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Denault A, Couture EJ, Perry T, Saade E, Calderone A, Zeng YH, Scherb D, Moses K, Potes C, Hammoud A, Beaubien-Souligny W, Elmi-Sarabi M, Grønlykke L, Lamarche Y, Lebon JS, Rousseau-Saine N, Desjardins G, Rochon A. Continuous Right Ventricular Pressure Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:1673-1682. [PMID: 38862285 DOI: 10.1053/j.jvca.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/10/2024] [Accepted: 04/19/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVE Right ventricular (RV) dysfunction in cardiac surgery can lead to RV failure, which is associated with increased morbidity and mortality. Abnormal RV function can be identified using RV pressure monitoring. The primary objective of the study is to determine the proportion of patients with abnormal RV early to end-diastole diastolic pressure gradient (RVDPG) and abnormal RV end-diastolic pressure (RVEDP) before initiation and after cardiopulmonary bypass (CPB) separation. The secondary objective is to evaluate if RVDPG before CPB initiation is associated with difficult and complex separation from CPB, RV dysfunction, and failure at the end of cardiac surgery. DESIGN Prospective study. SETTING Tertiary care cardiac institute. PARTICIPANTS Cardiac surgical patients. INTERVENTION Cardiac surgery. MEASUREMENTS AND MAIN RESULTS Automated electronic quantification of RVDPG and RVEDP were obtained. Hemodynamic measurements were correlated with cardiac and extracardiac parameters from transesophageal echocardiography and postoperative complications. Abnormal RVDPG was present in 80% of the patients (n = 105) at baseline, with a mean RVEDP of 14.2 ± 3.9 mmHg. Patients experienced an RVDPG > 4 mmHg for a median duration of 50.2% of the intraoperative period before CPB initiation and 60.6% after CPB separation. A total of 46 (43.8%) patients had difficult/complex separation from CPB, 18 (38.3%) patients had RV dysfunction, and 8 (17%) had RV failure. Abnormal RVDPG before CPB was not associated with postoperative outcome. CONCLUSION Elevated RVDPG and RVEDP are common in cardiac surgery. RVDPG and RVEDP before CPB initiation are not associated with RV dysfunction and failure but can be used to diagnose them.
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Affiliation(s)
- André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Etienne J Couture
- Department of Anesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Tjorvi Perry
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Elena Saade
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yu Hao Zeng
- Departments of Medicine and of Family Medicine, Jewish General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | - Ali Hammoud
- Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | | | - Mahsa Elmi-Sarabi
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Yoan Lamarche
- Department of Cardiothoracic Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Sébastien Lebon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Nicolas Rousseau-Saine
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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2
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Slivneva IV, Farulova IY, Skopin II, Pirushkina YD, Murysova DV, Marapov DI, Golukhova EZ. Right Ventricular Function in Surgical Treatment of Left Heart. KARDIOLOGIIA 2023; 63:11-21. [PMID: 38156485 DOI: 10.18087/cardio.2023.12.n2433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/17/2023] [Indexed: 12/30/2023]
Abstract
Aim The aim of this study was to evaluate right ventricular (RV) function during left chamber surgery.Material and methods This was a single-site prospective cohort study. The study included 197 patients with valvular pathology of heart left chambers. Mean age of patients was 58 [47; 65] years. Precordial echocardiography was performed preoperatively and within one week after surgery.Results Decreased parameters of the right ventricular (RV) longitudinal function and global contractile function were observed postoperatively in the majority of patients. More noticeable decreases were observed in parameters of the longitudinal function (p<0.001). Analysis of the changes in RV contractility depending on the underlying pathology revealed the greatest changes in the contractile function in the mitral insufficiency group. In the mitral stenosis group, the greatest difference was observed in the tricuspid annular systolic excursion (TAPSE) (p=0.027). In the groups with aortic defects, all parameters of RV contractile function, except for the fractional area change (FAC), showed statistically significant decreases after correction of the underlying defect (p<0.05).Conclusions Surgical intervention for left heart valvulopathy can result in a decrease in RV function unrelated with systolic deficit of the left ventricle. Modern technologies allow multi-vector assessment of the RV contractile function. To assess the RV function, it is advisable to use a combination of parameters that reflect both global and longitudinal function.
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Affiliation(s)
- I V Slivneva
- Bakulev National Medical Research Center for Cardiovascular Surgery
| | - I Yu Farulova
- Bakulev National Medical Research Center for Cardiovascular Surgery
| | - I I Skopin
- Bakulev National Medical Research Center for Cardiovascular Surgery
| | - Yu D Pirushkina
- Bakulev National Medical Research Center for Cardiovascular Surgery
| | - D V Murysova
- Bakulev National Medical Research Center for Cardiovascular Surgery
| | - D I Marapov
- Bakulev National Medical Research Center for Cardiovascular Surgery
| | - E Z Golukhova
- Bakulev National Medical Research Center for Cardiovascular Surgery
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3
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Sardo S, Tripodi VF, Guerzoni F, Musu M, Cortegiani A, Finco G. Pulmonary Vasodilator and Inodilator Drugs in Cardiac Surgery: A Systematic Review With Bayesian Network Meta-Analysis. J Cardiothorac Vasc Anesth 2023; 37:2261-2271. [PMID: 37652847 DOI: 10.1053/j.jvca.2023.07.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/22/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE The authors performed a systematic review to evaluate the effect of pharmacologic therapy on pulmonary hypertension in the perioperative setting of elective cardiac surgery (PROSPERO CRD42023321041). DESIGN Systematic review of randomized controlled trials with a Bayesian network meta-analysis. SETTING The authors searched biomedical databases for randomized controlled trials on the perioperative use of inodilators and pulmonary vasodilators in adult cardiac surgery, with in-hospital mortality as the primary outcome and duration of ventilation, length of stay in the intensive care unit, stage 3 acute kidney injury, cardiogenic shock requiring mechanical support, and change in mean pulmonary artery pressure as secondary outcomes. PARTICIPANTS Twenty-eight studies randomizing 1,879 patients were included. INTERVENTIONS Catecholamines and noncatecholamine inodilators, arterial pulmonary vasodilators, vasodilators, or their combination were considered eligible interventions compared with placebo or standard care. MEASUREMENTS AND MAIN RESULTS Ten studies reported in-hospital mortality and assigned 855 patients to 12 interventions. Only inhaled prostacyclin use was supported by a statistically discernible improvement in mortality, with a number-needed-to-treat estimate of at least 3.3, but a wide credible interval (relative risk 1.26 × 10-17 - 0.7). Inhaled prostacyclin and nitric oxide were associated with a reduction in intensive care unit stay, and none of the included interventions reached a statistically evident difference compared to usual care or placebo in the other secondary clinical outcomes. CONCLUSIONS Inhaled prostacyclin was the only pharmacologic intervention whose use is supported by a statistically discernible improvement in mortality in the perioperative cardiac surgery setting as treatment of pulmonary hypertension. However, available evidence has significant limitations, mainly the low number of events and imprecision.
