This study identified 9 independent predictors of low cardiac output syndrome after coronary artery bypass surgery:
1) Left ventricular ejection fraction less than 20%
2) Repeat operation
3) Emergency operation
4) Female gender
5) Diabetes
6) Age older than 70 years
7) Left main coronary artery stenosis
8) Recent myocardial infarction
9) Triple-vessel disease
The overall prevalence of low cardiac output syndrome was 9.1% and the operative mortality rate was higher for patients who developed it compared to those who did not.
This document discusses fractional flow reserve (FFR), a technique used during coronary catheterization to measure pressure differences across a coronary stenosis and determine if it is causing myocardial ischemia. An FFR value below 0.75 is considered functionally significant while a value above 0.80 rules out ischemia. FFR is useful for evaluating single-vessel disease, left main stenosis, tandem lesions, diffuse disease, grafts, and ostial lesions. Limitations include inability to assess plaque morphology.
This document discusses surgical options for treating heart failure. It begins by providing background on heart failure, including definitions, incidence rates, mortality rates, clinical types, and causes. It then discusses various surgical interventions for acute and chronic heart failure, such as CABG, valve surgery, ventricular reconstruction procedures like the Dor procedure, restraint devices like the Acorn and Myosplint, ventricular assist devices, total artificial hearts, and heart transplantation. The risks, benefits, indications, and outcomes of these different surgical treatments are summarized.
- Implantable cardioverter defibrillators (ICDs) are recommended for patients with hypertrophic cardiomyopathy (HCM) who have survived sudden cardiac arrest, have spontaneous sustained ventricular tachycardia, or meet certain high-risk criteria.
- Risk stratification should be performed at initial evaluation and periodically to determine ICD need based on factors like family history of sudden cardiac death and abnormal blood pressure response.
- For left ventricular outflow tract obstruction, beta blockers and calcium channel blockers are first-line medical therapies while septal myectomy or alcohol septal ablation are invasive options that provide long-term reduction in outflow gradient.
This document discusses the management of hypertrophic cardiomyopathy (HCM). It covers the natural history of HCM, risk stratification including the role of implantable cardioverter defibrillators, pharmacological treatments, and invasive treatments such as alcohol septal ablation and surgical myectomy. Key points discussed include the use of beta blockers as first-line pharmacological therapy, guidelines for ICD implantation, the technique and outcomes of alcohol septal ablation versus surgical myectomy, and recommendations for experienced centers to perform these invasive procedures.
This document discusses various surgical options for treating heart failure, including:
- Coronary artery revascularization to improve blood flow in ischemic cardiomyopathy.
- Valve surgery like mitral valve repair to address functional mitral regurgitation and reduce ventricular volume overload.
- Left ventricular reconstruction to remove scar tissue, restore a more elliptical chamber shape, and decrease wall stress.
- Passive cardiac support devices like the CorCap that provide external diastolic support to facilitate reverse remodeling.
- Mechanical circulatory support options for short-term support like IABP or long-term support like left ventricular assist devices as a bridge to transplant.
- Cardiac transplantation as the gold
This document provides an overview of mechanical circulatory support devices. It discusses the evolution of such devices and their terminology. Temporary devices discussed include intra-aortic balloon pumps and Impella pumps. Long-term devices discussed include pulsatile flow devices like HeartMate I as well as continuous flow devices like HeartMate II, HeartWare HVAD, and HeartMate 3. Clinical trials are summarized that evaluated these devices as bridges to transplant or destination therapy. Biventricular support devices like the total artificial heart are also covered. The document concludes with recommendations from organizations on the use of these devices.
This study identified 9 independent predictors of low cardiac output syndrome after coronary artery bypass surgery:
1) Left ventricular ejection fraction less than 20%
2) Repeat operation
3) Emergency operation
4) Female gender
5) Diabetes
6) Age older than 70 years
7) Left main coronary artery stenosis
8) Recent myocardial infarction
9) Triple-vessel disease
The overall prevalence of low cardiac output syndrome was 9.1% and the operative mortality rate was higher for patients who developed it compared to those who did not.
This document discusses fractional flow reserve (FFR), a technique used during coronary catheterization to measure pressure differences across a coronary stenosis and determine if it is causing myocardial ischemia. An FFR value below 0.75 is considered functionally significant while a value above 0.80 rules out ischemia. FFR is useful for evaluating single-vessel disease, left main stenosis, tandem lesions, diffuse disease, grafts, and ostial lesions. Limitations include inability to assess plaque morphology.
This document discusses surgical options for treating heart failure. It begins by providing background on heart failure, including definitions, incidence rates, mortality rates, clinical types, and causes. It then discusses various surgical interventions for acute and chronic heart failure, such as CABG, valve surgery, ventricular reconstruction procedures like the Dor procedure, restraint devices like the Acorn and Myosplint, ventricular assist devices, total artificial hearts, and heart transplantation. The risks, benefits, indications, and outcomes of these different surgical treatments are summarized.
- Implantable cardioverter defibrillators (ICDs) are recommended for patients with hypertrophic cardiomyopathy (HCM) who have survived sudden cardiac arrest, have spontaneous sustained ventricular tachycardia, or meet certain high-risk criteria.
- Risk stratification should be performed at initial evaluation and periodically to determine ICD need based on factors like family history of sudden cardiac death and abnormal blood pressure response.
- For left ventricular outflow tract obstruction, beta blockers and calcium channel blockers are first-line medical therapies while septal myectomy or alcohol septal ablation are invasive options that provide long-term reduction in outflow gradient.
This document discusses the management of hypertrophic cardiomyopathy (HCM). It covers the natural history of HCM, risk stratification including the role of implantable cardioverter defibrillators, pharmacological treatments, and invasive treatments such as alcohol septal ablation and surgical myectomy. Key points discussed include the use of beta blockers as first-line pharmacological therapy, guidelines for ICD implantation, the technique and outcomes of alcohol septal ablation versus surgical myectomy, and recommendations for experienced centers to perform these invasive procedures.
This document discusses various surgical options for treating heart failure, including:
- Coronary artery revascularization to improve blood flow in ischemic cardiomyopathy.
- Valve surgery like mitral valve repair to address functional mitral regurgitation and reduce ventricular volume overload.
- Left ventricular reconstruction to remove scar tissue, restore a more elliptical chamber shape, and decrease wall stress.
- Passive cardiac support devices like the CorCap that provide external diastolic support to facilitate reverse remodeling.
- Mechanical circulatory support options for short-term support like IABP or long-term support like left ventricular assist devices as a bridge to transplant.
- Cardiac transplantation as the gold
This document provides an overview of mechanical circulatory support devices. It discusses the evolution of such devices and their terminology. Temporary devices discussed include intra-aortic balloon pumps and Impella pumps. Long-term devices discussed include pulsatile flow devices like HeartMate I as well as continuous flow devices like HeartMate II, HeartWare HVAD, and HeartMate 3. Clinical trials are summarized that evaluated these devices as bridges to transplant or destination therapy. Biventricular support devices like the total artificial heart are also covered. The document concludes with recommendations from organizations on the use of these devices.
This article summarizes the results of a study on 53 patients who underwent alcohol septal ablation for hypertrophic obstructive cardiomyopathy over 8 years of follow up. Significant reductions in left ventricular outflow tract gradients and septal thickness were observed at 6 months follow up. Symptoms improved in the majority of patients. Ten percent of patients required pacemaker implantation. There was 92% survival rate at 8 years. The study demonstrates that alcohol septal ablation is an effective and safe nonsurgical option for treating hypertrophic obstructive cardiomyopathy that provides long-term relief of symptoms.
This document discusses the assessment of intracardiac shunts by cardiac catheterization. It describes how an oximetry run is performed to detect a left-to-right shunt by measuring oxygen saturation at various locations in the heart and great vessels. A significant step-up in oxygen saturation between the right atrium and ventricle or pulmonary artery suggests a left-to-right shunt. The document also discusses calculating shunt ratios using indicator dilution techniques and identifying shunt locations with angiography and pressure measurements. Complications of the procedure are outlined.
1) Cardiac arrhythmias are common in the ICU and represent a major source of morbidity and potential increased mortality. Arrhythmias may be the primary reason for admission or develop during critical illness.
2) Factors that increase the risk of life-threatening arrhythmias in ICU patients include their underlying critical illnesses, drugs, electrolyte imbalances, hypoxia, sepsis and other metabolic disturbances, and fluctuations in intravascular volume.
3) Arrhythmias can be life-threatening if the heart rate is too fast or slow resulting in hemodynamic instability, if it degenerates to ventricular fibrillation, or if associated with severe hypokalemia/hypomagnesemia or underlying
The document discusses the physiology of coronary blood flow and the microcirculation. Some key points include:
- Coronary blood flow is determined not only by proximal pressures but also by active compression and decompression of the microcirculation.
- Distal coronary pressure is influenced by both pressure transmitted from the aorta and pressure arising from the microcirculation.
- Fractional flow reserve (FFR) provides a measure of maximum achievable blood flow through a stenosis compared to a normal artery, indicating the functional significance of the stenosis.
- An FFR below 0.80 accurately identifies lesions causing ischemia, while a value above 0.80 reliably excludes ischemia.
Hypertrophic cardiomyopathy (HCM) is defined by a thickened left ventricular wall without an identifiable cause. It can range from asymptomatic to causing heart failure, arrhythmias, or sudden cardiac death. Treatment depends on whether the left ventricular outflow tract (LVOT) is obstructed. For symptomatic patients with LVOT obstruction despite maximum medical therapy, septal reduction procedures like alcohol septal ablation or surgical myectomy are recommended. Alcohol septal ablation involves injecting alcohol into a septal perforator artery to ablate tissue and reduce the gradient. Surgical myectomy directly resects septal muscle. Both procedures significantly reduce gradients and improve symptoms but surgical myectomy provides better gradient and symptom reduction with a lower risk of
Left ventricular assist devices (LVADs) can provide long-term support for patients with end-stage heart failure who are not candidates for transplant. Continuous-flow LVADs have high 1- and 2-year survival rates of 80% and 70% respectively. While LVADs improve survival and quality of life, patients face risks of complications like bleeding, infection, stroke, and device malfunction. Ongoing management requires careful monitoring and optimization of patient hemodynamics and medical therapies.
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/ARVC) is a genetic heart condition characterized by structural abnormalities and fatty infiltration of the right ventricle, leading to ventricular arrhythmias and sudden cardiac death. It is a common cause of sudden cardiac death in young athletes. Clinical features include palpitations, syncope, chest pain, and dyspnea. Diagnosis relies on a combination of ECG findings, echocardiogram abnormalities of the right ventricle, and genetic testing.
