|Year : 2022 | Volume
| Issue : 2 | Page : 156-163
Transesophageal echo-derived left ventricular ejection fraction versus myocardial performance index in predicting outcome following coronary artery bypass grafting surgery
Abhijeet Shitole1, Preeti Lamba1, Sharanagouda Patil1, Anand Vagarali1, Veerappa Kothiwale2, Jabbar Momin3
1 Department of Cardiac Anaesthesia, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed to-be University), Belagavi, Karnataka, India
2 Department of Internal Medicine, Jawaharlal Nehru Medical College and The Registrar, KLE Academy of Higher Education and Research (Deemed to-be University), Belagavi, Karnataka, India
3 Department of Cardiac Anaesthesia, KLE's Prabhakar Kore Hospital, Belagavi, Karnataka, India
|Date of Submission||05-Jan-2022|
|Date of Acceptance||28-Mar-2022|
|Date of Web Publication||24-May-2022|
Dr. Preeti Lamba
Department of Cardiac Anaesthesia, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed to-be University), Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
BACKGROUND AND AIMS: Although left ventricular ejection fraction (LVEF) is the most commonly studied echocardiographic parameter for predicting postoperative outcome, its utility is limited by its preload dependency and ability to measure the only systolic function of the left ventricle. The myocardial performance index (MPI), a ratio obtained by summing up the time required for isovolumetric contraction and relaxation against the systolic ejection phase of the cardiac cycle, is the least studied parameter of left ventricular performance in perioperative settings. So, being a composite measure of systolic and diastolic function of the heart, we hypothesized that MPI can be a better predictor of postoperative outcome following coronary artery bypass grafting (CABG). The present study aimed at finding a correlation of LVEF and MPI with postoperative outcome indicators such as vasoactive inotropic score (VIS), the requirement of intra-aortic balloon pump (IABP) to maintain cardiac output, duration of mechanical ventilation, stay in the intensive care unit (ICU), postoperative morbidity and mortality.
METHODS: A prospective, observational study was conducted on 110 subjects, scheduled for elective CABG. Transesophageal echocardiography (TEE) was performed after induction of anesthesia and before coronary grafting. Patients with no or grade I mitral regurgitation (vena contracta-VC <0.3 cm, effective regurgitant orifice area <0.2 cm2) and those in normal sinus rhythm were included. Patients with arrhythmia and MR of more than grade I (VC >0.3 cm, EROA >0.2 cm2) were excluded. Pre-CABG LVEF was measured using Simpson's biplane method. MPI was measured using Pulsed-wave Doppler across mitral inflow and left ventricular outflow tract. Subjects were labeled as “good” and “poor” outcomes based on standard criteria for defining the immediate postoperative outcome. Pre-CABG MPI and LVEF were correlated with these postoperative outcome variables following CABG.
RESULTS: Of 110 subjects, 14 were excluded due to the presence of more than grade I MR (n = 8) and arrhythmias (n = 6) before CABG. Out of 96 subjects, 66% (n = 63) had “good” outcome and 34% (n = 33) had a “poor” outcome. Pre-CABG MPI and LVEF were (0.51 ± 0.12 and 47.2% ± 8.8%) in subjects with “good” compared to (0.57 ± 0.13 and 42.00% ± 8.70%) (P = 0.032 and 0.007 respectively) “poor” outcome following CABG. A higher pre-CABG MPI (0.57 ± 0.13) alone significantly correlated with increased VIS (r = 0.325, P = 0.001) in contrast to lower LVEF (42% ± 8.7%) (r = −0.181, P = 0.077). Both, lower precardiopulmonary bypass LVEF (40.46% ± 8.81%) and higher MPI (0.6 ± 0.11) were significantly correlated with increased ICU stay in days (r = −0.218 and r = 0.287, respectively). The mean MPI was 0.57 ± 0.08 and LVEF was 39.55% ± 4.05% in those subjects who succumbed in the postoperative period following CABG.
CONCLUSION: MPI was a relatively better predictor of postoperative outcome following CABG. Increased Pre-CABG MPI was more consistent with the postoperative inotropic and vasopressor requirement. The requirement of an IABP to maintain cardiac output following CABG and mortality was correlated well with both low preoperative LVEF and higher MPI values.
