Case: OPCAB s/p plavix load

[vector2]

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Recently had a 73yo F PMH obesity, DM, HTN, smoker come into the ER on a Saturday AM with angina. EKG reveals STWIs and labs show a troponin leak. Echo shows normal biV function, no WMA, essentially normal valves, SPAPs mildly elevated by TR jet. Pt is hemodynamically stable and on 2L O2. Angina is relieved by SLN. Also receives ASA, BB, heparin gtt, and per this particular cardiologist, a plavix load. Goes to cath which shows 90% left main, 70% D1, 80% RCA, 80% CFX. Surgeon requests IABP be placed as he intends to take this pt for a 4-6 vessel OPCAB later tonight.

Questions for students, residents and fellows (or anyone else interested):

What are your primary pre operative concerns?

What is the SYNTAX trial and the SYNTAX score? How does it affect the management of pts diagnosed with CAD?

What is the mechanism of action of clopidogrel? What do guidelines say about the use of ADP or P2Y12 agents in acute coronary syndromes? What diagnostics can be ordered to assess platelet function and what (if any) interventions can be taken to minimize these agents' perioperative effects?

How does a IABP work? Is it beneficial for this pt getting this surgery? If so, to what degree?

Intraoperatively, what is your management gameplan?

 

[Noyac]

This is a good one.

 

[dchz]

Someone once said they get 50% of their learning from SDN. well, this is about 50% of my learning today. i'll give it a shot.
But let me first thank you for this type of threads, I eat this stuff up.
(also a clever omission of the oxford comma)



What are your primary pre operative concerns?
Atheroma load in aorta and aortic valve competency if IABP is a go. bleeding from deep femoral cut because of the Clopidogrel?
But also this pt's other risk factors that need to be optimized.
I am also trying to avoid the dunning-kreuger because i feel like i don't know what i dont know. (I might be missing someing big)

What is the SYNTAX trial and the SYNTAX score? How does it affect the management of pts diagnosed with CAD?
No clue what this is, will update score after i look it up.
Oh i've heard of the trial but never knew the name.
SYNTAX compared first gen DES to CABG in pts with LM and 3 vessel disesase. Higher Death, MI, Stroke, or revascularization in PCI.
I don't know enough details to do an accurate SYNTAX score, but a quick internet search got me a score of 19.

What is the mechanism of action of clopidogrel? What do guidelines say about the use of ADP or P2Y12 agents in acute coronary syndromes? What diagnostics can be ordered to assess platelet function and what (if any) interventions can be taken to minimize these agents' perioperative effects?
MOA: P2Y12 on ADP receptor blocker.
I think the guidelines say don't use it as it's not superior? benefit might not outweigh the risk specially if the pt needs surgery afterwards?
I think you're hinting at the PFA-100 or the TEG? In my mind the TEG is a more specific test of platelet function than the PFA-100.

How does a IABP work? Is it beneficial for this pt getting this surgery? If so, to what degree?
Inflates during diastole to agument filling in systemic and coronary arteries.
Not sure of the literature on how effective it is for this pt, but i'd imagine if the pt isn't in acute decompensated heart failure, the benefit can't be THAT big where it outweighs the bleeding risk.

Intraoperatively, what is your management gameplan?
Have all the platelets on standby.
Not sure what it does for the heparin requirements if you do go on bypass.

 

[thinkorswim]

4-6 vessel OPCAB in a patient with 90% left main disease? Sounds like a blast.

 

[sethco]

I got one question to add for debate. What was the indication for IABP placement in this patient? Do you agree with it? What are the standard indications?

Edit: Sorry just saw you asked this.

 

[Noyac]

4-6 vessel OPCAB in a patient with 90% left main disease? Sounds like a blast.

I was trained that OPCAB was only for the healthiest pts. Then I went into PP and found that it was even better for the sickest of the sick. This was a fairly common case give or take a few grafts. I’d guess that 70% of our cases were 3-4 bypasses with the LIMA almost always included.

 

[T-burglar]

Prop roc tube. Vec infusion.

Be prepared for malignant rhythms . Be Johnny on the spot with the BP control during cross clamp.

Tee.

PA catheter probably a good idea so you can watch filling pressures. Will be useful in the differential of worsening oxygenation or climbing airway pressure.

Not a fan of balloon pumps in general but definitely not in this guy. I hate watching Balloons chew up platelets. Won’t kill him on the table but it may cause morbidity or even mortality down the line.

 

[sethco]

Couple more questions for Residents and Fellows, what actions must be done to the IABP during the course of an Off Pump CABG? Would you keep the IABP at 1:1 or less? Would you keep it going while they are manipulating the heart during both Distal and proximal anastomosis?

 

[hankbb02]

It sounds like a case that should be on pump. The patient has severe multivessel CAD with a critical LM lesion. The manipulation of the heart required for some of the grafts will cause decreases in preload leading to hypotension and ischemia which will likely be poorly tolerated. The ischemia will be difficult to detect with TEE because of the lifting of the heart. IABP are placed for a patient that needs afterload reduction and CPP augmentation. This patient needs neither. I'm assuming they are placing it to get the patient through the off pump heart assault. Why not just do it on pump and avoid the nonsense?

 

[sethco]

I was trained that OPCAB was only for the healthiest pts. Then I went into PP and found that it was even better for the sickest of the sick. This was a fairly common case give or take a few grafts. I’d guess that 70% of our cases were 3-4 bypasses with the LIMA almost always included.

