postgraduate education for cardiothoracic anaesthesia and intensive care doctors in cardiac operations on patients with unstable ischemic heart disease

1. Unstable coronary patient
in the OR
Andreas Nygren
MD, PhD
Presentation for SSAI-CTVA
postgraduate course in cardiothoracic
anaesthesia and intensive care in
Aarhus april 2018

2. What to expect
Hemodynamically stable, nonischemic patients
Hemodynamically stable, ischemic patients.
Hemodynamically unstable, nonischemic patients
Hemodynamically unstable, ischemic patients

3. Acute myocardial infarction
Low EF
Stress, Pain
Cell swelling, arythmias
Hypoxia
Hypotension
Coagulation
Unconciousness
fibrillation

4. Statistics from Swedeheart
PCI/ CABG
Acute operations

5. Operation or PCI
Andreas Nygren

6. Primary decision proposed by the
angiographer following coronary
angiography in patients with
registered left main stem stenosis,
per hospital

7. Primary decision after coronary
angiography with finding of
three-vessel disease in
patients < 80 years with
diabetes mellitus (DM) and
stable coronary artery disease,
2016.

8. Heartsurgery/100000 inhabitants 2016
Andreas Nygren
Figure 14. Distribution of
isolated coronary surgery
among counties, operated
patients per 100 000
inhabitants, 2016.
The extremely skewed
distribution among counties
has been almost identical for
several years. The differences
of almost a factor of ten are
problematic from the point of
view that healthcare should
be equally offered to all
patients across the country.
The two most extreme
counties, Gävleborg and
Dalarna, referred even less
patients to CABG in 2016
compared with 2015.
Källa : Swedeheart årsrapport 2016

9. CABG in Sweden
Swedeheart 2014

10. Proportion PCI/CABG interventions in different counties
in Sweden 2016.
Andreas Nygren

11. Do STEMI patients come to OR?
Swedeheart 2016

12. Do STEMI patients come to OR?
Swedeheart 2014

13. Cardiogenic shock patients
Swedeheart 2014

14. Ischemic heart and surgery

15. Cardiogenic
shock
Myocardial infarctionMyocardial infarction
Myocardial dysfunctionMyocardial dysfunction
SystolicSystolic DiastolicDiastolic
Cardiac outputCardiac output
Stroke volumeStroke volume
HypotensionHypotension
CoronaryCoronary
Perfusion pressurePerfusion pressure
IschaemiaIschaemia
LVEDPLVEDP
Pulmonary congestionPulmonary congestion
HypoxemiaHypoxemia
CompensatoryCompensatory
vasoconstrictionvasoconstriction

16. MDO2 (myocardial oxygen delivery)
Heart frequenzy
– Tachycardia -> shorter diastolic time
– Bradycardia -> LA pressure increases,
diastoliskt pressure decreases
=> decreased CPP 
Perfusion pressure
– Hypotension –autoregulation
Stenosis
– Significant stenos =>pressure dependent
flow
Vasokonstriktion
Anemia, hypoxia
– oxygen content decreases
Coronary blood
flow pattern
Diastolic time

17. MVO2 (myocardial oxygen consumption)
Heart frequenzy (Tachycardi)
Wall tension
– Preload (end diastolic volume)
– afterload
– Thickness - Hypertrofy
Contractility
– Inotropic support

18. Vasodilation and coronary stenosis
-Coronary steal phenomenon
Steal prone anatomy
occluded vessel with stenotic supporting
collaterals
Dilation of vessels in normal area steals flow
from the collateral and the ischemic area
Anaesthesia gases dilates coronary
vessels
Isoflurane-A Powerful Coronary Vasodilator in
Patients with Coronary Artery Disease. Reiz S et al
Anestesiology 1983
Isoflurane does not induce steal
phenomenon in patients with normal
perfusion pressures
Isoflurane and coronary heart disease.Agnew NM.
Anaesthesia. 2002 Apr;57(4):338-47

19. Ischemic monitoring
ST analysis
With 5 lead ECG:
II + V5
-80-90% sensitivity for detection of
ischemia episodes,
II best for atrial dysrythmias

20. Ischemic monitoring
12 lead analysis ECG
ST analysis n=185
V3
-86% sensitivity for
detection of ischemia
Two precordial
-92-95% sensitivity for
detection of ischemia
Landesberg et al, Anestesiology 2002

