Significant Hemodynamic Deterioration Research Articles

Recurrent pulmonary hypertension after balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension

Balloon pulmonary angioplasty improves the hemodynamics of patients with inoperable chronic thromboembolic pulmonary hypertension; however, the clinical impact of recurrent pulmonary hypertension after balloon pulmonary angioplasty remains unclear. We retrospectively reviewed 262 consecutive patients with chronic thromboembolic pulmonary hypertension who underwent balloon pulmonary angioplasty between July 2009 and December 2020; 158 (65±12years; males, 20%; median follow-up period, 45 [26, 66]months) with follow-up right heart catheterization and no residual pulmonary hypertension were included. Recurrent pulmonary hypertension was defined as mean pulmonary arterial pressure <25mm Hg at the first evaluation after balloon pulmonary angioplasty and ≥25mm Hg at follow-up evaluation requiring additional treatment with balloon pulmonary angioplasty or pulmonary vasodilators. Recurrent pulmonary hypertension was observed in 11 patients; the state occupation probability of recurrence at 5years was 9.0% (95% confidence interval: 5.0%-18.9%). Only 1 case (0.6%) of recurrent pulmonary hypertension showed vascular restenosis and reocclusion of previously treated lesions, with more significant hemodynamic and exercise capacity deterioration than the other cases. Additional treatments for recurrent pulmonary hypertension (balloon pulmonary angioplasty in 9 patients, pulmonary vasodilators in 4 patients) improved the mean pulmonary arterial pressure from 27 [26, 29] to 22 [19, 23] mm Hg (p<0.01). Recurrence had a low probability of transitioning to death in an illness-death model. No specific risk factors for recurrent pulmonary hypertension were identified. Symptomatic recurrent pulmonary hypertension due to vascular restenosis or reocclusion after balloon pulmonary angioplasty was extremely rare. Most cases of recurrent pulmonary hypertension were mild, did not worsen clinically, and had favorable prognoses.

Development and testing of a transcatheter heart valve with reduced calcification potential.

Patients from developing countries who require heart valve surgery are younger and have less access to open heart surgery than those from developed countries. Transcatheter heart valves (THVs) may be an alternative but are currently unsuitable for young patients because of their inadequate durability. We developed and tested a THV utilizing two new types of decellularized bovine pericardial leaflets in an ovine model. The two decellularized tissues [one with a very low dose (0.05%) of monomeric glutaraldehyde (GA) fixation and detoxification (DF) and the other without glutaraldehyde (DE)] were compared to an industry standard [Glycar-fixed with the standard dose (0.625%) of glutaraldehyde]. THVs were manufactured with the three tissue types and implanted in the pulmonary position of nine juvenile sheep for 180 days. Baseline and post-explantation evaluations were performed to determine the hemodynamic performance of the valves and their dynamic strength, structure, biological interaction, and calcification. Heart failure occurred in one animal due to incompetence of its Glycar valve, and the animal was euthanized at 158 days. The gradients over the Glycar valves were higher at the explant than at the implant, but the DE and DF valves maintained normal hemodynamic performance throughout the study. The DF and DE tissues performed well during the mechanical testing of explanted leaflets. Glycar tissue developed thick pannus and calcification. Compared to Glycar, the DF tissue exhibited reduced pannus overgrowth and calcification and the DE tissue exhibited no pannus formation and calcification. All tissues were endothelialized adequately. There was a striking absence of host ingrowth in the DE tissue leaflets, yet these leaflets maintained integrity and mechanical function. In the juvenile sheep THV model, Glycar tissue developed significant pannus, calcification, and hemodynamic deterioration. Using a very low dose of monomeric GA to fix the decellularized bovine pericardium yielded less pannus formation, less calcification, and better hemodynamic function. We postulate that the limited pannus formation in the DF group results from GA. Bovine pericardium decellularized with our proprietary method resulted in inert tissue, which is a unique finding. These results justify further development and evaluation of the two decellularized tissue types in THVs for use in younger patients.

