Unraveling main perioperative management principles for patients with diastolic dysfunction

Full article

https://doi.org/10.53453/ms.2024.3.8

Unraveling main perioperative management principles for patients

with diastolic dysfunction

Gabrielė Žūkaitė

, Asta Mačiulienė

Lithuanian University of Health Sciences, Academy of Medicine, Faculty of Medicine, Kaunas, Lithuania

Lithuanian University of Health Sciences, Academy of Medicine, Anesthesiology clinic, Kaunas, Lithuania

Abstract

Background. The assessment of diastolic function is often overshadowed by the evaluation of significant valve

anomalies and systolic function, which is determined by ejection fraction. To accurately predict a surgical

procedure's outcome, it is beneficial to consider the diastolic evaluation findings alongside the conventional

perioperative risk assessment.

Aim. This article aims to provide a thorough summary of the diagnostic methods, treatment options, and how the

perioperative pathway can be optimized for patients with diastolic dysfunction (DD).

Methods. The literature used for this review was selected using “Elsevier”, “Pubmed”, and “UptoDate” databases.

The search used the following keywords and their combinations: diastolic dysfunction perioperatively, diastolic

heart failure, diastolic dysfunction and anaesthesia, perioperative hypertension, and diastolic dysfunction ESC.

Results. Echocardiography is a crucial diagnostic tool for assessing DD, providing detailed information about the

structure and function of the heart. Talking about the choice of anesthetic technique, sevoflurane better preserves

diastolic relaxation during spontaneous ventilation than propofol and isoflurane has no adverse lusitropic effects

and do not exacerbate preexisting DD. Several studies have demonstrated that reducing afterload, isoflurane,

sevoflurane, and desflurane can enhance left ventricular relaxation. Moreover, adequate blood pressure, heart rate,

rhythm, fluid status, and avoidance of noticeable variations in hemodynamics and volume are the cornerstones of

the perioperative care of DD.

Conclusion. Anesthesia plans should be individualized to minimize the potential impact on diastolic function and

maintain optimal hemodynamic stability. Close monitoring and vigilant management of fluid balance, heart rate,

and blood pressure are paramount intraoperatively.

Keywords: diastolic heart failure, diastolic dysfunction, anaesthesia, diastolic dysfunction perioperatively.

Journal of Medical Sciences. 11 Mar, 2024 - Volume 12 | Issue 2. Electronic - ISSN: 2345-0592

Medical Sciences 2024 Vol. 12 (2), p. 70-77, https://doi.org/10.53453/ms.2024.3.8

1. Introduction

The foundation of anesthesiology practice is

preoperative cardiac assessment. Despite its

importance, the assessment of diastolic function is

often overshadowed by the evaluation of significant

valve anomalies and systolic function, which is

determined by ejection fraction. 21% of the

population exhibits asymptomatic mild left ventricle

diastolic dysfunction, while 7% have moderate or

severe diastolic dysfunction. Identifying patients at

risk for diastolic dysfunction can prevent increased

risk for perioperative morbidity and mortality.

Hence, to accurately predict a surgical procedure's

outcome, it is beneficial to consider the diastolic

evaluation findings alongside the conventional

perioperative risk assessment. It is obligatory to

control hypertension, avoid tachycardia and

myocardial ischemia, preserve sinus rhythm and

normovolemia, and keep the heart rate below

diastolic blood pressure. This article aims to provide

a thorough summary of the diagnostic methods,

treatment options, and how the perioperative

pathway can be optimized for patients with diastolic

dysfunction.

2. Methods

The literature used for this review was selected using

“Elsevier”, “Pubmed”, and “UptoDate” databases.

The search used the following keywords and their

combinations: diastolic dysfunction perioperatively,

diastolic heart failure, diastolic dysfunction,

anaesthesia, perioperative hypertension, and

diastolic dysfunction ESC. Inclusion criteria: 1) full-

text articles; 2) the article analyzes diastolic

dysfunction etiology, pathogenesis, clinical

symptoms, diagnostics, treatment and links with

perioperative care or anaesthesia; 3) articles in

English. Criteria for rejecting articles: 1) the article

is not related to diastolic dysfunction and

perioperative care or anesthesia; 2) the article was

published earlier than 2006. The selected

publications were written in English and published

in 2006 - 2023 years. The majority of the articles

were published in the last 10 years. This literature

review included 33 articles published in peer-

reviewed journals that met the inclusion and

exclusion criteria.

