Right ventricle dysfunction does not predict mortality in patients with SARS-CoV-2-related acute respiratory distress syndrome on extracorporeal membrane oxygenation support

BACKGROUND The prognostic role of right ventricle dilatation and dysfunction(RVDD)has not been elucidated in patients with coronavirus disease(COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation(ECMO)support.AIM To assess whether pre veno-venous(VV)ECMO RVDD were related to inintensive care unit(ICU)mortality.METHODS We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU(an ECMO referral center)from 31th March 2020 to 31th August 2021.An echocardiographic exam was performed immediately before VV ECMO implantation.RESULTS Males were prevalent(73.8%)and patients with a body mass index>30 kg/m^(2) were the majority(46/61,75%).The overall in-ICU mortality rate was 54.1%(33/61).RVDD was detectable in more than half of the population(34/61,55.7%)and associated with higher simplified organ functional assessment(SOFA)values(P=0.029)and a longer mechanical ventilation duration prior to ECMO support(P=0.046).Renal replacement therapy was more frequently needed in RVDD patients(P=0.002).A higher in-ICU mortality(P=0.024)was observed in RVDD patients.No echo variables were independent predictors of in-ICU death.CONCLUSION In patients with COVID-related respiratory failure on ECMO support,RVDD(dilatation and dysfunction)is a common finding and identifies a subset of patients characterized by a more severe disease(as indicated by higher SOFA values and need of renal replacement therapy)and by a higher in-ICU mortality.RVDD(also when considered separately)did not result independently associated with in-ICU mortality in these patients.

Systemic right ventricle complications in levo-transposition of the great arteries: A case report and review of literature

BACKGROUND Congenitally corrected levo-transposition of the great arteries(L-TGA)is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy.In L-TGA,the double discordance,atrioventricular and ventriculoarterial,create an acyanotic milieu which allows patients to survive their early decades,however,progressive systemic right ventricle(sRV)dys-function creates complications later in life.sRV dysfunction and remodeling predisposes patients to intracardiac thrombus(ICT)formation.CASE SUMMARY A 40-year-old male with L-TGA presented with symptoms of acute decom-pensated heart failure.In childhood,he had surgical repair of a ventricular septal defect.In adulthood,he developed sRV dysfunction,systemic tricuspid valve(sTV)regurgitation,and left-bundle branch block for which he underwent cardiac resynchronization therapy.Transthoracic echocardiogram showed a sRV ejection fraction of 40%,severe sTV regurgitation,and a newly identified sRV ICT.ICT was confirmed by ultrasound-enhancing agents and transesophageal echocardio-graphy.Our patient was optimized with guideline-directed medical therapy and diuresis.Anticoagulation was achieved with a vitamin K antagonist(VKA)and he was later referred for evaluation by advanced heart failure and heart transplant services.CONCLUSION Anticoagulation with VKA is the mainstay of treatment in the absence of conclusive data supporting direct oral anticoagulant use in ICT in patients with congenital heart disease.This case illustrates the natural history of L-TGA and highlights the importance of surveillance and monitoring with dedicated cardiac imaging to identify complications.

One-Stage Correction with Intra- and Extraatrial Rerouting of Anomalous Systemic and Pulmonary Venous Return and Intraventricular Repair of Double Outlet Right Ventricle in a Patient with Heterotaxy Syndrome

We report a very rare case of successful intracardiac correction in a patient with heterotaxy syndrome.The cardiac malformations included dextrocardia,double outlet right ventricle,pulmonary stenosis,interrupted inferior vena cava,hemiazygos continuation and total anomalous pulmonary venous return.One-stage correction was performed.The atrial procedure consisted of intra-and extraatrial rerouting of the anomalous systemic and pulmonary venous return.The hepatic veins were detached and diverted to the left atrium via an extracardiac conduit.The correction of the double outlet right ventricle was accomplished by intraventricular redirection of the blood flow from the left ventricle to the aorta.The right ventricular outflow was ultimately remodeled using a valved conduit.For better perception of the complex morphology,a three-dimensional model was designed,using CT scan images.This proved to be very useful for surgical planning,especially with regard to the intraatrial reconstruction of the systemic and pulmonary venous rerouting.

