Impact of FloTrac/EV1000-guided intraoperative hemodynamic optimization on postoperative outcomes in cardiac valve surgery: a randomized controlled trial

Impact of FloTrac/EV1000-guided intraoperative hemodynamic optimization on postoperative outcomes in cardiac valve surgery: a randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of FloTrac/EV1000-guided intraoperative hemodynamic optimization on postoperative outcomes in cardiac valve surgery: a randomized controlled trial Sirirat Tribuddharat, Panaratana Ratanasuwan, Thepakorn Sathitkarnmanee, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7157970/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Cardiac valve surgery is associated with significant postoperative morbidity and mortality. This study evaluated the impact of intraoperative hemodynamic optimization using FloTrac/EV1000 on postoperative outcomes in patients undergoing cardiac valve surgery. Methods In this single-center, prospective, randomized controlled trial, 82 patients undergoing elective cardiac valve surgery were randomly allocated to either FloTrac/EV1000 management (EV1000 group, n = 42) or conventional management (Control group, n = 40). The primary outcomes were ICU length of stay, duration of mechanical ventilation, and hospital length of stay. Secondary outcomes included vasoactive drug requirements, fluid balance, and postoperative complications. Results The EV1000 group had significantly shorter ICU stay (44.6 ± 6.3 vs. 63.9 ± 39.9 hours, p = 0.002) and hospital stay (11.4 ± 2.9 vs 13.2 ± 4.0 days, p = 0.021) compared to the Control group. The EV1000 group required more vasoactive drugs during pre-bypass (p = 0.018) but fewer before ICU transfer (p = 0.003) and during their ICU stay (p < 0.05). The incidence of postoperative ventricular fibrillation (0% vs 15.0%, p = 0.011), bradycardia (11.9% vs. 35.0%, p = 0.016), atrial fibrillation with rapid ventricular response (14.3% vs. 25.0%, p = 0.032), acute respiratory distress syndrome (0% vs. 5.0%, p = 0.045), and acute kidney injury (0% vs. 5.0%, p = 0.045) was lower in the EV1000 group. Conclusions FloTrac/EV1000-guided hemodynamic optimization in cardiac valve surgery resulted in shorter ICU and hospital stays, reduced postoperative vasoactive drug requirements, and fewer postoperative complications compared to conventional management. Trial registration NCT04292951 (The full date of first registration on ClinicalTrials.gov: March 1, 2020) Cardiac valve surgery Hemodynamic optimization FloTrac EV1000 Postoperative outcomes Goal-directed therapy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Cardiac valve surgery elicits a more pronounced systemic inflammatory response, as evidenced by higher interleukin-6 (IL-6) levels compared to coronary artery bypass grafting (CABG) [ 1 ], and remains associated with considerable postoperative morbidity and mortality. The 30-day mortality is about 4–6%, nearly two-fold higher than CABG [ 2 ], with complications occurring in up to 0.7–3.5% per patient-year [ 3 ]. Major postoperative complications include atrial fibrillation (30–64%) [ 4 ], acute kidney injury (10–30%) [ 5 ], respiratory complications (10–30%) [ 6 ], and coagulopathy (5–15%) [ 7 ]. Specifically, post-valve surgery atrial fibrillation occurs in 30–50% of patients, potentially prolonging hospital stay and increasing healthcare costs [ 8 ]. Acute kidney injury after valve surgery is associated with a 5-fold increase in mortality risk [ 5 ], while major bleeding complications necessitating reoperation occur in 2–8% of cases [ 9 ]. Optimal perioperative hemodynamic management is crucial for improving outcomes; however, standardized protocols remain a topic of debate. The increasing complexity of valve procedures, often combined with CABG, presents additional challenges for intraoperative hemodynamic stability [ 10 ]. Goal-directed therapy (GDT) using minimally invasive cardiac output monitoring has shown promise in reducing complications and length of stay in major surgery [ 11 ]. However, the unique physiological changes during cardiopulmonary bypass and the specific hemodynamic targets for different valve pathologies create uncertainty about optimal management strategies. Traditional monitoring approaches rely heavily on static parameters and clinical experience, which may not adequately reflect the dynamic nature of cardiac performance during and after valve surgery [ 12 ]. Currently, two commonly utilized systems for minimally invasive cardiac output monitoring are the FloTrac/EV1000 and PiCCO. Both systems have demonstrated comparable performance in predicting fluid responsiveness [ 13 ]. The FloTrac/EV1000 system is preferred due to its calibration-free operation, whereas the PiCCO system necessitates calibration via the thermodilution technique. The FloTrac/EV1000 system (Edwards Lifesciences, Irvine, CA, USA) provides continuous cardiac output monitoring and dynamic parameters through arterial waveform analysis, offering potential advantages for guiding fluid and vasoactive (inotropes/vasopressors/vasodilators) therapy [ 14 , 15 ]. Stroke volume