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Clinical review : practical recommendations on the management of perioperative heart failure in cardiac surgery

Mebazaa, Alexandre and Pitsis, Antonis A. and Rudiger, Alain and Toller, Wolfgang and Longrois, Dan and Ricksten, Sven-Erik and Bobek, Ilona and De Hert, Stefan and Wieselthaler, Georg and Schirmer, Uwe and von Segesser, Ludwig K. and Sander, Michael and Poldermans, Don and Ranucci, Marco and Karpati, Peter C. J. and Wouters, Patrick and Seeberger, Manfred and Schmid, Edith R. and Weder, Walter and Follath, Ferenc. (2010) Clinical review : practical recommendations on the management of perioperative heart failure in cardiac surgery. Critical care, Vol. 14, H. 2. p. 201.

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Official URL: http://edoc.unibas.ch/dok/A6007519

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Abstract

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.
Faculties and Departments:03 Faculty of Medicine > Bereich Querschnittsfächer (Klinik) > Anästhesiologie
03 Faculty of Medicine > Departement Klinische Forschung > Bereich Querschnittsfächer (Klinik) > Anästhesiologie
UniBasel Contributors:Seeberger-Stucky, Manfred
Item Type:Article, refereed
Article Subtype:Further Journal Contribution
Bibsysno:Link to catalogue
Publisher:Current Science
ISSN:1364-8535
Note:Publication type according to Uni Basel Research Database: Journal item
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Last Modified:20 Jun 2014 07:56
Deposited On:20 Jun 2014 07:56

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