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BACKGROUND: Evaluation of the right ventricle (RV) using transthoracic echocardiography is challenging in patients with repaired tetralogy of Fallot (rTOF). AIMS: To evaluate the accuracy of conventional echocardiographic variables and real-time three-dimensional echocardiography (RT3DE) in assessing right ventricular (RV) volumes and function compared with magnetic resonance imaging (MRI), in adult patients with rTOF and referred for pulmonary valve replacement (PVR). METHODS: Complete echocardiography was performed on 26 consecutive patients referred for PVR, before and 1 year after surgery. All variables were compared with MRI. RESULTS: Correlations between conventional variables and MRI were absent or poor when assessing RV ejection fraction (RVEF), except for fractional area of change (FAC; r=0.70, P<0.01 before PVR; r=0.68, P<0.01 after PVR) and RT3DE (r=0.96, P<0.01 before PVR; r=0.98, P<0.01 after PVR). The RV volume correlation between RT3DE and MRI was excellent before and after surgery for RV end-diastolic volume (r=0.88, P<0.01 and r=0.91, P<0.01, respectively) and RV end-systolic volume (r=0.92, P<0.01 and r=0.95, P<0.01, respectively). The accuracy of these indices, as a diagnostic test for impaired RV (<45%), was good: Youden's indexes varied from 0.47 to 0.89; areas under the receiver operating characteristic curve before and after PVR were 0.86 and 0.81 for FAC and 0.98 and 0.97 for RT3DE, respectively. CONCLUSION: Commonly used echocardiography variables, such as tricuspid annular plane systolic excursion and tricuspid annular peak systolic velocity, did not sensitively evaluate global RVEF. A global approach, that includes the whole RV and integration of its different components, was more reliable in patients with rTOF.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Ecocardiografía Tridimensional , Implantación de Prótesis de Válvulas Cardíacas , Ventrículos Cardíacos/diagnóstico por imagen , Imagen por Resonancia Magnética , Insuficiencia de la Válvula Pulmonar/cirugía , Válvula Pulmonar/cirugía , Tetralogía de Fallot/cirugía , Disfunción Ventricular Derecha/diagnóstico por imagen , Función Ventricular Derecha , Adolescente , Adulto , Área Bajo la Curva , Estudios de Factibilidad , Femenino , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Análisis Multivariante , Valor Predictivo de las Pruebas , Válvula Pulmonar/diagnóstico por imagen , Válvula Pulmonar/fisiopatología , Insuficiencia de la Válvula Pulmonar/diagnóstico por imagen , Insuficiencia de la Válvula Pulmonar/etiología , Insuficiencia de la Válvula Pulmonar/fisiopatología , Curva ROC , Volumen Sistólico , Factores de Tiempo , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/fisiopatología , Disfunción Ventricular Derecha/etiología , Disfunción Ventricular Derecha/fisiopatología , Adulto JovenRESUMEN
PURPOSE: In critically ill patients with acute respiratory failure (ARF), fiberoptic bronchoscopy and bronchoalveolar lavage (FOB-BAL) are important tools in diagnostic strategies. In nonintubated patients, the patient's agitation may lead to desaturation and compromise the realization of FOB. The aim of this study was to assess the feasibility and safety of target-controlled (TCI) propofol sedation during FOB-BAL in nonintubated hypoxemic patients. METHODS: The first end point in our prospective investigation within an intensive care unit (ICU) was the avoidance of endotracheal intubation within 24 h. Secondary end points were changes in the PaO(2)/FiO(2) ratio, hemodynamic stability, patient comfort, occurrence of adverse effects, and quality of FOB. Patients self-evaluated their comfort after FOB. RESULTS: Twenty-four FOBs were performed in 23 patients with ARF. PaO(2)/FiO(2) before FOB was 181 ± 50 (range 85-286). All patients tolerated FOB with BAL. None was intubated during the 2 h after FOB. Loss of consciousness was obtained with an effect site concentration of propofol of 1.49 ± 0.46 µg/mL (range 2.6-0.6). No significant adverse events occurred. TCI propofol allowed us to obtain amnesia, patient comfort, and it did not impair airway protection. Any hemodynamic changes observed were modest and transient. CONCLUSIONS: FOB-BAL, under NIV and TCI with propofol, is feasible and safe in nonintubated patients with ARF. The TCI of propofol during FOB-BAL reduces patient discomfort with no significant adverse effects.
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Anestésicos Intravenosos/administración & dosificación , Broncoscopía/métodos , Tecnología de Fibra Óptica , Hipoxia , Respiración con Presión Positiva , Propofol/administración & dosificación , Adulto , Anciano , Lavado Broncoalveolar , Sistemas de Liberación de Medicamentos , Determinación de Punto Final , Estudios de Factibilidad , Femenino , Humanos , Infusiones Intravenosas , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Estudios Prospectivos , Síndrome de Dificultad Respiratoria , Seguridad , Encuestas y Cuestionarios , Adulto JovenRESUMEN
PURPOSE: Non-invasive ventilation (NIV) in critically ill patients is associated with a high failure rate. This prospective study assessed the feasibility and safety of target-controlled infusion (TCI) of propofol for conscious sedation during NIV in patients with NIV failure due to low tolerance. METHODS: Ten patients with NIV failure due to discomfort, agitation and/or refusal to continue with this ventilatory support were included; seven had acute respiratory failure and three had acute hypercapnic respiratory failure. Patients were sedated by TCI of propofol during NIV sessions. Blood gas analysis, cardiorespiratory and ventilatory parameters, propofol concentration (Cpt) required, comfort and adverse events were recorded. RESULTS: Patients received a total of 85 NIV sessions, totalling 180 h of NIV under TCI of propofol (mean Cpt, 0.82 ± 0.25 µg/ml). NIV under TCI of propofol significantly improved arterial blood gas analyses: mean Pa/FiO(2) ratio increased from 167 ± 68 pre-session to 195 ± 68 post-session (p < 0.05), mean PaCO(2) decreased from 57.8 ± 15.3 to 49 ± 9.8 mmHg (p < 0.05) and mean pH increased from 7.36 ± 0.04 to 7.4 ± 0.03 (p < 0.05). Three patients required endotracheal intubation, two due to evolution of underlying disease and one because of a seizure disorder. Eight patients were discharged from the intensive care unit and two died. CONCLUSIONS: This preliminary study shows that in a selected population, TCI of propofol can facilitate acceptance of NIV. Within the limits of a pilot study, TCI of propofol seems to be safe and effective for the treatment of NIV failure due to low tolerance.