The clinical performance of midline catheters-An observational study.

BACKGROUND: The use of peripheral venous catheters (PVCs) is hampered by short dwell time, and central venous catheters (CVCs) are often preferred for medium- to long-time intravenous treatment. Ultrasound techniques allow for easy catheter insertion into the major veins of the upper arm. A new generation of midline catheters, PowerGlide Pro, utilises a one-hand Seldinger technique and can be inserted by one single operator without assistance. This study aimed to evaluate the clinical performance of the PowerGlide Pro midline catheter. METHODS: Consecutively inserted midline catheters were followed in a prospective, observational quality control study. Endpoints were dwell time, the incidence of premature catheter removal, causes of catheter removal and the dwell time and incidence rates of predefined subgroups representing potential effect modifiers. RESULTS: Hundred midline catheters, of which 98 were accessible to follow-up, were inserted in 70 patients. Median dwell time was 8 days and 60 catheters were removed before the indication for intravenous therapy had ceased. The overall incidence for premature catheter removal was 71.8/1000 days and no significant effects of subgroups (sex, body mass index, catheter reinsertions, significant comorbidity, anticoagulant therapy, irritant infusions) were identified for either dwell time or the incidence rate for premature midline catheter removal. The most frequent reasons for premature catheter removal were pain during infusion, clotted catheter or signs of infection. CONCLUSION: The median dwell time of the midline catheters was 8 days with substantial variation, whereas the incidence for premature catheter removal was 71.8/1000 catheter days. The majority of midline catheters were removed prematurely.

Point-of-care ultrasound findings in unselected patients in an emergency department -results from a prospective observational trial.

BACKGROUND: Point-of-care ultrasound (POCUS) can improve patient management in the emergency department (ED). However, previous studies have focused only on selected groups of patients, such as trauma, shock, dyspnea, or critically ill patients, or patients with an already known diagnosis. Most patients seen in the ED do not match these criteria. We aim to present total prevalence of positive findings when basic POCUS is applied to the broad population of patients seen in an emergency department. METHODS: We conducted a single-center prospective explorative observational study of 405 unselected patients aged 18 years or over. A structured whole-body ultrasound examination was performed on all patients within 2 h of arrival to the ED. The ultrasound examination consisted of focused cardiac ultrasound, focused abdominal ultrasound, focused assessment with sonography for trauma (FAST), and focused lung ultrasound. RESULTS: We managed to perform 94.5% of all planned examinations. The study revealed positive findings in 39.3% of all included patients. This study presents the prevalence of positive findings among subgroups of patients. Divided among the categories of chief complaint, we found 62 positive examinations in 58 (14.3%; 95% CI, 10.9-17.7) unique patients with orthopedic complaints, 77 positive examinations among 59 (14.6%; 95% CI, 11.1-18.0) unique patients with medical complaints, and 55 positive examinations among 42 (10.4%; 95% CI, 7.4-13.3) unique patients with abdominal surgical complaints. CONCLUSION: POCUS revealed positive findings in more than one third of unselected patients in the emergency department. The study presents the findings and distribution among categories of chief complaints. Future investigations are necessary to elucidate the implication of the findings.

A successful model to learn and implement ultrasound-guided venous catheterization in apheresis.

BACKGROUND: Apheresis treatments can be performed with peripheral venous catheters (PVC), although central venous catheters (CVC) are inserted when PVCs fail or patient with history of difficult vascular access prior to the apheresis. Ultrasound guidance for PVC has shown promising results in other settings. PURPOSE: To investigate if ultrasound guidance for PVC could be implemented among apheresis nurses. Second, how implementation of ultrasound guidance affected the number of CVCs used for apheresis per patient. METHOD: Apheresis nurses completed a systematic training program for ultrasound-guided vascular access. All independent catheterizations were registered during the implementation stage. The number of CVCs in the pre- and postimplementation stages of the ultrasound guidance was compared. RESULTS: Six nurses completed the training program within a median of 48 days (range 38-83 days). In 77 patients, 485 independent ultrasound-guided PVC placements were performed during the implementation stage. All apheresis treatments (485/485) were accomplished using PVCs without requiring CVC as rescue. During the preimplementation stage, 125 of 273 (45.8%) procedures required a CVC for completion of apheresis procedures; during the postimplementation stage only 30 of 227 (13.2%) procedures required a CVC (p < 0.001). In the postimplementation stage, no CVCs were placed as rescue caused by failed PVCs but were only placed for patients where the ultrasound machine was unavailable. It indicates an effective success rate of 100% for ultrasound-guided PVC use. CONCLUSION: This study showed that ultrasound guidance could be implemented among apheresis nurses as a routine tool eliminating the need of CVC as a rescue.

