Postoperative Care of the Cardiac Surgical Patient Timothy A. Denton, M.D. High Desert Heart Institute Victorville, CA

Postoperative Care of thePostoperative Care of the

Cardiac Surgical PatientCardiac Surgical Patient

Timothy A. Denton, M.D.

High Desert Heart Institute

Victorville, CA

Outline

• Overview of surgical patients• Cardiac Surgery Knowledge base• Intraop issues• Postop Issues• Systems of care

Number of US Invasive Procedures

285000

331000

399000 398000

428000 434000

485000

452000

540000

599000

554000

262000 265000

308000 309000 318000

360000 367000 366000

336000355000

314000

0

100000

200000

300000

400000

500000

600000

700000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Year

Num

ber

National Hospital Discharge SurveyNational Center for Health Statistics

CABG

PTCA

7.5%

14%

STS Rates of Cardiac Surgeries (2000)

CABG82%

Valve9%

CABG+Valve9%

CABG

Valve

CABG+Valve

CSMC Rates of Cardiac Surgeries (2001)

CABG47%

Valve25%

CABG+Valve28%

CABG

Valve

CABG+Valve

Cardiac Surgery Knowledge BaseStage CABG AVR MVR MVRepair CABG+Valve

Preop PathologyIndicationsSurvival, QOLRisk assessment

EmbryologyPathologyIndicationsSurvival, QOLRisk Assessment

PathologyIndicationsSurvival, QOLRisk Assessment



Intraop Bypass pumpConduitsOPCAB

Bypass pumpValvesValve selection

Bypass pumpValvesValve selection

Bypass pumpRingsRepair methods

Special considerations

ICU Low COWeaningBleeding

HypotensionHypertension

Altered mental statusAfib prophylaxis

Tests: ECG, CxR, hemodynamicsFloor Afib

AnticoagulationDC protocol

Short-term

InfectionRecovery

AnticoagulationAntibiotic prophylaxis

Long-term

SurvivalQuality of life

AngicoagulationAntibiotic prophylaxis

Complications

Outline

• Pump -- Off-pump• Conduits• Low cardiac output• Hypotension• Bleeding• Hypertension• Altered mental status• Afib prophylaxis -- afib• Anticoagulation• DC protocol

John Gibbon’s First Pump-Oxygenator

1935 - Cat bypass for 26 minutes

1953 - Cecelia Bavolek ASD repair

Disk OxygenatorBubble Oxygenator

+ pump

Cobe Oxygenator

Reservoir

Oxygenator

6”

Cardio-Pulmonary Bypass

Reservoir

A

B

B

Heater/Cooler

Drug infusionmanifold

MembraneOxygenator

RotaryPump

Yankauer Coronary

Bubble/debrisfilter

Shunt

Effects of Cardiopulmonary Bypass

• Cytokine activiationIL-1 Procalcitonin Heat shock protein 70IL-6 C3aIL-8 C5aIL-18 TNFalpha

• Microemboli -- intrinsic cascade• Hemolysis• Platelet activation (small aggregates only, not large)• Granulocyte activation• Monocyte activation• Ischemia/reperfusion injury• Operative trauma• Endotoxemia

Systemic Inflammatory Response Syndrome (SIRS)

Effects of Cardiopulmonary Bypass

• Third-spacing (non-pulmonary)• Non-cardiogenic pulmonary edema• Fever• Vasodilatation• Coagulopathy• Hemolysis• “Post-pump syndrome”• Thrombocytopenia• Increased risk of infection

Systemic Inflammatory Response Syndrome (SIRS)

• Coronary suction• Cannulation of the aorta• Cannulation of the RA appendage• Handling of the heart• Aortic, Mitral, Tricuspid surgery

Mechanical Aspects of Cardiopulmonary Bypass

• Heparin• Anesthesia• Protamine

Chemical Effects of Cardiac Surgery

• Hypothermia

Other Effects of Cardiopulmonary Bypass

Off-Pump Coronary Bypass Surgery

Beating Heart Against Cardioplegic Arrest Study

Angelini et al, Lancet 2002;359:1194

Beating Heart Against Cardioplegic Arrest Study

Angelini et al, Lancet 2002;359:1194

Minimally Invasive Cardiac Surgery

OPCABEasier recovery?Fewer complications?Cheaper?Good anastomoses?

