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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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Rezoagli E, Redaelli S, Bittner EA, Fumagalli R, Ichinose F, Berra L. Role of hemolysis on pulmonary arterial compliance and right ventricular systolic function after cardiopulmonary bypass. Nitric Oxide 2024; 146:24-30. [PMID: 38521488 DOI: 10.1016/j.niox.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/10/2024] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is associated with intravascular hemolysis which depletes endogenous nitric oxide (NO). The impact of hemolysis on pulmonary arterial compliance (PAC) and right ventricular systolic function has not been explored yet. We hypothesized that decreased NO availability is associated with worse PAC and right ventricular systolic function after CPB. METHODS This is a secondary analysis of an observational cohort study in patients undergoing cardiac surgery with CPB at Massachusetts General Hospital, USA (2014-2015). We assessed PAC (stroke volume/pulmonary artery pulse pressure ratio), and right ventricular function index (RVFI) (systolic pulmonary arterial pressure/cardiac output), as well as NO consumption at 15 min, 4 h and 12 h after CPB. Patients were stratified by CPB duration. Further, we assessed the association between changes in NO consumption with PAC and RVFI between 15min and 4 h after CPB. RESULTS PAC was lowest at 15min after CPB and improved over time (n = 50). RVFI was highest -worse right ventricular function- at CPB end and gradually decreased. Changes in hemolysis, PAC and RVFI differed over time by CPB duration. PAC inversely correlated with total pulmonary resistance (TPR). TPR and PAC positively and negatively correlated with RVFI, respectively. NO consumption between 15min and 4 h after CPB correlated with changes in PAC (-0.28 ml/mmHg, 95%CI -0.49 to -0.01, p = 0.012) and RVFI (0.14 mmHg*L-1*min, 95%CI 0.10 to 0.18, p < 0.001) after multivariable adjustments. CONCLUSION PAC and RVFI are worse at CPB end and improve over time. Depletion of endogenous NO may contribute to explain changes in PAC and RVFI after CPB.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Roberto Fumagalli
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Jarry S, Couture EJ, Beaubien-Souligny W, Fernandes A, Fortier A, Ben-Ali W, Desjardins G, Huard K, Mailhot T, Denault AY. Clinical relevance of transcranial Doppler in a cardiac surgery setting: embolic load predicts difficult separation from cardiopulmonary bypass. J Cardiothorac Surg 2024; 19:90. [PMID: 38347542 PMCID: PMC10863099 DOI: 10.1186/s13019-024-02591-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND During cardiac surgery, transcranial Doppler (TCD) represents a non-invasive modality that allows measurement of red blood cell flow velocities in the cerebral arteries. TCD can also be used to detect and monitor embolic material in the cerebral circulation. Detection of microemboli is reported as a high intensity transient signal (HITS). The importance of cerebral microemboli during cardiac surgery has been linked to the increased incidence of postoperative renal failure, right ventricular dysfunction, and hemodynamic instability. The objective of this study is to determine whether the embolic load is associated with hemodynamic instability during cardiopulmonary bypass (CPB) separation and postoperative complications. METHODS A retrospective single-centre cohort study of 354 patients undergoing cardiac surgery between December 2015 and March 2020 was conducted. Patients were divided in tertiles, where 117 patients had a low quantity of embolic material (LEM), 119 patients have a medium quantity of microemboli (MEM) and 118 patients who have a high quantity of embolic material (HEM). The primary endpoint was a difficult CPB separation. Multivariate logistic regression was used to determine the potential association between a difficult CPB separation and the number of embolic materials. RESULTS Patients who had a difficult CPB separation had more HITS compared to patients who had a successful CPB separation (p < 0.001). In the multivariate analysis, patients with MEM decreased their odds of having a difficult CPB weaning compared to patients in the HEM group (OR = 0.253, CI 0.111-0.593; p = 0.001). In the postoperative period patients in the HEM group have a higher Time of Persistent Organ Dysfunction (TPOD), a longer stay in the ICU, a longer duration under vasopressor drugs and a higher mortality rate compared to those in the MEM and LEM groups. CONCLUSION The result of this study suggests that a high quantity of cerebral embolic material increases the odds of having a difficult CPB separation. Also, it seems to be associated to more complex surgery, a longer CPB time, a higher TPOD and a longer stay in the ICU. Six out of eight patients who died in this cohort were in the HEM group.
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Affiliation(s)
- Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Etienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada
| | | | - Armindo Fernandes
- Perfusion Service, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Annik Fortier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Walid Ben-Ali
- Department of Surgery and Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Karel Huard
- Université de Montréal, Montreal, QC, Canada
| | - Tanya Mailhot
- Research Center, Montreal Heart Institute, and Faculty of Nursing, Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada.
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Mattei A, Strumia A, Benedetto M, Nenna A, Schiavoni L, Barbato R, Mastroianni C, Giacinto O, Lusini M, Chello M, Carassiti M. Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:7152. [PMID: 38002763 PMCID: PMC10672350 DOI: 10.3390/jcm12227152] [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: 10/07/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.
