we present a case of a cardiac transplant candidate with an ejection fraction of less than 15% who underwent a laparoscopic cholecystectomy .
this is the first case in which intraoperative hemodynamic measurements were recorded in a patient with cardiopulmonary disease this severe .
the patient underwent the procedure while measurements were made at crucial intervals ( baseline , with incremental insufflation , reverse trendelenberg , at desufflation ) using a pulmonary artery catheter , transesophageal echocardiography with fractional area measurements , radial arterial line , as well as standard monitoring .
there was a rise in mean arterial and systemic vascular resistance with insufflation to 10 mm hg , which was further exaggerated by reverse trendelenberg .
we conclude that if a patient with congestive heart failure is medically optimized , and intra - abdominal pressures and surgical times are minimized , laparoscopic cholecystectomy may be performed with minimal risk to the patient .
increasingly , laparoscopic procedures are being utilized to decrease postoperative pain and length of hospital stay .
the one group in which laparoscopy may have adverse effects , that outweigh the potential benefits , is the patient with severe cardiopulmonary disease .
there has not been a case reported of a laparoscopic procedure with hemodynamic measurements on a patient with an ejection fraction of less than 20% .
we present a case of a patient with end - stage cardiac disease with an ejection fraction estimated at less than 15% who underwent laparoscopic cholecystectomy prior to becoming eligible for cardiac transplant .
the patient had asymptomatic cholelithiasis and was to undergo a laparoscopic vs. open cholecystectomy prior to becoming eligible for cardiac transplant .
an echocardiogram two weeks prior to admission revealed a normal sinus rhythm , global hypokinesis with an ejection fraction of less than 15% ; valvular abnormalities included mild mitral and tricuspid regurgitation .
a right and left cardiac catheterization one week prior to this admission confirmed the above , and revealed pulmonary hypertension with pulmonary artery pressures of 72/35 .
pertinent medications included metropolol 6.25 mg po bid , digoxin 0.125 mg po q d , enalapril 20 mg po bid , furosemide 40 mg po q d , and coumadin 4 mg po q d. physical exam was without evidence of congestive heart failure .
upon arrival in the operating room , the patient was connected to standard monitoring ( i.e. , 5-lead ekg , pulse oximetry , arterial blood pressure , capnography , and body temperature ) . prior to induction
, a radial arterial line and oximetric pulmonary artery catheter were placed through the right internal jugular vein .
induction was accomplished with etomidate 0.3 mg / kg , fentanyl 10 meg / kg , and succhinylcholine 1.0 mg / kg .
after entubation , a hewlett - packard biplanar transesophageal echocardiography probe ( model # 21362a ) at 5.0 mhz frequency was positioned to obtain a transgastric short axis view of the midpapillary level of the left ventricle .
anesthesia was maintained with isoflurane at 0.35 - 0.45% , nitrous oxide 50% in oxygen 50% .
muscle relaxation was accomplished with vecuronium maintaining 1 of 4 twitches on a train - of - four .
ventilation was controlled with the ph ranging between 7.35 - 7.40 and pco2 40 - 48 mm hg .
blood loss was minimal , and the patient received a total of 10ml / kg of lactated ringer 's intravenously .
measurements were taken pre - induction , immediately post - induction , five minutes after pneumoperitoneal insufflation to 5 mm hg , five minutes after insufflation to 10 mm hg , five minutes after 10 degrees of reverse trendelenburg position , and five minutes after return to the supine position and desufflation .
parameters measured included heart rate , blood pressure , pulmonary artery pressures , cardiac output , pulmonary artery occlusion pressure , and central venous pressure . with each change in table position ,
pressure transducer height was adjusted to maintain a constant phlebostatic axis with respect to the right atrium .
videotaped recordings of the intraoperative echocardiogram were used to evaluate for wall motion abnormalities and to calculate left ventricular fractional area change postoperatively .
analysis was performed via manual planimetry by a skilled observer ( dck ) blinded to intraoperative events .