Small ScarCosmesis

Khan, N. E. et. al. N Engl J Med 2004;350:21-28

Rates of Graft Patency in Each Territory in the On-Pump and Off-Pump Groups

Outline


Conduits• Saphenous vein• IMA• Radial• Artificial• Other

lesser saphenousarm veinsgastroepiploicinferior epigastric

Patency of Various Conduits

2-3 weekspost-op

Endo et al. Circulation 2001;104:2164

Patency of Various Conduits

Time Interval

Graft 2-3 weeks 1 year 3 years 4 years 5 years 10 years 15 years

IMA 98.8 99 98 97.8 81.5-97 90 90

LIMA 95.6 92

RIMA 100

Free IMA 95.2 95.2

MIDCAB IMA 96

Radial 98.9 90-94 94.5 83

SVG 100 47.6 88.8 62-64.7 68 50

Seq SVG 63

Gast Epi 100 98.7 91.1 91.7 84.4

Inf Epi 100 90.9

RA Background

•Long-term patency from 83-96%•Radial artery used in 50% of all CABG’s

at CSMC•Anecdotal complaints of sensory abnormalities

and rare complaints of hand weakness

Radialmuscles -- Triceps brachii

AnconeusBrachioradialisExtensor carpi radialis longus

sensory -- none

Superficial radial nervemuscles -- nonesensory -- dorsal hand

Path ofRadial Nerve

in the Forearm

Superficial Radial Nerve

Patient Population

•2/20/96 to 12/31/99•All patients with radial arteries•Compared to patients without

radial arteries over sametime period.

Results

Symptom N/total ProportionAny abnormality 169/560 30.1%Thumb strength 31/559 5.5%Sensation abnormality Dorsum Palm

101/55977/55971/559

18.1%13.8%12.7%

Other Abnormality 43/558 6.3%Improvement 101/560 18.0%

ResultsSymptom PredictorsAny abnormality Bilateral radial harvest

SmokingThumb strength DM

PVDCreatinineCHF

Any sensationabnormality

Smoking

Dorsal abnormality SmokingRight radial harvest

Palmar abnormality NoneOther Abnormality None

Problems

•Usually, thumb strength complaintsvia Flexor pollicus longusMOTOR MEDIAN NERVE

•Most palmar sensation abnormalitiesSENSORY MEDIAN NERVE

Results

Sensory AbnormalityLocation

ThumbWeakness

No ThumbWeakness

P value

Palmar Only 16.1% (5/31) 3.8% (20/528) 0.003Dorsal Only 6.5% (2/31) 5.6% (29/528) 0.97Both Palmar and Dorsal 35.5% (11/31) 6.6% (35/528) <0.001

Median Nerve

Problems

Data support median nerve damage

• Palmar abnormalities• Thumb weakness• Statistical associations

What is the mechanism of median damage?

Vascular Supply of Median Nerve

Type 1 - 70% Type 2 - 10% Type 3 - 20%Clin Orth and Rel Res 1973;97:144

Summary

•Clear evidence for radial nerve damage•Clear evidence for median nerve damage•Vascular disease contribution to damage

Outline


What is this?

RA = 20

PAD = 24

No Y descent

Therapy for Tamponade

Return mediastinum to atmospheric pressure

Differential Diagnosis ofLow Cardiac Output/Hypotension

• Tamponade• Tamponade• Tamponade• Tamponade• Hypovolemia• LV dysfunction / infarction• Hemorrhage

Chuttani et al. Am Heart J 1994;127:913

48

24 2734

13

65

81

0

20

40

60

80

100S

ensi

tivi

ty (

%)

5040

70 70

0

20

71

0

20

40

60

80

100

Sen

siti

vity

(%

)

47

165

16 21

89 86

0

20

40

60

80

100

PulsPara LoBP RV dc RA dc LA dc LV dc DiastEq

Sen

siti

vity

(%

)

Entire Group

Circumferencial Effusion

Local Effusion

Outline


Postoperative Blood Loss

0

50

100

150

200

250

300

1 2 3 4 5 6

Hour

cc b

lood + 2 SD’s

Mechanical

Coagulopathy

Etiology

• Mechanical• Coagulopathy

HeparinCoumadinAntiplatelet agentsTemperatureLow platelet count (rare)Poor platelet function

Therapy

• MechanicalReturn to surgery

• CoagulopathyCorrect PT (FFP 2 or more units)Correct PTT (Protamine 20-40 mg)Correct PFA (DDAVP 20-40 units)Correct Platelet count (platelets)Empiric therapy

Outline


Outline


Outline


Cardiac Arrhythmias following PneumonectomyNEJM 1943;229:356-359

•When was cardiac surgery started?•When was bypass started?•When was ECG monitoring started?

