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Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024; 28:447-452. [PMID: 38738193 PMCID: PMC11080090 DOI: 10.5005/jp-journals-10071-24705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/03/2024] [Indexed: 05/14/2024] Open
Abstract
Background Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys. Primary objective To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion. Methods and results This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD. Conclusion VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI. How to cite this article Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024;28(5):447-452.
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Affiliation(s)
- Rajeswari Natraj
- Pediatric Intensive Care Unit and Cardiothoracic Services, Apollo Children's Hospital, Chennai, Tamil Nadu, India
| | | | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, CEMTL; Intensive Care Unit, University of Montreal, Montreal, Canada
| | - Korbin Haycock
- Emergency Department, Riverside University Health System Medical Center, Moreno Valley, California, Loma Linda, United States
| | - Matthew TT Siuba
- Intensive Care Unit, Department of Critical Care Medicine, Integrated Hospital Care, Cleveland, Ohio, United States
| | - Suchitra Ranjit
- Department of Pediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, Tamil Nadu, India
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Wei J, Kee A, Dukes R, Franke J, Leonardo V, Flynn BC. The Association of the Pulmonary Artery Pulsatility Index and Right Ventricular Function after Cardiac Surgery. Crit Care Res Pract 2024; 2024:5408008. [PMID: 38379715 PMCID: PMC10878756 DOI: 10.1155/2024/5408008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/19/2023] [Accepted: 01/27/2024] [Indexed: 02/22/2024] Open
Abstract
Background The pulmonary artery pulsatility index (PAPi) has been shown to correlate with right ventricular (RV) failure in patients with cardiac disease. However, the association of PAPi with right ventricular function following cardiac surgery is not yet established. Methods PAPi and other hemodynamic variables were obtained postoperatively for 959 adult patients undergoing cardiac surgery. The association of post-bypass right ventricular function and other clinical factors to PAPi was evaluated using linear regression. A propensity-score matched cohort for PAPi ≥ 2.00 was used to assess the association of PAPi with postoperative outcomes. Results 156 patients (16.3%) had post-bypass right ventricular dysfunction defined by visualization on transesophageal echocardiography. There was no difference in postoperative PAPi based on right ventricular function (2.12 vs. 2.00, p=0.21). In our matched cohort (n = 636), PAPi < 2.00 was associated with increased incidence of acute kidney injury (23.0% vs 13.2%, p < 0.01) and ventilator time (6.0 hours vs 5.6 hours, p=0.04) but not with 30-day mortality or intensive care unit length of stay. Conclusion In a general cohort of patients undergoing cardiac surgery, postoperative PAPi was not associated with postcardiopulmonary bypass right ventricular dysfunction. A postoperative PAPi < 2 may be associated with acute kidney injury.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brigid C. Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
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Wei J, Franke J, Kee A, Dukes R, Leonardo V, Flynn BC. Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2024; 38:214-220. [PMID: 37973507 DOI: 10.1053/j.jvca.2023.10.010] [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: 07/30/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. DESIGN Single-center retrospective observational cohort study. SETTING The University of Kansas Medical Center, a tertiary-care academic medical center. PARTICIPANTS Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. INTERVENTIONS All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. MEASUREMENTS AND MAIN RESULTS Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. CONCLUSIONS The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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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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Guzman-Ramirez D, Trujillo-Garcia A, Lopez-Rincon M, Lopez RB. Right Ventricular Function and Exercise Tolerance in Patients with ST-Elevation Myocardial Infarction. Arq Bras Cardiol 2023; 120:e20220799. [PMID: 37703105 PMCID: PMC10519353 DOI: 10.36660/abc.20220799] [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: 11/22/2022] [Revised: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Following ST-segment elevation myocardial infarction (STEMI), patients with cardiac dysfunction have limitations in performing physical activity. Right ventricular (RV) function is a determinant in improving functional capacity, and cardiac rehabilitation (CR) is essential for this patient cohort. OBJECTIVE To evaluate the association of RV function with exercise tolerance after a CR program in patients with STEMI. METHODS Retrospective cohort study in patients with STEMI from January to December 2019. They underwent an echocardiographic assessment of RV function before a 16-session CR program. A cardiopulmonary exercise (CPX) testing was performed before and after the CR program. We analyzed whether RV function measured before CR was significantly associated with exercise tolerance before and after the CR program and the degree of improvement. Comorbidity, demographic and anatomic variables were documented. A p-value < 0.05 was considered statistically significant. RESULTS A total of 109 patients were included. Of all, 3.7% had global RV dysfunction, 10.1% had radial RV dysfunction, and 11% had longitudinal RV dysfunction. An association between radial or longitudinal RV dysfunction and the absence of improvement in cardiorespiratory fitness (> 1 peak VO2equivalents) was observed (p = 0.028, p = 0.008, respectively). A significant correlation was observed between longitudinal RV dysfunction with initial peak VO2equivalents (pVO2eq) (p = 0.046), final pVO2eq (p = 0.003), and difference in pVO2eq (p = 0.009). A correlation was also identified between global RV dysfunction and the initial pVO2eq (p = 0.045), final pVO2eq (p = 0.012), and difference in pVO2eq (p = 0.032). CONCLUSIONS RV dysfunction is associated with a lower capacity to exercise; CR programs can be extended or modified in these patients.
