Mean CVP Research Articles

Correlation analysis of central venous pressure and Intra-thoracic pressures in Acute Respiratory Distress Syndrome mechanical ventilated patients, a pilot Study

Abstract Background Positive end expiratory pressure can affect measurement of central venous pressure through increased intrathoracic pressure. However, when positive end expiratory pressure (PEEP) is applied, central venous pressure and pleural pressure often increases more than right atrial pressure, so that transmural right atrial pressure (true filling pressure) decreases. Aim of the study Primary end point was to recognizing correlation coefficient between mean CVP and intra- thoracic pressures on volume-controlled mode and spontaneous modes on same population of mechanically ventilated ARDS patients. The secondary end point is to compare the correlation coefficient R during both modes with parameters of ventilatory settings. Patient and Methods A cohort observational prospective study was done enrolling single group of patients with acute respiratory distress syndrome, who necessitate mechanical ventilation more than two days after connection to ventilators, the study was performed with demonstration of central venous pressure in cmH2O upon application of needed PEEP. Central venous catheter inserted for measuring CVP were processed in accordance with the standard guidelines. Results There were statistically significant differences between control and support group regarding the PEEP, Plateau pressure, mean CVP and mean airway pressure MAP. The data were higher in control than support group with p-value <0.001, 0.002 and 0.004, respectively. There was statistically significant positive correlation between R and CVP in the control group with p < 0.001 and r = 0.918. There was statistically significant positive correlation between R and ΔPIT in support group with p 0.001 and r = 0.926. The correlation between CVP and R among the control group was R = 0.028 + 0.032 * CVP with p-value <0.001, whereas the correlation between ΔPIT and R among the support group was R = 0.465 + 0.020 * ΔPIT with p-value = 0.022 Conclusion The relation between hemodynamics change of central venous pressures and intrathoracic pressure is new independent marker for evaluating ARDS mechanically ventilated patients. Values of R correlation are different in controlled mode relative to spontaneous mode during ARDS ventilated patients.

Exploring the optimal range of central venous pressure in sepsis and septic shock patients: A retrospective study in 208 hospitals

BackgroundThe aim of this study was to investigate the optimal CVP range in sepsis and septic shock patients admitted to intensive care unit. MethodsWe performed a retrospective study with adult sepsis patients with CVP records based on the eICU Collaborative Research Database. Multivariable logistic regression was performed to explore the associations between CVP level and hospital mortality. Non-linear correlations and optimal CVP range were explored using restricted cubic splines (RCS). ResultsA total of 5302 sepsis patients were included in this study. Patients in 4-8 mmHg group owned the lowest odds ratio for raw hospital mortality (19.7%). The logistic regression analyses revealed that hospital death risk increased significantly when mean CVP level exceeds 12 mmHg compared to 4-8 mmHg level. U-shaped association of CVP with hospital mortality was revealed by RCS model in septic shock patients and the optimal range was 5.6-12 mmHg. While, there was a J-shaped trend for non-septic shock patients. For non-septic shock patients, patients had an increased risk of hospital death only if CVP exceeded 11 mmHg. ConclusionsWe observed U-shaped association between mean CVP level and hospital mortality in septic shock patients and J-shaped association in non-septic shock patients. This may imply that patients with different severity of sepsis have different CVP requirements. We need to monitor and manage CVP according to the circulatory status of the sepsis patient.

