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Ortoleva J, Dalia AA, Pisano DV, Shapeton A. Diagnosis and Management of Vasoplegia in Temporary Mechanical Circulatory Support: A Narrative Review. J Cardiothorac Vasc Anesth 2024; 38:1378-1389. [PMID: 38490900 DOI: 10.1053/j.jvca.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/10/2024] [Accepted: 02/18/2024] [Indexed: 03/17/2024]
Abstract
Refractory vasodilatory shock, or vasoplegia, is a pathophysiologic state observed in the intensive care unit and operating room in patients with a variety of primary diagnoses. Definitions of vasoplegia vary by source but are qualitatively defined clinically as a normal or high cardiac index and low systemic vascular resistance causing hypotension despite high-dose vasopressors in the setting of euvolemia. This definition can be difficult to apply to patients undergoing mechanical circulatory support (MCS). A large body of mostly retrospective literature exists on vasoplegia in the non-MCS population, but the increased use of temporary MCS justifies an examination of vasoplegia in this population. MCS, particularly extracorporeal membrane oxygenation, adds complexity to the diagnosis and management of vasoplegia due to challenges in determining cardiac output (or total blood flow), lack of clarity on appropriate dosing of noncatecholamine interventions, increased thrombosis risk, the difficulty in determining the endpoints of adequate volume resuscitation, and the unclear effects of rescue agents (methylene blue, hydroxocobalamin, and angiotensin II) on MCS device monitoring and function. Care teams must combine data from invasive and noninvasive sources to diagnose vasoplegia in this population. In this narrative review, the available literature is surveyed to provide guidance on the diagnosis and management of vasoplegia in the temporary MCS population, with a focus on noncatecholamine treatments and special considerations for patients supported by extracorporeal membrane oxygenation, transvalvular heart pumps, and other ventricular assist devices.
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Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA.
| | - Adam A Dalia
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Alexander Shapeton
- Veterans Affairs Boston Healthcare System, Department of Anesthesia, Critical Care and Pain Medicine, and Tufts University School of Medicine, Boston, MA
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Heimansohn DA, Baker C, Rodriguez E, Takayama H, Dagenais F, Talton DS, Mumtaz MA, Pibarot P, Puskas JD. Mid-term outcomes of the COMMENCE trial investigating mitral valve replacement using a bioprosthesis with a novel tissue. JTCVS OPEN 2023; 15:151-163. [PMID: 37808026 PMCID: PMC10556809 DOI: 10.1016/j.xjon.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/02/2023] [Accepted: 05/17/2023] [Indexed: 10/10/2023]
Abstract
Objective Novel tissue leaflets (RESILIA tissue) may improve durability of bioprosthetic heart valves. The COMMENCE trial is an ongoing prospective study to evaluate valve replacement using RESILIA tissue. This report describes mid-term outcomes in the mitral cohort of COMMENCE. Methods Adult patients requiring mitral valve replacement were enrolled in a prospective, single-arm trial at 17 sites in the United States and Canada. An independent clinical events committee adjudicated safety events using definitions from established guidelines, and hemodynamic performance was evaluated by an independent echocardiographic core laboratory. Results Eighty-two patients (median age 70 years) successfully underwent mitral valve replacement with the study valve. Five-year event-free probabilities for all-cause mortality, structural valve deterioration, and reoperation were 79.9%, 98.7%, and 97.1%, respectively. Hemodynamic valve function measurements were stable through the 5-year follow-up period; valvular leaks were infrequently observed and primarily clinically insignificant/mild. Conclusions Mitral valve replacement patients implanted with a RESILIA tissue bioprosthesis had a good safety profile and clinically stable hemodynamic performance.