variation (SVV) was initially validated as a predictor of fluid responsiveness in closed-chest patients, leading to caution against its use in open-chest settings. However, more recent research has demonstrated that SVV, along with pulse pressure variation (PPV), remains a reliable tool for assessing fluid responsiveness even in patients undergoing open-chest or open-pericardial procedures [ 16 , 17 ]. Recent studies have demonstrated its efficacy in coronary artery bypass grafting (CABG), where its use was associated with reduced vasoactive drug requirements and shorter intensive care unit (ICU) stays [ 14 ]. In off-pump CABG procedures, hemodynamic optimization guided by FloTrac/EV1000 was associated with a shorter ICU stay and reduced hospital length of stay compared to conventional monitoring [ 14 ]. While these findings are promising for cardiac surgery in general, evidence specifically addressing its impact on valve surgery outcomes remains limited. A recent meta-analysis suggests that protocol-driven hemodynamic optimization can reduce postoperative complications, particularly in high-risk cardiac surgical patients [ 18 ]. However, the optimal monitoring platform and specific intervention thresholds remain undefined. The FloTrac/EV1000 system's ability to provide real-time SVV, stroke volume (SV)/Stroke volume index (SVI), cardiac output (CO)/cardiac index (CI), and systemic vascular resistance (SVR)/systemic vascular resistance index (SVRI) measurements without pulmonary artery catheterization may offer advantages for guiding perioperative management. This randomized controlled trial evaluated the effects of FloTrac/EV1000-guided intraoperative hemodynamic optimization on postoperative outcomes in cardiac valve surgery. We hypothesized that a GDT approach, targeting SVV, CI, and SVRI, would reduce vasoactive drug requirements, shorten ICU length of stay, and decrease postoperative complications compared to conventional management. Methods Study Design and Patient Population This prospective randomized controlled trial was approved by the Khon Kaen University Ethics Committee in Human Research (IRB: HE611321, September 11, 2019) and registered at ClinicalTrials.gov (NCT04292951, March 1, 2020) before commencement. The study adhered to the Declaration of Helsinki, ICH GCP guidelines, and CONSORT reporting standards. Written informed consent was obtained from all participants. The trial included two groups of participants randomized in a 1:1 ratio to either the FloTrac/EV1000-guided hemodynamic management (EV1000 group) or the conventional management (Control group). The sample size was calculated to detect a 25% reduction in ICU length of stay after cardiac surgery, based on data from a previous study reporting a mean ICU stay of 4.9 ± 1.8 days [ 12 ]. Assuming a significance level (α) of 0.05, a power of 80%, and accounting for a 20% dropout rate, 40 patients per group were required. Randomization was performed using a computer-generated block-of-four sequence, with allocation concealment ensured via sealed opaque envelopes. Inclusion criteria were: age 18–80 years, elective cardiac valve surgery (with or without concomitant CABG) at Srinagarind Hospital or Queen Sirikit Heart Center of the Northeast, Khon Kaen University, Khon Kaen, Thailand, and American Society of Anesthesiologists (ASA) classification 2–4. Patients were excluded if they required emergency or redo surgery, preoperative intra-aortic balloon pump, or had severe pulmonary hypertension. Blinding of patients and outcome assessors was implemented. Anesthesia and Monitoring All patients received standardized anesthetic care in accordance with institutional protocols. Standard monitoring included electrocardiography, pulse oximetry, non-invasive blood pressure measurement, capnography, nasopharyngeal temperature monitoring, and urine output assessment. Radial artery cannulation was performed in all patients. In the Control group, the arterial line was connected to a standard pressure transducer for invasive blood pressure (IBP) monitoring. In the EV1000 group, a FloTrac transducer connected to the EV1000 monitor (Edwards Lifesciences, Irvine, CA, USA) was used to measure IBP, SVV, SVI, and CI. To ensure comparability, all measured values were normalized to the patient's body surface area using index values in this study. Internal jugular/subclavian vein cannulation was also performed in all patients. In the Control group, the catheter was connected to a standard pressure transducer for central venous pressure (CVP) measurement. In contrast, the EV1000 group utilized a pressure transducer integrated with the FloTrac/EV1000 system to monitor SVRI. During cardiopulmonary bypass (CPB), the absence of a pulsatile arterial waveform precludes FloTrac monitoring. Anesthesia was induced with titrated propofol (1.5-2 mg/kg) or etomidate (0.2–0.3 mg/kg), and fentanyl (2–5 µg/kg) intravenously, followed by endotracheal intubation facilitated with cisatracurium (0.2 mg/kg) intravenously. Anesthesia was maintained with 50–60% oxygen in air and 1–2% sevoflurane or 3–6% desflurane, titrated