11th Annual Update on Cardiopulmonary Bypass

March 12-17, 2006
The Fairmont Chateau Whistler
Whistler, British Columbia, Canada

Co-Sponsored by the Society of Cardiovascular Anesthesiologists and the Canadian Society of Perfusionists

Lecture Objectives

SUNDAY, MARCH 12, 2006
WORKSHOPS

Session: Basic TEE Workshop - Moderator: JS Shanewise
Overall Workshop Objective: At the conclusion of this workshop, the participant will be able to:

  1. State the basic uses of TEE during surgery
  2. Explain how to use TEE to monitor cardiac function
  3. Identify major abnormalities in cardiac function with TEE
  4. Recognize major changes in cardiac function with TEE

How to Perform an Intraop TEE Exam RM Savage
At the conclusion of this lecture, the participant will be able to:

  1. State the indications for intraoperative TEE
  2. List the relative contraindications of TEE
  3. Describe the standard TEE views
  4. Recall the technique for TEE probe insertion

TEE Evaluation of Global & Regional Ventricular Function ATW Cheung
At the conclusion of this lecture, the participant will be able to:

  1. Assess global ventricular function with TEE
  2. Identify obvious regional abnormalities of ventricular function
  3. Explain several means of assessing ventricular function with echocardiography
  4. Describe the limitations of TEE assessment of ventricular function

TEE Evaluation of Aortic & Mitral Valves GM Janelle
At the conclusion of this lecture, the participant will be able to:

  1. Recognize the normal anatomy of the mitral and aortic valves
  2. Use TEE to assess the severity of aortic stenosis
  3. Describe the limitations of TEE assessment of valvular function
  4. Classify the causes of mitral regurgitation

TEE Evaluation of the Thoracic Aorta SN Konstadt
At the conclusion of this lecture, the participant will be able to:

  1. Describe how to examine the aorta with TEE
  2. Recognize aortic dissection with TEE
  3. Recall the echo features of atherosclerosis of the aorta
  4. Classify aneurysms of the thoracic aorta

TEE Masses, Pitfalls & Artifacts JS Shanewise
At the conclusion of this lecture, the participant will be able to:

  1. Describe the causes of echo artifacts
  2. Explain acoustic shadowing
  3. Recognize the echo characteristic of thrombus in the heart
  4. List the most common types of tumors in the heart

Session: Point of Care/Coagulation Testing Workshop
Moderators: L Shore-Lesserson, M England, CT Walker

Overall Workshop Objective: At the conclusion of the workshop, the participant will:

  1. Have an understanding of heparin's mechanism of action for anticoagulation
  2. Learn the hematologic abnormalities that arise after cardiopulmonary bypass
  3. Understand platelet physiology and receptor pharmacology
  4. Be exposed to point of care devices that measure platelet function
  5. Learn to design a transfusion algorithm that is suitable for their practice of cardiac surgery.

Session: Perfusion for the Anesthesiologist/Anesthetist & Surgeon Workshop
Moderators: C Gruenwald, T McDougall, C Vocelka, EA Hessel II

Overall Workshop Objective: At the conclusion of the workshop, the participant will:

  1. Will have a working knowledge of the key components and various options used in extracorporeal circuits for cardiopulmonary bypass (CPB).
  2. Will have had a hands-on an opportunity to practice going on, maintaining and coming off CPB.
  3. Will have been exposed to the common and or serious adverse events which occur during CPB and learned to analyze and manage these problems during simulated CPB.
  4. Will better understand the problems associated with conducting CPB, what impact surgeon and anesthesia activities can have on these, and how the surgeon and anesthesiologist can assist the perfusionist in managing undesirable events.

In addition, during this stimulating workshop, the Surgeon and Anesthesiologist/ Anesthetist will:

  1. Have an opportunity to learn and acquire skills necessary to manage the heart-lung machine and perfusion systems (in-vitro of course!)
  2. Be provided with an overview of the basic perfusion systems, monitoring, circuitry and safety devices
  3. Learn in an informative interactive environment that will encourage the participant's involvement
  4. Examine common apparatus utilized for cardiopulmonary bypass (CBP) such as the heart-lung-machine, level and bubble sensors, pressure and temperature monitoring and the perfusion circuitry
  5. Gain insight into the fundamental management of CPB and delve into the recognition and responses necessary to address common problems and complications during CPB
  6. Respond to real-time scenarios and enjoy the opportunity of identifying and reacting to catastrophic situations arising during CPB, and as a result will become a more effective communicator with your perfusion colleagues.

