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Table 3 Etiology and investigation of post-cardiopulmonary bypass ventricular dysfunction

From: Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery

Cause Investigation Finding  
General   
   Exacerbation of preoperative ventricular dysfunction with relative intolerance to cardioplegic asystolic, hypoxic arrest TOE Global or regional wall motion abnormality
   Reperfusion injury TOE Global wall motion abnormality
   Inadequate myocardial protection (underlying coronary anatomy, route of cardioplegia, type of cardioplegia) TOE Global wall motion abnormality
Case/patient specific   
   Ischaemia/infarction   
Vessel spasm (native coronaries, internal mammary artery) ECG, TOE, graft flow ECG changes, regional wall motion abnormality, poor graft flow
Emboli (air, clot, particulate matter) ECG, TOE, graft flow ECG changes, regional wall motion abnormality, poor graft flow
Technical graft anastomotic tissues ECG, TOE, graft flow ECG changes, regional wall motion abnormality, poor graft flow
Kink/clotting of bypass grafts, native vessels ECG, TOE, graft flow, inspection ECG changes, regional wall motion abnormality, poor graft flow
   Incomplete revascularization   
Non-graftable vessels   
Known intrinsic disease   
   Metabolic   
Hypoxia, hypercarbia ABG, electrolytes, check ventilation  
Hypokalemia, hyperkalemia Electrolytes  
   Uncorrected pathology   
Hypertrophic cardiomyopathy TOE Abnormal outflow gradient, SAM
Valve gradients TOE Abnormal valve gradient
Shunts TOE Abnormal Doppler jet
   Mechanical issues   
Prosthetic valve function TOE Poor leaflet motion, abnormal gradient
Intracardiac shunt (ASD, VSD) TOE Abnormal Doppler jet
   Conduction issues   
Bradycardia ECG Heart rate less than 60
Atrioventricular dissociation ECG Third degree heart block
Atrial fibrillation ECG, ABG, electrolytes Hypoxia, electrolyte abnormality
Ventricular arrhythmias ECG, ABG, electrolytes Hypoxia, electrolyte abnormality
Vasodilation Transpulmonary thermodilation, Swan-Ganz monitoring Decreased systemic vascular resistance
Hypovolemia Stroke volume monitoring Decreased stroke volume, increased SVV
   Pulmonary hypertension   
Pre-existing elevated pulmonary pressures, hypoxia, hypercarbia, fluid overload ABG Elevated pulmonary artery pressures, hypoxia, hypercarbia, RV distention
   Right ventricular failure   
Elevated pulmonary pressures, inadequate myocardial protection, emboli to native or bypass circulation, fluid overload Swan-Ganz monitoring, ABG, TOE RV distention, poor RV wall motion, elevated pulmonary artery pressure, elevated central venous pressure
  1. ABG = arterial blood gas; ASD, atrial septic defect; ECG, electrocardiogram, RV, right ventricle, SAM, systolic anterior motion of mitral valve leaflet; SVV, stoke volume variation; TOE, transoesophageal echocardiography; VSD, ventricular septal defect. Data taken from [80].