1
|
Sun W, Yuan Y, Shen X, Zhang Y, Dong N, Wang G, Li Y, Liang B, Lv Q, Zhang L, Xie M. Prognostic value of feature-tracking right ventricular longitudinal strain in heart transplant recipients. Eur Radiol 2022; 33:3878-3888. [PMID: 36538069 DOI: 10.1007/s00330-022-09327-9] [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: 05/21/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The prognostic value of cardiac magnetic resonance feature tracking (CMR-FT)-derived right ventricular longitudinal strain (RVLS) post-heart transplantation has not been studied. This study aimed to evaluate the prognostic significance of CMR-FT-derived RVLS, in patients post- heart transplantation and to directly compare its value with that of conventional RV ejection fraction (RVEF). METHODS In a cohort of consecutive heart transplantation recipients who underwent CMR for surveillance, RVLS from the free wall was measured by CMR-FT. The composite endpoint was all-cause death or major adverse cardiac events. The Cox regression model was used to examine the independent association between RVLS and the endpoint. RESULTS A total of 96 heart transplantation recipients were retrospectively included. Over a median follow-up of 41 months, 20 recipients reached the composite endpoint. The multivariate Cox analysis showed that the model with RVLS (hazard ratio [HR]:1.334; 95% confidence interval [CI]:1.148 to 1.549; p < 0.001; Akaike information criterion [AIC] = 140, C-index = 0.831) was better in predicting adverse events than the model with RVEF (HR:0.928; 95% CI: 0.868 to 0.993; p = 0.030; AIC = 149, C-index = 0.751). Furthermore, receiver operating characteristic curves revealed that the accuracy for predicting adverse events was greater for RVLS than RVEF (area under the curve: 0.85 vs 0.76, p = 0.03). CONCLUSIONS CMR-FT-derived RVLS is an independent predictor of adverse events in post-heart transplantation, and its predictive value was better than RVEF. Therefore, our study highlighted the importance of evaluating RVLS for risk stratification after heart transplantation. KEY POINTS • CMR-RVLS is an independent predictor of adverse events post-heart transplantation and provides greater predictive value. • CMR-RVLS may help clinicians to risk stratification in heart transplantation recipients.
Collapse
Affiliation(s)
- Wei Sun
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, 430022, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yating Yuan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xuehua Shen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Yiwei Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, 430022, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Guohua Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuman Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, 430022, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Bo Liang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Qing Lv
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, 430022, China.
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, 430022, China.
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, 430022, China.
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| |
Collapse
|
2
|
Changes in Right Ventricle Function After Mitral Valve Repair Surgery. Heart Lung Circ 2020; 29:785-792. [DOI: 10.1016/j.hlc.2019.06.724] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/13/2019] [Accepted: 06/25/2019] [Indexed: 01/05/2023]
|
3
|
Harrington JK, Richmond ME, Woldu KL, Pasumarti N, Kobsa S, Freud LR. Serial Changes in Right Ventricular Systolic Function Among Rejection-Free Children and Young Adults After Heart Transplantation. J Am Soc Echocardiogr 2019; 32:1027-1035.e2. [PMID: 31202590 DOI: 10.1016/j.echo.2019.04.413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evolution of right ventricular (RV) systolic function after pediatric heart transplantation (HT) has not been well described. METHODS We analyzed echocardiograms performed over the first year after HT among children and young adults who remained rejection-free. Ninety-six patients (median age 7.1 [0.1-24.4] years at HT) were included: 22 infants (≤1 year) and 74 noninfants (>1 year). Two-dimensional tricuspid annular plane systolic excursion (TAPSE), tissue Doppler-derived tricuspid annular systolic velocity (S'), fractional area change (FAC), myocardial performance index (MPI), and two-dimensional speckle-tracking-derived RV global longitudinal (GLS) and free wall strain (FWS) were assessed. RESULTS All measures of RV function were impaired immediately after HT and significantly improved over the first year: TAPSE z-score (-8.15 ± 1.88 to -3.94 ± 1.65, P < .0001), S' z-score (-4.30 ± 1.36 to -2.28 ± 1.33, P < .0001), FAC (24.37% ± 7.71% to 42.02% ± 7.09%, P < .0001), MPI (0.96 ± 0.47 to 0.41 ± 0.22, P < .0001), GLS (-10.37% ± 3.86% to -21.05% ± 3.41%, P < .0001), and FWS (-11.2% ± 4.08% to -23.66% ± 4.13%, P < .0001). By 1 year post-HT, TAPSE, S', GLS, and FWS, remained abnormal, whereas FAC and MPI nearly normalized. Patients transplanted during infancy demonstrated better recovery of RV systolic function. CONCLUSIONS Although RV systolic function improved over the first year after HT in children and young adults without rejection, measures that assess longitudinal contractility remained abnormal at 1 year post-HT. These findings contribute to our understanding of RV myocardial contractility after HT in children and young adults and improve our ability to assess function quantitatively in this population.