Abstract 11968: Association of Invasive Measures of Congestion With Short- and Long-Term Kidney Function Outcomes Among Patients With Acute Decompensated Heart Failure

Background: Reduced kidney function as evaluated by estimated glomerular filtration rate (eGFR) is a powerful risk factor for adverse outcomes among patients with acute decompensated heart failure (ADHF). Mechanisms for eGFR declines remain unclear. Studies evaluating congestion as a risk factor have been inconsistent. Hypothesis: Greater degree of congestion in patients with ADHF is associated with worse short- and long-term kidney function. Methods: We examined patients admitted for ADHF who required right heart catheterization from 2015-2021. Initial CVP and PCWP were used as measures of right- and left-sided congestion, respectively. Restricted cubic splines and linear mixed models for eGFR slopes were used to examine the relation between CVP and PCWP with baseline eGFR and in-hospital eGFR slope. End stage renal disease (ESRD) events were obtained from linkage to the US Renal Data System. Cox proportional hazards regression models were used to examine the relation of CVP and PCWP with mortality and ESRD. Results: Among 755 patients, the mean (SD) age and baseline eGFR were 62 (14) years and 58 (27) ml/min/1.73m 2 respectively. 440 (58%) required inotropes during hospitalization. Initial mean (SD) CVP and PCWP were 13.4 (6.6) and 23.4 (8.7) mmHg, respectively. Higher initial CVP and PCWP were significantly associated with lower baseline eGFR and in-hospital eGFR decline (Figure). Over median follow-up of 30 (IQR 10, 56) months, 62 (8.2%) reached ESRD and 264 (35%) died. In multivariable models, higher CVP and PCWP were each associated with increased risk for ESRD (HR [95%CI] per 1 SD higher CVP or PCWP were 1.49 [1.17, 1.91]; 1.30 [1.04, 1.64] respectively). Models were repeated with death as a competing event for ESRD and associations remained largely consistent (sHR 1.36 [1.03, 1.81] for CVP; sHR 1.25 [0.99, 1.57] for PCWP). Conclusion: Congestion is associated with lower baseline kidney function, greater acute declines in kidney function and increased risk of ESRD.

ASSESSMENT OF INFERIOR VENA CAVA DIAMETER MEASURED BY ULTRA-SONOGRAPHY IN CORRELATION WITH CENTRAL VENOUS PRESSURE VALUE IN PATIENTS WITH SEPSIS

Background: Bedside ultrasound is potentially a useful noninvasive adjunct to estimate the intravascular volume status in sepsis. Aim of the work: Evaluating the correlation between inferior vena cava diameter measured non-invasively with ultrasonography versus central venous pressure in assessment of intravascular volume status in patients with sepsis.Patients and methods: The study was conducted on sixty patients with sepsis (30 ventilated and 30 non-ventilated) in the Respiratory Intensive Care Unit at Abbassia Chest Hospital from January 2018 to September 2018. For all included patients demographic data were collected Recording vital sings, mean arterial pressure and Pao2/ Fio2were done. Laboratory investigation including complete blood count, serum lactic acid, arterial blood gas, quantitative C-reactiveprotein were also done. Sequential Organ Failure Assessment score (SOFA), Qsofa and Acute Physiology And Chronic Health Evaluation II score (APACHE II) were recorded. Finally measurement of IVC, CVP and intra-abdominal pressure were done Results: Males represent 75%while female were 25%withmean age of (47.40±14.49) years. The mean CVP was 12.48±3.78 cmH2O with an IVC maximum diameter of 17.95±3.28 mm and collapsibility index of 50.55±11.83 %. There was statistically significant positive correlation between CVP and IVC dmax and statistically significant negativecorrelation between CVP and IVC CI (%)in both ventilated and non ventilated groups. Also, CVP and IVC dmax were significantly correlated with outcome in both ventilated and non ventilated patients. The higher values of CVP and IVC dmax and the lower the value of IVC CI, the higher rates of mortality. Conclusion: US assessment of IVC diameter and caval index are simple and non invasive methods to assess intravascular volume status.

Perioperative hemodynamic monitoring: Still a place for cardiac filling pressures?

