Perioperative Right Ventricular Dysfunction: Analysis of Outcomes

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.

Intraoperative right ventricular end-systolic pressure-volume loop analysis in patients undergoing cardiac surgery: A proof-of-concept methodology

Background

Perioperative right ventricular (RV) dysfunction is associated with increased morbidity and mortality in cardiac surgery patients. This study aimed to demonstrate proof of concept in generating intraoperative RV pressure-volume (PV) loops and conducting an end-systolic PV relationship (ESPVR) analysis using data obtained from routinely used intraoperative monitors.

Methods

Adult patients undergoing cardiac surgery with the placement of a pulmonary artery catheter (PAC) between May 2023 and March 2024 were included prospectively. The PV loops were generated using 3-dimensional echocardiographic RV volume data and continuous RV pressure data obtained from a PAC. The volume-time and pressure-time curves were digitized using the semiautomatic WebPlotDigitizer program and synchronized to reconstruct an RV PV loop and analyze ESPVR using the previously validated single-beat method.

Results

Intraoperative RV PV loops were generated for 25 patients, including 17 patients with preserved RV systolic function (group 1) and 8 patients with reduced systolic function (group 2). Mean Ees, Ea, and Ees/Ea ratio were 0.63 ± 0.25 mm Hg/mL, 0.60 ± 0.23 mm Hg/mL, and 1.0 8 ± 0.31 mm Hg/mL, respectively, by the Pmax method and 0.56 ± 0.32 mm Hg/mL, 0.60 ± 0.23 mm Hg/mL, and 0.91 ± 0.21 mm Hg/mL, respectively, by the V0 method. Group 1 had a significantly higher Ees compared to group 2 regardless of the calculation method and a larger Ees/Ea ratio calculated by the V0 method.

Conclusions

It is clinically feasible to derive RV PV loops from routine hemodynamic and echocardiographic data. With further validation and technological support, this can be a potential real-time intraoperative RV function monitoring tool.

Artificial intelligence-analyzed computed tomography in patients undergoing transcatheter tricuspid valve repair

BACKGROUND

Baseline right ventricular (RV) function derived from 3-dimensional analyses has been demonstrated to be predictive in patients undergoing transcatheter tricuspid valve repair (TTVR). The complex nature of these cumbersome analyses makes patient selection based on established imaging methods challenging. Artificial intelligence (AI)-driven computed tomography (CT) segmentation of the RV might serve as a fast and predictive tool for evaluating patients prior to TTVR.

METHODS

Patients suffering from severe tricuspid regurgitation underwent full cycle cardiac CT. AI-driven analyses were compared to conventional CT analyses. Outcome measures were correlated with survival free of rehospitalization for heart-failure or death after TTVR as the primary endpoint.

RESULTS

Automated AI-based image CT-analysis from 100 patients (mean age 77 ± 8 years, 63% female) showed excellent correlation for chamber quantification compared to conventional, core-lab evaluated CT analysis (R 0.963-0.966; p < 0.001). At 1 year (mean follow-up 229 ± 134 days) the primary endpoint occurred significantly more frequently in patients with reduced RV ejection fraction (EF) <50% (36.6% vs. 13.7%; HR 2.864, CI 1.212-6.763; p = 0.016). Furthermore, patients with dysfunctional RVs defined as end-diastolic RV volume > 210 ml and RV EF <50% demonstrated worse outcome than patients with functional RVs (43.7% vs. 12.2%; HR 3.753, CI 1.621-8.693; p = 0.002).

CONCLUSIONS

Derived RVEF and dysfunctional RV were predictors for death and hospitalization after TTVR. AI-facilitated CT analysis serves as an inter- and intra-observer independent and time-effective tool which may thus aid in optimizing patient selection prior to TTVR in clinical routine and in trials.

Large Right Atrial Size on Cardiac MRI is Associated with Post-operative Right Ventricular Dysfunction After the Cone Operation for Ebstein Anomaly

