Anesthesia for Myocardial Revascularization

Providing anesthesia care for patients undergoing coronary artery bypass grafting (CABG) continues to be a challenging yet rewarding endeavor. Surgical, anesthetic, and technologic advances continue to drive changes in clinical routines at a rapid pace, even at a time when the numbers of cases have declined because of the growth of percutaneous coronary interventions (PCIs). Cardiac anesthesiologists who have been in practice for the past several decades have seen a variety of anesthetic and surgical practices come into vogue and fall out of favor based on new research and economic pressures. Perhaps the most striking example is the rise and fall of high-dose opioid anesthesia, which was initially driven by concern about excessive cardiovascular depression by volatile anesthetics in the 1970s and further accelerated in the mid-1980s by concerns about potential coronary steal with isoflurane. The prolonged postoperative mechanical ventilation resulting from the shift to high-dose opioids was also thought important to reduce stress on the recently revascularized myocardium. However, during the following decade, this approach was completely reversed by new basic and clinical research, such as lack of evidence for adverse effects of volatile agents, particularly as related to potential effects of coronary vasodilation on coronary steal, and by strong evidence of their benefits via rapid preconditioning; by social and economic factors (i.e., safety and efficacy of fast-tracking for most patients and recognition