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Vandenheuvel M, Bouchez S, Labus J, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2025; 43:305-322. [PMID: 40348545 DOI: 10.1016/j.anclin.2025.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2025]
Abstract
Echocardiography is a standard tool for assessing right ventricular (RV) function in the perioperative setting, but in high-risk cases, additional monitoring may be required. Patients with pulmonary hypertension, pre-existing RV failure, or undergoing complex surgeries (eg, pulmonary endarterectomy, LVAD implantation, or transplantation) are particularly vulnerable. Catheter-based techniques, such as pulmonary artery catheterization (PAC), provide continuous, functional data and may be valuable in intensive care or when echocardiography is limited. Despite concerns over complications, PACs can help assess hemodynamics, cardiac output, and RV performance, aiding early detection of RV failure in select high-risk patients.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Belgium
| | | | - Jakob Labus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne; Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Patrick Wouters
- Department Basic and Applied Medical Sciences, Ghent University Hospital, Belgium
| | - Eckhard Mauermann
- Department of Anesthesia, Zurich City Hospital, Birmensdorferstrasse, Switzerland; University of Basel, School of Medicine.
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Tempe DK. The Conundrum of Perioperative Management of Patients with Diastolic Dysfunction Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2025; 39:1098-1102. [PMID: 40044477 DOI: 10.1053/j.jvca.2025.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Revised: 02/14/2025] [Accepted: 02/19/2025] [Indexed: 04/14/2025]
Affiliation(s)
- Deepak K Tempe
- Officiating Vice Chancellor, Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
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Assanangkornchai N, Villeneuve V, McDonald S, Tim DS, Magder S, Mettasittigorn P, Hatzakorzian R. Reduction in Postoperative Right Ventricular Echocardiographic Indices Predicts Longer Duration of Vasoactive Support After Cardiac Surgery. J Cardiothorac Vasc Anesth 2025; 39:143-150. [PMID: 39567298 DOI: 10.1053/j.jvca.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/29/2024] [Accepted: 02/23/2024] [Indexed: 11/22/2024]
Abstract
OBJECTIVES To assess perioperative right ventricular (RV) echocardiographic indices and their relationship to vasopressor and inotropic support in cardiac surgical patients. The authors hypothesized that a reduction in echocardiographic parameters of RV function would be associated with a longer duration of vasopressor and inotropic support in the intensive care unit (ICU). DESIGN A prospective observational study. SETTING A quaternary care hospital affiliated with McGill University, Canada. PARTICIPANTS Adult patients undergoing elective cardiac surgery. INTERVENTIONS Transesophageal echocardiography and hemodynamics measurements with a pulmonary artery catheter were performed after induction of anesthesia (pre-cardiopulmonary bypass [CPB]) and at post-CPB. MEASUREMENTS AND MAIN RESULTS Echocardiographic measurements included anatomic M-mode tricuspid annular plane systolic excursion, fractional area change (FAC), tricuspid annulus peak systolic velocity (TAPSE), and myocardial performance index. The primary outcome was the duration of vasopressor and inotropic support in the ICU. Of the 122 patients who were enrolled in the study, 83 underwent coronary artery bypass graft surgery. At the end of the procedure, 94.3% of patients were supported with a vasopressor or inotrope. A reduction in post-CPB TAPSE was found in 88.2% (105) of patients, and 56.8% (63) of patients had a reduction in FAC. Patients with a post-CPB TAPSE below 17 mm and a post-CPB FAC below 35% required a longer duration of inotropic support in the ICU. CONCLUSION Patients with post-CPB TAPSE <17 mmHg require a longer duration of inotropic support in the ICU. From all measured RV echocardiographic indices, post-CPB FAC is an independent predictor of vasopressor and inotropic support. A reduction of post-CPB TAPSE and FAC in patients undergoing cardiac surgery is indicative of RV dysfunction requiring a longer use of vasopressor and inotropic support and potentially longer stay in the cardiovascular ICU.
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Affiliation(s)
- Nawaporn Assanangkornchai
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand; Department of Critical Care Medicine, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Valerie Villeneuve
- Department of Anesthesia, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Sarah McDonald
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network - Toronto General Hospital, Toronto, Ontario, Canada
| | - Dominique Shum Tim
- Department of Cardiac Surgery, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Sheldon Magder
- Department of Critical Care Medicine, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Pattra Mettasittigorn
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network - Toronto General Hospital, Toronto, Ontario, Canada; Department of Anesthesiology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Roupen Hatzakorzian
- Department of Critical Care Medicine, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada; Department of Anesthesia, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada.
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Ftikos P, Gkantinas G, Karageorgos V, Smirli A, Kogerakis N, Leontiadis E, Petsios K, Antoniou T, Theodoraki K. Intravenous Levosimendan versus Inhalational Milrinone in the Management of Pulmonary Hypertension during Adult Cardiac Surgery: A Randomized Clinical Trial. Life (Basel) 2024; 14:1164. [PMID: 39337947 PMCID: PMC11433114 DOI: 10.3390/life14091164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 09/11/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
Introduction: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery is challenging, mainly due to the potential risk of right ventricular failure (RVF). Levosimendan is a calcium-sensitizing agent that has primarily been used in the treatment of decompensated heart failure. However, recently levosimendan has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension and PH associated with left heart disease. The aim of this study was to investigate the potential utility of the preemptive administration of levosimendan in cardiac surgical patients with preexisting PH and to compare its effectiveness with milrinone, which represents an already established therapeutic option in the management of PH during cardiac surgery. Materials and Methods: In this study, 40 adult cardiac surgical patients with PH were randomly assigned to receive either levosimendan intravenously or milrinone via inhalation in a double-blind fashion prior to a cardiopulmonary bypass (CPB). Hemodynamic and echocardiographic parameters were recorded and evaluated before and after the administration of the drugs. Results and Conclusions: The results of this study demonstrated that both levosimendan and milrinone administered before CPB in cardiac surgical patients with PH may offer protective benefits, reducing pulmonary artery pressure and preventing the exacerbation of PH and RVF. Pulmonary vasodilation attributed to levosimendan is of longer duration and greater magnitude compared to pulmonary vasodilation afforded by milrinone.
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Affiliation(s)
- Panagiotis Ftikos
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (P.F.); (G.G.); (V.K.); (A.S.); (T.A.)
| | - Georgios Gkantinas
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (P.F.); (G.G.); (V.K.); (A.S.); (T.A.)
| | - Vlasios Karageorgos
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (P.F.); (G.G.); (V.K.); (A.S.); (T.A.)
| | - Anna Smirli
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (P.F.); (G.G.); (V.K.); (A.S.); (T.A.)
| | - Nektarios Kogerakis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Evangelos Leontiadis
- Department of Cardiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Konstantinos Petsios
- Faculty of Nursing, National and Kapodistrian University of Athens, 115 28 Athens, Greece;
| | - Theofani Antoniou
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (P.F.); (G.G.); (V.K.); (A.S.); (T.A.)
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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Beshara M, Bagchi A. Dynamic Right Ventricular Outflow Tract Obstruction: An Often-Overlooked Cause of Hemodynamic Instability After Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:2035-2040. [PMID: 38897889 DOI: 10.1053/j.jvca.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/24/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Michael Beshara
- University of Kansas Medical Center, Department of Anesthesiology, Kansas City, KS
| | - Aranya Bagchi
- Massachusetts General Hospital, Harvard Medical School, Department of Anesthesiology, Boston, MA.
