Changes In Central Venous Pressure Research Articles

The anatomy and physiology of the terminal thoracic duct and ostial valve in health and disease: potential implications for intervention.

The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD lymph (including gut lymph) because of its putative role in the promotion of systemic inflammation and organ dysfunction during acute and critical illness. Minimally invasive TD cannulation has recently been described as a potential method to access TD lymph for investigation. However, marked anatomical variability exists in the terminal segment and the physiology regarding the ostial valve and terminal TD is poorly understood. A systematic review was conducted using three databases from 1909 until May 2017. Human and animal studies were included and data from surgical, radiological and cadaveric studies were retrieved. Sixty-three articles from the last 108years were included in the analysis. The terminal TD exists as a single duct in its terminal course in 72% of cases and 13% have multiple terminations: double (8.5%), triple (1.8%) and quadruple (2.2%). The ostial valve functions to regulate flow in relation to the respiratory cycle. The patency of this valve found at the lymphovenous junction opening, is determined by venous wall tension. During inspiration, central venous pressure (CVP) falls and the valve cusps collapse to allow antegrade flow of lymph into the vein. During early expiration when CVP and venous wall tension rises, the ostial valve leaflets cover the opening of the lymphovenous junction preventing antegrade lymph flow. During chronic disease states associated with an elevated mean CVP (e.g. in heart failure or cirrhosis), there is a limitation of flow across the lymphovenous junction. Although lymph production is increased in both heart failure and cirrhosis, TD lymph outflow across the lymphovenous junction is unable to compensate for this increase. In conclusion the terminal TD shows marked anatomical variability and TD lymph flow is controlled at the ostial valve, which responds to changes in CVP. This information is relevant to techniques for cannulating the TD, with the aid of minimally invasive methods and high resolution ultrasonography, to enable longitudinal physiology and lymph composition studies in awake patients with both acute and chronic disease.

Phenylephrine increases cardiac output by raising cardiac preload in patients with anesthesia induced hypotension

Induction of general anesthesia frequently induces arterial hypotension, which is often treated with a vasopressor, such as phenylephrine. As a pure α-agonist, phenylephrine is conventionally considered to solely induce arterial vasoconstriction and thus increase cardiac afterload but not cardiac preload. In specific circumstances, however, phenylephrine may also contribute to an increase in venous return and thus cardiac output (CO). The aim of this study is to describe the initial time course of the effects of phenylephrine on various hemodynamic variables and to evaluate the ability of advanced hemodynamic monitoring to quantify these changes through different hemodynamic variables. In 24 patients, after induction of anesthesia, during the period before surgical stimulus, phenylephrine 2 µg kg−1 was administered when the MAP dropped below 80% of the awake state baseline value for > 3 min. The mean arterial blood pressure (MAP), heart rate (HR), end-tidal CO2 (EtCO2), central venous pressure (CVP), stroke volume (SV), CO, pulse pressure variation (PPV), stroke volume variation (SVV) and systemic vascular resistance (SVR) were recorded continuously. The values at the moment before administration of phenylephrine and 5(T5) and 10(T10) min thereafter were compared. After phenylephrine, the mean(SD) MAP, SV, CO, CVP and EtCO2 increased by 34(13) mmHg, 11(9) mL, 1.02(0.74) L min−1, 3(2.6) mmHg and 4.0(1.6) mmHg at T5 respectively, while both dynamic preload variables decreased: PPV dropped from 20% at baseline to 9% at T5 and to 13% at T10 and SVV from 19 to 11 and 14%, respectively. Initially, the increase in MAP was perfectly aligned with the increase in SVR, until 150 s after the initial increase in MAP, when both curves started to dissociate. The dissociation of the evolution of MAP and SVR, together with the changes in PPV, CVP, EtCO2 and CO indicate that in patients with anesthesia-induced hypotension, phenylephrine increases the CO by virtue of an increase in cardiac preload.

