Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction

Preoperative right ventricular strain as an early predictor of perioperative cardiac failure in patients undergoing mitral surgery: An exploratory study

Objectives

This study's primary purpose was to demonstrate the correlation of preoperative right ventricular free-wall longitudinal strain (RVFWLS) and pre-/postsurgical variation in strain (delta strain) with the clinical and echocardiographic diagnosis of right ventricular dysfunction. Its secondary purpose was to determine the correlation of RVFWLS and delta strain with length of stay (LOS) in the intensive care unit (ICU), ventilation days, trend of natriuretic peptide test. (NT-proBNP) and lactate in the first 48 h, incidence of acute renal failure, and 28-day mortality.

Design

Prospective observational study.

Setting

Cardio-thoracic and Vascular Anaesthesia Department and ICU of the University Hospital Integrated Trust of Verona.

Participants

Patients scheduled for mitral surgery.

Interventions

None.

Measurements and Main Results

All clinical and transoesophageal echocardiographic (TEE) parameters were collected at baseline, before surgery (T1) and at admission in the ICU postsurgery (T2). During the postoperative period, the clinical and echocardiographic diagnoses of right, left, or biventricular dysfunction were evaluated. TEE parameters were evaluated by a cardiologist offline. The patients were divided into two subgroups according to the development of any type of ventricular dysfunction. No statistically significant differences emerged between the two groups. According to a logistic regression model, a T1-RVFWLS value of -15% appeared to predict biventricular dysfunction (sensitivity: 100%; specificity: 91.3%). No correlation between T1- or T2-RVFWLS and creatinine, hours of ventilation or ICU LOS was found.

Conclusions

Our study introduces a new parameter that could be used in perioperative evaluations to identify patients at risk of postoperative biventricular dysfunction.

Epidemiology of perioperative RV dysfunction: risk factors, incidence, and clinical implications

In this edition of the journal, the Perioperative Quality Initiative (POQI) present three manuscripts describing the physiology, assessment, and management of right ventricular dysfunction (RVD) as pertains to the perioperative setting. This narrative review seeks to provide context for these manuscripts, discussing the epidemiology of perioperative RVD focussing on definition, risk factors, and clinical implications. Throughout the perioperative period, there are many potential risk factors/insults predisposing to perioperative RVD including pre-existing RVD, fluid overload, myocardial ischaemia, pulmonary embolism, lung injury, mechanical ventilation, hypoxia and hypercarbia, lung resection, medullary reaming and cement implantation, cardiac surgery, cardiopulmonary bypass, heart and lung transplantation, and left ventricular assist device implantation. There has however been little systematic attempt to quantify the incidence of perioperative RVD. What limited data exists has assessed perioperative RVD using echocardiography, cardiovascular magnetic resonance, and pulmonary artery catheterisation but is beset by challenges resulting from the inconsistencies in RVD definitions. Alongside differences in patient and surgical risk profile, this leads to wide variation in the incidence estimate. Data concerning the clinical implications of perioperative RVD is even more scarce, though there is evidence to suggest RVD is associated with atrial arrhythmias and prolonged length of critical care stay following thoracic surgery, increased need for inotropic support in revision orthopaedic surgery, and increased critical care requirement and mortality following cardiac surgery. Acute manifestations of RVD result from low cardiac output or systemic venous congestion, which are non-specific to the diagnosis of RVD. As such, RVD is easily overlooked, and the relative contribution of RV dysfunction to postoperative morbidity is likely to be underestimated.We applaud the POQI group for highlighting this important condition. There is undoubtedly a need for further study of the RV in the perioperative period in addition to solutions for perioperative risk prediction and management strategies. There is much to understand, study, and trial in this area, but importantly for our patients, we are increasingly recognising the importance of these uncertainties.

Programmatic approach to patients with advanced ischemic cardiomyopathy: Integrating microaxial support into strategies for the modern era

Patients with advanced ischemic cardiomyopathy manifesting as left ventricular dysfunction exist along a spectrum of severity and risk, and thus decision-making surrounding optimal management is challenging. Treatment pathways can include medical therapy as well as revascularization through percutaneous coronary intervention or coronary artery bypass grafting. Additionally, temporary and durable mechanical circulatory support, as well as heart transplantation, may be optimal for select patients. Given this spectrum of risk and the complexity of treatment pathways, patients may not receive appropriate therapy given their perceived risk, which can lead to sub-satisfactory outcomes. In this review, we discuss the identification of high-risk ischemic cardiomyopathy patients, along with our programmatic approach to patient evaluation and perioperative optimization. We also discuss our strategies for therapeutic decision-making designed to optimize both short- and long-term patient outcomes.

