The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision

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Abstract

Background

Right ventricular (RV) long-axis function is known to be depressed after cardiac surgery, but the mechanism is not known. We hypothesized that intraoperative transesophageal echocardiography could pinpoint the time at which this happens to help narrow the range of plausible mechanisms.

Method

Transthoracic echocardiography was conducted in 33 patients before and after elective coronary artery bypass graft. In an intensively monitored cohort of 9 patients, we also monitored RV function intraoperatively using serial pulsed wave tissue Doppler (PW TD) transesophageal echocardiography.

Results

There was no significant difference in myocardial velocities from the onset of the operation up to the beginning of pericardial incision, change in RV PW TD S′ velocities 3% ± 2% ( P = not significant).

Within the first 3 minutes of opening the pericardium, RV PW TD S′ velocities had reduced by 43% ± 17% ( P < .001). At 5 minutes postpericardial incision, 2 minutes later, the velocities had more than halved, by 54% ± 11% ( P < .0001). Velocities thereafter remained depressed throughout the operation, with final intraoperative S′ reduction being 61% ± 11% ( P < .0001).

One month after surgery, in the full 33-patient cohort, transthoracic echocardiogram data showed a 55% ± 12% ( P < .0001) reduction in RV S′ velocities compared with preoperative values.

Conclusions

Minute-by-minute monitoring during cardiac surgery reveals that, virtually, all the losses in RV systolic velocity occurs within the first 3 minutes after pericardial incision. Right ventricular long-axis reduction during coronary bypass surgery results not from cardiopulmonary bypass but rather from pericardial incision.

Related collections

Most cited references 38

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Assessment of right ventricular function using two-dimensional echocardiography.

Sanjiv Kaul, Chuwa Tei, James Hopkins … (1984)

With the use of two-dimensional echocardiography (2DE), we analyzed apical and subcostal four-chamber views for evaluation of right ventricular (RV) function in 30 individuals as compared to RV ejection fraction (RVEF) obtained by radionuclide angiography. In addition to previously reported parameters of changes in areas and chords, a new simple measurement of tricuspid annular excursion was correlated with RVEF. A close correlation was noted between tricuspid annular plane systolic excursion (TAPSE) and RVEF (r = 0.92). The RV end-diastolic area (RVEDA) and percentage of systolic change in area in the apical four-chamber view also showed close correlation with RVEF (r = -0.76 and 0.81); however, the entire RV endocardium could only be traced in about half of our patients. The end-diastolic transverse chord length and the percentage of systolic change in chord length in the apical view showed a poor correlation with RVEF. The correlation between RVEF and both areas and chords measured in the subcostal view was poor. It is concluded that the measurement of TAPSE offers a simple echocardiographic parameter which reflects RVEF. This measurement is not dependent on either geometric assumptions or traceable endocardial edges. When the endocardial outlines could be traced, the apical four-chamber view was superior to the subcostal view in assessment of RV function.

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Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function.

J Meluzín, L Spinarová, J Bakala … (2001)

Rapid, accurate, and widely available non-invasive evaluation of right ventricular function still presents a problem. The purpose of the study was to determine whether the parameters derived from Doppler tissue imaging of tricuspid annular motion could be used as indexes of right ventricular function in patients with heart failure. Standard and pulsed Doppler tissue echocardiography were obtained in 44 patients with heart failure (mean left ventricular ejection fraction 24 +/- 7%) and in 30 age- and sex-matched healthy volunteers. The tricuspid annular systolic and diastolic velocities were acquired in apical four-chamber views at the junction of the right ventricular free wall and the anterior leaflet of the tricuspid valve using Doppler tissue imaging. Within 2 h of Doppler tissue imaging, the first-pass radionuclide ventriculogram, determining right ventricular ejection fraction and equilibrium gated radionuclide ventriculography single photon emission computed tomography, were performed in all patients. In patients with heart failure, the peak systolic annular velocity was significantly lower and the time from the onset of the electrocardiographic QRS complex to the peak of systolic annular velocity was significantly greater than the corresponding values in healthy subjects (10.3 +/- 2.6 cm. s(-1) vs 15.5 +/- 2.6 cm.s(-1), P < 0.001, and 198 +/- 34ms vs 171 +/- 29 ms, P < 0.01, respectively). There was a good correlation between systolic annular velocity and right ventricular ejection fraction (r = 0.648, P <0.001). A systolic annular velocity < 11.5 cm.s(-1)predicted right ventricular dysfunction (ejection fraction < 45%) with a sensitivity of 90% and a specificity of 85%. We conclude that the evaluation of peak systolic tricuspid annular velocity using Doppler tissue imaging provides a simple, rapid, and non-invasive tool for assessing right ventricular systolic function in patients with heart failure. Copyright 2001 The European Society of Cardiology.