end - diastolic ( eda ) and end - systolic areas ( esa ) were planimetered on two consecutive cardiac cycles and averaged using the leading edge of the left ventricular endocardial border .
eda was determined by the greatest cross - sectional area obtained at the peak of the electrocardiogram r wave .
percent ejection fraction area ( % efa ) was determined from the formula % efa = ( eda - esa / eda )  100 .
laparoscopic cholecystectomy is becoming an increasingly popular alternative to open cholecystectomy . the laparoscopic procedure combines the benefit of completely removing the gallbladder with the advantages of a shorter hospital stay , less pain , and less chance of postoperative ileus compared to the open cholecystectomy .
these advantages should provide theoretical benefits for patients with heart disease requiring cholecystectomy ; however , the use of peritoneal insufflation , co2 as the insufflating gas , and reverse trendelenburg position necessary for a laparoscopic cholecystectomy have been shown to cause significant alterations in hemodynamic parameters .
some of these changes might discourage the use of laparoscopic cholecystectomy in high - risk cardiac patients , especially those with very low ejection fractions .
the three variables that effect the patient 's hemodynamic parameters are insufflation , the use of co2 as the insufflant , and patient position .
the extent of the cardiovascular changes associated with creation of pneumoperitoneum depends on the intra - abdominal pressure ( iap ) attained . with our patient ,
the iap was limited to 10 mm hg . because of her thin body habitus , this limitation was not difficult to accomplish , yet still provided adequate visualization for surgery . in healthy patients undergoing laparoscopic cholecystectomy ,
the filling pressures and mean arterial pressure ( map ) may increase , but cardiac output ( co ) typically remains unchanged . in patients with severe heart disease , however , changes in hemodynamic parameters have varied between investigators .
utilizing iaps of 12 mm hg , have described hemodynamic changes similar to our patient . however , safran et al . , using 15 mm hg iaps , noted that several high - risk cardiac patients experienced decreases in co and svo2 .
they felt that these patients were relatively volume depleted preinsufflation , then worsened with a further decrease in preload when insufflation was applied .
similarly describe a significant fall in cardiac index ( ci ) and stroke volume ( sv ) despite preoperative optimization of preload and cardiac output using fluid boluses .
neither safran nor iwase reported any intraoperative cardiac complications or any increase in postoperative morbidity or mortality .
portera , on the other hand , reported two cases of postoperative congestive heart failure .
he observed a progressive decrease in ci , sv , and left ventricular stroke work following desufflation in these patients ; but , he could not identify any obvious feature preoperatively , or at the time of insufflation , that might predict which patients might be at risk . the hemodynamic course of our patient was uneventful ( figure 1 ) . at 10 mm hg , our patient had changes similar to a healthy patient , documented by an increase in map and pulmonary artery wedge pressure ( pawp ) ; end diastolic volume ( estimated as end - diastolic area - eda ) and co remained unchanged .
systemic vascular resistance ( svr ) also increased with insufflation . with our patient 's complicated preoperative course , consisting of two admissions within four weeks for chf
, one would have expected her to be relatively volume depleted and as such respond with an increase in bp and hr .
prior to desufflation , the most unusual finding was the decrease in echocardiographic fractional area change ( fac ) to 12% ; this finding mirrors ( and is most probably explained by ) a peak increase in svr . following desufflation , all hemodynamic parameters corrected in an appropriate fashion : increased stroke volume secondary to improved preload , decreased svr ( reduced afterload ) with subsequent increase in cardiac output , and a decrease in heart rate . pulmonary artery wedge pressure ( pawp ) , fractional area change ( fac ) by transesophageal echo .