Right Ventricular Function in Surgical Treatment of Left Heart

Aim    The aim of this study was to evaluate right ventricular (RV) function during left chamber surgery.Material and methods    This was a single-site prospective cohort study. The study included 197 patients with valvular pathology of heart left chambers. Mean age of patients was 58 [47; 65] years. Precordial echocardiography was performed preoperatively and within one week after surgery.Results    Decreased parameters of the right ventricular (RV) longitudinal function and global contractile function were observed postoperatively in the majority of patients. More noticeable decreases were observed in parameters of the longitudinal function (p<0.001). Analysis of the changes in RV contractility depending on the underlying pathology revealed the greatest changes in the contractile function in the mitral insufficiency group. In the mitral stenosis group, the greatest difference was observed in the tricuspid annular systolic excursion (TAPSE) (p=0.027). In the groups with aortic defects, all parameters of RV contractile function, except for the fractional area change (FAC), showed statistically significant decreases after correction of the underlying defect (p<0.05).Conclusions    Surgical intervention for left heart valvulopathy can result in a decrease in RV function unrelated with systolic deficit of the left ventricle. Modern technologies allow multi-vector assessment of the RV contractile function. To assess the RV function, it is advisable to use a combination of parameters that reflect both global and longitudinal function.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery

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.

Interchangeability of transthoracic and transesophageal echocardiographic right heart measurements in the perioperative setting and correlation with hemodynamic parameters

Reduction of right ventricular (RV) function after cardiac surgery has been shown to impact outcomes. Conventional indices for right ventricular dysfunction are validated using transthoracic echocardiogram (TTE) which has limited use compared to transesophageal echocardiogram (TEE) in the perioperative settings. The aim of this study was to assess the agreement of RV systolic function assessment with TEE compared to TTE and assess the association of echocardiographic parameter with hemodynamic indices of RV dysfunction. This was a single center prospective observational study in an academic institution. Fifty adult patients undergoing elective cardiac surgery were included. TTE, TEE and stroke volume measurements pre-cardiopulmonary bypass (CPB) and post-CPB were performed. The variables of interest were anatomical M-mode tricuspid annular plane systolic excursion (AMM-TAPSE), fractional area change (FAC), tricuspid annular velocity (S') and myocardial performance index (MPI). FAC and AMM-TAPSE measured at the mid-esophageal 4 chamber view had substantial agreement with the TTE acquired parameters (Lin's concordance correlation coefficient (CCC) = 0.76, 95%CI 0.59-0.86 and CCC = 0.85, 95%CI 0.76-0.91). S' was significantly underestimated by TEE (CCC = 0.07, 95%CI 0.04-0.19) and MPI showed moderate agreement (CCC = 0.45 95%CI 0.19-0.65). Despite the significant changes in echocardiographic parameters, there were no corresponding changes in stroke volume (SV) or pulmonary artery pulsatility index at the post-CPB period. TEE acquired FAC and AMM-TAPSE had substantial agreement with pre-operative TTE values and no significant differences between the pre-CPB and post-CPB period. Systolic RV echocardiographic parameters decreased post-CPB but this was not accompanied by significant hemodynamic changes.

Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model

Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (E_es) following the development of an acute RV ischemic in a porcine model.

HYPOTHESIS

RV pressure monitoring can detect changes in RV systolic performance assess by RV E_es following the development of an acute RV ischemic model.

METHODS AND MODELS

Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV E_es obtained using a conductance catheter during inferior vena cava occlusions.

RESULTS

Acute ischemia resulted in a significant reduction in RV E_es from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between E_es and RV pressure-derived parameters. The reduction in RV E_es best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dt_max) and single-beat RV E_es. Adjusting RV dP/dt_max for heart rate resulted in an improved surrogate of RV E_es.

INTERPRETATION AND CONCLUSIONS

Stepwise decreases in RV E_es during acute ischemic RV dysfunction were accurately tracked by RV dP/dt_max derived from the RV pressure waveform.

Regional Right Ventricular Function Assessed by Intraoperative Three-Dimensional Echocardiography Is Associated With Short-Term Outcomes of Patients Undergoing Cardiac Surgery

Background

The assessment of right ventricular (RV) function in patients undergoing elective cardiac surgery is paramount for providing optimal perioperative care. The role of regional RV function assessment employing sophisticated state-of-the-art cardiac imaging modalities has not been investigated in this cohort. Hence, this study investigated the association of 3D echocardiography-based regional RV volumetry with short-term outcomes.

Materials and Methods

In a retrospective single-center study, patients undergoing elective cardiac surgery were included if they underwent 3D transesophageal echocardiography prior to thoracotomy. A dedicated software quantified regional RV volumes of the inflow tract, apical body and RV outflow tract employing meshes derived from 3D speckle-tracking. Echocardiographic, clinical and laboratory data were entered into univariable and multivariable logistic regression analyses to determine association with the endpoint (in-hospital mortality or the need for extracorporeal circulatory support).

Results

Out of 357 included patients, 25 (7%) reached the endpoint. Inflow RV ejection fraction (RVEF, 32 ± 8% vs. 37 ± 11%, p = 0.01) and relative stroke volume (rel. SV) were significantly lower in patients who reached the endpoint (44 ± 8 vs. 48 ± 9%, p = 0.02), while the rel. SV of the apex was higher (38 ± 10% vs. 33 ± 8%, p = 0.01). Global left and right ventricular function including RVEF and left ventricular global longitudinal strain did not differ. In univariable logistic regression, tricuspid regurgitation grade ≥ 2 [odds ratio (OR) 4.24 (1.66–10.84), p < 0.01], inflow RVEF [OR 0.95 (0.92–0.99), p = 0.01], inflow rel. SV [OR 0.94 (0.90–0.99), p = 0.02], apex rel. SV [OR 1.07 (1.02–1.13), p < 0.01] and apex to inflow rel. SV ratio [OR 5.81 (1.90–17.77), p < 0.01] were significantly associated with the endpoint. In a multivariable model, only the presence of tricuspid regurgitation [OR 4.24 (1.66–10.84), p < 0.01] and apex to inflow rel. SV ratio [OR 6.55 (2.09–20.60), p < 0.001] were independently associated with the endpoint.