3. Results

3.1 Ethiology

DD refers to an impairment in the relaxation phase

of the heart's cardiac cycle, specifically during

diastole when the heart is filling with blood [1]. One

primary contributor is hypertension, as sustained

high blood pressure can lead to structural changes in

the heart muscle, making it less compliant and

impairing its ability to relax [2]. Other cardio-

vascular factors include myocardial ischemia, where

inadequate blood supply compromises heart muscle

function [3]. Additionally, conditions such as

hypertrophic cardiomyopathy and restrictive

cardiomyopathy, characterized by abnormal

thickening or stiffening of the heart walls, can

contribute to DD [4]. Non-cardiovascular causes

may include diabetes, obesity, and ageing, all of

which can affect the elasticity and function of the

heart muscle. Some authors report that

approximately 34 % of diabetic patients experience

DD [5].

3.2 Diastolic dysfunction and atrial fibrillation

DD can significantly influence the development and

progression of atrial fibrillation (AF), a common and

potentially severe cardiac arrhythmia [6]. As the

impaired relaxation of the heart during diastole

occurs, there is an elevated pressure within the left

atrium, leading to increased strain on the atrial walls

[7]. This persistent pressure overload can contribute

to atrial structural remodeling, promoting fibrosis

and hypertrophy. DD is particularly relevant in the

Journal of Medical Sciences. 11 Mar, 2024 - Volume 12 | Issue 2. Electronic - ISSN: 2345-0592

context of AF, as it often results in elevated left

ventricular filling pressures and atrial dilation, both

of which are known triggers for arrhythmia [8].

Moreover, the altered hemodynamics associated

with DD can lead to abnormal atrial stretch,

triggering electrical abnormalities in the atrial tissue

[6,8]. The combination of impaired relaxation

during diastole and irregular heart rhythm in AF can

reduce cardiac output. As the heart struggles to fill

and pump blood efficiently, the body may

experience inadequate perfusion, contributing to

symptoms of diastolic heart failure [9–11]. The

presence of exercise intolerance, exertional dyspnea,

and pulmonary edema with average ejection

fraction, alongside symptoms and signs resembling

chronic obstructive pulmonary disease, may suggest

the company of diastolic heart failure which is a

symptomatic form of DD [12,13]. This hypothesis

can be further supported by echocardiographic or

angiographic data (table 1).

Table 1. Criteria for diastolic heart failure. All three measures are required for the diagnosis of diastolic heart

failure [9].

Criteria for diastolic heart failure

1. Signs and symptoms of congestive heart failure

Pulmonary edema, effort dyspnea, orthopnea

2. Normal or mildly reduced ejection fraction

Ejection fraction >50 %, normal left ventricle

end diastolic volume

3. Abnormal left ventricle relaxation; echocardiographic tissue Doppler (E/E’ >15); left ventricular end-

diastolic pressure >16 mmHg on cardiac catheterization; Biomarkers NT-proBNP >220 pg/ml or BNP

>200 pg/ml.

NT-proBNP: N-terminal pro-B-type Natriuretic Peptide, BNP: brain natriuretic peptide (B-type Natriuretic

Peptide)

3.3 Grading diastolic dysfunction

DD is often graded based on the severity of

impairment in the relaxation and filling of the heart

during diastole. During the initial phase (Grade I),

there is a reduction in early filling and an early

transmitral pressure gradient due to decreased left

ventricular relaxation, frequently resulting from

hypertrophy [4,14]. Another stage often involves

increased left atrial pressure due to delayed or

incomplete relaxation to compensate for the usual

stroke volume. The left atrium remodels to restore

the pressure gradient and fill against the abnormal

left ventricular end-diastolic pressure (Grade II) [4].

The term "pseudonormal" refers to a condition in

which left atrial pressure increases and early

diastolic filling becomes prominent again. In

echocardiography, this diastolic filling seems

identical to normal diastolic function [15].

Nevertheless, when the compliance of the left

ventricle decreases even more, the initial filling of

the left ventricle can only occur when there is an

extremely high-pressure gradient across the

transmitral valve [16,17]. However, this filling

quickly ceases as the pressures in the two chambers

become equal. Consequently, a restrictive diastolic

filling pattern emerges, which can be classified as

grade III or IV depending on whether the restricted

filling can be reversed by reducing preload (such as

during the Valsalva maneuver). It is important to

note that an irreversible restrictive DD is associated

with a significantly unfavorable prognosis in terms

of mortality [4].