The clinical profile of pulmonary arterial hypertension in newly diagnosed patients with connective tissue disease from the point of view of the cardiologist

Aim: to evaluate demographic and disease characteristics in pulmonary arterial hypertension associated with connective tissue disease (PAH-CTD) patients.Materials and methods: the study enrolls 68 patients with PAH-CTD. These patients were diagnosed in department of pulmonary hypertension and heart disease of the E.I. Chazov National Medical Research Centre of cardiology. Clinical, functional and hemodynamic characteristics of PAH patients were examined. The diagnosis was confirmed according to Eurasian (2019) and Russian (2020) guidelines for the diagnosis and treatment of pulmonary hypertension.Results: Of 68 patients with CTD 35 (51,5%) had systemic sclerosis, 11 (16,2%) - mixed CTD, 22 (32,3%) - other CTD. The median time from PAH onset to first visit to health care worker was 4 months, the median time from first visit to PAH diagnosis was 7,5 months. The median age was 59,5 years, 94,1% patients were women. The median 6-minute walking distance (6MWD) was 345 (259,25-400,00) m, which was corresponding to WHO functional class III, the median Borg dyspnea index was 5 (3,0-6,0). 12 (17,7%) patients did not undergo 6MWD due to severity of their condition. According to right heart catheterization data the median mean pulmonary arterial pressure was 51,0 (35,5-62,0) mmHg, the median cardiac index was 2,1 (1,7-2,5) liter/min/m2, the median pulmonary vascular resistance was 11,48 (5,99-15,71) Wood units. According to several risk stratification calculators, the vast majority of patients were at high risk of 1-year mortality: due to risk status, PAH-specific therapy was initiated to 88,3% patients: 42,7% received double and 8,8% - triple PAH-specific therapy.Conclusions: In Russian clinical practice, PAH-CTD is characterized by late- onset diagnosis. Newly diagnosed patients have significant functional and hemodynamic impairment, high risk of 1-year mortality, which results in combined PAH-specific therapy initiation.

Atrial septal defect with a rare occupying lesion in heart

BackgroundCardiac epicardium hemangiomas are exceedingly rare; however, they can cause significant hemodynamic impairment and large pericardial effusions. On rare occasion, cardiac tumors coexist with malformations of the heart.Case presentationWe present the case of a 10-month-old female infant with a rare cardiac surface hemangioma coexisting with malformations of the heart. It revealed an atrial septal defect (ASD) coexisting with an abnormal occupying lesion with high echogenicity. It was 35*12*9 mm in size and was found in the anterior atrioventricular junction to the posterior atrioventricular junction at the bottom of the ventricular septum by transthoracic echocardiography. We performed surgical treatment of the atrial septal defect and performed biopsy with the occupying lesion. The histopathological examination reported a benign tumor as hemangioma. As far as we know, this is the first case in which cardiac surface hemangioma was found to coexist with an atrial septal defect.ConclusionsCardiac epicardium hemangiomas is a rare solid tumor of the heart. If the mass is impossible to resect and does not cause hemodynamic impairment, only mass biopsy is possible.

Healthcare resource utilization and quality of life in patients with sarcoidosis-associated pulmonary hypertension.

A retrospective, observational cohort study was conducted to generate real‐world evidence in adult patients diagnosed with sarcoidosis‐associated pulmonary hypertension (SAPH) at a referral center in England between 2012 and 2019. Data from the referral center electronic medical record database were linked to the National Health Service Hospital Episode Statistics database to collect and analyze patient demographics, clinical characteristics, comorbidities, treatment patterns, health‐related quality of life (HRQoL; assessed using the EmPHasis‐10 questionnaire), healthcare resource utilization (HCRU), costs, and survival. Sixty‐two patients with SAPH were identified. At diagnosis, 84% were in WHO functional class III and presented with significant pulmonary hemodynamic impairment. Cardiovascular and respiratory comorbidities were commonly reported prediagnosis. Median EmPHasis‐10 score at diagnosis was 34, indicative of poor HRQoL. In the 1st year after diagnosis, median (Q1, Q3) per‐patient HCRU was 1 (0, 2) all‐cause inpatient hospitalizations; 3 (2, 4) same‐day hospitalizations; and 9 (6, 11) outpatient consultations. In 24 patients who were hospitalized longer than 1 day in the 1st year after diagnosis, the median duration of hospitalization was 4 days. With a median follow‐up of 1.8 years, the median overall survival was 2.9 years. In this cohort of patients with SAPH, poor HRQoL and high HCRU were observed following diagnosis. To our knowledge, this is the first study to report on HRQoL and HCRU in patients with SAPH. More research is needed on treatment options for this population with high unmet needs.