Conclusions

Regional RV function is associated with short-term outcomes in patients undergoing elective cardiac surgery and might be helpful for optimizing risk stratification.

A standardized definition for right ventricular failure in cardiac surgery patients

Right ventricular failure (RVF) is a significant cause of mortality and morbidity after cardiac surgery. Despite its prognostic importance, RVF remains under investigated and without a universally accepted definition in the perioperative setting. We foresee that the provision of a standardized perioperative definition for RVF based on practical and objective criteria will help to improve quality of care through early detection and facilitate the generalization of RVF research to advance this field. This article provides an overview of RVF aetiology, pathophysiology, current diagnostic modalities, as well as a summary of existing RVF definitions. This is followed by our proposal for a standardized definition of perioperative RVF, one that captures RV structural and functional abnormalities through a multimodal approach based on anatomical, echocardiographic, and haemodynamic criteria that are readily available in the perioperative setting (Central Image).

Subclinical right ventricular dysfunction in patients with mitral stenosis

BACKGROUND

Right ventricular (RV) dysfunction is a strong predictor of poor outcomes of patients with mitral stenosis (MS). The aim of this study was to detect a subclinical right ventricular dysfunction in patients with MS.

METHODS

We conducted a prospective study from January 2015 to June 2019 in 104 asymptomatic patients with MS (mean age: 46.1 ± 4.27 years), and compared to a group of 52 age and sex matched healthy subjects. Standard and speckle tracking echocardiography were performed; parameters of RV function were measured and compared.

RESULTS

Although they were in normal range, RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler and pulsed wave Doppler RV myocardial performance index (MPI) and peak systolic velocity (S') were decreased in patients with MS (p < 0.05). The global RV longitudinal strain (LSGRV) and the longitudinal strain of the free wall of the right ventricular (LSFRV) were lower in patients with MS (p, respectively, at 0.001 and < 0.001), 53.5% (n = 47) of patients had LSFRV < - 20%. A significant difference was noted between LSFRV and 2D strain of the septal wall (p = 0.002). No difference was found between patients with severe MS and moderate MS regarding LSFRV and LSGRV. No correlation between LSFRV and FAC (p = 0.85), MPI (p = 0.62), TAPSE (p = 0.31) and S' (p = 0.78) was found.

CONCLUSION

Our study showed the presence of subclinical systolic dysfunction of the right ventricle in patients with MS.

Femoral Vein Pulsatility: What Does It Mean?

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.

Clinically inapparent right heart dysfunction is associated with reduced myofilament force development in coronary artery disease

Background

Right ventricular dysfunction after CABG is associated with poor peri- and postoperative outcomes. We aimed to identify clinical and experimental predictors for preoperative inapparent right ventricular dysfunction and therefore hypothesized that reduced myofilament force development as well as altered levels of biomarkers might predict inapparent right ventricular dysfunction.

Methods

From 08/2016 to 02/2018, 218 patients scheduled for CABG were divided into two groups (TAPSE ≥ 20 mm, n = 178; TAPSE < 20 mm, n = 40). Baseline serum samples for biomarkers (Galectin, TGFß1, N Acyl-SDMA, Arginine, ADMA and Pentraxin-3), clinical laboratory and transthoracic echocardiographic parameters were evaluated. To examine the myocardial apparatus of the right ventricle intraoperative right auricular tissue was harvested for stepwise skinned fiber force measurements.

Results

Patients with TAPSE < 20 mm had a higher incidence of DM (55 vs. 34%, p = 0.018), preoperative AFib (43 vs. 16%, p < 0.001), reduced GFR (67 ± 18 vs. 77 ± 24 ml/min/1.73 m², p = 0.013), larger LA area (22 ± 6 vs. 20 ± 5 cm², p = 0.005) and reduced LVEF (50 vs. 55%, p = 0.008). Furthermore, higher serum ADMA (0.70 ± 0.13 vs. 0.65 ± 0.15 µmol/l, p = 0.046) and higher serum Pentraxin-3 levels (3371 ± 1068 vs. 2681 ± 1353 pg/dl, p = 0.004) were observed in these patients. Skinned fiber force measurements showed significant lower values at almost every step of calcium concentration (pCa 4.52 to pCa 5.5, p < 0.01 and pCa 5.75–6.0, p < 0.05). Multivariable analysis revealed DM (OR 2.53, CI 1.12–5.73, Euro Score II (OR 1.34, CI 1.02–1.78), preoperative AF (OR 4.86, CI 2.06–11.47), GFR (OR 7.72, CI 1.87–31.96), albumin (OR 1.56, CI 0.52–2.60), Pentraxin-3 (OR 19.68, CI 14.13–25.24), depressed LVEF (OR 8.61, CI 6.37–10.86), lower force values: (pCa 5.4; OR 2.34, CI 0.40–4.29 and pCa 5.2; OR 2.00, CI 0.39–3.60) as predictors for clinical inapparent right heart dysfunction.

