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Core Topics in CardiacAnesthesia, Second Edition

http://www.cambridge.org/9780521196857

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Core Topics in CardiacAnesthesia, Second Edition

Edited by

Jonathan H. Mackay FRCP FRCAConsultant AnaesthetistPapworth HospitalCambridge, UK

Joseph E. Arrowsmith MD FRCP FRCA FFICMConsultant AnaesthetistPapworth HospitalCambridge, UKExaminer, Royal College of Anaesthetists






C A M B R I D G E U N I V E R S I T Y P R E S S

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Library of Congress Cataloging-in-Publication Data

Core topics in cardiac anaesthesia / edited by Jonathan H. Mackay,Joseph E. Arrowsmith. – 2nd ed.

p. cm.Includes bibliographical references and index.ISBN 978-0-521-19685-7 (Hardback)

1. Anesthesia in cardiology. 2. Heart–Surgery.I. Mackay, Jonathan H. II. Arrowsmith, Joseph E. III. Title.RD87.3.H43C67 2012617.9067412–dc23

2011033949

ISBN 978-0-521-19685-7 Hardback

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Every effort has been made in preparing this book to provideaccurate and up-to-date information which is in accord withaccepted standards and practice at the time of publication. Althoughcase histories are drawn from actual cases, every effort has beenmadeto disguise the identities of the individuals involved. Nevertheless,the authors, editors and publishers can make no warranties thatthe information contained herein is totally free from error, not leastbecause clinical standards are constantly changing through researchand regulation. The authors, editors and publishers therefore dis-claim all liability for direct or consequential damages resulting fromthe use of material contained in this book. Readers are stronglyadvised to pay careful attention to information provided by themanufacturer of any drugs or equipment that they plan to use.






“Mother stuns medics as she suffers heart failure, gives birth and haslife-saving surgery . . . all in one day”

Mail Online, 17 April 2009

April 2009 Nina Whear (38) and her twins, [left] Evie (birthweight 3lb11oz/1673 g) and [right] Alfie (birthweight 4lb 10oz/2098 g). In January 2009,while in late pregnancy, Nina presented to her local hospital with acute typeA aortic dissection. She was transferred to Papworth Hospital, where sheunderwent emergency Cesarean section followed by replacement of herascending aorta under the care of John Kneeshaw (Chapter 36) and SamNashef (Chapters 17 and 18). Nina was the first mother of twins in the UK,and one of only a handful worldwide, to survive surgery for this lethalcomplication of pregnancy without fetal loss. Photograph: AlbanpixLtd/Rex Features, with permission. With thanks and best wishes to Nina,Alfie and Evie.






Contents

List of contributors xReviews of the first edition xivPreface xvPreface to the first edition xviForeword to the second edition xviiForeword to the first edition xviiiList of abbreviations xix

Section 1 – Anatomy and physiology1 Cardiac embryology and anatomy 1

Doris M. Rassl and Martin J. Goddard

2 Cardiac electrophysiology 8Stefan G. De Hert

3 Cardiac excitation–contractioncoupling 13M. L. Srikanth and Kenneth H. McKinlay

4 Ventricular performance 18Fabio Guarracino and Rubia Baldassarri

5 Coronary physiology 22Michael Haney

6 Cardiovascular control mechanisms 28Patrick Wouters

7 Anesthesia and the cardiovascularsystem 33Ben W. Howes and Alan M. Cohen

Section 2 – Cardiac pharmacology8 Cardiac receptors 39

Todd Kiefer and Mihai V. Podgoreanu

9 Inotropes and vasoactive drugs 48Mark Dougherty and Stephen T. Webb

10 Anti-dysrhythmic drugs 57Alan Ashworth and Kamen P. Valchanov

11 Anticoagulants and procoagulants 64Alan F. Merry

12 Effects of CPB on drug pharmacokinetics 71Jens Fassl and Berend Mets

Section 3 – Diagnosis of cardiacdisease

13 Symptoms and signs of cardiac disease 75Joseph E. Arrowsmith

14 Non-invasive diagnostic tests 81J. M. Tom Pierce and Sarah Marstin

15 Cardiac radiological imaging 87Catherine V. Koffel and Maximilien J. Gourdin

16 Invasive diagnosis techniques 95Herve Schlotterbeck and Stephane Noble

Section 4 – Cardiac surgery foranesthesiologists

17 Patient selection and risk stratification 103Samer A. M. Nashef

18 Basic principles of cardiac surgery 108Samer A. M. Nashef

19 Myocardial protection 113Betsy Evans and David P. Jenkins

20 Myocardial stunning, hibernation andpreconditioning 119Stefan G. De Hert

21 Prosthetic heart valves 124Yasir Abu-Omar and John J. Dunning

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Section 5 – Monitoring22 Routine clinical monitoring 133

