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Zochios V, Shelley B, Antonini MV, Chawla S, Sato R, Dugar S, Valchanov K, Roscoe A, Scott J, Bangash MN, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Yusuff H. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 1. J Cardiothorac Vasc Anesth 2023; 37:2073-2086. [PMID: 37393133 DOI: 10.1053/j.jvca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Center, Singapore
| | - Jeffrey Scott
- Jackson Health System, Miami Transplant Institute, Miami, FL
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
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John V, Thomas A, Chikkamadegowda M, Jambunathan R. Effect of off-pump coronary artery bypass graft surgery on transthoracic echocardiographic right ventricular function in Indian patients. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2020. [DOI: 10.4103/jiae.jiae_31_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Right ventricular function after cardiac surgery: the diagnostic and prognostic role of echocardiography. Heart Fail Rev 2019; 24:625-635. [DOI: 10.1007/s10741-019-09785-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Zochios V, Protopapas AD, Parhar K. Markers of Right Ventricular Dysfunction in Adult Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2017; 31:1570-1574. [DOI: 10.1053/j.jvca.2017.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Indexed: 11/11/2022]
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Bootsma IT, de Lange F, Koopmans M, Haenen J, Boonstra PW, Symersky T, Boerma EC. Right Ventricular Function After Cardiac Surgery Is a Strong Independent Predictor for Long-Term Mortality. J Cardiothorac Vasc Anesth 2017; 31:1656-1662. [DOI: 10.1053/j.jvca.2017.02.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Indexed: 12/31/2022]
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Pauliks LB, Valdes-Cruz LM, Perryman R, Scholl FG. Right ventricular wall-motion changes after infant open heart surgery--a tissue Doppler study. Echocardiography 2013; 31:209-17. [PMID: 24103038 DOI: 10.1111/echo.12347] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is a well-recognized complication of cardiopulmonary bypass surgery (CPB) in adults. Infants and neonates may also be at high risk for this due to immature myocardium. Conventional assessment of RV function is just qualitative, but novel tissue Doppler echocardiographic (TDI) markers including peak systolic strain rate (SR) and isovolumic contraction acceleration (IVA) permit noninvasive quantitation of RV function. This study assessed myocardial velocities, IVA and SR in infants and neonates undergoing open heart surgery using TDI to study regional myocardial function perioperatively. METHODS Transthoracic TDI data were obtained in the OR before and 24 hours post-CPB on 53 consecutive infants (age 0.39 ± 0.23 years). They were followed with TDI through hospital discharge. RESULTS Mean CPB time was 87 ± 49 min (cross-clamp 52 ± 26 min). Peak systolic (STDI ) and diastolic myocardial velocities (ETDI , ATDI ), IVA, and peak SR were recorded in RV and LV from standard views for offline analysis. Postoperatively, LV systolic function and diastolic longitudinal function were unchanged or improved from baseline. LV radial velocities were increased postoperatively indicating adequate support. In contrast, RV longitudinal systolic and diastolic function was significantly diminished after CPB. RV changes persisted through hospital discharge. CONCLUSIONS In infants and neonates, perioperative measurements of systolic and diastolic tissue Doppler parameters are feasible and revealed significant RV systolic and diastolic dysfunction post-CPB with preserved LV function. As such, TDI provides a sensitive tool to monitor the infant heart after CPB and may potentially be useful to assess different myocardial protection strategies.
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Affiliation(s)
- Linda B Pauliks
- Pediatric Cardiology, Penn State Hershey Medical College, Hershey, Pennsylvania
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Afilalo J, Flynn AW, Shimony A, Rudski LG, Agnihotri AK, Morin JF, Castrillo C, Shahian DM, Picard MH. Incremental value of the preoperative echocardiogram to predict mortality and major morbidity in coronary artery bypass surgery. Circulation 2013; 127:356-64. [PMID: 23239840 DOI: 10.1161/circulationaha.112.127639] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. METHODS AND RESULTS Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. CONCLUSIONS Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.
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Affiliation(s)
- Jonathan Afilalo
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Harvard University, Boston, MA 02114, USA.
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Joshi SB, Roswell RO, Salah AK, Zeman PR, Corso PJ, Lindsay J, Fuisz AR. Right ventricular function after coronary artery bypass graft surgery—a magnetic resonance imaging study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2010; 11:98-100. [DOI: 10.1016/j.carrev.2009.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 04/02/2009] [Indexed: 11/26/2022]
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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.
