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Myocardial performance index with sevoflurane-pancuronium versus fentanyl-midazolam-pancuronium in infants with a
Catherine M Ikemba1, Jason T Su, Stephen A Stayer
1Section of Pediatric Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Dallas, Texas, USA.
Insights
Anesthesia with fentanyl-midazolam or sevoflurane did not alter myocardial performance index (MPI) in infants with a single ventricle. However, fentanyl-midazolam decreased Doppler tissue imaging (DTI) velocities, indicating reduced ventricular function.
Area of Science:
- Pediatric Cardiology
- Anesthesiology
- Echocardiography
Background:
- Congenital heart disease with a functional single ventricle presents unique challenges for cardiac and noncardiac surgery.
- Conventional echocardiographic ejection fraction is unreliable in single-ventricle physiology due to altered geometry.
- Myocardial performance index (MPI) and Doppler tissue imaging (DTI) offer geometry-independent assessments of ventricular function.
Purpose of the Study:
- To evaluate the impact of two anesthetic regimens on ventricular function in infants with a functional single ventricle.
- Specifically, to assess changes in MPI and DTI parameters under fentanyl-midazolam and sevoflurane anesthesia.
Main Methods:
- A randomized study of 30 infants (4-12 months) with a functional single ventricle.
- Patients received either fentanyl-midazolam or sevoflurane anesthesia.
- Transthoracic echocardiography measured MPI and DTI at baseline and two anesthetic dose levels.
Main Results:
- MPI remained unchanged from baseline in both the fentanyl-midazolam and sevoflurane groups.
- DTI systolic (S-wave) and early diastolic (E-wave) velocities in lateral ventricular walls were unchanged with sevoflurane.
- Fentanyl-midazolam significantly decreased DTI S- and E-wave velocities, suggesting impaired longitudinal systolic and diastolic function.
Conclusions:
- MPI, a global measure of ventricular function, is unaffected by standard doses of fentanyl-midazolam or sevoflurane in infants with a functional single ventricle.
- Sevoflurane appears to preserve longitudinal ventricular function as assessed by DTI, while fentanyl-midazolam may impair it.
Background:
Patients with congenital heart disease characterized by a functional single ventricle make up an increasing number of patients presenting for cardiac or noncardiac surgery. Conventional echocardiographic methods to measure left ventricular function, i.e., ejection fraction, are invalid in these patients because of altered ventricular geometry. Two recently described Doppler echocardiographic modalities, the myocardial performance index and Doppler tissue imaging, can be applied to single-ventricle patients because they are independent of ventricular geometry. This study assessed the changes in myocardial performance index and Doppler tissue imaging in response to two anesthetic regimens, fentanyl-midazolam-pancuronium and sevoflurane-pancuronium.
Methods:
Thirty patients aged 4-12 months with a functional single ventricle were randomized to receive fentanyl-midazolam or sevoflurane. Myocardial performance index and Doppler tissue imaging were measured by transthoracic echocardiography at baseline and two clinically relevant dose levels.
Results:
Sixteen patients receiving sevoflurane and 14 receiving fentanyl-midazolam were studied. Myocardial performance index was unchanged from baseline with either agent (fentanyl-midazolam: 0.50 +/- 15 baseline vs. 0.51 +/- 0.15 at dose 2; sevoflurane: 0.42 +/- 0.14 baseline vs. 0.46 +/- 0.09 at dose 2). Doppler tissue imaging S (systolic)- and E (early diastolic)-wave velocities in the lateral ventricular walls at the level of the atrioventricular valve annulus were unchanged in the sevoflurane group; however, both Doppler tissue imaging S- and E-wave velocities were decreased significantly from baseline at dose 1 and dose 2 with fentanyl-midazolam, consistent with decreased longitudinal systolic and diastolic ventricular function.
Conclusions:
Myocardial performance index, a global measurement of combined systolic and diastolic ventricular function, is not affected by commonly used doses of fentanyl-midazolam or sevoflurane in infants with a functional single ventricle.
