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Bartels K, Karhausen J, Sullivan BL, Mackensen GB. Update on Perioperative Right Heart Assessment Using Transesophageal Echocardiography. Semin Cardiothorac Vasc Anesth 2014; 18:341-51. [DOI: 10.1177/1089253214522326] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose of the review. This review aims to summarize recent findings relevant for perioperative 2- and 3-dimensional imaging of the right heart with transesophageal echocardiography. Special attention is given to developments that are likely to affect future approaches for prevention and therapy of perioperative right heart failure. Recent findings. Three-dimensional transesophageal echocardiography techniques are becoming more common for the evaluation of anatomy, volumes, and functional indices. Summary. Right heart failure continues to contribute to morbidity and mortality in the context of cardiothoracic surgery. The advent and widespread clinical use of innovative tools permitting more accurate echocardiographic assessment of the right heart will open the door to renewed interest in novel therapeutic strategies.
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Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Jörn Karhausen
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - G. Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
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102
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Denault AY, Pearl RG, Michler RE, Rao V, Tsui SS, Seitelberger R, Cromie M, Lindberg E, D’Armini AM. Tezosentan and Right Ventricular Failure in Patients With Pulmonary Hypertension Undergoing Cardiac Surgery: The TACTICS Trial. J Cardiothorac Vasc Anesth 2013; 27:1212-7. [DOI: 10.1053/j.jvca.2013.01.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Indexed: 01/08/2023]
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Ternacle J, Berry M, Cognet T, Kloeckner M, Damy T, Monin JL, Couetil JP, Dubois-Rande JL, Gueret P, Lim P. Prognostic Value of Right Ventricular Two-Dimensional Global Strain in Patients Referred for Cardiac Surgery. J Am Soc Echocardiogr 2013; 26:721-6. [DOI: 10.1016/j.echo.2013.03.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Indexed: 11/17/2022]
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Abstract
PURPOSE OF REVIEW To evaluate new information on the importance of right ventricular function, diagnosis and management in cardiac surgical patients. RECENT FINDINGS There is growing evidence that right ventricular function is a key determinant in survival in cardiac surgery, particularly in patients with pulmonary hypertension. The diagnosis of this condition is helped by the use of specific hemodynamic parameters and echocardiography. In that regard, international consensus guidelines on the echocardiographic assessment of right ventricular function have been recently published. New monitoring modalities in cardiac surgery such as regional near-infrared spectroscopy can also assist management. Management of right ventricular failure will be influenced by the presence or absence of myocardial ischemia and left ventricular dysfunction. The differential diagnosis and management will be facilitated using a systematic approach. SUMMARY The use of right ventricular pressure monitoring and the publications of guidelines for the echocardiographic assessment of right ventricular anatomy and function allow the early identification of right ventricular failure. The treatment success will be associated by optimization of the hemodynamic, echocardiographic and near-infrared spectroscopy parameters.
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106
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St-Pierre P, Deschamps A, Cartier R, Basmadjian AJ, Denault AY. Inhaled milrinone and epoprostenol in a patient with severe pulmonary hypertension, right ventricular failure, and reduced baseline brain saturation value from a left atrial myxoma. J Cardiothorac Vasc Anesth 2013; 28:723-9. [PMID: 23623891 DOI: 10.1053/j.jvca.2012.10.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | - Arsène J Basmadjian
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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107
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Akiyama K, Arisawa S, Ide M, Iwaya M, Naito Y. Intraoperative cardiac assessment with transesophageal echocardiography for decision-making in cardiac anesthesia. Gen Thorac Cardiovasc Surg 2013; 61:320-9. [PMID: 23404310 DOI: 10.1007/s11748-013-0208-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Indexed: 11/25/2022]
Abstract
Transesophageal echocardiography is an invaluable hemodynamic monitoring modality. Extended and anatomically based evaluation of cardiac function with transesophageal echocardiography is essential to prompt and accurate decision-making in anesthetic management during cardiac surgery. Fractional shortening and fractional area changes are indices widely used to assess the global systolic performance of the left ventricle. Monitoring regional function using semi-quantitative scoring has been demonstrated to be a more sensitive indicator of myocardial ischemia. Assessment of left ventricular diastolic function should be performed in a systematic way, measuring transmitral flow, pulmonary venous flow, transmitral color M-mode flow propagation velocity, and mitral annulus tissue Doppler imaging. The unique anatomical features of the right ventricle make echocardiographic evaluation complicated and therefore less frequently employed. Right ventricular fractional area change, tricuspid annular plane systolic excursion, maximal systolic tricuspid annular velocity with tissue Doppler imaging, and myocardial performance index are indices successfully incorporated into intraoperative right ventricular assessment. Left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve may develop after cardiac procedures. Transesophageal echocardiography plays a central role in prevention as well as diagnosis of systolic anterior motion. Transesophageal echocardiography is extremely useful not only for detecting and locating intracardiac air, but also for guiding and evaluating the procedures to remove air. Air is likely to persist in the right and left superior pulmonary vein, left ventricular apex, left atrium, right coronary sinus of Valsalva, and ascending aorta. Accurate evaluation of cardiac function depends on performing TEE examination properly and obtaining optimal images.
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Affiliation(s)
- Koichi Akiyama
- Department of Anesthesia, Akashi Medical Center, 743-33 Okubo-cho Yagi, Akashi, 674-0063, Japan
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Afilalo J, Flynn AW, Shimony A, Rudski LG, Agnihotri AK, Morin JF, Castrillo C, Shahian DM, Picard MH. Incremental value of the preoperative echocardiogram to predict mortality and major morbidity in coronary artery bypass surgery. Circulation 2013; 127:356-64. [PMID: 23239840 DOI: 10.1161/circulationaha.112.127639] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. METHODS AND RESULTS Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. CONCLUSIONS Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.
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Affiliation(s)
- Jonathan Afilalo
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Harvard University, Boston, MA 02114, USA.