to 0.7–0.8 minimum alveolar concentration (MAC). CPB was initiated after heparinization (3–4 mg/kg via the central venous catheter) with an activated clotting time (ACT) > 480 seconds, maintained above 400–480 seconds with supplemental heparin (0.5-1 mg/kg). Moderate hypothermia (32°C) was maintained during CPB. Cardioplegia was administered via an aortic root catheter, with supplemental doses as needed at the surgeon's discretion. Mean arterial pressure (MAP) was maintained between 50–75 mmHg during CPB. Protamine (0.7-1 mg per 1 mg of pre-CPB heparin) was slowly administered intravenously for heparin reversal after CPB weaning. Postoperatively, patients were transferred to the ICU and received standard ICU care. They were either mechanically ventilated or extubated for spontaneous ventilation. Extubation criteria included: adequate consciousness and motor strength, cardiovascular stability, a PaO 2 /FiO 2 ratio ≥ 250 mmHg, and a respiratory rate of 10–25 breaths/min. ICU discharge criteria were: adequate consciousness and neurological status, cardiovascular stability without inotropic or vasopressor support, stable respiratory status with < 60% oxygen requirement, and no need for ICU monitoring. Hospital discharge criteria included: cardiovascular and respiratory stability, removal of all drains and catheters, normal ambulation, absence of infection or serious complications, wound suture removal, and tolerance to a normal diet. Intraoperative Hemodynamic Management Protocol The Control Group : Hemodynamic management was at the discretion of the attending anesthesiologists, who administered fluids, inotropes, and/or vasoactive medications as needed to maintain the following targets: MAP 65–90 mmHg, CVP 8–12 mmHg, urine output ≥ 0.5 mL/kg/h, SpO₂ ≥ 95%, and hematocrit 26–30% (22–25% during CPB). Hourly arterial blood gas analysis and electrolyte monitoring with appropriate correction were performed. The EV1000 Group Hemodynamic management in this group aimed to achieve similar targets ( MAP 65–90 mmHg, urine output ≥ 0.5 mL/kg/h, SpO₂ ≥ 95%, and hematocrit 26–30% [22–25% during CPB] ) but was guided by a structured algorithm utilizing FloTrac/EV1000-derived parameters (Fig. 1 ) Step 1: Preload assessment Preload adequacy was initially assessed using SVV, with a threshold of 10–13%. If SVV > 10–13%, a fluid challenge with 50–100 mL of crystalloid over 5–10 minutes was administered. In patients with anemia or coagulopathy, blood or blood components were transfused as needed. For those with signs of volume overload, diuretic therapy was considered. Following preload optimization (SVV < 10–13%), patients were classified based on MAP. If MAP ≥ 65 mmHg, the patient was considered purely hypovolemic. If MAP remained below 65 mmHg, further management was guided by assessments of afterload and contractility to determine the appropriate intervention. Step 2: Afterload assessment For low SVRI (< 1,800 dynes/sec/cm 5 /m 2 ): If systolic arterial pressure (SAP) < 90 mmHg or MAP < 65 mmHg with heart rate (HR) < 70 bpm, administer an intravenous ephedrine bolus of 3–6 mg. If SAP < 90 mmHg or MAP 70 bpm, administer norepinephrine (4–8 µg) or phenylephrine (50–100 µg) as an intravenous bolus. For high SVRI (> 2,500 dynes/sec/cm 5 /m 2 ): If SAP > 140 mmHg or MAP > 90 mmHg with HR 140 mmHg or MAP > 90 mmHg with HR > 70 bpm, administer an intravenous diltiazem bolus of 2–5 mg. Step 3 Contractility assessment For low CI ( 2,500 dynes/sec/cm⁵/m² with SAP < 90 mmHg or MAP < 65 mmHg, administer an intravenous low-dose epinephrine bolus (5–10 µg) or initiate a dobutamine infusion. If SVRI < 1,500 dynes/sec/cm⁵/m² with SAP < 90 mmHg or MAP 0.2 µg/kg/min). For high CI (> 5.5-6.0 L/min/m²) indicating a hyperdynamic state in septic shock: If SVRI < 1,200 dynes/sec/cm⁵/m² with SAP < 90 mmHg or MAP < 65 mmHg, initiate an intravenous infusion of norepinephrine or phenylephrine, along with treatment for the underlying cause of septic shock. Data Collection and Outcomes Collected data included primary outcomes such as ICU length of stay, duration of mechanical ventilation, and total hospital length of stay. Secondary outcomes encompassed vasoactive drug requirements (types and number of drugs) at different phases—pre-CPB, post-CPB, transfer to the ICU, and in the ICU—along with fluid balance and postoperative complications. Statistical Analysis The normality of continuous data was assessed using the Shapiro-Wilk test. Normally distributed data are presented as mean ± standard deviation (SD) and were compared using the unpaired Student's t-test. Non-normally distributed data are presented as median (interquartile range) and were compared using the Mann-Whitney U test. Categorical data are presented as number (%) and analyzed using the appropriate chi-squared (χ²) test or Fisher’s exact test. The primary outcome is reported as the mean difference with a 95% confidence interval (CI). Statistical significance was defined as P < 0.05. All analyses were conducted using SPSS 16.0 (SPSS Inc., Chicago, IL, USA). Results A total of 82 patients were recruited between March 2021 and