1
|
Labus J, Brand L, Feige K, Mehler O, Rahmanian P, Wahlers T, Böttiger BW, Wetsch WA, Mathes A. Intraoperative Assessment of Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2024; 38:2296-2306. [PMID: 39069381 DOI: 10.1053/j.jvca.2024.07.003] [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: 01/25/2024] [Revised: 06/12/2024] [Accepted: 07/03/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE Evaluation of noninvasive left ventricular (LV) myocardial work (MW) enables insights into cardiac contractility and efficacy beyond conventional echocardiography. However, there is limited intraoperative data on patients undergoing surgical aortic valve replacement (AVR). The aim of this study was to describe the feasibility and the intraoperative course of this technique of ventricular function assessment in these patients and compare it to conventional two (2D)- and three-dimensional (3D) echocardiographic measurements and strain analysis. DESIGN Prospective observational study. SETTING Single university hospital. PARTICIPANTS Twenty-five patients scheduled for isolated AVR with preoperative preserved left and right ventricular function, sinus rhythm, without significant other heart valve disease or pulmonary hypertension, and an uneventful intraoperative course. INTERVENTIONS Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Evaluation was performed in stable hemodynamics, in sinus rhythm or atrial pacing and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min. MEASUREMENTS AND MAIN RESULTS EchoPAC v206 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). Estimation of myocardial work was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF, GWI and GCW decreased significantly after AVR (T1 v T2, 1,647 ± 380 mmHg% v 1,021 ± 233 mmHg%, p < 0.001; T1 v T2, 2,095 ± 433 mmHg% v 1,402 ± 242 mmHg%, p < 0.001, respectively), while GWW remained unchanged (T1 v T2, 296 mmHg% [IQR 178-452) v 309 mmHg% [IQR 255-438), p = 0.97). This resulted in a decreased GWE directly after bypass (T1 v T2, 84% ± 6% v 78% ± 5%, p < 0.001), but GWE already improved at the end of surgery (T2 v T3, 78% ± 5% v 81% ± 5%, p = 0.003). There was no significant change in the values of GWI, GCW, or 2D and 3D LVEF before and after sternal closure (T2 v T3). CONCLUSION LV MW analysis showed a reduction of LV workload after bypass in our group of patients, which was not detected by conventional echocardiographic measures. This evolving technique provides deeper insights into cardiac energetics and efficiency in the perioperative course of aortic valve replacement surgery.
Collapse
Affiliation(s)
- Jakob Labus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany.
| | - Lukas Brand
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Katharina Feige
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Oliver Mehler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Bernd W Böttiger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Wolfgang A Wetsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Alexander Mathes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| |
Collapse
|
2
|
Labus J, Fassl J. Myocardial Work: A Response. J Cardiothorac Vasc Anesth 2024; 38:2130-2131. [PMID: 38880674 DOI: 10.1053/j.jvca.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Jakob Labus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Jens Fassl
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| |
Collapse
|
3
|
Doan V, Chaney M. Myocardial Work: Going Down A Rabbit Hole? J Cardiothorac Vasc Anesth 2024; 38:1451-1453. [PMID: 38553351 DOI: 10.1053/j.jvca.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Vivian Doan
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, IL.
| | - Mark Chaney
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, IL
| |
Collapse
|
4
|
Costescu A, Riendeau Beaulac G, Guensch DP, Lalancette JS, Couture P, Denault AY. Perioperative echocardiographic strain analysis: what anesthesiologists should know. Can J Anaesth 2024; 71:650-670. [PMID: 38600285 DOI: 10.1007/s12630-024-02713-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/26/2023] [Accepted: 10/28/2023] [Indexed: 04/12/2024] Open
Abstract
PURPOSE Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined. CLINICAL FEATURES This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period. CONCLUSION Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.
Collapse
Affiliation(s)
- Adrian Costescu
- Department of Anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Geneviève Riendeau Beaulac
- Department of Anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Dominik P Guensch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jean-Simon Lalancette
- Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institute, 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.
