Doppler-defined pulmonary hypertension in sepsis and septic shock

Elevated lactate/albumin ratio is associated with poor prognosis in sepsis patients: A systematic review and meta-analysis

Background

The aim of this study was to explore the association between lactate/albumin ratio and the prognosis of sepsis patients.

Methods

A computerized search was performed in Pubmed, EMbase, Ovid, Medline, and Google Scholar to collate relevant studies. The results were compared using standardized mean differences (SMD)/odds ratio (OR) and 95% confidence intervals (CI). Prospective and retrospective cohort studies were both included in this study.

Melatonin: A potential protective multifaceted force for sepsis-induced cardiomyopathy

Sepsis is a life-threatening condition manifested by organ dysfunction caused by a dysregulated host response to infection. Lung, brain, liver, kidney, and heart are among the affected organs. Sepsis-induced cardiomyopathy is a common cause of death among septic patients. Sepsis-induced cardiomyopathy is characterized by an acute and reversible significant decline in biventricular both systolic and diastolic function. This is accompanied by left ventricular dilatation. The pathogenesis underlying sepsis-induced cardiomyopathy is multifactorial. Hence, targeting an individual pathway may not be effective in halting the extensive dysregulated immune response. Despite major advances in sepsis management strategies, no effective pharmacological strategies have been shown to treat or even reverse sepsis-induced cardiomyopathy. Melatonin, namely, N-acetyl-5-methoxytryptamine, is synthesized in the pineal gland of mammals and can also be produced in many cells and tissues. Melatonin has cardioprotective, neuroprotective, and anti-tumor activity. Several literature reviews have explored the role of melatonin in preventing sepsis-induced organ failure. Melatonin was found to act on different pathways that are involved in the pathogenesis of sepsis-induced cardiomyopathy. Through its antimicrobial, anti-inflammatory, and antioxidant activity, it offers a potential role in sepsis-induced cardiomyopathy. Its antioxidant activity is through free radical scavenging against reactive oxygen and nitrogen species and modulating the expression and activity of antioxidant enzymes. Melatonin anti-inflammatory activities control the overactive immune system and mitigate cytokine storm. Also, it mitigates mitochondrial dysfunction, a major mechanism involved in sepsis-induced cardiomyopathy, and thus controls apoptosis. Therefore, this review discusses melatonin as a promising drug for the management of sepsis-induced cardiomyopathy.

Extracorporeal membrane oxygenation in adult patients with sepsis and septic shock: Why, how, when, and for whom

Sepsis and septic shock remain the leading causes of death in intensive care units. Some patients with sepsis fail to respond to routine treatment and rapidly progress to refractory respiratory and circulatory failure, necessitating extracorporeal membrane oxygenation (ECMO). However, the role of ECMO in adult patients with sepsis has not been fully established. According to existing studies, ECMO may be a viable salvage therapy in carefully selected adult patients with sepsis. The choice of venovenous, venoarterial, or hybrid ECMO modes is primarily determined by the patient's oxygenation and hemodynamics (distributive shock with preserved cardiac output, septic cardiomyopathy (left, right, or biventricular heart failure), or right ventricular failure caused by acute respiratory distress syndrome). Veno-venous ECMO can be used in patients with sepsis and severe acute respiratory distress syndrome when conventional mechanical ventilation fails, and early application of veno-arterial ECMO in patients with sepsis-induced refractory cardiogenic shock may be critical in improving their chances of survival. When ECMO is indicated, the choice of an appropriate mode and determination of the optimal timing of initiation and weaning are critical, particularly in an experienced ECMO center. Furthermore, some special issues, such as ECMO flow, anticoagulation, and antibiotic therapy, should be noted during the management of ECMO support.

Prognostic implication of a novel right ventricular injury score in septic patients

AIMS

We aim to investigate the prognostic value of a right ventricular (RV) injury score based on the concept of RV dilation, RV systolic dysfunction, and RV-pulmonary arterial (PA) decoupling in septic patients and to explore whether the RV injury (RVI) score can be used to grade the severity of RV dysfunction in these patients.

