Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients—an intraoperative transesophageal echocardiographic study
Chieh‐Ju ChaoDawn E. JaroszewskiPreetham N. KumarMennatAllah M. EwaisChristopher P. AppletonFarouk MookadamMichael B. GotwayTasneem Z. Naqvi
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Ventricular outflow tract
Right heart
Cardiac function was studied with Scintiview in 107 cases, 24 normal and 83 affected cases, and the following results were obtained. 1. Better data were obtained with converging collimeter than with parallel collimeter in cardiac study. (2) Red blood cells were sufficiently labeled with 99mTc using stannous chloride as reductant, and it was proven to be applicable to measurement of circulation blood volume. (3) Pulmonary circulation time and the systemic circulation time calculated from time activity curve, greater than 9.0 seconds and greater than 25 seconds, respectively, were considered abnormal prolongation. (4) Cardiac output index (cardiac output/circulation blood volume), less than 1.10 was considered decreased cardiac output. (5) Stroke volume index ((stroke volume/circulation blood volume)x 100, less than 1.70 was considered decreased stroke volume. (6) Ejection fraction, less than 60% was considered decreased left ventricular wall motion. (7) Cardiac function index (cardiac output index X ejection fraction), less than 80 was considered decreased cardiac performance.
Cardiac index
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Hemodynamic monitoring is used to identify deviations from hemodynamic goals and to assess responses to therapy. To accomplish these goals one must understand how the circulation is regulated. In this review I begin with an historical review of the work of Arthur Guyton and his conceptual understanding of the circulation and then present an approach by which Guyton's concepts can be applied at the bedside. Guyton argued that cardiac output and central venous pressure are determined by the interaction of two functions: cardiac function, which is determined by cardiac performance; and a return function, which is determined by the return of blood to the heart. This means that changes in cardiac output are dependent upon changes of one of these two functions or of both. I start with an approach based on the approximation that blood pressure is determined by the product of cardiac output and systemic vascular resistance and that cardiac output is determined by cardiac function and venous return. A fall in blood pressure with no change in or a rise in cardiac output indicates that a decrease in vascular resistance is the dominant factor. If the fall in blood pressure is due to a fall in cardiac output then the role of a change in the return function and cardiac function can be separated by the patterns of changes in central venous pressure and cardiac output. Measurement of cardiac output is a central component to this approach but until recently it was not easy to obtain and was estimated from surrogates. However, there are now a number of non-invasive devices that can give measures of cardiac output and permit the use of physiological principles to more rapidly appreciate the primary pathophysiology behind hemodynamic abnormalities and to provide directed therapy.
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Currently, critical care monitoring of cardiac function in the newborn human consists mainly of measuring heart rate and BP. A noninvasive technique for assessing cardiac output routinely in the critically ill neonate would facilitate clinical management. Impedance cardiography (IC) is a noninvasive technique which measures stroke volume on a beat-by-beat basis. This study compared cardiac output as measured by thermodilution (TD) to that measured by IC in seven canine pups 6 to 7 days old weighing 0.66 to 0.86 kg. Cardiac output was altered by the withdrawal and reinfusion of blood. There were no significant differences between the two methods for either the absolute value of cardiac output (r = .96) or the percent change in cardiac output (r = .97). Coefficients of variation were 3.0% for TD and 3.6% for IC. These results indicate that IC can be used to assess serially cardiac function in the newborn.
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The human heart is one of the most studied and vital organs to life. There are many ways to describe the status of the heart’s function and health. One measure of heart function is the cardiac index. The cardiac index relies on another important parameter, cardiac output, and turns cardiac output into a normalized value that accounts for the body size of the patient. For example, the cardiac output of a person who weighs 120 (54 kg) pounds might be expectedly different from a person who weighs 220 pounds (100 kg). For this reason, a simple cardiac output alone cannot be a reliable indicator of cardiac performance. Calculating a cardiac index helps solve this problem. The equation for the cardiac index is below with units of (Liters/minute)/(meter^2). Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Area
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Cardiac alterations may be defined as changes that lead to abnormal cardiac function. They include decrease in preload, increase in afterload, and depressed cardiac contractility. Cardiac dysfunction differs from cardiac failure: cardiac performance is altered, but this does not necessarily mean that the cardiovascular system is failing. Several tools are available to detect cardiac alterations. Some may continuously assess cardiac performance by mainly or exclusively measuring cardiac output, but no information is given about the mechanisms underlying the cardiac output decrease. Doppler echocardiography allows noncontinuous cardiac monitoring, but it is perfectly adapted to evaluation of cardiac performance. It directly visualizes cardiac contractility and assesses cardiac preload. Only when there is an imbalance between oxygen demand and oxygen transport is correction of cardiac alterations required. But the truth is that no study supports the use of one treatment rather than another. Changes in respiratory settings or in respiratory mechanics induce changes in cardiac function and must then be considered in the strategy.
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The usefulness of two‐dimensional transthoracic echocardiography (2 DTTE ) in the assessment of right heart compression and dysfunction produced by pectus excavatum chest wall deformity has been well described in the literature by several investigators. However, there is a paucity of reports describing incremental value of live/real time three‐dimensional transthoracic echocardiography (3 DTTE ) over the two‐dimensional technique in the evaluation of right heart function in these patients. We present a severe case of pectus excavatum chest wall deformity in a young male, in whom 3 DTTE provided incremental value over standard 2 DTTE in assessing compression of the right heart before surgery and marked improvement in right heart function parameters following surgical repair. In addition, an updated summary of salient features of this deformity, including 2D and 3 DTTE findings as well as right heart echocardiographic parameters by both 2D and 3 DTTE in normal/healthy subjects summarized from the literature have been provided in a tabular form for comparison.
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