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109
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Jainandunsing JS, Matyal R, Shahul SS, Wang A, Woltersom B, Mahmood F. 3-dimensional right ventricular volume assessment. J Cardiothorac Vasc Anesth 2012; 27:367-75. [PMID: 23089261 DOI: 10.1053/j.jvca.2012.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this review was to evaluate new computer software available for 3-dimensional right ventricular (RV) volume estimation. DESCRIPTION Based on 2-dimensional echocardiography, various algorithms have been used for RV volume estimation. These are complex, time-consuming techniques and are prone to significant error. The current clinical paradigm of RV volume assessment is based on the visual quantitative assessment of chamber size and the use of tricuspid annular and RV internal diameters as a surrogate measure of RV volume. Hence, there is a need for a practical method for the intraoperative assessment of RV volume. EVALUATION The evaluation consists of an objective review of the capabilities of this software and its potential application in the operating room. The authors also performed a detailed review of the potential limitations and possible improvements. CONCLUSIONS This new software has the potential to be incorporated into the existing workflow environment of the ultrasound systems in the future, making it clinically feasible to perform perioperative RV volume analysis.
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Affiliation(s)
- Jayant S Jainandunsing
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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110
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Tousignant C, Kim H, Papa F, Mazer CD. Evaluation of TAPSE as a measure of right ventricular output. Can J Anaesth 2012; 59:376-83. [PMID: 22302303 DOI: 10.1007/s12630-011-9659-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 12/20/2011] [Indexed: 11/26/2022] Open
Abstract
PURPOSE This study was designed to show the relationship between tricuspid annular plane systolic excursion (TAPSE) and stroke volume (SV) by thermodilution using three different methods and also to assess whether TAPSE can track hemodynamic changes associated with volume loading and ephedrine administration. METHODS This was an observational study in 61 elective patients with a pulmonary artery catheter who were undergoing coronary artery bypass graft surgery in a cardiac surgical centre. We measured TAPSE by three methods using transesophageal echocardiography: M mode, speckle tracking at the lateral wall, and tissue tracking at the inferior wall. There were two interventions: leg raising (volume recruitment) or administration of ephedrine 5 mg iv. Echo and hemodynamic measurements were performed before and after each intervention. RESULTS Eleven patients were excluded due to poor imaging. There were 26 patients in the leg raising group and 24 patients in the ephedrine group. The correlation coefficient between stroke volume (SV) and TAPSE by M mode, speckle tracking, and tissue tracking was 0.48, 0.44, and 0.09, respectively. There was a significant increase in SV following each intervention; however, the changes in TAPSE by any method and velocity were not large enough to reach statistical significance. CONCLUSION Tricuspid annular plane systolic excursion by M mode and by speckle tracking correlates modestly with SV. There was no correlation between TAPSE and SV by tissue tracking at the inferior wall of the right ventricle. Tricuspid annular plane systolic excursion by M mode and by speckle tracking does not track changes in SV following either volume loading or ephedrine administration.
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Affiliation(s)
- Claude Tousignant
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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111
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112
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Ostenfeld E, Carlsson M, Shahgaldi K, Roijer A, Holm J. Manual correction of semi-automatic three-dimensional echocardiography is needed for right ventricular assessment in adults; validation with cardiac magnetic resonance. Cardiovasc Ultrasound 2012; 10:1. [PMID: 22226082 PMCID: PMC3398276 DOI: 10.1186/1476-7120-10-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 01/06/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Three-dimensional echocardiography (3DE) and semi-automatic right ventricular delineation has been proposed as an appropriate method for right ventricle (RV) evaluation. We aimed to examine how manual correction of semi-automatic delineation influences the accuracy of 3DE for RV volumes and function in a clinical adult setting using cardiac magnetic resonance (CMR) as the reference method. We also examined the feasibility of RV visualization with 3DE. METHODS 62 non-selected patients were examined with 3DE (Sonos 7500 and iE33) and with CMR (1.5T). Endocardial RV contours of 3DE-images were semi-automatically assessed and manually corrected in all patients. End-diastolic (EDV), end-systolic (ESV) volumes, stroke volume (SV) and ejection fraction (EF) were computed. RESULTS 53 patients (85%) had 3DE-images feasible for examination. Correlation coefficients and Bland Altman biases between 3DE with manual correction and CMR were r = 0.78, -22 ± 27 mL for EDV, r = 0.83, -7 ± 16 mL for ESV, r = 0.60, -12 ± 18 mL for SV and r = 0.60, -2 ± 8% for EF (p < 0.001 for all r-values). Without manual correction r-values were 0.77, 0.77, 0.70 and 0.49 for EDV, ESV, SV and EF, respectively (p < 0.001 for all r-values) and biases were larger for EDV, SV and EF (-32 ± 26 mL, -21 ± 15 mL and - 6 ± 9%, p ≤ 0.01 for all) compared to manual correction. CONCLUSION Manual correction of the 3DE semi-automatic RV delineation decreases the bias and is needed for acceptable clinical accuracy. 3DE is highly feasible for visualizing the RV in an adult clinical setting.
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Affiliation(s)
- Ellen Ostenfeld
- Department of Cardiology, Malmö, Skåne University Hospital, Sweden.
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113
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Fusini L, Tamborini G, Gripari P, Maffessanti F, Mazzanti V, Muratori M, Salvi L, Sisillo E, Caiani EG, Alamanni F, Fiorentini C, Pepi M. Feasibility of Intraoperative Three-Dimensional Transesophageal Echocardiography in the Evaluation of Right Ventricular Volumes and Function in Patients Undergoing Cardiac Surgery. J Am Soc Echocardiogr 2011; 24:868-77. [DOI: 10.1016/j.echo.2011.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Indexed: 10/18/2022]
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Denault A, Deschamps A, Tardif JC, Lambert J, Perrault L. Pulmonary hypertension in cardiac surgery. Curr Cardiol Rev 2011; 6:1-14. [PMID: 21286273 PMCID: PMC2845789 DOI: 10.2174/157340310790231671] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 03/20/2009] [Accepted: 03/31/2009] [Indexed: 12/14/2022] Open
Abstract
Pulmonary hypertension is an important prognostic factor in cardiac surgery associated with increased morbidity and mortality. With the aging population and the associated increase severity of illness, the prevalence of pulmonary hypertension in cardiac surgical patients will increase. In this review, the definition of pulmonary hypertension, the mechanisms and its relationship to right ventricular dysfunction will be presented. Finally, pharmacological and non-pharmacological therapeutic and preventive approaches will be presented.