| |
Collapse
|
5
|
Sokalski V, Liu D, Hu K, Frantz S, Nordbeck P. Echocardiographic predictors of outcome in severe aortic stenosis patients with preserved or reduced ejection fraction. Clin Res Cardiol 2024; 113:481-495. [PMID: 38252146 PMCID: PMC10881626 DOI: 10.1007/s00392-023-02350-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/21/2023] [Indexed: 01/23/2024]
Abstract
AIMS Transcatheter aortic valve implantation (TAVI) has emerged as the treatment of choice for many patients with severe symptomatic aortic stenosis. We sought to identify the echocardiographic predictors of 30-day and 1-year outcomes after TAVI in patients with preserved or reduced left ventricular ejection fraction (LVEF). METHODS This single-centre study included 618 aortic stenosis patients (mean age 82 ± 6 years, 47.1% male; 74.8% LVEF > 50%) who underwent balloon-expandable TAVI between July 2009 and October 2018 in our hospital. All patients completed at least 6 months of follow-up by medical history review or telephone interview (median 24, quartiles 12-42 months). The primary endpoint was all-cause death. RESULTS All-cause mortality rate was 5.2% (LVEF > 50%: 4.3% vs. LVEF ≤ 50%: 7.7%, p = 0.141) at 30 days and 15.4% (LVEF > 50%: 14.7% vs. LVEF ≤ 50%: 17.3%, p = 0.443) at 12 months post TAVI. Overall all-cause mortality rate was 45.1% (LVEF > 50%: 44.6% vs. LVEF ≤ 50%: 46.8%, p = 0.643). Mean survival time post TAVI was 51 months [95% CI (48; 55)]. In TAVI patients with LVEF > 50%, multivariate Cox regression analysis revealed several independent predictors for increased risk of death after adjusting for echocardiographic and clinical covariates: TAPSE (≤ 17 vs. > 17 mm, HR 1.528, p = 0.016) and sPAP (> 30 vs. ≤ 30 mmHg, HR 1.900, p = 0.002) for overall mortality, E/E' septal for 30-day mortality (> 21 vs. ≤ 21, HR 14.462, p = 0.010) and 12-month mortality (> 21 vs. ≤ 21, HR 1.881, p = 0.026). In TAVI patients with LVEF ≤ 50%, no independent echocardiographic predictors for outcome could be identified. CONCLUSIONS LVEF is not a predictor of short- and long-term mortality after TAVI. In patients with preserved LVEF, left ventricular filling pressure (E/E´), systolic pulmonary artery pressure (sPAP), and TAPSE are echocardiographic risk factors for increased mortality post TAVI.
Collapse
Affiliation(s)
- Victoria Sokalski
- Department of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Dan Liu
- Department of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
- Comprehensive Heart Failure Center, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Kai Hu
- Department of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
- Comprehensive Heart Failure Center, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Stefan Frantz
- Department of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
- Comprehensive Heart Failure Center, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
- Comprehensive Heart Failure Center, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| |
Collapse
|
6
|
Labus J, Foit A, Mehler O, Rahmanian P, Wahlers T, Böttiger BW, Wetsch WA, Mathes A. Intraoperative Augmented Rotation and Circumferential Strain Compensate for Reduction of Left Ventricular Longitudinal Function After On-Pump CABG Surgery. J Cardiothorac Vasc Anesth 2023; 37:1912-1921. [PMID: 37393132 DOI: 10.1053/j.jvca.2023.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/25/2023] [Accepted: 06/06/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVES Left ventricular (LV) longitudinal function is reduced after on-pump coronary artery bypass grafting (CABG), while global LV function often is preserved. There are only limited data on the underlying compensatory mechanism. Therefore, the authors aimed to describe intraoperative changes of LV contractile pattern by myocardial strain analysis. DESIGN A prospective observational study. SETTING At a single university hospital. PARTICIPANTS A total of 30 patients scheduled for isolated on-pump CABG with an uneventful intraoperative course and preoperative preserved LV and RV function, sinus rhythm, without more-than-mild heart valve disease, or elevated pulmonary pressure. INTERVENTIONS Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Echocardiographic evaluation was performed under stable hemodynamics, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤0.1 µg/kg/min. MEASUREMENTS AND MAIN RESULTS EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2-dimensional (2D) and 3-dimensional (3D) LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global circumferential strain (GCS), LV global radial strain (GRS), LV apical rotation (aRot), LV basal rotation (bRot), and LV twist. Strain analysis was feasible in all included patients after termination of cardiopulmonary bypass (T2). Although there were no significant differences in the values of conventional echocardiographic parameters during the intraoperative interval, GLS deteriorated significantly after CABG compared to pre-bypass assessment (T1 v T2, -13.4% ± 2.9 v -11.8% ± 2.9; p = 0.007). GCS improved significantly after surgery (T1 v T2, -19.4% (IQR -17.1% to -21.2%) v -22.8% (IQR -21.1% to -24.7%); p < 0.001) as well as aRot (T1 v T2, -9.7° (IQR -7.1° to -14.1°) v -14.5° (IQR -12.1° to -17.1°); p < 0.001), bRot (T1 v T2, 5.1° (IQR 3.8°-6.7°) v 7.2° (IQR 5.6°-8.2°); p = 0.02), and twist (T1 v T2, 15.8° (IQR 11.7°-19.4°) v 21.6° (IQR 19.2°-25.1°); p < 0.001), while GRS remained unchanged. There were no significant changes in the values of GLS, GCS, GRS, aRot, bRot, or twist, as well as in the values of 2D and 3D LV EF before and after sternal closure (T2 v T3). CONCLUSION Beyond evaluation of longitudinal LV strain, measurements of circumferential and radial strain, as well as LV rotation and twist mechanics, were feasible in the intraoperative course of this study. Reduction of longitudinal function after on-pump CABG was compensated intraoperatively by improvement of GCS and rotation in the authors' group of patients. Perioperative assessment of GCS, GRS, as well as rotation and twist, might provide deeper insight into perioperative changes of cardiac mechanics.
