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Background: During cardiac surgery, right ventricular outflow tract obstruction (RVOTO) is defined as an instantaneous pressure difference ≥ 6 mm Hg between right ventricular systolic pressure (RVSP) and pulmonary artery systolic pressure (PASP), for ≥ 5 minutes. Risk factors for RVOTO remain poorly understood. This cohort study was designed to evaluate the incidence, characteristics, and outcomes of the patients who experienced RVOTO., Methods: Instantaneous pressure difference between RVSP and PASP was measured by means of a pulmonary artery catheter with a right ventricular port during cardiac surgery from a retrospective (n = 295) and a prospective (n = 105) cohort., Results: From the retrospective and prospective cohorts, respectively, incidence of RVOTO was 30.2% and 36.2% before cardiopulmonary bypass (CPB) initiation and 43.7% and 47.6% after CPB separation. Before CPB initiation, patients with RVOTO had higher cardiac output (4.2 ± 1.5 vs 3.8 ± 1.1 L/min; P = 0.033) and received more inhaled epoprostenol (79% vs 61%; P = 0.005) and inotropes (66% vs 51%; P = 0.016) compared with those without RVOTO. After CPB separation, patients with RVOTO had higher heart rate (62 ± 15 vs 58 ± 13 beats/min; P = 0.011), cardiac output (4.1 ± 1.4 vs 3.7 ± 1.1 L/min; P = 0.003), and CPB duration (90 ± 45 vs 77 ± 30 min, P = 0.014), had lower fluid balance (758 ± 1123 vs 1063 ± 1089 mL; P = 0.021), and were more exposed to intratracheal milrinone (12% vs 4%; P = 0.015) compared with those without RVOTO. The time with persistent organ dysfunction (T POD ) at 28 days after surgery was similar among patients who had an RVOTO event, before CPB initiation or after CPB separation, compared with those who did not., Conclusions: RVOTO is common in cardiac surgery. However, it is not associated with longer T POD ., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Right ventricular (RV) dysfunction in cardiac surgery can lead to RV failure, which is associated with increased morbidity and mortality. Abnormal RV function can be identified using RV pressure monitoring. The primary objective of the study is to determine the proportion of patients with abnormal RV early to end-diastole diastolic pressure gradient (RVDPG) and abnormal RV end-diastolic pressure (RVEDP) before initiation and after cardiopulmonary bypass (CPB) separation. The secondary objective is to evaluate if RVDPG before CPB initiation is associated with difficult and complex separation from CPB, RV dysfunction, and failure at the end of cardiac surgery., Design: Prospective study., Setting: Tertiary care cardiac institute., Participants: Cardiac surgical patients., Intervention: Cardiac surgery., Measurements and Main Results: Automated electronic quantification of RVDPG and RVEDP were obtained. Hemodynamic measurements were correlated with cardiac and extracardiac parameters from transesophageal echocardiography and postoperative complications. Abnormal RVDPG was present in 80% of the patients (n = 105) at baseline, with a mean RVEDP of 14.2 ± 3.9 mmHg. Patients experienced an RVDPG > 4 mmHg for a median duration of 50.2% of the intraoperative period before CPB initiation and 60.6% after CPB separation. A total of 46 (43.8%) patients had difficult/complex separation from CPB, 18 (38.3%) patients had RV dysfunction, and 8 (17%) had RV failure. Abnormal RVDPG before CPB was not associated with postoperative outcome., Conclusion: Elevated RVDPG and RVEDP are common in cardiac surgery. RVDPG and RVEDP before CPB initiation are not associated with RV dysfunction and failure but can be used to diagnose them., Competing Interests: Declaration of competing interest Dr. Denault received a research grant from Edwards Lifesciences. He is a consultant for CAE Healthcare and on the speakers bureau for Masimo. Daniel Scherb, Kevin Moses, and Cristhian Potes are engineers from Edwards Lifesciences, Irvine, CA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the impact of the ipsilateral arm position on ipsilateral shoulder pain after lung cancer resection by video-assisted thoracic surgery., Design: A prospective randomized controlled trial., Setting: A single academic center study., Participants: Patients undergoing video-assisted thoracic surgery pulmonary resection for cancer at the Institut Universitaire de Cardiologie et de Pneumologie de Québec from May 2020 to May 2022 were included., Interventions: Patients randomly were assigned with a 1:1 ratio to a supported or suspended ipsilateral arm position., Measurements and Main Results: Ipsilateral shoulder pain incidence, pain score, and opioid use were recorded in the postanesthesia care unit (PACU) on postoperative days 1 and 2. One hundred thirty-three patients were randomized, 67 in the suspended-arm group and 66 in the supported-arm group. Of the patients, 31% reported ipsilateral shoulder pain in the PACU with no difference between groups (19/67 [28.4%] v 22/66 patients (33.3%), p = 0.5767). There was no significant difference between the pain score in the PACU (3 [0-6] v 4 [0-6], p = 0.9055) at postoperative day 1 (4 [2-6] v 3 [2-5], p = 0.4113) and at postoperative day 2 (2 [0-5] v 2 [1-4], p = 0.9508). Ipsilateral shoulder pain score decreased rapidly on postoperative day 2. There was no statistical difference in opioid and gabapentinoid use between the groups., Conclusions: Ipsilateral arm position seems to have no impact on ipsilateral shoulder pain., Competing Interests: Declaration of competing interest None., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Transthoracic echocardiography is used routinely during the follow-up after heart transplant surgery to screen possible complications and adverse events such as rejection. It often results in incidental findings that bring diagnostic challenges for sonographers. This E-challenge shows a Doppler flow abnormality associated with a rare cardiovascular diagnosis. Its physiopathology and its association with echocardiography findings are reviewed., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: During cardiac surgery, transcranial Doppler (TCD) represents a non-invasive modality that allows measurement of red blood cell flow velocities in the cerebral arteries. TCD can also be used to detect and monitor embolic material in the cerebral circulation. Detection of microemboli is reported as a high intensity transient signal (HITS). The importance of cerebral microemboli during cardiac surgery has been linked to the increased incidence of postoperative renal failure, right ventricular dysfunction, and hemodynamic instability. The objective of this study is to determine whether the embolic load is associated with hemodynamic instability during cardiopulmonary bypass (CPB) separation and postoperative complications., Methods: A retrospective single-centre cohort study of 354 patients undergoing cardiac surgery between December 2015 and March 2020 was conducted. Patients were divided in tertiles, where 117 patients had a low quantity of embolic material (LEM), 119 patients have a medium quantity of microemboli (MEM) and 118 patients who have a high quantity of embolic material (HEM). The primary endpoint was a difficult CPB separation. Multivariate logistic regression was used to determine the potential association between a difficult CPB separation and the number of embolic materials., Results: Patients who had a difficult CPB separation had more HITS compared to patients who had a successful CPB separation (p < 0.001). In the multivariate analysis, patients with MEM decreased their odds of having a difficult CPB weaning compared to patients in the HEM group (OR = 0.253, CI 0.111-0.593; p = 0.001). In the postoperative period patients in the HEM group have a higher Time of Persistent Organ Dysfunction (TPOD), a longer stay in the ICU, a longer duration under vasopressor drugs and a higher mortality rate compared to those in the MEM and LEM groups., Conclusion: The result of this study suggests that a high quantity of cerebral embolic material increases the odds of having a difficult CPB separation. Also, it seems to be associated to more complex surgery, a longer CPB time, a higher TPOD and a longer stay in the ICU. Six out of eight patients who died in this cohort were in the HEM group., (© 2024. The Author(s).)