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Affiliation(s)
| | - Craig Baker
- Depertament of Cardiothoracic Surgery, Cardiovascular Thoracic Institute, University of Southern California, Los Angeles, Calif
| | | | - Hiroo Takayama
- Columbia University Irving Medical Center, New York Presbyterian Hospital, Division of Cardiothoracic and Vascular Surgery, New York, NY
| | | | - David S. Talton
- Institut Universitaire de Cardiology et Pneumologie de Quebec, Quebec, Canada
| | - Mubashir A. Mumtaz
- Department of Cardiovascular and Thoracic Surgery, UPMC Central Pennsylvania, Harrisburg, Pa
| | - Philippe Pibarot
- Department of Cardiology, Québec Heart and Lung Institute, Laval University, Quebec, Canada
| | - John D. Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY
| | - COMMENCE Trial Investigators
- St Vincent The Heart Center of Indiana, Indianapolis, Ind
- Depertament of Cardiothoracic Surgery, Cardiovascular Thoracic Institute, University of Southern California, Los Angeles, Calif
- Ascension Saint Thomas Heart, Nashville, Tenn
- Columbia University Irving Medical Center, New York Presbyterian Hospital, Division of Cardiothoracic and Vascular Surgery, New York, NY
- North Mississippi Medical Center, Tupelo, Miss
- Institut Universitaire de Cardiology et Pneumologie de Quebec, Quebec, Canada
- Department of Cardiovascular and Thoracic Surgery, UPMC Central Pennsylvania, Harrisburg, Pa
- Department of Cardiology, Québec Heart and Lung Institute, Laval University, Quebec, Canada
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY
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Maus TM, Nguyen L. Is the Leaning Tower of PISA Starting its Fall? J Cardiothorac Vasc Anesth 2022; 36:4231-4233. [PMID: 36163157 DOI: 10.1053/j.jvca.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 08/28/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Timothy M Maus
- Department of Anesthesiology, UCSD Medical Center-Sulpizio Cardiovascular Center La Jolla, CA
| | - Liem Nguyen
- Department of Anesthesiology, UCSD Medical Center-Sulpizio Cardiovascular Center La Jolla, CA
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Moreno Garijo J, Ibáñez C, Perdomo JM, Abel MD, Meineri M. Preintervention imaging and intraoperative management care of the hypertrophic obstructive cardiomyopathy patient. Asian Cardiovasc Thorac Ann 2021; 30:35-42. [PMID: 34558997 PMCID: PMC8941714 DOI: 10.1177/02184923211047126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With an estimated overall mortality of less than 1 percent per year, hypertrophic cardiomyopathy, is the most common genetic cardiomyopathy. Intraoperative transesophageal echocardiography is the standard of care for assessing patients with hypertrophic obstructive cardiomyopathy undergoing surgical septal myectomy, allowing surgical planning, intraoperative hemodynamic monitoring, and postprocedural assessment of the repair, including detection of immediate complications. At various phases during surgical septal myectomy, the changing hemodynamic conditions may lead to worsening or improvement in left ventricle outflow tract obstruction by change in preload or afterload, systolic anterior motion of the mitral valve, or sympathetic stimulation. These characteristics represent unique challenges in the management of these patients, requiring a comprehensive understanding of the management of all the conditions required to decrease the left ventricle outflow tract gradient avoiding obstruction, which include the maintenance of sinus rhythm, adequate rate avoiding tachycardia and bradycardia, and avoidance of systemic hypotension preserving preload and afterload, with adequate vasoactive agents. The aim of this review is to summarize the perioperative assessment and management of patients undergoing hypertrophic obstructive myopathy surgery.