February 2022, with 42 patients in the EV1000 group and 40 in the Control group (Fig. 2 ). Baseline characteristics were generally comparable between the groups. The EV1000 group had a significantly higher baseline prevalence of congestive heart failure (a clinical syndrome in which the heart is unable to pump blood effectively to meet the body's demands and requires medical treatment) (23.8% vs. 2.5%, p = 0.004) (Table 1 ). Table 1 Patient characteristics and perioperative clinical data (n = 82) EV1000 (n = 42) Control (n = 40) p value Sex : male/female 28 (66.7)/14 (33.3) 26 (65.0)/14 (35.0) 0.872 Age (y) 61.2 ± 10.5 63.0 ± 8.6 0.397 Body weight (kg) 60.5 ± 9.1 59.7 ± 9.7 0.701 Height (cm) 161.6 ± 8.9 163.5 ± 9.0 0.339 Ejection fraction (%) 58.6 ± 15.3 61.4 ± 15.4 0.411 Type of operation 0.442 MV repair/MVR 5 (11.9)/6 (14.3) 2 (5.0)/1 (2.5) MV repair + CABG 7 (16.7) 6 (15.0) MVR & TVA/MVR & TVA + CABG 4 (9.5)/2 (4.8) 4 (10.0)/1 (2.5) AVR 7 (16.7) 6 (15.0) AVR + CABG 10 (23.8) 5 (12.5) AVR & MV repair + CABG 1 (2.4) 1 (2.5) AVR & TVA/AVR & TVA + CABG 1(2.4)/1 (2.4) 0 (0)/1 (2.5) AVR & ascending aortic graft 1 (2.4) 0 (0) DVR & TVA ± LAA Closure 1 (2.4) 1 (2.5) DVR/DVR + CABG 1 (2.4)/2 (4.8) 1 (2.5)/2 (5.0) TVA & maze procedure 0 (0) 1 (2.5) TVA & ASD closer 1 (2.4) 2 (5.0) TVA & ASD closer + CABG 0 (0) 1 (2.5) Functional class 0.846 2 24 (57.1) 25 (62.5) 3 17 (40.5) 15 (37.5) 4 1 (2.4) 0 (0) ASA classification 0.703 2 12 (25.0) 13 (30.0) 3 30 (62.5) 27 (70.0) Underlying diseases Hypertension 20 (47.6) 18 (45.0) 0.812 Diabetes mellitus 14 (33.3) 11 (27.5) 0.567 Myocardial ischemia 24 (57.1) 19 (47.5) 0.382 Dyslipidemia 5 (11.9) 4 (10.0) 0.784 Congestive heart failure 10 (23.8) 1 (2.5) 0.004* Atrial fibrillation 8 (19.0) 10 (25.0) 0.513 Chronic kidney disease 12 (28.6) 6 (15.0) 0.138 Old cardiovascular accident 2 (4.8) 3 (7.5) 0.596 Coagulopathy 6 (14.3) 6 (15.0) 0.927 Preoperative Creatinine (mg/dL) 1.6 ± 2.0 1.0 ± 0.3 0.058 Sodium (mEq/L) 138.9 ± 3.0 139.6 ± 2.4 0.245 Potassium (mEq/L) 4.2 ± 0.4 4.1 ± 0.4 0.261 Blood sugar (mg/dL) 122.1 ± 50.2 114.8 ± 42.3 0.478 Hemoglobin (g/dL) 12.4 ± 2.0 12.6 ± 1.9 0.644 Albumin (mg/dL) 4.3 ± 0.4 4.1 ± 0.4 0.026* Platelet (x10 9 /L) 232.7 ± 88.7 239.3 ± 86.6 0.734 INR 1.1 ± 0.3 1.0 ± 0.4 0.205 Lactate (mmol/L) 0.9 ± 0.3 1.1 ± 0.4 0.012* Anesthesia time (min) 380.5 ± 88.5 362.4 ± 101.6 0.386 CPB time (min) 145.5 ± 42.0 139.5 ± 50.2 0.552 Aortic cross-clamp (min) 98.3 ± 27.3 90.5 ± 35.1 0.258 Operation time (min) 318.5 ± 83.2 310.4 ± 98.4 0.683 Crystalloid intake (mL) 1,576.7 ± 600.5 1,538.2 ± 663.6 0.784 Blood loss (mL) 1,023.3 ± 248.8 1,056.6 ± 293.9 0.574 Urine output (mL) 1,391.3 ± 727.6 993.4 ± 612.7 0.009* Data are presented as mean ± SD or n (%) * p < 0.05 MV, mitral valve; MVR, mitral valve replacement; CABG, coronary artery bypass graft; TVA, tricuspid valve annuloplasty; AVR, aortic valve replacement; DVR, double valve replacement; LAA, left atrial appendage; ASD, atrial septal defect; INR, international normalized ratio; CPB, cardiopulmonary bypass Preoperative laboratory values were similar across groups, though the EV1000 group had higher albumin levels (4.3 ± 0.4 vs. 4.1 ± 0.4 mg/dL, p = 0.026) and lower lactate levels (0.9 ± 0.3 vs. 1.1 ± 0.4 mmol/L, p = 0.012) (Table 1 ). The distribution of surgical procedures was similar between the groups (p = 0.442). Duration of anesthesia, CPB time, and aortic cross-clamp time were also comparable. However, the EV1000 group exhibited significantly higher urine output (1,391.3 ± 727.6 vs. 993.4 ± 612.7 mL, p = 0.009) (Table 1 ). The EV1000 group had a significantly shorter ICU stay (44.6 ± 6.3 vs. 63.9 ± 39.9 hours, mean difference: -19.3 hours, 95% CI: -31.8 to -6.8, p = 0.002) and a shorter hospital stay (11.4 ± 2.9 vs. 13.2 ± 4.0 days, mean difference: -1.8 days, 95% CI: -3.3 to -0.3, p = 0.021). Ventilation time was comparable between groups (13.3 ± 7.1 vs. 13.5 ± 12.1 hours, p = 0.924) (Table 2 ). Table 2 Postoperative outcomes (n = 82) EV1000 n = 42 Control n = 40 Mean difference 95% CI p value ICU stay (h) 44.6 ± 6.3 63.9 ± 39.9 -19.3 -31.8 to -6.8 0.002* Ventilator time (h) 13.3 ± 7.1 13.5 ± 12.1 -0.2 -4.5 to 4.1 0.924 Hospital stay (d) 11.4 ± 2.9 13.2 ± 4.0 -1.8 -3.3 to -0.3 0.021* Data are presented as mean ± SD * p < 0.05 ICU, intensive care unit Regarding vasoactive drug requirements in the operating room, the EV1000 group required more concurrent drugs during the pre-bypass phase (p = 0.018), showed no significant difference post-bypass (p = 0.267), and required fewer drugs before ICU transfer (p = 0.003) (Fig. 3 ). Immediately upon ICU admission, the EV1000 group required significantly less epinephrine (p = 0.001) and nitroglycerin (NTG) (p = 0.044). Over the total ICU stay, the EV1000 group required significantly less epinephrine (p < 0.001), dobutamine (p = 0.039), NTG (p = 0.033), and nicardipine (p = 0.027) (Fig. 4 ). The EV1000 group demonstrated a lower incidence of ventricular fibrillation (VF) (0% vs. 15.0%, p = 0.011), bradycardia (11.9% vs. 35.0%, p = 0.016), atrial fibrillation (AF) with rapid ventricular response (RVR) (14.3% vs. 