The impact of pericardial approach and myocardial protection onto postoperative right ventricle function reduction

Abstract

BackgroundThe reduction of RV function after cardiac surgery is a well-known phenomenon. It could persist up-to one year after the operation and often leads to an incomplete recovery at follow-up echocardiographic control. The aim of the present study is to analyze the impact of different modalities of pericardial incision (lateral versus anterior) and of myocardial protection protocols (Buckberg versus Custodiol) onto postoperative RV dynamic by relating two- and three-dimensional echocardiographic parameters in patients undergoing mitral valve repair through minimally invasive or traditional surgery approach.MethodsWe have analyzed 44 consecutive patients with severe degenerative mitral regurgitation who underwent mitral reparation with different surgical approach and cardioplegia type: Group 1 (17 pts): sternotomy with Buckberg cardioplegia protocol; Group 2 (10 pts): sternotomy with Custodiol cardioplegia; Group 3 (17 pts): mini-invasive surgery with Custodiol cardioplegia. Two-dimensional transthoracic echocardiography was performed pre- and 6 months post-surgery to evaluate RV function by tricuspid annular plane systolic excursion (TAPSE).ResultsAll patients underwent successful and uneventful. A postoperative TAPSE reduction was found in all groups. However, mini-invasive patients experienced a significant reduced variation versus traditional surgery.ConclusionsMini-invasive mitral repair, with lateral incision of pericardium, reduces postoperative TAPSE fall, while cardioplegia protocol fails to have an impact onto longitudinal RV function. In our study, the RV seems to experience a clinically irrelevant geometrical modification too, whose entity appears to be less evident in case of lateral pericardial approach. These results could strengthen the use of minimally invasive approach also to preserve RV function.

Conventional echocardiographic parameters or three-dimensional echocardiography to evaluate right ventricular function in percutaneous edge-to-edge mitral valve repair (PMVR)

“…From patient collectives undergoing surgical repair of MR, it is known that two-dimensional (2D) indexes of RV systolic performance decrease during and immediately after cardiac surgery [5]. Moreover, recovery to basal values is often incomplete and an echocardiographic dysfunction can persist even at one year after surgery [5].…”

“…From patient collectives undergoing surgical repair of MR, it is known that two-dimensional (2D) indexes of RV systolic performance decrease during and immediately after cardiac surgery [5]. Moreover, recovery to basal values is often incomplete and an echocardiographic dysfunction can persist even at one year after surgery [5]. Depression of RV function is also reported for other settings of cardiac surgery like coronary artery bypass grafting [6], and worsening of RV function and the magnitude of deterioration have important prognostic implications for interventions such as transcatheter aortic valve replacement (TAVR) [7].…”

Thoracotomy versus sternotomy? The effect of surgical approach on outcomes after left ventricular assist device implantation: A review of the literature and meta‐analysis

“…36 Reductions in right heart function have been well described after cardiac surgery, and are thought to be secondary to inadequate myocardial protection, use of cardiopulmonary bypass, postoperative adhesions to surrounding structures such as the sternum, and pericardial disruption. Reductions in echocardiographic measures of right heart function including right ventricular tissue Doppler velocities and transannular plane systolic excursion (TAPSE) and have been described in patients undergoing traditional procedures such as coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve repair (MVR) via sternotomy, 15,16,37,37,38 with an acute decline occurring just after pericardial incision. 15,16 Interestingly, these findings are not seen in patients undergoing non-sternotomy approaches, such as robotic CABG and ministernotomy-AVR, and thoracotomy MVR in which the anterior pericardial restraint over the right heart is preserved.…”

Effect of pericardial incision on left ventricular morphology and systolic function in patients during coronary artery bypass grafting

“…Several previous studies have reported a change of RV geometry or reduction of RV systolic function after pericardial incision without suture [ 7 , 15 – 17 ], which was similar with our study. Interestingly, the study by Zanobini M, et al [ 18 ] also reported the presence of decreased RV systolic function after pericardial incision even with reclosing the pericardium with a continuous suture in different surgical approach and cardioplegia type. The possible mechanisms of decreased RV function after cardiac surgery may be related to the cardiopulmonary bypass use, pericardial adhesions, modality of cardioplegia delivery and pericardial incision, and so on [ 18 ], and its clear-cut mechanisms were warranted to be further addressed in the future study.…”