Anesthesia for Interventional Cardiology

Pre-Anesthetic Assessment - Cardiac Checkpoint

• History & Symptoms:
  • Cardiac status: NYHA class, angina (CCS), prior MI/PCI/CABG.
  • Exercise tolerance: METs (>4 desirable).
  • Key symptoms: Dyspnea, orthopnea, PND, syncope.
• Comorbidities & Medications:
  • HTN, DM, CKD, OSA, PVD.
  • Antiplatelets (Aspirin, Clopidogrel, Ticagrelor), Anticoagulants (Warfarin, NOACs) - crucial management plan needed.
  • β-blockers, ACEi/ARBs.
  • Allergies: Especially contrast dye.
• Essential Investigations:
  • ECG: Baseline rhythm, ischemia, LVH, old MI signs.
  • Echocardiography (recent): LVEF (EF <35-40% = ↑risk), valvular function (esp. AS, MR), PAH, RWMA.
  • Labs: Hb, Platelets, PT/INR, aPTT, Creatinine, K+.
• Risk Stratification:
  • RCRI (Revised Cardiac Risk Index).
  • Functional capacity assessment.

⭐ Severe Aortic Stenosis (AS) (valve area <1.0 cm², mean gradient >40 mmHg, or jet velocity >4.0 m/s) significantly increases peri-procedural risk; meticulous hemodynamic management is paramount during interventional cardiology procedures.

Anesthesia Techniques - Cath Lab Calm

• Anesthesia Spectrum: MAC vs. GA
  • MAC (Monitored Anesthesia Care): Preferred for cooperative patients.
    • Agents: Propofol (TCI/bolus), Remifentanil, Dexmedetomidine.
    • 📌 Dexmed: Delivers Dreamy sedation, Doesn't Depress Dreathing.
  • GA (General Anesthesia): For uncooperative, long procedures, airway risk.
    • Agents: Volatiles or TIVA (Total Intravenous Anesthesia).
• Vigilant Monitoring
  • Standard ASA: ECG, NIBP, SpO₂, EtCO₂, Temp.
  • Invasive Lines: Arterial (complex cases), CVP.
  • TEE: For structural interventions (e.g., TAVI, MitraClip).
• Cath Lab Caveats
  • Radiation Safety: Lead protection, dosimeters.
  • Contrast: Vigilance for reactions.
  • Anticoagulation: Heparin (ACT >250-300s).

⭐ Dexmedetomidine is ideal for cath lab sedation: provides anxiolysis, analgesia, and sedation with minimal respiratory depression, maintaining spontaneous ventilation.

Intra-Op Issues - Code Cath

Rapid recognition & management of cath lab emergencies. "Code Cath" protocols vital.

• Hemodynamic Instability:
  • Hypotension: Fluids, vasopressors (phenylephrine, NE).
  • Hypertension: Labetalol, esmolol, NTG.
• Arrhythmias: (Follow ACLS)
  • Bradycardia: Atropine 0.5-1mg, pacing.
  • Tachyarrhythmias (VT/SVT with pulse): Amiodarone 150mg IV. Unstable: Cardiovert.
• Myocardial Ischemia/Infarction:
  • ECG changes, chest pain.
  • O2, NTG, aspirin, heparin. PCI/stent.
• Cardiac Tamponade:
  • Beck's Triad (hypotension, JVD, muffled sounds).
  • ECHO. Emergent pericardiocentesis.
• Contrast Reactions:
  • Mild: Antihistamines (diphenhydramine 25-50mg).
  • Anaphylaxis: Epinephrine (0.3-0.5mg IM or 0.1mg IV), O2, fluids, steroids.
• Vascular Access Complications:
  • Hematoma, pseudoaneurysm, retroperitoneal bleed.
  • Compression, US-guided thrombin, surgery.

⭐ For heparin reversal during bleeding, administer protamine sulfate: 1 mg for every 100 units of circulating heparin. Max dose 50 mg.

Post-Cath Care - Recovery Roadmap

• Handover: SBAR (Situation, Background, Assessment, Recommendation).
• Monitoring: Vital signs, access site (hematoma, bleeding), distal pulses.
• Pain Management: Multimodal analgesia; opioids for severe pain.
• Anticoagulation: Continue per protocol (e.g., DAPT post-stent, OAC for AF).
• Neurological Assessment: Especially post-TAVI or carotid interventions.
• Procedure-Specific Considerations:
  • TAVI: Monitor for conduction blocks, vascular complications.
  • EP Ablation: Groin care, monitor for pericardial effusion signs.
• Discharge Criteria: Stable vitals, no active bleeding, pain controlled.

⭐ Post-PCI, Dual Antiplatelet Therapy (DAPT) with Aspirin and a P2Y12 inhibitor is typically continued for 6-12 months, depending on stent type and patient's bleeding risk.

High-Yield Points - ⚡ Biggest Takeaways

• Conscious sedation (MAC) is common; GA for complex, long procedures or uncooperative patients.
• Crucial anticoagulation management: monitor Activated Clotting Time (ACT), targeting 250-350s with heparin.
• Prevent Contrast-Induced Nephropathy (CIN) via hydration and minimizing contrast volume.
• Strict radiation safety (ALARA principle) for patient and staff is essential.
• Monitor for vascular access site complications: hematoma, pseudoaneurysm, retroperitoneal bleed.
• Maintain hemodynamic stability: manage arrhythmias, hypotension, and potential ischemia.