METHODS AND RESULTS

Septic patients admitted to the ICU were prospectively included. We collected haemodynamic and echocardiographic parameters as well as prognostic information. RV dilation was defined as right and left ventricular end-diastolic area ratio (R/LVEDA) > 2/3. RVSD was defined as tricuspid annular plane systolic excursion (TAPSE) < 17 mm, right ventricular fractional area change (FAC) < 35%, or peak velocity of tricuspid annulus via tissue Doppler (S') < 10 cm/s. RV-PA decoupling was represented by the TAPSE/pulmonary arterial systolic pressure (PASP) ratio. RVI score were determined by the presence of the following findings: RVSD, RV dilation, and RV-PA decoupling, that is, one point for each finding. A total of 327 patients were enrolled in this study, among whom 276 survived and 51 died at 30 days after admission. Overall, 18.0% had RV dilation, 35.8% had RVSD, and 21.4% had RV-PA decoupling, with an appreciable overlap present. A multivariate Cox regression analysis showed that RV dilation (HR: 2.19, 95% CI: 1.19-4.01, P = 0.011), RVSD (HR: 2.25, 95% CI: 1.23-4.13, P = 0.009) and RV-PA decoupling (HR: 2.08, 95% CI: 1.19-3.65, P = 0.011) were independently associated with a 30 day mortality. Furthermore, RVI score was also an independent predictor, displayed additive effect with respect to 30 day mortality (RVI score 1 vs. RVI score 0, HR: 2.94, 95% CI: 1.20-7.20, P = 0.018; RVI score 2 vs. RVI score 0, HR: 3.20, 95% CI: 1.28-7.98, P = 0.013; RVI score 3 vs. RVI score 0, HR: 7.17, 95% CI: 2.65-19.38, P < 0.001), and had the best performance in model goodness of fit, discrimination and variance explained than the other RV indices.

CONCLUSIONS

The RVI score was independently related to 30 day mortality and had the potential to grade the severity of RV dysfunction in septic patients.

Association of sepsis-induced cardiomyopathy and mortality: a systematic review and meta-analysis

BACKGROUND

The implication of sepsis-induced cardiomyopathy (SIC) to prognosis is controversial, and its association with mortality at different stages remains unclear. We conducted a systematic review and meta-analysis to understand the association between SIC and mortality in septic patients.

METHODS

We searched and appraised observational studies regarding the mortality related to SIC among septic patients in PubMed and Embase from inception until 8 July 2021. Outcomes comprised in-hospital and 1-month mortality. We adopted the random-effects model to examine the mortality risk ratio in patients with and without SIC. Meta-regression, subgroup, and sensitivity analyses were applied to examine the outcome's heterogeneity.

RESULTS

Our results, including 20 studies and 4,410 septic patients, demonstrated that SIC was non-statistically associated with increased in-hospital mortality, compared to non-SIC (RR 1.28, [0.96-1.71]; p = 0.09), but the association was statistically significant in patients with the hospital stay lengths longer than 10 days (RR 1.40, [1.02-1.93]; p = 0.04). Besides, SIC was significantly associated with a higher risk of 1-month mortality (RR 1.47, [1.17-1.86]; p < 0.01). Among SIC patients, right ventricular dysfunction was significantly associated with increased 1-month mortality (RR 1.72, [1.27-2.34]; p < 0.01), while left ventricular dysfunction was not (RR 1.33, [0.87-2.02]; p = 0.18).

CONCLUSIONS

With higher in-hospital mortality in those hospitalized longer than 10 days and 1-month mortality, our findings imply that SIC might continue influencing the host's system even after recovery from cardiomyopathy. Besides, right ventricular dysfunction might play a crucial role in SIC-related mortality, and timely biventricular assessment is vital in managing septic patients.

N-terminal Pro-B-Type Natriuretic Peptide is a Myocardial Biomarker in Pulmonary Sepsis and Septic Shock

The objective: to study changes and prognostic significance of the blood NT-proBNP in the patients with pulmonary sepsis.

Subjects and Methods. The study included 34 patients aged 54.5 ± 2.9 years with pulmonary sepsis or septic shock. Lethality in the intensive care unit (ICU) was 47.1%. NT-proBNP, procalcitonin (PCT) levels, blood lactate and hemodynamic parameters were registered on the 1st day (stage 1) and on the 4th-5th day of the ICU stay (stage 2). Hemodynamics was assessed through transpulmonary thermodilution. The differences were considered statistically significant at p < 0.05.

