Fawzeya Aboul Fetouh
Professor of Anesthesia Cairo Universityfawziafetouhyahoocom
The last 10 years advances
6th Assiut Anesthesia Conference Hurghada 3-7 Dec 2012
1272012
Discuss lessons learned from SCA annual meeting Bullitin October 2012 ECTAS Cairo Feb 2012
EACTA June Amesterdam 2012 aimed to introduce update in cardiac anesthesia and to Evaluate
controversial issues
Update in biomedical technology
Surgical techniques update
Cardiac anesthesia update
Update in CPB and Perfusion techniques
Post operative strategy update
1272012
Innovative diagnostic and interventional techniques
Coronary angioplasty
Balloon valvoplasty
Hybrid valve surgery mitral and aorta
1272012
UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring
with wide range of accuracy Increase awareness of splanchnic circulation
introduction of gastric tonometry and TEE imaging of the portal circulation
Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient
Bed side monitoring of Hb and Meth Carboxy Hb
Mathews JP et al ASE SCA Recommendations and Guidelines for CQI in Perioperative Echo JASE + Anesth Analg 2009
1272012
Live 3D
Clinically-proven 3D technology
MiniaturizationNext generation micro-beam forming
+ Pure Wave CrystalExceptional image quality
+
Innovative use of 3D TEE minimization More resolution
1272012
MV AV
1272012
Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting
Transmyocardial laser revascularization
Stem cell therapy
Robotic surgery
Ballon valvoplasty
Transcatheter valve surgery
1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Discuss lessons learned from SCA annual meeting Bullitin October 2012 ECTAS Cairo Feb 2012
EACTA June Amesterdam 2012 aimed to introduce update in cardiac anesthesia and to Evaluate
controversial issues
Update in biomedical technology
Surgical techniques update
Cardiac anesthesia update
Update in CPB and Perfusion techniques
Post operative strategy update
1272012
Innovative diagnostic and interventional techniques
Coronary angioplasty
Balloon valvoplasty
Hybrid valve surgery mitral and aorta
1272012
UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring
with wide range of accuracy Increase awareness of splanchnic circulation
introduction of gastric tonometry and TEE imaging of the portal circulation
Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient
Bed side monitoring of Hb and Meth Carboxy Hb
Mathews JP et al ASE SCA Recommendations and Guidelines for CQI in Perioperative Echo JASE + Anesth Analg 2009
1272012
Live 3D
Clinically-proven 3D technology
MiniaturizationNext generation micro-beam forming
+ Pure Wave CrystalExceptional image quality
+
Innovative use of 3D TEE minimization More resolution
1272012
MV AV
1272012
Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting
Transmyocardial laser revascularization
Stem cell therapy
Robotic surgery
Ballon valvoplasty
Transcatheter valve surgery
1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Innovative diagnostic and interventional techniques
Coronary angioplasty
Balloon valvoplasty
Hybrid valve surgery mitral and aorta
1272012
UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring
with wide range of accuracy Increase awareness of splanchnic circulation
introduction of gastric tonometry and TEE imaging of the portal circulation
Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient
Bed side monitoring of Hb and Meth Carboxy Hb
Mathews JP et al ASE SCA Recommendations and Guidelines for CQI in Perioperative Echo JASE + Anesth Analg 2009
1272012
Live 3D
Clinically-proven 3D technology
MiniaturizationNext generation micro-beam forming
+ Pure Wave CrystalExceptional image quality
+
Innovative use of 3D TEE minimization More resolution
1272012
MV AV
1272012
Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting
Transmyocardial laser revascularization
Stem cell therapy
Robotic surgery
Ballon valvoplasty
Transcatheter valve surgery
1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
UPDATE IN MONITORING Regression of the of pulmonary artery Cather Introduction of Non invasive cardiac output monitoring
with wide range of accuracy Increase awareness of splanchnic circulation
introduction of gastric tonometry and TEE imaging of the portal circulation
Cerebral Oximetry which made revolution of the neurocognitive outcome in eldrly cardiac patient
Bed side monitoring of Hb and Meth Carboxy Hb
Mathews JP et al ASE SCA Recommendations and Guidelines for CQI in Perioperative Echo JASE + Anesth Analg 2009
1272012
Live 3D
Clinically-proven 3D technology
MiniaturizationNext generation micro-beam forming
+ Pure Wave CrystalExceptional image quality
+
Innovative use of 3D TEE minimization More resolution
1272012
MV AV
1272012
Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting
Transmyocardial laser revascularization
Stem cell therapy
Robotic surgery
Ballon valvoplasty
Transcatheter valve surgery
1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Live 3D
Clinically-proven 3D technology
MiniaturizationNext generation micro-beam forming
+ Pure Wave CrystalExceptional image quality
+
Innovative use of 3D TEE minimization More resolution
1272012
MV AV
1272012
Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting
Transmyocardial laser revascularization
Stem cell therapy
Robotic surgery
Ballon valvoplasty
Transcatheter valve surgery
1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
MV AV
1272012
Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting
Transmyocardial laser revascularization
