Top

Published in:

Open Access 01-12-2018 | Research article

Diastolic dysfunction is common and predicts outcome after cardiac surgery

Authors: Thomas S. Metkus, Alejandro Suarez-Pierre, Todd C. Crawford, Jennifer S. Lawton, Lee Goeddel, Jeffrey Dodd-o, Monica Mukherjee, Theodore P. Abraham, Glenn J. Whitman

Published in: Journal of Cardiothoracic Surgery | Issue 1/2018

Abstract

Background

Diastolic dysfunction (DD) identified on echocardiography predicts mortality after cardiac surgery, however the most useful diastolic parameters for assessment and the association of DD with prolonged mechanical ventilation, ICU re-admission, and hospital length of stay are not established.

Methods

We included patients that underwent coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or a combined procedure (CAB-AVR) from 2010 to 2016, and who had preoperative transthoracic echocardiography (TTE) at our institution within 6 months of the operation. Diastolic function was graded using the transmitral E and A waves and the septal tissue Doppler velocity. We performed logistic regression to assess the association of grade of DD with a composite endpoint of death, prolonged mechanical ventilation, ICU readmission during hospitalization, and hospital length of stay longer than 14 days.

Results

Between 2010 and 2016, 577 patients were eligible for inclusion. DD was common, with 42% of the cohort manifesting grade II or grade III DD. Rates of death and prolonged ventilation increased across grades of DD and across quartiles of increasing LV filling pressure, assessed by the E/e’ ratio. Adjusting for age, sex, procedure, systolic and diastolic function, both systolic (odds ratio 0.68 95% CI 0.55–0.85 per inter-quartile increase in LVEF) and diastolic function (odds ratio 1.31 95% CI 1.04–1.66 per increasing DD grade) both independently predicted outcome.

Conclusion

Diastolic dysfunction is common among patients undergoing cardiac surgery and is associated with death, prolonged mechanical ventilation, and prolonged hospital and ICU length of stay independent of systolic dysfunction.

Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelisa A. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr. 2009;10(2):165–93.CrossRefPubMed

Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, Flachskampf FA, Gillebert TC, Klein AL, Lancellotti P, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2016;17(12):1321–60.CrossRefPubMed

Sharma K, Kass DA. Heart failure with preserved ejection fraction: mechanisms, clinical features, and therapies. Circ Res. 2014;115(1):79–96.CrossRefPubMedPubMedCentral

Hurrell DG, Nishimura RA, Ilstrup DM, Appleton CP. Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol. 1997;30(2):459–67.CrossRefPubMed

Chin JH, Lee EH, Kim WJ, Choi DK, Hahm KD, Sim JY, Choi IC. Positive end-expiratory pressure aggravates left ventricular diastolic relaxation further in patients with pre-existing relaxation abnormality. Br J Anaesth. 2013;111(3):368–73.CrossRefPubMed

Juhl-Olsen P, Frederiksen CA, Hermansen JF, Jakobsen CJ, Sloth E. Echocardiographic measures of diastolic function are preload dependent during triggered positive pressure ventilation: a controlled crossover study in healthy subjects. Crit Care Res Pract. 2012;2012:703196.PubMedPubMedCentral

Juhl-Olsen P, Hermansen JF, Frederiksen CA, Rasmussen LA, Jakobsen CJ, Sloth E. Positive end-expiratory pressure influences echocardiographic measures of diastolic function: a randomized, crossover study in cardiac surgery patients. Anesthesiology. 2013;119(5):1078–86.CrossRefPubMed

Hedman A, Samad BA, Larsson T, Zuber E, Nordlander R, Alam M. Improvement in diastolic left ventricular function after coronary artery bypass grafting as assessed by recordings of mitral annular velocity using Doppler tissue imaging. Eur J Echocardiogr. 2005;6(3):202–9.CrossRefPubMed

Melduni RM, Suri RM, Seward JB, Bailey KR, Ammash NM, Oh JK, Schaff HV, Gersh BJ. Diastolic dysfunction in patients undergoing cardiac surgery: a pathophysiological mechanism underlying the initiation of new-onset post-operative atrial fibrillation. J Am Coll Cardiol. 2011;58(9):953–61.CrossRefPubMed

10.

Barbara DW, Rehfeldt KH, Pulido JN, Li Z, White RD, Schaff HV, Mauermann WJ. Diastolic function and new-onset atrial fibrillation following cardiac surgery. Ann Card Anaesth. 2015;18(1):8–14.CrossRefPubMedPubMedCentral

11.

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(1):62–7.CrossRefPubMed

12.

Jun NH, Shim JK, Kim JC, Kwak YL. Prognostic value of a tissue Doppler-derived index of left ventricular filling pressure on composite morbidity after off-pump coronary artery bypass surgery. Br J Anaesth. 2011;107(4):519–24.CrossRefPubMed

13.

Afilalo J, Flynn AW, Shimony A, Rudski LG, Agnihotri AK, Morin JF, Castrillo C, Shahian DM, Picard MH. Incremental value of the preoperative echocardiogram to predict mortality and major morbidity in coronary artery bypass surgery. Circulation. 2013;127(3):356–64.CrossRefPubMed

14.

Denault AY, Couture P, Buithieu J, Haddad F, Carrier M, Babin D, Levesque S, Tardif JC. Left and right ventricular diastolic dysfunction as predictors of difficult separation from cardiopulmonary bypass. Can J Anaesth. 2006;53(10):1020–9.CrossRefPubMed

15.