Effects of Progressive Hypoventilation on Left Ventricular Appearance: An Alternative Etiology of Acute Sonographic Short-Axis D-Shaping.

OBJECTIVES: The purpose of this study was to evaluate the effects of progressive hypoventilation on echocardiographic measures of the left ventricular (LV) appearance in a porcine model. METHODS: Ten piglets were included in the experimental group, and 5 served as controls. The experimental group underwent 3 interventions of progressive hypoventilation (baseline: tidal volume, 240 mL; respiratory frequency, 16 minutes-1 ; first intervention: tidal volume, 240 mL; respiratory frequency, 8 minutes-1; second intervention: tidal volume, 240 mL; respiratory frequency, 4 minutes-1 ; and third intervention: tidal volume, 120 mL; respiratory frequency, 4 minutes-1 ). Respiratory resuscitation was initiated if the MAP decreased to 50% of the baseline level or at the end of the third intervention. Transthoracic sonography and invasive measurements were obtained throughout. The primary end point was the LV end-diastolic eccentricity index, a measure of LV D-shaping. RESULTS: The median LV end-diastolic eccentricity index increased from 1.1 (interquartile range, 1.0-1.1) at baseline to 1.4 (1.3-1.4) 3 minutes after the third intervention (P < .001) and returned to baseline after resuscitation (P = .093). The MAP declined from 87 mm Hg (81-92 mm Hg) to 50 mmHg (33-66 mm Hg) after initiation of the third intervention (P < .001). The mean pulmonary arterial pressure increased from 20 mm Hg (15-21 mm Hg) to 39 mm Hg (38-40 mm Hg) during the second intervention (P < .001). CONCLUSIONS: Progressive hypoventilation led to a marked D-configuration of the LV and a sharp decrease in systemic blood pressure. After respiratory resuscitation, sonographic measures normalized. These findings were explainable by the pressure changes observed within the left and right ventricles.

Dobutamine aggravates haemodynamic deterioration induced by pleural effusion: A randomised controlled porcine study.

BACKGROUND: Pleural effusion is a common finding in critically ill patients and may contribute to circulatory instability and the need for inotropic support. OBJECTIVE: We hypothesised that dobutamine would affect the physiological determinants preload, afterload, contractility and changes of inferior vena cava characteristics during experimental pleural effusion. DESIGN: A randomised, controlled laboratory study. SETTING: Animal laboratory, conducted from March 2013 to May 2013. ANIMALS: Twenty-four Landrace and Yorkshire female piglets (21.3 ±â€Š1.7 kg). INTERVENTION: Twenty piglets were included in the analyses. After inducing bilateral pleural effusion (30 ml kg), the piglets were block randomised to either incremental dobutamine infusion (n = 10) or control (n = 10). MAIN OUTCOME MEASURES: Ultrasonographic measures of left ventricular end-diastolic area, left ventricular afterload, left ventricular fractional area change and inferior vena cava diameter and distensibility were used to assess the basic physiological effect of incremental dobutamine administration during experimental pleural effusion. RESULTS: In the dobutamine group, preload, measured as left ventricular end-diastolic area, decreased from 11.3 ±â€Š2.0 cm after creation of the pleural effusion to 8.1 ±â€Š1.5 cm at a dobutamine infusion rate of 20 µg kg min (P < 0.001). In the same period, central venous pressure and the expiratory diameter of the inferior vena cava decreased from 9 ±â€Š3 to 7 ±â€Š4 mmHg (P < 0.001) and from 1.1 ±â€Š0.2 to 0.9 ±â€Š0.1 cm (P = 0.008), respectively. CONCLUSION: In a porcine model of pleural effusion, dobutamine affected basic haemodynamic determinants substantially by decreasing left ventricular preload. Changes in central venous pressure and inferior vena cava characteristics were minimal, discouraging their use as indices of preload. This study underlines the significance of evaluating basic haemodynamic determinants to avoid inappropriate, potentially harmful treatment.

Transthoracic echocardiography in the perioperative setting.

