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

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

This article explores the growing significance of right ventricular (RV) function, particularly in perioperative settings. The right ventricle plays a crucial role in predicting morbidity and mortality, especially in cardiac surgeries. Right ventricular failure is associated with high in-hospital mortality, making accurate assessment vital. The article discusses echocardiographic evaluation, emphasizing both qualitative and quantitative measures, including tricuspid annular plane systolic excursion, fractional area change, and myocardial strain imaging. Understanding RV pathophysiology is essential for effective diagnosis and management, particularly in dynamic perioperative conditions influenced by ventilation, anesthesia, and extracorporeal circulation.

The association of right ventricular function with outcomes after cardiac surgery: a systematic review

PURPOSE

Assessment of right ventricular (RV) function is recommended as part of a comprehensive echocardiography exam, including before and after cardiac surgery. Nevertheless, the prognostic implications of various measures of RV function in patients undergoing cardiac surgery are not well characterized. Our goal was to conduct a focused systematic review to assess the association of quantitative parameters of RV function with postoperative outcomes in patients undergoing cardiac surgery.

METHODS

We conducted a systematic review of randomized controlled trials or observational studies in adult (≥ 18 yr) patients undergoing cardiac surgery with a reported echocardiogram within six months of surgery, intraoperatively, or shortly after surgery. We excluded case reports and case series. Databases included PubMed® and MEDLINE, and papers published from 1 January 1990 to 22 April 2024 were searched for. The primary predictors of interest were quantitative RV function parameters. The primary outcome of interest was postoperative mortality up to five years. The secondary outcome was all major adverse cardiac events (MACE).

RESULTS

We identified 7,187 potentially relevant studies, 27 of which were included; all of these were observational studies. Right ventricular fractional area change (RVFAC) was the most commonly reported parameter, but was inconsistently associated with mortality and MACE. Tricuspid annular plane systolic excursion (TAPSE) and strain were consistently associated with mortality. The most consistent predictor of MACE was RV myocardial performance index (MPI) across studies.

CONCLUSION

Pre- and perioperative assessment of RV function using at least two quantitative echocardiographic parameters may offer prognostic information in patients undergoing cardiac surgery. Right ventricular FAC, TAPSE, strain, and RV MPI have been frequently studied; however, further research is needed to delineate the role of echocardiographic RV quantification for perioperative prognostication.

STUDY REGISTRATION

PROSPERO ( CRD42023387383 ); first submitted 23 December 2022.

Reduction in Postoperative Right Ventricular Echocardiographic Indices Predicts Longer Duration of Vasoactive Support After Cardiac Surgery

OBJECTIVES

To assess perioperative right ventricular (RV) echocardiographic indices and their relationship to vasopressor and inotropic support in cardiac surgical patients. The authors hypothesized that a reduction in echocardiographic parameters of RV function would be associated with a longer duration of vasopressor and inotropic support in the intensive care unit (ICU).

DESIGN

A prospective observational study.

SETTING

A quaternary care hospital affiliated with McGill University, Canada.

PARTICIPANTS

Adult patients undergoing elective cardiac surgery.

INTERVENTIONS

Transesophageal echocardiography and hemodynamics measurements with a pulmonary artery catheter were performed after induction of anesthesia (pre-cardiopulmonary bypass [CPB]) and at post-CPB.

MEASUREMENTS AND MAIN RESULTS

Echocardiographic measurements included anatomic M-mode tricuspid annular plane systolic excursion, fractional area change (FAC), tricuspid annulus peak systolic velocity (TAPSE), and myocardial performance index. The primary outcome was the duration of vasopressor and inotropic support in the ICU. Of the 122 patients who were enrolled in the study, 83 underwent coronary artery bypass graft surgery. At the end of the procedure, 94.3% of patients were supported with a vasopressor or inotrope. A reduction in post-CPB TAPSE was found in 88.2% (105) of patients, and 56.8% (63) of patients had a reduction in FAC. Patients with a post-CPB TAPSE below 17 mm and a post-CPB FAC below 35% required a longer duration of inotropic support in the ICU.

CONCLUSION

Patients with post-CPB TAPSE <17 mmHg require a longer duration of inotropic support in the ICU. From all measured RV echocardiographic indices, post-CPB FAC is an independent predictor of vasopressor and inotropic support. A reduction of post-CPB TAPSE and FAC in patients undergoing cardiac surgery is indicative of RV dysfunction requiring a longer use of vasopressor and inotropic support and potentially longer stay in the cardiovascular ICU.