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Hoang JD, van Weperen VYH, Kang KW, Jani NR, Swid MA, Chan CA, Lokhandwala ZA, Lux RL, Vaseghi M. Antiarrhythmic Mechanisms of Epidural Blockade After Myocardial Infarction. Circ Res 2024; 135:e57-e75. [PMID: 38939925 PMCID: PMC11257785 DOI: 10.1161/circresaha.123.324058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Thoracic epidural anesthesia (TEA) has been shown to reduce the burden of ventricular tachycardia in small case series of patients with refractory ventricular tachyarrhythmias and cardiomyopathy. However, its electrophysiological and autonomic effects in diseased hearts remain unclear, and its use after myocardial infarction is limited by concerns for potential right ventricular dysfunction. METHODS Myocardial infarction was created in Yorkshire pigs (N=22) by left anterior descending coronary artery occlusion. Approximately, six weeks after myocardial infarction, an epidural catheter was placed at the C7-T1 vertebral level for injection of 2% lidocaine. Right and left ventricular hemodynamics were recorded using Millar pressure-conductance catheters, and ventricular activation recovery intervals (ARIs), a surrogate of action potential durations, by a 56-electrode sock and 64-electrode basket catheter. Hemodynamics and ARIs, baroreflex sensitivity and intrinsic cardiac neural activity, and ventricular effective refractory periods and slope of restitution (Smax) were assessed before and after TEA. Ventricular tachyarrhythmia inducibility was assessed by programmed electrical stimulation. RESULTS TEA reduced inducibility of ventricular tachyarrhythmias by 70%. TEA did not affect right ventricular-systolic pressure or contractility, although left ventricular-systolic pressure and contractility decreased modestly. Global and regional ventricular ARIs increased, including in scar and border zone regions post-TEA. TEA reduced ARI dispersion specifically in border zone regions. Ventricular effective refractory periods prolonged significantly at critical sites of arrhythmogenesis, and Smax was reduced. Interestingly, TEA significantly improved cardiac vagal function, as measured by both baroreflex sensitivity and intrinsic cardiac neural activity. CONCLUSIONS TEA does not compromise right ventricular function in infarcted hearts. Its antiarrhythmic mechanisms are mediated by increases in ventricular effective refractory period and ARIs, decreases in Smax, and reductions in border zone electrophysiological heterogeneities. TEA improves parasympathetic function, which may independently underlie some of its observed antiarrhythmic mechanisms. This study provides novel insights into the antiarrhythmic mechanisms of TEA while highlighting its applicability to the clinical setting.
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Affiliation(s)
- Jonathan D Hoang
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
- UCLA Molecular Cellular and Integrative Physiology Interdepartmental Program, Los Angeles, CA
| | - Valerie YH van Weperen
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
| | - Ki-Woon Kang
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
| | - Neil R Jani
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
| | - Mohammed A Swid
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
| | - Christopher A Chan
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
| | - Zulfiqar Ali Lokhandwala
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
| | - Robert L Lux
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Marmar Vaseghi
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, CA
- Neurocardiology Research Center of Excellence, UCLA, Los Angeles, CA
- UCLA Molecular Cellular and Integrative Physiology Interdepartmental Program, Los Angeles, CA
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Meinert-Krause JP, Mechelinck M, Hein M, Habigt MA. Intrinsic mechanisms of right ventricular autoregulation. Sci Rep 2024; 14:9356. [PMID: 38654031 DOI: 10.1038/s41598-024-59787-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
To elucidate the adaptation of the right ventricle to acute and intermittently sustained afterload elevation, targeted preload reductions and afterload increases were implemented in a porcine model involving 12 pigs. Preload reduction was achieved via balloon occlusion of the inferior vena cava before, immediately and 5 min after acute afterload elevation induced by pulmonary artery occlusion or thromboxane A2 analog (U46619) infusion. Ventricular response was monitored by registration of pressure-volume (PV) loops using a conductance catheter. The end-systolic pressure-volume relationship (ESPVR) during pure preload reduction was adequately described by linear regression (mean and SEM slope of ESPVR (Ees) 0.414 ± 0.064 mmHg/ml), reflecting the classical Frank-Starling mechanism (FSM). The ESPVR during acute afterload elevation exhibited a biphasic trajectory with significantly distinct slopes (mean and SEM Ees bilin1: 1.256 ± 0.066 mmHg ml; Ees bilin2: 0.733 ± 0.063 mmHg ml, p < 0.001). The higher slope during the first phase in the absence of ventricular dilation could be explained by a reduced amount of shortening deactivation (SDA). The changes in PV-loops during the second phase were similar to those observed with a preload intervention. The persistent increase in afterload resulted in an increase in the slopes of ESPVR and preload recruitable stroke work (PRSW) with a slight decrease in filling state, indicating a relevant Anrep effect. This effect became more pronounced after 5 min or TXA infusion. This study demonstrates, for the first time, the relevance of intrinsic mechanisms of cardiac autoregulation in the right ventricle during the adaptation to load. The SDA, FSM, and Anrep effect could be differentiated and occurred successively, potentially with some overlap. Notably, the Anrep effect serves to prevent ventricular dilation.