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Affiliation(s)
- Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy.
| | - Vincenzo Francesco Tripodi
- Department of Human Pathology, Unit of Anesthesia and Intensive Care, University Hospital of Messina, Messina, Italy
| | - Filippo Guerzoni
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Mario Musu
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Andrea Cortegiani
- Department of Surgical Oncological and Oral Science, University of Palermo, Palermo, Italy; Department of Anesthesia, Intensive Care, and Emergency, University Hospital "Policlinico Paolo Giaccone", Palermo, Italy
| | - Gabriele Finco
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
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Chung EYM, Badve SV, Heerspink HJL, Wong MG. Endothelin receptor antagonists in kidney protection for diabetic kidney disease and beyond? Nephrology (Carlton) 2023; 28:97-108. [PMID: 36350038 PMCID: PMC10100079 DOI: 10.1111/nep.14130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/11/2022]
Abstract
The burden of chronic kidney disease is increasing worldwide, largely due to the increasing global prevalence of diabetes mellitus and hypertension. While renin angiotensin system inhibitors and sodium-glucose cotransporter two inhibitors are the management cornerstone for reducing kidney and cardiovascular complications in patients with diabetic and non-diabetic kidney disease (DKD), they are partially effective and further treatments are needed to prevent the progression to kidney failure. Endothelin receptor antagonism represent a potential additional therapeutic option due to its beneficial effect on pathophysiological processes involved in progressive kidney disease including proteinuria, which are independently associated with progression of kidney disease. This review discusses the biological mechanisms of endothelin receptor antagonists (ERA) in kidney protection, the efficacy and safety of ERA in randomised controlled trials reporting on kidney outcomes, and its potential future use in both diabetic and non-DKDs.
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Affiliation(s)
- Edmund Y M Chung
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Sunil V Badve
- Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.,Department of Renal Medicine, St George Hospital, Kogarah, New South Wales, Australia
| | - Hiddo J L Heerspink
- Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.,Department of Clinical Pharmacoy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Muh Geot Wong
- Department of Renal Medicine, Concord Repatriation General Hospital, University of Sydney, Concord, New South Wales, Australia
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Elmi-Sarabi M, Jarry S, Couture EJ, Haddad F, Cogan J, Sweatt AJ, Rousseau-Saine N, Beaubien-Souligny W, Fortier A, Denault AY. Pulmonary Vasodilator Response of Combined Inhaled Epoprostenol and Inhaled Milrinone in Cardiac Surgical Patients. Anesth Analg 2023; 136:282-294. [PMID: 36121254 DOI: 10.1213/ane.0000000000006192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. Intraoperative management of patients at high risk of RV failure should aim to reduce RV afterload and optimize RV filling pressures, while avoiding systemic hypotension, to facilitate weaning from cardiopulmonary bypass (CPB). Inhaled epoprostenol and inhaled milrinone (iE&iM) administered in combination before CPB may represent an effective strategy to facilitate separation from CPB and reduce requirements for intravenous inotropes during cardiac surgery. Our primary objective was to report the rate of positive pulmonary vasodilator response to iE&iM and, second, how it relates to perioperative outcomes in cardiac surgery. METHODS This is a retrospective cohort study of consecutive patients with PH or RV dysfunction undergoing on-pump cardiac surgery at the Montreal Heart Institute from July 2013 to December 2018 (n = 128). iE&iM treatment was administered using an ultrasonic mesh nebulizer before the initiation of CPB. Demographic and baseline clinical data, as well as hemodynamic, intraoperative, and echocardiographic data, were collected using electronic records. An increase of 20% in the mean arterial pressure (MAP) to mean pulmonary artery pressure (MPAP) ratio was used to indicate a positive response to iE&iM. RESULTS In this cohort, 77.3% of patients were responders to iE&iM treatment. Baseline systolic pulmonary artery pressure (SPAP) (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.24-2.16 per 5 mm Hg; P = .0006) was found to be a predictor of pulmonary vasodilator response, while a European System for Cardiac Operative Risk Evaluation (EuroSCORE II) score >6.5% was a predictor of nonresponse to treatment (≤6.5% vs >6.5% [reference]: OR, 5.19; 95% CI, 1.84-14.66; P = .002). Severity of PH was associated with a positive response to treatment, where a higher proportion of responders had MPAP values >30 mm Hg (42.4% responders vs 24.1% nonresponders; P = .0237) and SPAP values >55 mm Hg (17.2% vs 3.4%; P = .0037). Easier separation from CPB was also associated with response to iE&iM treatment (69.7% vs 58.6%; P = .0181). A higher proportion of nonresponders had a very difficult separation from CPB and required intravenous inotropic drug support compared to responders, for whom easy separation from CPB was more frequent. Use of intravenous inotropes after CPB was lower in responders to treatment (8.1% vs 27.6%; P = .0052). CONCLUSIONS A positive pulmonary vasodilator response to treatment with a combination of iE&iM before initiation of CPB was observed in 77% of patients. Higher baseline SPAP was an independent predictor of pulmonary vasodilator response, while EuroSCORE II >6.5% was a predictor of nonresponse to treatment.
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Affiliation(s)
- Mahsa Elmi-Sarabi
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Etienne J Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, Canada
| | - François Haddad
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Jennifer Cogan
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Andrew J Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California
| | - Nicolas Rousseau-Saine
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - William Beaubien-Souligny
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal (CHUM) and Innovation Hub, Research Centre CHUM, Montreal, Quebec, Canada
| | - Annik Fortier
- Department of Statistics, Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - André Y Denault
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model. Crit Care Explor 2023; 5:e0847. [PMID: 36699251 PMCID: PMC9851694 DOI: 10.1097/cce.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (Ees) following the development of an acute RV ischemic in a porcine model. HYPOTHESIS RV pressure monitoring can detect changes in RV systolic performance assess by RV Ees following the development of an acute RV ischemic model. METHODS AND MODELS Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV Ees obtained using a conductance catheter during inferior vena cava occlusions. RESULTS Acute ischemia resulted in a significant reduction in RV Ees from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between Ees and RV pressure-derived parameters. The reduction in RV Ees best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dtmax) and single-beat RV Ees. Adjusting RV dP/dtmax for heart rate resulted in an improved surrogate of RV Ees. INTERPRETATION AND CONCLUSIONS Stepwise decreases in RV Ees during acute ischemic RV dysfunction were accurately tracked by RV dP/dtmax derived from the RV pressure waveform.
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Kontar L, Beaubien-Souligny W, Couture EJ, Jacquet-Lagrèze M, Lamarche Y, Levesque S, Babin D, Denault AY. Prolonged cardiovascular pharmacological support and fluid management after cardiac surgery. PLoS One 2023; 18:e0285526. [PMID: 37167244 PMCID: PMC10174538 DOI: 10.1371/journal.pone.0285526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVE To identify potentially modifiable risk factors related to prolonged cardiovascular pharmacological support after weaning from cardiopulmonary bypass (CPB). METHODS This is a secondary analysis of two prospective cohort study in a specialized cardiac surgery institution in adult patients undergoing cardiac surgery with the use of CPB between August 2016 and July 2017. Prolonged cardiovascular pharmacological support was defined by the need for at least one vasopressor or one inotropic agent 24 hours after separation from CPB. Risk factors were identified among baseline characteristics and peri-operative events through multivariable logistic regression. RESULTS A total of 247 patients were included and 98 (39.7%) developed prolonged pharmacological support. In multivariable analysis, left ventricular ejection fraction ≤ 30% (OR 9.52, 95% confidence interval (CI) 1.14; 79.25), elevated systolic pulmonary artery pressure (sPAP) > 30 and ≤ 55 mmHg (moderate) (OR 2.52, CI 1.15; 5.52) and sPAP > 55 mmHg (severe) (OR 8.12, CI 2.54; 26.03), as well as cumulative fluid balance in the first 24 hours after surgery (OR 1.76, CI 1.32; 2.33) were independently associated with the development of prolonged pharmacological support. CONCLUSIONS Prolonged cardiovascular pharmacological support is frequent after cardiac surgery on CPB. Severe LV systolic dysfunction, preoperative pulmonary hypertension and postoperative fluid overload are risk factors. Further studies are required to explore if those risk factors could be modified or not.