Collapse
Affiliation(s)
- Jamie K Harrington
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Kristal L Woldu
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Nikhil Pasumarti
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Serge Kobsa
- Department of Surgery, Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Lindsay R Freud
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York.
| |
Collapse
|
4
|
Zanobini M, Loardi C, Poggio P, Tamborini G, Veglia F, Di Minno A, Myasoedova V, Mammana LF, Biondi R, Pepi M, Alamanni F, Saccocci M. The impact of pericardial approach and myocardial protection onto postoperative right ventricle function reduction. J Cardiothorac Surg 2018; 13:55. [PMID: 29866151 PMCID: PMC5987597 DOI: 10.1186/s13019-018-0726-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 05/09/2018] [Indexed: 11/17/2022] Open
Abstract
Background The reduction of RV function after cardiac surgery is a well-known phenomenon. It could persist up-to one year after the operation and often leads to an incomplete recovery at follow-up echocardiographic control. The aim of the present study is to analyze the impact of different modalities of pericardial incision (lateral versus anterior) and of myocardial protection protocols (Buckberg versus Custodiol) onto postoperative RV dynamic by relating two- and three-dimensional echocardiographic parameters in patients undergoing mitral valve repair through minimally invasive or traditional surgery approach. Methods We have analyzed 44 consecutive patients with severe degenerative mitral regurgitation who underwent mitral reparation with different surgical approach and cardioplegia type: Group 1 (17 pts): sternotomy with Buckberg cardioplegia protocol; Group 2 (10 pts): sternotomy with Custodiol cardioplegia; Group 3 (17 pts): mini-invasive surgery with Custodiol cardioplegia. Two-dimensional transthoracic echocardiography was performed pre- and 6 months post-surgery to evaluate RV function by tricuspid annular plane systolic excursion (TAPSE). Results All patients underwent successful and uneventful. A postoperative TAPSE reduction was found in all groups. However, mini-invasive patients experienced a significant reduced variation versus traditional surgery. Conclusions Mini-invasive mitral repair, with lateral incision of pericardium, reduces postoperative TAPSE fall, while cardioplegia protocol fails to have an impact onto longitudinal RV function. In our study, the RV seems to experience a clinically irrelevant geometrical modification too, whose entity appears to be less evident in case of lateral pericardial approach. These results could strengthen the use of minimally invasive approach also to preserve RV function.
Collapse
Affiliation(s)
- Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Claudia Loardi
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Paolo Poggio
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Gloria Tamborini
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Fabrizio Veglia
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Alessandro Di Minno
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Veronika Myasoedova
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Liborio Francesco Mammana
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Raoul Biondi
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Mauro Pepi
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Francesco Alamanni
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, University of Milan, Via Parea, 4, 20138, Milan, Italy. .,Heart Center, University Hospital of Zürich, University of Zürich, Zürich, CH, Switzerland.
| |
Collapse
|
5
|
Postoperative Echocardiographic Reduction of Right Ventricular Function: Is Pericardial Opening Modality the Main Culprit? BIOMED RESEARCH INTERNATIONAL 2017; 2017:4808757. [PMID: 28589141 PMCID: PMC5446880 DOI: 10.1155/2017/4808757] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 04/20/2017] [Indexed: 11/17/2022]
Abstract
Echocardiographic reduction of RV function, measured using TAPSE, is a well described phenomenon after cardiac surgery. The aim of the present study was to investigate the relation between the modality of pericardial opening (lateral versus anterior) and the postoperative right ventricular systolic function by comparing echocardiographic parameters in patients undergoing minimally invasive or traditional mitral valve repair. 34 patients with severe mitral regurgitation due to mitral valve prolapse underwent traditional (sternotomy) operation (Group A) or minimally invasive surgery with right anterolateral thoracotomy (Group B). A postoperative TAPSE fall was found in both groups. Group A experienced a significant postoperative TAPSE fall versus Group B with p < 0.0001.
Collapse
|
6
|
Unsworth B, Casula RP, Yadav H, Baruah R, Hughes AD, Mayet J, Francis DP. Contrasting effect of different cardiothoracic operations on echocardiographic right ventricular long axis velocities, and implications for interpretation of post-operative values. Int J Cardiol 2011; 165:151-60. [PMID: 21917325 PMCID: PMC3635119 DOI: 10.1016/j.ijcard.2011.08.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 08/09/2011] [Accepted: 08/15/2011] [Indexed: 11/23/2022]
Abstract
Background Patients undergoing coronary artery bypass grafting (CABG) experience a reduction in right ventricular long axis velocities post surgery. Objectives We tested whether the phenomenon of right ventricular (RV) long axis velocity decline depends on the chest being opened fully by mid-line sternotomy, pericardial incision, or on the type of operation performed. Method By intraoperative transoesophageal echocardiography (TEE) we recorded serial right ventricular (RV) systolic pulse-wave tissue Doppler velocities during 6 types of elective procedure: 53 CABG surgery, 15 robotic-assisted minimally-invasive CABG (RCABG), 28 aortic valve replacement (AVR), 8 minimally-invasive aortic valve replacement (mini-AVR), 5 mediastinal mass excision, and 1 left atrial myxoma excision. Pre and post operative transthoracic echocardiography (TTE) were also conducted. Results Surgery without substantial opening of the pericardium did not significantly reduce RV systolic velocities (RCABG 13 ± 1.8 versus 12.4 ± 2.7 cm/s post; mini-AVR 11.9 ± 2.3 versus 11.1 ± 2.3 cm/s; mediastinal mass excision 13.9 ± 3.1 versus 13.8 ± 4 cm/s). In contrast, within 5 min of pericardial incision those whose surgery involved full opening of the pericardium had large reductions in RV velocities: 54 ± 11% decline with CABG (11.3 ± 1.9 to 5.1 ± 1.6 cm/s, p < 0.0001), 54 ± 5% with AVR (12.6 ± 1.4 to 5.7 ± 0.6 cm/s, p < 0.001) and 49% with left atrial myxoma excision (11.3 to 15.8 cm/s). This persisted immediately after pericardial opening to the end of surgery (61 ± 11%, p < 0.0001; 58 ± 7%, p < 0.0001; 59% respectively). Conclusions It is full opening of the pericardium, and not cardiac surgery in general, which causes RV long axis decline following cardiac surgery. The impact is immediate (within 5 min) and persistent.
