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Abstract
Objective: Adverse factors of postoperative hemodynamic and myocardial performance remain largely unexplored in children with congenital heart disease following cardiopulmonary bypass due to technical limitations. Pressure recording analytical method (PRAM) is a continuous hemodynamic and myocardial performance monitoring technique based on beat-to-beat arterial pressure waveform. Using PRAM, we examined the temporal trends and adverse factors, in clinical management, of these performances.Methods: We monitored blood pressure, cardiac index, cardiac cycle efficiency (CCE), dP/dTmax, and systematic vascular resistance index in 91 children (aged 186 ± 256 days) during their first 48 h after cardiopulmonary bypass. Above parameters, inotropic and vasoactive drug dosages, and serum lactate were recorded 3-hourly. NT-proBNP was measured daily.Results: CCE and dP/dTmax gradually increased (Ps < 0.0001), while systematic vascular resistance index, diastolic blood pressure and inotrope dosages decreased (Ps < 0.0001) over time. Cardiac index, systolic blood pressure, and heart rate did not change significantly (Ps ≥ 0.231). Patients undergoing deep hypothermic circulatory arrest had significantly higher heart rate and lower CCE (Ps ≤ 0.006) over time. Multivariate analyses indicated that epinephrine dose significantly correlated with systolic blood pressure, cardiac index, CCE, and dP/dTmax after polynomial transformation, with the peak ranging from 0.075 to 0.097.Conclusions: Systemic hemodynamic and myocardial performance gradually improved in the first 48 h after cardiopulmonary bypass without the “classic” nadir at 9–12 h. Deep hypothermic circulatory arrest and higher epinephrine doses were adversely associated with these performances. CCE, rather than cardiac index or other common-used parameters, was the most sensitive and consistent indicator.
Highlights
Hemodynamic monitoring is the definite cornerstone of the postoperative management in children with congenital heart disease (CHD) undergoing cardiopulmonary bypass surgery (CPB) [1]
By using pressure recording analytical method (PRAM), we aimed to examine the temporal trends of systemic hemodynamic and myocardial performance parameters of children with CHD during the first 48 post-CPB hours, and more importantly to identify adverse factors of these parameters in routine clinical management
Cardiac index (CI), systemic vascular resistance index (SVRI), the maximal slope of systolic upstroke, and cardiac cycle efficiency (CCE) [11]. dP/dTmax indicates the maximal rate of the rise of arterial pressure manifesting left ventricular pressure and is used as an index of myocardial contractility [11]
Summary
Hemodynamic monitoring is the definite cornerstone of the postoperative management in children with congenital heart disease (CHD) undergoing cardiopulmonary bypass surgery (CPB) [1]. Repeated cold saline injections are undesirable in the fragile condition of cardiac function after CPB. It has been rarely used in children after CPB [1]. Combined with arterial and venous blood gases, it is able to derive almost all elements of hemodynamics in varied circulations [5,6,7, 9]. It is technically and timely highly demanding and hardly used outside of clinical research settings [8]
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