The relationship between capacity management and central venous pressure and blood volume in continuous renal replacement therapy

Objective To investigate the correlate of erythrocyte parameters, central venous pressure and blood volume in ICU patients with continuous renal replacement therapy (CRRT), in order to guide the fluid management. Methods The study included two stages.The first stage observed the relation between erythrocyte parameters and central venous pressure (CVP) in ICU patients with CRRT, so that explored the optimum CVP and the optimum erythrocyte parameters.The second stage was to guide the fluid management using the optimum erythrocyte parameters, and analyzed the change of CVP before and after the treatment of fluid expansion or diuresis. Results ①In the first stage, when the class of CVP was >10, RBC, Hb and HCT were significantly lower than it of the classes of CVP 102 g/L, compared with it before treatment, CVP level increased significantly after adding fluid, and the difference had statistical significance(P<0.01). Conclusions CVP has significant negative correlations with the parameters of red blood cells.The corresponding optimum value of red blood cells to the optimum value of CVP had some guiding significance on the fluid management to the patients of continuous kidney substitution therapy. Key words: Central venous pressure; Erythrocyte parameters; Fluid management

Positive end-expiratory pressure-induced increase in external jugular venous pressure does not predict fluid responsiveness in laparoscopic prostatectomy.

Dynamic change in central venous pressure (CVP) was associated with fluid responsiveness. External jugular venous pressure (EJVP) may reliably estimate CVP and have the advantages of being less invasive. We investigated whether increase in EJVP induced by positive end-expiratory pressure (PEEP) could be a reliable predictor of fluid responsiveness in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). Fifty patients who underwent RALP with steep Trendelenburg position were enrolled. PEEP of 10cmH2O was applied for 5min and then 300ml of colloid was administered. EJVP, stroke volume variation (SVV), and cardiac index calculated by pulse contour method were measured before and after the PEEP challenge and colloid administration. Increase in cardiac index>10% was used to define the fluid responsiveness. Twenty-six patients were fluid responders. Neither the increase in EJVP after the initial PEEP nor SVV was significantly different between responders and non-responders. They were not significantly correlated with an increase in cardiac index. The areas under the receiver operating characteristic curve (AUC) of these two variables were not significantly greater than 0.5. However, a post hoc analysis revealed that AUC of a decrease in EJVP after removal of PEEP was significantly greater than 0.50. Our study results suggested that SVV and increase in EJVP after applying PEEP were not accurate predictors of fluid responsiveness during RALP. Further studies are required to find an adequate preload index in robot-assisted urologic surgery with steep Trendelenburg position.

Importance of dynamic central venous pressure in Fontan circulation.

We tested our hypotheses that central venous pressure (CVP) shows an excessive increase in response to volume overload in Fontan circulation according to the extent of the reduction in venous capacitance (Cv), and that the maximum CVP after volume loading is associated with hepatic congestion. Changes in CVP after angiography (volume loading) were examined in 40 patients with Fontan circulation and 29 controls with biventricular circulation. CVP significantly increased with angiography in both groups, but the changes were much more evident in the Fontan group than in controls (3.3±2.0 vs. 0.9±1.4mmHg, p=0.0003). Multivariate analysis demonstrated that reduced Cv was the only significant determinant of CVP increase, independent of the amount of injected contrast medium, blood volume, pulmonary resistance, and ventricular diastolic stiffness (p<0.05). Importantly, the use of a venodilator was associated with increased Cv and the resultant suppression of CVP elevation with volume load. In addition, CVP levels both at baseline (p=0.02) and after volume loading (p=0.01) were weakly but significantly correlated with the plasma levels of γ-glutamyl transpeptidase, a marker of hepatic congestion; however, multivariate analysis revealed that the CVP level after volume loading was a more important determinant of hepatic congestion. The results of this study highlight the importance of assessing dynamic in addition to static CVP for a better understanding of Fontan circulation. The potential importance of Cv as a therapeutic target for improving Fontan physiology needs further elucidation.