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Affiliation(s)
- Loay Kontar
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Division of Intensive Care Unit, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
- Medical Intensive Care Unit, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - William Beaubien-Souligny
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Etienne J Couture
- Department of Anesthesiology and Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, Quebec, Canada
| | - Matthias Jacquet-Lagrèze
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Sylvie Levesque
- Montreal Health Innovations Coordinating Centre, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Denis Babin
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Division of Intensive Care Unit, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Sehgal A, Behl T, Singh S, Sharma N, Albratty M, Alhazmi HA, Meraya AM, Aleya L, Sharma A, Bungau S. Exploring the pivotal role of endothelin in rheumatoid arthritis. Inflammopharmacology 2022; 30:1555-1567. [PMID: 36029362 DOI: 10.1007/s10787-022-01051-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/01/2022] [Indexed: 11/05/2022]
Abstract
A chronic inflammatory disorder, rheumatoid arthritis (RA) is an autoimmune and systemic disease characterized by progressive and prolonged destruction of joints. This results in increased mortality, physical disability and destruction. Cardiovascular disorders are one of the primary causes of mortality in patients with RA. It is multifactorial in nature and includes genetic, environmental and demographic factors which contribute to the severity of disease. Endothelin-1 (ET-1) is a peptide which acts as a potent vasoconstrictor and is generated through vascular smooth muscle and endothelial cells. Endothelins may be responsible for RA, as under certain circumstances they produce reactive oxygen species which further promote the production of pro-inflammatory cytokines. This enhances the production of superoxide anion, which activates pro-inflammatory cytokines, resulting in RA. The aim of this review is to elucidate the role of endothelin in the progression of RA. This review also summarizes the natural and synthetic anti-inflammatory drugs which have provided remarkable insights in targeting endothelin.
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Affiliation(s)
- Aayush Sehgal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tapan Behl
- School of Health Sciences, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India.
| | - Sukhbir Singh
- Department of Pharmaceutics, MM College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana-Ambala, 133207, Haryana, India
| | - Neelam Sharma
- Department of Pharmaceutics, MM College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana-Ambala, 133207, Haryana, India
| | - Mohammed Albratty
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Hassan A Alhazmi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jazan University, Jazan, Saudi Arabia.,Substance Abuse and Toxicology Research Center, Jazan University, Jazan, Saudi Arabia
| | - Abdulkarim M Meraya
- Pharmacy Practice Research Unit, Department of Clinical Pharmacy, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Lotfi Aleya
- Chrono-Environment Laboratory, UMR CNRS 6249, Bourgogne Franche-Comté University, Besançon, France
| | - Aditi Sharma
- School of Pharmaceutical Sciences, Shoolini University, Solan, Himachal Pradesh, India
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania.,Doctoral School of Biomedical Sciences, University of Oradea, Oradea, Romania
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9
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Endothelin and the Cardiovascular System: The Long Journey and Where We Are Going. BIOLOGY 2022; 11:biology11050759. [PMID: 35625487 PMCID: PMC9138590 DOI: 10.3390/biology11050759] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/12/2022]
Abstract
Simple Summary In this review, we describe the basic functions of endothelin and related molecules, including their receptors and enzymes. Furthermore, we discuss the important role of endothelin in several cardiovascular diseases, the relevant clinical evidence for targeting the endothelin pathway, and the scope of endothelin-targeting treatments in the future. We highlight the present uses of endothelin receptor antagonists and the advancements in the development of future treatment options, thereby providing an overview of endothelin research over the years and its future scope. Abstract Endothelin was first discovered more than 30 years ago as a potent vasoconstrictor. In subsequent years, three isoforms, two canonical receptors, and two converting enzymes were identified, and their basic functions were elucidated by numerous preclinical and clinical studies. Over the years, the endothelin system has been found to be critical in the pathogenesis of several cardiovascular diseases, including hypertension, pulmonary arterial hypertension, heart failure, and coronary artery disease. In this review, we summarize the current knowledge on endothelin and its role in cardiovascular diseases. Furthermore, we discuss how endothelin-targeting therapies, such as endothelin receptor antagonists, have been employed to treat cardiovascular diseases with varying degrees of success. Lastly, we provide a glimpse of what could be in store for endothelin-targeting treatment options for cardiovascular diseases in the future.
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10
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Levy D, Laghlam D, Estagnasie P, Brusset A, Squara P, Nguyen LS. Post-operative Right Ventricular Failure After Cardiac Surgery: A Cohort Study. Front Cardiovasc Med 2021; 8:667328. [PMID: 34195233 PMCID: PMC8236513 DOI: 10.3389/fcvm.2021.667328] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/11/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction: Right ventricular failure (RVF) after cardiac surgery is an important risk factor for morbidity and mortality. Its diagnosis is challenging, and thus, its incidence and predictors are not well-established. We investigated the incidence, complications, and variables associated with clinically relevant post-operative RVF. Methods: We included all patients who underwent cardiac surgery with cardiopulmonary bypass between 2016 and 2019 in a cardiac surgery center with standardized diagnostic and therapeutic management of RVF. RVF was considered only if clinically relevant: associated with hemodynamic instability requiring catecholamine support and inhaled nitric oxide relayed by sildenafil. Results: Overall, 3,826 patients were included, of whom, 110 (2.9%) developed post-operative RVF. Mortality was not different among patients who developed post-operative RVF, compared with the rest of the cohort (1.8 vs. 0.7%, p = 0.17). Using a composite outcome that combined death, reintubation, stroke, and prolonged intensive care unit stay (more than 14 days) yielded an incidence of 6.6%, and RVF was associated with this composite outcome with an odds ratio of 3.6 (2.2–5.8), p < 0.001. In a multivariable model, pre-operative variables independently associated with post-operative RVF were pre-operative atrial fibrillation (AF) {adjusted odds ratio (adjOR) 3.22 [95% confidence interval (95%CI) = 1.94–5.36], p < 0.001}, left ventricle ejection fraction below 50% [adjOR = 2.55 (95%CI = 1.52–4.33), p < 0.001], systolic pulmonary artery pressure above 55 mmHg [adjOR = 8.64 (95%CI = 5.27–14.1); p < 0.001], mitral valve surgery [adjOR = 2.17 CI (95%CI = 1.28–3.66), p = 0.004], and tricuspid valve surgery [adjOR = 10.33 (95%CI = 6.14–17.4), p < 0.001]. In patients who developed post-operative RVF requiring treatment, 32 (29.1%) showed RV dysfunction before surgery. Conclusion: In this cohort study, 2.9% of patients developed clinically significant post-operative RVF. Moreover, RVF was associated with severe adverse outcomes, including death, strokes, reintubation, and prolonged intensive care unit stay.