Incidence of Postop Afib

Ann Surg 1997;226:501

29.6

48.8

32.927.6

42.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Overall MVR AVR CABG Other

Surgery Type

Per

cent

EtiologyExternal•Inflammation•Contact

Internal•Pressure (wall tension)•Atrial size (wall tension)

Atrial•Ischemia•pH•Potassium•Magnesium•Trauma•Irritation•Catechols•Autonomic tone

J Thor CV Surg 1990;100:338

Predictors of Postop Afib

•Age•COPD•Preop beta blocker (+)•CRF

Rate of Afib per Decade

0102030405060708090

100

<40 40-49 50-59 60-69 >70

Decade

Per

cen

t

JAMA 1996;276:300


•Hx of afib•Preop Pulse > 100•Pulm vein venting•Male•Bicaval venous cannulation•CHF•Postop atrial pacing•Age•Cross-clamp time•Preop betablocker (lower)

Circ 1996;94:390


•Age•Male•HTN•IABP•Pneumonia•Prolonged ventilation•Return to ICU

Ann Thor Surg 1999;68:931-933

Does the Pump cause Afib?

•Retrospective•CABG (n=685)•Minimally invasive CABG (n=19)•TMLR (n=19)

36 37

5

0

10

20

30

40

50

60

70

80

90

100

CABG Off-Pump TMLR

Pos

t A

fib

Rat

e (%

)

P<0.01

J Thor CV Surg 1999;117:298

Does the Pump cause Afib?

•Retrospective•55 Off-pump vs control cohort

34

26

0

10

20

30

40

50

60

70

80

90

100

CABG Off-Pump

Pos

t A

fib

Rat

e (%

)

P=NS

Preventthe

Rhythm

Prophylaxis for Afib

• Potassium• Digoxin• Pacing• Beta blocker• Amiodarone• Verapamil• Sotalol

Prog CV Dis 1989;31:367

Prophylaxis for Afib

Method Random/Non-random

Drug(s) Control Intervention

Chee (n=182) Non DigoxinNo-Digoxin

72% 5%

Johnson (n=120) Random Preop DigoxinNo-Digoxin

26% 5%

Tyras Random Preop digoxinNo-digoxin

Less More

Csicsko Non Postop DigoxinNo Digoxin

5.9% 1.5%

Weiner Random Postop DigoxinNo Digoxin

15% 15%

Matangi(n=164)

Random Prop 5 mg q6 More Less

White(n=21)

Random Timolol More Less

Daudon Random Acebutolol 40% 0

Ann Thor Surg 1981;31:496

Prophylaxis with Digoxin and Propranolol

• Prospective, grouped by cardiologist• Control Digoxin 1mg POD 0 and 0.25 mg/day Dig as above + propanolol 20 mg tid POD#2

22 22.4

2.10

10

20

30

40

50

60

70

80

90

100

Placebo Dig Dig + Prop

Pos

t A

fib

Rat

e (%

)

p<0.01

Am Heart J 1999;138:144

Amiodarone for Postop Afib Prophylaxis•Randomized, double-blind•Amiodarone 2 grams over 4 days preop

then continued for 7 days Placebo•CABG only

32.8

24.7

0

10

20

30

40

50

60

70

80

90

100

Placebo Amio

Pos

t A

fib

Rat

e (%

)

p=0.3

NEJM 1998;337:1785

Amiodarone for Postop Afib Prophylaxis

•Randomized, double-blind•Amiodarone 200 mg tid x7days preop

then dc’ed on day of discharge Placebo•All cardiac surgery patients

53

25

0

10

20

30

40

50

60

70

80

90

100

Placebo Amio

Pos

t A

fib

Rat

e (%

)

p=0.003

What percentage of patients are seen 7 days preop?

JACC 1999;33:1981

Right Atrial and Biatrial Pacing

•Randomized to three groups (61 pts total)•No pacing, right atrial, biatrial•100 /min for 96 hours or until afib

3329

37

0

10

20

30

40

50

60

70

80

90

100

No Pacing RA Biatrial

Pos

t A

fib

Rat

e (%

)

P>0.7

Ann Thor Surg 1985;39:336

Prophylaxis with Verapamil

•Double-blind, randomized•Verapamil 80 mg q6h vs placebo•Observed 7 days for afib•13% hypotension on verapamil

23

14

0

10

20

30

40

50

60

70

80

90

100

Placebo Verapamil

Pos

t A

fib

Rat

e (%

)

P=0.1

JACC 1999;34:334-339

Sotalol for Postop Afib Prophylaxis

•Randomized, double-blind, placebo•85 patients•sotalol 1-2 days preop, +4 days postop vs placebo•sotalol 190 + 43 mg/day•5% bradycardia/hypotension

