e26
LETTERS TO THE EDITOR
Fig 2.
HVAD console at the time of echocardiographic flow measurement. (Color version of figure is available online.)
hematocrit. The maximum error is 1 liter/minute or 20%, according to the manufacturer; however, this estimation requires an accurate hematocrit to be entered. Other devices such as the Jarvik 2000 (Jarvik Heart, NY, NY) do not give any estimation of flow, potentially making TEE even more useful in guiding hemodynamic management for these patients. As the number of implanted LVADs continues to grow, TEE-guided hemodynamic management likely will become increasingly important in the cardiac surgical intensive care unit. Future studies should compare echocardiographicallyderived flow data measured at the inflow and outflow cannulae with other estimations of device output, such as thermodilution, to determine the level of accuracy in these measurements.
transesophageal echocardiography. Ann Card Anaesth 16:259-267, 2013 5. Schwarz KQ, Parikh SS, Chen X, et al: Non-invasive flow measurement of a rotary pump ventricular assist device using quantitative contrast echocardiography. J Am Soc Echocardiogr 23:324-329, 2010 6. Chumnanvej S, Wood MJ, MacGillivray TE, et al: Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 105:583-601, 2007
Philip Roman, MD, MPH* Andrew Walker, MD* Keshava Rajagopal, MD, PhD† Michael Mazzeffi, MD, MPH* Departments of *Anesthesiology †Cardiothoracic Surgery, University of Maryland Baltimore, MD
Arterial-Pressure-Based Cardiac Output Analysis Reveals the Usefulness of Pericardiocentesis
REFERENCES 1. Geisen M, Spray D, Fletcher SN: Echocardiography-based hemodynamic management in the cardiac surgery intensive care unit. J Cardiothorac Vasc Anesth : [Epub ahead of print], 2013 Dec 12 2. Go AS, Mozaffarian D, Roger VL, et al: Heart disease and stroke statistics—2013 update: A report from the American Heart Association. Circulation 127:e6-e245, 2013 3. UAB School of Medicine, Interagency Registry for Mechanically Assisted Circulatory Support: Quarterly Statistical Report. Available at: http://www.uab.edu/intermacs/. Accessed March 1, 2014 4. Patangi SO, George A, Pauli H, et al: Management issues during HeartWare left ventricular assist device implantation and the role of
http://dx.doi.org/10.1053/j.jvca.2014.04.036
To the Editor: Cardiac tamponade can develop as a complication of pericardial effusion and needs urgent invasive intervention, such as pericardiocentesis.1,2 Reports on hemodynamic changes during pericardiocentesis in humans are limited. Previous studies have measured changes in cardiac output (CO) and stroke volume (SV) using invasive pulmonary artery catheterization, once the pericardial effusion has been treated. More recently developed techniques, such as the FloTrac/ Vigileo system (Edwards Lifesciences, Irvine, CA), enable continuous measurement of CO and SV less invasively, using pulse contour analysis.3 We observed hemodynamic changes during pericardiocentesis, measured with FloTrac/Vigileo, in 2 patients.
LETTERS TO THE EDITOR
Patient 1 was a 37-year-old woman with metastatic breast cancer. She was hospitalized due to worsening dyspnea. On admission, her blood pressure (BP) was 115/91 mmHg, heart rate was 126 beats per minute, and respiratory rate was 28 breaths per minute. Echocardiography showed a sizeable pericardial effusion and diastolic collapse of the right atrium and right ventricle. We diagnosed cardiac tamponade on the basis of her low BP and echocardiographic findings and decided to perform pericardiocentesis. An arterial pressure catheter was inserted into the radial artery and connected to
e27
the FloTrac/Vigileo system. An 18-gauge needle was inserted into the pericardial space using the apical approach under echocardiographic monitoring. The needle was removed in exchange for a pigtail aspiration catheter with side holes. (Argyle, COVIDIEN, Tokyo, Japan) The changes in SV and mean BP during the procedure are shown in Figure 1A. We found a significant change in SV immediately after pericardiocentesis (pre-pericardiocentesis, 31 mL/beat; immediately post-pericardiocentesis, 44 mL/ beat), with a concomitant elevation in the mean BP. The total
Fig1. (A) Change in SV and mean BP during pericardiocentesis in patient 1. Black arrow shows point of puncture. (B) Changes in SV and mean BP during pericardiocentesis in patient 2. Black arrow shows point of puncture. Abbreviations: SV, stroke volume; BP, blood pressure.
