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Ann Thorac Surg 1997;63:921-922
© 1997 The Society of Thoracic Surgeons

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Correspondence

An Alternative Airway in Cardiac Surgery?

Department of Anaesthesia and Cardiac Surgery Glenfield Hospital Groby Rd Leicester LE3 9QP, UK

To the Editor:

Since its introduction in the early 1980s to current widespread use in anesthetic practice, the laryngeal mask airway (LMA) [1–3] has failed to be considered in some surgical specialties. We report a case of a 42-year-old man with ankylosing spondylitis and severe aortic regurgitation. He was also suffering from chronic anemia and in the past had undergone bilateral hip and knee arthroplasties. Before undergoing a spinal operation for severe spinal deformities, he was subjected to two formal tracheostomies prior to general anesthesia.

After premedication with a benzodiazepine, arterial and venous lines were inserted under local anesthesia. An inhalational induction was performed with preoxygenation of 100% oxygen and sevoflurane added until the patient was anesthetized. Despite limited mouth opening, a size 4 laryngeal mask was passed atraumatically. Fiberoptic laryngoscopy through the LMA was performed and the vocal cords were visualized, but no attempt was made to pass a gum elastic bougie. Ventilation was continued through the LMA. The operative procedure consisted of aortic valve replacement and was completed uneventfully. After the operation, the LMA was removed when the patient regained consciousness. He was discharged home on the sixth postoperative day.

Anesthesia for cardiac operations requires hemodynamic stability. Despite the advantages of LMA over tracheal intubation in this respect, the literature suggests that in open heart operations, LMA should not be used. Reasons include the high cuff pressures required with LMAs in intrathoracic operations potentiating pharyngeal mucosal ischemia and risk of regurgitation of gastric contents.

In treating our patient, we considered following anesthetic options: (1) awake fiberoptic intubation under local anesthesia before general anesthesia, (2) endotracheal intubation under deep inhalational anesthesia, (3) anesthesia through a formal tracheostomy under local anesthesia, and (4) insertion of LMA under deep inhalational anesthesia. Tracheal intubation would have been difficult in this patient due to limited temporo-mandibular joint movement and a rigid neck. Options 1 and 2 were rejected, due to the previous need for a tracheostomy. Option 3 was rejected at the request of the patient.

We have used LMAs as an alternative to endotracheal intubation in more than 250 cardiac patients without complication. In view of this extensive experience, we decided on controlled ventilation through the LMA to avoid the potential for trauma with tracheal manipulation and the possibility of hemorrhage into the bronchial tree should a gum elastic bougie be used.

This case report demonstrates the suitability of LMA as an alternative means of controlled ventilation to tracheal intubation in the majority of patients requiring a cardiac operation. It is also a positive adjunct to the philosophy of "fast tracking."

References

1. Brain AJ. The development of laryngeal mask—a brief history of the invention, early clinical studies and experimental work from which the laryngeal mask evolved. Eur J Anaesth 1991;4:5–17.
2. Takashi A, Morris S. The laryngeal mask airway: its features, effects and role. Can J Anaesth 1994;41:930–60.[Medline]
3. Llagunes J, Rodriguez-Hesles C, Agnar F. Laryngeal mask airway in cardiac surgery [Letter]. Can J Anaesth 1994;41:1016.[Medline]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ghosh, S. Articles by Spyt, T. J. Search for Related Content PubMed PubMed Citation Articles by Ghosh, S. Articles by Spyt, T. J.