Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery





Perioperative Myocardial Ischemia and Infarction


Definition


Perioperative myocardial ischemia is difficult to define, as it represents a continuum with clinically irrelevant events at one end of the spectrum and myocardial infarction (MI) leading to complete ventricular failure at the other end. The diagnosis of perioperative myocardial ischemia and/or infarction is challenging in the setting of cardiac surgery, specifically because of the elevation of cardiac enzymes that accompanies even uncomplicated procedures ( Fig. 13.1 A,B ). For instance, using high-sensitivity troponin release assays, Markman et al 1 demonstrated a rise in troponin even after transcutaneous aortic valve implantation. Similarly, the electrocardiographic (ECG) changes that typify ischemia and infarction in the nonoperative setting may instead reflect postoperative pericardial inflammation or subclinical myocardial injury incurred during routine surgical manipulation. Therefore, accurate determination of ongoing ischemia often requires a systematic, multifaceted approach, including serial evaluation of ECG changes, biochemical markers, echocardiography, and even angiography. Importantly, early detection of perioperative ischemia may prompt therapies to relieve the ischemia and minimize the incidence of subsequent infarction.




Fig. 13.1


(A) Changes in troponin T values after common cardiac surgery operations. (B) Biochemical values measured in patients who received uncomplicated cardiac surgery.

AVR , Aortic valve replacement; CABG , coronary artery bypass grafting; CK-MB , creatine kinase-MB isoenzyme; MVR , mitral valve repair/replacement; OPCAB, off-pump coronary artery bypass; TAVI , transfemoral aortic valve implantation. ([A] is adapted with permission from Markman PL, Tantiongco JP, Bennetts JS, et al. High-sensitivity troponin release profile after cardiac surgery. Heart Lung Circ . 2017;26:833-839. [B] is redrawn with permission from Holmvang L, Jurlander B, Rasmussen C, et al. Use of biochemical markers of infarction for diagnosing perioperative myocardial infarction and early graft occlusion after coronary artery bypass surgery. Chest . 2002;121:103–111.)




The interpretation of ECG changes remains valuable for defining ischemia in the perioperative period. Table 13.1 summarizes various clinical entities that may lead to ST-segment changes in this setting, including myocardial ischemia and infarction. After cardiac surgery, the initial ECG may be difficult to interpret because of lead placement changes related to surgical dressings, because of cardiac pacing, and because of the common presence of conduction abnormalities. For example, right bundle branch block and first-degree atrioventricular (AV) block occur very frequently but typically resolve within the first few postoperative hours.



Table 13.1

Conditions that affect ST-segment changes.

Adapted with permission from Wang K, Asinger RW, Marriott HJL. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med . 2003;349:2128–2135.














































Condition Electrocardiographic features
Left bundle branch block Wide QRS complex
ST-segment deviation
Acute pericarditis Diffuse ST-segment elevation
Reciprocal ST-segment depression in lead aVR, not in lead aVL
Elevation seldom > 5 mm
PR-segment depression
Hyperkalemia Widened QRS and tall, peaked, tented T waves
Low-amplitude or absent P waves
ST-segment usually downsloping
Pulmonary embolism Changes simulating myocardial infarction, seen often in both inferior and anteroseptal leads
Classically, right bundle branch block and S1Q3T3 pattern, right-axis deviation
Cardioversion Striking ST-segment elevation, often > 10 mm, lasting only minutes immediately after direct-current shock
Myocardial ischemia Flattened, downsloping ST-segment
T-wave inversion
Myocardial infarction ST-segment elevation with a plateau, shoulder, or upsloping
Reciprocal behavior between aVL and III; progression to Q waves