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Affiliation(s)
- Jan-Pit Meinert-Krause
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Mare Mechelinck
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Marc Hein
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Moriz A Habigt
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
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Hoang JD, van Weperen VY, Kang KW, Jani NR, Swid MA, Chan CA, Lokhandwala ZA, Lux RL, Vaseghi M. Thoracic epidural blockade after myocardial infarction benefits from anti-arrhythmic pathways mediated in part by parasympathetic modulation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.14.585127. [PMID: 38559001 PMCID: PMC10980055 DOI: 10.1101/2024.03.14.585127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Thoracic epidural anesthesia (TEA) has been shown to reduce the burden of ventricular tachyarrhythmias (VT) in small case-series of patients with refractory VT and cardiomyopathy. However, its electrophysiological and autonomic effects in diseased hearts remain unclear and its use after myocardial infarction (MI) is limited by concerns for potential RV dysfunction. Methods MI was created in Yorkshire pigs ( N =22) by LAD occlusion. Six weeks post-MI, an epidural catheter was placed at the C7-T1 vertebral level for injection of 2% lidocaine. RV and LV hemodynamics were recorded using Millar pressure-conductance catheters, and ventricular activation-recovery intervals (ARIs), a surrogate of action potential durations, by a 56-electrode sock and 64-electrode basket catheter. Hemodynamics and ARIs, baroreflex sensitivity (BRS) and intrinsic cardiac neural activity, and ventricular effective refractory periods (ERP) and slope of restitution (S max ) were assessed before and after TEA. VT/VF inducibility was assessed by programmed electrical stimulation. Results TEA reduced inducibility of VT/VF by 70%. TEA did not affect RV-systolic pressure or contractility, although LV-systolic pressure and contractility decreased modestly. Global and regional ventricular ARIs increased, including in scar and border zone regions post-TEA. TEA reduced ARI dispersion specifically in border zone regions. Ventricular ERPs prolonged significantly at critical sites of arrhythmogenesis, and S max was reduced. Interestingly, TEA significantly improved cardiac vagal function, as measured by both BRS and intrinsic cardiac neural activity. Conclusion TEA does not compromise RV function in infarcted hearts. Its anti-arrhythmic mechanisms are mediated by increases in ventricular ERP and ARIs, decreases in S max , and reductions in border zone heterogeneity. TEA improves parasympathetic function, which may independently underlie some of its observed anti-arrhythmic mechanisms. This study provides novel insights into the anti-arrhythmic mechanisms of TEA, while highlighting its applicability to the clinical setting. Abstract Illustration Myocardial infarction is known to cause cardiac autonomic dysfunction characterized by sympathoexcitation coupled with reduced vagal tone. This pathological remodeling collectively predisposes to ventricular arrhythmia. Thoracic epidural anesthesia not only blocks central efferent sympathetic outflow, but by also blocking ascending projections of sympathetic afferents, relieving central inhibition of vagal function. These complementary autonomic effects of thoracic epidural anesthesia may thus restore autonomic balance, thereby improving ventricular electrical stability and suppressing arrhythmogenesis. DRG=dorsal root ganglion, SG=stellate ganglion.