21. Ischemic Preconditioning
Early phase within first hour
Late phase after 24h
Short, transient periods of tissue ischemia render the tissue
resistant to subsequent usually lethal periods of ischemia
Preconditioning with ischemia: A delay of
lethal cell injury in ischemic myocardium.
Circulation 1986; 74:1124-36.
Murry CE, Jennings RB, Reimer KA:
Reduces infarction size 25% in
experimental setting

22. Pharmacologic preconditioning
”Gas-induced preconditioning”
 Comparable to ischemic preconditioning
 ATP sensitive potassium channels
Increases mitocondrial reactive oxygen
species ROS
 changes genetic expression
May be blocked by drugs
Ketamin, Propofol, B-blocker, Aprotinin
Tanaka K, Ludwig LM, Kersten JR et al. Mechanisms of
cardioprotection by volatile anesthetics. Anesthesiology
2004;100:707–21

23. Pharmacologic preconditioning
Curr Vasc Pharmacol. 2008 Apr;6(2):108-11.
Cardiac protection by volatile anaesthetics: a review.
Landoni G1, Fochi O, Torri G.
“In conclusion, the use of desflurane and
sevoflurane appears to yield a better
outcome, in terms of mortality and cardiac
morbidity, in patients undergoing cardiac
surgery.”
ACC/AHA 2007 Guideline
recommend the use of volatile anaesthetic
agents during non-cardiac surgery in
patients at risk for AMI (Class IIa, level B)

24. Pharmacologic preconditioning
“There is class Ia evidence for the myocardial
protective properties of sevoflurane and
desflurane in low risk patients undergoing
coronary artery bypass grafting surgery.
…..improve clinical outcomes
and health economics following cardiac
surgery, reducing intensive care and hospital stay”.
HSR Proceedings in Intensive Care and Cardiovascular Anesthesia 2010; 2: 105-109

25. Pharmacologic preconditioning
Conclusions
In cardiac, but not in noncardiac, surgery, compared to TIVA, general
anesthesia with volatile anesthetics was associated with major benefits in
outcome, including reduced mortality, as well as lower incidence of
pulmonary and other complications.
Anestesiology 2016

26. Gas-TIVA?
Conclusions—Compared with propofol, sevoflurane did not
reduce the incidence of myocardial ischemia in high-risk
patients undergoing major noncardiac surgery. The sevoflurane
and propofol groups did not differ in postoperative NT-proBNP
release, major adverse cardiac events at 1 year, or delirium
Giovanna A.L. Lurati Buse et al Circulation 2012.
Randomized Comparison of Sevoflurane Versus Propofol
to Reduce Perioperative Myocardial Ischemia in Patients
Undergoing Noncardiac Surgery
ACC/AHA 2014

27. Gas-TIVA?
2017 EACTS Guidelines on perioperative medication in adult cardiac surgery
Miguel Sousa-Uva* Stuart J Head Milan Milojevic Jean-Philippe Collet Giovanni Landoni Manuel Castella Joel Dunning Tóma
Author Notes
European Journal of Cardio-Thoracic Surgery, Volume 53, Issue 1, 1 January 2018, Pages 5–33, https://doi.org/10.1093/ejcts
Published:
06 October 2017

28. Andreas Nygren
Ongoing multicenter study: MYRIAD
MortalitY in caRdIAc surgery: A randomizeD controlled trial of volatile
anesthetics.
DESIGN:
Single blinded, international, multicenter randomized controlled trial with
1:1 allocation ratio.
SETTING:
Tertiary and University hospitals.
INTERVENTIONS:
Patients (n=10,600) undergoing coronary artery bypass graft will be
randomized to receive either volatile anesthetic as part of the anesthetic
plan, or total intravenous anesthesia.
The primary end point of the study will be one-year mortality (any
cause)

29. Remote preconditioning, RIPC
Repeted brief inflation of blood pressure cuff on arm and/or leg
Protects endothelial function.
Protects Myocardial injury in PCI and bypass surgery, and reperfused myocardial
infarction
Neuronal or humoral comunication
Can be transferred between animals
with plasma dialysate
Effect of remote ischaemic preconditioning on
clinical outcomes in patients undergoing
cardiac bypass surgery: a randomised
controlled clinical trial. Candilio, Heart 2015
Feb;101(3):185-92
Bypass patients n =180
Reduces
AUC high sens tropT 26%,
Atrial fibrillation 54%
Intensiv care stay 1day
Bypass patients n =329
Reduces
AUC tropI 266 v.s. 321
Mortalitet HR 0.27, p=0.046
Review
Remote ischaemic conditioning: cardiac
protection from afar
V. Sivaraman Anaesthesia 2015, 70, 732–748