Inferior vena cava diameter as a guide in hypotensive patients for appropriate saline therapy: An observational study

Background:Knowledge of intravascular volume (IV) status of a hypotensive patient is of utmost importance. Clinical evaluation and central venous pressure (CVP) measurement are routinely used as a guide for evaluation of IV in these patients. However, clinical assessment may be inaccurate, and CVP measurement is invasive. Moreover, CVP changes slowly with saline therapy, which is unfavorable for fluid resuscitation.Aim:Our aim is to find the correlation and sensitivity of inferior vena cava (IVC) diameter measured by ultrasound to provide a noninvasive method for evaluation of IV among patients with hypotension and hypovolemia in the emergency department (ED).Methods:We measured the IVC diameter of hypotensive patients before and after saline therapy. As all of the patients had central venous line (CV-line) in place, CVP was also measured before and after. Using MedCalc and SPSS software the correlation between these two was determined as expressed with “r.” Then, receiver operating characteristic (ROC) curve was sketched.Results:Ninety-nine patients, 49 (49.5%) males, were evaluated. Mean systolic blood pressure was 90 mmHg with a mean hazard ratio about 104. IVC diameter was 7.44 ± 5.13 mm before and 9.84 ± 5.29 after (P = 0.002) saline therapy. There was a high correlation between IVC diameter and CVP (r = 0.941, P < 0.0001 before saline therapy and r = 0.95, P < 0.0001 after saline therapy). ROC curve for IVC diameter shows a very high sensitivity for all criteria values.Conclusion:IVC diameter measurement using ultrasonography has excellent correlation with CVP. This method is very sensitive to rapid IV changes thus useful to guide saline therapy in hypotensive patients referred to ED. However, its use in certain subsets of patients' needs further studies.

The ultrasonic monitoring coupled with passive leg raising test for evaluation of fluid responsiveness in critical patients

Objective To explore the value of predicting fluid responsiveness using velocity time index variation (ΔVTI) and stroke volume variation (ΔSV) before and after passive leg raising (PLR) monitored by bedside temporary test equipment (TTE). Methods A cohort of 42 patients supported with mechanical ventilation in our hospital admitted from October 2014 to October 2015 were prospectively selected. The hemodynamic variables including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), VTI, SV and other parameters were monitored before and after after undergoing PLR. Fluid resuscitation volume expansion test was carried out after stroke volume index (SVI) monitored by pulse indicator continuous cardiac output monitoring (PICCO). Patients were divided into fluid responsiveness positive group and fluid responsiveness negative group according to presence or absence of SVI ≥ 15% after fluid resuscitation volume expansion. Results Of 42 patients, 22 belonged to fluid responsiveness positive group, 20 got into fluid responsiveness negative group. There were no significant differences in basic clinical data between two groups. Before and after PLR, there were no distinct changes in HR and CVP(P>0.05), while MAP, VTI and SV increased significantly(P 0.05), but HR, CVP and VTI increased significantly(P<0.05) in fluid responsiveness negative group. The degrees of ΔVTI and ΔSV in fluid responsiveness positive group were much higher than those in fluid responsiveness negative group (P<0.05). According to SVI ≥ 15% monitored by PICCO after fluid resuscitation volume expansion test as a standard, the area under the ROC (AUC) of ΔVTI between pre-PLR and post-PLR was 0.75 (95%CI: 0.593-0.907, P<0.01), the sensitivity and specificity were 63.6% and 95% respectively using ΔVTI 15.6% as threshold value. The AUC of ΔSV was 0.844 (95%CI: 0.716-0.972, P<0.01), the sensitivity and specificity were 81.8% and 85.0% respectively using ΔSV 10.5% as threshold value. Conclusion ΔVTI and ΔSV monitored by TTE before and after PLR could be employed for predicting fluid responsiveness of critical patients under the status of spontaneous respiration.Their value for prediction of critical patients could be further improved by combined employment of these two indexes of variation. Key words: Transthoracic echocardiography; Fluid responsiveness; Passive leg raising

Validity of Pulse Pressure Variation (PPV) Compared with Stroke Volume Variation (SVV) in Predicting Fluid Responsiveness.

Static monitors for assessing the fluid status during major surgeries and in critically ill patients have been gradually replaced by more accurate dynamic monitors in modern-day anaesthesia practice. Pulse pressure variation (PPV) and systolic pressure variation (SPV) are the two commonly used dynamic indices for assessing fluid responsiveness. In this prospective observational study, 50 patients undergoing major surgeries were monitored for PPV and SPV: after the induction of anaesthesia and after the administration of 500 mL of isotonic crystalloid bolus. Following the fluid bolus, patients with a cardiac output increase of more than 15% were classified as responders and those with an increase of less than 15% were classified as non-responders. There were no significant differences in the heart rate (HR), mean arterial pressure (MAP), PPV, SVV, central venous pressure (CVP) and cardiac index (CI) between responders and non-responders. Before fluid bolus, the stroke volume was significantly lower in responders (p=0.030). After fluid bolus, MAP was significantly higher in responders but there were no significant changes in HR, CVP, CI, PPV and SVV. In both responders and non-responders, PPV strongly correlated with SVV before and after fluid bolus. Both PPV and SVV are useful to predict cardiac response to fluid loading. In both responders and non-responders, PPV has a greater association with fluid responsiveness than SVV.