Collapse
Affiliation(s)
- Jakob Labus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany.
| | - André Foit
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Oliver Mehler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Bernd W Böttiger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Wolfgang A Wetsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Alexander Mathes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| |
Collapse
|
7
|
Sirico D, Spigariol G, Mahmoud HT, Basso A, Cuppini E, Avesani M, Sabatino J, Castaldi B, Di Salvo G. Acute Changes in Right Ventricular Function in Pediatric Patients with Pulmonary Valve Stenosis Undergoing Percutaneous Valvuloplasty: A Speckle-Tracking Study. J Clin Med 2023; 12:4344. [PMID: 37445378 DOI: 10.3390/jcm12134344] [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: 05/13/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Pulmonary valve stenosis determines multiple effects on the right ventricular dimension and function. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages. However, little is known regarding right ventricular function immediate changes after percutaneous balloon dilation. Pediatric patients with isolated pulmonary valve stenosis represent a pure clinical model of chronic RV pressure overload not affected by other confounders or comorbidities. AIM OF THE STUDY This study seeks to explore right ventricle (RV) mechanics in pediatric patients early after percutaneous balloon pulmonary valvuloplasty (BPV) for valvar pulmonary stenosis (PS). MATERIALS AND METHODS Forty-three pediatric patients (19 males), mean age 3.2 ± 4.9 years old, with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent standard transthoracic echocardiography (TTE), and speckle-tracking echocardiography (STE) with an analysis of right ventricle free-wall longitudinal strain (RVFWLS) one day before and one day after the procedure. For each patient, we collected invasive parameters during the interventional procedure before and after BPV. RESULTS After the procedure, there was an immediate significant reduction in both peak-to-peak transpulmonary gradient (peak-to-peak PG) and ratio between the right ventricle and aortic systolic pressure (RV/AoP) with a drop of ∆29.3 ± 14.67 mmHg and ∆0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop (∆50 ± 32.23 and ∆31 ± 17.97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, affecting 29% of our patients post-BPV (p = 0.007). The analysis of right ventricular mechanics showed a significant improvement of fractional area change (FAC) immediately after BPV (40.11% vs. 44.42%, p = 0.01). On the other hand, right ventricular longitudinal systolic function parameters, TAPSE and global RVFWLS, did not improve significantly after intervention. The segmental analysis of the RVFWLS showed a significant regional increase in the myocardial deformation of the apical segments. CONCLUSIONS Percutaneous BPV represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. The analysis of the right ventricular function on echocardiography demonstrated an immediate global systolic function improvement, while longitudinal systolic function was persistently impaired 24 h after intervention, possibly due to the necessity of a longer recovery time.