Jörn Karhausen and Jonathan B. Mark

23 Invasive hemodynamic monitoring 141Matthew E. Atkins and Jonathan B. Mark

24 Transesophageal echocardiography 147Roger M. O. Hall

25 Intraoperative assessment of ventricularfunction 154Yeewei W. Teo and Andrew Roscoe

26 Neurologic monitoring 160Joseph E. Arrowsmith

Section 6 – Routine coronary heartsurgery

27 Premedication, induction andmaintenance 169Paul H. M. Sadleir and Andrew I. Gardner

28 Routine conduct of cardiopulmonarybypass 175Barbora Parizkova and Stephen J. Gray

29 Routine early postoperative care 181Maura Screaton

30 Off-pump coronary surgery 186Jonathan H. Mackay and Joseph E. Arrowsmith

Section 7 – Anesthetic management ofspecific conditions

31 Aortic valve disease 193Jonathan H. Mackay and Joseph E. Arrowsmith

32 Mitral valve disease 200Jonathan H. Mackay and Francis C. Wells

33 Tricuspid and pulmonary valve disease 208Ving Yuen See Tho

34 Minimally invasive cardiac surgery 215Andrew C. Knowles and Jose Coddens

35 Redo surgery 220Jon Graham

36 Aortic dissection 223Andrew C. Knowles and John D. Kneeshaw

37 Aortic arch surgery 228Andrew C. Knowles and Coralie Carle

38 Descending thoracic aorta surgery 232David Riddington and Harjot Singh

39 Permanent pacemakers and implantabledefibrillators 241Maros Elsik and Simon P. Fynn

40 Anesthesia and electrophysiologicaldisorders 249Andrew J. Richardson and J. M. Tom Pierce

41 Acutemyocardial ischemia and infarction 257Andrew Neitzel and Bevan Hughes

42 Miscellaneous catheter laboratoryprocedures 261Tom Rawlings and Jean-Pierre van Besouw

43 Cardiomyopathies and constrictivepericarditis 268Florian Falter and Jonathan H. Mackay

44 Cardiac transplantation 275Clive J. Lewis

45 Pulmonary vascular disease 282Cameron Graydon and Roger M. O. Hall

46 Cardiac tumors 288Nigel Farnum and Joseph E. Arrowsmith

47 Cardiothoracic trauma 293Betsy Evans and John J. Dunning

48 Cardiac surgery during pregnancy 299Sarah Conolly and Khalid Khan

Section 8 – Pediatric cardiacanesthesia

49 General principles 303Isabeau A. Walker and Jon H. Smith

50 Conduct of anesthesia 307Jon H. Smith and Isabeau A. Walker

51 Common congenital heart lesions 313David J. Barron and Kevin P. Morris

Contents

viii






52 Common congenital heart operations 329David J. Barron and Kevin P. Morris

53 Postoperative care 335Fiona E. Reynolds and Kevin P. Morris

54 Adult congenital heart disease 339Craig R. Bailey and Helen M. Daly

Section 9 – Cardiopulmonarybypass

55 Cardiopulmonary bypass equipment 345John Whitbread and Stephen J. Gray

56 Failure to wean from bypass 355Simon Colah and Stephen J. Gray

57 Advanced mechanical support 359Stephen J. Gray and Simon Colah

58 Coagulopathy and blood conservation 366David Cardone and Andrew A. Klein

59 The systemic inflammatory response tocardiopulmonary bypass 374R. Clive Landis and Ravi J. De Silva

60 Temperature control, hypothermia andrewarming 382Charles Willmott

61 Deep hypothermic circulatory arrest 387Charles W. Hogue and Joseph E. Arrowsmith

62 Cardiopulmonary bypass emergencies 395David J. Daly

63 Controversies in cardiopulmonarybypass 400Christiana C. Burt and Florian Falter

64 Non-cardiac applications of cardiopulmonarybypass 406Joseph E. Arrowsmith and Jonathan H. Mackay

Section 10 – Cardiac intensive care65 Cardiovascular problems in the cardiac ICU 409

Trevor W. R. Lee and Jonathan H. Mackay

66 Resuscitation after adult cardiac surgery 413Jonathan H. Mackay

67 Respiratory complications 420Florian Falter

68 Gastrointestinal complications 424Britta Millhoff and Paul Quinton

69 Renal complications 430Shitalkumar Shah and William T. McBride

70 Neurologic complications 438Rabi Panigrahi and Charles W. Hogue

Section 11 – Miscellaneous topics71 Infection 447

Margaret I. Gillham and Juliet E. Foweraker

72 Regional anesthesia 453Trevor W. R. Lee

73 Pain management after cardiac surgery 458Siân I. Jaggar and Amod Manocha

74 Hematological problems 465Joseph E. Arrowsmith and Jonathan H. Mackay

75 Cardiovascular disease and non-cardiacsurgery 469Hans-Joachim Priebe

Appendix 1 479Appendix 2 480Appendix 3 481Index 482

Contents

ix






Contributors

Yasir Abu-OmarRegistrar in Cardiothoracic Surgery, PapworthHospital, Cambridge, UK

Matthew E. AtkinsFellow in Anesthesia, Duke University MedicalCenter, Durham, NC, USA

Joseph E. ArrowsmithConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

Alan AshworthConsultant Anaesthetist, Wythenshawe Hospital,Manchester, UK

Rubia BaldassarriCardiothoracic Department, University Hospitalof Pisa, Pisa, Italy

Craig R. BaileyConsultant Paediatric Anaesthetist, Evelina Children’sHospital, London, UK

David J. BarronConsultant Surgeon, Birmingham Children’sHospital, Birmingham, UK

Christiana C. BurtConsultant Cardiothoracic Anaesthetist (LT),The Heart Hospital, London, UK

David CardoneConsultant Anaesthetist, Royal Adelaide Hospital,Adelaide, South Australia

Coralie CarleAnaesthetic Specialty Registrar, Lancashire CardiacCentre, Blackpool, UK

Jose CoddensOnze Lieve Vrouw Clinic, Aalst, Belgium

Alan M. CohenConsultant Anaesthetist, Bristol Royal Infirmary,Bristol, UK

Simon ColahSenior Clinical Perfusion Scientist, CambridgePerfusion Services, Cambridge, UK

Sarah ConollyConsultant Anaesthetist, James Cook UniversityHospital, Middlesborough, UK

David J. DalyConsultant Anaesthetist, The Alfred Hospital,Melbourne, Australia

Helen M. DalyConsultant Paediatric Anaesthetist, Evelina Hospital,London, UK

Stefan G. De HertProfessor of Anesthesiology, University ofAmsterdam, Amsterdam, The Netherlands and GhentUniversity Hospital, Ghent, Belgium

Ravi J. De SilvaConsultant Cardiac Surgeon (LT), The Oxford HeartCentre, Oxford, UK

Mark DoughertyConsultant Cardiothoracic Anaesthetist, RoyalVictoria Hospital, Belfast, Northern Ireland, UK

John J. DunningConsultant Surgeon, PapworthHospital, Cambridge, UK

Maros ElsikFellowinCardiology,PapworthHospital,Cambridge,UK

Betsy EvansSpecialty Registrar in Cardiothoracic Surgery,Papworth Hospital, Cambridge, UKx






Florian FalterConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

Nigel FarnumConsultant Anaesthetist, Queen Elizabeth Hospital,Barbados, West Indies

Jens FasslDepartment of Anesthesiology, Penn State Collegeof Medicine, Penn State Milton S. Hershey MedicalCenter, Hershey, PA, USA

