John H. Eisenach*
Abstract
Demographic aging and its implications for healthcare delivery is a global concern. Heart failure is the
leading cause of hospital admission in patients older than age 65. It is a major risk factor for
postoperative morbidity and mortality, representing one of the most challenging and expensive
problems in medicine and surgery. Every anesthesia provider must be familiar with the definition,
classification, pathogenesis, and perioperative management associated with heart failure. This review
will focus on five key questions that anesthesiologists can incorporate into a strategic approach to
managing the surgical patient with heart failure.
Keywords: systolic heart failure; diastolic heart failure; cardiomyopathy; anesthesia; preoperative
evaluation; blood volume management
( J Perioper Sci 2014, 1:4 )
syndrome that results from a reduced filling of blood, life and life expectancy [8]. While there is no single
or reduced ejection of blood from the ventricle. The test that confirms the diagnosis of HF, the
unifying theme in HF is the clinical presentation of categorical feature of systolic HF is an EF less than
dyspnea and fatigue which may limit exercise 40%, compared to an EF greater than 50% in
tolerance. Fluid retention may lead to pulmonary diastolic HF, while individuals with an EF between
venous congestion and peripheral edema. Together, 41 and 49% are considered intermediate.
the ultimate consequence is a reduction in quality of
The heart consumes more energy than any other the uptake and conversion of free fatty acids and
organ, pumping about ten tons of blood throughout glucose into the Kreb’s cycle; 2) oxidative
the body per day. When cells in the myocardium phosphorylation: producing ATP from the
become deprived of energy, this abnormality of mitochondrial respiratory chain; and 3) transfer and
“myocardial energetics” plays a major role in utilization of high-energy phosphates (ATP) to the
progression of HF. There are three components of myofibrils [9]. Dysfunction in all three components
cellular energy metabolism: 1) substrate utilization: of myocardial energetics is early and integral to HF
Figure 1. Common and contrasting features of heart failure with reduced HF (HFrEF) and heart failure
with preserved HF (HFpEF). HFrEF or systolic HF is generally associated with an acute injury to myocardium, or
a genetic abnormality injurious to myocardium. The pathophysiology of HFpEF, or diastolic HF, is insidious in
onset primarily from poorly controlled hypertension, but also confounded by aging and poorly controlled co-
morbidities. While initial physiologic adaptations are common between syndromes, the maladaptive processes
distinguish the two. The arrows represent the cycle of heart failure that continues when inadequate therapies
exacerbate the syndrome.
For structural changes in systolic HF, ischemic heart oxidative stress, decreased antioxidant enzymes, and
disease is the leading cardiogenic cause. Myocardial possibly iron accumulation in cardiomyocytes
infarction changes the ventricular geometry within [12,13]. The incidence of heart failure after
hours to days. The area of myocardium expands and doxorubicin is dependent on age and dose, with an
becomes thinner. Global remodeling results in accelerated risk of myocardial toxicity when doses
ventricular dilatation (eccentric hypertrophy), exceed 550 mg/m2 [14]. Trastuzumab (Herceptin) is
decreased systolic function, mitral valve dysfunction, a monoclonal antibody against HER2 protein for the
and aneurysm formation [11]. For diastolic HF, treatment of positive HER2 breast cancer [15].
hypertensive heart disease is the leading cardiogenic Trastuzumab myocardial toxicity is not related to
cause associated with remodeling, as the ventricular dose, but potential cardiotoxicity increases when
walls become thickened (concentric hypertrophy) combined with anthracycline therapy, and the
and ejection fraction is preserved. effects are greater if the cumulative doxorubicin
Chemotherapy induced cardiomyopathy can be dose is > 300 mg/m² [16]. Other common
attributed to a variety of agents, with the most chemotherapy agents that are associated with
established class being anthracyclines. Doxorubicin myocardial depression are mitoxantrone
(Adriamycin) toxicity is thought to be due to (Novantrone), cyclophosphamide (Cytoxan),
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ifosfamide (Ifex), all-trans retinoic acid (Tretinoin), causes that reduce contractile function, such as
and imatinib (Gleevec) [17]. myocardial infarction. However, a major cause of
Detailed examples of additional structural causes non-ischemic contractile dysfunction is chronic
of HF are beyond the scope of this review but volume overload due to either severe mitral
include: gene mutations, inborn errors of regurgitation or severe aortic regurgitation. This
metabolism, toxins (i.e., alcohol, smoking, illicit leads to chamber dilation and eccentric hypertrophy.
