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Arora RC, Brown JK, Chatterjee S, Gan TJ, Singh G, Tong MZ. Perioperative management of the vulnerable and failing right ventricle. Perioper Med (Lond) 2024; 13:40. [PMID: 38750602 PMCID: PMC11097429 DOI: 10.1186/s13741-024-00397-5] [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: 01/17/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
Under recognition combined with suboptimal management of right ventricular (RV) dysfunction and failure is associated with significant perioperative morbidity and mortality. The contemporary perioperative team must be prepared with an approach for early recognition and prompt treatment. In this review, a consensus-proposed scoring system is described to provide a pragmatic approach for expeditious decision-making for these complex patients with a vulnerable RV. Importantly, this proposed scoring system incorporates the context of the planned surgical intervention. Further, as the operating room (OR) represents a unique environment where patients are susceptible to numerous insults, a practical approach to anesthetic management and monitoring both in the OR and in the intensive care unit is detailed. Lastly, an escalating approach to the management of RV failure and options for mechanical circulatory support is provided.
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Affiliation(s)
- R C Arora
- Harrington Heart and Vascular Institute - University Hospitals, Cleveland, OH, USA.
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
| | - J K Brown
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Chatterjee
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - T J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Singh
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- Departments of Critical Care Medicine and Surgery, University of Alberta, Edmonton, AB, Canada
| | - M Z Tong
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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2
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Wei J, Kee A, Dukes R, Franke J, Leonardo V, Flynn BC. The Association of the Pulmonary Artery Pulsatility Index and Right Ventricular Function after Cardiac Surgery. Crit Care Res Pract 2024; 2024:5408008. [PMID: 38379715 PMCID: PMC10878756 DOI: 10.1155/2024/5408008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/19/2023] [Accepted: 01/27/2024] [Indexed: 02/22/2024] Open
Abstract
Background The pulmonary artery pulsatility index (PAPi) has been shown to correlate with right ventricular (RV) failure in patients with cardiac disease. However, the association of PAPi with right ventricular function following cardiac surgery is not yet established. Methods PAPi and other hemodynamic variables were obtained postoperatively for 959 adult patients undergoing cardiac surgery. The association of post-bypass right ventricular function and other clinical factors to PAPi was evaluated using linear regression. A propensity-score matched cohort for PAPi ≥ 2.00 was used to assess the association of PAPi with postoperative outcomes. Results 156 patients (16.3%) had post-bypass right ventricular dysfunction defined by visualization on transesophageal echocardiography. There was no difference in postoperative PAPi based on right ventricular function (2.12 vs. 2.00, p=0.21). In our matched cohort (n = 636), PAPi < 2.00 was associated with increased incidence of acute kidney injury (23.0% vs 13.2%, p < 0.01) and ventilator time (6.0 hours vs 5.6 hours, p=0.04) but not with 30-day mortality or intensive care unit length of stay. Conclusion In a general cohort of patients undergoing cardiac surgery, postoperative PAPi was not associated with postcardiopulmonary bypass right ventricular dysfunction. A postoperative PAPi < 2 may be associated with acute kidney injury.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brigid C. Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
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Wei J, Franke J, Kee A, Dukes R, Leonardo V, Flynn BC. Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2024; 38:214-220. [PMID: 37973507 DOI: 10.1053/j.jvca.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. DESIGN Single-center retrospective observational cohort study. SETTING The University of Kansas Medical Center, a tertiary-care academic medical center. PARTICIPANTS Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. INTERVENTIONS All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. MEASUREMENTS AND MAIN RESULTS Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. CONCLUSIONS The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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Mattei A, Strumia A, Benedetto M, Nenna A, Schiavoni L, Barbato R, Mastroianni C, Giacinto O, Lusini M, Chello M, Carassiti M. Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:7152. [PMID: 38002763 PMCID: PMC10672350 DOI: 10.3390/jcm12227152] [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: 10/07/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.
