The introduction of combined cerebral monitoring using near-infrared spectroscopy (NIRS) and processed electroencephalography (pEEG) in cardiac surgery has led to changes in intraoperative management. We aimed to determine the incidence of four intraoperative states defined by the combined use of pEEG and NIRS and whether these states were associated with postoperative complications. We conducted a prospective observational single-centre cohort study of adult patients scheduled for cardiac surgery. Bilateral cerebral NIRS and frontal pEEG were continuously recorded during the intraoperative period. The primary endpoint was the incidence of four states: cerebral desaturation and Patient State Index (PSi) < 25 and/or suppression ratio (SR) > 0 (State 1), cerebral desaturation combined with PSi ≥ 50 and SR = 0 (State 2), cerebral desaturation with normal pEEG activity (State 3), and normal cerebral saturation with PSi < 25 and/or SR > 0 (State 4). We developed logistic regression models to predict postoperative delirium and longer time of persistent organ dysfunction (TPOD). Of the 148 patients included in this analysis, 95 NCT04643834 ); registered 25 November 2020.

Doppler ultrasound assessment of common femoral vein (CFV) flow could represent a simple, fast, and noninvasive technique to identify right ventricular dysfunction and venous congestion in patients undergoing cardiac surgery. Our primary objective was to determine the prevalence of abnormal CFV flow pulsatility before cardiac surgery. Secondary objectives included investigating its association with postoperative outcomes. We conducted a single-centre prospective cohort study and recruited adult patients undergoing cardiac surgery with cardiopulmonary bypass. We performed pulsed-wave Doppler ultrasound assessments of CFV flow at four timepoints: before surgery, after induction of anesthesia, immediately after surgery, and on postoperative day 1. When the Doppler profile showed cardiophasic variations in velocities, abnormal pulsatility was defined as a CFV pulsatility fraction ≥ 100 NCT05038267 ); first submitted 28 August 2021.

Background During cardiac surgery, right ventricular outflow tract obstruction (RVOTO) is defined as an instantaneous pressure difference ≥6 mmHg between right ventricular systolic pressure (RVSP) and pulmonary artery systolic pressure (PASP), for ≥5 minutes. Risk factors for RVOTO remain poorly understood. This cohort study is designed to evaluate the incidence, characteristics and outcomes of the patients who experienced RVOTO. Methods Instantaneous pressure difference between RVSP and PASP was measured using a pulmonary artery catheter with a right ventricular port during cardiac surgery from a retrospective (n=295) and a prospective (n=105) cohort. Results From the retrospective and prospective cohort, incidence of RVOTO was 30.2 and 36.2% before cardiopulmonary bypass (CPB) initiation and 43.7 and 47.6% after CPB separation. Before CPB initiation, patients with RVOTO had higher cardiac output (4.2±1.5 vs 3.8±1.1L⋅min-1, P=0.033), received more inhaled epoprostenol (79 vs 61%, P=0.005) and inotropes (66 vs 51%, P=0.016) compared to those without RVOTO. After CPB separation, patients with RVOTO had higher heart rate (62±15 vs 58±13 beats⋅min-1, P=0.011), cardiac output (4.1±1.4 vs 3.7±1.1L⋅min-1, P=0.003), CPB duration (90±45 vs 77±30mins, P=0.014), lower fluid balance (758±1123 vs 1063±1089mL, P=0.021) and were more exposed to intratracheal milrinone (12 vs 4%, P=0.015) compared to those without RVOTO. The time with persistent organ dysfunction (TPOD) at 28 days after surgery was similar among patients who had a RVOTO event, before CPB initiation or after CPB separation, compared to those who did not. Conclusion RVOTO is common in cardiac surgery. However, it is not associated with longer TPOD.

ObjectiveRight ventricular (RV) dysfunction in cardiac surgery can lead to RV failure which is associated with increased morbidity and mortality. Abnormal RV function can be identified using RV pressure monitoring. The primary objective of the study is to determine the proportion of patients with abnormal RV early to end-diastole diastolic pressure gradient (RVDPG) and abnormal RV end-diastolic pressure (RVEDP) before initiation and after cardiopulmonary bypass (CPB) separation. Secondary objective is to evaluate if RVDPG before CPB initiation is associated with difficult and complex separation from CPB, RV dysfunction and failure at the end of cardiac surgery.DesignProspective study.Setting patientsTertiary care cardiac institute.ParticipantsCardiac surgical patients.InterventionCardiac surgery.Measurements and Main ResultsAutomated electronic quantification of RVDPG and RVEDP were obtained. Hemodynamic measurements were correlated with cardiac and extracardiac parameters from TEE and post-operative complications. Abnormal RVDPG were present in 80% of the patients (n=105) at baseline, with a mean RVEDP of 14.2±3.9 mmHg. Patients experienced a RVDPG >4 mmHg for a median duration of 50.2% of the intra-operative period before CPB initiation and 60.6% after CPB separation. A total of 46 (43.8%) patients had difficult/complex separation from CPB, 18 (38.3%) patients with RV dysfunction and eight (17%) with RV failure. Abnormal RVDPG before CPB was not associated with post-operative outcome.ConclusionElevated RVDPG and RVEDP are common in cardiac surgery. RVDPG and RVEDP before CPB initiation are not associated with RV dysfunction and failure but can be used for their diagnosis.