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Affiliation(s)
- André Denault
- Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
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115
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Malasana G, Daccarett M, Kuppahally S, Wasmund SL, Litwin SE, Hamdan MH. High prevalence of right ventricular dysfunction in ICD patients with shocks: a potential new predictor in risk stratification. J Interv Card Electrophysiol 2011; 31:165-9. [DOI: 10.1007/s10840-010-9536-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 12/17/2010] [Indexed: 11/25/2022]
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Chou SH, Kuo CT, Hsu LA, Ho WJ, Wang CL. Single-Beat Determination of Right Ventricular Function in Patients with Atrial Fibrillation. Echocardiography 2010; 27:1188-93. [DOI: 10.1111/j.1540-8175.2010.01236.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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117
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Abstract
Ultrasound applications in perioperative medicine have expanded enormously over the past decade. Transoesophageal echocardiography has been performed by anaesthetists during cardiac surgery for over 20 years. With the increasing availability of portable ultrasound systems, the use of ultrasound to assist in vascular cannulation and regional anaesthesia has been well described. Portable ultrasound systems come with a range of probes for different applications, including transthoracic echocardiography. While transthoracic echocardiography has traditionally been the domain of cardiologists, its use has been increasing in critical care, the emergency room and, recently, by anaesthetists in the perioperative period. Unlike formal cardiology-based transthoracic echocardiography, focused, goal-directed transthoracic echocardiography is often more appropriate in the perioperative period to address a particular question and can be performed in just a few minutes. Transthoracic echocardiography allows rapid, noninvasive, point-of-care assessment of ventricular function, valvular integrity, volume status and fluid responsiveness. It can help distinguish undifferentiated systolic murmurs preoperatively, give valuable information on the aetiology of unexplained hypotension and cardiovascular collapse and assess response to therapeutic interventions such as vasoactive drugs and volume resuscitation. Focused transthoracic echocardiography should include qualitative assessment of left and right ventricular function, an estimate of aortic valve gradient, right ventricular systolic pressure and intravascular volume status as minimum requirements. Transthoracic echocardiography is a valuable tool in the perioperative period and ideally the equipment and expertise should be available in all operating rooms.
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Affiliation(s)
- B. S. Cowie
- Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia
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118
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Jo HR, Lee WK, Kim YH, Min JH, Chae YK, Choi IG, Kim YS, Lee YK. The effect of milrinone infusion on right ventricular function during coronary anastomosis and early outcomes in patients undergoing off-pump coronary artery bypass surgery. Korean J Anesthesiol 2010; 59:92-8. [PMID: 20740213 PMCID: PMC2926436 DOI: 10.4097/kjae.2010.59.2.92] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 04/15/2010] [Accepted: 05/10/2010] [Indexed: 11/23/2022] Open
Abstract
Background During coronary anastomosis in off-pump coronary artery bypass surgery (OPCAB), hemodynamic alternations can be induced by impaired diastolic function of the right ventricle. This study was designed to examine the effect of milrinone on right ventricular function and early outcomes in patients undergoing OPCAB. Methods Forty patients undergoing OPCAB were randomly assigned in a double-blind manner to receive either milrinone (milrinone group, n = 20) or normal saline (control group, n = 20). Hemodynamic variables were measured after pericardiotomy (T1), 5 min after stabilizer application for anastomosis of the left anterior descending coronary artery (LAD, T2), the obtuse marginalis branch (OM, T3), the right coronary artery (RCA, T4), 5 min after sternal closure (T5), and after ICU arrival. The right ventricular ejection fraction (RVEF) and right ventricular volumetric parameters were also measured using the thermodilution technique. For evaluation of early outcomes, the 30-day operative mortality and morbidity risk models were used. Results There was no significant difference in hemodynamic variables, including mean arterial pressure, between the 2 groups, except for the cardiac index and RVEF. The cardiac index and RVEF were significantly greater at T3 in the milrinone group than in the control group. Conclusions Continuous infusion of milrinone demonstrated a beneficial effect on cardiac output and right ventricular function in patients undergoing OPCAB, especially during anastomosis of the graft to the OM artery, and it had no adverse effect on early outcomes.
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Affiliation(s)
- Hyong Rae Jo
- Department of Anesthesiology and Pain Medicine, Kwandong University College of Medicine, Goyang, Korea
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119
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Denault AY, Deschamps A, Couture P. Intraoperative Hemodynamic Instability During and After Separation From Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2010; 14:165-82. [DOI: 10.1177/1089253210376673] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, more than 1 million patients worldwide undergo cardiac surgery. Because of the aging of the population, cardiac surgery will increasingly be offered to patients at a higher risk of complications. The consequence is a reduced physiological reserve and hence an increased risk of mortality. These issues will have a significant impact on future health care costs because the population undergoing cardiac surgery will be older and more likely to develop postoperative complications. One of the most dreaded complications in cardiac surgery is difficult separation from cardiopulmonary bypass (CPB). When separation from CPB is associated with right-ventricular failure, the mortality rate will range from 44% to 86%. Therefore, the diagnosis and the preoperative prediction of difficult separation from CPB will be crucial to improve the selection and care of patients and to prevent complications for this high-risk patient population.
