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Redo CABG Anesthesia: Managing Catastrophic RV Reentry Injury [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Redo CABG Anesthesia: Managing Catastrophic RV Reentry Injury =============================================================== A board-focused approach to high-risk resternotomy, emergency CPB, coagulopathy, and neurologic protection [ MDster Editorial Team ](https://mdster.com/about) · Aug 19, 2026 · 5 min read · 39 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Anesthesiology ](https://mdster.com/blog?tag=anesthesiology) [ Cardiac Anesthesia ](https://mdster.com/blog?tag=cardiac-anesthesia) [ Redo CABG ](https://mdster.com/blog?tag=redo-cabg) [ Cardiopulmonary Bypass ](https://mdster.com/blog?tag=cardiopulmonary-bypass) [ TEE ](https://mdster.com/blog?tag=tee) [ Board Examination ](https://mdster.com/blog?tag=board-examination) ![Redo CABG Anesthesia: Managing Catastrophic RV Reentry Injury](https://mdster.com/storage/blog/images/redo-cabg-anesthesia-managing-catastrophic-rv-reentry-injury.jpg) Share this article Share this post On this page 1. [ Why This Redo CABG Is High Risk ](#why-this-redo-cabg-is-high-risk) 2. [ Preparation Before Induction ](#preparation-before-induction) 3. [ When to Establish Peripheral CPB First ](#when-to-establish-peripheral-cpb-first) 4. [ Catastrophic RV Injury During Reentry ](#catastrophic-rv-injury-during-reentry) 5. [ Four Immediate Actions ](#four-immediate-actions) 6. [ TEE, Stroke Risk, and Post-CPB Bleeding ](#tee-stroke-risk-and-post-cpb-bleeding) 7. [ Key Points for Board Exams ](#key-points-for-board-exams) 8. [ Conclusion ](#conclusion) 9. [ Frequently Asked Questions ](#blog-faqs) 10. [ References ](#references-heading) On this page 1. [ Why This Redo CABG Is High Risk ](#why-this-redo-cabg-is-high-risk) 2. [ Preparation Before Induction ](#preparation-before-induction) 3. [ When to Establish Peripheral CPB First ](#when-to-establish-peripheral-cpb-first) 4. [ Catastrophic RV Injury During Reentry ](#catastrophic-rv-injury-during-reentry) 5. [ Four Immediate Actions ](#four-immediate-actions) 6. [ TEE, Stroke Risk, and Post-CPB Bleeding ](#tee-stroke-risk-and-post-cpb-bleeding) 7. [ Key Points for Board Exams ](#key-points-for-board-exams) 8. [ Conclusion ](#conclusion) 9. [ Frequently Asked Questions ](#blog-faqs) 10. [ References ](#references-heading) A 74-year-old man with unstable angina, CKD, diabetes, and NYHA III symptoms presents for urgent redo CABG. CT shows the RV densely adherent to the posterior sternum. When the oscillating saw enters the RV, blood pressure falls to 50/30 mmHg and the operative field disappears beneath blood. At that instant, survival depends less on diagnostic elegance than on whether the team has rehearsed rapid hemorrhage control and extracorporeal rescue. Why This Redo CABG Is High Risk ------------------------------- Risk is cumulative rather than attributable to one variable. DomainCase findingClinical implicationPatientAge 74, CKD, diabetesHigher risks of AKI, infection, bleeding, and organ dysfunctionCardiac reserveUnstable angina, NYHA IIIPoor tolerance of hypotension, tachycardia, and anemiaProcedureUrgent redo CABGLimited optimization and technically complex dissectionReentry anatomyRV adherent to sternumCatastrophic injury may occur before central cannulation is possible Preoperative CT should define the relationship between the sternum, RV, aorta, and previous grafts. Coronary angiography should establish graft patency and identify conduits that may be injured during dissection. Peripheral arterial anatomy also matters if femoral or axillary CPB is contemplated. [\[1\]](#cite-1 "Reference [1]") Preparation Before Induction ---------------------------- The airway is rarely the dominant threat; circulatory collapse before bypass is. Preparation should include: - Arterial monitoring before induction when feasible - Large-bore venous access and an immediately available rapid infuser - Crossmatched blood, cell salvage, and a massive-transfusion pathway - External defibrillation-pacing pads before positioning and draping - Perfusionist, primed CPB circuit, and peripheral cannulation equipment ready - Explicit allocation of roles if reentry hemorrhage occurs External pads permit defibrillation or pacing while the closed or blood-filled chest prevents rapid placement of internal paddles. Etomidate with a titrated opioid is reasonable, but no induction drug substitutes for slow dosing, vasopressor readiness, and preservation of coronary perfusion pressure. ### When to Establish Peripheral CPB First Exposure of femoral vessels provides rapid access but does not equal bypass. Pre-sternotomy cannulation or initiation of CPB becomes particularly compelling when CT shows the RV, aorta, or patent graft directly adherent to the sternum and controlled central cannulation would be impossible after injury. This remains an individualized surgical decision because peripheral CPB adds vascular, embolic, bleeding, and inflammatory risks. [\[2\]](#cite-2 "Reference [2]") > **Clinical Pearl:** If CT predicts that a reentry injury cannot be controlled long enough to establish CPB, the rescue plan should begin before the sternum is opened—not after hemorrhage starts. Catastrophic RV Injury During Reentry ------------------------------------- The immediate differential includes RV or RA laceration, aortic injury, innominate vein injury, and disruption of a patent graft. Dark, nonpulsatile blood suggests a right-sided source, whereas bright pulsatile hemorrhage raises concern for the aorta or an arterial graft. Visual distinction may be unreliable during profound shock. An RV tear diverts venous return into the operative field. Preload, LV filling, coronary perfusion, and cerebral perfusion collapse within seconds. ### Four Immediate Actions 1. **Stop and control the defect.