Anesthetic management of a child with double outlet right ventricle and severe polycythemia: A case report

BACKGROUND Double outlet right ventricle(DORV)is a rare and complex congenital heart defect,and the surgical repairs vary with type and pathophysiology consequences.Due to prolonged progressive hypoxemia,severe polycythemia is common in patients with DORV,which ultimately leads to coagulation dysfunction and increases the risk of thrombosis and infarction.Consequently,the anesthetic management is challenging and how to manage severe polycythemia and avoid hypoxia-related complications in such patients is of great significance.CASE SUMMARY Herein,we report the anesthetic management of a 10-year-old female patient with a DORV.She lived in the low-oxygen Qinghai-Tibet Plateau,and presented with severe polycythemia(hemoglobin,24.8 g/dL;hematocrit,75%).She underwent a modified Fontan surgery,which was satisfactory and without any perioperative complications.Our anesthetic management highlights the importance of perioperative hemodilution in decreasing the risk of thromboembolism and the importance of correcting coagulopathy in preventing hemorrhage.CONCLUSION Anesthetic management is challenging in rare cyanotic congenital heart disease patients with severe polycythemia.It is important to adopt perioperative hemodilution and correction of coagulopathy in preventing thrombosis and hemorrhage.

Concordant Atrioventricular Connection to L-Looped Ventricles with the Left Ventricle on Top of the Right Ventricle in Situs Solitus:A Case Report with 3D Modelling and Printing

We report the case of a rare complex cardiac anomaly involving situs solitus,concordant atrioventricular connection with left-hand ventricular topology,and L-looped ventricles.The ventricles had a superior-inferior relationship with an inferiorly located right ventricle,which had a double outlet with far posteriorly located great arteries.The left atrium was elongated,with juxta-positioned atrial appendages on the right side.The 3D-printed model using a computed tomography scan taken on the fourth day of birth demonstrated the anatomy clearly and helped us decide on the surgical management.

Lesson Eighty four Ventricular arrhythmias originating from papillary muscles in the right ventricle

Patientcharacteristics Patients in this study consisted of eight consecutive patients with frequent premature ventricular complexes(PVCs) or both PVCs and ventricular tachycardia(VT)who had been referred for catheter ablation and whose arrhythmia was mapped to one of the right ventricular(RV)papillary muscles(PAPs).The control group consisted of 10 consecutive patients who were referred for ablation of symptomatic idiopathic

Biventricular repair for endocardial cushion defects with double outlet right ventricle

Objective-Double outlet right ventricle,which often associated with total anomalous pulmonary venous connection and complete endocardial cushion defects,has been considered a risk factor for biventricular repair procedure. To reviewed cases treated by biventricular repair for endocardial cushion defects with double outlet right ventricle. Methods From July to November of 2009,6

Influence of positive end-expiratory pressure upregulation on the right ventricle in critical patients with acute respiratory distress syndrome:an observational cohort study

Background This study aimed to investigate the influence of positive end-expiratory pressure(PEEP)on the right ventricle(RV)of mechanical ventilation-assisted patients through echocardiography.Methods Seventy-six patients assisted with mechanical ventilation were enrolled in this study.Positive end-expiratory pressure was upregulated by 4 cm H_(2)O to treat acute respiratory distress syndrome,wherein echocardiography was performed before and after this process.Hemodynamic data were also recorded.All variables were compared before and after PEEP upregulation.The effect of PEEP was also evaluated in patients with and without decreased static lung compliance(SLC).Results Positive end-expiratory pressure upregulation significantly affected the RV function.Remarkable differences were observed in the following:Tei index(P=0.027),pulmonary artery pressure(P=0.039),tricuspid annular plane systolic excursion(P=0.014),early wave/atrial wave(P=0.002),diaphragm excursion(P<0.001),inferior vena cava collapsing index(P<0.001),and SLC(P<0.001).There were no significant changes in heart rate,respiratory rate,central venous pressure,mean arterial pressure,and base excess(P>0.05).Furthermore,the cardiac output of the RV was not significantly affected.In patients with decreased SLC(n=41),there were more significant changes in diaphragm excursion(P<0.001),inferior vena cava collapse index(P=0.025),pulmonary artery pressure(P<0.001),and tricuspid annular plane systolic excursion(P=0.007)than in those without decreased SLC(n=35).Conclusion Positive end-expiratory pressure upregulation significantly affected the RV function of critically ill patients with acute respiratory distress syndrome,especially in those with decreased SLC.