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Affiliation(s)
- Denisse Guzman-Ramirez
- Hospital de Cardiologia UMAEInstituto Mexicano del Seguro Social Delegacion Nuevo LeonDepartamento de EcocardiografíaMonterreyNuevo LeonMéxicoInstituto Mexicano del Seguro Social Delegacion Nuevo Leon – Hospital de Cardiologia UMAE – Departamento de Ecocardiografía, Monterrey, Nuevo Leon – México
| | - Anival Trujillo-Garcia
- Hospital de Cardiologia UMAEInstituto Mexicano del Seguro Social Delegacion Nuevo LeonDepartamento de EcocardiografíaMonterreyNuevo LeonMéxicoInstituto Mexicano del Seguro Social Delegacion Nuevo Leon – Hospital de Cardiologia UMAE – Departamento de Ecocardiografía, Monterrey, Nuevo Leon – México
| | - Meredith Lopez-Rincon
- Hospital de Cardiologia UMAEInstituto Mexicano del Seguro Social Delegacion Nuevo LeonDepartamento de EcocardiografíaMonterreyNuevo LeonMéxicoInstituto Mexicano del Seguro Social Delegacion Nuevo Leon – Hospital de Cardiologia UMAE – Departamento de Ecocardiografía, Monterrey, Nuevo Leon – México
| | - Roxella Botello Lopez
- Hospital de Cardiologia UMAEInstituto Mexicano del Seguro Social Delegacion Nuevo LeonDepartamento de EcocardiografíaMonterreyNuevo LeonMéxicoInstituto Mexicano del Seguro Social Delegacion Nuevo Leon – Hospital de Cardiologia UMAE – Departamento de Ecocardiografía, Monterrey, Nuevo Leon – México
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Sumin AN, Shcheglova AV, Korok EV, Sergeeva TJ. Indicators of the Right Ventricle Systolic and Diastolic Function 18 Months after Coronary Bypass Surgery. J Clin Med 2022; 11:jcm11143994. [PMID: 35887758 PMCID: PMC9318021 DOI: 10.3390/jcm11143994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/10/2022] Open
Abstract
Objective. Right ventricular (RV) dysfunction after coronary artery bypass grafting (CABG) is associated with increased mortality and morbidity. In previous studies, the parameters of RV systolic function were mainly assessed, while the dynamics of RV diastolic function after surgery was practically not studied. The aim of this study was to study the dynamics of indicators of systolic and diastolic RV function after CABG as well as to identify factors associated with their presence. Methods. The study included 160 patients who underwent CABG and 36 volunteers with no history of coronary artery disease (CAD) as a control group. Echocardiographic examination of patients was performed to assess systolic and diastolic RV dysfunction before surgery and 18 months after CABG. A level of s’t < 10 cm/sec or TAPSE < 16 mm was considered as a sign of existing RV systolic dysfunction. RV diastolic dysfunction was defined as an Et/At ratio < 0.8 or >2.1 and/or an Et/et’ ratio > 6. Results. In CAD patients 18 months after CABG, there was an increase in the frequency of the right ventricular systolic (from 7.5% to 30%, p < 0.001) and diastolic (from 41.8% to 57.5%, p < 0.001) dysfunction. An increase in TAPSE (p = 0.007), a decrease in e’t (p = 0.005), and the presence of RV systolic dysfunction before surgery (p = 0.023) was associated with a significant increase in the likelihood of detecting RV systolic dysfunction 18 months after CABG (χ2(3) = 17.4, p = 0.001). High values of At before surgery (p = 0.021) and old myocardial infarction (p = 0.023) were significantly associated with an increased likelihood of detection of RV diastolic dysfunction 18 months after CABG (χ2(2) = 10.78, p = 0.005). Conclusions. This study demonstrated that in CAD patients 18 months after CABG, there was an increase in the frequency of right ventricular systolic and diastolic dysfunction. We also established the initial clinical, echocardiographic parameters, and perioperative complications associated with the presence of these changes in the postoperative period. The clinical and prognostic significance of the presence of systolic and/or diastolic RV dysfunction in patients 18 months after CABG remains to be explored.