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Affiliation(s)
- David Levy
- Intensive Care Medicine Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Driss Laghlam
- Intensive Care Medicine Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Philippe Estagnasie
- Intensive Care Medicine Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Alain Brusset
- Intensive Care Medicine Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Pierre Squara
- Intensive Care Medicine Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Lee S Nguyen
- Intensive Care Medicine Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
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11
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Calderone A, Hammoud A, Jarry S, Denault A, Couture EJ. Femoral Vein Pulsatility: What Does It Mean? J Cardiothorac Vasc Anesth 2021; 35:2521-2527. [PMID: 33985881 DOI: 10.1053/j.jvca.2021.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.
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Affiliation(s)
- Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ali Hammoud
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Faculty of Nursing Graduate Studies, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery and Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Etienne J Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Canada
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12
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Liu C, Chen J, Gao Y, Deng B, Liu K. Endothelin receptor antagonists for pulmonary arterial hypertension. Cochrane Database Syst Rev 2021; 3:CD004434. [PMID: 33765691 PMCID: PMC8094512 DOI: 10.1002/14651858.cd004434.pub6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension is a devastating disease that leads to right heart failure and premature death. Endothelin receptor antagonists have shown efficacy in the treatment of pulmonary arterial hypertension. OBJECTIVES To evaluate the efficacy of endothelin receptor antagonists (ERAs) in pulmonary arterial hypertension. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the reference sections of retrieved articles. The searches are current as of 4 November 2020. SELECTION CRITERIA We included randomised trials and quasi-randomised trials involving participants with pulmonary arterial hypertension. DATA COLLECTION AND ANALYSIS Two of five review authors selected studies, extracted data and assessed study quality according to established criteria. We used standard methods expected by Cochrane. The primary outcomes were exercise capacity (six-minute walk distance, 6MWD), World Health Organization (WHO) or New York Heart Association (NYHA) functional class, Borg dyspnoea scores and dyspnoea-fatigue ratings, and mortality. MAIN RESULTS We included 17 randomised controlled trials involving a total of 3322 participants. Most trials were of relatively short duration (12 weeks to six months). Sixteen trials were placebo-controlled, and of these nine investigated a non-selective ERA and seven a selective ERA. We evaluated two comparisons in the review: ERA versus placebo and ERA versus phosphodiesterase type 5 (PDE5) inhibitor. The abstract focuses on the placebo-controlled trials only and presents the pooled results of selective and non-selective ERAs. After treatment, participants receiving ERAs could probably walk on average 25.06 m (95% confidence interval (CI) 17.13 to 32.99 m; 2739 participants; 14 studies; I2 = 34%, moderate-certainty evidence) further than those receiving placebo in a 6MWD. Endothelin receptor antagonists probably improved more participants' WHO functional class (odds ratio (OR) 1.41, 95% CI 1.16 to 1.70; participants = 3060; studies = 15; I2 = 5%, moderate-certainty evidence) and probably lowered the odds of functional class deterioration (OR 0.43, 95% CI 0.26 to 0.72; participants = 2347; studies = 13; I2 = 40%, moderate-certainty evidence) compared with placebo. There may be a reduction in mortality with ERAs (OR 0.78, 95% CI 0.58, 1.07; 2889 participants; 12 studies; I2 = 0%, low-certainty evidence), and pooled data suggest that ERAs probably improve cardiopulmonary haemodynamics and may reduce Borg dyspnoea score in symptomatic patients. Hepatic toxicity was not common, but may be increased by ERA treatment from 37 to 67 (95% CI 34 to 130) per 1000 over 25 weeks of treatment (OR 1.88, 95% CI 0.91 to 3.90; moderate-certainty evidence). Although ERAs were well tolerated in this population, several cases of irreversible liver failure caused by sitaxsentan have been reported, which led the licence holder for sitaxsentan to withdraw the product from all markets worldwide. As planned, we performed subgroup analyses comparing selective and non-selective ERAs, and with the exception of mean pulmonary artery pressure, did not detect any clear subgroup differences for any outcome. AUTHORS' CONCLUSIONS For people with pulmonary arterial hypertension with WHO functional class II and III, endothelin receptor antagonists probably increase exercise capacity, improve WHO functional class, prevent WHO functional class deterioration, result in favourable changes in cardiopulmonary haemodynamic variables compared with placebo. However, they are less effective in reducing dyspnoea and mortality. The efficacy data were strongest in those with idiopathic pulmonary hypertension. The irreversible liver failure caused by sitaxsentan and its withdrawal from global markets emphasise the importance of hepatic monitoring in people treated with ERAs. The question of the effects of ERAs on pulmonary arterial hypertension has now likely been answered.. The combined use of ERAs and phosphodiesterase inhibitors may provide more benefit in pulmonary arterial hypertension; however, this needs to be confirmed in future studies.
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Affiliation(s)
- Chao Liu
- Division of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junmin Chen
- Department of Haematology and Rheumatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yanqiu Gao
- The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bao Deng
- The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Kunshen Liu
- The First Hospital of Hebei Medical University, Shijiazhuang, China
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13
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Subramani S, Sharma A, Arora L, Hanada S, Krishnan S, Ramakrishna H. Perioperative Right Ventricular Dysfunction: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 36:309-320. [PMID: 33593648 DOI: 10.1053/j.jvca.2021.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Abstract
Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.1 The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.
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Affiliation(s)
- Sudhakar Subramani
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Archit Sharma
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Lovkesh Arora
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Satoshi Hanada
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Sundar Krishnan
- Department of Anesthesia, Duke University School of Medicine, Durham, NC
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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14
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Mihos CG, Horvath SA, Fernandez R, Nappi F, Xydas S. Early failure of mitral valve repair with anterior leaflet pericardial patch augmentation in rheumatic and radiation-induced valvulitis. J Thorac Dis 2020; 12:2977-2982. [PMID: 32642211 PMCID: PMC7330283 DOI: 10.21037/jtd.2020.01.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Sofia A Horvath
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Rafle Fernandez
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Steve Xydas
- Columbia University Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, FL, USA
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15
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Tokodi M, Németh E, Lakatos BK, Kispál E, Tősér Z, Staub L, Rácz K, Soltész Á, Szigeti S, Varga T, Gál J, Merkely B, Kovács A. Right ventricular mechanical pattern in patients undergoing mitral valve surgery: a predictor of post-operative dysfunction? ESC Heart Fail 2020; 7:1246-1256. [PMID: 32220010 PMCID: PMC7261576 DOI: 10.1002/ehf2.12682] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/14/2020] [Accepted: 03/01/2020] [Indexed: 11/20/2022] Open
Abstract
Aims The PREPARE‐MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) sought to investigate the alterations of right ventricular (RV) contraction pattern in patients undergoing mitral valve replacement/repair (MVR) and to explore the associations between pre‐operative RV mechanics and early post‐operative RV dysfunction (RVD). Methods and results We prospectively enrolled 42 patients (63 ± 11 years, 69% men) undergoing open‐heart MVR. Transthoracic three‐dimensional (3D) echocardiography was performed pre‐operatively, at intensive care unit discharge, and 6 months after surgery. The 3D model of the RV was reconstructed, and RV ejection fraction (RVEF) was calculated. We decomposed the motion of the ventricle to compute longitudinal ejection fraction (LEF) and radial ejection fraction (REF). Pulmonary artery catheterization was performed to monitor RV stroke work index (RVSWi). RVEF was slightly decreased after MVR [52 (50–55) vs. 51 (46–54)%; P = 0.001], whereas RV contraction pattern changed notably. Before MVR, the longitudinal shortening was the main contributor to global systolic RV function [LEF/RVEF vs. REF/RVEF; 0.53 (0.47–0.58) vs. 0.33 (0.22–0.42); P < 0.001]. Post‐operatively, the radial motion became dominant [0.33 (0.28–0.43) vs. 0.46 (0.37–0.51); P = 0.004]. However, this shift was temporary as 6 months later the two components contributed equally to global RV function [0.44 (0.38–0.50) vs. 0.41 (0.36–0.49); P = 0.775]. Pre‐operative LEF was an independent predictor of post‐operative RVD defined as RVSWi < 300 mmHg⋅mL/m2 [OR = 1.33 (95% CI: 1.08–1.77), P < 0.05]. Conclusions MVR induces a significant shift in the RV mechanical pattern. Advanced indices of RV mechanics are associated with invasively measured parameters of RV contractility and may predict post‐operative RVD.