Surgical Treatment of Double Outlet Right Ventricle Complicated by Pulmonary Hypertension

Background： Double outlet right ventricle （DORV） is a group of complex congenital heart abnormalities. Preoperative pulmonary hypertension （PH） is considered an important risk factor for early death during the surgical treatment of DORV. The aim of this study was to report our experience on surgical treatment of DORV complicated by PH. Methods： From June 2004 to November 2016, 61 patients （36 males and 25 females） aged 2 weeks to 26 years （median： 0.67 years and interquartile range： 0.42-1.67 years） with DORV （two great arteries overriding at least 50%） complicated by PH underwent surgical treatment in our center. All patients were categorized according to surgical age and lesion type, respectively. Pulmonary artery systolic pressure （PASP）, pulmonary artery diastolic pressure （PADP）, and mean pulmonary artery pressure （mPAP） were measured directly before cardiopulmonary bypass （CPB） was established and after CPB was removed. An intracardiac channel procedure was performed in 37 patients, arterial switch procedure in 19 patients, Rastelli procedure in three patient, Senning procedure in one patients, and Mustard procedure in one patient. The Student＇s t-test and Chi-squared test were performed to evaluate clinical outcomes of the surgical timing and operation choice. Results： Fifty-five patients had uneventful recovery. PASP fell from 55.3 ± 11.2 mmHg to 34.7±11.6 mmHg （t = 14.05, P 〈 0.001）, PADP fell from 29.7 ± 12.5 mmHgto 18.6± 7.9 mmHg （t = 7.39,P〈 0.001）, and mPAP fell from 40.3 ± 10.6 mmHgto25.7 ± 8.3 mmHg （t= 11.85, P 〈 0.001）. Six （9.8%） patients died owing to complications including low cardiac output syndrome in two patients, respiratory failure in two, pulmonary hemorrhage in one, and sudden death in one patient. Pulmonary artery pressure （PAP） dropped significantly in infant and child patients. Mortality of both infants （13.9%） and adults （33.3%） was high. Conclusions： PAP of patients with DORV complicated by PH can be expected to fall significantly after surgery. An arterial switch procedure can achieve excellent results in patients with transposition of the great arteries type. Higher incidence of complications may occur in patients with ventricular septal defect （VSD） type before 1 year of age. For those with remote VSD type, VSD enlargement and right ventricle outflow tract reconstruction are usually required with acceptable results. The degree of aortic overriding does not influence surgical outcome.

Pentalogy of Cantrell associated with a double-outlet right ventricle

ne of premature twins was noticed with thoracoabdominal ectopia cordis and abdominal-walldelect. Purthermore, the mlant was presented with symptoms of tachypnea and moderate cyanosis. Physical examination showed the giant and pulsating omphalocele measured 40 mm × 50 mm over the anterior abdominal wall. Room air oxygen saturation was 82%. Chest X-ray showed absence of the normal contour of heart in the chest, descensus of the heart to the epigastrium （FigureI A）. Echocardiography visualized abdominal ectopia cordis and double-outlet right ventricle with pulmonary stenosis, the ventricular septal defect and atrial septal defect. Computed tomography （CT） angiography demonstrated a ventral thoracoabdominal wall defect with

Magnolol attenuates right ventricular hypertrophy and fibrosis in hypoxia-induced pulmonary arterial hypertensive rats through inhibition of the JAK2/STAT3 signaling pathway