Purpose: There is an elevated incidence of hypoxemia during the airway management of the morbidly obese. We aimed to assess whether optimizing body position and ventilation during pre-oxygenation allow a longer safe non-hypoxic apnea period (SNHAP)., Methods: Fifty morbidly obese patients were recruited and randomized for this study. Patients were positioned and preoxygenated for three minutes in the ramp position associated with spontaneous breathing without additional CPAP or PEEP (RP/ZEEP group) or in the reverse Trendelenburg position associated with pressure support ventilation mode with pressure support of 8 cmH 2 O and an additional 10 cmH 2 O of PEEP while breathing spontaneously (RT/PPV group) according to randomization., Results: The SNHAP was significantly longer in the RT/PPV group (258.2 (55.1) vs. 216.7 (42.3) seconds, p = 0.005). The RT/PPV group was also associated to a shorter time to obtain a fractional end-tidal oxygen concentration (FEtO 2 ) of 0.90 (85.1(47.8) vs 145.3(40.8) seconds, p < 0.0001), a higher proportion of patients that reached the satisfactory FEtO 2 of 0.90 (21/24, 88% vs. 13/24, 54%, p = 0.024), a higher FEtO 2 during preoxygenation (0.91(0.05) vs. 0.89(0.01), p = 0.003) and a faster return to 97% oxygen saturation after ventilation resumption (69.8 (24.2) vs. 91.4 (39.2) seconds, p = 0.038)., Conclusion: In the morbidly obese population, RT/PPV, compared to RP/ZEEP, lengthens the SNHAP, decreases the time to obtain optimal preoxygenation conditions, and allows a faster resuming of secure oxygen saturation. The former combination allows a more significant margin of time for endotracheal intubation and minimizes the risk of hypoxemia in this highly vulnerable population., Trial Registration: NCT02590406, 29/10/2015., (© 2023. The Author(s).)

Objective: To identify potentially modifiable risk factors related to prolonged cardiovascular pharmacological support after weaning from cardiopulmonary bypass (CPB)., Methods: This is a secondary analysis of two prospective cohort study in a specialized cardiac surgery institution in adult patients undergoing cardiac surgery with the use of CPB between August 2016 and July 2017. Prolonged cardiovascular pharmacological support was defined by the need for at least one vasopressor or one inotropic agent 24 hours after separation from CPB. Risk factors were identified among baseline characteristics and peri-operative events through multivariable logistic regression., Results: A total of 247 patients were included and 98 (39.7%) developed prolonged pharmacological support. In multivariable analysis, left ventricular ejection fraction ≤ 30% (OR 9.52, 95% confidence interval (CI) 1.14; 79.25), elevated systolic pulmonary artery pressure (sPAP) > 30 and ≤ 55 mmHg (moderate) (OR 2.52, CI 1.15; 5.52) and sPAP > 55 mmHg (severe) (OR 8.12, CI 2.54; 26.03), as well as cumulative fluid balance in the first 24 hours after surgery (OR 1.76, CI 1.32; 2.33) were independently associated with the development of prolonged pharmacological support., Conclusions: Prolonged cardiovascular pharmacological support is frequent after cardiac surgery on CPB. Severe LV systolic dysfunction, preoperative pulmonary hypertension and postoperative fluid overload are risk factors. Further studies are required to explore if those risk factors could be modified or not., Competing Interests: Dr. Denault is on the Speakers Bureau for CAE Healthcare (2010), Masimo (2017) and Edwards (2019). No other conflict of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Kontar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Competing Interests: Conflicts of Interest Dr Denault is a speaker and consultant for CAE Healthcare (2010) and speaker for Edwards and Masimo (2017). He also received a research grant from Edwards in 2019.

