André Y Denault

Montreal Heart Institute, Montréal, Quebec, Canada

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Publications (107)291.58 Total impact

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    ABSTRACT: Purpose of review: To review the recent insights in the evaluation and management of perioperative right heart failure (RHF). Recent findings: Recent studies highlight the potential role of myocardial deformation imaging in the evaluation of patients at risk of postoperative RHF. There is also a growing interest to study the value of load-adaptation indices of the right heart in the setting of pulmonary hypertension or left ventricular assist device implantation. Finally, the field of temporary extracorporeal life support devices for RHF is rapidly evolving and new strategies are emerging. Summary: An integrated approach for assessing the cardiopulmonary axis combining imaging, hemodynamic and tissue perfusion monitoring is emerging, as particularly helpful in the field. Several developments in the field of temporary right heart support including the pumpless interventional lung assist membrane ventilator are offering new opportunities to support the right-heart pulmonary circulation. Future multicenter studies are needed to develop more effective preventive and therapeutic strategies for RHF.
    No preview · Article · Dec 2015 · Current Opinion in Anaesthesiology
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    ABSTRACT: This study sought to determine whether a simple score combining indexes of right ventricular (RV) function and right atrial (RA) size would offer good discrimination of outcome in patients with pulmonary arterial hypertension (PAH). Identifying a simple score of outcome could simplify risk stratification of patients with PAH and potentially lead to improved tailored monitoring or therapy. We recruited patients from both Stanford University (derivation cohort) and VU University Medical Center (validation cohort). The composite endpoint for the study was death or lung transplantation. A Cox proportional hazard with bootstrap CI adjustment model was used to determine independent correlates of death or transplantation. A predictive score was developed using the beta coefficients of the multivariable models. For the derivation cohort (n = 95), the majority of patients were female (79%), average age was 43 ± 11 years, mean pulmonary arterial pressure was 54 ± 14 mm Hg, and pulmonary vascular resistance index was 25 ± 12 Wood units m(2). Over an average follow-up of 5 years, the composite endpoint occurred in 34 patients, including 26 deaths and 8 patients requiring lung transplant. On multivariable analysis, RV systolic dysfunction grade (hazard ratio [HR]: 3.4 per grade; 95% confidence interval [CI]: 2.0 to 7.8; p < 0.001), severe RA enlargement (HR: 3.0; 95% CI: 1.3 to 8.1; p = 0.009), and systemic blood pressure <110 mm Hg (HR: 3.3; 95% CI: 1.5 to 9.4; p < 0.001) were independently associated with outcome. A right heart (RH) score constructed on the basis of these 3 parameters compared favorably with the National Institutes of Health survival equation (0.88; 95% CI: 0.79 to 0.94 vs. 0.60; 95% CI: 0.49 to 0.71; p < 0.001) but was not statistically different than the REVEAL (Registry to Evaluate Early and Long-Term PAH Disease Management) score c-statistic of 0.80 (95% CI: 0.69 to 0.88) with p = 0.097. In the validation cohort (n = 87), the RH score remained the strongest independent correlate of outcome. In patients with prevalent PAH, a simple RH score may offer good discrimination of long-term outcome. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · May 2015 · JACC. Cardiovascular imaging
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    ABSTRACT: To assess if right ventricular (RV) dysfunction is associated with increased mortality after cardiac surgery. Post-hoc analysis of a single-center double-blind randomized controlled trial. University hospital. A total of 120 patients undergoing simple or complex valvular surgery. Patients were randomized to receive intravenous amiodarone or placebo intraoperatively. As secondary analysis, patients were divided into those requiring or not requiring postoperative inotropic agents. After cardiopulmonary bypass (CPB), there were significant increases in heart rate, cardiac index, systolic and mean arterial pressures, central venous pressure and pulmonary capillary wedge pressure with reduction in systemic vascular resistance (p<0.05). Right ventricular end-systolic area became larger in those without inotropes and tricuspid annular plane systolic excursion was reduced in all patients; mitral annular systolic velocities were higher in patients receiving inotropes. Both right- and left-sided Doppler signals were altered significantly after CPB, which may be attributed to increased filling pressure. Inotropic agents were required in 56 patients after CPB (47%). The use of inotropic agents was associated with increased left and right atrial velocities (p<0.05). There were no differences in postoperative complications between groups; however, the number of deaths at 6 years was increased in patients who received inotropes after CPB (p = 0.0247). The increases in right-sided dimensions after CPB are associated with reduction in RV function and increased biventricular filling pressure, suggesting worsening biventricular function and interventricular dependence. Inotropic medications were associated with unaltered RV dimensions and increased biatrial activity. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jan 2015 · Journal of Cardiothoracic and Vascular Anesthesia
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    ABSTRACT: To retrospectively evaluate the effects of combined inhaled prostacyclin and milrinone to reduce the severity of pulmonary hypertension when administered prior to cardiopulmonary bypass. Retrospective case control analysis of high-risk patients undergoing cardiac surgery. Single cardiac center. Sixty one adult cardiac surgical patients with pulmonary hypertension, 40 of whom received inhalation therapy. Inhaled milrinone and inhaled prostacyclin were administered before cardiopulmonary bypass (CPB). Administration of both inhaled prostacyclin and milrinone was associated with reductions in central venous pressure, and mean pulmonary artery pressure, increases in cardiac index, heart rate, and the mean arterial-to-mean pulmonary artery pressure ratio (p < 0.05), with no significant change in mean arterial pressure. The rate of difficult and complex separation from CPB was 51% in the inhaled group and 70% in the control group (p = 0.1638). Postoperative vasoactive requirement was reduced at 12 hours (35.9 v 73.7% p<0.01) and 24 hours (25.6 v 57.9% p<0.05) postoperatively in the combined inhaled agent group. Hospital length of stay and mortality were similar between the groups. Preemptive treatment of pulmonary hypertension with a combination of inhaled prostacyclin and milrinone before CPB was associated with a reduction in the severity of pulmonary hypertension. In addition, a significant reduction in vasoactive support in the intensive care unit during the first 24 hours after cardiac surgery was observed. The impact of this strategy on postoperative survival needs to be determined. Copyright © 2014 Elsevier Inc. All rights reserved.
    No preview · Article · Oct 2014 · Journal of Cardiothoracic and Vascular Anesthesia