In my practice, about ~80% of my CABGs are Off Pump. With some of my surgeons, they do Off Pump 99% of the time. Vast majority of patients tolerate it well with Volume and Vasopressor support only. We rarely, if ever, place a Balloon Pump. Our usual IABP patients were having STEMIs at an outside hospital and the Cardiologist was worried about transport, so they place it. I have only seen a CT surgeon place a IABP once and that was with ****ty targets and questionable conduits, so ischemia continued necessitating placement with bringing the patient to the Cath lab postop

 

[dchz]

Couple more questions for Residents and Fellows, what actions must be done to the IABP during the course of an Off Pump CABG? Would you keep the IABP at 1:1 or less? Would you keep it going while they are manipulating the heart during both Distal and proximal anastomosis?

Def off during proximal anastamosis and manipulation for the RCA. I'd imagine you don't need 1:1 since the O2 demand is lower under GA. That's all i got.

 

[vector2]

@dchz - good attempt at some responses. A couple points- the original standard TEG is not approved to monitor platelet function on plavix, and you'll likely get some patients who have have normal MAs even with significant platelet inhibition. There are, however, specialized platelet mapping TEG and ROTEM products out there which do work with plavix, and these are becoming more common. PFA-100, even with a collagen/ADP cartridge, is still thought to be relatively insensitive to the degree of plavix effect. A nice review of plavix monitoring can be found here Monitoring the effectiveness of antiplatelet therapy: opportunities and limitations

In regard to SYNTAX, the real takeaway point is that if one has left main or 3VD, CABG is recommended over PCI. Revascularization and MACE goes down significantly with the flip side being a small increase in stroke. Some might have noticed that CABG rates went down a bit in the 00's only to rebound significantly in this decade. No longer are pts getting a wacky number of stents when they meet the CABG criteria in the 2012 ACCF guidelines found here SYNTAX - Wiki Journal Club

@sethco excellent points. My particular surgeon is one of those who OPCABs everyone from the get-go. Doesn't matter if they have an EF 20% and poor targets. The only thing that really stops him is cardiomegaly that's bad enough to preclude exposure or someone who does not tolerate verticalization after multiple attempts and an IABP.

In regard to the IABP, I do not think there was a strong indication to place one in this pt. Her angina was well controlled and function was normal. While it certainly didn't hurt having one, her CI dropped to 1.5 and SVO2 to 55 throughout much of the case. The CO augmentation is small and the increased CPP is likely superfluous when the pt is responding well to norepinephrine.


Appreciate the responses so far. I will wait to see if anyone chimes in before detailing what happened.

 

[AdmiralChz]

I have some thoughts on this but will update with a full response later.

Summary - Needs to be on pump, or at the very least cannulated with the ability to go on quickly - critical LM disease is no joke and I’d worry about malignant arrhythmias during the (very long) numerous anastomoses. OPCAB was hot 10-20 years ago, evidence is starting to catch up. Love the IABP idea - you have critical LM disease, you need SOMETHING to augment coronary perfusion. I’ll update with more later today.

 

[AdmiralChz]

OK so I refreshed my knowledge a bit for this one. Disclaimer - I've been exposed to far more on-pump CABG procedures, but we have one surgeon here that insists on doing it off-pump whenever possible so I have a reasonable beginner-level experience on the subject.

Preop concerns - Plavix loaded. I have nothing more to say about the SYNTAX score than @vector2 said above, but it sort of stinks that the patient got some. The best way to assess qualitative platelet function in this situation is using the PFA-100 assay (different institutions may label it differently) which specifically looks at ADP-receptor function. At our lab, it gives a <5-to-100 result with 100% being normal function. There are a significant number of Plavix (and ASA) non-responders out there, so the platelet function is not a guarantee to be impaired. This isn't a case that can wait for return of platelet function (at least 5-7 days) so the purpose here is more for product management toward the end of the case.

90% left main disease - that's the real deal, and something to be taken seriously. IABP is a reasonable option as this patient is at risk for malignant arrhythmias. No need to have it on 1:1 (max support) given the good biventricular function (for now), 1:2 will be enough coronary perfusion augmentation to make me happy. I hear the platelet effects, but we will be dealing with those anyway and they are likely barely functioning to begin with. Elevating the CPP with norepinephrine by increasing afterload isn't my preferred strategy here, and probably increases the work of the heart. This patient is high risk, and an honest discussion needs to be had with the family and patient about a possible bad outcome here and their wishes properly documented.
- Some cardiologists will put Impellas in these high-risk patients. You'd only need a femoral device (CP or 2.5), running at P4-P6.

Intraop - Monitors: Standard with right radial A-line just in case peripheral ECMO is required at the end (not out of the realm of possibility). CVL with PAC particularly for ICU management afterwards, TEE for intra-op but if it goes OPCAB the views will be mostly lost when the heart is verticalized.
- Make sure you evaluate the position of the IABP if it's there with TEE, it very frequently is out of place (too deep) and you don't want to place the renals at risk. Proper position is 1-3 cm from the L subclavian takeoff in the descending aorta.

OPCAB vs On-pump: The newer evidence (trials - ROOBY, CORONARY are the biggest with ~ 2K and 4K patients respectively) shows a 5 year similar outcome between them, but the 1 year outcomes were more significant with off-pump procedures. I am not sure this is a totally applicable situation to apply as critical left main disease likely would have disqualified the patient from the trials. If the surgeon feels strongly then attempting is fine but I am putting my foot down - given the high risk for malignant arrhythmia and severe hemodynamic instability venous and arterial cannulas need to be placed and a CPB pump attached and ready to go. The other consideration here is that 4-6 vessels is a LOT for OPCAB - the numbers above are one thing, but what does the surgeon plan to do - how many posterior anastomoses requiring verticalization when the hemodynamics are the worst?
- You'll need to volume load these patients sufficiently to handle the LV suction device, so watch closely with TEE so you don't overdo it.