Hemodynamic monitoring is a cornerstone in the assessment of patients with circulatory shock. Timely recognition of hemodynamic compromise and proper optimisation is essential to ensure adequate tissue perfusion and maintain renal, hepatic, abdominal, and cerebral functions. Hemodynamic monitoring has significantly evolved since the first inception of the pulmonary artery catheter more than 50 years ago. Bedside echocardiography, when combined with noninvasive and minimally invasive technologies, provides tools to monitor and quantify the cardiac output to promptly react and improve hemodynamic management in an acute care setting. Commonly used technologies include noninvasive pulse-wave analysis, pulse-wave transit time, thoracic bioimpedance and bioreactance, esophageal Doppler, minimally invasive pulse-wave analysis, transpulmonary thermodilution, and pulmonary artery catheter. These monitoring strategies are reviewed here, along with detailed analysis of their operating mode, particularities, and limitations. The use of artificial intelligence to enhance performance and effectiveness of hemodynamic monitoring is reviewed to apprehend future possibilities., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. Intraoperative management of patients at high risk of RV failure should aim to reduce RV afterload and optimize RV filling pressures, while avoiding systemic hypotension, to facilitate weaning from cardiopulmonary bypass (CPB). Inhaled epoprostenol and inhaled milrinone (iE&iM) administered in combination before CPB may represent an effective strategy to facilitate separation from CPB and reduce requirements for intravenous inotropes during cardiac surgery. Our primary objective was to report the rate of positive pulmonary vasodilator response to iE&iM and, second, how it relates to perioperative outcomes in cardiac surgery., Methods: This is a retrospective cohort study of consecutive patients with PH or RV dysfunction undergoing on-pump cardiac surgery at the Montreal Heart Institute from July 2013 to December 2018 (n = 128). iE&iM treatment was administered using an ultrasonic mesh nebulizer before the initiation of CPB. Demographic and baseline clinical data, as well as hemodynamic, intraoperative, and echocardiographic data, were collected using electronic records. An increase of 20% in the mean arterial pressure (MAP) to mean pulmonary artery pressure (MPAP) ratio was used to indicate a positive response to iE&iM., Results: In this cohort, 77.3% of patients were responders to iE&iM treatment. Baseline systolic pulmonary artery pressure (SPAP) (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.24-2.16 per 5 mm Hg; P = .0006) was found to be a predictor of pulmonary vasodilator response, while a European System for Cardiac Operative Risk Evaluation (EuroSCORE II) score >6.5% was a predictor of nonresponse to treatment (≤6.5% vs >6.5% [reference]: OR, 5.19; 95% CI, 1.84-14.66; P = .002). Severity of PH was associated with a positive response to treatment, where a higher proportion of responders had MPAP values >30 mm Hg (42.4% responders vs 24.1% nonresponders; P = .0237) and SPAP values >55 mm Hg (17.2% vs 3.4%; P = .0037). Easier separation from CPB was also associated with response to iE&iM treatment (69.7% vs 58.6%; P = .0181). A higher proportion of nonresponders had a very difficult separation from CPB and required intravenous inotropic drug support compared to responders, for whom easy separation from CPB was more frequent. Use of intravenous inotropes after CPB was lower in responders to treatment (8.1% vs 27.6%; P = .0052)., Conclusions: A positive pulmonary vasodilator response to treatment with a combination of iE&iM before initiation of CPB was observed in 77% of patients. Higher baseline SPAP was an independent predictor of pulmonary vasodilator response, while EuroSCORE II >6.5% was a predictor of nonresponse to treatment., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (E es ) following the development of an acute RV ischemic in a porcine model., Hypothesis: RV pressure monitoring can detect changes in RV systolic performance assess by RV E es following the development of an acute RV ischemic model., Methods and Models: Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV E es obtained using a conductance catheter during inferior vena cava occlusions., Results: Acute ischemia resulted in a significant reduction in RV E es from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between E es and RV pressure-derived parameters. The reduction in RV E es best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dt max ) and single-beat RV E es . Adjusting RV dP/dt max for heart rate resulted in an improved surrogate of RV E es ., Interpretation and Conclusions: Stepwise decreases in RV E es during acute ischemic RV dysfunction were accurately tracked by RV dP/dt max derived from the RV pressure waveform., Competing Interests: Mr. Moses, Dr. Potes, Mr. Garcia, and Dr. Paster work for Edwards Lifesciences—a manufacturer of healthcare devices and critical care solutions. Dr. Denault is on the speaker’s bureau for CAE Healthcare (2012), Masimo (2017) and received an equipment grant from Edwards (2019). He is a consultant for Masimo (2020) and CAE Healthcare (2020). Dr. Monge García is a consultant for Edwards Lifesciences and Dextera Medical. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Regional cerebral oxygen saturation (rS o2 ) obtained from near-infrared spectroscopy (NIRS) provides valuable information during cardiac surgery. The rS o2 is calculated from the proportion of oxygenated to total hemoglobin in the cerebral vasculature. Root O3 cerebral oximetry (Masimo) allows for individual identification of changes in total (ΔcHbi), oxygenated (Δ o2 Hbi), and deoxygenated (ΔHHbi) hemoglobin spectral absorptions. Variations in these parameters from baseline help identify the underlying mechanisms of cerebral desaturation. This case series represents the first preliminary description of Δ o2 Hbi, ΔHHbi, and ΔcHbi variations in 10 cardiac surgical settings. Hemoglobin spectral absorption changes can be classified according to 3 distinct variations of cerebral desaturation. Reduced cerebral oxygen content or increased cerebral metabolism without major blood flow changes is reflected by decreased Δ o2 Hbi, unchanged ΔcHbi, and increased ΔHHbi Reduced cerebral arterial blood flow is suggested by decreased Δ o2 Hbi and ΔcHbi, with variable ΔHHbi. Finally, acute cerebral congestion may be suspected with increased ΔHHbi and ΔcHbi with unchanged Δ o2 Hbi. Cerebral desaturation can also result from mixed mechanisms reflected by variable combination of those 3 patterns. Normal cerebral saturation can occur, where reduced cerebral oxygen content such as anemia is balanced by a reduction in cerebral oxygen consumption such as during hypothermia. A summative algorithm using rS o2 , Δ o2 Hbi, ΔHHbi, and ΔcHbi is proposed. Further explorations involving more patients should be performed to establish the potential role and limitations of monitoring hemoglobin spectral absorption signals., (Copyright © 2022 International Anesthesia Research Society.)