  • No preview · Article · Oct 2014 · The Canadian journal of cardiology
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    ABSTRACT: Background: Amiodarone is commonly used in the acute care setting. However the acute hemodynamic and echocardiographic effect of intravenous amiodarone administered intraoperatively on right ventricular (RV) systolic and diastolic function using transesophageal echocardiography (TEE) has not been described. Methods: The study design was a randomized controlled trial in elective cardiac surgical patients undergoing valvular surgery. Patients received an intravenous loading dose of 300 mg of either amiodarone or placebo in the operating room, followed by an infusion of 15 mg/kg for two days. Hemodynamic profiles, echocardiographic measurement of RV and left ventricular (LV) dimensions, Doppler interrogation of tricuspid and mitral valve, hepatic and pulmonary venous flow combined with tissue Doppler imaging of the tricuspid and mitral valve annulus were obtained before and after bolus. Results: Although more patients in the placebo group had chronic obstructive lung disease (14 vs 6, p=0.05) and diabetes (14 vs 5; p=0.0244), there was no difference in terms of baseline hemodynamic, 2D and Doppler variables. After bolus, a significant increase in pulmonary artery pressure, central venous pressure and pulmonary vascular resistance index (p<0.05) was observed in the amiodarone group with reduction in systolic to diastolic (S/D) ratio of the hepatic (p=0.0247) and pulmonary venous (p=0.0052) velocity. Conclusion: Acute administration of amiodarone is associated with alteration in RV diastolic properties and has minimal negative inotropic effect on RV systolic function in cardiac surgical patients with valvular disease.
    No preview · Article · Sep 2014 · European Heart Journal: Acute Cardiovascular Care
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    ABSTRACT: An analytical assay using liquid-liquid extraction and high-performance liquid chromatography with ultraviolet detection was developed for the quantification of total (conjugated and unconjugated) urinary concentrations of milrinone after the inhalation of a 5 mg dose in 15 cardiac patients undergoing cardiopulmonary bypass. Urine samples (700 μL) were extracted with ethyl-acetate and subsequently underwent acid back-extraction before and after deconjugation by mild acid hydrolysis. Milrinone was separated on a strong cation exchange analytical column. The mobile phase consisted of a constant mixture of acetonitrile:tetrahydrofurane-NaH2 PO4 buffer (40:60 v/v, pH 3.0). Thirteen calibration curves were linear in the concentration range of 31.25-4000 ng/mL, using olprinone as the internal standard (r(2) range 0.9911-0.9999, n = 13). Mean milrinone recovery and accuracy were respectively 85.2 ± 3.1% and ≥93%. Intra- and inter-day precisions (coefficients of variation) were ≤5% and ≤8%, respectively. Over a 24 h collection period, the cumulative urinary milrinone recovered from 15 patients was 26.1 ± 7.7% of the nominal 5 mg dose administered. The relative amount of milrinone glucuronic acid conjugate was negligible in the urine of patients undergoing cardiopulmonary bypass This method proved to be reliable, specific and accurate to determine the cumulative amount of total milrinone recovered in urine after inhalation. Copyright © 2014 John Wiley & Sons, Ltd.
    No preview · Article · Aug 2014 · Biomedical Chromatography

