Endovascular CPB MIDCAB Dr. Sayson

Anesthesia for Port Access Endovascular CPB Surgery Samuel C. Sayson, MD Anesthesia and Operative Service Brooke Army Medical Center Introduction Current state of Endovascular CPB  History of percutaneous cardiac support  Endovascular CPB (Heartport) Design  Surgical procedures  Monitoring  Comparision of Alternate Techniques  – EndoCPB vs Conventional CPB vs MIDCAB Current State of EndoCPB  Explosion of minimally invasive techniques – Consider Growth of laparscopic cholecystectomies Over 3000 EndoCPB cases performed  125 cardiac surgery centers in US  CABGs and MVRs  History of Percutaneous Cardiopulmonary Support 1962 - Dennis - left sided Bipass without thoracotomy  Most systems typically reserved for emergencies  Limitations  – inability to vent heart – inability to arrest heart – inability to protect heart Heartport Systems Four Catheters Closed, endovascular CBP system  Endovenous drainage system -28F  Endoarterial return catheter -21/23F  Endoaortic clamp - 10.5F triple lumen  Endopulmonary Vent cath 8.3F  Endocoronary Sinus Cath - for retrograde cardioplegia  Surgical Technique Anatomic considerations  Valvular and CABG surgery  IMA takedown  – Using ports – Using Keyhole methods Anesthetic Considerations  Fast Track Goals – IV/IH agents – Warm, dry, reversed post op – Hemodynamically stable Percutaneous defib/pacing pads essential  Multiple Monitors  Placement of Coronary Sinus Catheter TEE  Fluroscopy  Distal catheter tip pressure  Monitoring essential throughout CPB  Postioning of Endoaortic Clamp TEE for placement  Distal tip placed over wire just above Sinotubular junction  Evaluate for leaks  Use TEE, A-line, Doppler to monitor migration  Monitoring: Going on Pump  Venous drainage problems – – – – – relative frequent occurance venous pump flow low pulmonary vent cath flow >250ml/min pulsatile radial artery seen on A-line TEE show nonempty right ventricle Assessment of Coronary Sinus Catheter  Use all monitoring modalities to diagnose  Monitoring: Assessment of Endoaortic Catheter Monitors  TEE Ascending Aorta  Pulse wave Doppler of Right Carotid Artery  Balloon Pressure  Aortic Root Pressure  Right Radial Artery Pressure  Flouroscopy Monitoring: Assessment of Endoaortic Catheter Triple lumen Catheter  Ensure venting of Aortic root  – but not too aggressive, esp in MV surgery Compare Radial A-line vs. Aortic root pressure  Watch balloon pressure  Monitoring: Assessment of Endoaortic Catheter   Cardioplegia/Pressurization of Aortic root – Balloon migrates toward aortic arch Balloon can also move toward Aortic valve Monitoring: Assessment of Endoaortic Catheter Problems Aortic Valve incompetence  Coronary Artery Obstruction/Inability to antegrade plege  Loss of brachio-cephalic perfusion  …Plus the problems associated with CPB  Comparisons vs Alternative Techniques Minimally Invasive Coronary Artery Surgery (MIDCABs) Requires limited anterior thoracotomy  Trial occlusion/ischemic preconditioning  Warm ischemia  Isolated targeted lesion  Requires one-lung ventilation, induced brady cardia/sinus pauses, vasopressor  Definition: “Minimally Invasive”  Madison Avenue – MIDCABs – Heartport’s “Port Access” surgery  Surgical community – CPB vs no CPB “Minimally Invasive” Advantages vs CPB as per Madison Avenue Hospital stay shorter = Cheaper  Short RTW interval  Less pain and discomfort  Smaller Scars  MIDCAB and Heartport “Minimally Invasive” Surgical Advantages vs std CPB Skin incision, LAD, Anastamosis in line  Less pericardial scarring  Decreased Sternal dehiscence rate  Decreased Sternal wound infection  Heartport vs MIDCABs Similarities  IMA Graft patiency similar – Heartport – MIDCAB 98-10% 94-96% Minimal Surgical Incision  Fast track postop period  Heartport vs MIDCABs Unique Features  Heartport – Maintains advantages of CPB/cardioplegia – OLV not necessary – Multiple targets  MIDCAB – Avoids problems of CPB/cardioplegia – OLV – Single lesions Heartport vs Conventional Both provide CPB  Limited surgical exposure  – – – –  good for Madison Ave, bad for the OR consider intraop emergencies technical skills monitoring and equipment Sternotomy vs Port-thoracotomy wound MIDCAB vs Conventional Unique features of MIDCAB Wound size/Return to work  Avoids complications from Cannulations  MIDCAB avoids post-CPB dysfunction syndromes  – – – – – CNS Cardiac Pulmonary GI tract Hematologic/Cell Mediated Immunity MIDCAB vs Conventional Disadvantages of MIDCABs MIDCAB with limited applicability  CPB not available for hemodynamic support with MIDCABs  Outcome Data PA-CPB Surgery vs STS Database Port Access CPB surgery (N=987) 3.2 2 0.4 Port Access CABG 1.8 1.2 0.8 17 Cohort CABG Mortality(%) Stroke(%) MI(%) Afib(%) 3.1 2.2 1.2 4.8 (p<0.05) Presented at 1997 ACS Ann Mtg Summary Endovascular CPB provides features similar to CPB  Perhaps more cardio-surgical opportunities may develop  Satisfies consumer desires of less scars, quicker recovery 