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Zochios V, Shelley B, Antonini MV, Chawla S, Sato R, Dugar S, Valchanov K, Roscoe A, Scott J, Bangash MN, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Yusuff H. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 1. J Cardiothorac Vasc Anesth 2023; 37:2073-2086. [PMID: 37393133 DOI: 10.1053/j.jvca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Center, Singapore
| | - Jeffrey Scott
- Jackson Health System, Miami Transplant Institute, Miami, FL
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
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Giustiniano E, Nisi F, Piccioni F, Gambino F, Aceto R, Lungu R, Carrara A, Neganov M, Cecconi M. Right Ventricle Response to Major Lung Resection (the RIVER Study). J Cardiovasc Echogr 2023; 33:76-82. [PMID: 37772049 PMCID: PMC10529292 DOI: 10.4103/jcecho.jcecho_17_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/13/2023] [Accepted: 05/21/2023] [Indexed: 09/30/2023] Open
Abstract
Backgrounds Major lung resection is associated with high postoperative morbidity and mortality, especially due to cardiorespiratory complications. Right ventricle (RV) ejection, pulmonary artery (PA) pressure, and tone are tightly coupled. Since the RV is exquisitely sensitive to changes in afterload, an acute increase in RV outflow resistance (i.e., acute pulmonary embolism [PE]) will cause acute RV dilatation and, a reduction of left ventricle compliance too, rapidly spiraling to acute cardiogenic shock and death. We investigated the changing in RV performance after major lung resection. Materials and Methods We carried out transthoracic echocardiography (TTE) aiming at searching for the incidence of early RV systolic dysfunction (defined as tricuspid annulus plane systolic excursion [TAPSE] <17 cm, S'-tissue Doppler imaging <10 cm/s) and estimate the RV-PA coupling by the TAPSE/pulmonary artery pressures (PAPs) ratio after major lung resection. The TTE has been performed before and immediately after surgery. Results After the end of the operation the echocardiographic parameters of the RV function worsened. TAPSE decreased from 24 (21 ÷ 28) to 18 (16 ÷ 22) mm (P = 0.015) and PAPs increased from 26 (25 ÷ 30) to 30 (25 ÷ 39) mmHg (P = 0.013). TAPSE/PAPs ratio decreased from 0.85 (0.80 ÷ 0.90) to 0.64 (0.54 ÷ 0.79) mm/mmHg (P = 0.002). Conclusions In line with previous reports, after major lung resection the increase in afterload reduces the RV function, but the impairment remains clinically not relevant. The different clinical picture of an acute cor pulmonale due to PE implies that the pathogenesis of cardiac failure involves more pathways than the mere mechanic occlusion of the blood flow.
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Fulvio Nisi
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Federico Piccioni
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Francesco Gambino
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Romina Aceto
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Ramona Lungu
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Alfonso Carrara
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Maxim Neganov
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Shelley B, Glass A, Keast T, McErlane J, Hughes C, Lafferty B, Marczin N, McCall P. Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery: a narrative review. Br J Anaesth 2023; 130:e66-e79. [PMID: 35973839 PMCID: PMC9875905 DOI: 10.1016/j.bja.2022.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/15/2022] [Accepted: 06/25/2022] [Indexed: 01/28/2023] Open
Abstract
Although thoracic surgery is understood to confer a high risk of postoperative respiratory complications, the substantial haemodynamic challenges posed are less well appreciated. This review highlights the influence of cardiovascular comorbidity on outcome, reviews the complex pathophysiological changes inherent in one-lung ventilation and lung resection, and examines their influence on cardiovascular complications and postoperative functional limitation. There is now good evidence for the presence of right ventricular dysfunction postoperatively, a finding that persists to at least 3 months. This dysfunction results from increased right ventricular afterload occurring both intraoperatively and persisting postoperatively. Although many patients adapt well, those with reduced right ventricular contractile reserve and reduced pulmonary vascular flow reserve might struggle. Postoperative right ventricular dysfunction has been implicated in the aetiology of postoperative atrial fibrillation and perioperative myocardial injury, both common cardiovascular complications which are increasingly being appreciated to have impact long into the postoperative period. In response to the physiological demands of critical illness or exercise, contractile reserve, flow reserve, or both can be overwhelmed resulting in acute decompensation or impaired long-term functional capacity. Aiding adaptation to the unique perioperative physiology seen in patients undergoing thoracic surgery could provide a novel therapeutic avenue to prevent cardiovascular complications and improve long-term functional capacity after surgery.
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Affiliation(s)
- Ben Shelley
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Glasgow, Scotland, UK; Anaesthesia, Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, Scotland, UK.