Keywords: Coronary artery bypass grafting, left ventricular ejection fraction, myocardial performance index, pulsed wave Doppler, transesophageal echocardiography
|How to cite this article:|
Shitole A, Lamba P, Patil S, Vagarali A, Kothiwale V, Momin J. Transesophageal echo-derived left ventricular ejection fraction versus myocardial performance index in predicting outcome following coronary artery bypass grafting surgery. Indian J Health Sci Biomed Res 2022;15:156-63
|How to cite this URL:|
Shitole A, Lamba P, Patil S, Vagarali A, Kothiwale V, Momin J. Transesophageal echo-derived left ventricular ejection fraction versus myocardial performance index in predicting outcome following coronary artery bypass grafting surgery. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Jul 6];15:156-63. Available from: https://www.ijournalhs.org/text.asp?2022/15/2/156/345835
| Introduction|| |
Since the introduction of ultrasound in the field of medicine, transthoracic two-dimensional (2D) echocardiography is an integral part of cardiac assessment before cardiac surgical procedure. 2D echo-derived left ventricular ejection fraction (LVEF) is the most commonly considered parameter for assessing the degree of cardiac function in clinical practice. Literature shows the role of low preoperative ejection fraction in predicting both early and late postoperative morbidity and mortality following coronary artery bypass grafting (CABG) surgery., LVEF is an independent predictor of events such as prolonged postoperative ventilation, need of intra-aortic balloon placement (IABP), and prolonged intensive care unit (ICU) stay.,, Left ventricle (LV) ejection fraction is the fraction of end-diastolic volume which is ejected out of the LV during systole. It only measures the systolic function of the LV. Diastolic dysfunction is an unbiased predictor of cardiac failure-related morbidity and mortality following cardiac surgery hence, “Heart Failure with preserved Ejection Fraction” is now a well-known entity. Being a preload dependent measure, LVEF values vary with different loading conditions. The American Society of Echocardiography recommends Modified Simpson's biplane method for accurate estimation of LV ejection fraction., Tei described “myocardial performance index (MPI)” also known as “Tei index” which considers both systolic and diastolic phases of the cardiac cycle for the assessment of the left ventricular function. MPI is obtained by summing up the time required for isovolumetric contraction and relaxation of LV against the time required for the systolic ejection., So, being a composite measure of both systolic and diastolic performance of the LV, MPI can be a more reliable measure to predict the postoperative outcome following CABG. At present, though the literature is sparse to establish its utility in cardiac surgical patients, its prognostic value in individuals with heart diseases like myocardial infarction has been proved.,, Unlike LVEF, MPI is a load-independent measure of left ventricular function.,, In the present study, we used transesophageal echocardiography (TEE) for the assessment of LVEF and MPI. TEE is a valuable tool for intraoperative decision-making. At present, TEE is a class IIa recommendation in patients undergoing CABG. We hypothesized that being a composite measure of systolic and diastolic function MPI could be a better predictor of postoperative outcome following CABG. The aim of the study was to correlate the Pre-CABG MPI and LV ejection fraction with postoperative outcome variables such as the requirement of inotropic and vasopressor support (VIS), requirement of mechanical cardiovascular support (IABP), and length of ICCU stay, duration of mechanical ventilation, morbidity and mortality.