Results: At stage 1, NT-proBNP level was 5,220 [1,380‒17,850] pg/ml, did not decrease (p = 0.726) at stage 2 and amounted to 1,760 [631‒847] pg/ml. At stage 1, NT-proBNP correlated with extravascular lung water index (rho = 0.445; p = 0.038) and systolic pulmonary artery pressure (rho = 0.414; p = 0.023). At stage 2, NT-proBNP correlated with PCT (rho = 0.569; p = 0.003), blood lactate (rho = 0.525; p = 0.001), and mean arterial pressure to norepinephrine dosage ratio (rho = -0.422; p = 0.035). At stage 1, NT-proBNP was no predictor of lethality in the ICU: OR 1.0000; 95% CI 1.0000-1.0001. At stage 2, NT-proBNP > 4,260 pg/ml (sensitivity 87.5%, specificity 94.4%) was a predictor of lethality: OR 1.0004, 95% CI 1.0000-1.0008, p = 0.046 (AUC 0.893, 95% CI 0.732-0.974). Any increase of NT-proBNP level (> 0 pg/ml) between stages 2 and 1 was a predictor of lethality (sensitivity 87.5%, specificity 94.4%): OR 119.0, 95% CI 9.7432‒1,453.4241, p = 0.0002 (AUC 0.903, 95% CI 0.751-0.977).

Conclusion: Patients with pulmonary sepsis are characterized by a significant increase of blood NT-proBNP. At stage 1, the biomarker correlated with pulmonary hypertension and moderate pulmonary edema and was no predictor of lethality. At stage 2, NT-proBNP correlated with the indices of infection and sepsis severity (procalcitonin, blood lactate, and mean arterial blood pressure/norepinephrine dosage ratio). At this stage, NT-proBNP levels greater than 4,000 pg/mL and/or any degree of increase in blood levels of the biomarker were both sensitive and specific predictors of a lethal outcome. Specific features of etiopathogenesis of BNP hyperproduction in pulmonary sepsis make it difficult to interpret the elevation of NT-proBNP as an indicator of septic cardiomyopathy but does not reduce its value as a sensitive and specific predictor of lethality.

Epidemiology and outcomes of pulmonary hypertension in the cardiac intensive care unit

AIMS

Pulmonary hypertension (PH) has been consistently associated with adverse outcomes in hospitalized patients. Limited epidemiologic data exist regarding PH in the cardiac intensive care unit (CICU) population. Here, we describe the prevalence, aetiology, and outcomes of PH in the CICU.

METHODS AND RESULTS

Cardiac intensive care unit patients admitted from 2007 to 2018 who had right ventricular systolic pressure (RVSP) measured via transthoracic echocardiography near CICU admission were included. PH was defined as RVSP >35 mmHg, and moderate-to-severe PH as RVSP ≥50 mmHg. Predictors of in-hospital mortality were determined using multivariable logistic regression. Among 5042 patients (mean age 69.4 ± 14.8 years; 41% females), PH was present in 3085 (61%). The majority (68%) of patients with PH had left heart failure, and 29% had lung disease. In-hospital mortality occurred in 8.3% and was more frequent in patients with PH [10.9% vs. 4.2%, adjusted odds ratio (OR) 1.40, 95% confidence interval (CI) 1.03-1.92, P = 0.03], particularly patients with moderate-to-severe PH (14.4% vs. 6.2%, adjusted OR 1.65, 95% CI 1.27-2.14, P < 0.001). In-hospital mortality increased incrementally as a function of higher RVSP (adjusted 1.18 per 10 mmHg increase, 95% CI 1.09-1.28, P < 0.001). Patients with higher RVSP or moderate-to-severe PH had increased in-hospital mortality across admission diagnoses (all P < 0.05).

CONCLUSIONS

Pulmonary hypertension is very common in the CICU population and appears to be independently associated with a higher risk of death during hospitalization, although the strength of this association varies according to the underlying admission diagnosis. These data highlight the importance of PH in patients with cardiac critical illness.

Right Ventricular Pulmonary Artery Coupling and Mortality in Cardiac Intensive Care Unit Patients

Background

Impaired right ventricular (RV) pulmonary artery coupling has been associated with higher mortality in patients with chronic heart disease, but few studies have examined this metric in critically ill patients. We sought to evaluate the association between RV pulmonary artery coupling, defined by the ratio of tricuspid annular peak systolic tissue Doppler velocity (TASV)/estimated RV systolic pressure (RVSP), and mortality in cardiac intensive care unit patients.

