Labus Jakob, Foit André, Mehler Oliver, Rahmanian Parwis, Böttiger Bernd W, Wetsch Wolfgang A, Mathes Alexander
Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany.
Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany.
J Cardiothorac Vasc Anesth. 2023 Feb;37(2):221-231. doi: 10.1053/j.jvca.2022.10.025. Epub 2022 Oct 29.
Noninvasive echocardiographic analysis of left ventricular (LV) myocardial work (MW) enables insights into cardiac mechanics, contractility, and efficacy beyond ejection fraction (EF) and global longitudinal strain (GLS). However, there are limited perioperative data on patients undergoing coronary artery bypass graft (CABG) surgery. The authors aimed to describe the feasibility and the intraoperative course of this novel assessment tool of ventricular function in these patients, and compare it to conventional 2-dimensional (2D) and 3-dimensional (3D) echocardiographic parameters and strain analysis.
A prospective observational study.
At a single university hospital.
Twenty-five patients with preoperative preserved LV and right ventricular function, sinus rhythm, without significant heart valve disease or pulmonary hypertension, and an uncomplicated intraoperative course scheduled for isolated on-pump CABG surgery.
Transesophageal echocardiography (TEE) was performed intraoperatively after the induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). All measurements were performed under stable hemodynamic conditions, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min.
The EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LVEF, LV GLS, LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). The MW analysis was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF during the intraoperative interval, GLS deteriorated significantly after CABG compared to assessment after induction of anesthesia (T1 v T2, -13.3 ± 3.0% v -11.6 ± 3.1%; p = 0.012). The GWI declined significantly after surgery (T1 v T2, 1,224 ± 312 mmHg% v 940 ± 267 mmHg%; p < 0.001), as well as GCW (T1 v T2, 1,460 ± 312 mmHg% v 1,244 ± 336 mmHg%; p = 0.005). The GWW increased after CABG (T1 v T2, 143 mmHg% (IQR 99-183) v 251 mmHg% (IQR 179-361); p < 0.001), and GWE decreased (T1 v T2, 89% (IQR 85-92) v 80% (IQR 75-87); p < 0.001). There were no significant changes in the values of 2D and 3D EF, GLS, GWI, GCW, GWW, and GWE before and after sternal closure (T2 v T3).
The intraoperative analysis of noninvasive echocardiographically-assessed LV MW indices is feasible. In the short-term period after uncomplicated on-pump CABG, GLS, as well as global and constructive MW, decreased, whereas wasted work increased, resulting in a less efficient left ventricle. None of these aspects was detected by conventional echocardiographic parameters. Therefore, strain and MW analysis might be more sensitive parameters in detecting myocardial dysfunction by TEE in the perioperative setting, adding information on perioperative cardiac energetics.
对左心室（LV）心肌做功（MW）进行无创超声心动图分析，能够深入了解心脏力学、收缩性以及射血分数（EF）和整体纵向应变（GLS）之外的心脏效能。然而，关于接受冠状动脉旁路移植术（CABG）的患者围手术期数据有限。作者旨在描述这种新型心室功能评估工具在这些患者中的可行性及术中过程，并将其与传统二维（2D）和三维（3D）超声心动图参数及应变分析进行比较。
一项前瞻性观察性研究。
在一家大学医院。
25例术前左心室和右心室功能保留、窦性心律、无明显心脏瓣膜疾病或肺动脉高压且计划进行单纯体外循环CABG手术且术中过程无并发症的患者。
麻醉诱导后（T1）、体外循环结束后（T2）以及胸骨关闭后（T3）术中行经食管超声心动图（TEE）检查。所有测量均在稳定的血流动力学条件下、窦性心律或心房起搏以及去甲肾上腺素≤0.1μg/kg/min的血管升压药支持下进行。
使用EchoPAC v204软件（GE Vingmed Ultrasound AS，挪威）分析二维和三维左心室射血分数（LVEF）、左心室GLS、左心室整体做功指数（GWI）、左心室整体建设性做功（GCW）、左心室整体无用功（GWW）和左心室整体做功效率（GWE）。MW分析在所有患者中均可行。虽然术中二维和三维EF值无显著差异，但与麻醉诱导后评估相比，CABG术后GLS显著恶化（T1对比T2，-13.3±3.0%对比-11.6±3.1%；p = 0.012）。术后GWI显著下降（T1对比T2，1224±312 mmHg%对比940±267 mmHg%；p < 0.001），GCW也下降（T1对比T2，1460±312 mmHg%对比1244±336 mmHg%；p = 0.005）。CABG术后GWW增加（T1对比T2，143 mmHg%（四分位间距99 - 183）对比251 mmHg%（四分位间距179 - 361）；p < 0.001），GWE降低（T1对比T2，89%（四分位间距85 - 92）对比80%（四分位间距75 - 87）；p < 跟0.001）。胸骨关闭前后（T2对比T3）二维和三维EF、GLS、GWI、GCW、GWW和GWE值无显著变化。
无创超声心动图评估的左心室MW指标的术中分析是可行的。在单纯体外循环CABG术后短期内，GLS以及整体和建设性MW降低，而无用功增加，导致左心室效率降低。这些方面均未被传统超声心动图参数检测到。因此，应变和MW分析可能是TEE在围手术期检测心肌功能障碍时更敏感的参数，可提供围手术期心脏能量学方面的信息。
