Assessment of the diagnostic potential of transpulmonary thermodilution in young children after radical correction of tetralogy of Fallot

Lung Transplantation: Can PiCCO2 Navigate Perioperative Safe Harbor?

BackgroundEarly biventricular dysfunction in repaired tetralogy of Fallot (TOF) children may lead to poor clinical outcomes. We aimed to assess biventricular function in TOF children before and after surgery by speckle tracking echocardiography (STE) and compare them with the controls.MethodsTwenty repaired TOF children and 20 normal children as controls were assessed by STE. Tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF), biventricular strain, and strain rate were compared before and after surgery and between TOF children and controls.ResultsPostoperative LVEF (p = 0.001), strain (p = 0.001), and strain rate (p = 0.001) for left ventricle improved significantly compared to preoperative phase. However, postoperative left ventricular strain (p = 0.05) and strain rate (p = 0.01) in TOF children were significantly impaired compared to controls. Postoperative LVEF was correlated inversely with postoperative strain rate (r = −0.40, p = 0.04). Postoperative TAPSE (p = 0.001), strain (p = 0.001), and strain rate (p = 0.001) for right ventricle significantly worsened when compared with the preoperative phase. Moreover, postoperative TAPSE (p = 0.001), strain (p = 0.001), and strain rate (p = 0.01) were significantly impaired compared to controls. Postoperative right ventricular strain rate was correlated significantly with the weight of children (r = 0.48, p = 0.02), and postoperative left ventricular strain showed significant correlations with aortic clamp time (r = 0.44, p = 0.04) and with ICU stay (r = −0.46, p = 0.04).ConclusionDespite normal LVEF, TOF children exhibit impaired left ventricular strain and strain rate after surgery. TAPSE, strain, and strain rate for the right ventricle worsen after surgical repair. STE‐driven strain can be used to detect early ventricular dysfunction and the associated prognostic implications.

IntroductionThere is limited clinical experience with the single-indicator transpulmonary thermodilution (pulse contour cardiac output, or PiCCO) technique in critically ill medical patients, particularly in those with acute heart failure (AHF). Therefore, we compared the cardiac function of patients with AHF or sepsis using the pulmonary artery catheter (PAC) and the PiCCO technology.MethodsThis retrospective observational study was conducted in the medical intensive care unit of a university hospital. Twelve patients with AHF and nine patients with severe sepsis or septic shock had four simultaneous hemodynamic measurements by PAC and PiCCO during a 24-hour observation period. Comparisons between groups were made with the use of the Mann-Whitney U test. Including all measurements, correlations between data pairs were established using linear regression analysis and are expressed as the square of Pearson's correlation coefficients (r2).ResultsCompared to septic patients, AHF patients had a significantly lower cardiac index, cardiac function index (CFI), global ejection fraction, mixed venous oxygen saturation (SmvO2) and pulmonary vascular permeability index, but higher pulmonary artery occlusion pressure. All patients with a CFI less than 4.5 per minute had an SmvO2 not greater than 70%. In both groups, the CFI correlated with the left ventricular stroke work index (sepsis: r2 = 0.30, P < 0.05; AHF: r2 = 0.23, P < 0.05) and cardiac power (sepsis: r2 = 0.39, P < 0.05; AHF: r2 = 0.45, P < 0.05).ConclusionsIn critically ill medical patients, assessment of cardiac function using transpulmonary thermodilution technique is an alternative to the PAC. A low CFI identifies cardiac dysfunction in both AHF and septic patients.

The Impact of Intra-aortic Balloon Pumping on Cardiac Output Determination by Pulmonary Arterial and Transpulmonary Thermodilution in Pigs

The strategies of repair of tetralogy of Fallot change with the age of patients. In children older than 4 years and adults, the optimal strategy may be to use different method of reconstruction of the right ventricular outflow tract from those followed in younger children, so as to avoid, or reduce, the pulmonary insufficiency that is increasingly known to compromise right ventricular function. From April, 2001, through May, 2008, we undertook complete repair in 312 patients, 180 male and 132 female, with a mean age of 11.3 years +/-0.4 years, and a range from 4 to 48 years, with typical clinical and morphological features of tetralogy of Fallot, including 42 patients with the ventriculo-arterial connection of double outlet right ventricle. The operation was performed under moderate hypothermia using blood cardioplegia. The ventricular septal defect was closed with a Dacron patch. When it was considered necessary to resect the musculature within the right ventricular outflow tract, or perform pulmonary valvotomy, we sought to preserve the function of the pulmonary valve by protecting as far as possible the native leaflets, or creating a folded monocusp of autologous pericardium. The repair was achieved completely through right atrium in 192, through the right ventricular outflow tract in 83, and through the right atrium, the outflow tract, and the pulmonary trunk in 36 patients. A transjunctional patch was inserted in 169 patients, non-valved in all but 9. There were no differences regarding the periods of aortic cross-clamping or cardiopulmonary bypass. Of the patients, 5 died (1.6%), with no influence noted for the transjunctional patch. Of those having a non-valved patch inserted, three-tenths had pulmonary regurgitation of various degree, while those having a valved patch had minimal pulmonary insufficiency and good right ventricular function postoperatively, this being maintained after follow-up of 8 to 24-months. Based on our experience, we suggest that the current strategy of repair of tetralogy of Fallot in older children and adults should be based on minimizing the insertion of transjunctional patches, this being indicated only in those with very small ventriculo-pulmonary junctions. If such a patch is necessary, then steps should be taken to preserve the function of the pulmonary valve.

