Abstract
Purpose
As the evaluation of diastolic function can be complex in the setting of a busy cardiac operating room, its assessment may benefit from an algorithmic approach using transesophageal echocardiography. We developed a diagnostic algorithm which was then applied in a series of cardiac surgery patients to determine whether moderate to severe left ventricular diastolic dysfunction (LVDD) and right ventricular diastolic dysfunction (RVDD) can predict difficult separation from cardiopulmonary ypass (DSB).
Methods
An algorithm using pulsed-wave Doppler interrogation of the mitral and tricuspid valve, the pulmonary and hepatic venous flow, and tissue Doppler interrogation of the mitral and tricuspid annulus was developed. The study was divided in two phases involving two groups of patients undergoing cardiac surgery. In phase I, echocardiographic evaluations of patients (n = 74) were used to test the reproducibility of the algorithm and to evaluate inter-observer variability using Cohen’s kappa values which were calculated in three specific periods. In phase II, the algorithm was applied to a second group of patients (validation group, n = 179) to explore its prognostic significance. The primary end-point in phase II was DSB.
Results
In phase I, the kappa coefficients for LVDD and RVDD algorithms were 0.77 and 0.82, respectively. In phase II, moderate or severe degrees of LVDD were observed in 29 patients ( 16%) and moderate to severe RVDD was observed in 18 patients ( 10%) before cardiac surgery. Both moderate and severe LVDD (P = 0.017) and RVDD (P = 0.049) before surgery were observed more frequently in patients with DSB.
Conclusion
Moderate and severe LVDD and RVDD can be identified with very good reproducibility, and both degrees of diastolic dysfunction are associated with DSB.
Résumé
Objectif
L’évaluation de la fonction diastolique pouvant être complexe dans le contexte d’un bloc opératoire très actif en chirurgie cardiaque, on pourrait tirer profit d’un algorithme pour son évaluation avec l’échocardiographie transœsophagienne. Nous avons développé un algorithme en cardiochirurgie pour déterminer si la dysfonction ventriculaire diastolique gauche (DVDG) modérée ou sévère et la dysfonction ventriculaire diastolique droite (DVDD) pouvaient être des prédicteurs de difficultés de sevrage de la circulation extracorporelle (DSCE).
Méthode
Un algorithme utilisant l’examen Doppler pulsé pour évaluer la vélocité des valvules mitrale et tricuspide, la vélocité des veines pulmonaire et hépatique et l’examen Doppler tissulaire des anneaux mitral et tricuspide a été mis au point. L’étude, en deux phases, a comporté deux groupes de patients devant subir une opération cardiaque. Pendant la phase I, des évaluations échocardiographiques de patients (n = 74) ont permis de vérifier la reproductibilité de l’algorithme et d’évaluer la variabilité inter-observateur d’après les valeurs Kappa de Cohen qui ont été calculées à trois moments spécifiques. Pendant la phase II, l’algorithme a été appliqué au second groupe de patients (groupe de validation, n = 179) pour explorer sa portée pronostique. Le principal paramètre de la phase II était les DSCE.
Résultats
Pendant la phase I, les coefficients kappa pour les algorithmes de DVDG et DVDD ont été respectivement de 0,77 et 0,82. Pendant la phase II, des DVDG modérées ou sévères ont été observées chez 29 patients (16 %) et des DVDD chez 18 patients (10 %) avant l’opération cardiaque. Des DVDG modérées et sévères (P = 0,017) et des DVDD (P = 0,049) préchirurgicales ont été observées plus souvent chez les patients qui présentaient des DSCE.
Conclusion
Des DVDG et des DVDD modérées et sévères peuvent être observées avec une très bonne reproductibilité et les deux degrés de dysfonction diastolique sont associés à des DSCE.
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Acknowledgement of funding: Supported in part by by the Dr. Earl Wynands Research Award in Cardiovascular Anesthesia and/or Perioperative Blood Conservation, le Fonds de la recherche en santé du Québec, les Instituts de recherche en santé du Canada et la Fondation de l’Institut de Cardiologie de Montréal. Dr .Tardif holds the Pfizer and Canadian Institutes of Health Research Chair in atherosclerosis. Presented in part at the 2004 Annual Meeting of the Canadian Anesthesiologists’ Society. Competing interests: None declared.
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Denault, A.Y., Couture, P., Buithieu, J. et al. Left and right ventricular diastolic dysfunction as predictors of difficult separation from cardiopulmonary bypass. Can J Anesth 53, 1020–1029 (2006). https://doi.org/10.1007/BF03022532
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DOI: https://doi.org/10.1007/BF03022532