Which mechanical circulatory support should we use as first line optiondrucsamal
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
The SAFE-PCI for Women Trial was a prospective, randomized trial comparing radial versus femoral approaches for percutaneous coronary intervention (PCI) in women. 1787 women undergoing cardiac catheterization or PCI were randomized to radial or femoral access. The trial was terminated early due to lower than expected event rates. In the subgroup of women undergoing PCI (n=345 radial, n=346 femoral), there was no significant difference in the primary efficacy endpoint of bleeding or vascular complications between radial and femoral access. However, radial access was associated with a higher rate of needing conversion to femoral access. Overall, the results suggest an initial radial access strategy may be preferred for some women undergoing cardiac procedures.
Non cardiac surgery in cardiac patients moTamer Taha
This document discusses guidelines for evaluating and managing cardiac risk in patients undergoing non-cardiac surgery. It outlines factors that increase surgical risk like prolonged stress and changes in thrombotic factors. Complication rates are reported to be 7-11% with 0.8-1.5% mortality depending on precautions. Up to 42% of complications are cardiac related. It provides recommendations on pre-operative testing and risk stratification using indices. Risk reduction strategies discussed include use of beta-blockers, statins, and revascularization. Perioperative management of antiplatelets and anticoagulants is also covered.
HCM – Presentation, Hemodynamics and InterventionAnkur Gupta
This document describes a case of a 50-year-old female presenting with symptoms of breathlessness, angina, and presyncope. Echocardiography revealed asymmetric septal hypertrophy and systolic anterior motion of the mitral valve, consistent with hypertrophic obstructive cardiomyopathy (HOCM). The document then provides detailed background information on HOCM, including definitions, pathophysiology, clinical presentation, diagnostic testing, and treatment options such as beta-blockers, septal ablation, and disqualification from competitive sports in severe cases.
Tachycardia induced cardiomyopathy is a type of dilated cardiomyopathy caused by chronic or frequent tachycardia that leads to impaired left ventricular function. This impairment is partially or fully reversible by controlling the heart rate. The document discusses the criteria, types, pathophysiology, diagnosis, and treatment of tachycardia induced cardiomyopathy. Treatment focuses on heart rate control through medications, ablation, or devices, which can improve ejection fraction and heart failure symptoms over time.
Heart transplantation involves surgically removing a failing heart and replacing it with a donor heart. Some key events and indications for heart transplantation include:
- The first human heart transplant was performed in 1967.
- Survival rates after heart transplantation are around 69% after 5 years.
- Indications for heart transplantation include stage D heart failure, peak VO2 levels below certain thresholds, and refractory arrhythmias or restrictive cardiomyopathy.
- Contraindications include life expectancy under 2 years from other illnesses, irreversible organ dysfunction, and uncontrolled infections or malignancies.
This document discusses several topics related to vascular surgery:
1) Aorto-occlusive disease causes inadequate blood flow to organs and extremities. Myocardial dysfunction is a major cause of morbidity after vascular surgery.
2) Patients undergoing procedures like abdominal aortic aneurysm repair are at high risk of cardiac complications due to comorbidities like heart disease.
3) Carotid endarterectomy requires careful management to balance cerebral perfusion and cardiac stress during surgery.
Year in cardiology imaging 2019 - echocardiographyPraveen Nagula
This document summarizes findings from studies on cardiac imaging techniques. Key points include:
1) A study of over 1,000 individuals found that E/e'sr, a measure of left ventricular filling pressures using speckle tracking echocardiography, was a stronger predictor of cardiovascular death and events than E/E' and provided incremental value over current risk models.
2) Increased left ventricular mechanical dispersion, a measure of contraction heterogeneity, was associated with higher risk of cardiovascular death in a large population even after adjusting for factors.
3) Studies found a U-shaped relationship between left ventricular ejection fraction and mortality, with a nadir at 60-65%, indicating risks with both higher and lower
Cardiac transplantation involves surgically implanting a donor heart into a recipient with heart failure. It is indicated for end-stage heart disease that is refractory to maximal medical therapy. Absolute contraindications include active infections, cancers, and pulmonary hypertension. Evaluation of recipients includes cardiac testing and screening for medical/psychosocial risks. Donor hearts must be from brain dead individuals without systemic disease or infection. Post-operative care requires lifelong immunosuppression to prevent rejection while managing complications like infection, rejection, and arrhythmias. Long-term follow-up focuses on screening for issues like allograft vasculopathy.
This document discusses the diagnosis of peri-operative myocardial infarction. It defines peri-operative myocardial ischemia and explains why the traditional MI definition does not apply under anesthesia. The ACC criteria for diagnosing a peri-operative MI is described. The pathophysiology involves acute coronary syndrome (Type I) or oxygen supply-demand imbalance (Type II). Diagnostic tools include electrocardiography, cardiac enzymes, echocardiography, nuclear imaging techniques and cardiac MRI/CT. Early recognition can help prevent morbidity and mortality through pharmacological interventions.
The document discusses acute right ventricular (RV) failure, including:
1) The RV's main job is to maintain low right atrial pressure to optimize venous return to the heart. RV dysfunction can lead to reduced cardiac output.
2) Treatment for RV failure differs from left ventricular failure - RV failure may require fluid administration while left sided failure uses diuretics.
3) RV infarction is associated with worse outcomes than left ventricular infarction such as higher mortality, and requires a tailored treatment approach including fluid administration in some cases rather than diuretics. Early revascularization can help recovery.
Refractory heart failure - Diagnosis, Management, Device TherapyImran Ahmed
This document summarizes information about heart failure (HF), including:
1) HF is a major public health problem worldwide, affecting over 23 million people, with rates increasing with age.
2) Stages of HF range from risk factors to end-stage disease and influence treatment approaches.
3) Implantable devices like ICDs and CRT have been shown to improve symptoms and reduce mortality in HF, though guidelines around their use continue to be refined.
4) Ongoing research is exploring expanding the use of CRT to additional patient populations like those with narrow QRS complexes or milder disease.
This document discusses acute decompensated heart failure (ADHF), which refers to new or worsening signs and symptoms of heart failure requiring medical care or hospitalization. ADHF accounts for over 50% of heart failure costs in the US. It has a high mortality and readmission rate. The document outlines common causes and presentations of ADHF and emphasizes the importance of a thorough clinical evaluation to diagnose ADHF and distinguish it from other potential causes of symptoms like shortness of breath. It describes assessing signs of congestion and hypoperfusion to classify patients and guide initial treatment.
Perioperative myocardial infarction is a common cause of morbidity and mortality in patients undergoing noncardiac surgery. It can occur through acute coronary syndrome or prolonged myocardial ischemia in patients with stable coronary artery disease. Diagnosis is difficult as symptoms often do not present in anesthetized patients. Risk is determined by patient clinical factors, exercise capacity, and surgery risk. Management may include beta blockers, statins, aspirin, and evaluating need for revascularization based on standard criteria.
This article summarizes the results of a study on 53 patients who underwent alcohol septal ablation for hypertrophic obstructive cardiomyopathy over 8 years of follow up. Significant reductions in left ventricular outflow tract gradients and septal thickness were observed at 6 months follow up. Symptoms improved in the majority of patients. Ten percent of patients required pacemaker implantation. There was 92% survival rate at 8 years. The study demonstrates that alcohol septal ablation is an effective and safe nonsurgical option for treating hypertrophic obstructive cardiomyopathy that provides long-term relief of symptoms.
This document discusses the assessment of intracardiac shunts by cardiac catheterization. It describes how an oximetry run is performed to detect a left-to-right shunt by measuring oxygen saturation at various locations in the heart and great vessels. A significant step-up in oxygen saturation between the right atrium and ventricle or pulmonary artery suggests a left-to-right shunt. The document also discusses calculating shunt ratios using indicator dilution techniques and identifying shunt locations with angiography and pressure measurements. Complications of the procedure are outlined.
1) Cardiac arrhythmias are common in the ICU and represent a major source of morbidity and potential increased mortality. Arrhythmias may be the primary reason for admission or develop during critical illness.
2) Factors that increase the risk of life-threatening arrhythmias in ICU patients include their underlying critical illnesses, drugs, electrolyte imbalances, hypoxia, sepsis and other metabolic disturbances, and fluctuations in intravascular volume.
3) Arrhythmias can be life-threatening if the heart rate is too fast or slow resulting in hemodynamic instability, if it degenerates to ventricular fibrillation, or if associated with severe hypokalemia/hypomagnesemia or underlying
The document discusses the physiology of coronary blood flow and the microcirculation. Some key points include:
- Coronary blood flow is determined not only by proximal pressures but also by active compression and decompression of the microcirculation.
- Distal coronary pressure is influenced by both pressure transmitted from the aorta and pressure arising from the microcirculation.
- Fractional flow reserve (FFR) provides a measure of maximum achievable blood flow through a stenosis compared to a normal artery, indicating the functional significance of the stenosis.
- An FFR below 0.80 accurately identifies lesions causing ischemia, while a value above 0.80 reliably excludes ischemia.
Hypertrophic cardiomyopathy (HCM) is defined by a thickened left ventricular wall without an identifiable cause. It can range from asymptomatic to causing heart failure, arrhythmias, or sudden cardiac death. Treatment depends on whether the left ventricular outflow tract (LVOT) is obstructed. For symptomatic patients with LVOT obstruction despite maximum medical therapy, septal reduction procedures like alcohol septal ablation or surgical myectomy are recommended. Alcohol septal ablation involves injecting alcohol into a septal perforator artery to ablate tissue and reduce the gradient. Surgical myectomy directly resects septal muscle. Both procedures significantly reduce gradients and improve symptoms but surgical myectomy provides better gradient and symptom reduction with a lower risk of
Left ventricular assist devices (LVADs) can provide long-term support for patients with end-stage heart failure who are not candidates for transplant. Continuous-flow LVADs have high 1- and 2-year survival rates of 80% and 70% respectively. While LVADs improve survival and quality of life, patients face risks of complications like bleeding, infection, stroke, and device malfunction. Ongoing management requires careful monitoring and optimization of patient hemodynamics and medical therapies.
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/ARVC) is a genetic heart condition characterized by structural abnormalities and fatty infiltration of the right ventricle, leading to ventricular arrhythmias and sudden cardiac death. It is a common cause of sudden cardiac death in young athletes. Clinical features include palpitations, syncope, chest pain, and dyspnea. Diagnosis relies on a combination of ECG findings, echocardiogram abnormalities of the right ventricle, and genetic testing.
