Perioperative echocardiography-guided hemodynamic therapy in high-risk patients:a practical expert approach of hemodynamically focused echocardiography

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy

Efficacy and safety of percutaneous patent foramen ovale closure in patients with a hypercoagulable disorder

Abstract Background Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduce the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from the large randomized studies. Purpose To examine the effect of hypercoagulable state on clinical outcomes after PFO closure. Methods We retrospectively analyzed data of 800 consecutive patients undergoing percutaneous PFO closure at the Massachusetts general hospital. We compared the safety and efficacy of the procedure in patients with and without a hypercoagulable state. Periprocedural treatment included 3 months of anticoagulation followed by low dose aspirin. Results A hypercoagulable disorder was found in 239 patients (29.9%). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success rate, or complication rate between both groups. At median follow-up of 41.9 months there were no differences in the rate of stroke/transient ischemic attack (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p=0.349). Survival analysis of composite outcome that included: ischemic neurologic event, reintervention and procedural or neurologic death did not show significant difference between groups (Log-rank p=0.122). Conclusion Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Research funds of the Massachusetts general hospital </jats:sec

Abstract 111: Plasma Levels of Oxidative Stress Marker ADMA (Asymmetric Dimethylarginine) is Reduced by Successful PFO Closure

Background: Patent foramen ovale (PFO) is an independent risk factor of ischemic stroke. It enables the mixing of venous and arterial blood and therefore serves as a conduit for venous clots and vasoactive factors to enter into arterial circulation and contribute to a prothrombotic status. Asymmetric dimethylarginine (ADMA), an endogenous competitive inhibitor of nitric oxide synthase, contributes to vascular disease and has been linked with increased levels of homocysteine, which creates additional oxidative stress by decreasing the production of dimethylarginine dimethlyaminohydrolase (DDAH) and further inhibiting the clearance of ADMA. We previously identified a significant reduction of homocysteine by PFO closure. Here we study the influence of PFO on ADMA levels, a marker of oxidative stress. Method: 97 PFO-related stroke patients were prospectively recruited in accordance with IRB, of which 61 received PFO closure and 36 underwent medical therapy alone. Peripheral venous blood was collected at baseline (BL) and 1 year follow-up (FU) post treatments. Plasma ADMA was quantified by mass spectrometry. Result: Compared to baseline, plasma ADMA levels were statistically significantly reduced post PFO closure (p = 0.0026), while no changes were observed for the patients treated with medications alone (p = 0.5500) (Figure 1A). Moreover, among the patients receiving PFO closure, the reduction of ADMA was only pronounced for those without residual shunting (p = 0.0009) but not for those with residual shunting (p = 0.4557) (Figure 1B, C). Conclusion: PFO closure reduced oxidative stress marker ADMA in the circulation, but no changes were observed in patients on medical treatment only or those with residual shunting post PFO closure. Our results support the hypothesis that PFO-related right-to-left interatrial blood shunting may causally contribute to the high level of vasoactive factors in circulation. Further studies on an expanded cohort of PFO patients are ongoing. </jats:p