drugs, lead poisoning), infections such as viral (i.e, Pressure overload is a functional cause of diastolic
HIV), bacterial, Lyme disease, fungal, parasitic (i.e., HF, where chronic hypertension or chronic aortic
Chagas disease), and idiopathic. Indeed, the leading stenosis lead to ventricular remodeling which
cause of non-ischemic dilated cardiomyopathy is increases wall thickness in attempt to reduce the
idiopathic, present in up to 50% of patients where no wall stress through LaPlace’s relation for a hollow
definitive cause is found [18]. sphere:
Functional causes of HF are illustrated in Figure 2.
Functional causes may overlap with structural
Figure 2. Functional causes of left sided heart failure. Impaired contractility results from a combination of
structural damage to myocardium, most commonly by myocardial infarction and ischemic heart disease, with
functional causes that perpetuate the syndrome of heart failure, such as increased sympathetic nervous system
activity and neurohormonal activation. Pressure overload can induce left ventricular (LV) systolic or diastolic
dysfunction. Diastolic dysfunction is the abnormal relaxation or myocardial stiffness associated with chronic
hypertension, pressure overload, and myocardial thickening. Without proper management diastolic dysfunction
can progress to LV systolic dysfunction or HF with preserved EF.
Diastolic dysfunction is the abnormal relaxation include hypertrophic cardiomyopathy and restrictive
associated with chronic hypertension, pressure cardiomyopathy.
overload, and myocardial thickening. Without Another common functional cause of HF relevant
proper management it can progress to HF with to the anesthesiologist is tachyarrhythmia-induced
preserved EF. Other causes of diastolic dysfunction cardiomyopathy. A typical surgical presentation of
that aren’t directly caused from pressure overload tachyarrhythmia-induced cardiomyopathy is atrial
fibrillation with rapid ventricular response and
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associated arterial thrombosis (i.e., ischemic stroke, and optimization of HF before elective surgery [30].
mesenteric ischemia, or cold leg). Emergency Compensated HF or prior HF is now considered a
echocardiography may reveal severe global clinical risk factor warranting further assessment of
hypokinesis with a severely depressed ejection functional capacity, other clinical risk factors, and
fraction. When caught early, these tachyarrhythmia- surgical risk. Adapted from the original Goldman
induced cardiomyopathies are at least partially criteria, the Revised Cardiac Risk Index (RCRI) lists
reversible with rate control and medical “History of HF” as one of six independent predictors
management [19]. of cardiac risk in the determination of an
The pathophysiology of systolic HF.is a complex individual’s RCRI [31]. More recently, Sabate and
interaction between injury of the myocytes and colleagues identified HF as an independent risk
extracellular matrix, ventricular remodeling, factor for major adverse cardiac and cerebrovascular
sympathetic nervous system activation, and events following non-cardiac surgery [32].
activation of the renin-angiotensin-aldosterone Class: The New York Heart Association (NYHA)
system [20]. Sympathetic nerve activity is normally functional classification correlates with quality of
increased in aging, but substantially increased life and survival. Because the paramount symptom
during HF [21]. Circulating catecholamine levels of HF is dyspnea on exertion, the NYHA class
(norepinephrine, epinephrine) are increased, which stratifies patients based on the symptom severity as
leads to salt and fluid retention, peripheral described in Table 2. Class IV HF has a worse
vasoconstriction, and down-regulation of beta-1 prognosis than most cancers in the U.S., with a one-
adrenergic receptors in the heart [22]. Vagal year mortality approaching 45% [11].