30. Remote preconditioning
JAMA 2015

31. Remote preconditioning
ERICCA trial University College London Hospitals
randomized 1,612 patients (mean age 76 years; 70.8%
male) undergoing on-pump CABG to receive remote
ischemic preconditioning (n = 801) or a sham
procedure (n = 811) at 29 hospitals in the United
Kingdom.
Remote Ischemic Preconditioning and Outcomes of Cardiac Surgery
the ERICCA Trial Investigators
N Engl J Med 2015; 373:1408-1417October 8, 2015DOI: 10.1056/NEJMoa1413534

32. Anaesthesia induction of a
ischemic patent
Cardiac premedication
beta blocker,
Noncardiac premedication
bensodiazepines, opioids, scopolamine
Induction
pentothal, propofol, ketamine
pancuronium, rocuronium, vecuronium
fentanyl, sufentanil

33. Arterial and venous access
A rad sin v.s. dx
A femoralis
-Keep arterial lines from
card lab
SwanGanz?
Ultrasound guidance?
Cerebral monitoring?
BIS?
v. jug. Int.
v. subclavia

34. Peroperative TOE
• Wall motion abnormalities
• Cannulation site aorta
• Positioning of cannula in v cava inf
• weaning
Practice Guidelines for Perioperative Transesophageal Echocardiography

35. Monitoring -TOE
Pre bypass wall motion abnormalities
Post bypass wall motion abnormalities
Abnormal findings 11,4% decision making in 5,8%
Impact of intraoperative transesophageal schocardiography
in cardiac and thoracic aortic surgery: experience in 1011
cases
Kihara J of Cardiol 2009 okt vol 54 issue 2 p 282-288

36. Reperfusion
Myocardial stunning -reversible
reduction of function of contraction
Up to 1 day after operation
Changes in intracellular Ca++, decreased Ca++
sensitivity, free radicals
Experimentally reduced by antioxidants, calcium
antagonists
Reversed by expectancy/reperfusion, calcium injection
or inotropy

37. Weaning from ECC
Clinical Review: Management of weaning from cardiopulmonary
bypass after cardiac surgery
Licker et al Ann Card Anest 2012

38. Inotropic support
Toller, Anesthesiology 2006; 104:556–69

39. Choose drug depending on
expected effect

40. Levosimendan
Levosimendan in Patients with Left Ventricular Dysfunction
Undergoing Cardiac Surgery
R.H. Mehta, et al for the LEVO-CTS Investigators
N Engl J Med 2017;376:2032-42.
882 pts
CONCLUSIONS
Prophylactic levosimendan did not result in a rate of the short-term composite end
point of death, renal-replacement therapy, perioperative myocardial infarction, or
use of a mechanical cardiac assist device that was lower than the rate with placebo

41. Levosimendan
Levosimendan for Hemodynamic Support
after Cardiac Surgery
G. Landoni, et al for the CHEETAH Study Group*
N Engl J Med 2017;376:2021-31
stopped for futility after 506 patients were enrolled.
A multicenter, randomized, double-blind, placebo-controlled trial
involving patients in whom perioperative hemodynamic support was indicated
after cardiac surgery, according to prespecified criteria.
Patients were randomly assigned to receive levosimendan (in a continuous infusion at
a dose of 0.025 to 0.2 μg per kilogram of body weight per minute) or placebo, for up to
48 hours or until discharge from the intensive care unit (ICU), in addition to standard
care.
The primary outcome was 30-day mortality.
Conlucion Levosimendan not better than placebo

42. Levosimendan
Conclusion
In summary, the meta-analysis suggests that levosimendan therapy reduced
the risk of death in single-center trials and in trials of inferior
quality, but there was no benefit of levosimendan on
survival in multicentric and in high-quality trials.
levosimendan therapy was associated with reduced mortality
in patients with preoperative ventricular systolic dysfunction.
Furthermore, in these patients, levosimendan
therapy resulted in less renal replacement therapy and
shorter ICU stays.
Effect of levosimendan on prognosis in
adult patients undergoing cardiac surgery:
a meta-analysis of randomized controlled trials
Chen et al. Critical Care (2017) 21:253

43. Difficult to Wean from ECC
Clinical Review: Management of weaning from cardiopulmonary
bypass after cardiac surgery
Licker et al Ann Card Anest 2012

44. Thank you