A surgically treated case of severe upper gastrointestinal hemorrhage with gastritis cystica polyposa

BackgroundGastritis cystica polyposa (GCP) is a recently recognized entity histologically characterized by hyperplasia and cystic dilatation of the gastric glands spreading through the submucosal layer. Its symptoms include those affecting the upper gastrointestinal tract, such as upper abdominal pain, nausea, and anorexia, although some patients might be asymptomatic. GCP rarely causes severe hemorrhage. Recently, we encountered a GCP case that exhibited severe hemorrhage.Case presentationA 53 year-old man visited the emergency department complaining of hematemesis. He underwent distal gastrectomy and Billroth II reconstruction for duodenal ulcers 32 years ago. Upper gastrointestinal endoscopy detected bleeding from the reddened mucosa at the anastomosis; thus, tentative endoscopic hemostasis was conducted. Despite medical treatment with transfusion, melena with significant hemodynamic impairment persisted. He was treated again with endoscopic hemostasis and interventional radiology (IVR) but remained unresponsive to these procedures. He eventually underwent partial resection of the anastomosis site with Roux-en-Y reconstruction and finally achieved excellent postoperative recovery. Histopathological examination of the resected specimen suggested a GCP bleeding.ConclusionsGCP can indeed cause severe hemorrhage. Hemorrhage caused by GCP may not respond to endoscopic hemostasis or IVR; therefore, surgical treatment should be decided without delay.

Neovascularization Precedes Occlusion in Moyamoya Disease: Angiographic Findings in 172 Pediatric Patients

Background: Both basal collaterals (BC) and cortical microvascularization (CM) on angiography have been suggested as moyamoya disease (MMD)-specific findings; however, it is unknown whether the vascular network represents compensatory mechanisms for vascular occlusion or aberrant active neovascularization. Methods: We investigated the grade of antegrade MCA flow, the degree of BC, and the presence of CM on conventional angiography in relation to disease severity in pediatric MMD. CM was defined as enlarged and winding distal cortical arteries and categorized into anterior or posterior CM depending on their sources. Findings from basal and acetazolamide stress brain perfusion SPECT studies were also evaluated. Results: A total of 172 pediatric patients with MMD were enrolled in this study. As the severity of MMD increased, the grade of antegrade MCA flow gradually diminished. While the degree of BC peaked at Suzuki stage 3-4, CM was frequently observed at early MMD stages. About two-thirds of hemispheres with normal antegrade MCA flow on angiography and normal perfusion status on SPECT had anterior and/or posterior CM. Both anterior and posterior CM gradually decreased with the advancement of MMD. Conclusion: Our findings from a large cohort of angiographically confirmed pediatric MMD patients indicate that neovascularization may occur before significant hemodynamic impairment in MMD.

Review of Medical Treatment of Stable Ischemic Heart Disease

Medical treatment is the initial treatmentstrategy and is the cornerstone of management in patients with stable ischemicheart disease (IHD). Many patients are not suitable for percutaneous orsurgical revascularization because of unfavourable anatomy, or the presence ofco-morbidities. In addition, many patients have recurrence of anginafollowing revascularization due to restenosis or incomplete revascularization.Furthermore, randomized clinical trials comparing optimal medical treatment torevascularization have not clearly shown that myocardial revascularization issuperior to optimal medical treatment. Traditional drugs for angina treatmentinclude b-blockers, calcium channel blockers and nitrates. Newer drugs areavailable with different mechanisms of action and with equal efficacy that donot cause significant hemodynamic deterioration. The availability of thesenewer drugs expands the therapeutic potential of medical treatment to even awider population with stable IHD. Revascularization in patients with stableischemic heart disease has never been shown to reduce hard endpoints (death ormyocardial infarction) in randomized clinical trials.

