title: Clinical review: practical recommendations on the management of perioperative heart failure in cardiac surgery.
abstract: Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery.
authors.affiliation: Department of Anaesthesia and Intensive care, INSERM UMR 942, Lariboisière Hospital, University of Paris 7 - Diderot, 2 rue Ambroise Paré, Paris, France. alexandre.mebazaa@lrb.aphp.fr
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mebazaa
authors.forename: Antonis A
authors.initials: AA
authors.lastname: Pitsis
authors.forename: Alain
authors.initials: A
authors.lastname: Rudiger
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Toller
authors.forename: Dan
authors.initials: D
authors.lastname: Longrois
authors.forename: Sven-Erik
authors.initials: SE
authors.lastname: Ricksten
authors.forename: Ilona
authors.initials: I
authors.lastname: Bobek
authors.forename: Stefan
authors.initials: S
authors.lastname: De Hert
authors.forename: Georg
authors.initials: G
authors.lastname: Wieselthaler
authors.forename: Uwe
authors.initials: U
authors.lastname: Schirmer
authors.forename: Ludwig K
authors.initials: LK
authors.lastname: von Segesser
authors.forename: Michael
authors.initials: M
authors.lastname: Sander
authors.forename: Don
authors.initials: D
authors.lastname: Poldermans
authors.forename: Marco
authors.initials: M
authors.lastname: Ranucci
authors.forename: Peter C J
authors.initials: PC
authors.lastname: Karpati
authors.forename: Patrick
authors.initials: P
authors.lastname: Wouters
authors.forename: Manfred
authors.initials: M
authors.lastname: Seeberger
authors.forename: Edith R
authors.initials: ER
authors.lastname: Schmid
authors.forename: Walter
authors.initials: W
authors.lastname: Weder
authors.forename: Ferenc
authors.initials: F
authors.lastname: Follath
mesh_terms: D006348:Cardiac Surgical Procedures; D006333:Heart Failure / Q000209:etiology*; D006801:Humans; D019990:Perioperative Care / Q000458:organization & administration*; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D011379:Prognosis