Juliet E. FowerakerConsultant Microbiologist, Papworth Hospital,Cambridge, UK

Simon P. FynnConsultant Cardiologist, Papworth Hospital,Cambridge, UK

Andrew I. GardnerConsultant Anaesthetist, Sir Charles GairdnerHospital, Perth, Australia

Margaret I. GillhamConsultant Microbiologist, Papworth Hospital,Cambridge, UK

Martin J. GoddardConsultant Pathologist, Papworth Hospital,Cambridge, UK

Maximilien J. GourdinAnaesthetist, Cliniques Universitaires UCL deMont-Godinne, Yvoir, Belgium

Jon GrahamConsultant Anaesthetist, Austin and RepatriationMedical Centre, Melbourne, Australia

Stephen J. GrayConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

Cameron GraydonFellow in Anaesthesia, Hospital for Sick Children,Great Ormond Street, London, UK

Fabio GuarracinoDirector of Cardiothoracic Anaesthesia and IntensiveCare Medicine, Azienda Ospedaliera UniversitariaPisana, Pisa, Italy

Roger M. O. HallConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

Michael HaneyAssociate Professor of Anesthesia and Intensive CareMedicine, Umeå University, Umeå, Sweden

Charles W. HogueAssociate Professor of Anesthesiology and CriticalCare Medicine, The Johns Hopkins Hospital,Baltimore, MD, USA

Ben W. HowesConsultant Anaesthetist, Bristol University Hospitals,Bristol, UK

Bevan HughesConsultant Anesthesiologist, Vancouver GeneralHospital and Clinical Assistant Professor, Universityof British Columbia, Vancouver, Canada

Siân I. JaggarConsultant Anaesthetist, Royal Brompton Hospital,London, UK

David P. JenkinsConsultant Surgeon, Papworth Hospital,Cambridge, UK

Jörn KarhausenAssistant Professor, Division of CardiothoracicAnesthesia, Duke University Medical Center,Durham, NC, USA

Todd KieferAssistant Professor of Medicine,Division of Cardiovascular Medicine,Duke University Medical Center,Durham, NC, USA

Khalid KhanConsultant Anaesthetist, James Cook UniversityHospital, Middlesborough, UK

Andrew A. KleinConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

John D. KneeshawConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

List of contributors

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Andrew C. KnowlesConsultant Anaesthetist, Lancashire Cardiac Centre,Blackpool, UK

Catherine V. KoffelService d’Anesthésie Réanimation Cardiothoracique,Hôpital Cardiologique Louis Pradel,Lyon, France

R. Clive LandisEdmund Cohen Laboratory for Vascular Research,Chronic Disease Research Centre, University of theWest Indies, Barbados, West Indies

Trevor W. R. LeeAssistant Professor of Anaesthesia, St BonifaceHospital, Winnipeg, Manitoba, Canada

Clive J. LewisConsultant Transplant Cardiologist,Papworth Hospital, Cambridge, UK

Jonathan H. MackayConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

Amod ManochaAnaesthetic Specialty Registrar, Central LondonSchool of Anaesthesia, London, UK

Jonathan B. MarkProfessor and Vice Chairman,Department of Anesthesiology, Duke UniversityMedical Center, and Chief, Anesthesiology Service,Principal Investigator, Patient Safety Center ofInquiry, Veterans Affairs Medical Center,Durham, NC, USA

Sarah MarstinConsultant Anaesthetist (LT), Portsmouth Hospital,Portsmouth, UK

William T. McBrideConsultant Anaesthetist, Royal Victoria Hospital,Belfast, Northern Ireland, UK

Kenneth H. McKinlayConsultant Anaesthetist, Golden Jubilee Hospital,Glasgow, UK

Alan F. MerryProfessor of Anaesthesia, Auckland University,Auckland, New Zealand

Berend MetsEric A. Walker Professor and Chair, Department ofAnesthesiology, Penn State College of Medicine, PennState Milton S. Hershey Medical Center, Hershey, PA,USA

Britta MillhoffAnaesthetic Specialty Registrar, St George’s Hospital,London, UK

Kevin P. MorrisConsultant Paediatric Intensivist, BirminghamChildren’s Hospital, Birmingham, UK

Samer A. M. NashefConsultant Surgeon, Papworth Hospital,Cambridge, UK

Andrew NeitzelSenior Anesthesiology Resident, University of BritishColumbia, Vancouver, Canada

Stephane NobleChef de Clinique, Department of Cardiology,University Hospital of Geneva, Switzerland

Rabi PanigrahiAttending Cardiothoracic Anesthesiologist,Hartford Hospital, Hartford, CT, USA

Barbora ParizkovaConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

J. M. Tom PierceConsultant Cardiac Anaesthetist, SouthamptonGeneral Hospital, Southampton, UK

Mihai V. PodgoreanuAssociate Professor of Anesthesiology, DukeUniversity Medical Center, Durham, NC, USA

Hans-Joachim PriebeProfessor of Anaesthesia, University HospitalFreiburg, Freiburg, Germany

Paul QuintonConsultant Anaesthestist, St George’s Hospital,London, UK

C. Ramaswamy RajamohanAnaesthetic Specialist Registrar, Papworth Hospital,Cambridge, UK


xii






Doris M. RasslConsultant Pathologist, Papworth Hospital,Cambridge, UK

Tom RawlingsAnaesthetic Specialty Registrar, St George’s Hospital,London, UK

Fiona E. ReynoldsConsultant Anaesthetist, Birmingham Children’sHospital, Birmingham, UK

Andrew J. RichardsonConsultant Cardiac Anaesthetist, SouthamptonGeneral Hospital, Southampton, UK

David RiddingtonConsultant Anaesthetist, Queen Elizabeth Hospital,Birmingham, UK

Andrew RoscoeAssistant Professor in Anesthesia, Toronto GeneralHospital, Toronto, Canada

Paul H. M. SadleirConsultant Anaesthetist, Sir Charles GairdnerHospital, Perth, Australia

Ving Yuen See ThoConsultant Anaesthetist,Singapore General Hospital,Republic of Singapore

Herve SchlotterbeckChef de Clinique,Academic Anaesthetic Department,University Hospital of Geneva,Geneva, Switzerland

Maura ScreatonCritical Care Practitioner, Papworth Hospital,Cambridge, UK

Shitalkumar ShahAnaesthetic Specialty Registrar, Royal VictoriaHospital, Belfast, UK