Other ECG abnormalities in cardiac surgery patients are not uncommon findings, as noted in the Bypass Angioplasty Revascularization Investigation (BARI) study ( Table 13.2 ), and often portend increased cardiac mortality, especially the development of postprocedural Minnesota code Q-wave abnormalities ( Table 13.3 ). Therefore, most centers perform preprocedural and serial postprocedural ECGs. ECG alone, however, may lack sufficient sensitivity and specificity for the detection of myocardial ischemia. Transesophageal echocardiography (TEE), which has become a standard component of perioperative monitoring at most centers, provides a very effective adjunct to the diagnosis of myocardial ischemia and infarction. During surgical revascularization, normal wall motion indicates effective revascularization, whereas newly detected regional wall motion abnormalities usually reflect underlying ischemia or infarction. These regional wall motion abnormalities can consist of akinesia or dyskinesia in a ventricular segment that was normokinetic or hypokinetic preoperatively. A study of 351 coronary artery bypass graft (CABG) patients monitored with intraoperative TEE and ECG demonstrated that wall motion abnormalities detected by TEE were more common than ST-segment changes, but there was only a 17% positive concordance between the two modalities. In addition, TEE was found to be twice as predictive as ECG in identifying patients who ultimately met criteria for MI. These results indicate that TEE may be a more sensitive method of detecting myocardial ischemia in the perioperative setting and should probably be routinely used in cardiac surgery monitoring. An important observation with TEE is that new interventricular septal wall abnormalities appear to be common postprocedurally but do not appear to be associated with irreversible myocardial damage. Importantly, technical development of perioperative TEE has led to recent advances in 3D echocardiography, tissue Doppler imaging (TDI), and contrast echocardiography, all of which are readily being investigated in their utility to better detect perioperative ischemia in a number of studies.



Table 13.2

Incidence of new electrocardiographic abnormalities among 1427 patients after coronary artery bypass graft.

With permission from Yokoyama Y, Chaitman BR, Hardison RM, et al. Association between new electrocardiographic abnormalities after coronary revascularization and five-year cardiac mortality in BARI randomized and registry patients. Am J Cardiol . 2000;86:819–824.

























New ECG abnormality Incidence
n (%)
Major Q wave 65 (4.6)
ST elevation 216 (15.1)
ST depression 220 (15.4)
T-wave abnormality 557 (39.0)
No ECG abnormality 557 (39.0)


Table 13.3

Six-month mortality after coronary artery bypass graft surgery: effect of two-step Minnesota code worsening electrocardiographic abnormalities.

With permission from Klatte K, Chaitman BR, Theroux P, et al. Increased mortality after coronary artery bypass graft surgery is associated with increased levels of postoperative creatine kinase-myocardial band isoenzyme release. J Am Coll Cardiol . 2001;38:1070–1077.
















































































































































































































ECG Frequency Dead Alive Total Disease Disease 95% CI Incidence Relative
Abnormality (%) ( n ) ( n ) ( n ) Odds Odds (per 100) Risk 95% CI Ratio
None or one step 54.4 74 1194 1268 0.062 1.00 a 5.84 1.00 a
Two-step worsening 23.6 18 532 550 0.034 0.55 b 0.31-0.95 3.27 0.56 b 0.34-0.93
T wave
Two-step worsening 14.2 11 320 331 0.034 0.55 0.27-1.09 3.32 0.57 0.31-1.06
ST-segment elevation
Two-step worsening 2.7 4 59 63 0.068 1.09 0.33-3.24 6.35 1.09 0.41-2.88
ST-segment depression
Two-step worsening 0.4 0 10 10 0.000 0.00 0.00 0.00
ST-segment
elevation and
Two-step worsening
ST-segment
depression
Two-step worsening 4.7 12 98 110 0.122 1.98 0.98-3.90 10.91 1.87 b 1.05-3.33
Q wave

CI, Confidence interval.

a Reference category.


b P < .05.



Precise diagnostic criteria for defining perioperative myocardial ischemia have not been uniformly adopted, and thus the published incidence varies. A recent study found that 6.4% of patients undergoing CABG ( n = 2052) experienced perioperative myocardial ischemia, using the following criteria: (1) an increase in the creatine kinase-to-creatine kinase-MB isoenzyme (CK/CK-MB) ratio of greater than 10%; (2) new onset of elevated ST-segment change of greater than 1 minute’s duration and involving a shift from baseline of at least 0.1 mV and a new associated postoperative Q wave; (3) recurrent or sustained ventricular tachyarrhythmia or fibrillation; and (4) hemodynamic deterioration on inotropic support. In a meta-analysis of randomized controlled trials in patients undergoing cardiac surgery, 20 trials ( n = 1522 patients) had a 17% overall incidence of ischemic events. Ischemia was defined as an ST-segment deviation on the ECG or new wall motion abnormalities on the TEE.


