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Chen DX, Wang TH, Xiong XL, Shi J, Zhou L. Incidence, factors, and prognostic analyses of challenging cardiopulmonary bypass separation in Chinese cardiac surgical populations. Minerva Anestesiol 2024; 90:144-153. [PMID: 38127467 DOI: 10.23736/s0375-9393.23.17727-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Challenging separation from cardiopulmonary bypass (CPB) has been associated with multiple medical adversities, while its incidence, associated factors, and prognosis among cardiac surgery populations are substantially understudied. METHODS Adult cardiac surgical patients in two medical centers were retrospectively analyzed. Separation from CPB was stratified as easy, difficult, or complex, based on the use of pharmacologic assistance agents and mechanical supports. The various in-hospital adverse outcomes (e.g., mortality, common complications) were assessed. RESULTS The incidence of difficult and complex separation from CPB was 21.9% (1159 cases, 95% CI 20.8% to 23.1%), and 6.1% (320 cases, 95% CI 5.4% to 6.7%), respectively. High age, the presence of pulmonary hypertension or unstable angina, decreased ejection fraction, and emergency surgery were more frequently associated with challenging separation from CPB. Patients who experienced challenging separation from CPB had an elevated risk of adverse outcomes, including in-hospital mortality (complex: odds ratio [OR] 2.85), composite infection events (difficult: OR=1.82; complex: OR=1.88), major adverse cardiac events (difficult: OR=1.40; complex: OR=1.57), pulmonary complications (difficult: OR=1.31; complex: OR=1.20), acute kidney injury (difficult: OR=1.75; complex: OR=2.64), and prolonged postoperative hospital stays. CONCLUSIONS We depicted the incidence of challenging separation from CPB among cardiac surgery population. Additionally, results of influential factors and various adverse outcome analyses emphasize the potential of interventions aimed at preventing difficult or complex separation from CPB and reducing associated adverse outcomes.
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Affiliation(s)
- Dong X Chen
- Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China
| | - Tian H Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xing L Xiong
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Jing Shi
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Leng Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China -
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Mathis MR, Janda AM, Kheterpal S, Schonberger RB, Pagani FD, Engoren MC, Mentz GB, Shook DC, Muehlschlegel JD. Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis. Anesthesiology 2023; 139:122-141. [PMID: 37094103 PMCID: PMC10524016 DOI: 10.1097/aln.0000000000004593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
BACKGROUND Conflicting evidence exists regarding the risks and benefits of inotropic therapies during cardiac surgery, and the extent of variation in clinical practice remains understudied. Therefore, the authors sought to quantify patient-, anesthesiologist-, and hospital-related contributions to variation in inotrope use. METHODS In this observational study, nonemergent adult cardiac surgeries using cardiopulmonary bypass were reviewed across a multicenter cohort of academic and community hospitals from 2014 to 2019. Patients who were moribund, receiving mechanical circulatory support, or receiving preoperative or home inotropes were excluded. The primary outcome was an inotrope infusion (epinephrine, dobutamine, milrinone, dopamine) administered for greater than 60 consecutive min intraoperatively or ongoing upon transport from the operating room. Institution-, clinician-, and patient-level variance components were studied. RESULTS Among 51,085 cases across 611 attending anesthesiologists and 29 hospitals, 27,033 (52.9%) cases received at least one intraoperative inotrope, including 21,796 (42.7%) epinephrine, 6,360 (12.4%) milrinone, 2,000 (3.9%) dobutamine, and 602 (1.2%) dopamine (non-mutually exclusive). Variation in