Couture Pierre, Denault André Y, Shi Yanfen, Deschamps Alain, Cossette Mariève, Pellerin Michel, Tardif Jean-Claude
Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T1C8, Canada.
Can J Anaesth. 2009 May;56(5):357-65. doi: 10.1007/s12630-009-9068-z. Epub 2009 Apr 2.
To evaluate the effects of anesthetic induction on bi-ventricular function in patients with known preoperative left ventricular (LV) diastolic dysfunction undergoing coronary artery bypass grafting surgery (CABG).
Fifty patients with diastolic dysfunction undergoing CABG were studied. Preoperative transthoracic echocardiographic (TTE) examination was performed on the day before surgery and transesophageal echocardiography (TEE) assessment was undertaken after induction of anesthesia with sufentanil, midazolam, isoflurane, and pancuronium. Mean arterial pressure (MAP) and heart rate (HR) were recorded. The diameters of the left atrium (LA) and right atrium (RA) and right ventricular (RV) end-diastolic area (EDA), end-systolic area (ESA) and fractional area change (FAC) were obtained from the apical 4-chamber view. The LV EDA, LV ESA and LV FAC were measured from a transgastric midpapillary view. Pulsed wave Doppler of the transmitral flow (TMF) and transtricuspid flow (TTF), pulmonary venous flow (PVF) and hepatic venous flow (HVF) were measured. Mitral (Em, Am) and tricuspid (Et, At) annulus velocities were assessed by tissue Doppler imaging (TDI). Assessment of diastolic dysfunction was graded from normal to severe using a validated score.
Following induction of anesthesia, HR decreased (66 +/- 12 vs 55 +/- 9 beats.min(-1), P < 0.0001) while MAP remained unchanged (86.1 +/- 9.0 vs 85.6 +/- 26.5 mmHg, P = 0.94). The diameters of the LA, RA and RV chambers increased, and these increases were associated with opposite changes in LV dimensions. The RV FAC decreased, but the LV FAC remained unchanged. While most Doppler velocities decreased (P < 0.05), a greater reduction in the atrial components of the TMF, TTF and TDI ratios was observed. The LV diastolic function score improved after induction of anesthesia (100% of patients with a score > or = = 3 pre-induction compared to 58% of patients with a score > or = 3 post-induction; P = 0.0004).
In patients with left ventricular diastolic dysfunction, cardiac dimensions and bi-ventricular filling patterns are significantly altered after induction of general anesthesia. These changes can be explained to some extent by a reduction in venous return with general anesthesia, reduced atrial contractility, and the effect of positive pressure ventilation. Although the LV diastolic function score improved after induction of anesthesia, it is difficult to dissociate this effect from that of altered loading conditions.
评估麻醉诱导对已知术前存在左心室（LV）舒张功能障碍且接受冠状动脉旁路移植术（CABG）患者双心室功能的影响。
研究了50例接受CABG且存在舒张功能障碍的患者。术前一天进行经胸超声心动图（TTE）检查，并在使用舒芬太尼、咪达唑仑、异氟烷和泮库溴铵诱导麻醉后进行经食管超声心动图（TEE）评估。记录平均动脉压（MAP）和心率（HR）。从心尖四腔心切面获取左心房（LA）、右心房（RA）直径以及右心室（RV）舒张末期面积（EDA）、收缩末期面积（ESA）和面积变化分数（FAC）。从经胃中乳头肌切面测量LV EDA、LV ESA和LV FAC。测量二尖瓣血流（TMF）、三尖瓣血流（TTF）、肺静脉血流（PVF）和肝静脉血流（HVF）的脉冲波多普勒。通过组织多普勒成像（TDI）评估二尖瓣（Em，Am）和三尖瓣（Et，At）环速度。使用经过验证的评分将舒张功能障碍评估从正常分级到重度。
麻醉诱导后，HR下降（66±12对55±9次/分钟，P<0.0001），而MAP保持不变（86.1±9.0对85.6±26.5 mmHg，P = 0.94）。LA、RA和RV腔直径增加，且这些增加与LV尺寸的相反变化相关。RV FAC下降，但LV FAC保持不变。虽然大多数多普勒速度下降（P<0.05），但观察到TMF、TTF和TDI比值的心房成分下降幅度更大。麻醉诱导后LV舒张功能评分改善（诱导前评分≥3分的患者为100%，诱导后评分≥3分的患者为58%；P = 0.0004）。
在左心室舒张功能障碍患者中，全身麻醉诱导后心脏尺寸和双心室充盈模式发生显著改变。这些变化在一定程度上可通过全身麻醉导致的静脉回流减少、心房收缩力降低以及正压通气的影响来解释。虽然麻醉诱导后LV舒张功能评分有所改善，但很难将这种影响与负荷条件改变的影响区分开来。