, systemic vascular resistance ( svr ) , mean arterial pressure ( map ) , cardiac output ( co ) , heart rate ( hr ) recorded at 5 minutes after an intra - abdominal pressure of 5 mm hg , 10 mm hg , assuming 10 degrees reverse trendelenberg ( rt ) , and on return to supine and desufflation of the abdomen .
hypercarbia over 50 mm hg in healthy patients causes myocardial depression and is a direct vasodilator ; as a result , there is a decrease in co , svr , and ph . hypercarbia at levels less than 50 mm hg has been shown to produce minimal hemodynamic effects . in patients with ischemic heart disease , paco2 levels of 55 - 65 mm hg resulted in an increase in systolic bp , hr , and co. there was also a two to threefold increase in plasma catecholamine concentrations which suggests hypercarbia stimulates the sympathetic nervous system in this group of patients .
we had no difficulty maintaining a paco2 below 50 mm hg in our patient ; her lean body habitus was a contributing factor in our ability to maintain adequate ventilation .
it is unclear whether her upward trend in hr , map , and svr ( suggestive of an increase in sympathetic stimulation ) was related to the mild hypercarbia present , or to a drop in preload ( see edv , figure 1 ) .
theoretically , the change to reverse trendelenburg should cause cardiovascular compromise in the form of decreased venous return ( vr ) and co. this decline may be offset by a decrease in afterload leading to an insignificant change in co in otherwise healthy patients .
the study done by safran looking at laparoscopic cholecystectomy in patients with severe cardiac disease utilized an iap of 15 mm hg and maintained normal end - tidal co2 ( etco2 ) .
the reverse trendelenburg position was used in most of the 15 asa physical class iii and iv patients evaluated .
unfortunately , hemodynamic parameters were not measured after the establishment of pneumoperitoneum independently of assuming reverse trendelenburg .
a significant increase in map and svr accompanied by a decrease in co was found .
these changes were thought to be due to aggressive treatment of congestive heart failure preoperatively , thus leading to a volume depleted patient with little intravascular volume reserve . in our patient , the only significant finding on assuming 10 degrees of reverse trendelenburg position was an increase in the svo2 from 83% to 90% .
this elevation in svo2 came in conjunction with a decline in etco2 from 38 mm hg to 30 mm hg , adding further credence to the improvement in pulmonary function as the probable mechanism .
we evaluated transesophageal echocardiography ( tee ) as an aid to monitoring this patient during laparoscopic cholecystectomy . following the establishment of pneumoperitoneum and assumption of the reverse trendelenburg position , the fac via tee was assessed as an indirect measure of ejection fraction ( ef ) .
no significant changes or trends could be identified utilizing this technique , perhaps due to subtle changes in wall thickening and short axis diameters in a patient with a low ef .
were also unable to find benefit of tee use as an intraoperative monitor in laparoscopic patients with cardiac disease .
we conclude from this case that laparoscopic cholecystectomy can be performed safely in patients with severe cardiac disease and ejection fractions less than 20% . under these circumstances it is imperative that appropriate monitoring be utilized , and iap , reverse trendelenburg and surgical time minimized .
 background and objectives : laparoscopic procedures are becoming increasingly popular , even in the severely ill patient . 
 we present a case of a cardiac transplant candidate with an ejection fraction of less than 15% who underwent a laparoscopic cholecystectomy . 
 this is the first case in which intraoperative hemodynamic measurements were recorded in a patient with cardiopulmonary disease this severe.methods:the patient underwent the procedure while measurements were made at crucial intervals ( baseline , with incremental insufflation , reverse trendelenberg , at desufflation ) using a pulmonary artery catheter , transesophageal echocardiography with fractional area measurements , radial arterial line , as well as standard monitoring.results:this patient showed hemodynamic changes consistent with a person without severe heart disease . 
 there was a rise in mean arterial and systemic vascular resistance with insufflation to 10 mm hg , which was further exaggerated by reverse trendelenberg.heart rate and pulmonary artery wedge pressure increased slightly . 
 the cardiac output and fractional area change declined minimally.conclusions:we conclude that if a patient with congestive heart failure is medically optimized , and intra - abdominal pressures and surgical times are minimized , laparoscopic cholecystectomy may be performed with minimal risk to the patient . 