Low cardiac output syndrome is a postoperative complication caused by reperfusion and ensuing oxidative stress to the pulmonary and cardiac tissues. This syndrome is important to consider for its association with high morbidity and mortality due to impaired cardiovascular function.
Presentation
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].
Entire Body System
- Surgical Procedure
RESULTS: AM significantly decreased (p < 0.01) during and after the surgical procedure exhibiting a dip at the end of the CPB. [ncbi.nlm.nih.gov]
Infarkt (LITA-Bypass-Gebiet) auf. en In low - cardiac - output syndrome after cardiac surgical procedures, short-term devices are utilised to enable myocardial recovery. de Beim Postkardiotomie - Low cardiac output - Syndrom nach Eingriffen am offenen [de.glosbe.com]
Methodology: This retrospective cross sectional study included patients whopresented for cardiac surgical procedures due to different cardiac pathologies atQueen Alia Heart Institute between December 2013 and June 2014. [pkheartjournal.com]
Among surgical procedures, CABG with mitral and/or tricuspid valve repair/replacement had the highest risk (OR[95%CI]) of LCOS (2.01[1.76-2.29]), while isolated aortic valve surgery the lowest (0.52[0.47-0.58]) (Table 1). [asaabstracts.com]
- Falling
In March 2013, it took over the Syrian city of Raqqa - the first provincial capital to fall under rebel control. [bbc.com]
However, in patients who developed LCOS, TAC presented a sharp fall during and at the end of the operation ( ) (Figure 1). [hindawi.com]
Single-lead, atrial synchronous, ventricular triggered and inhibited, with and without rate modulation (VDD[R]) pacing Native atrial rate falls below programmed lower rate limit and VVI(R) pacing supervenes. See the figure above. [emedicine.medscape.com]
Although beating faster helps to maintain cardiac output as the stroke volume falls, a faster heart rate can be counterproductive because it allows less time for the ventricle to fill with blood after each heartbeat. [uofmhealth.org]
Last fall, the British media provided weeks of wall-to-wall coverage to a teenage ISIS captive held in Syria, even publishing exclusive stories providing readers with her opinions on recent negotiations over Brexit. [theintercept.com]
- Abdominal Obesity
Abdominal obesity and the spectrum of global cardiometabolic risks in US adults. Int J Obes 2009; 33: 239-48. 4) Bastien M, Poirier P, Lemieux I, Després JP. Overview of epidemiology and contribution of obesity to cardiovascular disease. [firattipdergisi.com]
- Infertility
She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative. [news-medical.net]
Cardiovascular
- 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]
- Left Ventricular Dysfunction
Prudent preoperative evaluation in patients with severe left ventricular dysfunction is critical. Further innovative research in myocardial protection and circulatory support is warranted in patients with severe left ventricular dysfunction. [ncbi.nlm.nih.gov]
[…] cardiopulmonary bypass Evidence Rating Level: 1 (Excellent) Study Rundown: Mortality after coronary artery bypass grafting remains high in patients with existing left ventricular dysfunction (ejection fraction <40%). [2minutemedicine.com]
C 8 Dependent edema and pulmonary rales are of limited value in diagnosing heart failure resulting from left ventricular dysfunction. [aafp.org]
ventricular dysfunction, ie, a left ventricular ejection fraction less than or equal to 40%, is associated with an odds ratio of 2.0 (95% CI 1.7-2.4).1 The low cardiac output syndrome is also associated with more frequent complications, including pulmonary [jamanetwork.com]
- Vascular Disease
Vascular disease is a complex field with primary care physicians and nurse practitioners as well as several specialties involved. [ingentaconnect.com]
Major topics of discussion include percutaneous techniques for valvular heart disease, septal defects at both the atrial and ventricular levels, adjunctive therapies during coronary interventions, and angioplasty to treat extracardiac vascular disease [books.google.de]
PVD: peripheral vascular disease. 2.1. [hindawi.com]
[…] tissue disease, previous open heart surgery Restrictive pericarditis Coronary artery disease, diabetes mellitus, hypercholesterolemia, hypertension, peripheral vascular disease, tobacco use Coronary artery disease Physical examination Abnormal deep tendon [aafp.org]
Other explanatory variables collected to more fully characterize these patients included recent myocardial infarction (MI), diabetes, dyslipidemia, peripheral vascular disease (PVD), history of hypertension, preoperative stroke, or transient ischemic [ahajournals.org]
- 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]
