ALCAPA repair
Clinical Procedure
 
Aliases:
Anomalous left coronary artery from the pulmonary artery repair

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See patient considerations at anomalous left-coronary-artery-from-the-pulmonary-artery

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Nov 22, 2012
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ECG may reveal evidence of myocardial ischaemia.

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Nov 06, 2012
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This is a procedure that usually benefits from having two anaesthetists present to manage the inherent haemodynamic instability.

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Before induction for an ALCAPA repair have your dose of arrest adrenaline drawn up and ready to give if needed.

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Ensure your peripheral volume line is connected up before induction in case the patient arrests and becomes rapidly covered in surgical drapes for emergent bypass.

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If the patient arrests at induction you may not get a chance to put a central line in.
If this happens let the surgeons know so they can place a triple lumen cvc in the right atrium.

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Insert the arterial catheter before intubation in case the stimulation associated with laryngoscopy and intubation results in cardiac arrest.

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Wait for the cardiothoracic surgeon to be in the room and scrubbed before intubating the patient.
Intubation may lead to decompensation and cardiac arrest requiring the team to crash the patient onto bypass.

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Consider how you're going to support the right ventricle coming off bypass.
Dobutamine will be a titratable inotrope/inodilator, and/or adrenaline.

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Great care should be taken at induction to maintain high normal pulmonary artery pressures to encourage anterograde flow throught the LCA or reduce the amount of retrograde flow which would increase the amount of "coronary steal" from the RCA via the RCA>LCA collaterals.
Do so by maintaining high pulmonary vascular-resistance and avoid a fall in the systemic vascular-resistance.
Tolerate some hypercarbia and hypoxia, and consider avoiding volatile anaesthetic-agents.

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If the patient will be coming off on LVAD consider running a noradrenaline infusion to maintain the patient's SVR and promote venous return to the venous cannula.

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