PURPOSE OF REVIEW: A need for further assessment of patients in the perioperative setting and an increasing availability of ultrasonography equipment have facilitated the diffusion of ultrasonography and lately focused transthoracic echocardiography (TTE) in anesthesiology practice. This review will discuss the possible use of focused TTE in the perioperative setting and provides an update on present and future perspectives. RECENT FINDINGS: Several studies focusing on patient management and diagnostic accuracy of perioperative, focused TTE, have been published recently. Several multidisciplinary guidelines addressing use and educational aspects of focused ultrasonography are available, yet guidelines focusing solely on the use in the perioperative setting are lacking. SUMMARY: Hemodynamically significant cardiac disease or pathophysiology can be disclosed using TTE. Focused TTE is feasible for perioperative patient management and monitoring and will be an inevitable and indispensable tool for the anesthetist. Future research should focus on the outcome of perioperative TTE performed by anesthetists, using rigorous study designs and patient-centered outcomes such as mortality and morbidity.

Follow-Up After Cardiac Surgery Should be Extended to at Least 120 Days When Benchmarking Cardiac Surgery Centers.

OBJECTIVE: Short-term (30 days) mortality frequently is used as an outcome measure after cardiac surgery, although it has been proposed that the follow-up period should be extended to 120 days to allow for more accurate benchmarking. The authors aimed to evaluate whether mortality rates 120 days after surgery were comparable to general mortality and to compare causes of death between the cohort and the general population. DESIGN: A multicenter descriptive cohort study using prospectively entered registry data. SETTING: University hospital. The cohort was obtained from the Western Denmark Heart Registry and matched to the Danish National Hospital Register as well as the Danish Register of Causes of Death. A weighted, age-matched general population consisting of all Danish patients who died within the study period was identified through the central authority on Danish statistics. PARTICIPANTS: A total of 11,988 patients (>15 years) who underwent cardiac-surgery at Aarhus, Aalborg and Odense University Hospitals from April 1, 2006 to December 31, 2012 were included. INTERVENTIONS: Coronary artery bypass grafting, valve surgery and combinations. MEASUREMENTS AND MAIN RESULTS: Mortality after cardiac surgery matches with mortality in the general population after 140 days. Mortality curves run almost parallel from this point onwards, regardless of The European system for cardiac operative risk evaluation (EuroSCORE) and intervention. The causes of death in the cohort differed statistically significantly from the background population (p<0.0001; one-sample t-test) throughout the first postoperative year. The leading cause of death in the cohort was cardiac (38%); 53% of which was categorized as heart failure. A total of 54% of these patients were assessed preoperatively as having normal or mildly impaired heart function (EuroSCORE). CONCLUSIONS: This study supported an extended follow-up period after cardiac surgery when benchmarking cardiac surgery centers. Regardless of preoperative heart function, heart failure was the consistent leading cause of death.

No significant effect of angiotensin II receptor blockade on intermediate cardiovascular end points in hemodialysis patients.

Agents blocking the renin-angiotensin-aldosterone system are frequently used in patients with end-stage renal disease, but whether they exert beneficial cardiovascular effects is unclear. Here the long-term effects of the angiotensin II receptor blocker, irbesartan, were studied in hemodialysis patients in a double-blind randomized placebo-controlled 1-year intervention trial using a predefined systolic blood pressure target of 140 mm Hg (SAFIR study). Each group of 41 patients did not differ in terms of age, blood pressure, comorbidity, antihypertensive treatment, dialysis parameters, and residual renal function. Brachial blood pressure decreased significantly in both groups, but there was no significant difference between placebo and irbesartan. Use of additional antihypertensive medication, ultrafiltration volume, and dialysis dosage were not different. Intermediate cardiovascular end points such as central aortic blood pressure, carotid-femoral pulse wave velocity, left ventricular mass index, N-terminal brain natriuretic prohormone, heart rate variability, and plasma catecholamines were not significantly affected by irbesartan treatment. Changes in systolic blood pressure during the study period significantly correlated with changes in both left ventricular mass and arterial stiffness. Thus, significant effects of irbesartan on intermediate cardiovascular end points beyond blood pressure reduction were absent in hemodialysis patients.

Development of left ventricular hypertrophy in a novel porcine model of mitral regurgitation.

