Low cardiac output syndrome (LCOS) is a reduction in cardiac output often seen in postoperative situations, especially those of coronary artery bypass grafting (CABG), and cardiopulmonary bypass (CPB) [1] [2]. It happens on account of the oxidative stress caused by reperfusion after surgical manipulations. The oxidative stress, as well as inflammatory reactions, cause a disturbance of function in the myocardium resulting in a necessity of inotropic support [3]. Pulmonary tissues also undergo reperfusion that participates in the development of vascular reactivity and damage to the alveoli causing pulmonary edema; the latter is responsible for poor tissue oxygenation [4].

There are no strict clinical criteria for diagnosing the patient with possible LCOS. Strong indications for LCOS is hemodynamic instability and impaired tissue oxygenation occurring postoperatively. Additionally, one of the essential pointers is the need for administration of afterload reduction agents or inotropic agents e.g. dobutamine, epinephrine, and dopamine in order to maintain sufficient cardiac function [5]. Intra-aortic balloon counterpulsation support and positive pressure oxygenation are also important factors contributing to the diagnosis [3] [2].

On examination, the patient will reveal cold extremities, particularly in the most distal parts like toes, an absence of pedal pulse and a decrease in the systolic pressure measuring under 90 mmHg. Likewise, weakened perception of sensation may be noted [6]. LCOS is considered to be associated with high risk of morbidity and mortality, thus prompt recognition and preservation of adequate circulation are of immense importance [2].

• Anemia

  This type of heart failure may occur in patients with severe anemia, arteriovenous malformations with shunting of blood, or hyperthyroidism. [aafp.org]

  High output also can happen when your body lacks enough oxygen-carrying red blood cells, a condition called anemia. That makes your heart pump more blood faster. [webmd.com]

  […] physical examination (breath sounds, murmurs, warmth of extremities, peripheral pulses) Hemodynamic measurements: assess filling pressures & determine CO with PAC, calculate SVR, measure SvO2 ABG (hypoxia, hypercarbia, acidosis/alkalosis), hematocrit (anemia [slideshare.net]

  Jarvis, 1996. forward heart failure a concept of heart failure emphasizing the inadequacy of cardiac output as the primary cause. high-output heart failure that in which cardiac output remains high, associated with conditions such as hyperthyroidism, anemia [medical-dictionary.thefreedictionary.com]

• Swelling

  If the latter, the patient may complain of weight gain, ankle swelling, or a bloating sensation). Nocturnal cough (± pink frothy sputum) or wheeze. Light-headedness or syncope. Anorexia. [patient.info]

  These symptoms include shortness of breath and swelling in the ankles and abdomen. [uofmhealth.org]

  Heart failure accompanied by edema, such as swelling of the legs and ankles and congestion in the lungs. Heart failure is a condition in which the heart can't pump enough blood throughout the body. [icd10data.com]

  Symptoms Breathlessness Duration and pattern Presence of orthopnea or paroxysmal nocturnal dyspnea Presence of frothy pink sputum Swelling of ankles Chest pain Ischemic or pleuritic in nature Exacerbating or relieving factors Palpitations Syncope Fatigue [cancertherapyadvisor.com]

• Hypotension

  Etiology Syndrome ass. with CV instability and hypotension. • Sepsis ( Hypotension with ed SVR) • Anaphylactic reaction (blood products, drugs) • Adrenal insufficiency (primary or pt with preoperative steroids) • Protamine reaction 14. [de.slideshare.net]

  Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension [ncbi.nlm.nih.gov]

  The prevalence of hypotension (57% vs. 48%), atrial fibrillation (50% vs. 40%), and other adverse events did not significantly differ between levosimendan and placebo. [acc.org]

• Cyanosis

  They include: Breathlessness Rapid shallow breathing Pounding heartbeat Weak pulse Mild cyanosis or a bluish-gray discoloration of the lips and around the mouth Signs of shock such as sweating and a cold, clammy skin Severe cyanosis is uncommon. [news-medical.net]

  In acute failure the patient may look ill and exhausted and there may be cyanosis. [patient.info]

  […] or tachycardia, bronze skin, joint inflammation, pallor, thyromegaly or thyroid nodule Cardiomyopathy Ascites, dependent edema, hepatomegaly, hepatojugular reflux, jugular venous distention, weight gain Right ventricular dysfunction Cool extremities, cyanosis [aafp.org]