Dobutamine aggravates haemodynamic deterioration induced by pleural effusion: A randomised controlled porcine study.

Pleural effusion is a common finding in critically ill patients and may contribute to circulatory instability and the need for inotropic support. We hypothesised that dobutamine would affect the physiological determinants preload, afterload, contractility and changes of inferior vena cava characteristics during experimental pleural effusion. A randomised, controlled laboratory study. Animal laboratory, conducted from March 2013 to May 2013. Twenty-four Landrace and Yorkshire female piglets (21.3 ± 1.7 kg). Twenty piglets were included in the analyses. After inducing bilateral pleural effusion (30 ml kg), the piglets were block randomised to either incremental dobutamine infusion (n = 10) or control (n = 10). Ultrasonographic measures of left ventricular end-diastolic area, left ventricular afterload, left ventricular fractional area change and inferior vena cava diameter and distensibility were used to assess the basic physiological effect of incremental dobutamine administration during experimental pleural effusion. In the dobutamine group, preload, measured as left ventricular end-diastolic area, decreased from 11.3 ± 2.0 cm after creation of the pleural effusion to 8.1 ± 1.5 cm at a dobutamine infusion rate of 20 μg kg min (P < 0.001). In the same period, central venous pressure and the expiratory diameter of the inferior vena cava decreased from 9 ± 3 to 7 ± 4 mmHg (P < 0.001) and from 1.1 ± 0.2 to 0.9 ± 0.1 cm (P = 0.008), respectively. In a porcine model of pleural effusion, dobutamine affected basic haemodynamic determinants substantially by decreasing left ventricular preload. Changes in central venous pressure and inferior vena cava characteristics were minimal, discouraging their use as indices of preload. This study underlines the significance of evaluating basic haemodynamic determinants to avoid inappropriate, potentially harmful treatment.

Clinical observation of hypertonic saline used for the treatment of acute intracranial hypertension in patients with hemorrhagic shock

Objective To observe the effect of hypertonic saline complex solution (hypertonic saline plus hydroxyethyl starch, HSH) on patients with severe cerebral trauma, high intracranial pressure and shock by the measurement of the changes of the mean arterial pressure (MAP), central venous pressure (CVP) and intracranial pressure (ICP), as well as GOS score changes followed up for 6 months, in order to determine the value of HSH treatment in severe cerebral trauma, intracranial hypertension and shock. Methods Sixty patients with severe brain injury and uncorrected hemorrhagic shock were selected, while the degree of coma was assessed by using GCS score, and shock severity was estimated by using the shock index (SI) score. The patients were randomly divided into HSH group (n=30) and mannitol group (MT group, n=30). Thirty minutes, 60 min and 120 min after administration either solution, The changes of MAP, CVP and ICP were observed in two groups, and all patients were followed up for 6 months to observe the outcomes of patients. Results There were no statistically significant differences in age, gender, GCS score, SI scores, and other medication between two groups (P>0.05), and they were comparable between two groups. After resuscitation of patients in two groups, MAP and CVP were elevated, but the effect of HSH appeared sooner and higher within 30 minutes [MAP (63.1±8.8) mmHg vs. (51.0±9.3) mmHg] (P<0.05); At the same time, ICP dropped more than 10% lower [ICP (27.3±5.9) mmHg vs. (32.8±4.1) mmHg] (P<0.05), while the effect of MT appeared more slowly in hemodynamic improvement; at 120 min, the increase in MAP and reduction in ICP in HSH group were more significant than those in MT group [MAP (65.9±13.2) mmHg vs. (60.4±7.2) mmHg] (P<0.01); the ICP [ (22.2±4.7) mmHg vs. (28.1±6.1) mmHg] (P< 0.01). Followed up for 6 months, good recovery rate in HSH group was higher and poor recovery rate was lower than those in MT group. Conclusions In patients with acute intracranial hypertension and uncorrected hemorrhagic shock, the employment of hypertonic saline plus hydroxyethyl starch solution can produce faster and more effective therapy for shock and reduce intracranial pressure, improving the long-term neurological function of patients. Key words: Intracranial hypertension; Hemorrhagic shock; Hypertonic sodium chloride; Hydroxyethyl