| Methodology|| |
Following approval of the institutional ethical committee and obtaining informed written consent 110 subjects posted for elective CABG surgery were enrolled prospectively from September 2020 to April 2021 at the cardiothoracic and vascular surgery unit of tertiary care hospital in northern Karnataka, India. Subjects with normal sinus rhythm and having stable hemodynamic were included in the study. Subjects with history or evidence of renal, liver and neurological dysfunction, undergoing emergency surgery for ventricular septal rupture or undergoing combined valve and coronary artery bypass surgery, presence of mitral regurgitation more than grade I (graded using vena contracta, VC width >0.3 cm or effective regurgitant orifice area, >0.2 cm2) were excluded. Six subjects who had pre-CABG hemodynamic instability and arrhythmias and eight subjects in whom intraoperative TEE showed more than grade I MR were excluded from the study. A total of 96 subjects were recruited for evaluation and analysis. Baseline demographic and clinical and biochemical characteristics were noted. Anesthetic induction was done as per the standard operating protocols ensuring vigilant invasive hemodynamic monitoring. Pulmonary artery catheter was placed in subjects with preoperative LVEF <45%. In rest, central venous catheter was inserted. Central venous pressure, pulmonary capillary wedge pressure, and pulmonary artery systolic and diastolic pressures were noted. Phillips X7-2T Adult X matrix array transesophageal echocardiography transducer probe was inserted after 5 ml of lignocaine 2% mucous jelly was instilled in the oral cavity. Undue force was avoided while inserting the probe in the esophagus. If such resistance was encountered, the probe insertion was done under direct vision using laryngoscopy. TEE was done to calculate the MPI and LVEF. To avoid the inter-observer bias, the readings of echocardiographic study variables were taken by a sole echocardiographer and an average of two readings was taken for final documentation. Six subjects who had pre-CABG hemodynamic instability and arrhythmias and eight subjects in whom intraoperative TEE showed more than grade I MR were excluded from the study. A total of 96 subjects were recruited for evaluation and analysis. Ethical clearance was obtained from Jawaharlal Nehru medical college institutional ethics committee with ref no MDC/DOME/353 dated 20.05.2020.
Myocardial performance index
Pulsed-wave Doppler with a sample volume of 4 mm was placed at the tips of mitral leaflets in the direction parallel to blood flow in midesophageal four-chamber view obtained at 0°–20° to get the velocity pattern across the mitral valve. Interval “a” was recorded from the end of the “A” wave to the beginning of the “E” wave of mitral inflow. This interval included isovolumetric contraction time (IVCT), ejection time (ET), and isovolumetric relaxation time (IVRT). The probe was then advanced to obtain the deep transgastric long-axis view at 120°–140° and the pulse-wave Doppler left ventricle outflow tract (LVOT) velocity was obtained by aligning Doppler interrogation parallel to the blood flow. A sample volume of 4 mm was placed in the LVOT 0.5 cm proximal to the aortic annulus. Interval “b” was measured as the duration of this flow profile which equaled the duration of the ET. Measurements were taken after sternotomy where the effects of anesthesia on cardiac function and systemic vascular resistance were nullified by surgical stimulation. All the measurements were obtained during a period when the patient was hemodynamically stable. Care was taken to ensure that the hemodynamic parameters remained unchanged during the process of recording. Any recording obtained during conditions that did not satisfy the above criteria were not considered for the study purpose. MPI was obtained from the equation ([a-b] ÷ b) which equals the value of ([IVCT + IVRT] ÷ET), [Figure 1].
|Figure 1: Calculation of myocardial performance index: Two-dimensional transesophageal echocardiography image on right shows pulsed wave Doppler signal velocities of mitral inflow in midesophageal four-chamber view obtained at 0°. Time “a” denotes the time required for the E wave to appear after the A wave of the previous cardiac cycle ends. It includes isovolumetric contraction time, left ventricular ejection time and isovolumetric relaxation time. Two-dimensional transesophageal echocardiography Image on the left shows the pulsed-wave Doppler interrogation across left ventricular outflow tract in transgastric long axis view obtained at 125°. Time “b” is a time required for left ventricular ejection. Myocardial performance index (Tei index) is given by the formula, myocardial performance index = (a-b)/b = (412 ms - 292 ms)/292 ms = 0.41|
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Left ventricular ejection fraction
Left ventricular ejection fraction was calculated using midesophageal four-chamber and midesophageal two-chamber views obtained at 0°–20° and 80°–100° respectively using modified Simpson's (biplane) method. Time and lateral gain compensation were adjusted to delineate the endocardial borders accurately. An average of values obtained in both views was taken and LV end-diastolic and end-systolic volumes and subsequent LV ejection fraction was calculated and noted down. LVEF was calculated using formula, LVEF = ([LV end-diastolic volume-LV end-systolic volume]/LV end-diastolic volume) × 100 [Figure 2] and [Figure 3].
