Right ventricular pressure-volume (PV) analysis characterizes ventricular systolic and diastolic properties independent of loading conditions like volume status and afterload. While long-considered the gold-standard method for quantifying myocardial chamber performance, it was traditionally only performed in highly specialized research settings. With recent advances in catheter technology and more sophisticated approaches to analyze PV data, it is now more commonly used in a variety of clinical and research settings. Herein, we review the basic techniques for PV loop measurement, analysis, and interpretation with the aim of providing readers with a deeper understanding of the strengths and limitations of PV analysis. In the second half of the review, we detail key scenarios in which right ventricular PV analysis has influenced our understanding of clinically relevant topics and where the technique can be applied to resolve additional areas of uncertainty. All told, PV analysis has an important role in advancing our understanding of right ventricular physiology and its contribution to cardiovascular function in health and disease.

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Invasive pressure-volume loop analysis allows direct monitoring of changing intraventricular cardiac mechanics during structural heart interventions. Our aim was to illustrate changes in right and left ventricular mechanics during transcatheter edge-to-edge tricuspid repair for severe tricuspid regurgitation. ( Level of Difficulty: Advanced. )

Background: Robot-assisted pancreatoduodenectomy (RAPD) is a challenging procedure for the perioperative anesthesiologist, e.g. because of prolonged pneumoperitoneum exposure and reversed-Trendelenburg positioning. Purpose of this retrospective cohort study is to identify differences in perioperative anesthesia-related factors between RAPD and open pancreatoduodenectomy (OPD) and to determine perioperative anesthetic factors associated with major morbidity (Clavien Dindo ≥ III) after RAPD. Methods: All consecutive patient undergoing pancreatoduodenectomy were retrospectively included during a two year inclusion period. Anesthesia charts were studied on fluid management details, rates of vasopressor administration and arterial blood gas results. All factors were compared between both surgical approaches. Within RAPD, factors were subsequently compared between patients with major (Clavien Dindo ≥ III) vs. without major postoperative morbidity and between procedures with high and low intraoperative blood loss. Perioperative factors associated with considerable postsurgical morbidity (Clavien Dindo ≥ III) were identified by constructing a logistic regression model.Results: RAPD was associated with higher administration of intraoperative vasopressors (9.5% of operative time vs. 0% in OPD, p=0.005) and a higher net intraoperative fluid balance (2497.6 vs. 1572.3 ml, p<0.001). OPD patients more frequently and quantitatively received colloids compared to RAPD patients (79.0% vs. 51.6%, p<0.001, 1000.0 vs. 500.0 ml, p<0.001). Intraoperative erythrocyte transfusion rate was 6.3% (4/64) for RAPD compared to 30.6% (19/62) for OPD (p<0.001). Colloid administration during surgery and hyperlactatemia after 12 hour postoperative admission were associated with major (Clavien Dindo ≥ III) morbidity after RAPD (OR 5.06 with 95% CI 1.49-17.20, p=0.009 and OR 3.18 with 95% CI 1.01-9.91, p=0.047, respectively).Conclusions: RAPD is a challenging procedure for the perioperative anesthesiologist e.g. considering a higher perioperative demand for vasopressors. Perioperative anesthetic factors, including hemodynamics and fluid strategy might alter postoperative morbidity. However, current data is insufficient to make specific recommendations.

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BackgroundRobot-assisted pancreatoduodenectomy (RAPD) poses several challenges concerning perioperative anesthetic guidance compared to open pancreatoduodenectomy (OPD), e.g. combined pneumoperiotoneum with reversed-Trendelenburg positioning. The primary objective of this observational study is to specify these anesthetic differences of RAPD versus OPD and secondly to identify independent anesthetic factors associated with patient morbidity following RAPD.MethodsAll consecutive patients who underwent either RAPD or OPD between 2017 and 2018 were included for analysis. Patient records were screened for intraoperative vasopressor and fluid administration as well as for results of perioperative arterial blood gas analysis. Variables were compared for the groups RAPD versus OPD, major morbidity following RAPD versus non-major morbidity following RAPD (resp. Clavien-Dindo score ≥ III vs. < III) and high versus low intraoperative blood loss during RAPD. Perioperative factors associated with major postoperative morbidity (Clavien-Dindo ≥ III ) were identified using a logistic regression model.ResultsN=64 RAPD and n=62 OPD patients were included for retrospective analysis. RAPD was associated with higher administration of intraoperative norepinephrine (9.5% of operative time vs. 0% in OPD, p=0.005) and a higher net intraoperative fluid balance (2497.6 vs. 1572.3 ml, p<0.001). During OPD, patients received more frequent and higher doses of colloid fluids compared to RAPD (79.0% vs. 51.6%, p<0.001, median 1000.0 vs. 500.0 ml, p<0.001). Colloid administration during surgery and hyperlactatemia 12 hours postoperatively were associated with major morbidity after RAPD (OR 5.06, 95% CI 1.49-17.20, p=0.009 and OR 3.18, 95% CI 1.01-9.91, p=0.047, respectively).ConclusionsRAPD is a challenging procedure for the anesthesiologist, e.g. considering a higher demand for vasopressors. Inotropic/vasopressor administration as well as the intraoperative fluid balance are associated with (major) morbidity following RAPD. However, it remains unclear whether and in which direction a causal relationship exists.Trial registration: Not applicable.