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Affiliation(s)
- Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Endre Németh
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Bálint K Lakatos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Erika Kispál
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | - Kristóf Rácz
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Ádám Soltész
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Szabolcs Szigeti
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Tamás Varga
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - János Gál
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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16
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Grønlykke L, Couture EJ, Haddad F, Amsallem M, Ravn HB, Raymond M, Beaubien-Souligny W, Demers P, Rochon A, Sarabi ME, Lamarche Y, Desjardins G, Denault AY. Preliminary Experience Using Diastolic Right Ventricular Pressure Gradient Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2116-2125. [PMID: 32037274 DOI: 10.1053/j.jvca.2019.12.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/31/2019] [Accepted: 12/31/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Right ventricular (RV) dysfunction in cardiac surgery is associated with increased mortality and morbidity and difficult separation from cardiopulmonary bypass (DSB). The primary objective of the present study was to describe the prevalence and characteristics of patients with abnormal RV diastolic pressure gradient (PG). The secondary objective was to explore the association among abnormal diastolic PG and DSB, postoperative complications, high central venous pressure (CVP), and high RV end-diastolic pressure (RVEDP). DESIGN Retrospective and prospective validation study. SETTING Tertiary care cardiac institute. PARTICIPANTS Cardiac surgical patients (n=374) from a retrospective analysis (n=259) and a prospective validation group (n=115). INTERVENTION RV pressure waveforms were obtained using a pulmonary artery catheter with a pacing port opened at 19 cm distal to the tip of the catheter. Abnormal RV diastolic PG was defined as >4 mmHg. Both elevated RVEDP and high CVP were defined as >16 mmHg. MEASUREMENTS AND MAIN RESULTS From the retrospective and validation cohorts, 42.5% and 48% of the patients had abnormal RV diastolic PG before cardiac surgery, respectively. Abnormal RV diastolic PG before cardiac surgery was associated with higher EuroSCORE II (odds ratio 2.29 [1.10-4.80] v 1.62 [1.10-3.04]; p = 0.041), abnormal hepatic venous flow (45% v 29%; p = 0.038), higher body mass index (28.9 [25.5-32.5] v 27.0 [24.9-30.5]; p = 0.022), pulmonary hypertension (48% v 37%; p = 0.005), and more frequent DSB (32% v 19%; p = 0.023). However, RV diastolic PG was not an independent predictor of DSB, whereas RVEDP (odds ratio 1.67 [1.09-2.55]; p = 0.018) was independently associated with DSB. In addition, RV pressure monitoring indices were superior to CVP in predicting DSB. CONCLUSION Abnormal RV diastolic PG is common before cardiac surgery and is associated with a higher proportion of known preoperative risk factors. However, an abnormal RV diastolic PG gradient is not an independent predictor of DSB in contrast to RVEDP.
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Affiliation(s)
- Lars Grønlykke
- Department of Cardiothoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Etienne J Couture
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Francois Haddad
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA
| | - Myriam Amsallem
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Meggie Raymond
- Department of Cardiothoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - William Beaubien-Souligny
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Philippe Demers
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Mahsa Elmi Sarabi
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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17
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Beaubien-Souligny W, Brand FZA, Lenoir M, Amsallem M, Haddad F, Denault AY. Assessment of Left Ventricular Diastolic Function by Transesophageal Echocardiography Before Cardiopulmonary Bypass: Clinical Implications of a Restrictive Profile. J Cardiothorac Vasc Anesth 2019; 33:2394-2401. [DOI: 10.1053/j.jvca.2019.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 12/23/2022]
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18
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Denault A, Haddad F, Lamarche Y, Bouabdallaoui N, Deschamps A, Desjardins G. Postoperative right ventricular dysfunction-Integrating right heart profiles beyond long-axis function. J Thorac Cardiovasc Surg 2019; 159:e315-e317. [PMID: 31301900 DOI: 10.1016/j.jtcvs.2019.05.064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/25/2022]
Affiliation(s)
- André Denault
- Department of Anesthesia & Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Francois Haddad
- Department of Cardiovascular Medicine, Stanford University, Stanford, Calif
| | - Yoan Lamarche
- Department of Cardiac Surgery, Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Alain Deschamps
- Department of Anesthesia & Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- Department of Anesthesia & Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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Kundra TS, Nagaraja PS, Bharathi KS, Kaur P, Manjunatha N. Inhaled levosimendan versus intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Ann Card Anaesth 2019; 21:328-332. [PMID: 30052230 PMCID: PMC6078018 DOI: 10.4103/aca.aca_19_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context: Inhaled levosimendan may act as selective pulmonary vasodilator and avoid systemic side effects of intravenous levosimendan, which include decrease in systemic vascular resistance (SVR) and systemic hypotension, but with same beneficial effect on pulmonary artery pressure (PAP) and right ventricular (RV) function. Aim: The aim of this study was to compare the effect of inhaled levosimendan with intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Settings and Design: The present prospective randomized comparative study was conducted in a tertiary care hospital. Subjects and Methods: Fifty patients were randomized into two groups (n = 25). Group A: Levosimendan infusion was started immediately after coming-off of cardiopulmonary bypass and continued for 24 h at 0.1 mcg/kg/min. Group B: Total dose of levosimendan which would be given through intravenous route over 24 h was calculated and then divided into four equal parts and administered through inhalational route 6th hourly over 24 h. Hemodynamic profile (pulse rate, mean arterial pressure, pulmonary artery systolic pressure [PASP], SVR) and RV function were assessed immediately after shifting, at 1, 8, 24, and 36 h after shifting to recovery. Statistical Analysis Used: Intragroup analysis was done using paired student t-test, and unpaired student t-test was used for analysis between two groups. Results: PASP and RV-fractional area change (RV-FAC) were comparable in the two groups at different time intervals. There was a significant reduction in PASP and significant improvement in RV-FAC with both intravenous and inhalational levosimendan. SVR was significantly decreased with intravenous levosimendan, but no significant decrease in SVR was observed with inhalational levosimendan. Conclusions: Inhaled levosimendan is a selective pulmonary vasodilator. It causes decrease in PAP and improvement in RV function, without having a significant effect on SVR.