The Effect of Combined Intrathecal Morphine and Clonidine on Stress Response, Extubation Time and Postoperative Analgesia after Cardiac Surgery

Background: Pain is a major complication after cardiac surgery, if it is poorly controlled, it will lead to more complication as respiratory depression, myocardial ischemia, delayed extubation, and more ICU stay, with the more analgesic consumption and patients suffering. Intrathecal morphine produces intense and prolonged analgesia and can be useful adjunct for controlling postoperative pain and facilitating early extubation after cardiac surgery. The addition of intrathecal clonidine to morphine allows the dose of intrathecal morphine to be reduced and reduces the risk of respiratory depression while maintaining good analgesia and allows early extubation. This randomized controlled study was carried out on 40 patients undergoing open cardiac surgery and was divided into two groups; group (I): is the control group (n=40) and group (II): is the morphine clonidine group (n=40), patients received intrathecal morphine 4 mcg/kg and clonidine 1 mic/kg. The aim of this study was to evaluate the effects of combined intrathecal morphine and clonidine on stress response, time of extubation, and postoperative analgesia after cardiac surgery. The results of our study revealed that, there was no statistical significant changes in CVP (central venous pressure), Sao2 (Oxygen saturation) and lactate level in both group, but there was a decrease in HR after induction and before bypass in the intrathecal morphine clonidine group compared with the control one, also there was a significant reduction in MAP after induction, before bypass and after bypass in morphine clonidine group vs. control group. Cortisol level was decreased after sternotomy, after ICU admission and after extubation in the morphine group vs. control group. Time to extubation, vas, and morphine consumption in 24 h were all decreased in the morphine group compared with the control one, with no significant differences in post-operative complication in both studied groups. Conclusion: In patients with well-preserved ventricular and respiratory function scheduled for fast-track cardiac surgery, the use of combined intrathecal morphine 250 μg and clonidine provides good postoperative analgesia and early extubation without side effects.

The influence of PEEP and positioning on central venous pressure and venous hepatic hemodynamics in patients undergoing liver resection.

In order to assess the occurrence of blood congestion in the liver during liver resection, we aimed to evaluate the influence of a positive-end-expiratory-pressure (PEEP) and positioning of patients on central venous pressure (CVP) and venous hepatic blood flow parameters. We further analyzed correlations between CVP and venous hepatic blood flow parameters. In 20 patients scheduled for elective liver resection we measured CVP and quantified venous hepatic hemodynamics by ultrasound assessment of flow-velocity and diameter of the right hepatic vein and the portal vein after equilibration following these maneuvers: M1: 0° supine position, PEEP 0cmH2O; M2: 0° supine position, PEEP 10cmH2O; M3: 20° reverse-trendelenburg position; PEEP 10cmH2O; M4: 20° reverse-trendelenburg position, PEEP 0cmH2O. Changing from supine to reverse-trendelenburg position led to a significant decrease in CVP (M3 5.95 ± 2.06 vs. M1 7.35 ± 2.18mmHg and M2 8.55 ± 1.79mmHg). A PEEP of 10cmH2O and reverse-trendelenburg position led to significant reduction of systolic (VsHV) and diastolic (VdHV) flow-velocities of the right hepatic vein (VsHV M3 19.96 ± 6.47 vs. M1 27.81 ± 11.03cm s-1;VdHV M3 14.94 ± 6.22 vs. M1 20.15 ± 10.34cm s-1 and M2 20.19 ± 13.19cm s-1) whereas no significant changes of flow-velocity occurred in the portal vein. No correlations between CVP and diameters or flow-velocities of the right hepatic and the portal vein were found. Changes of central venous pressure due to changes of PEEP and positioning were not correlated with changes of venous hepatic blood flow parameters as measured after equilibration. Strategies aiming for low central venous pressure cannot be supported by these results. However, before ruling out low-CVP-strategies during liver resections these results should be confirmed by further studies.