Collapse
Affiliation(s)
- Domenico Sirico
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
| | - Giulia Spigariol
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
| | - Heba Talat Mahmoud
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
| | - Alessia Basso
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
| | - Elena Cuppini
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
| | - Martina Avesani
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
| | - Jolanda Sabatino
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
- Experimental Cardiology, Paediatric Research Institute (IRP), Città della Speranza, University of Padova, 35122 Padua, Italy
| | - Biagio Castaldi
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
| | - Giovanni Di Salvo
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, 35128 Padua, Italy
- Experimental Cardiology, Paediatric Research Institute (IRP), Città della Speranza, University of Padova, 35122 Padua, Italy
| |
Collapse
|
8
|
Friess JO, Mikasi J, Baumann R, Ranjan R, Fischer K, Levis A, Terbeck S, Hirschi T, Gerber D, Erdoes G, Schoenhoff FS, Carrel TP, Madhkour R, Eberle B, Guensch DP. Hyperoxia-induced deterioration of diastolic function in anaesthetised patients with coronary artery disease - Randomised crossover trial. BJA OPEN 2023; 6:100135. [PMID: 37588173 PMCID: PMC10430862 DOI: 10.1016/j.bjao.2023.100135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 08/18/2023]
Abstract
Background There are no current recommendations for oxygen titration in patients with stable coronary artery disease. This study investigates the effect of iatrogenic hyperoxia on cardiac function in patients with coronary artery disease undergoing general anaesthesia. Methods Patients scheduled for elective coronary artery bypass graft surgery were prospectively recruited into this randomised crossover clinical trial. All patients were exposed to inspired oxygen fractions of 0.3 (normoxaemia) and 0.8 (hyperoxia) in randomised order. A transoesophageal echocardiographic imaging protocol was performed during each exposure. Primary analysis investigated changes in 3D peak strain, whereas secondary analyses investigated other systolic and diastolic responses. Results There was no statistical difference in systolic function between normoxaemia and hyperoxia. However, the response in systolic function to hyperoxia was dependent on ventricular function at normoxaemia. Patients with a normoxaemic left ventricular (LV) global longitudinal strain (GLS) poorer than the derived cut-off (>-15.4%) improved with hyperoxia (P<0.01), whereas in patients with normoxaemic LV-GLS <-15.4%, LV-GLS worsened with transition to hyperoxia (P<0.01). The same was seen for right ventricular GLS with a cut-off at -24.1%. Diastolic function worsened during hyperoxia indicated by a significant increase of averaged E/e' (8.6 [2.6]. vs 8.2 [2.4], P=0.01) and E/A ratio (1.4 (0.4) vs 1.3 (0.4), P=0.01). Conclusions Although the response of biventricular systolic variables is dependent on systolic function at normoxaemia, diastolic function consistently worsens under hyperoxia. In coronary artery disease, intraoperative strain analysis may offer guidance for oxygen titration. Clinical trial registration NCT04424433.
Collapse
Affiliation(s)
- Jan O. Friess
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jan Mikasi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rico Baumann
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rajevan Ranjan
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kady Fischer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anja Levis
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sandra Terbeck
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Trevor Hirschi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Gerber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian S. Schoenhoff
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thierry P. Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raouf Madhkour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Balthasar Eberle
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik P. Guensch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
9
|
Labus J, Winata J, Schmidt T, Nicolai J, Zwaag SV, Sveric K, Wilbring M, Scholz M, Fassl J. Normal range of intraoperative three-dimensionally derived right ventricular free-wall strain in coronary artery bypass surgery patients. Echocardiography 2023. [PMID: 37229579 DOI: 10.1111/echo.15624] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/13/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Data on intraoperative three-dimensionally derived right ventricular free-wall strain (3D-RV FWS) is sparse. OBJECTIVES We sought to evaluate the normal range of intraoperative 3D-RV FWS in patients scheduled for coronary artery bypass graft (CABG) surgery and compared to conventional echocardiographic parameters. Prospective observational study. METHODS A total of 150 patients with preserved left and right ventricular (RV) function and sinus rhythm, without significant heart valve disease or pulmonary hypertension undergoing isolated on-pump CABG surgery, with an uneventful, complication-free intraoperative course. 3D-RV FWS analysis and conventional echocardiographic assessment of RV function were performed intraoperatively in anesthetized and ventilated patients using transesophageal echocardiography (TEE). TomTec 4D RV-Function 2.0 software for assessment of 3D-RV FWS and three-dimensional right ventricular ejection fraction (3D-RV EF). Philips QLAB 10.8 was used to evaluate tissue velocity of the tricuspid annulus (RV S´), tricuspid annular systolic excursion (TAPSE), and RV fractional area change (FAC). All echocardiographic measurements were performed under stable hemodynamic conditions and predefined fluid management without any vasoactive support or pacing. The prospective observational study was performed in a single university hospital setting. RESULTS Assessment of 3D-RV FWS was feasible in 95% of patients. No included patient experienced any serious perioperative complication. In our group of patients, median values with interquartile range (IQR) for 3D-RV FWS and 3D-RV EF were -25.2 (IQR -29.9 to -21.8) and 46.3% (IQR 41.0%-50.1%), respectively. RV FAC, RV S´, and TAPSE accounted for 39.7% (IQR 34.5%-44.4%), 14.8 cm/s (IQR 11.8-19.0 cm/s), and 22 mm (IQR 20-25 mm). The normal range (2.5% to 97.5% percentile) for 3D-RV FWS was -37.1 to -12.8. There was no relevant correlation of 3D-RV FWS to postoperative outcome in this group of CABG patients. CONCLUSION We present distribution values for intraoperative 3D-RV FWS and conventional parameters of RV function assessment in a healthy on-pump CABG patient population without serious perioperative complications. We observed no correlations of these parameters with any of the outcome parameters considered. Therefore, we consider these values to be intraoperative TEE-assessed normal values, which can be expected in on-pump CABG patients.