|Figure 2: Calculation of the left ventricular ejection fraction by Simpson's biplane method: Two-dimensional transesophageal echocardiography image on the left shows ECG-gated left ventricular end-diastolic frame. The left ventricular end-diastolic volume is obtained by application of “left ventricular ejection fraction measurement software” and aligning the endocardial borders accurately in midesophageal four-chamber view obtained at 0°. The image on the right shows ECG-gated left ventricular end systolic frame. Left ventricular end-systolic volume is obtained by application of “left ventricular ejection fraction measurement software” and aligning the endocardial borders accurately in midesophageal four-chamber view obtained at 0°. The left ventricular ejection fraction is given by the formula, left ventricular ejection fraction = ([left ventricular end-diastolic volume - left ventricular end-systolic volume]/left ventricular end-diastolic volume) × 100 = [(96.7-55.9) 96.7] × 100 = 42.2%|
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|Figure 3: Calculation of left ventricular ejection fraction by Simpson's bi-plane method: Two-dimensional transesophageal echocardiography image on the left shows ECG-gated left ventricular end diastolic frame. The left ventricular end-diastolic volume is obtained by application of “left ventricular ejection fraction measurement software” and aligning the endocardial boarders accurately in midesophageal two-chamber view obtained at 103°. Image on the right shows ECG-gated left ventricular end systolic frame. Left ventricular end systolic volume is obtained by application of “left ventricular ejection fraction measurement software” and aligning the endocardial boarders accurately in midesophageal four-chamber view obtained at 103°. The left ventricular ejection fraction is given by the formula, left ventricular ejection fraction = ([left ventricular end diastolic volume - left ventricular end systolic volume]/left ventricular end diastolic volume) × 100 = ([83.5-50.0]/83.5) × 100 = 40.1%. (Average of the above two values, i.e., (42.2 + 40.1)/2 = 41.15 was considered for documentation of left ventricular ejection fraction and analysis)|
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CABG was performed by a single surgeon. Decision-making of whether to perform ON pump cardiopulmonary bypass (CPB) or an OFF pump CABG was completely a surgeon's choice depending on preoperative hemodynamics and quality of coronary arteries to be grafted. Hemodynamics were maintained adequately during OFF pump CABG. When the CPB was used, the institution of CPB and weaning off from CABG was done based on standard operating protocols of CPB. In all cases, care was taken to maintain mean arterial pressure >70 mmHg. To maintain it, infusion noradrenaline (0.02-0.1 mcg/kg/min) and dopamine (3–7 mcg/kg/min) were primarily used. If the contractility was poor epinephrine (0.05–0.1 mcg/kg/min) was considered. An intra-aortic balloon pump (IABP) was inserted to maintain adequate perfusion pressure if there was evidence of postoperative hemodynamic instability or new-onset ST-T changes. Additional vasopressors, inotropes and inodilators (dobutamine, vasopressin, and milrinone) were started whenever required. After surgery, subjects were transported to the postoperative intensive cardiac care unit. Postoperative standard outcome variables such as VIS in first 6 h, duration of mechanical ventilation in hours, duration of vasopressor/inotrope/inodilator use, the requirement of mechanical cardiovascular support (IABP), 24-h serum creatinine and hematocrit values, episodes of cardiac failure (defined as clinical or radiological evidence of pulmonary edema that requires diuretics, oxygen supplementation, noninvasive, or invasive ventilation), morbidity and mortality were noted. VIS was calculated using the formula Dopamine(μg/kg/min) + Dobutamine(μg/kg/min) + Milrinone(μg/kg/min × 10) +Epinephrine(μg/kg/min × 100) + Norepinephrine(μg/kg/min × 100) + Vasopressin (unit/kg/hour × 10,000). The “poor” outcome was labeled to subjects who had VIS >20 for more than 6 h and/or required IABP and/or required mechanical ventilation > 24 h, low cardiac output syndrome, suffered perioperative organ dysfunction such as respiratory failure, cerebrovascular accident, acute kidney injury (AKI), or those who succumbed. Subjects who did not require much pharmacological or mechanical cardiovascular support (VIS <20 in 6 h) and weaned off from mechanical ventilation within 24 h and did not suffer from low cardiac output syndrome, respiratory failure, AKI were labeled as “good” outcome class. Demographic, clinical and echocardiographic characteristics, operative variables and pre-CABG MPI and LVEF were compared in “good” and “poor” outcome classes. Pre-CABG MPI and LVEF values were correlated with the postoperative vasoactive inotropic score (VIS), duration of vasopressor/inotrope requirements, duration of mechanical ventilation (hrs), duration of ICCU stay, and requirement of mechanical cardiovascular support (IABP use) and mortality.
