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Article of the Month – March 2021

Perioperative Course of Three-Dimensional–Derived Right Ventricular Strain in Coronary Artery Bypass Surgery: A Prospective, Observational, Pilot Trial

URL: https://www.jcvaonline.com/article/S1053-0770(21)00061-6/fulltext

Doi: https://doi.org/10.1053/j.jvca.2021.01.026

Published: Journal of Cardiothoracic and Vascular Anesthesia

Authors: J. Labus, J. Winata, T. Schmidt, J. Nicolai, M. Tomko, K. Sveric, M. Wilbring, J. Fassl

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Article Description:

  • The two-dimensional (2D) echocardiographic assessment of the right ventricle’s complex geometry (RV) is limited with incomplete imaging of the complex crescent-shaped RV, angle dependency of Doppler and M-mode techniques, and reduction of longitudinal performance of the RV after cardiac surgery.
  • Three-dimensional derived RV strain (3D-RV strain) analysis is independent of geometric assumptions might offer potential advantages during the perioperative period.
  • This is a prospective observational pilot study aimed to compare the perioperative changes in the preoperative TTE values of 3D-RV free wall strain (FWS) in awake patients with intraoperative TEE values of 3D-RV FWS in anaesthetized patients and with postoperative TTE values assessed before hospital discharge following coronary artery bypass graft (CABG) surgery,


  • The authors included 40 adult patients undergoing CABG with preserved left and right ventricular ejection fractions without significant valvular heart diseases or pulmonary hypertension.
  • All echocardiographic measurements were without any significant influence of pacing, inotropic or vasopressor support or loading conditions.
  • Real-time 3D full-volume datasets were acquired from an apical four-chamber view with centred RV apex for TTE and a mid-oesophagal RV-focused four-chamber view TEE.
  • The investigators evaluated the 3D-RV FWS, the RV ejection fraction (EF), tricuspid annular systolic excursion (TAPSE), and RV fractional area change (FAC) preoperatively, before and after sternotomy, and postoperative before hospital discharge.
  • There were no significant differences between preoperative TTE and intraoperative TEE measurements for 3D-RV FWS (-22.35 [IQR -17.70 to -27.22] vs -24.35 [IQR -20.63 to -29.88]; not significant), nor in the values of TAPSE and RV FAC.
  • The bland-Altman analysis showed non-significant bias between the TTE and TEE measurements for 3D-RV FWS preoperatively and following anaesthesia induction.
  • Although 3D-RV FWS remained unchanged after sternotomy, it deteriorated significantly after CABG (preoperatively vs. postoperative before hospital discharge: -22.35 [IQR -17.70 to -27.22] v -18.5 [IQR -16.90 to -21.65]; p = 0.004).
  • By contrast, the RV FAC did not change along with other RV parameters in the postoperative period.
  • The authors acknowledge several limitations to the study: (1) The study included few patients. (2) the software used to calculate 3D-RV FWS was not incorporated on the echocardiography machines, and, therefore, the analysis was only available offline. (3) The intra-observer or interobserver variability was not calculated.


  • The authors concluded that the values for 3D-RV FWS did not differ significantly between awake, spontaneously breathing patients measured with TTE and anaesthetized patients under positive-pressure ventilation assessed with TEE. Further trials are needed to determine whether postoperative deterioration of 3D-RV FWS is associated with patient outcome.

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