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Affiliation(s)
- Alessia Mattei
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Alessandro Strumia
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intesive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40123 Bologna, Italy;
| | - Antonio Nenna
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Lorenzo Schiavoni
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Raffaele Barbato
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimiliano Carassiti
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
- Anesthesia and Intensive Care Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
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5
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Zochios V, Shelley B, Antonini MV, Chawla S, Sato R, Dugar S, Valchanov K, Roscoe A, Scott J, Bangash MN, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Yusuff H. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 1. J Cardiothorac Vasc Anesth 2023; 37:2073-2086. [PMID: 37393133 DOI: 10.1053/j.jvca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Center, Singapore
| | - Jeffrey Scott
- Jackson Health System, Miami Transplant Institute, Miami, FL
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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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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8
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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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Elmi-Sarabi M, Couture E, Jarry S, Saade E, Calderone A, Potes C, Denault A. Inhaled Epoprostenol and Milrinone Effect on Right Ventricular Pressure Waveform Monitoring. Can J Cardiol 2022; 39:474-482. [PMID: 36528279 DOI: 10.1016/j.cjca.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/10/2022] [Accepted: 12/03/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. This study aimed to evaluate the change in RV pressure waveform in patients receiving a combination of inhaled epoprostenol and inhaled milrinone (iE&iM) before cardiopulmonary bypass (CPB) and to assess the safety of this approach with a matched case-control group. METHODS A prospective single-centre cohort study of adult patients undergoing cardiac surgery administered iE&iM through an ultrasonic mesh nebulizer. RV pressure waveform monitoring was obtained by continuously transducing the RV port of the pulmonary artery (PA) catheter. RESULTS The final analysis included 26 patients receiving iE&iM. There was a significant drop in mean PA pressure (MPAP) (-4.8 ± 8.7, P = 0.010), systolic PA pressure (SPAP) (-8.2 ± 12.8, P = 0.003), RV end-diastolic pressure (RVEDP) (-2.1 ± 2.8, P < 0.001) and RV diastolic pressure gradient (RVDPG) (-1.7 ± 1.4, P < 0.001) after 17 ± 9 minutes of iE&iM administration. Patients also had a significant increase in RV outflow tract (RVOT) gradient (3.7 ± 4.7, P < 0.001), RV maximal rate of pressure rise during early systole (dP/dt max) (68.3 ± 144.7, P = 0.024), and left ventricular (LV) dP/dt max (66.4 ± 90.1, P < 0.001). Change in RVOT gradient was only observed in those with a positive pulmonary vasodilator response to treatment. Treatment with iE&iM did not present adverse effects when compared with a matched case-control group. CONCLUSIONS Coadministration of iE&iM in cardiac surgery patients presenting with PH or signs of RV dysfunction is a safe and effective treatment approach in improving RV function. Appearance of a transient increase in RVOT gradient after iE&iM could be useful to predict response to treatment.
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Affiliation(s)
- Mahsa Elmi-Sarabi
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Etienne Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Elena Saade
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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López-Candales A, Vallurupalli S. Echo-Doppler measures of right ventricular systolic function are affected by reduced left ventricular systolic function. Echocardiography 2022; 39:1540-1547. [PMID: 36433719 DOI: 10.1111/echo.15484] [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: 08/01/2022] [Revised: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Objective right ventricular (RV) systolic function assessment is attained using a series of well-described and validated echo-Doppler measurements. However, how left ventricular (LV) systolic function influences these RV functional measurements has not been previously studied. Consequently, we conducted a retrospective proof-of-concept analysis to answer this important question. METHODS A total of 100 echocardiographic studies were included and patients were divided into two groups according to their LV ejection fraction (LVEF). The following RV variables were acquired including, tricuspid annular systolic plane excursion (TAPSE), velocity of the systolic motion (TA TDI s'), RV outflow tract velocity time integral (VTI), pulmonary vascular resistance (PVR), and the TAPSE to pulmonary artery systolic pressure (PASP) ratio. RESULTS Not only TAPSE, TA DI s', RVOT VTI, PVR, and TAPSE/PASP were all significantly different between patients with normal versus abnormal LVEF; but most importantly, RVOT VTI (p < .0001) was the best discriminatory variable in assessing normal versus abnormal LVEF followed by TAPSE (p = .0001). Using receiver operating characteristic curve analysis, an RVOT VTI value > 11 identified patients with a normal LVEF with a sensitivity of 90% and specificity of 76%. CONCLUSION Based on our results, reduced LVEF affects the RV, likely mediated by mechanisms of interventricular dependence. Therefore, RV analysis cannot be performed in isolation as it not only reflects intrinsic RV systolic function but also, is dependent on LV systolic function. In cases of reduced LVEF, additional measures of RV assessment should be used to provide better objective assessments.
