3D & Speckle Tracking Together as a Sensitive Marker for Early Outcome in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery

All patients inside operating room, a wide bore i/v access and radial artery will be cannulated under local anesthesia. Standard opioid- propofol- relaxant based induction will be followed. After endotracheal intubation, an adult 2D Trans Eesophageal Echocardiography (TEE) probe (6VT-D probe of the GE vivid E9 echocardiography system (GE Medical Systems, Hortein, Norway) will be inserted. A 7 Fr triple lumen catheter and 8.5 Fr introducer sheath will be placed in the right internal jugular vein under ultrasound guidance. A 7 Fr Pulmonary Artery Catheter (PAC) (Swan Ganz catheter, Edwards Life Sciences) will be floated as per standard practice. Attempts to wedge will be discontinued if the catheter does not wedge beyond 8 cm into the main pulmonary artery.

Surgery will be performed through a midline sternotomy on cardiopulmonary bypass with bicaval cannulation and with intermittent antegrade warm blood cardioplegia. All surgical procedures were performed by experienced surgeons using standardized techniques.

Cardiopulmonary bypass (CPB) and anaesthesia management will be performed according to our standard operating procedures. Moderate hypothermic (28-32*C) CPB will be established with a non-pulsatile flow of 2,5 l/min/m2 and an arterial pressure > 60 mmHg without additional filtration. CPB will be primed with balanced electrolyte solution. Coagulation will be offset by 400 IU/kg heparin aiming at an Activated Clotting Time (ACT) > 480 seconds. Additionally, all patients will receive tranexamic acid 100mg/kg. Cardioplegic arrest will be induced and maintained by intermittent administration of ante grade potassium enriched solution.

Perioperative goal-oriented haemodynamic support (i.e. heart rate 80-100 beats/min, mean arterial pressure 65-85 mmHg, central venous pressure (CVP) 8-12 mmHg at positive end-expiratory pressure 5 cms of water, pulmonary artery occlusion pressure 12-15 mmHg, cardiac index >2.5 l /min/m2 2, stroke volume index >30 ml/m, mixed venous oxygen saturation >65) will be established according to institutional standards. Intraoperatively, patients will be monitored with transoesophageal echocardiography (6VT-D probe of the GE vivid E9 echocardiography system (GE Medical Systems, Hortein, Norway)) and a pulmonary artery catheter with or without continuous mixed venous oximetry measurement. In case of difficult CPB separation despite hemodynamic optimization, an intraaortic balloon pump (IABP) will be placed according to the team's assessment.

After chest closure, the patient will be transferred intubated and mechanically ventilated in the ICU. Patients will be kept sedated with morphine administration (20-40 mcg/kg/min) until cardiopulmonary stability is achieved, chest tube drainage is negligible (<100 ml/h), and the patient is judged to be extubated. If mechanical ventilation is required > 12 hours, sedation will be switched to midazolam (10-20 mcg/kg/min) combined with morphine (20-40 mcg/kg/min), and weaning from mechanical ventilation will be performed according to the standard operating procedures at our hospital. Hemodynamic optimization will be continuously accomplished according to the haemodynamic goals as mentioned above.