inotrope use was 22.6% attributable to the institution, 6.8% attributable to the primary attending anesthesiologist, and 70.6% attributable to the patient. The adjusted median odds ratio for the same patient receiving inotropes was 1.73 between 2 randomly selected clinicians and 3.55 between 2 randomly selected institutions. Factors most strongly associated with increased likelihood of inotrope use were institutional medical school affiliation (adjusted odds ratio, 6.2; 95% CI, 1.39 to 27.8), heart failure (adjusted odds ratio, 2.60; 95% CI, 2.46 to 2.76), pulmonary circulation disorder (adjusted odds ratio, 1.72; 95% CI, 1.58 to 1.87), loop diuretic home medication (adjusted odds ratio, 1.55; 95% CI, 1.42 to 1.69), Black race (adjusted odds ratio, 1.49; 95% CI, 1.32 to 1.68), and digoxin home medication (adjusted odds ratio, 1.48; 95% CI, 1.18 to 1.86). CONCLUSIONS Variation in inotrope use during cardiac surgery is attributable to the institution and to the clinician, in addition to the patient. Variation across institutions and clinicians suggests a need for future quantitative and qualitative research to understand variation in inotrope use affecting outcomes and develop evidence-based, patient-centered inotrope therapies. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Michael R. Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Allison M. Janda
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Milo C. Engoren
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Graciela B. Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Douglas C. Shook
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Bishawi M, Milano CA. Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00013-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
Rationale: Patients undergoing cardiac surgery often require vasopressor or inotropic ("vasoactive") medications, but patterns of postoperative use are not well described.Objectives: This study aimed to describe vasoactive medication administration throughout hospitalization for cardiac surgery, to identify patient- and hospital-level factors associated with postoperative use, and to quantify variation in treatment patterns among hospitals.Methods: Retrospective study using the Premier Healthcare Database. The cohort included adult patients who underwent coronary artery bypass grafting or open valve repair or replacement (or in combination) from January 1, 2016, to June 30, 2018. Primary outcome was receipt of vasoactive medication(s) on the first postoperative day (POD1). We identified patient- and hospital-level factors associated with receipt of vasoactive medications using multilevel mixed-effects logistic regression modeling. We calculated adjusted median odds ratios to determine the extent to which receipt of vasoactive medications on POD1 was determined by each hospital, then calculated quotients of Akaike Information Criteria to compare the relative contributions of patient and hospital characteristics and individual hospitals with observed variation.Results: Among 104,963 adults in 294 hospitals, 95,992 (92.2%) received vasoactive medication(s) during hospitalization; 30,851 (29.7%) received treatment on POD1, most commonly norepinephrine (n = 11,427, 37.0%). A median of 29.0% (range, 0.0-94.4%) of patients in each hospital received vasoactive drug(s) on POD1. After adjustment, hospital of admission was associated with twofold increased odds of receipt of any vasoactive medication on POD1 (adjusted median odds ratio, 2.07; 95% confidence interval, 1.93-2.21). Admitting hospital contributed more to observed variation in POD1 vasoactive medication use than patient or hospital characteristics (quotients of Akaike Information Criteria 0.58, 0.44, and <0.001, respectively).Conclusions: Nearly all cardiac surgical patients receive vasoactive medications during hospitalization; however, only one-third receive treatment on POD1, with significant variability by institution. Further research is needed to understand the causes of variability across hospitals and whether these differences are associated with outcomes.
