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Ayala S, Badakhsh O, Li D, Fleming NW. The effects of an IV fluid bolus on mitral annular velocity and the assessment of diastolic function: a prospective non-randomized study. BMC Anesthesiol 2024; 24:117. [PMID: 38532344 DOI: 10.1186/s12871-024-02503-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/18/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Abnormal diastolic function is an independent predictor of adverse postoperative outcomes. Mitral annular tissue Doppler velocity (e') is a key parameter for assessing diastolic function. The purpose of this study was to confirm that an acute increase in preload did not significantly impact the intraoperative measurement of e' and secondarily evaluate the impact of this acute intravascular volume increase on the clinical assessment of diastolic function using a previously described simplified algorithm. METHODS This was a prospective, non-randomized study in adult patients undergoing elective cardiac surgeries requiring transesophageal echocardiographic monitoring, arterial pressure and Swan-Ganz catheter placements as part of the surgical procedure. Following baseline echocardiographic and hemodynamic measurements, 500 ml of crystalloid solution was infused over 10 min. Hemodynamic and echocardiographic measurements were repeated 5 min after fluid administration. RESULTS Complete data sets were available from 84 of the 100 patients who were enrolled in this study. There was no significant change in the values of e'. The average baseline was 7.8 ± 2.0 cm/s (95%CI: 7.4, 8.2) and 8.1 ± 2.4 (95%CI: 7.6, 8.6) following the fluid bolus (p = 0.10). All hemodynamic variables associated with increased intravascular volume (central venous pressure, pulmonary arterial pressures and stroke volume variation) changed significantly. The overall distribution of diastolic function grades did not change following fluid administration (p = 0.69). However, there were many individual patient differences. When using this simplified algorithm, functional grading changed in 35 patients. Thirty of these 35 changes were only a single grade shift. 22 patients had worse functional grading after fluid administration while 13 had improved grading. Nine patients with normal diastolic function at baseline demonstrated diastolic dysfunction after fluid administration while 6 patients with baseline dysfunction normalized following the fluid bolus. CONCLUSION We confirmed that e' is a robust measurement that is reproducible in the intraoperative setting despite variable vascular volume loading conditions, however, the clinical assessment of diastolic function was still altered in 42% of the patients following an intravenous fluid bolus.
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Affiliation(s)
- Sebastian Ayala
- Department of Anesthesiology & Pain Medicine, University of California, Davis, 4150 V Street Suite 1200 PSSB, Sacramento, CA, 95817, USA
| | - Orode Badakhsh
- Department of Anesthesiology & Pain Medicine, University of California, Davis, 4150 V Street Suite 1200 PSSB, Sacramento, CA, 95817, USA
| | - David Li
- Department of Anesthesiology & Pain Medicine, University of California, Davis, 4150 V Street Suite 1200 PSSB, Sacramento, CA, 95817, USA
| | - Neal W Fleming
- Department of Anesthesiology & Pain Medicine, University of California, Davis, 4150 V Street Suite 1200 PSSB, Sacramento, CA, 95817, USA.
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Lee SH, Ahn HJ, Kim GM, Yang M, Kim JA, Lee SM, Heo BY, Choi JW, Lee JY, Jeong H, Kim J. Effect of Sevoflurane Anesthesia on Diastolic Function: A Prospective Observational Study. Anesth Analg 2024:00000539-990000000-00768. [PMID: 38412113 DOI: 10.1213/ane.0000000000006924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND The effect of sevoflurane on left ventricular diastolic function is not well understood. We hypothesized that parameters of diastolic function may improve under sevoflurane anesthesia in patients with preexisting diastolic dysfunction compared to patients with normal diastolic function. METHODS This observational study included 60 patients undergoing breast surgery or laparoscopic cholecystectomy. Patients were assigned to diastolic dysfunction (n = 34) or normal (n = 26) groups of septal e' < 8 or ≥ 8.0 cm/s on the first thoracic echocardiography (TTE) performed before anesthesia. During anesthesia, sevoflurane was maintained at 1 to 2 minimum alveolar concentration (MAC) to maintain the bispectral index at 40 to 50. At the end of surgery, the second TTE was performed under 0.8 to 1 MAC of sevoflurane with the patient breathing spontaneously without ventilator support. Primary end point was the percentage change (Δ) of e' on 2 TTEs (Δe'). Secondary end points were ΔE/e', Δleft atrial volume index (ΔLAVI), and Δtricuspid regurgitation maximum velocity (ΔTR Vmax). These percentage changes (Δ) were compared between diastolic dysfunction and normal groups. RESULTS e' (Δe': 30 [6, 64] vs 0 [-18, 11]%; P < .001), mitral inflow E wave velocity (E), mitral inflow E/A ratio (E/A), and mitral E velocity deceleration time (DT) improved significantly in diastolic dysfunction group compared to normal group. LAVI decreased in diastolic dysfunction group but did not reach statistical significance between the 2 groups (ΔLAVI:-15 [-31, -3] vs -4 [-20, 10]%, P = .091). ΔE/e' was not different between the 2 groups (11 [-16, 26] vs 12 [-9, 22]%, P = .853) (all: median [interquartile range, IQR]). TR was minimal in both groups. CONCLUSIONS In this study, echocardiographic parameters of diastolic function, including septal e', E, E/A, and DT, improved with sevoflurane anesthesia in patients with preexisting diastolic dysfunction, but remained unchanged in patients with normal diastolic function.
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Affiliation(s)
- Sang Hyun Lee
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Jamil Y, Huttler J, Alameddine D, Wu Z, Zhuo H, Mena-Hurtado C, Velazquez EJ, Guzman RJ, Ochoa Chaar CI. The Impact of Ejection Fraction on Major Adverse Limb Events after Lower Extremity Revascularization. Ann Vasc Surg 2024; 98:210-219. [PMID: 37802138 DOI: 10.1016/j.avsg.2023.08.009] [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: 04/20/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is commonly associated with coronary artery disease, and echocardiography is frequently performed before lower extremity revascularization (LER). However, the incidence of various echocardiographic findings in patients with PAD and their impact on the outcomes of LER has not been well studied. Reduced ejection fraction (EF) ≤ 40% is associated with increased major adverse limb events (MALE) after LER. METHODS The electronic medical records of patients undergoing LER in a single center were reviewed. Patients were divided based on the presence or absence of reduced EF. Patient, transthoracic echocardiogram, procedural characteristics, and outcomes were compared between the 2 groups. RESULTS A total of 1,114 patients (N = 131, 11.8% with reduced EF) underwent LER between 2013 and 2019. Patients with reduced EF were more likely to be male and have a history of coronary artery disease and heart failure. Furthermore, they were more likely to have diastolic dysfunction with moderate to severe mitral and tricuspid valve regurgitation. Patients with reduced EF were more likely to undergo LER for chronic limb-threatening ischemia, and to be treated with endovascular procedures. Perioperatively, patients with reduced EF were more likely to develop myocardial infarction. Lastly, the 2 groups had no difference in overall MALE or major amputation. However, on Kaplan-Meier curves, MALE-free survival was significantly lower for patients with reduced EF. Regression analysis demonstrated that indication and not EF was associated with MALE and MALE-free survival. CONCLUSIONS Reduced EF is associated with decreased MALE-free survival for patients with PAD undergoing LER.
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Affiliation(s)
- Yasser Jamil
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Dana Alameddine
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Zhen Wu
- Yale School of Public Health, New Haven, CT
| | | | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
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Sanfilippo F, Messina A, Scolletta S, Bignami E, Morelli A, Cecconi M, Landoni G, Romagnoli S. The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion. Anaesth Crit Care Pain Med 2023; 42:101283. [PMID: 37516408 DOI: 10.1016/j.accpm.2023.101283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Roma, Italy.
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Abstract
Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked-diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.
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Affiliation(s)
- Theodore J. Cios
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA,Theodore J. Cios, Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, 500 University Drive, H187, Hershey, PA 17033, USA.
| | - John C. Klick
- Department of Anesthesiology, The University of Vermont Medical Center, Burlington, VT, USA
| | - S. Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
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Meyer MJ, Jameson SA, Gillig EJ, Aggarwal A, Ratcliffe SJ, Baldwin M, Singh KE, Clouse WD, Blank RS. Clinical implications of preoperative echocardiographic findings on cardiovascular outcomes following vascular surgery: An observational trial. PLoS One 2023; 18:e0280531. [PMID: 36656845 PMCID: PMC9851553 DOI: 10.1371/journal.pone.0280531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/29/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Peripheral artery disease and cardiac disease are often comorbid conditions. Echocardiography is a diagnostic tool that can be performed preoperatively to risk stratify patients by a functional cardiac test. We hypothesized that ventricular dysfunction and valvular lesions were associated with an increased incidence of expanded major adverse cardiac events (Expanded MACE). METHODS AND MATERIALS Retrospective cohort study from 2011 to 2020 including all patients from a major academic center who had vascular surgery and an echocardiographic study within two years of the index procedure. RESULTS 813 patients were included in the study; a majority had a history of smoking (86%), an ASA score of 3 (65%), and were male (68%). Carotid endarterectomy was the most common surgery (24%) and the least common surgery was open abdominal aortic aneurysm repair (5%). We found no significant association between the echocardiographic findings of left ventricular dysfunction, right ventricular dysfunction, or valvular lesions and the postoperative development of Expanded MACE. CONCLUSIONS The preoperative echocardiographic findings of left ventricular dysfunction, right ventricular dysfunction and moderate to severe valvular lesions were not predictive of an increased incidence of postoperative Expanded MACE. We identified a significant association between RV dysfunction and post-operative dialysis that should be interpreted carefully due to the small number of outcomes. The transition from open to endovascular surgery and advances in perioperative management may have led to improved cardiovascular outcomes. TRIAL REGISTRATION Trial Registration: NCT04836702 (clinicaltrials.gov). https://www.google.com/search?client=firefox-b-d&q=NCT04836702.