Which mechanical circulatory support should we use as first line optiondrucsamal
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
The SAFE-PCI for Women Trial was a prospective, randomized trial comparing radial versus femoral approaches for percutaneous coronary intervention (PCI) in women. 1787 women undergoing cardiac catheterization or PCI were randomized to radial or femoral access. The trial was terminated early due to lower than expected event rates. In the subgroup of women undergoing PCI (n=345 radial, n=346 femoral), there was no significant difference in the primary efficacy endpoint of bleeding or vascular complications between radial and femoral access. However, radial access was associated with a higher rate of needing conversion to femoral access. Overall, the results suggest an initial radial access strategy may be preferred for some women undergoing cardiac procedures.
Non cardiac surgery in cardiac patients moTamer Taha
This document discusses guidelines for evaluating and managing cardiac risk in patients undergoing non-cardiac surgery. It outlines factors that increase surgical risk like prolonged stress and changes in thrombotic factors. Complication rates are reported to be 7-11% with 0.8-1.5% mortality depending on precautions. Up to 42% of complications are cardiac related. It provides recommendations on pre-operative testing and risk stratification using indices. Risk reduction strategies discussed include use of beta-blockers, statins, and revascularization. Perioperative management of antiplatelets and anticoagulants is also covered.
HCM – Presentation, Hemodynamics and InterventionAnkur Gupta
This document describes a case of a 50-year-old female presenting with symptoms of breathlessness, angina, and presyncope. Echocardiography revealed asymmetric septal hypertrophy and systolic anterior motion of the mitral valve, consistent with hypertrophic obstructive cardiomyopathy (HOCM). The document then provides detailed background information on HOCM, including definitions, pathophysiology, clinical presentation, diagnostic testing, and treatment options such as beta-blockers, septal ablation, and disqualification from competitive sports in severe cases.
Tachycardia induced cardiomyopathy is a type of dilated cardiomyopathy caused by chronic or frequent tachycardia that leads to impaired left ventricular function. This impairment is partially or fully reversible by controlling the heart rate. The document discusses the criteria, types, pathophysiology, diagnosis, and treatment of tachycardia induced cardiomyopathy. Treatment focuses on heart rate control through medications, ablation, or devices, which can improve ejection fraction and heart failure symptoms over time.
Heart transplantation involves surgically removing a failing heart and replacing it with a donor heart. Some key events and indications for heart transplantation include:
- The first human heart transplant was performed in 1967.
- Survival rates after heart transplantation are around 69% after 5 years.
- Indications for heart transplantation include stage D heart failure, peak VO2 levels below certain thresholds, and refractory arrhythmias or restrictive cardiomyopathy.
- Contraindications include life expectancy under 2 years from other illnesses, irreversible organ dysfunction, and uncontrolled infections or malignancies.
This document discusses several topics related to vascular surgery:
1) Aorto-occlusive disease causes inadequate blood flow to organs and extremities. Myocardial dysfunction is a major cause of morbidity after vascular surgery.
2) Patients undergoing procedures like abdominal aortic aneurysm repair are at high risk of cardiac complications due to comorbidities like heart disease.
3) Carotid endarterectomy requires careful management to balance cerebral perfusion and cardiac stress during surgery.
Year in cardiology imaging 2019 - echocardiographyPraveen Nagula
This document summarizes findings from studies on cardiac imaging techniques. Key points include:
1) A study of over 1,000 individuals found that E/e'sr, a measure of left ventricular filling pressures using speckle tracking echocardiography, was a stronger predictor of cardiovascular death and events than E/E' and provided incremental value over current risk models.
2) Increased left ventricular mechanical dispersion, a measure of contraction heterogeneity, was associated with higher risk of cardiovascular death in a large population even after adjusting for factors.
3) Studies found a U-shaped relationship between left ventricular ejection fraction and mortality, with a nadir at 60-65%, indicating risks with both higher and lower
Cardiac transplantation involves surgically implanting a donor heart into a recipient with heart failure. It is indicated for end-stage heart disease that is refractory to maximal medical therapy. Absolute contraindications include active infections, cancers, and pulmonary hypertension. Evaluation of recipients includes cardiac testing and screening for medical/psychosocial risks. Donor hearts must be from brain dead individuals without systemic disease or infection. Post-operative care requires lifelong immunosuppression to prevent rejection while managing complications like infection, rejection, and arrhythmias. Long-term follow-up focuses on screening for issues like allograft vasculopathy.
This document discusses the diagnosis of peri-operative myocardial infarction. It defines peri-operative myocardial ischemia and explains why the traditional MI definition does not apply under anesthesia. The ACC criteria for diagnosing a peri-operative MI is described. The pathophysiology involves acute coronary syndrome (Type I) or oxygen supply-demand imbalance (Type II). Diagnostic tools include electrocardiography, cardiac enzymes, echocardiography, nuclear imaging techniques and cardiac MRI/CT. Early recognition can help prevent morbidity and mortality through pharmacological interventions.
The document discusses acute right ventricular (RV) failure, including:
1) The RV's main job is to maintain low right atrial pressure to optimize venous return to the heart. RV dysfunction can lead to reduced cardiac output.
2) Treatment for RV failure differs from left ventricular failure - RV failure may require fluid administration while left sided failure uses diuretics.
3) RV infarction is associated with worse outcomes than left ventricular infarction such as higher mortality, and requires a tailored treatment approach including fluid administration in some cases rather than diuretics. Early revascularization can help recovery.
Refractory heart failure - Diagnosis, Management, Device TherapyImran Ahmed
This document summarizes information about heart failure (HF), including:
1) HF is a major public health problem worldwide, affecting over 23 million people, with rates increasing with age.
2) Stages of HF range from risk factors to end-stage disease and influence treatment approaches.
3) Implantable devices like ICDs and CRT have been shown to improve symptoms and reduce mortality in HF, though guidelines around their use continue to be refined.
4) Ongoing research is exploring expanding the use of CRT to additional patient populations like those with narrow QRS complexes or milder disease.
This document discusses acute decompensated heart failure (ADHF), which refers to new or worsening signs and symptoms of heart failure requiring medical care or hospitalization. ADHF accounts for over 50% of heart failure costs in the US. It has a high mortality and readmission rate. The document outlines common causes and presentations of ADHF and emphasizes the importance of a thorough clinical evaluation to diagnose ADHF and distinguish it from other potential causes of symptoms like shortness of breath. It describes assessing signs of congestion and hypoperfusion to classify patients and guide initial treatment.
Perioperative myocardial infarction is a common cause of morbidity and mortality in patients undergoing noncardiac surgery. It can occur through acute coronary syndrome or prolonged myocardial ischemia in patients with stable coronary artery disease. Diagnosis is difficult as symptoms often do not present in anesthetized patients. Risk is determined by patient clinical factors, exercise capacity, and surgery risk. Management may include beta blockers, statins, aspirin, and evaluating need for revascularization based on standard criteria.
Heart failure is a major public health problem worldwide, affecting over 60 million people. It presents a growing economic burden of $108 billion annually. The King Abdullah Medical City is establishing a comprehensive Heart Failure Program to improve outcomes through establishing specialized clinics, implementing treatment guidelines, promoting prevention through education, and supporting research. The program aims to reduce mortality, hospitalizations and improve quality of life for heart failure patients in the Holy City of Makkah.
This document provides an overview of tension pneumothorax, including its pathophysiology, epidemiology, presentation, and initial assessment and management. It notes that tension pneumothorax occurs when air accumulates in the pleural space, increasing intrapleural pressure above atmospheric pressure throughout breathing. Signs in spontaneously breathing patients may include shortness of breath and decreased breath sounds, while those on ventilation rapidly develop hypoxemia, tachycardia and hypotension, potentially leading to cardiac arrest if not treated. Initial management involves needle or tube thoracostomy to release trapped air.
The document discusses guidelines for pre-operative cardiac evaluation to identify patients at risk of peri-operative complications and determine the need for interventions. It outlines goals of evaluating a patient's history, physical exam, and tests to determine cardiac risk. Non-invasive tests include ECG, stress testing, and echocardiogram. Surgical risk is stratified as high, moderate, low. Guidelines provide a framework to screen patients. The evaluation involves assessing risk factors, functional capacity, surgical risk to categorize patients and guide management through anesthesia, medical optimization, or possible revascularization.
This document discusses total hip and knee replacement surgeries and associated comorbidities. It notes that osteoarthritis is a common cause of joint pain and disability in older individuals, and that joint replacement may be considered when conservative treatments fail. It then summarizes several major cardiovascular, neurological, thromboembolic, and pulmonary comorbidities that are important to assess preoperatively due to increased risks they pose. These include conditions like coronary artery disease, pulmonary hypertension, stroke risk, and chronic lung disease. A thorough evaluation and optimization of high-risk patients' comorbidities is recommended prior to surgery.
This document discusses anesthetic concerns for trauma victims requiring operative intervention who are too sick to anesthetize. It covers cardiac trauma such as blunt myocardial injury, traumatic aortic injury, and cardiac tamponade. It also discusses pulmonary trauma such as pulmonary contusions, flail chest, fat embolism syndrome, and acute lung injury. The case study presented is of an obese man in shock following a motor vehicle crash requiring emergency surgery. The priorities are stabilizing the patient's hemodynamics and oxygenation through fluid resuscitation and ventilation before inducing anesthesia to improve outcomes.
The document discusses the role of cardiopulmonary exercise testing (CPET) before, during, and after left ventricular assist device (LVAD) implantation for advanced heart failure. CPET is useful diagnostically and prognostically before LVAD implantation to help determine candidacy. It can also help guide cardiac rehabilitation and monitor recovery after LVAD implantation. CPET values are important criteria used to select candidates for LVAD and heart transplantation.
Perioperative myocardial ischaemia in non cardiac surgery-pptMukeshWadhwa6
This document discusses myocardial ischemia and infarction in the surgical population. It defines myocardial ischemia as insufficient blood flow to the heart muscle and myocardial infarction as death of heart muscle cells due to prolonged ischemia. The document notes that myocardial ischemia can lead to infarction and is a major cause of short and long term morbidity and mortality in surgical patients. It provides details on the pathophysiology, diagnosis, incidence, risk factors, and strategies for prevention and management of perioperative myocardial ischemia.