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Affiliation(s)
- Angel López-Candales
- Cardiovascular Medicine Division, University Health Truman Medical Center, University, of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Srikanth Vallurupalli
- Cardiology Division, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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11
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Jarry S, Halley I, Calderone A, Momeni M, Deschamps A, Richebé P, Beaubien-Souligny W, Denault A, Couture EJ. Impact of Processed Electroencephalography in Cardiac Surgery: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2022; 36:3517-3525. [PMID: 35618594 DOI: 10.1053/j.jvca.2022.03.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/24/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The use of brain function monitoring with processed electroencephalography (pEEG) during cardiac surgery is gaining interest for the optimization of hypnotic agent delivery during the maintenance of anesthesia. The authors sought to determine whether the routine use of pEEG-guided anesthesia is associated with a reduction of hemodynamic instability during cardiopulmonary bypass (CPB) separation and subsequently reduces vasoactive and inotropic requirements in the intensive care unit. DESIGN This is a retrospective cohort study based on an existing database. SETTING A single cardiac surgical center. PARTICIPANTS Three hundred patients undergoing cardiac surgery, under CPB, between December 2013 and March 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred and fifty patients had pEEG-guided anesthesia, and 150 patients did not have a pEEG-guided anesthesia. Multiple logistic regression demonstrated that pEEG-guided anesthesia was not associated with a successful CPB separation (p = 0.12). However, the use of pEEG-guided anesthesia reduced by 57% the odds of being in a higher category for vasoactive inotropic score compared to patients without pEEG (odds ratio = 0.43; 95% confidence interval: 0.26-0.73; p = 0.002). Duration of mechanical ventilation, fluid balance, and blood losses were also reduced in the pEEG anesthesia-guided group (p < 0.003), but there were no differences in organ dysfunction duration and mortality. CONCLUSION During cardiac surgery, pEEG-guided anesthesia allowed a reduction in the use of inotropic or vasoactive agents at arrival in the intensive care unit. However, it did not facilitate weaning from CPB compared to a group where pEEG was unavailable. A pEEG-guided anesthetic management could promote early vasopressor weaning after cardiac surgery.
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Affiliation(s)
- Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Isabelle Halley
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, UC Louvain, Institut de Recherche Expérimentale et Clinique, Brussels, Belgium
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Île de Montréal, Université de Montréal, Montreal, Canada
| | | | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada; Department of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.
| | - Etienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Canada
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12
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Bouchard-Dechêne V, Kontar L, Couture P, Pérusse P, Levesque S, Lamarche Y, Denault AY, Rochon A, Deschamps A, Desjardins G, Rousseau-Saine N, Lebon JS, Cogan J, Chamberland ME, Raymond M, Courbe A, Julien M, Ayoub C, Martins MR, Beaubien-Souligny W. Radial-to-femoral pressure gradient quantification in cardiac surgery. JTCVS OPEN 2021; 8:446-460. [PMID: 36004190 PMCID: PMC9390776 DOI: 10.1016/j.xjon.2021.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 07/30/2021] [Indexed: 11/22/2022]
Abstract
Background A radial-to-femoral pressure gradient (RFPG) can occur in roughly one-third of cardiac surgical patients. Such a gradient has been associated with smaller stature and potentially smaller radial artery diameter. We hypothesized that preoperative radial artery diameter could be a predictor of RFPG. We also investigated the clinical impact of using a femoral versus a radial arterial catheter in terms of vasoactive support. Methods Using ultrasound, we measured the bilateral radial artery diameters of 160 cardiac surgical patients. All arterial pressure values were continuously recorded. Significant RFPG was defined as ≥25 mm Hg in systolic and/or ≥10 mm Hg in mean arterial pressure. One hundred and forty-nine additional patients were used to validate the impact of our observations. Results Using 78,013 pressure datapoints in 129 patients, 34.8% of patients had an RFPG with a mean duration of 54 ± 48 minutes. Patients with a radial artery diameter <1.8 mm were more likely to have an RFPG (n = 14 [48.3%] vs 12 [22.2%]; P = .042). Patients with only a radial catheter received more phenylephrine (P = .016) despite undergoing shorter and less complex procedures. In the validation cohort, similar observations were made, and patients with a radial artery catheter received a longer duration of vasoactive support in the intensive care unit. Conclusions A significant RFPG occurs in one-third of cardiac surgical patients and in 48% of those with a radial artery diameter <1.8 mm. The use of a single radial arterial catheter instead of dual radial and femoral catheters was associated with greater vasopressor requirements in the operating room and in the intensive care unit. We do not recommend the use of a single radial artery catheter in cardiac surgery.
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Das P, Thandavarayan RA, Watanabe K, Velayutham R, Arumugam S. Right ventricular failure: a comorbidity or a clinical emergency? Heart Fail Rev 2021; 27:1779-1793. [PMID: 34826024 DOI: 10.1007/s10741-021-10192-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 11/28/2022]
Abstract
There has been ample data providing a convincing perception about the underlying mechanism pertaining to left ventricle (LV) hypertrophy progressing towards LV failure. In comparison, data available on the feedback of right ventricle (RV) due to volume or pressure overload is minimal. Advanced imaging techniques have aided the study of physiology, anatomy, and diseased state of RV. However, the treatment scenario of right ventricular failure (RVF) demands more attention. It is a critical clinical risk in patients with carcinoid syndrome, pulmonary hypertension, atrial septal defect, and several other concomitant diseases. Although the remodeling responses of both ventricles on an increase of end-diastolic pressure are mostly identical, the stressed RV becomes more prone to oxidative stress activating the apoptotic mechanism with diminished angiogenesis. This instigates the advancement of RV towards failure in contrast to LV. Empirical heart failure (HF) therapies have been ineffective in improving the mortality rate and cardiac function in patients, which prompted a difference between the underlying pathophysiology of RVF and LV failure. Treatment strategies should be devised, taking into consideration the anatomical and physiological characteristics of RV. This review would emphasize on the pathophysiology of the RVF and the differences between two ventricles in molecular response to stress. A proper insight into the underlying pathophysiology is required to develop optimized therapeutic management in RV-specific HF.