Swaminathan M, Nicoara A, Phillips-Bute BG, Aeschlimann N, Milano CA, Mackensen GB, Podgoreanu MV, Velazquez EJ, Stafford-Smith M, Mathew JP, et al. Utility of a simple algorithm to grade diastolic dysfunction and predict outcome after coronary artery bypass graft surgery. Ann Thorac Surg. 2011;91(6):1844–50.CrossRefPubMed

16.

Zaid RR, Barker CM, Little SH, Nagueh SF. Pre- and post-operative diastolic dysfunction in patients with valvular heart disease: diagnosis and therapeutic implications. J Am Coll Cardiol. 2013;62(21):1922–30.CrossRefPubMed

17.

Cho DH, Park SM, Kim MN, Kim SA, Lim H, Shim WJ. Presence of preoperative diastolic dysfunction predicts postoperative pulmonary edema and cardiovascular complications in patients undergoing noncardiac surgery. Echocardiography. 2014;31(1):42–9.CrossRefPubMed

18.

Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation. 2000;102(15):1788–94.CrossRefPubMed

19.

Kuznetsova T, Herbots L, Lopez B, Jin Y, Richart T, Thijs L, Gonzalez A, Herregods MC, Fagard RH, Diez J, et al. Prevalence of left ventricular diastolic dysfunction in a general population. Circ Heart Fail. 2009;2(2):105–12.CrossRefPubMed

20.

Yamada H, Goh PP, Sun JP, Odabashian J, Garcia MJ, Thomas JD, Klein AL. Prevalence of left ventricular diastolic dysfunction by Doppler echocardiography: clinical application of the Canadian consensus guidelines. J Am Soc Echocardiogr. 2002;15(10 Pt 2):1238–44.CrossRefPubMed

21.

Boyer JK, Thanigaraj S, Schechtman KB, Perez JE. Prevalence of ventricular diastolic dysfunction in asymptomatic, normotensive patients with diabetes mellitus. Am J Cardiol. 2004;93(7):870–5.CrossRefPubMed

22.

Fischer M, Baessler A, Hense HW, Hengstenberg C, Muscholl M, Holmer S, Doring A, Broeckel U, Riegger G, Schunkert H. Prevalence of left ventricular diastolic dysfunction in the community. Results from a Doppler echocardiographic-based survey of a population sample. Eur Heart J. 2003;24(4):320–8.CrossRefPubMed

23.

Stork T, Mockel M, Danne O, Voller H, Eichstadt H, Frei U. Left ventricular hypertrophy and diastolic dysfunction: their relation to coronary heart disease. Cardiovasc Drugs Ther. 1995;9(Suppl 3):533–7.CrossRefPubMed

24.

Salem R, Denault AY, Couture P, Belisle S, Fortier A, Guertin MC, Carrier M, Martineau R. Left ventricular end-diastolic pressure is a predictor of mortality in cardiac surgery independently of left ventricular ejection fraction. Br J Anaesth. 2006;97(3):292–7.CrossRefPubMed

25.

Mounsey JP, Griffith MJ, Heaviside DW, Brown AH, Reid DS. Determinants of the length of stay in intensive care and in hospital after coronary artery surgery. Br Heart J. 1995;73(1):92–8.CrossRefPubMedPubMedCentral

26.

Fukui T, Shibata T, Sasaki Y, Hirai H, Motoki M, Takahashi Y, Nakahira A, Suehiro S. Long-term survival and functional recovery after isolated coronary artery bypass grafting in patients with severe left ventricular dysfunction. Gen Thorac Cardiovasc Surg. 2007;55(10):403–8.CrossRefPubMed

27.

Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, Michler RE, Bonow RO, Doenst T, Petrie MC, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med. 2016;374(16):1511–20.CrossRefPubMedPubMedCentral

28.

Khir AW, Price S, Henein MY, Parker KH, Pepper JR. Intra-aortic balloon pumping: effects on left ventricular diastolic function. Eur J Cardiothorac Surg. 2003;24(2):277–82.CrossRefPubMed

29.

Malik V, Subramanian A, Hote M, Kiran U. Effect of Levosimendan on diastolic function in patients undergoing coronary artery bypass grafting: a comparative study. J Cardiovasc Pharmacol. 2015;66(2):141–7.CrossRefPubMed

30.

Kushwaha SS, Fallon JT, Fuster V. Restrictive cardiomyopathy. N Engl J Med. 1997;336(4):267–76.CrossRefPubMed

Title: Diastolic dysfunction is common and predicts outcome after cardiac surgery
Authors: Thomas S. Metkus
Alejandro Suarez-Pierre
Todd C. Crawford
Jennifer S. Lawton
Lee Goeddel
Jeffrey Dodd-o
Monica Mukherjee
Theodore P. Abraham
Glenn J. Whitman
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: Journal of Cardiothoracic Surgery / Issue 1/2018
Electronic ISSN: 1749-8090
DOI: https://doi.org/10.1186/s13019-018-0744-3

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Diastolic dysfunction is common and predicts outcome after cardiac surgery

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2018

Anomaly of Haughton type D left cervical aortic arch in combination with type B dissection: case report and literature review

Positive impact of retrograde autologous priming in adult patients undergoing cardiac surgery: a randomized clinical trial

Treatment of malignant primary cardiac lymphoma with tumor resection using minimally invasive cardiac surgery

Validity of upfront surgery for patients with unsuspected lymph node metastasis in esophageal cancer: a propensity scoring matching study

Is isolated aortic valve replacement sufficient to treat concomitant moderate functional mitral regurgitation? A propensity-matched analysis

Volume of mural thrombus plays a role in the elevation of inflammatory markers after endovascular aortic repair