Methods and Results

Using a database of unique cardiac intensive care unit admissions from 2007 to 2018, we included patients with TASV/RVSP ratio measured within 1 day of hospitalization. Hospital mortality was analyzed using multivariable logistic regression, and 1‐year mortality was analyzed using multivariable Cox proportional‐hazards analysis. We included 4259 patients with a mean age of 69±15 years (40.1% women). Admission diagnoses included acute coronary syndrome in 56%, heart failure in 52%, respiratory failure in 24%, and cardiogenic shock in 12%. The mean TASV/RVSP ratio was 0.31±0.14, and in‐hospital mortality occurred in 7% of patients. Higher TASV/RVSP ratio was associated with lower in‐hospital mortality (adjusted unit odds ratio, 0.68 per each 0.1‐unit higher ratio; 95% CI, 0.58–0.79; P<0.001) and lower 1‐year mortality among hospital survivors (adjusted unit hazard ratio, 0.83 per each 0.1‐unit higher ratio; 95% CI, 0.77–0.90; P<0.001). Stepwise decreases in hospital and 1‐year mortality were observed in each higher TASV/RVSP quintile. The TASV/RVSP ratio remained associated with mortality after adjusting for left ventricular systolic and diastolic function.

Conclusions

A low TASV/RVSP ratio is associated with increased short‐term and long‐term mortality among cardiac intensive care unit patients, emphasizing importance of impaired RV pulmonary artery coupling as a determinant of poor prognosis. Further study is required to determine whether interventions to optimize RV pulmonary artery coupling can improve outcomes.

Reporting of sex as a variable in cardiovascular studies using cultured cells: A systematic review

Reporting the sex of biological material is critical for transparency and reproducibility in science. This study examined the reporting of the sex of cells used in cardiovascular studies. Articles from 16 cardiovascular journals that publish peer-reviewed studies in cardiovascular physiology and pharmacology in the year 2018 were systematically reviewed using terms "cultured" and "cells." Data were collected on the sex of cells, the species from which the cells were isolated, and the type of cells, and summarized as a systematic review. Sex was reported in 88 (38.6%) of the 228 studies meeting inclusion criteria. Reporting rates varied with Circulation, Cardiovascular Research and American Journal of Physiology: Heart and Circulatory Physiology having the highest rates of sex reporting (>50%). A majority of the studies used cells from male (54.5%) or both male and female animals (32.9%). Humans (31.8%), rats (20.4%), and mice (43.8%) were the most common sources for cells. Cardiac myocytes were the most commonly used cell type (37.0%). Overall reporting of sex of experimental material remains below 50% and is inconsistent among journals. Sex chromosomes in cells have the potential to affect protein expression and molecular signaling pathways and should be consistently reported.

Understanding ventriculo-arterial coupling

In the late 19th century, Otto Frank published the first description of a ventricular pressure-volume diagram, thus laid the foundation for modern cardiovascular physiology. Since then, the analysis of the pressure-volume loops became a reference tool for the study of the ventricular pump properties. However, understanding cardiovascular performance requires both the evaluation of ventricular properties and the modulating effects of the arterial system, since the heart and the arterial tree are anatomically and functionally related structures. The study of the coupling between the cardiac function and the properties of the arterial system, or ventriculo-arterial (VA) coupling, provides then a comprehensive characterization of the performance of the cardiovascular system in both health and disease. The assessment of cardiovascular function is an essential element of the hemodynamic evaluation of critically ill patients. Both left and right ventricular dysfunction and arterial system disturbances are frequent in these patients. Since VA coupling ultimately defines de performance and efficiency of the cardiovascular system, the analysis of the interaction between the heart and the arterial system could offer a broader perspective of the hemodynamic disorders associated with common conditions, such as septic shock, heart failure, or right ventricular dysfunction. Moreover, this analysis could also provide valuable information about their pathophysiological mechanisms and may help to determine the best therapeutic strategy to correct them. In this review, we will describe the basic principles of the VA coupling assessment, its limitations, and the most common methods for its estimation at the bedside. Then, we will summarize the current knowledge of the application of VA coupling in critically ill patients and suggest some recommendations for further research.