Background: Portal vein Doppler ultrasound pulsatility measured by transoesophageal echocardiography is a marker of the haemodynamic impact of venous congestion in cardiac surgery. We investigated whether the presence of abnormal portal vein flow pulsatility is associated with a longer duration of invasive life support and postoperative complications in high-risk patients., Methods: In this multicentre cohort study, pulsed-wave Doppler ultrasound assessments of portal vein flow were performed during anaesthesia before initiation of cardiopulmonary bypass (before CPB) and after separation of cardiopulmonary bypass (after CPB). Abnormal pulsatility was defined as portal pulsatility fraction (PPF) ≥50% (PPF50). The primary outcome was the cumulative time in perioperative organ dysfunction (T POD ) requiring invasive life support during 28 days. Secondary outcomes included major postoperative complications., Results: 373 patients, 71 (22.0%) had PPF50 before CPB and 77 (24.9%) after CPB. PPF50 was associated with longer duration of T POD (median [inter-quartile range]; before CPB: 27 h [11-72] vs 19 h [8.5-42], P=0.02; after CPB: 27 h [11-61] vs 20 h [8-42], P=0.006). After adjusting for confounders, PPF50 before CPB showed significant association with T POD . PPF50 after CPB was associated with a higher rate of major postoperative complications (36.4% vs 20.3%, P=0.006)., Conclusions: Abnormal portal vein flow pulsatility before cardiopulmonary bypass was associated with longer duration of life support therapy after cardiac surgery in high-risk patients. Abnormal portal vein flow pulsatility after cardiopulmonary bypass separation was associated with a higher risk of major postoperative complications although this association was not independent of other factors., Clinical Trial Registration: NCT03656263., (Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Delirium is common in patients undergoing cardiac surgery, and venous congestion has been reported as an important risk factor. We report a 69-year-old patient who developed postoperative delirium in the intensive care unit following aortic valve replacement surgery. The postoperative course was complicated by delirium for which echographic signs of venous congestion on the portal and the renal but also the femoral veins and their resolution correlated with the course of delirium. The use of common femoral vein Doppler as a simple bedside technique to predict and identify congestive delirium has not been reported before., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Sepsis-induced cardiomyopathy (SCM) is an increasingly recognized problem encountered in critical care medicine. It generally is characterized as a decrease in left, right, or biventricular ejection fraction followed by a recovery of function over a period of days to weeks. Venoarterial extracorporeal membrane oxygenation (ECMO) has been used for the treatment of adults with various etiologies of shock, including cardiogenic and septic shock. This review summarizes current pathophysiologic mechanisms leading to SCM and provides a detection and treatment algorithm for SCM, as well as a discussion about the rationale and recent clinical data surrounding the use of ECMO and other forms of mechanical circulatory support for SCM., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The use of brain function monitoring with processed electroencephalography (pEEG) during cardiac surgery is gaining interest for the optimization of hypnotic agent delivery during the maintenance of anesthesia. The authors sought to determine whether the routine use of pEEG-guided anesthesia is associated with a reduction of hemodynamic instability during cardiopulmonary bypass (CPB) separation and subsequently reduces vasoactive and inotropic requirements in the intensive care unit., Design: This is a retrospective cohort study based on an existing database., Setting: A single cardiac surgical center., Participants: Three hundred patients undergoing cardiac surgery, under CPB, between December 2013 and March 2020., Interventions: None., Measurements and Main Results: One hundred and fifty patients had pEEG-guided anesthesia, and 150 patients did not have a pEEG-guided anesthesia. Multiple logistic regression demonstrated that pEEG-guided anesthesia was not associated with a successful CPB separation (p = 0.12). However, the use of pEEG-guided anesthesia reduced by 57% the odds of being in a higher category for vasoactive inotropic score compared to patients without pEEG (odds ratio = 0.43; 95% confidence interval: 0.26-0.73; p = 0.002). Duration of mechanical ventilation, fluid balance, and blood losses were also reduced in the pEEG anesthesia-guided group (p < 0.003), but there were no differences in organ dysfunction duration and mortality., Conclusion: During cardiac surgery, pEEG-guided anesthesia allowed a reduction in the use of inotropic or vasoactive agents at arrival in the intensive care unit. However, it did not facilitate weaning from CPB compared to a group where pEEG was unavailable. A pEEG-guided anesthetic management could promote early vasopressor weaning after cardiac surgery., Competing Interests: Conflict of Interest Dr. Denault is a speaker and consultant for CAE Healthcare, speaker for Edwards and Masimo. He received a research grant from Edwards (2019)., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose of Review: Right ventricular dysfunction has an important impact on the perioperative course of cardiac surgery patients. Recent advances in the detection and monitoring of perioperative right ventricular dysfunction will be reviewed here., Recent Findings: The incidence of right ventricular dysfunction in cardiac surgery has been associated with unfavorable outcomes. New evidence supports the use of a pulmonary artery catheter in cardiogenic shock. The possibility to directly measure right ventricular pressure by transducing the pacing port has expanded its use to track changes in right ventricular function and to detect right ventricular outflow tract obstruction. The potential role of myocardial deformation imaging has been raised to detect patients at risk of postoperative complications., Summary: Perioperative right ventricular function monitoring is based on echocardiographic and extra-cardiac flow evaluation. In addition to imaging modalities, hemodynamic evaluation using various types of pulmonary artery catheters can be achieved to track changes rapidly and quantitatively in right ventricular function perioperatively. These monitoring techniques can be applied during and after surgery to increase the detection rate of right ventricular dysfunction. All this to improve the treatment of patients presenting early signs of right ventricular dysfunction before systemic organ dysfunction ensue., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Data regarding post-pneumonectomy patient assessment for cardiac surgery is scarce. This retrospective study was conducted to define early and late outcomes in these patients, and to identify risk factors for poor outcomes., Methods: This study included patients with a previous history of pneumonectomy undergoing on-pump cardiac surgery with median sternotomy. The institutional database was reviewed from 1992 to 2018., Results: Sixteen post-pneumonectomy patients (all lung cancer) were identified. The age range was 53-81 years. The mean FEV1/FVC was 69%. The mean EuroSCORE II was 11.6%. Four patients had heart failure symptoms in the 2 weeks before surgery. Seven patients had isolated coronary artery bypass grafting (CABG) and six patients had CABG + aortic valve replacement (AVR). The major perioperative events affecting the ease and outcomes of the surgical procedures were structural shifts (5), extensive adhesions on heart and vessels (5), and extensive calcification of heart components (5). Important postoperative complications were respiratory (7), infections (5), and acute kidney injury (5). The median hospital length of stay was 7 days. Five patients died in hospital (none with isolated CABG) with a preoperative New York Heart Association classification (NYHA) of III-IV, a cardiopulmonary bypass time of 175.2 min and an aortic cross-clamp time of 104.0 min. The long-term survival data were recorded with a mean follow-up of 7.3 ± 7.1 years (range from 0 to 19). The overall, 5-year survival, was 50% for all cardiac surgeries, 71% for isolated CABG surgeries, and 17% for CABG + AVR surgeries, respectively., Conclusion: Post-pneumonectomy patients have acceptable postoperative outcomes and survival. Simple and short surgeries with careful planning can yield favorable outcomes for this high-risk subgroup of patients., (© 2022 Wiley Periodicals LLC.)