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Amouzegarzavareh SM, Lak M. The effect of pulsatile blood flow during proximal graft in facilitation weaning from cardiopulmonary bypass pump in coronary artery bypass graft surgery. Chirurgia (Bucur) 2020. [DOI: 10.23736/s0394-9508.19.05039-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Inotropes and Vasoactive Agents: Differences Between Europe and the United States. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00323-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Dayan V, Paganini JJ, Marichal A, Brusich D. On-Pump Beating/Non-Beating CABG in Stable Angina Have Similar Outcomes. Braz J Cardiovasc Surg 2019; 33:183-188. [PMID: 29898149 PMCID: PMC5985846 DOI: 10.21470/1678-9741-2017-0161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 10/05/2017] [Indexed: 11/05/2022] Open
Abstract
Objective On pump beating/non-beating coronary artery bypass grafts (CABG) has been
compared in patients with unstable angina and/or severe left ventricular
dysfunction. There is scarce evidence regarding the beneficial use of
on-pump beating CABG in patients with stable angina and normal left
ventricular function. Our aim was to study the postoperative results using
both techniques in this group of patients. Methods One thousand one hundred and forty-five patients with stable angina underwent
on-pump isolated CABG in Uruguay from 2011 to 2015. Patients were grouped
into beating/non-beating CABG. Operative mortality and long-term survival
were evaluated as primary outcome. Logistic regression analysis was
performed to define the predictive role of aortic cross clamp (AXC) on
prolonged inotropic support, ventilator support and intraoperative
glycemia. Results Among the included patients, 988 underwent aortic cross clamp. No differences
were found in operative mortality, stroke and long-term survival among both
groups. Patients without AXC showed higher intraoperative values of glycemia
and higher incidence of postoperative prolonged mechanical ventilator
support (7.6% vs. 2.4%; P=0.001). The need
for prolonged inotropic support was lower in this group of patients (27.4%
vs. 49.5%; P<0.001). Conclusion On-pump beating CABG has similar operative mortality and long-term survival
compared with conventional AXC. Higher intraoperative glycemia and higher
incidence for prolonged mechanical ventilator is associated with on-pump
beating CABG. On the contrary, higher incidence for prolonged inotropic
support is associated with AXC. Taking these factors into consideration,
both techniques are safe and allow the surgeon to choose the most
comfortable option.
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Affiliation(s)
- Victor Dayan
- Centro Cardiovascular Universitario, Hospital de Clinicas, Universidad de la Republica Oriental del Uruguay. Montevideo, Uruguay.,Instituto Nacional de Cirugía Cardíaca (INCC), Montevideo, Uruguay
| | - Juan Jose Paganini
- Centro Cardiovascular Universitario, Hospital de Clinicas, Universidad de la Republica Oriental del Uruguay. Montevideo, Uruguay
| | - Alvaro Marichal
- Centro Cardiovascular Universitario, Hospital de Clinicas, Universidad de la Republica Oriental del Uruguay. Montevideo, Uruguay
| | - Daniel Brusich
- Centro Cardiovascular Universitario, Hospital de Clinicas, Universidad de la Republica Oriental del Uruguay. Montevideo, Uruguay
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Belletti A, Jacobs S, Affronti G, Mladenow A, Landoni G, Falk V, Schoenrath F. Incidence and Predictors of Postoperative Need for High-Dose Inotropic Support in Patients Undergoing Cardiac Surgery for Infective Endocarditis. J Cardiothorac Vasc Anesth 2018; 32:2528-2536. [DOI: 10.1053/j.jvca.2017.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Indexed: 12/15/2022]
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Fernando RJ, Johnson SD, Augoustides JG, Patel PA, Gutsche JT, Ha B, Feinman JW, Weiss SJ, Cheruku S, McCartney SL, Dave N, Fabbro M, Morris BN. The Hostile Thoracic Aorta: Management Considerations for Severe Aortic Atheroma in a Challenging Case of Coronary Artery Bypass Grafting and Mitral Valve Replacement. J Cardiothorac Vasc Anesth 2018; 33:223-231. [PMID: 29685800 DOI: 10.1053/j.jvca.2018.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Sean D Johnson
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bao Ha
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sreekanth Cheruku
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sharon L McCartney
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Duke University, Durham, NC