| | - Adam Glass
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Glasgow, Scotland, UK; School of Anaesthesia, Northern Ireland Medical and Dental Training Agency, Belfast, Northern Ireland, UK
| | - Thomas Keast
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Glasgow, Scotland, UK; Anaesthesia, Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, Scotland, UK
| | - James McErlane
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Glasgow, Scotland, UK; Anaesthesia, Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, Scotland, UK
| | - Cara Hughes
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Glasgow, Scotland, UK; Anaesthesia, Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, Scotland, UK
| | - Brian Lafferty
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Glasgow, Scotland, UK; Anaesthesia, Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, Scotland, UK
| | - Nandor Marczin
- Division of Anaesthesia Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK; Department of Anaesthesia and Critical Care, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK; Department of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
| | - Philip McCall
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Glasgow, Scotland, UK; Anaesthesia, Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, Scotland, UK
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Glass A, McCall P, Arthur A, Mangion K, Shelley B. Pulmonary artery wave reflection and right ventricular function after lung resection. Br J Anaesth 2023; 130:e128-e136. [PMID: 36115714 PMCID: PMC9875909 DOI: 10.1016/j.bja.2022.07.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/02/2022] [Accepted: 07/26/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Lung resection has been shown to impair right ventricular function. Although conventional measures of afterload do not change, surgical ligation of a pulmonary artery branch, as occurs during lobectomy, can create a unilateral proximal reflection site, increasing wave reflection (pulsatile component of afterload) and diverting blood flow through the contralateral pulmonary artery. We present a cardiovascular magnetic resonance imaging (MRI) observational cohort study of changes in wave reflection and right ventricular function after lung resection. METHODS Twenty-seven patients scheduled for open lobectomy for suspected lung cancer underwent cardiovascular MRI preoperatively, on postoperative Day 2, and at 2 months. Wave reflection was assessed in the left and right pulmonary arteries (operative and non-operative, as appropriate) by wave intensity analysis and calculation of wave reflection index. Pulmonary artery blood flow distribution was calculated as percentage of total blood flow travelling in the non-operative pulmonary artery. Right ventricular function was assessed by ejection fraction and strain analysis. RESULTS Operative pulmonary artery wave reflection increased from 4.3 (2.1-8.8) % preoperatively to 9.5 (4.9-14.9) % on postoperative Day 2 and 8.0 (2.3-11.7) % at 2 months (P<0.001) with an associated redistribution of blood flow towards the nonoperative pulmonary artery (r>0.523; P<0.010). On postoperative Day 2, impaired right ventricular ejection fraction was associated with increased operative pulmonary artery wave reflection (r=-0.480; P=0.028) and pulmonary artery blood flow redistribution (r=-0.545; P=0.011). At 2 months, impaired right ventricular ejection fraction and right ventricular strain were associated with pulmonary artery blood flow redistribution (r=-0.634, P=0.002; r=0.540, P=0.017). CONCLUSIONS Pulsatile afterload increased after lung resection. The unilateral increase in operative pulmonary artery wave reflection resulted in redistribution of blood flow through the nonoperative pulmonary artery and was associated with right ventricular dysfunction. CLINICAL TRIAL REGISTRATION NCT01892800.
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Affiliation(s)
- Adam Glass
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK,School of Anaesthesia, Northern Ireland Medical and Dental Training Agency, Belfast, UK,Corresponding author.
| | - Philip McCall
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK,Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK
| | - Alex Arthur
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Kenneth Mangion
- British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Ben Shelley
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK,Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK
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Thalji NK, Patel SJ, Augoustides JG, Schiller RJ, Dalia AA, Low Y, Hamzi RI, Fernando RJ. Opioid-Free Cardiac Surgery: A Multimodal Pain Management Strategy With a Focus on Bilateral Erector Spinae Plane Block Catheters. J Cardiothorac Vasc Anesth 2022; 36:4523-4533. [PMID: 36184473 PMCID: PMC9745636 DOI: 10.1053/j.jvca.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Nabil K Thalji
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Jayant Patel
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin J Schiller
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Yinghui Low
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Rawad I Hamzi
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Management, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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Zhang A, De Gala V, Lementowski PW, Cvetkovic D, Xu JL, Villion A. Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review. Cureus 2022; 14:e28234. [PMID: 36158355 PMCID: PMC9488858 DOI: 10.7759/cureus.28234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 12/01/2022] Open
Abstract
Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.
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van Weperen VYH, Vos MA, Ajijola OA. Autonomic modulation of ventricular electrical activity: recent developments and clinical implications. Clin Auton Res 2021; 31:659-676. [PMID: 34591191 PMCID: PMC8629778 DOI: 10.1007/s10286-021-00823-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE This review aimed to provide a complete overview of the current stance and recent developments in antiarrhythmic neuromodulatory interventions, focusing on lifethreatening vetricular arrhythmias. METHODS Both preclinical studies and clinical studies were assessed to highlight the gaps in knowledge that remain to be answered and the necessary steps required to properly translate these strategies to the clinical setting. RESULTS Cardiac autonomic imbalance, characterized by chronic sympathoexcitation and parasympathetic withdrawal, destabilizes cardiac electrophysiology and promotes ventricular arrhythmogenesis. Therefore, neuromodulatory interventions that target the sympatho-vagal imbalance have emerged as promising antiarrhythmic strategies. These strategies are aimed at different parts of the cardiac neuraxis and directly or indirectly restore cardiac autonomic tone. These interventions include pharmacological blockade of sympathetic neurotransmitters and neuropeptides, cardiac sympathetic denervation, thoracic epidural anesthesia, and spinal cord and vagal nerve stimulation. CONCLUSION Neuromodulatory strategies have repeatedly been demonstrated to be highly effective and very promising anti-arrhythmic therapies. Nevertheless, there is still much room to gain in our understanding of neurocardiac physiology, refining the current neuromodulatory strategic options and elucidating the chronic effects of many of these strategic options.