Update on diagnosis and management of emergencies in cardiogenic shock. Gustavo Moreno
The aim of this article is to update the status of cardiogenic shock in particular detail in their diagnosis and especially in its current treatment on the stage of emergency. It was through the analysis of review articles that treat this condition as the main topic.
This document reviews the management of hypertensive emergencies associated with aortic dissection and thoracic aortic aneurysms. It discusses that immediate control of blood pressure is critical for these conditions to prevent further damage. For aortic dissections, surgery is usually recommended for Type A dissections while medical therapy is preferred for Type B dissections. The goals of treatment are to relieve symptoms, reduce complications, and prevent rupture. Several antihypertensive drugs are discussed for rapidly lowering blood pressure in hypertensive emergencies associated with these aortic conditions. Outcomes have improved but morbidity and mortality remain high, posing a significant treatment challenge.
The document discusses devices used in advanced heart failure syndromes. It provides definitions of heart failure and advanced heart failure. It discusses recommendations for implanting devices like ICDs and CRT to treat heart failure. It describes various mechanical circulatory support devices that can be used as bridges to decision, candidacy, transplantation or as destination therapy. It discusses patient selection criteria for long-term left ventricular assist devices based on INTERMACS profiles and guidelines.
This document reviews methods for evaluating congestion in patients with acute heart failure. It proposes combining available measurements including bedside assessment, laboratory tests, and dynamic maneuvers into a scoring system to quantify the degree of congestion. Key elements are clinical signs and symptoms, along with biomarkers and hemodynamic measurements. This congestion score could help guide therapy to optimize volume status during and after hospitalization.
This document from the European Society of Cardiology aims to identify reasons for the lack of progress in introducing new medicines for acute heart failure. It argues that clinical trials have failed due to the heterogeneous nature of patients with acute heart failure, which encompasses several different syndromes. The document also notes that trial designs have been flawed due to issues with the pharmacology of study drugs and inconsistent patient selection criteria across trials. It attempts to provide pragmatic solutions to simplify future clinical trials in order to advance treatment for this condition of unmet medical need.
Obstructive Shock, from Diagnosis to Treatment.pdfJonathanPuente6
The document summarizes the diagnosis and treatment of obstructive shock. It defines obstructive shock as shock caused by extra-cardiac diseases that reduce cardiac output through obstruction. The most common causes are listed as pulmonary embolism, pneumothorax, cardiac tamponade, and aortic dissection. The document recommends a three step approach to diagnosis: 1) clinical examination, 2) ultrasound examination using the RUSH protocol, and 3) radiological imaging if needed. Prognosis depends on the underlying cause and how quickly it is treated, with mortality rates ranging from 0.7% for pneumothorax to over 50% for pulmonary embolism with shock.
Aortic Dissection with Hemopericardium and Thrombosed Left Common Iliac Arter...Vinod Namana
#aortic dissection #tamponade #hemopericardium #pericardial effusion #leg ischemia #type a dissection #shock #cardiogenic shock.
An aortic dissection is an uncommon serious condition, which usually presents with chest pain or upper back pain. Symptoms of aortic dissection may mimic those of other diseases, often leading to delay in diagnosis. We report an unusual case of aortic dissection with hemopericardium and thrombosed left common iliac artery presenting as acute limb ischemia. Maintaining a high index of clinical suspicion for aortic pathology could possibly lead to identification and timely management of a greater number of patients who have atypical presentations. This would be especially true for patients who have catastrophic presentations with unexplained symptoms.
Preop evaluation of cardiac patient postd=ed for non cardiac surgery Rajesh Munigial
This document discusses pre-operative evaluation and preparation of cardiac patients for non-cardiac surgeries. It outlines that patients with coronary artery disease undergoing non-cardiac surgery are at increased risk of complications. A thorough pre-operative evaluation including history, physical exam, diagnostic tests, and knowledge of the planned surgery is important to assess risk factors and develop a management plan. Tests like ECG, stress testing, echocardiogram and in some cases angiography help evaluate cardiac status. Medical optimization including management of angina, heart failure, diabetes, etc. can help reduce perioperative risk. Timing of surgery depends on the clinical status and risk of delay. Intraoperative management focuses on preventing ischemia.
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Dr. Brijesh Savidhan discusses strategies for evaluating cardiac risk in patients undergoing non-cardiac surgery. The goals are to identify patients at risk, evaluate the severity of underlying heart disease, and stratify surgical risk. A thorough history, physical exam, electrocardiogram, and assessment of functional capacity are recommended. For higher-risk patients, stress testing and evaluation of left ventricular function may be considered to guide management and minimize perioperative complications. Overall, a multidisciplinary approach is important to optimize cardiac status, determine the safest location and timing of surgery, and develop an anesthesia plan tailored to each patient's cardiac condition.
This document discusses the management of acute heart failure. It notes that current therapies are based on improving hemodynamics and symptoms but lack evidence. There is heterogeneity in treatment approaches and outcomes. Biomarkers can help diagnosis but accuracy is still limited. The paradigm is that patients receive diuretics and vasodilators in the emergency department to relieve symptoms, but often still have residual congestion on discharge. This leads to high readmission rates. A shift in approach may be needed to better address the underlying disease progression.
This study optimized prebiotic mixtures in soybean milk using mixture experiments. Thirteen soybean milk formulations with varying proportions of inulin, galacto-oligosaccharides, and isomalto-oligosaccharides were evaluated based on sensory properties and growth of probiotic bacteria. The growth of Bifidobacterium bifidum, Lactobacillus plantarum, and Lactobacillus acidophilus were used to determine the best prebiotic mixture. The optimized formulation containing 0.11 inulin, 0.62 galacto-oligosaccharides, and 0.27 isomalto-oligosaccharides stimulated the highest growth of all three probiotic strains without affecting sensory attributes.
This document summarizes key concepts regarding drug chirality and stereoisomers in anesthesia. It defines terms like enantiomers, stereoisomers, and the R/S naming system. It discusses how stereoisomers can have different receptor affinities and pharmacokinetic profiles. As an example, it examines the local anesthetics bupivacaine, levobupivacaine (S-bupivacaine), and ropivacaine. It describes how these drugs act on sodium channels and reviews clinical studies comparing their sensory/motor blocking effects.
Anesthetic Effects On The Fetus And NewbornAhmed Shalabi
Anesthetics are generally not teratogenic, though some animal studies found increased abnormalities with nitrous oxide exposure. Epidemiological studies in humans found no association between anesthetic exposure and birth defects. While anesthetics are not structural teratogens, some may cause behavioral changes in developing brains by interfering with receptor development. Epidural analgesia is associated with increased maternal fever during labor, which epidemiological evidence links to higher risks of cerebral palsy and other neurological injuries in infants. However, the mechanisms linking epidurals, fever, and injury remain unclear.
Protocol For Endovasc Repair Of Rupture A AAhmed Shalabi
1) The authors established a protocol for endovascular repair of ruptured abdominal aortic aneurysms (r-AAAs) to address limitations in coordinating patient care between the emergency department and operating room.
2) As part of the protocol, 5 patients underwent simulated emergencies to test the protocol, which involved alerting vascular surgery and preparing an endovascular-capable operating room.
3) Since implementing the protocol, 40 of 42 actual r-AAA patients underwent successful endovascular repair, with a mortality rate of 18% once the protocol was established to streamline patient care.
This review article discusses the use of ketamine as an induction agent for rapid sequence induction (RSI) of anesthesia in emergency patients who are hemodynamically compromised. The authors argue that ketamine represents a rational choice for RSI in such patients due to its favorable pharmacological properties that confer hemodynamic stability compared to other induction agents. Specifically, ketamine has a short time to reach effective brain concentrations, does not significantly lower blood pressure, and maintains cerebral perfusion pressure and intracranial pressure within normal limits when used for induction and maintained with general anesthesia. While ketamine has traditionally been contraindicated when brain injury is present, the authors claim any adverse effects on intracranial pressure or cerebral blood flow are mit
perioperative management Pacemaker Insertion In Congenital HeartAhmed Shalabi
This document describes the perioperative management of a 6-month-old boy undergoing permanent pacemaker implantation for congenital complete heart block. Key aspects of management included premedication with atropine and promethazine to prevent vagal stimulation, induction with ketamine to avoid negative chronotropic effects, and maintenance with non-depressant anesthetics like isoflurane. Intraoperative monitoring and defibrillator equipment were readily available due to the risk of arrhythmias. The pacemaker implantation procedure and postoperative course were uncomplicated with this careful anesthetic approach.
Anesthesia For Children With Congenital Heart Disease1Ahmed Shalabi
This document discusses children with congenital heart disease and provides information on:
1. The incidence of congenital heart disease is 7 to 10 per 1000 live births, with certain populations having higher rates.
2. Congenital heart disease can range from simple defects like atrial septal defects to complex conditions like hypoplastic left heart syndrome.
3. Proper preoperative evaluation is important for anesthetic planning and involves understanding the child's specific cardiac anatomy and physiology.
Anesthesia And Congenital Heart DiseaseAhmed Shalabi
This document summarizes adult congenital heart disease and considerations for anesthesia management. It discusses that:
1) Congenital heart diseases are increasingly common as more children with complex defects now survive into adulthood.
2) Adults with CHD can be categorized as those with complete repair, partial/palliative repair, or no operation.
3) Five factors influence perioperative risk - pulmonary hypertension, cyanosis, reoperation, arrhythmias, and ventricular dysfunction.
1) Begin resuscitation immediately for patients with sepsis-induced hypotension or elevated lactate, aiming to achieve specific hemodynamic and perfusion goals within the first 6 hours.
2) Rapidly identify an infection source and implement source control measures like drainage or debridement as soon as resuscitation allows.
3) Administer broad-spectrum antibiotics within 1 hour of recognizing sepsis or septic shock and reassess daily to optimize treatment.
This document provides the table of contents for the book "Perioperative Critical Care Cardiology 2nd edition". The book contains 16 chapters covering topics in perioperative critical care cardiology including sudden death in heart failure, etiology and pathophysiology of heart failure, cardiac protection for noncardiac surgery, hypertensive crises, heart failure and related conditions, circulatory failure monitoring, perioperative risk stratification, hemodynamic monitoring, electrocardiography of heart failure, management of acute heart failure, device therapies, updates on resuscitation, circulatory shock, prevention of cardiac dysfunction associated with surgery, management of hypertension, and advances in dilated cardiomyopathy. The table of contents lists the chapter titles and authors for
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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or high cardiac output (CO) [1]. Epidemiological studies
have revealed the high morbidity and mortality of
hospitalised acute HF patients [2-4], and the European
Heart Failure Survey II (EHFS II) [5] and the EFICA study
(Epidémiologie Francaise de l’Insuffisance Cardiaque
Aiguë) [6] have provided insights into the epidemiology of
those admitted to ICUs. Differentiating between these
scenarios perioperatively might be more complex than in
non-cardiosurgical settings [7-9], as typical symptoms are
often missing, while measured physiologic parameters are
influenced by treatment. Additionally, frequently occur-
ring cardiac stunning - a transient, reversible, post-
operative contractility impairment - may require inotropic
support to prevent tissue hypoperfusion and organ
dysfunction.