Pulmonary artery catheter use in acute myocardial infarction-cardiogenic shock

Aims

The aim of this study is to evaluate the contemporary use of a pulmonary artery catheter (PAC) in acute myocardial infarction‐cardiogenic shock (AMI‐CS).

Methods and results

A retrospective cohort of AMI‐CS admissions using the National Inpatient Sample (2000–2014) was identified. Admissions with concomitant cardiac surgery or non‐AMI aetiology for cardiogenic shock were excluded. The outcomes of interest were in‐hospital mortality, resource utilization, and temporal trends in cohorts with and without PAC use. In the non‐PAC cohort, the use and outcomes of right heart catheterization was evaluated. Multivariable regression and propensity matching was used to adjust for confounding. During 2000–2014, 364 001 admissions with AMI‐CS were included. PAC was used in 8.1% with a 75% decrease during over the study period (13.9% to 5.4%). Greater proportion of admissions to urban teaching hospitals received PACs (9.5%) compared with urban non‐teaching (7.1%) and rural hospitals (5.4%); P < 0.001. Younger age, male sex, white race, higher comorbidity, noncardiac organ failure, use of mechanical circulatory support, and noncardiac support were independent predictors of PAC use. The PAC cohort had higher in‐hospital mortality (adjusted odds ratio 1.07 [95% confidence interval 1.04–1.10]), longer length of stay (10.9 ± 10.9 vs. 8.2 ± 9.3 days), higher hospitalization costs ($128 247 ± 138 181 vs. $96 509 ± 116 060), and lesser discharges to home (36.3% vs. 46.4%) (all P < 0.001). In 6200 propensity‐matched pairs, in‐hospital mortality was comparable between the two cohorts (odds ratio 1.01 [95% confidence interval 0.94–1.08]). Right heart catheterization was used in 12.5% of non‐PAC admissions and was a marker of greater severity but did not indicate worse outcomes.

Conclusions

In AMI‐CS, there was a 75% decrease in PAC use between 2000 and 2014. Admissions receiving a PAC were a higher risk cohort with worse clinical outcomes.

Natriuretic Peptides to Predict Short-Term Mortality in Patients With Sepsis: A Systematic Review and Meta-analysis

Data are conflicting regarding the optimal cutoffs of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) to predict short-term mortality in patients with sepsis. We conducted a comprehensive search of several databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus) for English-language reports of studies evaluating adult patients with sepsis, severe sepsis, and septic shock with BNP/NT-proBNP levels and short-term mortality (intensive care unit, in-hospital, 28-day, or 30-day) published from January 1, 2000, to September 5, 2017. The average values in survivors and nonsurvivors were used to estimate the receiver operating characteristic curve (ROC) using a parametric regression model. Thirty-five observational studies (3508 patients) were included (median age, 51-75 years; 12%-74% males; cumulative mortality, 34.2%). A BNP of 622 pg/mL had the greatest discrimination for mortality (sensitivity, 0.695 [95% CI, 0.659-0.729]; specificity, 0.907 [95% CI, 0.810-1.003]; area under the ROC, 0.766 [95% CI, 0.734-0.797]). An NT-proBNP of 4000 pg/mL had the greatest discrimination for mortality (sensitivity, 0.728 [95% CI, 0.703-0.753]; specificity, 0.789 [95% CI, 0.710-0.867]; area under the ROC, 0.787 [95% CI, 0.766-0.809]). In prespecified subgroup analyses, identified BNP/NT-proBNP cutoffs had higher discrimination if specimens were obtained 24 hours or less after admission, in patients with severe sepsis/septic shock, in patients enrolled after 2010, and in studies performed in the United States and Europe. There was inconsistent adjustment for renal function. In this hypothesis-generating analysis, BNP and NT-proBNP cutoffs of 622 pg/mL and 4000 pg/mL optimally predicted short-term mortality in patients with sepsis. The applicability of these results is limited by the heterogeneity of included patient populations.