Collapse
Affiliation(s)
- Jakob Labus
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Johan Winata
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Torsten Schmidt
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Joachim Nicolai
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Stanislaw Vander Zwaag
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Kunislav Sveric
- Department of Cardiology and Internal Medicine, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Manuel Wilbring
- Department of Heart Surgery, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Markus Scholz
- Institute for Medical Informatics, Statistics and Epidemiology, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Jens Fassl
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| |
Collapse
|
10
|
Kumar N, Iyer MH, Kumar J, Hussain N, Essandoh M. Prognosticating With Left Ventricular Global Longitudinal Strain: A New Opportunity for Cardiac Anesthesiologists. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00172-6. [PMID: 36990806 DOI: 10.1053/j.jvca.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Nicolas Kumar
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Julia Kumar
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| |
Collapse
|
11
|
Keller M, Magunia H, Rosenberger P, Koeppen M. Echocardiography as a Tool to Assess Cardiac Function in Critical Care-A Review. Diagnostics (Basel) 2023; 13:839. [PMID: 36899983 PMCID: PMC10001271 DOI: 10.3390/diagnostics13050839] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023] Open
Abstract
In critically ill patients, hemodynamic disturbances are common and often lead to a detrimental outcome. Frequently, invasive hemodynamic monitoring is required for patients who are hemodynamically unstable. Although the pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile, this technique carries a substantial inherent risk of complications. Other less invasive techniques do not offer a full range of results to guide detailed hemodynamic therapies. An alternative with a lower risk profile is transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). After training, intensivists can obtain similar parameters on the hemodynamic profile using echocardiography, such as stroke volume and ejection fraction of the right and left ventricles, an estimate of the pulmonary artery wedge pressure, and cardiac output. Here, we will review individual echocardiography techniques that will help the intensivist obtain a comprehensive assessment of the hemodynamic profile using echocardiography.
Collapse
Affiliation(s)
| | | | | | - Michael Koeppen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076 Tübingen, Germany
| |
Collapse
|
12
|
Labus J, Foit A, Mehler O, Rahmanian P, Böttiger BW, Wetsch WA, Mathes A. Intraoperative Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing On-Pump Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 2023; 37:221-231. [PMID: 36404229 DOI: 10.1053/j.jvca.2022.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Noninvasive echocardiographic analysis of left ventricular (LV) myocardial work (MW) enables insights into cardiac mechanics, contractility, and efficacy beyond ejection fraction (EF) and global longitudinal strain (GLS). However, there are limited perioperative data on patients undergoing coronary artery bypass graft (CABG) surgery. The authors aimed to describe the feasibility and the intraoperative course of this novel assessment tool of ventricular function in these patients, and compare it to conventional 2-dimensional (2D) and 3-dimensional (3D) echocardiographic parameters and strain analysis. DESIGN A prospective observational study. SETTING At a single university hospital. PARTICIPANTS Twenty-five patients with preoperative preserved LV and right ventricular function, sinus rhythm, without significant heart valve disease or pulmonary hypertension, and an uncomplicated intraoperative course scheduled for isolated on-pump CABG surgery. INTERVENTIONS Transesophageal echocardiography (TEE) was performed intraoperatively after the induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). All measurements were performed under stable hemodynamic conditions, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min. MEASUREMENTS AND MAIN RESULTS The EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LVEF, LV GLS, LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). The MW analysis was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF during the intraoperative interval, GLS deteriorated significantly after CABG compared to assessment after induction of anesthesia (T1 v T2, -13.3 ± 3.0% v -11.6 ± 3.1%; p = 0.012). The GWI declined significantly after surgery (T1 v T2, 1,224 ± 312 mmHg% v 940 ± 267 mmHg%; p < 0.001), as well as GCW (T1 v T2, 1,460 ± 312 mmHg% v 1,244 ± 336 mmHg%; p = 0.005). The GWW increased after CABG (T1 v T2, 143 mmHg% (IQR 99-183) v 251 mmHg% (IQR 179-361); p < 0.001), and GWE decreased (T1 v T2, 89% (IQR 85-92) v 80% (IQR 75-87); p < 0.001). There were no significant changes in the values of 2D and 3D EF, GLS, GWI, GCW, GWW, and GWE before and after sternal closure (T2 v T3). CONCLUSION The intraoperative analysis of noninvasive echocardiographically-assessed LV MW indices is feasible. In the short-term period after uncomplicated on-pump CABG, GLS, as well as global and constructive MW, decreased, whereas wasted work increased, resulting in a less efficient left ventricle. None of these aspects was detected by conventional echocardiographic parameters. Therefore, strain and MW analysis might be more sensitive parameters in detecting myocardial dysfunction by TEE in the perioperative setting, adding information on perioperative cardiac energetics.