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Affiliation(s)
- Matthew J. Meyer
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
- * E-mail:
| | - Slater A. Jameson
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Edward J. Gillig
- Department of Anesthesiology, Newton Wellesley Hospital, Newton, MA, United States of America
| | - Ankur Aggarwal
- Department of Surgery, Franciscan Physicians Network Vascular Surgeons, Indianapolis, IN, United States of America
| | - Sarah J. Ratcliffe
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Mary Baldwin
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Karen E. Singh
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - W. Darrin Clouse
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Randal S. Blank
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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Goeddel LA, Grant MC. Preoperative Evaluation and Cardiac Risk Assessment in Vascular Surgery. Anesthesiol Clin 2022; 40:575-585. [PMID: 36328616 DOI: 10.1016/j.anclin.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
We summarize epidemiologic trends, outcomes, and preoperative guidelines for vascular surgery patients from 2010 to 2022. Vascular surgery continues to evolve in technology and engineering to treat a surgical population that suffers from a high prevalence of comorbidities. Preoperative optimization seeks to characterize the burden of disease and to achieve medical control in the timeline available before surgery. Risk assessment, evaluation, optimization, and prediction of major adverse cardiac events is an evolving science where the Vascular Surgery Quality Initiative has made an impact. Ongoing investigation may demonstrate value for preoperative echocardiography, functional capacity, frailty, and mobility assessments.
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Affiliation(s)
- Lee A Goeddel
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6208J, 1800 Orleans, Baltimore, MD 21287, USA.
| | - Michael C Grant
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6208J, 1800 Orleans, Baltimore, MD 21287, USA
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 247] [Impact Index Per Article: 123.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Kyle B, Zawadka M, Shanahan H, Cooper J, Rogers A, Hamarneh A, Sivaraman V, Anwar S, Smith A. Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study. J Clin Med 2021; 10:jcm10215198. [PMID: 34768718 PMCID: PMC8584550 DOI: 10.3390/jcm10215198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Diastolic dysfunction is associated with major adverse outcomes following cardiac surgery. We hypothesized that multisystem endpoints of morbidity would be higher in patients with diastolic dysfunction. A total of 142 patients undergoing cardiac surgical procedures with cardiopulmonary bypass were included in the study. Intraoperative assessments of diastolic function according to the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines using transesophageal echocardiography were performed. Cardiac Postoperative Morbidity Score (CPOMS) on days 3, 5, 8, and 15; length of stay in ICU and hospital; duration of intubation; incidence of new atrial fibrillation; 30-day major adverse cardiac and cerebrovascular events were recorded. Diastolic function was determinable in 96.7% of the dataset pre and poststernotomy assessment (n = 240). Diastolic dysfunction was present in 70.9% (n = 88) of measurements before sternotomy and 75% (n = 93) after sternal closure. Diastolic dysfunction at either stage was associated with greater CPOMS on D5 (p = 0.009) and D8 (p = 0.009), with CPOMS scores 1.24 (p = 0.01) higher than in patients with normal function. Diastolic dysfunction was also associated with longer durations of intubation (p = 0.001), ICU length of stay (p = 0.019), and new postoperative atrial fibrillation (p = 0.016, OR (95% CI) = 4.50 (1.22–25.17)). We were able to apply the updated ASE/EACVI guidelines and grade diastolic dysfunction in the majority of patients. Any grade of diastolic dysfunction was associated with greater all-cause morbidity, compared with patients with normal diastolic function.
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Affiliation(s)
- Bonnie Kyle
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Mateusz Zawadka
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
- NIHR Biomedical Research Centre, William Harvey Research Institute, Barts, Queen Mary University of London, London E1 4NS, UK;
- 2 Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warsaw, Poland
- Polish National Agency for Academic Exchange, 00-635 Warsaw, Poland
- Correspondence: ; Tel.: +48-5992-002
| | - Hilary Shanahan
- Department of Anaesthesia and Critical Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB2 0AY, UK;
| | - Jackie Cooper
- NIHR Biomedical Research Centre, William Harvey Research Institute, Barts, Queen Mary University of London, London E1 4NS, UK;
| | - Andrew Rogers
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Ashraf Hamarneh
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Vivek Sivaraman
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Sibtain Anwar
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
- NIHR Biomedical Research Centre, William Harvey Research Institute, Barts, Queen Mary University of London, London E1 4NS, UK;
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Andrew Smith
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
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Subramaniam K, Subramanian H, Knight J, Mandell D, McHugh SM. An Approach to Standard Perioperative Transthoracic Echocardiography Practice for Anesthesiologists-Perioperative Transthoracic Echocardiography Protocols. J Cardiothorac Vasc Anesth 2021; 36:367-386. [PMID: 34629240 DOI: 10.1053/j.jvca.2021.08.100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 08/10/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022]
Abstract
The use of intraoperative transesophageal echocardiography (TEE) has become the standard of care for most cardiac surgical procedures. There are guidelines established for training, practice, and quality improvement in perioperative TEE by the joint efforts of the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists. Cardiac point-of-care ultrasound (POCUS) increasingly is being incorporated into anesthesiologists' training and practice. While a special "certification in Critical Care Echocardiography" was created by the National Board of Echocardiography in 2019, there currently exist no guidelines for training, certification, and practice of perioperative TTE by anesthesiologists. In this review, the authors describe the categories, indications and applications of perioperative TTE and provide a recommended sequence for performing an examination tailored to the evaluation of perioperative patients. Although the authors describe a protocol utilized at their institution, there are no standards described in the literature for PTTE. Cardiac anesthesiologists and cardiac anesthesia societies (Society of Cardiovascular Anesthesiologists, European Association of Cardiothoracic Anesthesiologists) must come forward to establish standards working in collaboration with echocardiography societies (American Society of Echocardiography, European Society of Cardiology).
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Daniel Mandell
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Stephen M McHugh
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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Mauermann E, Bouchez S, Bove T, Vandenheuvel M, Wouters P. Assessing Left Ventricular Early Diastolic Velocities With Tissue Doppler and Speckle Tracking by Transesophageal and Transthoracic Echocardiography. Anesth Analg 2021; 132:1400-1409. [PMID: 33857980 DOI: 10.1213/ane.0000000000005469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Assessing diastolic dysfunction is essential and should be part of every routine echocardiography examination. However, clinicians routinely observe lower mitral annular velocities by transesophageal echocardiography (TEE) under anesthesia than described by awake transthoracic echocardiography (TTE). It would be important to know whether this difference persists under constant loading conditions. We hypothesized that mean early diastolic mitral annular velocity, measured by tissue Doppler imaging (TDI, JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic1/v/2021-04-15T211206Z/r/image-tiff) would be different in the midesophageal 4-chamber (ME 4Ch) than in the apical 4-chamber (AP 4Ch) view under unchanged or constant loading conditions. Secondarily we examined (1) JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic2/v/2021-04-15T211206Z/r/image-tiff in an alternative transesophageal view with presumed superior Doppler beam alignment, the deep transgastric view (DTG), compared to those in the AP 4Ch, and (2) early diastolic speckle tracking-based strain rate (JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic3/v/2021-04-15T211206Z/r/image-tiff), in the ME 4Ch and in the AP 4Ch. METHODS Twenty-five consecutive adult patients undergoing on-pump cardiac surgery from February 2017 to July 2017 were included. Both TTE and TEE measurements were obtained under anesthesia in a randomized order in the AP 4Ch, ME 4Ch, and DTG views. Within-patient average values were compared by paired t tests with a Bonferroni adjustment. Box plots, correlation, and agreement by Bland-Altman were examined for all 3 comparisons. A second echocardiographer independently acquired and analyzed images; images were reanalyzed after 4 weeks. Image quality and reproducibility were also reported. RESULTS Averaged JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic4/v/2021-04-15T211206Z/r/image-tiff measurements were lower in the ME 4Ch than in the AP 4Ch (6.6 ± 1.7 cm/s vs 7.0 ± 1.5 cm, P = .028; within-patient difference mean ± standard deviation: 0.6 ± 1.2 cm/s). An alternative TEE view for JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic5/v/2021-04-15T211206Z/r/image-tiff, the DTG, also exhibited lower mean values (6.0 ± 1.6 cm/s, P = .006; within-patient difference mean ± standard deviation: 1.1 ± 1.8 cm/s). JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic6/v/2021-04-15T211206Z/r/image-tiff strain rate showed a low degree of bias, but greater variability (ME 4Ch: 0.87 ± 0.32%/s vs AP 4Ch: 0.73 ± 0.18%/s, P = .078; within-patient difference mean ± standard deviation: -0.1 ± 0.2%/s). CONCLUSIONS This study confirms that TEE modestly underestimates JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic7/v/2021-04-15T211206Z/r/image-tiff but not to a clinically relevant extent. While JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic8/v/2021-04-15T211206Z/r/image-tiff in the DTG is not a promising alternative, the future role for speckle tracking-based early diastolic strain rate is unknown.
