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doi: 10.1097/ALN.0000000000000392
Perioperative Medicine: PDF Only

Interatrial Septum Motion but Not Doppler Assessment Predicts Elevated Pulmonary Capillary Wedge Pressure in Patients Undergoing Cardiac Surgery.

Haji, Darsim L. M.B.Ch.B., Ph.D., F.A.C.E.M.; Ali, Mohamed M. M.B.B.S., M.Sc.; Royse, Alistair M.B.B.S., M.D., F.R.A.C.S., F.C.S.A.N.Z.; Canty, David J. M.B.B.S., Ph.D., F.A.N.Z.C.A.; Clarke, Sandy B.Sc., Ph.D., A.Stat.; Royse, Colin F. M.B.B.S., M.D., F.A.N.Z.C.A.

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Background: Left atrial pressure and its surrogate, pulmonary capillary wedge pressure (PCWP), are important for determining diastolic function. The role of transthoracic echocardiography (TTE) in assessing diastolic function is well established in awake subjects. The objective was to assess the accuracy of predicting PCWP by TTE and transesophageal echocardiography (TEE) during coronary artery surgery.
Methods: In 27 adult patients undergoing on-pump coronary artery surgery, simultaneous echocardiographic and hemodynamic measurements were obtained immediately before anesthesia (TTE), after anesthesia and mechanical ventilation (TTE and TEE), during conduit harvest (TEE), and after separation from cardiopulmonary bypass (TEE).
Results: Twenty patients had an ejection fraction (EF) of 0.5 or greater. With the exception of E/e' and S/D ratios, echocardiographic values changed over the echocardiographic studies. In patients with low EF, E velocity, deceleration time, pulmonary vein D, S/D, and E/e' ratios correlated well with PCWP before anesthesia. After induction of anesthesia using TTE or TEE, correlations were poor. In normal EF patients, correlations were poor for both TEE and TTE at all five stages. The sensitivity and specificity of echocardiographic values were not high enough to predict raised PCWP except for a fixed curve pattern of interatrial septum (area under the curve 0.89 for PCWP >=17, and 0.98 for >=18 mmHg) and S/D less than 1 (area under the curve 0.74 for PCWP >=17, and 0.78 for >=18 mmHg).
Conclusion: Doppler assessment of PCWP was neither sensitive nor specific enough to be clinically useful in anesthetized patients with mechanical ventilation. The fixed curve pattern of the interatrial septum was the best predictor of raised PCWP.
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