Continuous Right Ventricular Pressure Monitoring in Cardiac Surgery.

OBJECTIVE: Right ventricular (RV) dysfunction in cardiac surgery can lead to RV failure, which is associated with increased morbidity and mortality. Abnormal RV function can be identified using RV pressure monitoring. The primary objective of the study is to determine the proportion of patients with abnormal RV early to end-diastole diastolic pressure gradient (RVDPG) and abnormal RV end-diastolic pressure (RVEDP) before initiation and after cardiopulmonary bypass (CPB) separation. The secondary objective is to evaluate if RVDPG before CPB initiation is associated with difficult and complex separation from CPB, RV dysfunction, and failure at the end of cardiac surgery. DESIGN: Prospective study. SETTING: Tertiary care cardiac institute. PARTICIPANTS: Cardiac surgical patients. INTERVENTION: Cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Automated electronic quantification of RVDPG and RVEDP were obtained. Hemodynamic measurements were correlated with cardiac and extracardiac parameters from transesophageal echocardiography and postoperative complications. Abnormal RVDPG was present in 80% of the patients (n = 105) at baseline, with a mean RVEDP of 14.2 ± 3.9 mmHg. Patients experienced an RVDPG > 4 mmHg for a median duration of 50.2% of the intraoperative period before CPB initiation and 60.6% after CPB separation. A total of 46 (43.8%) patients had difficult/complex separation from CPB, 18 (38.3%) patients had RV dysfunction, and 8 (17%) had RV failure. Abnormal RVDPG before CPB was not associated with postoperative outcome. CONCLUSION: Elevated RVDPG and RVEDP are common in cardiac surgery. RVDPG and RVEDP before CPB initiation are not associated with RV dysfunction and failure but can be used to diagnose them.

A clinical prediction model to identify patients at high risk of hemodynamic instability in the pediatric intensive care unit.

BACKGROUND: Early recognition and timely intervention are critical steps for the successful management of shock. The objective of this study was to develop a model to predict requirement for hemodynamic intervention in the pediatric intensive care unit (PICU); thus, clinicians can direct their care to patients likely to benefit from interventions to prevent further deterioration. METHODS: The model proposed in this study was trained on a retrospective cohort of all patients admitted to a tertiary PICU at a single center in the United States, and validated on another retrospective cohort of all patients admitted to the PICU at a single center in the United Kingdom. The PICU clinical information system database (Intellivue Clinical Information Portfolio, Philips, UK) was interrogated to collect physiological and laboratory data. The model was trained using a variant of AdaBoost, which learned a set of low-dimensional classifiers, each of which was age adjusted. RESULTS: A total of 7052 patients admitted to the US PICU was used for training the model, and a total of 970 patients admitted to the UK PICU was used for validation. On the training/validation datasets, the model showed better prediction of hemodynamic intervention (area under the receiver operating characteristic (AUROC) = 0.81/0.81) than systolic blood pressure-based (AUCROC = 0.58/0.67) or shock index-based (AUCROC = 0.63/0.65) models. Both of these models were age adjusted using the same classifier. CONCLUSIONS: The proposed model reliably predicted the need for hemodynamic intervention in PICU patients and provides better classification performance when compared to systolic blood pressure-based or shock index-based models alone. This model could readily be built into a clinical information system to identify patients at risk of hemodynamic instability.

Spatial and temporal relationships of electrocorticographic alpha and gamma activity during auditory processing.

