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.

Assessing Splanchnic Compartment Using Portal Venous Doppler and Impact of Adding It to the EVEREST Score for Risk Assessment in Heart Failure.

BACKGROUND: The Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan (EVEREST) score has proven useful for risk prediction in acute decompensated heart failure (ADHF). However, this score does not include the characterization of the splanchnic compartment, which has been involved in worsening heart failure. Refining this score by integrating an assessment of the splanchnic compartment would allow for a better risk assessment. Therefore, we aimed to characterize the patterns of portal vein pulsatility (PVP), an ultrasound metric used for the assessment of splanchnic compartment and their determinants in patients with ADHF, to explore the relationships between abnormal patterns of PVP and outcomes, and to evaluate the added value of PVP to the EVEREST score for risk assessment in ADHF. METHODS: Portal vein flow was assessed prospectively on admission and at discharge in 95 patients with ADHF using pulsed-wave Doppler. Abnormal PVP was defined for values ≥ 50%. Cox proportional hazards models were used for the assessment of the relationship between PVP and outcomes. RESULTS: Overall, 64% of patients on admission and 24% at discharge had abnormal PVP. PVP on admission was inversely correlated with right ventricular function (tricuspid annular plane systolic excursion, ρ = -0.434) and pulmonary pressure (ρ = 0.346), P < 0.05. Although PVP was associated with all-cause mortality (hazard ratio, 1.028, P < 0.001), the addition of this metric to the EVEREST score had little effect on its C-index (0.813 vs 0.818) for risk assessment. CONCLUSIONS: Abnormal PVP is frequent and associated with right ventricular dysfunction in ADHF. Although abnormal PVP identifies higher-risk patients, this metric does not improve the performance of the EVEREST score for risk assessment.

CONTEXTE: Le score EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan) s'avère utile pour la prévision du risque dans les cas d'insuffisance cardiaque décompensée aiguë (ICDA). Cependant, ce score ne permet pas de caractériser le compartiment splanchnique, impliqué dans l'aggravation de l'insuffisance cardiaque. Affiner ce score en y intégrant une évaluation du compartiment splanchnique permettrait une meilleure évaluation du risque. Par conséquent, nous avons entrepris de caractériser les profils de la pulsatilité du flux de la veine porte (PFVP) (mesure échographique permettant d'évaluer le compartiment splanchnique et ses déterminants dans les cas d'ICDA) afin d'examiner les relations entre les profils anormaux de la PFVP et les résultats, et afin d'évaluer la valeur ajoutée de la PFVP dans l'évaluation du risque faisant appel au score EVEREST chez des patients atteints d'ICDA. MÉTHODOLOGIE: Le flux de la veine porte a été évalué prospectivement par échographie Doppler pulsée à l'admission et à la sortie de 95 patients atteints d'ICDA. La définition d'une PFVP anormale ciblait des valeurs de 50 % ou plus. Des modèles à risques proportionnels de Cox ont servi à évaluer la relation entre la PFVP et les résultats. RÉSULTATS: Globalement, la PFVP était anormale à l'admission chez 64 % des patients et à la sortie chez 24 % des patients. Une corrélation inverse a été notée entre la PFVP à l'admission et la fonction ventriculaire droite (excursion annulaire horizontale systolique de la tricuspide, ρ = -0,434) ainsi que la pression pulmonaire (ρ = -0,346), p < 0,05. Bien que la PFVP ait été associée à la mortalité toutes causes confondues (rapport des risques instantanés de 1,028, p < 0,001), l'ajout de cette mesure au score EVEREST a eu peu d'effet sur son indice C (0,813 vs 0,818) pour l'évaluation du risque. CONCLUSIONS: Une PFVP anormale est d'observation courante et se trouve associée à une dysfonctionn ventriculaire droite dans les cas d'ICDA. Bien qu'une PFVP anormale permette de déceler les patients qui présentent un risque plus élevé, son objectivation n'améliore pas la précision du score EVEREST dans l'évaluation du risque.

Assessment of Left Ventricular Diastolic Function by Transesophageal Echocardiography Before Cardiopulmonary Bypass: Clinical Implications of a Restrictive Profile.

