Anaesthetic Management of ALCAPA Surgery
The optimal anaesthetic management for ALCAPA surgery requires invasive arterial pressure monitoring, central venous pressure monitoring, and transesophageal echocardiography (TEE) for real-time assessment of ventricular function, with maintenance of adequate coronary perfusion pressure while avoiding tachycardia. 1
Preoperative Evaluation
Cardiac Function Assessment
- Evaluate left ventricular function, degree of mitral regurgitation, and extent of myocardial ischemia/fibrosis
- Review coronary anatomy via CT or MRI angiography to understand the anomalous coronary structure
- Assess collateral circulation, particularly from the right coronary artery
- Identify high-risk features:
- Severe LV dysfunction
- Significant mitral regurgitation
- Ventricular arrhythmias
Intraoperative Management
Monitoring
- Standard ASA monitors
- Invasive arterial pressure monitoring
- Central venous pressure monitoring
- Transesophageal echocardiography (TEE) - crucial for real-time assessment of:
- Ventricular function
- Regional wall motion abnormalities
- Valve function
- Consider cerebral oxygen saturation monitoring (NIRS) to detect cerebral hypoperfusion
- Consider pulmonary artery catheter in high-risk patients (severe LV dysfunction, pulmonary hypertension)
Anesthetic Technique
Induction:
- Etomidate or carefully titrated propofol
- Avoid pure vasodilators
- Short-acting opioids
- Consider benzodiazepines for amnesia
Maintenance:
- Balanced anesthesia with volatile anesthetics at low concentrations
- Opioid supplementation
- Consider dexmedetomidine for sympatholytic and analgesic properties
- Either volatile anesthetic or total intravenous anesthesia is reasonable, with choice determined by factors other than prevention of myocardial ischemia 2
Hemodynamic Goals
- Maintain adequate coronary perfusion pressure
- Avoid tachycardia which increases myocardial oxygen demand
- Maintain normal to slightly elevated systemic vascular resistance
- Avoid significant increases in pulmonary vascular resistance
- Implement lung-protective ventilation (tidal volumes 6-8 mL/kg)
- Maintain normocapnia to avoid pulmonary vasoconstriction
Cardiopulmonary Bypass (CPB) Management
- Close collaboration between anesthesiologist and surgeon during:
- Vascular cannulation
- Weaning from CPB
- Consider administration of low concentrations of volatile anesthetic via venous oxygenator during CPB to:
- Facilitate amnesia
- Reduce systemic vascular resistance
Pulmonary Vasodilator Therapy
- Consider inhaled nitric oxide during and after surgery, especially if pulmonary hypertension is present
Postoperative Management
- Admission to cardiac critical care unit for at least 24 hours
- Close hemodynamic monitoring
- Goal-directed fluid therapy
- Multimodal analgesia to minimize opioid use
- Early extubation when appropriate
- Early mobilization as part of enhanced recovery pathway
Special Considerations
Coronary Perfusion
- Neuraxial anesthesia for postoperative pain relief can be effective in reducing myocardial infarction in patients undergoing abdominal aortic surgery 2, but its role in ALCAPA surgery is not specifically established
- Maintain vigilance for signs of myocardial ischemia, as patients with anomalous coronary arteries are at higher risk for sudden cardiac death 2
Mitral Valve Assessment
- Many ALCAPA patients have concomitant mitral regurgitation requiring repair
- TEE is essential for evaluating mitral valve function before and after repair
Potential Complications
- Weaning from CPB may be challenging due to:
- Myocardial stunning
- Reperfusion injury
- Residual ventricular dysfunction
- Be prepared for inotropic and vasopressor support
- Avoid factors that increase pulmonary vascular resistance, which could compromise the newly established coronary circulation
Multidisciplinary Approach
- Assemble a team including surgeons and cardiac anesthesiologists to formulate the perioperative care approach
- Close communication between team members is essential, particularly during critical phases of surgery
Common Pitfalls and Caveats
- Underestimating the degree of ventricular dysfunction
- Failing to optimize preload before induction
- Inadequate monitoring during critical phases
- Not having TEE available for real-time assessment
- Insufficient preparation for difficult weaning from CPB
- Overlooking the need for pulmonary vasodilator therapy in patients with pulmonary hypertension
By following this structured approach to anesthetic management for ALCAPA surgery, the anesthesiologist can optimize conditions for successful surgical repair while minimizing perioperative risks.