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. 2010 Feb;159(2):314-22.
doi: 10.1016/j.ahj.2009.11.013.

The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision

Beth Unsworth  1 , Roberto P Casula, Andreas A Kyriacou, Hemang Yadav, Andrew Chukwuemeka, Ashok Cherian, Rex de Lisle Stanbridge, Thanos Athanasiou, Jamil Mayet, Darrel P Francis
Affiliations

The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision

Beth Unsworth et al. Am Heart J. 2010 Feb.

Abstract

Background: Right ventricular (RV) long-axis function is known to be depressed after cardiac surgery, but the mechanism is not known. We hypothesized that intraoperative transesophageal echocardiography could pinpoint the time at which this happens to help narrow the range of plausible mechanisms.

Method: Transthoracic echocardiography was conducted in 33 patients before and after elective coronary artery bypass graft. In an intensively monitored cohort of 9 patients, we also monitored RV function intraoperatively using serial pulsed wave tissue Doppler (PW TD) transesophageal echocardiography.

Results: There was no significant difference in myocardial velocities from the onset of the operation up to the beginning of pericardial incision, change in RV PW TD S' velocities 3% +/- 2% (P = not significant). Within the first 3 minutes of opening the pericardium, RV PW TD S' velocities had reduced by 43% +/- 17% (P < .001). At 5 minutes postpericardial incision, 2 minutes later, the velocities had more than halved, by 54% +/- 11% (P < .0001). Velocities thereafter remained depressed throughout the operation, with final intraoperative S' reduction being 61% +/- 11% (P < .0001). One month after surgery, in the full 33-patient cohort, transthoracic echocardiogram data showed a 55% +/- 12% (P < .0001) reduction in RV S' velocities compared with preoperative values.

Conclusions: Minute-by-minute monitoring during cardiac surgery reveals that, virtually, all the losses in RV systolic velocity occurs within the first 3 minutes after pericardial incision. Right ventricular long-axis reduction during coronary bypass surgery results not from cardiopulmonary bypass but rather from pericardial incision.

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Figures

Figure 1
Figure 1
Image on the left shows an example of a PW TD waveform obtained from transthoracic echocardiography. Images on the right show an example of PW TD waveform obtained from TEE.
Figure 2
Figure 2
Reduction in RV PW TD S′ (black), E′ (light gray), and A′ (dark gray) in 33 patients after routine CABG surgery.
Figure 3
Figure 3
Changes in RV TAPSE distance in 33 patients before and after routine CABG surgery.
Figure 4
Figure 4
Effect of surgery on RV PW TD velocities, separating patients according to whether the operation was on or off pump and whether they received right coronary artery graft. All 4 groups had similar declines in RV velocity.
Figure 5
Figure 5
Intraoperative TEE RV S′ during a routine on-pump CABG to left anterior descending and circumflex arteries. The preoperative TTE PW TD velocities are replicated at the time of general anesthesia and remain unchanged after skin incision and sternal opening. Immediately after pericardial incision, there is an immediate marked reduction in RV TD S′ velocities, which remains until the time of bypass cannulae insertion when measurements had to be suspended temporarily. After myocardial reperfusion, rewarming, and then weaning from cardiopulmonary bypass, data collection is resumed. Right ventricular TD S′ velocities remain depressed at the same level and do not improve during the rest of the operation. The last measurement at the time of skin closure show the same depressed velocities. One month later, the velocity remains equally depressed.
Figure 6
Figure 6
Intraoperative S′ velocity of the RV free wall during a routine off-pump CABG to left anterior descending and circumflex arteries.
Figure 7
Figure 7
The time course of RV velocities of all 9 patients in the intensively monitored cohort, zooming in to show the prelude to, and the first 40 minutes after, pericardial opening for each case. The gray dashed line indicates the time when the pericardium was incised. All 9 patients demonstrate an immediate decline in RV S′ myocardial velocities. This reduction occurs mostly within the first 3 minutes after pericardial incision and persists throughout the operation.
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References

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