Anesthesia Management
for Beating Heart Surgery

INTRODUCTION

Jerrold Levy, MD
Director,
Cardiothoracic Anesthesiology
Emory Healthcare
Atlanta, Georgia

The treatment of coronary artery disease (CAD) has evolved rapidly over the last two decades. The gold standard of surgical revascularization has been challenged by the development of balloon angioplasty catheters. Angioplasty was popularized in the United States in the early eighties in Atlanta, by Dr. Andreas Gruentzig who originally developed the procedure when he was working in Europe. Competition between Cardiologists and Cardiac Surgeons for patients with CAD has again intensified with the emergence of beating heart coronary artery bypass (CAB), which avoids the complications associated with cardiopulmonary bypass (CPB), yet offers the patient the benefit of long-term graft patency that greatly exceeds that of current endovascular technologies.1 The challenge now rests with the surgical community to effectively reduce the invasiveness of revascularization, yet maintain the benefits of long-term patency.

Surgical Paradigms for the Year 2000

Beating heart surgery (OPCAB*) Minimal incision (MIDCAB**) Use of IIb/IIIa receptor antagonists and coronary stents Repeat surgical procedures Blood conservation Anti-inflammatory strategies

Evolution of Cardiac Anesthesia

Since the early days of cardiac surgery, anesthesia has continued to evolve. The introduction of shorter-acting agents that cause less hemodynamic instability has facilitated the "fast tracking" of patients. The temporal evolution of cardiac anesthesiology is as follows:

1969:	High dose morphine, d-tubocurare
1978:	High dose fentanyl, metocurine, and pancuronium. These agents were revolutionary as they expanded the population of patients who could receive cardiac anesthetic. They provided hemodynamic stability and made it easy to provide anesthesia for patients undergoing cardiac and non-cardiac procedures.
1980's:	Sufentanil, vecuronium.
1990's:	Lower dose opioids, rocuronium. These agents continue to change and evolve due to "fast tracking" the patient and the introduction of beating heart surgery

Beating Heart Surgery Involves
the Active Participation of the
Anesthesiologist

• It is critical to understand not only the anesthetic techniques involved, but also the assertive and aggressive use of cardiovascular pharmacology to support the patients undergoing the surgical manipulations of beating heart procedures.
• The development of novel cardiac manipulation techniques and newer stabilization devices has made this procedure a reality for patients needing multivessel revascularization.
• The participation of the anesthesiologist is indispensable in caring for patients during this procedure.

The purpose of this monograph is to review the major aspects of the anesthesiologist’s role in the management and monitoring of the patient during beating heart surgery.