Post-operative Right Ventricular Failure After Cardiac Surgery: A Cohort Study

Abstract

Introduction: Right ventricular failure (RVF) after cardiac surgery is an important risk factor for morbidity and mortality. Its diagnosis is challenging, and thus, its incidence and predictors are not well-established. We investigated the incidence, complications, and variables associated with clinically relevant post-operative RVF.Methods: We included all patients who underwent cardiac surgery with cardiopulmonary bypass between 2016 and 2019 in a cardiac surgery center with standardized diagnostic and therapeutic management of RVF. RVF was considered only if clinically relevant: associated with hemodynamic instability requiring catecholamine support and inhaled nitric oxide relayed by sildenafil.Results: Overall, 3,826 patients were included, of whom, 110 (2.9%) developed post-operative RVF. Mortality was not different among patients who developed post-operative RVF, compared with the rest of the cohort (1.8 vs. 0.7%, p = 0.17). Using a composite outcome that combined death, reintubation, stroke, and prolonged intensive care unit stay (more than 14 days) yielded an incidence of 6.6%, and RVF was associated with this composite outcome with an odds ratio of 3.6 (2.2–5.8), p < 0.001. In a multivariable model, pre-operative variables independently associated with post-operative RVF were pre-operative atrial fibrillation (AF) {adjusted odds ratio (adjOR) 3.22 [95% confidence interval (95%CI) = 1.94–5.36], p < 0.001}, left ventricle ejection fraction below 50% [adjOR = 2.55 (95%CI = 1.52–4.33), p < 0.001], systolic pulmonary artery pressure above 55 mmHg [adjOR = 8.64 (95%CI = 5.27–14.1); p < 0.001], mitral valve surgery [adjOR = 2.17 CI (95%CI = 1.28–3.66), p = 0.004], and tricuspid valve surgery [adjOR = 10.33 (95%CI = 6.14–17.4), p < 0.001]. In patients who developed post-operative RVF requiring treatment, 32 (29.1%) showed RV dysfunction before surgery.Conclusion: In this cohort study, 2.9% of patients developed clinically significant post-operative RVF. Moreover, RVF was associated with severe adverse outcomes, including death, strokes, reintubation, and prolonged intensive care unit stay.

The right ventricle after cardiac surgery, hypotheses and evidences, and the role of advanced echocardiography modalities

“…Mechanisms of RV dysfunction after cardiac surgery are multifactorial, ranging from per-operative myocardial depression to factors affecting afterload or preload, along with potential effects of inflammatory cytokines on endothelial function, etc. [10]. Nevertheless, in uncomplicated cardiac surgery, like in the studied population presented by Wejner-Mik et al [6], we estimate that the impact of these factors is absent or minimal.…”

“…The micro-anatomy of the RV shows that myocytes are predominantly oriented in the longitudinal direction in the subendocardial layer, whereas circumferentially oriented myocytes are found in the thinner subepicardium; accordingly, the RV contraction pattern is predominantly longitudinal [10]. As a consequence, the RV output is mostly engendered by longitudinal contraction in physiological conditions.…”

Indicators of the Right Ventricle Systolic and Diastolic Function 18 Months after Coronary Bypass Surgery

“…There are fewer data on the clinical and prognostic significance of the development of RV dysfunction in the postoperative period. For example, the development of severe RV insufficiency after cardiac surgery was accompanied by severe complications and adverse outcomes [ 5 ]. However, the frequency of such significant right ventricular dysfunction in that study was low; thus, the less pronounced manifestations of right ventricular dysfunction detected by echocardiography attracted the attention of investigators.…”

“…For example, the development of right ventricular failure after cardiac surgery is associated with a high complication rate and poor prognosis. [ 2 , 3 , 4 , 5 ]. Accordingly, the diagnosis and treatment of RV dysfunction after CABG are important for prognosis improvement, both in the early postoperative period and in the more distant periods [ 6 , 7 , 8 , 9 ].…”

The Evolution of Percutaneous Right Ventricular Support and Development of a Right Ventricular Mechanical Support Team Led by Cardiac Anesthesiologists

“…2 Despite modifying preoperative risk factors, the patients who undergo the induction of anesthesia and then cardiopulmonary bypass are still at an independent risk for RV failure. 6 For cardiac anesthesiologists, acute RV failure presents a particularly important clinical challenge. Regardless of the preoperative optimization and planning, the intraoperative and postoperative RV systolic function can acutely deteriorate.…”