atrac – tachy)

MAINTENANCE

• Infusion of fentanyl, atracurium +/- Midazolam

• Isoflurane / O2/ air


INTRAOP PROBLEMS1. HYPOTENSION

– treated with volume loading

– Maintain adequate heart rate in sinus rhythm.

– increasing afterload to maintain systemic perfusion

pressures.

– Inotrope therapy - dopamine, epinephrine, dobutamine

infusion.

– Phenylephrine

– Inform surgeon - cotton packs can be placed under the

heart and the epicardial stabilizers should be repositioned.

– resting the heart in the pericardial cavity.

– If there is no improvement, an intra aortic balloon pump

support can be instituted.DR GEETANJALI S VERMA

2. ARRYTHYMIAS

- Rule out causes: MI, electrolyte imbalance, hypothermia

- Use lidocaine (without preservative) infusion if patient has

arrhythmia caused by myocardial ischaemia.

- Electrolyte imbalance - potassium chloride, magnesium

sulfate, calcium, bicarbonate – as suggested by ABG

- Temperature correction


3. HEPARINIZATION

- Dose of heparin is 2mg.kg -1 (200 units.kg -1 )

intravenously.

- ACT performed 3 minutes after administration.

- The goal is to keep the ACT between 250 - 300 seconds.

- ACT repeated hourly and repeat bolus of 5000 units

Heparin is essential if ACT <250 seconds.

- Heparin is reversed with protamine sulfate (1 mg/1mg of

heparin. )

- Acceptable ACT – upto 140 seconds after protamine

administration.

- A high ACT will require additional protamine in a dose of

25 to 50 mg.


4. HYPOTHERMIA

- Warm blanket covers

- OT room temp

- The time taken for sterile preparation by painting and

draping by sterile sheets should be kept to the minimum.

- Warm IV fluids

- Low fresh gas flows


5. MYOCARDIAL ISCHEMIA

- PREVENTION

- Maintaining systemic blood pressure (+/- 10%), keeping

MAP of at least 70 mm Hg at all times

- Reduction in myocardial oxygen consumption by

avoiding tachycardia using intra operative beta-blockers

or calcium channel blockers.

- Ischaemia during distal anastomosis can be prevented

by using intraluminal coronary shunts .


Intracoronary shunts

These are double limb shunts that fit into the proximal and distal ends of the open coronary artery


Intracoronary shuntsBenefits:-

Native coronary arterial blood flow is maintained

preventing intraoperative ischaemia.

Blood loss during coronary anastomosis is avoided or

decreased.

Prevents embolization of CO2 into the coronary arteries.

Prevents the surgeon from taking a suture on the posterior

wall of the coronary artery.

Assures proper coronary anastomosis.

Can reverse changes caused by ischaemia (like

myocardial oedema, endothelial and contractile

dysfunction)


OPCAB technology in use.



6. Haemodynamic changes related to heart position

Lifting and rotating the heart during OPCAB can alter the

haemodynamics such as cardiac output, stroke work, left

ventricular end diastolic pressure and right atrial pressure.

During grafting of right coronary artery, bradycardia can

occure due to reduction in blood supply to the sinus and AV

nodes, so if required use atropine and atrial pacing

During grafting of the right coronary artery and obtuse

marginal branches "verticalization" of the heart is required, so

posterior pericardial stitches and a gentle retracting socket will

greatly facilitate haemodynamics

Reduction in the dose of intravenous vasodilators can increase

the haemodynamic changes. During such times it may be

essential to reduce the dose of the vasodilator and add a

vasoconstrictor.DR GEETANJALI S VERMA

POST OP MGMT• MONITORING

• 5 lead ECG monitoring - for any fresh changes like

ischaemia or myocardial infarction - treated with LMWH,

anti platelet medications, insertion of an intra aortic

balloon pump or revision of grafting.

• SpO2, ETCO2, IBP, Temp., ABG

• Always carry prefilled syringes of diluted 1:200,000

adrenaline, 1.2mg of atropine and 100mg of lidocaine

(preservative free) to treat a crisis during the transfer

phase.


POST OP PAIN MGMT

• Epidural analgesia: epidural fentanyl infusion

with Fentanyl 3000 mcg (60 ml), 0.5% bupivacaine 55ml

and saline 155ml are added to make a final total volume

265 ml & start at a rate of 2ml.hour -1

• Intravenous opioids: Fentanyl 3000mcg and saline

215ml are added to make a final concentration 11

mcg.ml -1 of fentanyl.


ICU MGMT

VENTILATION

FiO2 of 0.8

• Vt 6-10 ml/kg

• RR: 12- 15/min

• I:E ratio of 1:2

• controlled mode of ventilation.

• ABG performed after thirty minutes.

• FiO2 is reduced to 0.4 if oxygenation, carbon dioxide

elimination and tissue perfusion maintained


Thirty minutes later, assessment of foll done:

blood loss (not more than 10% of blood volume)

fluid balance (not more than 10-15 ml.kg- 1 body weight)

core temperature ( not less than 35 deg Celsius ),

arrhythmias

urine output (at least 1-2 ml.kg -1 .hr -1 )

If the residual neuromuscular blockade is present then reversed

by injecting a combination of neostigmine and glycopyrrolate.

After confirming adequacy of reversal ventilatory mode is

switched to the spontaneous modes of ventilation, such as

pressure support, or continuous positive airway pressure.

Thirty minutes after supported ventilation, ABG analysis is

repeated and if the analysis shows satisfactory values of

oxygenation, carbon dioxide elimination and metabolism, the

patients are extubated.


