RESUMEN
The importance of right ventricular (RV) dysfunction in patients undergoing cardiac surgery is well recognized. There is extensive literature regarding the accurate assessment of RV dysfunction with both echocardiography and hemodynamic data, but the majority of these studies are with transthoracic echocardiography (TTE) and in awake patients. Many of the tools used to assess the RV with TTE are angle-dependent and, therefore, may be inaccurate with transesophageal echocardiography (TEE). Very few of these modalities have been validated either with TEE or in patients under general anesthesia. The purpose of this review is to discuss the intraoperative tools available to the cardiac anesthesiologist for the assessment of RV function. The authors review the available literature surrounding intraoperative RV assessment, from subjective assessment to traditional objective tools that were developed for TTE and newer technology that can be adapted to both TTE and TEE. Future work should focus on whether or not these intraoperative RV assessment tools predict outcome after cardiac surgery.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Disfunción Ventricular Derecha , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Ecocardiografía Transesofágica , Humanos , Estudios Prospectivos , Disfunción Ventricular Derecha/diagnóstico por imagen , Función Ventricular DerechaAsunto(s)
Apéndice Atrial , Procedimientos Quirúrgicos Cardíacos , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Presión Venosa Central , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Vena Cava SuperiorAsunto(s)
Insuficiencia Cardíaca , Corazón Auxiliar , Disfunción Ventricular Derecha , Adulto , Anciano , Presión Venosa Central , Femenino , Insuficiencia Cardíaca/diagnóstico , Corazón Auxiliar/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Arteria Pulmonar/diagnóstico por imagen , Estudios Retrospectivos , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/etiologíaRESUMEN
Objective: Chronic postthoracotomy pain (CPTP) is a persistent, occasionally debilitating pain lasting >2 months following thoracic surgery. This study investigates for the first time the prevalence and clinical impact of CPTP in patients who have undergone a transapical transcatheter aortic valve replacement (TA-TAVR). Design: This was a single-institution, prospective observational survey and a retrospective chart review. Setting: The study was conducted in the University Hospital. Participants: Patients. Materials and Methods: A survey of 131 participants with either a previous TA TAVR or transfemoral (TF) TAVR procedure was completed. A telephone interview was conducted at least 2 months following TAVR; participants were asked to describe their pain using the Short-Form McGill Pain Questionnaire. Measurements and Main Results: Odds ratio (OR) was calculated using the proportions of questionnaire responders reporting "sensory" descriptors in the TA-TAVR versus the TF-TAVR groups. Results were then compared to individual Kansas City Cardiomyopathy Questionnaire (KCCQ12) scores and 5-min walk test (5MWT) distances. A total of 119 participants were reviewed (63 TF, 56 TA). Among TA-TAVR questionnaire responders (n = 16), CPTP was found in 64.3% of participants for an average duration of 20.5-month postprocedure (OR = 10, [confidence interval (CI) 95% 1.91-52.5];P = 0.003). TA-TAVR patients identified with CPTP had significant reductions in 5MWT distances (-2.22 m vs. 0.92 m [P = 0.04]) as well as trend toward significance in negative change of KCCQ12 scores OR = 18.82 (CI 95% 0.85-414.99;P = 0.06) compared to those without CPTP. Conclusions: CPTP occurs in patients undergoing TA-TAVR and is possibly associated with a decline quality of life and overall function.
Asunto(s)
Dolor Crónico/epidemiología , Dolor Postoperatorio/epidemiología , Toracotomía/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: Severe right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation increases morbidity and mortality. We investigated the association between intraoperative right heart hemodynamic data, echocardiographic parameters, and severe versus nonsevere RVF. METHODS: A review of LVAD patients between March 2013 and March 2016 was performed. Severe RVF was defined by the need for a right ventricular mechanical support device, inotropic, and/or inhaled pulmonary vasodilator requirements for >14 days. From a chart review, the right ventricular failure risk score was calculated and right heart hemodynamic data were collected. Pulmonary artery pulsatility index (PAPi) [(pulmonary artery systolic pressure - pulmonary artery diastolic pressure)/central venous pressure (CVP)] was calculated for 2 periods: (1) 30 minutes before cardiopulmonary bypass (CPB) and (2) after chest closure. Echocardiographic data were recorded pre-CPB and post-CPB by a blinded reviewer. Univariate logistic regression models were used to examine the performance of hemodynamic and echocardiographic metrics. RESULTS: A total of 110 LVAD patients were identified. Twenty-five did not meet criteria for RVF. Of the remaining 85 patients, 28 (33%) met criteria for severe RVF. Hemodynamic factors associated with severe RVF included: higher CVP values after chest closure (18 ± 9 vs 13 ± 5 mm Hg; P = .0008) in addition to lower PAPi pre-CPB (1.2 ± 0.6 vs 1.7 ± 1.0; P = .04) and after chest closure (0.9 ± 0.5 vs 1.5 ± 0.8; P = .0008). Post-CPB echocardiographic findings associated with severe RVF included: larger right atrial diameter major axis (5.4 ± 0.9 vs 4.9 ± 1.0 cm; P = .03), larger right ventricle end-systolic area (22.6 ± 8.4 vs 18.5 ± 7.9 cm; P = .03), lower fractional area of change (20.2 ± 10.8 vs 25.9 ± 12.6; P = .04), and lower tricuspid annular plane systolic excursion (0.9 ± 0.2 vs 1.1 ± 0.3 cm; P = .008). Right ventricular failure risk score was not a significant predictor of severe RVF. Post-chest closure CVP and post-chest closure PAPi discriminated severe from nonsevere RVF better than other variables measured, each with an area under the curve of 0.75 (95% CI, 0.64-0.86). CONCLUSIONS: Post-chest closure values of CVP and PAPi were significantly associated with severe RVF. Echocardiographic assessment of RV function post-CPB was weakly associated with severe RVF.