Conclusions

These preliminary data showed that inapparent right heart dysfunction in CAD is already associated with reduced force development of the contractile apparatus.

Right Ventricular Dysfunction and Short-Term Outcomes Following Left-Sided Valvular Surgery: An Echocardiographic Study

Background The prognostic value of echocardiographic evaluation of right ventricular (RV) function in patients undergoing left-sided valvular surgery has not been well described. The objective of this study is to determine the role of broad echocardiographic assessment of RV function in predicting short-term outcomes after valvular surgery. Methods and Results Preoperative echocardiographic data, perioperative adverse outcomes, and 30-day mortality were analyzed in patients who underwent left-sided valvular surgery from 2006 to 2014. Echocardiographic parameters used to evaluate RV function include RV fractional area change, tricuspid annular plane systolic excursion, systolic movement of the RV lateral wall using tissue Doppler imaging (S'), RV myocardial performance index, and RV dP/dt. Subjects with at least 3 abnormal parameters out of the 5 aforementioned indices were defined as having significant RV dysfunction. The study included 269 patients with valvular surgery (average age: 67±15, 60.6% male, 148 aortic, and 121 mitral). RV dysfunction was found in 53 (19.7%) patients; 30-day mortality occurred in 20 patients (7.5%). Compared with normal RV function, patients with RV dysfunction had higher 30-day mortality (22.6% versus 3.8%; P=0.01) and were at risk for developing multisystem failure/shock (13.2% versus 3.2%; P=0.01). Multivariate analyses showed that preexisting RV dysfunction was the strongest predictor of increased 30-day mortality (odds ratio: 3.5; 95% CI, 1.1-11.1; P<0.05). Conclusions Preoperative RV dysfunction identified by comprehensive echocardiographic assessment is a strong predictor of adverse outcomes following left-sided valvular surgery.

Influence of preoperative right ventricular function on left ventricular remodeling and survival after subvalvular repair for functional mitral regurgitation

OBJECTIVES

The objective of this study was to analyze our surgical experiences with mitral valve plasty (MVP) combined with subvalvular procedures (SVPs) for functional mitral regurgitation (FMR) and to determine which preoperative factors affected clinical outcomes.

METHODS

This study retrospectively analyzed 33 patients who underwent MVP combined with SVPs for FMR with a left ventricular ejection fraction lower than 40% and advanced remodeled left ventricles. The mean follow-up period was 49 ± 33 months.

RESULTS

The preoperative mean right ventricular fractional area change (RVFAC) used to quantify right ventricular (RV) systolic function was 26 ± 11%. Sixteen patients (48%) had an RVFAC < 26%. One patient died during hospital stay, and nine more patients died of cardiac causes during follow-up. The 3- and 5-year rates of freedom from cardiac-related mortality were 78% and 68%, respectively. RVFAC was the significant predictor of cardiac-related mortality in a univariate analysis (risk ratio [RR] = 0.92, 95% confidence interval [CI] 0.85-0.99, p = 0.03) and demonstrated a non-significant tendency to predict cardiac-related mortality in the Cox multivariate analysis (RR = 0.94, 95% CI 0.86-1.003, p = 0.08). Continued reverse left ventricular remodeling was associated with an RVFAC ≥ 26%. At 3 years, there was also a significant difference in survival rates of cardiac-related mortality between patients with an RVFAC ≥ 26% and < 26% (94% vs. 61%; p = 0.03).

CONCLUSIONS

Preoperative RV function affected left ventricular remodeling and cardiac-related mortality after MV surgery. MVP combined with SVPs for FMR provided promising results for patients without severe RV dysfunction.

Perioperative Right Ventricular Dysfunction: Analysis of Outcomes

Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.¹ The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.^2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.

Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter

OBJECTIVE

This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE.

DESIGN

Prospective observational.

SETTING

Cardiac operating room at a single university hospital.

PARTICIPANTS

All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements.

CONCLUSION

A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.

Preexisting Right Ventricular Diastolic Dysfunction and Postoperative Cardiac Complications in Patients Undergoing Nonemergency Coronary Artery Bypass Surgery

OBJECTIVES

To evaluate whether the presence of preexisting right ventricular diastolic dysfunction (RVDD) in patients undergoing coronary artery bypass grafting (CABG) is associated with a greater incidence of postoperative cardiac complications.

DESIGN

Single-center, observational, retrospective, cohort study.

SETTING

Research institute hospital.

PARTICIPANTS

Patients undergoing CABG from February 2017 to November 2018 (n = 200).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Transthoracic echocardiography was performed to obtain the following values of right ventricular (RV) diastolic function: peak velocity of early (Et) and late (At) transtricuspid flow, e't, a't, s't, tricuspid annular plane systolic excursion, and the RV Tei index. All patients were divided into the following 2 groups: with RVDD (n = 92) or without RVDD (n = 108). Compared with control patients, the patients with RVDD developed postoperative heart failure (PHF) (primary outcome) more frequently (p = 0.026). RVDD, low left ventricular ejection fraction, were female, underwent cardiopulmonary bypass, increased left ventricular mass index, and an Et/At ratio that increased the risk of the development of PHF. However, only RVDD (odds ratio 4.82; p = 0.015), cardiopulmonary bypass (odds ratio 4.04; p = 0.028), and female sex were associated independently with the development of PHF in the multivariate analyses.

