History In the late 1940s Dr.vineberg first reported on the implantation of the LIMA on the myocardiom In 1950s Muray and coworkers reported on successful.

Slides:



Advertisements
Similar presentations
Off pump CABG has been performed for the first time 40 years ago. Although conventional CABG is considered both safe and effective, the use of CBP.
Advertisements

A Clinical Evaluation of Terumo’s Prescriptive Oxygenation™ Series Capiox® FX15 and FX25 Hollow Fiber oxygenators with Integrated Arterial Filter in the.
Wanawimol Saengchote M.D. Department of Anesthesiology, Ramathibodi Hospital, Mahidol U.
 Heart failure is a complex clinical syndrome Can result from:  structural or functional cardiac disorder  impairs the ability of the ventricle to.
General Principles of Postoperative Care The mortality of elective surgery of pulmonary and esophageal resection remains 2 to 4 times than that of elective.
Adequate cerebral perfussion during Cardiopulmonary bypass Present by R1 黃信豪.
Outcomes Research™ Medical Research to Guide Clinical Decisions ©
Spinal cord protection in surgery of descending thoracic aorta Present by R1 康庭瑞.
CARDIAC SURGERY QUESTION #1 Studies comparing CABG vs PTCA have shown that: A) CABG is better B) PTCA is better C) CABG involves more perioperative risk.
Department of O UTCOMES R ESEARCH. Thermoregulation & Heat Balance Thermoregulation during anesthesia Temperature monitoring Consequences of hypothermia.
A few basics of cardiac surgery…. Brett Sheridan, MD Assistant Professor Department of Surgery.
O UTCOMES R ESEARCH Providing the evidence for evidence-based medicine ©
Cardiogenic Shock and Hemodynamics. Outline Overview of shock – Hemodynamic Parameters – PA catheter, complications – Differentiating Types of Shock Cardiogenic.
ANESTHESIA FOR AORTIC SURGERY By: DR. Ahmed Mostafa Assist. Prof. of anesthesia Benha faculty of medicine.
The Vexing Problem of Vasoplegia
HOW I DO IT ? MODIFIED NORWOOD’S OPERATION
Anesthesia Cases.
Monitoring of Patients during Anesthesia and Surgery Haim Berkenstadt MD Director, Department of Anesthesiology Deputy Director, The Israel Center for.
Obstructive Sleep Apnea of Obese Adults Obstructive Sleep Apnea of Obese Adults Pathophysiology and Perioperative Airway Management Anesthesiology, 2009,
Ischemic heart disease. Indications and methods of surgical treatment. Surgery department №2.
Dr. Luc Tambeur Coronary artery bypass grafting CABG - OPCAB.
Coronary Artery Surgical Interventions. Percutaneous Coronary Intervention (PCI) These interventions include balloon angioplasty, intracoronary stent.
The New Priority: Decreasing Readmissions after Cardiothoracic Surgery: How Do We Get There? Michael Zhen-Yu Tong, MD, MBA Department of Cardiothoracic.
AAA stent and anesthetic consideration Presented by 劉志中.
Coronary Artery Disease in Diabetic Patients, Different from Non-diabetics?
Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery Emmanouil I. Kapetanakis, MD; Diego A. Medlam, MD; Kathleen R. Petro, MD; Elizabeth Haile,
Anesthetic agents in cardiopulmonary bypass 麻醉科 Ri 潘聖衛 羅立凱 2003/9/24.
KING ABDULAZIZ UNIVERSITY HOSPITAL CARDIAC SURGERY UNIT Dr. Khalid Al-Ibrahim Dr. Hussein Jabbad Dr. Khalid Medhat Dr. Ragab Shehata.
Adult Perfusion, Present and Future Emad Kashmiri KFNGH.
Without Deep Hypothermia
Chapter 16 Assessment of Hemodynamic Pressures