Collapse
Affiliation(s)
- Beth Unsworth
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, UK.
| | | | | | | | | | | | | |
Collapse
|
7
|
Unsworth B, Casula RP, Kyriacou AA, Yadav H, Chukwuemeka A, Cherian A, Stanbridge RDL, Athanasiou T, Mayet J, Francis DP. The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision. Am Heart J 2010; 159:314-22. [PMID: 20152232 PMCID: PMC2822903 DOI: 10.1016/j.ahj.2009.11.013] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 11/18/2009] [Indexed: 11/30/2022]
Abstract
Background Right ventricular (RV) long-axis function is known to be depressed after cardiac surgery, but the mechanism is not known. We hypothesized that intraoperative transesophageal echocardiography could pinpoint the time at which this happens to help narrow the range of plausible mechanisms. Method Transthoracic echocardiography was conducted in 33 patients before and after elective coronary artery bypass graft. In an intensively monitored cohort of 9 patients, we also monitored RV function intraoperatively using serial pulsed wave tissue Doppler (PW TD) transesophageal echocardiography. Results There was no significant difference in myocardial velocities from the onset of the operation up to the beginning of pericardial incision, change in RV PW TD S′ velocities 3% ± 2% (P = not significant). Within the first 3 minutes of opening the pericardium, RV PW TD S′ velocities had reduced by 43% ± 17% (P < .001). At 5 minutes postpericardial incision, 2 minutes later, the velocities had more than halved, by 54% ± 11% (P < .0001). Velocities thereafter remained depressed throughout the operation, with final intraoperative S′ reduction being 61% ± 11% (P < .0001). One month after surgery, in the full 33-patient cohort, transthoracic echocardiogram data showed a 55% ± 12% (P < .0001) reduction in RV S′ velocities compared with preoperative values. Conclusions Minute-by-minute monitoring during cardiac surgery reveals that, virtually, all the losses in RV systolic velocity occurs within the first 3 minutes after pericardial incision. Right ventricular long-axis reduction during coronary bypass surgery results not from cardiopulmonary bypass but rather from pericardial incision.
Collapse
|
8
|
Christensen D, Cardis B, Mahle W, Lewis R, Huckaby J, Favaloro-Sabatier J, Fyfe D. Pre- and Postoperative Quantitation of Right Ventricular Tissue Doppler Velocities in Infants with Hypoplastic Left Heart Syndrome. Echocardiography 2006; 23:303-7. [PMID: 16640707 DOI: 10.1111/j.1540-8175.2006.00207.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The purpose of this study was to use tissue Doppler imaging (TDI) to serially quantitate initial and preoperative right ventricular (RV) TDI velocities and compare them to postoperative RV TDI velocities as measures of RV function in newborns with hypoplastic left heart syndrome (HLHS). METHODS Twelve consecutive patients were prospectively studied with diagnosis of HLHS. Systolic (Sw) and early diastolic (Ew) velocities were recorded at the tricuspid annulus and the ventricular septum at (1) admission, (2) immediately preoperative, and (3) during recovery. All patients were treated preoperatively with prostaglandins (PGE). Velocities were compared using repeated measure analysis of variance. RESULTS Mean age at diagnosis was 1 day (0-4 days). Time from diagnosis to surgery was 4 days (1-9 days), age at surgery 5.3 days (2-10 days), and time from surgery to postoperative echo 12.3 days (5-19 days). Tricuspid annular and septal systolic velocities increased from admission to preoperative. Both tricuspid Sw and Ew and septal Sw velocities decreased postoperatively. No significant changes occurred in the ventricular septal diastolic (Ew) velocities from admission to preoperative. CONCLUSION These data indicate that following the institution of PGE and initial medical and ventilatory management, there is an increase in RV annular and septal systolic velocities from the initial to the preoperative period and that these indices as well as RV annular diastolic velocities decline significantly postoperatively. Initial septal diastolic velocities were severely abnormal and did not significantly change pre- and postoperatively. These data may have significance for both postoperative and subsequent long-term RV function.
