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Cardiac Transplantation

Key Points 1. Cardiac transplantation provides significant survival benefit for appropriate candidates and is superior to ventricular assist device implantation alone. 2. Primary graft dysfunction is a major cause of early morbidity and mortality after heart transplantation. 3. Donation after cardiac death and ex vivo cardiac perfusion are two major strategies to increase the cardiac donor pool. 4. Because the cardiac allograft is denervated, direct-acting sympathomimetic drugs…

Uncommon Cardiac Diseases

Key Points 1. Patients with uncommon cardiac diseases frequently have complicated medical conditions, the treatment for which should take place in the context of an institution capable of providing coordinated multidisciplinary perioperative care. 2. A cardiac mass is more likely to be a vegetation or thrombus, rather than a tumor. 3. Cardiac tumors are either primary or secondary (metastatic). Primary cardiac tumors are rare, and secondary…

Thoracic Aorta

Key Points 1. While medical treatment and surveillance can be used to manage select aortic pathology, it is not uncommon for patients with aortic disease to present for surgical intervention. In the setting of certain acute aortic syndromes, surgery is considered emergent. 2. Aortic surgery is complex, and, therefore, it requires an anesthetic tailored to the specific goals for hemodynamics, neurologic monitoring, and cerebral/spinal cord perfusion.…

Adult Congenital Heart Disease

Key Points 1. Comprehensive preoperative, intraoperative, and postoperative care of the adult with congenital heart disease (ACHD) requires a solid understanding of the most common congenital heart defects and the reparative and palliative procedures used to treat them. 2. The current American Heart Association/American College of Cardiology published guidelines for management of adults with congenital heart disease are based on anatomy, physiologic status, and functional class.…

Valvular Heart Disease: Repair and Replacement

Key Points 1. Although various valvular lesions generate different physiologic changes, all valvular heart disease is characterized by abnormalities of ventricular loading. Changes in atrial pressure and volume are now recognized in valvular pathologies as well. 2. The left ventricle normally compensates for increases in afterload by increases in preload. This increase in end-diastolic fiber stretch or radius further increases wall tension in accordance with Laplace’s…

Anesthesia for Myocardial Revascularization

Key Points 1. Anesthesiologists are part of a multidisciplinary patient management team. 2. Updated guidelines identify appropriate indications for coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with multivessel or left main coronary artery disease (CAD). 3. With the decline in CABG volume in favor of PCI, surgical candidates are often sicker, older, and with multiple comorbidities that increase perioperative risk. 4.…

Coagulation Monitoring

Key Points 1. Monitoring the effect of heparin is done using the activated clotting time (ACT), a functional test of heparin anticoagulation. The ACT is susceptible to prolongation because of hypothermia and hemodilution and to reduction because of platelet activation. 2. Heparin resistance can be congenital or acquired. Pretreatment heparin exposure predisposes a patient to altered heparin responsiveness because of antithrombin III depletion, platelet activation, or…

Central Nervous System Monitoring

Key Points 1. Cardiac surgery–associated brain injury is common, multifactorial, and often preventable. 2. Electroencephalography can detect both cerebral ischemia or hypoxia and seizures and can measure hypnotic effect. 3. Middle-latency auditory-evoked potentials objectively document inadequate hypnosis. 4. Brainstem auditory-evoked potentials measure the effects of cooling and rewarming on deep brain structures. 5. Somatosensory-evoked potentials may detect developing injury in cortical and subcortical brain structures and…

Transesophageal Echocardiography: Advanced Echocardiography Concepts

Key Points 1. Intraoperative transesophageal echocardiography (TEE) plays a valuable role in interventional cardiac procedures, when used to guide transseptal puncture, evaluation of left atrial thrombus, closure of paravalvular leaks, transcatheter valve deployment, and during removal of transvenous lead extractions. Real-time three-dimensional (3D) TEE can be displayed to both the interventionalist and the echocardiographer for guidance and intraprocedural monitoring. 2. Precise evaluation of left ventricular function…

Basic Intraoperative Transesophageal Echocardiography

Key Points 1. An ultrasound beam is a continuous or intermittent train of sound waves emitted by a transducer or wave generator. Ultrasound waves are characterized by their wavelength, frequency, and velocity. 2. Doppler frequency shift analysis can be used to obtain blood-flow velocity, direction, and acceleration of red blood cells, where the magnitude and direction of the frequency shift are related to the velocity and…