25.0%, p = 0.032), acute respiratory distress syndrome (ARDS) (0% vs. 5.0%, p = 0.045), and acute kidney injury (AKI) (0% vs. 5.0%, p = 0.045). Other complications, including supraventricular tachycardia, temporary pacemaker use, thrombocytopenia, AF with slow ventricular response, complete heart block, reintubation, and coagulopathy, showed no significant differences between groups (Fig. 5 ). Discussion This randomized controlled trial demonstrated that GDT using FloTrac/EV1000-guided hemodynamic management in cardiac valve surgery resulted in shorter ICU and hospital stays, reduced vasoactive drug requirements, and fewer postoperative complications compared to conventional management. The 19.3-hour reduction in ICU stay and 1.8-day decrease in hospital stay represent clinically significant findings. The pattern of vasoactive drug use varied notably between groups. While the EV1000 group required more vasoactive support during the pre-bypass period, they needed significantly fewer drugs before ICU transfer and throughout their ICU stay. This suggests that early hemodynamic optimization during the pre-bypass period may enhance cardiovascular stability in the postoperative period. The reduced vasoactive drug requirements in the ICU indicate better hemodynamic stability, likely contributing to the shorter ICU and hospital stays. Regarding postoperative complications, VF is an uncommon complication, with a reported incidence of 0.95%. The underlying mechanism of VF remains unclear, though elevated catecholamine levels and autonomic imbalance during the early recovery period of surgery may contribute to the initiation of dysrhythmias [ 19 ]. Postoperative bradycardia occurred in 5.25% of patients, with half requiring temporary cardiac pacing. Risk factors for postoperative bradycardia include the adequacy of intraoperative myocardial perfusion [ 20 ]. The lower incidence of postoperative arrhythmias (VF, bradycardia, and AF with RVR) in the EV1000 group is particularly noteworthy. The reduced incidence of postoperative AF with RVR (14.3% vs 25.0%) was consistent with the findings of Tribuddharat et al., which showed that GDT using FloTrac/EV1000 reduced the incidence of AF with RVR in patients undergoing CABG and off-pump coronary artery bypass (OPCAB) [ 14 , 15 ]. This reduction may be attributed to better perioperative hemodynamic optimization, as unstable hemodynamics and suboptimal tissue perfusion are well-recognized risk factors for postoperative arrhythmias [ 21 ]. The greater postoperative use of epinephrine in the Control group (p < 0.001), may have increased beta-adrenergic stimulation, potentially contributing to the higher incidence of ventricular fibrillation (15% vs. 0%) and atrial fibrillation with rapid ventricular response (25% vs. 14.3%) observed. This difference, possibly due to discretionary management, highlights the need for standardized postoperative protocols. The incidence of ARDS in the perioperative period of cardiac surgery has been reported to range from 0.4–8.1% [ 22 ]. The complete absence of ARDS in the EV1000 group in this study highlights the potential benefit of hemodynamic optimization using FloTrac/EV1000. Despite similar fluid administration between groups, the significantly higher urine output observed in the EV1000 group suggests better renal perfusion, which may explain the lower incidence of postoperative AKI. Our study showed a more substantial reduction in AKI (0% vs 5%) compared to the previous report by Meersch et al. (55.1% vs 71.7%) [ 23 ]. This improved renal outcome might be attributed to our strict adherence to hemodynamic optimization protocols and the higher urine output observed in the EV1000 group. This finding supports the idea that optimized hemodynamic management can help preserve organ function, particularly during the vulnerable perioperative period [ 24 ]. Interestingly, despite the higher incidence of preoperative congestive heart failure in the EV1000 group, these patients demonstrated better outcomes. This finding suggests that FloTrac/EV1000-guided management may be particularly beneficial for cardiac surgery patients. Although the EV1000 group showed statistically significant differences in higher albumin levels (4.3 vs. 4.1 g/dL, p = 0.026) and lower lactate levels (0.9 vs. 1.1 mmol/L, p = 0.012), both values remain within the normal physiological range and therefore are not considered clinically significant to influence the study outcomes. Since the FloTrac/EV1000 system derives hemodynamic information from the arterial waveform, it is limited during the CPB period, as the absence of an arterial waveform prevents the system from displaying any data. Our findings have important clinical implications for perioperative management in cardiac valve surgery. They align with several recent studies on minimally invasive cardiac output monitoring in cardiac surgery. GDT using FloTrac/EV1000 reduced ICU stay and the use of vasopressor or inotropic drugs in patients undergoing cardiac, including CABG and OPCAB surgery [ 12 , 14 , 15 , 25 , 26 ]. The 19.3-hour reduction in ICU stay observed in