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Affiliation(s)
- Valerie Y H van Weperen
- Department of Medical Physiology, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Center, UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, University of California, 100 Medical Plaza, Suite 660, Westwood Blvd, Los Angeles, CA, 90095-1679, USA
| | - Marc A Vos
- Department of Medical Physiology, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Center, UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, University of California, 100 Medical Plaza, Suite 660, Westwood Blvd, Los Angeles, CA, 90095-1679, USA.
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11
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Ren X, Liu S, Lian C, Li H, Li K, Li L, Zhao G. Dysfunction of the Glymphatic System as a Potential Mechanism of Perioperative Neurocognitive Disorders. Front Aging Neurosci 2021; 13:659457. [PMID: 34163349 PMCID: PMC8215113 DOI: 10.3389/fnagi.2021.659457] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
Perioperative neurocognitive disorder (PND) frequently occurs in the elderly as a severe postoperative complication and is characterized by a decline in cognitive function that impairs memory, attention, and other cognitive domains. Currently, the exact pathogenic mechanism of PND is multifaceted and remains unclear. The glymphatic system is a newly discovered glial-dependent perivascular network that subserves a pseudo-lymphatic function in the brain. Recent studies have highlighted the significant role of the glymphatic system in the removal of harmful metabolites in the brain. Dysfunction of the glymphatic system can reduce metabolic waste removal, leading to neuroinflammation and neurological disorders. We speculate that there is a causal relationship between the glymphatic system and symptomatic progression in PND. This paper reviews the current literature on the glymphatic system and some perioperative factors to discuss the role of the glymphatic system in PND.
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Affiliation(s)
- Xuli Ren
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shan Liu
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Chuang Lian
- Department of Anaesthesiology, Jilin City People's Hospital, Jilin, China
| | - Haixia Li
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Kai Li
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Longyun Li
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Guoqing Zhao
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China.,Jilin University, Changchun, China
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Wink J, Steendijk P, Tsonaka R, de Wilde RBP, Friedericy HJ, Braun J, Veering BT, Aarts LPHJ, Wouters PF. Biventricular function in exercise during autonomic (thoracic epidural) block. Eur J Appl Physiol 2021; 121:1405-1418. [PMID: 33615388 PMCID: PMC8064994 DOI: 10.1007/s00421-021-04631-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 02/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blockade of cardiac sympathetic fibers by thoracic epidural anesthesia (TEA) was previously shown to reduce right and left ventricular systolic function and effective pulmonary arterial elastance. At conditions of constant paced heart rate, cardiac output and systemic hemodynamics were unchanged. In this study, we further investigated the effect of cardiac sympathicolysis during physical stress and increased oxygen demand. METHODS In a cross-over design, 12 patients scheduled to undergo thoracic surgery performed dynamic ergometric exercise tests with and without TEA. Hemodynamics were monitored and biventricular function was measured by transthoracic two-dimensional and M-mode echocardiography, pulsed wave Doppler and tissue Doppler imaging. RESULTS TEA attenuated systolic RV function (TV S': - 21%, P < 0.001) and LV function (MV S': - 14%, P = 0.025), but biventricular diastolic function was not affected. HR (- 11%, P < 0.001), SVI (- 15%, P = 0.006), CI (- 21%, P < 0.001) and MAP (- 12%, P < 0.001) were decreased during TEA, but SVR was not affected. Exercise resulted in significant augmentation of systolic and diastolic biventricular function. During exercise HR, SVI, CI and MAP increased (respectively, + 86%, + 19%, + 124% and + 17%, all P < 0.001), whereas SVR decreased (- 49%, P < 0.001). No significant interactions between exercise and TEA were found, except for RPP (P = 0.024) and MV E DT (P = 0.035). CONCLUSION Cardiac sympathetic blockade by TEA reduced LV and RV systolic function but did not significantly blunt exercise-induced increases in LV and RV function. These data indicate that additional mechanisms besides those controlled by the cardiac sympathetic nervous system are involved in the regulation of cardiac function during dynamic exercise. Trial registration Clinical trial registration: Nederlands Trial Register, NTR 4880 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4880 .
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Affiliation(s)
- Jeroen Wink
- Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Paul Steendijk
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Roula Tsonaka
- Department of Biomedical Data Sciences, Medical Statistics Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob B P de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans J Friedericy
- Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Jerry Braun
- Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bernadette Th Veering
- Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Leon P H J Aarts
- Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Patrick F Wouters
- Department of Anesthesia, University Hospitals Ghent, Ghent, Belgium
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13
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Price LC, Martinez G, Brame A, Pickworth T, Samaranayake C, Alexander D, Garfield B, Aw TC, McCabe C, Mukherjee B, Harries C, Kempny A, Gatzoulis M, Marino P, Kiely DG, Condliffe R, Howard L, Davies R, Coghlan G, Schreiber BE, Lordan J, Taboada D, Gaine S, Johnson M, Church C, Kemp SV, Wong D, Curry A, Levett D, Price S, Ledot S, Reed A, Dimopoulos K, Wort SJ. Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. Br J Anaesth 2021; 126:774-790. [PMID: 33612249 DOI: 10.1016/j.bja.2021.01.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death. METHODS A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research. RESULTS Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning. CONCLUSIONS With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.