Send coags when rewarming (off pump) or during the last couple anastomoses - specifically, PT/PTT/INR, Fibrinogen, TEG (with heparinase), Platelet count. If the PFA-100 preop was <20, have 2U Plt ready to go. You'll probably need more, this is not the case where blood product conservation will be utilized. Depending on what the opening PA pressures were, you might need some Milrinone as an inodilator. Will likely need some norepinephrine for relative vasoplegia (this will iikely be a long pump run), have a low threshold to add Vasopressin as well if PAPs are a problem given its specificity for the systemic circuit over the pulmonary circuit. Assess function with TEE, low dose ionotrope with epinephrine may also be helpful.

Then assess bleeding, check those coags that were sent. If there is any renal dysfunction, add some DDAVP following protamine. You'll likely need at least platelets, but also FFP given the dilution from the volume load you had to do. Cryo if fibrinogen is low.

Watch closely over the next 30 min to 1 hour, these patients are at risk for decompensating after things have settled out (where the PAC will come into handy in the ICU). If there is an IABP, closely evaluate the function and discuss with the surgeon - if things look good, you can take it out vs set it to minimal modulation (1:4) and take out the next day when stable.

I think that's all I've got to say. Good case, definitely some wiggle room with regards to management.

 

[anbuitachi]

OK so I refreshed my knowledge a bit for this one. Disclaimer - I've been exposed to far more on-pump CABG procedures, but we have one surgeon here that insists on doing it off-pump whenever possible so I have a reasonable beginner-level experience on the subject.

Preop concerns - Plavix loaded. I have nothing more to say about the SYNTAX score than @vector2 said above, but it sort of stinks that the patient got some. The best way to assess qualitative platelet function in this situation is using the PFA-100 assay (different institutions may label it differently) which specifically looks at ADP-receptor function. At our lab, it gives a <5-to-100 result with 100% being normal function. There are a significant number of Plavix (and ASA) non-responders out there, so the platelet function is not a guarantee to be impaired. This isn't a case that can wait for return of platelet function (at least 5-7 days) so the purpose here is more for product management toward the end of the case.

90% left main disease - that's the real deal, and something to be taken seriously. IABP is a reasonable option as this patient is at risk for malignant arrhythmias. No need to have it on 1:1 (max support) given the good biventricular function (for now), 1:2 will be enough coronary perfusion augmentation to make me happy. I hear the platelet effects, but we will be dealing with those anyway and they are likely barely functioning to begin with. Elevating the CPP with norepinephrine by increasing afterload isn't my preferred strategy here, and probably increases the work of the heart. This patient is high risk, and an honest discussion needs to be had with the family and patient about a possible bad outcome here and their wishes properly documented.
- Some cardiologists will put Impellas in these high-risk patients. You'd only need a femoral device (CP or 2.5), running at P4-P6.

Intraop - Monitors: Standard with right radial A-line just in case peripheral ECMO is required at the end (not out of the realm of possibility). CVL with PAC particularly for ICU management afterwards, TEE for intra-op but if it goes OPCAB the views will be mostly lost when the heart is verticalized.
- Make sure you evaluate the position of the IABP if it's there with TEE, it very frequently is out of place (too deep) and you don't want to place the renals at risk. Proper position is 1-3 cm from the L subclavian takeoff in the descending aorta.

OPCAB vs On-pump: The newer evidence (trials - ROOBY, CORONARY are the biggest with ~ 2K and 4K patients respectively) shows a 5 year similar outcome between them, but the 1 year outcomes were more significant with off-pump procedures. I am not sure this is a totally applicable situation to apply as critical left main disease likely would have disqualified the patient from the trials. If the surgeon feels strongly then attempting is fine but I am putting my foot down - given the high risk for malignant arrhythmia and severe hemodynamic instability venous and arterial cannulas need to be placed and a CPB pump attached and ready to go. The other consideration here is that 4-6 vessels is a LOT for OPCAB - the numbers above are one thing, but what does the surgeon plan to do - how many posterior anastomoses requiring verticalization when the hemodynamics are the worst?
- You'll need to volume load these patients sufficiently to handle the LV suction device, so watch closely with TEE so you don't overdo it.

Send coags when rewarming (off pump) or during the last couple anastomoses - specifically, PT/PTT/INR, Fibrinogen, TEG (with heparinase), Platelet count. If the PFA-100 preop was <20, have 2U Plt ready to go. You'll probably need more, this is not the case where blood product conservation will be utilized. Depending on what the opening PA pressures were, you might need some Milrinone as an inodilator. Will likely need some norepinephrine for relative vasoplegia (this will iikely be a long pump run), have a low threshold to add Vasopressin as well if PAPs are a problem given its specificity for the systemic circuit over the pulmonary circuit. Assess function with TEE, low dose ionotrope with epinephrine may also be helpful.

Then assess bleeding, check those coags that were sent. If there is any renal dysfunction, add some DDAVP following protamine. You'll likely need at least platelets, but also FFP given the dilution from the volume load you had to do. Cryo if fibrinogen is low.

Watch closely over the next 30 min to 1 hour, these patients are at risk for decompensating after things have settled out (where the PAC will come into handy in the ICU). If there is an IABP, closely evaluate the function and discuss with the surgeon - if things look good, you can take it out vs set it to minimal modulation (1:4) and take out the next day when stable.