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Affiliation(s)
- Eckhard Mauermann
- From the Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium.,Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Basel, Switzerland
| | - Stefaan Bouchez
- From the Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Thierry Bove
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Michael Vandenheuvel
- From the Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Patrick Wouters
- From the Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
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12
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Congestive Heart Failure Predicts Major Complications and Increased Length of Stay in Lower Extremity Pedicled Flap Reconstruction. Plast Reconstr Surg 2021; 146:790e-795e. [PMID: 33234977 DOI: 10.1097/prs.0000000000007363] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Congestive heart failure affects 6.2 million people in the United States. Patients have a decreased cardiopulmonary reserve and often suffer from peripheral edema, important considerations in lower extremity reconstructive surgery. In this study, the authors sought to determine the impact of congestive heart failure on postoperative outcomes following lower extremity pedicled flap reconstruction using a national multi-institutional database. METHODS The authors isolated all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent lower extremity pedicled flap reconstruction from 2010 to 2016. Preoperative, intraoperative, and postoperative variables were compared between patients with and without congestive heart failure. Multivariable regressions were performed to determine the independent effect of congestive heart failure on postoperative outcomes. RESULTS The authors identified 1895 patients who underwent lower extremity pedicled flap reconstruction, of whom 34 suffered from congestive heart failure. No significant difference was observed between patients with versus without congestive heart failure in postoperative wound complications (superficial wound infection, deep wound infection, and wound dehiscence), renal failure, or readmission. On multivariable analysis, congestive heart failure was independently associated with increased cardiopulmonary complications (i.e., myocardial infarction, cardiac arrest, pneumonia, reintubation, and failed ventilator weaning) (OR, 3.92; 95 percent CI, 1.53 to 9.12), septic events (OR, 4.65; 95 percent CI, 2.05 to 10.02), and length of hospital stay (β, 0.37; 95 percent CI, 0.01 to 0.72). CONCLUSIONS In patients undergoing lower extremity pedicled flap reconstruction, congestive heart failure independently predicts a four-fold increase in postoperative sepsis and cardiopulmonary complications and a significantly increased length of hospital stay. The authors' findings highlight the need for heightened perioperative vigilance and medical optimization in this high-risk population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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13
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Chou J, Ma M, Gylys M, Salvatierra N, Kim R, Ailin B, Rinehart J. Preexisting right ventricular systolic dysfunction in high-risk patients undergoing non.emergent open abdominal surgery: A retrospective cohort study. Ann Card Anaesth 2021; 24:62-71. [PMID: 33938834 PMCID: PMC8081126 DOI: 10.4103/aca.aca_46_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: The prognostic value of right ventricular systolic dysfunction in high-risk patients undergoing non-emergent open abdominal surgery is unknown. Here, we aim to evaluate whether presence of preexisting right ventricular systolic dysfunction in this surgical cohort is independently associated with higher incidence of postoperative major adverse cardiac events and all-cause in-hospital mortality. Methods: This is a single-centered retrospective study. Patients identified as American Society Anesthesiology Classification III and IV who had a preoperative echocardiogram within 1 year of undergoing non-emergent open abdominal surgery between January 2010 and May 2017 were included in the study. Incidence of postoperative major cardiac adverse events and all-cause in-hospital mortality were collected. Multivariable logistic regression was performed in a step-wise manner to identify independent association between preexisting right ventricular systolic dysfunction with outcomes of interest. Results: Preexisting right ventricular systolic dysfunction was not associated with postoperative major adverse cardiac events (P = 0.26). However, there was a strong association between preexisting right ventricular systolic dysfunction and all-cause in-hospital mortality (P = 0.00094). After multivariate analysis, preexisting right ventricular systolic dysfunction continued to be an independent risk factor for all-cause in-hospital mortality with an odds ratio of 18.9 (95% CI: 1.8-201.7; P = 0.015). Conclusion: In this retrospective study of high-risk patients undergoing non-emergent open abdominal surgery, preexisting right ventricular systolic dysfunction was found to have a strong association with all-cause in-hospital mortality.
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Affiliation(s)
- Jody Chou
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 333 City Blvd. West Suite 2150
| | - Michael Ma
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 333 City Blvd. West Suite 2150
| | - Maryte Gylys
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 333 City Blvd. West Suite 2150
| | - Nicolas Salvatierra
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 333 City Blvd. West Suite 2150
| | - Robert Kim
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 333 City Blvd. West Suite 2150
| | - Barseghian Ailin
- Department of Interventional Cardiology, Internal Medicine - University of California Irvine Medical Center, 101 The City Drive South, Pavilion 4 Building 25 Orange, CA 868
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 333 City Blvd. West Suite 2150
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14
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Zawadka M, Marchel M, Dudek P, Andruszkiewicz P, Jakimowicz T, Gąsecka A, Kutka M, Poelaert J. Cardiac Stress in High-Risk Patients Undergoing Major Endovascular Surgery-Focus on Diastolic Function. J Cardiothorac Vasc Anesth 2020; 35:2345-2354. [PMID: 33342737 DOI: 10.1053/j.jvca.2020.11.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/16/2020] [Accepted: 11/23/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the relationship between the changes in diastolic function and their association with cardiac biomarkers in the perioperative period in patients undergoing complex endovascular aortic repair. DESIGN Prospective observational study. SETTING Single-center academic hospital, central teaching hospital in Warsaw, Poland. PARTICIPANTS The study comprised 27 high-risk patients scheduled for elective endovascular repair of aortic aneurysm. INTERVENTIONS Complex endovascular procedure using branched endograft of the thoracoabdominal aorta. Branches of the stent grafts included renal arteries, the superior mesenteric artery, and the celiac trunk. MEASUREMENTS AND MAIN RESULTS The primary outcome was to evaluate changes in diastolic function parameters assessed with transthoracic echocardiography at two and 24 hours postoperatively. The major secondary outcomes were changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) and troponin I concentrations, systolic function parameters, hemodynamic parameters at two and 24 hours, length of hospital stay, and 30-day mortality. There was a reduction in e' wave velocity on both the septal and lateral sides at two hours compared with the baseline (p = 0.041 and p = 0.05, respectively). There was an increase in both NT-proBNP and troponin I concentrations after surgery (p = 0.002 and p = 0.034, respectively), with troponin I peaking two hours after surgery and NT-proBNP peaking 24 hours after surgery. CONCLUSIONS Patients undergoing a branched endovascular aortic repair of a thoracoabdominal aortic aneurysm experience a cardiac insult that manifests with deterioration in diastolic parameters and concomitant increases of troponin and NT-proBNP concentrations. Additional large-scale prospective studies are required to confirm this phenomenon.
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Affiliation(s)
- M Zawadka
- 2nd Department of Anesthesiology and Intensive Care Medical University of Warsaw, Warsaw, Poland; Perioperative Medicine, Barts Heart Centre and St. Bartholomew's Hospital, London, UK; Polish National Agency for Academic Exchange, Warsaw, Poland
| | - M Marchel
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
| | - P Dudek
- 2nd Department of Anesthesiology and Intensive Care Medical University of Warsaw, Warsaw, Poland
| | - P Andruszkiewicz
- Department of Anesthesiology and Intensive Care, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - T Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - A Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - M Kutka
- 2nd Department of Anesthesiology and Intensive Care Medical University of Warsaw, Warsaw, Poland
| | - J Poelaert
- Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
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15
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Pagel PS, Tawil JN, Boettcher BT, Izquierdo DA, Lazicki TJ, Crystal GJ, Freed JK. Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:1839-1859. [PMID: 32747202 DOI: 10.1053/j.jvca.2020.07.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction (HFpEF). The proportion and hospitalization rate of patients with HFpEF are increasing steadily relative to patients in whom heart failure occurs as result of reduced ejection fraction. The predominance of the HFpEF phenotype most likely is explained by the prevalence of medical conditions associated with an aging population. A multitude of age-related, medical, and lifestyle risk factors for HFpEF have been identified as potential causes for the sustained low-grade proinflammatory state that accelerates disease progression. Profound left ventricular (LV) systolic and diastolic stiffening, elevated LV filling pressures, reduced arterial compliance, left atrial hypertension, pulmonary venous congestion, and microvascular dysfunction characterize HFpEF, but pulmonary arterial hypertension, right ventricular dilation and dysfunction, and atrial fibrillation also frequently occur. These cardiovascular features make patients with HFpEF exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery. With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for these unfortunate individuals. Patients with HFpEF present for surgery on a regular basis, and anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care. In this article, the authors review the diagnosis, pathophysiology, and treatment of HFpEF and also discuss its perioperative implications.
