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Cardiac Catheterization Laboratory: Diagnostic and Therapeutic Procedures in the Adult Patient

Key Points 1. The cardiac catheterization laboratory has evolved from a purely diagnostic facility to a therapeutic one in which many facets of cardiovascular disease can be effectively modified or treated. 2. Guidelines for diagnostic cardiac catheterization have established indications, contraindications, and criteria to identify high-risk patients. 3. Interventional cardiology began in the late 1970s as balloon angioplasty, with a success rate of 80% and emergent…

Cardiac Risk, Imaging, and the Cardiology Consultation

Key Points 1. Multivariate modeling has been used to develop risk indices that focus on preoperative variables, intraoperative variables, or both. 2. Key predictors of perioperative risk are dependent on the type of cardiac operation and the outcome of interest. 3. New risk models have become available for valvular heart surgery and for combined coronary and valvular cardiac procedures. 4. Perioperative cardiac morbidity is multifactorial, and…

General Critical Care

Key Points 1. Cardiac surgical patients who require intensive care represent a particular population whose outcomes are dependent on decision-making throughout the perioperative period. 2. Cardiac surgery patients are susceptible to acute kidney injury (AKI) from a variety of mechanisms including malperfusion, exposure to cardiopulmonary bypass (CPB), use of vasoactive medications, fluid resuscitation, and administration of blood products. 3. Chronic kidney disease is independently associated with…

Postoperative Care of the Heart and Lung Transplant Patient

Key Points 1. The care of heart and lung transplant patients requires a multidisciplinary approach by a team dedicated to collaborating to provide the best care. 2. Inotropic therapy is often required for patients undergoing heart or lung transplantation with lung transplant patients primarily requiring right heart support. 3. Atrial fibrillation impacts both heart and lung transplant patients. 4. Immunosuppression must be carefully monitored by the…

Intensive Care Unit Management of Patients on Mechanical Circulatory Support

Key Points 1. Intra-aortic balloon pump counterpulsation increases coronary artery perfusion pressure, increases coronary artery blood flow (particularly in cardiogenic shock), and augments cardiac output by approximately 5% to 15%. 2. Catheter-mounted ventricular assist devices (VADs) are available for isolated right ventricular and left ventricular support. Left ventricular support devices can provide between 2.5 and 5.5 L/min of blood flow, depending on the product. Echocardiography should…

Postoperative Cardiovascular Management

Key Points 1. Maintaining oxygen transport and oxygen delivery appropriately to meet the tissue metabolic needs is the goal of postoperative circulatory control. 2. Cardiac function worsens after cardiac surgery. Therapeutic approaches to reversing this dysfunction, including pharmacologic and mechanical support, are important and often can be discontinued in the first few postoperative days. 3. Myocardial ischemia often occurs postoperatively after coronary revascularization, and it is…

Postoperative Respiratory Care

Key Points 1. Pulmonary complications following cardiopulmonary bypass (CPB) are relatively common with up to 12% of patients experiencing some degree of acute lung injury and approximately 1% requiring tracheostomy for long-term ventilation. 2. Patients with preexisting chronic obstructive lung disease have higher rates of pulmonary complications, atrial fibrillation, and death. 3. Operating room events that increase risk include reoperations, blood transfusions, prolonged CPB time, and…

Critical Care Ultrasound

Key Points 1. Point-of-care ultrasound performed in the critical care setting is a valuable tool for augmenting traditional methods of clinical evaluation. 2. Key components of this examination include portable ultrasound imaging with “real-time” interpretation at the bedside in a focused, reproducible, goal-directed, and rapid fashion to answer specific clinical questions and guide subsequent clinical intervention. 3. In the intensive care unit, airway ultrasound can assess…

Central Nervous System Dysfunction After Cardiac Surgery

Key Points 1. Despite a progressive decrease in cardiac surgical mortality, the incidence of postoperative neurologic complications has remained relatively unchanged over the decades. During this same interval, the age and the extent of comorbidities in cardiac surgical patients have increased. 2. Neurologic complications range from coma, stroke, and visual field deficits to impairments of cognitive processes (e.g., delirium, impaired memory and attention, mood alterations). These…

Pain Management for the Cardiac Patient

Key Points 1. Inadequate postoperative analgesia and/or an uninhibited perioperative surgical stress response has the potential to initiate pathophysiologic changes in all major organ systems, including the cardiovascular, pulmonary, gastrointestinal, renal, endocrine, immunologic, and/or central nervous systems, all of which may lead to substantial postoperative morbidity. Adequate postoperative analgesia prevents unnecessary patient discomfort and may decrease morbidity, postoperative hospital length of stay, incidence of chronic pain,…