Collapse
Affiliation(s)
- Jakob Labus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany.
| | - André Foit
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Oliver Mehler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Bernd W Böttiger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Wolfgang A Wetsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Alexander Mathes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany
| |
Collapse
|
13
|
Cardiac function unchanged following reanimation with normothermic regional perfusion in donation after circulatory death. JTCVS Tech 2022; 15:136-143. [PMID: 36276687 PMCID: PMC9579788 DOI: 10.1016/j.xjtc.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives To determine whether hearts reanimated with normothermic regional perfusion (NRP) have clinically detectable changes in function using echocardiography comparing the prearrest and post-NRP imaging. As heart transplantation from donation after circulatory death (DCD) continues to increase, preliminary results suggest outcomes comparable with donation after brain death. It is unknown whether the obligatory period of warm ischemia experienced during DCD withdrawal process causes immediate changes in cardiac allograft function following in situ reanimation. Methods We retrospectively reviewed and compared predonation with postreanimation echocardiographic findings in all DCD donors at our institution from January to October 2021. All DCD donor organs were reanimated with in situ thoracoabdominal NRP after circulatory death. Echocardiographic assessment included (1) 2-dimensional and speckle-tracking measures of chamber size and function; (2) ejection fraction; (3) fractional area change; and (4) global longitudinal strain. Results Altogether, 4 DCD heart donations were performed during the study period. Basic demographics and withdrawal ischemic time periods are reported. There were no changes in left ventricular ejection fraction and right ventricular fractional area change when comparing the predonation and the postreanimation echocardiogram. There was a minimal, nonstatistically significant decrease in left ventricular global longitudinal strain and right ventricular free-wall systolic strain in 3 of the 4 donors following reanimation. Conclusions DCD cardiac allografts reanimated with NRP demonstrated no change in echocardiographic parameters used for a standard predonation donor heart evaluation. Findings suggest cardiac function of DCD allografts reanimated with thoracoabdominal NRP is not adversely impacted by limited period of warm ischemia following circulatory arrest.
Collapse
|
14
|
[Echocardiographic Assessment of Perioperative Right and Left Ventricular Function]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:344-358. [PMID: 35584707 DOI: 10.1055/a-1713-3088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The perioperative quantification of left and right ventricular function is cornerstone to provide optimal patient care. Echocardiography has emerged as the most important cardiac imaging modality in this setting, mainly due to its rapid availability, non-invasiveness and cost-efficiency. Both the transthoracic and the transesophageal acoustic windows offer manifold modes, e.g., doppler-based measurements or M-mode display, to assess systolic and diastolic ventricular function. An association with patient outcome and corresponding prognostic implications could be demonstrated for the majority of those parameters. Hence, a profound understanding of these measurements is key to delineate sufficient from failing left or right ventricular function and guide treatment decisions. This article gives the reader an overview over the most important measurements, reference values and pitfalls.
Collapse
|
15
|
[Intraoperative transesophageal echocardiography for emergency diagnostics in noncardiac surgery patients]. Anaesthesist 2021; 71:65-82. [PMID: 34821955 DOI: 10.1007/s00101-021-01034-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 10/19/2022]
Abstract
Due to the development of compact and mobile devices, transesophageal echocardiography (TEE) is now being used as one important point-of-care diagnostic method in emergency rooms, intensive care units and operating rooms. In the first part of this advanced training series, general aspects of the examination method and the procedure as well as indications and contraindications were outlined. In addition, an overview of application areas beyond cardiac surgery in which TEE can be used to monitor the patient or to assist with the operative procedure was provided. In the second part, the main findings during intraoperative TEE in the event of hemodynamic instability or unexplained hypoxemia are presented. A shortened emergency examination as proposed by Reeves et al. is outlined. The article concludes with an outlook on semiautomatic interpretation software and computer-aided image acquisition.