Based on a relevant previous relevant study, the calculated sample size was 96. Keeping the possibility of 10% attrition, a total of 110 subjects were approached and assessed for eligibility. Categorical/nominal variables were expressed as number/percent and were analyzed with the use of the Chi-square test. Continuous variables have been expressed as mean and standard deviation and analyzed with the use of an unbiased sample t-test for contrast among the two outcome categories. Correlation among two continuous variables was analyzed with the use of the Pearson correlation coefficient. P < 0.05 was considered statistically significant. Epi info model 220.127.116.11 statistical software was used for statistical analysis.
| Results|| |
65.6% of patients had “good” outcome and 34.4% had “poor” outcome. Baseline demographic, clinical and biochemical characteristics were similar in both classes. Except chronic obstructive pulmonary disease (COPD), none of the clinical parameters predicted “poor” outcome. CABG performed on CPB and requiring higher perioperative blood transfusion predicted “poor” outcome [Table 1]. LVEF in the “poor” outcome class was significantly lower (42% ± 8.7%) as compared to the “good” outcome group (47.2% ± 8.8%, P = 0.007). Similarly, mean MPI in “good” outcome class was lower (0.51 ± 0.12) than “poor” outcome class (0.57 ± 0.13, P = 0.032). A higher pre-CABG MPI (0.57 ± 0.13) alone significantly correlated with increased VIS [Graph 1] in contrast to lower LVEF 42% ± 8.7% (r = −0.181, P = 0.077) [Table 2]. In the same way, the duration of vasopressor/inotrope use was correlated with MPI [Graph 2] and [Table 2]. Both, lower pre-CPB LVEF (40.46% ± 8.81%) and higher MPI (0.6 ± 0.11) were significantly correlating with and predicted increased ICCU stay in days (r = −0.218 and r = 0.287 respectively) [Table 2]. The duration of ventilation neither correlated with MPI nor with LVEF. The mean MPI was 0.57 ± 0.08 and LVEF was 39.55% ± 4.05% in those subjects who succumbed in postoperative period following CABG [Table 2].
|Table 1: Demographic, clinical, biochemical, and procedure characteristics|
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|Table 2: Correlation and association of outcome variables with prebypass left ventricular ejection fraction and myocardial performance index|
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| Discussion|| |
In the present study, among 96 subjects fulfilling the inclusion criteria, 63 had a “good” outcome and 33 had a “poor” outcome. “Poor” outcome was defined by increased requirement of pharmacological (VIS >20 for more than 6 h) and/or mechanical cardiovascular supports (IABP) to maintain cardiac output and/or mechanical ventilation >24 h and/or evidence of organ dysfunction or mortality. Pre-CABG MPI (Tei index) was significantly higher (P = 0.032) and LV ejection fraction was significantly lower in “poor” outcome subjects. Length of ICCU stay, the incidence of IABP use was significantly higher in patients with low preoperative LVEF and high MPI value. In the present study, higher MPI value significantly correlated with increased requirement of vasopressor/inotrope (r = 0.325, P = 0.001) and duration of pharmacological support to maintain cardiac output (r = 0.312, P = 0.002). Lower LVEF (40.46 ± 8.81) (P = 0.008) and higher MPI (0.60 ± 0.11, P = 0.007). Moreover, thelength of HDU stay was significantly correlated with both lower LVEF (r = −0.218, P = 0.033) and higher MPI (r = 0.287, P = 0.005). The present study was the first of its kind in predicting outcome following CABG using transesophageal echo-derived MPI and LV ejection fraction.