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Akamkam A, Galand V, Jungling M, Delmas C, Dambrin C, Pernot M, Kindo M, Gaudard P, Rouviere P, Senage T, Chavanon O, Para M, Gariboldi V, Pozzi M, Litzler P, Babatasi G, Bouchot O, Radu C, Bourguignon T, D'Ostrevy N, Abi Akar R, Vanhuyse F, Gaillard M, Chatelier G, Fels A, Flecher E, Guihaire J. Association between pulmonary artery pulsatility and mortality after implantation of left ventricular assist device. ESC Heart Fail 2024; 11:2100-2112. [PMID: 38581135 PMCID: PMC11287349 DOI: 10.1002/ehf2.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024] Open
Abstract
AIMS Right ventricular failure after left ventricular assist device (LVAD) implantation is a major concern that remains challenging to predict. We sought to investigate the relationship between preoperative pulmonary artery pulsatility index (PAPi) and mortality after LVAD implantation. METHODS AND RESULTS A retrospective analysis of the ASSIST-ICD multicentre registry allowed the assessment of PAPi before LVAD according to the formula [(systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/central venous pressure]. The primary endpoint was survival at 3 months, according to the threshold value of PAPi determined by the receiver operating characteristic (ROC) curve. A multivariate analysis including demographic, echographic, haemodynamic, and biological variables was performed to identify predictive factors for 2 year mortality. One hundred seventeen patients were included from 2007 to 2021. The mean age was 58.45 years (±13.16), with 15.4% of women (sex ratio 5.5). A total of 53.4% were implanted as bridge to transplant and 43.1% as destination therapy. Post-operative right ventricular failure was observed in 57 patients (48.7%), with no significant difference between survivors and non-survivors at 1 month (odds ratio 1.59, P = 0.30). The median PAPi for the whole study population was 2.83 [interquartile range 1.63-4.69]. The threshold value of PAPi determined by the ROC curve was 2.84. Patients with PAPi ≥ 2.84 had a higher survival rate at 3 months [PAPi < 2.84: 58.1% [46.3-72.8%] vs. PAPi ≥ 2.84: 89.1% [81.1-97.7%], hazard ratio (HR) 0.08 [0.02-0.28], P < 0.01], with no significant difference after 3 months (HR 0.67 [0.17-2.67], P = 0.57). Other predictors of 2 year mortality were systemic hypertension (HR 4.22 [1.49-11.97], P < 0.01) and diabetes mellitus (HR 4.90 [1.83-13.14], P < 0.01). LVAD implantation as bridge to transplant (HR 0.18 [0.04-0.74], P = 0.02) and heart transplantation (HR 0.02 [0.00-0.18], P < 0.01) were associated with a higher survival rate at 2 years. CONCLUSIONS Preoperative PAPi < 2.84 was associated with a higher risk of early mortality after LVAD implantation without impacting 2 year outcomes among survivors.
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Affiliation(s)
- Ali Akamkam
- Department of Cardiovascular SurgeryMarie Lannelongue Hospital, Groupe Hospitalier Paris Saint JosephLe Plessis‐RobinsonFrance
| | - Vincent Galand
- Department of CardiologyUniversity of Rennes, CHU RennesRennesFrance
| | - Marie Jungling
- Department of Cardiac SurgeryLille University Hospital, Heart‐Lung InstituteLilleFrance
| | - Clément Delmas
- Department of CardiologyUniversity Hospital of ToulouseToulouseFrance
| | - Camille Dambrin
- Department of Cardiovascular SurgeryUniversity Hospital of ToulouseToulouseFrance
| | - Mathieu Pernot
- Haut‐Lévêque Cardiological HospitalBordeaux II UniversityBordeauxFrance
| | - Michel Kindo
- Department of Cardiovascular SurgeryUniversity Hospitals of StrasbourgStrasbourgFrance
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, PhyMedExpUniversity of Montpellier, INSERM, CNRS, CHU MontpellierMontpellierFrance
| | - Philippe Rouviere
- Department of Cardiac SurgeryUniversity of Montpellier, CHU MontpellierMontpellierFrance
| | - Thomas Senage
- Department of Cardiology and Heart Transplantation UnitCHU NantesNantesFrance
| | - Olivier Chavanon
- Department of Cardiology and Cardiovascular SurgeryCHU MichallonGrenobleFrance
| | - Marylou Para
- Department of Cardiology and Cardiac SurgeryBichat‐Claude Bernard HospitalParisFrance
| | - Vlad Gariboldi
- Department of Cardiac SurgeryLa Timone HospitalMarseilleFrance
| | - Matteo Pozzi
- Department of Cardiac Surgery‘Louis Pradel’ Cardiologic HospitalLyonFrance
| | - Pierre‐Yves Litzler
- Department of Cardiology and Cardiovascular SurgeryHospital Charles NicolleRouenFrance
| | - Gerard Babatasi
- Department of Cardiology and Cardiac SurgeryUniversity of Caen and University Hospital of CaenCaenFrance
| | - Olivier Bouchot
- Department of Cardiology and Cardiac SurgeryUniversity Hospital François MitterrandDijonFrance
| | - Costin Radu
- Department of Cardiology and Cardiac SurgeryAP‐HP CHU Henri MondorCréteilFrance
| | | | - Nicolas D'Ostrevy
- Department of Cardiac Surgery and CardiologyCHU Clermont‐FerrandClermont‐FerrandFrance
| | - Ramzi Abi Akar
- Department of Cardiovascular SurgeryEuropean Georges Pompidou HospitalParisFrance
| | - Fabrice Vanhuyse
- Department of Cardiology and Cardiac SurgeryCHU de Nancy, Hôpitaux de BraboisNancyFrance
| | - Maïra Gaillard
- Department of Cardiovascular SurgeryMarie Lannelongue Hospital, Groupe Hospitalier Paris Saint JosephLe Plessis‐RobinsonFrance
| | - Gilles Chatelier
- Department of Clinical ResearchHôpital Paris Saint‐Joseph, Groupe Hospitalier Paris Saint JosephParisFrance
| | - Audrey Fels
- Department of Clinical ResearchHôpital Paris Saint‐Joseph, Groupe Hospitalier Paris Saint JosephParisFrance
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular SurgeryUniversity of Rennes, CHU RennesRennesFrance
| | - Julien Guihaire
- Department of Cardiovascular SurgeryMarie Lannelongue Hospital, Groupe Hospitalier Paris Saint JosephLe Plessis‐RobinsonFrance
- School of MedicineUniversity of Paris SaclayLe Kremlin‐BicêtreFrance
- Inserm U999, Marie Lannelongue HospitalLe Plessis‐RobinsonFrance
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Munaf M, Suneel PR, Harikrishnan S, Sasikumar D, Koshy T. Tricuspid Annular Plane Systolic Excursion (TAPSE) for the Assessment of Right Ventricular Function in Adult and Pediatric Cardiac Surgery: Modified Two-dimensional and M-mode TAPSE by Transesophageal Echocardiography Compared to M-mode TAPSE by Transthoracic Echocardiography. J Cardiothorac Vasc Anesth 2024; 38:123-132. [PMID: 37845143 DOI: 10.1053/j.jvca.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVES To compare transesophageal echocardiography-guided 2-dimensional and M-mode tricuspid annular plane systolic excursion (TAPSE) to transthoracic echocardiography (TTE)-guided M-mode TAPSE in terms of accuracy, interobserver, and intra-observer variability. DESIGN A prospective, observational study. SETTING Adult and pediatric operating rooms. PARTICIPANTS Adult and pediatric patients (42 each) undergoing cardiac surgeries. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Modified midesophageal (Mod-ME), deep transgastric, and transgastric TAPSEs were analyzed for reliability and were compared to TTE TAPSE in both adult and pediatric groups. Modified ME TAPSE showed good method agreement with TTE TAPSE (bias = -0.97, p = 0.08 (adult); bias = 0.17, p = 0.71 [pediatric]), and showed a moderate correlation with right ventricular (RV) fractional area change (FAC) (r = 0.41, p = 0.006, [adult]; r = 0.57, p < 0.001, [pediatric]), with acceptable interobserver variability (percentage error =10.56 [adult]; 4.42 [pediatric]) and intraobserver variability (percentage error = 13.1 [adults]; 12.24 [pediatric]). Transgastric TAPSE poorly agreed with TTE TAPSE and had higher interobserver and intraobserver variability. Deep transgastric TAPSE had good method agreement with TTE TAPSE and had acceptable interobserver and intra-observer variability. CONCLUSIONS Modified ME TAPSE is a reliable and reproducible measure of RV function before pericardiotomy in both adult and pediatric cardiac surgery. Right ventricular FAC values reflected the RV systolic function better than TAPSE after pericardiotomy. Deep transgastric TAPSE is reliable and reproducible but is less accurate than Mod-ME TAPSE.