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Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Brent T Boettcher
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - David A Izquierdo
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lazicki
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - George J Crystal
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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Willingham M, Ayoubi SA, Doan M, Wingert T, Scovotti J, Howard-Quijano K, Neelankavil JP. Preoperative Diastolic Dysfunction and Postoperative Outcomes after Noncardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:679-686. [DOI: 10.1053/j.jvca.2019.09.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/17/2019] [Accepted: 09/20/2019] [Indexed: 01/22/2023]
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17
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Bohsali F, Klimpl D, Baumgartner R, Sieber F, Eid SM. Effect of Heart Failure With Preserved Ejection Fraction on Perioperative Outcomes in Patients Undergoing Hip Fracture Surgery. J Am Acad Orthop Surg 2020; 28:e131-e138. [PMID: 31977615 DOI: 10.5435/jaaos-d-18-00731] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Heart failure is a leading cause of morbidity and mortality in hip fracture surgery. The impact of heart failure with preserved ejection fraction (HFpEF) is poorly understood in this population. We designed a study to evaluate national perioperative outcomes in hip fracture for patients with HFpEF. METHODS Patients with hip fracture undergoing total hip arthroplasty, hemiarthroplasty, or open/closed reduction with internal and external fixation from January 2005 to December 2013 were identified using the Nationwide Inpatient Sample. Inpatient outcomes during the index hospitalization were compared between patients without heart failure and with HFpEF. Heart failure with reduced ejection fraction was included as a secondary comparator. Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs), defined as in-hospital all-cause death, acute myocardial infarction, and in-hospital cardiac arrest or acute ischemic stroke, were evaluated. RESULTS Among 2,020,712 hospitalizations for hip fracture surgery, perioperative MACCE occurred in 67,554 hospitalizations (3.3%), corresponding to an annual incidence of approximately 7,506 events after applying sample weights. Compared with patients without heart failure, patients with HFpEF experienced increased odds of MACCE, adjusted odds ratio [aOR], 1.69; 95% confidence interval (CI), 1.51 to 1.89. In comparison, the aOR of experiencing a MACCE event in the heart failure with reduced ejection fraction group was 1.75 (95% CI, 1.57 to 1.96). HFpEF was also associated with increased odds of acute respiratory failure (aOR, 1.71; 95% CI, 1.53 to 1.91) and acute renal failure (aOR, 1.52; 95% CI, 1.41 to 1.64). CONCLUSION HFpEF confers a significant perioperative risk of MACCE in patients undergoing hip fracture surgery.
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Affiliation(s)
- Fuad Bohsali
- From the Department of Medicine, Duke University School of Medicine, Durham, NC (Dr. Bohsali), the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Klimpl and Dr. Eid), the Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC (Dr. Baumgartner), and the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Sieber)
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18
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Smilowitz NR, Banco D, Katz SD, Beckman JA, Berger JS. Association between heart failure and perioperative outcomes in patients undergoing non-cardiac surgery. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 7:68-75. [PMID: 31873731 DOI: 10.1093/ehjqcco/qcz066] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 12/13/2022]
Abstract
AIMS Heart failure (HF) affects ∼5.7 million US adults and many of these patients develop non-cardiac disease that requires surgery. The aim of this study was to determine perioperative outcomes associated with HF in a large cohort of patients undergoing in-hospital non-cardiac surgery. METHODS AND RESULTS Adults ≥18 years old undergoing non-cardiac surgery between 2012 and 2014 were identified using the Healthcare Cost and Utilization Project National Inpatient Sample. Patients with HF were identified by ICD-9 diagnosis codes. The primary outcome was all-cause in-hospital mortality. Multivariable logistic regression models were used to estimate associations between HF and outcomes. A total of 21 560 996 surgical hospitalizations were identified, of which 1 063 405 (4.9%) had a diagnosis of HF. Among hospitalizations with HF, 4.7% had acute HF, 11.3% had acute on chronic HF, 27.8% had chronic HF, and 56.2% had an indeterminate diagnosis code that did not specify temporality. In-hospital perioperative mortality was more common among patients with any diagnosis of HF compared to those without HF [4.8% vs. 0.78%, P < 0.001; adjusted odds ratio (aOR) 2.15, 95% confidence interval (CI) 2.09-2.22], and the association between HF and mortality was greatest at small and non-teaching hospitals. Acute HF without chronic HF was associated with 8.0% mortality. Among patients with a chronic HF diagnosis, perioperative mortality was greater in those with acute on chronic HF compared to chronic HF alone (7.8% vs. 3.9%, P < 0.001; aOR 1.78, 95% CI 1.67-1.90). CONCLUSION In patients hospitalized for non-cardiac surgery, HF was common and was associated with increased risk of perioperative mortality. The greatest risks were in patients with acute HF.
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Affiliation(s)
- Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA.,Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, 423 East 23rd Street, 12W New York, NY 10010, USA
| | - Darcy Banco
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
| | - Joshua A Beckman
- Department of Medicine, Vanderbilt University School of Medicine, 1215 21st Ave South Nashville, TN 37232, USA
| | - Jeffery S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA.,Department of Surgery, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
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19
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Preoperative elevated E/e' (≥ 15) with preserved ejection fraction is associated with the development of postoperative heart failure in intermediate-risk non-cardiac surgical patients. J Anesth 2020; 34:250-256. [PMID: 31897609 PMCID: PMC7098923 DOI: 10.1007/s00540-019-02728-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/21/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Left ventricular diastolic dysfunction is an independent risk factor for adverse cardiovascular morbidities and mortalities in cardiovascular and high-risk surgical patients. However, there were only a few investigations among intermediate-risk surgical patients. This study aimed to investigate postoperative heart failure (HF) in intermediate-risk surgical patients who had preoperative diastolic dysfunction with preserved ejection fraction (EF). METHODS Consecutive patients underwent intermediate-risk surgery between January 2016 and December 2018 were retrospectively evaluated. Patients with preserved EF were divided into three groups using one of the parameters of diastolic function: the ratio of early diastolic filling velocity to the peak diastolic velocity of mitral medial annulus (E/e') ≥ 15, E/e' between 8 and 15, and E/e' < 8. Postoperative HF was defined as clinical symptoms and radiological evidence and low SpO2 less than 93%. The primary outcome was the incidence of postoperative HF and its relation to preoperative E/e'. Chi-squared test, unpaired t test with Welch's correction, and multivariate logistic regression were used for analysis. RESULTS In total, 965 patients were included in the final analysis. Postoperative HF developed in 36/965 (3.7%) patients with preserved EF. The incidence of postoperative HF was stratified according to the E/e', and the rates of HF occurrence in patients with E/e' < 8, 8-15, and ≥ 15 were 1.8%, 2.7%, and 15%, respectively (P < 0.01). CONCLUSION Preoperative elevated E/e' (≥ 15) was associated with the development of postoperative HF in intermediate-risk surgical patients with preserved EF.
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20
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Zawadka M, Marchel M, Andruszkiewicz P. Diastolic dysfunction of the left ventricle - a practical approach for an anaesthetist. Anaesthesiol Intensive Ther 2020; 52:237-244. [PMID: 32419432 PMCID: PMC10172939 DOI: 10.5114/ait.2020.94486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/21/2020] [Indexed: 01/06/2024] Open
Abstract
Bedside point-of-care echocardiography is being increasingly incorporated in peri-operative assessment and in intensive care units. Because of availability of tissue Doppler imaging in the modern ultrasound machines there has been an increased interest in research of diastolic function of left ventricle. The diastolic function is crucial for the hemodynamically effective function of the heart. Diastolic dysfunction is a well-established risk factor of the major adverse cardiac events during perioperative period, complications during weaning from ventilator and prognostic factor of mortality in septic shock.