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Affiliation(s)
- Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Guillermo Martinez
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Aimee Brame
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | | | | | - David Alexander
- Department of Anaesthesia, Royal Brompton Hospital, London, UK
| | - Benjamin Garfield
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Tuan-Chen Aw
- Department of Anaesthesia, Royal Brompton Hospital, London, UK
| | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Bhashkar Mukherjee
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - Carl Harries
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
| | - Aleksander Kempny
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael Gatzoulis
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Philip Marino
- Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - David G Kiely
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Rachel Davies
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Gerry Coghlan
- National Pulmonary Hypertension Service, Royal Free Hospital, London, UK
| | | | - James Lordan
- National Pulmonary Hypertension Service, Freeman Hospital, Newcastle upon Tyne, UK
| | - Dolores Taboada
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK
| | - Colin Church
- Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK
| | - Samuel V Kemp
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Davina Wong
- Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - Andrew Curry
- Cardiothoracic Anaesthesia, University Hospital Southampton, Southampton, Hampshire, UK
| | - Denny Levett
- Anaesthesia and Critical Care Research Area, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Anna Reed
- National Heart and Lung Institute, Imperial College London, London, UK; Respiratory and Lung Transplantation, Harefield Hospital, Uxbridge, UK
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephen John Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
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Lakatos BK, Nabeshima Y, Tokodi M, Nagata Y, Tősér Z, Otani K, Kitano T, Fábián A, Ujvári A, Boros AM, Merkely B, Kovács A, Takeuchi M. Importance of Nonlongitudinal Motion Components in Right Ventricular Function: Three-Dimensional Echocardiographic Study in Healthy Volunteers. J Am Soc Echocardiogr 2020; 33:995-1005.e1. [PMID: 32620323 DOI: 10.1016/j.echo.2020.04.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Global right ventricular (RV) function is determined by the interplay of different motion components related to the myofiber architecture, and the relative importance of these components is still not thoroughly characterized. The aims of this study were to quantify the relative contributions of longitudinal, radial, and anteroposterior motion components to global RV function and to examine their determining factors in a large cohort of healthy volunteers using three-dimensional echocardiography. METHODS Three hundred healthy adults with a balanced age range and an equal sex distribution were investigated at two centers. A three-dimensional mesh model of the right ventricle was generated, and its motion was decomposed along the three anatomically relevant axes. Multiplicative relative contributions were measured by dividing the ejection fraction (EF) values generated by shortening in the longitudinal, radial, and anteroposterior directions by global RV EF (longitudinal EF index [LEFi], radial EF index [REFi], and anteroposterior EF index, respectively). The circumferential contribution was defined as shortening in the radial and anteroposterior directions, omitting only longitudinal shortening. RESULTS Circumferential EF index was markedly higher compared with LEFi (79 ± 7% vs 47 ± 9%, P < .001). LEFi (47 ± 9%) and anteroposterior EF index (49 ± 7%) were found to be similar in the pooled population, whereas REFi (44 ± 10%) was lower (P < .001). In younger individuals (20-39 years of age), the relative contribution of longitudinal shortening was significantly higher compared with the radial component; however, in the older age groups, LEFi and REFi were comparable. Age, body surface area, heart rate, and RV end-diastolic volume were independent predictors of LEFi and REFi, but all with opposite effects on the two motion directions. CONCLUSIONS In contrast to the traditional viewpoint, the contributions of the radial and anteroposterior motion directions may be of comparable significance with that of longitudinal shortening in determining global RV function. Standard parameters referring only to longitudinal shortening of the right ventricle may be inadequate to characterize RV function thoroughly.
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Affiliation(s)
| | - Yosuke Nabeshima
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Márton Tokodi
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Yasufumi Nagata
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | | | - Kyoko Otani
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Tetsuji Kitano
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Alexandra Fábián
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Adrienn Ujvári
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | | | - Béla Merkely
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Attila Kovács
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary.