3.4 Central venous and pulmonary artery

catheters

Some authors recommend a central venous catheter

for vasopressors, inotropes, and other drugs that

Journal of Medical Sciences. 11 Mar, 2024 - Volume 12 | Issue 2. Electronic - ISSN: 2345-0592

cannot be given peripherally [18–20]. However,

others believe that using a central venous catheter

carries some risk, fluid responsiveness is difficult to

predict and is not very beneficial for perioperative

care of individuals with DD [18–20].

There is still much disagreement in the literature on

the utility of a pulmonary artery catheter as a

monitoring tool. Using a pulmonary artery catheter

is sometimes criticized for not changing patient

outcomes. Also, it is frequently utilized as a salvage

or rescue therapy [21]. Other authors believe a

pulmonary artery catheter may be justified

perioperatively under the right circumstances,

especially in individuals with severe DD [9]. A

pulmonary artery catheter enables the evaluation of

volume responsiveness through sequential assess-

ments of cardiac output following an intervention.

This valuable tool equips the attending physician

with essential data to aid in selecting appropriate

inotropes and vasopressors [22]. However, the

literature also describes the misinterpretation of data

associated with using pulmonary artery catheters.

Consequently, if one lacks proficiency in the

placement, utilization, and interpretation of such

catheters, it is advisable to refrain from their use

[18].

3.4.1 Echocardiography

Echocardiography is a crucial diagnostic tool for

assessing DD, providing detailed information about

the structure and function of the heart during the

relaxation and filling phases of the cardiac cycle

[16].

By evaluating the chamber pressure–volume

relationship, invasive cardiac catheterization is the

gold standard for defining DD. Nonetheless,

echocardiography has mostly replaced cardiac

catheterisation as the preferred method for quickly

detecting DD due to its non-invasiveness and

accessibility in the hospital [23]. Echocardiographic

assessment begins by evaluating the overall

morphology of the left atrium and left ventricle. This

evaluation is most effectively conducted using the

mid esophageal 4-chamber view in transesophageal

echocardiography or the apical 4-chamber view in

transthoracic echocardiography [17]. Left atrial

dilation may indicate remodelling caused by

elevated pressure within the left atrium, whereas left

ventricle hypertrophy may indicate reduced

compliance of the left ventricle [7,24]. Long-term

hypertension is one of the leading causes of DD, and

between 50 and 66 % of patients will have thicker

walls. The four most often applied methods are

colour M-mode propagation velocity, Doppler tissue

imaging of the mitral annulus, transmitral inflow,

and pulmonary venous inflow [25].

In critically ill patients, echocardiography surpasses

measurements obtained from a pulmonary artery

catheter as a means for assessing volume

responsiveness [21]. By examining mitral inflow

patterns and utilizing 2-dimensional measurements

of the left ventricular end-diastolic area,

echocardiography can accurately predict changes in

cardiac output. Before surgery, a transthoracic

echocardiography (TTE) evaluation can be

performed [26]. However, the utility of

transesophageal echocardiography (TEE) during

intraoperative procedures may be limited, especially

in cases involving significant volume shifts within

the chest or abdominal cavity, which can make TTE

challenging [13]. In such instances, TEE may be the

preferred modality. Not only does TEE assist in

guiding volume administration and addressing the

common clinical questions of whether more volume

is needed or if enough has been given, but it also

enables real-time assessment of diastolic function by

monitoring dynamic changes in pre-load and after-

load [17,27]. Therefore, it is recommended to use

TEE in complex cases with severe diseases and

when substantial volume shifts are expected [23,25].

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3.4.2 Choice of anesthetic technique

The potential benefits of avoiding general anesthesia

and using neuraxial or regional anesthetic

techniques in patients with DD are still uncertain due

to the lack of literature supporting any specific

recommendations [9,26].

T. Ryu et al. claim that spinal anesthesia is less

favorable than epidural anesthesia. Epidural anes-

thesia induces slower hemodynamic changes due to

its gradual onset and the gradual reduction of

sympathetic tone [9,26]. Furthermore, patients with

DD may have additional medical conditions such as

coronary artery disease or AF, which may necessi-

tate systemic anticoagulation [6,24]. In such cases,

it is crucial for clinicians to thoroughly review the

patient's medications and determine whether any

should be discontinued to avoid vertebral canal

haematoma [28].

