- Revascularization of coronary arteries to treat CAD
- Grafts used can be venous (saphenous, harvested from the legs) or arterial (radial, internal mammary, gastroepiploic artery)
- Can be done using CPB or off-pump (outcomes are equivocal, dependent on technique)
- Decision-making criteria for on-pump versus off-pump is evolving
- What is the exercise tolerance?
- What symptoms are present? Angina, dyspnea, fatigue
- What relieves the symptoms? Rest or medications?
- Results of cardiac catheterization, echo, stress test? What is the LVEF? Which vessels are occluded?
- Knowledge of coronary anatomy (Figure 87-1)
- Right coronary sinus anterior and left coronary sinus lateral and slightly posterior
- The left coronary artery (LCA) divides into the left anterior descending coronary artery (LAD) and left circumflex artery (LCx)
- LAD gives rise to the diagonal branches and supplies the anterior wall of the right ventricle, the anterior two-thirds of the interventricular septum, the anterior wall of the LV, and the ventricular apex.
- LCx gives rise to the obtuse marginal branches and supplies the left atrium, and the posterior and lateral walls of the LV.
- “Left main” designates a significant lesion in the LCA (high risk for ischemia affecting a large portion of the LV, causing rapid hemodynamic collapse and cardiac arrest).
- “Left main equivalent” designates high-grade obstructions in both the LAD and LCx: same risk as patients with left main disease.
- Other significant medical problems? DM, chronic obstructive pulmonary disease (COPD), renal insufficiency
- What medications are being taken? Should they be discontinued (e.g., metformin)
Figure 87-1. Coronary Anatomy
Reproduced from Longnecker DE, Brown DL, Newman MF, Zapol WM. Anesthesiology. Figure 51-1. Available at: www.accessanesthesiology.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.
Figure 87-2. Typical Perfusion Beds of the Epicardial Coronary Arteries
The above graphic demonstrates the midesophageal four-chamber view (A), the midesophageal two-chamber view (B), the midesophageal long-axis view (C), and the transgastric mid short-axis view. The different views provide the opportunity to observe the myocardium supplied by each of the three main coronary vessels, the left circumflex (Cx), the left anterior descending (LAD), and the right coronary artery (RCA). Areas of impaired myocardial perfusion are suggested by the inability of the myocardium to both thicken and move inwardly during systole. Image D is very useful for monitoring in the operating room because left ventricular myocardium supplied by each of the three vessels can be seen in one image. (Modified from: Shanewise JS, Cheung A, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination; recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society for Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg. 1999;89:870–884, with permission.)
- Pulse oximetry
- Arterial line (usually placed pre-induction)
- Central venous line (usually placed post-induction)
- ± Transesophageal echo...
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