Background: Despite increasing attention in the cardiac anesthesiology literature, continuous measurement of right ventricular pressure using a pulmonary artery catheter has not been described in orthotopic liver transplantation, despite similarities in the anesthetic approach to the two populations. We describe our preliminary experience with this technique in orthotopic liver transplantation, and by combining various derived measures with trans-esophageal echocardiography, make some early observations regarding the response of these measures of right ventricular function during the procedure., Methods: In this case series, ten patients (five men and five women) undergoing orthotopic liver transplantation in our institution had their surgeries performed while monitored with a pulmonary artery catheter with continuous right ventricular port transduction and trans-esophageal echocardiography. We recorded various right ventricular waveform (early-to-end diastolic pressure difference, right ventricular outflow tract gradient, right ventricular dP/dT and right ventricular end-diastolic pressure) and echocardiographic (right ventricular fractional area change, tricuspid annular plane systolic excursion, right ventricular lateral wall strain) and described their change relative to baseline at timepoints five minutes before and after portal vein reperfusion, immediately after hepatic artery reperfusion and on abdominal closure., Results: Except for tricuspid annular plane systolic excursion at five minutes prior to reperfusion (mean -0.8 cm; 95% CI-1.4, -0.3; p = 0.007), no echocardiographic metric was statistically significantly different at any timepoint relative to baseline. In contrast, changes in right ventricular outflow tract gradient and right ventricular dP/dt were highly significant at multiple timepoints, generally peaking immediately before or after reperfusion before reducing, but not returning to baseline in the neohepatic phase. Nine of 10 participants in this series demonstrated a degree of dynamic right ventricular outflow tract obstruction, which met criteria for hemodynamic significance (> 25 mmHg) in two participants. These changes were not materially affected by cardiac index., Conclusions: Dynamic right ventricular outflow tract obstruction of varying severity appears common in patients undergoing orthotopic liver transplantation. These results are hypothesis generating and will form the basis of future prospective research., Competing Interests: We have read the journal’s policy and the authors of this manuscript have the following competing interests: The institution for which Lachlan F. Miles works has received financial support from Edwards LifeSciences, although he himself is not the recipient of any grants or funding. Cristhian Potes is an employee of Edwards LifeSciences. Laurence Weinberg is a member of the speaker bureau for Edwards LifeSciences and Masimo and has received financial support from both organizations. André Y. Denault reports grants from Edwards LifeSciences outside the submitted work. He is a member of the speaker bureau and a key opinion leader for CAE Healthcare and Masimo. This does not alter our adherence to PLOS ONE policies on sharing data and materials. No other authors have any conflicts of interest to report.

Right ventricular outflow tract obstruction (RVOTO) is a rare cause of hemodynamic instability in the intensive care unit (ICU) after cardiac surgery. We report the first cases of RVOTO diagnosed in the ICU using continuous right ventricular pressure waveform monitoring. Our 2 cases reflect both mechanical and dynamic causes of obstruction, each of which require different approaches to treatment. Inotrope use can exacerbate RVOTO caused by dynamic etiology, whereas surgery is usually the treatment of choice for mechanical obstructions. Inability to recognize RVOTO or the correct etiology can lead to hemodynamic compromise and poor outcomes., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function., (Copyright © 2021 Elsevier Inc. All rights reserved.)

In 1959, Niels Lassen illustrated the cerebral autoregulation curve in the classic review article entitled Cerebral Blood Flow and Oxygen Consumption in Man. This concept suggested a relatively broad mean arterial pressure range (~60-150 mmHg) wherein cerebral blood flow remains constant. However, the assumption that this wide cerebral autoregulation plateau could be applied on a within-individual basis is incorrect and greatly variable between individuals. Indeed, each data point on the autoregulatory curve originated from independent samples of participants and patients and represented interindividual relationships between cerebral blood flow and mean arterial pressure. Nonetheless, this influential concept remains commonly cited and illustrated in various high-impact publications and medical textbooks, and is frequently taught in medical and science education without appropriate nuances and caveats. Herein, we provide the rationale and additional experimental data supporting the notion we need to lose this dogmatic view of cerebral autoregulation., (© 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Purpose: Double-lumen endotracheal tubes (DL-ETT) and bronchial blockers (BB) are frequently used to allow one-lung ventilation (OLV) during video-assisted thoracic surgery (VATS). Recently, faster lung collapse has been documented with a BB than with a DL-ETT. The physiologic mechanisms behind this faster collapse remained unknown. We aimed to measure ambient air absorption (V resorb ) and intra-bronchial pressure (P airway ) into the non-ventilated lung during OLV using DL-ETT and BB., Methods: Patients undergoing VATS and OLV for lung resection were randomly assigned to have measurements made of V resorb or P airway within the non-ventilated lung using either a DL-ETT or BB., Results: Thirty-nine patients were included in the analyses. The mean (standard error of the mean [SEM]) V resorb was similar in the DL-ETT and BB groups [504 (85) vs 630 (86) mL, respectively; mean difference, 126; 95% confidence interval [CI], -128 to 380; P = 0.31]. The mean (SEM) P airway became progressively negative in the non-ventilated lung in both the DL-ETT and the BB groups reaching [-20 (5) and -31 (10) cmH 2 O, respectively; mean difference, -11; 95% CI, -34 to 12; P = 0.44] at the time of the pleural opening., Conclusions: During OLV before pleural opening, entrainment of ambient air into the non-ventilated lung occurs when the lumen of the lung isolation device is kept open. This phenomenon is prevented by occluding the lumen of the isolation device before pleural opening, resulting in a progressive build-up of negative pressure in the non-ventilated lung. Future clinical studies are needed to confirm these physiologic results and their impact on lung collapse and operative outcomes., Trial Registration: www.clinicaltrials.gov (NCT02919267); registered 28 September 2016.

