The effects of anesthesia induction and positive pressure ventilation on right-ventricular function: an echocardiography-based prospective observational study

Harry Magunia, Anne Jordanow, Marius Keller, Peter Rosenberger, Martina Nowak-Machen, Harry Magunia, Anne Jordanow, Marius Keller, Peter Rosenberger, Martina Nowak-Machen

Abstract

Background: General anesthesia induction with the initiation of positive pressure ventilation creates a vulnerable phase for patients. The impact of positive intrathoracic pressure on cardiac performance has been studied but remains controversial. 3D echocardiography is a valid and MRI-validated bed-side tool to evaluate the right ventricle (RV). The aim of this study was to assess the impact of anesthesia induction (using midazolam, sufentanil and rocuronium, followed by sevoflurane) with positive pressure ventilation (PEEP 5, tidal volume 6-8 ml/kg) on 2D and 3D echocardiography derived parameters of RV function.

Methods: A prospective observational study on fifty-three patients undergoing elective cardiac surgery in a tertiary care university hospital was designed. Transthoracic echocardiography exams were performed before and immediately after anesthesia induction and were recorded together with hemodynamic parameters and ventilator settings.

Results: After anesthesia induction TAPSE (mean difference - 1.6 mm (95% CI - 2.6 mm to - 0.7 mm; p = 0.0013) as well as the Tissue Doppler derived tricuspid annulus peak velocity (TDITVs') were significantly reduced (mean difference - 1.9% (95% CI: - 2.6 to - 1.2; p < 0.0001), but global right ventricular ejection fraction (RVEF; p = 0.1607) and right ventricular stroke volume (RVSV; p = 0.1838) did not change.

Conclusions: This data shows a preserved right ventricular ejection fraction and right ventricular stroke volume after anesthesia induction and initiation of positive pressure ventilation. However, the baso-apical right ventricular function is significantly reduced. Larger studies are needed in order to determine the clinical impact of these findings especially in patients presenting with impaired right ventricular function before anesthesia induction.

Trial registration: Retrospecitvely registered, 6th June 2016, ClinicalTrials.gov Identifier NCT02820727 .

Keywords: Anesthesiology; Echocardiography; Positive-pressure respiration; Right ventricular function; Three-dimensional.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
a 3D full volume dataset of the left and right ventricle based on an apical 4-chamber view. b Endocardial border tracking by the Tomtec 4D RV-function package. The first column shows the enddiastolic frame, the second column shows the endsystolic frame. The First and second lines show medial and basal transversal planes of the RV. The third line shows the right ventricle in a reconstructed apical view. c Results of the Tomtec 4D RV-function package showing the volumetric model of the RV. The mesh grid shows the enddiastolic volume, the green inner model shows the endsystolic volume. Absolute values of volumes and the ejection fraction are also reported
Fig. 2
Fig. 2
a Bar graphs of the right ventricular end-diastolic volume indexed to body surface area (RVEDVI) and right ventricular ejection fraction (RVEF) before and after anesthesia induction are shown. No changes were observed regarding RVEDVI and RVEF. Right side shows an example of a volumetric model of the right ventricle together with an example of results given by the Tomtec 4D RV-function software. b Bar graphs of the tricuspid annular plane systolic excursion (TAPSE) and tissue Doppler-derived peak systolic velocity of the lateral tricuspid annulus (TDI TV s’) before and after anesthesia induction are shown. Significant reductions were observed for the TAPSE and TDI TV s’. Right side shows examples of the TAPSE measurement in M-Mode and the measurement of the TDI TV s’ in tissue spectral Doppler. c Bar graphs of the right ventricular peak systolic free wall strain (3DRVLS-fw) and septal wall strain (3DRVLS-sw) are shown. A significant decrease in 3DRVLS-fw was observed with no change in 3DRVLS-sw. Right side shows an example of the strain measurements in reconstructed 3D datasets

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