At the end of the procedure, weaning from CPB was guided by TEE assessment and hemodynamic measurements. After de-airing the cardiac cavities and resumption of mechanical ventilation, the pump flow was gradually reduced allowing filling of the cardiac chambers. In addition to fluid loading, electrical atrio-ventricular pacing, vasopressors and inotropes drugs as well as intra-aortic neither balloon pump (IABP) were eventually introduced to target the specific hemodynamic endoints: LV end-diastolic diameter (up to preoperative values or 2.2 and 2.8 cm/m2), MAP between 65 and 100 mmHg and heart rate between 70 and 100 beats/minute (see Figure Figure11).Figure 1Weaning protocol from Cardio-Pulmonary-Bypass.

The investigators performing the TEE were not involved in any therapeutic decision during the weaning process and the attending anesthesiologist in charge of the patient was blinded to the diastolic measurements. Pulmonary artery catheters were inserted in patients receiving inotropic support at the admission on the Intensive Care Unit (ICU).Study endpointsThe diagnostic criteria for post-CPB LV dysfunction was based on the need of inotropic support for at least two hours (dobutamine ��5 mcg/kg/min, epinephrine >0.05 mcg/kg/min, milrinone >0.25 mcg/kg/min, norepinephrine >0.02 mcg/kg/min) in the presence of low MAP (<60 mmHg ascertained by both invasive and noninvasive pressure monitors) and with persistent, new or worsening LV functional impairment (for example, FAC (fractional area change) <40%). Secondary outcome variables were any postoperative cardiac adverse event occurring in the ICU such as myocardial infarct (troponin-I ��1.

5 ng/ml associated with new Q waves or ST segment abnormalities on the ECG, or with coronary artery intervention), supra-ventricular or ventricular arrhythmias (requiring anti-arrhythmic drugs or electrical cardioversion) and low cardiac output syndrome (cardiac index <2.2 L/min/m2, need for inotropic and/or IABP support to maintain MAP >65 mmHg).MeasurementsDuring primary hospitalization, data related to patient demographic information, comorbidities, current medications, intraoperative TEE examination, indexed effective orifice area [19], anesthetic and surgical management as well as postoperative cardiac outcome were prospectively collected on a case report form and entered in a dedicated database.A comprehensive TEE examination was performed before CPB using two-dimensional, M-mode, pulsed Doppler and TDI to assess systolic and diastolic LV function. In the transgastric short axis view, posterior wall thickness (PWT), LV end-diastolic and end-systolic areas (EDA and ESA, respectively) were Dacomitinib measured. FAC of the LV was computed as (LVEDA -LVESA)/LVEDA.