38

12.5

0

10

20

30

40

50

60

70

80

90

100

Placebo Sotalol

Pos

t A

fib

Rat

e (%

)

p=0.008

Effect of Sot and Mag on Postop Afib

38

1412

2

0

10

20

30

40

50

60

70

80

90

100

Control Mag Sot Mag+Sot

Per

cent

Forlani S, et al. STS 38th Annual Meeting, 2001

Controlthe

AV node

Treatment of Postop Afib

Control the AV Node

• Beta blocker• Calcium channel blocker• Digoxin

Ann Int Med 1987;106:503-506

Digoxin Converting Recent Onset Afib

•Randomized, double-blind, placebo•36 patients with afib of <7 days•vent rate 85-175 (no complications)•digoxin orally 0.6, 0.4, 0.2, 0.2 mg at 0, 4, 8 & 14 hrs

44.450

0

10

20

30

40

50

60

70

80

90

100

Placebo Digoxin

Con

vers

ion

Rat

e (%

)

3.3 hrs 5.1 hrs

P=0.9

Rate Control Therapy

Can J Cardiol 1998;14:1363-1366

•Observational study•59 patients post-CABG•Rate control with dig/verapamil•follow-up at 2-4 weeks•55/59 patients in NSR (93.2%)

Convertthe

Rhythm

Convert the Rhythm

• Electrical• Pharmacologic

procainamideamiodaronepropafenonesotalolibutilide

AJC 1999;84:345

Propafenone and Procainamide

•Randomized, double-blind, placebo•IV propafenone 2 mg/kg or IV PA 20 mg/kg

59

76

18

61

0

10

20

30

40

50

60

70

80

90

100

15 minutes 60 min

Con

vers

ion

Rat

e (%

)

p<0.001 P=NS

Circ 1999;100:369

Ibutilide and Postop Afib

Ibutilide in Postop Afib

Circ 1999;100:369

•4 / 218 torsades (1.8%)•all in 1 mg group (5.6%)•3/4 had low EF

Our experience = 3 / 5 with torsades / VF

CSMC Protocol

•Control the AV node digoxin beta blocker calcium blocker

•Convert the Rhythm IV Procainaimide (15 mg/kg bolus, 2mg drip) Propafenone Amiodarone Electrical cardioversion

Outline


Anticoagulation

• Bioprosthetic valves/Ring RepairsINR = 2.0 for 12 weeks (unless contraindicated)“no rush” to INR of 2.0

• Mechanical valvesStart coumadin POD #3Pt leaves hospital at INR ~ 1.7Goal INR = 3.5

Outline


The GuidelinesThe Guidelines

Therapy GoalSmoking Complete cessationBP control 130-140/80-90Cholesterol LDL<100Exercise 30 min, 3-4x/weekWeight control BMI 18.5-25 kg/m2

DM Gluc~100, HbA1c < 7Antiplatelet/warfarin ASA 81-325 mgACE Post-MI, EF<40, AllBeta blockers Post-MI, All

How often do we provide these therapies?How often do we provide these therapies?

Therapy Rate ReferenceSmoking 48% Doescher J Fam Prac 2000;49;543

BP control 25% Berlowitz, NEJM 1998;339:1957Cholesterol 31.7% Fonarow Circ 2001;103:38

Exercise 19.1% MMWR 1998;47:91

Weight control 10.4% MMWR 1998;47:91DM 45% UKPDS AHJ 1999;138:353

Antiplatelet/warfarin 84% Rogers Circ 1994;90:2103ACE 75% (chf) J Gen Int Med 1997;12:563

Beta blockers 17.4% (iv) Rogers Circ 1994;90:2103PTCA (AMI) 30.3% Rogers Circ 1994;90:2103

Protocol in Cardiac Surgery• On discharge from the ICU -- ABC2D

aspirinbeta blockerconverting enzyme inhibitor (ACE)cholesterol-lowering agentdiabetes therapy and teaching

• Prior to discharge from the hospitalExerciseBMI recommendationsHTN therapy initiatedSmoking cessation

"Get with the Guidelines" Outcomes

85 82

67

38

0 0 0 0 0

95.5 9789.6

98.4 100 100 100 100 100100 100 100 100 100 100 100 100100

0

10

20

30

40

50

60

70

80

90

100

ASA Beta ACE Chol DM Smoke HTN Exerc BMI

Guideline

Pe

rce

nt

All CABG-only, 10/1/2001 to 12/31/2001compare to 1999 data

CSMC Cardiothoracic Surgery

Summary

• Fewer CABG, more valveand combinations

• Pump effects vs off-pump• Prophylaxis for postop

complications• “Systems of Care”

team speaks the same languageoptimal patient surgical and MEDICAL care

End

Documents

Postoperative Care of the Cardiac Surgical Patient Timothy A. Denton, M.D. High Desert Heart Institute Victorville, CA