Objective: to compare the efficiency of using the values of transpulmonary (PiCCO) and prepulmonary (Swan-Ganz catheter) thermodilution as guides to targeted therapy for hemodynamic disorders in the surgical correction of mixed cardiac valvular defects. Subjects and methods. The study enrolled 40 patients operated on for acquired cardiac diseases who were randomized to two matched groups. Hemodynamics was monitored by means of a Swan-Ganz catheter in Group 1 and by transpulmonary thermodilution in Group 2. Anesthesia was maintained with propofol and fentanyl. Infusion therapy was performed using crystalloid and colloid solutions. Continuous intravenous infusion of inotropic agents was used when heart failure was developed. Hemodynamic, clinical, and laboratory parameters were estimated intraoperatively and within 24 hours postoperatively. Results. The groups did not differ in the degree of baseline heart failure, the duration of an operation and myocardial ischemia, and the length of extracorporeal circulation. In the PiCCO group, postoperative infusion volume was 33% higher than that in the Swan-Ganz group, which ensured increases in stroke volume and oxygen delivery in the early postoperative period (p&lt;0.05). Respiratory support was 26% shorter in the PiCCO group (p&lt;0.04). Conclusion. After surgical interventions for mixed cardiac defects, the targeted therapy algorithm based on transpulmonary thermodilution provided more steady-state values of hemodynamics and oxygen transport, which was followed by the increased scope of infusion therapy and the shorter length of postoperative mechanical ventilation than that based on hemodynamics being corrected from the values of prepul-monary thermodilution. Key words: transpulmonary thermodilution, targeted therapy, prepulmonary ther-modilution, acquired heart disease.

Early Identification of Asymptomatic Subjects at Increased Risk of Heart Failure and Cardiovascular Events: Progress and Future Directions

Transpulmonary thermodilution cardiac output measurement is not affected by severe pulmonary oedema: a newborn animal study

Comparison of cardiac output measurements using transpulmonary thermodilution and conventional thermodilution techniques in anaesthetized dogs with fluid overload

To investigate the agreement (and its potential dependency on extra-vascular lung water) between transpulmonary (TPID) and standard pulmonary artery (PAID) thermodilution cardiac output measurements. One hundred and sixty simultaneous cardiac output measurements using transpulmonary and pulmonary artery thermodilution techniques were retrospectively compared in 18 patients with acute respiratory distress syndrome. In addition, extravascular lung water was determined using a double indicator technique (temperature and indocyanine green). Mean (+/- SD) difference ("bias") was 0.03 L/min (+/- 1.04 L/min), linear regression analysis resulted in TPID = 0.87 PAID + 1.16 (r = 0.91). Mean extra vascular lung water was 1625 mL (minimum-maximum: 403-3266 mL) and therefore markedly elevated as could have been expected in patients with ARDS. Bias (PAID-TPID) was not dependent on extravascular lung water. Transpulmonary and pulmonary artery thermodilution methods can be used interchangeably. The results demonstrate for the first time in humans that transpulmonary thermodilution provides valid cardiac output values in patients with markedly increased fluid content of the lungs.

Cardiac output can be measured with the transpulmonary thermodilution method in a paediatric animal model with a left-to-right shunt

Cardiac output (CO) can be measured using the transpulmonary thermodilution (TPTD) technique. TPTD is considered to be the gold standard in pediatric patients. We studied the influence of high levels of EVLW on the reliability of CO measurement using the TPTD technique in a pediatric animal model.