Enhanced Recovery Programs in Cardiac Surgery

Key Points 1. Enhanced recovery is a multidisciplinary approach to quality improvement that spans all phases of surgical care. 2. The patient’s experience, health-related outcomes, and functional recovery are optimized through the standardized application of perioperative care bundles consisting of best evidence-based practices. 3. Successful implementation of enhanced recovery programs requires collaboration, education, patient engagement, comprehensive audit, and strategies to initiate and sustain organizational change. 4.…

Coagulation and Transfusion Management

Key Points 1. Clinical hemostasis reflects an integrated interplay between the coagulation system, the fibrinolytic system, platelets, and the vascular endothelium. 2. The coagulation cascade has four main components, namely the contact activation, the extrinsic, the intrinsic, and the common pathways. There are multipole modulators of these coagulation pathways including thrombin, antithrombin III, protein C, protein S, tissue factor pathway inhibitor, and the von Willebrand factor.…

Extracorporeal Membrane Oxygenation

Key Points 1. Extracorporeal membrane oxygenation (ECMO) continues to experience a profound expansion as therapy for acute cardiopulmonary failure. 2. Advancements in equipment and improvements in techniques and management have led to improved outcomes for patients undergoing ECMO. 3. Venoarterial (VA) ECMO should be considered for patients with acute cardiac or combined cardiac and respiratory failure. 4. Venovenous (VV) ECMO is indicated for patients with adequate…

Discontinuing Cardiopulmonary Bypass

Key Points 1. The key to successful weaning from cardiopulmonary bypass (CPB) is proper preparation and close communication between the surgeon, anesthesiologist, and perfusionist. A checklist may be useful. 2. After rewarming the patient, correcting any abnormal blood gases, and inflating the lungs, make sure to turn on the ventilator. 3. To prepare the heart for discontinuing CPB, optimize the cardiac rate, rhythm, preload, myocardial contractility,…

Cardiopulmonary Bypass: Pathophysiology and Management

Key Points 1. All anesthesiologists who care for patients undergoing cardiopulmonary bypass (CPB) should be intimately familiar with the details and function of the extracorporeal circuit (ECC) or “heart-lung machine,” and be involved in the establishment of protocols and the conduct of CPB during cardiac surgery. Communication and teamwork are of paramount importance to the safe conduct of CPB. 2. The goal of CPB is to…

Electrophysiology Procedures

Key Points 1. Arrhythmias with triggered mechanisms are often initiated from repetitive depolarizations that occur after membrane repolarization. 2. Atrioventricular reciprocating tachycardia requires an accessory pathway to initiate and maintain the supraventricular arrhythmia. 3. Catheter-based ablation is a reasonable therapeutic intervention for atrial fibrillation with either radiofrequency or cryotherapy. 4. When esophageal temperature monitoring is limited in ablation procedures, core temperature monitoring at an alternative site…

Structural Heart Disease Procedures

Key Points 1. Structural heart disease intervention is a rapidly growing field that has expanded beyond transcatheter aortic valve implantation to include procedures that address each cardiac valve, as well as paravalvular leak, intracardiac shunts, and left atrial appendage occlusion for stroke and systemic embolism prevention. New devices and new indications for existing devices continue to be investigated. 2. Transcatheter aortic valve implantation is one of…

Durable Mechanical Circulatory Assist Devices for Heart Failure

Key Points 1. Mechanical circulatory support (MCS) for the failing heart has become a mainstay of the modern management of patients with both acute and chronic heart failure (HF) refractory to pharmacologic and other usual interventions. 2. Outcomes with MCS have improved so dramatically that the main focus of this arena has now shifted away from simple survival to mitigation of risk and minimization of adverse…

Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Key Points 1. Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolution of a pulmonary embolus (PE) or from recurrent PEs. It is an underappreciated phenomenon and incidence is difficult to estimate. 2. The cause of CTEPH after acute PE is not fully understood. Proposed mechanisms include abnormalities in fibrinolytic enzymes or resistance of the thrombus to fibrinolysis. 3. Pulmonary thromboendarterectomy (PTE) is the most effective…

Lung Transplantation

Key Points 1. Lung transplantation is a palliative procedure that provides a significant survival benefit for the appropriate candidates. 2. Primary graft dysfunction is the major cause of early morbidity and mortality after lung transplantation. 3. There are four types of end-stage lung disease, obstructive, restrictive, suppurative, and pulmonary vascular, and each type has its own specific perioperative management. 4. The use of extracorporeal membrane oxygenation…