MONDAY, MARCH 13, 2006

Session: Future Opportunities for Expansion of the Cardiac Team
Moderators: RD Weisel and RM Savage
Overall Session Objective: At the conclusion of this session, the participant will:

  1. Understand trends in cardiology and cardiac surgery
  2. See opportunities for surgery, perfusion and anesthesia
  3. Realize economic implications of various interventions

Where is Cardiovascular Care Going in the Future? L Benson/C Caldarone
At the conclusion of this lecture, the participant will:

  1. Know of risks and benefits present and emerging stent technologies
  2. Learn about valves put in through cath lab techniques

The Expanding Role of the Cardiovascular Anesthesiologist JG Ramsay
At the conclusion of this lecture, the participant will:

  1. Learn of new and expanding electrophysiology interventions
  2. Realize how cardiac anesthesia can contribute in the cardiac cath lab
  3. Think about how many people should be trained

Outcome Data: Surgery versus Percutaneous Interventions RD Weisel
At the conclusion of this lecture, the participant will:

  1. Realize short and long-term costs and risks for cardiac surgery
  2. Examine patient risks and how that effects which technology they should receive
  3. Question where cardiac care is headed in the future

Session: Optimal Perfusion: An Approach to Evidence-based Practice
Moderators: EA Hessel II

Overall Session Objective: At the conclusion of this session, the participant will be able to:

  1. Examine the strength of evidence and bases for currently popularly accepted beliefs about how to provide optimal perfusion during cardiopulmonary bypass. To identify best practices based on currently available best evidence.
  2. Ask questions, challenge the data which has been presented, and offer their views on how to measure and provide optimal perfusion.

What is Optimal Perfusion? EA Hessel II
At the conclusion of this lecture, the participant will:

  1. Know how to review the literature and other sources of information, in order to identify best practices.
  2. Know how to evaluate quality of evidence.
  3. List ways of defining "optimal perfusion".

What is Optimal Arterial Pressure and How Should We Achieve It? ATW Cheung
At the conclusion of this lecture, the participant will:

  1. Be able to identify the evidence that supports maintaining a particular arterial pressure during CPB.
  2. Determine if there are certain patient populations for which maintaining a certain arterial pressure is likely to improve outcome.
  3. Determine if there is a "best" way to maintain arterial pressure during CPB (eg. flow, vasoactive agents, hematocrit, or others.)

What is the Optimal Circuit and Way to Use It? RC Groom
At the conclusion of this lecture, the participant will be able to:

  1. Identify components, and methods of managing the extracorporeal circuit which impact clinical outcome of patients.
  2. Evaluate the evidence which favors one component or management strategy over another.

TUESDAY, MARCH 14, 2006

Session: Inflammation and Coagulation in Cardiopulmonary Bypass
Moderators: L Shore-Lesserson/BD Spiess
Overall Session Objective: At the conclusion of this panel, the participant will: learn the inciting events that lead to inflammation during cardiac surgical procedures. The participant will understand the interactions between inflammation, coagulation, and end-organ damage. Specific procedures, techniques, and pharmacologies that prevent or minimize inflammation will be discussed.

The Interaction of Inflammation and Coagulation M England
At the conclusion of this lecture, the participant will:

  1. Understand the complex interplay between inflammation and coagulation at the level of the endothelium and within the blood elements
  2. Be able to review the activation schemes of inflammation and the feedback mechanisms involved in regulating these reactions.

Perfusion Techniques to Reduce Inflammation C Vocelka
At the conclusion of this lecture, the participant will:

  1. Learn which perfusion techniques, oxygenators, pumps, and biological coatings have been studied to reduce inflammation in cardiopulmonary bypass.

Pharmacologic Techniques to Reduce Inflammation L Shore-Lesserson
At the conclusion of this lecture, the participant will:

  1. Have been exposed to numerous drugs that minimize or prevent activation of the inflammatory cascade. Studies that highlight the success or failure of these drug studies to reduce end-organ damage will be reviewed.

What are the End-organ Effects of Reducing Inflammation? GS Aldea
At the conclusion of this lecture, the participant will:

  1. Be able to discuss the end-organ detrimental effects of activation of inflammation. Specific focus on the heart, brain, kidney, gut, and hemostasis system will be made.

Case Discussion: Emergency Patient from the Cath Lab L Shore-Lesserson
At the conclusion of this lecture, the participant will:

  1. Understand the hematologic status of patients undergoing percutaneous procedures in the cardiac catheterization laboratory. A review will be made of the anticoagulants and anti-thrombotic agents used. The effects that these drugs have on the hematologic system of patients who need cardiac surgery will be reviewed.