e28
LETTERS TO THE EDITOR
Table 1. Change of Hemodynamic Parameters During Pericardiocentesis
Patient 1 Before After Patient 2 Before After
CO
CI
SV
SVV
SVR
HR
mean BP
L/min
L/min/m²
mL/beat
%
dyne-s/cm5
beats/min
mmHg
4.2 5.2
2.8 3.6
34 44
19 17
1762 1507
123 123
92 97
3.5 3.8
2.4 2.6
48 57
21 16
1591 1401
72 71
67 67
Abbreviations: CI, cardiac index; CO, cardiac output; HR, heart rate; mean BP, mean blood pressure; SV, stroke volume; SVR, systemic vascular resistance; SVV, stroke volume variation.
amount of pericardial effusion drained was 860 mL, with 60 mL drained in the first 5 minutes. Mean values (before and 10 minutes after pericardiocentesis) of other hemodynamic parameters, recorded by FloTrac/Vigileo, are shown in Table 1. The cytologic diagnosis was carcinomatous pericarditis. Patient 2 was a 78-year-old man with chronic kidney disease. He was transferred to our emergency department with worsening dyspnea. His blood pressure was 113/46 mmHg, with a heart rate of 72 beats per minute, and a respiratory rate of 20 breaths per minute. Blood tests revealed renal failure and hyperkalemia (creatinine, 13.7 mg/dL; blood urea nitrogen, 83.8 mg/dL; potassium, 8.0 mEq/L). Echocardiography revealed a pericardial effusion, and we performed pericardiocentesis using a procedure similar to that used in Patient 1. In this patient, we observed a considerable change in SV (prepericardiocentesis, 50 mL/min; immediately post-pericardiocentesis, 61 mL/min) (Fig 1B). The total amount of pericardial effusion drained was 630 mL, with 100 mL drained in the first 5 minutes. We considered uremic pericarditis to be a possible diagnosis. Our patients demonstrated that hemodynamic changes associated with pericardiocentesis can be observed using FloTrac/Vigileo. In both patients presented here, SV and CO changed significantly between pre- and post-puncture. After pericardiocentesis, the mean SV in patient 1 of approximately 42 to 44 mL/beat was less than the normal range. However, Arnold et al reported that SV with a heart rate of 120 beats per minute was approximately 40 mL/min, due to reduced ejection time.4 Arterial Pressure-Based Cardiac Output analysis is a less invasive means of assessing changes in hemodynamic parameters during pericardiocentesis. In addition, changes in SV, as measured by the FloTrac/ Vigileo, were more significant than changes in BP, regardless of the presence of cardiac tamponade. Despite the increase in SV, the mean BP in patient 2 did not increase. It is plausible that there is a difference in the hemodynamic condition, including intrapericardial pressure, between patients with cardiac tamponade, and those without.5,6 Reddy et al reported that compared with patients with cardiac tamponade, there were little or no hemodynamic changes in CO or BP during pericardiocentesis in patients without cardiac tamponade.5 Another possible mechanism is that the degree of increase in SV during pericardiocentesis determines the hemodynamic effects of the procedure. In both our patients, SV increased during pericardiocentesis; however, the increase in SV from
baseline was substantially greater in the presence of cardiac tamponade (cardiac tamponade, 41.9%; no cardiac tamponade, 22.0%). Finally, a significant decrease in BP after successful pericardiocentesis due to a change in peripheral vascular resistance has been documented previously.7 Our case findings, therefore, support those previously reported, which have shown that clinical improvement after pericardiocentesis might be related to an increase in SV, rather than an increase in BP.8 In conclusion, the results of this study showed that Arterial Pressure-Based Cardiac Output analysis can estimate changes in hemodynamic parameters during pericardiocentesis. Changes in SV, as measured using FloTrac/Vigileo, are a more sensitive indicator of response to pericardiocentesis than changes in BP. Masahiro Yamazoe, MD Atsushi Mizuno, MD Yutaro Nishi, MD Koichiro Niwa, MD, PhD *Division of Cardiology, St. Luke's International Hospital, Tokyo, Japan REFERENCES 1. Spodick DH: Acute