Recovery in the post operative period of Cardiovascular and Endovascular Surgery Course

DR. JUAN OLIVELLO

PRINCE FAISAL BIN KHALID CARDIAC CENTER

CARDIAC SURGEON Junior Staff
RECOVERY CSICU’S PATIENTS

2nd CLASS  LOW CARDIAC OUTPUT SYNDROME

LOW CARDIAC
OUTPUT
SYNDROME
Important for the conduct and analysis of
clinical research.
LCOS
Clinical condition that leads to decreased the systemic perfusion
secondary to myocardial dysfunction.

Linda Massé , Marie Antonacci Low cardiac output syndrome: identification and management. Critical Care Nursing Clinics of North America,
Volume 17, Issue 4, December 2005, Pages 375-383
The objective of this class
Try to introduce concepts and management to be able to:
1. Diagnose LCOS
2. Identify and solve the cause
3. Increase cardiac output
4. Minimize systemic impact
 SUSPECTED LCOS

RULE OUT HYPOVOLEMIA

LCOS CONFIRMED

1 2 3
1.Identify and solve the cause
2.Increase cardiac output
3.Minimize systemic impact
SUSPECTED LCOS
 Suspected LCOS
History of:
- Previous deterioration of systolic function
- Left main disease
- Has undergone surgery for mitral regurgitation or acute coronary syndrome
- Prolonged CPB pump time
- Difficult CPB weaning (EARLIEST MANIFESTATION OF LCOS)
 Not always: Pulmonary artery catheter (PAC) or
Pulse indicator of continuous cardiac output (PICCO)

Suspected LCOS
- Oliguria: < 500/400 mL in 24h or < 0.5 mL/kg/h
- Poor peripheral perfusion: cold periphery, clammy skin
- Lactic acidosis: High lactate
- Sensory deterioration: Altered reactions, responses or comments out of context, decreased reaction
to pain, etc.
- Hypotension
- Decrease in central venous saturation (ScvO2 <65% taking the sample from the central venous
catheter)
 Rule out hypovolemia!
Check
Fluid balance (Hydration status, CPB?, Diuresis)
Filling pressures (CVC line/Swan-Ganz) ???
 Trendelenburg test
Respiratory variability of blood pressure
Active bleeding
Response to expansion
When there are doubts about…
-filling of cavities
-contractility
-ventricular failure....

DO AN ECHOCARDIOGRAM!
Before confirm the LCOS…
Don’t increase the dose of inotropes

Suspected LCOS…
Once hypovolemia, active bleeding, low haemoglobin and
haematocrit have been ruled out, and/or these factors have been
corrected…
- Hypotension
- Oliguria
- Central venous saturation < 60% (with normal arterial saturation)
- Lactate >3mmol/l.
- Patient comes from the operating room with inotropes and/or IABP to achieve a stable
hemodynamic situation
• And the patient has a history of…
- Impaired ventricular function with low ejection fraction
- Left main disease
- Has undergone surgery for mitral regurgitation or acute coronary syndrome
- Prolonged CPB time
- Difficult CPB weaning
Most likely…
we will find ourselves facing an LCOS

ECHOCARDIOGRAM
“Global approach to LCOS”
AFTER 1. Diagnose LCOS

2. Identify and solve the cause

3. Increase cardiac output

4. Minimize systemic impact

2. Identify and solve the cause
2. Identify and solve the cause
Acute coronary syndrome (ACS)?
• ECG ? (changes not caused by ischemia )
- ST elevation due to pericarditis.
- Repolarization disorders due to changes in the internal environment.

• Cardiac enzymes ? (surgery itself causes an elevation of cardiac enzymes)

• Pain ? (limited), Angina?, Discomfort caused by the surgical wound?

 • Mantein hematocrit above 30%
• Reducing the double product (HR and BP)  B-Blockers
• If persist with ST elevation, the use of a IABP could help
ACS without ST elevation
• Coronary angiography study are options that should be considered.

ACS with ST elevation

• Not solve with vasodilators?  Revascularization

• Thrombolytics is contraindicated due to the high risk of bleeding
• CAG + PCI or OR?
Arrhythmia?
• Tachyarrhythmia
- Atrial fibrillation is the most frequent postoperative arrhythmia
 Cardioversion
- Atrial flutter
- Paroxysmal supraventricular tachycardia (Carotid sinus massage/Adenosine)
• Bradyarrhythmia
- Blocks are especially common in valvular patients
*Pacemaker wires well placed and tested before closing the sternum
 Alterations in the internal environment?