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Affiliation(s)
- Mamatha Munaf
- Division of Cardiothoracic Vascular Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Puthuvassery Raman Suneel
- Division of Cardiothoracic Vascular Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sivadasanpillai Harikrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Deepa Sasikumar
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Thomas Koshy
- Division of Cardiothoracic Vascular Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
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O Ibekwe S, Deschamps J, Grocott MPW, Liang Y, Shaw A, E Perry T, POQI IX Collaborators. Perioperative Quality Initiative (POQI) consensus statement on perioperative assessment of right ventricular function. Perioper Med (Lond) 2023; 12:66. [PMID: 38066632 PMCID: PMC10709971 DOI: 10.1186/s13741-023-00351-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/12/2023] [Indexed: 05/30/2025] Open
Abstract
BACKGROUND The right ventricle (RV) plays a central role in the maintenance of effective cardiac pump function. Despite overwhelming evidence that perioperative RV dysfunction (RVD) and failure (RVF) are associated with poor clinical outcomes, there are very few published recommendations or guidelines for comprehensive, evidence-based RV assessment on the risk of developing either during the perioperative period. MAIN TEXT To address this gap, the Perioperative Quality Initiative-IX (POQI-IX) investigators group, comprised of clinical experts in anesthesiology, cardiovascular surgery, internal medicine, critical care medicine, and advanced practice nursing, has developed a consensus statement based on current literature, published society recommendations, and the clinical expertise of the group. Herein, the group provides recommendations and evidence-based tools related to perioperative RV assessment, functional screening, staging, and the clinical implications of each. These assessment tools are based on comprehensive patient evaluation consisting of physical examination, biomarker data, imaging, and hemodynamic assessment. CONCLUSION This review presents a comprehensive tool for assessing perioperative RV function. We hope that this simple, intuitive tool can be applied to all phases of perioperative care and thereby improve patient outcomes.
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Affiliation(s)
- Stephanie O Ibekwe
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA.
| | - Jean Deschamps
- Integrated Hospital Care Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, UK
| | - Yafen Liang
- Department of Anesthesiology, Critical Care, and Pain Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Andrew Shaw
- Integrated Hospital Care Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Tjorvi E Perry
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
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Mattei A, Strumia A, Benedetto M, Nenna A, Schiavoni L, Barbato R, Mastroianni C, Giacinto O, Lusini M, Chello M, Carassiti M. Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:7152. [PMID: 38002763 PMCID: PMC10672350 DOI: 10.3390/jcm12227152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.
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Affiliation(s)
- Alessia Mattei
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Alessandro Strumia
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intesive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40123 Bologna, Italy;
| | - Antonio Nenna
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Lorenzo Schiavoni
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Raffaele Barbato
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimiliano Carassiti
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
- Anesthesia and Intensive Care Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
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10
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Ftikos P, Falara A, Rellia P, Leontiadis E, Samanidis G, Kamperi N, Piperakis A, Tamvakopoulos C, Antoniou T, Theodoraki K. Monitoring of Levosimendan Administration in Patients with Pulmonary Hypertension Undergoing Cardiac Surgery and Effect of Two Different Dosing Schemes on Hemodynamic and Echocardiographic Parameters. Pharmaceuticals (Basel) 2023; 16:815. [PMID: 37375762 DOI: 10.3390/ph16060815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery represents one of the most challenging clinical scenarios. This fact mainly depends on the relationship existing between PH and right ventricular failure (RVF). Levosimendan (LS) is an inodilator that might be an effective agent in the treatment of PH and RVF. The aim of this study was to examine the impact of the duration of cardiopulmonary bypass (CPB) on the therapeutic drug monitoring of LS and to evaluate the effect of preemptive administration of LS on perioperative hemodynamic and echocardiographic parameters in cardiac surgical patients with preexisting PH. MATERIALS AND METHODS In this study, LS was administered in adult patients undergoing cardiac surgery before CPB in order to prevent exacerbation of preexisting PH and subsequent right ventricular dysfunction. Thirty cardiac surgical patients with preoperatively confirmed PH were randomized to receive either 6 μg/kg or 12 μg/kg of LS after the induction of anesthesia. The plasma concentration of LS was measured after CPB. In this study, a low sample volume was used combined with a simple sample preparation protocol. The plasma sample was extracted by protein precipitation and evaporated; then, the analyte was reconstituted and detected using specific and sensitive bioanalytical liquid chromatography with mass spectrometry (LC-MS/MS) methodology. The clinical, hemodynamic, and echocardiographic parameters were registered and evaluated before and after the administration of the drug. RESULTS A fast bioanalytical LC-MS/MS methodology (a run time of 5.5 min) was developed for the simultaneous determination of LS and OR-1896, its main metabolite in human plasma. The LC-MS/MS method was linear over a range of 0.1-50 ng/mL for LS and 1-50 ng/mL for its metabolite OR-1896. Measured plasma concentrations of LS were inversely related to the duration of CPB. LS administration before CPB during cardiac surgery was effective in reducing pulmonary artery pressure and improving hemodynamic parameters after CPB, with a more pronounced and durable effect of the drug at the dose of 12 μg/kg. Additionally, administration of LS at a dose of 12 μg/kg in cardiac surgical patients with PH before CPB improved right ventricular function. CONCLUSION LS administration decreases pulmonary artery pressure and may improve right ventricular function in patients with PH undergoing cardiac surgery.
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Affiliation(s)
- Panagiotis Ftikos
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Areti Falara
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Panagiota Rellia
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | | | - George Samanidis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Natalia Kamperi
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Artemios Piperakis
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Constantin Tamvakopoulos
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Theofani Antoniou
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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11
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Interchangeability of transthoracic and transesophageal echocardiographic right heart measurements in the perioperative setting and correlation with hemodynamic parameters. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:555-563. [PMID: 36399180 DOI: 10.1007/s10554-022-02754-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/30/2022] [Indexed: 11/21/2022]
Abstract
Reduction of right ventricular (RV) function after cardiac surgery has been shown to impact outcomes. Conventional indices for right ventricular dysfunction are validated using transthoracic echocardiogram (TTE) which has limited use compared to transesophageal echocardiogram (TEE) in the perioperative settings. The aim of this study was to assess the agreement of RV systolic function assessment with TEE compared to TTE and assess the association of echocardiographic parameter with hemodynamic indices of RV dysfunction. This was a single center prospective observational study in an academic institution. Fifty adult patients undergoing elective cardiac surgery were included. TTE, TEE and stroke volume measurements pre-cardiopulmonary bypass (CPB) and post-CPB were performed. The variables of interest were anatomical M-mode tricuspid annular plane systolic excursion (AMM-TAPSE), fractional area change (FAC), tricuspid annular velocity (S') and myocardial performance index (MPI). FAC and AMM-TAPSE measured at the mid-esophageal 4 chamber view had substantial agreement with the TTE acquired parameters (Lin's concordance correlation coefficient (CCC) = 0.76, 95%CI 0.59-0.86 and CCC = 0.85, 95%CI 0.76-0.91). S' was significantly underestimated by TEE (CCC = 0.07, 95%CI 0.04-0.19) and MPI showed moderate agreement (CCC = 0.45 95%CI 0.19-0.65). Despite the significant changes in echocardiographic parameters, there were no corresponding changes in stroke volume (SV) or pulmonary artery pulsatility index at the post-CPB period. TEE acquired FAC and AMM-TAPSE had substantial agreement with pre-operative TTE values and no significant differences between the pre-CPB and post-CPB period. Systolic RV echocardiographic parameters decreased post-CPB but this was not accompanied by significant hemodynamic changes.
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12
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Behavior of echocardiographic parameters of right ventricular function after tricuspid surgery. Sci Rep 2022; 12:19447. [PMID: 36376476 PMCID: PMC9663697 DOI: 10.1038/s41598-022-24048-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Evaluation of right ventricular (RV) function after tricuspid valve surgery is complex. The objective was to identify the most appropriate RV function parameters for this purpose. This prospective study included 70 patients undergoing cardiac and tricuspid valve (TV) surgery. RV size and function parameters were determined at 3 months and 1-year post-surgery. Categorical variables were analyzed with the McNemar test and numerical variables with the Student's t-test for related samples or, when non-normally distributed, the Wilcoxon test. Spearman's rho was used to determine correlations between variables at 3 months and 1 year. RV diameters were reduced at 3 months post-surgery and were then unchanged at 1 year. Tricuspid annular plane systolic excursion (TAPSE) and S' wave values were worse at 3 months and then improved at 1 year (t-score-2.35, p 0.023; t-score-2.68; p 0.010). There was no significant reduction in free wall longitudinal strain (LS) or shortening fraction (SF) at 3 months (t-score 1.421 and - 1.251; p 0.218 and 0.172), and they were only slightly below pre-surgical values at 1 year. No relationship was found between RV function parameters and mortality or major complications. During the first few months after TV surgery, LS may be a more appropriate parameter to evaluate global ventricular function in comparison to TAPSE. At 1 year, good correlations are observed between TAPSE, S' wave, and LS values.