cardiac tamponade. N Engl J Med 349: 684-690, 2003 2. Ristić AD, Imazio M, Adler Y, et al: Triage strategy for urgent management of cardiac tamponade: A position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 35:2279-2284, 2014 3. Porhomayon J, El-Solh A, Papadakos P, et al: Cardiac output monitoring devices: An analytic review. Intern Emerg Med 7: 163-171, 2012 4. Wegner S, Agress CM: The relationship between left ventricular ejection time and stroke volume during passive cardiovascular stress. Acta Cardiol 28:284-294, 1973 5. Reddy PS, Curtiss EI, Uretsky BF: Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol 66:1487-1491, 1990 6. Shabetai R: Pericardial and cardiac pressure. Circulation 77: 1-5, 1988 7. Brown J, MacKinnon D, King A, et al: Elevated arterial blood pressure in cardiac tamponade. N Engl J Med 327: 463-436, 1992 8. Manyari DE, Kostuk WJ, Purves P: Effect of pericardiocentesis on right and left ventricular function and volumes in pericardial effusion. Am J Cardiol 52:159-162, 1983 http://dx.doi.org/10.1053/j.jvca.2014.11.004
LETTERS TO THE EDITOR
Fig 2.
HVAD console at the time of echocardiographic flow measurement. (Color version of figure is available online.)
hematocrit. The maximum error is 1 liter/minute or 20%, according to the manufacturer; however, this estimation requires an accurate hematocrit to be entered. Other devices such as the Jarvik 2000 (Jarvik Heart, NY, NY) do not give any estimation of flow, potentially making TEE even more useful in guiding hemodynamic management for these patients. As the number of implanted LVADs continues to grow, TEE-guided hemodynamic management likely will become increasingly important in the cardiac surgical intensive care unit. Future studies should compare echocardiographicallyderived flow data measured at the inflow and outflow cannulae with other estimations of device output, such as thermodilution, to determine the level of accuracy in these measurements.
transesophageal echocardiography. Ann Card Anaesth 16:259-267, 2013 5. Schwarz KQ, Parikh SS, Chen X, et al: Non-invasive flow measurement of a rotary pump ventricular assist device using quantitative contrast echocardiography. J Am Soc Echocardiogr 23:324-329, 2010 6. Chumnanvej S, Wood MJ, MacGillivray TE, et al: Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 105:583-601, 2007
Philip Roman, MD, MPH* Andrew Walker, MD* Keshava Rajagopal, MD, PhD† Michael Mazzeffi, MD, MPH* Departments of *Anesthesiology †Cardiothoracic Surgery, University of Maryland Baltimore, MD
Arterial-Pressure-Based Cardiac Output Analysis Reveals the Usefulness of Pericardiocentesis
REFERENCES 1. Geisen M, Spray D, Fletcher SN: Echocardiography-based hemodynamic management in the cardiac surgery intensive care unit. J Cardiothorac Vasc Anesth : [Epub ahead of print], 2013 Dec 12 2. Go AS, Mozaffarian D, Roger VL, et al: Heart disease and stroke statistics—2013 update: A report from the American Heart Association. Circulation 127:e6-e245, 2013 3. UAB School of Medicine, Interagency Registry for Mechanically Assisted Circulatory Support: Quarterly Statistical Report. Available at: http://www.uab.edu/intermacs/. Accessed March 1, 2014 4. Patangi SO, George A, Pauli H, et al: Management issues during HeartWare left ventricular assist device implantation and the role of
http://dx.doi.org/10.1053/j.jvca.2014.04.036
To the Editor: Cardiac tamponade can develop as a complication of pericardial effusion and needs urgent invasive intervention, such as pericardiocentesis.1,2 Reports on hemodynamic changes during pericardiocentesis in humans are limited. Previous studies have measured changes in cardiac output (CO) and stroke volume (SV) using invasive pulmonary artery catheterization, once the pericardial effusion has been treated. More recently developed techniques, such as the FloTrac/ Vigileo system (Edwards Lifesciences, Irvine, CA), enable continuous measurement of CO and SV less invasively, using pulse contour analysis.3 We observed hemodynamic changes during pericardiocentesis, measured with FloTrac/Vigileo, in 2 patients.