| | - Nisha Dave
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Benjamin N Morris
- Cardiothoracic and Critical Care Sections, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
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Vasoactive-inotropic score as a predictor of morbidity and mortality in adults after cardiac surgery with cardiopulmonary bypass. J Anesth 2018; 32:167-173. [DOI: 10.1007/s00540-018-2447-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/02/2018] [Indexed: 01/01/2023]
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Kumar A, Puri GD, Bahl A. Transesophageal Echocardiography, 3-Dimensional and Speckle Tracking Together as Sensitive Markers for Early Outcome in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1695-1701. [DOI: 10.1053/j.jvca.2017.04.006] [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: 01/27/2017] [Indexed: 01/01/2023]
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Evaluation and Optimisation of Current Milrinone Prescribing for the Treatment and Prevention of Low Cardiac Output Syndrome in Paediatric Patients After Open Heart Surgery Using a Physiology-Based Pharmacokinetic Drug–Disease Model. Clin Pharmacokinet 2013; 53:51-72. [DOI: 10.1007/s40262-013-0096-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Denault AY, Tardif JC, Mazer CD, Lambert J. Difficult and Complex Separation from Cardiopulmonary Bypass in High-Risk Cardiac Surgical Patients: A Multicenter Study. J Cardiothorac Vasc Anesth 2012; 26:608-16. [DOI: 10.1053/j.jvca.2012.03.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Indexed: 11/11/2022]
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Preoperative and intraoperative prediction of risk of cardiac dysfunction following open heart surgery. Eur J Anaesthesiol 2012; 29:143-51. [DOI: 10.1097/eja.0b013e32834de368] [Citation(s) in RCA: 14] [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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Levosimendan reduces heart failure after cardiac surgery: A prospective, randomized, placebo-controlled trial*. Crit Care Med 2011; 39:2263-70. [DOI: 10.1097/ccm.0b013e3182227b97] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nielsen DV, Johnsen SP, Madsen M, Jakobsen CJ. Variation in use of peroperative inotropic support therapy in cardiac surgery: time for reflection? Acta Anaesthesiol Scand 2011; 55:352-8. [PMID: 21288219 DOI: 10.1111/j.1399-6576.2010.02382.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is no well-established evidence-based clinical guidelines on the most appropriate use of peroperative inotropic support in cardiac surgery. We aimed to identify patient- and procedure-related factors associated with the use of peroperative inotropic support and to estimate physician-level variation. METHODS A population-based study using data from the Western Denmark Heart Registry on 3585 consecutive cardiac surgery cases from three university hospitals. Inotropic support was defined as infusion of inotropic drugs or nor epinephrine at the separation from cardiopulmonary bypass. Poisson's regression modelling was used to determine predictors of inotropic support and to compare use of high-dose inotropic support among experienced cardiac anaesthesiologists. RESULTS We identified a range of factors that were independently associated with an increased use of inotropic support therapy including pre-operative left ventricular dysfunction, pre-operative renal dysfunction, complex procedures, prior cardiac surgery, emergency surgery, pre-operative pulmonary hypertension, critical pre-operative state, extended extra corporal circulation-time and female gender. Further, we found substantial variation in use of inotropic support both at hospital- and at physician-level. The adjusted odds ratio of high-intensity inotropic support varied significantly at physician level from 2.3 [95% confidence interval (CI) 1.83-2.71] to 0.3 (95% CI 0.15-0.61) when the individual physicians were compared with the rest. CONCLUSION The use of inotropic support during cardiac surgery is associated with the pre-operative state of the patient, as well as type of surgery. However, the present study indicates that use of peroperative inotropic support is also highly dependent on physician's preferences, indicating the need for an evidence-based approach when initiating inotropic therapy in cardiac surgery.
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Affiliation(s)
- D V Nielsen
- Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Skejby, Aarhus, Denmark.