Spetsotaki et al. evaluated the advantages of OFF pump over ON pump CABG and concluded that OFF pump CABG was better than ON pump in maintaining systolic LV characteristics. In the present study, we found better outcomes in OFF pump surgeries. The utility of MPI as a tool to monitor cardiac function and predict its outcome had been proved in several studies on subjects with different cardiac problems; MPI was found useful in monitoring the severity of drug-induced cardiotoxicity, dilated cardiomyopathy, rejections after pediatrics cardiac transplantation.,,,, The utility of MPI as a predictive, monitoring and prognosticating tool in patients with CCF is proved in multiple studies.,, Parthenakis et al. in their study found that using a cut-off value of >0.47 for MPI, CCF was anticipated with 86% sensitivity and 82% specificity. They concluded that MPI is a sensitive indicator of global cardiac characteristics in patients with CCF. The results from our study are partly consistent with the results of Parthenakis et al., as we noticed a mean MPI of 0.57 ± 0.13 in the bad outcome group which is notably more than the good outcome group (0.51 ± 0.12). Kato et al. studied subjects with acute myocardial infarction and concluded that MPI >0.65 was proven to be an unbiased predictor of long-term mortality. Szymański et al. studied MPI in 90 subjects with documented anterior MI and followed them for 5 years. They did the multivariate analysis for prognosis following anterior MI. They concluded that MPI of >0.55 was an unbiased predictor of mortality. Our study yielded similar findings. Subjects with pre-CABG MPI >0.50 had an increased chance of adverse events. AI-Mukhaini et al. found MPI of >0.7 was significantly associated with death and CCF and LVEF <40% had a weaker specificity, correctness, and predictive utility than MPI >0·70 in patients with moderate to extreme MR undergoing correction surgery. They inferred that MPI was a presumably useful predictor of accelerated chance of perioperative loss of life or congestive cardiac failure. Although we have studied a smaller sample volume to comment on, our findings were similar to AI-Mukhaini et al. Mahmood F et al. studied echocardiographic determinants of detrimental events such as postoperative CHF, arrhythmia, or extended intubation time in patients undergoing aortic aneurysm repair surgeries. They found, mean MPIs of 0.48 ± 0.17, 0.51 ± 0.2, and 0.53 ± 0.13 in those who experienced CHF, prolonged intubation time and arrhythmias, respectively. In our study, 29 patients having MPI >0.50 had detrimental events. EURO score, Parsonate score, and other risk assessment score include the pre-operative LV ejection fraction as a variable that predict the adverse outcome successfully. Topkara et al. showed that the preoperative low LVEF is an element to predict risk of mortality and morbidity after cardiac surgery. Légaré et al. identified preoperative poor LVEF (<30%) as an unbiased predictor of extended postoperative ventilation. In our study, LV ejection fraction was consistently associated with adverse events such as LCOS and requirement of mechanical cardiovascular support (IABP) and duration of mechanical ventilation. The effect of diastolic function on the heart was not taken into account in any of the above studies or risk assessment models. Diastolic dysfunction/failure is an independent factor that influences the outcome, adverse cardiac events, morbidity and mortality. In our study, we could establish the correlation of adverse outcomes with the composite measure of LV systolic as well as diastolic function. Of 96, 19 subjects required mechanical circulatory support device (IABP), eight had a cardiac failure and four met with the unfortunate event of death (in-hospital mortality). The characteristics of subjects with cardiac failure were male sex, associated with comorbidities such as hypertension, smoking, diabetes mellitus and COPD, anterior wall MI, ON PUMP CABG, preoperative LVEF 27% to 38% and MPI >0.50. Cardiac failure was defined as reduction in the cardiac index to <2.0 L/min/m2, systolic BP <90 mmHg, cold clammy extremities, oliguria (<0.5 ml/kg/h), mental confusion, increased lactate levels >2 mg/dl in the absence of hypovolemia. MPI predicted the LCOS indirectly by predicting increased VIS, prolonged duration of vasopressor/inotrope use, and IABP use. The present study, could not establish a significant correlation between prolonged mechanical ventilation and LVEF or MPI, this may be due to the multifactorial association of mechanical ventilation with clinical characteristics, postoperative bleeding, perioperative transfusion, and surgeons' preference for elective ventilation. MPI has been shown as a consistent predictor of poor outcome following CABG. Mabrouk-Zerguini et al. correlated FAC and MPI with postoperative outcomes in severe grades of mitral regurgitation associated with CABG. The pre-CABG MPI was a better predictor of systolic function in these patients. LVEF in different grades of ischemic MR was erroneously high. However, MPI values did not alter in the presence of MR. Thus, MPI may be a better predictor of postoperative outcome following CABG. In the present study, if we had included patients with grade 1 MR similar results were shown in our study too.