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Affiliation(s)
- Jacobo Moreno Garijo
- Department of Anesthesia and Pain Management, 33540Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Cristina Ibáñez
- Department of Anesthesiology, Hospital Clínic, 16493University of Barcelona, Barcelona, Spain
| | - Juan M Perdomo
- Department of Anesthesiology, Hospital Clínic, 16493University of Barcelona, Barcelona, Spain
| | - Martin D Abel
- Department of Anesthesiology and Perioperative Medicine, 156400Mayo Clinic, Jacksonville, FL, USA
| | - Massimiliano Meineri
- Department of Anesthesiology and Critical Care, 40628Herzzentrum Leipzig, Leipzig, Germany
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Moreno Garijo J, Amador Y, Fan CS, Silverton N, Ralph-Edwards A, Woo A, Mashari A, Meineri M. Association Between Three-Dimensional Left Ventricular Outflow Tract Area and Gradients After Myectomy in Hypertrophic Obstructive Cardiomyopathy. J Cardiothorac Vasc Anesth 2020; 35:1654-1662. [PMID: 33431273 DOI: 10.1053/j.jvca.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Determine whether the intraoperative three-dimensional left ventricular outflow tract cross-sectional area may be inversely correlated with pressure gradients as a determinant of surgical success after septal myectomy in hypertrophic cardiomyopathy patients. DESIGN Perioperative data were obtained by retrospective review. SETTING Toronto General Hospital, University of Toronto, Toronto, Canada, a tertiary hospital. PARTICIPANTS The study comprised 67 patients with hypertrophic obstructive cardiomyopathy. INTERVENTIONS Transthoracic and intraoperative transesophageal echocardiographic assessment of pressure gradients. Transesophageal measurement of the three-dimensional left ventricular outflow tract cross-sectional area. MEASUREMENTS AND MAIN RESULTS The smallest left ventricular outflow tract area increased on average 1.883 cm2 (98.3%) after septal myectomy. There was a significant correlation between the increase in the area and the transesophageal pressure gradients (r = -0.32; p = 0.01) after myectomy, but none with postoperative transthoracic gradients at rest (r = -0.10; p = 0.42). Postoperative transesophageal and transthoracic gradients were significantly correlated (r = 0.26; p = 0.04). The best risk factors to predict high residual gradients were preoperative transesophageal gradient >97 mmHg, postoperative transesophageal area <3.16 cm2, and moderate or more residual transesophageal mitral regurgitation (specificity 89%, 81%, and 78%, respectively). CONCLUSIONS Three-dimensional left ventricular outflow tract area measurements with transesophageal echocardiography after myectomy correlated fairly well with postoperative transesophageal pressure gradients. Patients with residual transthoracic elevated gradients after surgery at follow-up had a smaller transesophageal area and higher transesophageal pressure gradients immediately after the procedure. However, transesophageal pressure gradients after myectomy correlated poorly with follow-up transthoracic gradients at rest.
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Affiliation(s)
- J Moreno Garijo
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.
| | - Y Amador
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - C S Fan
- Department of Biostatistics, Toronto General Hospital, Toronto, ON, Canada
| | - N Silverton
- Department of Anesthesiology, University of Utah Health, Salt Lake City, UT
| | - A Ralph-Edwards
- Department of Cardiac Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - A Woo
- Department of Cardiology, Toronto General Hospital, Toronto, ON, Canada
| | - A Mashari
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - M Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
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Zaky A, Meers JB, Townsley MM. Appraising the Left Ventricular Outflow Tract: An Ongoing Challenge. J Cardiothorac Vasc Anesth 2020; 35:796-798. [PMID: 33309495 DOI: 10.1053/j.jvca.2020.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - J Brad Meers
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