OBJECTIVES: We aimed to develop a porcine model for chronic nonischemic mitral regurgitation (MR) to investigate left ventricular (LV) enlargement and eccentric hypertrophy. DESIGN: Nonischemic MR was induced in 30 pigs by open-chest immobilization of the posterior mitral leaflet by transannular traction sutures that where applied in transmyocardial fashion. A sham operated control group (n = 13) was included. Echocardiographic LV size and heart weight assessed at euthanasia were used to evaluate the development of LV enlargement and eccentric hypertrophy after 8 weeks follow-up. RESULTS: Eight pigs died and seven were excluded due to mediastinal infection (n = 2) or failure to produce MR (n = 5). Thus, 28 pigs were included and were divided into three groups: controls (n = 12), mild MR (mMR; n = 10), and moderate to severe MR (sMR; n = 6). The change in LV internal diameter in diastole (LVIDd) from baseline to follow-up was significantly higher in the sMR group compared to that of the control group (P = 0.0017). Furthermore, LV weight was significantly increased in the mMR (P = 0.047) and the sMR (P = 0.0087) groups compared to that of the control group. CONCLUSIONS: A new model for chronic moderate to severe nonischemic MR with development of LV enlargement and eccentric hypertrophy within 8 weeks has been established in pigs.

Drainage of large pleural effusions increases left ventricular preload.

OBJECTIVES: The aim of the study was to investigate if pleurocentesis in patients with pleural effusion would lead to changes in systolic and diastolic function of the left ventricle. DESIGN: The study was descriptive, and patients were their own controls. SETTING: The setting was a single-center university hospital. PARTICIPANTS: Patients with pleural effusion requiring pleurocentesis were eligible for inclusion. INTERVENTIONS: The participants who had pleurocentesis performed were available for analysis. MEASUREMENTS AND MAIN RESULTS: Prior to pleurocentesis and approximately 1 hour after, patients were examined primarily with transthoracic echocardiography. The examination included measurements of left ventricular volumes and measures of diastolic function assessed by Doppler echocardiography. Thirty-five patients were included, and 11 later were excluded, yielding a study population of 24. Preload, expressed as left ventricular end-diastolic volume, increased significantly from before to after pleurocentesis (p=0.014). None of the diastolic parameters showed significant results. Significant changes were observed for heart rate, supplementary O2, respiratory frequency, and saturation. CONCLUSIONS: Pleurocentesis increased left ventricular preload and improved respiratory function.

Positive end-expiratory pressure influences echocardiographic measures of diastolic function: a randomized, crossover study in cardiac surgery patients.

BACKGROUND: Ultrasonography of the cardiovascular system is pivotal for hemodynamic assessment. Diastolic function is evaluated with a combination of tissue Doppler (e' and a') and pulsed Doppler (E and A) measures of transmitral- and mitral valve annuli velocities. However, accurate echocardiographic evaluation in the intensive care unit or perioperative setting is contingent on relative resistance to positive pressure ventilation and changes in preload. This study aimed to evaluate the effects of positive end-expiratory pressure (PEEP) and positioning on echocardiographic measures of diastolic function. METHODS: The study was a prospective, randomized, crossover study. Cardiac surgery patients with ejection fraction greater than 45% and averaged e' of 9 or more were included. Postoperatively, anesthetized patients were randomized into six combinations of PEEP (0, 6, 12 cm H2O) and positions (horizontal, Trendelenburg). At each combination, e' (primary endpoint), a', E, and A were obtained with transesophageal echocardiography along with left ventricular area. Image analysis was performed blinded to the protocol. RESULTS: Thirty patients completed the study. PEEP decreased lateral e' from 6.6±3.6 to 5.3±3.0 cm/s (P<0.001) in the horizontal position and from 7.4±4.2 to 6.5±3.3 cm/s (P<0.001) in Trendelenburg. Similar results were found for septal e', a' bilaterally and transmitral pulsed Doppler measures, and PEEP decreased left ventricular area. E/A, E/e', and e'/a' remained unaffected by PEEP and positioning. CONCLUSIONS: When evaluating diastolic function by echocardiography, the levels of PEEP and its effect on ventricular area have to be taken into account. In addition, this study dissuades the use of E/e' for tracking changes in left ventricular filling pressures in cardiac surgery patients.

Point-of-care ultrasonography changes patient management following open heart surgery.