Collapse
Affiliation(s)
- Douglas Christensen
- Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia 30329, USA.
| | | | | | | | | | | | | |
Collapse
|
9
|
Durand M, Chavanon O, Tessier Y, Casez M, Gardellin M, Blin D, Girardet P. Right Ventricular Function After Coronary Surgery with or Without Bypass. J Card Surg 2006; 21:11-6. [PMID: 16426341 DOI: 10.1111/j.1540-8191.2006.00161.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Myocardial protection during aortic clamp period may sometimes be inadequate, especially for the right. The aim of this study was to compare right ventricle function after cardiac surgery with or without bypass. METHODS Patients undergoing multivessel coronary surgery with proximal severe right coronary lesion were included in a prospective observational cohort study including 29 patients undergoing coronary surgery with or without bypass. All patients were monitored with a pulmonary artery catheter with continuous right ventricular function. Right ventricular ejection fraction was measured at the arrival in ICU, 1, 3, 6, and 18 hours later. RESULTS The number of grafts that was higher in the bypass group (4.0 +/- 1.3) than in the off-pump group (2.6 +/- 0.6, p = 0.001). In the on-pump group, the right ventricular ejection fraction significantly decreased from 32.9 +/- 2.8 at arrival in ICU to 26.1 +/- 2.4, 6 hours later whereas in the off-pump group, it did not significantly change (32.4 +/- 1.8 to 31.9 +/- 2.3). Meanwhile, at the same time intervals, CVP was significantly lower in the off-pump group. CONCLUSIONS In patients with severe right coronary stenosis, off-pump cardiac surgery seemed to provide better right ventricular protection.
Collapse
Affiliation(s)
- Michel Durand
- Department of Anaesthesia, Grenoble University Hospital, Grenoble, France.
| | | | | | | | | | | | | |
Collapse
|
10
|
Honkonen EL, Kaukinen L, Kaukinen S, Pehkonen EJ, Laippala P. Dopexamine unloads the impaired right ventricle better than iloprost, a prostacyclin analog, after coronary artery surgery. J Cardiothorac Vasc Anesth 1998; 12:647-53. [PMID: 9854661 DOI: 10.1016/s1053-0770(98)90236-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the ventricle-unloading properties of dopexamine and iloprost and to compare their effects on right ventricular (RV) function and oxygen transport in patients with low RV ejection fraction (RVEF) after cardiac surgery. DESIGN A prospective, randomized, double-blind, cross-over, clinical study. SETTING University hospital. PARTICIPANTS Twenty patients with proximal total stenosis of the right coronary artery studied immediately after coronary artery surgery. INTERVENTIONS Treatment drugs were administered in a random order in doses equipotent with respect to cardiac output response. Infusion rates were increased stepwise to induce a 25% increase in cardiac index. A washout period of 60 minutes was allowed between treatments. MEASUREMENTS AND MAIN RESULTS Central hemodynamics, RV function assessed by the EF (fast-response thermodilution), end-systolic and end-diastolic volumes, and systemic oxygenation were measured before and after the first drug, after the washout period, and after the second drug. Central filling pressures remained constant during treatments. Both drugs decreased pulmonary vascular resistance index, but iloprost was more effective (p < 0.05). Iloprost decreased mean arterial and pulmonary artery pressure, which were unaffected by dopexamine. Dopexamine increased EF significantly more than iloprost (p < 0.001). End-systolic volume index decreased subsequent to dopexamine only (p < 0.001). Iloprost increased intrapulmonary shunt more than dopexamine (p < 0.001). Changes in oxygen delivery, consumption, and extraction were similar. CONCLUSION The findings suggest that dopexamine is more effective than iloprost for support and unloading of the postoperatively disturbed RV in terms of RVEF and end-systolic volume. The reduction of pulmonary vascular resistance after administration of iloprost without a decrease in end-systolic volume might not be considered a reduction of RV afterload. Iloprost increases the pulmonary shunt fraction, however, more than dopexamine, indicating a more prominent vasodilator effect.