  No other covariate (gender, pH, temperature, RACHS-1 categories, creatinine clearance, gestational age, cyanosis, malnutrition) influenced the pharmacokinetics. [ccforum.biomedcentral.com]

• Orthostatic Hypotension

  Hypotension - Seizure, mental status change, diaphoresis, and signs of orthostatic hypotension and shock. Low cardiac output - Fatigue, weakness, dyspnea on exertion, lethargy, and lightheadedness. [en.wikipedia.org]

• Bounding Pulse

  pulses, wide pulse pressure, accentuated heart sounds, peripheral vasodilatation, increased cardiac output and ejection fraction, moderate four-chamber enlargement Low cardiac output syndrome Fatigue, loss of lean body mass, prerenal azotemia, peripheral [aafp.org]

• Tremor

  Although, there are not unique clinical and physical examination findings for ischemic hepatitis, patients may present with symptoms of nausea, vomiting, anorexia, malaise, right-upper quadrant pain, jaundice, oliguria, and flapping tremor representing [ncbi.nlm.nih.gov]

Low cardiac output syndrome can be the cause of decreased tissue oxygenation and disturbance in the cardiovascular system. Parameters evaluating the dynamics of this syndrome are linked with measurements of the arterial blood gas, central venous pressure, blood pressure, and estimates of the cardiac output.

It is possible to assess cardiac output (CO) directly by thermodilution. This technique includes a placement of the pulmonary artery catheter and is considered a gold standard for measuring the CO. It also gives data of right ventricle activity, such as right ventricular ejection fraction and right ventricular end diastolic volume. Although there are some drawbacks to this method, firstly it is an invasive procedure and secondly, it is not meant for continuous measurement of the CO [7]. There are other less invasive techniques for measuring the CO e.g. with transthoracic (TTE) or transesophageal (TEE) echocardiography.

LCOS is considered if the cardiac index (which is calculated with CO as a variable) is less than 2.2 L/min/m2, pulmonary artery occlusion pressure (PAOP) is more than 16 mmHg, and oxygen saturation drops to less than 60% [6] [8].

In the case of poor oxygenation caused by LCOS, serum lactate levels increase to more than 2 mmol/L for at least 2 hours and metabolic acidosis is recognized. Compensatory mechanisms will be exhibited by oliguria with urine output of less than 1.0 mL/kg/h [6].

Arterial blood gas analysis may uncover changes in partial arterial oxygen tension with less than 100 mmHg and partial arterial carbon dioxide tension of value exceeding the normal range of 35–45 mmHg. Central venous pressure is also likely to deviate from the norm of 6–8 mmHg [6] [9].

• Pericardial Effusion

  Keywords Pericardial Effusion Cardiac Tamponade Fractional Shorten Anterior Chest Wall Transesophageal Echocardiogram These keywords were added by machine and not by the authors. [link.springer.com]

  Left anterolateral thoracotomy should be reserved for surgery for pyogenic and effusive pericardial diseases. 8. [scitcentral.com]

  Common etiologies include hypertension, coronary disease, congenital problems, myocardial ischemia and infarction, congestive heart failure, shock, arrhythmias, genetic diseases, structural abnormalities, pericardial effusions, emboli, tamponade, and [ncbi.nlm.nih.gov]

  Any pericardial effusion causing hemodynamic compromise or a low cardiac state should be drained as a matter of urgency. This can be done percutaneously or surgically. [cancertherapyadvisor.com]

Three trials with high overall risk of bias compared levosimendan to standard treatment (enoximone or dobutamine) or placebo. [ncbi.nlm.nih.gov]

The treatment with alprostadil was continued until surgery to maintain patency of the PDA. [annals.in]

Milrinone, epinephrine, dopamine and dobutamine are mostly used, and should be prioritised for future research on LCOS treatment. [adc.bmj.com]

In this respect, the prognosis was clearly poorer among the patients with cardiogenic shock. Two relevant findings were made in our study: 1. [medintensiva.org]

The prognosis for people with heart failure and preserved LV ejection fraction is a little better than the prognosis for people with heart failure and reduced ejection fraction. Generally, the lower the ejection fraction, the poorer the prognosis. [patient.info]

In this type of surgery, prior cardiovascular status is extremely important for prognosis and the, considerably higher, perioperative mortality is the most important individual factor taken into account when evaluating the quality of surgical programs [revespcardiol.org]

英文摘要: Low cardiac output syndrome is a common complication after pediatric cardiac surgery, which has brought many adverse effects on the prognosis of patients. [xxgzz.com.cn]

