Identifying risk factors for perioperative decline in right ventricular performance in cardiac surgery patients: a prospective observational study in a tertiary care hospital.

OBJECTIVES: Impaired right ventricular (RV) function after cardiac surgery is associated with morbidity and long-term mortality. The purpose of this study was to identify factors that play a role in the development of RV dysfunction in the perioperative cardiac surgery setting. DESIGN: We performed a prospective, observational, single centre study. Over a 2-year period, baseline and perioperative characteristics were recorded. For analysis, subjects were divided into three groups: patients with a ≥3% absolute increase in postoperative RV ejection fraction (RVEF) in comparison to baseline (RVEF+), patients with a ≥3% absolute decrease in RVEF (RVEF-) and patients with a <3% absolute change in RVEF (RVEF=). SETTING: Tertiary care hospital in the Netherlands. PARTICIPANTS: We included all cardiac surgery patients ≥18 years of age equipped with a pulmonary artery catheter and admitted to the ICU in 2015-2016. There were no exclusion criteria. A total number of 267 patients were included (65.5% men). OUTCOME MEASURES: Risk factors for a perioperative decline in RV function. RESULTS: A reduction in RVEF was observed in 40% of patients. In multivariate analysis, patients with RVEF- were compared with patients with RVEF= (first-mentioned OR) and RVEF+ (second-mentioned OR). Preoperative use of calcium channel blocker (CCB) (OR 3.06, 95% CI 1.24 to 7.54/OR 2.73, 95% CI 1.21 to 6.16 (both p=0.015)), intraoperative fluid balance (FB) (OR 1.45, 95% CI 1.02 to 2.06 (p=0.039)/OR 1.09, 95% CI 0.80 to 1.49 (p=0.575)) and baseline RVEF (OR 1.22; 95% CI 1.14 to 1.30/OR 1.27, 95% CI 1.19 to 1.35 (both p<0.001)) were identified as independent risk factors for a decline in RVEF during surgery. CONCLUSION: Apart from the impact of the perioperative FB, preoperative use of a CCB as a risk factor for perioperative reduction in RVEF is the most prominent new finding of this study.

High Versus Normal Blood Pressure Targets in Relation to Right Ventricular Dysfunction After Cardiac Surgery: A Randomized Controlled Trial.

OBJECTIVE: Management of right ventricular (RV) dysfunction is challenging. Current practice predominantly is based on data from experimental and small uncontrolled studies and includes augmentation of blood pressure. However, whether such intervention is effective in the clinical setting of cardiac surgery is unknown. DESIGN: Randomized controlled trial. SETTING: Single-center study in a tertiary teaching hospital. PARTICIPANTS: The study comprised 78 patients equipped with a pulmonary artery catheter (PAC), classified according to PAC-derived RV ejection fraction (RVEF); 44 patients had an RVEF of <20%, and 34 patients had an RVEF between ≥20% and <30%. INTERVENTIONS: Patients randomly were assigned to either a normal target group (mean arterial pressure 65 mmHg) or a high target group [mean arterial pressure 85 mmHg]). The primary end- point was the change in RVEF over a one-hour study period. MEASUREMENTS AND MAIN RESULTS: There was no significant between-group difference in change of RVEF <20% (-1% [-3.3 to 1.8] in the normal-target group v 0.5% [-1 to 4] in the high-target group; p = 0.159). There was no significant between-group difference in change in RVEF 20%-to-30% (-1% [-3 to 0] in the normal-target group v 1% [-1 to 3] in the high-target group; p = 0.074). These results were in line with the simultaneous observation that echocardiographic variables of RV and left ventricular function also remained unaltered over time, irrespective of either baseline RVEF or treatment protocol. CONCLUSION: In a mixed cardiac surgery population with RV dysfunction, norepinephrine-mediated high blood pressure targets did not result in an increase in PAC-derived RVEF compared with normal blood pressure targets.

Hemodynamic Characteristics of Mechanically Ventilated COVID-19 Patients: A Cohort Analysis.

