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Principles and Practice of Anesthesia for Thoracic Surgery pp 661–673Cite as

Anaesthesia for Combined Cardiac and Thoracic Procedures

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Abstract

Combined cardiac and thoracic procedures are rare; however thanks to progress of surgical techniques and recent advances in the use of extracorporeal life support (ECLS) techniques the number of these procedures is increasing.

Anaesthesia and optimal perioperative management for these complex, high-risk surgical interventions requires an expertise in both cardiac and pulmonary physiologies, lung isolation techniques, the multiorgan impact of cardiopulmonary bypass (CPB) and additional monitoring techniques (e.g. transesophageal echocardiography-TEE). Combined procedures may include excision of invasive tumours, pulmonary endarterectomy, cardiac revascularization combined with lung resection and cardiac procedures combined with lung transplantation (e.g. PFO closure). Optimal management of these procedures remains controversial and is not well described; in fact it is mainly limited to case reports (Marseu K et al. A A Case Rep 8:61–63, 2017; Slinger et al. Perioperative care in cardiac anaesthesia and surgery. Lippincott, Williams & Wilkins, Philadelphia/Baltimore/New York/London/Buenos Aires/Hong Kong/Sydney/Tokyo, 43–48, 2006). Proponents of single-stage operations will argue in favour of the avoidance of a second surgery and anaesthetic and reduced hospital stay (Slinger et al. Perioperative care in cardiac anesthesia and surgery. Lippincott, Williams & Wilkins, Philadelphia/Baltimore/New York/London/Buenos Aires/Hong Kong/Sydney/Tokyo, 43–48, 2006; Rao et al. Ann Thorac Surg 62:342-347, 1996). The opponents will argue for divided, two-stage procedures on the basis of limiting surgical trauma, blood loss, multiorgan impact of cardiopulmonary bypass and high intensive care morbidity and thus may potentially confer a better long-term survival (Rao et al. Ann Thorac Surg 62:342-347, 1996; Ciracio et al. Eur J Cardiothorac Surg 22:35–40, 2002).

The following chapter will briefly describe the anaesthetic management for various combined thoracic and cardiac procedures. For a better understanding of why CPB is detrimental for lung function, the author will briefly describe the structure and function of the air-blood barrier and pathophysiology of its injury during procedures with use of CPB.

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Author information

Authors and Affiliations

  1. Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesia University of Toronto, Toronto, ON, Canada

    Marcin Wąsowicz

  2. Cardiovascular Intensive Care Unit, Toronto General Hospital, Toronto, ON, Canada

    Marcin Wąsowicz

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  1. Marcin Wąsowicz
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Correspondence to Marcin Wąsowicz .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Case Presentation

Case Presentation

Case

A 21-year-old patient admitted for redo cardiac surgery for resection of recurrent left atrial angiosarcoma invading pulmonary tissue which was demonstrated on a recent follow-up chest X-ray and CT scan (see Figs. 40.6 and 40.7). The proposed procedure will also involve resection of pulmonary parenchyma. His previous surgery was performed 3 years ago without complications and followed by multiple courses of chemotherapy. He has no other significant co-morbidities. Anaesthesiologist is asked to decide whether patient is going to tolerate combined cardiac-thoracic procedure and what additional test he would like to perform.

Fig. 40.6
figure 6

Chest X-ray taken before surgery

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Fig. 40.7
figure 7

Computed tomogram showing invasion of the tumour obtained before surgery

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Questions

  • What additional tests would you order?

  • Will the patient tolerate procedure? What kind of thoracic procedure will the patient require to achieve complete eradication of his tumour?

  • What is your anaesthetic plan?

  • Do you have any specific concerns related to intraoperative management?

  • What kind of postoperative complications can you expect?

Picture presents intraoperative transesophageal echo findings (Figs. 40.8 and 40.9).

Fig. 40.8
figure 8

Picture obtained during intraoperative, transesophageal examination. Mid-esophageal, four-chamber view

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Fig. 40.9
figure 9

Picture obtained during intraoperative, transesophageal examination. Mid-esophageal, two-chamber view

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Questions

  • What cardiac procedure should be performed?

  • Which pulmonary veins are invaded?

  • What postoperative complications would you expect?

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Wąsowicz, M. (2019). Anaesthesia for Combined Cardiac and Thoracic Procedures. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_40

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