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Kirkpatrick JN, Lang RM. Surgical Echocardiography of Heart Valves: A Primer for the Cardiovascular Surgeon. Semin Thorac Cardiovasc Surg 2010; 22:200.e1-22. [DOI: 10.1053/j.semtcvs.2010.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2010] [Indexed: 01/11/2023]
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Pitkin AD, Blas ML, Klodell CT, Oware A, Augoustides JG. Case 4—2010Successful Use of Transesophageal Echocardiography After Esophagogastrectomy. J Cardiothorac Vasc Anesth 2010; 24:700-5. [DOI: 10.1053/j.jvca.2010.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Indexed: 12/28/2022]
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Denault AY, Deschamps A, Couture P. Intraoperative Hemodynamic Instability During and After Separation From Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2010; 14:165-82. [DOI: 10.1177/1089253210376673] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, more than 1 million patients worldwide undergo cardiac surgery. Because of the aging of the population, cardiac surgery will increasingly be offered to patients at a higher risk of complications. The consequence is a reduced physiological reserve and hence an increased risk of mortality. These issues will have a significant impact on future health care costs because the population undergoing cardiac surgery will be older and more likely to develop postoperative complications. One of the most dreaded complications in cardiac surgery is difficult separation from cardiopulmonary bypass (CPB). When separation from CPB is associated with right-ventricular failure, the mortality rate will range from 44% to 86%. Therefore, the diagnosis and the preoperative prediction of difficult separation from CPB will be crucial to improve the selection and care of patients and to prevent complications for this high-risk patient population.
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Affiliation(s)
- André Y. Denault
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada,
| | - Alain Deschamps
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
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Licker M, Cikirikcioglu M, Inan C, Cartier V, Kalangos A, Theologou T, Cassina T, Diaper J. Preoperative diastolic function predicts the onset of left ventricular dysfunction following aortic valve replacement in high-risk patients with aortic stenosis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R101. [PMID: 20525242 PMCID: PMC2911741 DOI: 10.1186/cc9040] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 11/20/2009] [Accepted: 06/03/2010] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Left ventricular (LV) dysfunction frequently occurs after cardiac surgery, requiring inotropic treatment and/or mechanical circulatory support. In this study, we aimed to identify clinical, surgical and echocardiographic factors that are associated with LV dysfunction during weaning from cardiopulmonary bypass (CPB) in high-risk patients undergoing valve replacement for aortic stenosis. METHODS Perioperative data were prospectively collected in 108 surgical candidates with an expected operative mortality >or=9%. All anesthetic and surgical techniques were standardized. Reduced LV systolic function was defined by an ejection fraction <40%. Diastolic function of the LV was assessed using standard Doppler-derived parameters, tissue Doppler Imaging (TDI) and transmitral flow propagation velocity (Vp). RESULTS Doppler-derived pulmonary flow indices and TDI could not be obtained in 14 patients. In the remaining 94 patients, poor systolic LV was documented in 14% (n = 12) and diastolic dysfunction in 84% of patients (n = 89), all of whom had Vp <50 cm/s. During weaning from CPB, 38 patients (40%) required inotropic and/or mechanical circulatory support. By multivariate regression analysis, we identified three independent predictors of LV systolic dysfunction: age (Odds ratio [OR] = 1.11; 95% confidence interval (CI), 1.01 to 1.22), aortic clamping time (OR = 1.04; 95% CI, 1.00 to 1.08) and Vp (OR = 0.65; 95% CI, 0.52 to 0.81). Among echocardiographic measurements, Vp was found to be superior in terms of prognostic value and reliability. The best cut-off value for Vp to predict LV dysfunction was 40 cm/s (sensitivity of 72% and specificity 94%). Patients who experienced LV dysfunction presented higher in-hospital mortality (18.4% vs. 3.6% in patients without LV dysfunction, P = 0.044) and an increased incidence of serious cardiac events (81.6 vs. 28.6%, P < 0.001). CONCLUSIONS This study provides the first evidence that, besides advanced age and prolonged myocardial ischemic time, LV diastolic dysfunction characterized by Vp <or= 40 cm/sec identifies patients who will require cardiovascular support following valve replacement for aortic stenosis.