As with myocardial ischemia, there is considerable disagreement on the diagnostic criteria used to define perioperative myocardial infarction (PMI), which again explains discordant reports in the literature of its incidence and prognostic implications. In the same meta-analysis cited earlier, 22 trials of 1853 patients had a 5% overall incidence of PMI. Across the literature, the reported rate of PMI ranges from 5% to 15%. Despite advances in cardiac surgery, this incidence does not appear to be declining. The diagnosis of PMI has classically relied heavily on the development of new and persistent pathologic Q waves on an ECG, which may not always be truly representative of transmural necrosis. Indeed, in an autopsy study performed on cardiac surgery patients who died within 1 month after surgery, 23% of patients had significant transmural myocardial necrosis but no pathologic Q waves, and 20% of patients without transmural necrosis exhibited new postprocedural Q waves. Reliance on the presence of Q waves alone to diagnose PMI can dangerously overlook infarctions. In a study of cardiac surgery patients, transthoracic quantitative echocardiography analysis with ECG and radionuclide ventriculography demonstrated non–Q-wave PMI to be three times more common than Q-wave PMI, with equally deleterious effects on left ventricular (LV) function. A study evaluating the clinical significance of a new Q wave after cardiac surgery suggested that patients with this pathologic ECG change, without any concomitant elevation in myocardial enzyme markers or other indicators of PMI, had uneventful outcomes. These findings highlight the critical importance of combining various diagnostic modalities to define PMI.


Although Q waves do not necessarily reflect transmural necrosis, appreciation of these and other ECG changes and their linkage to adverse outcomes cannot be disregarded. New perioperative ST-segment changes (> 0.1 mV) have been identified as an independent predictor of PMI, which accounts for up to 40% of preoperative CABG deaths. In the Coronary Artery Surgery Study (CASS; n = 1340 patients), 62 patients with a new Q wave postoperatively experienced 9.7% in-hospital mortality, compared with 1.0% in the remaining 1278 patients. In patients who survived to hospital discharge, the presence of new postoperative Q waves did not adversely affect 3-year survival. Among the 1427 CABG patients in the BARI trial, 5-year cardiac mortality was increased with new Q-wave development (8.2% versus 3.7% for no new ECG changes; adjusted relative risk, 2.6) ( Fig. 13.2 ). Results from the GUARD during Ischemia Against Necrosis (GUARDIAN) study of 2918 high-risk CABG patients further emphasize the negative impact of Q-wave development on survival ( Table 13.3 ). Namay et al 22 reported a 5-year survival rate of 76% in CABG patients ( n = 77) with new Q waves compared with 90% in the unaffected CABG patients ( n = 1790).




Fig. 13.2


(A) Bypass angioplasty revascularization investigation (BARI) randomized and registry patients’ cumulative survival from cardiac mortality. Patients had undergone coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). The development of major Q waves was associated with significantly increased long-term risk for cardiac mortality in the CABG patients ( P = .02). (B) Five-year Kaplan-Meier cardiac mortality and adjusted relative risk for cardiac mortality for any postprocedural electrocardiographic (ECG) changes. Cardiac mortality was significantly increased by the development of new postprocedural major Q waves, regardless of the type of coronary revascularization procedure performed. In this analysis, the postprocedural ECG variables were adjusted for study group, treated diabetes, age, prior myocardial infarction, renal dysfunction, congestive heart failure, ejection fraction, body mass index, presence of class C lesions, baseline ST elevation, and baseline ST depression. CI, Confidence interval.

(Redrawn with permission from Yokoyama Y, Chaitman BR, Hardison RM, et al. Association between new electrocardiographic abnormalities after coronary revascularization and five-year cardiac mortality in BARI randomized and registry patients. Am J Cardiol . 2000;86:819–824.)