Collapse
Affiliation(s)
- E L Honkonen
- Department of Anesthesia and Intensive Care, Tampere University Hospital, Finland
| | | | | | | | | |
Collapse
|
11
|
Brookes CI, White PA, Bishop AJ, Oldershaw PJ, Redington AN, Moat NE. Validation of a new intraoperative technique to evaluate load-independent indices of right ventricular performance in patients undergoing cardiac operations. J Thorac Cardiovasc Surg 1998; 116:468-76. [PMID: 9731789 DOI: 10.1016/s0022-5223(98)70013-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Assessment of right ventricular performance in the perioperative period is difficult because there is no generally accepted method of measuring right ventricular volume. We set out to determine whether conductance technology could provide a valuable technique for the investigation of intraoperative right ventricular function. METHODS AND RESULTS Three validating studies were performed in 25 patients undergoing routine coronary revascularization. Study 1: The influence of conductance catheter position in the right ventricle was examined in 10 patients. Insertion of the conductance catheter through the outflow tract was associated with a larger gain constant and a smaller parallel conductance compared with insertion through the tricuspid valve. Study 2: The reproducibility of contractility measurements with the use of a conductance catheter was examined in 7 additional patients. Removal and reinsertion of the conductance catheter was not associated with any significant difference in right ventricular volume or contractile function. Study 3: Right ventricular performance before and after cardiopulmonary bypass was compared in 8 additional patients. There was a fall in the slope of the right ventricular preload recruitable stroke work from 15.6 (3.8) to 11.0 (5.1) mm Hg (P=.01) and an increase in the slope of the end-diastolic pressure-volume relations from 0.05 (0.02) to 0.11 (0.05) mm Hg/mL (P=.001). CONCLUSIONS The conductance technique can be used to study perioperative changes in right ventricular performance. Insertion of the conductance catheter through the outflow tract provides stable and reproducible data. There is significant impairment of right ventricular contractility in the early postoperative period.
Collapse
Affiliation(s)
- C I Brookes
- Department of Pediatric Cardiology, Royal Brompton National Heart/Lung Institute, Royal Brompton Hospital, London, United Kingdom
| | | | | | | | | | | |
Collapse
|
12
|
Honkonen EL, Kaukinen L, Pehkonen EJ, Kaukinen S. Combined antegrade-retrograde blood cardioplegia does not protect right ventricle better than either technique alone in patients with occluded right coronary artery. Scand Cardiovasc J Suppl 1997; 31:289-95. [PMID: 9406296 DOI: 10.3109/14017439709069550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To study the hypothesis that combined antegrade-retrograde delivery of cardioplegia might overcome the limitations in myocardial protection of either technique alone, we compared the distribution of the different cardioplegic approaches by assessing myocardial cooling and evaluated the effects on right ventricular (RV) function in elective coronary artery bypass grafting (CABG) patients with occluded right coronary artery (RCA). In a randomized trial, 15 patients received exclusively antegrade (ante group), 14 patients received exclusively retrograde (retro group) and 15 patients received combined, alternating antegrade-retrograde (combi group) cold blood cardioplegia. Myocardial temperatures were measured at four sites in the heart. Right ventricular function was assessed by determining the ejection fraction (fast-response thermodilution) and preload-related RV stroke work in repeated measurements. Myocardial cooling was similarly uneven and the posterior wall of the RV remained above 20 degrees C after all three methods of delivering hypothermic (5-7 degrees C) cardioplegia. The RV ejection fraction and preload-related (right atrial pressure) RV stroke work decreased postoperatively similarly in all groups. The results suggest that combined antegrade-retrograde cold blood cardioplegia could not provide more homogeneous myocardial cooling or better RV recovery than either technique alone in three-vessel-diseased CABG patients with occluded RCA.
Collapse
Affiliation(s)
- E L Honkonen
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, Medical School of the University of Tampere, Finland
| | | | | | | |
Collapse
|
13
|
Honkonen EL, Kaukinen L, Pehkonen EJ, Kaukinen S. Atrial natriuretic peptide and N-terminal atrial natriuretic peptide in plasma reflect right ventricular volumes following coronary artery surgery. Acta Anaesthesiol Scand 1997; 41:685-93. [PMID: 9241326 DOI: 10.1111/j.1399-6576.1997.tb04767.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Atrial natriuretic peptide (ANP) and the more stable N-terminal fragment (N-ANP) of prohormone are peptides, released in equimolar amounts from cardiac myocytes in response to atrial stretch or ventricular overload and myocardial ischaemia. Protection of the right ventricular (RV) myocardium during ischaemia in cardiac surgery is difficult, especially in patients with severe right coronary artery (RCA) disease. This prospective study was designed to ascertain a possible relationship between changes in plasma ANP/N-ANP concentration and RV function in RCA-diseased patients. METHODS Plasma ANP and N-ANP concentrations and RV function, measured by fast-response thermodilution, were determined serially in 15 patients with total RCA stenosis and in another 15 with no significant RCA disease (controls) before, during and after coronary surgery. RESULTS The RV ejection fraction was lower and the RV end-systolic volume index higher in the RCA-diseased patients than in the controls (P < 0.05) on the second postoperative day, and both ANP and N-ANP were higher in the RCA patients (P < 0.05) from 6 h after cardiopulmonary bypass till the second postoperative day. At the same time the changes in N-ANP concentrations from the levels before induction of anaesthesia correlated with RV ejection fraction and RV volume indexes, but not with heart rate or parameters indirectly reflecting left-sided loading. Right atrial pressure did not differ between the groups nor did it increase significantly during the study. CONCLUSIONS The relationships found between N-ANP and RV volume indexes and RV ejection fraction suggest ventricular expression of ANP: ANP release may be stimulated by RV distension, the more so the poorer the RV function.