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Affiliation(s)
- Alessia Mattei
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Alessandro Strumia
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intesive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40123 Bologna, Italy;
| | - Antonio Nenna
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Lorenzo Schiavoni
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Raffaele Barbato
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimiliano Carassiti
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
- Anesthesia and Intensive Care Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
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Sumin AN, Shcheglova AV, Korok EV, Sergeeva TJ. Indicators of the Right Ventricle Systolic and Diastolic Function 18 Months after Coronary Bypass Surgery. J Clin Med 2022; 11:jcm11143994. [PMID: 35887758 PMCID: PMC9318021 DOI: 10.3390/jcm11143994] [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] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/10/2022] Open
Abstract
Objective. Right ventricular (RV) dysfunction after coronary artery bypass grafting (CABG) is associated with increased mortality and morbidity. In previous studies, the parameters of RV systolic function were mainly assessed, while the dynamics of RV diastolic function after surgery was practically not studied. The aim of this study was to study the dynamics of indicators of systolic and diastolic RV function after CABG as well as to identify factors associated with their presence. Methods. The study included 160 patients who underwent CABG and 36 volunteers with no history of coronary artery disease (CAD) as a control group. Echocardiographic examination of patients was performed to assess systolic and diastolic RV dysfunction before surgery and 18 months after CABG. A level of s’t < 10 cm/sec or TAPSE < 16 mm was considered as a sign of existing RV systolic dysfunction. RV diastolic dysfunction was defined as an Et/At ratio < 0.8 or >2.1 and/or an Et/et’ ratio > 6. Results. In CAD patients 18 months after CABG, there was an increase in the frequency of the right ventricular systolic (from 7.5% to 30%, p < 0.001) and diastolic (from 41.8% to 57.5%, p < 0.001) dysfunction. An increase in TAPSE (p = 0.007), a decrease in e’t (p = 0.005), and the presence of RV systolic dysfunction before surgery (p = 0.023) was associated with a significant increase in the likelihood of detecting RV systolic dysfunction 18 months after CABG (χ2(3) = 17.4, p = 0.001). High values of At before surgery (p = 0.021) and old myocardial infarction (p = 0.023) were significantly associated with an increased likelihood of detection of RV diastolic dysfunction 18 months after CABG (χ2(2) = 10.78, p = 0.005). Conclusions. This study demonstrated that in CAD patients 18 months after CABG, there was an increase in the frequency of right ventricular systolic and diastolic dysfunction. We also established the initial clinical, echocardiographic parameters, and perioperative complications associated with the presence of these changes in the postoperative period. The clinical and prognostic significance of the presence of systolic and/or diastolic RV dysfunction in patients 18 months after CABG remains to be explored.
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Affiliation(s)
- Alexey N. Sumin
- Correspondence: ; Tel.: +7-(3842)-64-44-61 or +7-8-903-940-8668; Fax: +7-(3842)-64-27-18
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Welker C, Huang J, Nunez-Gil I, Villavicencio MA, Ramakrishna H. Percutaneous Right Ventricular Mechanical Circulatory Support- Analysis of Recent Data. J Cardiothorac Vasc Anesth 2022; 36:2783-2788. [DOI: 10.1053/j.jvca.2022.01.022] [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: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022]
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Prolonged mechanical rib separation is a key element to prevent thoracic compartment syndrome in penetrating chest trauma: A case report. Trauma Case Rep 2021; 34:100498. [PMID: 34258370 PMCID: PMC8255934 DOI: 10.1016/j.tcr.2021.100498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/22/2022] Open
Abstract
Penetrating cardiac injury in trauma patients is highly morbid. Most cases do not survive long enough to manifest the severe physiologic consequences of massive blood product resuscitation, namely, thoracic compartment syndrome and right ventricular (RV) failure. This case exhibits a thoracic compartment syndrome and RV failure so severe that the open chest management required mechanical separation of a clamshell thoracotomy. The resuscitation and the techniques utilized to maintain an open chest will be described.