Ventricular arrhythmia in patients with prolonged QT interval during liver transplantation: two cases report.

QT interval prolongation is associated with an increased risk of ventricular arrhythmia in various conditions. Cardiac electrophysiologic abnormalities including QT interval prolongation are well documented in patients with advanced liver cirrhosis. We report two cases of patients with QT interval prolongation on preoperative electrocardiography who exhibited repetitive ventricular arrhythmias with significant hemodynamic deterioration during liver transplantation. For the treatment and prevention of ventricular arrhythmias during the intraoperative period, we performed intravenous administration of lidocaine and isoproterenol, corrected imbalances of electrolytes including potassium and magnesium, and prepared a defibrillator. These cases emphasize that preoperative recognition of QT interval prolongation and adequate management to prevent fatal arrhythmias are important in patients undergoing liver transplantation.

Isolated central venous pressure elevation caused by hematoma formation compressing the superior vena cava following a Bentall operation: a case report

We present a case of a patient exhibiting isolated elevation of the central venous pressure with minimal hemodynamic deterioration in an immediate postoperative period after Bentall operation requiring re-exploration. Isolated elevation of the central venous pressure usually alerts physicians of a volume overload or right ventricular dysfunction. However, even in the absence of significant hemodynamic deterioration, the development of loculated hematoma that compresses the superior vena cava should be ruled out, as it can be life-threatening through the formation of cerebral and laryngeal edema, similar to superior vena cava syndrome. This case emphasizes the importance of a prompt differential diagnosis of the isolated central venous pressure elevation after cardiac surgery with transesophageal echocardiography for the administration of appropriate treatment.

Evolving Basilar Artery Stenosis with Watershed Ischemia

Basilar artery stenosis where flow restriction constitutes the main pathomechanism are exceptional. Here, we report a case where the lesion progression was characterized by watershed infarct between the anterior inferior-superior cerebellar arteries and deep pontine arteries, indicating a significant hemodynamic impairment.

Hemodynamic Response to Dynamic Changes in Upper Airway Impedance?A Volunteer Study

Introduction: Intermittent airway obstruction may occurring both intubated and non-intubated critically ill patients due to endotracheal tube obstruction or kinking in the former and loss of oropharyngeal tone particularly during sedation in the latter patient group. Spontaneous breathing efforts against high airway resistance invoke shifts in intrathoracic pressure, which could potentially negatively affect cardiac performance. Previous studies utilized the Mueller Maneuver as a model for pathophysiologic changes during these episodes. However, this model only accounts for the state of maximum inspiration. To study progressive airway obstruction of various degrees, we devised an experimental setup allowing for a dynamic simulation and identification of associated short-term effects of breathing against discretely increasing airway resistance. Material and methods: 14 healthy volunteers (9 female, 5 male; mean age 27.8 ± 4.1 years, mean body mass index 26.1 ± 3.6 kg/m2) were asked to breathe through a set of endotracheal tubeswith decreasing internal diameter, while cardiovascular and hemodynamic parameters were recorded.StrokeVolume (SV) and Cardiac Index (CI) were recorded using thoracic bioreactance. Heart Rate (HR), non-invasive arterial blood pressure, oxygen saturation and spirometry parameters were also recorded. Results: Baseline SV, HR and CI averaged 99.8 ml, 69.5/min and 4.01 l/min/m2. During respiration through tubes with decreasing diameters, SV, HR and CI decreased significantly. At maximum airway resistance, SV, HR and CI averaged 90.7 ml, 65.0/min and 3.38 l/min/m2, representing mean percent changes from baseline of -9.1% (p=0.0041), -6.5% (p<0.0001) and -15.7% (p<0.0001). Strong inverse Pearson correlations were detectible between calculated additional airway resistance (Hagen-Poiseuille) and SV (R=-0.143, p=0.013), and CI (R=-0.147, p=0.011), respectively. Blood pressure, arterial oxygen saturation and spirometry parameters did not differ significantly. Conclusions: Increases in airway resistance were dynamically associated with significant hemodynamic deterioration. Ensuring the maintenance of airway patency is therefore an important factor to consider in hemodynamically unstable patients.