OBJECTIVE: Left ventricular (LV) diastolic function can be assessed by transesophageal echocardiography before cardiopulmonary bypass in the setting of cardiac surgery. The objective of this study was to determine whether the assessment of LV diastolic dysfunction (LVDD) improves mortality risk prediction. DESIGN: Retrospective single-center cohort study. SETTING: Single tertiary cardiac surgery center. PARTICIPANTS: Data from patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) and for which an evaluation for LVDD was performed before CPB between February 1999 and November 2015. INTERVENTIONS: Cases were reviewed retrospectively from a transesophageal echocardiography hemodynamic database. LV diastolic function was graded as normal, impaired relaxation (grade 1), pseudo-normalization (grade 2), or restrictive (grade 3) determined by mitral inflow waves, tissue Doppler imaging of the mitral annulus, and pulmonary venous flow. The main outcome was in-hospital mortality. MEASUREMENTS AND MAIN RESULTS: A total of 760 patients were included, 144 (18.9%) patients with normal diastolic function, 331 (43.6%) patients with grade 1 LVDD, 218 (28.7%) patients with grade 2 LVDD, and 67 (8.8%) patients with grade 3 LVDD. In-hospital mortality occurred in 31 patients (4.1%). The presence of grade 3 LVDD was associated with an increased likelihood of in-hospital mortality (odds ratio [OR]: 19.39, confidence interval [CI]: 2.37-158.48, p = 0.006). In contrast, LV systolic dysfunction was not independently associated with increased mortality. When added to the Parsonnet score, the addition of diastolic function resulted in a net reclassification improvement of in-hospital mortality (NRI: 0.419 CI: 0.049-0.759, p = 0.02), and in integrated discrimination improvement (IDI: 0.0179 CI: 0.0049-0.031, p = 0.007). Difficult separation from CPB was observed more frequently in patients with grade 3 LVDD (62.9% v 36.1%, p = 0.01). CONCLUSIONS: In contrast to LV systolic dysfunction, restrictive LVDD is associated with an increased risk of in-hospital mortality in cardiac surgical patients. Further studies should explore how this information may be used by the attending anesthesiologist to tailor perioperative management.

Acute Kidney Injury Due to Inferior Vena Cava Stenosis After Liver Transplantation: A Case Report About the Importance of Hepatic Vein Doppler Ultrasound and Clinical Assessment.

RATIONALE: Acute kidney injury (AKI) is a frequent complication after liver transplantation. In some patients, prompt intervention targeted at a specific etiology is of paramount importance. PRESENTING CONCERNS OF THE PATIENTS: A 25 years old man with advanced liver cirrhosis caused by sclerosing cholangitis and autoimmune hepatitis underwent orthotopic liver transplantation. One month after surgery, severe AKI developed in conjunction with recurrent ascites and lower extremity edema. Notable clinical findings included a persistently low urinary sodium excretion, a bland urinary sediment, and an abnormally monophasic hepatic vein waveform on Doppler ultrasound. DIAGNOSES: Inferior vena cava stenosis. INTERVENTIONS: Angioplasty with stent installation. OUTCOMES: Rapid improvement of renal function after stent installation. LESSONS LEARNED: The following case illustrates the importance of integrating clinical cues, ultrasound features, and laboratory findings. The combination of AKI associated with lower extremity edema, abnormal monophasic hepatic vein flow on Doppler ultrasound, and a low urinary sodium excretion after liver transplantation should evoke the possibility of inferior vena cava stenosis as the etiologic factor.

FONDEMENT: L'insuffisance rénale aiguë (IRA) est une complication survenant fréquemment à la suite d'une greffe hépatique. Pour certains patients, une intervention rapide et ciblée sur l'étiologie spécifique s'avère d'une importance capitale. PRÉSENTATION DU CAS: Un homme âgé de 25 ans atteint d'une cirrhose hépatique avancée causée par une cholangite sclérosante et une hépatite auto-immune a subi une greffe hépatique orthotopique. Un mois après l'intervention, le patient a développé une sévère IRA conjointement à des ascites récurrentes et un œdème des membres inférieurs. Parmi les principales manifestations cliniques figuraient la persistance d'une faible excrétion urinaire du sodium, la présence de sédiments urinaires neutres et une forme d'onde anormalement monophasique pour la veine hépatique à l'échographie Doppler. DIAGNOSTIC: Sténose de la veine cave inférieure. INTERVENTION: Angioplastie avec implantation d'une endoprothèse vasculaire. RÉSULTATS: Amélioration rapide de la fonction rénale à la suite de l'implantation de l'endoprothèse vasculaire. ENSEIGNEMENTS TIRÉS: Ce cas illustre l'importance d'intégrer les indicateurs cliniques, les informations obtenues à l'échographie et les résultats de laboratoire. L'IRA survenant à la suite d'une greffe hépatique, lorsqu'elle est associée à de l'œdème des membres inférieurs, à des ondes anormalement monophasiques de la veine hépatique à l'échographie Doppler, de même qu'à une faible excrétion urinaire de sodium, devrait évoquer la possibilité d'une sténose de la veine cave inférieure comme facteur étiologique.

A Simplified Approach to Extravascular Lung Water Assessment Using Point-of-Care Ultrasound in Patients with End-Stage Chronic Renal Failure Undergoing Hemodialysis.