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13
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Jabagi H, Nantsios A, Ruel M, Mielniczuk LM, Denault AY, Sun LY. A standardized definition for right ventricular failure in cardiac surgery patients. ESC Heart Fail 2022; 9:1542-1552. [PMID: 35266332 PMCID: PMC9065859 DOI: 10.1002/ehf2.13870] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/28/2022] [Accepted: 02/17/2022] [Indexed: 11/07/2022] Open
Abstract
Right ventricular failure (RVF) is a significant cause of mortality and morbidity after cardiac surgery. Despite its prognostic importance, RVF remains under investigated and without a universally accepted definition in the perioperative setting. We foresee that the provision of a standardized perioperative definition for RVF based on practical and objective criteria will help to improve quality of care through early detection and facilitate the generalization of RVF research to advance this field. This article provides an overview of RVF aetiology, pathophysiology, current diagnostic modalities, as well as a summary of existing RVF definitions. This is followed by our proposal for a standardized definition of perioperative RVF, one that captures RV structural and functional abnormalities through a multimodal approach based on anatomical, echocardiographic, and haemodynamic criteria that are readily available in the perioperative setting (Central Image).
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Affiliation(s)
- Habib Jabagi
- Division of Cardiac Surgery, Valley Health System, Ridgewood, NJ, USA
| | - Alex Nantsios
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - André Y Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute and Université de Montréal, Montreal, QC, Canada
| | - Louise Y Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Room H-2206, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
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14
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Varma PK, Jose RL, Krishna N, Srimurugan B, Valooran GJ, Jayant A. Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 1-anatomy, pathophysiology, and diagnosis). Indian J Thorac Cardiovasc Surg 2022; 38:45-57. [PMID: 34898875 PMCID: PMC8630124 DOI: 10.1007/s12055-021-01240-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023] Open
Abstract
Right ventricle (RV) dysfunction and failure are now increasingly recognized as an important cause of perioperative morbidity and mortality after cardiac surgery. Although RV dysfunction is common, RV failure is very rare (0.1%) after routine cardiac surgery. However, it occurs in 3% of patients after heart transplantation and in up to 30% of patients after left ventricular assist device implantation. Significant RV failure after cardiac surgery has high mortality. Knowledge of RV anatomy and physiology are important for understanding RV dysfunction and failure. Echocardiography and haemodynamic monitoring are the mainstays in the diagnosis of RV dysfunction and failure. While detailed echocardiography assessment of right heart function has been extensively studied and validated in the elective setting, gross estimation of RV chamber size, function, and some easily obtained quantitative parameters on transesophageal echocardiography are useful in the perioperative setting. However, detailed knowledge of echocardiography parameters is still useful in understanding the differences in contractile pattern, ventriculo-arterial coupling, and interventricular dependence that ensue after open cardiac surgery. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s12055-021-01240-y.
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Affiliation(s)
- Praveen Kerala Varma
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Reshmi Liza Jose
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Balaji Srimurugan
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | | | - Aveek Jayant
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
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15
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Calderone A, Hammoud A, Jarry S, Denault A, Couture EJ. Femoral Vein Pulsatility: What Does It Mean? J Cardiothorac Vasc Anesth 2021; 35:2521-2527. [PMID: 33985881 DOI: 10.1053/j.jvca.2021.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.
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Affiliation(s)
- Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ali Hammoud
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Faculty of Nursing Graduate Studies, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery and Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Etienne J Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Canada
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17
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Bianco JC, Stang MV, Denault AY, Marenchino RG, Belziti CA, Musso CG. Acute Kidney Injury After Heart Transplant: The Importance of Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2020; 35:2052-2062. [PMID: 33414071 DOI: 10.1053/j.jvca.2020.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether relative pulmonary hypertension (PH), defined as the ratio of mean arterial pressure to mean pulmonary artery pressure, is associated with severe acute kidney injury (AKI) after heart transplant (HT). DESIGN An institutional review board-approved retrospective observational study. SETTING Tertiary care university hospital. PARTICIPANTS A total of 184 consecutive adult patients who underwent HT between January 2009 and December 2017 were included, and were followed up through December 2019. Using the Kidney Disease: Improving Global Outcomes classification, recipients were categorized into two groups: patients who developed stage 3 AKI (severe AKI) and those with minor or without AKI (nonsevere AKI) within seven days after transplant. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the included patients, 83.2% developed AKI, in whom 40.8%, 19.6%, and 22.8% were stage 1, 2, and 3, respectively. With use of the multivariate logistic regression analysis, independent risk factors for stage 3 AKI post-HT included preoperative relative PH (odds ratio [OR]: 1.62, 95% confidence interval [95% CI]: 1.05-2.49, p = 0.028), central venous-to-pulmonary capillary wedge pressure ratio ≥0.86 (OR: 3.59, 95% CI: 1.13-11.43, p = 0.030), and postoperative right ventricular dysfunction (OR: 3.63, 95% CI: 1.50-8.75, p = 0.004). Conversely, preoperative estimated glomerular filtration rate (OR: 0.99, 95% CI: 0.97-1.00, p = 0.143) was not related to the development of stage 3 AKI post-HT. CONCLUSIONS Preoperative relative PH, central venous-to-pulmonary capillary wedge pressure ratio, and postoperative right ventricular failure by echocardiographic assessment were associated with severe AKI post-HT.
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Affiliation(s)
- Juan C Bianco
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - María V Stang
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - André Y Denault
- Department of Anesthesiology and Intensive Care Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Ricardo G Marenchino
- Department of Cardiovascular Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - César A Belziti
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos G Musso
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Facultad de Ciencias de la Salud. Universidad Simón Bolivar, Barranquilla, Colombia
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Zhang H, Chen X, Lian H, Zhang Q, Wang X, Zheng M, Liu D. Prognostic Value of Tricuspid Annular Plane Systolic Excursion and Right Ventricular Outflow Tract Fractional Shortening in Mechanically Ventilated Septic Patients. J Cardiothorac Vasc Anesth 2020; 35:S1053-0770(20)31059-4. [PMID: 34756352 DOI: 10.1053/j.jvca.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to explore whether tricuspid annular plane systolic excursion (TAPSE) and right ventricular outflow fractional shortening (RVOT-FS) were associated with long-term prognosis in mechanically ventilated septic patients. DESIGN A prospective observational study. SETTING A tertiary hospital intensive care unit (ICU). PARTICIPANTS One hundred eighty-one septic patients who were on mechanical ventilation. INTERVENTIONS Echocardiography was performed within 24 hours of ICU admission. MEASUREMENTS AND MAIN RESULTS Several echocardiographic parameters, including TAPSE and RVOT-FS, as well as prognostic information, were collected. A Cox regression survival analysis showed that TAPSE was independently associated with one-year all-cause mortality (hazard ratio [HR] 0.407, 95% confidence interval [CI]: 0.200-0.827, p = 0.013), but ROVT-FS was not (HR 0.997, 95% CI: 0.970-1.025, p = 0.828). ROC analysis showed that the optimal cutoff value for TAPSE and RVOT-FS to determine one-year mortality was TAPSE <18 mm and RVOT-FS <40%. The one-year mortality in patients with low TAPSE (n = 88) and in patients with both low TAPSE and low RVOT-FS (n = 60) was 45.5% and 48.3%, respectively; p = 0.724. In a multivariate analysis, RVOT-FS did not add significant prognostic information to that provided by TAPSE <18 mm (p = 0.197). CONCLUSIONS TAPSE was an independent predictor of one-year all-cause mortality in mechanically ventilated septic patients. RVOT-FS was not associated with one-year mortality and added no prognostic value to TAPSE in these patients.