In a recent prospective survey, the presentation and Figure 1. Kaplan Meier curves showing survival rates of ICU
epidemiology of acute HF were compared in a medical patients with different acute heart failure (HF) syndromes over
and a cardiosurgical ICU [10]. The clinical course varied time, starting at the day of ICU admission. The small vertical lines
indicate the time points when patients had their last follow-up. The
considerably in the three specified patient subgroups
survival curves between the groups are significantly different (log
(medical, elective and emergency cardiosurgical patients), rank P < 0.001). Data were derived from [10].
with outcome mostly influenced by co-morbidities, organ
dysfunction, and surgical treatment options. The
distinction between cardiogenic shock and transient • the EuroSCORE predicts perioperative cardiovascular
postoperative cardiac stunning - diagnosed in 45% of alteration in cardiac surgery well, although in those
elective patients - is important as they are associated with older than 80 years it overestimates mortality
different hospital paths and outcomes (Figure 1). Patients • B-type natriuretic peptide level before surgery is an
with only postoperative stunning can usually be rapidly additional risk stratification factor
weaned off inotropic support. Risk stratification is increasingly used in open-heart
In another study, postcardiotomy cardiogenic shock surgery to help adjust available resources to predicted
occurred in only 2% to 6% of all adult cardiosurgical outcome. The latter is mostly calculated by the
procedures, albeit associated with high mortality rates EuroSCORE (European System for Cardiac Operative
[11]. Twenty-five percent of patients undergoing elective Risk Evaluation; Table 1) [16].
coronary artery bypass graft (CABG) surgery require As the simple EuroSCORE sometimes underestimates
inotropic support for postoperative myocardial dys- risk when certain combinations of risk factors co-exist, a
function [12]. Transesophageal echocardiography (TEE) more complete logistical version has been developed,
shows that right ventricular (RV) dysfunction is present resulting in more accurate risk prediction for particularly
in about 40% of postoperative patients who develop high risk patients. Figure 2 depicts the predicted factors
shock [13]. Postoperative cardiovascular dysfunction may of postoperative low CO syndrome (abscissa) versus the
also be characterised by unexpectedly low systemic logit score (ordinate) for several combinations of
vascular resistance (SVR), that is, vasodilatory shock. covariate risk factors for low CO syndrome [17].
These findings could help in the evaluation of therapeutic Table 2 lists other scoring systems besides the
options [14,15]. EuroSCORE used to assess risk in cardiac surgery.
Essentially, according to all risk indices HF constitutes a
high risk, and a left ventricular ejection fraction ≤35%
Risk stratification could be an indicator of adverse outcome [18]. Compared
Group recommendations to other risk factors, HF is especially related to poor long-
• Indicators of major clinical risk in the perioperative term outcome. Preoperative assessment opens up a ‘golden
period are: unstable coronary syndromes, decom- hour’ for identification and initiation of therapeutic
pensated HF, significant arrhythmias and severe interventions in patients with myocardial viability, such as
valvular disease coronary revascularization, cardiac resynchronization, and
• Clinical risk factors include history of heart disease, medical therapy. Due to therapeutic advances, the
compensated HF, cerebrovascular disease, presence of EuroSCORE slightly overestimates the perioperative risk,
diabetes mellitus, renal insufficiency and high-risk which is why a project to update the sensitivity of the
surgery EuroSCORE is currently being considered [19-24].
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Table 1. EuroSCORE: risk factors, definitions and scores [16]
Definition Score
Patient-related factors
Age Per 5 years or part thereof over 60 years 1
Sex Female 1
Chronic pulmonary disease Long-term use of bronchodilators or steroids for lung disease 1
Extracardiac arteriopathy Any one or more of the following: claudication, carotid occlusion or >50% stenosis, 2
previous or planned intervention on the abdominal aorta, limb arteries or carotids
Neurological dysfunction Disease severely affecting ambulation or day-to-day functioning 2
Previous cardiac surgery Requiring opening of the pericardium 3
Serum creatinine >200 μmol/l preoperatively 2
Active endocarditis Patient still under antibiotic treatment for endocarditis at the time of surgery 3
Critical preoperative state Any one or more of the following: ventricular tachycardia or fibrillation or aborted 3
sudden death, preoperative cardiac massage, preoperative ventilation before arrival in
the anaesthetic room, preoperative inotropic support, intraaortic balloon counterpulsation
or preoperative acute renal failure (anuria or oliguria <10 ml/h)
Cardiac-related factors
Unstable angina Rest angina requiring intravenous nitrates until arrival in the anaesthetic room 2
LV dysfunction Moderate or LVEF 30 to 50% 1
Poor or LVEF <30 3
Recent myocardial infarct <90 days 2
Pulmonary hypertension Systolic PAP >60 mmHg 2
Operation-related factors
Emergency Carried out on referral before the beginning of the next working day 2
Other than isolated CABG Major cardiac procedure other than or in addition to CABG 2
Surgery on thoracic aorta For disorder of ascending, arch or descending aorta 3
Postinfarct septal rupture 4
Application of scoring system: 0-2 (low risk); 3-5 (medium risk); 6 plus (high risk). CABG, coronary artery bypass graft; LV, left ventricular; LVEF, left ventricular ejection
fraction; PAP, pulmonary arterial pressure.
In addition to scoring systems, levels at hospital • Volatile anaesthetics seem to be promising cardio-
admission of B-type natriuretic peptide (BNP) and the protective agents
amino-terminal fragment of pro-BNP (NT-pro-BNP) are • Levosimendan, introduced more recently, also seems
powerful predictors of outcome with regard to in-hospital to have cardioprotective properties
mortality and re-hospitalization in HF patients [25,26]. In • Large trials are still needed to assess the best cardio-
open-heart surgery patients, preoperative BNP levels protective agent(s) and the optimal protocol to adopt
>385 pg/ml were an independent predictor of post- Besides cardioplegic and coronary perfusion optimisation
operative intra-aortic balloon pump (IABP) use, hospital techniques, cardioprotective agents aim to prevent or
length of stay, and 1-year mortality [27]. In patients diminish the extent of perioperative ischaemia-
undergoing aortic valve replacement, BNP levels reperfusion-induced myocardial dysfunction. The
>312 pg/ml were an independent predictor of death [28]. mechanisms leading to myocardial injury seem to be free
Similarly, NT-pro-BNP was shown to be equivalent to radical formation, calcium overload, and impairment of
the EuroSCORE and more accurate than preoperative left the coronary vasculature [30].
ventricular ejection fraction in predicting postoperative The ultimate goal of perioperative cardioprotective
complications [29]. strategies is to limit the extent and consequences of
myocardial ischaemia-reperfusion injury. Protective
Risk modulation: cardioprotective agents strategies include preserving and replenishing myocardial
Group recommendations high energy phosphate stores, modulating intracellular
• Aggressively preserving heart function during cardiac gradients, and the use of free radical oxygen scavengers
surgery is a major goal and/or antioxidants, and inhibitors of the complement
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Figure 2. Predictive probability of low cardiac output syndrome after coronary artery bypass graft. Left ventricular grade (LVGRADE) scored
from 1 to 4. Repeat aorto-coronary bypass (ACB REDO), diabetes, age older than 70 years, left main coronary artery disease (L MAIN DISEASE), recent
myocardial infarction (RECENT MI), and triple-vessel disease (TVD) scored 0 for no, 1 for yes. M, male; F, female; E, elective; S, semi-elective; U, urgent.
Data were derived from [17].
systems and neutrophil activation. Most of these Levosimendan improves cardiac performance in
approaches (using adenosine modulators, cardioplegia myocardial stunning after percutaneous intervention
solution adjuvants, Na+/H+ exchange inhibitors, KATP [40]. The latest meta-analysis, including 139 patients
channel openers, anti-apoptotic agents, and many other from 5 randomized controlled studies, showed that
drugs with proven or anticipated effects on the levosimendan reduces postoperative cardiac troponin
complement-inflammation pathways) have been shown release irrespective of cardiopulmonary bypass (CPB;
to be effective in experimental and even observational Figure 3). [41] Tritapepe and colleagues [12] showed that
clinical settings. levosimendan pre-treatment improved outcome in 106
Clinical studies of volatile anaesthetics, which exhibit patients undergoing CABG. A single dose of levo-
pharmacological preconditioning effects, have failed to simendan (24 μg/kg over 10 minutes) administered before
demonstrate unequivocally beneficial effects with regard CPB reduced time to tracheal extubation, overall ICU
to the extent of postischaemic myocardial function and length of stay and postoperative troponin I concentrations.
damage [31]. The use of a volatile versus intravenous In another recent study, levosimendan before CPB lowered
anaesthetic regimen might be associated with better the incidence of postoperative atrial fibrillation [42]. Due
preserved myocardial function with less evidence of to the complex effects of levosimendan, and such
myocardial damage [32-35]. The protective effects seemed preclinical and clinical results, the term inoprotector has
most pronounced when the volatile anaesthetic was been proposed to describe it [43].
applied throughout the entire surgical procedure [36].
Desflurane and sevoflurane have cardioprotective effects
that result in decreased morbidity and mortality Monitoring
compared to an intravenous anaesthetic regimen [37]. Group recommendations
Postoperative morbidity and clinical recovery remains • The aim of monitoring is the early detection of peri-
to be established. In a retrospective study, cardiac-related operative cardiovascular dysfunction and assessment
mortality seemed to be lower with a volatile anaesthetic of the mechanism(s) leading to it
regimen, but non-cardiac death seemed to be higher in • Volume status is ideally assessed by ‘dynamic’ measures
this patient population, with no difference in 30-day total of haemodynamic parameters before and after volume
mortality [38]. challenge rather than single ‘static’ measures
Levosimendan is increasingly described as a myocardial • Heart function is first assessed by echocardiography
protective agent. Its anti-ischaemic effects are mediated followed by pulmonary arterial pressure, especially in
by the opening of ATP-sensitive potassium channels [39]. the case of right heart dysfunction
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Table 2. Scoring systems used in cardiac surgery
Incidence in Mortality in
EF with highest risk high-risk group* high-risk group Reference
EuroSCORE <30% 3 of all, ≥6 10.25 to 12.16% [16]
Pons Score - (NYHA IV) 10 of all, ≥30 54.4% [85]
French Score ≤30% 5 of all, >6 21.2% [86]
Ontario Province Risk Score <20% 3 of all, ≥8 14.51% [87]
Cleveland Clinic Score <35% 3 of all, 10 to 31 44.6% [88]
Parsonnet Score <30% 4 of all, ≥20 >20% [89]
EF, ejection fraction; NYHA, New York Heart Association.