function in the heart is also reduced in proportion to Stage: Historically, there have not been wide-
the severity of heart failure [23,24]. spread screening efforts for HF. Risk factors for HF
Concomitant with overdriving sympathetic nerve were either poorly defined or poorly publicized. In
traffic, HF is associated with an over-active renal an attempt to prevent or reverse HF progression, the
angiotensin-aldosterone system (RAAS) [25]. This ACCF/AHA guidelines developed clinical staging
further increases salt and fluid retention, and the criteria to identify patients at risk for—or in early
RAAS hormones mediate some of the maladaptive stages of—HF [1]. The staging criteria allow for
effects on the myocardium[26,27]. Natriuretic patients to be stratified into clinical trials. Results of
peptides are released, and circulating cytokines such these trials form the guidelines for medical
as interferons and tumor necrosis factor further management. In contrast to NYHA class where
mediate dysfunctional myocardial remodeling [28]. patients can move up or down a continuum of
Interestingly, co-morbid conditions tend to functional status, patients move through the stages
segregate between systolic and diastolic HF. of HF in one direction, not reverse.
Previous myocardial infarction is the major risk
factor for systolic HF, followed by sleep apnea, What are the current medications?
hypertension, and diabetes. Diastolic HF is
By understanding the treatment strategy,
associated with a greater variety of diseases, with
summarized in Table 2, one can determine a
the major risks being obesity, hypertension, and
patient’s current HF stage. The medications in HF
diabetes, followed by chronic lung disease, dialysis,
serve to reduce cardiac sympathetic stimulation,
and sleep apnea [11].
lessen sodium and water retention, and decrease
afterload, collectively breaking the cycle of
What is the stage and class of heart failure?
physiological adaptations and pathologic
The patient’s functional status remains a key feature maladaptations depicted in Figure 1.
in preoperative cardiac evaluation. In previous On the electrocardiogram, a prolonged QRS
ACC/AHA guidelines for preoperative clinical complex is present in approximately 1/3 of HF
predictors of anesthesia risk, decompensated HF patients, which is associated with worse outcome
was classified as a major clinical risk factor, and [33]. The associated bundle branch block produces a
compensated or prior HF, an intermediate risk factor loss of ventricular coordination called dyssynchrony
[29]. The most recent ACC/AHA guidelines for or mechanoenergetic uncoupling which hastens
preoperative cardiovascular evaluation list maladaptive remodeling [34]. Cardiac
decompensated HF as an “active cardiac condition,” resynchronization therapy (CRT) is an attempt to
for which the HF patient should undergo evaluation coordinate ventricular depolarization. With pacer
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leads in both ventricles, CRT brings synchronized regurgitation if present, improve ejection fraction,
contraction to the ventricles, which reverses and can improve symptoms and NYHA class [35].
pathologic remodeling, may improve mitral
There is strong evidence to suggest that CRT is ECG, sinus rhythm, and NYHA class II or III
indicated in patients with left ventricular EF less symptoms [1]. Weaker evidence suggests a benefit
than or equal to 35%, a QRS complex greater than of CRT in patients with atrial fibrillation with EF
120 milliseconds, a left bundle branch pattern on less than 35%, optimal medical therapy, and fully
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dependent on ventricular pacing [1]. Importantly, in exercise tolerance; 2) Fluid retention; 3) With no
approximately 80% of biventricular pacers will symptoms or with symptoms of another cardiac
include an automated internal cardiac defibrillator disorder or noncardiac disorder. The complete
(ICD). history and physical exam will delineate cardiac
There are two strong indications for ICD’s in HF. versus noncardiac causes of presentation. The
This first is to prevent sudden cardiac death in routine ECG and chest X-ray have low sensitivity
patients with non-ischemic cardiomyopathy, and specificity for diagnosing a cardiac cause of HF,
ischemic cardiomyopathy > 40 days post myocardial but are useful in the general assessment of cardiac
infarction, an EF less than or equal to 35%, and have and pulmonary pathology.
a NYHA class II or III with a reasonably predicted The most useful diagnostic test is
survival beyond one year [1]. The second indication echocardiography to address three main questions: 1)
is to prevent sudden cardiac death in patients with ejection fraction; 2) left ventricular structure,
an EF less than or equal to 30%, with NYHA class I dimension, wall motion; and 3) non-left ventricular
symptoms while receiving optimal medical abnormalities (i.e., valve, pericardium, right
management, who are also expected to live beyond ventricle). Additional echocardiography indices will
one year [1] . CRT is not indicated for patient with include atrial size and pressure, characteristics of
comorbidities and an poor expected survival. One LV filling, and pulmonary arterial pressure. The
must weigh the benefits against the potential for comprehensive echocardiogram will also provide a
worsening quality of life because of the discomfort baseline for future comparison and therapeutic
from shock delivery. management. Laboratory testing will include
natriuretic peptides (BNP and/or NT-proBNP)Figure
What workup does this patient need before 3, complete blood count, urinalysis, electrolyte
surgery? panel, hemoglobin A-1c, lipid panel, renal, liver,
and thyroid function, as well as viral screening.