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Affiliation(s)
- Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiukai Chen
- Pittsburgh Heart, Lung, Blood, and Vascular Institute, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Min Zheng
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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Mondal S, Sankova S, Lee K, Sorensen E, Kaczorowski D, Mazzeffi M. Intraoperative and Early Postoperative Management of Patients Undergoing Minimally Invasive Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2020; 35:616-630. [PMID: 32505605 DOI: 10.1053/j.jvca.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Susan Sankova
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Erik Sorensen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - David Kaczorowski
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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Guihaire J, Haddad F, Hoppenfeld M, Amsallem M, Christle JW, Owyang C, Shaikh K, Hsu JL. Physiology of the Assisted Circulation in Cardiogenic Shock: A State-of-the-Art Perspective. Can J Cardiol 2020; 36:170-183. [PMID: 32036862 PMCID: PMC7121859 DOI: 10.1016/j.cjca.2019.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 01/18/2023] Open
Abstract
Mechanical circulatory support (MCS) has made rapid progress over the last 3 decades. This was driven by the need to develop acute and chronic circulatory support as well as by the limited organ availability for heart transplantation. The growth of MCS was also driven by the use of extracorporeal membrane oxygenation (ECMO) after the worldwide H1N1 influenza outbreak of 2009. The majority of mechanical pumps (ECMO and left ventricular assist devices) are currently based on continuous flow pump design. It is interesting to note that in the current era, we have reverted from the mammalian pulsatile heart back to the continuous flow pumps seen in our simple multicellular ancestors. This review will highlight key physiological concepts of the assisted circulation from its effects on cardiac dynamic to principles of cardiopulmonary fitness. We will also examine the physiological principles of the ECMO-assisted circulation, anticoagulation, and the haemocompatibility challenges that arise when the blood is exposed to a foreign mechanical circuit. Finally, we conclude with a perspective on smart design for future development of devices used for MCS.
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Affiliation(s)
- Julien Guihaire
- Department of Cardiac Surgery, Research and Innovation Unit, RHU BioArt Lung 2020, Marie Lannelongue Hospital, Paris-Sud University, Le Plessis-Robinson, France.
| | - Francois Haddad
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Mita Hoppenfeld
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Myriam Amsallem
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Clark Owyang
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Khizer Shaikh
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joe L Hsu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
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22
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Grønlykke L, Couture EJ, Haddad F, Amsallem M, Ravn HB, Raymond M, Beaubien-Souligny W, Demers P, Rochon A, Sarabi ME, Lamarche Y, Desjardins G, Denault AY. Preliminary Experience Using Diastolic Right Ventricular Pressure Gradient Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2116-2125. [PMID: 32037274 DOI: 10.1053/j.jvca.2019.12.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/31/2019] [Accepted: 12/31/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Right ventricular (RV) dysfunction in cardiac surgery is associated with increased mortality and morbidity and difficult separation from cardiopulmonary bypass (DSB). The primary objective of the present study was to describe the prevalence and characteristics of patients with abnormal RV diastolic pressure gradient (PG). The secondary objective was to explore the association among abnormal diastolic PG and DSB, postoperative complications, high central venous pressure (CVP), and high RV end-diastolic pressure (RVEDP). DESIGN Retrospective and prospective validation study. SETTING Tertiary care cardiac institute. PARTICIPANTS Cardiac surgical patients (n=374) from a retrospective analysis (n=259) and a prospective validation group (n=115). INTERVENTION RV pressure waveforms were obtained using a pulmonary artery catheter with a pacing port opened at 19 cm distal to the tip of the catheter. Abnormal RV diastolic PG was defined as >4 mmHg. Both elevated RVEDP and high CVP were defined as >16 mmHg. MEASUREMENTS AND MAIN RESULTS From the retrospective and validation cohorts, 42.5% and 48% of the patients had abnormal RV diastolic PG before cardiac surgery, respectively. Abnormal RV diastolic PG before cardiac surgery was associated with higher EuroSCORE II (odds ratio 2.29 [1.10-4.80] v 1.62 [1.10-3.04]; p = 0.041), abnormal hepatic venous flow (45% v 29%; p = 0.038), higher body mass index (28.9 [25.5-32.5] v 27.0 [24.9-30.5]; p = 0.022), pulmonary hypertension (48% v 37%; p = 0.005), and more frequent DSB (32% v 19%; p = 0.023). However, RV diastolic PG was not an independent predictor of DSB, whereas RVEDP (odds ratio 1.67 [1.09-2.55]; p = 0.018) was independently associated with DSB. In addition, RV pressure monitoring indices were superior to CVP in predicting DSB. CONCLUSION Abnormal RV diastolic PG is common before cardiac surgery and is associated with a higher proportion of known preoperative risk factors. However, an abnormal RV diastolic PG gradient is not an independent predictor of DSB in contrast to RVEDP.
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Affiliation(s)
- Lars Grønlykke
- Department of Cardiothoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Etienne J Couture
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Francois Haddad
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA
| | - Myriam Amsallem
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Meggie Raymond
- Department of Cardiothoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - William Beaubien-Souligny
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Philippe Demers
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Mahsa Elmi Sarabi
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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23
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Sargsyan LA, Faiz SA. Pulmonary Hypertension in an Oncologic Intensive Care Unit. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7123640 DOI: 10.1007/978-3-319-74588-6_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Pulmonary hypertension (PH) is the condition of elevated pressures in the pulmonary circulation. PH can develop acutely in patients with critical illness such as acute respiratory distress syndrome, sepsis, massive pulmonary embolism, left ventricular dysfunction, or after surgery. In a cancer patient, unique etiologies such as myeloproliferative disorders, tyrosine kinase inhibitors, or tumor emboli may result in PH. Early recognition and treatment of the causative condition may reverse acute PH or return chronic PH to its baseline status. Progression of the disease or its decompensation due to infection, a thromboembolic event, or other triggers can lead to admission to an intensive care unit. Regardless of etiology, the development or worsening of PH may precipitate hypoxemia, hemodynamic instability, or right ventricular failure, which can be challenging to manage or even fatal. In select cases, rapid institution of advanced treatment modalities may be warranted. This chapter reviews the etiology, epidemiology, pathophysiology, clinical features, diagnosis, and prognosis of PH and presents a comprehensive analysis of PH and right heart failure management strategies in the critical care setting. In particular, a unique perspective on oncologically relevant PH is provided.
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24
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Vandenheuvel M, Bouchez S, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2019; 37:697-712. [PMID: 31677686 DOI: 10.1016/j.anclin.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium; Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Spitalstrasse 21, Basel 4031, Switzerland.
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25
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Perioperative hemodynamic monitoring: Still a place for cardiac filling pressures? Best Pract Res Clin Anaesthesiol 2019; 33:155-163. [PMID: 31582095 DOI: 10.1016/j.bpa.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 11/21/2022]
Abstract
The clinical usefulness of the so-called "static" cardiac filling pressures - central (CVP) and pulmonary-artery-occlusion-pressure (PAOP) - has come into question for guiding hemodynamic therapy due to their poor ability to predict fluid responsiveness in comparison with other monitoring modalities such as transpulmonary thermodilution-derived volumetric measurements, dynamic variables for assessing fluid responsiveness, and the potential risks associated with pulmonary artery catheterization. This contrasts with observations in multiple patient populations showing a clear association between increased CVP and PAOP levels and poor outcomes, probably due to a reduction in effective perfusion pressure (mean arterial pressure minus CVP) and their role as effectiveness parameters of the cardiovascular system. Furthermore, clinical studies have revealed beneficial effects when interpreting CVP and PAOP dynamically and combining them with flow-related hemodynamic variables. Taking into account the additional information derived from bedside CVP and PAOP pulse curve interpretation, cardiac filling pressures remain an important hemodynamic monitoring tool.
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26
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Jabagi H, Ruel M, Sun LY. Can Biomarkers Provide Right Ventricular-Specific Prognostication in the Perioperative Setting? J Card Fail 2019; 26:776-780. [PMID: 31539620 DOI: 10.1016/j.cardfail.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 09/05/2019] [Accepted: 09/07/2019] [Indexed: 01/11/2023]
Abstract
Since the introduction of biomarkers in the late 1980s, considerable research has been dedicated to their validation and application. As a result, many biomarkers are now commonly used in clinical practice. However, the role of biomarkers in the prediction of right ventricular failure (RVF) and in the prognostication for patients with RVF remains underexplored. Barriers include a lack of awareness of the importance of right ventricular function, especially in the perioperative setting, as well as a lack of reproducible means to assess right ventricular function in this setting. We provide an overview of biomarkers with right ventricular prognostic capabilities that could be further explored in patients expecting cardiac surgery, who are notoriously susceptible to developing RVF. We discuss biomarkers' mechanistic pathways and highlight their potential strengths and weaknesses in use in research and clinical care.