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Affiliation(s)
- Pamelika Das
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, 700054, West Bengal, India
| | | | - Kenichi Watanabe
- Department of Laboratory Medicine and Clinical Epidemiology for Prevention of Noncommunicable Diseases, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, NiigataNiigata, 951-8510, Japan
| | - Ravichandiran Velayutham
- National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, 700054, West Bengal, India.
| | - Somasundaram Arumugam
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, 700054, West Bengal, India.
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14
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Zeng YH, Calderone A, Rousseau-Saine N, Elmi-Sarabi M, Jarry S, Couture ÉJ, Aldred MP, Dorval JF, Lamarche Y, Miles LF, Beaubien-Souligny W, Denault AY. Right Ventricular Outflow Tract Obstruction in Adults: A Systematic Review and Meta-analysis. CJC Open 2021; 3:1153-1168. [PMID: 34746729 PMCID: PMC8551422 DOI: 10.1016/j.cjco.2021.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background Right ventricular outflow tract obstruction (RVOTO) is a cause of hemodynamic instability that can occur in several situations, including cardiac surgery, lung transplantation, and thoracic surgery, and in critically ill patients. The timely diagnosis of RVOTO is important because it requires specific considerations, including the adverse effects of positive inotropes, and depending on the etiology, the requirement for urgent surgical intervention. Methods The objective of this systematic review and meta-analysis was to determine the prevalence of RVOTO in adult patients, and the distribution of all reported cases by etiology. Results Of 233 available reports, there were 229 case reports or series, and 4 retrospective cohort studies, with one study also reporting a prospective cohort. Of 291 reported cases of RVOTO, 61 (21%) were congenital, 56 (19%) were iatrogenic, and 174 (60%) were neither congenital nor iatrogenic (including intracardiac tumour). The mechanism of RVOTO was an intrinsic obstruction in 169 cases (58%), and an extrinsic obstruction in 122 cases (42%). A mechanical obstruction causing RVOTO was present in 262 cases (90%), and 29 cases of dynamic RVOTO (10%) were reported. In the 5 included cohorts, with a total of 1122 patients, the overall prevalence was estimated to be 4.0% (1%-9%). Conclusions RVOTO, though rare, remains clinically important, and therefore, multicentre studies are warranted to better understand the prevalence, causes, and consequences of RVOTO.
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Affiliation(s)
- Yu Hao Zeng
- 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
| | - Nicolas Rousseau-Saine
- 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
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Étienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Quebec Heart & Lung Institute, Quebec, Quebec, Canada
| | - Matthew P Aldred
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Francois Dorval
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Lachlan F Miles
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia and Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - William Beaubien-Souligny
- Department of Medicine, Nephrology Division, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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15
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Sia YT, Gebhard CE, Denault AY. Reversal of Acute Right Ventricular Failure Early Post Left Ventricular Assist Device Placement by Intratracheal Milrinone Administration: Case Report. Chest 2021; 159:e57-e60. [PMID: 33422243 DOI: 10.1016/j.chest.2020.01.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/11/2019] [Accepted: 01/25/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Ying Tung Sia
- Department of Medicine, Service of Cardiology and Critical Care, CIUSSS-MCQ, Trois-Rivières, QC, Canada
| | - Caroline E Gebhard
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - André Y Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
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16
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Barros LN, Uchoa RB, Mejia JAC, Nunes RR, Barros DASN, Rodrigues Filho F. Anesthetic protocol for right ventricular dysfunction management in heart transplantation: systematic review, development and validation. BMC Anesthesiol 2021; 21:46. [PMID: 33573599 PMCID: PMC7877082 DOI: 10.1186/s12871-021-01261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Right Ventricular Dysfunction (RVD) is the most frequent intraoperative hemodynamic complication in Heart Transplantation (HTx). RVD occurs in 0.04-1.0% of cardiac surgeries with cardiotomy and in 20-50% of HTx, with mortality up to 75%. No consensus has been established for how anesthesiologists should manage RVD, with management methods many times remaining unvalidated. METHODS We conducted a systematic review, following PRISMA guidelines, to create an anesthetic protocol to manage RVD in HTx, using databases that include PubMed and Embase, until September 2018 based on inclusion and exclusion criteria. The articles screening for the systematic review were done two independent reviewers, in case of discrepancy, we consulted a third independent reviewer. Based on the systematic review, the anesthetic protocol was developed. The instrument selected to perform the validation of the protocol was AGREE II, for this purpose expert anesthetists were recruited to do this process. The minimum arbitration score for domains validation cutoff of AGREE II is arbitered to 70%. This study was registered at PROSPERO (115600). RESULTS In the systematic review, 152 articles were included. We present the protocol in a flowchart with six steps based on goal-directed therapy, invasive monitoring, and transesophageal echocardiogram. Six experts judged the protocol and validated it. CONCLUSION The protocol has been validated by experts and new studies are needed to assess its applicability and potential benefits on major endpoints.
