Question: 60 yo s/p cabg

[PinchandBurn]

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So here's a question from a course (somewhat revised). Even though the exact question was on this review twice, two different answers were given. 🙄

59 y/o Male s/p CABG x2 of LAD and Circ. You separate from Bypass, here are your values: CVP-20 PAP 52/31 CI-1.2 BP -97/66 . What is the best Tx option?
A) IABP
B) inhaled Nitric Oxide
C)DBT
D) NTG
E) return to CPB


My assesment. This patient has right sided failure as seen by the high CVP and ultra high PAP. His CI is also low. BP is marginal at best.

What's the next best step: maybe returning the patient back to CPB
What's the best tx option: Was thinking give the inhaled NO to decrease the high PAP, which should help with the right heart failure.

One of explanations reads that the patient is actually having left heart failure. Nitric Oxide if given will depress the heart and also "heighten the risk of significant VAE" (totally irrelevant in my opinion as there is no concern of that just yet).

So in one of the answer keys B is the answer and the other the answer is E ! Clearly D and A are wrong. C, well I dont think you want to give DBT when the BP is marginal although the CI maybe augmented.

Thoughts?

 

[sevoflurane]

I would want to know what my starting numbers were. CI of 1.2 is concerning. PA pressures are high... but not devestating. CVP's can run in the high teens... depending on where you start a CVP of 20 could be normal.

This question has many answers. But of the ones given, return to CPB or IAB.... If it's a protamine reaction, then maybe some NTG with background epi gtt.

Inhaled NO is somthing I've never done during a routine 2 vessel CABG, but maybe they want you to think of a way to drop your PA's without hypotension.

 

[Robert Loblaw]

So here's a question from a course (somewhat revised). Even though the exact question was on this review twice, two different answers were given. 🙄

59 y/o Male s/p CABG x2 of LAD and Circ. You separate from Bypass, here are your values: CVP-20 PAP 52/31 CI-1.2 BP -97/66 . What is the best Tx option?
A) IABP
B) inhaled Nitric Oxide
C)DBT
D) NTG
E) return to CPB


My assesment. This patient has right sided failure as seen by the high CVP and ultra high PAP. His CI is also low. BP is marginal at best.

What's the next best step: maybe returning the patient back to CPB
What's the best tx option: Was thinking give the inhaled NO to decrease the high PAP, which should help with the right heart failure.

One of explanations reads that the patient is actually having left heart failure. Nitric Oxide if given will depress the heart and also "heighten the risk of significant VAE" (totally irrelevant in my opinion as there is no concern of that just yet).

So in one of the answer keys B is the answer and the other the answer is E ! Clearly D and A are wrong. C, well I dont think you want to give DBT when the BP is marginal although the CI maybe augmented.

Thoughts?

almost definitely left heart failure--cardiac INDEX of 1.2 is extremely low. the h/o of left sided disease speaks to an ischemic etiology of either acute and/or chronic failure. the question as to whether IABP or return to bypass probably depends on the chronicity of the problem and the surgical issues, i.e. was there inadequate plegia, can they do another/different jump if acute, did they mess up the bypass in a techincal fashion0? obviously TEE is not an option but it would be very helpful in this instance to assess LV function and compare to prior, if available. i would lean towards IABP if the indication for the procedure was USA/NSTEMI with a possibility of some myocardial stunning (and recovery) and the surgeons were certain that the repair was technically completely successful

 

[dhb]

Agree with Robert : left side failure

 

[Idiopathic]

if you are treating this patient in the ICU they get an inotrope, and i believe thats what they need here. now, maybe cpb is the best option given that you are in the OR and they dont need volume (at least not directed to the right heart). i think dobutamine is a reasonable answer.

 

[Surfer]

if you are treating this patient in the ICU they get an inotrope, and i believe thats what they need here. now, maybe cpb is the best option given that you are in the OR and they dont need volume (at least not directed to the right heart). i think dobutamine is a reasonable answer.

I agree. Left sided heart failure. A touch of dobutamine could fix the problem. IABP is not the correct answer as that is just a bridge to surgery and you're already in the OR. Bypass is ok if the ionotrope doesn't fix the problem, but you have to think there's some ischemia you're going to fix.

I'd give DBT

 

[pgg]

i think dobutamine is a reasonable answer.

That would be my first answer too, absent a diagnosis.

The PA pressures aren't outrageous and 97/66 isn't exactly death's door. Going back on bypass or going for the IABP seems a bit aggressive.

 

[proman]

This question requires you to recognize Low Cardiac Output Syndrome (essentially a CI <2). I think E is the best answer. The primary treatment of LCOS immediately post CPB is, I think, to go back on pump to rest the heart and try again.

 

[sevoflurane]

IABP is not the correct answer as that is just a bridge to surgery and you're already in the OR.

This statement is mostly true. There are some cases where you place an IABP near the end of the case, cuz things ain't looking too good. My last MVR/AVR with post stenotic dilatation was like this.... went to the ICU with a newly placed IABP and higher than normal inotropes. It came out the next evening. The point is.... sometimes it's a bridge from the OR to the ICU when things are a little crazy. It's happened to me once in PP and a couple of times during residency. But surfer is right... most of the time it's a bridge to the OR.

 

[Narcotized]

My assesment. This patient has right sided failure as seen by the high CVP and ultra high PAP.

If the pump is failing, fluids are backing up. The right heart backs up into the venous system (high CVP). A failing pump of any kind (heart, water, pool, tire, etc) can't be the reason for high pressures going forward (high PAP would not be caused by right heart failure).