Harjot SinghConsultant Anaesthetist, Queen Elizabeth Hospital,Birmingham, UK

Jon H. SmithConsultant Anaesthetist, Freeman Hospital,Newcastle upon Tyne, UK

M. L. SrikanthAnaesthetic Specialty Registrar, Golden JubileeHospital, Glasgow, UK

Yeewei W. TeoClinical Fellow in Anaesthesia, WythenshaweHospital, Manchester, UK

Kamen P. ValchanovConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

Jean-Pierre van BesouwConsultant Anaesthestist, St George’s Hospital,London, UK

Isabeau A. WalkerConsultant Anaesthetist, Great Ormond StreetHospital, London, UK

Stephen T. WebbConsultant Anaesthetist, Papworth Hospital,Cambridge, UK

Francis C. WellsConsultant Cardiothoracic Surgeon, PapworthHospital, Cambridge, UK

John WhitbreadSenior Clinical Perfusion Scientist, CambridgePerfusion Services, Cambridge, UK

Charles WillmottDirector of Cardiothoracic Anaesthesia, PrincessAlexandra Hospital, Brisbane, Queensland, Australia

Patrick WoutersProfessor of Anesthesia, University of Gent, Gent,Belgium


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Reviews of the first edition

“The book has set itself clear objectives and very largely achieves them.Whilst trying not to be all-encompassing nor the only reference bookrequired for this burgeoning field, it covers all the necessary and relevantareas to provide a sound basis and grounding in good clinical practice.”“The extensive list of abbreviations . . . reduces confusion and enhances theflow of the text.”“There is little cross-over between chapters and each chapter covers thetopic in sufficient detail to make it useful as a stand-alone reference text.”“. . . a thoughtfully produced and well-written book.”

Jonathan J. Ross, Sheffield, UK.British Journal of Anaesthesia 2005; 94(6): 868

“The book relies heavily on tables and figures, which makes it an effectivedidactic teaching tool.”“The pharmacology section includes a succinct summary of the drugs usedevery day in the cardiac operating rooms.”“. . . the chapter on signs and symptoms of cardiac disease is one of thebest this reviewer has seen.”“. . . an excellent introductory text book for the trainee in cardiacanesthesia.”“likely to become a classic in the resident or fellow library.”

Pablo Motta MD, Cleveland Clinic Foundation, USA.Anesthesia & Analgesia 2006; 102(2): 657

“. . . the ubiquitous use of well-labeled diagrams, photographs and clinicaltracings adds understanding at every level . . . a delight to use as a teachingdevice.”“. . . a rare text that is without institutional bias or personal beliefs.”“. . . I would advise curious learners to save their time and money untilthey have absorbed all that this book has to offer!”

J. Cousins, London, UKPerfusion 2006; 21(3): 193

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Preface

Despite the passage of seven years since the publica-tion of Core Topics in Cardiac Anaesthesia, the funda-mental principles of cardiac anesthesia remainunchanged. In contrast, the clinical landscape hasundergone significant change – the resurgence of pri-mary percutaneous intervention in acute coronarysyndromes, new developments in electrophysiology,use of percutaneous devices in patients previouslyconsidered inoperable, a reawakening of interest inextracorporeal support in the wake of global influenzapandemics, and the withdrawal of aprotinin.

Although primarily aimed at residents and fellowsin anesthesia, Core Topics in Cardiac Anaesthesiaproved popular with residents and fellows in cardiacsurgery, clinical perfusionists and critical care nurses.In preparing the second edition we have carefully con-sidered the advice of our readers and reviewers. Theirsuggestions were unambiguous; explain complex topicsin an easy to digest and a readily accessible manner, usefigures and tables in preference to text, and avoid allunnecessary repetition and bias. Above all they wereanxious for us to retain the first edition’s brevity, clarityand portability. Accordingly, our instructions to con-tributing authors and editorial aims were unchanged;produce a concise yet comprehensive overview of thesubject emphasizing pathophysiology, basic scientificprinciples and the key elements of practice.

The title, selection of contributors and style ofcontent of the second edition have been carefullyadjusted to give it a greater international appeal. Thepharmacology section has been changed to present alarge volume of data in an accessible and moreappealing format. There are new chapters on rightheart valves, pulmonary vascular disease, cardiac

tumors and cardiac trauma. Acknowledging thechanging role of the cardiothoracic anesthesiologist,we have added chapters on catheter laboratory andhybrid operating room procedures, and acute coron-ary syndromes. Extracorporeal support is now dis-cussed in a separate chapter and antimicrobialprophylaxis, resuscitation and perioperative transeso-phageal echocardiography (TEE) have been updatedto reflect changes in international guidelines. Lastly,we present a eulogy to aprotinin.

Certification and accreditation in perioperativeTEE has now become the de facto “Board” qualifica-tion for cardiothoracic anesthesiologists in manycountries. Unfortunately, this merely assures the qual-ity of echocardiography instead of the wide range ofknowledge and competencies expected of a wellrounded specialist in cardiac anesthesia. Because thereare already several excellent TEE books, we havestrenuously resisted the temptation to turn our secondedition into a “TEE manual”.

We would like to thank all of those who have madethe publication of this volume possible; our inter-national panel of contributors for taking the time toshare their knowledge and expertise; Deborah Russelland Joanna Chamberlin of Cambridge UniversityPress for their encouragement, advice, generosityand seemingly inexhaustible patience; and our Spe-cialist Registrars for their advice and proofreading.Last, we wish to thank our families for their unstintingsupport during this enterprise.

Jon MackayJoe ArrowsmithMay 2011

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Preface to the first edition

This book is primarily aimed at anaesthetic trainees inthe first 3–6 months of subspecialty training in cardiacanaesthesia and critical care. It is our response to themany trainees who have regularly asked us to recom-mend a small textbook on cardiac anaesthesia.

We realise that it is impossible to produce a trulycomprehensive review of cardiac anaesthesia in~120,000 words but hope that this book provides asound grounding in all of the core topics. The contentof this book has been very much guided by The RoyalCollege of Anaesthetists’ CCST in Anaesthesiamanual,The Society of Cardiovascular Anesthesiologists’ Pro-gram Requirements for Resident Education, and recentexamination papers from the United Kingdom, NorthAmerica and Australasia.