Along with new postoperative Q-wave development, enzymatic criteria are routinely used to define PMI and to enhance the overall sensitivity and specificity of PMI detection. In a study performed on 499 cardiac surgery patients at the Brigham and Women’s Hospital, PMI occurred in 5% of patients and was designated by the following criteria: total peak CK greater than 7000 μg/L, CK-MB greater than 30 ng/mL, and new Q waves on ECG. In the GUARDIAN study of 2918 CABG patients, the 6-month mortality associated with a postoperative peak CK-MB of less than 5, of between 5 and 10, of between 10 and 20, and of greater than 20 times the upper limit of normal (ULN) was 3.4%, 5.8%, 7.8%, and 20.2%, respectively ( Fig. 13.3 ). This highly significant association was conserved even after adjusting for other risk factors. The Cleveland Clinic experience with 3812 CABG patients revealed that a postoperative CK-MB level 10 times ULN was independently predictive of increased mortality at 3 years ( Table 13.4 and Fig. 13.4 ). The Arterial Revascularization Therapies Study (ARTS) prospectively evaluated 496 CABG patients and also demonstrated that increased levels of CK-MB (> 5 times ULN) was highly predictive of cardiac death and recurrent MI after the postoperative period ( Fig. 13.5 ).




Fig. 13.3


Association between survival after coronary artery bypass grafting (CABG) and level of postoperative creatine kinase-MB isoenzyme (CK-MB). All pairwise comparisons between the categories were significant, except for the ≥ 5 and < 10 upper limits of normal (ULN) group versus the ≥ 10 and < 20 ULN group ( P = .26).

(Redrawn with permission from Klatte K, Chaitman BR, Theroux P, et al. Increased mortality after coronary artery bypass graft surgery is associated with increased levels of postoperative creatine kinase-myocardial band isoenzyme release. J Am Coll Cardiol . 2001;38:1070–1077.)


Table 13.4

Three-year mortality rates associated with elevation of creatine kinase isoenzyme MB after coronary artery bypass graft surgery.

With permission from Brener SJ, Lytle BW, Schneider JP, et al. Association between CK-MB elevation after percutaneous or surgical revascularization and three-year mortality. J Am Coll Cardiol . 2002;40:1961–1967.


































CABG patients ( N = 3812)
CK-MB level At risk, no. (%) Death (%)
≤ 1 × ULN 386 (10) 7.2
1–3 × ULN 1922 (50) 7.7
3–5 × ULN 853 (22) 6.3
5–10 × ULN 427 (11) 7.5
> 10 × ULN 224 (6) 20.8
P (trend) < .001

ULN, Upper limit of normal.



Fig. 13.4


Cumulative survival in patients with coronary artery bypass grafting, stratified by postoperative degree of creatine kinase-MB isoform elevation. ULN, Upper limit of normal.

(Redrawn with permission from Brener SJ, Lytle BW, Schneider JP, et al. Association between CK-MB elevation after percutaneous or surgical revascularization and three-year mortality. J Am Coll Cardiol . 2002;40:1961–1967.)



Fig. 13.5


Relationship between creatine kinase-MB isoform (CK-MB) levels and major postoperative complications after cardiac surgery. Kaplan-Meier curves illustrate the incidence of major adverse cardiac complications at 1-year follow-up in patients with normal CK-MB levels (dashed blue line) , greater than one to three times normal (solid blue line) , three or more to five times normal (dashed red line) , and greater than five times normal (solid black lines) . MACCE, Combined major cardiac death, myocardial infarction, repeat revascularization, and cerebrovascular events.

(Redrawn with permission from Costa MA, Carere RG, Lichtenstein S V, et al. Incidence, predictors, and significance of abnormal cardiac enzyme rise in patients treated with bypass surgery in the arterial revascularization therapies study (ARTS). Circulation . 2001;104:2689–2693.)


The specificity of CK and CK-MB as markers of myocardial injury is limited by the fact that these enzymes are also present in and released from skeletal muscle. Significant skeletal muscle injury and release of large quantities of CK-MB occurs during cardiac surgery. An abundance of experimental evidence has emerged in the literature on the superior sensitivity and specificity of serum troponins as biochemical markers of myocardial damage and predictors of adverse outcomes. Cardiac troponin isoforms I and T (cTnI, cTnT) are cardiac-specific proteins involved in regulation of muscle contraction via the tropomyosin complex. No cross-reactivity with skeletal muscle isoforms has been described, and the levels of cardiac troponins do not increase in healthy subjects, even when they are exposed to strenuous muscular activity or after noncardiac operations. The levels of cTnI also appear to be unaltered by renal dysfunction, and its plasma concentration decreases very slowly, allowing for retrospective detection of myocardial damage if necessary. Interestingly, troponin levels drawn preoperatively may also enable stratification of patients into subgroups with increased risk for postoperative cardiac complications, notably PMI ( Fig. 13.6 ). Outcomes for these high-risk patients, who presumably have undetected ongoing myocardial injury, might be improved with a tailored perioperative approach that would include pharmacologic support or an intra-aortic balloon pump (IABP).