Background:Neurocognitive disorder and venous congestion are related in cardiac surgery. Femoral vein (FV) Doppler allows noninvasive assessment of venous congestion. This study aims to associate postoperative neurocognitive disorder in cardiac surgery with FV pulsatility. Method:A secondary analysis was conducted using data from retrospective and prospective cohorts. FV Doppler and neurocognitive disorder were measured upon admission to the intensive care unit (ICU) after surgery. An index of FV pulsatility of ≥ 50% was considered abnormal. The presence of neurocognitive disorder was assessed using the Intensive Care Delirium Score Checklist (ICDSC). Descriptive statistical analyses and logistic regression were used to test the association between FV Doppler pulsatility and neurocognitive disorder. Results:A total of 273 patients from both cohorts were analyzed, 155 (57%) patients had FV pulsatility indexes ≥ 50%. Abnormal pulsatile Doppler was associated with the presence of neurocognitive disorder compared with normal FV Doppler profile (57 vs 43%, odds ratio [OR], 1.73; 95% confidence interval [CI], 1.06-2.81). FV pulsatility was also associated with age, higher rate of stroke, prolongation of intubation duration and a longer ICU stay. Conclusions:FV pulsatility is associated with the presence of neurocognitive disorder and postoperative complications in cardiac surgery. The FV Doppler technique is simple and fast, offering the potential to anticipate complications related to venous congestion, such as delirium. Future multicentre studies with larger samples will be necessary to consolidate these findings. Clinical Registration Number:NCT04092855 and NCT05038267.

Delirium is common in patients undergoing cardiac surgery. and venous congestion has been reported as an important risk factor. We report a 69-year-old patient who developed postoperative delirium in the intensive care unit following aortic valve replacement surgery. The postoperative course was complicated by delirium for which echographic signs of venous congestion on the portal and the renal but also the femoral veins and their resolution correlated with the course of delirium. The use of common femoral vein Doppler as a simple bedside technique to predict and identify congestive delirium has not been reported before.

Right ventricular outflow tract obstruction (RVOTO) is a rare cause of hemodynamic instability in the intensive care unit (ICU) after cardiac surgery. We report the first cases of RVOTO diagnosed in the ICU using continuous right ventricular pressure waveform monitoring. Our 2 cases reflect both mechanical and dynamic causes of obstruction, each of which require different approaches to treatment. Inotrope use can exacerbate RVOTO caused by dynamic etiology, whereas surgery is usually the treatment of choice for mechanical obstructions. Inability to recognize RVOTO or the correct etiology can lead to hemodynamic compromise and poor outcomes.

Background In patient requiring vasopressors, the radial artery pressure may underestimate the true central aortic pressure leading to unnecessary interventions. When using a femoral and a radial arterial line, this femoral-to-radial arterial pressure gradient (FR-APG) can be detected. Our main objective was to assess the accuracy of non-invasive blood pressure (NIBP) measures; specifically, measuring the gradient between the NIBP obtained at the brachial artery and the radial artery pressure and calculating the non-invasive brachial-to-radial arterial pressure gradient (NIBR-APG) to detect an FR-APG. The secondary objective was to assess the prevalence of the FR-APG in a targeted sample of critically ill patients. Methods Adult patients in an intensive care unit requiring vasopressors and instrumented with a femoral and a radial artery line were selected. We recorded invasive radial and femoral arterial pressure, and brachial NIBP. Measurements were repeated each hour for 2 h. A significant FR-APG (our reference standard) was defined by either a mean arterial pressure (MAP) difference of more than 10 mmHg or a systolic arterial pressure (SAP) difference of more than 25 mmHg. The diagnostic accuracy of the NIBR-APG (our index test) to detect a significant FR-APG was estimated and the prevalence of an FR-APG was measured and correlated with the NIBR-APG. Results Eighty-one patients aged 68 [IQR 58–75] years and an SAPS2 score of 35 (SD 7) were included from which 228 measurements were obtained. A significant FR-APG occurred in 15 patients with a prevalence of 18.5% [95%CI 10.8–28.7%]. Diabetes was significantly associated with a significant FR-APG. The use of a 11 mmHg difference in MAP between the NIBP at the brachial artery and the MAP of the radial artery led to a specificity of 92% [67; 100], a sensitivity of 100% [95%CI 83; 100] and an AUC ROC of 0.93 [95%CI 0.81–0.99] to detect a significant FR-APG. SAP and MAP FR-APG correlated with SAP ( r 2 = 0.36; p < 0.001) and MAP ( r 2 = 0.34; p < 0.001) NIBR-APG. Conclusion NIBR-APG assessment can be used to detect a significant FR-APG which occur in one in every five critically ill patients requiring vasoactive agents.

OBJECTIVES:To report the use of common femoral vein Doppler interrogation as a simple technique to diagnose right ventricular dysfunction.DESIGN:Case report.SETTING:Cardiac surgical ICU.PATIENTS:Postoperative cardiac surgical patients.INTERVENTIONS:Common femoral pulsed-wave and color Doppler examination associated with hepatic, portal, and renal venous Doppler measurement were obtained in both patients and before and after treatment in patient number 1. In addition, right ventricular pressure waveform examination was obtained in patient number 2.MEASUREMENTS AND MAIN RESULTS:The technique to obtain common femoral venous Doppler is described. Two cases of patients presenting with right ventricular dysfunction and fluid overload with portal and renal venous congestion in the perioperative period undergoing complex multivalvular cardiac surgery are presented. Hemodynamic waveform monitoring was performed alongside echocardiographic, hepatic, and renal venous flow Doppler assessment, and spectral Doppler profiles of the common femoral veins were examined. Those findings were useful in confirming our diagnosis and guiding our response to treatment. An algorithm was developed and tested on two additional hemodynamically unstable patients.CONCLUSIONS:Doppler examination of the common femoral vein is a simple, fast, and noninvasive technique that could be useful to rule in the presence of right ventricular dysfunction with venous congestion and help guide the management of such patients.