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
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16
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Tello K, Seeger W, Naeije R, Vanderpool R, Ghofrani HA, Richter M, Tedford RJ, Bogaard HJ. Right heart failure in pulmonary hypertension: Diagnosis and new perspectives on vascular and direct right ventricular treatment. Br J Pharmacol 2019; 178:90-107. [PMID: 31517994 DOI: 10.1111/bph.14866] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/15/2019] [Accepted: 09/04/2019] [Indexed: 12/18/2022] Open
Abstract
Adaptation of right ventricular (RV) function to increased afterload-known as RV-arterial coupling-is a key determinant of prognosis in pulmonary hypertension. However, measurement of RV-arterial coupling is a complex, invasive process involving analysis of the RV pressure-volume relationship during preload reduction over multiple cardiac cycles. Simplified methods have therefore been proposed, including echocardiographic and cardiac MRI approaches. This review describes the available methods for assessment of RV function and RV-arterial coupling and the effects of pharmacotherapy on these variables. Overall, pharmacotherapies for pulmonary hypertension have shown beneficial effects on various measures of RV function, but it is often unclear if these are direct RV effects or indirect results of afterload reduction. Studies of the effects of pharmacotherapies on RV-arterial coupling are limited and mostly restricted to experimental models. Simplified methods to assess RV-arterial coupling should be validated and incorporated into routine clinical follow-up and future clinical trials. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.
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Affiliation(s)
- Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Robert Naeije
- Physiology, Erasme University Hospital, Brussels, Belgium
| | | | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Harm J Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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17
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Nagel C, Marra AM, Benjamin N, Blank N, Cittadini A, Coghlan G, Distler O, Denton CP, Egenlauf B, Fiehn C, Fischer C, Harutyunova S, Hoeper MM, Lorenz HM, Xanthouli P, Bossone E, Grünig E. Reduced Right Ventricular Output Reserve in Patients With Systemic Sclerosis and Mildly Elevated Pulmonary Artery Pressure. Arthritis Rheumatol 2019; 71:805-816. [PMID: 30615302 DOI: 10.1002/art.40814] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This prospective study was undertaken to evaluate right ventricular function and pulmonary arterial compliance (PAC; ratio of stroke volume to pulse pressure) at rest and during exercise in patients with systemic sclerosis (SSc) with normal mean pulmonary artery pressure (PAP), patients with SSc with mildly elevated mean PAP, and patients with SSc with manifest pulmonary hypertension (PH). METHODS Patients with SSc (n = 112) underwent clinical assessment and right-sided heart catheterization at rest and during exercise and were divided into 3 groups according to their resting mean PAP values: normal mean PAP (≤20 mm Hg), mildly elevated mean PAP (21-24 mm Hg), and PH (mean PAP ≥25 mm Hg). Results were compared between groups by analysis of variance followed by post hoc Student's t-test. RESULTS Compared to patients with normal mean PAP, patients with mildly elevated mean PAP had a lower 6-minute walking distance (P = 0.008), lower cardiac index (P = 0.027) and higher pulmonary vascular resistance (P = 0.0002) during exercise, and lower PAC at rest (P = 0.016) and different stages of exercise (P = 0.033 for 25W and P = 0.024 for 75W). CONCLUSION The results of this study suggest that impaired 6-minute walking distance in SSc patients with mildly elevated mean PAP might be caused by reduced PAC during exercise and reduced right ventricular output reserve, presumably due to impaired coupling between the right ventricle and the pulmonary vasculature. These findings provide further evidence of the clinical relevance of mildly elevated mean PAP in patients with SSc.
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Affiliation(s)
- Christian Nagel
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany, and Klinikum Mittelbaden Baden-Baden Balg, Baden-Baden, Germany
| | - Alberto M Marra
- SDN Scientific Institute for Research and Healthcare, Naples, Italy
| | - Nicola Benjamin
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | | | | | | | - Benjamin Egenlauf
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Satenik Harutyunova
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Panagiota Xanthouli
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | - Ekkehard Grünig
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
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18
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Effects of Thoracic Epidural Anesthesia on Neuronal Cardiac Regulation and Cardiac Function. Anesthesiology 2019; 130:472-491. [DOI: 10.1097/aln.0000000000002558] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Cardiac sympathetic blockade with high-thoracic epidural anesthesia is considered beneficial in patients undergoing major surgery because it offers protection in ischemic heart disease. Major outcome studies have failed to confirm such a benefit, however. In fact, there is growing concern about potential harm associated with the use of thoracic epidural anesthesia in high-risk patients, although underlying mechanisms have not been identified. Since the latest review on this subject, a number of clinical and experimental studies have provided new information on the complex interaction between thoracic epidural anesthesia–induced sympatholysis and cardiovascular control mechanisms. Perhaps these new insights may help identify conditions in which benefits of thoracic epidural anesthesia may not outweigh potential risks. For example, cardiac sympathectomy with high-thoracic epidural anesthesia decreases right ventricular function and attenuates its capacity to cope with increased right ventricular afterload. Although the clinical significance of this pathophysiologic interaction is unknown at present, it identifies a subgroup of patients with established or pending pulmonary hypertension for whom outcome studies are needed. Other new areas of interest include the impact of thoracic epidural anesthesia–induced sympatholysis on cardiovascular control in conditions associated with increased sympathetic tone, surgical stress, and hemodynamic disruption. It was considered appropriate to collect and analyze all recent scientific information on this subject to provide a comprehensive update on the cardiovascular effects of high-thoracic epidural anesthesia and cardiac sympathectomy in healthy and diseased patients.