Session: Heparin-induced Thrombocytopenia
Moderators: A DeAnda/GS Aldea

Overall Session Objective: At the conclusion of this session, the participant will:

  1. Understand the development of antibodies to heparin and heparin-like substances, including the incidence and pathophysiology of this development.
  2. Related the presence of heparin antibodies to and reactions to the development of clinically relevant syndromes.
  3. Be able to identify alternatives to heparin, with an understanding of the results of clinical trials using such alternatives and the risk-benefit profile of these drugs.
  4. Be aware of alterations in clinical practice when alternatives to heparin are utilized.

The Overview of the Physiology of Heparin-induced Thrombocytopenia BD Spiess
At the conclusion of this lecture, the participant will:

  1. Learn about the immune response of humans to heparin
  2. Find out the incidence and severity of HiTT
  3. Realize that HiTT can both cause bleeding as well as thrombosis
  4. Develop a sense of the severity and risks of HiTT

The Far Reaching Implications of Heparin Platelet Factor-4 Antibodies A DeAnda
At the conclusion of this lecture, the participant will:

  1. See that antibodies themselves create under-appreciated risk for bad outcomes
  2. Review the latest studies regarding antibody existence, bleeding, death and embolic events

The Human Trials of Direct Thrombin Inhibitors GS Aldea
At the conclusion of this lecture, the participant will:

  1. Learn of the history of DTIs in the cath lab
  2. Review the early trials from New Zealand
  3. See the data from the just-concluded bivalirudin trials

A Perfusionist's Tricks of the Trade with Regards to New or Novel Anticoagulants C Vocelka
At the conclusion of this lecture, the participant will:

  1. Understand the monitoring of anticoagulation using bivalirudin
  2. Be able to modify the CPB circuit when using an alternative anticoagulant
  3. Realize the necessity to modify the conduct of CPB when using an alternative anticoagulant

WEDNESDAY, MARCH 15, 2006

Session: The Old and New of Coronary Revascularization
Moderators: RD Weisel/M Borger

Overall Session Objective: At the conclusion of this session, the participant will:

  1. Understand the historical development of coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI)
  2. Compare contemporary outcomes for CABG and PCI
  3. Understand the decreasing CABG rates in North America and its implications for cardiac programs
  4. Appreciate the future possibilities for surgical and percutaneous coronary revascularization

A Historical View of CABG Surgery: Have we Passed the Peak? M Borger
At the conclusion of this lecture, the participant will:

  1. Understand the historical development of coronary bypass surgery
  2. Recall the most significant changes in CABG surgery over time
  3. Know the current indications for CABG
  4. Appreciate the future uncertainty of coronary bypass surgery

Biological Options for Improving Coronary Revascularization RD Weisel
At the conclusion of this lecture, the participant will:

  1. Be aware of the different biological alternatives that are being developed for coronary revascularization
  2. Have a working knowledge of the rationale and methodology behind biological revascularization options
  3. Know the major pitfalls that must be overcome for these biological interventions
  4. Understand how biological options may change the future climate of coronary revascularization

Emerging Surgical and Percutaneous Technologies for Coronary Revascularization: Who Will Come Out on Top? MJ Mack
At the conclusion of this lecture, the participant will:

  1. Be aware of recent developments in coronary bypass surgery
  2. Be aware of recent developments in percutaneous coronary interventions
  3. Understand the current dynamic climate between cardiac surgery and interventional cardiology in coronary revascularization
  4. Predict what will happen to CABG and PCI rates over time

Case Discussion: How Should the Patient Choose What is Best? RD Weisel
At the conclusion of this lecture, the participant will:

  1. Be aware of the options that patients are currently exposed to for coronary revascularization
  2. Appreciate the factors that patients consider when making a decision regarding coronary revascularization
  3. Understand how patient options may be influenced by health care personnel and resources
  4. Understand how patient choices will influence future CABG and PCI volumes

Session: Critical Care Issues in Cardiac Surgery
Moderators: DM Rothenberg/RN Sladen

Overall Session Objective: At the conclusion of this session, the participant will:

  1. Recognize of the problem of sleep deprivation in critically ill patients and how it affects recovery.
  2. Understand the most efficacious way to provide sedation and/or analgesia to critically ill patients, and review appropriate protocols.
  3. Discuss the etiologies of appropriate treatment modalities of atrial fibrillation after cardiopulmonary bypass.
  4. Review the proper physiology of acute hepatic dysfunction following cardiopulmonary bypass.