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Affiliation(s)
- Mateusz Zawadka
- 2 Department of Anaestesiology and Intensive Therapy, Medical University of Warsaw, Warsaw, Poland
| | - Michał Marchel
- 1 Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Andruszkiewicz
- 2 Department of Anaestesiology and Intensive Therapy, Medical University of Warsaw, Warsaw, Poland
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21
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Effect of left ventricular diastolic dysfunction on development of primary graft dysfunction after lung transplant. Curr Opin Anaesthesiol 2019; 33:10-16. [PMID: 31789901 DOI: 10.1097/aco.0000000000000811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is one of the most common complications after lung transplant and is associated with significant early and late morbidity and mortality. The cause of primary graft dysfunction is often multifactorial involving patient, donor, and operational factors. Diastolic dysfunction is increasingly recognized as an important risk factor for development of PGD after lung transplant and here we examine recent evidence on the topic. RECENT FINDINGS Patients with end-stage lung disease are more likely to suffer from cardiovascular disease including diastolic dysfunction. PGD as result of ischemia-reperfusion injury after lung transplant is exacerbated by increased left atrial pressure and pulmonary venous congestion impacted by diastolic dysfunction. Recent studies on relationship between diastolic dysfunction and PGD after lung transplant show that patients with diastolic dysfunction are more likely to develop PGD with worse survival outcome and complicated hospital course. SUMMARY Patients with diastolic dysfunction is more likely to suffer from PGD after lung transplant. From the lung transplant candidate selection to perioperative and posttransplant care, thorough evaluation and documentation diastolic dysfunction to guide patient care are imperative.
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Jun IJ, Kim J, Kim HG, Koh GH, Hwang JH, Kim YK. Risk factors of postoperative major adverse cardiac events after radical cystectomy: implication of diastolic dysfunction. Sci Rep 2019; 9:14096. [PMID: 31575918 PMCID: PMC6773750 DOI: 10.1038/s41598-019-50582-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 09/16/2019] [Indexed: 12/12/2022] Open
Abstract
Radical cystectomy, which is a standard treatment of muscle invasive and high-grade non-invasive bladder tumour, is accompanied with high rates of postoperative complications including major adverse cardiac events (MACE). Diastolic dysfunction is associated with postoperative complications. We evaluated perioperative risk factors including diastolic dysfunction related with MACE within 6 months after radical cystectomy. The 546 patients who underwent elective radical cystectomy were included. Diastolic dysfunction was defined as early transmitral flow velocity (E)/early diastolic mitral annulus velocity (e′) > 15. Logistic regression analysis, Kaplan-Meier survival analysis and log-rank test were performed. MACE within 6 months after radical cystectomy developed in 43 (7.9%) patients. MACE was related with female (odds ratio 2.546, 95% confidence interval 1.166–5.557, P = 0.019) and diastolic dysfunction (odds ratio 3.077, 95% confidence interval 1.147–8.252, P = 0.026). The 6-month mortality were significantly higher in the MACE group, and hospital stay and intensive care unit stay were significantly longer in the MACE group compared to the non-MACE group. Accordingly, preoperative diastolic dysfunction (E/e′ > 15) was related with postoperative MACE and MACE was related with 6-month survival after radical cystectomy. These results suggest that preoperative diastolic dysfunction can provide useful information on postoperative complications.
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Affiliation(s)
- In-Jung Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, University of Hallym College of Medicine, Seoul, Korea
| | - Junghwa Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, University of Hallym College of Medicine, Seoul, Korea
| | - Hyun-Gyu Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, University of Hallym College of Medicine, Seoul, Korea
| | - Gi-Ho Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Mahmood E, Khabbaz KR, Bose R, Mitchell J, Zhang Q, Chaudhary O, Mahmood F, Matyal R. Immediate Preoperative Transthoracic Echocardiography for the Prediction of Postoperative Atrial Fibrillation in High-Risk Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:719-725. [PMID: 31635984 DOI: 10.1053/j.jvca.2019.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/17/2019] [Accepted: 09/18/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study aimed to validate the utility of bedside cardiac ultrasound to identify patients for the risk of postoperative atrial fibrillation (POAF). DESIGN A prospective cohort study of consecutive patients. SETTING Single-center tertiary referral center. PARTICIPANTS After Institutional Review Board consent, 169 patients undergoing elective cardiac surgery were enrolled in the study. INTERVENTIONS A preoperative transthoracic echocardiographic interrogation assessing diastolic function was performed. Measurements were assessed offline with experienced echocardiographers blinded to clinical outcomes. MEASUREMENTS AND MAIN RESULTS The primary outcome was POAF during the first 72 hours after surgery. A total of 169 patients completed the study, 44 of whom (26.0%) developed POAF, and 39 (25.2%) had diastolic dysfunction. Patients with POAF had a higher rate of postoperative heart failure, reintubation within 24 hours of surgery, and length of stay (p = 0.002, 0.01, and 0.0006, respectively). Predictors significant for POAF included increasing age, left atrial volume indexed to body surface area (LAVI), and diastolic dysfunction (p = 0.02, 0.0001, and 0.001, respectively). Multivariate spline regressions demonstrated a nonlinear correlation between increasing LAVI and risk of POAF. CONCLUSION Left atrial volume can be assessed efficiently preoperatively to provide superior risk stratification over clinical factors and diastolic parameters alone for the prediction of POAF. Furthermore, the present study demonstrated that the cutoffs of chamber quantification currently used do not appropriately capture the increased risk of POAF. Thus, LAVI provides a simple measure to identify patients who are in need of targeted prophylaxis for POAF.
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Affiliation(s)
- Eitezaz Mahmood
- Department of Cardiothoracic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ruma Bose
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - John Mitchell
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Qianqian Zhang
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Omar Chaudhary
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robina Matyal
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
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Beaubien-Souligny W, Brand FZA, Lenoir M, Amsallem M, Haddad F, Denault AY. Assessment of Left Ventricular Diastolic Function by Transesophageal Echocardiography Before Cardiopulmonary Bypass: Clinical Implications of a Restrictive Profile. J Cardiothorac Vasc Anesth 2019; 33:2394-2401. [DOI: 10.1053/j.jvca.2019.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 12/23/2022]
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Zhou Y, Liu L, Cheng T, Wang DX, Yang HY, Zhang BW, Yang Y, Chen F, Li XY. Grade 3 Echocardiographic Diastolic Dysfunction Is Associated With Increased Risk of Major Adverse Cardiovascular Events After Surgery: A Retrospective Cohort Study. Anesth Analg 2019; 129:651-658. [PMID: 31425203 PMCID: PMC6693928 DOI: 10.1213/ane.0000000000003807] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diastolic dysfunction is common and may increase the risk of cardiovascular complications. This study investigated the hypothesis that, in patients with isolated left ventricular diastolic dysfunction, higher grade diastolic dysfunction was associated with greater risk of major adverse cardiovascular events (MACEs) after surgery. METHODS This was a retrospective cohort study. Data of adult patients with isolated echocardiographic diastolic dysfunction (ejection fraction, ≥50%) who underwent noncardiac surgery from January 1, 2015 to December 31, 2015 were collected. The primary end point was the occurrence of postoperative MACEs during hospital stay, which included acute myocardial infarction, congestive heart failure, stroke, nonfatal cardiac arrest, and cardiac death. The association between the grade of diastolic dysfunction and the occurrence of MACEs was assessed with a multivariable logistic model. RESULTS A total of 2976 patients were included in the final analysis. Of these, 297 (10.0%) developed MACEs after surgery. After correction for confounding factors, grade 3 diastolic dysfunction was associated with higher risk of postoperative MACEs (odds ratio, 1.71; 95% confidence interval, 1.28-2.27; P < .001) when compared with grades 1 and 2. Patients with grade 3 diastolic dysfunction developed more non-MACE complications when compared with grades 1 and 2 (uncorrected odds ratio, 1.44; 95% confidence interval, 1.07-1.95; P = .017). CONCLUSIONS In patients with isolated diastolic dysfunction undergoing noncardiac surgery, 10.0% develop MACEs during hospital stay after surgery; grade 3 diastolic dysfunction is associated with greater risk of MACEs.
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Affiliation(s)
- Yan Zhou
- From the Departments of Anesthesiology and Critical Care Medicine
| | | | - Tong Cheng
- From the Departments of Anesthesiology and Critical Care Medicine
| | - Dong-Xin Wang
- From the Departments of Anesthesiology and Critical Care Medicine
| | | | | | | | | | - Xue-Ying Li
- Biostatistics, Peking University First Hospital, Beijing, China
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Sharkey A, Mahmood F, Matyal R. Diastolic dysfunction - What an anesthesiologist needs to know? Best Pract Res Clin Anaesthesiol 2019; 33:221-228. [PMID: 31582101 DOI: 10.1016/j.bpa.2019.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 06/27/2019] [Accepted: 07/09/2019] [Indexed: 01/24/2023]
Abstract
Diastolic dysfunction (DD) is a common condition that is increasingly encountered in patients undergoing both cardiac and noncardiac surgery as the age profile of our patient population increases and the noninvasive diagnosis of DD becomes more accessible. There is a growing body of evidence demonstrating the significance of DD and adverse perioperative outcomes, and thus, it is becoming imperative for anesthesiologists to have an understanding of the pathophysiology, diagnosis, and management of patients with DD. Current guidelines are based on transthoracic echocardiogram (TTE) measurements in patients who are spontaneously breathing and in a euvolemic state and, consequently, not applicable to the perioperative period. In this review article, we discuss the grading of DD as well as introduce a practical approach to the diagnosis and management of patients with DD during the perioperative period.