Monitoring of the Heart and Vascular System

Key Points 1. Standard monitoring for cardiac surgery patients includes electrocardiography, invasive blood pressure, central venous pressure, urine output, temperature, capnometry, pulse oximetry, and intermittent blood gas analysis. 2. Additional monitoring is based on specific patient, surgical, and environmental factors. Potential benefits must be weighed against potential risks on an individual basis. 3. Transesophageal echocardiography (TEE) is recommended for all patients undergoing cardiac surgery, unless contraindications…

Cardiovascular Pharmacology

Key Points Antiischemic Drug Therapy 1. Ischemia during the perioperative period demands immediate attention. The impact of ischemia may be both acute (impending infarction, hemodynamic compromise) and chronic (a marker of previously unknown cardiac disease, a prognostic indicator of poor outcome). 2. Nitroglycerin is indicated in nearly all conditions of perioperative myocardial ischemia. Mechanisms of action include coronary vasodilation and favorable alterations in preload and afterload.…

Cardiovascular Pharmacology of Anesthetics

KEY POINTS 1. Isoflurane, desflurane, and sevoflurane decrease myocardial contractility, delay left ventricular (LV) relaxation, and attenuate early LV filling, but do not affect LV compliance. 2. Volatile anesthetics dilate arteriolar resistance and venous capacitance vessels, but do not alter compliance of the aorta and proximal great vessels or affect characteristic aortic impedance. 3. Isoflurane, desflurane, and sevoflurane preserve LV-arterial coupling and mechanical efficiency at lower…

Coronary Physiology

Key Points 1. The coronary circulation is composed of several types of blood vessels, each with different structure and function, including the superficial conductive arteries, prearterioles, arterioles (resistance vessels), capillaries, and veins. 2. The major determinants of coronary blood flow are extravascular compression, metabolic regulation, pressure-flow autoregulation, and the autonomic nervous system. 3. In the left coronary circulation, extravascular compressive forces during systole (due to high…

Cardiac Physiology

Key Points 1. The cartilaginous skeleton, myocardial fiber orientation, valves, blood supply, and conduction system of the heart determine its mechanical capabilities and limitations. 2. The cardiac myocyte is engineered for contraction and relaxation, not protein synthesis. 3. Laplace’s law allows transformation of alterations in muscle tension and length observed during contraction and relaxation in vitro into phasic changes in pressure and volume that occur in the…

The Cardiorespiratory Effects of COVID-19

Key Points 1. The coronavirus disease 2019 (COVID-19) continues to have a devastating impact on virtually all aspects of human life, from the healthcare system to the economy, social relations, and mental health. 2. Key mechanisms that may have a role in the pathophysiology of multiorgan injury secondary to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) include direct viral toxicity, endothelial cell damage and…

Cardiac Implantable Electronic DevicesPeter M. Schulman, MDEric C. Stecker, MD, MPH

Key Points 1. Transvenous cardiac implantable electronic devices (CIEDs) include pacemakers (PMs), implantable cardioverter defibrillators (ICDs), and cardiac resynchronization therapy pacemakers (CRT-Ps) and defibrillators (CRT-Ds). In addition to delivering antitachycardia therapy, all modern transvenous ICDs and CRT-Ds have antibradycardia pacing capability (ie also function as a PM). 2. CIEDs now also include the subcutaneous ICD (S-ICD) and leadless PM, which both function and respond to magnet…

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

Key Points 1. The cardiac catheterization laboratory (CCL) has evolved from a purely diagnostic facility to a therapeutic one in which many facets of cardiovascular disease can be effectively modified or treated. Despite improvements in equipment, the quality of the procedure depends on well-trained and experienced physicians with proper certification, adequate procedural volume, and personnel committed to the continuous quality improvement process. 2. Guidelines for diagnostic…

Cardiology Consultation and Assessment of Cardiac Risk 1

Key Points 1. Perioperative cardiac morbidity is multifactorial, and understanding the predictive risk factors helps define the risk for individual patients. 2. Assessment of myocardial injury is based on the integration of information from myocardial imaging, electrocardiography, and serum biomarkers. 3. Multivariate modeling has been used to develop risk indices that focus on preoperative variables, intraoperative variables, or both. 4. Echocardiography is the most widely used…