Right Ventricular Hemodynamics in the Acute Respiratory Distress Syndrome: Monitoring and Implications for Clinical Management.

Right ventricular injury (including right ventricular dilatation/dysfunction/limitation/failure) and pulmonary vascular dysfunction are common in patients with acute respiratory distress syndrome. Despite increasing recognition, right ventricular injury is associated with increased mortality in patients with the acute respiratory distress syndrome and implementation of multi-modal monitoring and timely right ventricle-targeted interventions may therefore confer outcome benefit. The aim of this narrative review is to explore the clinical applications of diagnostic modalities for the right ventricle and pulmonary circulation in invasively ventilated patients with the acute respiratory distress syndrome, including the complementary roles of invasive hemodynamics, echocardiography, and pulmonary monitoring.

Femoral Vein Pulsatility and Neurocognitive Disorder in Cardiac Surgery.

Background: Neurocognitive disorder and venous congestion are related in cardiac surgery. Femoral vein (FV) Doppler allows noninvasive assessment of venous congestion. This study aims to associate postoperative neurocognitive disorder in cardiac surgery with FV pulsatility.

Prevalence of abnormal common femoral vein pulsatility on Doppler ultrasound in patients undergoing cardiac surgery and its association with adverse events: a prospective cohort study.

Purpose: Doppler ultrasound assessment of common femoral vein (CFV) flow could represent a simple, fast, and noninvasive technique to identify right ventricular dysfunction and venous congestion in patients undergoing cardiac surgery. Our primary objective was to determine the prevalence of abnormal CFV flow pulsatility before cardiac surgery. Secondary objectives included investigating its association with postoperative outcomes.

Perioperative echocardiographic strain analysis: what anesthesiologists should know.

Purpose: Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

Clinical relevance of transcranial Doppler in a cardiac surgery setting: embolic load predicts difficult separation from cardiopulmonary bypass.

Background: During cardiac surgery, transcranial Doppler (TCD) represents a non-invasive modality that allows measurement of red blood cell flow velocities in the cerebral arteries. TCD can also be used to detect and monitor embolic material in the cerebral circulation. Detection of microemboli is reported as a high intensity transient signal (HITS).

Higher portal venous pulsatility is associated with worse clinical outcomes following congenital heart surgery: a single-centre prospective cohort study.

Purpose: Increased portal venous flow pulsatility is associated with major complications after adult cardiac surgery. Nevertheless, no data are available for pediatric patients with congenital heart disease. We hypothesized that Doppler parameters including portal flow pulsatility could be associated with postoperative outcomes in children undergoing various cardiac surgeries.

Doppler identified venous congestion in septic shock: protocol for an international, multi-centre prospective cohort study (Andromeda-VEXUS).

Introduction: Venous congestion is a pathophysiological state where high venous pressures cause organ oedema and dysfunction. Venous congestion is associated with worse outcomes, particularly acute kidney injury (AKI), for critically ill patients. Venous congestion can be measured by Doppler ultrasound at the bedside through interrogation of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV) and intrarenal veins (IRV).

Evaluation of Portal, Splenic, and Hepatic Vein Flows in Children Undergoing Congenital Heart Surgery.

Objective: Little is known about changes in portal, splenic, and hepatic vein flow patterns in children undergoing congenital heart surgery. This study aimed to determine the characteristics of portal, splenic, and hepatic vein flow patterns using ultrasonography in children undergoing cardiac surgery.

Design: Single-center, prospective observational study.

Prolonged cardiovascular pharmacological support and fluid management after cardiac surgery.

Objective: To identify potentially modifiable risk factors related to prolonged cardiovascular pharmacological support after weaning from cardiopulmonary bypass (CPB).

Methods: This is a secondary analysis of two prospective cohort study in a specialized cardiac surgery institution in adult patients undergoing cardiac surgery with the use of CPB between August 2016 and July 2017. Prolonged cardiovascular pharmacological support was defined by the need for at least one vasopressor or one inotropic agent 24 hours after separation from CPB.

Inhaled milrinone in cardiac surgical patients: pharmacokinetic and pharmacodynamic exploration.

Mean arterial pressure to mean pulmonary arterial pressure ratio (mAP/mPAP) has been identified as a strong predictor of perioperative complications in cardiac surgery. We therefore investigated the pharmacokinetic/pharmacodynamic (PK/PD) relationship of inhaled milrinone in these patients using this ratio (R) as a PD marker. Following approval by the ethics and research committee and informed consent, we performed the following experiment.

Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model.