  • No preview · Article · Jul 2014 · Transplantation
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    ABSTRACT: Objective: Whereas it is established that endothelin-1 elicits sustained deleterious effects on the cardiovascular system during cardiopulmonary bypass (CPB), presently it remains unknown whether the inhaled administration of the dual ETA and ETB antagonist tezosentan prevents the development of pulmonary endothelial dysfunction. Design: A prospective, randomized laboratory investigation. Setting: University research laboratory. Participants: Landrace swine. Interventions: Three groups of animals underwent a 90-minute period of full bypass followed by a 60-minute period of reperfusion. Among treated groups, one received tezosentan through inhalation prior to CPB, whereas the other one received it intravenously at weaning from CPB; the third group remained untreated. Pulmonary vascular reactivity studies, realized on a total of 285 rings, were performed in all groups, including 1 sham. Measurements and Main Results: The contractility of pulmonary arteries to prostaglandin F-2 alpha and to the thromboxane A(2) mimetic U46619 was preserved in animals submitted to CPB. By contrast, there were significant increases both in the maximal contraction to endothelin-1 and in the plasma levels of the peptide 60 minutes after reperfusion. Tezosentan administered by inhalation or intravenously did not prevent the development of pulmonary CPB-associated endothelial dysfunction. However, while hemodynamic disturbances were improved with both routes, the inhaled administration had a beneficial effect on oxygen parameters over intravenous administration. Conclusions: Despite the blockade of the endothelin-1 pathway with tezosentan, the development of the pulmonary endothelial dysfunction associated with CPB still occurred. However, only the inhalation route had a significant impact on gas exchange during CPB.
    No preview · Article · Jun 2014 · Journal of Cardiothoracic and Vascular Anesthesia
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    ABSTRACT: Milrinone administered through inhalation is an emerging method aimed at specifically reducing pulmonary hypertension without affecting systemic pressures. Its administration has been shown useful both in patients undergoing cardiac surgery and for persistent pulmonary hypertension of the newborn. These populations are prone to receive many concomitant medications and/or blood sampling may require a low volume quantification method. In order to address these issues in view of pharmacokinetic studies, this paper aims to develop and validate a specific and sensitive analytical assay using HPLC and MS/MS detection for the quantification of milrinone plasma concentrations after inhalation in patients undergoing cardiac surgery. Plasma samples (50 µL) were extracted using ethyl acetate. Milrinone was separated on a C18 analytical column at 50°C. The mobile phase consisted of methanol and 10 mM ammonium acetate (45:55 v/v). The electrospray was operated in the negative ionization mode and monitored the following mass transitions: m/z 212.1 → 140.0 at 36 eV for milrinone and m/z 252.1 → 156.1 at 32 eV for olprinone. Calibration curves followed a quadratic regression in the concentration range of 0.3125-640 ng/mL. The lower limit of quantification is 0.3125 ng/mL and is based on a low plasma volume of 50 µL. Mean drug recovery and accuracy were ≥ 72.3% and 96.0%, respectively. Intra- and inter-day precision (CV%) was ≤ 7.4 % and ≤ 11.5%, respectively. The specificity allowed milrinone quantification in the multidrug administration conditions of cardiopulmonary bypass. This validated micromethod proved to be highly sensitive and specific while using a low volume of plasma. Its low volume and its lower limit of quantification indicate that this approach is suitable for further characterisation of milrinone pharmacokinetics in both adults (inhalation) and neonates.
    No preview · Article · Mar 2014 · Therapeutic drug monitoring
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    André Y Denault