The clinical usefulness of the so-called "static" cardiac filling pressures - central (CVP) and pulmonary-artery-occlusion-pressure (PAOP) - has come into question for guiding hemodynamic therapy due to their poor ability to predict fluid responsiveness in comparison with other monitoring modalities such as transpulmonary thermodilution-derived volumetric measurements, dynamic variables for assessing fluid responsiveness, and the potential risks associated with pulmonary artery catheterization. This contrasts with observations in multiple patient populations showing a clear association between increased CVP and PAOP levels and poor outcomes, probably due to a reduction in effective perfusion pressure (mean arterial pressure minus CVP) and their role as effectiveness parameters of the cardiovascular system. Furthermore, clinical studies have revealed beneficial effects when interpreting CVP and PAOP dynamically and combining them with flow-related hemodynamic variables. Taking into account the additional information derived from bedside CVP and PAOP pulse curve interpretation, cardiac filling pressures remain an important hemodynamic monitoring tool.

A case series of perioperative variables in relation to short-term outcomes in pediatric renal transplant recipients.

Multiple perioperative variables have been shown in existing literature to influence long-term outcomes of pediatric RTx, such as allograft survival. Their impact on short-term outcomes is not as well-documented. This case series aims to investigate the effects of nine perioperative variables on two short-term outcomes in pRTR: 1-week post-operative eGFR and post-operative LOS. A total of 73 pRTR transplanted over 3years from 2012 to 2014 at a single center were studied retrospectively and statistical analyses were performed. There was higher 1-week post-operative eGFR in pRTR who received living donor transplants compared to those who received deceased donor transplants (P=.01), with mean eGFR of 135mL/min/1.73m2 and 82mL/min/1.73m2 , respectively. Aorta-IVC anastomosis was associated with longer LOS compared to iliac vessel anastomosis (P=.03), with median LOS of 19 and 13days, respectively. There were no significant effects on 1-week eGFR or LOS of the seven other variables: pRTR age and gender, donor age, preoperative donor SBP, intraoperative mean CVP before graft perfusion, intraoperative median SBP z score after graft perfusion, and intraoperative fluid volume. Living donor transplants were associated with higher 1-week post-operative eGFR compared to deceased donor transplants. Aorta-IVC anastomosis was significantly associated with longer LOS compared to iliac vessel anastomosis.

Validity of Shock Index, Modified Shock Index, Central Venous Pressure and Inferior Vena Cava Collapsibility Index in Evaluation of Intravascular Volume among Hypovolemic Egyptians Patients.

Introduction: assessment of intravascular volume is an important component in care of hypovolemia. Physical examination is inaccurate tools in the assessment of intravascular volume, leading to the need for more objective method and accuracy tool. Aims: the prediction of Validation of Shock Index, Modified Shock Index, Central Venous Pressure and Inferior Vena Cava collapsibility index in Assessment of Intravascular Volume. Methods:-This study was conducted as cross-sectional, observational study on 150 Egyptians patients attending to the Emergency Room with hypovolemia state (systolic blood pressure 100 beat /min and capillary refill >2 sec. and clinical signs with symptoms suggestive any types of shocks.) and all patients enter resuscitation room once they arrive to ER. With Applied resuscitations guidelines methods and treat all the life threading conditions if present to all participants. Results: The studied patients revealed negative correlation between CVP value and (SI and MSI) but positive correlation with IVC-CI value. And the mean CVP was 3.2 ± 2.2 but the mean collapsibility index of IVC was74.9 ± 10.5%. MSI has 100% sensitivity and 98% specificity,CVP has 100% sensitivity and specificity and IVC-CI has 100% sensitivity and specificity in diagnosis of hypovolemia when > 1.3 ,≤ 8 cmH2O and ≥ 50 % respectively. Conclusion: assessment of intravascular volume is an important diagnostic tools and management of hypovolemic patients with determining collapsibility (greater than 50%) of the inferior vena cava by bedside ultrasonography in conjunction with common clinical markers predictors e.g. Shock Index, Modified Shock Index and Central Venous Pressure.

