Prevalence, Diagnosis, Perioperative Monitoring and Treatment of Right Ventricular Dysfunction and/or Pulmonary Arterial Hypertension in Cardiac Surgical Patients in Germany—A Postal Survey

Abstract

Background Sparse data are available on the prevalence of right ventricular dysfunction and/or pulmonary arterial hypertension in patients scheduled for cardiac surgery in Germany as well as on the intensity and modalities used for diagnosis, perioperative monitoring, and treatment of these comorbidities.

Methods A postal survey including questions on the prevalence of preoperative right ventricular dysfunction and/or pulmonary arterial hypertension in patients undergoing cardiac surgery in 2009 was sent to 81 German heart centers. Total 47 of 81 (58%) heart centers returned the questionnaires. The centers reported data on 51,095 patients, and 49.8% of the procedures were isolated coronary artery bypass grafting.

Results Data on the prevalence of preoperative pulmonary hypertension and/or right ventricular dysfunction were not available in 54% and 64.6% of centers. In the remaining hospitals, 19.5% of patients presented right heart dysfunction and 10% pulmonary arterial hypertension. Preoperative echocardiography was performed in only 45.3% of the coronary artery bypass grafting cases. Preoperative pharmacologic treatment of pulmonary hypertension or right ventricular dysfunction with oral sildenafil, inhaled prostanoids, or nitric oxide was initiated in 71% and 95.7% of the centers, respectively. Intra- and postoperative treatment was most frequently accomplished with phosphodiesterase-III inhibitors.

Conclusion The prevalence of preoperative right heart dysfunction and pulmonary arterial hypertension in cardiac surgical patients in Germany seems to be substantial. However, in more than 50% of the patients, no preoperative data on right ventricular function and pulmonary arterial pressure are available. This may lead to underestimation of perioperative risk and inappropriate management of this high-risk population.

Keywords

cardiac - pulmonary vascular resistance/hypertension - surgery - complications

Note

This abstract was presented at the annual meeting of the European Association of Cardiothoracic Anesthetists (EACTA) in Barcelona, Spain on June 7th, 2013.

Funding

This work was supported by institutional grants of the Department of Anesthesiology and Intensive Care Medicine, University of Lübeck and the Department of Anesthesiology, Heart and Diabetic Center NRW, Ruhr University of Bochum, Bad Oeynhausen, Germany. No external funding source has been involved.

• References

• 1 Haddad F, Couture P, Tousignant C, Denault AY. The right ventricle in cardiac surgery, a perioperative perspective: II. Pathophysiology, clinical importance, and management. Anesth Analg 2009; 108 (02) 422-433
• 2 Maslow AD, Regan MM, Panzica P, Heindel S, Mashikian J, Comunale ME. Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction. Anesth Analg 2002; 95 (06) 1507-1518
• 3 Boeken U, Feindt P, Litmathe J, Kurt M, Gams E. Intraaortic balloon pumping in patients with right ventricular insufficiency after cardiac surgery: parameters to predict failure of IABP support. Thorac Cardiovasc Surg 2009; 57 (06) 324-328
• 4 Haddad F, Denault AY, Couture P. , et al. Right ventricular myocardial performance index predicts perioperative mortality or circulatory failure in high-risk valvular surgery. J Am Soc Echocardiogr 2007; 20 (09) 1065-1072
• 5 Yadav H, Unsworth B, Fontana M. , et al. Selective right ventricular impairment following coronary artery bypass graft surgery. Eur J Cardiothorac Surg 2010; 37 (02) 393-398
• 6 Schosser R, Forst H, Racenberg J, Messmer K. Open chest and open pericardium affect the distribution of myocardial blood flow in the right ventricle. Basic Res Cardiol 1990; 85 (05) 508-518
• 7 Unsworth B, Casula RP, Kyriacou AA. , et al. The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision. Am Heart J 2010; 159 (02) 314-322
• 8 de Groote P, Millaire A, Foucher-Hossein C. , et al. Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure. J Am Coll Cardiol 1998; 32 (04) 948-954
• 9 Murninkas D, Alba AC, Delgado D. , et al. Right ventricular function and prognosis in stable heart failure patients. J Card Fail 2014; 20 (05) 343-349
• 10 Mohammed SF, Hussain I, AbouEzzeddine OF. , et al. Right ventricular function in heart failure with preserved ejection fraction: a community-based study. Circulation 2014; 130 (25) 2310-2320
• 11 Garatti A, Castelvecchio S, Di Mauro M, Bandera F, Guazzi M, Menicanti L. Impact of right ventricular dysfunction on the outcome of heart failure patients undergoing surgical ventricular reconstruction. Eur J Cardiothorac Surg 2015; 47 (02) 333-340 , discussion 340
• 12 Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16 (01) 9-13
• 13 Strumpher J, Jacobsohn E. Pulmonary hypertension and right ventricular dysfunction: physiology and perioperative management. J Cardiothorac Vasc Anesth 2011; 25 (04) 687-704
• 14 Fisher MR, Forfia PR, Chamera E. , et al. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med 2009; 179 (07) 615-621
• 15 Özpelit E, Akdeniz B, Özpelit EM. , et al. Impact of severe tricuspid regurgitation on accuracy of echocardiographic pulmonary artery systolic pressure estimation. Echocardiography 2015; 32 (10) 1483-1490
• 16 Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J 2003; 24 (09) 881-882
• 17 Nashef SA, Roques F, Sharples LD. , et al. EuroSCORE II. Eur J Cardiothorac Surg 2012; 41 (04) 734-744 , discussion 744–745
• 18 Janda S, Shahidi N, Gin K, Swiston J. Diagnostic accuracy of echocardiography for pulmonary hypertension: a systematic review and meta-analysis. Heart 2011; 97 (08) 612-622
• 19 Taleb M, Khuder S, Tinkel J, Khouri SJ. The diagnostic accuracy of Doppler echocardiography in assessment of pulmonary artery systolic pressure: a meta-analysis. Echocardiography 2013; 30 (03) 258-265
• 20 Carl M, Alms A, Braun J. , et al. S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system. Ger Med Sci 2010; 8: Doc12
• 21 Hillis LD, Smith PK, Anderson JL. , et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124 (23) e652-e735
• 22 Wijns W, Kolh P, Danchin N. , et al; Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI). Guidelines on myocardial revascularization. Eur Heart J 2010; 31 (20) 2501-2555
• 23 Rudski LG, Lai WW, Afilalo J. , et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23 (07) 685-713, quiz 786–788
• 24 Kastrup M, Markewitz A, Spies C. , et al. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand 2007; 51 (03) 347-358
• 25 Kastrup M, Carl M, Spies C, Sander M, Markewitz A, Schirmer U. Clinical impact of the publication of S3 guidelines for intensive care in cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand 2013; 57 (02) 206-213