Синдром низкого сердечного выброса в кардиохирургии

Low cardiac output syndrome is one of the most common and serious complications in cardiac surgery and is associated with increased morbidity and mortality. Several prognostic features have been recognized, including preoperative, intraoperative risk factors and laboratory predictors. The pathophysiologic mechanisms of low cardiac output syndrome are not limited by ventricular systolic dysfunction only, diastolic dysfunction and valvular abnormalities also contribute to low cardiac output syndrome development. There is a broad spectrum of monitoring techniques during cardiac surgery, all of them are different in their invasiveness and reliability. Goal-directed hemodynamic therapy should be based on the most informative and accurate monitoring methods and its goal is to optimize the balance between oxygen delivery and consumption. Treatment of low cardiac output syndrome is intended to increase tissue oxygen delivery and prevent organ dysfunction providing adequate hemodynamic support. The first line of low cardiac output syndrome therapy, to be initiated as soon as the volume status is optimized, is the use of inotropes, vasopressors and vasodilators to improve contractility, preload and afterload. In the most severe cases the need of mechanical support might take place, including intra-aortic balloon pump, ventricular assist devices and extracorporeal membrane oxygenation.Синдром низкого сердечного выброса - одно из самых грозных и часто встречающихся осложнений в кардиохирургии. Оно значительно повышает риск развития осложнений и летальности. Выявлено множество прогностических признаков возникновения данного синдрома, включая предоперационные и интраоперационные факторы риска, а также различные лабораторные предикторы. Патофизиологические механизмы развития синдрома низкого сердечного выброса ограничены не только систолической дисфункцией миокарда - его развитию могут также способствовать диастолическая дисфункция и клапанные нарушения. Существует широкий спектр методов гемодинамического мониторинга, каждый из которых имеет определенную инвазивность и достоверность. Целенаправленная гемодинамическая терапия должна основываться на наиболее информативных и точных техниках мониторинга, а ее задачей представляется поддержание баланса между доставкой и потреблением кислорода. Лечение синдрома низкого сердечного выброса позволяет обеспечить адекватную гемодинамическую поддержку, тем самым увеличивая доставку кислорода к тканям и предотвращая органную дисфункцию. Терапией первой линии, сразу после коррекции волемического статуса, является использование инотропных, вазопрессорных и вазодилатирующих препаратов, что способствует повышению сократимости и оптимизации преднагрузки и постнагрузки. В наиболее тяжелых случаях может возникнуть необходимость применения средств механической поддержки, таких как внутриаортальный баллонный контрпульсатор, устройства вспомогательного кровообращения и экстракорпоральная мембранная оксигенация

Rationale and design of the PeriOperative ISchemic Evaluation-3 (POISE-3): a randomized controlled trial evaluating tranexamic acid and a strategy to minimize hypotension in noncardiac surgery

Background For patients undergoing noncardiac surgery, bleeding and hypotension are frequent and associated with increased mortality and cardiovascular complications. Tranexamic acid (TXA) is an antifibrinolytic agent with the potential to reduce surgical bleeding; however, there is uncertainty about its efficacy and safety in noncardiac surgery. Although usual perioperative care is commonly consistent with a hypertension-avoidance strategy (i.e., most patients continue their antihypertensive medications throughout the perioperative period and intraoperative mean arterial pressures of 60 mmHg are commonly accepted), a hypotension-avoidance strategy may improve perioperative outcomes. Methods The PeriOperative Ischemic Evaluation (POISE)-3 Trial is a large international randomized controlled trial designed to determine if TXA is superior to placebo for the composite outcome of life-threatening, major, and critical organ bleeding, and non-inferior to placebo for the occurrence of major arterial and venous thrombotic events, at 30 days after randomization. Using a partial factorial design, POISE-3 will additionally determine the effect of a hypotension-avoidance strategy versus a hypertension-avoidance strategy on the risk of major cardiovascular events, at 30 days after randomization. The target sample size is 10,000 participants. Patients ≥45 years of age undergoing noncardiac surgery, with or at risk of cardiovascular and bleeding complications, are randomized to receive a TXA 1 g intravenous bolus or matching placebo at the start and at the end of surgery. Patients, health care providers, data collectors, outcome adjudicators, and investigators are blinded to the treatment allocation. Patients on ≥ 1 chronic antihypertensive medication are also randomized to either of the two blood pressure management strategies, which differ in the management of patient antihypertensive medications on the morning of surgery and on the first 2 days after surgery, and in the target mean arterial pressure during surgery. Outcome adjudicators are blinded to the blood pressure treatment allocation. Patients are followed up at 30 days and 1 year after randomization. Discussion Bleeding and hypotension in noncardiac surgery are common and have a substantial impact on patient prognosis. The POISE-3 trial will evaluate two interventions to determine their impact on bleeding, cardiovascular complications, and mortality.Trial registration ClinicalTrials.gov NCT03505723. Registered on 23 April 2018.Maura Marcucci, Thomas W. Painter, David Conen, Kate Leslie, Vladimir V. Lomivorotov, Daniel Sessler ... et al