The correlation between CVP-derived parameters and the prognosis of critically ill patients

ObjectiveTo investigate the effect of central venous pressure on the organ dysfunction and prognosis of critically ill patients. MethodsWe conducted a retrospective observational cohort study of 488 ICU patients with central venous pressure and its derived parameters in a half-year period in one single ICU centre to compare the length of ICU stay, critical illness scores (SOFA and APACHE II), serum creatinine and lactate levels. ResultsThe initial, peak and mean CVP levels of critically ill patients and length of ICU stay, peak lactate levels and SOFA scores were significantly correlated. While the peak CVP and peak creatinine levels were significantly correlated, the correlation of initial and mean CVP levels with peak creatinine was not significant. Subgroup analysis showed that in the patients with a peak CVP value above 12mmHg, the length of stay was significantly prolonged, organ function was significantly worse, and the SOFA score was significantly higher. ROC analysis showed peak levels of CVP above 11.5mmHg had the greatest ability to predict mortality of critically ill patients. ConclusionExposure to higher levels of central venous pressure in critically ill patients is associated with a poorer prognosis and worse organ function. Therefore, central venous pressure should be kept as low as possible during hemodynamic therapy in critically ill patients.

PO-0042 Prevalence And Outcome Of Diastolic Dysfunction In Children With Fluid Refractory Septic Shock – A Prospective Observational Study

Background and aims Severe sepsis is often characterised by disturbances in cardiac function, popularly known as sepsis induced myocardial dysfunction (SIMD). SIMD may be systolic (SD), diastolic (DD) or global. Diastolic dysfunction has been infrequently reported in only a few studies on adult patients till date. Detecting DD early in the course has important therapeutic and prognostic implications in the management of septic shock. Our aim was therefore, to determine the prevalence and outcome of DD in children with septic shock and to generate evidence for possible early clinical predictors of DD in such patients. Methods Consecutive children ≤17 years of age with fluid refractory septic shock and not on mechanical ventilation admitted to our ICU from June 2011 to August 2012 were included. DD was defined as an abnormal ‘E’, mitral annulus velocity on tissue Doppler imaging at admission. Results A total of 56 children were included. The prevalence of DD was 41.1% (95% CI: 27.8 to 54.4) and the mortality rate was 43% in those with DD. On univariable analysis of possible early predictors of DD, we observed that children with DD tended to have higher mean CVP (13 vs. 6; p Conclusion Diastolic dysfunction is common in children with fluid refractory septic shock and immediate outcome may be poorer in such patients. Increased CVP after initial fluid resuscitation may be an early indicator of DD and warrant urgent bedside echocardiography.

Reduced sevoflurane consumption in cirrhotic compared to non-cirrhotic patients undergoing major hepatic surgery

BackgroundThere is evidence in literature that chronic hepatic patients need less anesthesia compared with healthy ones. Liver cirrhosis leads to a reduction in liver mass and hepatic blood flow with an effect on drug clearance and cardiovascular stability.AimTo evaluate sevoflurane consumption during entropy monitored general anesthesia in cirrhotic and non-cirrhotic patients during transition from consciousness to unconsciousness and throughout the procedure of major hepatic surgical procedures.Patients and methodsForty patients scheduled for major hepatic resection at the National Liver Institute, Menofiya University, Egypt, were studied prospectively and randomized into two equal groups. Group I (n. 20) cirrhotic patients (Child Pugh Grade A) with focal lesion, Group II (n. 20) healthy live liver donors undergoing major hepatectomies. Sevoflurane inhalational concentration was adjusted to achieve a state and response entropy of 40–60, and when RE increases 5–10 units above SE; more intravenous analgesics were given.ResultsMean (SD) Sevoflurane consumption in Group II showed higher consumption 23.5 (3.23) ml, compared to Group I 16 (2.19) ml. Mean (SD) sevoflurane consumption after 4 and 6 h from induction also showed a lower value in Group I 10.7(1.94), 9(1.22) ml, than in Group II 17.2(1.69), 14.1(2.19) ml, respectively. Mean (SD) end tidal sevoflurane concentration was lower in Group I 1.4(0.12) after 2 h from induction than in Group II 1.7(0.11). After 4 and 6 h from induction Group I demonstrated a lower value compared to Group II (P < 0.05.). Mean blood pressure, heart rate, urine output and CVP showed no significant changes during maintenance between the two groups.ConclusionThis study demonstrated that cirrhotic patients require less sevoflurane consumption and lower end-tidal concentration to maintain general anesthesia with entropy guidance. This could also have an important impact on the economic costs when applied on a larger scale.

