Céline Gonzalez1, Marie-Eve Chamberland1, Matthew P Aldred1, Etienne Couture2, William Beaubien-Souligny3, Alexander Calderone1, Yoan Lamarche4, André Denault5,6. 1. Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada. 2. Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie, Quebec, QC, Canada. 3. Department of Medicine, Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada. 4. Department of Cardiac Surgery and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada. 5. Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada. andre.denault@umontreal.ca. 6. Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada. andre.denault@umontreal.ca.
Abstract
PURPOSE: Pulsatile flow of the portal vein has been implicated as an indicator of right ventricular dysfunction in cardiac patients. In patients with significantly elevated right atrial pressure, pulsatile venous flow may be transmitted to the portal, splenic, renal, and femoral veins. We describe the evolution of these echocardiographic findings in four patients with constrictive pericarditis (CP) undergoing pericardiectomy with simultaneous hemodynamic waveform and cerebral oximetry monitoring in the operating room and in the intensive care unit. CLINICAL FEATURES: Patient 1 presented classic signs of CP, including equalization of left and right diastolic pressures, a "square root" sign on the diastolic portion of the right ventricular pressure curve, and elevated right atrial pressure. Preoperative transesophageal echocardiography showed a hyperdynamic left ventricle and dilated right ventricle with abnormal pulsatile waveforms in the portal and splenic veins. Surgical decompression of the pericardium gradually normalized the Doppler waveforms. Increased venous return following pericardiectomy during surgery in patients 2 and 3 and during the postoperative period in patient 4 resulted in right ventricular (RV) failure due to significantly increased preload. Venous pulsatility was also observed in the portal, splenic, and femoral veins. CONCLUSION: In patients with CP, changes in hemodynamic and echocardiographic signs of RV dysfunction are rapidly reflected by changes in peripheral venous velocities. Identifying signs of splanchnic and peripheral vascular venous congestion could help identify patients at higher risk of developing postoperative complications following pericardiectomy.
PURPOSE: Pulsatile flow of the portal vein has been implicated as an indicator of right ventricular dysfunction in cardiac patients. In patients with significantly elevated right atrial pressure, pulsatile venous flow may be transmitted to the portal, splenic, renal, and femoral veins. We describe the evolution of these echocardiographic findings in four patients with constrictive pericarditis (CP) undergoing pericardiectomy with simultaneous hemodynamic waveform and cerebral oximetry monitoring in the operating room and in the intensive care unit. CLINICAL FEATURES: Patient 1 presented classic signs of CP, including equalization of left and right diastolic pressures, a "square root" sign on the diastolic portion of the right ventricular pressure curve, and elevated right atrial pressure. Preoperative transesophageal echocardiography showed a hyperdynamic left ventricle and dilated right ventricle with abnormal pulsatile waveforms in the portal and splenic veins. Surgical decompression of the pericardium gradually normalized the Doppler waveforms. Increased venous return following pericardiectomy during surgery in patients 2 and 3 and during the postoperative period in patient 4 resulted in right ventricular (RV) failure due to significantly increased preload. Venous pulsatility was also observed in the portal, splenic, and femoral veins. CONCLUSION: In patients with CP, changes in hemodynamic and echocardiographic signs of RV dysfunction are rapidly reflected by changes in peripheral venous velocities. Identifying signs of splanchnic and peripheral vascular venous congestion could help identify patients at higher risk of developing postoperative complications following pericardiectomy.
Authors: André Y Denault; Matthew P Aldred; Ali Hammoud; Yu Hao Zeng; William Beaubien-Souligny; Etienne J Couture; Stéphanie Jarry; Caroline E Gebhard; Stephane Langevin; Yoan Lamarche; Pierre Robillard Journal: Crit Care Explor Date: 2020-09-28