Sleep Deprivation in Critically Ill Patients DM Rothenberg
At the conclusion of this lecture, the participant will:

  1. Understand the physiology of normal sleep.
  2. Recognize the clinical situations in which sleep deprivation occurs.
  3. Discuss the role of noise and light reduction in establishing sleep
  4. Be able to develop a plan to reduce sleep deprivation in critically ill patients.

Postoperative Analgesia/Sedation Therapy RN Sladen
At the conclusion of this lecture, the participant will:

  1. Learn of the importance of pain control in ICU care
  2. Realize advances using dopaminergic pain care
  3. Learn of some key regional pain interventions
  4. Look at stress reduction and its far-reaching effects with adequate, balanced care in the ICU

Perioperative Management of Atrial Fibrillation JG Ramsay
At the conclusion of this lecture, the participant will:

  1. Know the incidence of atrial fibrillation
  2. Realize the costs in length of stay for patients who experience atrial fib
  3. Learn of possible mechanisms for atrial fib
  4. Find some key interventions that have failed or succeeded

Hepatic Dysfunction RN Sladen
At the conclusion of this lecture, the participant will:

  1. Learn of the importance of hepatic failure in outcome
  2. Realize the effects of hepatic failure on respiratory function
  3. Be able to predict which patients are at risk for hepatic failure

THURSDAY, MARCH 16, 2006

Session: Congenital Heart Disease: The Emerging Cardiac Challenges from Infants to Adults
Moderators: LK Davies and C Gruenwald

Overall Session Objective: At the conclusion of this session, the participant will:

  1. Realize that many previously treated children are living to require future surgeries
  2. Understand some of the more common operations both in infancy and later
  3. Realize that new technologies are creating new controversies

How Should We Manage the Older Patient with Congenital Heart Disease? C Caldarone
At the conclusion of this presentation the participants will have an overview of congenital heart disease (CHD) in the adult with emphasis on the technical challenges related to re-operations in the adult with CHD.

Changing Techniques in Managing the Infant with Congenital Heart Disease-What is the Role of the Interventionalist? L Benson
The participants will be given an update on treatment strategies that have evolved for complex heart disorders either as staged procedures (catheterization laboratory then surgery) or combined procedures (hybrid where surgery takes place in the catheterization lab.

Bypass Differences-Focus on Adult with Congenital Heart Disease T McDougall
The audience will understand the various perfusion techniques utilized for the patient with ACHD at the completion of this presentation. The specific challenges and requirements for these complex patients will be highlighted.

Older Patient with Congenital Heart Disease: How do they Transition from Pediatric to Adult Care? C Gruenwald
As the ACHD specialty continues to evolve, the complex needs of the pediatric patient living with CHD will become more evident. The participants will explore the specific requirements that health care professionals, government and society will be required to address.

Case Discussion: Pregnancy LK Davies
At the conclusion of this interactive session, the audience will understand some of the unique concerns in managing the pregnant patient with congenital heart disease. Emphasis will be placed on understanding the physiologic changes associated with pregnancy and how these changes interface with the challenges of maintaining stability in the patient with ACHD.

Session: Ischemic Mitral Regurgitation
Moderators: M Borger and SN Konstadt

Overall Session Objective: At the conclusion of this session, the participant will be able to:

  1. Identify the mechanisms of mitral regurgitation
  2. Identify the considerations of mitral valve replacement and mitral valve repair
  3. Recognize the uses and limitations of percutaneous mitral valve repair
  4. Describe the state of the art methods to preserve myocardial function
  5. Recognize different clinical scenarios and understand the treatment options.

Transesophageal Echocardiographic Exam and Appreciation of the Dynamics of Mitral Regurgitation SN Konstadt
At the conclusion of this lecture, the participant will:

  1. Have obtained the TEE views to analyze mitral valve function
  2. Be able to determine the severity of mitral regurgitation
  3. Be able to identify the mechanisms of mitral regurgitation.

When Should the Valve be Replaced versus Repaired? M Borger
At the conclusion of this lecture, the participant will be able to identify the:

  1. Considerations of mitral valve replacement and mitral valve repair
  2. Surgical techniques in mitral valve repair

Percutaneous Approaches to the Mitral Valve: Should we be concerned? MJ Mack
At the conclusion of this lecture, the participant will be able to recognize the:

  1. Technique of percutaneous mitral valve repair
  2. Uses and limitations of percutaneous mitral valve repair

How do we Protect the Heart and What is New? RC Groom
At the conclusion of this lecture, the participant will be able to recognize:

  1. Current myocardial protection techniques
  2. New techniques to preserve myocardial function

FRIDAY, MARCH 17, 2006

Session: Gender Issues: Is What's Good for the Gander Good for the Goose?
Moderators: NA Nussmeier and J Walker

Overall Session Objective: At the conclusion of this session, the participant will:

  1. Interpret the data and controversies surrounding female gender as a risk factor for in-hospital mortality and morbidity after cardiac surgery.
  2. Describe differences in recovery and long-term outcomes in women versus men after cardiac surgery.
  3. Understand recent advances in surgical techniques for revascularization and heart failure, as they apply specifically to women.