The patient with HF presents in one of three ways: 1)
A noticeable onset of exertional dyspnea or decrease
Figure 3. Brain-type natriuretic peptide. BNP is also called brain type natriuretic peptide because it was first
discovered in brain tissue. In cardiac myocytes, dilation and pressure overload on the cell causes expression of the
gene that translates the pro-hormone. The pro-hormone gets cleaved into an N-terminal pro-BNP that is inactive
but measurable, and C-terminal BNP which is the active hormone that inhibits the renin angiotensin aldosterone
system (RAAS), promotes diuresis and vasodilation, and thereby decreases preload and afterload. NT-proBNP has
a half-life of 1-2 hours and BNP has a half-life of 20 minutes.
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The pre-operative holding area: Is this patient in the prevalence of a-fib in patients with acute HF is
heart failure? Certainly patients in acute HF should greater than 30% [37]. Of note, the reason serum
not undergo elective procedures, and anesthesia BNP or NT-proBNP is not listed as a positive
providers must be prepared to diagnose and triage predictor is because it can also be elevated in
HF patients in the holding area. A meta-analysis of advanced age and critical illness. This would include
HF diagnostic criteria in patients presenting to the renal failure, acute coronary syndrome, lung disease
emergency room with dyspnea can be extrapolated with cor pulmonale, acute pulmonary embolus, and
to our pre-operative evaluations [36]. If a patient is high output cardiac states such as sepsis. However,
dyspneic, the positive predictors that suggest HF are if BNP is low, this suggests that a patient does not
listed in Table 3. The strongest predictor of HF in a have HF. The most negative predictors that would
dyspneic patient is medication non-adherence. Atrial dissuade the diagnosis of HF are also listed in Table
fibrillation is an important predictor of HF because 3.
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Preoperative medications: For preoperative prevent sudden cardiac death. Defibrillators are
continuation of anti-hypertensive agents, concerns accompanied by either single chamber, dual
have arisen with respect to profound and refractory chamber, or biventricular pacemakers. If a
intraoperative hypotension in patients who take an biventricular pacemaker device has an ICD, a
angiotensin converting enzyme inhibitor (ACEI) or magnet should inactivate the defibrillator but may
an angiotensin receptor blocker (ARB). A study at not change the pacemaker settings. To prevent
our institution found that discontinuation of unnecessary shocks the ICD should be inactivated in
ACEI/ARB therapy at least 10 hour before the holding area. Continuous ECG monitoring is
anesthesia was associated with a reduced risk of indicated until reactivation.
immediate postinduction hypotension [38]. Stage C patients may have a biventricular
Therefore, our pre-operative evaluation clinic pacemaker with or without an implantable
recommends that patients hold their ACEI and ARB defibrillator. Again, magnet placement should
on the day of surgery, provided that their blood deactivate the defibrillator, but will not change the
pressure is well-controlled. If their hypertension is pacemaker settings. For electrical interference,
poorly controlled at the time of their preoperative these devices are programmed with a ventricular
visit, these medications are continued on the day of noise reversion back-up mode, referred to as the
surgery. The lipid-lowering agent is generally taken “VNR.” This is the automatic default setting when
at night, and while postoperative outcomes data are the pacemaker senses electrical noise such as
less clear on HF patients, the use of preoperative electrocautery. When electrical interference is
statins has shown a reduction in postoperative atrial sensed, the device typically converts to VOO at a
fibrillation and hospital length-of-stay in cardiac rate between 60-90 bpm. These devices should be
surgery patients [39]and therefore can be continued interrogated postoperatively to confirm the desired
up to surgery. settings and reactivation of the ICD.