Unlabelled: Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (E) following the development of an acute RV ischemic in a porcine model.

Pulsatile Femoral Vein Doppler and Congestive Delirium, What Is the Relationship?: A Case Report.

Delirium is common in patients undergoing cardiac surgery, and venous congestion has been reported as an important risk factor. We report a 69-year-old patient who developed postoperative delirium in the intensive care unit following aortic valve replacement surgery. The postoperative course was complicated by delirium for which echographic signs of venous congestion on the portal and the renal but also the femoral veins and their resolution correlated with the course of delirium.

Regional pleural strain measurements during mechanical ventilation using ultrasound elastography: A randomized, crossover, proof of concept physiologic study.

Background: Mechanical ventilation is a common therapy in operating rooms and intensive care units. When ill-adapted, it can lead to ventilator-induced lung injury (VILI), which is associated with poor outcomes. Excessive regional pulmonary strain is thought to be a major mechanism responsible for VILI.

Pulmonary Vasodilator Response of Combined Inhaled Epoprostenol and Inhaled Milrinone in Cardiac Surgical Patients.

Background: Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. Intraoperative management of patients at high risk of RV failure should aim to reduce RV afterload and optimize RV filling pressures, while avoiding systemic hypotension, to facilitate weaning from cardiopulmonary bypass (CPB). Inhaled epoprostenol and inhaled milrinone (iE&iM) administered in combination before CPB may represent an effective strategy to facilitate separation from CPB and reduce requirements for intravenous inotropes during cardiac surgery.

Early Detection and Correction of Cerebral Desaturation With Noninvasive Oxy-Hemoglobin, Deoxy-Hemoglobin, and Total Hemoglobin in Cardiac Surgery: A Case Series.

Regional cerebral oxygen saturation (rS o2 ) obtained from near-infrared spectroscopy (NIRS) provides valuable information during cardiac surgery. The rS o2 is calculated from the proportion of oxygenated to total hemoglobin in the cerebral vasculature. Root O3 cerebral oximetry (Masimo) allows for individual identification of changes in total (ΔcHbi), oxygenated (Δ o2 Hbi), and deoxygenated (ΔHHbi) hemoglobin spectral absorptions.

Radial-to-femoral pressure gradient quantification in cardiac surgery.

Background: A radial-to-femoral pressure gradient (RFPG) can occur in roughly one-third of cardiac surgical patients. Such a gradient has been associated with smaller stature and potentially smaller radial artery diameter. We hypothesized that preoperative radial artery diameter could be a predictor of RFPG.

New developments in the understanding of right ventricular function in acute care.

Purpose Of Review: Right ventricular dysfunction has an important impact on the perioperative course of cardiac surgery patients. Recent advances in the detection and monitoring of perioperative right ventricular dysfunction will be reviewed here.

Recent Findings: The incidence of right ventricular dysfunction in cardiac surgery has been associated with unfavorable outcomes.

A standardized definition for right ventricular failure in cardiac surgery patients.

Right ventricular failure (RVF) is a significant cause of mortality and morbidity after cardiac surgery. Despite its prognostic importance, RVF remains under investigated and without a universally accepted definition in the perioperative setting. We foresee that the provision of a standardized perioperative definition for RVF based on practical and objective criteria will help to improve quality of care through early detection and facilitate the generalization of RVF research to advance this field.

Preliminary experience with continuous right ventricular pressure and transesophageal echocardiography monitoring in orthotopic liver transplantation.

Background: Despite increasing attention in the cardiac anesthesiology literature, continuous measurement of right ventricular pressure using a pulmonary artery catheter has not been described in orthotopic liver transplantation, despite similarities in the anesthetic approach to the two populations. We describe our preliminary experience with this technique in orthotopic liver transplantation, and by combining various derived measures with trans-esophageal echocardiography, make some early observations regarding the response of these measures of right ventricular function during the procedure.

Methods: In this case series, ten patients (five men and five women) undergoing orthotopic liver transplantation in our institution had their surgeries performed while monitored with a pulmonary artery catheter with continuous right ventricular port transduction and trans-esophageal echocardiography.

Right Ventricular Outflow Tract Obstruction in the Intensive Care Unit: A Case Report of 2 Patients.

Right ventricular outflow tract obstruction (RVOTO) is a rare cause of hemodynamic instability in the intensive care unit (ICU) after cardiac surgery. We report the first cases of RVOTO diagnosed in the ICU using continuous right ventricular pressure waveform monitoring. Our 2 cases reflect both mechanical and dynamic causes of obstruction, each of which require different approaches to treatment.