LETTERS TO THE EDITOR
Patient 1 was a 37-year-old woman with metastatic breast cancer. She was hospitalized due to worsening dyspnea. On admission, her blood pressure (BP) was 115/91 mmHg, heart rate was 126 beats per minute, and respiratory rate was 28 breaths per minute. Echocardiography showed a sizeable pericardial effusion and diastolic collapse of the right atrium and right ventricle. We diagnosed cardiac tamponade on the basis of her low BP and echocardiographic findings and decided to perform pericardiocentesis. An arterial pressure catheter was inserted into the radial artery and connected to
e27
the FloTrac/Vigileo system. An 18-gauge needle was inserted into the pericardial space using the apical approach under echocardiographic monitoring. The needle was removed in exchange for a pigtail aspiration catheter with side holes. (Argyle, COVIDIEN, Tokyo, Japan) The changes in SV and mean BP during the procedure are shown in Figure 1A. We found a significant change in SV immediately after pericardiocentesis (pre-pericardiocentesis, 31 mL/beat; immediately post-pericardiocentesis, 44 mL/ beat), with a concomitant elevation in the mean BP. The total
Fig1. (A) Change in SV and mean BP during pericardiocentesis in patient 1. Black arrow shows point of puncture. (B) Changes in SV and mean BP during pericardiocentesis in patient 2. Black arrow shows point of puncture. Abbreviations: SV, stroke volume; BP, blood pressure.
e28
LETTERS TO THE EDITOR
Table 1. Change of Hemodynamic Parameters During Pericardiocentesis
Patient 1 Before After Patient 2 Before After
CO
CI
SV
SVV
SVR
HR
mean BP
L/min
L/min/m²
mL/beat
%
dyne-s/cm5
beats/min
mmHg
4.2 5.2
2.8 3.6
34 44
19 17
1762 1507
123 123
92 97
3.5 3.8
2.4 2.6
48 57
21 16
1591 1401
72 71
67 67
Abbreviations: CI, cardiac index; CO, cardiac output; HR, heart rate; mean BP, mean blood pressure; SV, stroke volume; SVR, systemic vascular resistance; SVV, stroke volume variation.