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Affiliation(s)
- Tanveer Singh Kundra
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - P S Nagaraja
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - K S Bharathi
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Parminder Kaur
- Department of Critical Care, Sir Ganga Ram Hospital, New Delhi, India
| | - N Manjunatha
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Raymond M, Grønlykke L, Couture EJ, Desjardins G, Cogan J, Cloutier J, Lamarche Y, L'Allier PL, Ravn HB, Couture P, Deschamps A, Chamberland ME, Ayoub C, Lebon JS, Julien M, Taillefer J, Rochon A, Denault AY. Perioperative Right Ventricular Pressure Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:1090-1104. [DOI: 10.1053/j.jvca.2018.08.198] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Indexed: 11/11/2022]
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21
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Gebhard CE, Rochon A, Cogan J, Ased H, Desjardins G, Deschamps A, Gavra P, Lebon JS, Couture P, Ayoub C, Levesque S, Elmi-Sarabi M, Couture EJ, Denault AY. Acute Right Ventricular Failure in Cardiac Surgery During Cardiopulmonary Bypass Separation: A Retrospective Case Series of 12 Years’ Experience With Intratracheal Milrinone Administration. J Cardiothorac Vasc Anesth 2019; 33:651-660. [DOI: 10.1053/j.jvca.2018.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 12/19/2022]
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22
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Effect of iloprost inhalation on postoperative outcome in high-risk cardiac surgical patients: a prospective randomized-controlled multicentre trial (ILOCARD). Can J Anaesth 2019; 66:907-920. [DOI: 10.1007/s12630-019-01309-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 12/13/2022] Open
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Eljaiek R, Cavayas Y, Rodrigue E, Desjardins G, Lamarche Y, Toupin F, Denault A, Beaubien-Souligny W. High postoperative portal venous flow pulsatility indicates right ventricular dysfunction and predicts complications in cardiac surgery patients. Br J Anaesth 2019; 122:206-214. [DOI: 10.1016/j.bja.2018.09.028] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/29/2018] [Accepted: 09/23/2018] [Indexed: 12/20/2022] Open
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Kundra TS, Prabhakar V, Kaur P, Manjunatha N, Gandham R. The Effect of Inhaled Milrinone Versus Inhaled Levosimendan in Pulmonary Hypertension Patients Undergoing Mitral Valve Surgery — A Pilot Randomized Double-Blind Study. J Cardiothorac Vasc Anesth 2018; 32:2123-2129. [DOI: 10.1053/j.jvca.2018.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Indexed: 11/11/2022]
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Gavra P, Denault AY, Théoret Y, Perrault LP, Varin F. Pharmacokinetics and Pharmacodynamics of Nebulized and Intratracheal Milrinone in a Swine Model of Hypercapnia Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Reply to: alveolar recruitment manoeuvres after cardiac surgery. Eur J Anaesthesiol 2018; 35:62-63. [PMID: 29658900 DOI: 10.1097/eja.0000000000000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lung recruitment improves right ventricular performance after cardiopulmonary bypass: A randomised controlled trial. Eur J Anaesthesiol 2018; 34:66-74. [PMID: 27861261 DOI: 10.1097/eja.0000000000000559] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Atelectasis after cardiopulmonary bypass (CPB) can affect right ventricular (RV) performance by increasing its outflow impedance. OBJECTIVE The aim of this study was to determine whether a lung recruitment manoeuvre improves RV function by re-aerating the lung after CPB. DESIGN Randomised controlled study. SETTING Single-institution study, community hospital, Córdoba, Argentina. PATIENTS Forty anaesthetised patients with New York Heart Association class I or II, preoperative left ventricular ejection fraction at least 50% and Euroscore 6 or less scheduled for cardiac surgery with CPB. INTERVENTIONS Patients were assigned to receive either standard ventilation with 6 cmH2O of positive end-expiratory pressure (PEEP; group C, n = 20) or standard ventilation with a recruitment manoeuvre and 10 cmH2O of PEEP after surgery (group RM, n = 20). RV function, left ventricular cardiac index (CI) and lung aeration were assessed by transoesophageal echocardiography (TOE) before, at the end of surgery and 30 min after surgery. MAIN OUTCOME MEASURES RV function parameters and atelectasis assessed by TOE. RESULTS Haemodynamic data and atelectasis were similar between groups before surgery. At the end of surgery, CI had decreased from 2.9 ± 1.1 to 2.6 ± 0.9 l min m in group C (P = 0.24) and from 2.8 ± 1.0 to 2.6 ± 0.8 l min m in group RM (P = 0.32). TOE-derived RV function parameters confirmed a mild decrease in RV performance in 95% of patients, without significant differences between groups (multivariate Hotelling t-test P = 0.16). Atelectasis was present in 18 patients in group C and 19 patients in group RM (P = 0.88). After surgery, CI decreased further from 2.6 to 2.4 l min m in group C (P = 0.17) but increased from 2.6 to 3.7 l min m in group RM (P < 0.001). TOE-derived RV function parameters improved only in group RM (Hotelling t-test P < 0.001). Atelectasis was present in 100% of patients in group C but only in 10% of those in group RM (P < 0.001). CONCLUSION Atelectasis after CPB impairs RV function but this can be resolved by lung recruitment using 10 cmH2O of PEEP. TRIAL REGISTRATION Protocol started on October 2014.
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Tremblay JA, Couture ÉJ, Albert M, Beaubien-Souligny W, Elmi-Sarabi M, Lamarche Y, Denault AY. Noninvasive Administration of Inhaled Nitric Oxide and its Hemodynamic Effects in Patients With Acute Right Ventricular Dysfunction. J Cardiothorac Vasc Anesth 2018; 33:642-647. [PMID: 30206010 DOI: 10.1053/j.jvca.2018.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to assess the hemodynamic effects and demonstrate the feasibility of inhaled nitric oxide (iNO) in hemodynamically unstable patients with acute right ventricular (RV) dysfunction and to explore the safety profile of this approach. DESIGN Retrospective cohort study. SETTING Intensive care unit (ICU) of 2 tertiary care centers between January 2013 and 2017. PARTICIPANTS All patients with RV dysfunction in whom iNO was initiated without invasive mechanical ventilation. INTERVENTION Noninvasive administration of iNO. MEASUREMENTS AND MAIN RESULTS Eighteen patients received the intervention during the study period; 8 of these patients had a pulmonary artery catheter and 2 had a pulse contour analysis device. Median (interquartile range) iNO concentration was 20 (20-20) ppm, and therapy duration was 24 (12-46) hours. Most patients received iNO through nasal prongs (66.7%) or a high-flow nasal cannula (27.8%). Within 1 hour, iNO reduced pulmonary vascular resistance from 219.1 to 165.4 dyn•s/cm5 (n = 7; p < 0.001), mean pulmonary artery pressure from 28.4 to 25.3 mmHg (n = 8; p = 0.01), and central venous pressure from 17.5 to 13.1 mmHg (n = 16; p = 0.001). Indexed cardiac output increased from 2.0 to 2.6 L/min/m2 (n = 9; p = 0.004). ICU mortality was 27.78%, and median ICU length of stay was 7 (5-9) days. Two significant bleeding episodes requiring intervention and 1 acute kidney injury occurred during iNO therapy. No headache was reported. CONCLUSION Noninvasively administered iNO was associated with favorable hemodynamic effects in ICU patients with acute RV dysfunction. These results suggest the safety and feasibility of this therapy for which further prospective study is warranted.