Our instructions to contributing authors andeditorial aims were simple; produce a concise yetcomprehensive overview of the subject emphasisingpathophysiology, basic scientific principles and thekey elements of practice. We hope that the use of apresentation format that relies on figures and tables inpreference to text will aid comprehension and recall.

We have endeavoured to avoid repetition of informa-tion, long lists of references and institutional bias. Wetrust that the curious trainee will turn to the largertextbooks and the Internet for more detailed discus-sions and exhaustive literature reviews. Finally, wehope that many sections of this book will also appealto those preparing trainees for examinations and toclinical nurse specialists working in the field of cardio-thoracic intensive care.

We would like to thank all of those who have madethe publication of this volume possible; our inter-national panel of contributors for taking the time toshare their knowledge and expertise; Gill Clark andGavin Smith of Greenwich Medical Media for theirencouragement, advice and patience; and our Special-ist Registrars for their advice and proof reading. Last,we wish to thank our families for their willing, andoccasionally unwilling, support during this enterprise.

Jon MackayJoe ArrowsmithJanuary 2004

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Foreword to the second edition

The first edition of Core Topics in Cardiac Anesthesiaprovided a unique collection of short, succinct reviewsof key topics in cardiac anesthesia. Purposefully aimingto avoid being encyclopedic, the authors summarizedinformation by effective use of tables, graphs, and briefdigestible text, concluding with bulleted key points anda short reference list. This approach proved quite suc-cessful, enabling trainees to read an entire short chapterwhilst preparing for an upcoming case. By presentingimportant basic information in a format that can bequickly grasped, as well as additional depth in selectedareas, the book answered a critical need for trainees.

This second edition builds on this strong trad-ition. The editors have kept the excellent formatwhile adding key topics relevant to modern cardiacanesthesiology beyond the conventional operatingroom and expanding to treatment of patients withcardiopulmonary pathophysiology. Updated andstunning illustrations along with informative tablesare another hallmark of this new edition. Carefullyselected international authors keep the book free ofinstitutional or country-specific bias. The result is adelightful and effective update that retains all of the

original positives while making the book overallmore comprehensive and valuable to an expandedaudience. Indeed, we predict that many of these con-cise chapters will be helpful in providing quickreviews to not only trainees, but to all practicinganesthetists and other cardiovascular practitionerswho wish an instant refresher before delivering careto a particularly complicated patient with cardiovas-cular disease. As such, this edition not only addressesan unmet need, it has all the makings of a classic!

Debra A. Schwinn, MDProfessor & Chair, Department of AnesthesiologyAllan J Treuer Endowed Professor in AnesthesiologyUniversity of Washington, Seattle, WA, USA

G. Burkhard Mackensen, MD, PhDProfessor & Chief, Division of CardiothoracicAnesthesiologyUWMedicine Research & Education Endowed Professorin AnestesiologyDepartment of AnesthesiologyUniversity of Washington, Seattle, WA, USA

xvii






Foreword to the first edition

Cardiac anaesthesia brings many divergent disciplinesinto one unifying practice, making it one of the mostcomplex anaesthetic subspecialties. It requires anunderstanding of pathology, physiology, pharmacol-ogy, internal medicine, cardiology, cardiac surgeryand intensive care. The ever-expanding nature of thespecialty presents considerable challenges for both theeveryday practitioner and the trainee – for whom thistext is particularly targeted.

In this day and age, when a vast amount of infor-mation is already available both in print and on-line, onemay be forgiven for questioning the need for yet anotherprinted textbook. Byway of an answer, the Editors (bothof whom have worked in the UK and the USA) haveproduced a textbook (rather than a cookbook) thataddresses a relatively unfulfilled need – a source that isspecifically directed towards those who represent thefuture of our specialty. By incorporating contributionsfrom authors from many countries, the Editors havelargely avoided national and institutional bias.

Today’s anaesthetic trainees are confronted withthe seemingly impossible task of assimilating,

understanding and memorizing an almost infinitebody of information. Those who succeed in this taskare invariably those who can confidently identify coreprinciples without getting distracted by minute details.The Editors never intended to produce an exhaustivereference and the need to consult other sources ofdetailed information has, therefore, not been com-pletely eliminated. This book does, however, providethe trainee with a very convenient framework ontowhich further knowledge can be added as it is acquired.The manner in which the authors have organized andpresented information in this book should help thereader to more quickly see the “bigger picture” andappreciate the subtleties of cardiac anaesthesia.

Hilary P. Grocott, MD, FRCPCAssociate Professor of Anesthesiology

Mark F. Newman, MDMerel H. Harmel Chair and Professor of AnesthesiologyDuke University, Durham, NC, USA

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Abbreviations

AAAA Abdominal aortic aneurysmABG Arterial blood gasAC Adenylyl cyclaseACA Anterior cerebral arteryACC American College of CardiologyACE Angiotensin converting enzymeACEI Angiotensin converting enzyme

inhibitorACh AcetylcholineACHD Adult congenital heart diseaseACoA Anterior communicating (cerebral)

arteryACP American College of PhysiciansACS Acute coronary syndrome(s)ACT Activated clotting timeACTH Adrenocorticotrophic hormoneADP Adenosine diphosphateADQI Acute Dialysis Quality InitiativeAECC American-European Consensus

ConferenceAED Automatic external defibrillatorAEP Auditory evoked potentialAF Atrial fibrillationAHA American Heart AssociationAKI Acute kidney injuryALI Acute lung injuryALS Advanced life supportAMVL Anterior mitral valve leafletAMP Adenosine monophosphateANH Acute normovolemic hemodilutionANP Atrial natriuretic peptideANS Autonomic nervous systemAP Action potentialAPD Action potential durationAPB Atrial premature (ectopic) beatAPC Activated protein CAPL AntiphospholipidAPOE Apolipoprotein EAPTT Activated partial thromboplastin

time

APUD Amine precursor uptakedecarboxylation

AR Aortic regurgitation(incompetence)

