Background: Because the abdominal insufflation and desufflation associated with laparoscopic procedures may adversely effect a compromised myocardium, patients with significant cardiopulmonary disease should be closely monitored during these procedures. The utility of intraoperative pulmonary artery catheter (PAC) and transesophageal echocardiography (TEE) monitoring was studied in 10 patients with moderate to severe cardiopulmonary disease to identify patients at greatest risk for cardiovascular complications during laparoscopic cholecystectomy.
Methods: Ten patients were enrolled in this prospective study; 7 had suffered a previous myocardial infarction, 6 had undergone coronary artery bypass grafting, and 9 had disease classified as Goldman's class II or greater. The heart was monitored by TEE throughout the laparoscopic cholecystectomy by using real-time, two-dimensional mode to study the wall thickness and motion. Several PAC measurements were taken directly: cardiac output, systemic vascular resistance, pulmonary artery wedge pressure, and central venous pressure. Heart rate and blood pressure were also obtained at corresponding intervals. Cardiac index, stroke volume, and left and right ventricular stroke work were then calculated.
Results: TEE demonstrated no significant changes in ventricular wall motion throughout laparoscopy. In patients who had postoperative cardiovascular complications, significant changes in cardiac index, left ventricular stroke work, and stroke volume were seen after pneumoperitoneum release. Compared to that of patients who did not develop complications, the cardiac index in those with complications dropped 42% (3.10 +/- 0.72 versus 1.80 +/- 0.10 L/min per m2, respectively; P < 0.01); left ventricular stroke work dropped 64% (139.00 +/- 11.36 versus 50.38 +/- 10.55 g x min/beat, respectively; P < 0.01); and stroke volume dropped 51% (86.90 +/- 12.68 versus 42.50 +/- 5.08 mL/beat, respectively; P < 0.01).
Conclusions: PCA monitoring in patients with compromised cardiac function is useful in identifying patients who may not tolerate hemodynamic changes after pneumoperitoneum release. Normalization of hemodynamic changes secondary to abdominal insufflation and desufflation in patients with compromised hearts may not occur in patients with compromised hearts may not occur for hours postoperatively. Abnormal hemodynamic changes occur within the first hour after desufflation in patients who later develop cardiovascular complications, which are heralded by significant drops in left ventricular stroke work, cardiac index, and stroke volume. TEE did not prove to be useful for intraoperative monitoring.