OBJECTIVE Right ventricular(RV)remodeling is one of the essential pathological features in pulmonary arterial hypertension(PAH).RV hypertrophy or fibrosis are the leading causes of RV remodeling.Magnolol is a compound isolated from Magnolia officinalis.It possesses multiple pharmacological activities,such as anti-oxidation and anti-inflammation.This study aims to evaluate the effects and underlying mechanisms of magnolol on RV remodeling in hypoxia-induced PAH.METHODS①Male SD rats(220 g)were randomly divided into 5 groups(n=10):the normoxia group,the hypoxia group,the hypoxia plus Magnolol(10 and 20 mg·kg^(-1)·d-1)group,and the vehicle group.Rats in the normoxia group were kept in a normoxia environment for 4 weeks,while rats in the hypoxia group were kept in a hypoxic chamber(10%O2).The rats in the hypoxia plus magnolol groups were administered with magnolol at 10 or 20 mg·kg^(-1)(ip)once a day for 4 weeks.At the end of 4 weeks,the heart function was assessed by Doppler echocardiography,and then the rats were anesthetized with sodium pentobarbital(30 mg·kg^(-1),ip).The RVSP was measured by the right heart catheterization method.The heart tissues were collected and dissected to calculate the index of RV remodeling(RV/LV+IVS,RV/tibial length,or RV/body weight).Part of the RV samples was fixed with 4%paraformaldehyde for morphological analysis,while other samples were frozen at-80℃for molecular studies(measurements of ANP,BNP,α-SMA,and collagenⅠ/ⅢmRNA expression as well as p-JAK2/JAK2 and p-STAT3/STAT3 protein levels).②To evaluate the effect of magnolol on hypoxia-induced myocardial hypertrophy and fibrosis,H9c2 or cardiac fibroblasts were divided into 7 groups:the control group,cells were cultured under normal conditions;the hypoxia group,cells were cultured under hypoxic condition(3%O2);the hypoxia plus magnolol 10 mg·kg^(-1) group,magnolol10μmol·L^(-1) was added to the culture medium before the hypoxia treatment;the hypoxia plus magnolol 30 mg·kg^(-1) group,magnolol 20μmol·L^(-1) was added to the culture medium before the hypoxia treatment;the hypoxia plus TG-101348 group,TG-101348(a specific inhibitor of JAK2)1μmol·L^(-1) was added to the culture medium before the hypoxia treatment;the hypoxia plus JSI-124 group,JSI-124(a specific inhibitor of JAK2)1μmol·L^(-1) was added to the culture medium before the hypoxia treatment;and the hypoxia plus vehicle group,an equal volume of vehicle(DMSO)was added to the culture medium before the hypoxia treatment.At the end of the experiments,the cells were collected for morphological and molecular analysis.RESULTS In vivo,male Sprang-Daley rats were exposed to 10%O2 for 4 weeks to establish an RV remodeling model,which showed hypertrophic and fibrotic features(increases of RV remodeling index,cellular size,hypertrophic and fibrotic marker expression),accompanied by an elevation in phosphorylation levels of JAK2 and STAT3;these changes were attenuated by treating rats with magnolol.In vitro,the cultured H9c2 cells or cardiac fibroblasts were exposed to 3%O2 for 48 h to induce hypertrophy or fibrosis,which showed hypertrophic(increases in cellular size as well as the expression of ANP and BNP)or fibrotic features(increases in the expression of collagenⅠ,collagenⅢandα-SMA).Administration of magnolol and TG-101348 or JSI-124 (JAK2 selective inhibitors) could prevent the process of myocardial hypertrophy and fibrosis, accompanied by the decrease in the phosphorylation level of JAK2 and STAT3. CONCLUSION Magnolol can attenuate RV hypertrophy and fibrosis in hypoxia-induced PAH rats through a mechanism involving inhibition of the JAK2/STAT3 signaling pathway.

Tissue Doppler,speckling tracking and four-dimensional echocardiographic assessment of right ventricular function in children with dilated cardiomyopathy

BACKGROUND Right ventricular(RV)function is frequently overlooked during dilated cardiomyopathy(DCM)evaluation.AIM To evaluate RV function in children with idiopathic DCM using relatively recent echocardiographic modalities.METHODS We prospectively studied the cardiac function in 50 children with idiopathic DCM and 50 healthy children as a control group,using four-dimensional echocardiography(4-DE),Tissue Doppler Imaging(TDI),and two-dimensional-speckles tracking echocardiography(2-D-STE).RV EF was measured by 4-DE.RESULTS The auto left(LV)ejection fractions(EF)measured by 2-D-STE were significantly lower in the patients'group than in the control.The sphericity index was also significantly lower in children with DCM than in the control.RV EF measured by 4-DE was significantly lower in the patient's group than the control.RV S wave,e´/a'ratio,myocardial performance index(MPI),and tricuspid annular plane systolic excursion(TAPSE)were significantly impaired in children with DCM than in control.Both LV and RV global longitudinal strains(GLS)were significantly reduced in children with DCM than in control.RVGLS was significantly associated with the duration since diagnosis,tricuspid annulus S wave,RV MPI,and TAPSE,but not with the age of the patients,RV EF,or e´/a'ratio.CONCLUSION There was impairment of the RV LGS and other systolic and diastolic parameters in children with DCM.STE and TDI can help to detect the early decline of RV function.