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Affiliation(s)
- Jan-Alexis Tremblay
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Étienne J Couture
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Martin Albert
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada; Department of Medicine and Critical Care, Sacré-Coeur Hospital and Montreal Heart Institute, Montreal, QC, Canada
| | | | - Mahsa Elmi-Sarabi
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Yoan Lamarche
- Department of Medicine and Critical Care, Sacré-Coeur Hospital and Montreal Heart Institute, Montreal, QC, Canada; Department of Cardiac Surgery Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada; Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
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Konstam MA, Kiernan MS, Bernstein D, Bozkurt B, Jacob M, Kapur NK, Kociol RD, Lewis EF, Mehra MR, Pagani FD, Raval AN, Ward C. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e578-e622. [DOI: 10.1161/cir.0000000000000560] [Citation(s) in RCA: 335] [Impact Index Per Article: 55.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose:
The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.
Methods:
The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.
Results:
Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.
Conclusions:
RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.
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Deshpande SP, Mazzeffi MA, Strauss E, Hollis A, Tanaka KA. Prostacyclins in Cardiac Surgery: Coming of Age. Semin Cardiothorac Vasc Anesth 2017; 22:306-323. [DOI: 10.1177/1089253217749298] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Prostacyclin (prostaglandin I2 [PGI2]) is an eicosanoid lipid mediator produced by the endothelial cells. It plays pivotal roles in vascular homeostasis by virtue of its potent vasodilatory and antithrombotic effects. Stable pharmacological analogues of PGI2 are used for treatment of pulmonary hypertension and right ventricular failure. PGI2 dose dependently inhibits platelet activation induced by adenosine-5′-diphosphate, arachidonic acid, collagen, and low-dose thrombin. This property has led to its use as an alternative to direct thrombin inhibitors in patients with type II heparin-induced thrombocytopenia (HIT) undergoing cardiac surgery. The aims of this review are the following: (1) to review the pharmacology of PGI2 and its derivatives, (2) to present the evidence for their use in pulmonary hypertension and right heart failure, and (3) to discuss their utility in the management of HIT in cardiac surgery.
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Affiliation(s)
| | | | - Erik Strauss
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison Hollis
- University of Maryland School of Medicine, Baltimore, MD, USA
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Gavra P, Laflamme M, Denault AY, Théoret Y, Perrault LP, Varin F. Use of nebulized milrinone in cardiac surgery; Comparison of vibrating mesh and simple jet nebulizers. Pulm Pharmacol Ther 2017; 46:20-29. [DOI: 10.1016/j.pupt.2017.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 06/30/2017] [Accepted: 08/03/2017] [Indexed: 10/19/2022]
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Inhaled milrinone for pulmonary hypertension in high-risk cardiac surgery: silver bullet or just part of a broader management strategy? Can J Anaesth 2016; 63:1122-1127. [PMID: 27473721 DOI: 10.1007/s12630-016-0708-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 07/15/2016] [Indexed: 11/27/2022] Open
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A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients. Can J Anaesth 2016; 63:1140-1153. [DOI: 10.1007/s12630-016-0709-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/02/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022] Open
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Haddad F, Elmi-Sarabi M, Fadel E, Mercier O, Denault AY. Pearls and pitfalls in managing right heart failure in cardiac surgery. Curr Opin Anaesthesiol 2016; 29:68-79. [DOI: 10.1097/aco.0000000000000284] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Breitling S, Ravindran K, Goldenberg NM, Kuebler WM. The pathophysiology of pulmonary hypertension in left heart disease. Am J Physiol Lung Cell Mol Physiol 2015; 309:L924-41. [DOI: 10.1152/ajplung.00146.2015] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/20/2015] [Indexed: 12/17/2022] Open
Abstract
Pulmonary hypertension (PH) is characterized by elevated pulmonary arterial pressure leading to right-sided heart failure and can arise from a wide range of etiologies. The most common cause of PH, termed Group 2 PH, is left-sided heart failure and is commonly known as pulmonary hypertension with left heart disease (PH-LHD). Importantly, while sharing many clinical features with pulmonary arterial hypertension (PAH), PH-LHD differs significantly at the cellular and physiological levels. These fundamental pathophysiological differences largely account for the poor response to PAH therapies experienced by PH-LHD patients. The relatively high prevalence of this disease, coupled with its unique features compared with PAH, signal the importance of an in-depth understanding of the mechanistic details of PH-LHD. The present review will focus on the current state of knowledge regarding the pathomechanisms of PH-LHD, highlighting work carried out both in human trials and in preclinical animal models. Adaptive processes at the alveolocapillary barrier and in the pulmonary circulation, including alterations in alveolar fluid transport, endothelial junctional integrity, and vasoactive mediator secretion will be discussed in detail, highlighting the aspects that impact the response to, and development of, novel therapeutics.
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Affiliation(s)
- Siegfried Breitling
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute for Chemistry and Biochemistry, Freie Universität Berlin, Germany
| | - Krishnan Ravindran
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Neil M. Goldenberg
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Wolfgang M. Kuebler
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Germany
- Departments of Surgery and Physiology, University of Toronto, Toronto, Ontario, Canada; and
- German Heart Institute Berlin, Berlin, Germany
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Laflamme M, Perrault LP, Carrier M, Elmi-Sarabi M, Fortier A, Denault AY. Preliminary Experience With Combined Inhaled Milrinone and Prostacyclin in Cardiac Surgical Patients With Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2015; 29:38-45. [DOI: 10.1053/j.jvca.2014.06.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Indexed: 11/11/2022]
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Mommerot A, Denault AY, Dupuis J, Carrier M, Perrault LP. Cardiopulmonary bypass is associated with altered vascular reactivity of isolated pulmonary artery in a porcine model: therapeutic potential of inhaled tezosentan. J Cardiothorac Vasc Anesth 2015; 28:698-708. [PMID: 24917060 DOI: 10.1053/j.jvca.2013.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Whereas it is established that endothelin-1 elicits sustained deleterious effects on the cardiovascular system during cardiopulmonary bypass (CPB), presently it remains unknown whether the inhaled administration of the dual ETA and ETB antagonist tezosentan prevents the development of pulmonary endothelial dysfunction. DESIGN A prospective, randomized laboratory investigation. SETTING University research laboratory. PARTICIPANTS Landrace swine. INTERVENTIONS Three groups of animals underwent a 90-minute period of full bypass followed by a 60-minute period of reperfusion. Among treated groups, one received tezosentan through inhalation prior to CPB, whereas the other one received it intravenously at weaning from CPB; the third group remained untreated. Pulmonary vascular reactivity studies, realized on a total of 285 rings, were performed in all groups, including 1 sham. MEASUREMENTS AND MAIN RESULTS The contractility of pulmonary arteries to prostaglandin F2α and to the thromboxane A2 mimetic U46619 was preserved in animals submitted to CPB. By contrast, there were significant increases both in the maximal contraction to endothelin-1 and in the plasma levels of the peptide 60 minutes after reperfusion. Tezosentan administered by inhalation or intravenously did not prevent the development of pulmonary CPB-associated endothelial dysfunction. However, while hemodynamic disturbances were improved with both routes, the inhaled administration had a beneficial effect on oxygen parameters over intravenous administration. CONCLUSIONS Despite the blockade of the endothelin-1 pathway with tezosentan, the development of the pulmonary endothelial dysfunction associated with CPB still occurred. However, only the inhalation route had a significant impact on gas exchange during CPB.