Specific beta-blockers in HF management are
bisoprolol, carvedilol, or sustained-release How should I care for this patient during and
metoprolol [1]. These medications should be after surgery?
continued on the day of surgery [40,41]. Diuretics
Induction and maintenance of anesthesia: An
should be held on the morning of surgery, primarily
awake arterial catheter prior to induction is helpful
because patients are fasting and therefore may be at
for any patient in acute or decompensated HF
risk of volume depletion with the use of their
presenting for emergency surgery, for any HF
diuretic. Aldosterone antagonists (i.e.,
patient in a higher functional class or stage of HF,
spironolactone, eplerenone), digoxin, and long-
and for any HF patient with severe systolic or
acting nitrates can be continued on the day of
diastolic dysfunction, pulmonary hypertension, or
surgery.
significant valvular disease. Rapid atrial fibrillation
Pacemaker interrogation: Pacemaker settings vary
in a HF patient would also indicate arterial line
by patient and device manufacturer. Interrogation of
placement, with aggressive attempts to adequately
these devices is essential to determine whether a
stabilize ventricular rate control prior to surgery.
patient’s heart rhythm is pacemaker dependent and
The choice of medications for induction is less
if so, the device should be re-programmed to
critical when real-time monitoring of heart rate and
asynchronous demand pacing (e.g., VOO). The
arterial pressure allow for careful titration of these
device settings and magnet responses should be
agents. For example, propofol or thiopental have the
reviewed with the manufacturer and/or the hospital
potential to cause profound hypotension in the HF
pacemaker service. If neither is available and the
patient because of the chronically elevated
device is a single chamber (right atrium) or dual-
sympathetic nervous system activity [42,43]. These
chamber (right atrium + right ventricle) pacemaker,
agents can be given simultaneously with pressor
a magnet placed on the chest should convert a
administration. Etomidate and ketamine have less
pacemaker to VOO. Importantly, these responses are
effect on sympathetic-mediated maintenance of
not universal, particularly for older devices. This
blood pressure [42,44]. The sympathomimetic effect
stresses the importance of reviewing all pacemakers
of ketamine may increase myocardial oxygen
prior to surgery.
demand, but this can be offset by short-acting beta-
Stage B patients with asymptomatic ischemic
blockade. Maintenance of anesthesia in HF patients
cardiomyopathy, who are at least 40 days after
is generally dependent on the surgical procedure, the
myocardial infarction, and have an LVEF ≤30%,
expected duration of procedure, blood loss, fluid
may have an internal cardiac defibrillator (ICD) to
shifts, and the need for additional monitoring develop hypotension secondary to low cardiac
techniques. output. If the patient has adequate intravascular
Hemodynamic supportive infusions for volume, then inotropes (dopamine, dobutamine)
perioperative management: The agents useful for should be initiated. If blood pressure is stable, then
maintaining cardiac performance and blood pressure these patients may benefit from the vasodilatory and
support are listed in Table 4. Patients with severe inotropic effect of milrinone. Milrinone may be
systolic dysfunction or dilated cardiomyopathy may bolused over 10 minutes prior to infusion.
Systolic dysfunction
(↓ CO + congestion)
Dopamine DA1, β1, α1, α2 ag. Inotropy, pressor 5 mcg/kg/min
For patients with diastolic HF, an imbalance in oral dose, with additional doses titrated to effect.
myocardial oxygen supply and demand, particularly Nesiritide is a recombinant natriuretic peptide that
in the setting of volume overload and severe has been shown to improve dyspnea and
hypertension, may lead to deterioration of cardiac hemodynamic parameters in patients with
function and flash pulmonary edema. Nitroglycerin decompensated heart failure [45]but no
generally decreases preload by venodilation in order improvement in renal function or mortality [46].
to reduce myocardial oxygen demand, while the Because the half-life and duration of action of
arteriodilator effect reduces afterload. Nitroprusside nesiritide is longer than the nitric oxide mediated
provides potent afterload reduction. Both agents vasodilators, it’s use is limited in the perioperative
must be titrated with caution as patients with period.