Assessment of central venous physiology of Fontan circulation using peripheral venous pressure

ObjectiveElevated central venous pressure is a major cause of morbidity and mortality after the Fontan operation. The difference between mean circulatory filling pressure and central venous pressure, a driving force of venous return, is important in determining dynamic changes in central venous pressure in response to changes in ventricular properties or loading conditions. Thus, noninvasive central venous pressure and mean circulatory filling pressure estimation may contribute to optimal management in patients undergoing the Fontan operation. We tested the hypothesis that central venous pressure and mean circulatory filling pressure in those undergoing the Fontan operation can be simply estimated using peripheral venous pressure and arm equilibrium pressure, respectively. MethodsThis study included 30 patients after the Fontan operation who underwent cardiac catheterization (median 8.6, 3.4-42 years). Peripheral venous pressure was measured at the peripheral vein in the upper extremities. Mean circulatory filling pressure was calculated by the changes of arterial pressure and central venous pressure during the Valsalva maneuver. Arm equilibrium pressure was measured as equilibrated venous pressure by rapidly inflating a blood pressure cuff to 200 mm Hg. ResultsCentral venous pressure and peripheral venous pressure were highly correlated (central venous pressure = 1.6 + 0.68 × peripheral venous pressure, R = 0.86, P < .0001). Stepwise multivariable regression analysis showed that only peripheral venous pressure was a significant determinant of central venous pressure. Central venous pressure was accurately estimated using regression after volume loading by contrast injection (R = 0.82, P < .0001). In addition, arm equilibrium pressure measurements were highly reproducible and robustly reflected invasively measured mean circulatory filling pressure (mean circulatory filling pressure = 9.1 + 0.63 × arm equilibrium pressure, R = 0.88, P < .0001). ConclusionsCentral venous pressure and mean circulatory filling pressure can be noninvasively estimated by peripheral venous pressure and arm equilibrium pressure, respectively. This should help clarify unidentified Fontan pathophysiology and the mechanisms of Fontan failure progression, thereby helping construct effective tailor-made approaches to prevent Fontan failure.

Point-of-Care Echocardiography Improves Assessment of Volume Status in Cirrhosis and Hepatorenal Syndrome

The management of patients with cirrhosis along with acute kidney injury is complex and depends in large part on accurate assessment of intravascular volume status. Assessment of intravascular volume status by point-of-care echocardiography often relies solely on inferior vena cava size and variability evaluation; however, this parameter should be interpretated with an understanding of right ventricular function integrated with stroke volume and flow. Attempts to optimize intra-abdominal hemodynamics favorably are clearly problematic when physical examination findings or rudimentary assessments of central venous pressure or change in central venous pressure are used. Here, we have demonstrated the potential utility of point-of-care echocardiography to optimize the hemodynamic state in patients with decompensated cirrhosis along with acute kidney injury. This case is very unique and describes how this technique may have great promise in optimizing the intra-abdominal hemodynamics and predict the timing of large-volume paracentesis in patients with decompensated cirrhosis, which in turn can aid in promoting favorable renal recovery.

Comparison of positive end-expiratory pressure–induced increase in central venous pressure and passive leg raising to predict fluid responsiveness in patients with atrial fibrillation