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Affiliation(s)
- Alexey N. Sumin
- Correspondence: ; Tel.: +7-(3842)-64-44-61 or +7-8-903-940-8668; Fax: +7-(3842)-64-27-18
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Ma GG, Xu LY, Luo JC, Hou JY, Hao GW, Su Y, Liu K, Yu SJ, Tu GW, Luo Z. Change in left ventricular velocity time integral during Trendelenburg maneuver predicts fluid responsiveness in cardiac surgical patients in the operating room. Quant Imaging Med Surg 2021; 11:3133-3145. [PMID: 34249640 PMCID: PMC8250022 DOI: 10.21037/qims-20-700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 03/03/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid responsiveness is an important topic for clinicians. We investigated whether changes in left ventricular outflow tract (LVOT) velocity time integral (VTI) during a Trendelenburg position (TP) maneuver can predict fluid responsiveness as a non-invasive marker in coronary artery bypass graft (CABG) surgery patients in the operating room. METHODS This prospective, single-center observational study, performed in the operating room, enrolled 65 elective CABG patients. Hemodynamic data coupled with transesophageal echocardiography monitoring of the LVOT VTI and the peak velocity were collected at each step [baseline 1, TP, baseline 2 and fluid challenge (FC)]. Patients whose VTI increased ≥15% after FC (500 mL of Gelofusine infusion within 30 min) were considered responders. RESULTS Twenty-eight (43.1%) patients were responders to fluid administration. VTI changes during the TP maneuver predicted fluid responsiveness with an area under the receiver operating characteristic curve (AUC) of 0.90 (95% CI, 0.79-0.96), with a sensitivity of 100%, and a specificity of 70% at a threshold of 10% (gray zone, 8-15%). The increase in VTI during the TP was correlated with the VTI changes induced by FC (r=0.61, P<0.0001). Changes in peak velocity and pulse pressure during the TP were poorly predictive of fluid responsiveness, with an AUC of 0.72 (95% CI: 0.60-0.82) and 0.66 (95% CI: 0.53-0.77), respectively. CONCLUSIONS An increase in VTI induced by the TP could predict fluid responsiveness in CABG patients in the operating room. However, changes in peak velocity and pulse pressure stimulated by the TP could not reliably predict fluid responsiveness.
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Affiliation(s)
- Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Center of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Li-Ying Xu
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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Allen BS. Myocardial protection: a forgotten modality. Eur J Cardiothorac Surg 2021; 57:263-270. [PMID: 31364690 DOI: 10.1093/ejcts/ezz215] [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] [Received: 02/28/2019] [Revised: 06/20/2019] [Accepted: 06/28/2019] [Indexed: 12/25/2022] Open
Abstract
The goals of a cardiac surgical procedure are both technical excellence and complete protection of cardiac function. Cardioplegia is used almost universally to protect the heart and provide a quiet bloodless field for surgical accuracy. Yet, despite the importance of myocardial protection in cardiac surgery, manuscripts or dedicated sessions at major meetings on this subject have become relatively rare, as though contemporary techniques now make them unnecessary. Nevertheless, septal dysfunction and haemodynamic support (inotropes, intra-aortic balloon pump, assist devices) are common in postoperative patients, indicating that myocardial damage following cardiac surgery is still prevalent with current cardioplegic techniques and solutions. This article first describes why cardiac enzymes and septal function are the ideal markers for determining the adequacy of myocardial protection. It also describes the underappreciated consequences of postoperative cardiac enzyme release or septal dysfunction (which currently occurs in 40-80% of patients) from inadequate protection, and how they directly correlate with early and especially late mortality. Finally, it reviews the various myocardial protection techniques available to provide a detailed understanding of the cardioplegic methods that can be utilized to protect the heart. This will allow surgeons to critically assess their current method of protection and, if needed, make necessary changes to provide their patients with optimal protection.
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Affiliation(s)
- Bradley S Allen
- Division of Acute Care Surgery, Department of Surgery, USC Keck School of Medicine and Los Angeles County Medical Center, Los Angeles, CA, USA
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Calderone A, Hammoud A, Jarry S, Denault A, Couture EJ. Femoral Vein Pulsatility: What Does It Mean? J Cardiothorac Vasc Anesth 2021; 35:2521-2527. [PMID: 33985881 DOI: 10.1053/j.jvca.2021.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.