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Shim JK, Bang SO, Lee JH, Oh YJ, Yoo KJ, Kwak YL. Effect of intracoronary shunt on right ventricular function during off-pump grafting of dominant right coronary artery with poor collateral. J Korean Med Sci 2008; 23:373-7. [PMID: 18583869 PMCID: PMC2526513 DOI: 10.3346/jkms.2008.23.3.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although numerous studies have validated the efficacy of intracoronary shunt on reducing left ventricular dysfunction during off-pump coronary artery bypass surgery (OPCAB), there is lack of evidence supporting its role on right ventricular (RV) function during right coronary artery (RCA) revascularization. Therefore, we studied the effect of intracoronary shunt during grafting of dominant RCA without visible collateral supply on global RV function using thermodilution method. Forty patients scheduled for multivessel OPCAB with right dominant coronary circulation without collateral supply confirmed by angiography were randomized to RCA revascularization either with a shunt (n=20) or soft snare occlusion (n=20). RV ejection fraction (RVEF) was recorded at baseline, during RCA grafting, and 15 min after reperfusion. Corresponding RV stroke work index (RVSWI) was calculated. RVEF and RVSWI decreased significantly during RCA grafting and returned to baseline values after reperfusion in both groups without any significant differences between the groups. Intracoronary shunt did not exert any beneficial effect on global RV function during RCA grafting, even in the absence of visible collateral supply. Regarding the possibility of graft failure by intracoronary shunt-induced endothelial damage, routine use of intracoronary shunt during RCA grafting is not recommended in patients with preserved biventricular function.
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Affiliation(s)
- Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University Health System, Seoul, Korea
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Janardhanan R, Burden L, Senior R. Usefulness of myocardial contrast echocardiography in predicting collateral blood flow in the presence of a persistently occluded acute myocardial infarction-related coronary artery. Am J Cardiol 2004; 93:1207-11. [PMID: 15135690 DOI: 10.1016/j.amjcard.2004.01.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2003] [Revised: 01/21/2004] [Accepted: 01/21/2004] [Indexed: 11/17/2022]
Abstract
Adequate collateral blood flow at rest can sustain myocardial viability despite persistent occlusion of the infarct-related artery (IRA) in acute myocardial infarction (AMI). This has therapeutic and prognostic implications. Studies addressing the value of intravenous myocardial contrast echocardiography (MCE) to detect collateral blood flow after AMI in humans are limited. Accordingly, 70 consecutive patients with AMI underwent low-power intravenous MCE using a Sonovue infusion 7 to 10 days after thrombolysis. Myocardial perfusion detected by MCE was analyzed (qualitatively and quantitatively) in the akinetic segments in 20 patients (29%) with an occluded IRA who subsequently underwent revascularization. Contractile reserve, which is a marker of myocardial viability, was assessed with low-dose dobutamine 12 weeks after mechanical revascularization. Of the 102 akinetic segments (32%), 37 (36%) showed contractile reserve. Contractile reserve was present in 24 of the 29 segments (83%) with homogenous contrast opacification and absent in 60 of the 73 segments (82%) with reduced/absent opacification. Quantitative peak contrast intensity, microbubble velocity, and myocardial blood flow were significantly higher (p <0.0001) in the segments with contractile reserve than in those without contractile reserve. Multiple logistic regression analysis using electrocardiographic, biochemical, and myocardial contrast echocardiographic markers of collateral blood flow showed that MCE (odds ratio 26.0, 95% confidence interval 6.3 to 108.0, p <0.001) was the only independent predictor of collateral blood flow as demonstrated by the presence of contractile reserve. MCE may thus be used as a reliable bedside technique for the accurate evaluation of collateral blood flow in the presence of an occluded IRA after AMI.