    Preview · Article · Jan 2014
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    ABSTRACT: The objective of this study was to determine the factors independently associated with septal curvature in patients with pulmonary arterial hypertension (PAH). Eighty-five consecutive patients with PAH who had an echocardiogram and a right heart catheterization within 24 hours of each others were included in the study. Septal curvature was assessed at the mid-papillary level using the eccentricity index (EI). Marked early systolic septal anterior motion was defined as a change in EI > 0.2 between end-diastole and early systole. Inter-ventricular mechanical delay was calculated as the percent time difference between right ventricular (RV) to left ventricular (LV) end-ejection time normalized for the RR interval. Average age was 45 ± 11 years and the majority of patients were women (75%). Mean right atrial pressure was 11 ± 7 mmHg, mean PAP was 52 ± 13 mmHg, relative RV area 1.8 ± 0.9, and RV fractional area change 24 ± 8%. End-diastolic EI was 1.6 ± 0.4 and systolic EI was 2.5 ± 0.8. On multivariate analysis relative pulmonary pressure, relative RV area, and inter-ventricular mechanical delay were independently associated with systolic EI (R(2) = 0.72, P < 0.001). Independent determinants of diastolic EI included relative RV area and mean PAP (R(2) = 0.69, P < 0.001). A systolic EI >1.08 differentiated patients with PAH from healthy controls with an AUC = 0.99. Patients with early systolic septal anterior motion (44% of subjects) had lower exercise capacity, more extensive ventricular remodeling, and worst ventricular function. Septal curvature is a useful marker of structural, hemodynamic, and electromechanical ventricular interdependence in PAH.
    No preview · Article · Dec 2013 · Echocardiography
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    ABSTRACT: To assess the usefulness of central venous pressure (CVP), diastolic right ventricular pressure, and pulmonary capillary wedge pressure (PCWP) waveform analysis in predicting fluid responsiveness. A prospective observational study. Tertiary care university hospital. Forty-four patients undergoing coronary artery bypass grafting. Analysis of the a/v wave ratio of the PCWP, CVP, and right ventricular dP/dt to predict an increase in stroke volume >15% after the administration of 500mL of colloid. Forty-four patients were enrolled in this study and 7 were excluded. There were 24 responders and 13 nonresponders. No differences in mean CVP and PCWP values between the responders and the nonresponders were found. The only parameter associated with a significant response to volume infusion was the ratio of the a/v waves of the PCWP tracing (p = 0.0001). The performance of the a/v wave ratio>1 of the PCWP tracing in predicting fluid responsiveness was evaluated by constructing a receiver operating characteristic curve. The area under the receiver operating characteristic curve was 0.89 (95% confidence interval, 0.79-0.99; p<0.05). The a/v ratio measured on the PCWP tracing is a predictor of fluid responsiveness in patients with preserved left ventricular function undergoing coronary artery bypass grafting.
    No preview · Article · Aug 2013 · Journal of cardiothoracic and vascular anesthesia
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    ABSTRACT: To determine the perioperative predictors of long-term mortality after aortic valve replacement (AVR). The authors hypothesized that perioperative variables are more important predictors of mortality than patient-prosthesis mismatch (PPM). A retrospective study of prospectively collected data. A tertiary care university hospital. One-hundred-ninety-nine adult patients who underwent AVR. After Research and Ethics Committee approval, the authors studied consecutive adult patients that underwent AVR in 1999 from the time of procedure to 5 years later. Demographic data, hemodynamic profile obtained after the induction of anesthesia, and perioperative data were analyzed. Primary endpoint was 5-year survival. Actuarial survival rate was 95.98%, 91.46%, and 81.91% at 30 days, 1 year, and 5 years, respectively. On univariate analysis, patients who died were significantly older (p<0.0001), had pulmonary hypertension (PHT), longer cardiopulmonary bypass (CPB) (p = 0.0001) and