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Calderone A, Hammoud A, Jarry S, Denault A, Couture EJ. Femoral Vein Pulsatility: What Does It Mean? J Cardiothorac Vasc Anesth 2021; 35:2521-2527. [PMID: 33985881 DOI: 10.1053/j.jvca.2021.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.
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Affiliation(s)
- Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ali Hammoud
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Faculty of Nursing Graduate Studies, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery and Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Etienne J Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Canada
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Ramzy D. Commentary: Elusive right ventricle, do we know thee? Today a little more. J Thorac Cardiovasc Surg 2020; 164:596-597. [PMID: 33341265 DOI: 10.1016/j.jtcvs.2020.11.091] [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: 11/17/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Danny Ramzy
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
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10
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Lorusso R, Raffa GM, Heuts S, Lo Coco V, Meani P, Natour E, Bidar E, Delnoij T, Loforte A. Pulmonary artery cannulation to enhance extracorporeal membrane oxygenation management in acute cardiac failure. Interact Cardiovasc Thorac Surg 2020; 30:215-222. [PMID: 31665308 DOI: 10.1093/icvts/ivz245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Pulmonary artery (PA) cannulation during peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has been shown to be effective either for indirect left ventricular (LV) unloading or to allow right ventricular (RV) bypass with associated gas-exchange support in case of acute RV with respiratory failure. This case series reports the results of such peculiar ECMO configurations with PA cannulation in different clinical conditions. METHODS All consecutive patients receiving PA cannulation (direct or percutaneous) from January 2015 to September 2018 in 3 institutions were retrospectively reviewed. Isolated LV unloading or RV support, as well as dynamic support including initial drainage followed by perfusion through the PA cannula, was used as part of the ECMO configuration according to the type of patient and the patient's haemodynamic/functional needs. RESULTS Fifteen patients (8 men, age range 45-73 years, EuroSCORE log range 14.45-91.60%) affected by acute LV, RV or biventricular failure of various aetiologies, were supported by this ECMO mode. Percutaneous PA cannulation was performed in 10 patients and direct PA cannulation, in 5 cases. Dynamic ECMO management (initially draining and then perfusing through the PA cannula) was carried out in 6 patients. Mean ECMO duration was 9.1 days (range 6-17 days). One patient exhibited pericardial fluid during the implant of a PA cannula (no lesion found when the chest was opened), and weaning from temporary circulatory support was achieved in 14 patients (1 who received a transplant). Three patients (20%) died in-hospital, and 12 patients were successfully discharged without major complications. CONCLUSIONS Effective indirect LV unloading in peripheral venoarterial ECMO as well as isolated RV support can be achieved by PA cannulation. Such an ECMO configuration may allow the counteraction of common venoarterial ECMO shortcomings or allow dynamic/adjustable management of ECMO according to specific ventricular dysfunction and haemodynamic needs. Percutaneous PA cannulation was shown to be safe and feasible without major complications. Additional investigation is needed to confirm the safety and efficacy of such an ECMO configuration and management in a larger patient population.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands.,Cardiac Surgery Unit, Spedali Civili Hospital, Brescia, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Samuel Heuts
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Valeria Lo Coco
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Paolo Meani
- Cardiology Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands.,Intensive Care Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ehsan Natour
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Elham Bidar
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Thijs Delnoij
- Cardiology Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands.,Intensive Care Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, Bologna University, Bologna, Italy
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Grønlykke L, Korshin A, Gustafsson F, Nilsson JC, Ravn HB. The Effect of Common Interventions in the Intensive Care Unit on Right Ventricular Function After Cardiac Surgery—An Intervention Study. J Cardiothorac Vasc Anesth 2020; 34:1211-1219. [DOI: 10.1053/j.jvca.2019.11.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/21/2019] [Accepted: 11/27/2019] [Indexed: 11/11/2022]
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12
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Vandenheuvel M, Bouchez S, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2019; 37:697-712. [PMID: 31677686 DOI: 10.1016/j.anclin.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium; Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Spitalstrasse 21, Basel 4031, Switzerland.