Multifactorial in etiology, this article will discuss the pathophysiology of low cardiac output syndrome, including myocardial depression following bypass, altered cardiac loading conditions, and inflammation driving a hypermetabolic state. [eurekaselect.com]

Etiology ed after load • Vasoconstriction • Fluid overload Diastolic dysfunction ( common finding after cardioplegic arrest) 13. [de.slideshare.net]

384) Neurology (250) Infectology (236) Surgery, Traumatology and Orthopaedics (228) Physiology and Pathophysiology (226) Medical Chemistry and Biochemistry (185) Microbiology (174) Genetics (136) Dermatology (131) Gastroenterology and Hepatology (115) Epidemiology [portal.mefanet.cz]

Although the symptoms, causes, prevalence, and epidemiology of the six different types of heart failure are somewhat different, there is substantial overlap, and types may coexist. [aafp.org]

Epidemiology The exact prevalence and incidence of LoHF in the general population is completely unknown. At present, there are no population-based epidemiological data specific to LoHF. [oatext.com]

Criteria abstracted from The Users' Guide to Medical Literature, from the Health Information Research Unit and Clinical Epidemiology and Biostatistics, McMaster University Highlighted lines and questions below provide links to the pertinent description [pedsccm.org]

Epidemiology [ 1, 3 ] Currently around 920,000 people in the UK have a diagnosis of heart failure. Prevalence in developed countries is approximately 1-2% of the adult population, increasing to 10% or more in those over 70 years of age. [patient.info]

Title: Pathophysiology of Post-Operative Low Cardiac Output Syndrome VOLUME: 14 ISSUE: 1 Author(s): Conrad L. Epting, Mary E. McBride, Eric L. Wald and John M. [eurekaselect.com]

TY - JOUR T1 - Pathophysiology of post-operative low cardiac output syndrome AU - Epting, Conrad L AU - McBride, Mary Eileen AU - Wald, Eric L AU - Costello, John M. [scholars.northwestern.edu]

Multifactorial in etiology, this article will discuss the pathophysiology of low cardiac output syndrome, including myocardial depression following bypass, altered cardiac loading conditions, and inflammation driving a hypermetabolic state. [ncbi.nlm.nih.gov]

The low cardiac output syndrome complicates 1 in 10 coronary bypass operations and is associated with a heightened risk of perioperative death.1 The pathophysiology of this syndrome is complex, with likely contributions from reperfusion injury, systemic [nejm.org]

OBJECTIVE: Characterize current hospital practices related to preventive drug therapy for low cardiac output syndrome (LCOS) in children with open heart surgery (OHS) in Europe. [ncbi.nlm.nih.gov]

[…] time for myocardial recovery whilst preventing ongoing damage to other organ systems Veno-arterial (VA) ECMO, and LV and/or RV assist devices are the two commonest methods of mechanical support. [powershow.com]

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3. Kunt AS, Andac MH. Decrease of Total Antioxidative Capacity in Developed Low Cardiac Output Syndrome. Oxid Med Cell Longev. 2012;2012:356301.
4. Hiramatsu T, Imai Y, Kurosawa H, et al. Effects of dilutional and modified ultrafiltration in plasma endothelin-1 and pulmonary vascular resistance after the Fontan procedure. Ann Thorac Surg. 2002;73(3):861–865.
5. Kucewicz-Czech E, Kiecak K, Urbańska E, et al. Perioperative care in elderly cardiac surgery patients. Kardiochir Torakochirurgia Pol. 2016;13(4):340-346.
6. Chowdhury UK, Sheil A, Kapoor PM, et al. Short-term prognostic value of perioperative coronary sinus-derived-serum cardiac troponin-I, creatine kinase-MB, lactate, pyruvate, and lactate-pyruvate ratio in adult patients undergoing open heart surgery. Ann Card Anaesth. 2016;19(3):439-453.
7. Huygh J, Peeters Y, Bernards J, Malbrain MLNG. Hemodynamic monitoring in the critically ill: an overview of current cardiac output monitoring methods. F1000Res. 2016;5:2855.
8. Levin R, Degrange M, Del Mazo C, Tanus E, Porcile R. Preoperative levosimendan decreases mortality and the development of low cardiac output in high-risk patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting with cardiopulmonary bypass. Exp Clin Cardiol. 2012;17(3):125-130.
9. Lobos A-T, Lee S, Menon K. Capillary refill time and cardiac output in children undergoing cardiac catheterization. Pediatr Crit Care Med. 2012;13(2):136–140.