The cone operation has revolutionized care for patients with Ebstein anomaly; however, acute post-operative right ventricular dysfunction (RVD) is common in this patient population. A single-center, retrospective review of 28 patients with Ebstein anomaly who underwent cardiac MRI (CMR) prior to cone reconstruction of the tricuspid valve was conducted. Measurements of atrial and ventricular size/function were assessed. Post-operative RVD was defined as the presence of moderate or severe systolic dysfunction on discharge echo. A two-tail t test was employed to compare the two groups. The average age at operation was 21.4 years (range 1.6-57.8) and 14 (50%) had RVD at discharge. Patients with post-operative RVD had significantly larger pre-operative right atrial (RA) maximum volume (p = 0.016) and RA minimum volume (p = 0.030). Patients with RVD had smaller pre-operative left atrial (LA) minimum volume (p = 0.012). Larger pre-operative right ventricular (RV) end-systolic volume (p = 0.046), lower RV ejection fraction (0.029), and smaller left ventricular (LV) end-diastolic volume (p = 0.049) were significantly associated with post-operative RVD. Post-operative RVD was associated with longer milrinone duration (p = 0.009) and higher maximum milrinone dose (p = 0.005) but was not associated with intensive care or hospital length of stay (p = 0.19 and 0.67, respectively). Increased RA and RV dilation and decreased LA and LV volumes are associated with the development of post-operative RVD following cone operation for Ebstein anomaly. Post-operative RVD affects milrinone dose and duration but is not associated with increased length of stay.

Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies

Arrhythmias frequently complicate the course of advanced pulmonary hypertension, often leading to hemodynamic compromise, functional impairment, and mortality. Given the importance of right atrial function in this physiology, the restoration and maintenance of sinus rhythm are of critical importance. In this review, we outline the pathophysiology of arrhythmias and their impact on right heart performance; describe considerations for antiarrhythmic drug selection, anesthetic and periprocedural management; and discuss the results of catheter ablation techniques in this complex and challenging patient population.

The Role of Artificial Intelligence and Machine Learning in the Prediction of Right Heart Failure after Left Ventricular Assist Device Implantation: A Comprehensive Review

One of the most challenging and prevalent side effects of LVAD implantation is that of right heart failure (RHF) that may develop afterwards. The purpose of this study is to review and highlight recent advances in the uses of AI in evaluating RHF after LVAD implantation. The available literature was scanned using certain key words (artificial intelligence, machine learning, left ventricular assist device, prediction of right heart failure after LVAD) was scanned within Pubmed, Web of Science, and Google Scholar databases. Conventional risk scoring systems were also summarized, with their pros and cons being included in the results section of this study in order to provide a useful contrast with AI-based models. There are certain interesting and innovative ML approaches towards RHF prediction among the studies reviewed as well as more straightforward approaches that identified certain important predictive clinical parameters. Despite their accomplishments, the resulting AUC scores were far from ideal for these methods to be considered fully sufficient. The reasons for this include the low number of studies, standardized data availability, and lack of prospective studies. Another topic briefly discussed in this study is that relating to the ethical and legal considerations of using AI-based systems in healthcare. In the end, we believe that it would be beneficial for clinicians to not ignore these developments despite the current research indicating more time is needed for AI-based prediction models to achieve a better performance.

Perioperative Quality Initiative (POQI) consensus statement on perioperative assessment of right ventricular function

BACKGROUND

The right ventricle (RV) plays a central  role in the maintenance of effective cardiac pump function. Despite overwhelming evidence that perioperative RV dysfunction (RVD) and failure (RVF) are associated with poor clinical outcomes, there are very few published recommendations or guidelines for comprehensive, evidence-based RV assessment on the risk of developing either during the perioperative period.

MAIN TEXT

To address this gap, the Perioperative Quality Initiative-IX (POQI-IX) investigators group, comprised of clinical experts in anesthesiology, cardiovascular surgery, internal medicine, critical care medicine, and advanced practice nursing, has developed a consensus statement based on current literature, published society recommendations, and the clinical expertise of the group. Herein, the group provides recommendations and evidence-based tools related to perioperative RV assessment, functional screening, staging, and the clinical implications of each. These assessment tools are based on comprehensive patient evaluation consisting of physical examination, biomarker data, imaging, and hemodynamic assessment.

CONCLUSION

This review presents a comprehensive tool for assessing perioperative RV function. We hope that this simple, intuitive tool can be applied to all phases of perioperative care and thereby improve patient outcomes.

Role of Echocardiography for the Perioperative Assessment of the Right Ventricle

Purpose of Review

This review aims to highlight the perioperative echocardiographic evaluation of right ventricular (RV) function with strengths and limitations of commonly used and evolving techniques. It explains the value of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and describes the perioperative changes of RV function echocardiographers should be aware of.

Recent Findings

RV dysfunction is an entity with strong influence on outcome. However, its definition and assessment in the perioperative interval are not well-defined. Moreover, values assessed by TTE and TEE are not interchangeable; while some parameters seem to correlate well, others do not. Myocardial strain analysis and three-dimensional echocardiography may overcome the limitations of conventional echocardiographic measures and provide further insight into perioperative cardiac mechanics.

Summary

Echocardiography has become an essential part of modern anesthesiology in patients with RV dysfunction. It offers the opportunity to evaluate not only global but also regional RV function and distinguish alterations of RV contraction.