Anesthetic Management of ALCAPA Surgery
The optimal anesthetic management for ALCAPA surgery requires a fellowship-trained cardiac anesthesiologist credentialed in perioperative transesophageal echocardiography (TEE) to provide or supervise anesthetic care, with close collaboration between the anesthesiologist and surgeon during critical phases of the procedure. 1, 2
Preoperative Assessment and Preparation
Cardiac Function Evaluation
- Assess 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
- Evaluate collateral circulation from the right coronary artery (critical for survival)
- Identify high-risk features: severe LV dysfunction, significant mitral regurgitation, ventricular arrhythmias
Preoperative Optimization
- Continue antiarrhythmic medications perioperatively
- Consider introducing calcium channel blockers or beta-blockers to reduce arrhythmia risk
- Formulate a clear anesthetic plan with the surgical team through a formalized checklist-guided multidisciplinary communication
Intraoperative Monitoring
Essential Monitoring
- Standard ASA monitors
- Invasive arterial pressure monitoring
- Central venous pressure monitoring
- Transesophageal echocardiography (TEE) for real-time assessment of:
- Ventricular function
- Regional wall motion
- Valve function (particularly mitral valve)
- Coronary reimplantation assessment
Advanced Monitoring
- Cerebral oxygen saturation monitoring (NIRS) to detect cerebral hypoperfusion
- Pulmonary artery catheter in high-risk patients (severe LV dysfunction, pulmonary hypertension)
Anesthetic Technique
Induction
- Etomidate or carefully titrated propofol for induction to maintain hemodynamic stability
- Avoid pure vasodilators that may compromise coronary perfusion
- Short-acting opioids for analgesia
- Consider benzodiazepines for amnesia
Maintenance
- Volatile anesthetic-based regimen at low concentrations to facilitate early extubation and reduce patient recall 1
- Opioid supplementation for analgesia
- Consider dexmedetomidine for its sympatholytic and analgesic properties
Hemodynamic Management
Key Goals
- Maintain adequate coronary perfusion pressure
- Avoid tachycardia (shortens diastolic filling time)
- Maintain normal to slightly elevated systemic vascular resistance
- Avoid significant increases in pulmonary vascular resistance
- Target balanced myocardial oxygen supply and demand
Cardiopulmonary Bypass (CPB) Management
- Close collaboration between anesthesiologist and surgeon during vascular cannulation and weaning from CPB 1
- Administration of low concentrations of volatile anesthetic via venous oxygenator during CPB
- Careful monitoring during displacement of the heart and application of stabilizer devices
- Meticulous attention to hemodynamic alterations during manipulation of the heart and great vessels
Ventilation Strategy
- Implement lung-protective ventilation (tidal volumes 6-8 mL/kg)
- Maintain normocapnia to avoid pulmonary vasoconstriction
- Apply protective one-lung ventilation combining tidal volume 6 mL/kg, PEEP, and alveolar recruitment maneuvers if thoracoscopic approach is used 1
Fluid Management
- Administer between 2-6 mL/kg/h of baseline intraoperative fluid 1
- Consider titrating intraoperative fluid management using esophageal Doppler-guided hemodynamic monitoring 1
Post-CPB Management
- Assess coronary reimplantation with TEE
- Evaluate for regional wall motion abnormalities
- Assess mitral valve function (common concomitant issue)
- Consider inhaled nitric oxide if pulmonary hypertension is present
- Prepare for potential need for inotropic/vasopressor support
Postoperative Management
Immediate Care
- 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
Analgesia
- Postoperative locoregional analgesia technique after thoracotomy or thoracoscopy 1
- Consider continuous paravertebral block rather than thoracic epidural analgesia due to better safety profile 1
- Short courses of NSAIDs postoperatively (avoid COX-2 inhibitors) 1
Potential Complications and Management
- Myocardial ischemia: Monitor for ECG changes, regional wall motion abnormalities
- Arrhythmias: Maintain electrolyte balance, consider antiarrhythmic medications
- Bleeding: Monitor chest tube output, coagulation parameters
- Right ventricular dysfunction: Consider inhaled pulmonary vasodilators
- Mitral regurgitation: Assess with TEE, communicate with surgical team
Long-term Follow-up
- Clinical evaluation with echocardiography and noninvasive stress testing every 3-5 years 2
- Monitor for coronary perfusion abnormalities, myocardial function, and valvular function
- Assess for potential complications: coronary obstruction, stenosis at anastomosis site, residual mitral regurgitation
By following this comprehensive approach to anesthetic management for ALCAPA surgery, the anesthesiologist can optimize patient outcomes while minimizing perioperative risks.