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Affiliation(s)
- Habib Jabagi
- Division of Cardiac Surgery, University of Ottawa Heart Institute
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute
| | - Louise Y Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute; School of Epidemiology and Public Health, University of Ottawa.
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27
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Denault A, Shaaban Ali M, Couture EJ, Beaubien-Souligny W, Bouabdallaoui N, Brassard P, Mailhot T, Jacquet-Lagrèze M, Lamarche Y, Deschamps A. A Practical Approach to Cerebro-Somatic Near-Infrared Spectroscopy and Whole-Body Ultrasound. J Cardiothorac Vasc Anesth 2019; 33 Suppl 1:S11-S37. [DOI: 10.1053/j.jvca.2019.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Jabagi H, Mielniczuk LM, Liu PP, Ruel M, Sun LY. Biomarkers in the Diagnosis, Management, and Prognostication of Perioperative Right Ventricular Failure in Cardiac Surgery-Are We There Yet? J Clin Med 2019; 8:jcm8040559. [PMID: 31027170 PMCID: PMC6517903 DOI: 10.3390/jcm8040559] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 03/27/2019] [Accepted: 04/22/2019] [Indexed: 12/19/2022] Open
Abstract
Right ventricular failure (RVF) is a major risk factor for end organ morbidity and mortality following cardiac surgery. Perioperative RVF is difficult to predict and detect, and to date, no convenient, accurate, or reproducible measure of right ventricular (RV) function is available. Few studies have examined the use of biomarkers in RVF, and even fewer have examined their utility in the perioperative setting of patients undergoing cardiac surgery. Of the available classes of biomarkers, this review focuses on biomarkers of (1) inflammation and (2) myocyte injury/stress, due to their superior potential in perioperative RV assessment, including Galectin 3, ST2/sST2, CRP, cTN/hs-cTn, and BNP/NT-proBNP. This review was performed to help highlight the importance of perioperative RV function in patients undergoing cardiac surgery, to review the current modalities of RV assessment, and to provide a review of RV specific biomarkers and their potential utilization in the clinical and perioperative setting in cardiac surgery. Based on current evidence, we suggest the potential utility of ST2, sST2, Gal-3, CRP, hs-cTn, and NT-proBNP in predicting and detecting RVF in cardiac surgery patients, as they encompass the multifaceted nature of perioperative RVF and warrant further investigation to establish their clinical utility.
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Affiliation(s)
- Habib Jabagi
- Divisions of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.
| | - Lisa M Mielniczuk
- Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.
| | - Peter P Liu
- Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.
| | - Marc Ruel
- Divisions of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.
| | - Louise Y Sun
- Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada.
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29
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Raymond M, Grønlykke L, Couture EJ, Desjardins G, Cogan J, Cloutier J, Lamarche Y, L'Allier PL, Ravn HB, Couture P, Deschamps A, Chamberland ME, Ayoub C, Lebon JS, Julien M, Taillefer J, Rochon A, Denault AY. Perioperative Right Ventricular Pressure Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:1090-1104. [DOI: 10.1053/j.jvca.2018.08.198] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Indexed: 11/11/2022]
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30
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Gebhard CE, Rochon A, Cogan J, Ased H, Desjardins G, Deschamps A, Gavra P, Lebon JS, Couture P, Ayoub C, Levesque S, Elmi-Sarabi M, Couture EJ, Denault AY. Acute Right Ventricular Failure in Cardiac Surgery During Cardiopulmonary Bypass Separation: A Retrospective Case Series of 12 Years’ Experience With Intratracheal Milrinone Administration. J Cardiothorac Vasc Anesth 2019; 33:651-660. [DOI: 10.1053/j.jvca.2018.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 12/19/2022]
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31
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Chaney MA, Lowe ME, Minhaj MM, Santise G, Jacobsohn E. Inferior Vena Cava Stenosis After Bicaval Orthotopic Heart Transplantation. J Cardiothorac Vasc Anesth 2019; 33:2561-2568. [PMID: 31142438 DOI: 10.1053/j.jvca.2019.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| | - Michael E Lowe
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mohammed M Minhaj
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Gianluca Santise
- Department of Cardiac Surgery, Sant'Anna Hospital, Catanzaro, Italy
| | - Eric Jacobsohn
- University of Manitoba, Health Sciences Centre, Winnipeg, Manitoba, Canada
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32
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Hwang JW. Assessment of Right Ventricular Systolic Function: Conventional Methods and Modified Tricuspid Annular Plane Systolic Excursion. J Cardiovasc Imaging 2019; 27:34-36. [PMID: 30701714 PMCID: PMC6358428 DOI: 10.4250/jcvi.2019.27.e13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ji Won Hwang
- Division of Cardiology, Department of Medicine, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, Korea.
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33
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Dhawan I, Makhija N, Choudhury M, Choudhury A. Modified Tricuspid Annular Plane Systolic Excursion for Assessment of Right Ventricular Systolic Function. J Cardiovasc Imaging 2019; 27:24-33. [PMID: 30701713 PMCID: PMC6358432 DOI: 10.4250/jcvi.2019.27.e8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/08/2018] [Accepted: 12/26/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Tricuspid annular plane systolic excursion (TAPSE) has become a popular tool for assessing right ventricular (RV) systolic function because of its ease of application. TAPSE using transesophageal echocardiography (TEE) is limited by alignment with the lateral wall of the RV. Modified TAPSE (m-TAPSE) is a novel method for measuring TAPSE. m-TAPSE is the difference in the ‘apical to lateral tricuspid annulus distance’ during diastole and systole. The aim of the present study was to compare prospectively m-TAPSE with the most commonly used parameter TAPSE and near-gold standard 2D echocardiographic parameter RV fractional area change (RV FAC). METHODS We conducted a prospective observational study of 125 consecutive patients undergoing coronary artery bypass graft surgery in a single tertiary care center. Post-anesthetic induction TAPSE was recorded using transthoracic echocardiography (TTE). m-TAPSE was recorded using TEE in the mid-esophageal four-chamber view. RV FAC was also assessed using TEE. m-TAPSE < 16 mm, TAPSE < 16 mm and RV FAC < 35% were taken as cut-offs for RV systolic dysfunction. Correlations were assessed using the Pearson correlation coefficient. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using 2 × 2 cross table. RESULTS m-TAPSE was significantly correlated with TAPSE (r = 0.797, p < 0.001). Similarly, a significant correlation was observed between m-TAPSE and RV FAC (r = 0.602, p < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of m-TAPSE were 100%, 98.3%, 80%, 100% and 98.4%, respectively. CONCLUSIONS m-TAPSE correlated well with both RV FAC and TAPSE. Therefore, m-TAPSE can be considered an easily measurable alternative parameter for evaluating RV systolic function in a busy intraoperative setting.
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Affiliation(s)
- Ira Dhawan
- Department of Cardiac Anesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India
| | - Neeti Makhija
- Department of Cardiac Anesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India.
| | - Minati Choudhury
- Department of Cardiac Anesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India
| | - Arindam Choudhury
- Department of Cardiac Anesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India
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Utility of Novel Cardiorenal Biomarkers in the Prediction and Early Detection of Congestive Kidney Injury Following Cardiac Surgery. J Clin Med 2018; 7:jcm7120540. [PMID: 30545066 PMCID: PMC6306702 DOI: 10.3390/jcm7120540] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 12/17/2022] Open
Abstract
Acute Kidney Injury (AKI) in the context of right ventricular failure (RVF) is thought to be largely congestive in nature. This study assessed the utility of biomarkers high sensitivity cardiac troponin T (hs-cTnT), N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and neutrophil gelatinase-associated lipocalin (NGAL) for prediction and early detection of congestive AKI (c-AKI) following cardiac surgery. This prospective nested case-control study recruited 350 consecutive patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. Cases were patients who developed (1) AKI (2) new or worsening RVF, or (3) c-AKI. Controls were patients free of these complications. Biomarker levels were measured at baseline after anesthesia induction and immediately postoperatively. Patients with c-AKI had increased mean duration of mechanical ventilation and length of stay in hospital and in the intensive care unit (p < 0.01). For prediction of c-AKI, baseline NT-proBNP yielded an area under the curve (AUC) of 0.74 (95% CI, 0.60–0.89). For early detection of c-AKI, postoperative NT-proBNP yielded an AUC of 0.78 (0.66–0.91), postoperative hs-cTnT yielded an AUC of 0.75 (0.58–0.92), and ∆hs-cTnT yielded an AUC of 0.80 (0.64–0.96). The addition of baseline creatinine to ∆hs-cTnT improved the AUC to 0.87 (0.76–0.99), and addition of diabetes improved the AUC to 0.93 (0.88–0.99). Δhs-cTnT alone, or in combination with baseline creatinine or diabetes, detects c-AKI with high accuracy following cardiac surgery.