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Affiliation(s)
- Marc Licker
- Faculty of Medicine, University of Geneva, Department of Anaesthesiology, University Hospital, CH-1211 Geneva 14, Switzerland
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Svedjeholm R, Vidlund M, Vanhanen I, Håkanson E. A metabolic protective strategy could improve long-term survival in patients with LV-dysfunction undergoing CABG. SCAND CARDIOVASC J 2010; 44:45-58. [DOI: 10.3109/14017430903531008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, Khandheria BK, Levine RA, Marx GR, Miller FA, Nakatani S, Quiñones MA, Rakowski H, Rodriguez LL, Swaminathan M, Waggoner AD, Weissman NJ, Zabalgoitia M. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr 2009; 22:975-1014; quiz 1082-4. [PMID: 19733789 DOI: 10.1016/j.echo.2009.07.013] [Citation(s) in RCA: 924] [Impact Index Per Article: 61.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- William A Zoghbi
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
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Ahmed I, House CM, Nelson WB. Predictors of inotrope use in patients undergoing concomitant coronary artery bypass graft (CABG) and aortic valve replacement (AVR) surgeries at separation from cardiopulmonary bypass (CPB). J Cardiothorac Surg 2009; 4:24. [PMID: 19519919 PMCID: PMC2706226 DOI: 10.1186/1749-8090-4-24] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 06/12/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Left ventricular dysfunction is common after coronary artery bypass graft and valve replacement surgeries and is often treated with inotropic drugs to maintain adequate hemodynamic status. In this study, we aimed to identify the demographic, clinical, laboratory, echocardiographic and hemodynamic factors that are associated with use of inotropic drugs in patients undergoing concomitant coronary artery bypass graft and aortic valve replacement surgery. METHODS The study included 97 patients who had undergone concomitant coronary artery bypass graft and aortic valve replacement at Regions Hospital, University of Minnesota Medical School from January 2006 to December 2008. All data were collected retrospectively after reviewing electronic medical records. Inotropic support was defined as the use of dopamine [greater than or equal to] 5 ug/kg/min; any dose of epinephrine, norepinephrine, dobutamine, and milrinone at the separation from cardiopulmonary bypass. RESULTS Inotropic support was used in a total of 50 patients (52%) at the separation from cardiopulmonary bypass. Average age of the patients requiring inotropic support was 72.2 +/- 8.8 years. The study identified four significant, independent predictors of inotrope use: (1) Cardiac index [less than or equal to] 2.5 L/min/m2, (2) LVEDP [greater than or equal to] 20 mm Hg, (3) LVEF [less than or equal to] 40%, and (4) CKD stage 3 to 5. CONCLUSION We identified four independent risk factors for postoperative use of inotropic support in patients undergoing concomitant coronary artery bypass graft and arotic valve replacement surgery at the separation from cardiopulmonary bypass. The study results will be helpful to prospectively identify patients who will likely to require inotropic support at the separation from cardiopulmonary bypass.
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Affiliation(s)
- Imdad Ahmed
- Department of Hospital Medicine, Regions Hospital, University of Minnesota Medical School, St Paul, Minnesota, USA.
