Precardiopulmonary Bypass Right Ventricular Function Is Associated with Poor Outcome After Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Systolic Dysfunction

Maslow, Andrew; Regan, Meredith M.; Panzica, Peter; Heindel, Stephanie; Mashikian, John; Comunale, Mark E.

doi:10.1097/00000539-200212000-00009

Cited by 182 publications

(119 citation statements)

References 47 publications

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“…One series of 74 patients showed that tricuspid annular plane systolic excursion was not predictive of death or readmission after CABG, 27 whereas another series of 41 patients with severe LV dysfunction showed that RV FAC assessed by intraoperative TEE was predictive of ventilator hours and inotrope requirements in the early postoperative period. 28 The latter study was difficult to extrapolate because RV FAC had been measured under anesthetized conditions, in a highly selected patient population, with a small sample size underpowered to detect differences in clinical endpoints (only 7 patients had an abnormal RV FAC). Our series of 667 diverse patients has shown more definitively that RV FAC assessed by resting preoperative TTE was predictive of major clinical endpoints.…”

Section: Discussionmentioning

confidence: 99%

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

et al. 2013

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Background— Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. Methods and Results— Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. Conclusions— Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.

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Section: Discussionmentioning

confidence: 99%

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

et al. 2013

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“…2,3,24 Assessing RV reserve in the presence of abnormal constraints may further help to predict outcome and survival. Rapid and easy methods (i.e., leg raising and ephedrine administration), which can be applied in the operating room, could provide the interventions necessary to assess RV recruitment.…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, RV dysfunction assessed using RV ejection fraction (RVEF), RV stroke work, RV fractional area of change, or tricuspid annular systolic plane excursion (TAPSE) is a predictor of outcome in cardiac surgery, transplantation, and patients with pulmonary hypertension. [1][2][3] Due to its simplicity and ease of application, TAPSE has become a commonly measured variable in the assessment of RV function, however, it remains one dimensional. Tricuspid annular systolic plane excursion is commonly measured using M mode, but it can be measured using speckle tracking (tracking of B mode markers) or tissue tracking (TT) [integrating annular velocity (S') measured by colour tissue Doppler].…”

Section: Résumémentioning

confidence: 99%

Evaluation of TAPSE as a measure of right ventricular output

Tousignant

Kim

Papa

et al. 2012

Can J Anesth/J Can Anesth

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Purpose This study was designed to show the relationship between tricuspid annular plane systolic excursion (TAPSE) and stroke volume (SV) by thermodilution using three different methods and also to assess whether TAPSE can track hemodynamic changes associated with volume loading and ephedrine administration. Methods This was an observational study in 61 elective patients with a pulmonary artery catheter who were undergoing coronary artery bypass graft surgery in a cardiac surgical centre. We measured TAPSE by three methods using transesophageal echocardiography: M mode, speckle tracking at the lateral wall, and tissue tracking at the inferior wall. There were two interventions: leg raising (volume recruitment) or administration of ephedrine 5 mg iv. Echo and hemodynamic measurements were performed before and after each intervention.Results Eleven patients were excluded due to poor imaging. There were 26 patients in the leg raising group and 24 patients in the ephedrine group. The correlation coefficient between stroke volume (SV) and TAPSE by M mode, speckle tracking, and tissue tracking was 0.48, 0.44, and 0.09, respectively. There was a significant increase in SV following each intervention; however, the changes in TAPSE by any method and velocity were not large enough to reach statistical significance. Conclusion Tricuspid annular plane systolic excursion by M mode and by speckle tracking correlates modestly with SV. There was no correlation between TAPSE and SV by tissue tracking at the inferior wall of the right ventricle. Tricuspid annular plane systolic excursion by M mode and by speckle tracking does not track changes in SV following either volume loading or ephedrine administration. RésuméObjectif Cette e´tude a e´te´conçue pour montrer le rapport entre le de´placement systolique du plan de l'anneau tricuspidien (TAPSE) avec le volume d'e´jection systolique (SV) par thermodilution en utilisant trois me´thodes diffe´rentes et aussi pour de´terminer si le TAPSE peut suivre les modifications he´modynamiques associe´es a`une charge volumique et a`une administration d'e´phe´drine. Méthodes Il s'agit d'une e´tude observationnelle mene´e chez 61 patients se´lectionne´s porteurs d'un cathe´ter de l'arte`re pulmonaire qui devaient subir un pontage coronarien dans un centre de chirurgie cardiaque. Nous avons mesure´le TAPSE par trois me´thodes diffe´rentes al 'aide d'une e´chocardiographie transoesophagienne: mode M;suivi de granularite´s (speckle tracking) sur la paroi late´rale; et suivi de tissu (tissue tracking) sur la paroi infe´rieure. Il y a eu deux interventions: jambes releve´es

