on Statement: Society of Echocardiography is accreditedby theAccreditationCouncil for edical Education to provide continuingmedical education for physicians. n Society of Echocardiography designates this educational activity for of 1.0 AMA PRA Category 1 Credits . Physicians should only claim credit te with the extent of their participation in the activity. CCI recognize ASE’s certificates and have agreed to honor the credit hours registry requirements for sonographers. Society of Echocardiography is committed to ensuring that its educational ll sponsored educational programs are not influencedby the special interests ation or individual, and itsmandate is to retain only those authors whose fists canbeeffectively resolved tomaintain thegoals andeducational integrity y. While a monetary or professional affiliation with a corporation does not fluence an author’s presentation, the Essential Areas and policies of the ire that any relationships that could possibly conflict with the educational activity be resolved prior to publication and disclosed to the audience. f faculty and commercial support relationships, if any, have been indicated. ience: is designed for all cardiovascular physicians and cardiac sonographers with erest and knowledge base in the field of echocardiography; in addition, reschers, clinicians, intensivists, and other medical professionals with a spein cardiac ultrasound will find this activity beneficial.

https://www.nationaljewish.org/getattachment/programs/directory/cardiology/pulmonary-hypertension-center/Echo-Guidelines-for-RV-JASE-2010.pdf.aspx

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61692-4.pdf

Maternal and child undernutrition: consequences for adult health and human capital.

There is increasing recognition that systematic post–cardiac arrest care after return of spontaneous circulation (ROSC) can improve the likelihood of patient survival with good quality of life. This is based in part on the publication of results of randomized controlled clinical trials as well as a description of the post–cardiac arrest syndrome. 1–3 Post–cardiac arrest care has significant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multiorgan failure and brain injury. 3,4 This section summarizes our evolving understanding of the hemodynamic, neurological, and metabolic abnormalities encountered in patients who are initially resuscitated from cardiac arrest. The initial objectives of post–cardiac arrest care are to ● Optimize cardiopulmonary function and vital organ perfusion. ● After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive post–cardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia. ● Transport the in-hospital post–cardiac arrest patient to an appropriate critical-care unit capable of providing comprehensive post–cardiac arrest care. ● Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest.

http://www.kardio.hu/feltoltott/dokumentumok/fajl_201148104747Cardiopulm_resuscit_Pt9_Post_cardiac.pdf

Part 9: Post-Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1

Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below).

Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9

It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.110.971101

Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

https://anestesiar.org/WP/uploads/2011/01/7-neonatos-ERC-2010.pdf

European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary.

The normal right ventricular pressure-volume relation was studied by recording biplane right ventriculograms with simultaneous high fidelity pressure recordings in 10 adults found to have normal coronary arteries and haemodynamic function at diagnostic cardiac catheterisation. Right ventricular volume was measured frame by frame from digitised ventriculograms by a modification of Simpson's rule. The accuracy of this method was tested in a study of 22 human and animal right ventricular casts. There was excellent agreement between calculated volumes and those measured by fluid displacement. The derived regression equations were used to correct right ventricular volumes calculated from in vivo studies. The mean (SD) end diastolic volume index for the group was 62 (13) ml/m2, the stroke volume index was 43 (8) ml/m2, and the ejection fraction was 62 (6)%. Right ventricular pressure-volume loops were generated by combining simultaneous volume and pressure curves. The normal right ventricular pressure-volume loop was triangular, departing significantly from the square or rectangle of the normal left ventricular pressure-volume loop. Ejection from the right ventricle began early during the pressure rise and continued as right ventricular pressure fell. As a result phases of isovolumic contraction and relaxation were difficult to define. These observations show that normal right ventricular pressure-volume relations differ considerably from those of the normal left ventricle, presumably reflecting the different loading conditions of the two ventricles.

https://heart.bmj.com/content/heartjnl/59/1/23.full.pdf

Characterisation of the normal right ventricular pressure-volume relation by biplane angiography and simultaneous micromanometer pressure measurements.

Ventricular pressure-volume diagrams were obtained from the right ventricle in patients before and after relief of right ventricular pressure load, in patients with volume loaded right ventricles, and from the left ventricle in patients after the Mustard procedure for transposition of the great arteries. The patterns of ejection during pressure development and decline were similar in patients after relief of pressure load and in those with isolated volume load. A right ventricular pressure load, however, reduced ejection during the two "isovolumic" periods, and the overall shape of the pressure-volume loop resembled that of the normal left ventricle. Pressure-volume diagrams obtained from the left ventricle after the Mustard procedure were indistinguishable from the normal right ventricle, which accords with the hypothesis that the normal right ventricular contraction pattern is a consequence of loading conditions rather than a reflection of an intrinsic property of the myocardium.

https://heart.bmj.com/content/heartjnl/63/1/45.full.pdf

Changes in the pressure-volume relation of the right ventricle when its loading conditions are modified.

The pattern of pulmonary blood flow was studied in three patients after a total cavopulmonary shunt procedure. Doppler studies showed a phasic pattern of flow which varied with the respiratory cycle. Pulmonary blood flow was increased with normal inspiration, and was much augmented by the Mueller manoeuvre. This suggests that flow was occurring when a negative intrathoracic pressure was generated. During a brief Valsalva manoeuvre blood flowed away from the lungs. With a sustained Valsalva manoeuvre there was no spontaneous forward flow; instead there was low velocity pulsatile pulmonary blood flow that coincided with ventricular systole. Left ventricular cavity dimensions decreased, reflecting a considerably reduced pulmonary blood flow. Pulmonary blood flow after the total cavopulmonary shunt operation is critically dependent on changes in intrathoracic pressure. This has important implications in terms of the immediate postoperative management of these patients.

https://heart.bmj.com/content/heartjnl/65/4/213.full.pdf

Pulmonary blood flow after total cavopulmonary shunt.

Biplane right ventriculograms with simultaneous high fidelity pressure recordings were obtained in 24 patients with tetralogy of Fallot. Twelve patients were studied before repair and 12 were studied 67 (42) months after radical surgical repair without the use of a transannular patch. In the patients who had repair right ventricular end diastolic and end systolic volume indices were higher, and the ejection fraction was lower. Time to peak ventricular filling and the peak rate of ventricular fillings were also lower in this group and there was a significant relation between peak filling rate and ejection fraction. Postoperative pressure-volume loops from nine patients showed an increase in cavity volume during the decline in right ventricular pressure, which indicated pulmonary regurgitation. The mean regurgitant volume for the group correlated with end diastolic volume index, stroke volume index, and peak filling rate, but not with ejection fraction. These data show that both systolic and diastolic abnormalities of right ventricular function are detected in most patients after radical repair of tetralogy of Fallot. The reduction of ejection fraction previously reported in these patients is unrelated to the degree of pulmonary regurgitation and primarily reflects an impairment of contractile function that presumably is related to intraoperative events.

https://heart.bmj.com/content/heartjnl/60/1/57.full.pdf

A new technique for the assessment of pulmonary regurgitation and its application to the assessment of right ventricular function before and after repair of tetralogy of Fallot.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)02068-7.pdf

A N Redington

Papers

Characterisation of the normal right ventricular pressure-volume relation by biplane angiography and simultaneous micromanometer pressure measurements.

Changes in the pressure-volume relation of the right ventricle when its loading conditions are modified.

Pulmonary blood flow after total cavopulmonary shunt.

A new technique for the assessment of pulmonary regurgitation and its application to the assessment of right ventricular function before and after repair of tetralogy of Fallot.

Fetal origins of reduced arterial distensibility in the donor twin in twin-twin transfusion syndrome