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Aguirre MA, Lynch I, Hardman B. Perioperative Management of Pulmonary Hypertension and Right Ventricular Failure During Noncardiac Surgery. Adv Anesth 2018; 36:201-230. [PMID: 30414638 DOI: 10.1016/j.aan.2018.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Marco A Aguirre
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-7208, USA.
| | - Isaac Lynch
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-7208, USA
| | - Bailor Hardman
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-7208, USA
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Rana M, Yusuff H, Zochios V. The Right Ventricle During Selective Lung Ventilation for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018; 33:2007-2016. [PMID: 30595486 DOI: 10.1053/j.jvca.2018.11.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Indexed: 12/25/2022]
Abstract
The right ventricle (RV) has been an area of evolving interest after decades of being ignored and considered less important than the left ventricle. Right ventricular dysfunction/failure is an independent predictor of mortality and morbidity in cardiac surgery; however, very little is known about the incidence or impact of RV dysfunction/failure in thoracic surgery. The pathophysiology of RV dysfunction/failure has been studied in the context of acute respiratory distress syndrome (ARDS), cardiac surgery, pulmonary hypertension, and left ventricular failure, but limited data exist in literature addressing the issue of RV dysfunction/failure in the context of thoracic surgery and one-lung ventilation (OLV). Thoracic surgery and OLV present as a unique situation where the RV is faced with sudden changes in afterload, preload, and contractility throughout the perioperative period. The authors discuss the possible pathophysiologic mechanisms that can affect adversely the RV during OLV and introduce the term RV injury to the myocardium that is affected adversely by the various intraoperative factors, which then makes it predisposed to acute dysfunction. The most important of these mechanisms seems to be the role of intraoperative mechanical ventilation, which potentially could cause both ventilator-induced lung injury leading to ARDS and RV injury. Identification of at-risk patients in the perioperative period using focused imaging, particularly echocardiography, is paramount. The authors also discuss the various RV-protective strategies required to prevent RV dysfunction and management of established RV failure.
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Affiliation(s)
- Meenal Rana
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
| | - Hakeem Yusuff
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK.
| | - Vasileios Zochios
- University Hospitals Birmingham National Health Service Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
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Lakatos BK, Tokodi M, Assabiny A, Tősér Z, Kosztin A, Doronina A, Rácz K, Koritsánszky KB, Berzsenyi V, Németh E, Sax B, Kovács A, Merkely B. Dominance of free wall radial motion in global right ventricular function of heart transplant recipients. Clin Transplant 2018; 32:e13192. [PMID: 29315873 DOI: 10.1111/ctr.13192] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2018] [Indexed: 12/28/2022]
Abstract
Assessment of right ventricular (RV) function using conventional echocardiography might be inadequate as the radial motion of the RV free wall is often neglected. Our aim was to quantify the longitudinal and the radial components of RV function using three-dimensional (3D) echocardiography in heart transplant (HTX) recipients. Fifty-one HTX patients in stable cardiovascular condition without history of relevant rejection episode or chronic allograft vasculopathy and 30 healthy volunteers were enrolled. RV end-diastolic (EDV) volume and total ejection fraction (TEF) were measured by 3D echocardiography. Furthermore, we quantified longitudinal (LEF) and radial ejection fraction (REF) by decomposing the motion of the RV using the ReVISION method. RV EDV did not differ between groups (HTX vs control; 96 ± 27 vs 97 ± 2 mL). In HTX patients, TEF was lower, however, tricuspid annular plane systolic excursion (TAPSE) decreased to a greater extent (TEF: 47 ± 7 vs 54 ± 4% [-13%], TAPSE: 11 ± 5 vs 21 ± 4 mm [-48%], P < .0001). In HTX patients, REF/TEF ratio was significantly higher compared to LEF/TEF (REF/TEF vs LEF/TEF: 0.58 ± 0.10 vs 0.27 ± 0.08, P < .0001), while in controls the REF/TEF and LEF/TEF ratio was similar (0.45 ± 0.07 vs 0.47 ± 0.07). Current results confirm the superiority of radial motion in determining RV function in HTX patients. Parameters incorporating the radial motion are recommended to assess RV function in HTX recipients.
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Affiliation(s)
| | - Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Kristóf Rácz
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | | | - Viktor Berzsenyi
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Endre Németh
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Balázs Sax
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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