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Hunter C, Chen T, Gorgone M, Apruzzese P, Mahmood F, Maslow A. The Left Ventricular Outflow Tract Changes in Size and Shape From Pre- to Post-Cardiopulmonary Bypass: Three-Dimensional Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2020; 35:786-795. [PMID: 33183933 DOI: 10.1053/j.jvca.2020.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare two-dimensional (2D) and 3D imaging of the left ventricular outflow tract (LVOT) and to evaluate geometric changes pre- to post-cardiopulmonary bypass (CPB). DESIGN Retrospective review of intraoperative transesophageal echocardiographic examinations. SETTING Single academic medical center. PARTICIPANTS The study comprised 69 cardiac surgical patients-27 with aortic valve stenosis (AS) and 42 without AS. INTERVENTIONS Two-dimensional and 3D analysis of the LVOT pre- and post-CPB. MEASUREMENTS AND MAIN RESULTS Pre- and post-CPB 2D assessment of LVOT diameter (2D LVOTd) was compared with 3D analysis of the minor (3D LVOTd-min) and major diameters. LVOT areas (LVOTa) were calculated using LVOTd to yield 2D LVOTa and 3D LVOTa-min. These were compared with LVOTa measured by planimetry (3D LVOTa-plan). An ellipticity ratio (ER) (ER = 3D minor/major axes) was calculated. The 2D LVOTd was larger than the 3D LVOTd-min before (2.12 v 2.02 cm respectively (resp); p < 0.001) and after (1.96 v 1.85 cm resp; p = 0.04) CPB. Compared with pre-CPB, there were significant decreases in the 2D LVOTd (p = 0.003) and the 3D LVOTd-min (p < 0.001) post-CPB. Ellipticity increased after CPB (ER 0.80 v 0.75; p = 0.004), and the 2D LVOTa was larger than the 3D LVOTa-min before CPB (3.60 cm2v 3.28 cm2; p < 0.001) and less so after CPB (3.11 cm2v 2.79 cm2; p = 0.053). Compared with pre-CPB, all LVOTa measurements decreased significantly after CPB (p < 0.001). The 3D LVOTa-plan decreased after CPB by approximately 10% (4.05 cm2v 3.61 cm2; p < 0.001). The 2D LVOTa and 3D LVOTa-min underestimated the 3D LVOTa-plan before and after CPB (p < 0.001) by 11% to 14% and 19% to 23%, respectively. When compared with non-AS patients, patients with AS had a smaller LVOTa pre- and post-CPB (p < 0.05). CONCLUSIONS The LVOT is smaller and more elliptical after CPB. Patients with AS have a smaller LVOT compared with non-AS patients. LVOTa calculated using LVOTd underestimates the 3D LVOTa-plan by as much as 23% depending on patient type and timing of measurement. Accurate assessment of the LVOT requires 3D imaging.
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Affiliation(s)
- Caroline Hunter
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Tzonghuei Chen
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Michelle Gorgone
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | | | - Feroze Mahmood
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
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Ahmed AA, Matyal R, Mahmood F, Feng R, Berry GB, Gilleland S, Khabbaz KR. Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis. Echo Res Pract 2019. [PMID: 31682093 PMCID: PMC6826166 DOI: 10.1530/erp-19-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.
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Affiliation(s)
- Andaleeb A Ahmed
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Robina Matyal
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Feroze Mahmood
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruby Feng
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Graham B Berry
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott Gilleland
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Nabeshima Y, Nagata Y, Negishi K, Seo Y, Ishizu T, Sato K, Aonuma K, Koto D, Izumo M, Akashi YJ, Yamashita E, Oshima S, Otsuji Y, Takeuchi M. Direct Comparison of Severity Grading Assessed by Two-Dimensional, Three-Dimensional, and Doppler Echocardiography for Predicting Prognosis in Asymptomatic Aortic Stenosis. J Am Soc Echocardiogr 2018; 31:1080-1090.e3. [DOI: 10.1016/j.echo.2018.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Indexed: 10/28/2022]
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Hui S, Mahmood F, Matyal R. Aortic Valve Area-Technical Communication: Continuity and Gorlin Equations Revisited. J Cardiothorac Vasc Anesth 2018; 32:2599-2606. [PMID: 30055989 DOI: 10.1053/j.jvca.2018.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Shangyi Hui
- Beth Israel Deaconess Medical Center, Boston, MA; Peking Union Medical College Hospital, Beijing, China
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Szymanski T, Maslow A, Mahmood F, Singh A. Three-Dimensional Echocardiographic Assessment of Coaptation After Aortic Valve Repair. J Cardiothorac Vasc Anesth 2017; 31:993-1000. [DOI: 10.1053/j.jvca.2016.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Indexed: 11/11/2022]
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