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Affiliation(s)
- André Y. Denault
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada,
| | - Alain Deschamps
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
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Tousignant C, Desmet M, Bowry R, Harrington AM, Cruz JD, Mazer CD. Speckle Tracking for the Intraoperative Assessment of Right Ventricular Function: A Feasibility Study. J Cardiothorac Vasc Anesth 2010; 24:275-9. [DOI: 10.1053/j.jvca.2009.10.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Indexed: 11/11/2022]
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Joshi SB, Roswell RO, Salah AK, Zeman PR, Corso PJ, Lindsay J, Fuisz AR. Right ventricular function after coronary artery bypass graft surgery—a magnetic resonance imaging study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2010; 11:98-100. [DOI: 10.1016/j.carrev.2009.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 04/02/2009] [Indexed: 11/26/2022]
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Sugiki H, Nakashima K, Vermes E, Loisance D, Kirsch M. Temporary Right Ventricular Support with Impella Recover RD Axial Flow Pump. Asian Cardiovasc Thorac Ann 2009; 17:395-400. [DOI: 10.1177/0218492309338121] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Post-cardiotomyright ventricular failure is a serious complication that frequently results in adverse outcomes. We reviewed our experience with the Impella Recover RD (Impella Cardiosystems GMbH, Aachen, Germany). From January 2007 to December 2007, 7 patients (5 males, 54 + 7 years old) had this device implanted for temporary support after heart transplantation in 4, after repeat mitral valve replacement in 2, and with a left ventricular assist device in 1. Devices were implanted during initial operation ( n = 5) or shortly thereafter ( n = 2). Six patients underwent implantation without cardiopulmonary bypass. Effective support with pump flows of 4.0-4.5 L · min−1 and adequate unloading (central venous pressure decreased from 15.3 ± 1.4 to 9.4 ± 1.2 mm Hg) was achieved in all patients. Patients were assisted for a mean duration of 4.9 ± 4.5 days. Three patients could be weaned after 7.0 ± 5.6 days of support and underwent device explantation without cardiopulmonary bypass. One of these patients died of recurrent right ventricular failure, 2 remained stable but died later of sepsis. The patient with a left ventricular assist device was switched to an alternative device for prolonged support. Two patients experienced pump dysfunction. Our preliminary experience shows that the Impella Recover RD is an effective device that can be easily implanted and explanted. However, its mechanical reliability needs to be improved.
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Affiliation(s)
- Hiroshi Sugiki
- Department of Cardiothoracic Surgery Henri Mondor Hospital Créteil, France
| | - Kuniki Nakashima
- Department of Cardiothoracic Surgery Henri Mondor Hospital Créteil, France
| | - Emmanuelle Vermes
- Department of Cardiothoracic Surgery Henri Mondor Hospital Créteil, France
| | - Daniel Loisance
- Department of Cardiothoracic Surgery Henri Mondor Hospital Créteil, France
| | - Matthias Kirsch
- Department of Cardiothoracic Surgery Henri Mondor Hospital Créteil, France
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Induction of anesthesia does not alter tricuspid annular velocities: a tissue Doppler assessment. Can J Anaesth 2009; 56:757-62. [DOI: 10.1007/s12630-009-9157-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 07/15/2009] [Indexed: 10/20/2022] Open
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Aune E, Baekkevar M, Rodevand O, Otterstad JE. The limited usefulness of real-time 3-dimensional echocardiography in obtaining normal reference ranges for right ventricular volumes. Cardiovasc Ultrasound 2009; 7:35. [PMID: 19580673 PMCID: PMC2713207 DOI: 10.1186/1476-7120-7-35] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 07/06/2009] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND To obtain normal reference ranges and intraobserver variability for right ventricular (RV) volume indexes (VI) and ejection fraction (EF) from apical recordings with real-time 3-dimensional echocardiography (RT3DE), and similarly for RV area indexes (AI) and area fraction (AF) with 2-dimensional echocardiography (2DE). METHODS 166 participants; 79 males and 87 females aged between 29-79 years and considered free from clinical and subclinical cardiovascular disease. Normal ranges are defined as 95% reference values and reproducibility as coefficients of variation (CV) for repeated measurements. RESULTS None of the apical recordings with RT3DE and 2DE included the RV outflow tract. Upper reference values were 62 ml/m2 for RV end-diastolic (ED) VI and 24 ml/m2 for RV end-systolic (ES) VI. Lower normal reference value for RVEF was 41%. The respective reference ranges were 17 cm2/m2 for RVEDAI, 11 cm2/m2 for RVESAI and 27% for RVAF. Males had higher upper normal values for RVEDVI, RVESVI and RVEDAI, and a lower limit than females for RVEF and RVAF. Weak but significant negative correlations between age and RV dimensions were found with RT3DE, but not with 2DE. CVs for repeated measurements ranged between 10% and 14% with RT3DE and from 5% to 14% with 2DE. CONCLUSION Although the normal ranges for RVVIs and RVAIs presented in this study reflect RV inflow tract dimensions only, the data presented may still be regarded as a useful tool in clinical practice, especially for RVEF and RVAF.
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Affiliation(s)
- Erlend Aune
- Department of Cardiology, Vestfold Hospital Trust, Box 2168, NO-3103 Toensberg, Norway
| | - Morten Baekkevar
- Department of Cardiology, Vestfold Hospital Trust, Box 2168, NO-3103 Toensberg, Norway
| | - Olaf Rodevand
- Department of Cardiology, Feiringklinikken, Feiring, Norway
| | - Jan Erik Otterstad
- Department of Cardiology, Vestfold Hospital Trust, Box 2168, NO-3103 Toensberg, Norway
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125
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Maslow A, Schwartz C, Mahmood F, Singh A, Heerdt PM. Case report: paradoxical ventricular septal motion in the setting of primary right ventricular myocardial failure. Can J Anaesth 2009; 56:510-7. [PMID: 19475470 DOI: 10.1007/s12630-009-9108-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Revised: 03/30/2009] [Accepted: 04/06/2009] [Indexed: 11/24/2022] Open
Abstract
PURPOSE In this report, a case of right ventricular (RV) failure, hemodynamic instability, and systemic organ failure is described to highlight how paradoxical ventricular systolic septal motion (PVSM), or a rightward systolic displacement of the interventricular septum, may contribute to RV ejection. CLINICAL FEATURES Multiple inotropic medications and vasopressors were administered to treat right heart failure and systemic hypotension in a patient following combined aortic and mitral valve replacement. In the early postoperative period, echocardiographic evaluation revealed adequate left ventricular systolic function, akinesis of the RV myocardial tissues, and PVSM. In the presence of PVSM, RV fractional area of contraction was > or =35% despite akinesis of the primary RV myocardial walls. The PVSM appeared to contribute toward RV ejection. As a result, the need for multiple inotropes was re-evaluated, in considering that end-organ dysfunction was the result of systemic hypotension and prolonged vasopressor administration. After discontinuation of phosphodiesterase inhibitors, native vascular tone returned and the need for vasopressors declined. This was followed by recovery of systemic organ function. Echocardiographic re-evaluation two years later, revealed persistent akinesis of the RV myocardial tissues and PVSM, the latter appearing to contribute toward RV ejection. CONCLUSIONS This case highlights the importance of left to RV interactions, and how PVSM may mediate these hemodynamic interactions.
