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Evaluation of augmented pulse pressure variation using the Valsalva manoeuvre as a predictor of fluid responsiveness under open-chest conditions: A prospective observational study

Min, Jeong Jin; Kim, Tae Kyong; Lee, Jong-Hwan; Park, Jiyeon; Cho, Hyun Sung; Kim, Wook Sung; Lee, Young Tak

European Journal of Anaesthesiology: May 2017 - Volume 34 - Issue 5 - p 254–261
doi: 10.1097/EJA.0000000000000613
Cardiac anaesthesia

BACKGROUND: Pulse pressure variation (PPV) is a well known dynamic preload indicator of fluid responsiveness. However, its usefulness in open-chest conditions remains controversial.

OBJECTIVE: We evaluated whether augmented PPV during a Valsalva manoeuvre can predict fluid responsiveness after sternotomy.

DESIGN: A prospective, observational study.

SETTING: Single-centre trial, study period from October 2014 to June 2015.

PATIENTS: Forty-nine adult patients who underwent off-pump coronary arterial bypass grafting.

INTERVENTION: After midline sternotomy, haemodynamic parameters were measured before and after volume expansion (6 ml kg−1 of crystalloids). PPV was calculated both automatically (PPVauto) and manually (PPVmanual). For PPV augmentation, we performed Valsalva manoeuvres with manual holding of the rebreathing bag and constant airway pressure of 30 cmH2O for 10 s before fluid loading and calculated PPV during the Valsalva manoeuvre (PPVVM).

MAIN OUTCOME MEASURES: The predictive ability of PPVVM for fluid responsiveness using receiver-operating characteristic curve analysis. Responders were identified when an increase in cardiac index of at least 12% occurred after fluid loading.

RESULTS: Twenty-one patients were responders and 28 were nonresponders. PPVVM successfully predicted fluid responsiveness with an area under the curve (AUC) of 0.88 [95% confidence interval (95% CI) 0.75 to 0.95; sensitivity 91%, specificity 79%, P < 0.0001] and a threshold value of 55%. Baseline PPVauto and PPVmanual also predicted fluid responsiveness [AUC 0.75 (0.62 to 0.88); sensitivity 79%, specificity 75%; and 0.76 (0.61 to 0.87]; sensitivity 71%, specificity 71%, respectively). However, only PPVVM showed a significant AUC-difference from that of central venous pressure (P = 0.008) and correlated with the change of cardiac index induced by volume expansion (r = 0.6, P < 0.001).

CONCLUSION: Augmented PPV using a Valsalva manoeuvre can be used as a clinically reliable predictor of fluid responsiveness under open-chest condition.

TRIAL REGISTRATION: identifier: NCT02457572.

From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (JJM, J-HL, JP, HSC), Department of Anesthesiology and Pain Medicine, Seoul National University Hospital (TKK), and Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (WSK, YTL)

Correspondence to Jong-Hwan Lee, MD, PhD, Associate Professor, Department of Anaesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82 2 3410 1928; fax: +82 2 3410 0361; e-mail:

Published online 15 February 2017

© 2017 European Society of Anaesthesiology