BACKGROUND: Solid data on cardiovascular derangements in critically ill COVID-19 patients remain scarce. The aim of this study is to describe hemodynamic characteristics in a cohort of COVID-19-related critically ill patients. METHODS: A retrospective observational cohort study in twenty-eight consecutive mechanically ventilated COVID-19 patients. Pulse contour analysis-derived data were obtained from all patients, using the PiCCO® system. RESULTS: The mean arterial pressure increased from 77 ± 10 mmHg on day 1 to 84 ± 9 mmHg on day 21 (p=0.04), in combination with the rapid tapering and cessation of norepinephrine and the gradual use of antihypertensive drugs in the vast majority of patients. The cardiac index increased significantly from 2.8 ± 0.7 L/min/m2 on day 1 to 4.0 ± 0.8 L/min/m2 on day 21 (p < 0.001). Dobutamine was administered in only two patients. Mean markers of left ventricular contractility and peripheral perfusion, as well as lactate levels, remained within the normal range. Despite a constant fluid balance, extravascular lung water index decreased significantly from 17 ± 7 mL/kg on day 1 to 11 ± 4 mL/kg on day 21 (p < 0.001). Simultaneously, intrapulmonary right-to-left shunt fraction (Q s/Q t) decreased significantly from 27 ± 10% in week 1 to 15 ± 9% in week 3 (p=0.007). PaO2/FiO2 ratio improved from 159 ± 53 mmHg to 319 ± 53 mmHg (p < 0.001), but static lung compliance remained unchanged. CONCLUSIONS: In general, this cohort of patients with COVID-19 respiratory failure showed a marked rise in blood pressure over time, not accompanied by distinctive markers of circulatory failure. Characteristically, increased extravascular lung water, vascular permeability, and intrapulmonary shunt diminished over time, concomitant with an improvement in gas exchange.

The Reduction in Right Ventricular Longitudinal Contraction Parameters Is Not Accompanied by a Reduction in General Right Ventricular Performance During Aortic Valve Replacement: An Explorative Study.

OBJECTIVE: The aim of the present study was to identify whether the decrease of longitudinal parameters after cardiothoracic surgery (ie, tricuspid annular systolic plane excursion [TAPSE] and systolic excursion velocity [S']) is accompanied by a reduction in global right ventricular (RV) performance. DESIGN: Prospective, observational study. SETTING: Single-center explorative study in a tertiary teaching hospital. PARTICIPANTS: The study comprised 20 patients who underwent aortic valve replacement with or without coronary artery bypass grafting. INTERVENTIONS: During cardiac surgery, simultaneous measurements of RV function were performed with a pulmonary artery catheter and transesophageal echocardiography. MEASUREMENTS AND MAIN RESULTS: TAPSE and S' were reduced significantly directly after surgery compared with the time before surgery (TAPSE from 20.8 [16.6-23.4] mm to 9.1 [5.6-15.5] mm; p < 0.001 and S' from 8.7 [7.9-10.7] cm/s to 7.2 [5.7-8.6] cm/s; p = 0.041). However, the reduction in TAPSE and S' was not accompanied by a reduction in RV performance, as assessed with the TEE-derived myocardial performance index (MPI) and pulmonary artery catheter-derived RV ejection fraction (RVEF). Both remained statistically unaltered before and after the procedure (MPI from 0.52 [0.43-0.58] to 0.50 [0.42-0.88]; p = 0.278 and RVEF from 27% [22%-32%] to 26% [22%-28%]; p = 0.294). CONCLUSIONS: In the direct postoperative phase, the reduction of echocardiographic parameters of longitudinal RV contractility (TAPSE and S') were not accompanied by a reduction in global RV performance, expressed as MPI and RVEF. Solely relying on a single RV parameter as a marker for global RV performance may not be adequate to assess the complex adaptation of the right ventricle to aortic valve replacement.

Right Ventricular Function and Long-Term Outcome in Sepsis: A Retrospective Cohort Study.

