Detection of intraoperative myocardial ischaemia--a comparison among electrocardiographic, myocardial metabolic, and haemodynamic measurements in patients with reduced ventricular function.

Abstract

This study determined the sensitivity and specificity of haemodynamic and ECG monitors to detect the development of intraoperative myocardial ischaemia utilizing myocardial lactate production as the standard. In 29 patients with reduced ejection fraction (0.27-0.50) undergoing coronary artery revascularization, measurements were made at the awake, post-induction, post-intubation, first skin incision, post-sternotomy, pre-protamine, immediately post-cardiopulmonary bypass, and skin suture intervals. At each interval, measurement of a haemodynamic profile (including pulmonary artery occlusion (PAOP) and central venous (CVP) pressures, heart rate, and pressure rate quotient); myocardial lactate extraction and flux; changes in ST segments in ECG leads, V5 and II utilizing a Siemens 1280 intraoperative monitor, and a Marquette 8500 Holter monitor utilizing leads V5, V2, and AVF were made. "Ischaemia" was considered to be present when myocardial lactate production (MLP) occurred, PAOP or CVP increased by 5 mmHg above the baseline value, the pressure rate quotient was < 1, or ST segment deviation (> 1 mm) occurred in any lead for > 1 min. Variables positive when MLP was positive were the pressure rate quotient (sensitivity 32.8%, specificity 71.9%), CVP (sensitivity 10.9%, specificity 92.6%), and PAOP (sensitivity 1.6%, specificity 99.2%). Holter monitoring had a 100% positive predictive value but poor sensitivity (1.6%). The ECG (Lead V5 + II) measures of ischaemia were insensitive (17.5%) and relatively non-specific (87.7%). We conclude that, in this patient group and using myocardial lactate production as the standard, the pressure rate quotient, elevations in CVP or PAOP, or ST segment changes are insensitive measures of intraoperative myocardial ischaemia.