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• W2950349617 abstract "Central MessagePrecision perioperative RV and pulmonary artery pressure monitoring integrates 3D volumetric assessment, RV strain, splanchnic and renal venous congestion repercussions, and air embolic burden.See Article page 1430 in the April 2020 issue. Precision perioperative RV and pulmonary artery pressure monitoring integrates 3D volumetric assessment, RV strain, splanchnic and renal venous congestion repercussions, and air embolic burden. See Article page 1430 in the April 2020 issue. Right ventricular (RV) failure has been long recognized by cardiac surgeons as a major cause of morbidity and mortality.1Dávila-Román V.G. Waggoner A.D. Hopkins W.E. Barzilai B. Right ventricular dysfunction in low output syndrome after cardiac operations: assessment by transesophageal echocardiography.Ann Thorac Surg. 1995; 60: 1081-1086Abstract Full Text PDF PubMed Scopus (88) Google Scholar, 2Maslow A.D. Regan M.M. Panzica P. Heindel S. Mashikian J. Comunale M.E. Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction.Anesth Analg. 2002; 95: 1507-1518Crossref PubMed Scopus (161) Google Scholar, 3Haddad F. Hunt S.A. Rosenthal D.N. Murphy D.J. Right ventricular function in cardiovascular disease, part I: anatomy, physiology, aging, and functional assessment of the right ventricle.Circulation. 2008; 117: 1436-1448Crossref PubMed Scopus (1055) Google Scholar, 4Kormos R.L. Teuteberg J.J. Pagani F.D. Russell S.D. John R. Miller L.W. et al.HeartMate II Clinical InvestigatorsRight ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes.J Thorac Cardiovasc Surg. 2010; 139: 1316-1324Abstract Full Text Full Text PDF PubMed Scopus (667) Google Scholar, 5Denault A.Y. Pearl R.G. Michler R.E. Rao V. Tsui S.S. Seitelberger R. et al.Tezosentan and right ventricular failure in patients with pulmonary hypertension undergoing cardiac surgery: the TACTICS trial.J Cardiothorac Vasc Anesth. 2013; 27: 1212-1217Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 6Ternacle J. Berry M. Cognet T. Kloeckner M. Damy T. Monin J.L. et al.Prognostic value of right ventricular two-dimensional global strain in patients referred for cardiac surgery.J Am Soc Echocardiogr. 2013; 26: 721-726Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 7Denault A.Y. Bussières J.S. Arellano R. Finegan B. Gavra P. Haddad F. et al.A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients.Can J Anaesth. 2016; 63: 1140-1153Crossref PubMed Scopus (53) Google Scholar Through the years, studies have focused on identifying more sensitive markers of RV dysfunction. The study of Singh and colleagues8Singh A. Huang X. Dai L. Wyler D. Alfirevic A. Blackstone E.H. et al.Right ventricular function is reduced during cardiac surgery independent of procedural characteristics, reoperative status, or pericardiotomy.J Thorac Cardiovasc Surg. 2020; 159: 1430-1438Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar in this issue of the Journal brings novel insights into perioperative changes in RV function, focusing on annular, longitudinal shortening (RV myocardial strain) as well as area changes. Its strength lies in describing the dynamic of RV changes at key perioperative moments and in variable types of surgery. Almost 30 years ago, Popp and associates9Wranne B. Pinto F.J. Hammarstrom E. St Goar F.G. Puryear J. Popp R.L. Abnormal right heart filling after cardiac surgery: time course and mechanisms.Br Heart J. 1991; 66: 435-442Crossref PubMed Scopus (98) Google Scholar observed impairment in tricuspid annular excursion following cardiac surgery. One important question raised by this observation was whether longitudinal RV function reflects global systolic function. In fact, one of the challenges in assessing RV function resides it its complex geometry. By means of 3-dimensional echocardiography, Tamborini and coworkers10Tamborini G. Muratori M. Brusoni D. Celeste F. Maffessanti F. Caiani E.G. et al.Is right ventricular systolic function reduced after cardiac surgery? A two- and three-dimensional echocardiographic study.Eur J Echocardiogr. 