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Affiliation(s)
- Lucas Nepomuceno Barros
- State University of Ceará, Fortaleza, Brazil.
- Dr Carlos Alberto Studart Gomes - Messejana Hospital, Fortaleza, Brazil.
- Fortaleza General Hospital, Fortaleza, Brazil.
| | | | - Juan Alberto Cosquillo Mejia
- State University of Ceará, Fortaleza, Brazil
- Dr Carlos Alberto Studart Gomes - Messejana Hospital, Fortaleza, Brazil
| | | | | | - Filadelfo Rodrigues Filho
- State University of Ceará, Fortaleza, Brazil
- Dr Carlos Alberto Studart Gomes - Messejana Hospital, Fortaleza, Brazil
- Professor in Professional Master's in Transplants, State University of Ceará, Fortaleza, Brazil
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Liu H, Jones TE, Jeng E, Peng KL, Peng YG. Risk Stratification and Optimization to Prevent Right Heart Failure During Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2020; 35:3385-3393. [DOI: 10.1053/j.jvca.2020.09.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/08/2020] [Accepted: 09/27/2020] [Indexed: 01/20/2023]
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Khoche S, Silverton NA, Zimmerman J, Poorsattar S, Kothari P, Haughton R, Maus TM. The Year in Perioperative Echocardiography: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:2036-2046. [PMID: 32482504 DOI: 10.1053/j.jvca.2020.03.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 01/09/2023]
Abstract
This article is the fourth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board, for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles targetted the use of perioperative echocardiography in general.
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Affiliation(s)
- Swapnil Khoche
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Natalie A Silverton
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Joshua Zimmerman
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Sophia Poorsattar
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Perin Kothari
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Robert Haughton
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Timothy M Maus
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA.
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Zarragoikoetxea I, Vicente R, Pajares A, Carmona P, Lopez M, Moreno I, Argente P, Hornero F, Valera F, Aguero J. Quantitative Transthoracic Echocardiography of the Response to Dobutamine in Cardiac Surgery Patients With Low Cardiac Output Syndrome. J Cardiothorac Vasc Anesth 2020; 34:87-96. [DOI: 10.1053/j.jvca.2019.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022]
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20
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Silverton NA, Lee JP, Morrissey CK, Tanner C, Zimmerman J. Regional Versus Global Measurements of Right Ventricular Strain Performed in the Operating Room With Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2020; 34:48-57. [DOI: 10.1053/j.jvca.2019.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 11/11/2022]
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21
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Kim JH, Lerose CC, Landoni G, Di Prima AL, Licheri M, Oriani A, Alaidroos M, Zangrillo A, Monaco F. Differences in Biomarkers Pattern Between Severe Isolated Right and Left Ventricular Dysfunction After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:650-658. [PMID: 31473115 DOI: 10.1053/j.jvca.2019.07.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/10/2019] [Accepted: 07/14/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To find out if there are any differences in biomarkers between severe isolated right ventricular (RV) dysfunction and severe isolated left ventricular (LV) dysfunction after cardiac surgery using cardiopulmonary bypass. DESIGN Observational study. SETTING Teaching hospital. PARTICIPANTS A total of 46 patients who had severe isolated RV or LV dysfunction after cardiac surgery. INTERVENTION The authors collected perioperative clinical and biomarker data. MEASUREMENTS AND MAIN RESULTS Severe isolated RV dysfunction patients (n = 20) had higher postoperative direct bilirubin (p = 0.030), total bilirubin (p = 0.044), glucose (p = 0.011), and international normalized ratio (INR) (p = 0.050) by repeated measure analysis of variance when compared with patients with severe isolated LV dysfunction (n = 26). The RV group also showed lower preoperative alanine transferase (19.3 ± 1.5 v 32.7 ± 4.2, p = 0.001), higher 4-hour INR (1.5 ± 0.3 v 1.4 ± 0.2, p = 0.008), and higher 48-hour INR (1.8 ± 0.4 v 1.4 ± 0.1, p < 0.001). None in the LV group died, whereas 4 patients in the RV group died (all of them had preoperative atrial fibrillation and underwent double valve replacement surgery). CONCLUSION The authors observed biomarkers differences between severe isolated RV dysfunction and severe isolated RV dysfunction.