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Affiliation(s)
- Rajesh Janardhanan
- Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow HA1 3UJ, United Kingdom
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Hedman A, Alam M, Zuber E, Nordlander R, Samad BA. Decreased right ventricular function after coronary artery bypass grafting and its relation to exercise capacity: A tricuspid annular motion–based study. J Am Soc Echocardiogr 2004; 17:126-31. [PMID: 14752486 DOI: 10.1016/j.echo.2003.10.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Decreased right ventricular (RV) function is a known echocardiographic finding after coronary artery bypass grafting (CABG). For patients with heart failure, RV dysfunction is a predictor of poor exercise capacity. The significance and time course of RV dysfunction and its relation to exercise capacity after CABG have not been elucidated, however. OBJECTIVES In this prospective study, we assessed RV function measured from echocardiographic tricuspid annular motion (TAM) before and after CABG and its relation to exercise capacity. METHODS In 99 patients accepted for CABG, we did a baseline echocardiographic investigation before operation, followed by repeated echocardiograms 3 months and 1 year after CABG. RV function was assessed using the magnitude of TAM measured at the RV free wall. An exercise stress test and coronary angiography were performed before and 3 months after CABG. RESULTS RV function assessed by TAM was significantly reduced 3 months after CABG (22.4 vs 14.5 mm, P <.001) compared with preoperative measurements and remained so after 1 year (14.7 mm, P <.001). Left ventricular systolic function was unchanged 3 months after CABG. The 1-year echocardiographic follow-up showed paradoxical septal movement in 96% of the patients. Exercise capacity improved significantly 3 months after CABG compared with before (1.6 vs 1.83 W/kg, P <.001). These finding are independent of the state of the right coronary artery. CONCLUSIONS One year after CABG, RV function remained depressed and septal motion remained paradoxical compared with the preoperative investigation, suggesting that these postoperative findings might be permanent in the majority of patients. Despite the reduced RV function, exercise performance 3 months after CABG was improved. The depressed RV function, measured from TAM after CABG, probably lacks clinical significance.
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Affiliation(s)
- Anders Hedman
- Department of Cardiology, Karolinska Institute at Söder Hospital (Södersjukhuset), S-11883 Stockholm, Sweden.
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Maslow AD, Regan MM, Panzica P, Heindel S, Mashikian J, Comunale ME. Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction. Anesth Analg 2002; 95:1507-18, table of contents. [PMID: 12456409 DOI: 10.1097/00000539-200212000-00009] [Citation(s) in RCA: 142] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Patients with severe left ventricular systolic dysfunction (LVSD) undergoing coronary artery bypass grafting (CABG) have an increased risk for morbidity and mortality. The purpose of this study was to assess the association of pre-CABG right ventricular (RV) function with outcome for patients with severe LVSD. We performed a retrospective evaluation of 41 patients with severe LVSD (left ventricular ejection fraction [LVEF] < or =25%) scheduled for nonemergent CABG. Data were obtained from review of medical records, transesophageal echocardiography tapes, and phone interview. The pre- and post-cardiopulmonary bypass (CPB) LVEF and the RV fractional area of contraction (RVFAC) were calculated by using intraoperative transesophageal echocardiography. Group 1 patients had an RVFAC < or =35% (n = 7), whereas Group 2 patients had RVFAC >35% (n = 34). The durations of mechanical ventilation and of intensive care unit and hospital stays are presented as the median. Pre-CABG LVEF was similar between Groups 1 and 2 (15.8% +/- 3.3% versus 17.8% +/- 3.9%). Compared with Group 2, Group 1 patients required greater duration of mechanical ventilation (12 days versus 1 day; P < 0.01), longer intensive care unit (14 versus 2 days; P < 0.01) and hospital (14 versus 7 days; P = 0.02) stays, had a more frequent incidence and severity of LV diastolic dysfunction, and had a smaller change in LVEF immediately after CPB (4.1% +/- 8.3% versus 12.5% +/- 9.2%; P = 0.03). All Group 1 patients died of cardiac causes within 2 yr of surgery; five died during the same hospital admission. Three Group 2 patients died: one of colon cancer at 18 mo after CABG and two of cardiac causes 24 and 48 mo after surgery. A fourth patient was awaiting cardiac transplantation 4 yr after surgery. The remaining Group 2 patients were New York Heart Association Classification I or II. For patients with severe LVSD undergoing CABG, pre-CPB RV dysfunction was associated with poor outcome. Patients with RVFAC >35% had a relatively uneventful perioperative course and good long-term survival, whereas patients with RVFAC < or =35% had a poor early and late outcome. Assessment of RV function is useful to further assess the risk of CABG. IMPLICATIONS Right ventricular function before cardiopulmonary bypass is associated with poor outcome after coronary artery surgery in patients with poor left ventricular function.
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Affiliation(s)
- Andrew D Maslow
- Department of Anesthesiology, Rhode Island Hospital, Brown Medical School, Providence 02903, USA.
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