Abstract
We investigated the role of echocardiographic indices consisting of left ventricular end-diastolic area (LVEDA) in combination with Doppler-derived surrogates of diastolic compliance and filling (E/E′, E′/S′, E′/A′; early transmitral flow velocity (E), tissue Doppler-derived early (E′) diastolic, late (A′) diastolic, or peak systolic (S′) velocity of the mitral annulus) in predicting fluid responsiveness in off-pump coronary surgery. Hemodynamic and echocardiographic variables were prospectively assessed under general anesthesia before and after a fluid challenge of 6 mL/kg during apnea at atmospheric pressure in 64 patients with LV ejection fraction ≥40%. Forty patients (63%) were fluid responders (≥15% increase in stroke volume index). E/E′ and E′/S′ could predict fluid responsiveness with area under the receiver operating characteristic curve (AUROC) of 0.71 (95% confidence interval [CI], 0.56–0.85; p = 0.006) and 0.68 (95% CI, 0.54–0.82; p = 0.017), respectively. The combination of LVEDA and E/E′ showed incremental predictive ability for fluid responsiveness compared with LVEDA (AUROC, 0.60; p = 0.170) or pulse pressure variation (AUROC, 0.70; p = 0.002), yielding the highest AUROC of 0.78 (95% CI, 0.66–0.90; p < 0.001). The combined index of echocardiographic variables reflecting LV dimension (LVEDA) and diastolic compliance and filling (E/E′) is a potentially useful predictor of fluid responsiveness.
Highlights
For perioperative and critical care, appropriate fluid resuscitation guided by reliable preload indices is of pivotal importance as only half of the patients are fluid responsive [1]and superfluous fluid administration leads to increased mortality [2]
Emerging evidence advocates the ability of dynamic preload indices, such as pulse pressure variation (PPV) or stroke volume variation, to determine a patient’s status on the Frank–Starling curve and fluid responsiveness [3]
These dynamic indices are subject to limitations related to heart–lung interaction and arrhythmia [4], which may preclude their use in patients receiving lung-protective ventilation or those with a rhythm other than sinus, spontaneous breathing efforts, pulse pressure hypertension or pulmonary hypertension [5,6]
Summary
For perioperative and critical care, appropriate fluid resuscitation guided by reliable preload indices is of pivotal importance as only half of the patients are fluid responsive [1]and superfluous fluid administration leads to increased mortality [2]. These dynamic indices are subject to limitations related to heart–lung interaction and arrhythmia [4], which may preclude their use in patients receiving lung-protective ventilation or those with a rhythm other than sinus, spontaneous breathing efforts, pulse pressure hypertension or pulmonary hypertension [5,6]. The assessment of static preload indices is feasible regardless of heart rhythm or heart–lung interaction, while they are unable to predict fluid responsiveness. The use of invasively acquired measures of filling pressures using a pulmonary artery catheter (PAC) for assessing fluid responsiveness has been discouraged [7]. The predictive ability of a static echocardiographic index, left ventricular end-diastolic area (LVEDA), for fluid responsiveness is poor [3]. Echocardiographic measurements of combinations of early transmitral flow velocity (E), tissue Dopplerderived early (E0 ) diastolic, late (A0 ) diastolic, or peak systolic (S0 ) velocity of the mitral annulus may provide surrogate information regarding LV filling pressure (E/E0 ), preload (E0 /S0 ) and stiffness (E0 /A0 ) [8,9,10,11]
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