• Blood ion monitoring: calcium, phosphorus, magnesium or potassium

• pH? : <7.30 can have a negative inotropic effect

ALWAYS CORRECT ALTERATIONS

IN THE INTERNAL ENVIRONMENT AND PH
What was the VEF before surgery?
“The lower the preoperative ejection fraction, the greater the risk of low cardiac
output syndrome”
• <40% : Suggest left ventricular failure.
• ON or OFF pump surgery? : Post on pump surgery can cause varying degrees of
myocardial stunning.
• <40% EF + ON PUMP SURGERY: deterioration in systolic function

DO AN ECHOCARDIOGRAM
Probable left ventricular failure
• Wedge Pressure: greater than 18 mm Hg.
• Signs of peripheral hypoperfusion: oliguria, sensory impairment, cold limbs
• Pulmonary congestion: dyspnea, tachypnea, crackles, and hypoxemia

• Same complication with preserved EF, without ACS: protection during extracorporeal
circulation was not adequate…
DIFFICULT WEANING OF CARDIO-PULMONARY BY PASS
REQUEST
ECHOCARDIOGRAM
ECHOCARDIOGRAM
• Even with a swan ganz catheter, when a patient cannot be easily stabilized,
PERFORM AN ECHOCARDIOGRAM

• A TRANSTHORACIC ECHOCARDIOGRAM is not enough?

• Perform a TRANSESOPHAGEAL ECHOCARDIOGRAM

• Right ventricular failure
• Dynamic intraventricular gradient (DIG)
• Tamponade
• Diastolic failure
• Mismatch
• Right ventricular failure
Common in patients with
- Prior impairment of right ventricular systolic function
- Pulmonary hypertension
- Who have undergone heart transplantation
• Dynamic intraventricular gradient (DIG)
Dynamic intraventricular gradient (DIG)
• After an aortic valve replacement with previous preserved systolic function
• Women with small ventricles
• Sudden reduction in afterload

NO inotropes and vasodilators (increase the degree of obstruction )

REDUCE THE GRADIENT :

 Adequate ventricular filling (sufficient preload)

 Reducing Heart Rate

 Avoiding Hypovolemia
Tamponade
 • Tamponade?
• Preceded by excessive bleeding?
• Don't expect to find Beck's triad
• Clot located next to the right atrium (in the absence of a pericardial effusion)
• If suspicion persists: TRANSOESOPHAGEAL ECHOCARDIOGRAM
• Diastolic failure
• Diastolic failure?

• Ventricular stiffness (inadequate protection)

• Concentric hypertrophy + prolonged pump times
NO inotropes
 Adequate ventricular filling (sufficient preload)
 Reducing Heart Rate

• TRENDELENBURG TEST
• Mismatch
 • Mismatch?
• Common in obese patients, women, or those receiving a biologic valve
(because the effective orifice of the valve is usually smaller than that of
mechanical valves)

• Quantify Mismatch: EOA/BSA

When this index is <0.6 = severe mismatch
Rule out:
-Anemia
-Valve dysfunction due to thrombus (not common in the immediate postoperative
period)
- Overestimation of gradients due to measurement errors
“Global approach to LCOS”
1. Diagnose LCOS DONE

AFTER 2. Identify and solve the cause

3. Increase cardiac output

4. Minimize systemic impact

3. Increase cardiac output
Increase
Cardiac
Output
• Excessive preload
• Excessive afterload
• Inappropriate heart rate
• Atrioventricular asynchrony
For each phenomenon, a treatment
Excessive preload
• - Low oxygen saturation (either on the monitor or in the ABG),
• - Increase in work of breathing (manifested either by the use of accessory muscles or
respiratory rate) and
• - An x-ray with pulmonary congestion
• -Increased pressure in a right chamber catheter
• - Echocardiogram with RV dysfunction.

To reduce the preload

- Vasodilator drugs

- Diuretics

- And implement a fluid restriction plan

Excessive afterload
- Correct high blood pressure (NOT USUAL)

- Swan-Ganz Catheter / Echocardiogram

- Vasodilators

- Be careful of generating hypotension

Inappropriate heart rate

Atrioventricular asynchrony

• Tachycardia, bradycardia and asynchrony can have negative effects on cardiac output
and must be corrected.
Does low cardiac output persist?

Impaired systolic function

Inotropes
Norepinephrine  excessive vasodilation or hypotension

Dobutamine or Isoproterenol increases contractility force and heart rate

Milrinone  No increase in heart rate and vasodilator.

Levosimendan  when the rest of the inotropics have not been enough.

Phenylephrine and Vasopressin  Be careful not to excessively increase afterload and have a harmful
effect on cardiac output.
Mechanical circulatory support (MCS)
devices (IABP, others)

Consider emergency transplant

“Global approach to LCOS”
Diagnose LCOS DONE

Identify and solve the cause DONE

Increase cardiac output DONE

Minimize systemic impact

Minimize systemic impact

Increase oxygen supply and reduce oxygen demand.

Management: Pain, hypotension, anemia,

hypoxemia, fever....
 Conclusions
1. LCOS is very common in the postoperative period of cardiovascular and endovascular surgery and is a very
extensive topic, which requires an in-depth study and recognition of the signs, symptoms and parameters to
identify its causes.

2. Availability and knowledge of the normal values offered by a Swan Ganz catheter is essential in these cases.

3. The speed of echocardiogram availability determines the speed of implementation of corrective measures.

4. The use of inotropes/increasing doses should be reserved after having corrected the most frequent causes.

5. Algorithmic thinking leads to quick reading of the picture and accurate decision making.
Thank you very much!

juanolivello@gmail.com