amount of pericardial effusion drained was 860 mL, with 60 mL drained in the first 5 minutes. Mean values (before and 10 minutes after pericardiocentesis) of other hemodynamic parameters, recorded by FloTrac/Vigileo, are shown in Table 1. The cytologic diagnosis was carcinomatous pericarditis. Patient 2 was a 78-year-old man with chronic kidney disease. He was transferred to our emergency department with worsening dyspnea. His blood pressure was 113/46 mmHg, with a heart rate of 72 beats per minute, and a respiratory rate of 20 breaths per minute. Blood tests revealed renal failure and hyperkalemia (creatinine, 13.7 mg/dL; blood urea nitrogen, 83.8 mg/dL; potassium, 8.0 mEq/L). Echocardiography revealed a pericardial effusion, and we performed pericardiocentesis using a procedure similar to that used in Patient 1. In this patient, we observed a considerable change in SV (prepericardiocentesis, 50 mL/min; immediately post-pericardiocentesis, 61 mL/min) (Fig 1B). The total amount of pericardial effusion drained was 630 mL, with 100 mL drained in the first 5 minutes. We considered uremic pericarditis to be a possible diagnosis. Our patients demonstrated that hemodynamic changes associated with pericardiocentesis can be observed using FloTrac/Vigileo. In both patients presented here, SV and CO changed significantly between pre- and post-puncture. After pericardiocentesis, the mean SV in patient 1 of approximately 42 to 44 mL/beat was less than the normal range. However, Arnold et al reported that SV with a heart rate of 120 beats per minute was approximately 40 mL/min, due to reduced ejection time.4 Arterial Pressure-Based Cardiac Output analysis is a less invasive means of assessing changes in hemodynamic parameters during pericardiocentesis. In addition, changes in SV, as measured by the FloTrac/ Vigileo, were more significant than changes in BP, regardless of the presence of cardiac tamponade. Despite the increase in SV, the mean BP in patient 2 did not increase. It is plausible that there is a difference in the hemodynamic condition, including intrapericardial pressure, between patients with cardiac tamponade, and those without.5,6 Reddy et al reported that compared with patients with cardiac tamponade, there were little or no hemodynamic changes in CO or BP during pericardiocentesis in patients without cardiac tamponade.5 Another possible mechanism is that the degree of increase in SV during pericardiocentesis determines the hemodynamic effects of the procedure. In both our patients, SV increased during pericardiocentesis; however, the increase in SV from
baseline was substantially greater in the presence of cardiac tamponade (cardiac tamponade, 41.9%; no cardiac tamponade, 22.0%). Finally, a significant decrease in BP after successful pericardiocentesis due to a change in peripheral vascular resistance has been documented previously.7 Our case findings, therefore, support those previously reported, which have shown that clinical improvement after pericardiocentesis might be related to an increase in SV, rather than an increase in BP.8 In conclusion, the results of this study showed that Arterial Pressure-Based Cardiac Output analysis can estimate changes in hemodynamic parameters during pericardiocentesis. Changes in SV, as measured using FloTrac/Vigileo, are a more sensitive indicator of response to pericardiocentesis than changes in BP. Masahiro Yamazoe, MD Atsushi Mizuno, MD Yutaro Nishi, MD Koichiro Niwa, MD, PhD *Division of Cardiology, St. Luke's International Hospital, Tokyo, Japan REFERENCES 1. Spodick DH: Acute cardiac tamponade. N Engl J Med 349: 684-690, 2003 2. Ristić AD, Imazio M, Adler Y, et al: Triage strategy for urgent management of cardiac tamponade: A position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 35:2279-2284, 2014 3. Porhomayon J, El-Solh A, Papadakos P, et al: Cardiac output monitoring devices: An analytic review. Intern Emerg Med 7: 163-171, 2012 4. Wegner S, Agress CM: The relationship between left ventricular ejection time and stroke volume during passive cardiovascular stress. Acta Cardiol 28:284-294, 1973 5. Reddy PS, Curtiss EI, Uretsky BF: Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol 66:1487-1491, 1990 6. Shabetai R: Pericardial and cardiac pressure. Circulation 77: 1-5, 1988 7. Brown J, MacKinnon D, King A, et al: Elevated arterial blood pressure in cardiac tamponade. N Engl J Med 327: 463-436, 1992 8. Manyari DE, Kostuk WJ, Purves P: Effect of pericardiocentesis on right and left ventricular function and volumes in pericardial effusion. Am J Cardiol 52:159-162, 1983 http://dx.doi.org/10.1053/j.jvca.2014.11.004