Early experience in anesthesia of robot assisted cystoprostatectomy

ObjectiveRobot assisted cystectomies have recently been undertaken in our institute. We will discuss the perioperative management of the first 25 cases of robot-assisted cystprostatectomies with urinary diversion.MethodologyThe study was conducted on 25 consecutive patients who underwent robotic radical cystprostatectomies with urinary diversion. Hemodynamic, pulmonary data and ABG changes were recorded.ResultsThere were significant increase in mean arterial blood pressure, CVP and arterial carbon dioxide tension, plateau airway pressure after pneumoperitoneum and trendlenberg position with significant decrease in lung compliance.ConclusionRobotic assisted radical cystectomy in the exaggerated trendlenberg position is a challenging clinical setting to anesthetists. Continuous monitoring intraoperatively and postoperatively with rapid interaction with anticipated events and potential risks is essential.

Obesity is Associated with Reduced Brain Tissue Oxygen Tension After Severe Brain Injury

BackgroundObesity has been associated with compromised tissue oxygenation and reduced organ perfusion. The brain is critically dependent on oxygen delivery, and reduced brain tissue oxygen tension (PbtO2) may result in poor outcome after brain injury. We tested the hypothesis that obesity is associated with compromised PbtO2 after severe brain injury.MethodsPatients with severe brain injury (GCS score ≤ 8) who underwent continuous PbtO2 monitoring were retrospectively identified from a prospective single-center database. Patients, were classified by body mass index (BMI = weight (kg)/m2) and were included if they were obese (BMI ≥ 30) or non-obese (BMI = <30).ResultsSixty-nine patients (mean age 46.4 ± 17.0 years) were included. Mean daily PbtO2 was 25.8 (9.6) mmHg for the 28 obese and 31.8 (12.3) mmHg for the 41 non-obese patients (P = 0.03). Initial PbtO2 and mean daily maximum PbtO2 measurements also were significantly lower in obese patients than in non-obese patients. Univariate predictors of compromised PbtO2 (defined as minutes PbtO2 < 20 mmHg) included elevated BMI (P = 0.02), presence of ARDS (P < 0.01), mean PaO2 (P < 0.01), maximum FiO2 (P < 0.01), mean PaO2:FiO2 (P < 0.01), and mean CVP (P < 0.01). In multivariable analysis, BMI was significantly associated with compromised PbtO2 (P = 0.02). Sex, age, and mean CVP were also identified as significant predictors of compromised PbtO2; ARDS and PF ratio were not.ConclusionsIn patients with severe brain injury, obesity was found to be an independent predictor of compromised PbtO2. This effect may be mediated through obesity-related pulmonary dysfunction and inadequate compensatory mechanisms.

Intensivist Use of Hand-Carried Ultrasonography to Measure IVC Collapsibility in Estimating Intravascular Volume Status: Correlations with CVP