Collapse
Affiliation(s)
- E L Honkonen
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, Finland
| | | | | | | |
Collapse
|
14
|
Affiliation(s)
- A A Bert
- Department of Anesthesiology, Rhode Island Hospital, Providence 02903, USA
| | | | | | | |
Collapse
|
15
|
Honkonen EL, Kaukinen L, Pehkonen EJ, Kaukinen S. Myocardial cooling and right ventricular function in patients with right coronary artery disease: antegrade vs. retrograde cardioplegia. Acta Anaesthesiol Scand 1997; 41:287-96. [PMID: 9062615 DOI: 10.1111/j.1399-6576.1997.tb04681.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Protection of the right ventricular (RV) myocardium during ischaemia in cardiac surgery is difficult, especially in patients with severe right coronary artery (RCA) disease. Retrograde coronary sinus cardioplegia is thought to distribute uniformly, but doubts still remain as to its adequacy in RV preservation. This study evaluated distribution of antegrade vs. exclusively retrograde coronary sinus cold blood cardioplegia by assessing myocardial cooling and compared the effects on RV function. METHODS Fifty-eight patients scheduled for elective coronary artery surgery-29 patients with significant RCA disease and another 29 with no significant RCA stenosis (controls)-were randomised to receive either antegrade or retrograde cold blood cardioplegia through either aortic root or conventional self-inflating coronary sinus catheter (RCA-ante, RCA-retro, C-ante and C-retro groups). RV function was assessed by fast-response thermodilution. Myocardial temperatures were measured in the anterior and posterior wall of the right and left ventricle. RESULTS Cooling of the posterior wall of the RV was effective only in the control patients given antegrade cardioplegia (14.7 degrees C), whereas in the other groups the lowest myocardial temperatures there remained above 20 degrees C (P < 0.001). In patients with obstructed RCA both antegrade and retrograde cold cardioplegia led to uneven cooling of the myocardium. After cardiopulmonary bypass the RV ejection fraction (RVEF), RV stroke work index (RVSWI) and cardiac index (CI) were significantly reduced in the RCA-retro group, and RVSWI and CI in the C-retro group, too. Regression analysis showed an inverse relationship between the temperatures of the posterior walls of the ventricles and changes in the RVEF and CI. CONCLUSIONS Retrograde and antegrade cardioplegia alone were not effective in reducing the temperature of the posterior wall of the RV in the patients with obstructed RCA, in whom with retrograde cardioplegia RV haemodynamics were impaired for 1 hour following bypass. Neither retrograde nor antegrade cardioplegia alone can be relied on to protect the posterior wall of the RV in the patients with obstructed RCA.
Collapse
Affiliation(s)
- E L Honkonen
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, Finland
| | | | | | | |
Collapse
|
16
|
Sato N, Miura M, Uchida N, Fukuju T, Mohri H, Koiwa Y, Takagi T, Tezuka F. Changes in viscoelasticity of the myocardium during cardioplegic arrest. TOHOKU J EXP MED 1996; 178:251-61. [PMID: 8727707 DOI: 10.1620/tjem.178.251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
To evaluate the efficacy of myocardial preservation during open heart surgery, we measured the viscoelasticity of the canine myocardium during cardioplegic arrest. A transfer function method was used for the measurement with a monitoring system consisting of a vibrator, a function generator, accerometers and a signal processor. Six mongrel dogs were put on cardiopulmonary bypass and after measurement of control hemodynamics, they were subjected to cardioplegic arrest at myocardial temperatures ranging from 4 to 32 degrees C. Viscoelasticity was measured at every 15 min and the cardioplegic solution was added every 30 min. After two hr of cardioplegic arrest, the myocardium was reperfused and postischemic hemodynamics were measured after 30 min of non-working beating. Satisfactory myocardial function returned in 3 hearts with the myocardial temperatures below 24 degrees C with myocardial viscoelasticity within the control range. Moderately decreased myocardial contractility was noted in a heart kept at temperature of 27 degrees C and its viscoelasticity remained in the control range of 90 min of ischemia and then began to decrease. In 2 hearts kept at temperatures higher than 29 degrees C, severely depressed myocardial contractility was noted, and viscoelasticity decreased transiently at 45 to 60 min and then returned to control levels. These results suggested usefulness of continuous monitoring of the viscoelasticity in early detection of its degenerative alterations due to impaired myocardial preservation during open heart surgery.