BackgroundPositive end-expiratory pressure (PEEP)–induced increase in central venous pressure (CVP) has been suggested to be a robust indicator of fluid responsiveness, with heart rhythm having minimal influence. We compared the ability of PEEP-induced changes in CVP with passive leg raising (PLR)–induced changes in stroke volume index (SVI) in patients with atrial fibrillation after valvular heart surgery. MethodsIn 43 patients with atrial fibrillation after cardiac surgery, PEEP was increased from 0 to 10 cm H2O for 5 min and changes in CVP were assessed. After returning the PEEP to 0 cm H2O, PLR was performed for 5 min and changes in SVI were recorded. Finally, 300 ml of colloid was infused and haemodynamic variables were assessed 5 min after completion of a fluid challenge. Fluid responsiveness was defined as an increase in SVI ≥10% measured by a pulmonary artery catheter. ResultsFifteen (35%) patients were fluid responders. There was no correlation between PEEP-induced increases in CVP and changes in SVI after a fluid challenge (β coefficient −0.052, P+0.740), whereas changes in SVI during PLR showed a significant correlation (β coefficient 0.713, P<0.001). The area under the receiver operating characteristic curve of the PEEP-induced increase in CVP and changes in SVI during PLR for fluid responsiveness was 0.556 [95% confidence interval (CI) 0.358–0.753, P+0.549) and 0.771 (95% CI 0.619–0.924, P+0.004), respectively. ConclusionsA PEEP-induced increase in CVP did not predict fluid responsiveness in patients with atrial fibrillation after cardiac surgery, but increases in SVI during PLR seem to be a valid predictor of fluid responsiveness in this subset of patients.

Value of Virtual Touch Quantification Elastography for Assessing Liver Congestion in Patients With Heart Failure.

Heart failure (HF) causes organ congestion, which is thought to increase organ stiffness. The virtual touch quantification (VTQ) method can be used to assess liver stiffness in patients with chronic liver diseases. This study aimed to measure liver and kidney stiffness using VTQ and to determine its value for assessing organ congestion in patients with HF. This study included 10 normal subjects and 38 HF patients (age 52.3±16.7 years, left ventricular ejection fraction 27.0±9.4%, plasma B-type natriuretic peptide [BNP] 1,297.3±1,155.1 pg/ml). We investigated the relationships between clinical characteristics and hemodynamics and liver and kidney stiffness, and assessed the effects of medical treatment on these measurements. Liver stiffness was significantly higher in HF patients (1.17±0.13 m/s vs. 2.03±0.91 m/s, P=0.004) compared with normal subjects, but kidney stiffness was similar in both groups. Central venous pressure (CVP) (P=0.021) and BNP (P=0.025) were independent predictive factors for increased liver stiffness in HF patients. Liver stiffness decreased significantly from 2.37±1.09 to 1.27±0.33 m/s (P<0.001) after treatment. Changes in liver stiffness in HF patients significantly correlated with changes in CVP (R=0.636, P=0.014) and cardiac index (R=-0.557, P=0.039) according to univariate analysis, and with changes in CVP in multivariate analysis. Liver stiffness measured by noninvasive VTQ methods can be used to assess liver congestion and therapeutic effects in patients with HF. (Circ J 2016; 80: 1187-1195).

Abstract 18452: Importance of “Dynamic” Rather Than “Static” Central Venous Pressure and Venous Capacitance in Fontan Circulation During Exercise

Background: High central venous pressure (CVP) is a key driver of developing late complications in patients after Fontan operation. However, we often realize diversity of clinical outcome among patients with similar levels of CVP measured at resting condition during catheterization. We hypothesized that CVP variably increases with exercise and that degree of the increase is associated with clinical outcomes. We also hypothesized that venous capacitance (VC) is an important determinant of the CVP elevation. Methods: Dynamic changes in CVP estimated from continuous monitoring of peripheral venous pressure were measured during treadmill exercise (TM) in 21 Fontan patients and 10 age-matched control patients with biventricular (BV) circulation. The VC was calculated during temporal occlusion of inferior vena cava (IVC) at the time of catheterization. Results: Fontan patients exhibited significantly shorter duration of exercise with limited increases in heart rate and cardiac output. CVP significantly increased during exercise in both groups, but the degree of CVP elevation was much higher in Fontan patients than in controls (Fontan: from 10.8 to 18.4 mmHg vs. control: from 4.3 to 8.8 mmHg, P&lt;0.05). Importantly, maximum CVP during exercise in Fontan group varied considerably among patients with similar resting CVP, and is significantly and positively correlated with a liver fibrosis marker of type 4 collagen 7S (P &lt;0.01). Furthermore, maximum CVP during exercise in Fontan group negatively correlated with the VC, but not with pulmonary resistance. Conclusions: CVP of the Fontan circulation easily rises during exercise in proportion to the reduced VC, and the degree of CVP rise may be a contributor of hepatic complication. These results suggest the importance of assessing dynamic CVP in patients after Fontan operation. The results also suggest potential importance of daily life modification and/or medical treatment to minimize the dynamic changes in CVP to improve the prognosis of Fontan patients. VC may be a viable target for this purpose.