Volume status assessment is an important aspect of patient management in the surgical intensive care unit (SICU). Echocardiologist-performed measurement of IVC collapsibility index (IVC-CI) provides useful information about filling pressures, but is limited by its portability, cost, and availability. Intensivist-performed bedside ultrasonography (INBU) examinations have the potential to overcome these impediments. We used INBU to evaluate hemodynamic status of SICU patients, focusing on correlations between IVC-CI and CVP. Prospective evaluation of hemodynamic status was conducted on a convenience sample of SICU patients with a brief (3 to 10 minutes) INBU examination. INBU examinations were performed by noncardiologists after 3 hours of didactics in interpreting and acquiring two-dimensional and M-mode images, and > or =25 proctored examinations. IVC-CI measurements were compared with invasive CVP values. Of 124 enrolled patients, 101 had CVP catheters (55 men, mean age 58.3 years, 44.6% intubated). Of these, 18 patients had uninterpretable INBU examinations, leaving 83 patients with both CVP monitoring devices and INBU IVC evaluations. Patients in three IVC-CI ranges (<0.20, 0.20 to 0.60, and >0.60) demonstrated significant decrease in mean CVP as IVC-CI increased (p = 0.023). Although <5% of patients with IVC-CI <0.20 had CVP <7 mmHg, >40% of this group had a CVP >12 mmHg. Conversely, >60% of patients with IVC-CI >0.6 had CVP <7 mmHg. Measurements of IVC-CI by INBU can provide a useful guide to noninvasive volume status assessment in SICU patients. IVC-CI appears to correlate best with CVP in the setting of low (<0.20) and high (>0.60) collapsibility ranges. Additional studies are needed to confirm and expand on findings of this study.

Central Venous Pulse Pressure Analysis Using an R-Synchronized Pressure Measurement System

The information derived from central venous catheters is underused. We developed an EKG-R synchronization and averaging system to obtained distinct CVP waveforms and analyzed components of these. Twenty-five paralyzed surgical patients undergoing CVP monitoring under mechanical ventilation were studied. CVP and EKG signals were analyzed employing our system, the mean CVP and CVP at end-diastole during expiration were compared, and CVP waveform components were measured using this system. CVP waveforms were clearly visualized in all patients. They showed the a peak to be 1.8+/- 0.7 mmHg, which was the highest of three peaks, and the x trough to be lower than the y trough (-1.6+/- 0.7 mmHg and -0.9+/- 0.5 mmHg, respectively), with a mean pulse pressure of 3.4 mmHg. The difference between the mean CVP and CVP at end-diastole during expiration was 0.58+/- 0.81 mmHg. The mean CVP can be used as an index of right ventricular preload in patients under mechanical ventilation with regular sinus rhythm. Our newly developed system is useful for clinical monitoring and for education in circulatory physiology.

Interactions of plasma osmolality with arterial and central venous pressures in control of sympathetic activity and heart rate in humans

Plasma osmolality alters control of sympathetic activity and heart rate in animal models; however, it is unknown whether physiological increases in plasma osmolality have such influences in humans and what effect concurrent changes in central venous and/or arterial pressures may have. We tested whether physiological increases in plasma osmolality (similar to those during exercise dehydration) alter control of muscle sympathetic nerve activity (MSNA) and heart rate (HR) in humans. We studied 17 healthy young adults (7 women, 10 men) at baseline and during arterial pressure (AP) transients induced by sequential injections of nitroprusside and phenylephrine, under three conditions: control (C), after 1 ml/kg intravenous hypertonic saline (HT1), and after 2 ml/kg hypertonic saline (HT2). We continuously measured HR, AP, central venous pressure (CVP; peripherally inserted central catheter) and MSNA (peroneal microneurography) in all conditions. Plasma osmolality increased from 287 +/- 1 mosmol/kg in C to 290 +/- 1 mosmol/kg in HT1 (P < 0.05) but did not increase further in HT2 (291 +/- 1 mosmol/kg; P > 0.05 vs. C). Mean AP and CVP were similar between C and HT1, but both increased slightly in HT2. HR increased slightly but significantly during both HT1 and HT2 vs. C (P < 0.05). Sensitivity of baroreflex control of MSNA was significantly increased vs. C in HT1 [-7.59 +/- 0.97 (HT1) vs. -5.85 +/- 0.63 (C) arbitrary units (au).beat(-1).mmHg(-1); P < 0.01] but was not different in HT2 (-6.55 +/- 0.94 au.beat(-1).mmHg(-1)). We conclude that physiological changes in plasma osmolality significantly alter control of MSNA and HR in humans, and that this influence can be modified by CVP and AP.

