Influence of intraaortic balloon pump counterpulsation on transesophageal echocardiography derived determinants of diastolic function.

INTRODUCTION: Intraaortic balloon pump counterpulsation (IABP) is often used in patients with acute coronary syndrome for its favourable effects on left ventricular (LV) systolic function and coronary perfusion. However, the effects of IABP on LV diastolic function have not been comprehensively investigated. Acute diastolic dysfunction has been linked to increased morbidity and mortality. The aim of this study was to examine the influence of IABP on LV diastolic dysfunction using standard TEE derived parameters. METHODS: Intraoperative TEE was performed in 10 patients (mean age 65 ± 11 yrs) undergoing urgent coronary artery bypass graft surgery (CABG), who had received an IABP preoperatively. TEE derived measures of diastolic dysfunction included early to late transmitral Doppler inflow velocity ratio (E/A), deceleration time (Dt), pulmonary venous systolic to diastolic Doppler velocity ratio (S/D), transmitral propagation velocity (Vp), and the ratio of early to late mitral annular tissue Doppler velocities (e'/a'). Statistical analyses included the Wilcoxon Sign-Rank test, and a p<0.05 was considered significant. RESULTS: Transmitral inflow E/A ratios increased significantly from 0.86 to 1.07 (p < 0.05), while Dt decreased significantly from 218 to 180 ms (p < 0.05) with the use of IABP. Significant increases in Vp (34 cm/s to 43 cm/s; p < 0.05), and e'/a' (0.58 to 0.71; p < 0.05) suggested a favourable influence of intraaortic counterpulsation on diastolic function. CONCLUSION: The use of perioperative IABP significantly improves TEE derived parameters of diastolic function consistent with a favourable impact on LV relaxation in cardiac surgery patients undergoing CABG.

The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients.

BACKGROUND: Intraoperative echocardiography has become a mainstay monitor of cardiac function and a popular diagnostic tool in patients undergoing cardiac procedures. Previous reports suggest that epiaortic ultrasonography (EU) is superior to transesophageal echocardiography and manual palpation in identifying ascending aortic atheroma. Its impact on surgical decision making has not been thoroughly investigated, however. METHODS: We retrospectively analyzed the medical records of 6051 consecutive patients who underwent EU of their ascending aorta during cardiac operations between 1996 and 2006 to determine a potential impact on intraoperative surgical decision making. Aortic atheroma was graded according to standard classification. Neurologic complications were evaluated according to the Society of Thoracic Surgeon definition for stroke and transient ischemic attack (TIA). RESULTS: The overall impact of EU on surgical decision making was 4.1% and included a change in the technique for inducing cardiac arrest in 1.8%, aortic atherectomy or replacement surgery in 0.8%, requirement for off-pump coronary artery bypass grafting (CABG) in 0.6%, avoidance of aortic cross-clamping and use of ventricular fibrillatory arrest in 0.5%, change in arterial cannulation site in 0.2%, or avoidance of aortic cannulation in 0.2%. The greatest affect of EU was observed in patients undergoing combined CABG with aortic/mitral valve procedures (6.7%). The smallest impact was seen in patients undergoing mitral valve operations (1.4%). Aortic atheroma was more frequent on the anterior aspect of the aorta (n = 171) in patients with a change in surgical plan than on the posterior aspect (n = 78). The overall stroke rate was lower in patients with intraoperative EU compared with all patients undergoing surgical procedures. CONCLUSIONS: Epiaortic ultrasonography is a useful technique to detect ascending aortic atheroma, has a significant impact on surgical decision making in more than 4% of cardiac surgical patients, and might result in improved perioperative neurologic outcome.

Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy.

Patients undergoing pulmonary embolectomy often experience hemodynamic deterioration during induction of general anesthesia (GA). Therefore, we studied the incidence and possible risk factors for hemodynamic deterioration during GA induction. Fifty-two consecutive patients undergoing emergent pulmonary embolectomy at our institution were included. Hemodynamic collapse after GA induction was defined as hypotension refractory to vasopressor, inotrope, or fluid administration, requiring cardiopulmonary resuscitation followed by urgent institution of cardiopulmonary bypass (CPB). Demographic variables, comorbidities, specific location of thromboemboli, preoperative inotropic support, and anesthetic drugs used for GA induction were evaluated as possible risk factors. After GA induction, hemodynamic collapse occurred in 19% of patients (n = 10). However, the occurrence of hemodynamic instability was not predicted by any of the evaluated risk factors. In addition, the incidence of in-hospital mortality did not differ between hemodynamically stable or unstable patients (10%; 4 of 42 versus 10%; 1 of 10 patients, respectively). In conclusion, hemodynamic deterioration after GA induction develops frequently during emergent pulmonary embolectomy. On the basis of our experience from this study and the unpredictable nature of hemodynamic deterioration, we suggest that patients undergoing pulmonary embolectomy should be prepared and draped before GA induction, and a cardiac surgical team should immediately be available for emergent institution of cardiopulmonary bypass.