• If both volaemia and heart function are in the normal alterations associated with changes in circulating
range, cardiovascular dysfunction is very likely related volumes do not correlate significantly with changes in
to vascular dysfunction end-diastolic volume and stroke volume. The ‘gold
standard’ haemodynamic technique guiding volume
Assessing optimal volume status management in critically ill patients is yet to be
Heart failure cannot be ascertained unless volume determined. Continuous monitoring techniques are more
loading is optimal. The evaluation of effective circulating appropriate in assessing the perioperative volume status
blood volume is more important than the total blood of HF patients.
volume. Signs of increased sympathetic tone and/or
organ hypoperfusion (increased serum lactate and Echocardiography
decreased mixed venous saturation (SvO2) or central Intraoperative and postoperative transoesophageal echo-
venous O2 saturation (ScvO2)) indicate increased oxygen cardiography (TOE) and postoperative transthoracic echo-
extraction secondary to altered cardiovascular physiology/ cardiography enable bedside visualization of the heart.
hypovolaemia. Echocardiography may immediately identify causes of
It is difficult to estimate volume status using single cardiovascular failure, including cardiac and valvular
haemodynamic measures. Pressure estimates, such as dysfunction, obstruction of the RV (pulmonary embolism)
central venous pressure and pulmonary capillary wedge or LV outflow tract (for example, systolic anterior motion
pressure (PCWP) - previously considered reliable of the anterior mitral valve leaflet), or obstruction to
measures of RV and LV preload - are generally insensitive cardiac filling in tamponade. It might differentiate between
indicators of volaemia; while low values may reflect acute right, left and global HF as well as between systolic
hypovolaemia, high values do not necessarily indicate and diastolic dysfunction. Transoesophageal echo-
volume overload [44-47]. The uncoupling between cardiography influences both anaesthetists’ and surgeons’
PCWP and LV end-diastolic pressure can be the conse- therapeutic options, especially perioperatively [53].
quence of elevated pulmonary vascular resistance,
pulmonary venoconstriction, mitral stenosis and Pulmonary artery catheter (Swan-Ganz catheter)
reductions in transmural cardiac compliance. After almost four decades, the pulmonary artery catheter
Volumetric estimates of preload seem more predictive (PAC) remains a monitoring method for directly measur-
of volume status [46]. Transoesophageal echocardio- ing circulatory blood flow in critically ill patients,
graphy is used clinically for assessing LV end-diastolic including cardiosurgical patients. With regard to manag-
area, while the transpulmonary thermal-dye indicator ing perioperative HF, the four crucial components remain
dilution technique measures intrathoracic blood volume measurements of heart rate, volaemia, myocardial
[48], which reflects both changes in volume status and function and vessel tone.
ensuing alteration in CO, a potentially useful clinical In RV failure, except if caused by tamponade, a PAC
indicator of overall cardiac preload [49,50]. should be introduced after an echocardiographically
In predicting fluid responsiveness in ICU patients, it is established diagnosis. PACs can differentiate between
preferable to use more reliable dynamic indicators pulmonary hypertension and RV ischaemia, necessitating
reflecting hypovolaemia than static parameters [51,52]. a reduction of RV afterload, as the ischaemic RV is very
In particular, stroke volume variation enables real-time sensitive to any afterload increase [54]. They are even
prediction and monitoring of LV response to preload more important in the worst scenario for the RV:
enhancement postoperatively and guides volume therapy. combined increased pulmonary arterial pressure and RV
By contrast, central venous pressure and PCWP ischaemia.
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Figure 3. Cardioprotective effect of levosimendan in cardiac surgery. Figure taken from [41]. Data are from Barisin et al., Husedzinovic et
al., Al-Shawaf et al. [69], Tritapepe et al. [12], and De Hert et al. [74]. CI, confidence interval; df, degrees of freedom; SD, standard deviation; WMD,
weighted mean differences.
Alternative measures of stroke volume postoperative morbidity and mortality and, thus,
Recently, several devices have been designed to assess increased health care costs. However, excess inotrope
cardiac function based on pulse contour analysis of an usage could also be associated with deleterious effects
arterial waveform (Table 3). Their value in assessing the through complex mechanisms [55].
failing heart’s function is still under investigation. A wide range of inotropic agents is available. Consensus
regarding the pharmacological inotropic treatment for
Pharmacological treatment of left ventricular postcardiotomy heart failure and randomized controlled
dysfunction after cardiac surgery trials focusing on clinically important outcomes are both
Group recommendations lacking. The vast majority of reports focus on post-
• In case of myocardial dysfunction, consider the operative systemic haemodynamic effects and, to some
following three options either alone or combined: extent, on regional circulatory effects of individual ino-
• Among catecholamines, consider low-to-moderate doses tropic agents. Furthermore, there is a shortage of
of dobutamine and epinephrine: they both improve comparative studies evaluating the differential systemic
stoke volume and increase heart rate while PCWP is and regional haemodynamic effects of various inotropes
moderately decreased; catecholamines increase myo- on CO in postoperative HF. Catecholamines and
cardial oxygen consumption phosphodiesterase inhibitors are two main groups of
• Milrinone decreases PCWP and SVR while increasing inotropes used for treatment of cardiac failure in heart
stoke volume; milrinone causes less tachycardia than surgery [56]. The calcium sensitizer levosimendan has
dobutamine recently become an interesting option for treatment of
• Levosimendan, a calcium sensitizer, increases stoke HF as well as in postcardiotomy ventricular dysfunction.
volume and heart rate and decreases SVR
• Norepinephrine should be used in case of low blood Catecholamines
pressure due to vasoplegia to maintain an adequate All catecholamines have positive inotropic and chrono-
perfusion pressure. Volaemia should be repeatedly tropic effects. In a comparison of epinephrine with
assessed to ensure that the patient is not hypovolaemic dobutamine in patients recovering from CABG, they had
while under vasopressors similar effects on mean arterial pressure, central venous
• Optimal use of inotropes or vasopressors in the pressure, PCWP, SVR, pulmonary vascular resistance,
perioperative period of cardiac surgery is still and LV stroke work [57]. Furthermore, when stoke
controversial and needs further large multinational volume was increased comparably, dobutamine increased
studies heart rate more than epinephrine. Epinephrine, dobuta-
Cardiac surgery may cause acute deterioration of mine and dopamine all increase myocardial oxygen
ventricular function during and after weaning from CPB. consumption (MVO2) postoperatively [58-60]. However,
Pharmacological treatment of low CO and reduced only with dobutamine is this matched by a proportional
oxygen delivery to vital organs may be required. increase in coronary blood flow [58,59], suggesting that
Inadequate treatment may lead to multiple organ failure, the other agents may impair coronary vasodilatory
one of the main causes of prolonged hospital stay, reserve postoperatively. Of note, commonly encountered
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Table 3. Etiology and investigation of post-cardiopulmonary bypass ventricular dysfunction
Cause Investigation Finding
General
Exacerbation of preoperative ventricular dysfunction with relative TOE Global or regional wall
intolerance to cardioplegic asystolic, hypoxic arrest motion abnormality
Reperfusion injury TOE Global wall motion abnormality
Inadequate myocardial protection (underlying coronary anatomy, TOE Global wall motion abnormality
route of cardioplegia, type of cardioplegia)
Case/patient specific
Ischaemia/infarction
Vessel spasm (native coronaries, internal mammary artery) ECG, TOE, graft flow ECG changes, regional wall motion
abnormality, poor graft flow
Emboli (air, clot, particulate matter) ECG, TOE, graft flow ECG changes, regional wall motion
abnormality, poor graft flow
Technical graft anastomotic tissues ECG, TOE, graft flow ECG changes, regional wall motion
abnormality, poor graft flow
Kink/clotting of bypass grafts, native vessels ECG, TOE, graft flow, ECG changes, regional wall motion
inspection abnormality, poor graft flow
Incomplete revascularization
Non-graftable vessels
Known intrinsic disease
Metabolic
Hypoxia, hypercarbia ABG, electrolytes,
check ventilation
Hypokalemia, hyperkalemia Electrolytes
Uncorrected pathology
Hypertrophic cardiomyopathy TOE Abnormal outflow gradient, SAM
Valve gradients TOE Abnormal valve gradient
Shunts TOE Abnormal Doppler jet
Mechanical issues
Prosthetic valve function TOE Poor leaflet motion, abnormal
gradient
Intracardiac shunt (ASD, VSD) TOE Abnormal Doppler jet
Conduction issues
Bradycardia ECG Heart rate less than 60
Atrioventricular dissociation ECG Third degree heart block
Atrial fibrillation ECG, ABG, electrolytes Hypoxia, electrolyte abnormality
Ventricular arrhythmias ECG, ABG, electrolytes Hypoxia, electrolyte abnormality
Vasodilation Transpulmonary thermodilation, Decreased systemic vascular
Swan-Ganz monitoring resistance
Hypovolemia Stroke volume monitoring Decreased stroke volume,
increased SVV
Pulmonary hypertension
Pre-existing elevated pulmonary pressures, hypoxia, ABG Elevated pulmonary artery
hypercarbia, fluid overload pressures, hypoxia, hypercarbia,
RV distention
Right ventricular failure
Elevated pulmonary pressures, inadequate myocardial Swan-Ganz monitoring, ABG, RV distention, poor RV wall motion,
protection, emboli to native or bypass circulation, fluid overload TOE elevated pulmonary artery pressure,
elevated central venous pressure
ABG = arterial blood gas; ASD, atrial septic defect; ECG, electrocardiogram, RV, right ventricle, SAM, systolic anterior motion of mitral valve leaflet; SVV, stoke volume
variation; TOE, transoesophageal echocardiography; VSD, ventricular septal defect. Data taken from [80].