Central Venous Pressure Dropped Early is Associated with Organ Function and Prognosis in Septic Shock Patients: A Retrospective Observational Study.

The aim of this study was to investigate changes in central venous pressure (CVP) of patients with septic shock over 7 days after intensive care unit admission and its effect on organ function and clinical prognosis. Baseline data, 7 days' CVP, and laboratory data of 105 patients with septic shock were consecutively recorded. According to the value of mean CVP of 7 days, cases were divided into three groups: low (<8 mmHg), normal (8-12 mmHg), and high (>12 mmHg) CVP. According to whether CVP dropped to less than 8 mmHg, cases were divided into two groups. There were significant differences in serum creatinine on day 5 and lactate on days 2 to 5 among low, normal, and high-CVP groups (P < 0.05). Total bilirubin on days 5 to 7, lactate on days 2 and 4 to 7, and SOFA (Sepsis-related Organ Failure Assessment) scores on days 5 and 7 in groups with CVP did not drop to less than 8 mmHg were higher than those in groups with CVP that dropped to less than 8 mmHg (P < 0.05). PO2/FIO2 on day 7 was lower in the group whose CVP did not drop to less than 8 mmHg (226 [184-278]) vs. 254 [214-306]; P = 0.048), whereas 28-day mortality was lower in the group whose CVP dropped to less than 8 mmHg (18.3% vs. 37.8%, P = 0.026). Central venous pressure was associated with kidney, liver, and lung function; SOFA scores; and lactate. Septic shock patients whose CVP dropped to less than 8 mmHg during 7 days had a higher survival rate.

Sex difference in the influence of central blood volume mobilization on the exercise pressor response.

To determine the sex difference in the impact of central venous pressure (CVP) on the pressor response induced by ischemic handgrip exercise. Twelve young healthy individuals (six males, 25 ± 3 years) performed ischemic handgrip exercise during mild levels of lower body negative pressure (LBNP, -5 mmHg) and during a 10° head-down tilt (HDT) to lower and increase CVP, respectively. The protocol consisted of 3 min of baseline ischemia, followed by 2 min of isometric handgrip exercise at 35 % of maximal voluntary contraction force, and 2 min of post-exercise circulatory occlusion. Mean arterial pressure (MAP) was assessed continuously by finger plethysmography and CVP was estimated from the venous pressure of the non-exercising dependent arm. Baseline CVP was greater during HDT than LBNP (8.4 ± 1.8 vs. 6.5 ± 1.8 mmHg, p < 0.01). MAP was greater during LBNP than HDT throughout the protocol (p = 0.05). During ischemic handgrip exercise, CVP increased in males but not in females (Group × protocol interaction: p = 0.01). A group × condition interaction was also observed for MAP, with males showing a greater MAP during LBNP than HDT (110 ± 2 vs. 103 ± 2 mmHg, p < 0.01). Baseline CVP inversely affected the pressor response to handgrip exercise in all individuals, with a greater MAP response observed during LBNP than HDT. Increase in CVP in males may be due to a greater splanchnic vasoconstrictor response to ischemic handgrip exercise. Therefore, combined baseline CVP and changes in CVP likely contributed to the greater MAP response observed during LBNP in males.

Tailored therapy for aggressive dilatation of systemic veins and arteries may result in improved long-term Fontan circulation

switch procedure. Pulmonary artery banding is not a benign procedure, and mechanical support after surgery can be unpredictable, with the potential for significant bleeding issues as a result of anticoagulation. In this particular case, the presence of a restrictive muscular VSD provided the opportunity to stent the VSD open to allow preparation of the left ventricle. Stenting the VSD obviated the need for initial palliative surgery and allowed easy monitoring of the progress of the left ventricle. One caveat with this technique is that not all VSDs are amenable to stenting, because the risk of inducing heart block is high in the more commonly seen perimembranous type of VSD. In this reported case, the VSD was muscular, however, which made the risk of heart block low. The use of interventional cardiology procedures for initial palliation is a relatively new and promising alternative. Some groups have explored stenting of the right