High thoracic epidural analgesia improves left ventricular function in patients with ischemic heart
ABSTRACT In patients with ischemic heart disease, high thoracic epidural analgesia (HTEA) has been proposed to improve myocardial function. Tissue Doppler Imaging (TDI) is a tool for quantitative determination of myocardial systolic and diastolic velocities and a derivative of TDI is tissue tracking (TT), which allows quantitative assessment of myocardial systolic longitudinal displacement during systole. The purpose of this study was to evaluate the effect of thoracic epidural analgesia on left ventricular (LV) systolic and diastolic function by means of two-dimensional (2D) echocardiography and TDI in patients with ischemic heart disease.
The effect of a high epidural block (at least Th1-Th5) on myocardial function in patients (N=15) with ischemic heart disease was evaluated. Simpson's 2D volumetric method was used to quantify LV volume and ejection fraction. Systolic longitudinal displacement was assessed by the TT score index and the diastolic function was evaluated from changes in early (E'') and atrial (A'') peak velocities during diastole.
After HTEA, 2D measures of left ventricle function improved significantly together with the mean TT score index [from 5.87 +/- 1.53 to 6.86 +/- 1.38 (P<0.0003)], reflecting an increase in LV global systolic function and longitudinal systolic displacement. The E''/A'' ratio increased from 0.75 +/- 0.27 to 1.09 +/- 0.32 (P=0.0026), indicating improved relaxation.
A 2D-echocardiography in combination with TDI indicates both improved systolic and diastolic function after HTEA in patients with ischemic heart disease.
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ABSTRACT: Objective To evaluate the effect of high thoracic epidural analgesia (HTEA) in congestive heart failure (CHF). Design Rat model of CHF. Setting Harbin Medical University, Harbin, Heilongjiang, China. Participants One hundred thirty-five rats. Interventions HTEA involved 5 times daily injections of 0.1% lidocaine at the T3-T4 level. Measurements and Main Results The authors examined myocardial norepinephrine (NE), angiotensin II (Ang II), endothelin-1 (ET1), and tumor necrosis factor-α (TNF-α) concentrations 2, 4, and 6 weeks after the start of HTEA. They also examined histologic changes in heart tissue and myocardial expression of apoptosis-inducing factor (AIF) and poly (ADP-ribose) polymerase (PARP). Sham rats were used as a control. In the time course, myocardial NE, Ang II, ET1, and TNF-α concentrations were significantly higher in the CHF group compared with the HTEA and sham groups (p< 0.05). Similarly, PARP and AIF protein expression levels were significantly higher in the CHF group compared with the HTEA and sham groups (p< 0.05). Microscopy revealed pronounced damage to myocardial cell structures in the CHF group; this damage clearly was reduced in the HTEA group. In addition, cardiac function evaluation indicated treatment with HTEA resulted in similar heart function as animals that did not have surgically induced CHF. Conclusions The findings suggest that HTEA induces changes in sympathetic nervous system, renin-angiotensin system, endothelial, and inflammatory process activity involved in CHF.Journal of Cardiothoracic and Vascular Anesthesia 04/2014; 28(2):317–322. DOI:10.1053/j.jvca.2013.05.017 · 1.48 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the addition of high thoracic epidural analgesia (HTEA) to general anesthesia in cardiac surgery patients to enhance the fast-track and improvement in outcome. Retrospective cohort study of prospectively registered data using population-based healthcare databases. One thousand seven hundred thirteen consecutive patients scheduled for elective coronary artery bypass grafting, aortic valve replacement, mitral valve surgery, and combinations eligible for supplementation with epidural analgesia. One thousand sixteen patients were matched and analyzed. University hospital, single center. To minimize bias and confounding, epidural patients were matched using EuroSCORE criteria to nonepidural in a 1:1 ratio requiring exact match on sex, age, patient factors, cardiac factors, and procedure type together with normal/moderate/poor left ventricular function, insulin-dependent diabetes, and on-pump/off-pump surgery. All together, 1,016 patients (508 each group) were identified with matching criteria. Outcome parameters were 30-day and 6-month mortality, postoperative dialysis, stroke, and myocardial infarction. Univariate analysis showed that epidural analgesia was associated with lower 6-month mortality (p = 0.021), lower frequency of postoperative dialysis (p = 0.029), and lower frequency of myocardial infarction (p = 0.049). No difference was seen in stroke (p = 0.341). However, adjusted odds ratio of selected perioperative variables showed that HTEA only had a positive impact on the frequency of postoperative dialysis (0.22 [0.06-0.74]). This large, uniquely matched single-center cohort was generated, and, subject to the listed limitations the authors concluded that supplemental HTEA to general anesthesia had a better outcome in low-risk cardiac surgery patients, with a significantly lower 6-month mortality rate compared with the control group. However, regression analysis revealed that HTEA only had an independently positive effect on the frequency of postoperative dialysis.Journal of cardiothoracic and vascular anesthesia 07/2013; DOI:10.1053/j.jvca.2012.12.001 · 1.48 Impact Factor
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ABSTRACT: Approach of the epidural space is different at the thoracic level due to a more acute angle of spinous processes that varies from 25° to 45° from T4 to T10. Thoracic epidural volume is less important. Epidural pressure is more negative at the level of upper segments. Thoracic epidural space can be identified by the hanging drop technique or by loss of resistance to saline. The haemodynamic consequences of a thoracic block (bradycardia, hypotension, decrease of left ventricle inotropism) are mild when the extension of the block is limited; a more extended block related to lower thoracic segments injections may induce splanchnic block and venous blood sequestration. Thoracic epidural anaesthesia improves myocardial oxygen balance in patients with myocardial ischaemia. Local anaesthetic administration into the thoracic epidural space improves postoperative respiratory mechanical dysfunction and shortens the duration of postoperative ileus. Continuous administration of a local anaesthetic combined with a lipid soluble opioid guarantees a good quality analgesia.Le Praticien en Anesthésie Réanimation 11/2009; 13(5). DOI:10.1016/j.pratan.2009.09.003