OBJECTIVES: Although pericardial effusions (PE) and pleural effusions (PLE) may lead to life-threatening respiratory and circulatory deterioration following open heart surgery the postoperative frequency is not fully recognized. The diagnosis is typically based on ultrasonography, X-ray or computer tomography and often disclosed when circulatory collapse is evident. Point-of-care (POC) ultrasonography protocols constitute a noninvasive evaluation of the cardiopulmonary status. We hypothesized that POC ultrasonography could diagnose unknown PE and PLE. DESIGN: Patients scheduled for open heart surgery were eligible for inclusion. Baseline evaluation including POC examination and dyspnea score was performed one day prior to surgery and repeated on the 4th and 30th postoperative day. RESULTS: Eighty patients were included and complete follow-up was 80%. Thirteen patients (19%) had PE on the 4th day postsurgery and 19 patients (30%) had PE on the 30th day. Ultrasonography facilitated change in management in one patient with PE requiring drainage. Forty-nine patients (70%) had PLE on the 4th day following surgery and 19 patients (30%) had PLE on the 30th postoperative day. Ultrasonography facilitated a change in management in seven patients with PLE requiring drainage. CONCLUSION: POC ultrasonography detected pathology, otherwise undisclosed, and was responsible for a change in management in a considerable number of cases.

Animal laboratory training improves lung ultrasound proficiency and speed.

BACKGROUND: Although lung ultrasound (US) is accurate in diagnosing pneumothorax (PTX), the training requirements and methods necessary to perform US examinations must be defined. OBJECTIVE: Our aim was to test whether animal laboratory training (ALT) improves the diagnostic competency and speed of PTX detection with US. METHODS: Twenty medical students without lung US experience attended a 1-day course. Didactic, practical, and experimental lectures covered the basics of US physics, US machines, and lung US, followed by hands-on training to demonstrate the signs of normal lung sliding and PTX. Each student's diagnostic skill level was tested with three subsequent examinations (at day 1, day 2, and 6-month follow-up) using experimentally induced PTX in porcine models. The outcome measures were sensitivity and specificity for US detection of PTX, self-reported diagnostic confidence, and scan time. RESULTS: The students improved their skills between the initial two examinations: sensitivity increased from 81.7% (range 69.1%-90.1%) to 100.0% (range 94.3%-100.0%) and specificity increased from 90.0% (range 82.0%-94.8%) to 98.9% (range 92.3%-100.0%); with no deterioration 6 months later. There was a significant learning curve in choosing the correct answers (p = 0.018), a 1-point increase in the self-reported diagnostic confidence (7.8-8.8 on a 10-point scale; p < 0.05), and a 1-min reduction in the mean scan time per lung (p < 0.05). CONCLUSIONS: Without previous experience and after undergoing training in an animal laboratory, medical students improved their diagnostic proficiency and speed for PTX detection with US. Lung US is a basic technique that can be used by novices to accurately diagnose PTX.

Ultrasound of the inferior vena cava does not predict hemodynamic response to early hemorrhage.

BACKGROUND: Ultrasonographic evaluation of the inferior vena cava (IVC) provides information on central hemodynamics and predicts fluid responsiveness during positive pressure ventilation. In spontaneously breathing patients, the correlations between IVC dynamics and the hemodynamic response to volume shifts remain to be described. OBJECTIVES: We aimed to describe the correlation between IVC dynamics and the changes in cardiac output (CO) caused by controlled hemorrhage. METHODS: Healthy donors from the blood bank were eligible for inclusion. Measurements of the IVC and CO were performed before and immediately after blood donation using ultrasound methods. A control group served to evaluate the effect of resting. RESULTS: Thirty-seven participants completed the study. IVC collapsibility index (IVC-CI) and IVC end expiratory diameter (IVCe) both changed significantly after blood donation (p < 0.001). The baseline IVC-CI and IVCe did not correlate with the change in CO (p-values ≥ 0.40). The alterations in IVC-CI and IVCe induced by blood donation also did not correlate with the change in CO (p ≥ 0.71). The sensitivities of IVC-CI or IVCe, defined as an increase in IVC-CI and a decrease in IVCe, for picking up any decrease in CO were 81.3% and 84.4%, respectively. In the control group, no effect was seen between measurements. CONCLUSION: IVC-CI and IVCe did not correlate with the magnitude of hemodynamic response to early hemorrhage. The sensitivity of serial IVC measurements was approximately 80% for detecting early blood loss.

Echocardiographic evaluation of systolic and diastolic function: a preoperative study of correlation with serum NT-proBNP.

