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Early Left and Right Ventricular Response to Aortic Valve Replacement.
Anesth Analg 2017; 124(2):406-418A&A

Abstract

BACKGROUND

The immediate effect of aortic valve replacement (AVR) for aortic stenosis on perioperative myocardial function is unclear. Left ventricular (LV) function may be impaired by cardioplegia-induced myocardial arrest and ischemia-reperfusion injury, especially in patients with LV hypertrophy. Alternatively, LV function may improve when afterload is reduced after AVR. The right ventricle (RV), however, experiences cardioplegic arrest without benefiting from improved loading conditions. Which of these effects on myocardial function dominate in patients undergoing AVR for aortic stenosis has not been thoroughly explored. Our primary objective is thus to characterize the effect of intraoperative events on LV function during AVR using echocardiographic measures of myocardial deformation. Second, we evaluated RV function.

METHODS

In this supplementary analysis of 100 patients enrolled in a clinical trial (NCT01187329), 97 patients underwent AVR for aortic stenosis. Of these patients, 95 had a standardized intraoperative transesophageal echocardiographic examination of systolic and diastolic function performed before surgical incision and repeated after chest closure. Echocardiographic images were analyzed off-line for global longitudinal myocardial strain and strain rate using 2D speckle-tracking echocardiography. Myocardial deformation assessed at the beginning of surgery was compared with the end of surgery using paired t tests corrected for multiple comparisons.

RESULTS

LV volumes and arterial blood pressure decreased, and heart rate increased at the end of surgery. Echocardiographic images were acceptable for analysis in 72 patients for LV strain, 67 for LV strain rate, and 54 for RV strain and strain rate. In 72 patients with LV strain images, 9 patients required epinephrine, 22 required norepinephrine, and 2 required both at the end of surgery. LV strain did not change at the end of surgery compared with the beginning of surgery (difference: 0.7 [97.6% confidence interval, -0.2 to 1.5]%; P = 0.07), whereas LV systolic strain rate improved (became more negative) (-0.3 [-0.4 to -0.2] s; P < 0.001). In contrast, RV systolic strain worsened (became less negative) at the end of surgery (difference: 4.6 [3.1 to 6.0]%; P < 0.001) although RV systolic strain rate was unchanged (0.0 [97.6% confidence interval, -0.1 to 0.1]; P = 0.83).

CONCLUSIONS

LV function improved after replacement of a stenotic aortic valve demonstrated by improved longitudinal strain rate. In contrast, RV function, assessed by longitudinal strain, was reduced.

Authors+Show Affiliations

From the Departments of *Cardiothoracic Anesthesia and †Outcomes Research, Cleveland Clinic, Cleveland, Ohio; ‡Anesthesia Institute, §Department of Cardiothoracic Anesthesia, ‖Department of Quantitative Health Sciences, ¶Department of Cardiovascular Medicine, and #Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

26702865

Citation

Duncan, Andra E., et al. "Early Left and Right Ventricular Response to Aortic Valve Replacement." Anesthesia and Analgesia, vol. 124, no. 2, 2017, pp. 406-418.
Duncan AE, Sarwar S, Kateby Kashy B, et al. Early Left and Right Ventricular Response to Aortic Valve Replacement. Anesth Analg. 2017;124(2):406-418.
Duncan, A. E., Sarwar, S., Kateby Kashy, B., Sonny, A., Sale, S., Alfirevic, A., ... Sessler, D. I. (2017). Early Left and Right Ventricular Response to Aortic Valve Replacement. Anesthesia and Analgesia, 124(2), pp. 406-418. doi:10.1213/ANE.0000000000001108.
Duncan AE, et al. Early Left and Right Ventricular Response to Aortic Valve Replacement. Anesth Analg. 2017;124(2):406-418. PubMed PMID: 26702865.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Early Left and Right Ventricular Response to Aortic Valve Replacement. AU - Duncan,Andra E, AU - Sarwar,Sheryar, AU - Kateby Kashy,Babak, AU - Sonny,Abraham, AU - Sale,Shiva, AU - Alfirevic,Andrej, AU - Yang,Dongsheng, AU - Thomas,James D, AU - Gillinov,Marc, AU - Sessler,Daniel I, PY - 2015/12/26/pubmed PY - 2017/7/20/medline PY - 2015/12/26/entrez SP - 406 EP - 418 JF - Anesthesia and analgesia JO - Anesth. Analg. VL - 124 IS - 2 N2 - BACKGROUND: The immediate effect of aortic valve replacement (AVR) for aortic stenosis on perioperative myocardial function is unclear. Left ventricular (LV) function may be impaired by cardioplegia-induced myocardial arrest and ischemia-reperfusion injury, especially in patients with LV hypertrophy. Alternatively, LV function may improve when afterload is reduced after AVR. The right ventricle (RV), however, experiences cardioplegic arrest without benefiting from improved loading conditions. Which of these effects on myocardial function dominate in patients undergoing AVR for aortic stenosis has not been thoroughly explored. Our primary objective is thus to characterize the effect of intraoperative events on LV function during AVR using echocardiographic measures of myocardial deformation. Second, we evaluated RV function. METHODS: In this supplementary analysis of 100 patients enrolled in a clinical trial (NCT01187329), 97 patients underwent AVR for aortic stenosis. Of these patients, 95 had a standardized intraoperative transesophageal echocardiographic examination of systolic and diastolic function performed before surgical incision and repeated after chest closure. Echocardiographic images were analyzed off-line for global longitudinal myocardial strain and strain rate using 2D speckle-tracking echocardiography. Myocardial deformation assessed at the beginning of surgery was compared with the end of surgery using paired t tests corrected for multiple comparisons. RESULTS: LV volumes and arterial blood pressure decreased, and heart rate increased at the end of surgery. Echocardiographic images were acceptable for analysis in 72 patients for LV strain, 67 for LV strain rate, and 54 for RV strain and strain rate. In 72 patients with LV strain images, 9 patients required epinephrine, 22 required norepinephrine, and 2 required both at the end of surgery. LV strain did not change at the end of surgery compared with the beginning of surgery (difference: 0.7 [97.6% confidence interval, -0.2 to 1.5]%; P = 0.07), whereas LV systolic strain rate improved (became more negative) (-0.3 [-0.4 to -0.2] s; P < 0.001). In contrast, RV systolic strain worsened (became less negative) at the end of surgery (difference: 4.6 [3.1 to 6.0]%; P < 0.001) although RV systolic strain rate was unchanged (0.0 [97.6% confidence interval, -0.1 to 0.1]; P = 0.83). CONCLUSIONS: LV function improved after replacement of a stenotic aortic valve demonstrated by improved longitudinal strain rate. In contrast, RV function, assessed by longitudinal strain, was reduced. SN - 1526-7598 UR - https://www.unboundmedicine.com/medline/citation/26702865/Early_Left_and_Right_Ventricular_Response_to_Aortic_Valve_Replacement_ L2 - http://Insights.ovid.com/pubmed?pmid=26702865 DB - PRIME DP - Unbound Medicine ER -