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Relative value of pressures and volumes in assessing fluid responsiveness after valvular and coronary artery surgery

^a Department of Intensive Care, Institute for Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
^b Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
^c Department of Clinical Epidemiology and Biostatistics, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands

Received 28 February 2008; received in revised form 12 August 2008; accepted 13 August 2008.

^_* Corresponding author. Tel.: +31 20 4444178; fax: +31 20 4442392. (Email: johan.groeneveld{at}vumc.nl).

Background and aims: Cardiac function may differ after valvular (VS) and coronary artery (CAS) surgery and this may affect assessment of fluid responsiveness. The aim of the study was to compare VS and CAS in the value of cardiac filling pressures and volumes herein. Methods: There were eight consecutive patients after VS and eight after CAS, with femoral and pulmonary artery catheters in place. In each patient, five sequential fluid loading steps of 250 ml of colloid each were done. We measured central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP) and, by transpulmonary thermodilution, cardiac index (CI) and global end-diastolic (GEDVI) and intrathoracic blood volume (ITBVI) indices. Fluid responsiveness was defined by a CI increase >5% or >10% per step. Results: Global ejection fraction was lower and PAOP was higher after VS than CAS. In responding steps after VS (n = 9–14) PAOP and volumes increased, while CVP and volumes increased in responding steps (n = 12–19) after CAS. Baseline PAOP was lower in responding steps after VS only. Hence, baseline PAOP as well as changes in PAOP and volumes were of predictive value after VS and changes in CVP and volumes after CAS, in receiver operating characteristic curves. After VS, PAOP and volume changes equally correlated to CI changes. After CAS, only changes in CVP and volumes correlated to those in CI. Conclusions: While volumes are equally useful in monitoring fluid responsiveness, the predictive and monitoring value of PAOP is greater after VS than after CAS. In contrast, the CVP is of similar value as volume measurements in monitoring fluid responsiveness after CAS. The different value of pressures rather than of volumes between surgery types is likely caused by systolic left ventricular dysfunction in VS. The study suggests an effect of systolic cardiac function on optimal parameters of fluid responsiveness and superiority of the pulmonary artery catheter over transpulmonary dilution, for haemodynamic monitoring of VS patients.

Key Words: Valvular surgery • Coronary artery surgery • Preload recruitability • Fluid responsiveness • Single indicator transpulmonary thermodilution cardiac output