OBJECTIVE: The authors hypothesized that preoperative N-terminal probrain natriuretic peptide (NT-proBNP) correlates well with longitudinal strain measurements and with Doppler measurements of diastolic function. DESIGN: Prospective observational study. SETTING: University teaching hospital. PARTICIPANTS: Forty patients undergoing elective cardiac surgery. INTERVENTIONS: Aortic valve replacement, coronary artery bypass grafting, or a combination of these procedures. MEASUREMENTS AND MAIN RESULTS: Plasma NT-proBNP concentration was obtained by analyzing blood samples with a commercially available kit. Left ventricular systolic function was assessed by speckle tracking ultrasound strain measurements and left ventricular diastolic function was assessed by 2 Doppler methods: E/A ratio and E/E' ratio. Tissue Doppler imaging velocities (E' and A') were measured in the basal septum (annular) and pulse-wave Doppler was used to measure mitral in-flow profile (E and A). The correlation between global strain data from the speckle tracking ultrasound measurement and NT-proBNP levels was ρ = 0.35 (p = 0.026). With a cutoff value of -15% in global strain measurements, there was a significant difference in NT-proBNP levels (117 v 57 pg/mL, p = 0.048). E/E' values correlated with NT-proBNP levels (ρ = 0.46, p = 0.011). With a cutoff of 15 in E/E' values, there were significant differences in corresponding NT-proBNP levels (33 v 113 pg/mL, p = 0.004). CONCLUSIONS: A correlation was found between plasma levels of NT-proBNP and speckle tracking ultrasound strain measurements by an easily employed method applicable in the anesthesia and preoperative settings. In addition, the well-established marker of diastolic function, E/E', correlated well with NT-proBNP, whereas the E/A ratio failed to show any association.

High thoracic epidural analgesia in cardiac surgery. Part 2--high thoracic epidural analgesia does not reduce time in or improve quality of recovery in the intensive care unit.

OBJECTIVE: To evaluate the postoperative effect of high thoracic epidural analgesia on the time in the intensive care unit (ICU) and the quality of cardiac recovery in patients undergoing cardiac surgery. DESIGN: A randomized prospective study. PARTICIPANTS: Sixty low-risk patients 65 to 80 years of age scheduled for elective coronary artery bypass graft surgery with or without aortic valve replacement. SETTING: A university hospital. INTERVENTIONS: Patients randomized to receive high thoracic epidural analgesia (HTEA) as a supplement to general anesthesia. MEASUREMENTS AND MAIN RESULTS: The eligible time to discharge from the ICU and the quality of recovery were evaluated by an objective ICU scoring system. The time to eligible discharge from the ICU, the ventilation time, and the actual time in the ICU were not shorter in the HTEA group compared with patients receiving conventional general anesthesia. Patients receiving HTEA in addition to general anesthesia received less morphine postoperatively but with no consequent beneficial effect on respiration, nausea, sedation, or motor function. CONCLUSIONS: HTEA does not reduce the time in the ICU or improve the quality of recovery in the ICU.

High thoracic epidural analgesia in cardiac surgery. Part 1--high thoracic epidural analgesia improves cardiac performance in cardiac surgery patients.

OBJECTIVE: The purpose of this study was to evaluate the perioperative cardioprotective effect of high thoracic epidural analgesia (HTEA), primarily expressed as an effect on cardiac performance and hemodynamics in patients undergoing cardiac surgery. DESIGN: A randomized, prospective study. PARTICIPANTS: Sixty low-to-moderate risk patients between the ages of 65 and 80 years scheduled for elective coronary artery bypass graft surgery with or without aortic valve replacement. SETTING: A university hospital. INTERVENTION: Patients randomized to receive HTEA as a supplement to general anesthesia. MEASUREMENTS AND MAIN RESULTS: Perioperative hemodynamic measurements, perioperative fluid balance, and postoperative release of cardiac enzymes were collected. The end-diastolic volume index (EDVI), the stroke volume index (overall 38 v 32 mL), the cardiac index (overall 2.35 v. 2.18 L/minute/m(2)), the central venous pressure, and central venous oxygenation were higher in the HTEA group. The mean arterial blood pressure was marginally lower in the HTEA group, whereas no difference was noted in the heart rate or peripheral saturation between the groups. No differences were found in the postoperative levels of troponin T and CK-MB between groups. NT-proBNP changed over time (p < 0.001) and was lower in the HTEA group (p = 0.013), with maximal values of 291 ± 265 versus 326 ± 274. CONCLUSIONS: The findings of a higher stroke volume index and central venous oxygenation without an increase in heart rate or mean arterial pressure suggest that HTEA improves cardiac performance in elderly cardiac surgery patients.