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Del Rio JM, Grecu L, Nicoara A. Right Ventricular Function in Left Heart Disease. Semin Cardiothorac Vasc Anesth 2018; 23:88-107. [DOI: 10.1177/1089253218799345] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Right ventricular (RV) function is an independent prognostic factor for short- and long-term outcomes in cardiac surgical patients. Patients with mitral valve (MV) disease are at increased risk of RV dysfunction before and after MV operations. Yet RV function is not part of criteria for decision making or risk stratification in this setting. The role of MV disease in the development of pulmonary hypertension (PHTN) and the ultimate impact of PHTN on RV function have been well described. Nonetheless, there are other mechanisms by which MV disease and MV surgery affect RV performance. Research suggests that PHTN may not be the most important determinant of RV dysfunction. Both RV dysfunction and PHTN have independent prognostic significance. This review explores the unique anatomic and functional features of the RV and the pathophysiologic and prognostic implications of RV dysfunction in patients with MV disease in the perioperative period.
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Affiliation(s)
- J. Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Loreta Grecu
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Alina Nicoara
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
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14
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Steffen HJ, Kalverkamp S, Zayat R, Autschbach R, Spillner JW, Hagendorff A, Hatam N. Is Systolic Right Ventricular Function Reduced after Thoracic Non-Cardiac Surgery? A Propensity Matched Echocardiographic Analysis. Ann Thorac Cardiovasc Surg 2018; 24:238-246. [PMID: 29877218 PMCID: PMC6198000 DOI: 10.5761/atcs.oa.18-00046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose: To assess whether thoracic non-cardiac surgery has an influence on right ventricular function (RVF) compared to known impaired postoperative RV function after cardiac surgery. Methods: In all, 50 patients (mean age: 61 years), who underwent thoracic non-cardiac surgery were included and matched using propensity score to 50 patients, receiving coronary artery bypass graft surgery (CABG) (CABGmatched). All patients had transthoracic echocardiography (TTE) including two-dimensional speckle tracking (2D-STE) and tissue Doppler imaging (TDI) pre- and 1 week postoperatively. Results: No significant changes in RV measurements including tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV), RV fractional area change (RV-FAC), and 2D-STE of the RV and RV freewall within the thoracic non-cardiac surgery patients comparing pre- and postoperative values. Comparing RV TTE values between CABGmatched patients and thoracic surgery patients, only TAPSE differed between groups preoperatively (p <0.0001), where postoperatively, all RV measurements differed significantly between the two groups: TAPSE (p <0.0001), TASV (p <0.001), RVFAC (p = 0.005), and RV 2D-STE (p <0.0001) indicating impairment of RV function post-CABG surgery compared to thoracic non-cardiac surgery. Conclusion: Thoracic non-cardiac surgery including an opening of the pleural cavity did not influence RV function early postoperative, whereas CABG surgery with pericardiotomy led to an impaired global RV function.
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Affiliation(s)
- Henning Johann Steffen
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian Kalverkamp
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan-Wilhelm Spillner
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Nima Hatam
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
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Roscoe A, Tomey MI, Torregrossa G, Galhardo C, Parhar K, Zochios V. Chagas Cardiomyopathy: A Comprehensive Perioperative Review. J Cardiothorac Vasc Anesth 2018; 32:2780-2788. [PMID: 29803311 DOI: 10.1053/j.jvca.2018.04.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Andrew Roscoe
- Department of Cardiothoracic Anesthesia and Critical Care Medicine, Papworth Hospital, Cambridge, United Kingdom
| | - Matthew I Tomey
- Cardiovascular Institute and Institute for Critical Care Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Mount Sinai Saint Luke, Mount Sinai Health System, New York, NY
| | - Carlos Galhardo
- Department of Anesthesia, National Institute of Cardiology, Rio de Janeiro, Brazil
| | - Ken Parhar
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Vasileios Zochios
- University Hospitals Birmingham NHS Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom; Perioperative Critical Care and Trauma Trials Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom.
