High postoperative portal venous flow pulsatility indicates right ventricular dysfunction and predicts complications in cardiac surgery patients

Abstract

Background: Right ventricular failure after cardiac surgery is associated with morbidity and mortality. Right ventricular dysfunction results in hepatic venous congestion, which impacts the portal circulation. We aimed to determine whether an increased portal flow pulsatility fraction was associated with right ventricular dysfunction in cardiac surgery patients. We also aimed to describe the haemodynamic factors and postoperative complications associated with an increased portal pulsatility in this setting. Methods: We conducted a prospective single-centre cohort study, recruiting adults undergoing cardiac surgery. Portal flow was assessed before, during, and after surgery by Doppler ultrasound. A detailed haemodynamic and echocardiographic assessment was performed at the same time points. Results: A total of 115 patients were included. Both systolic and diastolic right ventricular dysfunction were associated with a higher portal pulsatility fraction (P¼0.008 and <0.001, respectively). A positive association was present between portal pulsatility fraction and measurements representative of venous pressure (central venous pressure, inferior vena cava diameter). A post-procedural portal pulsatility fraction !50% measured in the operating room was present in 21 (18.3%) patients and was associated with an increased risk of major complications (odds ratio¼5.83, confidence interval, 2.04e16.68, P¼0.001). The addition of portal flow assessment to a predictive model including EuroSCORE II and systolic right ventricular dysfunction improved prediction of postoperative complications. Conclusions: High portal flow pulsatility fraction is associated with right ventricular dysfunction, signs of venous congestion and decreased perfusion, and an increased risk of major complications. Portal vein Doppler ultrasound appears to be promising for risk assessment in the perioperative period. Clinical trials registration: NCT02658006.

Whole body ultrasound in the operating room and intensive care unit

“…Bedside ultrasound of the whole body patients with right heart dysfunction after cardiac surgery, portal pulsatility ( Fig. 4) predicts complications such as bleeding, re-intervention, and renal failure after cardiac surgery [18][19][20].…”

Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system

“…Several markers of the high pressures associated with this congestive process have been proposed including the assessment of large veins (vena cava, internal jugular) as well as detecting abnormal venous waveforms suggestive that the limit of the systemic venous compliance in the portal vein, hepatic veins and intra-renal veins [17]. All of these markers have been associated with adverse consequences of venous hypertension, both in acute and chronic settings [18][19][20][21]. However, they also all have significant limitations that may hamper their clinical usefulness when interpreted in isolation [22][23][24].…”

Looking backwards: is it time to assess veno-atrial interactions in pulmonary arterial hypertension?

“…This phenomenon can be explained by venous backflow in the setting of an elevated right atrial pressure and a noncompliant RV. To this day the determinants of venous backflow have yet to be worked out, but there is a strong clinical relevance, including the effects on RV workload and venous congestion mediated hepatic and renal dysfunction [4,5].With normal right ventricular function, ventricular contraction results in the movement of blood from the ventricle into the pulmonary circulation for oxygenation and subsequent delivery to the rest of the body (figure 1a). Invasive assessments of normal venous blood flow in dogs and healthy individuals demonstrate that the flow is remarkably pulsatile [1,6].…”

“…This phenomenon can be explained by venous backflow in the setting of an elevated right atrial pressure and a noncompliant RV. To this day the determinants of venous backflow have yet to be worked out, but there is a strong clinical relevance, including the effects on RV workload and venous congestion mediated hepatic and renal dysfunction [4,5].…”

“…Lastly, CMR derived venous backflow fraction should be compared to Doppler ultrasound derived surrogates of venous backflow including portal vein and intrarenal vein flow assessments. Increased portal vein pulsatility can easily be measured with portable ultrasound at the bedside and observational studies suggest correlation with RV failure, and renal and hepatic dysfunction [4,23].…”