Collapse
|
16
|
Traunero K, Gartman C, Patel SJ, Augoustides JG. Global Left Ventricular Strain: Exciting Applications In Perioperative Practice. J Cardiothorac Vasc Anesth 2021; 36:175-177. [PMID: 34801394 DOI: 10.1053/j.jvca.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Kelsey Traunero
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania Philadelphia, PA
| | - Charles Gartman
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania Philadelphia, PA
| | - Saumil J Patel
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania Philadelphia, PA.
| |
Collapse
|
17
|
Labus J, Winata J, Schmidt T, Nicolai J, Uhlig C, Sveric K, Alexiou K, Scholz M, Fassl J. Perioperative Two-Dimensional Left Ventricular Global Longitudinal Strain in Coronary Artery Bypass Surgery: A Prospective Observational Pilot Study. J Cardiothorac Vasc Anesth 2021; 36:166-174. [PMID: 34526240 DOI: 10.1053/j.jvca.2021.08.004] [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: 04/19/2021] [Revised: 07/30/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES There are limited data on perioperative left ventricular strain. The authors aimed to describe the entire perioperative course of two-dimensional left ventricular global longitudinal strain in patients undergoing coronary artery bypass graft (CABG) surgery and compare to common parameters of LV function assessment. DESIGN Prospective observational study. SETTING Single university hospital. PARTICIPANTS Forty patients scheduled for isolated on-pump CABG surgery with preserved left and right ventricular function with an unremarkable, complication-free perioperative course. INTERVENTIONS Two-dimensional strain analysis and standard echocardiographic assessment of left ventricular function were performed pre- (T1) and postoperatively (T4) by transthoracic echocardiography (TTE) and intraoperatively pre- (T2) and poststernotomy (T3) by transesophageal echocardiography (TEE). Echocardiography was performed under stable hemodynamics and predefined fluid management, in sinus rhythm without any vasoactive support. MEASUREMENTS AND MAIN RESULTS Analysis of two-dimensional LV global longitudinal strain (2D-LV GLS) was performed using Tomtec 2D Cardiac Performance Analysis software. Philips QLAB 10.8 was used to analyze left ventricular ejection fraction (LV EF) and tissue velocity of the lateral mitral annulus (LV S ́). There were no significant differences (median with interquartile range [IQR]) after induction of anesthesia in values of LV EF and 2D-LV GLS (T1 v T2; 59% [IQR, 52 to 64] v 56% [IQR, 51.75 to 63] and -15.2 [IQR, -18.05 to -13.08] v -15.6 [IQR, -17.65 to -13.88]; both not significant [ns]), while LV S´ declined (T1 v T2, 7 cm/s [IQR, 5.25 to 8] v 5.25 cm/s [IQR, 4.6 to 6.83]; p < 0.001). Bland-Altman analysis for this comparison of 2D-LV GLS (T1 v T2) showed that bias was not significant between both techniques; however, there were limits of agreement. After sternotomy (T2 v T3) neither LV EF nor 2D-LV GLS or LV S´ declined. 2D-LV GLS deteriorated significantly after CABG (T1 v T4; -15.2 [IQR, -18.05 to -13.08] v -11.3 [IQR, -15.8 to -9.78]; p < 0.001). In contrast, LV EF and LV S´ did not change significantly in the perioperative interval (T1 v T4; 59% [IQR, 52 to 64] v 56% [IQR, 51.5 to 64.25] and 7 cm/s [IQR, 5.25 to 8] v 7 cm/s [IQR, 6 to 8]; both ns). CONCLUSION Values of 2D-LV GLS did not differ in awake, spontaneously breathing patients assessed by TTE and in anesthetized and ventilated patients with stable hemodynamics measured by TEE. 2D-LV GLS did not change after sternotomy; however, it declined significantly after on-pump CABG, while LV EF and LV S´ remained unchanged.
Collapse
Affiliation(s)
- Jakob Labus
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany; Department of Anesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty, Cologne University, Cologne, Germany
| | - Johan Winata
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Torsten Schmidt
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Joachim Nicolai
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Christopher Uhlig
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Kunislav Sveric
- Department of Cardiology and Internal Medicine, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Konstantin Alexiou
- Department of Heart Surgery, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Markus Scholz
- Institute for Medical Informatics, Statistics and Epidemiology, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Jens Fassl
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany.
| |
Collapse
|
18
|
Labus J, Uhlig C. Role of Echocardiography for the Perioperative Assessment of the Right Ventricle. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00474-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
This review aims to highlight the perioperative echocardiographic evaluation of right ventricular (RV) function with strengths and limitations of commonly used and evolving techniques. It explains the value of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and describes the perioperative changes of RV function echocardiographers should be aware of.
Recent Findings
RV dysfunction is an entity with strong influence on outcome. However, its definition and assessment in the perioperative interval are not well-defined. Moreover, values assessed by TTE and TEE are not interchangeable; while some parameters seem to correlate well, others do not. Myocardial strain analysis and three-dimensional echocardiography may overcome the limitations of conventional echocardiographic measures and provide further insight into perioperative cardiac mechanics.