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Qiu J, Jia L, Hao Y, Huang S, Ma Y, Li X, Wang M, Mao Y. Efficacy and safety of levosimendan in patients with acute right heart failure: A meta-analysis. Life Sci 2017; 184:30-36. [PMID: 28689804 DOI: 10.1016/j.lfs.2017.07.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/22/2017] [Accepted: 07/01/2017] [Indexed: 01/13/2023]
Abstract
AIMS Right heart failure (RHF), which is caused by a variety of heart and lung diseases, has a high morbidity and mortality rate. Levosimendan is a cardiac inotropic drug and vasodilator. The effect of levosimendan on RHF remains unclear. We sought to evaluate the efficacy and safety of levosimendan in patients with acute RHF. MATERIALS AND METHODS We systematically searched PubMed, Cochrane Library, EMBASE, and ClinicalTrials.gov to identify studies reporting the efficacy and safety of levosimendan for the treatment of RHF. KEY FINDINGS Ten trials, including 359 participants from 6 RCTs and 4 self-controlled trials, were evaluated. In the 6 RCTs, we found that patients treated with levosimendan for 24h showed a significant increase in tricuspid annular plane systolic excursion [1.53; 95% CI (0.54, 2.53); P=0.002] and ejection fraction [3.59; 95% CI (1.21, 5.98); P=0.003] as well as a significant reduction in systolic pulmonary artery pressure [-6.15; 95% CI (-9.29, -3.02); P=0.0001] and pulmonary vascular resistance [-39.48; 95% CI (-65.59, -13.38); P=0.003], whereas changes in mean pulmonary pressure were nonsignificant. Adverse events did not significantly differ between the two groups. SIGNIFICANCE Our study shows that levosimendan exhibits short-term efficacy for treating RHF in patients with a variety of heart and lung diseases. Additional strict multicentre RCTs with long follow-up times and large sample sizes are required to further validate the efficacy and safety of this treatment.
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Affiliation(s)
- Jiayong Qiu
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Lei Jia
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yingying Hao
- Department of Infectious Diseases, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Shenshen Huang
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yaqing Ma
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Xiaofang Li
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Min Wang
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yimin Mao
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.
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Estrada VHN, Franco DLM, Moreno AAV, Gambasica JAR, Nunez CCC. Postoperative Right Ventricular Failure in Cardiac Surgery. Cardiol Res 2016; 7:185-195. [PMID: 28197291 PMCID: PMC5295509 DOI: 10.14740/cr500e] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 12/11/2022] Open
Abstract
Two cases of patients that developed right ventricular failure (RVF) after cardiac valve surgery are presented with a narrative revision of the literature. RVF involves a great challenge due to the severity of this condition; it has a low incidence among non-congenital cardiac surgery patients, is more likely associated with cardiovascular and pulmonary complications related to cardiopulmonary bypass (CPB), and is a cause of acute graft failure and of a higher early mortality in cardiac transplant. The morphologic and hemodynamic characteristics of the right ventricle and some specific factors that breed pulmonary hypertension after cardiac surgery are in favor of the onset of RVF. Due to the possibility of complications after cardiac valve repair or replacement, measures as appropriate hemodynamic monitoring, to manage oxygenation, ventilation, sedation, acid base equilibrium and perfusion goals are a requirement, as well as a normal circulating volume, and the prevention of a disproportionate rise in the afterload, to preserve the free wall of the right ventricle (RV) and the septum's contribution to the right ventricular global function and geometry. If there is no response to these basic measures, the use of advanced therapy with inotropics, intravenous or inhaled pulmonary vasodilation agents is recommended; the use of mechanical ventricular assistance stands as a last resource.