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Affiliation(s)
- Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ali Hammoud
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Faculty of Nursing Graduate Studies, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery and Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Etienne J Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Canada
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Right ventricular transverse displacement increases following cardiac surgery: possibly compensating loss in tricuspid annular plane systolic excursion (TAPSE). J Clin Monit Comput 2020; 34:1139-1148. [DOI: 10.1007/s10877-020-00466-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/21/2020] [Indexed: 12/22/2022]
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Vandenheuvel M, Bouchez S, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2019; 37:697-712. [PMID: 31677686 DOI: 10.1016/j.anclin.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium; Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Spitalstrasse 21, Basel 4031, Switzerland.
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Djordjevic I, Eghbalzadeh K, Sabashnikov A, Deppe AC, Kuhn EW, Seo J, Weber C, Merkle J, Adler C, Rahmanian PB, Liakopoulos OJ, Mader N, Kuhn-Regnier F, Zeriouh M, Wahlers T. Single center experience with patients on veno arterial ECMO due to postcardiotomy right ventricular failure. J Card Surg 2019; 35:83-88. [PMID: 31692108 DOI: 10.1111/jocs.14332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Right ventricular (RV) failure is associated with poor outcome and increased mortality in cardiac surgery. Aim of our study was to analyze the outcome of veno arterial extracorporeal membrane oxygenation (va ECMO) therapy in patients with isolated RV failure in postcardiotomy cardiogenic shock (PCS) and to evaluate risk factors associated with 30-day-mortality. METHODS Between August 2006 until August 2016, 64 consecutive patients with va ECMO therapy due to fulminant RV failure in PCS were identified and included in this retrospective observation. Further, outcome data and a comparison of va ECMO survivors and nonsurvivors was conducted. RESULTS The mean age of the patient cohort was 63 ± 14 years. Patients were treated with va ECMO for 79 ± 61 hours. Twenty-eight patients (44%) were successfully weaned off ECMO support. Overall 30-day-mortality was 88% (56/64). Hemoglobin concentration before ECMO implantation, maximum rise of muscle-brain type creatine kinase during ECMO therapy, as well as lactic acid concentration 24 hours after initiation of va ECMO therapy were predictive for 30-day mortality. CONCLUSION ECMO therapy in RV failure due to PCS is shown to be associated with an excessive mortality. Regarding our data, va ECMO might only be an appropriate short-term mechanical assist device separating patients form cardiopulmonary bypass with an acceptable weaning rate. Particularly, in case of failed hemodynamic recovery of the right heart on va ECMO, direct RV bypass systems might function as a bailout option. Additionally, cardiac enzymes and lactic acid might provide valuable information in meeting therapy-related decisions.
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Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Elmar W Kuhn
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Joon Seo
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Christoph Adler
- Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Parwis B Rahmanian
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Ferdinand Kuhn-Regnier
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,Heart Centre, ECMO Centre Cologne, University Hospital Cologne, Cologne, Germany
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Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements. Anesthesiol Clin 2019; 37:675-695. [PMID: 31677685 DOI: 10.1016/j.anclin.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article reviews transesophageal echocardiography-based assessment of perioperative right ventricular function and failure, including catheter-based methods, three-dimensional echocardiography, and their combination to make pressure-volume loops. It outlines right ventricular pathophysiology, multiple assessment methods, and their relationship to analogous transthoracic echocardiogram measurements. technologies used and developed for transthoracic or left ventricular assessment show significant limitations when applied to transesophageal assessment of the right ventricle. The article provides an overview of right ventricular assessment modalities that can be used in transesophageal echocardiography. Ultimately, clinicians must know limitations of measurements, synthesize information, and assess it in the clinical context.
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Korshin A, Grønlykke L, Nilsson JC, Møller-Sørensen H, Ihlemann N, Kjøller SM, Damgaard S, Lehnert P, Hassager C, Kjaergaard J, Ravn HB. Tricuspid annular plane systolic excursion is significantly reduced during uncomplicated coronary artery bypass surgery: A prospective observational study. J Thorac Cardiovasc Surg 2019; 158:480-489. [DOI: 10.1016/j.jtcvs.2018.09.114] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/23/2018] [Accepted: 09/27/2018] [Indexed: 11/24/2022]
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Korshin A, Grønlykke L, Nilsson JC, Møller-Sørensen H, Ihlemann N, Kjøller M, Damgaard S, Lehnert P, Hassager C, Kjaergaard J, Ravn HB. The feasibility of tricuspid annular plane systolic excursion performed by transesophageal echocardiography throughout heart surgery and its interchangeability with transthoracic echocardiography. Int J Cardiovasc Imaging 2018; 34:1017-1028. [DOI: 10.1007/s10554-018-1306-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/24/2018] [Indexed: 11/27/2022]
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