I think that's all I've got to say. Good case, definitely some wiggle room with regards to management.

What is the reasoning for R radial A line being standard? And what is CP 2.5 P4-6? Haven't had exposure yet

 

[Noyac]

I don’t do hearts any longer. But I wonder if it would be better to bypass the LM and anterior vessels off pump then go on pump for the remainder? I would worry about the IABP during all the manipulation of the npheart during off pump.

 

[drmwvr]

I don’t do hearts any longer. But I wonder if it would be better to bypass the LM and anterior vessels off pump then go on pump for the remainder? I would worry about the IABP during all the manipulation of the npheart during off pump.

Whatever benefit for being off pump that would be gained would be a wash once he went on CPB. Going on pump is going on pump. Two vessels or four. Unless the surgeon has stupid long cross clamp times, that is...

 

[Psai]

Whatever benefit for being off pump that would be gained would be a wash once he went on CPB. Going on pump is going on pump. Two vessels or four. Unless the surgeon has stupid long cross clamp times, that is...

Wouldn't you want to limit bypass time as much as possible anyway to minimize ischemia reperfusion, renal/neuro/other deficits, platelet and coagulation dysfunction, etc

 

[thinkorswim]

I was trained that OPCAB was only for the healthiest pts. Then I went into PP and found that it was even better for the sickest of the sick. This was a fairly common case give or take a few grafts. I’d guess that 70% of our cases were 3-4 bypasses with the LIMA almost always included.

That's interesting. I have only done two OPCAB cases, although I am just finishing up fellowship and my future practice may do things differently. For now, most of our CABG patients have reduced EF and about half will have a balloon pump either from the cath lab or placed by the surgeon prior to separating from bypass.

With regard to on-pump versus off-pump, I was under the impression that there is no significant difference with regards to outcomes and it was mostly just done these days for a surgeon's pride. Also, do people still graft more than 3-4 vessels at a time?

Wouldn't you want to limit bypass time as much as possible anyway to minimize ischemia reperfusion, renal/neuro/other deficits, platelet and coagulation dysfunction, etc

Cross-clamp time is much more important than bypass time when it comes to myocardial function.

 

[drmwvr]

Wouldn't you want to limit bypass time as much as possible anyway to minimize ischemia reperfusion, renal/neuro/other deficits, platelet and coagulation dysfunction, etc

20 or so more minutes of bypass doesn't make a difference with modern bypass circuits/oxygenators. Faster surgery, better cardioplegia...once you take the plunge and go on bypass, you'd might as well as accept the downsides and take advantage of the benefits.

 

[thinkorswim]

What is the reasoning for R radial A line being standard? And what is CP 2.5 P4-6? Haven't had exposure yet

A right radial a-line is used for ABG sampling in patients on VA ECMO since it reflects the blood that the heart is ejecting. In this patient with a normal EF, the likelihood of requiring ECMO is so minimal that I would just place an arterial line in the patient's non-dominant hand since it stays in for a couple days postoperatively.

With regards to the CP and 2.5, those are just different Impella types. Most places will use either a 2.5 or a 5.0, which reflect the cardiac output agumentation (in L/min) that they can provide.

 

[Lurch]

You don’t have to cross clamp. That’s a crutch for academicians. Warm beating cabg is a nice fallback for opcabgs that don’t tolerate it.

 

[OB1🤙]

Yeah, on-pump beating-heart cabg is a very nice middle ground. We do more of that than OPCABG or cross-clamped TBH. Try it, you might like it. I prefer off-pump, but it's not for everyone.

I feel like I do this case once every couple weeks.

 

[pgg]

With regard to on-pump versus off-pump, I was under the impression that there is no significant difference with regards to outcomes and it was mostly just done these days for a surgeon's pride.

Surgeons who do it all the time can get really good at it.

In some countries it's much more common. No pump run saves a lot of disposable expensive equipment.

 

[sethco]

OK so I refreshed my knowledge a bit for this one. Disclaimer - I've been exposed to far more on-pump CABG procedures, but we have one surgeon here that insists on doing it off-pump whenever possible so I have a reasonable beginner-level experience on the subject.

Preop concerns - Plavix loaded. I have nothing more to say about the SYNTAX score than @vector2 said above, but it sort of stinks that the patient got some. The best way to assess qualitative platelet function in this situation is using the PFA-100 assay (different institutions may label it differently) which specifically looks at ADP-receptor function. At our lab, it gives a <5-to-100 result with 100% being normal function. There are a significant number of Plavix (and ASA) non-responders out there, so the platelet function is not a guarantee to be impaired. This isn't a case that can wait for return of platelet function (at least 5-7 days) so the purpose here is more for product management toward the end of the case.

90% left main disease - that's the real deal, and something to be taken seriously. IABP is a reasonable option as this patient is at risk for malignant arrhythmias. No need to have it on 1:1 (max support) given the good biventricular function (for now), 1:2 will be enough coronary perfusion augmentation to make me happy. I hear the platelet effects, but we will be dealing with those anyway and they are likely barely functioning to begin with. Elevating the CPP with norepinephrine by increasing afterload isn't my preferred strategy here, and probably increases the work of the heart. This patient is high risk, and an honest discussion needs to be had with the family and patient about a possible bad outcome here and their wishes properly documented.
- Some cardiologists will put Impellas in these high-risk patients. You'd only need a femoral device (CP or 2.5), running at P4-P6.