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Grønlykke L, Ravn HB, Gustafsson F, Hassager C, Kjaergaard J, Nilsson JC. Right ventricular dysfunction after cardiac surgery – diagnostic options. SCAND CARDIOVASC J 2016; 51:114-121. [DOI: 10.1080/14017431.2016.1264621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Lars Grønlykke
- Department of Cardiothoracic Anaesthesiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anaesthesiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens C. Nilsson
- Department of Cardiothoracic Anaesthesiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Spratt JR, Raveendran G, Liao K, John R. Novel percutaneous mechanical circulatory support devices and their expanding applications. Expert Rev Cardiovasc Ther 2016; 14:1133-50. [DOI: 10.1080/14779072.2016.1214573] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Garcia Gigorro R, Renes Carreño E, Mayordomo S, Marín H, Perez Vela JL, Corres Peiretti MA, Montejo González JC. Evaluation of right ventricular function after cardiac surgery: The importance of tricuspid annular plane systolic excursion and right ventricular ejection fraction. J Thorac Cardiovasc Surg 2016; 152:613-20. [DOI: 10.1016/j.jtcvs.2016.04.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 03/05/2016] [Accepted: 04/12/2016] [Indexed: 11/30/2022]
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Maus TM. Only With a New Ruler Do You Realize the Value of the Old. J Cardiothorac Vasc Anesth 2015; 29:829-30. [DOI: 10.1053/j.jvca.2015.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Indexed: 11/11/2022]
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Inhaled nitric oxide in cardiac surgery: Evidence or tradition? Nitric Oxide 2015; 49:67-79. [PMID: 26186889 DOI: 10.1016/j.niox.2015.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/08/2015] [Accepted: 06/25/2015] [Indexed: 12/15/2022]
Abstract
Inhaled nitric oxide (iNO) therapy as a selective pulmonary vasodilator in cardiac surgery has been one of the most significant pharmacological advances in managing pulmonary hemodynamics and life threatening right ventricular dysfunction and failure. However, this remarkable story has experienced a roller-coaster ride with high hopes and nearly universal demonstration of physiological benefits but disappointing translation of these benefits to harder clinical outcomes. Most of our understanding on the iNO field in cardiac surgery stems from small observational or single centre randomised trials and even the very few multicentre trials fail to ascertain strong evidence base. As a consequence, there are only weak clinical practice guidelines on the field and only European expert opinion for the use of iNO in routine and more specialised cardiac surgery such as heart and lung transplantation and left ventricular assist device (LVAD) insertion. In this review the authors from a specialised cardiac centre in the UK with a very high volume of iNO usage provide detailed information on the early observations leading to the European expert recommendations and reflect on the nature and background of these recommendations. We also provide a summary of the progress in each of the cardiac subspecialties for the last decade and initial survey data on the views of senior anaesthetic and intensive care colleagues on these recommendations. We conclude that the combination of high price tag associated with iNO therapy and lack of substantial clinical evidence is not sustainable on the current field and we are risking loosing this promising therapy from our daily practice. Overcoming the status quo will not be easy as there is not much room for controlled trials in heart transplantation or in the current atmosphere of LVAD implantation. However, we call for international cooperation to conduct definite studies to determine the place of iNO therapy in lung transplantation and high risk mitral surgery. This will require new collaboration between the pharmaceutical companies, national grant agencies and the clinical community. Until these trials are realized we should gather multi-institutional experience from large retrospective studies and prospective data from a new international registry. We must step up international efforts if we wish to maintain the iNO modality in the armamentarium of hemodynamic tools for the perioperative management of our high risk cardiac surgical patients.
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Jentzer JC, Mathier MA. Pulmonary Hypertension in the Intensive Care Unit. J Intensive Care Med 2015; 31:369-85. [PMID: 25944777 DOI: 10.1177/0885066615583652] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/16/2015] [Indexed: 12/19/2022]
Abstract
Pulmonary hypertension occurs as the result of disease processes increasing pressure within the pulmonary circulation, eventually leading to right ventricular failure. Patients may become critically ill from complications of pulmonary hypertension and right ventricular failure or may develop pulmonary hypertension as the result of critical illness. Diagnostic testing should evaluate for common causes such as left heart failure, hypoxemic lung disease and pulmonary embolism. Relatively few patients with pulmonary hypertension encountered in clinical practice require specific pharmacologic treatment of pulmonary hypertension targeting the pulmonary vasculature. Management of right ventricular failure involves optimization of preload, maintenance of systemic blood pressure and augmentation of inotropy to restore systemic perfusion. Selected patients may require pharmacologic therapy to reduce right ventricular afterload by directly targeting the pulmonary vasculature, but only after excluding elevated left heart filling pressures and confirming increased pulmonary vascular resistance. Critically-ill patients with pulmonary hypertension remain at high risk of adverse outcomes, requiring a diligent and thoughtful approach to diagnosis and treatment.