Cerebral Hemodynamic Reserve and Vascular Remodeling in C57/BL6 Mice Are Influenced by Age

Age is the most important risk factor for ischemic stroke. Recent experiments evidenced an age-associated rarefaction of the native collateral vasculature. The purpose of this study was to assess in what way age and arteriogenesis influence cortical perfusion and recovery of hemodynamic impairment in aged and young C57/BL6 mice. After model establishment of chronic cerebral hypoperfusion in the C57/BL6 strain, sustained hemodynamic impairment was induced by permanent unilateral internal carotid artery occlusion in animals aged 4 to 6 weeks, 12 weeks, and 18 months. Functional and morphological outcome was assessed by laser speckle imaging before and during acetazolamide challenge on Days 0, 3, 7, and 14 and latex/carbon black angiography and immunohistochemistry on Day 21. Although internal carotid artery occlusion did not result in a reduction of baseline perfusion, it led to significant hemodynamic impairment in all age groups. Furthermore, baseline perfusion in sham and cerebrovascular reactivity after internal carotid artery occlusion were significantly lower in animals aged 18 months (468±57 Flux; 20.8%±17%) compared with mice aged 4 to 6 weeks (568±120 Flux; 30.3%±17%) and 12 weeks (591±72 Flux; 34.2%±12%) from the beginning until Day 7 of the monitoring period. Functional outcome was in line with a 27% reduction of native leptomeningeal anastomoses in aged mice and only limited collateral outgrowth compared with young animals. Strikingly, all age groups reached spontaneous functional compensation by Day 14. Next to limited collateral remodeling, our results suggest that a hampered cerebrovascular response with age could intensify the risk for hemodynamic stroke in the elderly.

Management of Postoperative Arrhythmias in Pediatric Patients

Post-operative arrhythmias occur commonly following pediatric cardiac surgery and can result in significant hemodynamic deterioration. Arrhythmias are more likely in the immediate post-operative period due to myocardial injury and ischemia, high catecholamine levels and electrolyte disturbances. At the same time, these arrhythmias are more likely to cause hemodynamic compromise due to the relatively tenuous cardiovascular function of patients immediately after cardiac surgery. Treatment of tachyarrhythmias often requires addressing two separate goals: termination of the arrhythmia and prevention of recurrences. These two objectives necessitate different treatment strategies in reentrant arrhythmias such as orthodromic reciprocating tachycardia, atrial fibrillation and intra-atrial reentrant tachycardia, including atrial flutter. Termination usually involves vagal maneuvers, adenosine administration, rapid pacing, or direct-current cardioversion. Prevention of recurrences, on the other hand, may require antiarrhythmic medications, although removal of central venous lines in the heart should be considered. Conversely, for automatic tachyarrhythmias, such as junctional ectopic tachycardia and ectopic atrial tachycardia, termination and prevention of recurrences usually involve similar modalities, including cooling, antiarrhythmic medications and correction of electrolyte abnormalities. Bradyarrhythmias, either sinus node dysfunction or AV block, can be treated by pacing with temporary epicardial wires in the short-term. In patients with persistent AV block for 7days, however, permanent pacemaker placement may be required.

