Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery
-
* Corresponding author: Alexandre Mebazaa alexandre.mebazaa@lrb.aphp.fr
1 Department of Anaesthesia and Intensive care, INSERM UMR 942, Lariboisière Hospital, University of Paris 7 - Diderot, 2 rue Ambroise Paré, 75010 Paris, France
2 Thessaloniki Heart Institute, St Luke's Hospital, Thessaloniki, Greece, 552 36
3 Intensive Care Unit, Department of Internal Medicine, University Hospital Zurich, Raemistrasse 100, CH 8091 Zurich, Switzerland
4 Department of Anaesthesiology and Intensive Care Medicine, Medical University Graz, 8036 Graz, Austria
5 APHP, Hôpital Bichat-Claude Bernard, Département d'Anesthésie-Réanimation, University Paris 7 Denis Diderot, Unité INSERM U 698, Paris, France
6 Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden
7 Department of Nephrology Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy
8 Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, 1105 Amsterdam, Netherlands
9 Department for Cardiothoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
10 Institute of Anaesthesiology Heart and Diabetes-Center, Nordrhein-Westfalen University Clinic of Ruhr-University Bochum, Georgstrasse 11, D-32545 Bad Oeynhausen, Germany
11 Department of Cardio-Vascular Surgery, CHUV, Rue du Bugnon 46, 10113 Lausanne, Switzerland
12 Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, 10098 Berlin, Germany
13 Department of Vascular Surgery, Erasmus Medical Centre, 's Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands
14 Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico S Donato, 20097 Milan, Italy
15 Department of Anesthesia, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
16 Department of Anesthesia, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, ER Schmid Institute of Anaesthesiology, Division of Cardiovascular Anaesthesia, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
17 Department of Anesthesia, University Hospital, University of Basel, 4031 Basel, Switzerland
18 Institute of Anaesthesiology, Division of Cardiovascular Anaesthesia, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
19 Division of Thoracic surgery, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
20 University Hospital Zürich, CH 8091 Zürich, Rämistr. 100, Switzerland
Critical Care 2010, 14:201 doi:10.1186/cc8153
Published: 28 April 2010Abstract
Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery.