Case 4-1992 A 62-Year-old man is scheduled for a new cardiac surgical procedure: Dynamic cardiomyoplasty

right ventricle (RV), with mild to moderate mitral regurgitation, mild aortic insufficiency, and mild tricuspid insufficiency, and an LVEF of 8%. A MUGA scan confirmed an LVEF of 10% at rest and 12% with exercise. Exercise testing showed failure of a BP rise with exercise. Cardiac catheterization revealed the following pressures: RV 50110 mmHg, pulmonary artery pressure (PAP) 50124 mmHg, LV 90130 mmHg, pulmonary capillary wedge pressure (PCWP) 32120 mmHg, and a cardiac index (CI) of 1.43 L/min/m$ coronary arteries were normal. The patient was premedicated with 1.5 mg of oral diazepam and brought to the operating room (OR) breathing 50% oxygen by face mask. Fresh frozen plasma was infused to normalize the prothrombin time prior to the operativc procedure. Cardiopulmonary bypass (CPB) was set up in the OR on standby. Following placement of a large-bore IV cannula, a radial arterial catheter, and pulse oximetry monitoring, the patient was prehydrated with 500 mL of Ringer’s lactate. Steps were taken to actively keep the patient from becoming hypothermie. A warming blanket was placed on the OR table and intravenous solutions were administered through a blood warmer. Anesthesia was induced with sufentanil (10 ug/kg), administered over 2 to 3 minutes, and pancuronium (0.15 mg/kg). The patient was intubated with a 39-French leftsided endobronchial double-lumen tube and ventilated with an air-oxygen mixture (tidal volume of 12 mL/kg x 10, inspired oxygen concentration of 0.5) to maintain an end-tidal CO2 of 35 to 40 mmHg. The left lung was collapsed to facilitate the flotation of a calibrated Oximetrix fiberoptic pulmonary artery catheter (PAC) into the right pulmonary artery; the lung was then reexpanded. Postinduction the patient was in sinus rhythm and hemodynamic measurements revealed a cardiac output (CO) of 2.6 Limin, PAP of 42/20 mmHg, PCWP of 16 mmHg, mixed venous oxygen saturation (SCO,) of 71%, BP of 95155 mmHg, and heart rate (HR) of 60 beatsimin. A sufentanil infusion was started at a rate of 1.5 kg/kg/ hour. The patient’s bladder was catheterized with a temperature-sensing Foley catheter. The surgeons then inserted a J-wire into the right femoral artery in case CPB was required. The patient was positioned in the right lateral decubitus position for the first stage of the operation. Lorazepam, 4 mg, was given IV and SvOZ remained unchanged. Fifteen minutes later, 50% NzO was added, BP fel1 from 86170 mmHg to 79/51 mmHg and STO, fel1 from 72% to 65% (Fig 2A); N20 was discontinued and SiO? rose