Intraop - Monitors: Standard with right radial A-line just in case peripheral ECMO is required at the end (not out of the realm of possibility). CVL with PAC particularly for ICU management afterwards, TEE for intra-op but if it goes OPCAB the views will be mostly lost when the heart is verticalized.
- Make sure you evaluate the position of the IABP if it's there with TEE, it very frequently is out of place (too deep) and you don't want to place the renals at risk. Proper position is 1-3 cm from the L subclavian takeoff in the descending aorta.

OPCAB vs On-pump: The newer evidence (trials - ROOBY, CORONARY are the biggest with ~ 2K and 4K patients respectively) shows a 5 year similar outcome between them, but the 1 year outcomes were more significant with off-pump procedures. I am not sure this is a totally applicable situation to apply as critical left main disease likely would have disqualified the patient from the trials. If the surgeon feels strongly then attempting is fine but I am putting my foot down - given the high risk for malignant arrhythmia and severe hemodynamic instability venous and arterial cannulas need to be placed and a CPB pump attached and ready to go. The other consideration here is that 4-6 vessels is a LOT for OPCAB - the numbers above are one thing, but what does the surgeon plan to do - how many posterior anastomoses requiring verticalization when the hemodynamics are the worst?
- You'll need to volume load these patients sufficiently to handle the LV suction device, so watch closely with TEE so you don't overdo it.

Send coags when rewarming (off pump) or during the last couple anastomoses - specifically, PT/PTT/INR, Fibrinogen, TEG (with heparinase), Platelet count. If the PFA-100 preop was <20, have 2U Plt ready to go. You'll probably need more, this is not the case where blood product conservation will be utilized. Depending on what the opening PA pressures were, you might need some Milrinone as an inodilator. Will likely need some norepinephrine for relative vasoplegia (this will iikely be a long pump run), have a low threshold to add Vasopressin as well if PAPs are a problem given its specificity for the systemic circuit over the pulmonary circuit. Assess function with TEE, low dose ionotrope with epinephrine may also be helpful.

Then assess bleeding, check those coags that were sent. If there is any renal dysfunction, add some DDAVP following protamine. You'll likely need at least platelets, but also FFP given the dilution from the volume load you had to do. Cryo if fibrinogen is low.

Watch closely over the next 30 min to 1 hour, these patients are at risk for decompensating after things have settled out (where the PAC will come into handy in the ICU). If there is an IABP, closely evaluate the function and discuss with the surgeon - if things look good, you can take it out vs set it to minimal modulation (1:4) and take out the next day when stable.

I think that's all I've got to say. Good case, definitely some wiggle room with regards to management.

Good response, but a couple of critiques...

1) I completely agree that there are Plavix non-responders out there and a single loading dose may not be that significant for some patients. I like Platelet mapping to show me how activity the Plavix is inhibiting. We usually try to wait for 5 days from last dose before proceeding with Cardiac surgery unless the situation dictates it. Its questionable, whether this patient dictates immediate surgery if they are not having ongoing angina with a NTG/Heparin gtt (and an IABP)
2) Malignant arrhythmias are not really prevented with IABP placement unless you believe that the cause of the arrythmia is due to low Coronary Perfusion Pressure. If this was a true Off Pump case, I would keep the rate at 1:1 with pausing the IABP when doing the heartstrings for the proximal anastomosis. After revascularization is complete then I would bring the IABP down to 1:2 or 1:3. However, I disagree with most people here that an IABP is even needed in the first place. Despite the high grade left main dx, pt is hemodynamically stable, has no ST elevations (and never did), no wall motion abnormalities, has normal LV function, and angina is controlled with sublingual NTG. I would seriously question any Cardiologist who would put in an Impella in this type of pt with normal heart function. Levophed is my drug of choice for off pump along with optimal volume titration. I also wouldn't call this pt high risk. If it wasn't for the IABP (which is questionable in the first place), this pt would have a low STS score. However, yes all CABG patients can have bad outcomes, left main disease or not. I dont think you need to put the fear of god into this patient or their family
3) What concerns you about this patient that ECMO might be needed? Also, TEE is extremely useful for detected ischemia in Off Pump cases. I can tell you I have no problem seeing these even during manipulation/positioning of the heart for the distal anastomosis. I agree regarding the positioning of the TEE, however its not the Renals that I worry about, it is occlusion of the perfusion to the arch vessels. Like you, I try to find the Left Subclavian and make sure I see the tip distal this.
4) Regarding the Off vs On Pump debate, most CT surgeons would call the studies flawed and feel that each individual surgeon should stick to whatever they are good at. However, you should definitely commit one way or the other. It can be unless and maybe even harmful to place cannulas and connect the circuit but stay Off pump, unless I am interpreting you incorrectly (did you mean femoral cannulation)? Also, there are other stabilizing devices than just the suction device, as I am sure your aware.
5) Would you use Milrinone in a Normal biventricular function patient with high PA pressures? I find this to do more harm than good in Off pump cases. Also there is no "rewarming" period during Off pump or Warm/Beating On Pump. Platelets are my biggest concern with the IABP in place. I usually don't use Inotropes with CABGs unless they had a dilated Cardiomyopathy to start. Also, after revascularization, what makes you think this patient is at risk for decompensating (vs regular CABG patients without left main disease)? Are you surgeons checking blood flow in their grafts with doppler or medistim?

