1

André Denault FRCPC, CSPQ, ABIM-CCM Professeur agrégé de cliniqueDépartement d’anesthésiologie

Institut de Cardiologie de MontréalService des soins intensifs

Centre Hospitalier Universitaire de Montréal

Instabilité hémodynamique

Cours de science de base2007

Fondation de la Recherche en Santé du QuébecCAS/Abbott Laboratories Ltd Career in Anesthesia

Montreal Heart Institute Foundation

Consultant for Actelion

Support and disclosure

Étiology of hemodynamic

instability in cardiac surgery

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0

20

40

60

80

100

PASP RAP PCWP RAP / PCWP

mm

Hg

RV Dysfunction (n = 17)RV and LV Dysfunction (19)LV Dysfunction (n = 18)Normal (n = 21)

0

20

40

60

80

100

%

Davila-Roman VG, Ann Thorac Surg 1995;60:1081-6

Right Ventricular Dysfunction in Low Output Syndrome After Cardiac Operations: Assessment by TEE

*

*

N = 75

Critical Care Medicine 2002

3

Diagnostic concordance

Admission SICU 2hr SICU 4hr0.33 0.47 0.28Kappa Kappa Kappa

The hemodynamically unstable patient in the intensive care unit:

Hemodynamic vs TEE monitoring

Limitations of the Swan-Ganz catheterHypovolemiaHypovolemia

LowLow PaPPaP

Pseudo-normal PapSwan Ganz

LV LV dysfunctiondysfunction

ElevatedElevated PaPPaP

Echographic diagnosis

48 evaluations had2 causes of hemodynamic instability or more (82%)

72% diastolic dysfunction45% RV systolic dysfunction38% LV systolic dysfunction

29% hypovolemia

Our hypothesis

4

2005

LV hypertrophy: wall thickness

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Systole Diastole

1 2 3 4 5 6 7

200

100

80

60

40

20

0 LeftLeft ventricularventricularpressurepressure

Left atrial pressure LeftLeft atrial pressure atrial pressure

EKGEKG

ArterialArterial pressurepressure

Adapted from Bettex D. Échocardiographie transoesophagienne en anesthésie-réanimation 1997

Pre

ssur

e

Volume

Diastolic function

Systolic function

Pre

ssur

e

Volume

Pressure-Volume loop

LVEDVLVESV

LVESP

LVEDP

←Stroke volume→

6

SV = LVEF x LVEDV

Cardiac performance

Systolic function

Filling

Diastolic function

LVEF = SVLVEF = SVLVEDVLVEDV

Pre

ssur

e

Volume

Strokevolume

LVEDVLVESV

LVESP

LVEDP

Pre

ssio

n

Volume

Pressure-volume loop

Adapted from Bettex D. Échocardiographie transoesophagienne en anesthésie-réanimation 1997

1 2 3 4 5 6 7

200

100

80

60

40

20

0LeftLeft ventricularventricularpressurepressure

Left atrial pressure LeftLeft atrial pressure atrial pressure

EKGEKG

ArterialArterial pressurepressure

Stroke Stroke workwork

Pre

ssur

e

Volume

Pressure-Volume loop estimation

ESA EDA

Stroke volume = COHR

LVEDP Wedge

LVESPSAP

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LV performance

• Load dependantCardiac outputLVEF and FACLV stroke workdP/dTMyocardial Performance Index

• Load independentElastance

Hype

r rea

ctor

Health

y, yo

ung

Depressed

Adequ

ate

Shock

Adapted from Shoemaker Textbook of critical care Saunders 1989

LV stroke work

Critical Care Medicine 2004

8

200 60 80 10040

Bouchard et al CCM 2004

Normal range

Myocardial dysfonction after sucessfulresuscitation from cardiac arrest

Gazmuri RJ et al. CCM 1996

Pres

sure

Volume

Left ventricular dysfunction

9

Volume (ml)40 100 160

100

10

Stroke volume 60 ml 60 mlLVSW (X 0.0136) 60 X (100-10) 60 X (100-10)

Limitation of LVSW measurement

Pres

sure

(mm

Hg)

Stroke Work Stroke Work

Stroke Work Stroke Work

LVEF 60 ml/100ml 60 ml/160ml= 60% = 40%

Limitation of LVSW measurement

Volume (ml)40 100 160

100

10

Pres

sure

(mm

Hg)

Contractility

Pre

ssur

e

Volume

Pre

ssur

e

Volume

10

Gorcsan J. Circulation 1994;89:180-90

Assessment of the immediate effects of cardiopulmonary bypass on left ventricular

performance by on-line pressure-area relations

dP/dT

1-Estimation of LV function in mitral regurgitation2-Estimation of left atrial systolic pressure3-Estimation of systolic arterial pressure: is your radial arterial pressure reliable?