Fig. 13.6


Predictive value of preoperative troponin T levels and cardiac events after coronary artery bypass grafting. The positive correlation between circulating troponin T levels before the operation and the rate of postoperative myocardial infarction (MI) ( P = .03), congestive heart failure (CHF) ( P = .0006), and combined cardiac events (MI + CHF) ( P = .0001) was significant. Group 2 was composed of patients with troponin T levels below the discriminator value of 0.02 μg/L. Group 1 patients had elevated troponin T values. They were divided into two subgroups: those with troponin T values between 0.02 μ/L and 0.1 μg/L and those with values > 0.1 μg/L.

(Redrawn with permission from Carrier M, Pelletier LC, Martineau R, et al. In elective coronary artery bypass grafting, preoperative troponin T level predicts the risk of myocardial infarction. J Thorac Cardiovasc Surg . 1998;115:1328–1334.)


A study comparing the efficacies of cTnT and CK-MB in a series of 224 cardiac surgery patients indicated that serum cTnT concentrations greater than 1.58 ng/mL (which represented the upper quintile) were the most powerful independent predictor of postoperative death or shock within the first 24 hours after surgery. Greenson and colleagues demonstrated that stratification of cardiac surgery patients by peak cTnI levels of less than 40 and greater than 60 ng/mL was exquisitely predictive of intensive care unit (ICU) length of stay, prolonged mechanical ventilation, new arrhythmia development, and especially cardiac events ( Fig. 13.7 ). Similar results were obtained in a larger series of 502 patients undergoing conventional heart surgery, where the cTnI level proved to be an independent predictor of in-hospital mortality and associated with other major postoperative complications such as PMI, ventricular arrhythmias, low cardiac output, prolonged mechanical ventilation, and acute renal failure requiring dialysis ( Table 13.5 ). The long-term prognostic value of cTnI levels has also been validated, and it is clearly associated with increased mortality, death from cardiac causes, and nonfatal cardiac events within 2 years after CABG ( Fig. 13.8 ). The variable cutoffs of predictive troponin values reported by different studies is concerning and may be attributed to lack of standardization of troponin detection kits by different suppliers.




Fig. 13.7


Usefulness of cardiac troponin I (cTnI) in patients undergoing cardiac surgery. (A) Troponin I levels after cardiac surgery. Levels of troponin I were plotted over time in patients with and without cardiac events. P < .0001 between groups by use of analysis of variance. (B) Cardiac events by peak troponin level. Patients with and without cardiac events are shown with their respective peak cTnI levels. An upper level of 60 ng/mL and a lower level of 40 ng/mL are illustrated.

(Redrawn with permission from Greenson N, Macoviak J, Krishnaswamy P, et al. Usefulness of cardiac troponin I in patients undergoing open heart surgery. Am Heart J . 2001;141:447–455.)




Table 13.5

Cardiac troponin I concentrations and clinical outcome among 502 patients.

From Lasocki S, Provenchère S, Benessiano J, et al: Anesthesiology 2002;97:405–411.


































































cTnI Concentration a ( ng/mL)
Complication With Without
complication complication
(No. of patients) (No. of patients)
Q-wave perioperative 56.5 [43; 175.5] b 4.2 [2.4; 7.6]
myocardial ( n = 7) ( n = 495)
infarction
Ventricular 8.4 [4.2; 28.2] b 4.3 [2.4; 8.0]
arrhythmias ( n = 17) ( n = 485)
Low cardiac output 9.5 [4.4; 26.78] b 4.3 [2.4; 7.7]
( n = 81) ( n = 421)
Prolonged (48-h) 56.5 [5.2; 22.3] b 4.5 [2.5; 8.1]
mechanical ( n = 46) ( n = 456)
ventilation
Acute renal failure 18.2 [9.1; 33.5] b 4.6 [2.5; 8.2]
requiring dialysis ( n = 18) ( n = 484)

a cTnI values are expressed as median [25th; 75th percentiles].


b P < .0001.