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Affiliation(s)
- Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, USA.
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126
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Haddad F, Couture P, Tousignant C, Denault AY. The right ventricle in cardiac surgery, a perioperative perspective: II. Pathophysiology, clinical importance, and management. Anesth Analg 2009; 108:422-33. [PMID: 19151265 DOI: 10.1213/ane.0b013e31818d8b92] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in cardiac surgery and heart transplantation. In the first article of this review, key features of RV anatomy, physiology, and assessment were presented. In this second part, we review the pathophysiology, clinical importance, and management of RV failure in cardiac surgery.
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Affiliation(s)
- François Haddad
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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127
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Inhaled Nitric Oxide Therapy in Adult Cardiac Surgery. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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128
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Shim JK, Bang SO, Lee JH, Oh YJ, Yoo KJ, Kwak YL. Effect of intracoronary shunt on right ventricular function during off-pump grafting of dominant right coronary artery with poor collateral. J Korean Med Sci 2008; 23:373-7. [PMID: 18583869 PMCID: PMC2526513 DOI: 10.3346/jkms.2008.23.3.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although numerous studies have validated the efficacy of intracoronary shunt on reducing left ventricular dysfunction during off-pump coronary artery bypass surgery (OPCAB), there is lack of evidence supporting its role on right ventricular (RV) function during right coronary artery (RCA) revascularization. Therefore, we studied the effect of intracoronary shunt during grafting of dominant RCA without visible collateral supply on global RV function using thermodilution method. Forty patients scheduled for multivessel OPCAB with right dominant coronary circulation without collateral supply confirmed by angiography were randomized to RCA revascularization either with a shunt (n=20) or soft snare occlusion (n=20). RV ejection fraction (RVEF) was recorded at baseline, during RCA grafting, and 15 min after reperfusion. Corresponding RV stroke work index (RVSWI) was calculated. RVEF and RVSWI decreased significantly during RCA grafting and returned to baseline values after reperfusion in both groups without any significant differences between the groups. Intracoronary shunt did not exert any beneficial effect on global RV function during RCA grafting, even in the absence of visible collateral supply. Regarding the possibility of graft failure by intracoronary shunt-induced endothelial damage, routine use of intracoronary shunt during RCA grafting is not recommended in patients with preserved biventricular function.
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Affiliation(s)
- Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University Health System, Seoul, Korea
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129
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Tousignant CP, Miller AL, Denault A, Zhu L, Bowry R. The effect of heart rate on tricuspid annular velocities in cardiac surgical patients with atrial fibrillation. J Cardiothorac Vasc Anesth 2008; 22:565-9. [PMID: 18662632 DOI: 10.1053/j.jvca.2008.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Tricuspid annular isovolumic acceleration is a load-independent measure of contractility, but its relationship to heart rate is unknown in humans. The authors investigated the effect of heart rate on measurements of isovolumic acceleration and systolic wave velocities in postoperative cardiac surgical patients with atrial fibrillation. DESIGN This was a prospective observational study. SETTING Single-university hospital setting. PARTICIPANTS Postoperative cardiac surgical patients with atrial fibrillation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Lateral tricuspid isovolumic acceleration and peak systolic wave velocity were measured using color-tissue Doppler. The corresponding heart rate was calculated from the preceding R-R interval. Regression analysis was used to assess the relationship between heart rate and tricuspid annular velocity. A heart rate threshold value was determined at which the tissue Doppler variables were significantly altered by heart rate. Seven hundred fifteen beats in 15 patients were analyzed. There was a positive linear correlation between isovolumic acceleration and heart rate and a negative polynomial correlation between the systolic wave and heart rate. A significant reduction in systolic wave velocity occurred at heart rates greater than 110 beats/min. CONCLUSIONS In this patient population, isovolumic acceleration significantly increased with increasing heart rate. Tachycardia-induced preload alterations and impaired force-frequency responses may have been responsible for the decrease in systolic wave velocities.
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Affiliation(s)
- Claude P Tousignant
- Department of Anesthesia and Critical Care, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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130
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Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation 2008; 117:1717-31. [PMID: 18378625 DOI: 10.1161/circulationaha.107.653584] [Citation(s) in RCA: 877] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- François Haddad
- Division of Cardiovascular Medicine, Stanford University, 770 Welch Rd, Ste 400, Palo Alto, CA 94304-5715, USA.
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131
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Qizilbash B, Couture P, Denault A. Impact of Perioperative Transesophageal Echocardiography in Aortic Valve Replacement. Semin Cardiothorac Vasc Anesth 2008; 11:288-300. [DOI: 10.1177/1089253207311789] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intraoperative transesophageal echocardiography (TEE) is currently being used routinely during aortic valve replacement (AVR). TEE provides information that can lead to modifications of anesthetic and surgical care that leads to improved outcome. Numerous studies have shown that modifications in therapy occur from 10% to more than 40% of cases. The impact of TEE can be divided among modifications of therapy before, during, and after cardiopulmonary bypass. Before cardiopulmonary bypass, TEE can provide prognostic information, optimize hemodynamics, and diagnose conditions that were not appreciated before surgery, including patient—prosthesis mismatch. TEE can guide and modify the placement of various bypass cannulae. After bypass, TEE verifies the surgical result, rules out left and right ventricular outflow tract obstruction, and assures stable hemodynamics. Although current guidelines state that aortic valve surgery is a class IIa indication for TEE use, the authors' experience suggests that TEE should be routinely used in AVR.