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Affiliation(s)
- Aidan Sharkey
- Department of Anesthesia Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, Boston, MA, 02215, USA.
| | - Feroze Mahmood
- Department of Anesthesia Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, Boston, MA, 02215, USA
| | - Robina Matyal
- Department of Anesthesia Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, Boston, MA, 02215, USA
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Averina II, Bockeria OL, Mironenko MY, Aleksandrova SA. [A. N. Bakoulev Scientific Center for Cardiovascular Surgery]. KARDIOLOGIYA 2019; 59:26-35. [PMID: 31131765 DOI: 10.18087/cardio.2019.5.10256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 05/25/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE to assess dynamics of diastolic function for detection of development of diastolic dysfunction (DD) and it's causes, to evaluate the effect of DD on prognosis in the postoperative period in patients with acquired heart diseases. MATERIALS AND METHODS We included in this study 112 patients with aortic and mitral valve diseases (90 men, 22 women, median age 51 [35; 57] years). All patients underwent echocardiography (echo), tissue Doppler, speckle tracking echo prior to surgery, in the early postoperative period (8-14 days) and in 12-36 months after surgery. In 28 patients dynamic contrast-enhanced magnetic resonance imaging was also performed. Patients were divided into groups according to prognosis: group 0 - without complications; group 1 - with postoperative heart failure (HF) and preserved left ventricular ejection fraction (EF); group 2 - with HF and EF <45 %. The following parameters were used for identifying left ventricular (LV) DD: septal velocity es <7 cm / sec, lateral el <10 cm / sec, average E / e ratio >14, left atrial (LA) volume index >34 ml / m2, peak tricuspid regurgitation velocity >2.8 m / sec. RESULTS Initially diastolicLV function was normal in 34 of 112 patients (30.4 %), in early postoperative period DD emerged in 9 (26.5 %) of these patients. The appearance of LV DD was associated with decrease of septal es immediately after surgery and its subsequent progressive decline in the long-term postoperative period from 8.5±0.71 to 4.6 ±0.53 cm / sec (p=0.005). Worsening of diastolic function and lowering of septal velocity was detected namely in patients with presence of fibrosis. In the group of other patients in whom fibrosis was not studied and the degree of DD increased there was a transient decrease of lateral el (from 10.2±3.1 to 7.5±2.43 cm / sec, p=0.035) and an increase of the E / el (from 10.53±4.07 to 14.5±5.23, p=0.05) in the early period after the operation. There were no correlations between DD and LV EF,LV volumes, and development of arrhythmias. The prognostic model for DD included average longitudinal deformation of LA (global LA longitudinal strain) and E / e ratio on the tricuspid lateral annular velocity. CONCLUSIONS Appearance of DD in postoperative period after correction of acquired heart defects was due to damage of the septal diastolic function which correlated with fibrosis and was indicative of inadequate myocardial protection. The model of development of heart failure with normal EF after operation was designed.
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Affiliation(s)
- I I Averina
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
| | - O L Bockeria
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
| | - M Yu Mironenko
- A. N. Bakoulev Scientific Center for Cardiovascular Surgery
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Yamashita K, Kohjitani A, Miyata M, Ohno S, Tohya A, Ohishi M, Sugimura M. Predictive Factors of Postoperative Blood Pressure Abnormalities Following a Minor-to-Moderate Surgery. Int Heart J 2018; 59:1359-1367. [PMID: 30369572 DOI: 10.1536/ihj.17-612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Myocardial ischemic events after non-cardiac surgery is still a serious problem, especially in older, high-risk patients. However, the prevalence and risk factors of blood pressure (BP) abnormalities, which may possibly lead to myocardial ischemic attack, have not been reported. Our aim is to elucidate predictive factors of postoperative BP abnormalities following a minor-to-moderate surgery, employing preoperative left ventricular diastolic function. Patients who underwent cardiac echocardiogram examination and received oral and maxillofacial surgery under general anesthesia were enrolled. The echocardiographic parameters of diastolic function were compared between patients who had postoperative BP abnormalities (hypertension-systolic blood pressure [SBP] ≥ 170 mmHg-or hypotension-SBP < 80 mmHg-episode) that required therapeutic interventions until 7 days after surgery and those who had no BP abnormalities. Of the 173 patients analyzed, 25 (14.4%) had BP abnormalities. BP abnormalities patients were older, having a larger proportion of diabetes mellitus, lower E/A ratio and e', and larger E/e' and left atrial dimension than those without BP abnormalities. Subanalyses revealed that the independent risk factors responsible for hypertension episodes (14 patients) were the mean e' (odd ratio [OR]: 0.434; 95% confidence interval [CI]: 0.229-0.824), diabetes mellitus (OR: 5.018; 95% CI: 1.030-24.436), SBP at hospitalization (OR: 1.099; 95% CI: 1.036-1.165), and operation time (hour; OR: 1.326; 95%CI: 1.109-1.586), while hypotension episodes (11 patients) were associated solely with operation time (OR: 1.206; 95% CI: 1.046-1.391). In conclusion, left ventricular diastolic dysfunction, increased insulin resistance, boosted SBP at hospitalization, and prolonged operation should be taken into consideration as risk factors of postoperative BP abnormalities, especially hypertension, following minor-to-moderate surgery.
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Affiliation(s)
- Kaoru Yamashita
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Atsushi Kohjitani
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Masaaki Miyata
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Sachi Ohno
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Akina Tohya
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mitsutaka Sugimura
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
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Sanfilippo F, Scolletta S, Morelli A, Vieillard-Baron A. Practical approach to diastolic dysfunction in light of the new guidelines and clinical applications in the operating room and in the intensive care. Ann Intensive Care 2018; 8:100. [PMID: 30374644 PMCID: PMC6206316 DOI: 10.1186/s13613-018-0447-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/20/2018] [Indexed: 12/26/2022] Open
Abstract
There is growing evidence both in the perioperative period and in the field of intensive care (ICU) on the association between left ventricular diastolic dysfunction (LVDD) and worse outcomes in patients. The recent American Society of Echocardiography and European Association of Cardiovascular Imaging joint recommendations have tried to simplify the diagnosis and the grading of LVDD. However, both an often unknown pre-morbid LV diastolic function and the presence of several confounders-i.e., use of vasopressors, positive pressure ventilation, volume loading-make the proposed parameters difficult to interpret, especially in the ICU. Among the proposed parameters for diagnosis and grading of LVDD, the two tissue Doppler imaging-derived variables e' and E/e' seem most reliable. However, these are not devoid of limitations. In the present review, we aim at rationalizing the applicability of the recent recommendations to the perioperative and ICU areas, discussing the clinical meaning and echocardiographic findings of different grades of LVDD, describing the impact of LVDD on patients' outcomes and providing some hints on the management of patients with LVDD.
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Affiliation(s)
- F. Sanfilippo
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - S. Scolletta
- Unit of Intensive Care Medicine, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - A. Morelli
- Department of Anaesthesiology and Intensive Care, University of Rome, “La Sapienza”, Rome, Italy
| | - A. Vieillard-Baron
- Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France
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Chou J, Ma M, Gylys M, Seong J, Salvatierra N, Kim R, Jiang L, Barseghian A, Rinehart J. Preexisting Right Ventricular Dysfunction Is Associated With Higher Postoperative Cardiac Complications and Longer Hospital Stay in High-Risk Patients Undergoing Nonemergent Major Vascular Surgery. J Cardiothorac Vasc Anesth 2018; 33:1279-1286. [PMID: 30429063 DOI: 10.1053/j.jvca.2018.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate whether the presence of preexisting right ventricular (RV) dysfunction in high-risk patients undergoing nonemergent major vascular surgery is associated independently with higher incidents of postoperative cardiac complications and a longer length of hospital stay. DESIGN Retrospective chart review. SETTING Single-center university hospital setting. PARTICIPANTS The patient population consisted of those identified as American Society of Anesthesiologists classification III and above who had a preoperative echocardiogram within 1 year of undergoing nonemergent major vascular surgery between January 2010 and May 2017. MEASUREMENTS AND MAIN RESULTS After multivariate analyses, RV dysfunction (RVD) is associated independently with a higher incidence of postoperative major cardiac complications with an odds ratio = 6.3 (95% confidence interval [CI], 1.0-38.5; p = 0.046). In addition, patients with RVD had a 50% longer length of stay than those without RVD (incident rate ratio [95% CI], 1.5 [1.2-1.8]; p < 0.001). CONCLUSION In this retrospective study of high-risk patients undergoing major vascular surgery, RV dysfunction was associated independently with a higher incidence of postoperative major cardiovascular events and longer length of hospital stays. Based on current findings, the prognostic value of RVD extends beyond the cardiac surgical cohort. Knowledge in management of patients with RVD in the perioperative setting should be understood by all anesthesiologists. Of note, a future study with a larger sample size is needed to validate the current findings given the small sample size of this study.