Introduction: Older patients undergoing cardiac surgery carry the highest risk for developing major postoperative neurocognitive disorder (postoperative NCD or P-NCD) with up to 25% incidence 3 months after surgery. P-NCD is associated with significant morbidity, mortality, loss of independence, premature retirement and increased healthcare costs. This multicentre randomised trial is investigating the efficacy of postoperative dexmedetomidine sedation in reducing the incidence of major P-NCD after cardiac surgery compared with standard protocols. CODEX will be the largest interventional trial with major P-NCD as the primary outcome., Methods and Analysis: CODEX is recruiting patients ≥60 years old, undergoing elective cardiac surgery and without pre-existing major cognitive dysfunction or dementia. Eligible participants are randomised to receive postoperative dexmedetomidine or standard institutional sedation protocols in the intensive care unit. Baseline preoperative cognitive function is assessed with the computer-based Cogstate Brief Battery. The primary outcome, major P-NCD, 3 months after surgery is defined as a decrease in cognitive function ≥1.96 SD below age-matched, non-operative controls. Secondary outcomes include delirium, major P-NCD at 6/12 months, depressive symptoms, mild P-NCD and quality of surgical recovery at 3/6/12 months. The specific diagnostic criteria used in this protocol are consistent with the recommendations for clinical assessment and management of NCD from the Nomenclature Consensus Working Group on perioperative cognitive changes. Intention-to-treat analysis will compare major P-NCD at 3 months between study groups., Ethics and Dissemination: CODEX was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB) (Project ID 1743). This will be the first multicentre, randomised controlled trial to assess the efficacy of a pharmacological intervention to reduce the incidence of major P-NCD after cardiac surgery in patients ≥60 years old. Dissemination of the study results will include briefings of key findings and interpretation, conference presentations and peer-reviewed publications., Trial Registration Number: NCT04289142., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Transcranial Doppler (TCD) ultrasound is a non-invasive monitor of cerebral blood velocity that can be used intraoperatively. The purpose of this report is to describe how different patterns seen on TCD can help identify the cause of cerebral desaturation when near-infrared spectroscopy (NIRS) oximetry is used concomitantly., Clinical Features: A 69-yr-old male patient undergoing coronary revascularisation and aortic valve replacement developed perioperative complications that were detected using a combination of transtemporal TCD of the middle cerebral artery along with cerebral and somatic NIRS. Initial brain desaturation was secondary to hypocapnia during which TCD-derived blood velocity and somatic NIRS values remained unchanged. After the procedure, a second episode of brain desaturation occurred secondary to a technical issue with the aortic valve prosthesis requiring a return to cardiopulmonary bypass (CPB); there were no high-intensity transient signals (HITS) on TCD. Brain desaturation occurred a third time following the second attempt to separate from CPB at which time TCD detected a significant amount of HITS suggesting air emboli that were associated with acute right ventricular dysfunction; there was also a reduction in somatic NIRS., Conclusions: Combining TCD with cerebral NIRS allows for the rapid identification of three different mechanisms of brain desaturation. An algorithm is proposed to help identify the origin of NIRS cerebral desaturation. Prospective clinical trials are needed to investigate potential benefits of multimodal brain monitoring and its impact on short and/or long-term clinical outcomes.

Dynamic right ventricular outflow tract obstruction is rare in the cardiac surgical population. Significant obstruction developing in the perioperative period can contribute to systemic hemodynamic instability. We describe 2 cases of dynamic right ventricular outflow tract obstruction that developed immediately after separation from cardiopulmonary bypass, due to temporary right ventricular epicardial pacing. Both patients had systemic hypotension which improved once ventricular pacing was discontinued. We discuss the recognition of right ventricular outflow tract obstruction as a contributing factor to hemodynamic instability, as well as the importance of identifying the underlying cause such as to institute appropriate management in these patients.