Fig. 13.8


Cumulative percentage of surviving patients according to elevation of cardiac troponin I (cTnI). Group 1 ( n = 174; cTnI, < 13 ng/mL; solid red line) and group 2 ( n = 28; cTnI, ≥ 13 ng/mL; dashed red line). Only one patient (in group 1) was lost to follow-up after 1 year. P value refers to between-group comparison (log-rank test).

(Redrawn with permission from Fellahi JL, Gué X, Richomme X, et al. Short- and long-term prognostic value of postoperative cardiac troponin I concentration in patients undergoing coronary artery bypass grafting. Anesthesiology . 2003;99:270–274.)


Etiology


During the preprocedural phase of cardiac surgery, myocardial ischemia usually represents extension of an acute coronary presentation triggered by hypertension, hypotension, hypoxia, tachycardia, bleeding, or surgical manipulation. Causes for postprocedural myocardial ischemic injury include inadequate myocardial protection during surgery, coronary graft failure, native coronary or graft spasm, extension of a preoperative infarction, inadequate revascularization, coronary injury secondary to a valve procedure, and distal coronary embolization. These etiologic considerations are notorious predictors of myocardial ischemia, PMI, and other adverse outcomes in cardiac surgery. Predictors of PMI have been defined and include advanced age, emergent procedure, previous revascularization, longer duration of cardiopulmonary bypass (CPB) or aortic cross-clamp time, need for inotropic support, need for coronary relocation (or reimplantation), prior MI, and preoperative ventricular dysfunction. Awareness of high-risk patients may increase monitoring and enable earlier intervention.


Prior to the widespread implementation of cold potassium cardioplegia and other advancements in myocardial preservation, PMI often resulted from suboptimal myocardial preservation. Consistent with this etiology was the pathologic finding of contraction band necrosis, which indicated intraoperative ischemia and subsequent reperfusion injury. A high percentage of infarctions analyzed from patients in these early studies were in areas supplied by patent grafts, again suggestive of injury mediated by an ischemia-reperfusion phenomenon. Improvements in techniques of myocardial preservation have reduced the incidence of perioperative myocardial ischemia and PMI.


Myocardial preservation techniques have undergone significant evolution during the past five decades. The implementation of cold crystalloid cardioplegia was an important early advancement that improved overall outcomes. The introduction of blood cardioplegia led to further improvements in maintaining myocardial energy stores and reducing anaerobic lactate production. Clinically, the advantage of blood cardioplegia is supported in studies that show a reduction in PMI and other morbidity when directly compared with crystalloid cardioplegia. The advent of retrograde delivery of cardioplegia via the coronary sinus was another important advance in myocardial protection, allowing fewer cardioplegic interruptions, perfusion to regions supplied by stenosed arteries, and enhanced cardioplegic delivery to the subendocardial region.


An important, relatively recent advance in cardioplegia has been the introduction and wide adoption of del Nido cardioplegia in the adult cardiac surgery population. The crystalloid components of this solution include a 1-L Plasma-Lyte base solution with mannitol, magnesium sulfate, sodium bicarbonate, potassium chloride, and lidocaine added. Unlike other cardioplegia solutions, del Nido is given as a single dose, with less need for frequent redosing. Even in low-risk, first-time CABG patients, the use of del Nido cardioplegia was associated with less defibrillation and lower costs. Its use has significantly increased in minimally invasive cardiac surgery, mainly due to decreased need for additional dosing. In a recent study by Vistarini et al, del Nido cardioplegia was found to be safe and easy in a group of consecutive patients undergoing minimally invasive aortic valve replacement. Most of the data related to the use of del Nido in adult cardiac surgery patients has been retrospective in nature, with the lack of large-scale randomized controlled trials.


Ischemic injury in the current era may be more frequently the result of technical issues, early graft occlusion, anastomotic stenosis, graft, or native coronary spasm ( Figs. 13.9 to 13.11 ), poor distal runoff, incomplete revascularization, steal phenomena, or embolization. Graft compression by mediastinal chest drains has even been described as a cause of ischemic injury ( Fig. 13.12 ). Atheromatous embolization in the coronary microcirculation can also occur intraoperatively and lead to PMI. Potential embolic sources include atherosclerotic plaque present in the ascending aorta or major epicardial coronary arteries. In the reoperative setting, mechanical disruption of atheroma in old vein grafts has also been described. Retrograde cardioplegia may be protective in cases of coronary or graft embolization.