BACKGROUND: Fluid overload leading to pulmonary congestion is an important issue in patients undergoing hemodialysis. This study aimed to determine if a simplified method of extravascular lung water assessment using ultrasound provided clinically relevant information. METHODS: This prospective study recruited 47 patients from a single hemodialysis center. Pulmonary ultrasound was performed before and after 2 hemodialysis sessions in 28 regions on the thorax. The B-line score was defined as the percentage regions where B-lines were present. RESULTS: When B-lines were detected before hemodialysis, a significant relationship was found between fluid removal and the change in B-line score. Patients with a B-line score of ≥21.4% (4th quartile) after the second hemodialysis session were more likely to be hospitalized for pulmonary edema or acute coronary syndrome. CONCLUSIONS: A simplified pulmonary assessment using ultrasound provides relevant information about pulmonary congestion in hemodialysis patients and identifies patients at risk of hospitalization for heart-related problems.

Assessment of fluid responsiveness with end-tidal carbon dioxide using a simplified passive leg raising maneuver: a prospective observational study.

BACKGROUND: Assessing fluid responsiveness is important in the management of patients with hemodynamic instability. Passive leg raising (PLR) is a validated dynamic method to induce a transient increase in cardiac preload and predict fluid responsiveness. Variations in end-tidal carbon dioxide (ETCO2) obtained by capnography correlate closely with variations in cardiac output when alveolar ventilation and carbon dioxide production are kept constant. In this prospective observational study, we tested the hypothesis that variations in ETCO2 induced by a simplified PLR maneuver can track changes in the cardiac index (CI) and thus predict fluid responsiveness. METHOD: A five-minute standardized PLR maneuver was performed in 90 paralyzed hemodynamically stable cardiac surgical patients receiving mechanical ventilation. Cardiac index was measured by thermodilution before and one minute after PLR. End-tidal CO2 measurements using capnography were obtained during the entire PLR maneuver. Fluid responsiveness was defined as a 15% increase in the CI. The Chi square test and Student's t test were used to compare responders and non-responders. Logistic regression analyses were then performed to determine factors of responsiveness. RESULTS: There were no differences between responders and non-responders in demographic and baseline hemodynamic variables. Fluid responsiveness was associated with an ETCO2 variation (ΔETCO2) of ≥ 2 mmHg during PLR [odds ratio (OR), 7.3; 95% confidence interval (CI), 2.7 to 20.2; P < 0.01; sensitivity 75%]. A low positive predictive value (54%) and a high negative predictive value (NPV) (86%) were observed. No other clinical or hemodynamic predictors were associated with fluid responsiveness. A logistic regression model established that a combination of ΔETCO2 ≥ 2 mmHg and a change in systolic blood pressure ≥ 10 mmHg induced by passive leg raising was predictive of fluid responsiveness (OR, 8.9; 95% CI, 2.5 to 32.2; P = 0.005). CONCLUSION: Use of a passive leg raising maneuver to induce variation in ETCO2 is a noninvasive and useful method to assess fluid responsiveness in paralyzed cardiac surgery patients receiving mechanical ventilation. Given its high NPV, fluid responsiveness is unlikely if a passive leg raising maneuver induces ΔETCO2 of < 2 mmHg.

The right ventricle in cardiac surgery, a perioperative perspective: I. Anatomy, physiology, and assessment.

The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in heart failure, congenital heart disease, valvular disease, and cardiac surgery. In the first of our two articles, we will review key features of RV anatomy, physiology, and assessment. In the first article, the main discussion will be centered on the echographic assessment of RV structure and function. In the second review article, pathophysiology, clinical importance, and management of RV failure in cardiac surgery will be discussed.

Expert consensus for training in perioperative echocardiography in the province of Quebec.

PURPOSE: Establish an expert consensus for training in perioperative echocardiography in the province of Quebec. METHODS: Cardiac anesthesiologists practicing in the province of Quebec with expertise in echocardiography were involved in the development of a multicentre expert consensus on training in perioperative echocardiography. Guidelines for training in adult echocardiography, transesophageal echocardiography and perioperative echocardiography by the American Society of Echocardiography (ASE), the American College of Cardiology (ACC) and/or the Society of Cardiovascular Anesthesiologists (SCA) were reviewed. RESULTS: A basic, advanced and director level of expertise were identified for training in perioperative echocardiography. The total number of echocardiographic examinations to achieve each of these levels of expertise remains unchanged from the 2002 ASE-SCA guidelines. However, the recommended proportion of examinations performed personally is increased in the Quebec expert consensus for both the basic and the advanced level of training to ensure proficiency in echocardiography while providing anesthesia care to the patient. A level of autonomy in perioperative echocardiography is also identified in the basic level of training as defined in the Quebec expert consensus. Maintenance of competence, certification in the perioperative transesophageal echocardiography (PTE) examination and duration of training are outlined for each of the three levels of training in the Quebec expert consensus but are not part of the recent 2002 ASE-SCA guidelines. CONCLUSION: Adequate perioperative echocardiographic training is an important aspect of cardiovascular anesthesia. The ACC, ASE and SCA guidelines for training in echocardiography were modified to reflect the expert consensus of anesthesiologists in the province of Quebec.