Right ventricular (RV) dysfunction is the most important determinant of survival in patients with pulmonary hypertension (PH). The manifestations of RV dysfunction not only include changes in global RV systolic function but also abnormalities in the pattern of contraction and synchrony. The effects of PH on the right ventricle have been mainly studied in patients with pulmonary arterial hypertension (PAH). However, with the demographic shift towards an aging population, heart failure with preserved ejection fraction (HFpEF) has become an important etiology of PH in recent years. There are significant differences in RV mechanics, function and adaptation between patients with PAH and HFpEF (with or without PH), which are related to different patterns of remodeling and dysfunction. Due to the unique features of the RV chamber, its connection with the main pulmonary artery and the pulmonary circulation, an understanding of the mechanics of RV function and its clinical significance is mandatory for both entities. In this review, we describe the mechanics of the pressure overloaded right ventricle. We review the different mechanical components of RV dysfunction and ventricular dyssynchrony, followed by insights via analysis of pressure-volume loop, energetics and novel blood flow patterns, such as vortex imaging. We conduct an in-depth comparison of prevalence and characteristics of RV dysfunction in HFpEF and PAH, and summarize key outcome studies. Finally, we provide a perspective on needed and expected future work in the field of RV mechanics., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/cdt-20-479). The series “Right Ventricular Dysfunction” was commissioned by the editorial office without any funding or sponsorship. GH served as the unpaid Guest Editor of the series. GH reports grants from German Research Foundation (DFG; HA4348/2-2 and HA4348/6-2 KFO311), from Federal Ministry of Education and Research (BMBF ViP+ program-03VP08053; BMBF 01KC2001B), from European Pediatric Pulmonary Vascular Disease Network (www.pvdnetwork.org), outside the submitted work. AYD reports grants from Edwards (2019) research (equipment grant), outside the submitted work; and Speaker bureau and KOL for CAE Healthcare and Masimo. Dr. FSdM reports grants from The Netherlands CardioVascular Research Initiative: the Dutch Heart Foundation, Dutch Federation of University Medical Centres, the Netherlands Organisation for Health Research and Development, and the Royal Netherlands Academy of Sciences (CVON-2012-08 PHAEDRA, CVON-2018-29 PHAEDRA-IMPACT, CVON-2017-10 Dolphin-Genesis), from The Netherlands Organization for Scientific Research (NWO-VIDI: 917.18.338), from The Dutch Heart Foundation Dekker senior post-doc grant (2018T059), outside the submitted work. The authors have no other conflicts of interest to declare., (2020 Cardiovascular Diagnosis and Therapy. All rights reserved.)

Objectives: To report the use of common femoral vein Doppler interrogation as a simple technique to diagnose right ventricular dysfunction., Design: Case report., Setting: Cardiac surgical ICU., Patients: Postoperative cardiac surgical patients., Interventions: Common femoral pulsed-wave and color Doppler examination associated with hepatic, portal, and renal venous Doppler measurement were obtained in both patients and before and after treatment in patient number 1. In addition, right ventricular pressure waveform examination was obtained in patient number 2., Measurements and Main Results: The technique to obtain common femoral venous Doppler is described. Two cases of patients presenting with right ventricular dysfunction and fluid overload with portal and renal venous congestion in the perioperative period undergoing complex multivalvular cardiac surgery are presented. Hemodynamic waveform monitoring was performed alongside echocardiographic, hepatic, and renal venous flow Doppler assessment, and spectral Doppler profiles of the common femoral veins were examined. Those findings were useful in confirming our diagnosis and guiding our response to treatment. An algorithm was developed and tested on two additional hemodynamically unstable patients., Conclusions: Doppler examination of the common femoral vein is a simple, fast, and noninvasive technique that could be useful to rule in the presence of right ventricular dysfunction with venous congestion and help guide the management of such patients., Competing Interests: Dr. Denault is on the Speakers’ Bureau for CAE Healthcare (2010), Masimo (2017), Edwards (2019) and received an equipment grant from Edwards (2019). The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objectives: Right ventricular (RV) dysfunction in cardiac surgery is associated with increased mortality and morbidity and difficult separation from cardiopulmonary bypass (DSB). The primary objective of the present study was to describe the prevalence and characteristics of patients with abnormal RV diastolic pressure gradient (PG). The secondary objective was to explore the association among abnormal diastolic PG and DSB, postoperative complications, high central venous pressure (CVP), and high RV end-diastolic pressure (RVEDP)., Design: Retrospective and prospective validation study., Setting: Tertiary care cardiac institute., Participants: Cardiac surgical patients (n=374) from a retrospective analysis (n=259) and a prospective validation group (n=115)., Intervention: RV pressure waveforms were obtained using a pulmonary artery catheter with a pacing port opened at 19 cm distal to the tip of the catheter. Abnormal RV diastolic PG was defined as >4 mmHg. Both elevated RVEDP and high CVP were defined as >16 mmHg., Measurements and Main Results: From the retrospective and validation cohorts, 42.5% and 48% of the patients had abnormal RV diastolic PG before cardiac surgery, respectively. Abnormal RV diastolic PG before cardiac surgery was associated with higher EuroSCORE II (odds ratio 2.29 [1.10-4.80] v 1.62 [1.10-3.04]; p = 0.041), abnormal hepatic venous flow (45% v 29%; p = 0.038), higher body mass index (28.9 [25.5-32.5] v 27.0 [24.9-30.5]; p = 0.022), pulmonary hypertension (48% v 37%; p = 0.005), and more frequent DSB (32% v 19%; p = 0.023). However, RV diastolic PG was not an independent predictor of DSB, whereas RVEDP (odds ratio 1.67 [1.09-2.55]; p = 0.018) was independently associated with DSB. In addition, RV pressure monitoring indices were superior to CVP in predicting DSB., Conclusion: Abnormal RV diastolic PG is common before cardiac surgery and is associated with a higher proportion of known preoperative risk factors. However, an abnormal RV diastolic PG gradient is not an independent predictor of DSB in contrast to RVEDP., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Sepsis remains a major cause of morbidity and mortality, and sepsis-induced cardiomyopathy (SCM) has been recognized as a relevant complication. In this article, the pathophysiology of SCM and the literature regarding the clinical care with a focus on the use of mechanical circulatory support for the rescue of patients with severe SCM are reviewed. Lastly, a pragmatic approach to the care of this complex patient population is provided using a representative case example., (Copyright © 2019. Published by Elsevier Inc.)