BACKGROUND: Sepsis-related myocardial dysfunction is associated with impaired outcome. Traditionally, in this setting the main focus has been on left ventricular performance. Currently, specific knowledge on the prognostic importance of right ventricular dysfunction is scarce. The aim of this study was to determine whether right ventricular ejection fraction (RVEF) is predictive of long-term mortality in sepsis. METHODS: Single-centre retrospective cohort study in adult patients admitted to the ICU with severe sepsis and septic shock, and equipped with a pulmonary artery catheter within the first day after admission. RVEF was recorded as an average over the first 24 h (sample rate of 1 per min). Patients were separated a priori into subgroups according to their RVEF: RVEF less than 20% (A), RVEF 20% to 30% (B), and RVEF more than 30% (C). The primary endpoint was 1-year all-cause mortality. RESULTS: In a 7-year period, 101 patients fulfilled all entry criteria and 98 were included in the study. One-year all-cause mortality was significantly different between groups: 57% in group A (n = 21), 18% in group B (n = 55), and 23% in group C (n = 22); P = 0.003. Kaplan-Meier survival analysis revealed a clear separation between groups A and B/C (X = 14.00, P = 0.001). In a multivariate logistic regression analysis RVEF, both as a categorical variable (RVEF <20%) and as a continuous variable remained independently associated with the primary endpoint (odds ratio [OR] 4.1; 95% confidence interval [CI], 1.3-13.4; P = 0.018 and OR 0.92; 95% CI, 0.85-0.99; P = 0.018, respectively). CONCLUSIONS: RVEF was independently associated with 1-year all-cause mortality in a highly selected group of patients with severe sepsis and septic shock.

Impaired right ventricular ejection fraction after cardiac surgery is associated with a complicated ICU stay.

BACKGROUND: Right ventricular (RV) dysfunction is a known risk factor for increased mortality in cardiac surgery. However, the association between RV performance and ICU morbidity is largely unknown. METHODS: We performed a single-centre, retrospective study including cardiac surgery patients equipped with a pulmonary artery catheter, enabling continuous right ventricular ejection fraction (RVEF) measurements. Primary endpoint of our study was ICU morbidity (as determined by ICU length of stay, duration of mechanical ventilation, usage of inotropic drugs and fluids, and kidney dysfunction) in relation to RVEF. Patients were divided into three groups according to their RVEF; < 20%, 20-30%, and > 30%. RESULTS: We included 1109 patients. Patients with a RVEF < 20% had a significantly longer stay in ICU, a longer duration of mechanical ventilation, higher fluid balance, a higher incidence of inotropic drug usage, and more increase in postoperative creatinine levels in comparison to the other subgroups. In a multivariate analysis, RVEF was independently associated with increased ICU length of stay (OR 0.934 CI 0.908-0.961, p < 0.001), prolonged duration of mechanical ventilation (OR 0.969, CI 0.942-0.998, p = 0.033), usage of inotropic drugs (OR 0.944, CI 0.917-0.971, p < 0.001), and increase in creatinine (OR 0.962, CI 0.934-0.991, p = 0.011). CONCLUSIONS: A decreased RVEF is independently associated with a complicated ICU stay.

Right Ventricular Function After Cardiac Surgery Is a Strong Independent Predictor for Long-Term Mortality.

OBJECTIVE: To establish the all-cause mortality of right ventricular dysfunction after cardiac surgery in a heterogeneous group of cardiac surgery patients. DESIGN: Retrospective analysis of a heterogeneous group of 1,109 cardiac surgery patients in a 4-year period. SETTING: Single-center study in a tertiary teaching hospital. PARTICIPANTS: One thousand one hundred nine cardiac surgery patients. By protocol, patients were monitored with a pulmonary artery catheter, enabling continuous right ventricular ejection fraction (RVEF) measurements. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Measurements were performed once per minute for the first 24 postoperative hours and expressed as average over the complete period. Primary outcome was 2-year all-cause mortality. RVEF was categorized into 3 subgroups: <20%, 20-30%, and >30%. Median follow-up time was 739 days. Two-year mortality was significantly different across groups: 4.1% for patients with RVEF >30%, 8.2% in the group with RVEF 20-30%, and 16.7% for patients with RVEF <20%, p < 0.001. Additional risk factors for a poor RVEF were age, body weight, New York Heart Association class, chronic obstructive pulmonary disease, poor left ventricular function, and higher risk scores (Acute Physiology and Chronic Health Evaluation and European System for Cardiac Operative Risk Evaluation). In a multivariate analysis, RVEF as a continuous variable was associated independently with the primary outcome (odds ratio 0.95 confidence interval 0.91-0.99, p = 0.011.) Odds ratios for RVEF <20% were 1.88 (confidence interval 1.18-3.00, p = 0.008). CONCLUSIONS: Right ventricular function is associated independently with 2-year all-cause mortality in a heterogenic cardiac surgery population.