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phenomena associated with epinephrine use include – failure to wean
hyperlactateaemia and hyperglycaemia. Dopexamine has – postcardiotomy
no haemodynamic advantage over dopamine or dobuta- and on the haemodynamic severity of the condition of
mine [61,62] in LV dysfunction. the patient:
– crash and burn
Phosphodiesterase III inhibitors – deteriorating fast
Phosphodiesterase III inhibitors, such as amrinone, – stable but inotrope dependent
milrinone or enoximone, are all potent vasodilators that In cardiosurgical patients the timing of surgical
cause reductions in cardiac filling pressures, pulmonary intervention in relationship to the development of acute
vascular resistance and SVR [63-65]; they are commonly HF with subsequent cardiogenic shock is of utmost
used in combination with β1-adrenergic agonists. Com- importance, leading to three distinct clinical scenarios:
pared to dobutamine in postoperative low CO, phos- precardiotomy HF, failure to wean and postcardiotomy
phodiesterase III inhibitors caused a less pronounced HF. While their names are self-explanatory, these three
increase in heart rate and decreased the likelihood of distinct clinical scenarios differ from each other
arrhythmias [66-68]; also, the incidence of postoperative substantially concerning diagnosis, monitoring and
myocardial infarction was significantly lower (0%) with management.
amrinone compared to dobutamine (40%) [66]. This There is consensus that cardiogenic shock is the
could be explained by phosphodiesterase III inhibitors severest form of HF; regardless of aetiology, patho-
decreasing LV wall tension without increasing MVO2, physiology, or initial clinical presentation, it can be the
despite increases in heart rate and contractility, in final stage of both acute and chronic HF, with the highest
striking contrast to catecholamines [59]. mortality (Table 4).
Levosimendan Precardiotomy heart failure
Levosimendan has been recommended for the In the precardiotomy HF profile the underlying pathology
treatment of acute HF [8] and was recently used for the may still be obscure. Altered LV function primarily due
successful treatment of low CO after cardiac surgery to myocardial ischaemia is one of the most frequent
[69-71]. The effects of levosimendan have been causes of precardiotomy low output syndrome. The
compared to those of dobutamine [72,73] and milrinone patient may be anywhere in the hospital or pre-hospital
[69,74]. Levosimendan has been shown to decrease the setting, with or without an initial working diagnosis, and
time to extubation compared to milrinone [74]. quite often only basic monitoring options are available.
Compared to dobutamine, levosimendan decreases the The availability of life support measures may be limited
incidence of postoperative atrial fibrillation [42] and compared with the other two scenarios. The primary aim
myocardial infarction, ICU length of stay [73], acute being the patient’s survival, priorities focus on deciding
renal dysfunction, ventricular arrhythmias, and the steps necessary for diagnosis and treatment. The next
mortality in the treatment of postoperative LV priority should be surgery avoiding further alterations in
dysfunction. Levosimendan showed little change in myocardial function, possibly by introducing an IABP
MVO2 [75] and improved early heart relaxation after preoperatively. As described above, preoperative poor LV
aortic valve replacement. [76]. function is the most important predictor of postoperative
In summary, the above described inotropic agents can morbidity and mortality after CABG. However, the
be started either alone or in combination with an agent dysfunctional myocardium may not be irreversibly
from another class (multimodal approach) in myocardial damaged and possibly only ‘stunned’ or ‘hibernating’.
depression. Common examples include norepinephrine Revascularization of the reversibly injured heart areas
with dobutamine or phosphodiesterase III inhibitors, and may result in improved LV performance. Still cold injury
dobutamine with levosimendan. The beneficial effects of or inhomogeneous cardioplegic delivery may exacerbate
treatment with inotropic agents on outcome in the perioperative ischaemic injury, resulting in inadequate
management of postoperative low CO need to be early postoperative ventricular function [77]. Prolonged
confirmed in a large multicentre study. reperfusion with a terminal ‘hot shot’ of cardioplegic
solution may restore function in patients with poor
Clinical scenarios ventricular function [78]. Warm cardioplegia may
Group recommendations improve postoperative LV function in patients with high-
• The classification of cardiac impairment in the peri- risk conditions [77]. Some patients will continue to have
operative period of cardiac surgery should be based on poor ventricular function postoperatively, restricting the
the time of occurrence: role of myocardial protection to limiting the extent of
– precardiotomy perioperative injury [79].
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Table 4. The three clinical heart failure scenarios and the clinical profiles in each scenario
Clinical scenarios Clinical profiles in each scenario
Precardiotomy heart failure
Precardiotomy crash and burn Refractory cardiogenic shock requiring emergent salvage operation: CPR en route to the
operating theatre or prior to anaesthesia induction
Refractory cardiogenic shock (STS definition SBP <80 mmHg and/or CI <1.8 L/minute/m2
despite maximal treatment) requiring emergency operation due to ongoing, refractory (difficult,
complicated, and/or unmanageable) unrelenting cardiac compromise resulting in life threatening
haemodynamic compromise
Precardiotomy deteriorating fast Deteriorating haemodynamic instability: increasing doses of intravenous inotropes and/or IABP
necessary to maintain SBP > 80mmHg and/or CI >1.8 L/minute/m2. Progressive deterioration.
Emergency operation required due to ongoing, refractory (difficult, complicated, and/or
unmanageable) unrelenting cardiac compromise, resulting in severe haemodynamic compromise
Precardiotomy stable on inotropes Inotrope dependency: intravenous inotropes and/or IABP are necessary to maintain SBP
>80 mmHg and/or CI >1.8 L/minute/m2 without clinical improvement. Failure to wean from
inotropes (decreasing inotropes results in symptomatic hypotension or organ dysfunction).
Urgent operation is required
Failure to wean from CPB
Failure to wean from CPB Cardiac arrest after prolonged weaning time (>1 hour)
Deteriorating fast on withdrawal Deteriorating haemodynamic instability on withdrawal of CBP after prolonged weaning time
from CPB (>1 hour)
Increasing doses of intravenous inotropes and/or IABP necessary to maintain SBP >80 mmHg
and/or CI >1.8 L/minute/m2
Stable but inotrope dependent on Inotrope dependency on withdrawal of CBP after weaning time >30 minutes. Intravenous
withdrawal from CPB inotropes and/or IABP are necessary to maintain SBP >80 mmHg and/or CI >1.8 L/minute/m2
without clinical improvement
The high incidence of complications after VAD implantation is directly related to prolonged
attempted weaning periods from CPB. Application of IABP within 30 minutes from the first
attempt to wean from CPB and mechanical circulatory support within 1 hour from the first
attempts to wean from the CPB are suggested [90]
Postcardiotomy cardiogenic shock
Postcardiotomy crash and burn Cardiac arrest requiring CPR until intervention
Refractory cardiogenic shock (SBP <80 mmHg and/or CI <1.8 L/minute/m2, critical organ
hypoperfusion with systemic acidosis and/or increasing lactate levels despite maximal treatment,
including inotropes and IABP) resulting in life threatening haemodynamic compromise.
Emergency salvage intervention required
Postcardiotomy deteriorating fast Deteriorating haemodynamic instability. Increasing doses of intravenous inotropes and/or IABP
necessary to maintain SBP >80 mmHg and/or CI >1.8 L/minute/m2. Progressive deterioration,
worsening acidosis and increasing lactate levels. Emergent intervention required due to ongoing,
refractory unrelenting cardiac compromise, resulting in severe haemodynamic compromise
Postcardiotomy stable on inotropes Inotrope dependency: intravenous inotropes and/or IABP necessary to maintain SBP
>80 mmHg and/or CI >1.8 L/minute/m2 without clinical improvement. Failure to decrease
inotropic support
CI, cardiac index; CPB, cardiopulmonary bypass; CPR, cardiopulmonary resuscitation; IABP, intra-aortic balloon pump; SBP, systolic blood pressure; STS, Society of
Thoracic Surgeons; VAD, ventricular assist device.
Failure to wean Postcardiotomy heart failure
In the failure to wean from CPB profile, although the As patients with postcardiotomy HF are usually in the
reason to perform surgery is more or less established, the ICU, we can usually guesstimate the diagnosis. Sophis-
basis for a successful therapeutic approach is establishing ticated monitoring and diagnostic and therapeutic
a correct diagnosis of cardiac failure as soon as possible. options are readily available should the need arise.
Acute HF associated with failure to wean patients off Although the chest remains closed, it can be reopened
CPB may be surgery related, patient specific or both, as quickly if needed, either in the ICU bed or in theatre
summarized in Table 3 [80]. Table 3 also lists the investi- following the patient’s transfer back there. Support with
gations necessary to ascertain the underlying cause of cardiac assist devices can also be initiated, although not
failure to wean from CPB. as promptly as in the failure to wean scenario. The
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priority is preserving end organ function and bridging Catheter based axial flow devices
the patient to recovery. Experiences with the first miniaturized 14 Fr catheter
The initial strategy for management of postcardiotomy based axial flow pump, used in the early 1980s
cardiac dysfunction includes the optimization of both (Hemopump®), provided flow rates in the range of 2.0 to
preload appropriate to LV function and rhythm and 2.5 L/minute, but initial mechanical problems limited its
support with positive inotropic and/or vasopressor clinical application in supporting the failing heart.
agents and IABP. This strategy will restore haemo- A new design (Impella pump®) provides a more stable
dynamics in most patients. Requirements for optimal LV mechanical function through modifications and improve-
function and preservation of RV coronary perfusion ments, including both the pump-head and the
include careful assessment of right-left ventricular inter- miniaturized motor mounted on the tip of the catheter.
actions, ventricular-aorta coupling and adequate mean However, even with these improvements transfemoral
arterial pressure. [81] placement is only possible with the smallest version of this
When in postcardiotomy HF an IABP becomes pump; larger diameter versions require surgical placement.
necessary, survival rates between 40% and 60% have been Pump versions are available for both LV and RV support.
reported. In more severe cases of postcardiotomy HF, Increased flow rates in the range of 2.5 to 5.0 L/minute can
reported rates of hospital discharge have been dis- be achieved directly in proportion with increasing
appointing (6% to 44%) even with the implementation of diameter of the pumps. It is CE-marked for temporary use
extracorporeal ventricular assist devices [82]. of 5 to 10 days only, and seems efficient in medium flow
A perioperative clinical severity classification of severe demands in postcardiotomy low CO syndrome.
acute HF is suggested in Table 4.