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Heringlake M, Berggreen AE. Intratracheal Milrinone for Acute Right Heart Dysfunction: Another Tool in the Pocket. J Cardiothorac Vasc Anesth 2018; 33:661-662. [PMID: 30420313 DOI: 10.1053/j.jvca.2018.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
| | - Astrid Ellen Berggreen
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
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Naoum EE, Schofield PT, Shen T, Andrawes MN, Kuo AS. Agreement Between Transesophageal Echocardiographic Tricuspid Annular Plane Systolic Excursion Measurement Methods in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2018; 33:717-724. [PMID: 30583929 DOI: 10.1053/j.jvca.2018.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the agreement between 2-dimensional tricuspid annular plane systolic excursion (2D-TAPSE), 2D-TAPSE-apex, and 2D speckle tracking echocardiography (STE-TAPSE) in a cross-section of routine cardiac surgery patients. DESIGN Retrospective, observational study. SETTING Tertiary, academic referral hospital. PARTICIPANTS Patients undergoing elective cardiac surgery with intraoperative transesophageal echocardiography (TEE) imaging. INTERVENTIONS TEE imaging was reviewed and evaluated for the following three different measurements of transthoracic echocardiography-TAPSE surrogates: 2D-TAPSE, 2D-TAPSE-apex, and STE-TAPSE. Statistical analyses, including 2-sample t tests, linear regression, and agreement using the Bland-Altman methods, were performed. MEASUREMENTS AND MAIN RESULTS Modest correlation was demonstrated between STE-TAPSE and 2D-TAPSE (R2 = 0.37; p < 0.001) and between STE-TAPSE and 2D-TAPSE-apex (R2 = 0.34; p < 0.001). There was good correlation between 2D-TAPSE and 2D-TAPSE-apex (R2 = 0.77, p < 0.001). The Bland-Altman analysis between these methods showed minimal bias: STE-TAPSE and 2D-TAPSE 0.84 mm, STE-TAPSE and 2D-TAPSE-apex 0.14 mm, and 2D-TAPSE and 2D-TAPSE-apex 0.98 mm. However, the agreement was poor, with 95% limits of agreement of -10.67 to 8.99 mm, -10.67 to 10.96 mm, and -4.91 to 6.88 mm, respectively. CONCLUSIONS Correlation and minimal bias were found between the several proposed TEE surrogates of transthoracic echocardiography-TAPSE; however, there was poor agreement. Therefore, these surrogates are not interchangeable, and each method needs to be separately validated for clinical use to relevant perioperative outcomes.
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Affiliation(s)
- Emily E Naoum
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.
| | - Patrick T Schofield
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Tao Shen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Michael N Andrawes
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Alexander S Kuo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Del Rio JM, Grecu L, Nicoara A. Right Ventricular Function in Left Heart Disease. Semin Cardiothorac Vasc Anesth 2018; 23:88-107. [DOI: 10.1177/1089253218799345] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Right ventricular (RV) function is an independent prognostic factor for short- and long-term outcomes in cardiac surgical patients. Patients with mitral valve (MV) disease are at increased risk of RV dysfunction before and after MV operations. Yet RV function is not part of criteria for decision making or risk stratification in this setting. The role of MV disease in the development of pulmonary hypertension (PHTN) and the ultimate impact of PHTN on RV function have been well described. Nonetheless, there are other mechanisms by which MV disease and MV surgery affect RV performance. Research suggests that PHTN may not be the most important determinant of RV dysfunction. Both RV dysfunction and PHTN have independent prognostic significance. This review explores the unique anatomic and functional features of the RV and the pathophysiologic and prognostic implications of RV dysfunction in patients with MV disease in the perioperative period.
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Affiliation(s)
- J. Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Loreta Grecu
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Alina Nicoara
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
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Morita Y, Lencho T, Gunasekaran S, Modak R. Modified Tricuspid Annular Plane Systolic Excursion Using Transesophageal Echocardiography and Its Utility to Predict Postoperative Course in Heart Transplantation and Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2018; 32:1316-1324. [DOI: 10.1053/j.jvca.2017.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Indexed: 11/11/2022]
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Vieillard-Baron A, Naeije R, Haddad F, Bogaard HJ, Bull TM, Fletcher N, Lahm T, Magder S, Orde S, Schmidt G, Pinsky MR. Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper. Intensive Care Med 2018; 44:774-790. [PMID: 29744563 DOI: 10.1007/s00134-018-5172-2] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors. RESULTS The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.
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Affiliation(s)
- Antoine Vieillard-Baron
- Service de Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France.
- INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France.
| | - R Naeije
- Professor Emeritus at the Université Libre de Bruxelles, Brussels, Belgium
| | - F Haddad
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford, USA
| | - H J Bogaard
- Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - T M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - N Fletcher
- Department of Cardiothoracic Critical Care, St Georges University Hospital NHS Trust, London, SW17 0QT, UK
| | - T Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - S Magder
- Department of Critical Care, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - S Orde
- Intensive Care Unit, Nepean Hospital, Kingswood, Sydney, NSW, Australia
| | - G Schmidt
- Department of Internal Medicine and Critical Care, University of Iowa, Iowa City, USA
| | - M R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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Perdhana F, Purnomo H. Review Article: Management of Perioperative Anesthesia in Right Heart Failure. FOLIA MEDICA INDONESIANA 2018. [DOI: 10.20473/fmi.v54i1.8056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Right ventricular dysfunction and failure receive much less attention than the left ventricular failure. Right ventricular dysfunction or failure is associated with increased mortality rates in cardiac surgery, surgical cases other than cardiac surgery and also in patients treated in the ICU. The purpose of this article review was to describe the anatomy, physiology and pathophysiology of right ventricular failure, its detection and diagnosis, and management considerations from anesthetic point of view, including preoperative, intraoperative and postoperative stages. Cardiac surgery may result in right ventricular failure. For example, 0.1% post cardiotomy patients experience severe right heart failure and require long-term inotropic support, and so do 2-3% of post-transplant patients, and 20-30% of patients installed with instrument in his left heart. Therefore, anesthesiologists play a major role in perioperative and postoperative intensive care and are obliged to comprehend the nature of right ventricular dysfunction and failure so as to carry out early detection, prevent and manage patients with right ventricular dysfunction.
