Intraoperative Echo: When to go Back on Pump

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Transcription:

Intraoperative Echo: When to go Back on Pump Madhav Swaminathan, MD, FASE Professor of Anesthesiology Division of Cardiothoracic Anesthesia & Critical Care Duke University School of Medicine Disclosures None

Outline What happens on pump? Staying on versus coming off When is it helpful to go back on? Cases Summary What happens on pump? Surgeons do 3 things Put together Replace Remove

What happens on pump? Revascularized zones New prosthetic valves/devices Fixed shunts, leaks Unintended consequences Even the best designs can fail

What happens on pump? What happens on pump?

What happens on pump? What happens on pump?

What happens on pump? What happens on pump?

What happens on pump? What happens on pump?

What happens on pump? What happens on pump?

What happens on pump? What happens on pump?

What happens on pump? What happens on pump?

What happens on pump? What happens on pump?

What happens on pump? Myocardial protection Physical injury to cannulation sites Air entrainment Stunning Inotropic choice Uncommon What happens on pump? Myocardial protection Physical injury to cannulation sites Air entrainment Aortic dissection Vena cava injury Coronary sinus injury

What happens on pump? Myocardial protection Physical injury to cannulation sites Air entrainment What happens on pump? Myocardial protection Physical injury to cannulation sites Air entrainment

What happens on pump? Myocardial protection Physical injury to cannulation sites Air entrainment What happens on pump? Myocardial protection Physical injury to cannulation sites Air entrainment

Outline What happens on pump? Staying on versus coming off When is it helpful to go back on? Cases Summary Outline What happens on pump? Staying on versus coming off When is it helpful to go back on? Cases Summary

Outline What happens on pump? Staying on versus coming off When is it helpful to go back on? Cases Summary Stay or come off pump? Depends Some critical questions Will staying on help? Is the patient ready to come off? Can they handle the preload? Inotrope selection? Pacing choice? Trial separation

Outline What happens on pump? Staying on versus coming off When is it helpful to go back on? Cases Summary When is it helpful to go back on? 1. When you should not have come off in the first place! 2. When there s something to do Surgeons do 3 things Put together Replace Remove

Outline What happens on pump? Staying on versus coming off When is it helpful to go back on? Cases Summary Outline What happens on pump? Staying on versus coming off When is it helpful to go back on? Cases Summary

Case 1 A 68-year old woman presented with NYHA class IV symptoms and had a long history of a murmur. Workup revealed moderate AS with moderate AI. Scheduled for elective AVR. Intra-operative TEE Case 1 A 68-year old woman presented with NYHA class IV symptoms and had a long history of a murmur. Workup revealed moderate AS with moderate AI. Scheduled for elective AVR. Intra-operative TEE

Case 1 A 68-year old woman presented with NYHA class IV symptoms and had a long history of a murmur. Workup revealed moderate AS with moderate AI. Scheduled for elective AVR. Intra-operative TEE Case 1 A 68-year old woman presented with NYHA class IV symptoms and had a long history of a murmur. Workup revealed moderate AS with moderate AI. Scheduled for elective AVR. Intra-operative TEE

Case 1 A 68-year old woman presented with NYHA class IV symptoms and had a long history of a murmur. Workup revealed moderate AS with moderate AI. Scheduled for elective AVR. Intra-operative TEE Case 1 A 68-year old woman presented with NYHA class IV symptoms and had a long history of a murmur. Workup revealed moderate AS with moderate AI. Scheduled for elective AVR. Intra-operative TEE

Case 2 Case 2 A 73-year old woman with severe MR due to a flail P2 was scheduled for elective MVR with a mechanical valve Post st-cpb TEE revealed A 73-year old woman with severe MR due to a flail P2 was scheduled for elective MVR with a mechanical valve Post st-cpb TEE revealed

Case 2 Case 2 A 73-year old woman with severe MR due to a flail P2 was scheduled for elective MVR with a mechanical valve Post st-cpb TEE revealed A 73-year old woman with severe MR due to a flail P2 was scheduled for elective MVR with a mechanical valve Post st-cpb TEE revealed

Summary The decision to go back on pump is challenging Principal drivers of the decision should be: 1. How will it help? 2. What can the surgeon do? TEE plays a pivotal role in this decision

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