Neuroimaging approaches have implicated multiple brain sites in musical perception, including the posterior part of the superior temporal gyrus and adjacent perisylvian areas. However, the detailed spatial and temporal relationship of neural signals that support auditory processing is largely unknown. In this study, we applied a novel inter-subject analysis approach to electrophysiological signals recorded from the surface of the brain (electrocorticography (ECoG)) in ten human subjects. This approach allowed us to reliably identify those ECoG features that were related to the processing of a complex auditory stimulus (i.e., continuous piece of music) and to investigate their spatial, temporal, and causal relationships. Our results identified stimulus-related modulations in the alpha (8-12 Hz) and high gamma (70-110 Hz) bands at neuroanatomical locations implicated in auditory processing. Specifically, we identified stimulus-related ECoG modulations in the alpha band in areas adjacent to primary auditory cortex, which are known to receive afferent auditory projections from the thalamus (80 of a total of 15,107 tested sites). In contrast, we identified stimulus-related ECoG modulations in the high gamma band not only in areas close to primary auditory cortex but also in other perisylvian areas known to be involved in higher-order auditory processing, and in superior premotor cortex (412/15,107 sites). Across all implicated areas, modulations in the high gamma band preceded those in the alpha band by 280 ms, and activity in the high gamma band causally predicted alpha activity, but not vice versa (Granger causality, p<1e(-8)). Additionally, detailed analyses using Granger causality identified causal relationships of high gamma activity between distinct locations in early auditory pathways within superior temporal gyrus (STG) and posterior STG, between posterior STG and inferior frontal cortex, and between STG and premotor cortex. Evidence suggests that these relationships reflect direct cortico-cortical connections rather than common driving input from subcortical structures such as the thalamus. In summary, our inter-subject analyses defined the spatial and temporal relationships between music-related brain activity in the alpha and high gamma bands. They provide experimental evidence supporting current theories about the putative mechanisms of alpha and gamma activity, i.e., reflections of thalamo-cortical interactions and local cortical neural activity, respectively, and the results are also in agreement with existing functional models of auditory processing.

Inhaled Epoprostenol and Milrinone Effect on Right Ventricular Pressure Waveform Monitoring.

BACKGROUND: Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. This study aimed to evaluate the change in RV pressure waveform in patients receiving a combination of inhaled epoprostenol and inhaled milrinone (iE&iM) before cardiopulmonary bypass (CPB) and to assess the safety of this approach with a matched case-control group. METHODS: A prospective single-centre cohort study of adult patients undergoing cardiac surgery administered iE&iM through an ultrasonic mesh nebulizer. RV pressure waveform monitoring was obtained by continuously transducing the RV port of the pulmonary artery (PA) catheter. RESULTS: The final analysis included 26 patients receiving iE&iM. There was a significant drop in mean PA pressure (MPAP) (-4.8 ± 8.7, P = 0.010), systolic PA pressure (SPAP) (-8.2 ± 12.8, P = 0.003), RV end-diastolic pressure (RVEDP) (-2.1 ± 2.8, P < 0.001) and RV diastolic pressure gradient (RVDPG) (-1.7 ± 1.4, P < 0.001) after 17 ± 9 minutes of iE&iM administration. Patients also had a significant increase in RV outflow tract (RVOT) gradient (3.7 ± 4.7, P < 0.001), RV maximal rate of pressure rise during early systole (dP/dt max) (68.3 ± 144.7, P = 0.024), and left ventricular (LV) dP/dt max (66.4 ± 90.1, P < 0.001). Change in RVOT gradient was only observed in those with a positive pulmonary vasodilator response to treatment. Treatment with iE&iM did not present adverse effects when compared with a matched case-control group. CONCLUSIONS: Coadministration of iE&iM in cardiac surgery patients presenting with PH or signs of RV dysfunction is a safe and effective treatment approach in improving RV function. Appearance of a transient increase in RVOT gradient after iE&iM could be useful to predict response to treatment.

Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model.

Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (Ees) following the development of an acute RV ischemic in a porcine model. HYPOTHESIS: RV pressure monitoring can detect changes in RV systolic performance assess by RV Ees following the development of an acute RV ischemic model. METHODS AND MODELS: Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV Ees obtained using a conductance catheter during inferior vena cava occlusions. RESULTS: Acute ischemia resulted in a significant reduction in RV Ees from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between Ees and RV pressure-derived parameters. The reduction in RV Ees best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dtmax) and single-beat RV Ees. Adjusting RV dP/dtmax for heart rate resulted in an improved surrogate of RV Ees. INTERPRETATION AND CONCLUSIONS: Stepwise decreases in RV Ees during acute ischemic RV dysfunction were accurately tracked by RV dP/dtmax derived from the RV pressure waveform.

Dynamics of electrocorticographic (ECoG) activity in human temporal and frontal cortical areas during music listening.

Previous studies demonstrated that brain signals encode information about specific features of simple auditory stimuli or of general aspects of natural auditory stimuli. How brain signals represent the time course of specific features in natural auditory stimuli is not well understood. In this study, we show in eight human subjects that signals recorded from the surface of the brain (electrocorticography (ECoG)) encode information about the sound intensity of music. ECoG activity in the high gamma band recorded from the posterior part of the superior temporal gyrus as well as from an isolated area in the precentral gyrus was observed to be highly correlated with the sound intensity of music. These results not only confirm the role of auditory cortices in auditory processing but also point to an important role of premotor and motor cortices. They also encourage the use of ECoG activity to study more complex acoustic features of simple or natural auditory stimuli.