Patients with poor functional capacity are at a higher

risk when undergoing general anesthesia [14]. It is

advisable to opt for intravenous induction and main-

tenance using a combination of balanced anesthesia

with volatile agents and opioids [9,29]. The impact

of inhaled anesthetics on left ventricular compliance

and relaxation has been the subject of several

investigations. Using Doppler echocardiography in

individuals with established DD, one study disco-

vered that sevoflurane administration significantly

enhanced early left ventricular relaxation (measured

by E' velocity) [13]. Also, sevoflurane better

preserves diastolic relaxation during spontaneous

ventilation than propofol [9]. Neuhauser et al.

showed that isoflurane had no adverse lusitropic

effects and did not exacerbate preexisting DD [30].

Several studies have demonstrated that reducing

afterload, isoflurane, sevoflurane, and desflurane

can enhance left ventricular relaxation [4].

3.4.3 Treatment

No significant multicenter randomized controlled

study has been conducted to analyze the

perioperative DD management particularly.

American Heart Association guidelines suggest

taking care of patients with DD by lowering

pulmonary venous pressure, sustaining synchronous

atrial contraction and extending diastole time by

heart rate regulation [31]. Reducing diastolic

volume and diastolic pressure can be accomplished

by lowering central blood volume with nitrates,

restricting fluid and sodium intake or using diuretics,

and downregulating the renin-angiotensin-aldos-

terone system with angiotensin-converting enzyme

inhibitors or angiotensin receptor blockers [32].

The systolic blood pressure should remain within

10-20 % of the baseline value, while the pulse

pressure should be kept below the diastolic blood

pressure. The combination of low doses of

nitroglycerin and phenylephrine titration could be

helpful for pulse pressure control, but the presence

of either agent individually can potentially worsen

hemodynamics [9].

Two crucial aspects of acute perioperative treatment

for individuals with DD are the avoidance of

tachycardia and the preservation of sinus rhythm.

Tachycardia shortens the coronary perfusion time

and raises myocardial oxygen demand. Also,

tachycardia preferentially reduces diastole in the

cardiac cycle, which can result in a decline in left

ventricle filling, stroke volume, and cardiac output

[2,13,33]. Regarding reducing heart rate, rate

control medications like beta and calcium channel

blockers are great options. They may be helpful for

both acute and long-term treatment [14,26]. Atrial

arrhythmias such as AF have a noticeable impact on

hemodynamic stability as these patients frequently

have poor passive filling and primarily depend on

atrial contraction for cardiac output.

Anesthesiologists must act fast to identify this and

consider the early use of cardioversion to restore

sinus rhythm compared to patients without DD

[12,14].

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In the postoperative period, hypoxemia, pulmonary

edema, and AF are the most common complications

due to decompensation. These events can happen

very fast, even for patients who seem to be stable,

therefore careful monitoring is essential. Also, it is

crucial to avoid perioperative risk factors that can

lead from DD to diastolic heart failure: shivering,

anemia, hypoxia, electrolytic imbalance,

deterioration in DD, myocardial ischemia,

hypovolemia or hypervolemia (extreme volume

shifting), tachycardia, rhythms other than sinus,

postoperative sympathetic stimulation and

hypertensive crisis [9].

In conclusion, adequate blood pressure, heart rate,

rhythm, fluid status, and avoidance of noticeable

variations in hemodynamics and volume are the

cornerstones of the perioperative care of DD [9].

4. Conclusions

Anesthesiologists in perioperative settings may face

significant clinical difficulties because of the

complicated and growing issue of DD. As explored

throughout this article, DD presents unique

challenges and considerations for anesthesiologists

when caring for patients undergoing surgical

procedures or medical interventions. Careful

preoperative assessment is essential, including a

thorough understanding of the patient's medical

history, echocardiographic findings, and overall

cardiovascular status. Anesthesia plans should be

individualized to minimize the potential impact on

diastolic function and maintain optimal

hemodynamic stability. Echocardiography can be a

beneficial tool in determining the degree of

dysfunction and volume status, which can influence

clinical decision-making. Close monitoring and

vigilant management of fluid balance, heart rate, and

blood pressure are paramount intraoperatively.

Techniques such as goal-directed fluid therapy and

advanced monitoring tools can aid in achieving and

maintaining hemodynamic goals while avoiding

exacerbation of DD.

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Unraveling main perioperative management principles for patients with diastolic dysfunction