Intrathecal Morphine for Analgesia in Robotic Totally Endoscopic Coronary Artery Bypass and Myocardial Bridge Unroofing

Published:October 26, 2022DOI:
      A 43-year-old man had a past medical history of coronary artery disease with drug-eluting stents placed in 2016 in the midleft anterior descending (LAD) and proximal diagonal artery. He eventually developed severe in-stent stenosis of the diagonal stent and underwent angioplasty in 2018. He remained stable until early 2021 when he presented to an emergency room with severe angina after exertion. A left heart catheterization at that time demonstrated patent stents. However, in the months following his emergency room visit, his symptoms worsened such that he had severe angina and dyspnea with minimal exertion; a repeat left heart catheterization in September 2021 revealed 90% in-stent stenosis of the previously angioplastied diagonal stent, and a new 90% stenosis in the proximal LAD. The patient was referred for coronary artery bypass grafting, and he selected totally endoscopic coronary artery bypass (TECAB) to avoid sternotomy.

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        • Shah J
        • Vyas A
        • Vyas D.
        The history of robotics in surgical specialties.
        Am J Robot Surg. 2014; 1: 12-20
        • Deshpande SP
        • Lehr E
        • Odonkor P
        • et al.
        Anesthetic management of robotically assisted totally endoscopic coronary artery bypass surgery (TECAB).
        J Cardiothorac Vasc Anesth. 2013; 27: 586-599
        • Lehr EJ
        • Zimrin D
        • Vesely M
        • et al.
        Axillary-coronary sequential vein graft for total endoscopic triple coronary artery bypass.
        Ann Thorac Surg. 2010; 90: e79-e81
        • Kofler M
        • Stastny L
        • Reinstadler JS
        • et al.
        Robotic versus conventional coronary artery bypass grafting: Direct comparison of long-term clinical outcome.
        Innovations (Phila). 2017; 12: 239-246
        • Balkhy HH
        • Wann LS
        • Krienbring D
        • et al.
        Integrating coronary anastomotic connectors and robotics toward a totally endoscopic beating heart approach: Review of 120 cases.
        Ann Thorac Surg. 2011; 92: 821-827
        • Wang H
        • Pargaonkar VS
        • Hironaka CE
        • et al.
        Off-pump minithoracotomy versus sternotomy for left anterior descending myocardial bridge unroofing.
        Ann Thorac Surg. 2021; 112: 1474-1482
        • Mirzai S
        • Patel B
        • Balkhy HH.
        Robotic totally endoscopic off-pump unroofing of left anterior descending coronary artery myocardial bridge: A report of two cases.
        J Card Surg. 2019; 34: 735-737
        • Corban MT
        • Hung OY
        • Eshtehardi P
        • et al.
        Myocardial bridging.
        J Am Coll Cardiol. 2014; 63: 2346-2355
        • Boyd JH
        • Pargaonkar VS
        • Scoville DH
        • et al.
        Surgical unroofing of hemodynamically significant left anterior descending myocardial bridges.
        Ann Thorac Surg. 2017; 103: 1443-1450
        • Murtaza G
        • Mukherjee D
        • Gharacholou SM
        • et al.
        An Updated Review on Myocardial Bridging.
        Cardiovasc Revasc Med. 2020; 21: 1169-1179
        • Bayman EO
        • Parekh KR
        • Keech J
        • et al.
        A prospective study of chronic pain after thoracic surgery.
        Anesthesiology. 2017; 126: 938-951
        • Draeger TB
        • Gibson VR
        • Fernandes G
        • et al.
        enhanced recovery after thoracic surgery (ERATS).
        Heart Lung Circ. 2021; 30: 1251-1255
        • Wei S
        • Zhang G
        • Ma J
        • et al.
        Randomized controlled trial of an alternative drainage strategy vs routine chest tube insertion for postoperative pain after thoracoscopic wedge resection.
        BMC Anesthesiol. 2022; 22: 27
        • Dhawan R
        • Daubenspeck D
        • Wroblewski KE
        • et al.
        Intrathecal morphine for analgesia in minimally intrathecal morphine for analgesia in minimally invasive cardiac surgery: A randomized, placebo-controlled, double-blinded clinical trial.
        Anesthesiology. 2021; 135: 864-876
        • Katz J
        • Jackson M
        • Kavanagh BP
        • et al.
        Acute pain after thoracic surgery predicts long-term post-thoracotomy pain.
        Clin J Pain. 1996; 12: 50-55
        • Noss C
        • Prusinkiewicz C
        • Nelson G
        • et al.
        Enhanced recovery for cardiac surgery.
        J Cardiothorac Vasc Anesth. 2018; 32: 2760-2770
        • Freiling TP
        • Dhawan R
        • Balkhy HH
        • et al.
        Myocardial bridge: Diagnosis, treatment, and challenges.
        J Cardiothorac Vasc Anesth. 2022; 36: 3955-3963
        • Hemmati P
        • Schaff HV
        • Dearani JA
        • et al.
        Clinical outcomes of surgical unroofing of myocardial bridging in symptomatic patients.
        Ann Thorac Surg. 2020; 109: 452-457
        • Allen KB
        • Brovman EY
        • Chhatriwalla AK
        • et al.
        Opioid-related adverse events: Incidence and impact in patients undergoing cardiac surgery.
        Semin Cardiothorac Vasc Anesth. 2020; 24: 219-226
        • Wheeler M
        • Oderda GM
        • Ashburn MA
        • et al.
        Adverse events associated with postoperative opioid analgesia: A systematic review.
        J Pain. 2002; 3: 159-180
        • Brown CR
        • Chen Z
        • Khurshan F
        • et al.
        Development of persistent opioid use after cardiac surgery.
        JAMA Cardiol. 2020; 5: 889-896
        • Kwanten LE
        • O'Brien B
        • Anwar S
        Opioid-based anesthesia and analgesia for adult cardiac surgery: History and narrative review of the literature.
        J Cardiothorac Vasc Anesth. 2019; 33: 808-816
        • Grant MC
        • Suffredini G
        • Cho BC.
        Is it time to eliminate the use of opioids in cardiac surgery?.
        JTCVS Open. 2021; 7: 247-252
        • Wu CL
        • King AB
        • Geiger TM
        • et al.
        American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on perioperative opioid minimization in opioid-naïve patients.
        Anesth Analg. 2019; 129: 567-577
        • Mittnacht AJC
        • Shariat A
        • Weiner MM
        • et al.
        Regional techniques for cardiac and cardiac-related procedures.
        J Cardiothorac Vasc Anesth. 2019; 33: 532-546
        • Kowalski S
        • Goldie D
        • Maguire D.
        High spinal anesthesia combined with general anesthesia versus general anesthesia alone: A retrospective cohort study in cardiac surgical patients.
        Acta Anaesth. 2019; 70: 63-70
        • Ng W
        • Carroll J
        • Djaiani G.
        Dose response study of intrathecal morphine for off-pump coronary artery bypass grafting: A pilot prospective randomized double-blinded controlled clinical trial.
        J Cardiol Cardiovasc Ther. 2017; 3555610
        • Elgendy H
        • Helmy HAR.
        Intrathecal morphine improves hemodynamic parameters and analgesia in patients undergoing aortic valve replacement surgery: A prospective, double-blind, randomized trial.
        Pain Physician. 2017; 20: 405-412
        • Mogahed MM
        • Ezzat Hamed JM
        • Elkahwagy MS.
        The effect of combined intrathecal morphine and clonidine on stress response, extubation time and postoperative analgesia after cardiac surgery.
        J Anesth Clin Res. 2017; 8: 739
        • Ellenberger C
        • Sologashvili T
        • Bhaskaran K
        • et al.
        Impact of intrathecal morphine analgesia on the incidence of pulmonary complications after cardiac surgery: A single center propensity-matched cohort study.
        BMC Anesthesiol. 2017; 17: 109
        • Mukherjee C
        • Koch E
        • Banusch J
        • et al.
        Intrathecal morphine is superior to intravenous PCA in patients undergoing minimally invasive cardiac surgery.
        Ann Card Anaesth. 2012; 15: 122-127
        • Nordberg G
        • Hedner T
        • Mellstrand T
        • et al.
        Pharmacokinetic aspects of intrathecal morphine analgesia.
        Anesthesiology. 1984; 60: 448-454
        • Mathews ET
        • Abrams LD.
        Intrathecal morphine in open heart surgery.
        Lancet. 1980; 316: 543
        • Vanstrum GS
        • Bjornson KM
        • Ilko R.
        Postoperative effects of intrathecal morphine in coronary artery bypass surgery.
        Anesth Analg. 1988; 67: 261-267
        • Chaney MA
        • Furry PA
        • Fluder EM
        • et al.
        Intrathecal morphine for coronary artery bypass grafting and early extubation.
        Anesth Analg. 1997; 84: 241-248
        • Chaney MA
        • Nikolov MP
        • Blakeman BP
        • et al.
        Intrathecal morphine for coronary artery bypass graft procedure and early extubation revisited.
        J Cardiothorac Vasc Anesth. 1999; 13: 574-578
        • Jacobson L
        • Chabal C
        • Brody MC.
        A dose-response study of intrathecal morphine: Efficacy, duration, optimal dose, and side effects.
        Anesth Analg. 1988; 67: 1082-1088
        • Koning MV
        • Reussien E
        • Vermeulen BAN
        • et al.
        Serious adverse events after a single shot of intrathecal morphine: A case series and systematic review.
        Pain Res Manag. 2022; 20224567192
        • Ho AMH
        • Chung DC
        • Joynt GM.
        Neuraxial blockade and hematoma in cardiac surgery.
        Chest. 2000; 117: 551-555

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