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Affiliation(s)
- Jun Hyun Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Caterina Cecilia Lerose
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Moad Alaidroos
- Clinical Research Unit Cardiovascular Department, IRCCS - Policlinico San Donato, Milan, Italy; Vascular Surgery Unit Policlinico San Marco, Zingonia, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Rong LQ, Yum B, Abouzeid C, Palumbo MC, Brouwer LR, Devereux RB, Girardi LN, Weinsaft JW, Gaudino M, Kim J. Echocardiographic predictors of intraoperative right ventricular dysfunction: a 2D and speckle tracking echocardiography study. Cardiovasc Ultrasound 2019; 17:11. [PMID: 31174537 PMCID: PMC6556018 DOI: 10.1186/s12947-019-0161-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/29/2019] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative or post procedure right ventricular (RV) dysfunction confers a poor prognosis in the post-operative period. Conventional predictors for RV function are limited due the effect of cardiac surgery on traditional RV indices; novel echocardiographic techniques hold the promise to improve RV functional stratification. Methods Comprehensive echocardiographic data were collected prospectively during elective cardiac surgery. Tricuspid annular plane systolic excursion (TAPSE), peak RV systolic velocity (S′), and RV fractional area change (FAC) were quantified on transesophageal echo (TEE). RV global and regional (septal and free wall) longitudinal strain was quantified using speckle-tracking echo in RV-focused views. Two intraoperative time points were used for comparison: pre-sternotomy (baseline) and after chest closure. Results The population was comprised of 53 patients undergoing cardiac surgery [15.1% coronary artery bypass graft (CABG) only, 28.3% valve only, 50.9% combination (e.g. valve/CABG, valve/aortic graft) surgeries], among whom 38% had impaired RV function at baseline defined as RV FAC < 35%. All conventional RV functional indices including TAPSE, S′ and FAC declined immediately following CPB (1.5 ± 0.3 vs.1.1 ± 0.3 cm, 8.0 ± 2.1 vs. 6.2 ± 2.5 cm/s, 36.8 ± 9.3 vs. 29.3 ± 10.6%; p < 0.001 for all). However, left ventricular (LV) and RV hemodynamic parameters remained unchanged (LV ejection fraction (EF): 56.8 ± 13.0 vs. 55.8 ± 12.9%; p = 0.40, pulmonary artery systolic pressure (PASP): 26.5 ± 7.4 vs 27.3 ± 6.7 mmHg; p = 0.13). Speckle tracking echocardiographic data demonstrated a significant decline in RV global longitudinal strain (GLS) [19.0 ± 6.5 vs. 13.5 ± 6.9%, p < 0.001]. Pre-procedure FAC, GLS and free wall strain predicted RV dysfunction at chest closure (34.7 ± 9.1 vs. 41.6 ± 8.1%, p = 0.01, 17.7 ± 6.5 vs. 21.8 ± 5.4%; p = 0.03, 20.3 ± 6.4 vs. 24.2 ± 5.8%; p = 0.04), whereas traditional linear RV indices such as TAPSE and RV S′ at baseline had no impact on intraoperative RV dysfunction (p = NS for both). Conclusions Global and regional RV function, as measured by 2D indices and strain, acutely decline intraoperatively. Impaired RV strain is associated with intraoperative RV functional decline and provides incremental value to traditional RV indices in predicting those who will develop RV dysfunction.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
| | - Brian Yum
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Christiane Abouzeid
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Maria Chiara Palumbo
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Lillian R Brouwer
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Richard B Devereux
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
| | - Jonathan W Weinsaft
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
| | - Jiwon Kim
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA.
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23
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Raina A, Meeran T. Right Ventricular Dysfunction and Its Contribution to Morbidity and Mortality in Left Ventricular Heart Failure. Curr Heart Fail Rep 2019; 15:94-105. [PMID: 29468529 DOI: 10.1007/s11897-018-0378-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE In patients with left-sided HF, there has been less emphasis on the pathophysiology of the RV in terms of diagnostic evaluation and treatment, versus focus on structural abnormalities of the LV. This review seeks to delineate the importance of RV dysfunction in terms of its contribution to symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. RECENT FINDINGS Recent studies have demonstrated that RV dysfunction is common in both HFpEF and HFrEF, but more pronounced in HFrEF. LV dysfunction and atrial fibrillation are most commonly associated with RV dysfunction in left-sided HF. RV dysfunction may develop due to afterload-dependent and afterload-independent pathways. Regardless, RV dysfunction is strongly associated with functional limitations and worsened survival in patients with left-sided HF. In patients with HFpEF, a recent study showed that RV failure was the most common cause of overall mortality. Among LVAD patients and patients post-cardiac transplantation, RV dysfunction is also strongly associated with survival. Despite a number of previous and ongoing clinical trials that target the RV directly or decrease RV afterload in left-sided HF, there are no definitive therapies specifically targeting RV dysfunction in left-sided HF patients CONCLUSIONS: RV dysfunction is an important determinant of symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. Further research is needed to developed pharmacotherapy that may target the RV specifically in left-sided HF patients.