CONCLUSIONS

Preoperative RVDD, cardiopulmonary bypass, and female sex are independent risk factors for the development of PHF after CABG in coronary artery disease patients. The decreased Et/At ratio was the best echocardiographic marker predicting PHF development after CABG. Nevertheless, the possibility of assessing preoperative diastolic RV function to predict the development of PHF after CABG requires confirmation in additional studies.

Changes in Right Ventricular Function After Off-Pump Coronary Artery Bypass Grafting

OBJECTIVE

Right ventricular (RV) dysfunction is associated with poor outcomes after cardiac surgery. The aim of this study was to assess RV systolic and diastolic function in the perioperative period after off-pump coronary artery bypass grafting (OPCAB).

DESIGN

Prospective observational study.

SETTINGS

Tertiary care hospital.

PARTICIPANTS

Thirty adult patients undergoing OPCAB.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Transthoracic echocardiography was performed twice: first preoperatively and second postoperatively, when patients were moved to wards. The following five parameters of RV systolic function were used: tricuspid annular plane systolic excursion (TAPSE), systolic tissue Doppler imaging of lateral tricuspid annulus (S'), fractional area change (FAC), RV myocardial performance index (RIMP), and isovolumic acceleration (IVA). Grading of RV diastolic function (RVDD) was done as per guidelines. Paired t test was used for comparing means and χ² test was used for categorical and ordinal data. The parameters of RV longitudinal function (TAPSE and S') reduced significantly (preoperative 21.93 ± 2.80 mm and 13.24 ± 2.24 cm/s to postoperative 11.67 ± 1.91 mm and 10.31 ± 1.56 cm/s, respectively, p < 0.001), whereas parameters of RV global function (FAC, RIMP, and IVA) remained preserved (preoperative 46.75 ± 6.80%, 0.34 ± 0.06, and 4.66 ± 0.87 m/s² to postoperative 46.21 ± 6.44%, 0.36 ± 0.06, and 4.37 ± 0.83 m/s²; p values of 0.76, 0.13, and 0.11, respectively). The median grade of RVDD worsened from normal in the preoperative period to pseudo-normal in the postoperative period (p < 0.001). The changes in both RV systolic and diastolic function were similar in patients with normal and reduced left ventricular systolic function.

CONCLUSIONS

RV function can be assessed in perioperative settings with two-dimensional and tissue Doppler imaging. For systolic function assessment, exclusive measurement of longitudinal parameters might be inadequate; use of complementary global parameters like FAC, RIMP, and IVA is essential to complete the RV assessment after OPCAB. RVDD worsened significantly after OPCABG.

Right ventricular assessment can improve prognostic value of Euroscore II

BACKGROUND

The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery.

METHODS

This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II.

CONCLUSIONS

This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.

Right Ventricular Systolic Assessment by Transesophageal Versus Transthoracic Echocardiography: Displacement, Velocity, and Myocardial Deformation

OBJECTIVE

First, to compare tricuspid annular displacement and velocity in transthoracic and transesophageal echocardiography (TTE, TEE) using conventional angle-dependent technologies. Second, to evaluate both alternative TEE views as well as an alternative technology (speckle tracking) for overcoming proposed differences in TTE and TEE.

DESIGN

Prospective, comparative, cross-over study with a randomized order of image acquisition.

SETTING

University hospital.

PARTICIPANTS

Adults undergoing cardiac surgery.

INTERVENTIONS

Postinduction standardized image acquisition and analysis in TTE and TEE by 2 echocardiographers.

MEASUREMENTS AND MAIN RESULTS

The authors measured tricuspid annular plane systolic excursion (TAPSE) by M-mode and velocity by tissue Doppler (S') in the apical 4-chamber TTE view and midesophageal 4-chamber TEE view (AP4C, ME4C). They then examined (1) the same measurements in alternative TEE views with proposed better ultrasound angulation; and (2) speckle tracking-based endpoints (TAPSE by speckle tracking, strain, and strain rate). Data were available in 24 of 25 patients. Conventional TAPSE by M-mode and velocity by tissue Doppler (TDI) were underestimated in the ME4C compared with the AP4C reference (mean ± standard deviation: TAPSE: 13.1 ± 3.8 mm v 17.3 ± 4.0 mm; S': 6.7 ± 2.1 cm/s v 9.1 ± 2.2 cm/s; both p < 0.001). Neither a modified deep transgastric view (TAPSE 14.5 ± 4.7 mm, p = 0.017; S' 6.8 ± 1.8 cm/s, p < 0.001) nor a transgastric right ventricular inflow view (TAPSE 12.3 ± 4.0 mm, p = 0.001; S' 6.0 ± 1.3 cm/s, p < 0.001) was similar to the AP4C. Speckle tracking TAPSE was unbiased but with high variability (mean bias = -0.3 mm, 95% limits of agreement = -9.1 to 8.4); strain and strain rate were higher in TEE than for TTE (-17.7 ± 3.6 v -12.6 ± 2.1, p < 0.001; -1.0 ± 0.2/s v -0.7 ± 0.1/s, p < 0.001).

