(197) VExUS-Guided Hemodynamic Management of Postoperative Pericardiectomy Acute Kidney Injury

Introduction: Constrictive pericarditis is challenging in both the pre- and postoperative setting and requires nuanced volume and inotropic management to ensure forward flow and prevent organ congestion. Venous excess ultrasound (VExUS) may be helpful to ensure that invasive measurements accurately reflect adequate preload in rapidly changing clinical conditions.

Description: A 58-year-old male with chronic constrictive pericarditis underwent coronary artery bypass grafting, mitral valve repair, tricuspid valve repair, and radical pericardiectomy after pulmonary artery catheter-guided volume optimization. Post-operatively, he had ongoing evidence of congestion by VExUS with low urine output (UO) on diuretics despite adequate cardiac index (CI) with central venous pressure (CVP) 12-13 on inotropic support while extubated. He was reintubated on postoperative day (POD) 3 for hypoxic respiratory failure from a combination of pulmonary edema and possible pneumonia. Post-intubation, he had mixed vasoplegic and cardiogenic shock with low CI and CVP 16-18, and oliguric acute kidney injury (AKI) despite furosemide infusion and inhaled epoprostenol. Echocardiography showed a severely dysfunctional and non-dilated right ventricle (RV) without any significant valvulopathies. VExUS on POD 5 confirmed ongoing congestion and dobutamine was added for additional forward flow support and diastolic relaxation, with improvement in UO. Progressive AKI with ongoing high CVP in setting of double inotropic support prompted consideration of renal replacement therapy (RRT) on POD 7. Repeat VExUS showed improvement in portal vein pulsatility, mean portal vein flow, and absence of renal congestion despite CVP 12-14, which delayed initiation of RRT. Creatinine ultimately plateaued and then decreased by POD 10, with progressive decrease in inotropic support.

Discussion: Constrictive pericarditis is a challenging disease process to manage. Traditional measurements of volume status such as CVP may not be reliable in the setting of rapidly changing vasomotor tone, negative vs positive pressure ventilation, and type of inotropic support. VExUS can provide information about the impact of filling pressures on end-organ congestion in the setting of difficult to interpret traditional echocardiographic findings.