ARDS Acute respiratory distresssyndrome

ARF Acute renal failureARVC Arrhythmogenic right ventricular

cardiomyopathyARVD Arrhythmogenic right ventricular

dysplasiaAS Aortic stenosisASA American Society of

AnesthesiologistsASD Atrial septal defectASE American Society of

EchocardiographyASH Asymmetrical septal hypertrophyAT Antithrombin

Atrial tachycardiaAT-I Angiotensin IAT-II Angiotensin IIATP Adenosine triphosphateAV Aortic valveA-V AtrioventricularAVA Aortic valve (orifice) areaAVN Atrioventricular nodeAVR Aortic valve replacementAVSD Atrioventricular septal defectAXC Aortic cross-clamp

BBA Basilar arteryBAER Brainstem auditory evoked responseBBB Bundle branch blockBCPS Bidirection cavopulmonary shuntBD Bis die (twice daily)

� Q12H (Quaque 12 hora)BIS Bispectral (index)BiVAD Biventricular assist deviceBJ Bezold-Jarisch

xix






BLS Basic life supportBNF British National FormularyBNP Brain natriuretic peptideBP Blood pressureBPd Diastolic blood pressureBPs Systolic blood pressureBPEG British Pacing and Electrophysiology

GroupBSAC British Society for Antimicrobial

ChemotherapybTG b-ThromboglobulinB-T Blalock–Taussig (shunt)

CCABG Coronary artery bypass graftCAD Coronary artery diseasecAMP Cyclic adenosine monophosphateCASS Coronary Artery Surgery StudycAVSD Complete atrioventricular septal

defectCBF Cerebral blood flowCBFV Cerebral blood flow velocityCCS Canadian Cardiovascular SocietyCCU Critical/coronary care unitCFAM Cerebral function analyzing

monitorCFD Color-flow DopplerCFM Cerebral function monitorcGMP Cyclic guanosine monophosphateCHARGE Coloboma, heart, atresia,

retardation, genital, earCHB Complete (third degree) heart blockCHD Congenital heart diseaseCI Cardiac indexCICR Calcium-induced calcium releaseCK-MB Creatinine kinase MB (isoenzyme)CMRO2 Cerebral metabolic rate (for oxygen)CNS Central nervous systemCO Cardiac outputCOA Coarctation of the aortaCOMT Catechol-o-methyltransferaseCOPD Chronic obstructive pulmonary

diseaseCPAP Continuous positive airway pressureCPB Cardiopulmonary bypassCP CavopulmonaryCPP Cerebral perfusion pressureCPR Cardiopulmonary resuscitationCRA Chronic refractory angina

CRI Cardiac risk indexCRP C-reactive proteinCRT Cardiac resynchronization therapyCSA Cross-sectional areaCSF Cerebrospinal fluidCT Computed tomogram/tomographyCTA CT angiographyCTEPH Chronic thromboembolic

pulmonary hypertensionCVA Cerebrovascular accidentCVD Cerebrovascular disease

Cardiovascular diseaseCVP Central venous pressureCVS Cardiovascular systemCVVHF Continuous veno-venous

hemofiltrationCWD Continuous-wave DopplerCXR Chest X-ray/radiograph

D2D Two dimensionalDA Ductus arteriosusDAG DiacylglycerolDASI Duke Activity Status IndexDavO2 Arteriovenous oxygen differenceDC Direct currentDCM Dilated cardiomyopathyDDAVP Desmopressin (1-desamino-8-d-

arginine vasopressin)DFT Defibrillation energy thresholdDHCA Deep hypothermic circulatory arrestDH Dorsal hornDIC Disseminated intravascular

coagulationDM Diabetes mellitusDNA Deoxyribonucleic acidDNAR Do not attempt resuscitationDPTA Diethylenetriaminepentaacetic acidDSCT Dual-source CTDVT Deep vein thrombosis

EEa Arterial elastanceEACA e-Aminocaproic acidEBCT Electron-beam CTEC Ejection clickECC Extracorporeal circulationECG ElectrocardiographECLS Extracorporeal life support

List of abbreviations

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ECMO Extracorporeal membraneoxygenation

ECT Ecarin clotting timeEDHF Endothelium-derived

hyperpolarizing factorEDM Early diastolic murmur

Esophageal Doppler monitorEDPVR End-diastolic pressure–volume

relationshipEDV End-diastolic volumeEEG ElectroencephalographEes End-systolic elastanceEF Ejection fractionELISA Enzyme-linked immunosorbent assayEMD Electromechanical dissociationEMI Electromagnetic interferenceEP Electrophysiological /

electrophysiologyEPIC Evaluation & Prevention of Ischemic

Complications (study)EPO ErythropoietinERC European Resuscitation CouncilERP Effective refractory periodESBL Extended-spectrum beta-lactamaseESC European Society of CardiologyESPVR End-systolic pressure–volume

relationshipET EndothelinETT Endotracheal tube

FFAC Fractional area changeFAST Focused abdominal sonogram for

traumaFDG FluorodeoxyglucoseFDPs Fibrin(ogen) degradation productsFFA Free fatty acidFFP Fresh-frozen plasmaFFR Fractional flow reserveFO Fossa ovalis

Foramen ovaleFOB Fiberoptic bronchoscopyFRC Functional residual capacityFTT Failure to thriveFVL Factor V Leiden

GGABA Gamma aminobutyric acidGCS Glasgow coma scale

Gd-ceMRI Gadolinium contrast-enhancedmagnetic resonance imaging

Gd-DTPA Gadoliniumdiethylenetriaminepentaacetic acid

GFR Glomerular filtration rateGI GastrointestinalGMP Guanosine monophosphateGP GlycoproteinGPCR G-protein-coupled receptorsGRE Glyopeptide-resistant EnterococcusGRK G-protein-coupled receptor kinaseGSW Gunshot woundGTN Glyceryl trinitrateGTP Guanosine triphosphateGUCH Grown-up congenital heart