Near-infrared spectroscopy (NIRS) is an emerging noninvasive monitoring modality based on chromophore absorption of infrared light. Because NIRS provides instantaneous information on cerebral and somatic tissue oxygenation, it becomes mandatory to identify rapidly the etiology of impaired regional oxygenation and thus perfusion. To do so, the use of whole-body ultrasound (WHOBUS) represents a significant advance in the management of patients experiencing cerebral or somatic desaturation. This narrative review describes the authors' experience since 2002 in the use of combined NIRS and WHOBUS. A practical approach in the use of both modalities and their respective limitations is described., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The double lumen tube (DLT) has become the most popular way to isolate the lungs for thoracic surgery. The variable anatomy of the right main stem bronchus (RMSB) seems to be the main reason clinicians are unwilling to use the right-sided DLT (R-DLT). The factors that could compromise the adequate ventilation of the right lung are mostly the variable length of the RMSB and the misalignment of the lateral orifice of the R-DLT in regard to the right upper lobe bronchus (RULB). The objectives of this study were to validate an alternative method to estimate the RMSB length, and to determine the distribution of the angulation of the ostium of the RULB., Methods: From high-resolution computed tomography scans of the thorax of 106 consecutive patients, the length of the RMSB was measured using Kim's method and the carina-to-carina method. The angle between the RULB origin and the lateral aspect of the RMSB was also measured. All these measurements were correlated and inter-observer variation documented., Results: From the Kim's method, the mean (standard deviation [SD]) length of the RMSB was 25.5 (4.7) mm. From the alternative carina-to-carina method, the mean (SD) length of RMSB was 29.4 (4.6) mm. The inter-observer agreement was substantial with both methods (Kim's method: intraclass correlation coefficient [ICC] = 0.84; carina-to-carina method: ICC = 0.95). Both measures were closely related (ICC = 0.93; P < 0.001). The RULB presented a wide range angulation [mean (SD), 0.1 (9.5)°; range, -28.6 to 21.2]., Conclusion: These anatomic observations provide a better understanding of the variable anatomy of the right bronchial tree and may guide thoracic anesthesiologists in the choice of the best lung isolation device for their patients.

Purpose: Cerebral oximetry is a monitoring tool used in the perioperative care of cardiac surgery patients to ensure adequate cerebral perfusion and oxygenation. When combined with somatic oximetry, the differential diagnosis of cerebral desaturation can be better identified and managed more specifically, as somatic oximetry serves as a global or localized perfusion monitor (depending on its regional position). The use of processed electroencephalography (pEEG) in cardiac surgery could further guide the management of desaturation episodes, as reductions in pEEG activity without a change in the anesthetic agent level indicate potential cerebral ischemia. Continuous integration of multiple monitoring modalities are thus desirable to assess organ perfusion and organ function., Clinical Features: Four clinical cases are presented in which the combination of pEEG and cerebro-somatic oximetry assisted with understanding the mechanism of cerebral desaturation encountered during cardiac surgery., Conclusion: Integrating combinations of different monitoring modalities such as cerebral and somatic oximetry with pEEG can help the diagnosis and treatment of organ malperfusion and related dysfunction.

Right ventricular (RV) dysfunction is a cause of increased morbidity and mortality in both cardiac surgery and noncardiac surgery and in the intensive care unit. Early diagnosis of this condition still poses a challenge. The diagnosis of RV dysfunction traditionally is based on a combination of echocardiography, hemodynamic measurements, and clinical symptoms. This review describes the method of using RV pressure waveform analysis to diagnose and grade the severity of RV dysfunction. The authors describe the technique, optimal use, and pitfalls of this method, which has been used at the Montreal Heart Institute since 2002, and review the current literature on this method. The RV pressure waveform is obtained using a pulmonary artery catheter with the capability of measuring RV pressure by connecting a pressure transducer to the pacemaker port. The authors describe how RV pressure waveform analysis can facilitate the diagnosis of systolic and diastolic RV dysfunction, the evaluation of RV-arterial coupling, and help diagnose RV outflow tract obstruction. RV pressure waveform analysis also can be used to guide pharmacologic treatment and fluid resuscitation strategies for RV dysfunction., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We describe the cases of 2 patients free from mechanical ventilation after a cardiac surgery with systemic venous congestion from right ventricular (RV) failure. Management of these patients included RV preload reduction with diuretics and RV afterload reduction with inhaled pulmonary vasodilators. Noninvasive combination of inhaled epoprostenol and inhaled milrinone through the AirLife filtered nebulizer system (CareFusion) was used. Reduction of splanchnic venous congestion was assessed by Doppler portal flow pulsatility.

Objective: To report the authors' 12 years of experience with intratracheal milrinone administration and to assess the efficacy and limitations of intratracheal milrinone bolus administration for the treatment of unexpected acute right ventricular (RV) failure in patients undergoing cardiac surgery., Design: Retrospective analysis., Setting: Single-center university hospital., Participants: One hundred seventy-six patients (4.6%) undergoing on-pump cardiac surgery., Interventions: Endotracheal tube administration of milrinone (5-mg bolus) after unexpected acute RV failure during separation from cardiopulmonary bypass (CPB) weaning. RV failure was defined as the simultaneous presence of all of the following criteria: (1) hemodynamic instability or difficult separation from CPB with associated elevated central venous pressure or abnormal RV pressure waveform, (2) >20% reduction of RV fractional area change from baseline evaluated by transesophageal echocardiography, and (3) anatomical visualization of impaired or absent RV wall motion by direct intraoperative visual inspection., Measurements and Main Results: Intratracheal milrinone administration was found to improve RV failure in 109 patients (61.9%) whereas RV failure persisted in 67 patients (38.1%). Using a multiple logistic regression model, severely decreased left ventricular ejection fraction (<35% v >50%) (adjusted odds ratio [OR] 3.72; 95% confidence interval [CI] 1.2-11.3; p = 0.012), longer CPB time (adjusted OR 1.014; CI 1.01-1.02; p = 0.001) and elevated postoperative fluid balance (adjusted OR 1.39; CI 1.1-1.8; p = 0.02) were found to be significant predictors of persistent RV failure., Conclusion: Intratracheal instillation of milrinone was associated with clinical improvement of RV failure occurring during separation from CPB in almost two-thirds of patients. Factors limiting its therapeutic efficacy include severe left ventricular dysfunction, increased fluid balance, and long CPB time., (Copyright © 2018 Elsevier Inc. All rights reserved.)