Decompensated right heart failure, intensive care and perioperative management in patients with pulmonary hypertension: Updated recommendations from the Cologne Consensus Conference 2018.

In June 2016, members of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) met for a Consensus Conference in Cologne, Germany. Aim of this Conference was to compile consensus based practice recommendations based on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. This article summarizes the results and updated recommendations 2018 of the working group on decompensated right heart failure (RHF), intensive care and perioperative management in patients with pulmonary hypertension. The RHF section comprises definition and pathophysiology, diagnosis and monitoring, identification of triggering factors and supportive therapy of RHF, volume management as well as PAH targeting therapy, therapy with inotropic, inodilator and vasopressor drugs, extracorporeal support and transplantation. The second part of this article summarizes preoperative management, perioperative monitoring and choice of anesthesia.

Critical importance of unsuspected findings detected by intraoperative transesophageal echocardiography for decision making during cardiac surgery.

AIMS: To report the frequency of unsuspected pathologies detected by presurgical and/or postsurgical intraoperative transesophageal echocardiography (IOTEE) and its impact on the extent of cardiac surgery and the number of pathologies remaining unoperated. METHODS AND RESULTS: In a 2-year study period, 469 patients (male/female = 273/196; age 68.0 ± 11.9 years) with presurgical and/or postsurgical IOTEE out of 2,035 patients submitted for cardiac surgery were analyzed retrospectively. Presurgical IOTEE was performed in all patients referred to valve surgery or suspicious valve disease or valve diseases with open surgical decision. Postsurgical IOTEE was performed in all patients after valve surgery. Pathologies relevant for surgery were defined as valve disease of moderate degree or higher or structural disease like shunt lesions. In 464 patients (98.9 %), a total number of 757 IOTEEs were successfully performed including 351 presurgical and 384 postsurgical studies, 1-s presurgical IOTEE, 20-s postsurgical, and one-third postsurgical IOTEE. Surgically relevant unsuspected findings were detected in 33.0 % of presurgical IOTEE leading to alteration of surgery in 27.6 %. Relevant pathologies detected by postsurgical IOTEE were found in 7.8 % as remnant valvular dysfunction of the operated valve and in 12.3 % related to other structures. Relevant pathologies detected by postsurgical IOTEE finally remained unoperated in 21.2 % of patients with only postsurgical IOTEE versus only 10.7 % (p < 0.05) of patients with both presurgical and postsurgical IOTEE. CONCLUSION: We found an alarming high number of unsuspected pathologies by IOTEE causing substantial alterations of surgery. Beyond this, whether patients received presurgical IOTEE or not made a significant difference on the number of pathologies left unoperated.