Right Ventricular Endomyocardial Fibrosis in Neonate—A Case Report

Endomyocardial fibrosis is characterized by the formation of fibrous tissue in the endocardium. Although the disease may affect both ventricles, isolated or not, the right ventricle is more frequently involved. Endocardial fibrosis may be present in the entire ventricular cavity, being usually more marked in the apical region and right ventricular inflow tract. Its etiology, however, still remains unknown. Background—Reports on endomyocardial fibrosis in pediatric patients are not common. It is more frequent from the fourth year of age on, with few reports in the first 2 years of life. This case aimed at reporting right ventricular endomyocardial fibrosis in 7 days old male neonate, in addition to discussing the etiopathogenesis and future perspective of the disease.

Right Ventricular Myxoma—A Case Report

From an epidemiologic perspective, cardiac myxomas are best divided into the following 2 categories: those that arise in isolation and those that arise in the setting of a syndrome (so called Carney Complex). The former account for about 90% - 95% of cases, while the later account for a minority of cases and those arise from the right or left ventricle constitute as 3% each. Real-time two-dimensional echocardiography has proved to be extremely useful in defining intracavitary masses. With two-dimensional echocardiography accurate visualization of the right ventricular body and outflow tract can be accomplished consistently. The acoustic nature and anterior location of the right ventricular myxomas make them appear as bright, mobile masses. The mobile nature of the tumor can easily be appreciated and its point of attachment, or stalk can be visualized accurately. Background of this case illustrates the transthoracic 2D echocardiographic pattern of right ventricular myxoma and its attachment by a pedicle to the anterior papillary muscle, masquerading as ball-valve thrombus and cardiac “stone” in tilted parasternal long axis-3 chamber views in a 15-year-old girl. Mahaim criteria to distinguish myxoma from organizing thrombus had been highlighted.

Story of a Little Right Ventricular Pseudoaneurysm

Cardiac trauma caused by Swann-Ganz catheter may very rarely cause cardiac perforation, tamponade and right ventricular pseudoaneurysm. In contrast to left ventricular equivalants, pseudoaneurysms of the RV have a weak tendency to rupture. Its impact on patient outcomes should be assesed very carefully depending on its size, filling rate/capacity. It is possible not to operate the patient and follow progression of RV pseudoaneurysm by clinical and echocardiographic findings. This case is a good sample for it and describes the lifespan of a small RV pseudoaneurysm. It is not only the unique right ventricle pseudoaneurysm due to cardiac trauma caused by Swann Ganz catheter, but medically treated case without surgery and recovered completely.

Apical Right Ventricular Hypertrophic Cardiomyopathy—A Case Report

A relatively infrequent form of hypertrophic cardiomyopathy is the isolated apical variant and it is more common in oriental people, especially in the Japanese. It contributes 25% of cases of hypertrophic cardiomyopathy in Japan but only 1% to 2% in the non-Japanese population. It may occasionally present in the elderly and classically involve the apex of the left ventricle. An isolated apical right ventricular involvement had been detected in an elderly female by transthoracic two-dimensional echocardiographic imaging.

Interventricular Septal Hematoma after Congenital Cardiac Defects Repair at a Single Institution