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Affiliation(s)
- Baqir Qizilbash
- Department of Anesthesiology, Montreal Heart Institute/ Université de Montréal, Montreal, Quebec, Canada,
| | - Pierre Couture
- 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
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132
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Alzeer AH, Al-Mobeirek AF, Al-Otair HAK, Elzamzamy UAF, Joherjy IA, Shaffi AS. Right and left ventricular function and pulmonary artery pressure in patients with bronchiectasis. Chest 2007; 133:468-73. [PMID: 18071019 DOI: 10.1378/chest.07-1639] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Bronchiectasis may have deleterious effects on cardiac function secondary to pulmonary hypertension (PH). This study was designed to assess cardiac function and determine the prevalence of PH in patients with cystic and cylindrical bronchiectasis. METHODS A cross-sectional study of patients with bronchiectasis diagnosed by CT scan was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia between December 2005 and January 2007. Pulmonary function tests were performed, arterial blood gas measurements were made, and cardiac function and systolic pulmonary artery pressure (SPAP) were assessed by echocardiography. RESULTS Of 94 patients (31% men, n = 29), 62 patients (66%) had cystic bronchiectasis and 32 patients (34%) had cylindrical bronchiectasis. Right ventricular (RV) systolic dysfunction was observed in 12 patients (12.8%), left ventricular (LV) systolic dysfunction was observed in 3 patients (3.3%), and LV diastolic dysfunction was observed in 11 patients (11.7%); all had cystic bronchiectasis. RV dimensions were significantly greater in the cystic bronchiectasis group, and were positively correlated with SPAP (p < 0.0001) and negatively correlated with Pao2 (p < 0.016). Other hemodynamic variables were not different between groups. PH in 31 patients (32.9%) was significantly greater in patients with cystic bronchiectasis compared with cylindrical bronchiectasis (p = 0.04). In cystic bronchiectasis, SPAP was positively correlated with Paco2 (p = 0.001), and inversely correlated with Pao2 (p = 0.03), diffusion capacity of the lung for carbon monoxide percentage (p = 0.02), and FEV1 (p = 0.02). CONCLUSIONS RV systolic dysfunction and PH were more common than LV systolic dysfunction in bronchiectatic patients. LV diastolic dysfunction was mainly seen in severe PH. We recommend detailed assessment of cardiac function, particularly LV diastolic function, in patients with bronchiectasis.
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Affiliation(s)
- Abdulaziz H Alzeer
- Division of Pulmonary and Critical Care, Department of Medicine, King Khalid University Hospital, PO Box 18321, Riyadh 1145, Kingdom of Saudi Arabia.
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133
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Chumnanvej S, Wood MJ, MacGillivray TE, Melo MFV. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 2007; 105:583-601. [PMID: 17717209 DOI: 10.1213/01.ane.0000278088.22952.82] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ventricular assist devices (VADs) are systems for mechanical circulatory support of the patient with severe heart failure. Perioperative transesophageal echocardiography is a major component of patient management, and important for surgical and anesthetic decision making. In this review we present the rationale and available data for a comprehensive echocardiographic assessment of patients receiving a VAD. In addition to the standard examination, device-specific pre-, intra-, and postoperative considerations are essential to the echocardiographic evaluation. These include: (a) the pre-VAD insertion examination of the heart and large vessels to exclude significant aortic regurgitation, tricuspid regurgitation, mitral stenosis, patent foramen ovale, or other cardiac abnormality that could lead to right-to-left shunt after left VAD placement, intracardiac thrombi, ventricular scars, pulmonic regurgitation, pulmonary hypertension, pulmonary embolism, and atherosclerotic disease in the ascending aorta; and to assess right ventricular function; and (b) the post-VAD insertion examination of the device and reassessment of the heart and large vessels. The examination of the device aims to confirm completeness of device and heart deairing, cannulas alignment and patency, and competency of device valves using two-dimensional, and color, continuous and pulsed wave Doppler modalities. The goal for the heart examination after implantation should be to exclude aortic regurgitation, or an uncovered right-to-left shunt; and to assess right ventricular function, left ventricular unloading, and the effect of device settings on global heart function. The variety of VAD models with different basic and operation principles requires specific echocardiographic assessment targeted to the characteristics of the implanted device.
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Affiliation(s)
- Siriluk Chumnanvej
- Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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134
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Salem R, Denault AY, Couture P, Bélisle S, Fortier A, Guertin MC, Carrier M, Martineau R. Left ventricular end-diastolic pressure is a predictor of mortality in cardiac surgery independently of left ventricular ejection fraction. Br J Anaesth 2006; 97:292-7. [PMID: 16835254 DOI: 10.1093/bja/ael140] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Several risk factors have been shown to increase mortality in cardiac surgery. However, the importance of left ventricular end-diastolic pressure (LVEDP) as an independent risk factor before cardiac surgery is unclear. Method. This observational study investigated 3024 consecutive adult patients who underwent cardiac surgical procedures at the Montreal Heart Institute from 1996 to 2000. The primary outcome was in-hospital mortality with 99 deaths (3.3%) among these patients. RESULTS Of the 35 variables subjected to univariate analysis, 23 demonstrated a significant association with mortality. Stepwise multivariate logistic regression identified LVEDP as an independent predictor of mortality after cardiac surgery. The area under the receiver operating characteristic curve of the model predicting mortality was 0.85. CONCLUSIONS Elevated LVEDP is an independent predictor of mortality in cardiac surgery. This variable is independent of left ventricular ejection fraction.