diastolic HF are particularly volume sensitive. With Monitors: Regardless of surgery, the ACCF/AHA
either decompensated systolic or diastolic HF, guidelines recommend invasive hemodynamic
furosemide is the agent of choice for diuresis. monitoring in HF patients whose fluid status,
Based on the oral bioavailability (60%), the initial perfusion, or systemic or pulmonary vascular
I.V. bolus dose is approximately one-half the daily resistance is uncertain; whose systolic pressure
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remains low, or is associated with symptoms, that analyzes the pulse contour to estimate SV. SV
despite initial therapy; whose renal function is variability is derived from one respiratory cycle and
worsening with therapy; or those who require is calculated as the maximal SV minus the minimal
parenteral vasoactive agents[1]. Because of SV divided by the average of these two pressures. It
pathophysiologic relevance of intravascular volume is also expressed as a percentage.
for both systolic and diastolic HF, the most critical Finally, commercial modules exist that determine
aspect of intraoperative and postoperative variability in the amplitude of the pulse oximetry
monitoring for HF patients involves careful fluid waveform. The variability in pulse oximeter
management. “Static” variables are those that plethysmography waveform (ΔPOP) is calculated as
estimate cardiac filling pressure or cardiac filling the maximal minus minimal plethysmographic
volume (as an estimate of end-diastolic volume, or amplitude, divided by the maximal amplitude. This
preload) [47]. Central venous catheters are placed too can be determined over one respiratory cycle.
for tracking changes in filling pressure but in All of the examples of static and dynamic
isolation will not discriminate between changes in methods of tracking intravascular volume changes
ventricular dysfunction and volume overload. The have advantages and disadvantages, including cost
pulmonary arterial catheter estimates changes in left and training expertise. Moreover, ventricular
ventricular filling pressure (pulmonary diastolic and systolic and diastolic dysfunction associated with
wedge pressure) and provides thermodilution-based HF may have a confounding effect on these
measures of cardiac output. variables. No readily available technique has
Even with minimal user training, transesophageal demonstrated superiority. In this context, one must
echocardiography (TEE) provides real-time image practice the basics of fluid management, including
estimates of end-diastolic ventricular volume, and maintenance fluid requirements, surgery-specific
global and regional ventricular contractile function insensible losses, urine output, estimated blood loss,
[48]. TEE is often considered the monitor of choice and careful fluid resuscitation.
to differentiate between cardiogenic, hypovolemic,
and vasodilatory causes of shock. The intrathoracic Postoperative Management: Postoperative
thermodilution method utilizes a central venous line planning for HF patients depends on the
for injection of iced saline, and a thermodilution preoperative functional status, the complexity of the
catheter in a proximal artery (i.e., femoral or axillary) procedure including intravascular fluid shifts, and
to sense the temperature change from the cold saline potential for postoperative acute decompensating
injection [49]. The accompanying commercial HF. Cardiac devices must be interrogated and
monitor module estimates stroke volume and reactivated when available. Large intraoperative
intrathoracic blood volume and global end-diastolic fluid shifts increase the risk for major adverse
volume without dependence on the respiratory cycle. cardiac events and acute congestion. The entire
“Dynamic” variables estimate changes in clinical picture must be considered for postoperative
intravascular volume based on characteristics of the monitoring with a low threshold for intensive care.
arterial waveform that vary with the respiratory In summary, HF is a syndrome with multiple
cycle [47]. A regular rhythm is also necessary. classifications, etiologies, and treatment strategies.
During positive pressure ventilation, systolic blood Understanding the recently-standardized treatment
pressure variation is the difference between the algorithm will facilitate the preoperative evaluation.
maximum and minimum systolic pressure values Anesthesia providers need to recognize
over the respiratory cycle. Hypovolemia is compensated versus decompensated HF in order to
suggested when systolic pressure variation is greater guide decision-making. Careful anesthetic planning,
than 10 mmHg. Similarly, pulse pressure (PP) will device interrogation, fluid management, and
vary over the respiratory cycle in accord with postoperative monitoring will optimize perioperative
hypovolemia. management.
Pulse pressure variability can also be derived
from one respiratory cycle and is calculated as the Competing interests
maximal PP minus the minimal PP, divided by the
average of these two pressures, expressed as a The authors declare that they have no conflict of
percentage. Similarly, stroke volume (SV) varies interests.
over the respiratory cycle in accord with
hypovolemia. The calculation of SV variability References
requires a commercial module on the arterial line
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