Perioperative Doppler ultrasound assessment of portal vein flow pulsatility in high-risk cardiac surgery patients: a multicentre prospective cohort study

André Denault; Etienne J Couture; Étienne De Medicis; Jae-Kwang Shim; Michael Mazzeffi; Reney A Henderson; Stephan Langevin; Richa Dhawan; Martin Michaud; Dominik P Guensch; David Berger; Joachim M Erb; Caroline E Gebhard; Colin Royse; David Levy; Yoan Lamarche; François Dagenais; Alain Deschamps; Georges Desjardins; William Beaubien-Souligny

doi:10.1016/j.bja.2022.07.053

Perioperative Doppler ultrasound assessment of portal vein flow pulsatility in high-risk cardiac surgery patients: a multicentre prospective cohort study

Br J Anaesth. 2022 Nov;129(5):659-669. doi: 10.1016/j.bja.2022.07.053. Epub 2022 Sep 30.

Authors

André Denault¹, Etienne J Couture², Étienne De Medicis³, Jae-Kwang Shim⁴, Michael Mazzeffi⁵, Reney A Henderson⁵, Stephan Langevin², Richa Dhawan⁶, Martin Michaud⁷, Dominik P Guensch⁸, David Berger⁹, Joachim M Erb¹⁰, Caroline E Gebhard¹¹, Colin Royse¹², David Levy¹³, Yoan Lamarche¹⁴, François Dagenais¹⁵, Alain Deschamps¹⁶, Georges Desjardins¹⁶, William Beaubien-Souligny¹⁷

Affiliations

¹ Department of Anesthesiology and Critical Care Division, Université de Montréal, Montreal, Canada. Electronic address: andre.denault@umontreal.ca.
² Department of Anesthesiology and Intensive Care Medicine Division, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Canada.
³ Department of Anesthesiology, Centre Hospitalier de l'Université de Sherbrooke, Sherbrooke, Quebec, Canada.
⁴ Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea.
⁵ Department of Anesthesiology, University of Maryland, Baltimore, MD, USA.
⁶ Department of Anesthesiology, University of Chicago Medicine, Chicago, IL, USA.
⁷ Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada.
⁸ Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
⁹ Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
¹⁰ Department of Anesthesiology, University Hospital Basel, Basel, Switzerland.
¹¹ Intensive Care Unit, University Hospital Basel, Basel, Switzerland.
¹² Department of Anaesthesiology and of Surgery, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA.
¹³ Department of Intensive Care Medicine, CMC Ambroise Paré, Neuilly-sur-Seine, France.
¹⁴ Department of Cardiac Surgery and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
¹⁵ Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Canada.
¹⁶ Department of Anesthesiology and Critical Care Division, Université de Montréal, Montreal, Canada.
¹⁷ Division of Nephrology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada; Innovation Hub, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada.

PMID: 36184294
DOI: 10.1016/j.bja.2022.07.053

Abstract

Background: Portal vein Doppler ultrasound pulsatility measured by transoesophageal echocardiography is a marker of the haemodynamic impact of venous congestion in cardiac surgery. We investigated whether the presence of abnormal portal vein flow pulsatility is associated with a longer duration of invasive life support and postoperative complications in high-risk patients.

Methods: In this multicentre cohort study, pulsed-wave Doppler ultrasound assessments of portal vein flow were performed during anaesthesia before initiation of cardiopulmonary bypass (before CPB) and after separation of cardiopulmonary bypass (after CPB). Abnormal pulsatility was defined as portal pulsatility fraction (PPF) ≥50% (PPF50). The primary outcome was the cumulative time in perioperative organ dysfunction (T_POD) requiring invasive life support during 28 days. Secondary outcomes included major postoperative complications.

Results: 373 patients, 71 (22.0%) had PPF50 before CPB and 77 (24.9%) after CPB. PPF50 was associated with longer duration of T_POD (median [inter-quartile range]; before CPB: 27 h [11-72] vs 19 h [8.5-42], P=0.02; after CPB: 27 h [11-61] vs 20 h [8-42], P=0.006). After adjusting for confounders, PPF50 before CPB showed significant association with T_POD. PPF50 after CPB was associated with a higher rate of major postoperative complications (36.4% vs 20.3%, P=0.006).

Conclusions: Abnormal portal vein flow pulsatility before cardiopulmonary bypass was associated with longer duration of life support therapy after cardiac surgery in high-risk patients. Abnormal portal vein flow pulsatility after cardiopulmonary bypass separation was associated with a higher risk of major postoperative complications although this association was not independent of other factors.

Clinical trial registration: NCT03656263.

Keywords: Doppler ultrasound; heart failure; hepatic vein; perioperative transoesophageal echocardiography; portal vein; right ventricular dysfunction; venous congestion.

Publication types

Multicenter Study

MeSH terms

Cardiac Surgical Procedures* / adverse effects
Cohort Studies
Humans
Portal Vein* / diagnostic imaging
Postoperative Complications / etiology
Prospective Studies
Ultrasonography, Doppler

Associated data

ClinicalTrials.gov/NCT03656263