cross-clamping duration (p = 0.003), more frequent return to CPB (p = 0.036), or the use of an intra-aortic balloon pump to wean from CPB (p = 0.015). PPM was not related to 5-year mortality (p = 0.0649). Using Cox survival analysis, the only independent risk factors related to 5-year mortality after AVR were PHT using the mean arterial pressure-to-mean pulmonary artery pressure ratio (HR: 1.39, 95% CI 1.01-1.92, p = 0.0413) and the presence of complex separation from CPB (HR: 2.66, 95% CI 1.08-6.50, p = 0.0324). In patients undergoing AVR, 5-year survival was mostly related to the severity of PHT and intraoperative factors, mainly complexity of weaning from CPB.
    Full-text · Article · Aug 2013 · Journal of cardiothoracic and vascular anesthesia
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    ABSTRACT: Aims: To investigate the physiological correlates of indices of RV function in a model of chronic pressure overload. Methods and results: Chronic pulmonary hypertension (PH) was induced in piglets by ligation of the left pulmonary artery (PA) followed by weekly embolization of right lower lobe arteries for 5 weeks (the PH group, n = 11). These animals were compared with sham-operated animals (controls, n = 6). At 6 weeks, a subgroup of five PH pigs underwent surgical reperfusion of the left lung and four others were followed until 12 weeks without treatment. Right ventricular function was assessed using echocardiography and conductance catheter measurements. At 6 weeks, mean PA pressure was higher in PH group compared with controls (35 ± 9 vs. 14 ± 2 mmHg, P < 0.01). Although RV elastance (Ees) increased at 6 weeks in the PH group (0.55 ± 0.09 vs. 0.38 ± 0.05 mmHg/mL, P < 0.001), ventricular-arterial coupling measured by the ratio of Ees on PA elastance (Ea) was decreased (0.68 ± 0.17 vs. 1.18 ± 0.18, P < 0.001). There was a strong direct relationship between Ees/Ea and indices of RV function, while relationship between Ees and indices of RV function was moderate. Changes in indices of RV function with time and after left lung reperfusion were associated with changes in Ees/Ea. Conclusion: Usual indices of RV function are associated with ventricular-arterial coupling rather than with ventricular contractility in a model of chronic pressure overload.
    Preview · Article · May 2013 · European Heart Journal Cardiovascular Imaging
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    ABSTRACT: Objective: Overwhelming postsplenectomy infection progresses rapidly and shows unacceptably high mortality even when treated with optimal antibiotics. Recent reports have described beneficial effects of intravenous immunoglobulin in sepsis. However, the underlying mechanisms, especially the roles of the pathogen-specific antibody fraction in intravenous immunoglobulin, remain unclear. We investigated the effects of intravenous immunoglobulin on overwhelming postsplenectomy infection and the role of pathogen-specific antibody. Design: Prospective, controlled, and randomized animal study. Setting: University laboratory. Subjects: Male C57BL/6JJcl mice. Interventions: Mice underwent splenectomy or a sham operation at 8 weeks old. At 4 weeks after the operation, mice were injected intravenously with 106 colony-forming units pneumococcus. Intraperitoneal injection of 300 mg/kg IV immunoglobulins was conducted simultaneously with infection. Specific antibody–depleted IV immunoglobulin prepared using immunoprecipitation was also injected into the animals. Measurements and Main Results: IV immunoglobulin markedly improved splenectomized mice survival. Removal of pneumococcus-specific antibody canceled it completely. Fluorescence microscopy results indicated significantly increased phagocytosis of antibody-bound bacteria in the livers of splenectomized mice treated with intact IV immunoglobulins. Immunomodulation, including suppression of marginal zone B-cell activation, was induced by IV immunoglobulin. Conclusions: IV immunoglobulin showed a significantly protective effect on overwhelming postsplenectomy infection via enhancement of specific antibody–mediated phagocytosis in the liver. Specific antibody, more than immunological modulation, is crucial for effects of IV immunoglobulin on overwhelming postsplenectomy infection.
    No preview · Article · May 2013 · Critical care medicine