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Affiliation(s)
- Jody Chou
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA.
| | - Michael Ma
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Maryte Gylys
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Jenny Seong
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Nicolas Salvatierra
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Robert Kim
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Luohua Jiang
- Department of Epidemiology, School of Medicine - University of California Irvine, Irvine, CA
| | - Ailin Barseghian
- Department of Interventional Cardiology, Internal Medicine - University of California Irvine Medical Center, Irvine, CA
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
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Toda H, Nakamura K, Nakagawa K, Watanabe A, Miyoshi T, Nishii N, Shimizu K, Hayashi M, Morita H, Morimatsu H, Ito H. Diastolic Dysfunction Is a Risk of Perioperative Myocardial Injury Assessed by High-Sensitivity Cardiac Troponin T in Elderly Patients Undergoing Non-Cardiac Surgery. Circ J 2018; 82:775-782. [PMID: 29151453 DOI: 10.1253/circj.cj-17-0747] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin T (hs-cTnT) is useful for detecting myocardial injury and is expected to become a prognostic marker in patients undergoing non-cardiac surgery. The aim of this pilot study evaluating the efficacy of β-blocker therapy in a perioperative setting (MAMACARI study) was to assess perioperative myocardial injury (PMI) in elderly patients with preserved ejection fraction (EF) undergoing non-cardiac surgery.Methods and Results:In this prospective observational cohort study of 151 consecutive patients with preserved EF and aged >60 years who underwent non-cardiac surgery, serum levels of hs-cTnT were measured before and on postoperative days 1 and 3 after surgery. PMI was defined as postoperative hs-cTnT >0.014 ng/mL and relative hs-cTnT change ≥20%. A total of 36 (23.8%) of the patients were diagnosed as having PMI. The incidence of a composite of cardiovascular events within 30 days after surgery, including myocardial infarction, stroke, worsening heart failure, atrial fibrillation and pulmonary embolism, was significantly higher in patients with PMI than in patients without PMI (odds ratio (OR) 9.25, P<0.001, 95% confidence interval (CI) 2.65-32.3). Multivariate analysis revealed that left ventricular diastolic dysfunction defined by echocardiography was independently associated with PMI (OR: 3.029, 95% CI: 1.341-6.84, P=0.008). CONCLUSIONS PMI is frequently observed in elderly patients undergoing non-cardiac surgery. Diastolic dysfunction is an independent predictor of PMI.
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Affiliation(s)
- Hironobu Toda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazuyoshi Shimizu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masao Hayashi
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences.,Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morimatsu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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Sanfilippo F, Corredor C, Arcadipane A, Landesberg G, Vieillard-Baron A, Cecconi M, Fletcher N. Tissue Doppler assessment of diastolic function and relationship with mortality in critically ill septic patients: a systematic review and meta-analysis. Br J Anaesth 2017; 119:583-594. [DOI: 10.1093/bja/aex254] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
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Abstract
This article will address common cardiac conditions that require evaluation prior to noncardiac surgery, characterization of urgency and the risk associated with surgical procedures, calculation of preoperative risk assessment, indications for diagnostic testing to quantify cardiac risk, and perioperative strategies to minimize the risk of cardiac complications.
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Affiliation(s)
- Waseem Chaudhry
- Cardiovascular Institute, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA; Cardiovascular Institute, Tufts University School of Medicine, Boston, MA, USA.
| | - Mylan C Cohen
- Cardiovascular Institute, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA; Cardiovascular Institute, Tufts University School of Medicine, Boston, MA, USA; Cardiac Imaging and Diagnostics, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA
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Shillcutt SK, Chacon MM, Brakke TR, Roberts EK, Schulte TE, Markin N. Heart Failure With Preserved Ejection Fraction: A Perioperative Review. J Cardiothorac Vasc Anesth 2017; 31:1820-1830. [PMID: 28869075 DOI: 10.1053/j.jvca.2017.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Sasha K Shillcutt
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE.
| | - M Megan Chacon
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Tara R Brakke
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Ellen K Roberts
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Thomas E Schulte
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Nicholas Markin
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
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Abstract
Diastolic dysfunction ranging from impaired relaxation of the left ventricle to heart failure with preserved ejection fraction (HFpEF) is a common finding in the cardiac surgery population. It is important for the peri-operative echocardiographer to have a developed understanding of the pathophysiology of diastolic dysfunction and the echocardiographic features that determine where on the spectrum of diastolic function and dysfunction a patient lies
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Affiliation(s)
- Candice Morrissey
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84132-2501, USA
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36
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Rafiq A, Sklyar E, Bella JN. Cardiac Evaluation and Monitoring of Patients Undergoing Noncardiac Surgery. Health Serv Insights 2017; 9:1178632916686074. [PMID: 28469459 PMCID: PMC5398290 DOI: 10.1177/1178632916686074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/24/2016] [Indexed: 12/25/2022] Open
Abstract
Surgical management of disease has a tremendous impact on our health system. Millions of people worldwide undergo surgeries every year. Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient's medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks. Different risk assessment tools and calculators have also been developed to aid in this process, each with their own advantages and limitations. After such a comprehensive evaluation, a physician will be able to provide a risk assessment or it may all lead to further testing if it is believed that a change in management after such testing will help to reduce perioperative morbidity and mortality. There is extensive literature on the significance of multiple perioperative testing modalities and how they can change management. The purpose of our review is to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.
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Affiliation(s)
- Arsalan Rafiq
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eduard Sklyar
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan N Bella
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Impact of ejection fraction on infectious, renal, and respiratory morbidity for patients undergoing noncardiac surgery. J Clin Anesth 2017; 36:1-9. [DOI: 10.1016/j.jclinane.2016.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 08/08/2016] [Accepted: 08/14/2016] [Indexed: 11/20/2022]
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Ryu T, Song SY. Perioperative management of left ventricular diastolic dysfunction and heart failure: an anesthesiologist's perspective. Korean J Anesthesiol 2017; 70:3-12. [PMID: 28184260 PMCID: PMC5296384 DOI: 10.4097/kjae.2017.70.1.3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 12/12/2022] Open
Abstract
Anesthesiologists frequently see asymptomatic patients with diastolic dysfunction or heart failure for various surgeries. These patients typically show normal systolic function but abnormal diastolic parameters in their preoperative echocardiographic evaluations. The symptoms that are sometimes seen are similar to those of chronic obstructive pulmonary disease. Patients with diastolic dysfunction, and even with diastolic heart failure, have the potential to develop a hypertensive crisis or pulmonary congestion. Thus, in addition to conventional perioperative risk quantification, it may be important to consider the results of diastolic assessment for predicting the postoperative outcome and making better decisions. If anesthesiologists see female patients older than 70 years of age who have hypertension, diabetes, chronic renal disease, recent weight gain, or exercise intolerance, they should focus on the patient's diastologic echocardiography indicators such as left atrial enlargement or left ventricular hypertrophy. In addition, there is a need for perioperative strategies to mitigate diastolic dysfunction-related morbidity. Specifically, hypertension should be controlled, keeping pulse pressure below diastolic blood pressure, maintaining a sinus rhythm and normovolemia, and avoiding tachycardia and myocardial ischemia. There is no need to classify these diastolic dysfunction, but it is important to manage this condition to avoid worsening outcomes.
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Affiliation(s)
- Taeha Ryu
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Seok-Young Song
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
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Effect of diastolic dysfunction on postoperative outcomes after cardiovascular surgery: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2016; 152:1142-53. [DOI: 10.1016/j.jtcvs.2016.05.057] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/29/2016] [Accepted: 05/30/2016] [Indexed: 01/08/2023]
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Nowak-Machen M. The role of transesophageal echocardiography in aortic surgery. Best Pract Res Clin Anaesthesiol 2016; 30:317-29. [DOI: 10.1016/j.bpa.2016.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 05/09/2016] [Indexed: 12/12/2022]
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Perioperative Diastolic Dysfunction in Patients Undergoing Noncardiac Surgery Is an Independent Risk Factor for Cardiovascular Events. Anesthesiology 2016; 125:72-91. [DOI: 10.1097/aln.0000000000001132] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Background
The prognostic value of perioperative diastolic dysfunction (PDD) in patients undergoing noncardiac surgery remains uncertain, and the current guidelines do not recognize PDD as a perioperative risk factor. This systematic review aimed to investigate whether existing evidence supports PDD as an independent predictor of adverse events after noncardiac surgery.
Methods
Ovid MEDLINE, PubMed, EMBASE, the Cochrane Library, and Google search engine were searched for English-language citations in April 2015 investigating PDD as a risk factor for perioperative adverse events in adult patients undergoing noncardiac surgery. Two reviewers independently assessed the study risk of bias. Extracted data were verified. Random-effects model was used for meta-analysis, and reviewers’ certainty was graded.