HHb HemoglobinHb-SS Hemoglobin-SS (Homozygous

sickle)HCC Hepatocardiac canalHD HemodialysisHF HemofiltrationHFOV High freq. oscillatory ventilation5-HIAA 5-Hydroxyindoleacetic acidHIT Heparin-induced thrombocytopeniaHITS Heparin-induced thrombocytopenia

syndromeHLHS Hypoplastic left heart syndromeHMWK High-molecular-weight kininogenHOCM Hypertrophic obstructive

cardiomyopathyHPVC Hypoxic pulmonary

vasoconstrictionHR Heart rateHU Hounsfield units

IIABP Intra-aortic balloon pumpIAS Interatrial septumICA Internal carotid arteryICAM Intercellular adhesion moleculeICD Implantable cardiodefibrillatorICP Intracranial pressureICS Intercostal spaceICU Intensive care unitID Internal diameterIDDM Insulin-dependent diabetes

mellitus


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Ig ImmunoglobulinIGF Insulin-like growth factorIHD Ischemic heart diseaseIHSS Idiopathic hypertrophic subaortic

stenosisIJV Internal jugular veinIL InterleukinILR Implantable loop recorderINR International normalized ratioIPAH Idiopathic pulmonary arterial

hypertensionIPPB Intermittent positive-pressure

breathingIPPV Intermittent positive-pressure

ventilationIRI Ischemia-reperfusion injuryIRV Inverse ratio ventilationITP Idiopathic thrombocytopenic

purpuraITU Intensive therapy unitIV IntravenousIVI Intravenous infusionIVC Inferior vena cavaIVRT Isovolumic relaxation timeIVS Interventricular septumIVUS Intravascular ultrasound

JJGA Juxtaglomerular apparatusJW Jehovah’s Witness

KKIU Kallikrein inhibitory unitsKK Kallikrein

LLA Left atrium/atrialLAA Left atrial appendageLAD Left anterior descending (coronary

artery)LAHB Left anterior hemiblockLAP Left atrial pressureLAST Left anterior short thoracotomyLAX Long axisLBBB Left bundle branch blockLBP Lipopolysaccharide binding proteinLCA Left coronary arteryLCC Left coronary cuspLCOS Low cardiac output state

LHC Left heart catheterizationLICA Left internal carotid arteryLIJ Left internal jugularLIMA Left internal mammary arteryLLSE Left lower sternal edgeLMWH Low-molecular-weight heparinLMS Left main stem (coronary artery)LPA Left pulmonary arteryLPHB Left posterior hemiblockLPS LipopolysaccharideLSC Late systolic clickLSCA Left subclavian arteryLSCV Left subclavian veinLSPV Left superior pulmonary veinLUSE Left upper sternal edgeLV Left ventricle/ventricularLVAD Left ventricular assist deviceLVEDA Left ventricular end-diastolic areaLVEDP Left ventricular end-diastolic

PressureLVEDV Left ventricular end-diastolic volumeLVEF Left ventricular ejection fractionLVESA Left ventricular end-systolic areaLVESPVR Left ventricular end-systolic

pressure–volume relationshipLVESV Left ventricular end-systolic volumeLVID Left ventricular internal diameterLVF Left ventricular failureLVH Left ventricular hypertrophyLVOT Left ventricular outflow tract

MMAC Minimal alveolar concentration

Membrane attack complexMAO Monoamine oxidaseMAP Mean arterial pressureMAPCAs Major aorta pulmonary collateral

arteriesMAPK Mitogen-activated protein kinaseMCA Middle cerebral arteryMcSPI Multicenter Study of Perioperative

IschemiaMDCT Multidetector row CTMDO2 Myocardial oxygen deliveryME Mid-esophagealMEP Motor evoked potentialMET Medical emergency teamMETs Metabolic equivalentsMI Myocardial infarction


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MIBI Methoxyisobutyl nitrileMICS Minimally invasive coronary

surgeryMinimally invasive cardiac surgery

MIDCAB Minimally invasive direct coronaryartery bypass

MOF Multi-organ (system) failureMPA Main pulmonary arteryMPAP Mean pulmonary artery pressureMPI Myocardial performance indexMR Mitral regurgitation

(incompetence)MRI Magnetic resonance imagingMRSA Methicillin-resistant

Staphylococcus aureusMS Mitral stenosisMSM Midsystolic murmurMUF Modified ultrafiltrationMUGA Multiple gated acquisitionMV Mitral valveMVO2 Myocardial oxygen consumptionMVP Mitral valve prolapseMVR Mitral valve replacementMW Molecular weight

NN2O Nitrous oxideNAD Nicotinamide adenine dinuleotideNASPE North American Society of Pacing

and ElectrophysiologyNCC Non-coronary cusp

Non-compaction cardiomyopathyNDMR Non-depolarizing muscle relaxantNEC Necrotizing enterocolitisNG NasogastricNIBP Non-invasive blood pressureNICE National Institute for Health and

Clinical ExcellenceNIDDM Non-insulin-dependent diabetes

mellitusNIH National Institutes of HealthNIRS Near infrared spectroscopyNIV Non-invasive ventilationNMB Neuromuscular blockade/blockerNMDA N-methyl-d-aspartateNO Nitric oxideNOS Nitric oxide synthetaseNPV Negative predictive valueNR Nuclear receptors

NSAID Non-steroidal anti-inflammatorydrug

NSR Normal sinus rhythmNSTEMI Non-ST-elevation myocardial

infarctionNTS Nucleus tractus solitariusNYHA New York Heart Association

OOD Once dailyOPCAB Off-pump coronary artery bypassOS Opening snap

PPA Pulmonary arteryPABD Preoperative autologous blood

donationPAD Pulmonary artery diastolicPAFC Pulmonary artery floatation

catheterPAH Pulmonary arterial hypertensionPAI Plasminogen activator inhibitorPAP Pulmonary artery pressurePAPVD Partial anomalous pulmonary

venous drainagepAVSD Partial atrioventricular septal defectPAWP Pulmonary artery wedge pressurePBF Pulmonary blood flowPCA Patient-controlled analgesia

Posterior cerebral arteryPulse contour analysis

PCC Prothrombin complex concentratePCH Pulmonary capillary

hemangiomatosisPCI Percutaneous coronary interventionPCoA Posterior communicating (cerebral)

arteryPCR Polymerase chain reactionPCV Pressure-controlled ventilationPD Peritoneal dialysisPDA Patent ductus arteriosus