Collapse
Affiliation(s)
- N Sato
- Second Department of Surgery, Ehime University School of Medicine, Shigenobu, Japan
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Christakis GT, Buth KJ, Weisel RD, Rao V, Joy L, Fremes SE, Goldman BS. Randomized study of right ventricular function with intermittent warm or cold cardioplegia. Ann Thorac Surg 1996; 61:128-34. [PMID: 8561538 DOI: 10.1016/0003-4975(95)00933-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transient right ventricular dysfunction has been previously documented after bypass operations despite adequate myocardial protection with intermittent antegrade cold blood cardioplegia. Recently warm blood cardioplegia has been interrupted during construction of distal anastomoses to improve visualization. The effects of intermittent antegrade warm blood cardioplegia, and the resultant periods of right ventricular normothermic ischemia, on postoperative right ventricular function are unknown. METHODS To assess the effects of cardioplegia on right ventricular protection, 52 patients undergoing isolated bypass grafting were randomized to intermittent warm or cold blood cardioplegia. The two groups were similar with respect to age, sex, ventricular function, and right coronary stenoses. Cross-clamp times were similar (warm, 64 +/- 22 minutes; cold, 63 +/- 15 minutes; not significant). The cumulative time of cardioplegia interruption was longer in the cold group (42 +/- 8 minutes) than in the warm group (31 +/- 14 minutes; p < 0.002). A rapid-response thermodilution catheter was employed to assess postoperative right ventricular ejection fraction and end-diastolic and end-systolic volume indices. RESULTS The right ventricular ejection fraction was greater in the warm group at 6 hours (warm, 0.46 +/- 0.06; cold, 0.37 +/- 0.08; p < 0.05) and 8 hours (warm, 0.43 +/- 0.08; cold, 0.37 +/- 0.08; p < 0.05) postoperatively. The right ventricular end-diastolic volume index was less in the warm group 8 hours postoperatively (warm, 83 +/- 11 mL/m2; cold, 94 +/- 16 mL/m2; p < 0.05). There were no differences in pulmonary arterial pressures or right ventricular stroke work index. CONCLUSIONS Despite intermittent normothermic ischemia of half the cross-clamp time, patients receiving warm cardioplegia maintained right ventricular hemodynamics after bypass grafting.
Collapse
Affiliation(s)
- G T Christakis
- Division of Cardiovascular Surgery, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
18
|
Quintilio C, Voci P, Bilotta F, Luzi G, Chiarotti F, Acconcia MC, Mercanti C, Marino B. Risk factors of incomplete distribution of cardioplegic solution during coronary artery grafting. J Thorac Cardiovasc Surg 1995; 109:439-47. [PMID: 7877304 DOI: 10.1016/s0022-5223(95)70274-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Myocardial distribution of cardioplegic solution infused by combined antegrade/retrograde routes was assessed with myocardial contrast echocardiography in 18 patients with chronic stable angina and three-vessel disease undergoing elective coronary artery bypass grafting. Overall myocardial opacification was significantly greater in retrograde than in antegrade cardioplegia (77.7% +/- 13.4% versus 59.1% +/- 15.7%; p = 0.0009). The difference was affected by collateral circulation, as pointed out by the significant interaction between coronary collateral circulation and percent of myocardial opacification after antegrade and retrograde cardioplegia (p = 0.002). When we performed multiple comparisons, in patients with good collaterals the opacification difference between antegrade and retrograde cardioplegia was not statistically significant (66.4% +/- 10.2% versus 76.0% +/- 15.2%; p = not significant), whereas in patients with poor collaterals myocardial opacification during retrograde cardioplegia was significantly greater (44.3% +/- 15.0% versus 81.2% +/- 9.0%; p < 0.02). During antegrade cardioplegia, patients with poor collaterals showed a lower degree of myocardial opacification than patients with good collaterals (44.3% +/- 15.0% versus 66.4% +/- 10.2%; p < 0.01). Our results show that retrograde cardioplegia in patients undergoing elective coronary artery bypass grafting offers no advantage over antegrade cardioplegia when collateral circulation is well developed. On the other hand, conventional aortic root infusion may not provide adequate myocardial protection in the subset of patients with significantly narrowed or occluded coronary arteries and poor collaterals.
Collapse
Affiliation(s)
- C Quintilio
- Department of Cardiac Surgery, University of Florence, Italy
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Bert AA, Singh AK. Right ventricular function after normothermic versus hypothermic cardiopulmonary bypass. J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)33969-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
20
|
Reed CE, Dorman BH, Spinale FG. Assessment of right ventricular contractile performance after pulmonary resection. Ann Thorac Surg 1993; 56:426-31; discussion 431-2. [PMID: 8379712 DOI: 10.1016/0003-4975(93)90874-h] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Right ventricular (RV) performance deteriorates after pulmonary resection. The mechanism remains unclear and could be related to changes in loading conditions or contractility. To assess the role of alteration in RV contractility, we developed a simple and reliable means to measure RV contractile performance in adult patients. Using thermodilution methods and rapid volume infusion in the preoperative setting, the relationship between RV stroke work (RVSWI) and end-diastolic volume (RVEDVI), termed the preload recruitable stroke work relation, was plotted using linear regression. Experimental studies have demonstrated that the preload recruitable stroke work relation is a linear and load-insensitive index of RV contractile performance. Our study confirms this finding in adult patients: RVSWI = 0.33 (RVEDVI) - 20.4 (n = 108; r = 0.94; p < 0.01). Examination of RV pump function and hemodynamic parameters in the early postresection period (up to 24 hours postoperatively) revealed significant changes in loading conditions, but isochronal RVEDVI and RVSWI values were within the confidence limits of the preload recruitable stroke work relation. Thus, depressed RV contractility does not appear to play a predominant role in this early postoperative period. Further study in a larger patient population will be required to verify this observation and to assess RV performance beyond 24 hours after resection.