Psychiatrical
- Suggestibility
Persistent lactate release during reperfusion suggests a delayed recovery of aerobic myocardial metabolism and may be related to intraoperative misadventure or inadequate myocardial protection. [ncbi.nlm.nih.gov]
- Withdrawn
Syndrome Acute Coronary Syndrome Cardiogenic Shock Cardiopulmonary Bypass Heart Defects, Congenital Inflammation Any 17 and under 18 - 34 35 - 50 51 - 69 70+ Available Active, not recruiting Not yet recruiting Recruiting Completed Terminated Suspended Withdrawn [patientwing.com]
Samples were withdrawn from central vein into heparinized tubes and immediately stored on ice at 4°C. [hindawi.com]
Urogenital
- Renal Insufficiency
Our results suggest that LCOS is highly prevalent in female patients with preoperative renal insufficiency and poor LV function. [ahajournals.org]
Preoperative high risk, such as low ejection fraction, recent MI, and renal insufficiency, may lead to inadequate ventricular function in the early postoperative period in patients who developed LCOS undergoing CABG. [hindawi.com]
Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. [ccforum.biomedcentral.com]
The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction. J Am Coll Cardiol. 2000 Mar 1. 35 (3):681-9. [Medline]. [emedicine.medscape.com]
- Kidney Failure
Adverse events Reported adverse events included abnormal blood loss, bradycardia, hypertension, junctional rhythm, kidney failure, premature atrial and ventricular contractions and ST elevation (Table 2). [cochranelibrary.com]
Neurologic
- Stroke
Decreasing incidence of stroke during valvular surgery. Circulation. 1998; 98: 137–143.Google Scholar 9 Herzog CA, Ma JZ, Collins AJ. [ahajournals.org]
After the first hour of treatment, an increase in cardiac index, systolic index and left ventricular stroke work index, and a decrease in right and left loading pressures, pulmonary artery pressure, systemic vascular resistance and pulmonary vascular [ncbi.nlm.nih.gov]
There is not a value of PAOP that has been shown to provide you with a maximal stroke volume. [cancertherapyadvisor.com]
How does the heart increase its stroke volume? To increase its stroke volume, your heart can try to: Get more blood into your heart. [uofmhealth.org]
AV synchrony is particularly important in LCOS as the effects of atrial systole (atrial kick) on ventricular preload can be significant, and contributing up to 20 of stroke volume. [powershow.com]
- Headache
Hemodynamic - Pulsation in the neck and abdomen, choking sensation, jaw pain, right upper quadrant (RUQ) pain, chest colds, and headache. [en.wikipedia.org]
660 7 (1.1%) 660 Follath (LIDO) 2002 Extrasystoles 1 (1.0%) 103 3 (3.0%) 100 Follath (LIDO) 2002 Flushing 1 (1.0%) 103 3 (3.0%) 100 Follath (LIDO) 2002 Gastrointestinal disorders 2 (1.9%) 103 7 (7.0%) 100 Follath (LIDO) 2002, Mebazaa (SURVIVE) 2007 Headache [cochranelibrary.com]
Workup
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].
Serum
- Dyslipidemia
Other explanatory variables collected to more fully characterize these patients included recent myocardial infarction (MI), diabetes, dyslipidemia, peripheral vascular disease (PVD), history of hypertension, preoperative stroke, or transient ischemic [ahajournals.org]
Univariate analysis revealed that LCOS was significantly associated with year of operation, increasing age, female gender, increasing NYHA class, absence of dyslipidemia, preoperative cardiogenic shock, congestive heart failure, poor preoperative LV function [circ.ahajournals.org]
Treatment
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]
Prognosis
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]
Etiology
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]
Epidemiology
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]
Pathophysiology
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]
Prevention
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]
References
- Nashef SA, Roques F, Sharples LD, et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41:734–44.
- Chandler HK, Kirsch R. Management of the Low Cardiac Output Syndrome Following Surgery for Congenital Heart Disease. Curr Cardiol Rev. 2016;12(2):107-111.
- Kunt AS, Andac MH. Decrease of Total Antioxidative Capacity in Developed Low Cardiac Output Syndrome. Oxid Med Cell Longev. 2012;2012:356301.
- 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.
- Kucewicz-Czech E, Kiecak K, Urbańska E, et al. Perioperative care in elderly cardiac surgery patients. Kardiochir Torakochirurgia Pol. 2016;13(4):340-346.
- 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.
- 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.
- 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.
- 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.