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Shen T, Picard MH, Hua L, Burns SM, Andrawes MN. Assessment of Tricuspid Annular Motion by Speckle Tracking in Anesthetized Patients Using Transesophageal Echocardiography. Anesth Analg 2018; 126:62-67. [PMID: 29116970 DOI: 10.1213/ane.0000000000002614] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The perioperative assessment of right ventricular (RV) function remains a challenge. Tricuspid annular plane systolic excursion (TAPSE) using M-mode is a widely used measure of RV function. However, accurate alignment of the ultrasound beam with the direction of annular movement can be difficult with transesophageal echocardiography (TEE) to measure TAPSE, precluding effective use of M-mode to measure annular excursion. Tracking of specular reflectors in the myocardium may provide an angle-independent method to assess annular motion with TEE. We hypothesized that TEE speckle tracking of the lateral tricuspid annular motion represents a comparable measurement to the well-validated M-mode TAPSE on transthoracic echocardiogram (TTE), and may be considered as a reasonable alternative to TAPSE. METHODS This is a prospective, observational cohort study. We included all patients, who were in sinus rhythm, with a preoperative TTE within 3 months of scheduled cardiac surgery that required intraoperative TEE. Tissue motion annular displacements (TMAD) of the lateral (L), septal (S), and midpoint (M) tricuspid annulus were measured (QLAB Cardiac Motion Quantification; Philips Medical, Andover, MA) after induction of general anesthesia. This was compared to the preoperative M-mode TAPSE on TTE. RESULTS Seventy-two consecutive patients who met eligibility requirements were enrolled from September to November 2016. Twelve were excluded due to poor image quality, allowing TMAD to be analyzed in 60 patients. TMAD was analyzed offline and TMAD analysis was able to track tricuspid annular motion in all patients. The mean TMAD (L), TMAD (S), and TMAD (M) were 17.4 ± 5.2, 10.2 ± 4.8, and 14.2 ± 4.8 mm, respectively. TMAD (L) showed close correlation with M-mode TAPSE on TTE (r = 0.87, 95% confidence interval, 0.79-0.92; P < .01). All patients with a preoperative TAPSE <17 mm had a TMAD (L) <17 mm, while 71% of those with a TAPSE ≥ 17 mm had a TMAD (L) ≥ 17 mm. There was strong positive correlation between TMAD (L) and intraoperative RV fractional area change (r = 0.86, 95% confidence interval, 0.77-0.91; P < .01). Reproducibility analysis of TMAD within and across observers showed excellent correlation. CONCLUSIONS TMAD is a quick and angle-independent method to quantitatively assess RV longitudinal function by TEE. It correlates strongly with M-mode TAPSE on TTE. Because TMAD and TAPSE were not simultaneously measured in this study, their correlation is subject to differences in loading conditions, general anesthesia, and changes in the disease process. TMAD may be easily applied in routine clinical settings and its role in the perioperative environment deserves to be further explored.
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Affiliation(s)
- Tao Shen
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lanqi Hua
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sara M Burns
- From the Department of Anesthesia, Critical Care and Pain Medicine
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Theodoraki K, Thanopoulos A, Rellia P, Leontiadis E, Zarkalis D, Perreas K, Antoniou T. A retrospective comparison of inhaled milrinone and iloprost in post-bypass pulmonary hypertension. Heart Vessels 2017; 32:1488-1497. [PMID: 28717881 DOI: 10.1007/s00380-017-1023-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 07/14/2017] [Indexed: 11/28/2022]
Abstract
During cardiac operations, weaning from cardiopulmonary bypass (CPB) may prove challenging as a result of superimposed acute right ventricular dysfunction in the setting of elevated pulmonary vascular resistance (PVR). The aim of this study was to retrospectively evaluate the effect of inhaled milrinone versus inhaled iloprost in patients with persistent pulmonary hypertension following discontinuation of CPB. Eighteen patients with elevated PVR post-bypass were administered inhaled milrinone at a cumulative dose of 50 μg kg-1. These patients were retrospectively matched with 18 patients who were administered 20 μg of inhaled iloprost. Both drugs were administered through a disposable aerosol-generating jet nebulizer device and inhaled for a 15-min period. Hemodynamic measurements were performed before and after cessation of the inhalation period. Both inhaled milrinone and inhaled iloprost induced significant reductions in mean pulmonary artery pressure and PVR and significant increases in cardiac index in patients with post-CPB pulmonary hypertension. The favorable effect of both agents on the pulmonary vasculature was confirmed by echocardiographic measurements. Both agents were devoid of systemic side effects, since mean arterial pressure and systemic vascular resistance were not affected. A decrease in intrapulmonary shunt by inhalation of both agents was also demonstrated. Pulmonary vasodilatation attributed to iloprost seems to be of greater magnitude and of longer duration as compared to that of inhaled milrinone. Both substances proved to be selective pulmonary vasodilators. The greater magnitude and of longer duration vasodilatation attributed to iloprost may be due to its longer duration of action.
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Affiliation(s)
- Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, Vassilissis Sofias 76, 11528, Athens, Greece.
- National and Kapodistrian University of Athens, Athens, Greece.
| | | | - Panagiota Rellia
- Department of Anesthesiology, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Dimitrios Zarkalis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Theophani Antoniou
- Department of Anesthesiology, Onassis Cardiac Surgery Center, Athens, Greece
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Tremblay JA, Beaubien-Souligny W, Elmi-Sarabi M, Desjardins G, Denault AY. Point-of-Care Ultrasonography to Assess Portal Vein Pulsatility and the Effect of Inhaled Milrinone and Epoprostenol in Severe Right Ventricular Failure. ACTA ACUST UNITED AC 2017; 9:219-223. [DOI: 10.1213/xaa.0000000000000572] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Head to toe ultrasound: Current opinion on its role in hemodynamic instability, hypoxemia, oligoanuria and the patient with altered neurological status☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201710000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Denault AY, Casas C, Puentes W, Eljaiek R, Iglesias I. Head to toe ultrasound: Current opinion on its role in hemodynamic instability, hypoxemia, oligoanuria and the patient with altered neurological status. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Denault AY, Casas C, Puentes W, Eljaiek R, Iglesias I. Ultrasonido de la cabeza a los pies: opinión actual sobre su utilidad en inestabilidad hemodinámica, hipoxemia, oligoanuria y en el paciente con estado neurológico alterado. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Hargrave J. Con: Preinduction Pulmonary Artery Catheter Placement Is Advisable in Patients With Right Ventricular Dysfunction Secondary to Severe Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2017; 31:1514-1518. [DOI: 10.1053/j.jvca.2017.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Indexed: 12/26/2022]
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Hu T, Collin Y, Lapointe R, Carrier FM, Massicotte L, Fortier A, Lambert J, Vandenbroucke-Menu F, Denault AY. Preliminary Experience in Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation. J Cardiothorac Vasc Anesth 2017; 32:73-84. [PMID: 29229261 DOI: 10.1053/j.jvca.2017.07.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The use of cerebral near-infrared spectroscopy (NIRS) has become widespread in cardiac surgery after research demonstrated an association between perioperative cerebral desaturations and postoperative complications. Somatic NIRS desaturation also is associated with an increased risk of postoperative complications and mortality. The objective of this study was to explore the trends of both somatic and cerebral NIRS during liver transplantation. DESIGN A prospective, single-site, observational case series. SETTING Tertiary care center. PARTICIPANTS The study comprised 10 patients undergoing liver transplantation. INTERVENTIONS NIRS sensors were placed on the forehead (cerebral regional oxygen saturation [rSO2]) and on the right arm and right leg (somatic rSO2) to measure tissue perfusion. Desaturation was defined as a 20% decrease of baseline values for 15 seconds. MEASUREMENTS AND MAIN RESULTS In all patients, parallel changes in both cerebral and somatic rSO2 values were observed during phlebotomy, bleeding, transfusion, portal vein clamping, and the use of vasoactive agents. Induction of anesthesia increased cerebral rSO2 more than it did somatic values. However, ascites removal, abdominal manipulation, and clamping of the inferior vena cava (IVC) were associated with nonparallel changes in cerebral and somatic rSO2. Ascites removal was associated with increased somatic leg rSO2, and IVC clamping and abdominal hypertension were associated with a significant reduction in somatic leg rSO2. Somatic leg desaturation instead of arm or cerebral desaturation was associated with more postoperative complications. CONCLUSIONS The use of combined NIRS monitoring allows for the identification of the source of somatic or cerebral desaturation. Compromised venous flow from the IVC from clamping or abdominal compartment syndrome typically is associated with the appearance of more pronounced leg than arm desaturation.
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Affiliation(s)
- Tina Hu
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yves Collin
- Hepato Pancreatic Surgery Unit, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Réal Lapointe
- Hepato Pancreatic Surgery Unit, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - François Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada; Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Annik Fortier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Jean Lambert
- Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Franck Vandenbroucke-Menu
- Hepato Pancreatic and Liver Transplantation Surgery Unit, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada.
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Flo Forner A, Hasheminejad E, Sabate S, Ackermann MA, Turton EW, Ender J. Agreement of tricuspid annular systolic excursion measurement between transthoracic and transesophageal echocardiography in the perioperative setting. Int J Cardiovasc Imaging 2017; 33:1385-1394. [DOI: 10.1007/s10554-017-1128-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/25/2017] [Indexed: 11/29/2022]
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Hrymak C, Strumpher J, Jacobsohn E. Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Can J Cardiol 2017; 33:61-71. [DOI: 10.1016/j.cjca.2016.10.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/29/2016] [Accepted: 10/30/2016] [Indexed: 12/29/2022] Open
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