Cerebral Oxygenation Impairment and S-100β Protein Release During Off-Pump Coronary Artery Revascularization

To elucidate the magnitude of global cerebral oxygenation impairment, using cerebral oxygenation indices and S-100β protein as potential markers, during off-pump coronary artery bypass grafting (OPCAB). Prospective cohort study. Tertiary cardiac center. Thirty-five patients undergoing OPCAB. Jugular bulb and arterial blood samples for cerebral oxygenation indices (arterial oxygen and carbon dioxide partial pressures, jugular bulb oxygen saturation, arterial-jugular bulb oxygen content, arterial-jugular carbon dioxide partial pressure, brain oxygen extraction ratio, and estimated respiratory quotient) and S-100β protein determination were collected at anesthesia induction; anterior, inferior, and posterior wall anastomoses; after sternal closure; and 6 hours postoperatively. Concomitant hemodynamic data were obtained. The S-100β determination was extended to 12 and 24 hours postoperatively. Heart positioning for the target vessel exposure induced significant hemodynamic deterioration (p < 0.001). Although cerebral oxygenation indices were influenced adversely by a low-cardiac-output state mainly during vertical heart dislocation (p < 0.001), they remained within normal limits. Hemodynamic and cerebral oxygenation statuses reverted to baseline within 6 hours postoperatively. Similarly, S-100β jugular bulb and arterial protein levels presented a gradual increase, which peaked by the end of surgery (means, 0.54 and 0.62 μg/L, respectively; p < 0.001) and then decreased by the first postoperative day. Jugular bulb-arterial S-100β levels were maximized during posterior wall anastomosis (0.098 μg/L; p < 0.01). Although exposure of the 3 main coronary arteries during OPCAB promotes derangement of the cerebral oxygen indices and S-100β release, this seems to be transient, remains within the near-normal range, and is reversible almost completely 6 hours postoperatively.

An Exogenous Hydrogen Sulphide Donor, NaHS, Inhibits the Nuclear Factor κB Inhibitor Kinase/Nuclear Factor κB Inhibitor/Nuclear Factor-κB Signaling Pathway and Exerts Cardioprotective Effects in a Rat Hemorrhagic Shock Model

Hemorrhagic shock (HS) is a common condition and leading cause of death in trauma patients universally. Severe inflammatory responses during HS finally lead to multiple-organ failure. Hydrogen sulphide (H₂S) is increasingly recognized as an important signaling molecule with various protective effects. In the present study, we investigated the antiinflammatory and cardioprotective effects of an exogenous H₂S donor, sodium hydrosulfide (NaHS), in an HS rat model. Male Sprague-Dawley rats were randomly divided into the sham-operated, sham-operated treated with NaHS (28 µmol/kg, intraperitoneally (i.p.)), HS, and HS treated with NaHS (28 µmol/kg, i.p.) groups. The HS groups were subjected to mimicked HS for 1 h and then treated with NaHS or left untreated. The rats were then resuscitated with Ringer lactate solution for 1 h. Myocardial enzymes and inflammatory cytokines were evaluated. Morphologic changes in cardiac tissue and ultrastructural injury were also analyzed. HS resulted in significant hemodynamic deterioration and increased myocardial enzyme and inflammatory cytokine levels. Intraperitoneal administration of NaHS significantly prevented hemodynamic deterioration and decreased the elevation of myocardial enzymes. NaHS also inhibited the nuclear factor κB inhibitor kinase (IKK)/nuclear factor κB inhibitor (IκB)/nuclear factor κB (NF-κB) signaling pathway. The results suggest that NaHS exerts cardioprotective effects against HS. The protective effects of NaHS may occur via down-regulation of the IKK/IκB/NF-κB signaling pathway.