Collapse
Affiliation(s)
- C E Reed
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston 29425
| | | | | |
Collapse
|
21
|
Hines R, Rafferty T. Right ventricular ejection fraction catheter: toy or tool? Pro: a useful monitor. J Cardiothorac Vasc Anesth 1993; 7:236-40. [PMID: 8477034 DOI: 10.1016/1053-0770(93)90224-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- R Hines
- Department of Anesthesiology, Yale University School of Medicine, Yale-New Haven Hospital, CT 06510
| | | |
Collapse
|
22
|
Rafferty T, Durkin M, Harris S, Elefteriades J, Hines R, Prokop E, O'Connor T. Transesophageal two-dimensional echocardiographic analysis of right ventricular systolic performance indices during coronary artery bypass grafting. J Cardiothorac Vasc Anesth 1993; 7:160-6. [PMID: 8477020 DOI: 10.1016/1053-0770(93)90210-c] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Sixteen patients (aged 59 +/- 14 years) undergoing coronary artery bypass surgery were evaluated to delineate the intraoperative course of transesophageal echocardiographic right ventricular (RV) systolic performance indices. Pre-induction data included thermodilution RV ejection fraction (RVEFTD), 0.43 +/- 0.13, RV end-diastolic volume index (EDVI), 110 +/- 33 mL/m2, cardiac index (CI), 3.4 +/- 1.0 L/min/m2, RV end-diastolic pressure (EDP), 7.1 +/- 4.2 mmHg, and mean pulmonary artery pressure (PAP), 21 +/- 6 mmHg. Eleven patients had significant right coronary artery (RCA) disease (> 70% occlusion). Five patients arrived with an ongoing nitroglycerin infusion (1 to 3 micrograms/kg/min), which was maintained intraoperatively. Echocardiographic measurements included longitudinal-axis (LA) and short-axis (SA) planimetered area excursion fractions (2DLA and 2DSA, respectively) and LA maximal major and minor axis shortening fractions (max majorLA and max minorLA, respectively). Hemodynamic measurements included RVEFTD, EDVI, CI, EDP, and PAP. Measurements were determined following induction/endotracheal intubation, following sternotomy/pericardiotomy, and after cardiopulmonary bypass (CPB) with the chest open. All patients were maintained on vasodilator therapy post-CPB (nitroglycerin, 1 to 3 micrograms/kg/min [N = 16] and nitroprusside, 0.5 to 4.5 microgram/kg/min [N = 4]) post-CPB. Two patients received inotropic support (epinephrine, 0.2 to 0.3 microgram/kg/min). CPB was associated with significant decreases in max major axisLA and 2DLA (P < 0.05) as compared to measurements determined prior to CPB. Maximum major axisLA values pre-CPB were 0.35 +/- 0.06 and 0.33 +/- 0.08 versus post-CPB values of 0.24 +/- 0.08.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- T Rafferty
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510
| | | | | | | | | | | | | |
Collapse
|
23
|
Spinale FG, Mukherjee R, Tanaka R, Zile MR. The effects of valvular regurgitation on thermodilution ejection fraction measurements. Chest 1992; 101:723-31. [PMID: 1541138 DOI: 10.1378/chest.101.3.723] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Through the use of thermodilution principles and rapid response thermistors, it is now possible to measure right ventricular ejection fractions serially in patients. However, to our knowledge, the extent to which tricuspid regurgitation affects the accuracy of thermodilution ejection fraction measurements has not been quantified. The purpose of this study was to compare actual and thermodilution ejection fraction measurements in an in vitro model of tricuspid regurgitation over a wide range of ejection fractions. Stepwise perforation of the inlet valve resulted in regurgitant fractions ranging from 4 to 40 percent. At each increment of inlet valve regurgitation, triplicate sets of thermodilution (EFthermo) ejection fraction measurements were obtained and compared with actual ejection fractions (EFactual). The mean difference between EFactual and EFthermo significantly increased with 8 percent regurgitation and significantly increased with greater increments of inlet valve regurgitation. EFthermo consistently underestimated EFactual over the entire range of regurgitant values. Linear regression analysis revealed a significant correlation between EFactual and EFthermo for all degrees of regurgitation; however, the correlation coefficient significantly declined from control valves with 13 percent regurgitation and declined further with 33 percent regurgitation. Qualitative classification of the inlet valve regurgitation into mild, moderate, and severe regurgitation was performed using pulsed Doppler echocardiography. Mild inlet valve regurgitation resulted in a significantly increased difference between EFactual and EFthermo from control values. A significant increase in the difference between EFactual and EFthermo was observed with both moderate and severe regurgitation. In summary, thermodilution underestimated actual ejection fraction in a direct linear relationship to the degree of inlet valve regurgitation. Thus, in the presence of tricuspid regurgitation, this method may still be useful in serially measuring changes in right ventricular ejection fraction.
Collapse
Affiliation(s)
- F G Spinale
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston
| | | | | | | |
Collapse
|