Lecture Overview: Gender in Cardiac Surgery (A Female Perspective) NA Nussmeier
At the conclusion of this lecture, the participant will:

  1. Recognize the growing national focus on women's heart disease, including research efforts and funding.
  2. Understand typical comorbid conditions in female patients.
  3. Describe statistical differences in short- and long-term outcomes after cardiac surgery in women.

Lecture: Surgical Revascularization in Women: Is Off-Pump Better? J Walker
At the conclusion of this lecture, the participant will:

  1. Recognize the technical challenges inherent in surgical revascularization procedures in female patients.
  2. Interpret data comparing surgical outcomes after on-pump versus off-pump revascularization.
  3. Describe future studies that are needed to define improvements in techniques and outcomes in women (as well as men).

Lecture: Long-term Benefits of Surgery: Are the Gains for Women Less? CG Koch
At the conclusion of this lecture, the participant will:

  1. Recognize gender differences in long-term outcomes in women undergoing cardiac surgery, including survival, symptoms, physical functioning, quality of life, and patient satisfaction.
  2. Describe the role of patient characteristics, procedural factors, and management strategies during and after cardiac surgery in impacting long-term outcomes.
  3. Understand the controversy regarding lower female enrollment in postoperative cardiac rehabilitation programs and how this impacts long-term outcomes.

Lecture: Surgery for Heart Failure: Gender Differences N Nussmeier
At the conclusion of this lecture, the participant will:

  1. Describe the available medical and surgical alternatives for women with heart failure due to various etiologies.
  2. Recognize the technical challenges and understand current outcome data in women requiring ventricular assist devices.
  3. Explain the areas of research needed for development of future medical therapy, surgical procedures, and devices for heart failure.

Session: Heroic Measures: VADS, ECMO and Life Support
Moderators: A DeAnda and DM Rothenberg

Overall Session Objective: At the completion of this session, participants will understand better the:

  1. Ethical and medical considerations for extra-corporeal membrane oxygenation (ECMO) in the child, and how these considerations differ from those in the adult. Additionally, the use of ECMO during emergency resuscitation of a child will be discussed
  2. Uses of ventricular assist devices (VAD), in particular the complications associated with these devices peri- and post-operatively, and how these complications modify treatment options
  3. Considerations of informed consent, with specific thought to the perioperative DNR order
  4. Use and abuse of various life-support technologies, and the interface of the physician in the clinical and ethical decision making for the employment of these devices.

Rescue ECMO in Children C Gruenwald
At the conclusion of this lecture, the participant will:

  1. Have reviewed the cardiac indications and contraindications for the use of ECMO in children
  2. Discuss the outcomes in the various cardiac categories where ECMO is utilized
  3. Understand the process and components of a rapid deployment ECLS Program
  4. Consider the complexity of ethical considerations in children where ECLS is utilized

Complications/Problems of Air Embolism with VADS GM Janelle
At the conclusion of this lecture, the participant will:

  1. Consider the ethical and medical issues for ventricular assist devices (VADs) in the management of acute or chronic congestive heart failure
  2. Understand the emerging changes in VAD indications: bridge to recovery vs. bridge to transplantation vs. destination therapy and associated survival rates
  3. Review the early and late complications related to VADs
  4. Understand how these complications affect treatment options

Perioperative DNR Orders DM Rothenberg
At the conclusion of this lecture, the participant will:

  1. Have reviewed the four major concepts of medical ethics
  2. Be able to apply the concepts of medical ethics to understanding the DNR order
  3. Be able to relate the DNR order to patients undergoing surgery
  4. Be able to formulate a plan to manage patients with DNR orders who require surgery

Case Discussion: Who is Appropriate for Salvage and Heroics? A DeAnda
At the conclusion of this lecture, the participant will:

  1. Have considered the question of the patient unable to give consent, requiring a life-saving procedure
  2. Have discussed the ethics of a government agency dictating patient care, even when such care is not the standard
  3. Have discussed the obligation of the "second-opinion" physician to render heroic care
  4. Have considered when is heroic care not in the best interest of the patient? the family? the physician? Society?

 

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