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PRE-OPERATIVE MODERATE TO SEVERE LEFT AND RIGHT VENTRICULAR DIASTOLIC DYSFUNCTION ARE PREDICTIVE OF DIFFICULT SEPARATION FROM BYPASS

Introduction: We have previously demonstrated that left ventricular diastolic dysfunction (DD) is a predictor of difficult separation from bypass (DSB) (1, 2). However, right ventricular DD can also be present before cardiac surgery and its relationship with DSB is unclear.

Method: 179 consecutive patients undergoing cardiac surgery were studied. Patients with pacemaker, atrial fibrillation, non-sinus rhythm, moderate to severe mitral or tricuspid regurgitation were excluded. Patients undergoing mitral valve surgery or with aortic insufficiency were excluded for the evaluation of left ventricular diastolic dysfunction. DSB was defined as as systolic blood pressure below 80 mm Hg confirmed with central measurement (femoral or aortic), diastolic pulmonary artery pressure or pulmonary artery capillary wedge pressure > 15 mm Hg during progressive weaning from CPB and the use of inotropic or vasopressive support (norepinephrine > 4 µg.min^–1, epinephrine > 2 µg.min^–1, dobutamine > 2 µg.kg^–1.min^–1) or the use of amrinone, milrinone, mechanical support or IABP to be weaned from bypass or to leave the operating room. The use of dopamine from 0.5–3.0 ug/kg/min was excluded from the definition. Left ventricular diastolic dysfunction was classified according to published guidelines (3) and newer modalities such as tissue Doppler and color M Mode (2). Normal or relaxation abnormalities were classified as mild DD, pseudonormal and restrictive were classified as moderate to severe left DD. Right ventricular DD was classified as moderate to severe right DD if the Doppler systolic hepatic venous flow was inferior to the diastolic waveform or if the systolic waveform was reversed. Groups were compared using descriptive statistics. A p < 0.05 was considered significant.Results: A total of 179 patients were studied (57 women, 122 man). Evaluation of left and right ventricular diastolic function was obtained before CPB in 144 (80%) and 162(91%) patients respectively. In patients with pre-CPB severe left ventricular DD (n = 29), DSB occurred in 66% (p = 0.0173). In patients with pre-CPB right ventricular DD (n=18), DSB occurred in 72% (p = 0.0455). DSB was also more common in complex surgeries (p=0.0024) and aortic surgeries (p = 0.0455).

Left ventricular diastolic dysfunction before CPB Normal or Mild Moderate or Severe Total number No DSB 68 (60%) 10 (34%) 78 DSB 47(40%) 19 (66%) 66 Total 115 29 144

Right ventricular diastolic dysfunction before CPB Normal or Mild Moderate or Severe Total number No DSB 76 (53%) 5(28%) 81 DSB 68 (47%) 13 (72%) 81 Total 144 18 162

Conclusion: Both moderate to severe left and right ventricular diastolic dysfunction are associated with DSB. Further studies will be required to determine the impact of pre-operative DD on other outcome variables.

References

1 Bernard et al Anesth Anal 2001;92:291–8[Abstract/Free Full Text]

2 Garcia et al JACC 1998;32 :865–875[Abstract/Free Full Text]

3 Rakowski et al JASE 1996;5:736–760

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