“…Global assessment of the RV is recommended; thus, we chose RVFAC as the echocardiographic parameter in this study. Three-dimensional (3D) echocardiography may improve the situation; however, especially in intraoperative TEE, measuring 3D RVEF in real time remains difficult owing to some technological issues, and does not seem to be practical at least in the current clinical settings ( 9 , 30 , 31 ). Since QRS RV could simply indicate the electrophysiological activity of the RV, it might have bypassed the above limitations of echocardiography and might have revealed perioperatively reduced RV function after CPB, which RVFAC did not capture.…”
Section: Discussionmentioning
confidence: 99%
“…However, despite its importance, accurately assessing RV function is still clinically challenging because of the complex anatomy of the RV ( 3 – 5 ). Cardiac magnetic resonance imaging (MRI) is the gold standard for the assessment, and echocardiography is considered less accurate ( 9 , 10 ), albeit currently the most practical method to evaluate cardiac function in the perioperative period.…”
BackgroundThe clinical importance of the right ventricle (RV) has recently been recognized; however, assessing its function during cardiac surgery remains challenging owing to its complex anatomy. A temporary transvenous pacing catheter is a useful tool in the small surgical field of minimally invasive cardiac surgery, and an electrocardiogram recorded through the catheter is composed of the direct electrophysiological activity of the RV. Therefore, we hypothesized that QRS duration in the RV (QRSRV) could be a useful monitoring parameter for perioperative RV function.MethodsWe conducted a prospective cohort analysis involving adult patients undergoing robotic mitral valve repair. A bipolar pacing catheter was inserted using x-ray fluoroscopy, and the QRSRV duration was assessed at four time points: preoperative baseline, during one-lung ventilation, after weaning from cardiopulmonary bypass, and before the end of surgery. At the same time points, right ventricular fractional area change (RVFAC) measured by transesophageal echocardiography and QRS duration at V5 lead of the body surface electrocardiogram (QRSV5) were also evaluated.ResultsIn the 94 patients analyzed, QRSRV duration was significantly prolonged during robotic mitral valve repair (p = 0.0009), whereas no significant intraoperative changes in RVFAC were observed (p = 0.2). By contrast, QRSV5 duration was significantly shortened during surgery (p < 0.00001). Multilinear regression showed a significant correlation of QRSRV duration with RVFAC (p = 0.00006), but not with central venous pressure (p = 0.9), or left ventricular ejection fraction (p = 0.3). When patients were divided into two groups by postoperative QRSRV > 100 or ≤100 ms, 25 patients (26.6%) exhibited the prolonged QRSRV duration, and the mean increase in the postoperative QRSRV from preoperative baseline was 12 ms (p = 0.001), which was only 0.6 ms in patients with QRSRV ≤ 100 ms (p = 0.6). Cox regression analysis showed that prolonged postoperative QRSRV duration was the only significant parameter associated with a longer ICU stay after surgery (p = 0.02; hazard ratio, 0.55).ConclusionOur data suggest that QRSRV duration is a useful parameter for monitoring the RV during cardiac surgery, possibly better than a commonly used echocardiographic parameter, RVFAC. An electrophysiological assessment by QRSRV duration could be a practical tool for the complex anatomy of the RV, especially with limited modalities in perioperative settings.