CONCLUSIONS

Right ventricular displacement, velocity, and myocardial deformation measured by TEE versus TTE are different. Neither alternative transesophageal echocardiography views nor speckle tracking-based deformation is promising; TAPSE by speckle tracking is unbiased but imprecise.

The Reduction in Right Ventricular Longitudinal Contraction Parameters Is Not Accompanied by a Reduction in General Right Ventricular Performance During Aortic Valve Replacement: An Explorative Study

OBJECTIVE

The aim of the present study was to identify whether the decrease of longitudinal parameters after cardiothoracic surgery (ie, tricuspid annular systolic plane excursion [TAPSE] and systolic excursion velocity [S']) is accompanied by a reduction in global right ventricular (RV) performance.

DESIGN

Prospective, observational study.

SETTING

Single-center explorative study in a tertiary teaching hospital.

PARTICIPANTS

The study comprised 20 patients who underwent aortic valve replacement with or without coronary artery bypass grafting.

INTERVENTIONS

During cardiac surgery, simultaneous measurements of RV function were performed with a pulmonary artery catheter and transesophageal echocardiography.

MEASUREMENTS AND MAIN RESULTS

TAPSE and S' were reduced significantly directly after surgery compared with the time before surgery (TAPSE from 20.8 [16.6-23.4] mm to 9.1 [5.6-15.5] mm; p < 0.001 and S' from 8.7 [7.9-10.7] cm/s to 7.2 [5.7-8.6] cm/s; p = 0.041). However, the reduction in TAPSE and S' was not accompanied by a reduction in RV performance, as assessed with the TEE-derived myocardial performance index (MPI) and pulmonary artery catheter-derived RV ejection fraction (RVEF). Both remained statistically unaltered before and after the procedure (MPI from 0.52 [0.43-0.58] to 0.50 [0.42-0.88]; p = 0.278 and RVEF from 27% [22%-32%] to 26% [22%-28%]; p = 0.294).

CONCLUSIONS

In the direct postoperative phase, the reduction of echocardiographic parameters of longitudinal RV contractility (TAPSE and S') were not accompanied by a reduction in global RV performance, expressed as MPI and RVEF. Solely relying on a single RV parameter as a marker for global RV performance may not be adequate to assess the complex adaptation of the right ventricle to aortic valve replacement.

Preliminary Experience Using Diastolic Right Ventricular Pressure Gradient Monitoring in Cardiac Surgery

OBJECTIVES

Right ventricular (RV) dysfunction in cardiac surgery is associated with increased mortality and morbidity and difficult separation from cardiopulmonary bypass (DSB). The primary objective of the present study was to describe the prevalence and characteristics of patients with abnormal RV diastolic pressure gradient (PG). The secondary objective was to explore the association among abnormal diastolic PG and DSB, postoperative complications, high central venous pressure (CVP), and high RV end-diastolic pressure (RVEDP).

DESIGN

Retrospective and prospective validation study.

SETTING

Tertiary care cardiac institute.

PARTICIPANTS

Cardiac surgical patients (n=374) from a retrospective analysis (n=259) and a prospective validation group (n=115).

INTERVENTION

RV pressure waveforms were obtained using a pulmonary artery catheter with a pacing port opened at 19 cm distal to the tip of the catheter. Abnormal RV diastolic PG was defined as >4 mmHg. Both elevated RVEDP and high CVP were defined as >16 mmHg.

MEASUREMENTS AND MAIN RESULTS

From the retrospective and validation cohorts, 42.5% and 48% of the patients had abnormal RV diastolic PG before cardiac surgery, respectively. Abnormal RV diastolic PG before cardiac surgery was associated with higher EuroSCORE II (odds ratio 2.29 [1.10-4.80] v 1.62 [1.10-3.04]; p = 0.041), abnormal hepatic venous flow (45% v 29%; p = 0.038), higher body mass index (28.9 [25.5-32.5] v 27.0 [24.9-30.5]; p = 0.022), pulmonary hypertension (48% v 37%; p = 0.005), and more frequent DSB (32% v 19%; p = 0.023). However, RV diastolic PG was not an independent predictor of DSB, whereas RVEDP (odds ratio 1.67 [1.09-2.55]; p = 0.018) was independently associated with DSB. In addition, RV pressure monitoring indices were superior to CVP in predicting DSB.

CONCLUSION

Abnormal RV diastolic PG is common before cardiac surgery and is associated with a higher proportion of known preoperative risk factors. However, an abnormal RV diastolic PG gradient is not an independent predictor of DSB in contrast to RVEDP.

Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters?

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.

Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements

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.

Use of Pulmonary Artery Pulsatility Index in Cardiac Surgery

OBJECTIVE

This study evaluated whether the pulmonary artery pulsatility index (PAPi) collected before and after cardiopulmonary bypass (CPB) is predictive and diagnostic of new onset right ventricular (RV) failure in the elective cardiac surgical population.