Favorable 90-Day Mortality in Obese Caucasian Patients with Septic Shock According to the Sepsis-3 Definition

Septic shock is a frequent life-threatening condition and a leading cause of mortality in intensive care units (ICUs). Previous investigations have reported a potentially protective effect of obesity in septic shock patients. However, prior results have been inconsistent, focused on short-term in-hospital mortality and inadequately adjusted for confounders, and they have rarely applied the currently valid Sepsis-3 definition criteria for septic shock. This investigation examined the effect of obesity on 90-day mortality in patients with septic shock selected from a prospectively enrolled cohort of septic patients. A total of 352 patients who met the Sepsis-3 criteria for septic shock were enrolled in this study. Body-mass index (BMI) was used to divide the cohort into 24% obese (BMI ≥ 30 kg/m²) and 76% non-obese (BMI < 30 kg/m²) patients. Kaplan-Meier survival analysis revealed a significantly lower 90-day mortality (31% vs. 43%; p = 0.0436) in obese patients compared to non-obese patients. Additional analyses of baseline characteristics, disease severity, and microbiological findings outlined further statistically significant differences among the groups. Multivariate Cox regression analysis estimated a significant protective effect of obesity on 90-day mortality after adjustment for confounders. An understanding of the underlying physiologic mechanisms may improve therapeutic strategies and patient prognosis.

Complications of Temporary Percutaneous Mechanical Circulatory Support for Cardiogenic Shock: An Appraisal of Contemporary Literature

Cardiogenic shock (CS) is associated with hemodynamic compromise and end-organ hypoperfusion due to a primary cardiac etiology. In addition to vasoactive medications, percutaneous mechanical circulatory support (MCS) devices offer the ability to support the hemodynamics and prevent acute organ failure. Despite the wide array of available MCS devices for CS, there are limited data on the complications from these devices. In this review, we seek to summarize the complications of MCS devices in the contemporary era. Using a systems-based approach, this review covers domains of hematological, neurological, vascular, infectious, mechanical, and miscellaneous complications. These data are intended to provide a balanced narrative and aid in risk-benefit decision-making in this acutely ill population.

The role of natriuretic peptides in the management, outcomes and prognosis of sepsis and septic shock

Sepsis continues to be a leading public health burden in the United States and worldwide. With the increasing use of advanced laboratory technology, there is a renewed interest in the use of biomarkers in sepsis to aid in more precise and targeted decision-making. Natriuretic peptides have been increasingly recognized to play a role outside of heart failure. They are commonly elevated among critically ill patients in the setting of cardiopulmonary dysfunction and may play a role in identifying patients with sepsis and septic shock. There are limited data on the role of these biomarkers in the diagnosis, management, outcomes and prognosis of septic patients. This review seeks to describe the role of natriuretic peptides in fluid resuscitation, diagnosis of ventricular dysfunction and outcomes and the prognosis of patients with sepsis. B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) have been noted to be associated with left ventricular systolic and diastolic and right ventricular dysfunction in patients with septic cardiomyopathy. BNP/NT-proBNP may predict fluid responsiveness, and trends of these peptides may play a role in fluid resuscitation. Despite suggestions of a correlation with mortality, the role of BNP in mortality outcomes and prognosis during sepsis needs further evaluation.

The 2016 ASE/EACVI recommendations may be able to more accurately identify patients at risk for diastolic dysfunction in living donor liver transplantation

Background

The aim of this study was to compare the prevalence of diastolic dysfunction between the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and 2009 ASE/European Association of Echocardiography recommendations in patients undergoing living-donor liver transplantation (LDLT).

Patients and methods

A total of 312 adult patients who underwent LDLT at our hospital from January 2010 to December 2017 were retrospectively analyzed. Exclusion criteria were systolic dysfunction, arrhythmia, myocardial ischemia, and mitral or aortic valvular insufficiency.

Results

The study population was largely male (68.3%), and the median age was 54 (49–59) years. The median model for end-stage liver disease score was 12 (6–22) points. A predominant difference in the prevalence rates of diastolic dysfunction was observed between the two recommendations. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the two recommendations was poor. The proportion of patients with a high brain natriuretic peptide level (> 100 pg/mL) decreased significantly during surgery in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction showed a poorer overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the two recommendations. A significant difference in patient survival rate was observed between the dysfunction and indeterminate groups according to the 2009 recommendations; however, the difference was not significant in the 2016 recommendations.

Conclusions

The 2016 classification may be better able to identify patients with a risk for diastolic dysfunction. Particularly, patients in the 2016 indeterminate group seemed to require a cardiac diastolic functional evaluation more frequently during and after surgery than those in the 2009 indeterminate group.