Department of Anaesthesia and Intensive care, INSERM UMR 942, Lariboisière Hospital, University of Paris 7 - Diderot, 2 rue Ambroise Paré, Paris, France.
Crit Care. 2010;14(2):201. doi: 10.1186/cc8153. Epub 2010 Apr 28.
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.
围术期超过 20%的心脏手术患者会出现急性心功能障碍，但目前的急性心力衰竭（HF）分类并不适用于这一时期。主要围术期风险指标包括不稳定型冠状动脉综合征、失代偿性 HF、严重心律失常和瓣膜疾病。临床危险因素包括心脏病史、代偿性 HF、脑血管疾病、糖尿病、肾功能不全和高危手术。EuroSCORE 可可靠预测年龄<80 岁患者的围术期心血管变化。术前 B 型利钠肽水平是另一个风险分层因素。在心脏手术中积极保护心功能是一个主要目标。挥发性麻醉剂和左西孟旦似乎是有前途的心脏保护剂，但仍需要大型试验来评估最佳心脏保护剂和最佳方案。监测的目的是早期发现和评估围术期心血管功能障碍的机制。理想情况下，应通过血流动力学参数的“动态”测量来评估容量状态。首先通过超声心动图评估心功能，然后使用肺动脉导管（尤其是在右心功能障碍时）。如果血容量和心功能处于正常范围，则心血管功能障碍很可能与血管功能障碍有关。在治疗心肌功能障碍时，可考虑以下单独或联合使用的方法：低至中等剂量的多巴酚丁胺和肾上腺素、米力农或左西孟旦。在血管扩张性低血压中，使用去甲肾上腺素维持足够的灌注压。在使用血管加压素的患者中，通过反复评估容量来排除低血容量。心脏手术中最佳的围术期正性肌力药/血管加压药的使用仍存在争议，需要进一步开展大型多中心研究。心脏手术围术期心脏损伤的分类应基于发生时间（心脏切开前、脱机失败、心脏切开后）和患者病情的血液动力学严重程度（崩溃和燃烧、快速恶化、稳定但依赖正性肌力药）。对于疑似冠状动脉低灌注引起的心脏功能障碍，强烈建议使用主动脉内球囊泵。在终末器官功能障碍出现之前，应考虑心室辅助装置。体外膜肺氧合是一种作为恢复和/或决策桥梁的优雅解决方案。本文根据欧洲专家的意见，为心脏手术围术期 HF 提供了实用的管理建议。它还强调需要进行大型调查和研究，以评估心脏手术围术期 HF 的最佳管理方法。
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