DP34: BALANCING CEREBRAL AND CARDIAC PERFUSION: ANESTHETIC STRATEGIES FOR MOYAMOYA DISEASE IN CABG
Adriana Vivas, MD; Madina Akhmetkaliyeva; Alimzhan Begulov; Javier Lopez, MD
HCA Florida Kendall Hospital
Introduction: Moyamoya disease is a rare cerebrovascular disorder characterized by progressive stenosis of the internal carotid arteries, leading to collateral vessel formation. Managing anesthesia for coronary artery bypass grafting (CABG) in such patients presents significant challenges due to the risk of cerebral hypoperfusion and stroke. We report the anesthetic and perioperative management of a 61-year-old female with Moyamoya disease undergoing CABG.
Methods: A 61-year-old female with a history of type 2 diabetes, obesity, and hypertension presented for elective cardiac catheterization, which revealed significant coronary artery occlusions requiring CABG. Preoperative imaging demonstrated 50-69% stenosis of the proximal right internal carotid artery and complete occlusion of the distal left internal carotid artery, raising suspicion for Moyamoya disease. Angiography confirmed diffuse intracerebral vascular stenosis. The patient opted to proceed with CABG despite the risk of stroke.
The anesthetic plan prioritized cerebral perfusion and hemodynamic stability. Induction was performed with midazolam, fentanyl, propofol, etomidate, and succinylcholine. A beta-blocker was administered post-intubation. Invasive monitoring included a Swan-Ganz catheter and an arterial line. Maintenance anesthesia consisted of sevoflurane and dexmedetomidine. Transesophageal echocardiography revealed preserved ejection fraction with left ventricular hypertrophy. Hemodynamic goals included maintaining mean arterial pressure (MAP) above 75 mmHg and cardiopulmonary bypass at 34°C. Cerebral protection strategies involved intracerebral pulse oximetry monitoring, norepinephrine and phenylephrine to prevent hypotension, and ventilator settings adjusted to prevent hyperventilation and hypercapnia. The surgery was completed without complications.
Results: Postoperatively, the patient was extubated the same day but developed acute hypoxic respiratory failure, anemia, and a transient left-hand sensory deficit. She required supplemental oxygen, blood transfusions, and vasopressor support. A chest X-ray showed pleural effusions and atelectasis. By postoperative day nine, the patient’s condition improved, and she was discharged on day 12.
Conclusion: This case highlights the importance of meticulous anesthetic and hemodynamic management in patients with Moyamoya disease undergoing cardiac surgery. Maintaining cerebral perfusion, preventing hypotension, and implementing adaptive strategies were essential in optimizing outcomes. A multidisciplinary approach is critical for successful perioperative management in such complex cases.