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“…Although exact chamber volumes and, therefore, accurate ejection fractions are difficult, it is possible to calculate the fractional area of contraction by tracing the endocardial area and to perform wall motion analyses similar to that of the LV. 12 A TAPSE [1.9 cm is associated with normal RV function, while severe RV failure is noted in patients with a TAPSE\1.4 cm. 13 In this study, RV function was assessment-based on chamber This is followed by paradoxical motion of the IVS starting in early systole, with the IVS moving toward the RV and a reduction in RV area (Panels-B and E).…”

Section: Assessing Rv Functionmentioning

confidence: 96%

Case report: paradoxical ventricular septal motion in the setting of primary right ventricular myocardial failure

Maslow

Schwartz

Mahmood

et al. 2009

Can J Anesth/J Can Anesth

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Purpose In this report, a case of right ventricular (RV) failure, hemodynamic instability, and systemic organ failure is described to highlight how paradoxical ventricular systolic septal motion (PVSM), or a rightward systolic displacement of the interventricular septum, may contribute to RV ejection. Clinical features Multiple inotropic medications and vasopressors were administered to treat right heart failure and systemic hypotension in a patient following combined aortic and mitral valve replacement. In the early postoperative period, echocardiographic evaluation revealed adequate left ventricular systolic function, akinesis of the RV myocardial tissues, and PVSM. In the presence of PVSM, RV fractional area of contraction was C35% despite akinesis of the primary RV myocardial walls. The PVSM appeared to contribute toward RV ejection. As a result, the need for multiple inotropes was re-evaluated, in considering that end-organ dysfunction was the result of systemic hypotension and prolonged vasopressor administration. After discontinuation of phosphodiesterase inhibitors, native vascular tone returned and the need for vasopressors declined. This was followed by recovery of systemic organ function. Echocardiographic re-evaluation two years later, revealed persistent akinesis of the RV myocardial tissues and PVSM, the latter appearing to contribute toward RV ejection. Conclusions This case highlights the importance of left to RV interactions, and how PVSM may mediate these hemodynamic interactions. RésuméObjectif Dans ce compte-rendu, un cas de de´faillance ventriculaire droite (VD), d'instabilite´he´modynamique et de de´faillance organique syste´mique est de´crit afin de souligner la manie`re dont le mouvement systolique paradoxal du septum interventriculaire (PVSM), ou un de´placement systolique de la cloison interventriculaire vers la droite, peut jouer un rôle dans l'e´jection du VD. É léments cliniques De nombreux me´dicaments inotropes et vasopresseurs ont e´te´administre´s pour traiter une de´faillance cardiaque droite ainsi qu'une hypotension syste´mique chez un patient a`la suite d'une chirurgie valvulaire aortique et mitrale combine´e. Au de´but de la pe´riode postope´ratoire, l'e´valuation e´chocardiographique a re´ve´le´une fonction systolique ade´quate du ventricule Electronic supplementary material The online version of this article

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Precardiopulmonary Bypass Right Ventricular Function Is Associated with Poor Outcome After Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Systolic Dysfunction

Abstract: Right ventricular function before cardiopulmonary bypass is associated with poor outcome after coronary artery surgery in patients with poor left ventricular function.

Cited by 182 publications

References 47 publications

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

Evaluation of TAPSE as a measure of right ventricular output

Case report: paradoxical ventricular septal motion in the setting of primary right ventricular myocardial failure

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