  • No preview · Article · Apr 2013 · Journal of cardiothoracic and vascular anesthesia
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    ABSTRACT: Pulmonary vascular resistance (PVR) and pulmonary arterial compliance (PAC) are important determinants of right ventricular (RV) afterload. We compared the relationship between PVR and PAC and indices of systolic and diastolic RV function in PAH.Methods and MaterialsWe conducted a retrospective cohort study of adult patients with a diagnosis of PAH who underwent right heart catheterization and echocardiography within 24 hours between January 2000 and December 2010. RV function was assessed using indexed stroke volume, RV fractional area change (RVFAC), tricuspid annular systolic excursion, RV myocardial performance index, and RV myocardial isovolumetric acceleration and right atrial pressure. Regression analysis was performed to determine the association between PVR and PAC with several indices of systolic and diastolic function and Cox proportional hazard model was used to determine independent correlates of death or transplantation.ResultsA total of 85 patients with PAH were included. Average age was 45±11years and 75% were female. Mean pulmonary arterial pressure averaged 52±14 mmHg, indexed PVR was 13±7 WU and indexed PAC was 1.1±0.7 mL/ mmHg. A strong inverse relationship was observed between PAC and PVR (R2=0.84, p<0.001). A moderate association between PVR and PAC with indices of systolic function was found (r=-0.65, p<0.001 and r=0.73, p<0.001 for RVFAC), while a weaker association was observed with diastolic parameters (r=0.23, p=0.03 and r=−0.33, p=0.002 for right atrial pressure and indexed right atrial area respectively). On Cox proportional hazard regression, indices of RV size and function were strongly related. In contrast, PVR or PAC did not significantly relate to outcome.Conclusions In patients with PAH, resistance and compliance are inversely related and are moderately associated with indices of RV function. Indices of RV function and remodeling are more strongly associated with outcome than PAC or PVR.
    No preview · Article · Apr 2013 · The Journal of Heart and Lung Transplantation
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    ABSTRACT: OBJECTIVE: To evaluate the efficacy of tezosentan in reducing the incidence of right ventricular (RV) failure and associated mortality in patients with pre-existing pulmonary hypertension. The primary endpoint was the proportion of patients with RV failure during weaning from cardiopulmonary bypass (CPB), assessed 30 min after the end of CPB. DESIGN: Multicenter, double-blind, randomized, placebo-controlled trial. SETTING: Thirty-one cardiac surgical centers in 14 countries. PARTICIPANTS: Two hundred seventy-four patients with pulmonary hypertension aged≥18 years scheduled to undergo cardiac surgery. INTERVENTION: Intravenous tezosentan (5 mg/h) during surgery and up to 24 hours afterwards (1 mg/h), or matched placebo. MEASUREMENTS AND MAIN RESULTS: One-hundred and thirty-three patients received tezosentan and 141 placebo. RV failure occurred in 30 patients (10.9%), 37% of whom died. There was no difference in the incidence of RV failure between the two treatment groups (relative risk reduction: 0.07 [95% CI-0.83, 0.53; p = 0.8278]). CONCLUSION: A reduction in RV failure with tezosentan was not observed in this study.(Current Controlled Trials, identifier NCT00458276).
    No preview · Article · Mar 2013 · Journal of cardiothoracic and vascular anesthesia
  • André Yvan Denault · Francois Haddad · Eric Jacobsohn · Alain Deschamps
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    ABSTRACT: Purpose of review: To evaluate new information on the importance of right ventricular function, diagnosis and management in cardiac surgical patients. Recent findings: There is growing evidence that right ventricular function is a key determinant in survival in cardiac surgery, particularly in patients with pulmonary hypertension. The diagnosis of this condition is helped by the use of specific hemodynamic parameters and echocardiography. In that regard, international consensus guidelines on the echocardiographic assessment of right ventricular function have been recently published. New monitoring modalities in cardiac surgery such as regional near-infrared spectroscopy can also assist management. Management of right ventricular failure will be influenced by the presence or absence of myocardial ischemia and left ventricular dysfunction. The differential diagnosis and management will be facilitated using a systematic approach. Summary: The use of right ventricular pressure monitoring and the publications of guidelines for the echocardiographic assessment of right ventricular anatomy and function allow the early identification of right ventricular failure. The treatment success will be associated by optimization of the hemodynamic, echocardiographic and near-infrared spectroscopy parameters.
    No preview · Article · Dec 2012 · Current opinion in anaesthesiology

Publication Stats

1k Citations
291.58 Total Impact Points

Institutions

  • 1999-2015
    • Montreal Heart Institute
      • Department of Anesthesiology
      Montréal, Quebec, Canada
  • 1997-2014
    • Université de Montréal
      • • Department of Anesthesiology
      • • Faculty of Pharmacy
      Montréal, Quebec, Canada
  • 2011-2013
    • Stanford University
      • Department of Medicine
      Stanford, California, United States
  • 2012
    • University of Manitoba
      • Department of Anesthesia and Perioperative Medicine
      Winnipeg, Manitoba, Canada
  • 2002
    • Centre hospitalier de l'Université de Montréal (CHUM)
      Montréal, Quebec, Canada