Effects of QRS Duration and Pacing Location on Pressure-Volume Loop Evaluation of Cardiac Resynchronization Therapy in End-Stage Heart Failure

Cardiac resynchronization therapy (CRT) decreases the morbidity and mortality in patients with end-stage heart failure. However, patient selection remains challenging, because a considerable 30% to 50% do not respond. Controversy exists on the cutoff values for the QRS duration and the optimal lead location. The present study relates these parameters on an individual basis to acute pump function improvement using invasively obtained pressure-volume loops. Fifty-seven patients with symptomatic end-stage heart failure were included in our temporary biventricular stimulation study and were grouped according to the QRS duration (QRS <20 ms, QRS ≥120 ms but <150 ms, and QRS ≥150 ms). All patients underwent pressure-volume loop assessment of the response to biventricular pacing, comparing the baseline measurements to both right ventricular apex pacing combined with a left ventricular lead in the posterolateral and anterolateral region of the LV. Group analysis during conventional (posterolateral and right ventricular apex) CRT did not show improvement in stroke work and dP/dt(max) (-2%, p = NS; and -7%; p <0.001) in the narrow QRS group but a significant increase in the intermediate (+27%, p = 0.020, and +5%, p = 0.044) and wide (+48%, p = 0.002, and +18%, p <0.001) QRS groups. CRT using the anterolateral and right ventricular apex configuration evoked a consistently lower response compared to posterolateral and right ventricular apex, resulting in a significant hemodynamic deterioration in the narrow QRS group. However, analysis on an individual basis identified 25% of patients with narrow QRS duration showing possible hemodynamic benefit from CRT compared to 83% of patients with intermediate and wide QRS combined. In contrast, 15% of patients had deterioration by conventional (posterolateral right ventricular apex) CRT in the intermediate and wide QRS groups compared to 31% in the narrow QRS group; 19% of patients could be improved by lead placement in the anterolateral rather than the posterolateral region. In conclusion, the acute hemodynamic response to CRT is generally in line with the long-term results from large randomized trials; however, the individual variation is large. The temporary biventricular stimulation protocol might aid in individual patient selection and in research aiming at a reduction of nonresponders and improvement in lead positioning.

Alterações hemodinâmicas durante a revascularização do miocárdio sem utilização de circulação extracorpórea

JUSTIFICATIVA E OBJETIVOS: O posicionamento e a estabilização cardíaca durante a revascularização miocárdica sem circulação extracorpórea (CEC) podem causar alterações hemodinâmicas de acordo com o local abordado. O objetivo deste estudo foi avaliar essas alterações durante a realização das anastomoses coronarianas distais. MÉTODOS: Vinte pacientes adultos submetidos à revascularização do miocárdio sem CEC receberam monitoração com cateter de artéria pulmonar e ecodoppler transesofágico. Os dados hemodinâmicos foram coletados: (1) após ajustes volêmicos, (2) no início das anastomoses distais e (3) após 5 minutos, antes da remoção do estabilizador de parede. As coronárias tratadas foram agrupadas segundo sua localização: na parede lateral, anterior ou posterior. Realizaram-se ANOVA de duplo fator com repetição e pós-teste de Newman-Keuls. Considerou-se significativo p inferior a 0,05. RESULTADOS: Durante a revascularização do miocárdio sem CEC, a pressão de oclusão de artéria pulmonar elevou-se de 17,7 ± 6,1 para 19,2 ± 6,5 (p < 0,001) e 19,4 ± 5,9 mmHg (p < 0,001), enquanto a pressão venosa central de 13,9 ± 5,4 subiu para 14,9 ± 5,9 (p = 0,007) e 15,1 ± 6,0 mmHg (p = 0,006). O débito cardíaco intermitente sofreu redução de 4,70 ± 1,43 para 4,23 ± 1,22 (p < 0,001) e 4,26 ± 1,27 L.min-1 (p < 0,001). Houve interação grupo-tempo significativa no débito cardíaco obtido por Doppler transesofágico, que sofreu redução no grupo lateral de 4,08 ± 1,99 para 2,84 ± 1,81 (p = 0,02) e 2,86 ± 1,73 L.min-1 (p = 0,02), e no fluxo sanguíneo aórtico, de 2,85 ± 1,39 para 1,99 ± 1,26 (p = 0,02) e 2,00 ± 1,21 L.min-1 (p = 0,02). Não se observaram outras alterações hemodinâmicas durante as anastomoses. CONCLUSÕES: Houve deterioração hemodinâmica significativa durante a revascularização do miocárdio sem CEC. Com o Doppler transesofágico detectou-se redução do débito cardíaco apenas no grupo lateral.