Invasive cardiac output monitoring was not instituted for perioperative monitoring. The diagnosis of the left ventricular dysfunction was made purely based on clinical and echocardiographic data. Perioperative serum lactate was also not considered for diagnostic criteria of LCOS.
MPI was calculated using a conventional method derived from assessment in two different cardiac cycles. Tissue Doppler imaging method of calculation of MPI could have been a better option.
| Conclusion|| |
MPI and LVEF significantly predicted the requirement of postoperative mechanical cardiovascular support. MPI alone proved to be a better predictor of postoperative inotropic and vasopressor (pharmacological) support requirements to maintain cardiac output. Higher pre-CABG MPI and lower LV ejection fraction, higher LV end-diastolic and systolic volumes, higher fractional area change were the principal determinants of poor outcome following CABG.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al.
ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: Summary article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003;108:1146-62.
Hamad MA, van Straten AH, Schönberger JP, ter Woorst JF, de Wolf AM, Martens EJ, et al.
Preoperative ejection fraction as a predictor of survival after coronary artery bypass grafting: Comparison with a matched general population. J Cardiothorac Surg 2010;5:29.
Légaré JF, Hirsch GM, Buth KJ, MacDougall C, Sullivan JA. Preoperative prediction of prolonged mechanical ventilation following coronary artery bypass grafting. Eur J Cardiothorac Surg 2001;20:930-6.
Risum O, Nitter-Hauge S, Abdelnoor M, Levorstad K, Arafa O, Svennevig JL. Mortality and morbidity after coronary artery bypass surgery related to pre-operative left ventricular ejection fraction: A follow-up study. Eur Heart J 1996;17:874-9.
Vaskelyte J, Stoskute N, Kinduris S, Ereminiene E. Coronary artery bypass grafting in patients with severe left ventricular dysfunction: Predictive significance of left ventricular diastolic filling pattern. Eur J Echocardiogr 2001;2:62-7.
Adamczak DM, Oduah MT, Kiebalo T, Nartowicz S, Bęben M, Pochylski M, et al.
Heart failure with preserved ejection fraction – A concise review. Curr Cardiol Rep 2020;22:82.
Klaeboe LG, Edvardsen T. Echocardiographic assessment of left ventricular systolic function. J Echocardiogr 2019;17:10-6.
Chengode S. Left ventricular global systolic function assessment by echocardiography. Ann Card Anaesth 2016;19:S26-34.
] [Full text]
Tei C. New non-invasive index for combined systolic and diastolic ventricular function. J Cardiol 1995;26:135-6.
Murphy GS, Marymont JH, Szokol JW, Avram MJ, Vender JS. Correlation of the myocardial performance index with conventional echocardiographic indices of systolic and diastolic function: A study in cardiac surgical patients. Echocardiography 2007;24:26-33.
Poulsen SH, Jensen SE, Tei C, Seward JB, Egstrup K. Value of the Doppler index of myocardial performance in the early phase of acute myocardial infarction. J Am Soc Echocardiogr 2000;13:723-30.
Møller JE, Poulsen SH, Egstrup K. Effect of preload alternations on a new Doppler echocardiographic index of combined systolic and diastolic performance. J Am Soc Echocardiogr 1999;12:1065-72.
Lavine SJ. Effect of heart rate and preload on index of myocardial performance in the normal and abnormal left ventricle. J Am Soc Echocardiogr 2005;18:133-41.
Muralidhar K, Tempe D, Chakravarthy M, Shastry N, Kapoor PM, Tewari P, et al.
Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists. Ann Card Anaesth 2013;16:268-78.
] [Full text]
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd
, Fleisher LA, et al.