Hemodynamic variables related to outcome in septic shock

To assess the impact of hemodynamic variables on the outcome of critically ill patients in septic shock and to identify the optimal threshold values related to outcome with special reference to continuously monitored mean arterial pressure (MAP) and mixed venous oxygen saturation (SvO2). Retrospective cohort study in a university hospital intensive care unit (ICU). All consecutive 111 patients with septic shock treated in our ICU between 1 Jan. 1999 and 30 Jan. 2002. The data on the hemodynamic and respiratory monitoring and circulation-related laboratory tests over the first 48 h of treatment in the ICU were collected from the clinical data management system. Data from 6 h and 48 h were analyzed separately. The 30-day mortality rate was 33% (36 of 111). Univariate analysis and forward stepwise logistic regression analysis were performed using the 30-day mortality as the primary endpoint. Mean MAP and lactate on arrival during 6 h, while mean MAP, the area of SvO2 under 70%, and mean CVP during 48 h were independently associated with mortality. MAP level of 65 mmHg and SvO2 of 70% had the highest areas under receiver characteristics curves. MAP, SvO2, CVP, and initial lactate were independently associated with mortality in septic shock, with threshold values supporting those published in recent guidelines.

AN EVALUATION OF THE FLOW BALANCE BETWEEN LVAD AND RVAD

Background: The clinical benefits of left ventricular assist device (LVAD) have been well proven for the patients of severe heart failure. However, severe right heart failure occurs in approximately 20% to 30% of LVAD patients. Although BVAD implantation is a very effective option for those patients, the flow balance between LVAD and RVAD is still controversial. Methods: Sixteen healthy half-Dexter calves which survived more than two weeks after BVAD implantation were divided into two groups based on the initial two weeks ratio of the left / right pump flow rate (L/R ratio). Survival, mean arterial pressure, mean left atrial pressure, mean pulmonary arterial pressure, CVP and heart rate were compared. Results: Survival in group A (L/R ratio<0.9, n=7) and group B (L/R ratio 0.9, n=9) were 70±23 (37–90) days and 42±16 (22–60) days, respectively. Three out of seven experimental calves in group A were electively sacrificed on post-operative day 90 following the protocol. The results of the other measurements are listed on the table.TableConclusions: From this study, it is recommended to keep the L/R ratio less than 0.9 for initial two weeks after BVAD implantation for longer term survival of BVAD animals. Contrary to what was generally believed traditionally used higher flow for the left pump over right pump did not produce longer survival of calves with BVAD implantation.

Fulminant myocarditis in adults and children: bi-ventricular assist device for recovery

Fulminant myocarditis (FM) is uncommon and may be followed by a rapidly intractable cardiogenic shock. We report five consecutive patients with FM successfully bridged to recovery with a mechanical paracorporel biventricular assist device (BiVAD). Five patients, four adults and one child (mean age 27+/-6 years, range, 5-36 years) underwent implantation from November 1999 to May 2003, for FM. Prior to implantation, all patients required maximal inotropic support, three of them had an intra-aortic balloon pump, the child had an extra-corporel membrane oxygenation (ECMO) support previously inserted in another institution. Cardiac catheterisation showed a mean CPW of 37+/-1 mmHg, mean CVP 18+/-2 mmHg, and mean CI 1.7+/-0.1l/min. Echocardiogram showed a severe biventricular hypokinesia, without any ventricular dilatation and a mean LVEF at 12.5%. Two patients were implanted in cardiac arrest under external cardiac resuscitation. All patients underwent BiVAD implantation (MEDOS HIA-VAD). A 72 ml right paracorporel ventricle (a 23 ml in the child) was instituted between the double stage venous canula used during CPB and a pulmonary artery outflow canula. A 80 ml left paracorporel ventricle (a 25 ml in the child) was instituted between a left ventricle apical canula and an aorta outflow canula. There was no death. The mean duration support time was 11+/-6 days (from 7 to 21 days). Two patients experienced transitory deficiency due to a stroke. Four patients showed signs of FM on histological findings. Despite serologic examination and viral genome research on myocardial biopsies, pathogenic agents were not identified. At mean follow-up of 31+/-15 months, all the patients fully recovered with a mean LVEF=60% and no left ventricular dilatation. In FM with intractable cardiogenic shock, the use of a BiVAD as a bridge to recovery is a life saving approach and should be considered before multi-end organ failure.