FAST TRACK ANESTHESIA

• Defined as tracheal extubation within 8 hours after

cardiac surgery, early mobilization of patient and early

discharge from the hospital.

• Use of short acting opioid medications

• Long acting sedatives should be avoided

• Early extubation resulted in regaining the cough reflex

and thus a lower incidence of atelectasis and pneumonia.

• Patients not suitable - bleeding, dysrryhtmias and

haemodynamic instability


COMPARING ON AND OFF PUMP CABG

1. Systemic inflammatory response syndrome (SIRS) -Acombination of non pulsatile flow, myocardial ischaemia,hypothermia and contact of the patient blood with theartificial surface of the extra corporeal circuit is responsiblefor the inflammatory process.

2. Coagulopathy-disruption of the coagulation system andhaemodilution after cardiopulmonary bypass is avoided inOPCAB

Less blood loss in OPCABAscine – Eur. J. Cardioth. Surg. 1999

Puskas – Ann. Thor. Surg. 1998


3. Neurologic dysfunction- due to embolization,

inflammation, hypoperfusion and hyperthermia.

Type 1 - Death either due to stroke or hypoxic

encephalopathy, stupor & coma. (Risk factors are DM,

atherosclerosis in the proximal aorta and pre existing

impairment of cerebral blood flow)

Type 2 - Intellectual dysfunction - memory deficits,

confusion or agitation - due to small micro emboli and

inadequate perfusion

The incidence of stroke after OPCAB is about 1% when

compared to 9% after ON pump CABG


Neurological Outcome

Only few prospective Randomized Trials showed superiority of OPCAB Vs CABG.

1. Sedrakan - Stroke 2006

41 randomized trials – 50% reduction of stoke in OPCAB

2. Glenville –Ann. Thor. Surg. 2004

Elderly P. Stroke CABG – 3% OPCAB 1%

3. Mohr –Ann. Thor. Surg. 2003

16,184 p. Stroke CABG - 3.8% OPCAB 1.9%

Others

1. Alamanni – Eur. J. Cardioth. Surg. 2007

No difference stroke rate

2. Lund –Ann. Thorac. Surg. 2005

No difference in long term cognitive function or MRI evidence of brain injury

On the Other Hand

Puskas –Ann. Thor. Surg. 2000

In series of 10,800 p. found 3 independent variables for prediction of stroke –age, previous Tia, carotid bruit


4. MYOCARDIAL INJURY as assessed by biochemical

markers is much less after OPCAB when compared to

CABG. Rastan – Eur. J Cardioth. Surg. 2005

5. PULMONARY DYSFUNCTION caused by

atelectasis, inflammation, increased shunting and

volume infusion. Reddy. Eur. J. Cardthor. Surg. 2006

6. RENAL DYSFUNCTION - lower in patients

undergoing OPCAB.


An example of outcome between CABG Vs. OPCAB is

presented in study of “Care Registry”

CABG OPCABNo. of patients 654 597Mean no. of grafts 3.4 +1 2.9+1.2Op. Mortality 1.7% 1.7%Stroke 0.9% 0.7%Reop. for bleeding 2.6% 1.0%Prolonged Ventilation 10.0% 3.4%Atrial Fibrillation 23.0% 15.0%Transfusions needed 51.0% 35.0%Hospital stay 7.5 d 6.2 dMortality 1 y 4.9% 4.6%Myocardial Infarction 1y 1.0% 0.7%Need for Re-vascularization 2.8% 4.1%

Ann. Thor. Surg. 2007


Innovations in OPCAB

- Possible to operate in patients with neoplasticcomorbidities.(Decrease in: inflammatory response, coagulopathy disorders, immunity response and spreading ofmalignancy).

- Possiblity to perform in SEMI awake patient CABG(Br. J. Anaesth. (2008) 100 (2): 184-189.)

- Hybrid Re-vascularization(defined by the performance of coronary bypass surgery and coronary stenting during the same operation.)


OPCAB in a patient with extensive aortic and carotid artery atherosclerotic calcification,

analogous to our case presentation.



OPCAB in a patient with extensive aortic and carotid artery atherosclerotic calcification, In this patient, complete arterial revascularization was performed using the OPCAB technologywithout aortic manipulation, cannulation, or proximal

anastomosis. The left internal thoracic artery (LITA) was anastomosed to the LAD, with a free radial T graft from the LITA anastomosed to both the second obtuse marginal and posterior descending branches. An angiogram showing a radial T graft appears to the right.

RELATED ARTICLES

• Chakravarthy MR, Prabhakumar D. Anaesthesia for off pump coronaryartery bypass grafting - the current concepts. Indian J Anaesth 2007;51:334. http://www.ijaweb.org/text.asp?2007/51/4/334/61162

• Frank W. Sellke, MD, Co-Chair; J. Michael DiMaio, MD. Comparing On-Pump and Off-Pump Coronary Artery Bypass Grafting. Circulation. 2005;111: 2858-2864

• Does off-pump coronary artery bypass (OPCAB) surgery improve theoutcome in high-risk patients?: a comparative study of 1398 high-riskpatients. Eur J Cardiothorac Surg (2003) 23 (1): 50-55. doi: 10.1016/S1010-7940(02)00654-1

• Diastolic dysfunction and off-pump coronary artery bypass. Br. J. Anaesth.(2009) 102 (6): 887-888. doi: 10.1093/bja/aep118

• Haemodynamic changes in OPCAB procedures regarding different coronary artery anastomoses. European Journal of Anaesthesiology: July 2001 - Volume 18 - Issue - p 25–26


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opcab

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compressive devices