Results
Seventeen studies met eligibility criteria; however, 13 contributed to evidence synthesis. The entire body of evidence addressing the research question was based on a total of 3,876 patients. PDD was significantly associated with pulmonary edema/congestive heart failure (odds ratio [OR], 3.90; 95% CI, 2.23 to 6.83; 3 studies; 996 patients), myocardial infarction (OR, 1.74; 95% CI, 1.14 to 2.67; 3 studies; 717 patients), and the composite outcome of major adverse cardiovascular events (OR, 2.03; 95% CI, 1.24 to 3.32; 4 studies; 1,814 patients). Evidence addressing other outcomes had low statistical power, but higher long-term cardiovascular mortality was observed in patients undergoing open vascular repair (OR, 3.00; 95% CI, 1.50 to 6.00). Reviewers’ overall certainty of the evidence was moderate.
Conclusion
Evidence of moderate certainty indicates that PDD is an independent risk factor for adverse cardiovascular outcomes after noncardiac surgery.
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Borde DP, Asegaonkar B, Apsingekar P, Khade S, Futane S, Khodve B, Kedar M, Deodhar A, Takalkar U, George A, Joshi S. Monitoring diastolic dysfunction using a simplified algorithm in patients undergoing off-pump coronary artery bypass grafting surgery. Ann Card Anaesth 2016; 19:231-9. [PMID: 27052062 PMCID: PMC4900366 DOI: 10.4103/0971-9784.179591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Context: Left ventricle diastolic dysfunction (LVDD) is gaining importance as useful marker of mortality and morbidity in cardiac surgical patients. Different algorithms have been proposed for the intraoperative grading of DD. Knowledge of the particular grade of DD has clinical implications with the potential to modify therapy, but there is a paucity of literature on the role of diastolic function evaluation during off-pump coronary artery bypass grafting (OPCABG) surgery. Aims: The aim of this study was to monitor changes in LVDD using simplified algorithm proposed by Swaminathan et al. in patients undergoing OPCABG. Settings and Design: The study was conducted in a tertiary care level hospital; this was a prospective, observational study. Subjects and Methods: Fifty consecutive patients undergoing OPCABG were enrolled. Hemodynamic and echocardiographic parameters were measured at 6 stages in every patient namely after anesthetic induction (baseline), during left internal mammary artery (LIMA) to left anterior descending (LAD) grafting (LIMA → LAD), saphenous vein graft (SVG) to obtuse marginal (OM) grafting (SVG → OM), SVG to posterior descending artery (PDA) grafting (SVG → PDA), during proximal anastomosis of SVG to aorta, and postprotamine. The patients were classified in grades of LVDD as per simplified algorithm proposed by Swaminathan et al. using only intraoperatively measured E and E’. Results: The success rate of measurement and classification of LVDD was 98.92% (277 out of 280 measurements). The grades of LVDD varied significantly as per surgical steps with maximum downgrading occurring during OM and LAD grafting. During OM grafting, none of the patients had normal diastolic function while 29% of patients exhibited restrictive pattern (Grade 3 LVDD). Patients with normal baseline LV diastolic function also exhibited downgrading during OM and LAD grafting. Postprotamine, 37% of patients with normal baseline diastolic function continued to exhibit some degree of DD. Conclusions: The LVDD changes dynamically during various stages of OPCABG, which can be successfully monitored with simplified algorithm.
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Affiliation(s)
- Deepak Prakash Borde
- Department of Cardiac Anesthesia, Ozone Anesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
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McIlroy DR, Lin E, Durkin C. Intraoperative Transesophageal Echocardiography: A Critical Appraisal of Its Current Role in the Assessment of Diastolic Dysfunction. J Cardiothorac Vasc Anesth 2015; 29:1033-43. [DOI: 10.1053/j.jvca.2015.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Indexed: 12/26/2022]
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Scali S, Bertges D, Neal D, Patel V, Eldrup-Jorgensen J, Cronenwett J, Beck A. Heart rate variables in the Vascular Quality Initiative are not reliable predictors of adverse cardiac outcomes or mortality after major elective vascular surgery. J Vasc Surg 2015; 62:710-20.e9. [PMID: 26067200 DOI: 10.1016/j.jvs.2015.03.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Heart rate (HR) parameters are known indicators of cardiovascular complications after cardiac surgery, but there is little evidence of their role in predicting outcome after major vascular surgery. The purpose of this study was to determine whether arrival HR (AHR) and highest intraoperative HR are associated with mortality or major adverse cardiac events (MACEs) after elective vascular surgery in the Vascular Quality Initiative (VQI). METHODS Patients undergoing elective lower extremity bypass (LEB), aortofemoral bypass (AFB), and open abdominal aortic aneurysm (AAA) repair in the VQI were analyzed. MACE was defined as any postoperative myocardial infarction, dysrhythmia, or congestive heart failure. Controlled HR was defined as AHR <75 beats/min on operating room arrival. Delta HR (DHR) was defined as highest intraoperative HR - AHR. Procedure-specific MACE models were derived for risk stratification, and generalized estimating equations were used to account for clustering of center effects. HR, beta-blocker exposure, cardiac risk, and their interactions were explored to determine association with MACE or 30-day mortality. A Bonferroni correction with P < .004 was used to declare significance. RESULTS There were 13,291 patients reviewed (LEB, n = 8155 [62%]; AFB, n = 2629 [18%]; open AAA, n = 2629 [20%]). Rates of any preoperative beta-blocker exposure were as follows: LEB, 66.5% (n = 5412); AFB, 57% (n = 1342); and open AAA, 74.2% (n = 1949). AHR and DHR outcome association was variable across patients and procedures. AHR <75 beats/min was associated with increased postoperative myocardial infarction risk for LEB patients across all risk strata (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.03-1.9; P = .03), whereas AHR <75 beats/min was associated with decreased dysrhythmia risk (OR, 0.42; 95% CI, 0.28-0.63; P = .0001) and 30-day death (OR, 0.50; 95% CI, 0.33-0.77; P = .001) in patients at moderate and high cardiac risk. These HR associations disappeared in controlling for beta-blocker status. For AFB and open AAA repair patients, there was no significant association between AHR and MACE or 30-day mortality, irrespective or cardiac risk or beta-blocker status. DHR and extremes of highest intraoperative HR (>90 or 100 beats/min) were analyzed among all three operations, and no consistent associations with MACE or 30-day mortality were detected. CONCLUSIONS The VQI AHR and highest intraoperative HR variables are highly confounded by patient presentation, operative variables, and beta-blocker therapy. The discordance between cardiac risk and HR as well as the lack of consistent correlation to outcome makes them unreliable predictors. The VQI has elected to discontinue collecting AHR and highest intraoperative HR data, given insufficient evidence to suggest their importance as an outcome measure.
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Affiliation(s)
- Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Daniel Bertges
- Division of Vascular Surgery, University of Vermont, Burlington, Vt
| | - Daniel Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Virendra Patel
- Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | | | - Jack Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Adam Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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Sanfilippo F, Corredor C, Fletcher N, Landesberg G, Benedetto U, Foex P, Cecconi M. Diastolic dysfunction and mortality in septic patients: a systematic review and meta-analysis. Intensive Care Med 2015; 41:1004-13. [DOI: 10.1007/s00134-015-3748-7] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/09/2015] [Indexed: 12/23/2022]
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Thanavaro JL. Cardiac risk assessment: decreasing postoperative complications. AORN J 2015; 101:201-12. [PMID: 25645037 DOI: 10.1016/j.aorn.2014.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/02/2014] [Accepted: 03/16/2014] [Indexed: 11/26/2022]
Abstract
Preoperative cardiac assessment helps identify patients undergoing noncardiac surgery who are at risk for significant postoperative cardiac complications and those who may benefit from additional preoperative evaluation and perioperative care. Advanced practice nurses can identify surgery- and patient-related risks by conducting a thorough health history and physical examination. Multiple risk indices and evidence-based guidelines are available to inform health care providers regarding patient evaluation and strategies to reduce postoperative cardiac risk. In general, preoperative tests are recommended only if the findings will influence medical therapy or perioperative monitoring or will require postponement of surgery until a cardiac condition can be corrected or stabilized. Medication management is a crucial component of the preoperative assessment; providers may need to initiate the use of beta-blockers and make decisions regarding continuing or withholding antiplatelet and anticoagulant therapy. Preoperative cardiac risk stratification, medication reconciliation, and device management are essential for providing safe care for patients.
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Expanding role of perioperative transesophageal echocardiography in the general anesthesia practice and residency training in the USA. Curr Opin Anaesthesiol 2015; 28:95-100. [DOI: 10.1097/aco.0000000000000146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77-137. [PMID: 25091544 DOI: 10.1016/j.jacc.2014.07.944] [Citation(s) in RCA: 813] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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