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Affiliation(s)
- Arnaud Mommerot
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Cardiovascular Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Jocelyn Dupuis
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Michel Carrier
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Cardiovascular Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Louis P Perrault
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Cardiovascular Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada.
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Denault AY, Couture P, Beaulieu Y, Haddad F, Deschamps A, Nozza A, Pagé P, Tardif JC, Lambert J. Right Ventricular Depression After Cardiopulmonary Bypass for Valvular Surgery. J Cardiothorac Vasc Anesth 2015; 29:836-44. [PMID: 25976606 DOI: 10.1053/j.jvca.2015.01.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess if right ventricular (RV) dysfunction is associated with increased mortality after cardiac surgery. DESIGN Post-hoc analysis of a single-center double-blind randomized controlled trial. SETTING University hospital. PARTICIPANTS A total of 120 patients undergoing simple or complex valvular surgery. INTERVENTIONS Patients were randomized to receive intravenous amiodarone or placebo intraoperatively. As secondary analysis, patients were divided into those requiring or not requiring postoperative inotropic agents. MEASUREMENTS AND MAIN RESULTS After cardiopulmonary bypass (CPB), there were significant increases in heart rate, cardiac index, systolic and mean arterial pressures, central venous pressure and pulmonary capillary wedge pressure with reduction in systemic vascular resistance (p<0.05). Right ventricular end-systolic area became larger in those without inotropes and tricuspid annular plane systolic excursion was reduced in all patients; mitral annular systolic velocities were higher in patients receiving inotropes. Both right- and left-sided Doppler signals were altered significantly after CPB, which may be attributed to increased filling pressure. Inotropic agents were required in 56 patients after CPB (47%). The use of inotropic agents was associated with increased left and right atrial velocities (p<0.05). There were no differences in postoperative complications between groups; however, the number of deaths at 6 years was increased in patients who received inotropes after CPB (p = 0.0247). CONCLUSIONS The increases in right-sided dimensions after CPB are associated with reduction in RV function and increased biventricular filling pressure, suggesting worsening biventricular function and interventricular dependence. Inotropic medications were associated with unaltered RV dimensions and increased biatrial activity.
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Affiliation(s)
- André Y Denault
- Departments of Anesthesiology; Division of Critical Care, Centre Hospitalier de l'Université de Montréaland Montreal Heart Institute.
| | | | - Yanick Beaulieu
- Department of Medicine, Sacré-Coeur de Montréal Hospital, Montreal, Quebec, Canada
| | - Francois Haddad
- Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | | | - Anna Nozza
- Montreal Heart Institute Coordinating Center
| | - Pierre Pagé
- Cardiac Surgery, Montreal Heart Institute and Université de Montréal
| | | | - Jean Lambert
- Department of Preventive and Social Medicine, Université de Montréal, Montreal, Quebec, Canada
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Kowalczyk A, Kleniewska P, Kolodziejczyk M, Skibska B, Goraca A. The role of endothelin-1 and endothelin receptor antagonists in inflammatory response and sepsis. Arch Immunol Ther Exp (Warsz) 2014; 63:41-52. [PMID: 25288367 PMCID: PMC4289534 DOI: 10.1007/s00005-014-0310-1] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 07/18/2014] [Indexed: 12/12/2022]
Abstract
Endothelin-1 (ET-1) is a potent endogenous vasoconstrictor, mainly secreted by endothelial cells. It acts through two types of receptors: ETA and ETB. Apart from a vasoconstrictive action, ET-1 causes fibrosis of the vascular cells and stimulates production of reactive oxygen species. It is claimed that ET-1 induces proinflammatory mechanisms, increasing superoxide anion production and cytokine secretion. A recent study has shown that ET-1 is involved in the activation of transcription factors such as NF-κB and expression of proinflammatory cytokines including TNF-α, IL-1, and IL-6. It has been also indicated that during endotoxaemia, the plasma level of ET-1 is increased in various animal species. Some authors indicate a clear correlation between endothelin plasma level and morbidity/mortality rate in septic patients. These pathological effects of ET-1 may be abrogated at least partly by endothelin receptor blockade. ET-1 receptor antagonists may be useful for prevention of various vascular diseases. This review summarises the current knowledge regarding endothelin receptor antagonists and the role of ET-1 in sepsis and inflammation.
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Affiliation(s)
- Agata Kowalczyk
- Chair of Experimental and Clinical Physiology, Department of Cardiovascular Physiology, Medical University of Lodz, Mazowiecka 6/8, 92-215, Lodz, Poland,
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Denault A, Lamarche Y, Rochon A, Cogan J, Liszkowski M, Lebon JS, Ayoub C, Taillefer J, Blain R, Viens C, Couture P, Deschamps A. Innovative approaches in the perioperative care of the cardiac surgical patient in the operating room and intensive care unit. Can J Cardiol 2014; 30:S459-77. [PMID: 25432139 DOI: 10.1016/j.cjca.2014.09.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/11/2014] [Accepted: 09/24/2014] [Indexed: 02/07/2023] Open
Abstract
Perioperative care for cardiac surgery is undergoing rapid evolution. Many of the changes involve the application of novel technologies to tackle common challenges in optimizing perioperative management. Herein, we illustrate recent advances in perioperative management by focusing on a number of novel components that we judge to be particularly important. These include: the introduction of brain and somatic oximetry; transesophageal echocardiographic hemodynamic monitoring and bedside focused ultrasound; ultrasound-guided vascular access; point-of-care coagulation surveillance; right ventricular pressure monitoring; novel inhaled treatment for right ventricular failure; new approaches for postoperative pain management; novel approaches in specialized care procedures to ensure quality control; and specific approaches to optimize the management for postoperative cardiac arrest. Herein, we discuss the reasons that each of these components are particularly important in improving perioperative care, describe how they can be addressed, and their impact in the care of patients who undergo cardiac surgery.
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Affiliation(s)
- André Denault
- Department of Anesthesiology, Critical Care Program, Montreal Heart Institute, and Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada.
| | - Yoan Lamarche
- Department of Cardiac Surgery and Critical Care Program, Montreal Heart Institute, and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Mark Liszkowski
- Department of Medicine, Cardiology and Critical Care Program, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Sébastien Lebon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Christian Ayoub
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean Taillefer
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Robert Blain
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Claudia Viens
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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