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Hemodynamic management during off-pump coronary artery bypass surgery: a narrative review of proper targets for safe execution and troubleshooting

Authors
 Jae-Kwang Shim  ;  Kwang-Sub Kim  ;  Pierre Couture  ;  André Denault  ;  Young-Lan Kwak  ;  Kyung-Jong Yoo  ;  Young-Nam Youn 
Citation
 KOREAN JOURNAL OF ANESTHESIOLOGY, Vol.76(4) : 267-279, 2023-08 
Journal Title
KOREAN JOURNAL OF ANESTHESIOLOGY
ISSN
 2005-6419 
Issue Date
2023-08
MeSH
Cardiac Output ; Coronary Artery Bypass, Off-Pump* / adverse effects ; Echocardiography, Transesophageal ; Hemodynamics / physiology ; Humans ; Oxygen
Keywords
Cardiac tamponade ; Hemodynamic monitoring ; Mixed venous oxygen saturation ; Off-pump coronary artery bypass ; Swan-ganz catheterization ; Transesophageal echocardiography
Abstract
Off-pump coronary surgery requires mechanical cardiac displacement, which results in bi-ventricular systolic and diastolic dysfunction. Although transient, subsequent hemodynamic deterioration can be associated with poor prognosis and, in extreme cases, emergency conversion to on-pump surgery, which is associated with high morbidity and mortality. Thus, appropriate decision-making regarding whether the surgery can be proceeded based on objective hemodynamic targets is essential before coronary arteriotomy. For adequate hemodynamic management, avoiding myocardial oxygen supply-demand imbalance, which includes maintaining mean arterial pressure above 70 mmHg and preventing an increase in oxygen demand beyond the patient's coronary reserve, must be prioritized. Maintaining mixed venous oxygen saturation above 60%, which reflects the lower limit of adequate global oxygen supply-demand balance, is also essential. Above all, severe mechanical cardiac displacement incurring compressive syndromes, which cannot be overcome by adjusting major determinants of cardiac output, should be avoided. An uncompromising form of cardiac constraint can be ruled out as long as the central venous pressure is not equal to or greater than the pulmonary artery diastolic (or occlusion) pressure, as this would reflect tamponade physiology. In addition, transesophageal echocardiography should be conducted to rule out mechanical cardiac displacement-induced ventricular interdependence, dyskinesia, severe mitral regurgitation, and left ventricular outflow tract obstruction with or without systolic motion of the anterior leaflet of the mitral valve, which cannot be tolerated during grafting. Finally, the ascending aorta should be carefully inspected for gas bubbles to prevent hemodynamic collapse caused by a massive gas embolism obstructing the right coronary ostium.
Files in This Item:
T202305051.pdf Download
DOI
10.4097/kja.23103
Appears in Collections:
1. College of Medicine (의과대학) > Dept. of Anesthesiology and Pain Medicine (마취통증의학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Dept. of Thoracic and Cardiovascular Surgery (흉부외과학교실) > 1. Journal Papers
Yonsei Authors
Kwak, Young Lan(곽영란) ORCID logo https://orcid.org/0000-0002-2984-9927
Kim, Kwang-Sub(김광섭)
Shim, Jae Kwang(심재광) ORCID logo https://orcid.org/0000-0001-9093-9692
Yoo, Kyung Jong(유경종) ORCID logo https://orcid.org/0000-0002-9858-140X
Youn, Young Nam(윤영남)
URI
https://ir.ymlib.yonsei.ac.kr/handle/22282913/196296
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