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Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA. .,Pulmonary Hypertension Program, Section of Heart Failure/Transplant/MCS & Pulmonary Hypertension, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212-4772, USA.
| | - Talha Meeran
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
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24
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Silverton N, Djaiani G. Right Ventricular Function and Perioperative Risk Assessment: The Time Has Come to Stop Being Sinister. J Cardiothorac Vasc Anesth 2018; 33:1287-1289. [PMID: 30685155 DOI: 10.1053/j.jvca.2018.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Natalie Silverton
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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25
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Huang SJ, Nalos M, Smith L, Rajamani A, McLean AS. The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research. Intensive Care Med 2018; 44:868-883. [PMID: 29789861 DOI: 10.1007/s00134-018-5211-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/05/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study. METHODS Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized. RESULTS Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices. CONCLUSIONS TAPSE seemed to be the most popular index in the last 2-3 years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.
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Affiliation(s)
- Stephen J Huang
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
| | - Marek Nalos
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Louise Smith
- Cardiovascular Ultrasound Laboratory, Intensive Care Unit, Nepean Hospital, Sydney, NSW, Australia
| | - Arvind Rajamani
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Anthony S McLean
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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26
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Raina A, Patarroyo-Aponte M. Prevention and Treatment of Right Ventricular Failure During Left Ventricular Assist Device Therapy. Crit Care Clin 2018; 34:439-452. [PMID: 29907275 DOI: 10.1016/j.ccc.2018.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Left ventricular assist devices (LVAD) are increasingly used for the treatment of end-stage heart failure. Right ventricular (RV) failure after LVAD implantation is an increasingly common clinical problem, occurring in patients early after continuous flow LVAD implant. RV failure is associated with a substantial increase in post-LVAD morbidity and mortality. RV failure can be predicted using preoperative hemodynamic, clinical, and echocardiographic variables and a variety of risk prediction algorithms. However, RV failure may also develop due to unanticipated intraoperative or perioperative factors. Early recognition and treatment are critical in terms of mitigating the impact of RV failure on post-LVAD outcomes.
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Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772, USA.
| | - Maria Patarroyo-Aponte
- Cardiovascular Institute, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772, USA
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27
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Soltani A, Lahti J, Järvelä K, Curtze S, Laurikka J, Hokka M, Kuokkala VT. An Optical Method for the In-Vivo Characterization of the Biomechanical Response of the Right Ventricle. Sci Rep 2018; 8:6831. [PMID: 29717224 PMCID: PMC5931522 DOI: 10.1038/s41598-018-25223-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/17/2018] [Indexed: 11/25/2022] Open
Abstract
The intraoperative in-vivo mechanical function of the left ventricle has been studied thoroughly using echocardiography in the past. However, due to technical and anatomical issues, the ultrasound technology cannot easily be focused on the right side of the heart during open-heart surgery, and the function of the right ventricle during the intervention remains largely unexplored. We used optical imaging and digital image correlation for the characterization of the right ventricle motion and deformation during open-heart surgery. This work is a pilot study focusing on one patient only with the aim of establishing the framework for long term research. These experiments show that optical imaging and the analysis of the images can be used to obtain similar parameters, and partly at higher accuracy, for describing the mechanical functioning of the heart as the ultrasound technology. This work describes the optical imaging based method to characterize the mechanical response of the heart in-vivo, and offers new insight into the mechanical function of the right ventricle.
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Affiliation(s)
- A Soltani
- Tampere University of Technology, Laboratory of Materials Science, POB 589, FI33101, Tampere, Finland.
| | - J Lahti
- Tampere University Hospital Heart Center, POB 2000, FI-33521, Tampere, Finland
| | - K Järvelä
- Tampere University Hospital Heart Center, POB 2000, FI-33521, Tampere, Finland
| | - S Curtze
- Tampere University of Technology, Laboratory of Materials Science, POB 589, FI33101, Tampere, Finland
| | - J Laurikka
- Tampere University Hospital Heart Center, POB 2000, FI-33521, Tampere, Finland.,University of Tampere, Faculty of Medicine and Life Sciences, POB 100, Tampere, FI-33014, Finland
| | - M Hokka
- Tampere University of Technology, Laboratory of Materials Science, POB 589, FI33101, Tampere, Finland
| | - V-T Kuokkala
- Tampere University of Technology, Laboratory of Materials Science, POB 589, FI33101, Tampere, Finland
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28
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Bouchard-Dechêne V, Couture P, Su A, Deschamps A, Lamarche Y, Desjardins G, Levesque S, Denault AY. Risk Factors for Radial-to-Femoral Artery Pressure Gradient in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2017; 32:692-698. [PMID: 29217231 DOI: 10.1053/j.jvca.2017.09.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify risk factors associated with radial-to-femoral pressure gradient during cardiac surgery with cardiopulmonary bypass (CPB). DESIGN This is a retrospective, observational study. SETTING Single specialized cardiothoracic hospital in Montreal, Canada. PARTICIPANTS Consecutive patients that underwent heart surgery with CPB between 2005 and 2015 (n = 435). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A radial-to-femoral pressure gradient occurred in 146 patients of the 435 patients (34%). Based on the 10,000 bootstrap samples, simple logistic regression models identified the 17 most commonly significant variables across the bootstrap runs. Using these variables, a backward multiple logistic model was performed on the original sample and identified the following independent variables: body surface area (m2) (odds ratio [OR] 0.08, 95% confidence interval [CI] 0.030-0.232), clamping time (minutes) (OR 1.01, 95% CI 1.007-1.018), fluid balance (for 1 liter) (OR 0.81, 95% CI 0.669-0.976), and preoperative hypertension (OR 1.801, 95% CI 1.131-2.868). CONCLUSION A radial-to-femoral pressure gradient occurs in 34% of patients during cardiac surgery. Patients at risk seem to be of smaller stature, hypertensive, and undergo longer and more complex surgeries.
