Perioperative and Non-invasive Estimation of Mean Left Atrial Pressure From Transesophageal Echocardiography Measures of Pulmonary Vein Diameter and Collapsibility in Cardiac Surgery: a Prospective Study
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 30
- 试验地点
- 1
- 主要终点
- left upper pulmonary vein diameter (in millimeters) measured by transesophageal echocardiography, compared to the contemporary measure of left atrial pressure by pulmonary arterial catheter.
研究概览
简要总结
Left atrial pressure (LAP) is a crucial hemodynamic parameter during cardiac surgery. Elevated LAP leads to pulmonary edema and other cardiopulmonary complications. The pulmonary capillary wedge pressure (PCWP) measured by a pulmonary arterial catheter (PAC) is the gold-standard method to estimate LAP. However, the placement of a PAC is an invasive procedure associated with adverse events. Transesophagial echocardiophy (TEE) is a non-invasive method to estimate LAP during cardiac surgery. Pulsed Doppler mitral flow, pulmonary vein flow, tricuspid regurgitation peak flow and left atrial volume are validated parameters to estimate LAP. Nevertheless, these parameters are not always valid in cardiac surgery, mainly because of mitral valve pathology or prothesis.
As the diameter and collapsibility of inferior vena cava is the recommended method for non-invasive right atrial pressure assessment in patients under mechanical ventilation, the investigators made the hypothesis that diameter and collapsibility of the pulmonary veins could be an additional method to estimate LAP during cardiac surgery. This has never been investigated in cardiology or cardiac surgery.
In this prospective study, pulmonary vein diameter and collapsibility will be correlated to invasive PCWP to assess LAP perioperatively in 30 patients undergoing cardiac surgery
详细描述
The evaluation of left ventricle filling pressures (LVFP) perioperatively in cardiac surgery could be challenging. This is particularly relevant after separation from cardiopulmonary bypass because the hemodynamic state is dynamic, with changes in heart rate, loading conditions, and deterioration in diastolic function being common. Elevated LVFP leads to pulmonary edema, arrhythmia, pulmonary hypertension and RV failure.
To estimate the LVFP, the gold standard method is the pulmonary capillary wedge pressure (PCWP) measured by a pulmonary arterial catheter (PAC). However, placement of a PAC is an invasive procedure associated with adverse events.
Recommandations released by the American Society of Echocardiography for the evaluation of left ventricular diastolic function pointed out some difficulties concerning the evaluation of elevated LAP perioperativly in cardiac surgery. The commonly used parameters, such as the mitral pulsed Doppler flow, could be faulted by mitral valve regurgitation, atrial fibrillation, or fast changes in loading conditions. In cardiac surgery, additional diagnostic methods are needed to diagnose elevated LVFP.
In the right heart, measurements of the inferior vena cava diameter and collapsibility index are recommended for the evaluation of the right atrial pressure. Since it has been previously described that alterations of the pulmonary vein Doppler flow are correlated with elevated LAP, pulmonary vein diameter dilatation or lack of collapsibility have never been investigated as a marker of elevated LAP, neither in cardiology nor in cardiac surgery.
In this study, the investigators made the hypothesis that pulmonary vein diameter increase when LAP increase (in the absence of confounding factors, such as pulmonary vein stenosis or mitral regurgitation directed toward the pulmonary vein). In the same way,the investigators hypothized that cyclic variations of pulmonary vein diameter under mechanical ventilation decrease when the LAP increase. The ventilation parameters will be standardized.
研究设计
- 研究类型
- Observational
- 观察模型
- Cohort
- 时间视角
- Prospective
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patients aged of 18 years or more,
- •Scheduled for an elective cardiac surgery at the Montpellier University Hospital,
- •Requiring a pulmonary arterial catheter monitoring due to the complexity of cardiac surgery or severe cardiopulmonary comorbidities.
排除标准
- •Failure of the pulmonary artery catheterization,
- •Failure of PCWP measurement,
- •Failure of TEE measure of the left upper pulmonary vein diameter and collapsibility,
- •Refusal to participate expressed secondarily.
- •Non-inclusion criteria :
- •Cardiac transplantation,
- •Left ventricule assist device,
- •Pulmonary vein stenosis,
- •Contraindications to TEE or PAC,
- •Refusal to participate,
- •Patient under juridical protection
结局指标
主要结局
left upper pulmonary vein diameter (in millimeters) measured by transesophageal echocardiography, compared to the contemporary measure of left atrial pressure by pulmonary arterial catheter.
时间窗: One hour postoperatively in ICU
The left upper pulmonary vein (LUPV), which enters the left atrium (LA) just lateral to the LA appendix (LAA) from an anterior to posterior trajectory, can be examined in the mid-esophageal (ME) view at 40 - 60° by slightly withdrawing and turning the probe to the left to expose the superior and lateral aspect of the LA (where the LAA is seen). The LUPV is superior (in the display) to the LAA and separated by the Coumadin ridge. Maximal and minimal LUPV diameters will be measured (using a 10 cycle video-loop) and the collapsibility index will be calculated as the ratio : (maximum diameter ¬¬- minimum diameter) / (maximum diameter). These echocardiographic views are part of the standard TEE exam and performed with Philips® Epiq™ 7 ultrasound machines.
次要结局
- Calculation of collapsibility indexes of left upper and right upper pulmonary veins(One hour postoperatively in ICU)
- Measurement of the other pulmonary vein diameters(One hour postoperatively in ICU)
- Measurement of the other echocardiographic parameters estimating the LAP or the left ventricle diastolic function(One hour postoperatively in ICU)