Background: Interventricular septal hematoma is a rare complication after congenital cardiac repair. The managementvaries according to the literature. We present our experience with this rare complication. Methods:Echocardiography database were reviewed with the term ‘‘hematoma’’ or “hypoechoic mass” for patients whounderwent congenital heart surgery from January 2018 to December 2021 at our institution to identify potentialinterventricular septal hematoma cases. Relevant data of the patients identified were collected. Focus was put onthe presentation, management, outcomes according to patent medical charts and serial echocardiographic reportdata. Results: In total, there were 5 patients included. The mean age and weight at surgery were 5.5 ± 3.6 monthsand 5.5 ± 1.4 kg, respectively. Four patients were diagnosed with ventricular septal defect and the other one beingdouble outlet of the right ventricle. While all patients had intraoperative transesophageal echocardiography, 80%(4 of 5) of Interventricular septal hematoma were revealed intraoperatively. Only one patient received hematomadrainage intraoperatively while the other 3 identified in the operating room were only closely observed. One afterventricular septal defect repair presented continuous dysfunction of the left ventricle at the last follow-up, whilethe others were doing well. All hematomas resolved completely with a mean time to interventricular septal hematomaresolution of 35.8 ± 16.9 days. Conclusion: Infants seem to be at a higher risk for Interventricular septalhematoma following congenital heart surgery. While the majority of interventricular septal hematoma has abenign postoperative course, some may result in ventricular dysfunction. Management strategies may be chosenon a case-by-case basis.

Appropriate Heart Rate in a Patient with Repaired Tetralogy of Fallot

Appropriate heart rate in a failing pulmonary ventricle remains unknown, particularly in congenital heart diseasewith unique hemodynamics. A 71-year-old male with repaired tetralogy of Fallot and a pacemaker for a sinusnode dysfunction suffered from heart failure symptoms with preserved left ventricular function. Simply changingthe pacemaker’s lower rate from 60 to 75 bpm, New York Heart Association classification improved from III to II,and hemodynamic parameters drastically improved. We regarded this case as informative. Appropriate heart ratecould be higher in congenital patients with failing right and non-failing left ventricles than in adults with malfunctioningLV.

Holmes Heart and HIV: A Rare Combination of Two “H”s in a 23-Year-Old Widow

A 23-year-old, lean, scoliotic female presented to our hospital with a history of shortness of breath and cyanosis on exertion. Her 2D echocardiography revealed single left ventricle with both atrio-ventricular valves opening in it. She had normally related great arteries, with severe pulmonary artery hypertension, without pulmonary stenosis. Her blood tests indicated that she was reactive to human immunodeficiency virus (HIV-1). The patients died within 2 months despite treatments with anti-retroviral therapy and decongestive therapy.

Assessment of right ventricular function by pressure-volume loops in off-pump coronary artery bypass surgery

Background Right ventricular function plays an important role in the hemodynamic derangement during off-pump coronary artery bypass （OPCAB） surgery. Pressure-volume loops have been shown to provide load-independent information of cardiac function. Therefore, the aim of this study was to investigate the feasibility of construction of right ventricular pressure-volume loops with pressure and volume data measured by a volumetric pulmonary artery catheter （PAC） and to evaluate right ventricular systolic and diastolic function by end-systolic elastance （EEs） and end-diastolic stiffness （EED） in OPCAB surgery. Methods Twenty-eight patients who underwent OPCAB surgery were included. After anesthesia induction, a volumetric PAC was placed via the right internal jugular vein. Data were recorded at： anesthesia steady-state before skin incision （T1）; 5 minutes after the stabilizer device was placed for anastomosis on the heart＇s anterior wall （T2）, lateral wall （T3）, posterior wall （T4）, respectively; after sternal closure （T5）. Three sets of data were collected at each time point： first, hemodynamic variables were measured; second, right ventricular EEs and EED were calculated; third, right ventricular pressure-volume loops were constructed with pressure and volume data measured from end-diastole point, end-isovolumic systole point, peak-ejection point, end-systole point and end-isovolumic diastole point. Results Right ventricular pressure-volume loops generally shifted to the left during OPCAB surgery. Especially, the end-diastolic point shifted upward and to the left at T2--T5 compared with that at T1. Decrease in right ventricular ejection fraction, stroke volume index and end-diastolic volume index occurred （P 〈0.05） at T4 compared with values at TI. Pulmonary vascular resistance index at T4 increased relatively compared with that at T2 and T3. The change of EEs was not statistically significant during operation. Right atrial pressure increased only during coronary anastomoses （T2-- T4, P 〈0.05）, whereas EED increased throughout OPCAB surgery （P 〈0.05）. Conclusions Right ventricular pressure-volume loops can be constructed using a volumetric PAC. Right ventricular systolic dysfunction occurred during anastomoses on the heart＇s posterior wall not due to impaired myocardial contractility but as a result of reduced preload and a relative increase in afterload. Right ventricular diastolic function was impaired throughout OPCAB surgery.