Assessment of Left Ventricular Diastolic Function by Transesophageal Echocardiography Before Cardiopulmonary Bypass: Clinical Implications of a Restrictive Profile
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Noninvasive Determination of Vortex Formation Time Using Transesophageal Echocardiography During Cardiac Surgery
Published on: November 28, 2018
William Beaubien-Souligny1, Fanny Z Acero Brand1, Marien Lenoir2
1Department of Anesthesia and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
Insights
Assessing left ventricular diastolic dysfunction (LVDD) before cardiac surgery significantly improves mortality risk prediction. Restrictive LVDD, in particular, is linked to higher in-hospital mortality rates, guiding perioperative care.
Area of Science:
- Cardiology
- Cardiac Surgery
- Echocardiography
Background:
- Left ventricular (LV) diastolic function is crucial in cardiac surgery.
- Transesophageal echocardiography can assess LV diastolic function before cardiopulmonary bypass (CPB).
- The predictive value of LV diastolic dysfunction (LVDD) for mortality risk in this setting requires further investigation.
Purpose of the Study:
- To determine if assessing LVDD before CPB improves mortality risk prediction in cardiac surgery patients.
- To evaluate the association between different grades of LVDD and in-hospital mortality.
- To assess the impact of LVDD on the accuracy of existing mortality prediction scores.
Main Methods:
- Retrospective single-center cohort study of 760 patients undergoing cardiac surgery with CPB.
- LV diastolic function was graded (normal, grade 1, 2, or 3 restrictive) using transesophageal echocardiography before CPB.
- In-hospital mortality was the primary outcome; statistical analysis included odds ratios, confidence intervals, and reclassification metrics.
Main Results:
- Grade 3 LVDD was significantly associated with increased in-hospital mortality (OR: 19.39).
- LVDD assessment improved the prediction of in-hospital mortality when added to the Parsonnet score (NRI: 0.419, IDI: 0.0179).
- Difficult separation from CPB was more frequent in patients with grade 3 LVDD.
Conclusions:
- Restrictive left ventricular diastolic dysfunction (grade 3 LVDD) is an independent predictor of increased in-hospital mortality in cardiac surgery patients.
- LV diastolic function assessment enhances mortality risk prediction beyond traditional scores.
- Further research is needed to integrate these findings into perioperative management strategies.
Objective:
Left ventricular (LV) diastolic function can be assessed by transesophageal echocardiography before cardiopulmonary bypass in the setting of cardiac surgery. The objective of this study was to determine whether the assessment of LV diastolic dysfunction (LVDD) improves mortality risk prediction.
Design:
Retrospective single-center cohort study.
Setting:
Single tertiary cardiac surgery center.
Participants:
Data from patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) and for which an evaluation for LVDD was performed before CPB between February 1999 and November 2015.
Interventions:
Cases were reviewed retrospectively from a transesophageal echocardiography hemodynamic database. LV diastolic function was graded as normal, impaired relaxation (grade 1), pseudo-normalization (grade 2), or restrictive (grade 3) determined by mitral inflow waves, tissue Doppler imaging of the mitral annulus, and pulmonary venous flow. The main outcome was in-hospital mortality.
Measurements And Main Results:
A total of 760 patients were included, 144 (18.9%) patients with normal diastolic function, 331 (43.6%) patients with grade 1 LVDD, 218 (28.7%) patients with grade 2 LVDD, and 67 (8.8%) patients with grade 3 LVDD. In-hospital mortality occurred in 31 patients (4.1%). The presence of grade 3 LVDD was associated with an increased likelihood of in-hospital mortality (odds ratio [OR]: 19.39, confidence interval [CI]: 2.37-158.48, p = 0.006). In contrast, LV systolic dysfunction was not independently associated with increased mortality. When added to the Parsonnet score, the addition of diastolic function resulted in a net reclassification improvement of in-hospital mortality (NRI: 0.419 CI: 0.049-0.759, p = 0.02), and in integrated discrimination improvement (IDI: 0.0179 CI: 0.0049-0.031, p = 0.007). Difficult separation from CPB was observed more frequently in patients with grade 3 LVDD (62.9% v 36.1%, p = 0.01).
Conclusions:
In contrast to LV systolic dysfunction, restrictive LVDD is associated with an increased risk of in-hospital mortality in cardiac surgical patients. Further studies should explore how this information may be used by the attending anesthesiologist to tailor perioperative management.
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