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Gadhinglajkar SV, Sreedhar R, Jacob D, Jayakumar K, Adil S, Nagi GS, Skubas NJ, Chaney MA. Case 1--2009. Retrocardiac sponge-induced hemodynamic instability after cardiac surgery. J Cardiothorac Vasc Anesth 2009; 23:102-9. [PMID: 19159842 DOI: 10.1053/j.jvca.2008.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Indexed: 11/11/2022]
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Minhaj M, Patel K, Muzic D, Tung A, Jeevanandam V, Raman J, Chaney MA. The Effect of Routine Intraoperative Transesophageal Echocardiography on Surgical Management. J Cardiothorac Vasc Anesth 2007; 21:800-4. [DOI: 10.1053/j.jvca.2007.04.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Indexed: 11/11/2022]
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Bredin F, Franco-Cereceda A. Experiences of levosimendan as an inotropic agent in conjunction with passive containment surgery. SCAND CARDIOVASC J 2007; 41:197-200. [PMID: 17487771 DOI: 10.1080/14017430601137160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Levosimendan is a calcium sensitizer with a positive inotropic effect without increasing oxygen consumption. We have evaluated the immediate effects of levosimendan on cardiac index when given peri-operatively to patients with dilated cardiomyopathy in conjunction with passive containment surgery. DESIGN Ten patients with dilated cardiomyopathy undergoing passive containment surgery with the ACORN Cardiac Support Device, either as the sole procedure or in combination with other open heart surgery, were after anaesthesia induction given levosimendan as a bolus dose of 12 microg/kg followed by an infusion of 0.1microg/kg/min for 24 hours. Cardiac index were measured before extra corporal circulation, immediately after extra corporal circulation, at arrival to the intensive care unit and on post operative day 1. The need for inotropic support was recorded. RESULTS Nine of ten patients were preoperatively in a low cardiac output situation. At postoperative day 1 there was a significant increase in cardiac index from 2.1+/-0.1 to 2.8+/-0.2. CONCLUSIONS This study confirms the theoretical benefits of levosimendan judged by an immediate significant positive effect on cardiac index.
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Affiliation(s)
- Fredrik Bredin
- Department of Cardiothoracic Surgery & Anesthesiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.
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Leineweber K, Bogedain P, Wolf C, Wagner S, Weber M, Jakob HG, Heusch G, Philipp T, Brodde OE. In patients chronically treated with metoprolol, the demand of inotropic catecholamine support after coronary artery bypass grafting is determined by the Arg389Gly-β1-adrenoceptor polymorphism. Naunyn Schmiedebergs Arch Pharmacol 2007; 375:303-9. [PMID: 17541557 DOI: 10.1007/s00210-007-0166-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Accepted: 05/04/2007] [Indexed: 11/25/2022]
Abstract
In vitro, the Arg389Gly-beta(1)-adrenoceptor (AR) polymorphism exhibits decreased receptor signaling. In vivo, dobutamine infusion evoked smaller heart rate and/or contractility increases in subjects carrying Gly389Gly-beta(1)AR vs subjects carrying Arg389Arg-beta(1)AR. The aim of this study was to find out whether the Arg389Gly-beta(1)AR polymorphism might also determine demand of catecholamine-induced inotropic support in patients with low cardiac index (CI) after coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB). For this purpose, we assessed in 82 patients, who were preoperatively chronically treated with metoprolol, after CABG surgery with CPB, the dose and duration of adrenaline-induced inotropic support in relation to the Arg389Gly-beta(1)AR genotype. Patients homozygous for the Arg389-beta(1)AR variant (n = 45) required, in comparison to patients homozygous for the Gly389-beta(1)AR variant (n = 9), lower adrenaline doses (53 +/- 24 vs 164 +/- 39 ng/kg body weight/min, p < 0.05) to reach a stable and comparable hemodynamic status and a CI >or= 3.0 l/min/m(2). Moreover, the time necessary for inotropic support tended to be shorter in patients homozygous for the Arg389-beta(1)AR than in patients homozygous for the Gly389-beta(1)AR (10.5 +/- 6 vs 20.5 +/- 12 h). Values for patients heterozygous for the Arg389Gly-beta(1)AR (n = 28) were in between. We conclude that the Arg389Gly-beta(1)AR polymorphism appears to be a determinant of cardiac responses to catecholamine stimulation. Thus, by assessment of the Arg389Gly-beta(1)AR polymorphism, it might be possible to predict demand of and therapeutic responses to beta AR agonist treatment.
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Affiliation(s)
- Kirsten Leineweber
- Department of Pathophysiology and Nephrology, University of Essen School of Medicine, Hufelandstr. 55, 45147, Essen, Germany
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Givertz MM, Stevenson LW, Colucci WS. Strategies for Management of Decompensated Heart Failure. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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