Posterior descending (coronary)artery

PDE PhosphodiesterasePDGF Platelet-derived growth factorPE Pulmonary embolus/embolismPEA Pulmonary (thrombo)

endarterectomyPEEP Positive end-expiratory pressure


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PET Positron emission tomographyPF3 Platelet factor 3PF4 Platelet factor 4PFO Patent foramen ovalePGE2 Prostaglandin E2PGI2 Prostaglandin I2 (prostacyclin)PH-T Pressure half-timePHT Pulmonary hypertensionPISA Proximal isovelocity surface areaPKA Protein kinase APKC Protein kinase CPLB PhospholambanPMI Perioperative myocardial

infarctionPMR Papillary muscle rupturePO Per os (by mouth)PONV Postoperative nausea and

vomitingPPAR Peroxisome proliferator-activated

receptorsPPB Plasma protein bindingPPCI Primary percutaneous coronary

interventionPPM Permanent pacemakerPPHN Persistent pulmonary hypertension

of the newbornPPV Pulse pressure variation

Prone position ventilationPositive predictive value

PR Pulmonary regurgitation(incompetence)

PRBC Packed red blood cellsPS Pulmonary stenosisPSM Pansystolic murmurPSV Pressure-support ventilationPT Prothrombin timePTCA Percutaneous transluminal coronary

angioplastyPV Pulmonary valve

Pulmonary veinPVC Polyvinyl chloridePVd Pulmonary vein diastolicPVD Pulmonary vascular diseasePVF Pulmonary venous flowPVOD Pulmonary veno-occlusive

diseasePVR Pulmonary vascular resistancePVs Pulmonary vein systolicPWD Pulsed-wave Doppler

QQP Pulmonary flowQS Systemic flowQDS Quater die sumendus (four times

daily)� Q6H (Quaque 6 hora)

RRA Right atrium/atrialRAA Right atrial appendageRAD Right axis deviationRBBB Right bundle branch blockRBC Red blood cellRBF Renal blood flowRCA Right coronary arteryRCC Right coronary cuspRCP Retrograde cerebral perfusionRCCV Right common cardinal veinRCRI Revised cardiac risk indexREMATCH Randomized evaluation of

mechanical assistance for thetreatment of congestive heartfailure

RHC Right heart catheterizationRICA Right internal carotid arteryRIJ Right internal jugularRIND Reversible ischemic neurologic

deficitRMP Resting membrane potentialRNA Ribonucleic acidRPA Right pulmonary arteryRPM Revolutions per minuteRR Respiratory rateRRT Renal replacement therapyRSCA Right subclavian arteryRSCV Right subclavian veinRTA Road traffic accidentRV Right ventricle/ventricularRVAD Right ventricular assist deviceRVEDP Right ventricular end-diastolic

pressureRVEF Right ventricular ejection fractionRVH Right ventricular hypertrophyRVOT Right ventricular outflow tractRWMA Regional wall motion abnormality

SS1 First heart soundS2 Second heart sound


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S3 Third heart soundS4 Fourth heart soundSA SinoatrialSACP Selective antegrade cerebral

perfusionSAM Systolic anterior motion (of the

anterior mitral valve leaflet)SAN Sinoatrial nodeSaO2 Arterial oxygen saturationSAX Short axisSC SubcutaneousSCA Society of Cardiovascular

AnesthesiologistsSCS Spinal cord stimulationSCUBA Self-contained underwater breathing

apparatusSERCA Sarcoplasmic reticulum calcium

ATPaseSIRS Systemic inflammatory response to

sepsisSjvO2 Jugular venous oxygen saturationSLE Systemic lupus erythematosusSNP Sodium nitroprussideSNS Sympathetic nervous systemSPECT Single photon emission computed

tomographySR Sarcoplasmic reticulumSSEP Somatosensory evoked potentialSSFP Steady-state free precessionST Sinus tachycardiaSTEMI ST-elevation myocardial infarctionSV Stroke volumeSVC Superior vena cavaSVG Saphenous vein graftSvO2 Mixed venous oxygen saturationSVR Systemic vascular resistanceSVT Supraventricular tachycardia

TT3 TriiodothyronineT4 ThyroxineTA Truncus arteriosusTAPSE Tricuspid annular plane systolic

excursionTAPVD Total anomalous pulmonary venous

drainageTAVI Transcatheter aortic valve

implantationTB Tuberculosis

TCD Transcranial DopplerTCPC Total cavopulmonary venous

connectionTDI Tissue Doppler imagingTDS Ter die sumendus (three times daily)

� Q8H (Quaque 8 hora)TEA Thoracic epidural analgesicTEE Transesophageal echocardiographyTEG Thromboelastogram/

thromboelastographyTENS Transcutaneous electrical nerve

stimulationTG TransgastricTGA Transposition of the great arteriesTGF Transforming growth factorTIA Transient ischemic attackTIVA Total intravenous anesthesiaTMF Transmitral flowTnC Troponin CTnI Troponin ITnT Troponin TTNF Tumor necrosis factorTOF Tetrology of fallottPA Tissue plasminogen activatorTPG Transpulmonary gradientTR Tricuspid regurgitation

(incompetence)TS Tricuspid stenosisTT Thrombin timeTTE Transthoracic echocardiographyTV Tricuspid valveTXA Tranexamic acid

UUA Unstable anginaUHF Unfractionated heparinu-PA Urokinase plasminogen activatorUTI Urinary tract infectionUV Umbilical vein

VVA Vertebral arteryVACTERL (syndrome) Vertebral anomalies,

Anal atresia, Cardiovascularanomalies, Tracheoesophagealfistula, Esophageal atresia, Renal,Limb defects

VAD Ventricular assist deviceVALI Ventilator-associated lung injury


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VC Vena contractaVd Volume of distributionVEP Visual evoked potentialVF Ventricular fibrillationVHD Valvular heart diseaseVHF Very high frequencyVIP Vasoactive intestinal peptideVLM Ventrolateral medullaVo2 Oxygen consumptionVOT Ventricular outflow tractVPB Ventricular premature (ectopic)

beatVRE Vancomycin-resistant Enterococcus

VSD Ventricular septal defectVSR Ventricular septal ruptureVT Ventricular tachycardiaVt Tidal volumeVTI Velocity-time integralVV Vitelline veinvWF Von Willebrand factorVWR Ventricular (free) wall rupture

WWBC White blood cell (count)WPW Wolf–Parkinson–White

(syndrome)


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core topics in cardiac anesthesia, second...

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