Aortique et radiale

Radial pressure

Femoral pressure

69 yo woman after MVR and AVR

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Radial pressure = 111 mmHg

Presssure gradient = 111 mmHg = LVESP - LAP

LV systolic pressure = PG + LAP ≈ Aortic pressure= 111 mmHg + pulmonary artery wedge pressure (v wave)= 111 mmHg + 18 mmHg

Aortic pressure = 129 mmHg

Aortic pressure measured by surgeon = 125 mmHg

Prevalence of a central to radial pressure gradient in high-risk surgery

Dr Antonio Su

Percentage of central-to-radial gradients in complex surgeries

N = 60

12

René Magritte

Why is this patient hemodynamically unstable?

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2D Longitudinal strain rate

Inferior wall

Anterior wall

JACC 1997

14

Salem

British Journal Anesthesia 2006N = 3024

Volume

Pre

ssur

e

Diastolic dysfunction

End-systolic areaEnd-diastolic area

Wedge = 5 mmHg

15

Adapté de Khoury et al JASE 2004

Summary

Evaluation of diastolic fillingof left ventricle in healthand disease: Doppler

echocardiography is the clinician's Rosetta Stone

Nishimura RA JACC 1997

16

17

Anesth Analgesia 2001;92:291-8

Canadian J Anesthesia 2006

Grade I: relaxation abnormality

LVV

LVP

18

76 yo woman with aortic stenosis

A A wavewave

EmAm

EA

EmAm

SAPSAP

PAPPAPCVPCVP

Grade III: Increased Chamber Stifness

LVV

LVP

62 yo patient unstable after AVR

19

Beginnning post-bypass

End post-bypass

Chamber Dilatation

LVV

LVP

Systolic Failure

Normal

Normal diastolicchamberdistensibility

Left

Ven

tricu

larP

ress

ure

Left Ventricular Volume

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Impaired Left Ventricular Filling Due to Right Ventricular Pressure Overload inPrimary Pulmonary Hypertension*Noninvasive Monitoring Using MRI

Marcus JT Chest 2001;119:1761-5

Pericardial Restraint

LVV

LVPPericardialThoracic

Abdominal

Kaplan Cardiac anesthesia 1998

Effet de la fréquence cardiaque sur la fonction diastolique

Volume (mL /m2)

Pres

sure

(mm

Hg)

50

40

30

20

10

50

0 20 40 60 80

84 bmp110 bmp135 bmp

21

Hemodynamically unstableafter cardiac surgery: paced

Slow down the pacemaker

Hemodynamically unstableafter cardiac surgery

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Noradrenaline 4ug/min Noradrenaline 0.5 ug/min

Homme de 70 ans instable après RVA

100 mmHg 100 mmHg

Unexpected hemodynamicinstability. What happened?

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LVOT obstruction

Courtesy of Gaudiani

Normally

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Fearful consequence

ME

With permission from Lang et al JASE 2005;18:1440-1463

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JASE 2007 (In press)

Right ventricular pressure monitoring

ME: Normal RV waveform

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HVF: RV dysfunctionPra

Prv

RA and RV pressure waveform correlation

HVF

A wave

V wave Abnormal RV diastolic slope

56 yo woman: CABG, MVR and LV remodeling

*

Effect of adrenalinand thoracic closure

End of CPB Adrenalin Thoracic closure

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Évolution ScO2

Effect of adrenalin upon weaning from CPB

RV dysfunction impact

Another confounding factor

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Right ventricular outflow tract obstruction

Right ventricular outflow tract obstruction

Right ventricular outflow tract obstruction

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Septal interaction

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38 yo woman with grade IV SHA

Takotsubo syndrome

In summaryHemodynamic instability often result from several mechanismsThe concept of the pressure-volume allow the understanding of these various causesEvery diagnosis can be diagnosed with TEE and has associated hemodynamic and ECG cluesThe hemodynamic clues are more often based on the appearance of the waveform rather than absolute pressure valuesDiastolic dysfunction or filling abnormalities is invariably present with or without systolic dysfunctionThe treatment of hemodynamic instability should be based on the underlying mechanism

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L’équipe de recherche:

Denis Babin MSc Inh

Jean-Claude Tardif MD FRCP

Alain Deschamps MD FRCPC PhD

Jean Lambert PhDBiostatistics

Thesis director

Pierre Couture MD FRCPC

Louis P.PerraultMD PhD FRCSC