Fig. 13.9


Treatment of right coronary artery (RCA) spasm after coronary artery bypass grafting (CABG). (A) Coronary artery angiogram showing a diffuse spasm of the RCA beyond the level of the anastomosis (arrow) with the right internal mammary artery (RIMA). (B) RCA spasm resolution after intracoronary infusion of nitroglycerin.

(With permission from Trimboli S, Oppido G, Santini F, et al. Coronary artery spasm after off-pump coronary artery by-pass grafting. Eur J Cardiothorac Surg . 2003;24:830–833.)



Fig. 13.10


Postcoronary artery bypass grafting (CABG) angiography. Narrowing of a left internal mammary artery to left anterior descending artery bypass graft (square) . The segment above the anastomosis and the toe of the anastomosis are stenotic. There was no response to intraluminal nitroglycerin. This graft underwent surgical revision. At revision, the upper stenosis was diagnosed to be a spasm, which had been fixed by fibrin glue. The stenosis at the toe was the result of surgical technique. After revision, an open anastomosis and perfect flow were present.

(With permission from Bonatti J, Danzmayr M, Schachner T, et al. Intraoperative angiography for quality control in MIDCAB and OPCAB. Eur J Cardiothoracic Surg . 2003;24:647–649.)



Fig. 13.11


Coronary artery spasm after coronary artery bypass grafting (CABG). (A) Postoperative coronary angiogram showing the left anterior descending artery (LAD) coronary artery spasm just distal to the left internal mammary artery (LIMA) to LAD anastomosis and the first diagonal coronary artery spasm. (B) Postoperative angiographic control after intracoronary verapamil and nitroglycerin infusion produced relief of the coronary spasm.

(With permission from Caputo M, Nicolini F, Franciosi G, et al. Coronary artery spasm after coronary artery bypass grafting. Eur J Cardiothorac Surg . 1999;15:545–548.)



Fig. 13.12


Angiogram for perioperative myocardial infarction after coronary artery bypass grafting. (A) The saphenous vein graft to the posterior descending artery was externally compressed by a mediastinal chest tube (arrow) . (B) Obstruction was relieved by removal of tube.


PMI caused by coronary spasm occurs with an incidence as high as 1% and involves both grafted and ungrafted vessels. Coronary spasm can lead to sudden hemodynamic collapse and is often heralded by acute hypotension. Conventional treatment methods for perioperative hypotension, such as pressor agents, may only exacerbate the vasospastic reaction in this scenario. Similarly, in patients experiencing PMI associated with a hyperdynamic state, elevated circulating catecholamine levels create an environment conducive to persistent coronary spasm. Mechanistically, abrupt withdrawal of preoperative calcium channel blockers can lead to rebound vasoconstriction of the native coronary arteries and is an important factor to consider in preoperative planning. Additional factors that may render cardiac surgical patients particularly susceptible to coronary vasospasm include thromboxane release caused by heparin–protamine interactions, CPB, platelet activation, anaphylactic reactions, calcium administration, and increased alpha-adrenergic tone from vasoconstrictor administration.


Another well-described etiology related to perioperative ischemic injury is the internal mammary artery (IMA) malperfusion syndrome, caused by inadequate myocardial perfusion through the IMA graft. In a series of 2326 CABG patients in which the IMA was used, 45 patients (1.9%) with this syndrome were identified. Although the IMA is the proven conduit of choice for myocardial revascularization, immediate flow through this arterial graft is generally less than through a saphenous vein graft and may not adequately meet myocardial demand. Other factors that may precipitate this syndrome include vasospasm, kinking, or overstretching of the IMA; steal phenomena via flow diversion into major intercostal side branches; and residual competitive flow from the native coronary artery. As with radial artery grafts, direct mechanical manipulation of the IMA during harvesting may produce transient endothelial dysfunction and provoke a vasospastic response.


