The effects of anesthesia induction and positive pressure ventilation on right-ventricular function: An echocardiography-based prospective observational study

Abstract

Background: General anesthesia induction with the initiation of positive pressure ventilation creates a vulnerable phase for patients. The impact of positive intrathoracic pressure on cardiac performance has been studied but remains controversial. 3D echocardiography is a valid and MRI-validated bed-side tool to evaluate the right ventricle (RV). The aim of this study was to assess the impact of anesthesia induction (using midazolam, sufentanil and rocuronium, followed by sevoflurane) with positive pressure ventilation (PEEP 5, tidal volume 6 – 8 ml/kg) on 2D and 3D echocardiography derived parameters of RV function. Methods: A prospective observational study on fifty-three patients undergoing elective cardiac surgery in a tertiary care university hospital was designed. Transthoracic echocardiography exams were performed before and immediately after anesthesia induction and were recorded together with hemodynamic parameters and ventilator settings. Results: After anesthesia induction TAPSE (mean difference -1.6mm (95% CI -2.6mm to -0.7mm; p=0.0013) as well as the Tissue Doppler derived tricuspid annulus peak velocity (TDITVs’) were significantly reduced (mean difference -1.9% (95% CI: -2.6 to -1.2; p<0.0001), but global right ventricular ejection fraction (RVEF; p=0.1607) and right ventricular stroke volume (RVSV; p=0.1838) did not change. Conclusions: This data shows a preserved right ventricular ejection fraction and right ventricular stroke volume after anesthesia induction and initiation of positive pressure ventilation. However, the baso-apical right ventricular function is significantly reduced. Larger studies are needed in order to determine the clinical impact of these findings especially in patients presenting with impaired right ventricular function before anesthesia induction.

Right ventricular volume-strain loops using 3D echocardiography-derived mesh models: proof-of-concept application on patients undergoing different types of open-heart surgery

“…All included patients received standardized 3D TEE during hemodynamic stability under general anesthesia both prior to sternotomy ("pre") and after sternal closure ("post"). The institutional protocol for intraoperative 3D TEE acquisition has been extensively described elsewhere (19)(20)(21)(22). In brief, a RV-focused 3D recording was performed using multi-beat acquisition to achieve sufficient frame rates for STE-based volumetry (Figure 2A).…”

Einfluss der perioperativen Echokardiografie auf das chirurgische Management

“…Andererseits sollte bei der Evaluation der ventrikulären Funktion in Narkose der Einfluss der Anästhetika und der Überdruckbeatmung auf die Herzfunktion berücksichtigt werden. So kann sich beispielsweise die rechtsventrikuläre Funktion, wenn man sie ausschließlich anhand der longitudinalen Kontraktion untersucht, schlechter als präoperativ darstellen 5 . Ob diese beobachtete „Verschlechterung“ einen Einfluss auf die Hämodynamik oder gar das Patienten-Outcome hat, ist bisher nicht untersucht.…”

Acute changes of global and longitudinal right ventricular function: an exploratory analysis in patients undergoing open-chest mitral valve surgery, percutaneous mitral valve repair and off-pump coronary artery bypass grafting

“…Anesthesia for MVS and OPCAB was provided according to an institutional standard protocol by experienced cardiac anesthesiologists as described recently [15,19]. Induction was achieved intravenously by the administration of midazolam (0.1-0.15 mg / kg bw), sufentanil (0.3-0.5 μg / kg bw) and rocuronium (0.5-1 mg / kg bw).…”