Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting
Off-pump coronary surgery requires mechanical cardiac displacement, which results in bi-ventricular systolic and diastolic dysfunction. Although transient, subsequent hemodynamic deterioration can be associated with poor prognosis and, in extreme cases, emergency conversion to on-pump surgery, which...
| Main Authors: | , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
Korean Society of Anesthesiologists
2023-08-01
|
| Series: | Korean Journal of Anesthesiology |
| Subjects: | |
| Online Access: | http://ekja.org/upload/pdf/kja-23103.pdf |
| _version_ | 1797771636222459904 |
|---|---|
| author | Jae-Kwang Shim Kwang-Sub Kim Pierre Couture André Denault Young-Lan Kwak Kyung-Jong Yoo Young-Nam Youn |
| author_facet | Jae-Kwang Shim Kwang-Sub Kim Pierre Couture André Denault Young-Lan Kwak Kyung-Jong Yoo Young-Nam Youn |
| author_sort | Jae-Kwang Shim |
| collection | DOAJ |
| description | Off-pump coronary surgery requires mechanical cardiac displacement, which results in bi-ventricular systolic and diastolic dysfunction. Although transient, subsequent hemodynamic deterioration can be associated with poor prognosis and, in extreme cases, emergency conversion to on-pump surgery, which is associated with high morbidity and mortality. Thus, appropriate decision-making regarding whether the surgery can be proceeded based on objective hemodynamic targets is essential before coronary arteriotomy. For adequate hemodynamic management, avoiding myocardial oxygen supply-demand imbalance, which includes maintaining mean arterial pressure above 70 mmHg and preventing an increase in oxygen demand beyond the patient’s coronary reserve, must be prioritized. Maintaining mixed venous oxygen saturation above 60%, which reflects the lower limit of adequate global oxygen supply-demand balance, is also essential. Above all, severe mechanical cardiac displacement incurring compressive syndromes, which cannot be overcome by adjusting major determinants of cardiac output, should be avoided. An uncompromising form of cardiac constraint can be ruled out as long as the central venous pressure is not equal to or greater than the pulmonary artery diastolic (or occlusion) pressure, as this would reflect tamponade physiology. In addition, transesophageal echocardiography should be conducted to rule out mechanical cardiac displacement-induced ventricular interdependence, dyskinesia, severe mitral regurgitation, and left ventricular outflow tract obstruction with or without systolic motion of the anterior leaflet of the mitral valve, which cannot be tolerated during grafting. Finally, the ascending aorta should be carefully inspected for gas bubbles to prevent hemodynamic collapse caused by a massive gas embolism obstructing the right coronary ostium. |
| first_indexed | 2024-03-12T21:40:27Z |
| format | Article |
| id | doaj.art-7c7006529003444987482181dfc9e7c1 |
| institution | Directory Open Access Journal |
| issn | 2005-6419 2005-7563 |
| language | English |
| last_indexed | 2024-03-12T21:40:27Z |
| publishDate | 2023-08-01 |
| publisher | Korean Society of Anesthesiologists |
| record_format | Article |
| series | Korean Journal of Anesthesiology |
| spelling | doaj.art-7c7006529003444987482181dfc9e7c12023-07-27T00:56:44ZengKorean Society of AnesthesiologistsKorean Journal of Anesthesiology2005-64192005-75632023-08-0176426727910.4097/kja.231038885Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshootingJae-Kwang Shim0Kwang-Sub Kim1Pierre Couture2André Denault3Young-Lan Kwak4Kyung-Jong Yoo5Young-Nam Youn6 Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea Department of Anesthesiology, Université de Montréal, Montreal, Canada Department of Anesthesiology, Université de Montréal, Montreal, Canada Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, KoreaOff-pump coronary surgery requires mechanical cardiac displacement, which results in bi-ventricular systolic and diastolic dysfunction. Although transient, subsequent hemodynamic deterioration can be associated with poor prognosis and, in extreme cases, emergency conversion to on-pump surgery, which is associated with high morbidity and mortality. Thus, appropriate decision-making regarding whether the surgery can be proceeded based on objective hemodynamic targets is essential before coronary arteriotomy. For adequate hemodynamic management, avoiding myocardial oxygen supply-demand imbalance, which includes maintaining mean arterial pressure above 70 mmHg and preventing an increase in oxygen demand beyond the patient’s coronary reserve, must be prioritized. Maintaining mixed venous oxygen saturation above 60%, which reflects the lower limit of adequate global oxygen supply-demand balance, is also essential. Above all, severe mechanical cardiac displacement incurring compressive syndromes, which cannot be overcome by adjusting major determinants of cardiac output, should be avoided. An uncompromising form of cardiac constraint can be ruled out as long as the central venous pressure is not equal to or greater than the pulmonary artery diastolic (or occlusion) pressure, as this would reflect tamponade physiology. In addition, transesophageal echocardiography should be conducted to rule out mechanical cardiac displacement-induced ventricular interdependence, dyskinesia, severe mitral regurgitation, and left ventricular outflow tract obstruction with or without systolic motion of the anterior leaflet of the mitral valve, which cannot be tolerated during grafting. Finally, the ascending aorta should be carefully inspected for gas bubbles to prevent hemodynamic collapse caused by a massive gas embolism obstructing the right coronary ostium.http://ekja.org/upload/pdf/kja-23103.pdfcardiac tamponadehemodynamic monitoringmixed venous oxygen saturationoff-pump coronary artery bypassswan-ganz catheterizationtransesophageal echocardiography |
| spellingShingle | Jae-Kwang Shim Kwang-Sub Kim Pierre Couture André Denault Young-Lan Kwak Kyung-Jong Yoo Young-Nam Youn Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting Korean Journal of Anesthesiology cardiac tamponade hemodynamic monitoring mixed venous oxygen saturation off-pump coronary artery bypass swan-ganz catheterization transesophageal echocardiography |
| title | Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting |
| title_full | Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting |
| title_fullStr | Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting |
| title_full_unstemmed | Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting |
| title_short | Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting |
| title_sort | hemodynamic management during off pump coronary artery bypass surgery a narrative review of proper targets for safe execution and troubleshooting |
| topic | cardiac tamponade hemodynamic monitoring mixed venous oxygen saturation off-pump coronary artery bypass swan-ganz catheterization transesophageal echocardiography |
| url | http://ekja.org/upload/pdf/kja-23103.pdf |
| work_keys_str_mv | AT jaekwangshim hemodynamicmanagementduringoffpumpcoronaryarterybypasssurgeryanarrativereviewofpropertargetsforsafeexecutionandtroubleshooting AT kwangsubkim hemodynamicmanagementduringoffpumpcoronaryarterybypasssurgeryanarrativereviewofpropertargetsforsafeexecutionandtroubleshooting AT pierrecouture hemodynamicmanagementduringoffpumpcoronaryarterybypasssurgeryanarrativereviewofpropertargetsforsafeexecutionandtroubleshooting AT andredenault hemodynamicmanagementduringoffpumpcoronaryarterybypasssurgeryanarrativereviewofpropertargetsforsafeexecutionandtroubleshooting AT younglankwak hemodynamicmanagementduringoffpumpcoronaryarterybypasssurgeryanarrativereviewofpropertargetsforsafeexecutionandtroubleshooting AT kyungjongyoo hemodynamicmanagementduringoffpumpcoronaryarterybypasssurgeryanarrativereviewofpropertargetsforsafeexecutionandtroubleshooting AT youngnamyoun hemodynamicmanagementduringoffpumpcoronaryarterybypasssurgeryanarrativereviewofpropertargetsforsafeexecutionandtroubleshooting |