 

[Noyac]

Give DBT. If it doesn't help then you can go back on CPB.

 

[aredoubleyou]

I dont think there is enough information given to say for certain what the etiology is. Its another poorly worded question. Some of u guys see L failure, I interpret that as having a high liklihood of right heart failure. It seems to me you need a tee to rule out wall motion abnormalities/ akenesis/ hypokenesis/ etc to say for certain its left failure. If they said the PCWP was 20 and not cvp, then I think youve got the information you need to call it left failure.

 

[Idiopathic]

My assesment. This patient has right sided failure as seen by the high CVP and ultra high PAP. His CI is also low. BP is marginal at best.

even thought its been said, i just want to reinforce that the right heart failure in this scenario, while real, is likely purely secondary to the left heart dysfunction

 

[Idiopathic]

I dont think there is enough information given to say for certain what the etiology is. Its another poorly worded question. Some of u guys see L failure, I interpret that as having a high liklihood of right heart failure. It seems to me you need a tee to rule out wall motion abnormalities/ akenesis/ hypokenesis/ etc to say for certain its left failure. If they said the PCWP was 20 and not cvp, then I think youve got the information you need to call it left failure.

so your other alternative is that the left heart is empty...i guess you could also have severe MR, right? maybe this is the point of the question - you dont know the true etiology and so the best answer is just to go back on pump and double check everything

 

[PinchandBurn]

so your other alternative is that the left heart is empty...i guess you could also have severe MR, right? maybe this is the point of the question - you dont know the true etiology and so the best answer is just to go back on pump and dsouble check everything

The "review' also stated in the critique, perhaps coming of you had severe mitral regurg?

Just odd how we all have different answers! how can they write q's like this!

 

[IN2B8R]

I dont think there is enough information given to say for certain what the etiology is. Its another poorly worded question. Some of u guys see L failure, I interpret that as having a high liklihood of right heart failure. It seems to me you need a tee to rule out wall motion abnormalities/ akenesis/ hypokenesis/ etc to say for certain its left failure. If they said the PCWP was 20 and not cvp, then I think youve got the information you need to call it left failure.

Bingo, best answer I have read. 👍

 

[Idiopathic]

yeah well it doesnt exactly work that way for the written exam, right? i mean you give the best answer based on the data, so for this scenario we dont have wall motion, we dont have wedge pressure, we dont have pulse pressure variation...i still think its pretty easy to say it seems to be left heart driven and work from there. I mean, your wedge could be 25 and you still couldnt rule out severe MR so you clearly cant make a formal diagnosis without TEE or some other info. i guess you go back on pump but id still plan on inotropic support if that wasnt an option.

 

[Idiopathic]

I dont think there is enough information given to say for certain what the etiology is. Its another poorly worded question. Some of u guys see L failure, I interpret that as having a high liklihood of right heart failure. It seems to me you need a tee to rule out wall motion abnormalities/ akenesis/ hypokenesis/ etc to say for certain its left failure. If they said the PCWP was 20 and not cvp, then I think youve got the information you need to call it left failure.

right sided failure is most commonly due to left sided failure and the fact that they didnt work on the RCA should suggest to you that the right failure is not the primary culprit. am i way off base? this seems pretty obvious to me.

 

[Planktonmd]

Here is a real world answer: (echoing what noyac said)
Give dobutamine and if no good go back on bypass.
Sometimes it is worth it to quit masturbating!

 

[SexPanther]

If the pump is failing, fluids are backing up. The right heart backs up into the venous system (high CVP). A failing pump of any kind (heart, water, pool, tire, etc) can't be the reason for high pressures going forward (high PAP would not be caused by right heart failure).

But acute pulmonary HTN can cause R heart failure which can cause hemodynamic parameters consistent with what was given in the stem.

I agree with you, idio, DHB, Rob etc. that this is likely L heart failure though. This stem requires you to read between the lines due to incomplete information. He had revascularization of his LAD/LCx, he has no h/o pulmonary HTN given, no reason for acute pulm. HTN given etc.

Dobutamine is a nice option because it will be beneficial in both L and R heart failure states. If it doesn't improve things, go on pump and sort it out.

 

[Robert Loblaw]

Here is a real world answer: (echoing what noyac said)
Give dobutamine and if no good go back on bypass.
Sometimes it is worth it to quit masturbating!

in the real world, we'd all have come off pump on something so the correct answer would be increase or restart your inotrope.

 

[DrN2O]

Low CO state, elevated PADP (likely PCWP), and mildly elevated CVP--most people seem to agree it is LV failure. If it's MR, then maybe you would see abnormal V wave on your PA tracing (if you don't have TEE). Inotrope first, then back on pump, and I would discuss with the surgeon about placing a balloon pump before weaning off pump. If there is a suspicion about RV function, I would consider milrinone as an alternative to dobutamine, as the former would decrease PVR, and also cause less tachycardia. I have seen preop and intraop IABP, and all of them go back to the ICU with the pump going, makes everything a little easier.

 

[proman]

I have seen preop and intraop IABP, and all of them go back to the ICU with the pump going, makes everything a little easier.

I've definitely had a number of low EF patients (and some who've had an incomplete revascularization) get an IABP inserted for post-op use. The reason most pre-op IABPs get turned back on may have to do more with issues related to their removal. IABPs require around 30 minutes of direct pressure for removal due to the size of introducer used. If an unused IABP is not removed rapidly, the risk of it clotting (and then showering before or during removal) becomes very high. IABPs cannot be left turned off in a patient who isn't systemically heparinized.