Transesophageal echocardiography in thoracic anesthesia: pulmonary hypertension and right ventricular function

Lung recruitment improves right ventricular performance after cardiopulmonary bypass: A randomised controlled trial

BACKGROUND

Atelectasis after cardiopulmonary bypass (CPB) can affect right ventricular (RV) performance by increasing its outflow impedance.

OBJECTIVE

The aim of this study was to determine whether a lung recruitment manoeuvre improves RV function by re-aerating the lung after CPB.

DESIGN

Randomised controlled study.

SETTING

Single-institution study, community hospital, Córdoba, Argentina.

PATIENTS

Forty anaesthetised patients with New York Heart Association class I or II, preoperative left ventricular ejection fraction at least 50% and Euroscore 6 or less scheduled for cardiac surgery with CPB.

INTERVENTIONS

Patients were assigned to receive either standard ventilation with 6 cmH2O of positive end-expiratory pressure (PEEP; group C, n = 20) or standard ventilation with a recruitment manoeuvre and 10 cmH2O of PEEP after surgery (group RM, n = 20). RV function, left ventricular cardiac index (CI) and lung aeration were assessed by transoesophageal echocardiography (TOE) before, at the end of surgery and 30 min after surgery.

MAIN OUTCOME MEASURES

RV function parameters and atelectasis assessed by TOE.

RESULTS

Haemodynamic data and atelectasis were similar between groups before surgery. At the end of surgery, CI had decreased from 2.9 ± 1.1 to 2.6 ± 0.9 l min m in group C (P = 0.24) and from 2.8 ± 1.0 to 2.6 ± 0.8 l min m in group RM (P = 0.32). TOE-derived RV function parameters confirmed a mild decrease in RV performance in 95% of patients, without significant differences between groups (multivariate Hotelling t-test P = 0.16). Atelectasis was present in 18 patients in group C and 19 patients in group RM (P = 0.88). After surgery, CI decreased further from 2.6 to 2.4 l min m in group C (P = 0.17) but increased from 2.6 to 3.7 l min m in group RM (P < 0.001). TOE-derived RV function parameters improved only in group RM (Hotelling t-test P < 0.001). Atelectasis was present in 100% of patients in group C but only in 10% of those in group RM (P < 0.001).

CONCLUSION

Atelectasis after CPB impairs RV function but this can be resolved by lung recruitment using 10 cmH2O of PEEP.

TRIAL REGISTRATION

Protocol started on October 2014.

Intraoperative Monitoring of Pulmonary Artery Physiology With Transesophageal Echocardiography in a Patient With an Extensive Pulmonary Aneurysm Undergoing Partial Nephrectomy

Surgical patients with pulmonary hypertension present a significant challenge to the anesthesiologist. Continuous perioperative monitoring of pulmonary artery (PA) pressure is recommended and most often accomplished with a PA catheter. Placement of a PA catheter may be difficult or contraindicated, and in these cases, transesophageal echocardiography is a useful alternative to monitor dynamic PA physiology. In this case, we used intraoperative transesophageal echocardiography to detect changes in peak PA pressure and guide clinical treatment in a patient with pulmonary hypertension and an extensive PA aneurysm undergoing partial nephrectomy.