Summary
Echocardiography has become an essential part of modern anesthesiology in patients with RV dysfunction. It offers the opportunity to evaluate not only global but also regional RV function and distinguish alterations of RV contraction.
Collapse
|
19
|
Gold AK, Kiefer JJ, Feinman JW, Augoustides JG. Left Atrial Strain-A Valuable Window on Left Ventricular Diastolic Function. J Cardiothorac Vasc Anesth 2021; 35:1626-1627. [PMID: 33750662 DOI: 10.1053/j.jvca.2021.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Andrew K Gold
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse J Kiefer
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
20
|
Labus J, Winata J, Schmidt T, Nicolai J, Tomko M, Sveric K, Wilbring M, Fassl J. Perioperative Course of Three-Dimensional-Derived Right Ventricular Strain in Coronary Artery Bypass Surgery: A Prospective, Observational, Pilot Trial. J Cardiothorac Vasc Anesth 2021; 35:1628-1637. [PMID: 33582011 DOI: 10.1053/j.jvca.2021.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Few data exist on perioperative three-dimensional-derived right ventricular strain. The authors aimed to describe the perioperative course of three-dimensional-derived right ventricular strain in coronary artery bypass graft (CABG) surgery patients. DESIGN Prospective, observational, pilot trial. SETTING Single university hospital. PARTICIPANTS The study comprised 40 patients with preserved left ventricular and right ventricular (RV) function undergoing isolated on-pump CABG surgery. INTERVENTIONS Three-dimensional strain analysis and standard echocardiographic evaluation of RV function were performed preoperatively (T1) and postoperatively (T4) with transthoracic echocardiography (TTE) and intraoperatively before sternotomy (T2) and after sternotomy (T3) with transesophageal echocardiography (TEE). All echocardiographic measurements were performed under stable hemodynamic conditions and predefined fluid management without any vasoactive support. MEASUREMENTS AND MAIN RESULTS The measurements of three-dimensional-derived RV free-wall strain (3D-RV FWS) and RV ejection fraction were performed using TomTec 4D RV-Function 2.0 software. Philips QLAB 10.8 was used to analyze tissue velocity of the tricuspid annulus, tricuspid annular systolic excursion, and RV fractional area change. There were no significant differences (median [interquartile range {IQR}]) between preoperative TTE and intraoperative TEE measurements for 3D-RV FWS (T1 v T2: -22.35 [IQR -17.70 to -27.22] v -24.35 [IQR -20.63 to -29.88]; not significant). 3D-RV FWS remained unchanged after sternotomy (T2 v T3: -24.35 [IQR -20.63 to -29.88] v -23.75 [IQR -20.25 to -29.28]; not significant) but deteriorated significantly after CABG (T1 v T4: -22.35 [IQR -17.70 to -27.22] v -18.5 [IQR -16.90 to -21.65]; p = 0.004). CONCLUSION In patients undergoing on-pump CABG, 3D-RV FWS values for awake, spontaneously breathing patients measured with TTE and values assessed in patients under general anesthesia with TEE did not significantly differ. Three-dimensional RV FWS did not change after sternotomy but deteriorated after on-pump CABG.
Collapse
Affiliation(s)
- Jakob Labus
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Johan Winata
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Torsten Schmidt
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Joachim Nicolai
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Matus Tomko
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Kunislav Sveric
- Department of Cardiology and Internal Medicine, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Manuel Wilbring
- Department of Heart Surgery, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Jens Fassl
- Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany.
| |
Collapse
|
21
|
Shah R, Pulton D, Wenger RK, Ha B, Feinman JW, Patel S, Lau C, Rong LQ, Weiss SJ, Augoustides JG, Daubenspeck D, Chaney MA. Aortic Dissection During Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:323-331. [PMID: 32928651 DOI: 10.1053/j.jvca.2020.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ronak Shah
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Pulton
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert K Wenger
- Division of Cardiac Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bao Ha
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Division of Cardiac Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY
| | - Stuart J Weiss
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danisa Daubenspeck
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| |
Collapse
|
22
|
Capdeville M, Hargrave J, Patel PA, Patel KM, Desai RG, Trivedi KC, Feinman JW, Garner C, Fernando RJ, Gordon EK, Augoustides JG. Contemporary Challenges for Fellowship Training in Adult Cardiothoracic Anesthesiology: Perspectives From Program Directors Around the United States. J Cardiothorac Vasc Anesth 2020; 34:2047-2059. [DOI: 10.1053/j.jvca.2020.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 12/11/2022]
|