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Monaco et al. Vessel Plus 2023;7:23 https://dx.doi.org/10.20517/2574-1209.2023.113 Page 7 of 14

Table 2. Overall view of the main echocardiographic criteria of right and left ventricular (RV and LV, respectively) dysfunction
Criteria of ventricular dysfunction
Right (RV) Left (LV)
RVFAC < 30% PAOP > 15 mmHg
Tricuspid annular plane systolic excursion < 16 mm EF < 50%
Tissue Doppler index < 10 cm/s LVOT VTI < 20 cm/s with good RV function
RV/LV > 0.6
RVFAC: Right ventricular fractional area change; RV/LV: right ventricular to left ventricular diameter ratio; PAOP: pulmonary artery occlusion
pressure; EF: ejection fraction; LVOT VTI: left ventricular outflow tract (LVOT) velocity time integral (VTI); RV: right ventricular.

The RV is particularly sensitive to increased pulmonary resistance from vasoconstriction secondary to
hypercapnia, hypoxia, acidosis, and polytransfusion. Therefore, the first-line treatment of RV dysfunction is
the optimization of gas exchange with a high fraction of inspired oxygen (FiO ) and moderate
2
hyperventilation.

When moderate pulmonary hypertension (Tricuspid Annular Plane Systolic Excursion [TAPSE] > 16 mm
or Tissue Doppler Imaging [TDI] > 10 cm/s and Pulmonary artery systolic pressure [PAPs] > 30 mmHg)
with preserved systolic function (ejection fraction [EF] > 60%) and low preload (CVP < 10 mmHg) occurs,
fluid challenge is recommended. High CVP (> 15mmHg) should be treated aggressively with diuretic
therapy. Poor RV contractility (TAPSE < 16 mm or TDI < 10 cm/s) may be associated with poor inotropism
secondary to pre-existing coronary artery disease (CAD), and myocardial hypoperfusion due to low
coronary artery gradient from left-sided dysfunction.

In cases of moderate RV dysfunction, dobutamine infusion is the first-line treatment. Adrenaline is
indicated in cases of biventricular dysfunction, hypotension, or severe RV dysfunction. In patients with RV
failure and low pulmonary vascular resistance but no pre-existing pulmonary hypertension, norepinephrine
is effective in maintaining adequate coronary perfusion pressure (CPP). Therapeutic targets are summarized
in Figure 2.

Left ventricular dysfunction
LV function is equally of paramount importance in preventing SCI. The development of low cardiac output
syndrome (LCOS) with refractory and prolonged hypotension has catastrophic effects on spinal cord
perfusion. Early recognition and treatment can mitigate its effects. The criteria for LV dysfunction are
summarized in Table 2.

In particular, reduced ejection fraction (EF < 50%) in the postoperative period due to ischemic events or the
onset of supraventricular arrhythmias is a relatively frequent cause of hypotension during the days following
surgery, and may be a direct cause of the development of SCI .
[26]

The presence of atrial fibrillation (AF) is associated with prolonged hospitalization, higher in-hospital
[27]
mortality, and reduced mid-term survival . As observed by Coselli et al. in a series of more than 1,000
patients undergoing type II TAAA, the presence of preoperative CAD is one of the main predictors of SCI
on multivariate analysis, increasing the risk of paraplegia in the postoperative period by 80% .
[26]

With regard to treatment, the evaluation of myocardial contractility and wall motion abnormalities should
be conducted following preload optimization. Poor contractility is managed with adrenaline and
dobutamine infusion. MAP is also critical in regard to coronary perfusion; in fact, it is not uncommon to
observe MAP-dependent ST abnormalities.