2009; 10: 630-634Crossref PubMed Scopus (169) Google Scholar showed that despite the postoperative reduction of tricuspid annular excursion, 3-dimensional RV ejection fraction remained preserved at 3 postoperative months. The study of Singh and colleagues8Singh A. Huang X. Dai L. Wyler D. Alfirevic A. Blackstone E.H. et al.Right ventricular function is reduced during cardiac surgery independent of procedural characteristics, reoperative status, or pericardiotomy.J Thorac Cardiovasc Surg. 2020; 159: 1430-1438Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar also demonstrates that RV fractional area change is less impaired than annular or strain indices, at least in patients undergoing coronary revascularization. Systolic parameters are, however, only one component of right heart performance.11Lang R.M. Badano L.P. Mor-Avi V. Afilalo J. Armstrong A. Ernande L. et al.Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2015; 28: 1-39.e14Abstract Full Text Full Text PDF PubMed Scopus (6973) Google Scholar Other components can be divided as consequences or mechanism of RV failure (Figure 1). Hemodynamic elements, such as central venous pressure and the mean pulmonary arterial pressure to systemic arterial pressure ratio (yielding insights into both the pulmonary and systemic circulations13Robitaille A. Denault A.Y. Couture P. Bélisle S. Fortier A. Guertin M.C. et al.Importance of relative pulmonary hypertension in cardiac surgery: the mean systemic-to-pulmonary artery pressure ratio.J Cardiothorac Vasc Anesth. 2006; 20: 331-339Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 14Bianco J.C. Qizilbash B. Carrier M. Couture P. Fortier A. Tardif J.C. et al.Is patient-prosthesis mismatch a perioperative predictor of long-term mortality after aortic valve replacement?.J Cardiothorac Vasc Anesth. 2013; 27: 647-653Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 15Haddad F. Guihaire J. Skhiri M. Denault A.Y. Mercier O. Al-Halabi S. et al.Septal curvature is marker of hemodynamic, anatomical, and electromechanical ventricular interdependence in patients with pulmonary arterial hypertension.Echocardiography. 2014; 31: 699-707Crossref PubMed Scopus (51) Google Scholar, 16Rebel A. Nguyen D. Bauer B. Sloan P.A. DiLorenzo A. Hassan Z.U. Systemic-to-pulmonary artery pressure ratio as a predictor of patient outcome following liver transplantation.World J Hepatol. 2016; 8: 1384-1391Crossref PubMed Scopus (9) Google Scholar, 17Bianco J.C. Mc Loughlin S. Denault A.Y. Marenchino R.G. Rojas J.I. Bonofiglio F.C. Heart transplantation in patients >60 years: importance of relative pulmonary hypertension and right ventricular failure on midterm survival.J Cardiothorac Vasc Anesth. 2018; 32: 32-40Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar) are useful to monitor; however, combined pulmonary artery and RV pressure waveform (Figure 1, A)18Denault A.Y. Chaput M. Couture P. Hébert Y. Haddad F. Tardif J.C. Dynamic right ventricular outflow tract obstruction in cardiac surgery.J Thorac Cardiovasc Surg. 2006; 132: 43-49Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar appears to be a promising method for detecting abnormal RV function.19Raymond M. Grønlykke L. Couture E.J. Desjardins G. Cogan J. Cloutier J. et al.Perioperative right ventricular pressure monitoring in cardiac surgery.J Cardiothorac Vasc Anesth. 2019; 33: 1090-1104Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The current understanding of RV failure combines the ventricular and the arterial elastance as an index of RV-arterial coupling.20Vieillard-Baron A. Naeije R. Haddad F. Bogaard H.J. Bull T.M. Fletcher N. et al.Diagnostic workup, etiologies and management of acute right ventricle failure: a state-of-the-art paper.Intensive Care Med. 2018; 44: 774-790Crossref PubMed Scopus (88) Google Scholar When this RV-arterial coupling is less than 1, then the RV will enlarge to maintain cardiac output, but at the expense of venous congestion. This concept in recent years has led to an emphasis beyond systolic and diastolic RV parameters toward both forward (low cardiac output) and backward (venous congestion) consequences of RV dysfunction. This can lead to a vicious cycle of decreased overall tissue perfusion and congestion to the brain, liver, spleen, gut, and kidney21Sundaram V. Fang J.C. Gastrointestinal and liver issues in heart failure.Circulation. 