DESIGN

This was a prospective observational study of patients who underwent cardiac surgery between 2017 and 2019.

SETTING

Weill Cornell Medicine, a single large academic medical center.

PARTICIPANTS

The study comprised 119 patients undergoing elective cardiac surgery.

INTERVENTIONS

Cardiopulmonary bypass, transesophageal echocardiography, pulmonary artery catheter, and elective cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Echocardiographic and hemodynamic data were collected at 2 time points: pre-CPB and post-chest closure/post-CPB. Patients with and without post-CPB RV dysfunction fractional area of change (<35%) were compared, and receiver operating characteristic curves were constructed. One hundred and nineteen patients undergoing elective surgery-coronary artery bypass grafting (23%), aortic valve replacement (21%), aortic surgery (19%), and combined surgery (37%)-were evaluated. Post-CPB RV dysfunction was associated with lower pre-CPB PAPi values (2.0 ± 1.0 v 2.5 ± 1.2; p = 0.001 and p = 0.03) and higher pre-CPB central venous pressure (8.3 ± 3.6 and 6.9 ± 2.7; p = 0.003 and p = 0.02, respectively). Pre-CPB PAPi (0.98 [95% confidence interval {CI} 0.96-0.99]), end systolic area (0.99 [95% CI 0.98-0.99]), and end diastolic area (1.01 [95% CI 1.001-1.02]) were independently associated with RV dysfunction in multivariable modeling, with a lower PAPi and end systolic area and higher end diastolic area demonstrating a greater risk of RV dysfunction post-CPB (post-CPB area under the curve for PAPi 0.80 [95% CI 0.71-0.88; sensitivity = 0.68, specificity = 0.93, optimal cutoff = 1.9]).

CONCLUSIONS

PAPi measured pre-CPB is a potential predictor and marker of post-CPB RV dysfunction and may have diagnostic utility in cardiac surgery. Additional, large-scale studies are needed to confirm this finding.

[Surgical Treatment of Ischemic Cardiomyopathy: Current State of the Problem]

In this article we present discussion of the current state of the problem of surgical treatment of ischemic cardiomyopathy (ICM). The pathophysiological aspects of left ventricular remodeling in patients with ICM are also covered. A detailed characterization of methods for assessing the myocardial viability is given and their role in patients with ICM is shown. The problem of right ventricular dysfunction in ICM is discussed. Main attention is focused on the methods of surgical treatment of ICM. Limitations of the Surgical Treatment for Ischemic Heart Failure (STICH) study are analyzed. The article is intended for cardiologists, general practitioners and cardiac surgeons.

Echocardiographic predictors of intraoperative right ventricular dysfunction: a 2D and speckle tracking echocardiography study

Background

Intraoperative or post procedure right ventricular (RV) dysfunction confers a poor prognosis in the post-operative period. Conventional predictors for RV function are limited due the effect of cardiac surgery on traditional RV indices; novel echocardiographic techniques hold the promise to improve RV functional stratification.

Methods

Comprehensive echocardiographic data were collected prospectively during elective cardiac surgery. Tricuspid annular plane systolic excursion (TAPSE), peak RV systolic velocity (S′), and RV fractional area change (FAC) were quantified on transesophageal echo (TEE). RV global and regional (septal and free wall) longitudinal strain was quantified using speckle-tracking echo in RV-focused views. Two intraoperative time points were used for comparison: pre-sternotomy (baseline) and after chest closure.

Results

The population was comprised of 53 patients undergoing cardiac surgery [15.1% coronary artery bypass graft (CABG) only, 28.3% valve only, 50.9% combination (e.g. valve/CABG, valve/aortic graft) surgeries], among whom 38% had impaired RV function at baseline defined as RV FAC < 35%. All conventional RV functional indices including TAPSE, S′ and FAC declined immediately following CPB (1.5 ± 0.3 vs.1.1 ± 0.3 cm, 8.0 ± 2.1 vs. 6.2 ± 2.5 cm/s, 36.8 ± 9.3 vs. 29.3 ± 10.6%; p < 0.001 for all). However, left ventricular (LV) and RV hemodynamic parameters remained unchanged (LV ejection fraction (EF): 56.8 ± 13.0 vs. 55.8 ± 12.9%; p = 0.40, pulmonary artery systolic pressure (PASP): 26.5 ± 7.4 vs 27.3 ± 6.7 mmHg; p = 0.13). Speckle tracking echocardiographic data demonstrated a significant decline in RV global longitudinal strain (GLS) [19.0 ± 6.5 vs. 13.5 ± 6.9%, p < 0.001]. Pre-procedure FAC, GLS and free wall strain predicted RV dysfunction at chest closure (34.7 ± 9.1 vs. 41.6 ± 8.1%, p = 0.01, 17.7 ± 6.5 vs. 21.8 ± 5.4%; p = 0.03, 20.3 ± 6.4 vs. 24.2 ± 5.8%; p = 0.04), whereas traditional linear RV indices such as TAPSE and RV S′ at baseline had no impact on intraoperative RV dysfunction (p = NS for both).