ESOPHAGEAL DOPPLER MONITORING

S87 INTRODUCTION: We have recently demonstrated that Esophageal Doppler Monitor (EDM) measurements of cardiac output (COe) and preload (FTc) correlate with aortic flow probe and end-diastolic area (EDA) measurements respectively. [1] EDM also measures the maximal or peak velocity (PV) of blood ejected from the heart during systole. This study was designed to evaluate the influences of preload, afterload, and contractility on EDM-derived peak velocity (PV). METHODS: Following IRB approval and informed consent, we studied 34 patients undergoing surgery with cardiopulmonary bypass (CPB). Hemodynamic data were collected using an aortic flow probe, an esophageal doppler monitor (Deltex Medical, Irving, TX), a transesophageal echocardiography probe (TEE) and a pulmonary artery catheter (PAC). Data were collected at baseline, following each of two 300 mL volume challenges pre-CPB, and at 2 timepoints (5[prime] and 15[prime]) post-CPB. The aortic flow probe was our "gold standard" for cardiac output (CO), and the TEE end diastolic area (EDA) was used to assess preload. A contractility index was determined from Frank-Starling Response (FSR) curves for each patient by plotting CO vs. EDA for the three pre-CPB timepoints. [2] The slope of the FSR curves was used as an index of contractility. The afterload, or systemic vascular resistance (SVR), was calculated using CO (flow probe), mean systemic blood pressure and CVP (PAC). Standard linear regression analysis was performed for each variable with p < 0.05 considered significant. RESULTS: The EDM-derived PV directly correlated with the CO from the aortic flow probe (r = 0.585; p < 0.0001). The PV did not correlate with either preload, measured by EDV (Figure 1) or our contractility index (r = -0.3923, p = 0.1329). The PV had a strong inverse correlation with SVR (Figure 2).Figure 1: PV vs. End-Diastolic AreaFigure 2: PV vs. SVRCONCLUSION: These data suggest that peak velocity is most influenced by the afterload conditions imposed on the ejecting ventricle and thus may serve as an index of SVR. This correlation seems reasonable in that one would expect the velocity of blood flow to be higher when blood is ejected into a lower resistance system. This index, if validated, may provide information about SVR independent of other more invasive monitors.

EFFECTS OF EPINEPHRINE INFUSION ON RENAL AND MESENTERIC PERFUSION IN THE AWAKE PIGLET DURING NORMOVOLEMIA AND HYPOVOLEMIA. † 1146

Objective: To determine the dose related effects of continuous epinephrine (Epi) infusion on renal and mesenteric blood flow in both healthy and shocked newborn piglets. Methods: Superior mesenteric artery(SMA) and left renal artery (RA) ultrasonic flow probes were implanted into 16, 1-3 day old piglets. 2 d later, the effects of Epi on SMA and RA flow (f), mean arterial pressure (MAP) and CVP were measured in awake animals. Vascular resistances (vr) were calculated. Epi doses of 0.2, 0.4, 0.8, 1.6 and 3.2μg/kg/min were infused in random order for 20 minutes, with 15 minute recovery periods. Piglets were then hemorrhaged to mild hypotension (20 ml/kg) and Epi was repeated. Results: Percentage change from baseline is shown, Mean (SD).*=p<0.05 ANOVA. Conclusion: Low to moderate dose Epi does not cause renal or mesenteric ischemia either in the normovolemic or hypovolemic neonatal piglet. Hypovolemic shock has only minor effects on circulatory Epi responses, with a slight decrease in vasoconstriction.Table