BENEFITS OF PULMONARY-ARTERY CATHETER AND TRANSESOPHAGEAL ECHOCARDIOGRAPHIC MONITORING IN LAPAROSCOPIC CHOLECYSTECTOMY PATIENTS WITH CARDIAC DISEASE

BACKGROUND: Because the abdominal insufflation and desufflation associ ated with laparoscopic procedures may adversely effect a compromised m yocardium, patients with significant cardiopulmonary disease should be closely monitored during these procedures. The utility of intraoperat ive pulmonary artery catheter (PAC) and transesophageal echocardiograp hy (TEE) monitoring was studied in 10 patients with moderate to severe cardiopulmonary disease to identify patients at greatest risk for car diovascular complications during laparoscopic cholecystectomy. METHODS : Ten patients were enrolled in this prospective study; 7 had suffered a previous myocardial infarction, 6 had undergone corollary artery by pass grafting, and 9 had disease classified as Goldman's class II or g reater. The heart was monitored by TEE throughout the laparoscopic cho lecystectomy by using real-time, two-dimensional mode to study the wal l thickness and motion. Several PAC measurements were taken directly: cardiac output, systemic vascular resistance, pulmonary artery wedge p ressure, and central venous pressure. Heart rate and blood pressure we re also obtained at corresponding intervals. Cardiac index, stroke vol ume, and left and right ventricular stroke work were then calculated. RESULTS: TEE demonstrated no significant changes in ventricular wall m otion throughout laparoscopy. In patients who had postoperative cardio vascular complications, significant changes in cardiac index, left ven tricular stroke work, and stroke volume were seen after pneumoperitone um release. Compared to that of patients who did not develop complicat ions, the cardiac index in those T with complications dropped 42% (3.1 0 +/- 0.72 versus 1.80 +/- 0.10 L/min per m(2), 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, respective ly; P <0.01). CONCLUSIONS: PAC monitoring in patients with compromised cardiac function is useful in identifying patients who may not tolera te hemodynamic changes after pneumoperitoneum release. Normalization o f hemodynamic changes secondary to abdominal insufflation and desuffla tion in patients,vith compromised hearts slay not occur for hours post operatively Abnormal hemodynamic changes occur within the first hour a fter desufflation in patients who later develop cardiovascular complic ations, which are heralded by significant drops in left ventricular st roke work, cardiac index, and stroke volume. TEE did not prove to be u seful for intraoperative monitoring.