Hemodynamic Changes during Myocardial Revascularization without Extracorporeal Circulation

Cardiac positioning and stabilization during myocardial revascularization without extracorporeal circulation (ECC) may cause hemodynamic changes dependent to the surgical site. The objective of this study was to evaluate these changes during distal coronary anastomosis. Twenty adult patients undergoing myocardial revascularization without ECC were monitored by pulmonary artery catheter and transesophageal Echo Doppler. Hemodynamic data were collected at the following times before removing the stabilizer wall: (1) after volume adjustments, (2) at the beginning of distal anastomosis, and (3) after 5 minutes. Treated coronary arteries were grouped according to their location in the lateral, anterior, or posterior wall. Two-way ANOVA with repetition and Newman-Keuls post-test were used in the analysis. A p value < 0.05 was considered statically significant. During myocardial revascularization without ECC, pulmonary artery wedge pressure showed elevation from 17.7 ± 6.1 to 19.2 ± 6.5 (p < 0.001) and 19.4 ± 5.9 mmHg (p < 0.001), while the central venous pressure went from 13.9 ± 5.4 to 14.9 ± 5.9 mmHg (p = 0.007) and 15.1 ± 6.0 mmHg (p = 0.006). Intermittent cardiac output was reduced from 4.70 ± 1.43 to 4.23 ± 1.22 (p < 0.001) and 4.26 ± 1.25 L.min(-1) (p < 0.001). According to transesophageal Doppler, a significant group-time interaction was observed in cardiac output, which was reduced in the lateral group from 4.08 ± 1.99 to 2.84 ± 1.82 (p = 0.02) and 2.86 ± 1.73 L.min(-1) (p = 0.02), and aortic blood flow, which went from 2.85 ± 1.39 to 1.99 ± 1.26 (p = 0.02) and 2.00 ± 1.21 L.min(-1) (p = 0.02). Other hemodynamic changes were not observed during anastomoses. A significant hemodynamic deterioration was observed during myocardial revascularization without ECC. Transesophageal Doppler detected a decrease in cardiac output only in the lateral group.

Hemodynamic effects of PEEP in a porcine model of HCl‐induced mild acute lung injury

Positive end-expiratory pressure (PEEP) and sustained inspiratory insufflations (SI) during acute lung injury (ALI) are suggested to improve oxygenation and respiratory mechanics. We aimed to investigate the hemodynamic effects of PEEP with and without alveolar recruiting maneuver in a mild ALI model induced by inhalation of hydrochloric acid. Thirty-two pigs were randomly allocated into four groups (Control-PEEP, Control-SI, ALI-PEEP and ALI-SI). ALI was induced by intratracheal instillation of hydrochloric acid. PEEP values were progressively increased and decreased from 5, 10, 15 and 20 cmH2O in all groups. Three SIs maneuvers of 30 cmH2O for 20 s were applied to the assignable groups between each PEEP level. Transesophageal echocardiography (TEE), global hemodynamics, oxygenation indexes and gastric tonometry were measured 5 min after the maneuvers had been concluded and at each established value of PEEP (5, 10, 15 and 20 cmH2O). The cardiac index, ejection fraction and end-diastolic volume of right ventricle were significantly (P < 0.001) decreased with PEEP in both Control and ALI groups. Left ventricle echocardiography showed a significant decrease in end-diastolic volume at 20 cmH2O of PEEP (P < 0.001). SIs did not exert any significant hemodynamic effects either early (after 5 min) or late (after 3 h). In a mild ALI model induced by inhalation of hydrochloric acid, significant hemodynamic impairment characterized by cardiac function deterioration occurred during PEEP increment, but SI, probably due to low applied values (30 cmH2O), did not exert further negative hemodynamic effects. PEEP should be used cautiously in ALI caused by acid gastric content inhalation.