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Affiliation(s)
- Jacob C Jentzer
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael A Mathier
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA
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Kukulski T, She L, Racine N, Gradinac S, Panza JA, Velazquez EJ, Chan K, Petrie MC, Lee KL, Pellikka PA, Romanov A, Biernat J, Rouleau JL, Batlle C, Rogowski J, Ferrazzi P, Zembala M, Oh JK. Implication of right ventricular dysfunction on long-term outcome in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting with or without surgical ventricular reconstruction. J Thorac Cardiovasc Surg 2014; 149:1312-21. [PMID: 25451487 DOI: 10.1016/j.jtcvs.2014.09.117] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/03/2014] [Accepted: 09/28/2014] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Whether right ventricular dysfunction affects clinical outcome after coronary artery bypass grafting with or without surgical ventricular reconstruction is still unknown. The aim of the study was to assess the impact of right ventricular dysfunction on clinical outcome in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting with or without surgical ventricular reconstruction. METHODS Of 1000 patients in the Surgical Treatment for Ischemic Heart Failure with coronary artery disease, left ventricular ejection fraction 35% or less, and anterior dysfunction, who were randomized to undergo coronary artery bypass grafting or coronary artery bypass grafting + surgical ventricular reconstruction, baseline right ventricular function could be assessed by echocardiography in 866 patients. Patients were followed for a median of 48 months. All-cause mortality or cardiovascular hospitalization was the primary end point, and all-cause mortality alone was a secondary end point. RESULTS Right ventricular dysfunction was mild in 102 patients (12%) and moderate or severe in 78 patients (9%). Moderate to severe right ventricular dysfunction was associated with a larger left ventricle, lower ejection fraction, more severe mitral regurgitation, higher filling pressure, and higher pulmonary artery systolic pressure (all P < .0001) compared with normal or mildly reduced right ventricular function. A significant interaction between right ventricular dysfunction and treatment allocation was observed. Patients with moderate or severe right ventricular dysfunction who received coronary artery bypass grafting + surgical ventricular reconstruction had significantly worse outcomes compared with patients who received coronary artery bypass grafting alone on both the primary (hazard ratio, 1.86; confidence interval, 1.06-3.26; P = .028) and the secondary (hazard ratio, 3.37; confidence interval, 1.36-8.37; P = .005) end points. After adjusting for all other prognostic clinical factors, the interaction remained significant with respect to all-cause mortality (P = .022). CONCLUSIONS Adding surgical ventricular reconstruction to coronary artery bypass grafting may worsen long-term survival in patients with ischemic cardiomyopathy with moderate to severe right ventricular dysfunction, which reflects advanced left ventricular remodeling.
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Affiliation(s)
- Tomasz Kukulski
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Disease, Medical University of Silesia, Zabrze, Poland.
| | - Lilin She
- Duke Clinical Research Institute, Durham, NC
| | - Normand Racine
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Canada
| | | | | | - Eric J Velazquez
- Duke Clinical Research Institute, Durham, NC; Department of Medicine-Cardiology, Duke University School of Medicine, Durham, NC
| | - Kwan Chan
- University of Ottawa Heart Institute, Ottawa, Canada
| | | | - Kerry L Lee
- Duke Clinical Research Institute, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | | | | | - Jean L Rouleau
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Canada
| | | | | | | | - Marian Zembala
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Disease, Medical University of Silesia, Zabrze, Poland
| | - Jae K Oh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
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