Journal of

CardiothoracicAnesthesia
VOL 4, NO 6, SUPPL 5

Management

DECEMBER 1990

of Surgical

Low Cardiac Output Syndrome

Introduction

N 1908, WHEN the symptoms of the low cardiac output syndrome were first described,
little was known about the underlying pathophysiology of congestive heart failure. Since then,
ongoing research has led to better understanding
of the etiology of this disorder and the discovery
of many treatment approaches for the management of the decreased myocardial function that
is observed in this syndrome.
In the cardiac surgical patient, the operative
procedure itself may cause the low cardiac output
syndrome, particularly in patients with poor
ventricular function. Following cardiac surgery,
a direct myocardial insult can occur, which decreases contractility. Cardiac output then decreases and dysrhythmias may result. Contractility is reduced further, filling pressures increase,
and perfusion pressure decreases, further perpetuating the downward spiral of the low cardiac
output syndrome. An appropriate management
strategy needs to be developed to prevent this
downward spiral. The classic pharmacological
management tool has been inotropes.
The ideal pharmacological agent would
improve cardiac output by altering preload, afterload, and contractility without triggering
tachycardia or dysrhythmias or increasing myocardial oxygen consumption. Catecholamines,
which stimulate /3,- and &-receptors and often
cu-receptors, alter contractility but may cause
dysrhythmias and increases in heart rate and
myocardial oxygen consumption. This result may
further compromise the balance of myocardial
oxygen supply and demand and further exacerbate ventricular dysfunction.
The phosphodiesterase-III (PDE-III) inhib-

Journal of Cardiorhomcic Anesthesia, Vol4.

No 6, SuppI

itors are the newest drugs in the nonadrenergic/

inotropic class. These agents increase cyclic
adenosine monophosphate in cardiac and vascular smooth muscle by inhibiting fraction III
phosphodiesterase, not by stimulating (Y-or j3adrenergic receptors. In the case of patients with
chronic congestive heart failure this mechanism
of action is especially beneficial because these patients may have down-regulation of their fi-receptors. Amrinone, the prototype of the PDE-III
inhibitors, provides positive inotropic support
combined with systemic and pulmonary vasodilation, making it a valuable agent during the
perioperative period.
Management of surgical low cardiac output
was the focus of a symposium held on May 12,
1990, in Orlando, FL, where experts met to discuss therapeutic options in the failing heart.
Topics discussed included the intraoperative and
prophylactic use of inotropes in cardiac surgery;
the use of inotropes in general surgery; the use
of amrinone in the hemodynamic support of
transplant patients; the pharmacokinetics and
pharmacodynamics of PDE-III inhibitors; as well
as an overview of myocardial protection. Highlights of that symposium are included in this
supplement.

(December), 1990: p 1

Jerrold H. Levy, MD

Emory University School of Medicine

Atlanta, GA
J. Earl Wynands, MD

Ottawa Civic Hospital & Heart Institute

Ottawa, Ontario, Canada
Guest Editors