Extra-corporeal membrane oxygenation
Mechanical circulatory support Extra-corporeal membrane oxygenation (ECMO) is
Group recommendations increasingly used for temporary mechanical circulatory
• In case of heart dysfunction with suspected coronary support due to the relatively low cost of the system and
hypoperfusion, IABP is highly recommended disposables, as well as its broad availability (practically
• Ventricular assist device should be considered early accessible to all cardiosurgical units, without requiring a
rather than later, before end organ dysfunction is major investment in hardware). Indications include all
evident types of ventricular failure, for example, intraoperative or
• Extra-corporeal membrane oxygenation is an elegant perioperative low CO syndrome, severe acute myocardial
solution as a bridge to recovery or decision making infarction, and cardiac resuscitation. An additional
advantage is its versatile use not only in LV, RV or
Intra-aortic balloon pump biventricular support, but also for respiratory assistance
IABP is the first choice device in intra- and perioperative and even renal support by addition of a haemofilter.
cardiac dysfunction. Its advantages include easy insertion ECMO is a simplified CPB using a centrifugal pump (5
(Seldinger technique), the modest increase in CO and to 6 L/minute), allowing for augmentation of venous
coronary perfusion, and four decades of refined tech- drainage despite relatively small cannulas, with the
nology and experience resulting in a low complication option of taking the full workload over from the heart.
rate. The IABP’s main mechanism of action is a reduction ECMO is not only used as a bridge to recovery, a bridge
of afterload and increased diastolic coronary perfusion to transplantation, or a bridge to assist with middle and
via electrocardiogram triggered counterpulsation. However, long-term assist devices, but also as a bridge to decision
the newer generations of IABPs are driven by aorta flow making - for example, neurological assessment after
detection, thereby overcoming limitations in patients with resuscitation prior to long-term assist/transplantation.
atrial fibrillation and other arrhythmias. IABP reduces heart The limitations of ECMO mainly stem from the
work and myocardial oxygen consumption, favourably necessity of permanent operator supervision and
modifying the balance of oxygen demand/supply. intervention. Currently, many different ECMO configura-
Consequently, it is an ideal application in post- tions are available for temporary use up to 30 days.
cardiotomy cardiac dysfunction, especially in suspected Although patients supported by ECMO can be extubated,
coronary hypoperfusion. IABP insertion should be they are usually bed-ridden and have to stay in the ICU,
considered as soon as evidence points to possible cardiac which is very much in contrast to modern ventricular
dysfunction, preferably intraoperatively to avoid the assist device therapy (see below).
excessive need of inotropic support.
IABP is contraindicated for patients with severe aortic Ventricular assist device
insufficiency, and advanced peripheral and aortic Mechanical blood pumps, capable of taking over the full
vascular disease. CO of the failing heart, are used today as an established
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therapy option for patients with end-stage HF. In the Table 5. Mechanical circulatory support used in the three
majority of cases only the failing LV needs mechanical clinical heart failure scenarios
support; pumps are therefore left ventricular assist Clinical scenarios Commonly used devices
devices. Patients with pronounced biventricular failure or Precardiotomy HF IABP
patients in cardiogenic shock will nowadays receive
Micro-axial flow pumpa
biventricular mechanical support.
Percutaneous (transfemoral) ECMO
Besides achieving adequate perfusion of the peripheral
organs, thereby facilitating survival in the ICU, LA femoral artery centrifugal pumpb
increasingly the objective of modern ventricular assist Failure to wean from CPB IABP
device therapy is to obtain a level of functionality that Micro-axial flow pumpa
results in an acceptable quality of life for the patient. ECMO
Hence, weaning from the ventilator, mobilisation,
Centrifugal pumps as LVAD, RVAD,
transfer from the ICU to the general ward, excursions, BVAD
discharge home, and ultimately return to work must be
Percutaneous pulsatile devices as
the goals when transplantation is not feasible within a LVAD, RVAD, BVADc
reasonable time frame. Long-term implantable devices
In terms of technology, the available pumps provide
Postcardiotomy HF IABP
either pulsatile or continuous flow (may be modulated by
Micro-axial flow pump
residual ventricular function). In continuous flow, axial
and centrifugal designs are distinguished. Almost all ECMO
currently available second-generation rotary axial and Centrifugal pumpsd as LVAD, RVAD,
centrifugal pumps require a transcutaneous drive line or BVAD
cable, a serious limitation for the patient as well as a port Percutaneous pulsatile devicesc as
LVAD, RVAD, BVAD
of entry for infections. However, they can easily be
miniaturized, produce no noise, have thin and flexible Long-term implantable devices first,
second and third generation
drive-lines and their driving units can be miniaturized to
a
Impella; bTandemHeart; cAbiomed BVS 5000, AB 5000; Thoratec PVAD, Berlin
the size of a cigarette package. In third-generation rotary
Heart EXCOR; dCentrimag Levitronix, Biomedicus Medtronic etc. ll devices except
pumps the spinning rotor floats by means of either a those specified as long term are for short-term support. BVAD, bi-ventricular
magnetic field or hydrodynamic levitation, never touch- assist device; CPB, cardiopulmonary bypass; ECMO, extracorporeal membrane
oxygenation; HF, heart failure; IABP, intra-aortic balloon pump; LA, left atrial;
ing the pump housing, thereby eliminating mechanical LVAD, left ventricular assist device; PVAD, paracorporeal ventricular assist device;
wear. The second and third generation pumps have RVAD, right ventricular assist device.
prospective lifetimes of more than 10 years, producing an
acceptable quality of life. long-term mechanical circulatory devices used in the
Steadily increasing implant numbers have improved three clinical scenarios.
clinical outcomes, with 1- and 2-year survival rates of
approximately 90% and 80%, respectively [83,84]. Conclusion
In summary, in this day and age mechanical circulatory This review offers practical recommendations for
support should be considered as a course of treatment managing perioperative HF in cardiac surgery based
and not as a last effort in patients with failing hearts, mostly on European experts’ opinion. It outlines typical
especially those with perioperative cardiac dysfunction scenarios and profiles classifying and defining low CO
inadequately responding to advanced inotropic treat- syndrome and cardiogenic shock in cardiac surgery. As
ment. Initially, most patients demonstrating peri- the role of inotropes is accentuated, the cardiosurgical
operative low CO syndrome receive short-term mecha- community needs to have evidence-based facts on the
nical support. Under this initial support they stabilize or short- and long-term mortality in cardiac surgery in
recover and can be weaned from the pump (bridge to European cardiosurgical centres. The impact of inotropes
recovery). Patients, whose cardiac function does not is increasingly studied outside of cardiac surgery,
recover during the initial support and are eligible for highlighting the urgent necessity for cardiac surgery to
cardiac transplantation can be switched to long-term mimic these studies. Similarly, large trials are still
mechanical support (bridge to transplantation, chronic required to assess the best cardioprotective agent(s) and
mechanical support as an alternative to transplantation). optimal protocol(s) for their use. The continuously
If the haemodynamics are inadequate with an unclear expanding implementation of mechanical circulatory
indication for potentially long-term assist, ECMO support - by means of short-term (extra- or para-
provides an elegant low cost and short-term solution as a corporeal) and long-term (implantable) devices - demand
bridge to recovery. Table 5 summarizes short- and its documentation and study in a European registry.
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Competing interests 26:384-416.
All coauthors received reimbursement of travel expenses and/or a fee 2. Rudiger A, Harjola VP, Muller A, Mattila E, Saila P, Nieminen M, Follath F: Acute
to participate at the workshop, entitled ‘Management of Perioperative heart failure: clinical presentation, one-year mortality and prognostic
Cardiovascular Failure in Cardiothoracic Surgery’ that was held in Zurich factors. Eur J Heart Fail 2005, 7:662-670.
the 7th-8th of November 2008 for which event an Educational grant was 3. Siirila-Waris K, Lassus J, Melin J, Peuhkurinen K, Nieminen MS, Harjola VP:
received from Abbott. Dr Follath has received lecture fees and advisory board Characteristics, outcomes, and predictors of 1-year mortality in patients
honoraria from Abbott. Dr Longrois reported being a consultant for Abbott hospitalized for acute heart failure. Eur Heart J 2006, 27:3011-3017.
and Orion Pharma. Dr Mebazaa reported being a consultant for Abbott, Orion 4. Tavazzi L, Maggioni AP, Lucci D, Cacciatore G, Ansalone G, Oliva F, Porcu M:
Pharma, Pronota, Inverness and Bayer Pharma and receiving lecture fees from Nationwide survey on acute heart failure in cardiology ward services in
Abbott and Edwards Life Sciences. Dr Ranucci received consultancy fees from Italy. Eur Heart J 2006, 27:1207-1215.
Edwards Lifesciences in the years 2006-2008 for Educational programs in the 5. Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP,
field of Hemodynamic monitoring; Edwards Lifesciences is not sponsoring Hochadel M, Komajda M, Lassus J, Lopez-Sendon JL, Ponikowski P, Tavazzi L;
this article. Dr Toller has received speaker’s fees and advisory board fees from EuroHeart Survey Investigators; Heart Failure Association, European Society
Abbott. Dr Wouters has received speaker’s fees from Abbott for lectures on of Cardiology: EuroHeart Failure Survey II (EHFS II): a survey on hospitalized
topics unrelated to this manuscript. Dr Seeberger is the principal investigator acute heart failure patients: description of population. Eur Heart J 2006,
of the ongoing investigator initiated study: “The TEAM-project: multi-center 27:2725-2736.
trial on the effect of anesthetics on morbidity and mortality in patients 6. Zannad F, Mebazaa A, Juillière Y, Cohen-Solal A, Guize L, Alla F, Rougé P, Blin P,
undergoing major non cardiac surgery” that has received partial research Barlet MH, Paolozzi L, Vincent C, Desnos M, Samii K; EFICA Investigators:
funding by Abbott. Clinical profile, contemporary management and one-year mortality in
patients with severe acute heart failure syndromes: The EFICA study. Eur J
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This initiative was sponsored by way of an educational grant from Abbott. 7. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE,
The views expressed in this supplement are not necessarily the views of the Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF; ACC/AHA
sponsor. TASK FORCE MEMBERS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL,
Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin
Author details JL, Hiratzka LF, Hunt SA, Lytle BW, Md RN, Ornato JP, Page RL, et al.: ACC/AHA
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1011 Lausanne, Switzerland. 12Department of Anaesthesiology and Intensive diagnosis and treatment of acute and chronic heart failure 2008: the Task
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Campus Virchow-Klinikum, 10098 Berlin, Germany. 13Department of Vascular 2008 of the European Society of Cardiology. Developed in collaboration
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Raemistrasse 100, CH-8091 Zurich, Switzerland. 19Division of Thoracic surgery,
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