G. Rainey Williams Symposium September 30, 2005 CABG in the Elderly Patient: On or Off pump? A Single Center Experience R. Nathan Grantham, M.D.
Heart Surgery Georgia Baptist College of Nursing NUR 351 Critical Care Nursing Dr. Kathy Plitnick.
Post-Operative Care Adenocarcinoma. Post-Operative Care After esophagectomy, patients go to an intensive care unit for 24 to 48 hours. They are usually.
Top Papers in Critical Care 2013 Janna Landsperger RN, MSN, ACNP-BC.
Surgical Site Infections Claude Laflamme MD, FRCPC Medical Director Cardiovascular Anesthesia Assistant Professor University of Toronto Faculty, Safer.
Early goal directed therapy in the treatment of sepsis Nouf Y.Akeel General surgery demonstrator Saudi board trainee R3.
Sorin HeartLink – Perfusion Systems and Solutions Christian Chlela Senior Clinical Expert Sorin Group.
Bispectral Index Guided Anesthetic Practice in Cardiac Surgery Dr. Mohamed Essam, MD Assistant Professor, Anesthesia Department Ain Shams University.
Hypothermic ventricular fibrillation. Introduction Cary W. Akins Basic principles developed in Most surgeons use hyperkalemic cardioplegic.
Introduction to anaesthesia
Dr.K.Alizadeh. Assistant Professor of Cardiac Surgery Dr.M.Tabari. Assistant Professor of Anesthesiology Ghaem hospital,Mashad University of Medical Science.
Lund – Malmö, SWEDEN. Is the Era of Off-pump Surgery over? ARASH MOKHTARI, MD, PHD.
 Hiroshima, Japan), 2010 and July 2012, the new shunt tube was used in 100 consecutive patients undergoing OPCABG new coronary shunt tube was easily.
N Engl J Med 2010;362: R3 CHAE JUNGMIN/ Prof KIM MYENGGON.
M.H. Nezafati Associate Professor of Cardiac Surgery
Anesthesia for Non-Obstetric Surgery Most common reasons for surgery: – Appendicitis – Cholecystitis – Trauma – Ovarian torsion.
Minimalist Approach to T-AVR
Revascularization of the Heart
ICU Management of Minimally Invasive Cardiac Surgery
Yadegarynia, D. MD..
EXTRACORPOREAL CIRCULATION
ISCHEMIC HEART DISEASE
Patient Blood Management: Acute Normovolemic Hemodilution
John. J Ricotta, MD, FACS Professor of Surgery, Georgetown University
Safety and Quality in the Cardiothoracic Operating Room
Cardiothoracic Surgery
CRT 2017 Interventional Challenging Case Anterior ST- Elevation Myocardial Infarction Resulting From Acute Occlusion of Left Internal Mammary Artery Graft.
General Anesthesia (GA)
Open Repair of Distal Aortic Arch and Proximal Descending Thoracic Aortic Aneurysm Using a Stepwise Distal Anastomosis  Hitoshi Ogino, MD  Operative Techniques.
Open Repair of Distal Aortic Arch and Proximal Descending Thoracic Aortic Aneurysm Using a Stepwise Distal Anastomosis  Hitoshi Ogino, MD  Operative Techniques.
Catastrophic Events Michael F. Hancock, CCP.
Dr. PJ Devereaux on behalf of POISE Investigators
Mechanical Circulatory Support Devices HOSEIN PASANDI.
James C Hart, MD  The Annals of Thoracic Surgery 
Off-Pump Coronary Revascularization: Operative Technique
Mark W. Connolly, Valavanur A. Subramanian, Nilesh U. Patel 
Risk Factors for Mortality After the Norwood Procedure Using Right Ventricle to Pulmonary Artery Shunt  Shunji Sano, MD, Shu-Chien Huang, MD, Shingo Kasahara,
SURGICAL MYTHS HOW TO IMPROVE THE MANAGEMENT OF OUR SURGICAL PATIENTS
Khalid AlHabib Professor of Cardiac Sciences Cardiology Consultant
Presentation transcript:

History In the late 1940s Dr.vineberg first reported on the implantation of the LIMA on the myocardiom In 1950s Muray and coworkers reported on successful case of coronary endarterectomy In 1961, Goetz, anastemosed RIMA to the RCA and demonstrated for the first time that direct myocardial revascularization without CPB. In 1967, Kolessove, grafted LIMA to the LAD through a left thoracotomy(MIDCAB) During the years following, as a consequence of technical difficulties related to the initial experience with off-pump myocardial revascularization and refinements of techniques of CPB, the off-pump approach was largely abandoned. In 1980 two independent groups continued their work on off-pump and reported favorable outcomes.

Surgical and Anesthetic Concerns Define basic anesthetic concerns Define Off-pump CABG Surgery

Anesthetic Management GETA with or without Thoracic Epidural Monitors – Arterial Line, CVC, PAC, TEE, Cerebral Oximetry, 5Lead EKG IVF – Fluid warmers, Colloid vs Crystalloid, RBCs Drugs – Low dose Heparin, Antifibrinolytics, Narcotics CPB on Backup

There are three anesthetic approach in OPCAB 1. GA with opioids and inhalation anesthesia or total intravenous anesthesia(TIVA) 2. Combined GA with controlled ventilation and neuraxial blockade using high thoracic epidural analgesia(TEA)or combined GA/intrathecal morphine(ITM) 3. Awake regional anesthesia with apontaneous ventilation using TEA alone.

High TEA combined with GA provides: better analgesia better pulmonary outcome reduction in perioperative morbidity &mortality reduction in extubation time shorter hospital stay

High TEA attenuates neuro-hormonal response, provides : thoracic sympatholysis (which improves coronary and mammary artery perfusion) ensures hemodynamic stability decreases myocardial oxygen demand improves myocardial blood flow reduces the risk of arrhythmia myocardial ischemia improves renal function significantly decreases heart rate.

A wake OPCAB : combined femoral block/TEA or spinal anesthesia/TEA or TEA alone Awake cardiac surgery might have some benefits, such as: Short ICU stay, maintenance of spontaneous respiration avoids the disadvantages of mechanical ventilation and GA in high-risk patients Awake cardiac surgery is feasible, but should be performed only in selected patients by highly specialized and experienced health care.

Hemodynamic changes during OPCAB Heart positioning can lead to reduced SV and BP and increases CVP and RVEDP During heart tilting compression free wall RV which is thin and easily deformable lead to abstraction of RV outflow The atria increase their size and become larger than ventricles, contributing to the reduction cardiac output Distortion of mitral and tricuspid annuli leads to MR and TR Terendelenburg position (20 head down) inotropes, adequate fluids, pleuropericardial position, IABP, is helpful

Management ischemia Good collaboration between anesthesiologist and surgeon Maintaining MAP>70 mmHg allows an adequate coronary perfusion Changes in SvO2 and PaCO2 are associated with changes in SjO2 Maintaining value of SvO2>70% maybe important to prevent reduction in cerebral blood flow during OPCAB Heart rate between 70 and 80 bpm, treat tachycardia and prophylactic administration of anti-arrhythmic agents To maintain to myocardial perfusion the surgeon can insert a small shunt into the coronary artery

Benefits of OPCAB Surgery Avoidance of CPB Coagulopathy Neurologic Deficit Air/Plaque Embolism Aortic Manipulation/Clamping Avoidance of Ventricular Arrest, Defibrilation, Pacing Difficulty of separation from CPB Transfusion PRBC, FFP, PLT, Cryo Cannulation site trauma/bleeding Risk of full dose Heparin and Protamine Risk of deep hypothermia <34 Risk of Hemodilution and Volume Shifts Potentially Faster Surgery

Benefits of OPCAB Surgery Decreased Cost to Patient Decreased ICU and Hospital stay Decreased duration of Intubation Decreased requirement for Inotropic, Chronotropic, or Vasoconstrictive support Potentially decreased risk of infection and improved wound healing Potentially Faster recovery

Technical aspects of Off-Pump Surgical approaches Exposure of the coronary targets - Hemodynamic consequences of cardiac elevation and displacement -Preserving hemodynamics during cardiac elevation Mechanical stabilizers The use of the coronary snare - Intracoronary shunts Improving visualization:the co2 blower/saline aeroslizer

CABG+ETCSequ SVG Sequ LIMA CABGYear TotalOFFON Total Mean Number Grafts: 3.76

Conclusion Historically,one of the main obstacles to complete revascularization without CPB has been represented by the inability to adequately: expose the coronary targets minimize their motion preserving cardiac function hemodynamic stability The introduction: the stabilizers of the new generation refinements in techniques of coronary revascularization on the beating heart have improved the feasibility and reliability with which distal anastomosis to all coronary arteries can now be constructed

Thank you for your attention