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Affiliation(s)
- R Salem
- Department of Anesthesiology, Montreal Heart Institute Montreal, Quebec, H1T 1C8, Canada
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135
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Shi Y, Denault AY, Couture P, Butnaru A, Carrier M, Tardif JC. Biventricular diastolic filling patterns after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2006; 131:1080-6. [PMID: 16678593 DOI: 10.1016/j.jtcvs.2006.01.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 01/10/2006] [Accepted: 01/13/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We sought to study the evolution of biventricular filling properties after coronary artery bypass grafting. BACKGROUND The evolution of diastolic function as defined with newer echocardiographic modalities after coronary artery bypass grafting surgery is unknown in patients with preoperative left ventricular diastolic dysfunction. METHODS Transthoracic echocardiography was performed preoperatively and 48 hours and 6 months after coronary artery bypass grafting in 49 patients (randomized to milrinone [n = 25]) or placebo [n = 24]) with preoperative left ventricular diastolic dysfunction classified according to published criteria. Mild right ventricular diastolic dysfunction was defined as the ratio of early to atrial filling velocity of less than 1 in transtricuspid flow or the velocity of reversed atrial flow of greater than 50% of that of systolic flow in hepatic venous flow or the ratio of tricuspid annulus velocity during early and atrial filling of less than 1 if both the ratio of early to atrial filling velocity and the ratio of systolic to diastolic velocity was greater than 1 in hepatic venous flow. Moderate right ventricular diastolic dysfunction was diagnosed when there was a ratio of early to atrial filling velocity of greater than 1 with a ratio of systolic to diastolic velocity of less than 1. Severe right ventricular diastolic dysfunction was defined as a ratio of early to atrial filling velocity of greater than 1 associated with reversed systolic wave in hepatic venous flow. RESULTS Moderate and severe left ventricular diastolic dysfunction increased from preoperatively to 48 hours after coronary artery bypass grafting from 8.2% to 53.7% and from 2.0% to 9.7%, respectively (P < .0001, 48 hours vs preoperatively for both), and the patterns at 6 months were similar to those observed preoperatively. Similar evolution over time was found for right ventricular diastolic dysfunction. CONCLUSIONS In patients with preoperative left ventricular diastolic dysfunction, biventricular filling patterns are impaired initially but return to preoperative status 6 months after coronary artery bypass grafting.
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Affiliation(s)
- Yanfen Shi
- Department of Medicine, Montreal Heart Institute, and University of Montreal, Montreal, Quebec, Canada
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136
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Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MSJ, Stewart WJ. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2006; 18:1440-63. [PMID: 16376782 DOI: 10.1016/j.echo.2005.10.005] [Citation(s) in RCA: 8649] [Impact Index Per Article: 480.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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137
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Clark TJ, Sheehan FH, Bolson EL. Characterizing the normal heart using quantitative three-dimensional echocardiography. Physiol Meas 2006; 27:467-508. [PMID: 16603799 DOI: 10.1088/0967-3334/27/6/004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We present normative data on cardiac volume, geometry and shape derived using three-dimensional echocardiography (3-DE). Three-dimensional reconstructions were created using the piecewise smooth surface subdivision (PSSS) reconstruction technique of the left and right ventricular (LV and RV) endocardium and the mitral and tricuspid annuli (MA and TA) of 67 normal subjects. We derived LV end-diastolic (ED) and end-systolic (ES) volume indices (VI) of 76.5 +/- 16.8 ml m(-2) and 35.3 +/- 14.1 ml m(-2), LV ejection fraction (EF) of 56.1 +/- 9.93%, RV EDVI and ESVI of 93.2 +/- 20.0 ml m(-2) and 49.9 +/- 13.5 ml m(-2) and RVEF of 47.3 +/- 7.69%, along with data on the geometry and shape of the MA, TA, LV and RV. There was no pattern of consistent understatement or overstatement of volumes or dimensions compared with other imaging modalities, and observed variance in data can largely be accounted for through examination of the physics or protocol of each modality.
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Affiliation(s)
- T J Clark
- University of Washington Cardiovascular Research and Training Center, 1959 NE Pacific St, Box 356422, Seattle, WA 98195, USA.
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138
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Carricart M, Denault AY, Couture P, Limoges P, Babin D, Levesque S, Fortier A, Pellerin M, Tardif JC, Buithieu J. Incidence and significance of abnormal hepatic venous Doppler flow velocities before cardiac surgery. J Cardiothorac Vasc Anesth 2006; 19:751-8. [PMID: 16326300 DOI: 10.1053/j.jvca.2004.11.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the incidence and significance of abnormal hepatic Doppler venous flow velocities as signs of an abnormal right ventricular filling pattern before cardiac surgery. DESIGN Retrospective and prospective validation study. SETTING Tertiary care hospital. PARTICIPANTS Cardiac surgical patients (121 patients). INTERVENTIONS Not applicable. MEASUREMENTS Demographic, hemodynamic, and echocardiographic variables; vasoactive support; and difficult separation from bypass were compared between patients with or without abnormal hepatic venous Doppler flow. Logistic regression analysis was performed to identify predictors of difficult separation from bypass. Abnormal hepatic venous flow was observed in 23 (29%) and 17 patients (41%) in the retrospective and prospective study. Abnormal hepatic venous flow before surgery was associated with more vasoactive support in both the retrospective (p = 0.0362) and prospective study (p = 0.0163). In the prospective study, abnormal hepatic venous flow was associated with a higher Parsonnet score (p = 0.0005), more atrial fibrillation (p < 0.0001), pacemaker requirement (p = 0.0124), mitral valve replacement (p = 0.0325), reoperation (p = 0.0050), lower mean arterial pressure to pulmonary artery pressure ratio (p = 0.0127), higher wall motion score index (p = 0.0491), and higher incidence of abnormal right ventricular systolic function (p = 0.0139). Abnormal hepatic venous flow was not found to be an independent predictor of difficult separation from bypass. CONCLUSIONS Abnormal hepatic venous flow velocities before cardiac surgery are frequent and are associated with increased need for vasoactive support after cardiopulmonary bypass. However, it is not an independent predictor of difficult separation from bypass and worse outcome.
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Affiliation(s)
- Maïté Carricart
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
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139
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Durand M, Chavanon O, Tessier Y, Casez M, Gardellin M, Blin D, Girardet P. Right Ventricular Function After Coronary Surgery with or Without Bypass. J Card Surg 2006; 21:11-6. [PMID: 16426341 DOI: 10.1111/j.1540-8191.2006.00161.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Myocardial protection during aortic clamp period may sometimes be inadequate, especially for the right. The aim of this study was to compare right ventricle function after cardiac surgery with or without bypass. METHODS Patients undergoing multivessel coronary surgery with proximal severe right coronary lesion were included in a prospective observational cohort study including 29 patients undergoing coronary surgery with or without bypass. All patients were monitored with a pulmonary artery catheter with continuous right ventricular function. Right ventricular ejection fraction was measured at the arrival in ICU, 1, 3, 6, and 18 hours later. RESULTS The number of grafts that was higher in the bypass group (4.0 +/- 1.3) than in the off-pump group (2.6 +/- 0.6, p = 0.001). In the on-pump group, the right ventricular ejection fraction significantly decreased from 32.9 +/- 2.8 at arrival in ICU to 26.1 +/- 2.4, 6 hours later whereas in the off-pump group, it did not significantly change (32.4 +/- 1.8 to 31.9 +/- 2.3). Meanwhile, at the same time intervals, CVP was significantly lower in the off-pump group. CONCLUSIONS In patients with severe right coronary stenosis, off-pump cardiac surgery seemed to provide better right ventricular protection.