Stem cell therapy
Robotic surgery
Ballon valvoplasty
Transcatheter valve surgery
1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Establishment of Off-pump coronary artery bypass (OPCAB) and Total arterial grafting
Transmyocardial laser revascularization
Stem cell therapy
Robotic surgery
Ballon valvoplasty
Transcatheter valve surgery
1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
1) one lung ventilation during TMR2) hemodynamic monitoring guided by transesophageal echocardiography3) hemodynamic support by pharmacological and mechanical interventions
such as catecholamines and intra-aortic balloon pump for myocardial dysfunction during and following TMR
4) potential risk of bleeding from the perforation following TMR and this risk should be more emphasized if systemic anticoagulation is required
5) early recovery and epidural anesthesia for postoperative analgesia when the operation is performed without cardiopulmonary bypass
1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
1 It is fast-track anesthesia protocol 2 Rapid ventricular pacing and cessation of mechanical ventilation
interrupts cardiac ejection and minimizes heart translocation3 Vasopressor administration before pacing and cardioversion may
restore adequate hemodynamics4 Transesophageal echocardiography is used to assess valve size and for
hemodynamic monitoring 5 Mostly off pump procedure with CPB machine backup
1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Anesthesia- have evolved with improvements in surgicalradiological technique Low incidence conversion to open repair
Types local anesthesia + sedation regional combined regionalGA or GA alone
AAA- std ASA monitors art line 2 PIVs TAA- add CSF drain IOTEE
May need to darr BP during stent deployment SNP NTG adenosine rapid pacing
Michael Andritsos Anesthesia and the endovascular stenting patient 1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Robot can accomplish surgery via smaller portal than with conventional minimally invasive techniques
Further reduction in size of incision
May ultimately provide opportunity for ldquotelesurgeryrdquo where operator could be at long distance from patient
1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Introduction of TEE in pediatric patient
more complicated anomalies is now makes an intraoperative challenge for the pediatric cardiac anesthesiologist
Early surgical interference more young age
Progressive interventional Minimally invasive palliative procedures in the cath lab as Ballonvalvoplasty closusure of ASD VSD and PD puts a load on the pediatric cardiac anesthiologists
1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Warm or tepid cardioplegia
Ultrafiltration as routine use in CPB
Portable modular CPB
1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
(1) Bruckenberger E Herzbericht 2006
(2) Tebbe U et al Ruumlckgang der Krankenhaus-Sterblichkeithellip Dtsch Med Wochenschr 2007 132 1559 ndash1556(3)ESC Euro Heart Survey ndashCardiovascular Diseases in Europe 2006(4)Heller Guumlnther Sterblichkeitsrisiko von Frauen und Maumlnnern nach Myokardinfarkt Dtsch Arztebl 2008 105(15)279-85 1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Introduction of concept of cardioprotection brain protection
Introduction of the concept of ischemic preconditioning
Introduction of newer concept of intropicagents
1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Based on TEE assessment of the cardiac output LV function after separation from CPB
No ldquounnecessaryrdquo Preemptive inotropes
More awareness to afterload reduction and hemodynamic parameters modulation
1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Cardiac glycosides Calcium sensitizers Liothyronine (T3)
1272012
Binds to troponin C [Cai] ndashdependently does not impair diastolic relaxation
Effects continue 24 hours after drug stopped in CHF patients active metabolite
Small trials in cardiac surgery patients using 8-36 μgkg load plusmn 02-03 μgkgmin infusion (uarrCO darrSVR and darrPVR)
Kivikko Circulation 200310781-86Follath Lancet 2002360196-202
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
bull IABP (Intra-aortic balloon pump)
coronary perfusion with inotropes to
activate oxygen deprived cells
Mortality with 3 inotropes= 80 1
bullMortality with multi-organ failure
two organs = 80 2
bullImpella unloads left ventricle
bullIncreases flow to heart and organs
without inotropes amp reduces
workload 3
1 Publication Samuels LE amp al J Card Surg 1999 Jul-Aug14(4)288-93 100 Post-CS 1996-1999
2 PAMI-II Stone et al J Am Coll Cardiol 291459 19973 MValgimigli et alCatheterization amp Cardiovascular Interventions 65263ndash
267 (2005)
IABP
blood outlet
blood inlet
pigtail
9F-Catheter
1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
Introduction of recombinant factor VIIa in intractable medical bleeding and in Dissecting AA
Regression of aprotinin Wide spread use of tranexemic acid Cell saver tchnology Use of ROTEM to assess coagulopathy and use
target therapy
1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
1048708 Cardiac function temperature bleeding respiratory function and mental status are deciding factors
1048708 Requires committed Critical Care Nursing and clear protocol for early Extubation
Fast-Track Anesthesia and Cardiac Surgery A Retrospective Cohort Study of 7989 PatientsANESTHESIA amp ANALGESIA Vol 108 No 3 March 2009
Thank you1272012
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