** The surgeon stops the saw and applies direct digital, swab, or instrument-assisted tamponade without extending the injury. 2. **Activate hemorrhage and CPB rescue.** Deliver 100% oxygen, rapidly infuse blood, correct ionized calcium, and use vasoactive support as a bridge rather than a substitute for volume and hemorrhage control. 3. **Coordinate systemic heparinization.** Give full CPB anticoagulation when the surgeon and perfusionist confirm that cannulation can proceed immediately, then verify the circuit-appropriate ACT target. 4. **Establish extracorporeal support.** Cannulate the exposed femoral artery and vein. If venous cannulation is delayed, heparinized shed blood may be recovered through cardiotomy suction and returned through the arterial circuit while definitive venous drainage is established. This sequence is dynamic. Heparin given before usable access may intensify uncontrolled bleeding; conversely, delaying anticoagulation when cannulation is ready postpones definitive rescue. Current CPB guidance emphasizes protocolized anticoagulation, monitoring, and multidisciplinary crisis management. [\[3\]](#cite-3 "Reference [3]") TEE, Stroke Risk, and Post-CPB Bleeding --------------------------------------- TEE provides continuous assessment of biventricular function, filling, regional wall motion, cannula position, intracardiac air, and the adequacy of repair. It therefore adds diagnostic information that arterial pressure and filling pressures cannot provide. TEE complements rather than replaces epiaortic ultrasound, which is better suited to identifying ascending aortic disease at proposed cannulation or clamping sites. [\[4\]](#cite-4 "Reference [4]") Stroke mechanisms include: - Atheroembolism from the ascending aorta or friable old grafts - Cerebral hypoperfusion during hemorrhagic shock or CPB - Air embolism during cardiac repair and de-airing Epiaortic scanning, meticulous de-airing, and avoidance of diseased aortic segments reduce preventable embolic exposure. After CPB, bleeding may reflect a surgical source, residual heparin, hypofibrinogenemia, platelet dysfunction, factor dilution, fibrinolysis, hypothermia, or acidosis. Goal-directed TEG or ROTEM algorithms are recommended over empiric component therapy. Platelet-function testing is particularly useful after recent P2Y12 exposure or when qualitative dysfunction is suspected; platelet mapping is not mandatory in every redo CABG. [\[5\]](#cite-5 "Reference [5]") Key Points for Board Exams -------------------------- - CT evidence of RV-sternal adherence predicts dangerous resternotomy. - External pads are applied because internal defibrillation may be inaccessible. - A controlled induction preserves coronary perfusion and avoids tachycardia. - Catastrophic RV injury requires compression, blood resuscitation, coordinated heparinization, and immediate CPB. - TEE guides physiology and repair; epiaortic ultrasound guides aortic manipulation. - Treat post-CPB bleeding with surgical reassessment and goal-directed coagulation testing. Conclusion ---------- Redo CABG is won during planning. Imaging-defined reentry risk must determine access, monitoring, cannulation strategy, and a rehearsed response to catastrophic hemorrhage. This discussion reflects evidence available through August 2026. Frequently Asked Questions ---------------------------- ### Why are external defibrillation pads placed before redo sternotomy? They permit immediate defibrillation or pacing when the chest is closed, inaccessible, or obscured by hemorrhage and internal paddles cannot be applied promptly. ### Does RV adherence to the sternum mandate pre-sternotomy CPB? Not automatically. It strongly supports peripheral cannulation or CPB before reentry when an injury would be difficult to control or central cannulation would be inaccessible. ### Should heparin be administered immediately after an RV tear? Heparinization should be coordinated with the surgeon and perfusionist when immediate cannulation is ready. Premature administration may worsen bleeding if extracorporeal support cannot yet be established. ### Is platelet mapping required for every bleeding patient after CPB? No. Viscoelastic-guided transfusion is central; additional platelet-function testing is most useful with recent antiplatelet exposure or suspected qualitative platelet dysfunction. References (6) ------------------ 1. 1. [ Anaesthesia for adult cardiac surgery requiring repeat sternotomy ](https://pmc.ncbi.nlm.nih.gov/articles/PMC10941097/) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ pubmed.ncbi.nlm.nih.gov/18805254 ](https://pubmed.ncbi.nlm.nih.gov/18805254/) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ 2024 EACTS/EACTAIC/EBCP Guidelines on cardiopulmonary bypass in adult cardiac surgery ](https://pmc.ncbi.nlm.nih.gov/articles/PMC11826094/) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ AHA Scientific Statement: Intraoperative TEE During Adult Cardiac Surgery ](https://professional.heart.org/en/guidelines-statements/considerations-of-intraoperative-transesophageal-echocardiography-during-adultcir0000000000001342) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management ](https://www.sts.org/sites/default/files/Guidelines/Patient%20Blood%20Management%20Guideline_Final.pdf) [↩](#cite-ref-5-1 "Back to text") 6. 6. 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