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Impact of Anesthetic and Ventilation Strategies on Invasive Hemodynamic Measurements in Pediatric Heart Transplant Recipients

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Abstract

Background

Care of pediatric heart transplant recipients relies upon serial invasive hemodynamic evaluation, generally performed under the artificial conditions created by anesthesia and supportive ventilation.

Objectives

This study aimed to evaluate the hemodynamic impacts of different anesthetic and ventilatory strategies.

Methods

We compared retrospectively the cardiac index, right- and left-sided filling pressures, and pulmonary and systemic vascular resistances of all clinically well and rejection-free heart transplant recipients catheterized from 2005 through 2017. Effects of spontaneous versus positive pressure ventilation and of sedation versus general anesthesia were tested with generalized linear mixed models for repeated measures using robust sandwich estimators of the covariance matrices. Least squared means showed adjusted mean outcome values, controlled for appropriate confounders.

Results

720 catheterizations from 101 recipients met inclusion criteria. Adjusted cardiac index was 3.14 L/min/m2 (95% CI 3.01–3.67) among spontaneously breathing and 2.71 L/min/m2 (95% CI 2.56–2.86) among ventilated recipients (p < 0.0001). With spontaneous breathing, left filling pressures were lower (9.9 vs 11.0 mmHg, p = 0.030) and systemic vascular resistances were higher (24.0 vs 20.5 Woods units, p < 0.0001). After isolating sedated from anesthetized spontaneously breathing patients, the observed differences in filling pressures and resistances emerged as a function of sedation versus general anesthesia rather than of spontaneous versus positive pressure ventilation.

Conclusion

In pediatric heart transplant recipients, positive pressure ventilation reduces cardiac output but does not alter filling pressures or vascular resistances. Moderate sedation yields lower left filling pressures and higher systemic vascular resistances than does general anesthesia. Differences are quantitatively small.

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Abbreviations

CHLA:

Children’s Hospital of Los Angeles

CI:

Cardiac index

TD:

Thermodilution

RVEDP:

Right ventricular end-diastolic pressure

PCWP:

Pulmonary capillary wedge pressure

PVR:

Pulmonary vascular resistance

SVR:

Systemic vascular resistance

PEEP:

Positive end-expiratory pressure

VO2:

Oxygen consumption

pCO2:

Partial pressure of carbon dioxide

paO2:

Partial pressure of oxygen

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Funding

Supported by the Department of Anesthesiology & Critical Care and by the Heart Institute at the Children’s Hospital of Los Angeles, Los Angeles, CA, USA. The authors have no personal or financial relationships or affiliations that could influence or bias their decisions, work, or manuscript.

Author information

Authors and Affiliations

  1. Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA

    Sheldon Stohl, Margaret J. Klein, Patrick A. Ross & Sabine vonBusse

  2. Department of Anesthesiology and Critical Care Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel

    Sheldon Stohl

  3. Department of Pediatrics, University of Southern California, Los Angeles, CA, USA

    Patrick A. Ross & JonDavid Menteer

  4. Department of Anesthesiology and Critical Care Medicine, University of Southern California, Los Angeles, CA, USA

    Sabine vonBusse

  5. Division of Pediatric Cardiology, Children’s Hospital of Los Angeles, Los Angeles, CA, USA

    JonDavid Menteer

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  1. Sheldon Stohl
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Correspondence to Sheldon Stohl.

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Stohl, S., Klein, M.J., Ross, P.A. et al. Impact of Anesthetic and Ventilation Strategies on Invasive Hemodynamic Measurements in Pediatric Heart Transplant Recipients. Pediatr Cardiol 41, 962–971 (2020). https://doi.org/10.1007/s00246-020-02344-9

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  • DOI: https://doi.org/10.1007/s00246-020-02344-9

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