2017 AHA/ACC Focused Update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017;135:e1159-95.
Alston RP, Pechon P. Dysaesthesia associated with sternotomy for heart surgery. Br J Anaesth 2005;95:153-8.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al.
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129-200.
Jha AK, Malik V, Gharde P, Chauhan S, Kiran U, Hote MP. Echocardiographic predictors of immediate postoperative outcomes in patients with severe left ventricular systolic dysfunction undergoing on-pump coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2017;31:184-90.
Spetsotaki K, Zayat R, Donuru S, Autschbach R, Schnoering H, Hatam N. Evaluation of left ventricular myocardial work performance in patients undergoing on-pump and off-pump coronary artery bypass surgery. Ann Thorac Cardiovasc Surg 2020;26:276-85.
Eidem BW, Sapp BG, Suarez CR, Cetta F. Usefulness of the myocardial performance index for early detection of anthracycline-induced cardiotoxicity in children. Am J Cardiol 2001;87:1120-2, A9.
Pattoneri P, Pelà G, Montanari E, Pesci I, Moruzzi P, Borghetti A. Evaluation of the myocardial performance index for early detection of mitoxantrone-induced cardiotoxicity in patients with multiple sclerosis. Eur J Echocardiogr 2007;8:144-50.
Dujardin KS, Tei C, Yeo TC, Hodge DO, Rossi A, Seward JB. Prognostic value of a Doppler index combining systolic and diastolic performance in idiopathic-dilated cardiomyopathy. Am J Cardiol 1998;82:1071-6.
Mooradian SJ, Goldberg CS, Crowley DC, Ludomirsky A. Evaluation of a noninvasive index of global ventricular function to predict rejection after pediatric cardiac transplantation. Am J Cardiol 2000;86:358-60.
Harjai KJ, Scott L, Vivekananthan K, Nunez E, Edupuganti R. The Tei index: A new prognostic index for patients with symptomatic heart failure. J Am Soc Echocardiogr 2002;15:864-8.
Bruch C, Schmermund A, Marin D, Katz M, Bartel T, Schaar J, et al.
Tei-index in patients with mild-to-moderate congestive heart failure. Eur Heart J 2000;21:1888-95.
Parthenakis FI, Kanakaraki MK, Kanoupakis EM, Skalidis EI, Diakakis GF, Filippou OK, et al.
Value of Doppler index combining systolic and diastolic myocardial performance in predicting cardiopulmonary exercise capacity in patients with congestive heart failure: Effects of dobutamine. Chest 2002;121:1935-41.
Kato M, Dote K, Sasaki S, Goto K, Takemoto H, Habara S, et al.
Myocardial performance index for assessment of left ventricular outcome in successfully recanalised anterior myocardial infarction. Heart 2005;91:583-8.
Szymański P, Rezler J, Stec S, Budaj A. Long-term prognostic value of an index of myocardial performance in patients with myocardial infarction. Clin Cardiol 2002;25:378-83.
Al-Mukhaini M, Argentin S, Morin JF, Benny C, Cusson D, Huynh T. Myocardial performance index as predictor of adverse outcomes following mitral valve surgery. Eur J Echocardiogr 2003;4:128-34.
Mahmood F, Matyal R, Maslow A, Subramaniam B, Mitchell J, Panzica P, et al.
Myocardial performance index is a predictor of outcome after abdominal aortic aneurysm repair. J Cardiothorac Vasc Anesth 2008;22:706-12.
Topkara VK, Cheema FH, Kesavaramanujam S, Mercando ML, Cheema AF, Namerow PB, et al
. Coronary artery bypass grafting in patients with low ejection fraction. Circulation 2005;112:1344-50.
Mebazaa A, Combes A, van Diepen S, Hollinger A, Katz JN, Landoni G, et al.
Management of cardiogenic shock complicating myocardial infarction. Intensive Care Med 2018;44:760-73.
Mabrouk-Zerguini N, Léger P, Aubert S, Ray R, Leprince P, Riou B, et al.
Tei index to assess perioperative left ventricular systolic function in patients undergoing mitral valve repair. Br J Anaesth 2008;101:479-85.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]