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Affiliation(s)
- Vincent Bouchard-Dechêne
- Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Antonio Su
- Department of Anesthesiology, Hôpital Cité de la Santé de Laval, Université de Montréal, Montreal, Quebec, Canada
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Surgery, Division of Cardiovascular Critical Care, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Sylvie Levesque
- Montreal Health Innovations Coordinating Centre, Montreal Heart Institute, Montreal, Quebec, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Surgery, Division of Cardiovascular Critical Care, Montreal Heart Institute, Montreal, Quebec, Canada.
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29
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30
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Extracardiac Signs of Fluid Overload in the Critically Ill Cardiac Patient: A Focused Evaluation Using Bedside Ultrasound. Can J Cardiol 2016; 33:88-100. [PMID: 27887762 DOI: 10.1016/j.cjca.2016.08.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
Fluid balance management is of great importance in the critically ill cardiac patient. Although intravenous fluids are a cornerstone therapy in the management of unstable patients, excessive administration coupled with cardiac dysfunction leads to elevation in central venous pressure and end-organ venous congestion. Fluid overload is known to have a detrimental effect on organ function and is responsible for significant morbidity in critically ill patients. Multisystem bedside point of care ultrasound imaging can be used to assess signs of fluid overload and venous congestion in critically ill patients. In this review we describe the ultrasonographic extracardiac signs of fluid overload and how they can be used to complement clinical evaluation to individualize patient management.
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31
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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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32
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Kramm T, Guth S, Wiedenroth CB, Ghofrani HA, Mayer E. [Treatment of acute and chronic right ventricular failure]. Med Klin Intensivmed Notfmed 2016; 111:463-80. [PMID: 27241776 DOI: 10.1007/s00063-016-0181-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/17/2016] [Accepted: 04/04/2016] [Indexed: 11/28/2022]
Abstract
Acute or chronic right ventricular failure is an often misdiagnosed cause of cardiopulmonary insufficiency. In addition to clinical symptoms or laboratory testing, echocardiography and invasive hemodynamic measurement by means of right-heart catheterization are essential for diagnosis and treatment control. In case of acute right ventricular failure, adequate symptomatic treatment of the life-threatening situation is important. Main issues are maintenance of coronary artery perfusion pressure and myocardial oxygen delivery as well as reduction of right ventricular afterload. In persistent right ventricular failure extracorporeal or intracorporeal assist devices are increasingly used as bridging or destination therapy. On a long-term basis, the targeted therapy of the underlying disease is crucial.
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Affiliation(s)
- T Kramm
- Abteilung für Thoraxchirurgie, Kerckhoff Klinik gGmbH, Benekestr. 2‑8, 61231, Bad Nauheim, Deutschland.
| | - S Guth
- Abteilung für Thoraxchirurgie, Kerckhoff Klinik gGmbH, Benekestr. 2‑8, 61231, Bad Nauheim, Deutschland
| | - C B Wiedenroth
- Abteilung für Thoraxchirurgie, Kerckhoff Klinik gGmbH, Benekestr. 2‑8, 61231, Bad Nauheim, Deutschland
| | - H A Ghofrani
- Abteilung für allgemeine Pneumologie, Kerckhoff-Klinik gGmbH, Bad Nauheim, Deutschland.,Medizinische Klinik II, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Universitätsklinikum Gießen und Marburg GmbH, Gießen, Deutschland
| | - E Mayer
- Abteilung für Thoraxchirurgie, Kerckhoff Klinik gGmbH, Benekestr. 2‑8, 61231, Bad Nauheim, Deutschland
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33
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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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34
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Ramakrishna H, Gutsche JT, Evans AS, Patel PA, Weiner M, Morozowich ST, Gordon EK, Riha H, Shah R, Ghadimi K, Zhou E, Fernadno R, Yoon J, Wakim M, Atchley L, Weiss SJ, Stein E, Silvay G, Augoustides JGT. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2015. J Cardiothorac Vasc Anesth 2015; 30:1-9. [PMID: 26847747 DOI: 10.1053/j.jvca.2015.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Indexed: 12/14/2022]
Affiliation(s)
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam S Evans
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Menachem Weiner
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | | | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hynek Riha
- Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ronak Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamrouz Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - Elizabeth Zhou
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh Fernadno
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeongae Yoon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mathew Wakim
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lance Atchley
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Erica Stein
- Department of Anesthesiology, Ohio State University, Columbus, OH
| | - George Silvay
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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