1 André Denault FRCPC, CSPQ, ABIM-CCM Professeur agrégé de clinique Département d’anesthésiologie Institut de Cardiologie de Montréal Service des soins intensifs Centre Hospitalier Universitaire de Montréal Instabilité hémodynamique Cours de science de base 2007 Fondation de la Recherche en Santé du Québec CAS/Abbott Laboratories Ltd Career in Anesthesia Montreal Heart Institute Foundation Consultant for Actelion Support and disclosure Étiology of hemodynamic instability in cardiac surgery
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André Denault FRCPC, CSPQ, ABIM-CCM Professeur agrégé de cliniqueDépartement d’anesthésiologie
Institut de Cardiologie de MontréalService des soins intensifs
Centre Hospitalier Universitaire de Montréal
Instabilité hémodynamique
Cours de science de base2007
Fondation de la Recherche en Santé du QuébecCAS/Abbott Laboratories Ltd Career in Anesthesia
Left atrial pressure LeftLeft atrial pressure atrial pressure
EKGEKG
ArterialArterial pressurepressure
Adapted from Bettex D. Échocardiographie transoesophagienne en anesthésie-réanimation 1997
Pre
ssur
e
Volume
Diastolic function
Systolic function
Pre
ssur
e
Volume
Pressure-Volume loop
LVEDVLVESV
LVESP
LVEDP
←Stroke volume→
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SV = LVEF x LVEDV
Cardiac performance
Systolic function
Filling
Diastolic function
LVEF = SVLVEF = SVLVEDVLVEDV
Pre
ssur
e
Volume
Strokevolume
LVEDVLVESV
LVESP
LVEDP
Pre
ssio
n
Volume
Pressure-volume loop
Adapted from Bettex D. Échocardiographie transoesophagienne en anesthésie-réanimation 1997
1 2 3 4 5 6 7
200
100
80
60
40
20
0LeftLeft ventricularventricularpressurepressure
Left atrial pressure LeftLeft atrial pressure atrial pressure
EKGEKG
ArterialArterial pressurepressure
Stroke Stroke workwork
Pre
ssur
e
Volume
Pressure-Volume loop estimation
ESA EDA
Stroke volume = COHR
LVEDP Wedge
LVESPSAP
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LV performance
• Load dependantCardiac outputLVEF and FACLV stroke workdP/dTMyocardial Performance Index
• Load independentElastance
Hype
r rea
ctor
Health
y, yo
ung
Depressed
Adequ
ate
Shock
Adapted from Shoemaker Textbook of critical care Saunders 1989
LV stroke work
Critical Care Medicine 2004
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200 60 80 10040
Bouchard et al CCM 2004
Normal range
Myocardial dysfonction after sucessfulresuscitation from cardiac arrest
Gazmuri RJ et al. CCM 1996
Pres
sure
Volume
Left ventricular dysfunction
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Volume (ml)40 100 160
100
10
Stroke volume 60 ml 60 mlLVSW (X 0.0136) 60 X (100-10) 60 X (100-10)
Limitation of LVSW measurement
Pres
sure
(mm
Hg)
Stroke Work Stroke Work
Stroke Work Stroke Work
LVEF 60 ml/100ml 60 ml/160ml= 60% = 40%
Limitation of LVSW measurement
Volume (ml)40 100 160
100
10
Pres
sure
(mm
Hg)
Contractility
Pre
ssur
e
Volume
Pre
ssur
e
Volume
10
Gorcsan J. Circulation 1994;89:180-90
Assessment of the immediate effects of cardiopulmonary bypass on left ventricular
performance by on-line pressure-area relations
dP/dT
1-Estimation of LV function in mitral regurgitation2-Estimation of left atrial systolic pressure3-Estimation of systolic arterial pressure: is your radial arterial pressure reliable?
With permission from Lang et al JASE 2005;18:1440-1463
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JASE 2007 (In press)
Right ventricular pressure monitoring
ME: Normal RV waveform
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HVF: RV dysfunctionPra
Prv
RA and RV pressure waveform correlation
HVF
A wave
V wave Abnormal RV diastolic slope
56 yo woman: CABG, MVR and LV remodeling
*
Effect of adrenalinand thoracic closure
End of CPB Adrenalin Thoracic closure
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Évolution ScO2
Effect of adrenalin upon weaning from CPB
RV dysfunction impact
Another confounding factor
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Right ventricular outflow tract obstruction
Right ventricular outflow tract obstruction
Right ventricular outflow tract obstruction
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Septal interaction
30
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38 yo woman with grade IV SHA
Takotsubo syndrome
In summaryHemodynamic instability often result from several mechanismsThe concept of the pressure-volume allow the understanding of these various causesEvery diagnosis can be diagnosed with TEE and has associated hemodynamic and ECG cluesThe hemodynamic clues are more often based on the appearance of the waveform rather than absolute pressure valuesDiastolic dysfunction or filling abnormalities is invariably present with or without systolic dysfunctionThe treatment of hemodynamic instability should be based on the underlying mechanism