Preliminary experience with continuous right ventricular pressure and transesophageal echocardiography monitoring in orthotopic liver transplantation.

BACKGROUND: Despite increasing attention in the cardiac anesthesiology literature, continuous measurement of right ventricular pressure using a pulmonary artery catheter has not been described in orthotopic liver transplantation, despite similarities in the anesthetic approach to the two populations. We describe our preliminary experience with this technique in orthotopic liver transplantation, and by combining various derived measures with trans-esophageal echocardiography, make some early observations regarding the response of these measures of right ventricular function during the procedure. METHODS: In this case series, ten patients (five men and five women) undergoing orthotopic liver transplantation in our institution had their surgeries performed while monitored with a pulmonary artery catheter with continuous right ventricular port transduction and trans-esophageal echocardiography. We recorded various right ventricular waveform (early-to-end diastolic pressure difference, right ventricular outflow tract gradient, right ventricular dP/dT and right ventricular end-diastolic pressure) and echocardiographic (right ventricular fractional area change, tricuspid annular plane systolic excursion, right ventricular lateral wall strain) and described their change relative to baseline at timepoints five minutes before and after portal vein reperfusion, immediately after hepatic artery reperfusion and on abdominal closure. RESULTS: Except for tricuspid annular plane systolic excursion at five minutes prior to reperfusion (mean -0.8 cm; 95% CI-1.4, -0.3; p = 0.007), no echocardiographic metric was statistically significantly different at any timepoint relative to baseline. In contrast, changes in right ventricular outflow tract gradient and right ventricular dP/dt were highly significant at multiple timepoints, generally peaking immediately before or after reperfusion before reducing, but not returning to baseline in the neohepatic phase. Nine of 10 participants in this series demonstrated a degree of dynamic right ventricular outflow tract obstruction, which met criteria for hemodynamic significance (> 25 mmHg) in two participants. These changes were not materially affected by cardiac index. CONCLUSIONS: Dynamic right ventricular outflow tract obstruction of varying severity appears common in patients undergoing orthotopic liver transplantation. These results are hypothesis generating and will form the basis of future prospective research.

Right Ventricular Outflow Tract Obstruction in the Intensive Care Unit: A Case Report of 2 Patients.

Right ventricular outflow tract obstruction (RVOTO) is a rare cause of hemodynamic instability in the intensive care unit (ICU) after cardiac surgery. We report the first cases of RVOTO diagnosed in the ICU using continuous right ventricular pressure waveform monitoring. Our 2 cases reflect both mechanical and dynamic causes of obstruction, each of which require different approaches to treatment. Inotrope use can exacerbate RVOTO caused by dynamic etiology, whereas surgery is usually the treatment of choice for mechanical obstructions. Inability to recognize RVOTO or the correct etiology can lead to hemodynamic compromise and poor outcomes.

Prevalence and Temporal Distribution of Extrasystoles in Septic ICU Patients: The Feasibility of Predicting Fluid Responsiveness Using Extrasystoles.

BACKGROUND: Extrasystoles may be useful for predicting the response to fluid therapy in hemodynamically unstable patients but their prevalence is unknown. The aim of this study was to estimate the availability of extrasystoles in intensive care unit patients diagnosed with sepsis. The study aim was not to validate the fluid responsiveness prediction ability of extrasystoles. METHODS: Twenty-four-hour ECG recordings from a convenience sample of 50 patients diagnosed with sepsis were extracted from the MIMIC-II waveform database, and ECGs were visually examined for correct QRS complex detection. Custom-made algorithms identified potential extrasystoles based on RR intervals. Two raters visually confirmed or rejected the potential extrasystoles and then classified them as ventricular, supraventricular, or unknown origin. Extrasystole availability was calculated as extrasystolic coverage for each 24 h ECG recording, that is, the percentage of the 24 h recording where an extrasystole had occurred in the preceding 30 minutes. RESULTS: Mean extrasystolic coverage was 53.3% (confidence interval: [42.8; 63.6]%) and ventricular extrasystolic coverage was 21.4 [13.5; 29.8]%. Interrater reliability was strong for confirming/rejecting extrasystoles. CONCLUSIONS: Extrasystoles are available for fluid responsiveness prediction in septic patients in about half of the time. With this extrasystolic availability, we believe the method to be considered for clinical use, provided that future studies validate the method's fluid responsiveness prediction ability.

An ensemble boosting model for predicting transfer to the pediatric intensive care unit.

BACKGROUND: Early deterioration indicators have the potential to alert hospital care staff in advance of adverse events, such as patients requiring an increased level of care, or the need for rapid response teams to be called. Our work focuses on the problem of predicting the transfer of pediatric patients from the general ward of a hospital to the pediatric intensive care unit. OBJECTIVES: The development of a data-driven pediatric early deterioration indicator for use by clinicians with the purpose of predicting encounters where transfer from the general ward to the PICU is likely. METHODS: Using data collected over 5.5 years from the electronic health records of two medical facilities, we develop machine learning classifiers based on adaptive boosting and gradient tree boosting. We further combine these learned classifiers into an ensemble model and compare its performance to a modified pediatric early warning score (PEWS) baseline that relies on expert defined guidelines. To gauge model generalizability, we perform an inter-facility evaluation where we train our algorithm on data from one facility and perform evaluation on a hidden test dataset from a separate facility. RESULTS: We show that improvements are witnessed over the modified PEWS baseline in accuracy (0.77 vs. 0.69), sensitivity (0.80 vs. 0.68), specificity (0.74 vs. 0.70) and AUROC (0.85 vs. 0.73). CONCLUSIONS: Data-driven, machine learning algorithms can improve PICU transfer prediction accuracy compared to expertly defined systems, such as a modified PEWS, but care must be taken in the training of such approaches to avoid inadvertently introducing bias into the outcomes of these systems.

ECoG high gamma activity reveals distinct cortical representations of lyrics passages, harmonic and timbre-related changes in a rock song.

Listening to music moves our minds and moods, stirring interest in its neural underpinnings. A multitude of compositional features drives the appeal of natural music. How such original music, where a composer's opus is not manipulated for experimental purposes, engages a listener's brain has not been studied until recently. Here, we report an in-depth analysis of two electrocorticographic (ECoG) data sets obtained over the left hemisphere in ten patients during presentation of either a rock song or a read-out narrative. First, the time courses of five acoustic features (intensity, presence/absence of vocals with lyrics, spectral centroid, harmonic change, and pulse clarity) were extracted from the audio tracks and found to be correlated with each other to varying degrees. In a second step, we uncovered the specific impact of each musical feature on ECoG high-gamma power (70-170 Hz) by calculating partial correlations to remove the influence of the other four features. In the music condition, the onset and offset of vocal lyrics in ongoing instrumental music was consistently identified within the group as the dominant driver for ECoG high-gamma power changes over temporal auditory areas, while concurrently subject-individual activation spots were identified for sound intensity, timbral, and harmonic features. The distinct cortical activations to vocal speech-related content embedded in instrumental music directly demonstrate that song integrated in instrumental music represents a distinct dimension in complex music. In contrast, in the speech condition, the full sound envelope was reflected in the high gamma response rather than the onset or offset of the vocal lyrics. This demonstrates how the contributions of stimulus features that modulate the brain response differ across the two examples of a full-length natural stimulus, which suggests a context-dependent feature selection in the processing of complex auditory stimuli.

CortiQ - clinical software for electrocorticographic real-time functional mapping of the eloquent cortex.

Planning for epilepsy surgery depends substantially on the localization of brain cortical areas responsible for sensory, motor, or cognitive functions, clinically also known as eloquent cortex. In this paper, we present the novel software package 'cortiQ' that allows clinicians to localize eloquent cortex, thus providing a safe margin for surgical resection with a low incidence of neurological deficits. This software can be easily used in addition to traditional mapping procedures such as the electrical cortical stimulation (ECS) mapping. The software analyses task-related changes in gamma activity recorded from implanted subdural electrocorticography electrodes using extensions to previously published methods. In this manuscript, we describe the system's architecture and workflow required to obtain a map of the eloquent cortex. We validate the system by comparing our mapping results with those acquired using ECS mapping in two subjects. Our results indicate that cortiQ reliably identifies eloquent cortex much faster (several minutes compared to an hour or more) than ECS mapping. Next-neighbour analyses show that there are no false positives and an average of 1.24% false negatives.