“…Global assessment of the RV is recommended; thus, we chose RVFAC as the echocardiographic parameter in this study. Three-dimensional (3D) echocardiography may improve the situation; however, especially in intraoperative TEE, measuring 3D RVEF in real time remains difficult owing to some technological issues, and does not seem to be practical at least in the current clinical settings ( 9 , 30 , 31 ). Since QRS RV could simply indicate the electrophysiological activity of the RV, it might have bypassed the above limitations of echocardiography and might have revealed perioperatively reduced RV function after CPB, which RVFAC did not capture.…”
Section: Discussionmentioning
confidence: 99%
“…However, despite its importance, accurately assessing RV function is still clinically challenging because of the complex anatomy of the RV ( 3 – 5 ). Cardiac magnetic resonance imaging (MRI) is the gold standard for the assessment, and echocardiography is considered less accurate ( 9 , 10 ), albeit currently the most practical method to evaluate cardiac function in the perioperative period.…”
BackgroundThe clinical importance of the right ventricle (RV) has recently been recognized; however, assessing its function during cardiac surgery remains challenging owing to its complex anatomy. A temporary transvenous pacing catheter is a useful tool in the small surgical field of minimally invasive cardiac surgery, and an electrocardiogram recorded through the catheter is composed of the direct electrophysiological activity of the RV. Therefore, we hypothesized that QRS duration in the RV (QRSRV) could be a useful monitoring parameter for perioperative RV function.MethodsWe conducted a prospective cohort analysis involving adult patients undergoing robotic mitral valve repair. A bipolar pacing catheter was inserted using x-ray fluoroscopy, and the QRSRV duration was assessed at four time points: preoperative baseline, during one-lung ventilation, after weaning from cardiopulmonary bypass, and before the end of surgery. At the same time points, right ventricular fractional area change (RVFAC) measured by transesophageal echocardiography and QRS duration at V5 lead of the body surface electrocardiogram (QRSV5) were also evaluated.ResultsIn the 94 patients analyzed, QRSRV duration was significantly prolonged during robotic mitral valve repair (p = 0.0009), whereas no significant intraoperative changes in RVFAC were observed (p = 0.2). By contrast, QRSV5 duration was significantly shortened during surgery (p < 0.00001). Multilinear regression showed a significant correlation of QRSRV duration with RVFAC (p = 0.00006), but not with central venous pressure (p = 0.9), or left ventricular ejection fraction (p = 0.3). When patients were divided into two groups by postoperative QRSRV > 100 or ≤100 ms, 25 patients (26.6%) exhibited the prolonged QRSRV duration, and the mean increase in the postoperative QRSRV from preoperative baseline was 12 ms (p = 0.001), which was only 0.6 ms in patients with QRSRV ≤ 100 ms (p = 0.6). Cox regression analysis showed that prolonged postoperative QRSRV duration was the only significant parameter associated with a longer ICU stay after surgery (p = 0.02; hazard ratio, 0.55).ConclusionOur data suggest that QRSRV duration is a useful parameter for monitoring the RV during cardiac surgery, possibly better than a commonly used echocardiographic parameter, RVFAC. An electrophysiological assessment by QRSRV duration could be a practical tool for the complex anatomy of the RV, especially with limited modalities in perioperative settings.
“…Expeditious evaluation is possible with transthoracic ultrasound (in MAC or regional cases) or TEE during general anesthesia but requires an experienced operator. TEE provides valuable information by enabling serial assessment of RV performance, fluid status, and assessment of other etiologies (Haddad et al 2009 ; Silverton et al 2022 ).…”
Under recognition combined with suboptimal management of right ventricular (RV) dysfunction and failure is associated with significant perioperative morbidity and mortality. The contemporary perioperative team must be prepared with an approach for early recognition and prompt treatment. In this review, a consensus-proposed scoring system is described to provide a pragmatic approach for expeditious decision-making for these complex patients with a vulnerable RV. Importantly, this proposed scoring system incorporates the context of the planned surgical intervention. Further, as the operating room (OR) represents a unique environment where patients are susceptible to numerous insults, a practical approach to anesthetic management and monitoring both in the OR and in the intensive care unit is detailed. Lastly, an escalating approach to the management of RV failure and options for mechanical circulatory support is provided.
“… 8 In patients whose portal vein cannot be imaged, a splenic venous Doppler signal has previously been detected with TEE and may similarly reflect splanchnic drainage congestion. 9 Fig. 7 Pulsed wave Doppler showing predominantly monophasic portal venous flow with minimal pulsatility Fig.…”
Purpose
Obtaining an objective, reproducible, and accurate assessment of volume status is one of the more difficult tasks in the perioperative arena. Since its advent in 2020, the Venous Excess Ultrasound (VExUS) score has gained popularity in the minimally invasive assessment of venous congestion. The VExUS exam has been well described as an additional series of images (hepatic vein, portal vein, and intrarenal vein) obtained with a phased-array probe during a transthoracic echocardiogram. Nevertheless, there are no descriptions of comprehensive VExUS exams performed using transesophageal echocardiography (TEE)—a modality that is routinely employed in patients undergoing cardiac surgery.
Clinical features
We describe techniques to acquire and interpret a comprehensive TEE-supported VexUS exam, which may be used to optimize the perioperative care of cardiac surgical patients.
Conclusion
Given the risks of fluid overload in critically ill cardiac surgery patients, TEE-supported VExUS examination may be a way to reduce morbidity in this population.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12630-023-02688-9.
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