Conclusions

Global and regional RV function, as measured by 2D indices and strain, acutely decline intraoperatively. Impaired RV strain is associated with intraoperative RV functional decline and provides incremental value to traditional RV indices in predicting those who will develop RV dysfunction.

Impaired right ventricular ejection fraction after cardiac surgery is associated with a complicated ICU stay

Background

Right ventricular (RV) dysfunction is a known risk factor for increased mortality in cardiac surgery. However, the association between RV performance and ICU morbidity is largely unknown.

Methods

We performed a single-centre, retrospective study including cardiac surgery patients equipped with a pulmonary artery catheter, enabling continuous right ventricular ejection fraction (RVEF) measurements. Primary endpoint of our study was ICU morbidity (as determined by ICU length of stay, duration of mechanical ventilation, usage of inotropic drugs and fluids, and kidney dysfunction) in relation to RVEF. Patients were divided into three groups according to their RVEF; < 20%, 20-30%, and > 30%.

Results

We included 1109 patients. Patients with a RVEF < 20% had a significantly longer stay in ICU, a longer duration of mechanical ventilation, higher fluid balance, a higher incidence of inotropic drug usage, and more increase in postoperative creatinine levels in comparison to the other subgroups. In a multivariate analysis, RVEF was independently associated with increased ICU length of stay (OR 0.934 CI 0.908-0.961, p < 0.001), prolonged duration of mechanical ventilation (OR 0.969, CI 0.942-0.998, p = 0.033), usage of inotropic drugs (OR 0.944, CI 0.917-0.971, p < 0.001), and increase in creatinine (OR 0.962, CI 0.934-0.991, p = 0.011).

Conclusions

A decreased RVEF is independently associated with a complicated ICU stay.

Utility of Novel Cardiorenal Biomarkers in the Prediction and Early Detection of Congestive Kidney Injury Following Cardiac Surgery

Acute Kidney Injury (AKI) in the context of right ventricular failure (RVF) is thought to be largely congestive in nature. This study assessed the utility of biomarkers high sensitivity cardiac troponin T (hs-cTnT), N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and neutrophil gelatinase-associated lipocalin (NGAL) for prediction and early detection of congestive AKI (c-AKI) following cardiac surgery. This prospective nested case-control study recruited 350 consecutive patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. Cases were patients who developed (1) AKI (2) new or worsening RVF, or (3) c-AKI. Controls were patients free of these complications. Biomarker levels were measured at baseline after anesthesia induction and immediately postoperatively. Patients with c-AKI had increased mean duration of mechanical ventilation and length of stay in hospital and in the intensive care unit (p < 0.01). For prediction of c-AKI, baseline NT-proBNP yielded an area under the curve (AUC) of 0.74 (95% CI, 0.60–0.89). For early detection of c-AKI, postoperative NT-proBNP yielded an AUC of 0.78 (0.66–0.91), postoperative hs-cTnT yielded an AUC of 0.75 (0.58–0.92), and ∆hs-cTnT yielded an AUC of 0.80 (0.64–0.96). The addition of baseline creatinine to ∆hs-cTnT improved the AUC to 0.87 (0.76–0.99), and addition of diabetes improved the AUC to 0.93 (0.88–0.99). Δhs-cTnT alone, or in combination with baseline creatinine or diabetes, detects c-AKI with high accuracy following cardiac surgery.

Pre-operative right ventricular echocardiographic parameters associated with short-term outcomes and long-term mortality after CABG

Background This analysis aims to assess the prognostic value of pre-operative right ventricular echocardiographic parameters in predicting short-term adverse outcomes and long-term mortality after coronary artery bypass graft (CABG). Methods Study design: Observational retrospective cohort. Pre-operative echocardiographic data, perioperative adverse outcomes (POAO) and long-term mortality were retrospectively analyzed in 491 patients who underwent isolated CABG at a single academic center between 2006 and 2014. Results Average age of enrolled subjects was 66 ± 11.5 years with majority being male (69%). 227/491 patients had 30 days POAO (46%); most common being post-operative atrial fibrillation (27.3%) followed by prolonged ventilation duration (12.7%). On multivariate analysis, left atrial volume index ≥42 mL/m2 (LAVI) (OR (95% CI): 1.98 (1.03-3.82), P = 0.04), mitral E/A >2 (1.97 (1.02-3.78), P = 0.04), right atrial size >18 cm2 (1.86 (1.14-3.05), P = 0.01), tricuspid annular plane systolic excursion (TAPSE) <16 mm (1.8 (1.03-3.17), P = 0.04), right ventricular systolic pressure (RVSP) ≥36 mmHg (pulmonary hypertension) (1.6 (1.03-2.38), P = 0.04) and right ventricle myocardial performance index (RVMPI) >0.55 (1.58 (1.01-2.46), P = 0.04) were found to be associated with increased 30-day POAO. On 3.5-year follow-up, cumulative survival was decreased in patients with myocardial performance index (MPI) ≥0.55 (log rank: 4.5, P = 0.034) and in patients with mitral valve E/e' ≥14 (log rank: 4.9, P = 0.026). Conclusion Pre-operative right ventricle dysfunction (RVD) is associated with increased perioperative complications. Furthermore, pre-operative RVD and increased left atrial pressures are associated with long-term mortality post CABG.