In summary, I think this case could probably be done Off pump (with or without an IABP), but ding it On Pump warm beating is a good fall back option

 

[anbuitachi]

A right radial a-line is used for ABG sampling in patients on VA ECMO since it reflects the blood that the heart is ejecting. In this patient with a normal EF, the likelihood of requiring ECMO is so minimal that I would just place an arterial line in the patient's non-dominant hand since it stays in for a couple days postoperatively.

With regards to the CP and 2.5, those are just different Impella types. Most places will use either a 2.5 or a 5.0, which reflect the cardiac output agumentation (in L/min) that they can provide.

Does that even make a difference? Is it so you can see pulsatility a little bit better than Left side? I'm guessing it's standard to put the pulse ox on the R side too?

 

[dchz]

Does that even make a difference? Is it so you can see pulsatility a little bit better than Left side? I'm guessing it's standard to put the pulse ox on the R side too?

I think the R radial A line is good for VA ecmo that has femoral arterial cannulation. The R radial artery is the fartherest away from the arterial cannulation site in that case. but if you're cannulating at the proximal aorta centrally. I don't think it matters which arm you have the A line, or if anything the L radial is probably the fartherest away.

Someone please correct me if i'm wrong.

 

[psychbender]

Does that even make a difference? Is it so you can see pulsatility a little bit better than Left side? I'm guessing it's standard to put the pulse ox on the R side too?

ABGs. The blood from the right radial artery is most proximal to the heart, and most reflects native lung function, unless ECMO flows can completely overcome native cardiac function (also reflective of what the heart and brain are getting). Left radial may be more reflective of the ECMO-circulated blood, depending on the location of the mixing cloud in the aorta. If native cardiac function is returning, that mixing cloud can be pushed farther down the aorta, with both radials being roughly the same. If the lungs suck, that leads to differential oxygenation, with poor oxygenation of the head, heart, arms, and good oxygenation of the rest of the body.

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[crash2500]

Yes right radial a-line is needed in peripheral va ecmo because you will have a mixing point due to femoral cannulation. Right radial will give you the best approximation of what kind of oxygenation the brain is seeing.

 

[thinkorswim]

Does that even make a difference? Is it so you can see pulsatility a little bit better than Left side? I'm guessing it's standard to put the pulse ox on the R side too?

For peripheral VA ECMO, yes it does matter. The right radial artery is used to ensure adequate myocardial and cerebral oxygenation. This is the blood that is being ejected from the heart and has the potential to be hypoxemic. The left radial arterial line is generally used to measure the blood being delivered retrograde from the ECMO circuit, assuming the mixing point is more proximal to this.

With central VA ECMO, it doesn't matter where you draw ABG samples from since the entire body is theoretically receiving blood from the ECMO circuit and the risk of cerebral hypoxemia is much less.

Look up North-South Syndrome for more information.

 

[dchz]

Monitoring the effectiveness of antiplatelet therapy: opportunities and limitations.

Wow that was a long read just to get the message that there are no good clinical point-of-care tests for platelet function. But now i will remember that forever....

Pt is hemodynamically stable and on 2L O2. Angina is relieved by SLN.

Surgeon requests IABP be placed as he intends to take this pt for a 4-6 vessel OPCAB later tonight.

Now flipping the script back on @vector2 , @sethco , @Hawaiian Bruin , @thinkorswim , and @AdmiralChz :

Given that there are no good point-of-care tests, and assuming the pt got a loading dose of 600mg of clopidogrel, how many of yall wait the 5 days before CABG?

If the decision was made to go to surgery later that night, how does your management of heparinization change if you need to go on pump? if at all?

@sethco mentioned heartstring, is that device used pretty commonly out there?

 

[dchz]

- Make sure you evaluate the position of the IABP if it's there with TEE, it very frequently is out of place (too deep) and you don't want to place the renals at risk. Proper position is 1-3 cm from the L subclavian takeoff in the descending aorta.

Like you, I try to find the Left Subclavian and make sure I see the tip distal this.

Interesting side note: My buddy presented a case at the SCA which the IABP was occluding the celiac artery. I've never tried but could yall see the celiac artery take off with TEE?

 

[T-burglar]

You can sometimes see the celiac axis,but the balloon artifact would make it difficult to see if you’re covering it or not. You’d have to locate the artery prior to balloon placement and note the TEE depth marking at the teeth . Then you could more surely tell if there is balloon artifact over the site of the celiac later.

It’s not really routine to do this, but this is how you would do it. The routine thing to do is just size the dam thing correctly for the patient and use TEE to place the tip of it just distal to the last arch vessel.


Balloons cause all kinds of problems and I think it’s wishful thinking to believe they help anything.

 

[OB1🤙]

You wait for pharmacologic washout if you can, but if there's unstable angina the surgeon will want to go. Then you just have to deal with the inevitable postop bleeding. But hey, all bleeding eventually stops.

I also hate balloons. They are occasionally nice to have, but more often than not don't contribute much to the patient's well-being and add nontrivial morbidity.

 

[Ronin786]

For peripheral VA ECMO, yes it does matter. The right radial artery is used to ensure adequate myocardial and cerebral oxygenation. This is the blood that is being ejected from the heart and has the potential to be hypoxemic. The left radial arterial line is generally used to measure the blood being delivered retrograde from the ECMO circuit, assuming the mixing point is more proximal to this.

With central VA ECMO, it doesn't matter where you draw ABG samples from since the entire body is theoretically receiving blood from the ECMO circuit and the risk of cerebral hypoxemia is much less.

Look up North-South Syndrome for more information.

Differential oxygenation should only be a concern in someone with really bad lungs (ARDS). In this patient I'd just put the a-line where the pulse was better or non-dominant as mentioned above.