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Affiliation(s)
- Michel Durand
- Department of Anaesthesia, Grenoble University Hospital, Grenoble, France.
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140
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Augoustides JG, Ochroch EA. Pro: Inhaled Prostaglandin as a Pulmonary Vasodilator Instead of Nitric Oxide. J Cardiothorac Vasc Anesth 2005; 19:400-2. [PMID: 16130073 DOI: 10.1053/j.jvca.2005.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John G Augoustides
- Cardiothoracic Section, Hospital of the University of Pennsylvania, PA 19104, USA.
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141
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Abstract
PURPOSE OF REVIEW The evaluation of hemodynamic status in critically ill patients is a leading recommended indication of transesophageal echocardiography in the intensive care unit. Advantages and diagnostic yield of transesophageal echocardiography in this setting are particularly relevant when considering limitations and questioned prognostic impact of pulmonary artery catheterization. RECENT FINDINGS Recent clinical studies have been performed to validate and assess the value of transesophageal echocardiography in determining cardiac output, cardiac preload dependence, right ventricular function, and left ventricular filling pressure. In addition, diagnostic capacity and therapeutic impact of transesophageal echocardiography have been widely reported in various intensive care unit settings. SUMMARY Transesophageal echocardiography appears well suited for the determination of cardiac index and to track its variations after therapeutic interventions. Although repeated measurements of left ventricular end-diastolic dimension allows to accurately track preload variations, a single determination is not reliable to predict fluid responsiveness in intensive care unit patients. Identification of preload dependence in hemodynamically unstable patients currently tends to rely mainly on dynamic parameters that use cardiopulmonary interactions under mechanical ventilation. Transesophageal echocardiography also allows to adequately assess right ventricular function and left ventricular filling pressure using combined Doppler modalities. Adequate education and training of intensivists and anesthesiologists is crucial to further develop the use of transesophageal echocardiography in the intensive care unit setting. Despite the absence of randomized controlled studies documenting transesophageal echocardiography benefits on patient outcome, present evidence and experience strongly recommend a larger use of echocardiography Doppler for a comprehensive functional hemodynamic assessment of critically ill patients with circulatory failure.
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Affiliation(s)
- Philippe Vignon
- Medical-surgical intensive care unit, Dupuytren Teaching Hospital, Limoges, France.
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142
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Affiliation(s)
- John G Augoustides
- Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA
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143
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Zink W, Nöll J, Rauch H, Bauer H, Desimone R, Martin E, Böttiger BW. Continuous assessment of right ventricular ejection fraction: new pulmonary artery catheter versus transoesophageal echocardiography. Anaesthesia 2004; 59:1126-32. [PMID: 15479324 DOI: 10.1111/j.1365-2044.2004.03876.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In 25 cardiac surgical patients, right ventricular ejection fraction was continuously measured with a new pulmonary artery catheter and transoesophageal echocardiography, scanning the 'fractional area change' in a standardised transatrial cross section area. Measurements were recorded at three predefined time points (pre-, intra-, and postoperatively). Both methods were compared using the Bland-Altman analysis. Comparing right ventricular ejection fraction values obtained from the pulmonary artery catheter with those assessed by transoesophageal echocardiography, bias was -3.7%, with a precision of 30.9%. Bias and precision significantly improved when the heart rate was less than 100 beats.min(-1), pulmonary artery pressures were low and cardiac performance adequate. In conclusion, the new continuous pulmonary artery catheter system appears to be a valid and useful bedside monitoring device in the haemodynamic management of critically ill patients.
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Affiliation(s)
- W Zink
- Department of Anaesthesiology, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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144
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Fortier S, DeMaria RG, Lamarche Y, Malo O, Denault A, Desjardins F, Carrier M, Perrault LP. Inhaled prostacyclin reduces cardiopulmonary bypass-induced pulmonary endothelial dysfunction via increased cyclic adenosine monophosphate levels. J Thorac Cardiovasc Surg 2004; 128:109-16. [PMID: 15224029 DOI: 10.1016/j.jtcvs.2003.09.056] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass triggers a systemic inflammatory response that alters pulmonary endothelial function, which can contribute to pulmonary hypertension. This study was designed to demonstrate that inhaled prostacyclin, a selective pulmonary vasodilator prostaglandin, prevents pulmonary arterial endothelial dysfunction induced by cardiopulmonary bypass. METHODS Three groups of Landrace swine were compared: control without cardiopulmonary bypass (control group); 90 minutes of normothermic cardiopulmonary bypass (bypass group); 90 minutes of cardiopulmonary bypass and treated with prostacyclin during cardiopulmonary bypass (continuous nebulization with continuous positive airway pressure until the end of the cardiopulmonary bypass; prostacyclin group). After 60 minutes of reperfusion, swine were put to death and pulmonary arteries harvested. After contraction to phenylephrine, endothelium-dependent relaxation to bradykinin and acetylcholine was studied in standard organ chamber experiments. The pulmonary artery intravascular cyclic adenosine monophosphate content was compared between the 3 groups (post-cardiopulmonary bypass). RESULTS There was a statistically significant improvement of the endothelium-dependent relaxation to bradykinin in the prostacyclin group when compared with the bypass group (P <.05). There was no statistically significant difference for endothelium-dependent relaxation to acetylcholine (P >.05) between the prostacyclin and the bypass groups. There was a statistically significant decrease in the cyclic adenosine monophosphate content and a statistically significant increase of the mean pulmonary artery pressure in the bypass group only (P <.05). CONCLUSION Prophylactic use of inhaled prostacyclin has a favorable impact on the pulmonary endothelial dysfunction induced by cardiopulmonary bypass associated with preservation of pulmonary intravascular cyclic adenosine monophosphate content and the pulmonary vascular tone.
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Affiliation(s)
- S Fortier
- Research Center and Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
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