2016; 133: 1696-1703Crossref PubMed Scopus (82) Google Scholar, 22Beaubien-Souligny W. Bouchard J. Desjardins G. Lamarche Y. Liszkowski M. Robillard P. et al.Extracardiac signs of fluid overload in the critically ill cardiac patient: a focused evaluation using bedside ultrasound.Can J Cardiol. 2017; 33: 88-100Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar (Figure 1, B through D) In 2 recent prospective studies in which portal venous flow Doppler was interrogated before, during, and after cardiac surgery,23Beaubien-Souligny W. Benkreira A. Robillard P. Bouabdallaoui N. Chassé M. Desjardins G. et al.Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective observational cohort study.J Am Heart Assoc. 2018; 7: e009961Crossref PubMed Scopus (78) Google Scholar, 24Eljaiek R. Cavayas Y.A. Rodrigue E. Desjardins G. Lamarche Y. Toupin F. et al.High postoperative portal venous flow pulsatility indicates right ventricular dysfunction and predicts complications in cardiac surgery patients.Br J Anaesth. 2019; 122: 206-214Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar the presence of portal pulsatility greater than 50% (used as a surrogate for splanchnic congestion) was associated with all the commonly used hemodynamic and echocardiographic variables related to RV dysfunction. In addition, both abnormal portal and renal venous pulsatilities were associated with prolonged duration of stay in the intensive care unit, excessive bleeding, reoperation, acute renal failure, and increased overall complication rate.23Beaubien-Souligny W. Benkreira A. Robillard P. Bouabdallaoui N. Chassé M. Desjardins G. et al.Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective observational cohort study.J Am Heart Assoc. 2018; 7: e009961Crossref PubMed Scopus (78) Google Scholar, 24Eljaiek R. Cavayas Y.A. Rodrigue E. Desjardins G. Lamarche Y. Toupin F. et al.High postoperative portal venous flow pulsatility indicates right ventricular dysfunction and predicts complications in cardiac surgery patients.Br J Anaesth. 2019; 122: 206-214Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Finally, air embolization (Figure 1, E through H) should always be considered as contributing mechanism of RV dysfunction after cardiac surgery. Beyond direct visualization of air emboli in the coronary artery, ST elevation in the inferior lead on weaning form cardiopulmonary bypass with simultaneous hyperintensity transient signals in the middle cerebral artery on transcranial Doppler25Couture E.J. Desjardins G. Denault A.Y. Transcranial Doppler monitoring guided by cranial two-dimensional ultrasonography.Can J Anesth. 2017; 64: 885-887Crossref PubMed Scopus (12) Google Scholar, 26Denault A.Y. Brassard P. Jacquet-Lagrèze M. Halwagi A.E. Targeting optimal blood pressure monitoring: what’s next?.J Thorac Dis. 2018; 10: S3281-S3285Crossref PubMed Scopus (5) Google Scholar and in the hepatic artery may also be suggestive of such a mechanism. In conclusion, we are currently entering an era of precision right heart monitoring. This monitoring integrates RV and pulmonary artery pressure monitoring, 3-dimensional volumetric and strain assessments, assessment of congestive end-organ repercussion, as well as perioperative monitoring for air embolic burden. Right ventricular function is reduced during cardiac surgery independent of procedural characteristics, reoperative status, or pericardiotomyThe Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 4PreviewLong-axis right ventricular (RV) function, which provides nearly 80% of RV ejection, acutely decreases during cardiac surgery. RV dysfunction increases risk for perioperative morbidity and mortality. Our objective was to characterize the change in perioperative RV long-axis and global function by determining the influence of procedure type, surgical approach, and reoperative status and examining its temporal relationship to pericardiotomy versus cardiopulmonary bypass (CPB) and cardioplegia. Full-Text PDF Open Archive" @default.
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• W2950349617 title "Postoperative right ventricular dysfunction—Integrating right heart profiles beyond long-axis function" @default.
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