 

[AdmiralChz]

Brief note - was also assuming if a surgeon was considering 6 bypasses (I’ve never done more 4), then radial artery harvest of the non-dominant hand would probably have to be done. So another reason for right radial.

 

[vector2]

Excellent responses so far. So, here's what happened:

Both the surgeon and I were a bit dismayed by the plavix but this kind of thing happens occasionally. Even though her angina was stable, he wanted to proceed quickly given the large amount of myocardium at risk. Unfortunately, this case was occurring at the partly physician owned hospital across town from the mothership and no one was available to send blood over for a PFA on a Saturday. There's a decent volume of cardiac and vascular here, but the resources are scant beyond what you need to get the average pump case from the OR to the ICU. Regardless of PFA availability, I'm not sure how much it would've changed management considering how much transfusion takes place based upon the clinical situation.

IABP placement goes swimmingly and this lady is chilling in the ICU. Vitals are great, still on 2L. We roll in the room around 5pm. 1u of platelets has already gone in and another 1u is dripping in as we go to sleep. Uneventful induction, swan, and TEE placement. Heart is banging, IABP is in good position.

As soon as incision starts and dissection is occurring, the chest already looks wet. Not crazy wet at this point but it's definitely oozing more than the usual sternotomy. Starting HGB is around 11-12 at this point IIRC. Bovie, bovie, bovie, things are looking good. Surgeon likes his targets. This lady is an absolute champ from a MAP standpoint during heart rotation and verticalization. Got 1L plasmalyte and 500 albumin on board and was able to maintain solid IABP DBP augs of 100-150 the entire time on 0.05-0.2 norepi with occasional boluses. Surgeon at this time decides he wants to be a hero and go for 6 vessels since the PA got a ridiculous amount of vein. Tried to give her rest here and there throughout case but 3 to 4 hours in, Hgb is now 7-8ish, and even on 1:1 her CI is dropping to 1.5, SVO2 to 55-60, and she becomes acidotic to ~7.2 and lactate is climbing. LVEDA looking small on echo, filling pressures decreased from baseline when resting. Drip in 1u prbc, tell the surgeon we need to rest her for a little longer. SVO2 perks up, acidosis improves, and surgeon ends up doing all 6 vessels (LIMA-LAD, and then veins to OM, diag, RCA, PDA, PL). It's around 1230am at this point when the prox's are getting finished up. IABP off for prox's, turned back to 1:2 when we've finished. Give protamine. Chest still wet. No POC tests here so give 2 ffp, 2 more plt, 20 cryo. I leave another 5g amicar to finish up in the unit instead of my normal practice of taking it off the pump before rolling out. Chest is drying up now. Echo and ABG look good before we roll out of the room.

Get over to ICU and handoff. Get called over the intubate/a-line another patient which takes 20-30 min. I go back and check on my lady and there's already 500 in the mediastinal. Talk with surgeon about just taking her back now while most of us are still here. He wants to empirically give 2 more plt and then wait on PT/PTT/fibrinogen before more products as her oxygenation is OK but not stellar at this point. All right, fine. Head home and can't sleep since I'm still on call and expecting my cell to go off any second when he changes his mind.

Get the call at 8am. We're going back to the OR for exploration/washout (duh). Her med has put out three point two freakin' liters overnight. Transfusion in the ICU has not kept up with her blood loss. Instead, the geniuses in charge of her care have been giving a couple units of prbcs and plasma here and there and mostly just titrated up her norepi and started some epi for the low CI. I call for 4, 4, and 2 for the OR as I'm driving in.

She's in moderate (soon to be severe) extremis when we go to get her. CI is 1.5, augs are now 80-100 depending on where we are in the ventilation cycle. Hgb is around 7-8 on ABG but likely it's lagging behind the active loss. Start squeezing in some albumin while we're rolling to the room because products are taking forever. We get her moved to the OR table and then all of a sudden her a-line tracing goes flat to 40 mmhg and the IABP stops triggering. F&CK. Start compressions, blood miraculously arrives at this point. 2 rounds of compressions, 500 mcg epi and 10u vasopressin to temporize while surgeon puts on gloves and we're getting the blood rolling in. ROSC. Surgeon gets into chest and sucks out a large amount of clot. TEE not showing tamponade physiology, just mostly hypovolemia (for all the padawans out there, 8 times out of 10 your surgeon is dead wrong about a crunking, bleeding takeback being tamponade, and you should be squeezing volume IN and turning the crazy high inotropes DOWN unless you have echocardiographic evidence showing otherwise). I imagined it was going to be mostly diffuse surface bleeding in there but surgeon says the RCA prox is bleeding at the anastomosis. Source found and fixed. Once I get 4 prbc and 2 ffp in, I'm able to turn norepi off and I leave the epi at 0.02 since the 300lb circulator just jackhammered her RV.

Prolonged intubation in ICU 2/2 to pulm edema but extubated after a few days. Lady is doing OK now but not great. Case was a couple weeks ago and heart looks fantastic, but her mental status is not back to baseline. Apparently she had small old stroke on CT but repeat CTs don't show anything new. Given the nature of this case there's a lot of reasons for post-op cognitive dysfunction, but hoping it resolves with time.

 

[deleted171991]

This is a textbook case how not to do surgery (so typical of big ego cardiac surgeons). This case should have become a minimalist one the moment it was clear that her bleeding would be an issue. The enemy of good is better. I assume the surgeon thought the higher EF would compensate for the lower IQ. 🙄

Also this is the typical bad ICU acute care surgical patients can get from midlevels or medical intensivists. I know of cases where the patient was bleeding out and the latter were working the patient up for PE. That patient should have gone back to the OR hours before - assuming she was getting platelets/FFP/cryo as expected. (Or the surgeon was lazy and didn't want to come back in the middle of the night.)