A number of large angiographic studies have correlated clinical suspicion of myocardial ischemia or PMI with angiographic evidence of graft failure. In a series of 2003 CABG patients, 71 (3.5%) had suspected myocardial ischemia and underwent acute reangiography ( n = 59) or an immediate reoperation ( n = 12) if they were hemodynamically unstable. Angiographic findings in the first group included the following: occluded vein graft(s) (32%), poor distal runoff to the grafted coronary vessel (17%), IMA stenosis (7%), IMA occlusion (5%), vein graft stenoses (5%), and IMA subclavian artery steal (3%). In the immediately reoperated group, 92% of patients had graft occlusions. A more recent study including 2052 CABG patients had similar findings. These studies emphasize that the majority of patients who experience myocardial ischemia or PMI following revascularization have underlying graft failure warranting angiography and either percutaneous or surgical reintervention.


Valvular procedures may lead to technical complications with a specific myocardial ischemia. The proximity of the posterior mitral annulus and the left circumflex coronary artery predisposes to circumflex injury and LV lateral wall ischemia with mitral reconstruction. An analogous situation exists for tricuspid valve surgery and the right coronary artery. Aortic valve procedures may compromise either the left main coronary or the right coronary ostia, and cases of coronary ostial thrombosis with severe ischemia have been reported. Finally, debrided valvular material may also be involved in deleterious coronary embolization.


Management


Intraoperative Preprocedural Phase


The preprocedural phase is a critical period during which appropriate clinical management can prevent myocardial ischemia and PMI. Stabilization of blood pressure and maintenance of normal sinus rhythm should be the goal. A rate–pressure product below 12,000 may minimize perioperative myocardial ischemia. The importance of precise and continuous hemodynamic measurements cannot be overemphasized. It should at least include continuous monitoring of the ECG, cuff blood pressure, direct arterial pressure, central venous pressure (CVP), continuous pulse oximetry, and end-tidal CO 2 . Placement of a pulmonary artery (PA) catheter is warranted for high-risk patients, for example, in cases of unstable angina, ventricular hypertrophy, poor ventricular function, and combined valvular and coronary artery disease pathology. The PA catheter enables continuous assessment and maintenance of cardiac filling pressures, cardiac output, and mixed venous oxygen saturation (MVO 2 ) to prevent myocardial ischemia.


Pharmacotherapy with vasodilators such as intravenous nitroglycerin (NTG) may be required preoperatively for patients with unstable angina. The reduction in total ischemic burden may improve prognosis with regard to infarct progression and may prevent deterioration of LV function. Intravenous NTG has also been shown to improve postinduction regional wall motion abnormalities in a prospective study of CABG patients. On the basis of these results, TEE-guided NTG use after induction may yield a more optimal baseline echocardiogram. Other important pharmacotherapies to reduce ischemia include intravenous beta-blockers, with esmolol as the most titratable agent. Beta-blockers reduce heart rate, contractility, and blood pressure and thereby greatly reduce overall myocardial work. Beta-blockers also reduce the incidence of ischemic ventricular and atrial arrhythmias. Use of intravenous NTG and beta-blockers requires careful monitoring and titration, as both agents can induce hypotension; in patients with fixed coronary stenosis, reduced perfusion pressure can result in dangerous ischemia and subsequent myocardial dysfunction.


In patients with cardiogenic shock or medically refractory ischemia, preoperative stabilization with an IABP has been shown to reduce overall surgical mortality and improve outcomes in high-risk coronary patients. IABP counterpulsation enhances myocardial perfusion via augmentation of diastolic blood pressure and redistribution of coronary blood flow toward regions of myocardial ischemia. IABP provides partial LV assistance. Proper timing consists of balloon inflation just after aortic valve closure and deflation immediately prior to systole ( Fig. 13.13 ). Balloon inflation during diastole augments coronary perfusion, whereas deflation during systole reduces afterload, decreases cardiac work (myocardial oxygen consumption), and increases stroke volume and cardiac output. Efficacy of IABP support is determined by several factors, including balloon volume; location in the aorta; rate of inflation and deflation; and, most important, timing relative to the cardiac cycle. IABP counterpulsation is less effective in the presence of moderate or severe aortic regurgitation and should be avoided. Furthermore, timing may be difficult because of tachycardia or arrhythmias. Aortoiliac or femoral occlusive disease may make placement more difficult and increases the risk for limb ischemia.


Jun 9, 2021 | Posted by in ANESTHESIA | Comments Off on Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery
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