Background Transthoracic echocardiography (TTE) is commonly used after pediatric cardiac surgery to monitor cardiac function and adequacy of surgery; however it depends on the availability of good echo window and operator skill [1]. Transpulmonary thermodilution (TPTD) is feasible along with calibrated continuous cardiac output measurement in children but seldom used due to cost and the need for a specialized catheter [2]. We hypothesized that TTE would be as good as TPTD, but limited in feasibility following pediatric cardiac surgery. Hence, the concordance, agreement as well as feasibility and trending of cardiac output monitoring by TTE was compared against a reference TPTD method in real-world usage in children after congenital heart surgery. Methods This was a secondary analysis of data from a previously registered and conducted study in our unit. TPTD monitoring was instituted in children undergoing congenital heart disease repair on cardiopulmonary bypass with a 3F femoral arterial cannula and a central venous injectate temperature sensor. Cardiac output was also measured by transthoracic echocardiography by measurement of the left ventricular outflow tract (LVOT) diameter, LVOT velocity time integral (VTI) and the heart rate as previously described [3,4]. Measurements were taken after arrival in the ICU, and every 12 hours till after extubation. Correlation, Bland-Altman analysis and polar analysis was done for cardiac output measured by TPTD and TTE. Results TTE and TPTD measurements of cardiac output correlated well (Pearson's correlation coefficient 0.94; 95% CI 0.90–0.96) (Fig. 1A). Bland Altman analysis showed a mean bias of 0.15 l/min and upper and lower limits of agreement of 0.81 and −0.51 l/min respectively (Fig. 1B). Cardiac output measurement by TTE was possible in 72 instances while TPTD allowed measurement in all 113 instances. Hence, TTE was not feasible in 41 instances across 14 patients, including 19 instances in acyanotic and 22 instances in cyanotic patients. Polar analysis revealed acceptable trending. Conclusions TTE derived cardiac output demonstrated good correlation, minimal bias and narrow limits of agreement versus TPTD, and was feasible in most cases. This suggests TTE is an acceptable cardiac output measurement modality post pediatric cardiac surgery, as in adults [5]. TPTD-based continuous cardiac output monitoring might have a complementary role in pediatric cardiac critical care, particularly in high risk cases. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Institutional Special Research Grant from Postgraduate Institute of Medical Education and Research, Chandigarh, India. Figure 1

The assessment of hemodynamic variables is a mainstay in the management of critically ill patients. Hemodynamic variables may help physicians to choose among use of a vasopressor, an inotropic agent, or discontinuation of drugs. In this study, we aimed to investigate the usefulness of advanced hemodynamic variables in clinical decision-making. Surveys regarding the case were administered to 25 surgeons working in nationally designated trauma centers or on trauma teams, using a voting system at a medical conference. The patient was a 67-year-old male with a crush injury of the left leg after a pedestrian traffic accident, who had aggravated pulmonary edema after leg amputation. Three clinical situations were given and the decision choices were: immediately after amputation, in 8 hours, and on the second day after amputation. Three kinds of variables from hemodynamic monitoring systems were provided for each clinical situation: conventional hemodynamic variables, including central venous pressure; variables from pulse contour analysis (PCA) [cardiac output (CO), stroke volume index, stroke volume variation (SVV), and systemic vascular resistance index); and variables from transpulmonary thermodilution (TPTD) technique (global ejection fraction and extravascular lung water index). The changes in decisions according to each provided hemodynamic variable were investigated and analyzed. The advanced hemodynamic parameters were considered to have a decisive effect on choosing vasopressors and inotropic agents. The decision was changed in 88% (22/25) of physicians using variables from the advanced monitoring systems. Among them, 82% (18/22) of physicians chose hemodynamic variables from the TPTD technique as their reason for change regarding management of a patient with severe pulmonary edema. Advanced monitoring systems might be helpful in decision-making for critically ill patients. Multiple parameters and trends in change could be more important than a single value. Clinicians should select the system most appropriate according to its advantages and limitations, and interpret the variables obtained correctly.

IntroductionMonitoring of hemodynamic and volumetric parameters after severe burns is of critical importance. Pulmonary artery catheters, however, have been associated with many risks. Our aim was to show the feasibility of continuous monitoring with minimally invasive transpulmonary thermodilution (TPTD) in severely burned pediatric patients.MethodsThis prospective cohort study was conducted in patients with severe burns over 40% of the total body surface area (TBSA) who were admitted to the hospital within 96 hours after sustaining the injury. TPTD measurements were performed using the PiCCO system (Pulsion Medical Systems, Munich, Germany). Cardiac Index (CI), Intrathoracic Blood Volume Index (ITBVI) (Stewart-Hamilton equation), Extravascular Lung Water Index (EVLWI) and Systemic Vascular Resistance Index (SVRI) measurements were recorded twice daily. Statistical analysis was performed using one-way repeated measures analysis of variance with the post hoc Bonferroni test for intra- and intergroup comparisons.ResultsSeventy-nine patients with a mean age (±SD) of 9 ± 5 years and a mean TBSA burn (±SD) of 64% ± 20% were studied. CI significantly increased compared to level at admission and was highest 3 weeks postburn. ITBVI increased significantly starting at 8 days postburn. SVRI continuously decreased early in the perioperative burn period. EVLWI increased significantly starting at 9 days postburn. Young children (0 to 5 years old) had a significantly increased EVLWI and decreased ITBVI compared to older children (12 to 18 years old). EVLWI was significantly higher in patients who did not survive burn injury.ConclusionsContinuous PiCCO measurements were performed for the first time in a large cohort of severely burned pediatric patients. The results suggest that hyperdynamic circulation begins within the first week after burn injury and continues throughout the entire intensive care unit stay.