 

[NightNight]

Still trying to figure out why you couldn’t keep her inpatient for 5 days and do a 4v on-pump CABG without an IABP?

 

[deleted162650]

I assume the surgeon thought the higher EF would compensate for the lower IQ. 🙄

😆

Sorta like in ortho where bench press makes up for IQ.

 

[vector2]

Still trying to figure out why you couldn’t keep her inpatient for 5 days and do a 4v on-pump CABG without an IABP?

Yes, at my main ivory tower gig this likely would've been the plan. At a community, physician-owned hospital the surgeons slice and dice 'em, the cardiologists treat and street 'em. The 25 bed combined ICU/step down/floor (each room is the pt's only room from admission to discharge) runs max capacity 95% of the time. This lady would've been taking up 5 days of valuable ICU space which the surgeon would very much like to use for another privately insured open heart.

If anyone wonders why eat what you kill models sometimes get a bad rap, look no further than places like this or those rural cath labs which got busted by CMS for doing 400% more angio/PCI than the national average.

 

[sethco]

"Elective" CABG at 1700 on a Saturday! I don't think much else needs to be said.

 

[anbuitachi]

If anyone wonders why eat what you kill models sometimes get a bad rap, look no further than places like this or those rural cath labs which got busted by CMS for doing 400% more angio/PCI than the national average.

man it's so messed up sometimes what people are willing to do for a bit more money. we entered the profession to heal and do the right thing!

 

[Ronin786]

This is a textbook case how not to do surgery (so typical of big ego cardiac surgeons). This case should have become a minimalist one the moment it was clear that her bleeding would be an issue. The enemy of good is better. I assume the surgeon thought the higher EF would compensate for the lower IQ. 🙄

Also this is the typical bad ICU acute care surgical patients can get from midlevels or medical intensivists. I know of cases where the patient was bleeding out and the latter were working the patient up for PE. That patient should have gone back to the OR hours before - assuming she was getting platelets/FFP/cryo as expected. (Or the surgeon was lazy and didn't want to come back in the middle of the night.)

Crazy to think this lady got ~4 more hours of cardiac surgery and spent 6 hours bleeding into her chest because of the cardiac surgeon's ego. It's why I can't stand working with them and their outdated rituals (most not all). Especially when they come to the ICU and start everybody on dopamine and sodium bicarb.

 

[OB1🤙]

Yeah, I've seen that movie before.

Major teaching point here is that these ICUs are generally not used to massive bleeding and are woefully unprepared for the all-hands-on-deck resuscitation that these cases require.

 

[AdmiralChz]

Cool case, being a hero and going for 6 bypasses past midnight probably wasn’t the best move but hindsight is always 20/20.

Yep, I’ve seen these cases (even “normal” ventricular function) go very awry and that informs my current practice, even if it’s in its infancy. Including one patient who pretty much died on the table (wasted away for 5 days with anoxic brain injury first, sadly). In high riskers, prepare for the worst but hope for the best.

Still trying to figure out why you couldn’t keep her inpatient for 5 days and do a 4v on-pump CABG without an IABP?

With such high grade lesions, that patient is probably one ruptured plaque away from serious complications or even sudden cardiac death. That would be hard to defend, since blood product transfusion (even though it carries risk) can deal with coagulopathy. While some might question the IABP use, it’s doubtful it made things worse here. The surgeons I know wouldn’t have waited either, and the Cardiologists wouldn’t have either.

 

[deleted171991]

Major teaching point is that serious cardiac surgery should not be done in a place with an ICU run by amateurs/midlevels at night (which probably would eliminate 25-50% of the community hospices, I mean hospitals).

There should be a TEE/TTE-trained surgical intensivist in-house, to properly diagnose and manage the patient, and with the appropriate resources, not just "telemedicine" based on numbers (because this is 1988), by the cardiac surgeon. Cardiac (and not only) surgeons should stop practicing intensive care; they suck at it.

 

[T-burglar]

The care in a Cardiac SICU will always be dangerous and scary unless there is an intensivist around that really knows this medicine including TEE. This is the toughest critically ill patient set in my opinion.

In my community hospital we are getting ready to start a VAD program and our ICU is all midlevels. Lol

 

[AdmiralChz]

The care in a Cardiac SICU will always be dangerous and scary unless there is an intensivist around that really knows this medicine including TEE. This is the toughest critically ill patient set in my opinion.

In my community hospital we are getting ready to start a VAD program and our ICU is all midlevels. Lol

Hire some fellowship-trainined midlevels and all will be well! *sarcasm*

Even those that have some exposure almost invariably make the wrong calls with echo. Somehow, surgeon-trained intensivists that I’ve seen are some of the worst at echo while training these mid levels. I really hope that’s just my anecdotal experience. Sigh.

 

[T-burglar]

Hire some fellowship-trainined midlevels and all will be well! *sarcasm*

Even those that have some exposure almost invariably make the wrong calls with echo. Somehow, surgeon-trained intensivists that I’ve seen are some of the worst at echo while training these mid levels. I really hope that’s just my anecdotal experience. Sigh.

I sort of think you’re only getting the TEE expertise you need by doing a ACTA fellowship , unfortunately . Even cardiologists miss things like severe hypovolemia in my experience if they don’t do much time in the post bypass period.