CABG & MVR: Acute HF
Quadruple CABG and MVR in a morbidly obese patient with recent MI and IABP support.
"A 52 y.o., 130 kg man is scheduled for quadruple coronary artery bypass grafting and mitral valve replacement. HPI: Patient suffered an acute MI complicated by chronic heart failure and post-infarct mitral insufficiency 5 days ago. Cardiac function is supported by dobutamine and IABP..."
Management of acute MR, low ejection fraction (30%), and the risks of morbid obesity.
Expect probing questions on induction choice and IABP management. Valvular lesions appear in nearly every examination cycle.
How a Board-Certified Consultant answers this scenario.
This patient is in cardiogenic shock with acute mitral regurgitation (MR) and is hemodynamically fragile despite IABP and dobutamine. My anesthetic goals are to maintain forward flow by avoiding bradycardia and managing afterload, essentially following the 'fast, forward, and full' principle of MR management.
For induction, I will use an etomidate or high-dose opioid technique to minimize myocardial depression. I will have emergency vasoactive medications (epinephrine, norepinephrine) primed and ready. I must be extremely cautious with positive pressure ventilation, as it can decrease venous return and further exacerbate low cardiac output in a heart dependent on preload. Intraoperative TEE is mandatory to assess the repair and manage the ongoing heart failure. I will maintain IABP throughout the induction and procedure until weaning from bypass is confirmed successful.