our study was comparable to the findings of Kapoor et al. who reported a mean reduction of 2.3 days in moderate to high-risk cardiac surgery patients [ 12 ]. In patients undergoing CABG and OPCAB, Kapoor et at. reported a reduction in ICU stay of 0.33 and 1.7 days [ 25 , 26 ], while Tribuddharat et al. reported a reduction of 29.5 hours and 1.3 days, respectively [ 14 , 15 ]. Our structured GDT algorithm provided a systematic approach to hemodynamic management through a stepwise assessment of preload, contractility, and afterload (Fig. 1 ). By incorporating specific intervention thresholds, including HR and SVRI for drug selection, the algorithm enabled precise hemodynamic optimization. This approach differs from a previous expert review that relied on more generalized hemodynamic targets, such as pulse pressure variation, pleth variability index, and changes in stroke volume during a mini-fluid challenge or passive leg raising [ 27 ]. The observed pattern of vasoactive drug use—with more intensive optimization pre-bypass followed by reduced postoperative requirements—reflects the structured nature of the algorithm. The higher initial vasoactive requirements in the EV1000 group likely resulted from strict adherence to specific hemodynamic thresholds, including MAP > 65 mmHg, CI > 2.2 L/min/m², and SVV < 10–13%. We prefer to give vasoactive drugs as titrated bolus doses when indicated to restore the deviated parameters to normal ranges as soon as possible. Our principle of “ identify the right causes, give the right drugs, at the right time ” ensures optimal organ perfusion throughout the perioperative period, thereby minimizing postoperative vasoactive drug requirements and reducing complications. This proactive approach to hemodynamic management may explain the observed improvements in postoperative stability and the reduction in complications The investment in advanced hemodynamic monitoring technology appears justified by the reduction in complications and length of stay, which likely leads to lower healthcare costs and improved patient outcomes [ 28 ]. The implementation of FloTrac/EV1000-guided management protocols could be particularly beneficial for high-risk cardiac surgical patients, where precise hemodynamic optimization is crucial. Limitations The main limitation of this study is its single-center nature and relatively small sample size. Additionally, the inability to blind the anesthesiologists to group allocation may have introduced some bias. Future multicenter studies with larger populations are needed to confirm these findings and establish optimal hemodynamic targets for specific valve pathologies. Given the demonstrated intraoperative benefits of the FloTrac/EV1000 system, its application in postoperative ICU monitoring warrants consideration. However, advanced systems such as PiCCO, which provide measurements of extravascular lung water and global end-diastolic volume, may offer complementary data for optimizing fluid management and addressing respiratory complications in the ICU. Future studies are needed to compare the performance and clinical utility of these monitoring systems in the postoperative setting. Conclusions Goal-directed hemodynamic management using FloTrac/EV1000 monitoring in cardiac valve surgery reduced ICU and hospital length of stay, postoperative vasoactive drug requirements, and major complications. The structured algorithm incorporating SVV, CI, SVRI, and HR parameters provided an effective framework for optimizing hemodynamic stability. This approach was particularly beneficial in reducing postoperative arrhythmias and organ dysfunction. Future multicenter studies should focus on refining hemodynamic targets for specific valve pathologies. Abbreviations ACT Activated clotting time AF Atrial fibrillation AKI Acute kidney injury ARDS Acute respiratory distress syndrome ASA American Society of Anesthesiologists CABG Coronary artery bypass grafting CI Cardiac index CO Cardiac output CPB Cardiopulmonary bypass CVP Central venous pressure GDT Goal-directed therapy HR Heart rate IBP Invasive blood pressure ICU Intensive care unit MAC Minimum alveolar concentration MAP Mean arterial pressure NTG Nitroglycerine OPCAB Off-pump coronary artery bypass PPV Pulse pressure variation RVR Rapid ventricular response SAP Systolic blood pressure SV Stroke volume SVI Stroke volume index SVR Systemic vascular resistance SVRI Systemic vascular resistance index SVV Stroke volume variation VF Ventricular fibrillation Declarations Ethics approval and consent to participate This study was approved by The Khon Kaen University Ethics Committee in Human Research (HE611321; approved on September 11, 2019). Written informed consent was obtained from all participants prior to enrollment. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests" in this section. Funding Not applicable. Authors’ contribution Conception and design: ST, PR, and TS. Registration of clinical trial: TS. Data collection: ST, NC, LP, and PM. Analysis and interpretation of the data: ST, PR, and TS. Writing the manuscript: ST, PR, and TS. All authors read and approved the final version of the manuscript. References Takayama H, Soltow LO, Chandler WL, Vocelka CR, Aldea GS. Does the type of surgery effect systemic response following cardiopulmonary bypass? J Card Surg. 2007;22:307-13. Liu Y, Xiao J, Duan X, Lu X, Gong X, Chen J, et al. The multivariable prognostic models for severe complications after heart valve surgery. BMC Cardiovasc Disord. 2021;21:491. Misawa Y. Valve-related complications after mechanical heart valve implantation. Surg Today. 2015;45:1205-9. Rho RW. The management of atrial fibrillation after cardiac surgery. Heart. 2009;95:422-9. O'Neal JB, Shaw AD, Billings FTt. Acute kidney injury following cardiac surgery: current understanding and future directions. Crit Care. 2016;20:187. Mohamed MA, Cheng C, Wei X. Incidence of postoperative pulmonary complications in patients undergoing minimally invasive versus median sternotomy valve surgery: propensity score matching. J Cardiothorac Surg. 2021;16:287. Bolliger D, Tanaka KA. Coagulation Management Strategies in Cardiac Surgery. Curr Anesthesiol Rep. 2017;7:265-72. Kalra R, Patel N, Doshi R, Arora G, Arora P. Evaluation of the Incidence of New-Onset Atrial Fibrillation After Aortic Valve Replacement. JAMA Intern Med. 2019;179:1122-30. Bolliger D, Tanaka KA. Point-of-Care Coagulation Testing in Cardiac Surgery. Semin Thromb Hemost. 2017;43:386-96. Potestio C, Xu X. Intraoperative Hemodynamic Monitoring for the Cardiac Surgery Patient. In: Awad MDMBAAS, editor. Cardiac Anesthesia: The Basics of Evaluation and Management. Cham: Springer International Publishing; 2021. p. 155-79. Giglio M, Biancofiore G, Corriero A, Romagnoli S, Tritapepe L, Brienza N, et al. Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis. J Anesth Analg Crit Care. 2021;1:26. Kapoor PM, Kakani M, Chowdhury U, Choudhury M, Lakshmy, Kiran U. Early goal-directed therapy in moderate to high-risk cardiac surgery patients. Ann Card Anaesth. 2008;11:27-34. Hofer CK, Senn A, Weibel L, Zollinger A. Assessment of stroke volume variation for prediction of fluid responsiveness using the modified FloTrac and PiCCOplus system. Crit Care. 2008;12:R82. Tribuddharat S, Sathitkarnmanee T, Ngamsangsirisup K, Nongnuang K. Efficacy of Intraoperative Hemodynamic Optimization Using FloTrac/EV1000 Platform for Early Goal-Directed Therapy to Improve Postoperative Outcomes in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Randomized Controlled Trial. Med Devices (Auckl). 2021;14:201-9. Tribuddharat S, Sathitkarnmanee T, Ngamsaengsirisup K, Sornpirom S. Efficacy of early goal-directed therapy using FloTrac/EV1000 to improve postoperative outcomes in patients undergoing off-pump coronary artery bypass surgery: a randomized controlled trial. J Cardiothorac Surg. 2022;17:196. Reuter DA, Goepfert MS, Goresch T, Schmoeckel M, Kilger E, Goetz AE. Assessing fluid responsiveness during open chest conditions. Br J Anaesth. 2005;94:318-23. Sander M, Spies CD, Berger K, Grubitzsch H, Foer A, Kramer M, et al. Prediction of volume response under open-chest conditions during coronary artery bypass surgery. Crit Care. 2007;11:R121. Aya HD, Cecconi M, Hamilton M, Rhodes A. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth. 2013;110:510-7. Yeung-Lai-Wah JA, Qi A, McNeill E, Abel JG, Tung S, Humphries KH, et al. New-onset sustained ventricular tachycardia and fibrillation early after cardiac operations. Ann Thorac Surg. 2004;77:2083-8. Udzik J, Sienkiewicz S, Biskupski A, Szylinska A, Kowalska Z, Biskupski P. Cardiac Complications Following Cardiac Surgery Procedures. J Clin Med. 2020;9:3347. Vincent JL, Pelosi P, Pearse R, Payen D, Perel A, Hoeft A, et al. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. Crit Care. 2015;19:224. Sanfilippo F, Palumbo GJ, Bignami E, Pavesi M, Ranucci M, Scolletta S, et al. Acute Respiratory Distress Syndrome in the Perioperative Period of Cardiac Surgery: Predictors, Diagnosis, Prognosis, Management Options, and Future Directions. J Cardiothorac Vasc Anesth. 2022;36:1169-79. Meersch M, Zarbock A. Prevention of cardiac surgery-associated acute kidney injury. Curr Opin Anaesthesiol. 2017;30:76-83. Xiao C, Yang M, Cao L, Chen F, Jing S, Tan Y, et al. The impact of intraoperative hypotension on postoperative acute kidney injury, mortality and length of stay following off-pump coronary artery bypass grafting surgery: a single-center retrospective cohort study. BMC Anesthesiol. 2024;24:224. Kapoor PM, Magoon R, Rawat R, Mehta Y. Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: "A clinical outcome and biomarker-based study". Ann Card Anaesth. 2016;19:638-82. Kapoor PM, Magoon R, Rawat RS, Mehta Y, Taneja S, Ravi R, et al. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth. 2017;20:83-9. Fellahi JL, Futier E, Vaisse C, Collange O, Huet O, Loriau J, et al. Perioperative hemodynamic optimization: from guidelines to implementation-an experts' opinion paper. Ann Intensive Care. 2021;11:58. Sornpirom S, Tribuddharat S, Sathitkarnmanee T. Cost-Effectiveness of Early Goal-Directed Therapy Using the FloTrac/EV1000 Platform in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Retrospective Analysis. J Med Assoc Thai. 2023;106:1015-9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7157970","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498191213,"identity":"648b8499-7508-4549-baf9-ca2a00d7ead7","order_by":0,"name":"Sirirat Tribuddharat","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Sirirat","middleName":"","lastName":"Tribuddharat","suffix":""},{"id":498191214,"identity":"93bbee30-ed4f-412c-9bca-f2d571997d73","order_by":1,"name":"Panaratana Ratanasuwan","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Panaratana","middleName":"","lastName":"Ratanasuwan","suffix":""},{"id":498191215,"identity":"81fe80a7-01bc-4949-9428-3d6c77f91dd6","order_by":2,"name":"Thepakorn Sathitkarnmanee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYDACCRBxAEQwg0gJGYI6eBBa2BJAWnhI0cJjACYJarGXbj724McZm3xz/jOfX92oseBhYD98dANeW2SOpRv23Eiz3Dkjd5t1zjGgw3jS0m7gd1iOmQTPh8MGBjd4txnnsAG1SPCYEdCS/03yD0jL+TPPjHP+EaUlh02a5wZQy4Ec5se5bcRouZFmbixzJg3osDQz5tw+CR42Qn5hn5H87OGbYzZAhx1+/DnnW50cP/vhY3i1AAEbnCGBwiVGC/MHIlSPglEwCkbBCAQA5qJG8Dj/1tMAAAAASUVORK5CYII=","orcid":"","institution":"Khon Kaen University","correspondingAuthor":true,"prefix":"","firstName":"Thepakorn","middleName":"","lastName":"Sathitkarnmanee","suffix":""},{"id":498191216,"identity":"4b0090c9-8733-45ac-8347-fb768c58e6ed","order_by":3,"name":"Netinai Chaimala","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Netinai","middleName":"","lastName":"Chaimala","suffix":""},{"id":498191217,"identity":"6d92416e-d763-4453-a315-68cd23b85ee8","order_by":4,"name":"Lampai Polsena","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Lampai","middleName":"","lastName":"Polsena","suffix":""},{"id":498191218,"identity":"4f43a8a6-f8ea-4741-9e96-7bde61bde13a","order_by":5,"name":"Patchareeporn Mantruad","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Patchareeporn","middleName":"","lastName":"Mantruad","suffix":""}],"badges":[],"createdAt":"2025-07-18 13:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7157970/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7157970/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88836997,"identity":"aa42bdc3-08f6-4273-b3ee-722a9c07f05a","added_by":"auto","created_at":"2025-08-12 01:21:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":785782,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAlgorithm for goal-directed therapy (GDT) in intraoperative fluid and hemodynamic management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBP, blood pressure; CO, cardiac output; CI, cardiac index; SVR, systemic vascular resistance; SVRI, systemic vascular resistance index; SV, stroke volume; SVI, stroke volume index; HR, heart rate; dP/dt, the derivative of pressure over time; Eadyn, dynamic arterial elastance; SVV, stroke volume variation; NorE, norepinephrine; PhenylEp, phenylephrine; NTG, nitroglycerine; MAP, mean arterial pressure\u003c/p\u003e","description":"","filename":"Figure1Algorithm.png","url":"https://assets-eu.researchsquare.com/files/rs-7157970/v1/4e1eb96478d5a5c6d1b66dc4.png"},{"id":88836268,"identity":"9d811b89-4c3e-451d-99b2-a1b6c943cea2","added_by":"auto","created_at":"2025-08-12 01:13:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":284171,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT diagram of the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2CONSORTdiagramofthestudy.png","url":"https://assets-eu.researchsquare.com/files/rs-7157970/v1/c29757b5afbf1cdd97b3783d.png"},{"id":88837822,"identity":"366780c1-d703-4f52-8604-afa155b00f54","added_by":"auto","created_at":"2025-08-12 01:29:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":625999,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDrug requirements at different intraoperative stages in the operating room\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe concentric circles represent the percent of patients, while each radial spoke indicates the number of drugs required (0-3 drugs). Values plotted on the graph show the distribution of patients according to their drug requirements.\u003c/p\u003e","description":"","filename":"Figure3Drugrequirementsduringdifferentstages.png","url":"https://assets-eu.researchsquare.com/files/rs-7157970/v1/b2f86830add7ac40a6235352.png"},{"id":88836270,"identity":"aa6b04a9-aa8c-4a3a-b579-f383cc96af6e","added_by":"auto","created_at":"2025-08-12 01:13:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":717210,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDrug requirements in the ICU during the immediate and total ICU stay\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNTG, nitroglycerine\u003c/p\u003e","description":"","filename":"Figure4DrugrequirementsinICU.png","url":"https://assets-eu.researchsquare.com/files/rs-7157970/v1/8e04bc392dc8cb95ee83e491.png"},{"id":88836998,"identity":"154db544-353e-43f5-b57d-15e3e7cc553e","added_by":"auto","created_at":"2025-08-12 01:21:04","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1201566,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostoperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVF, ventricular fibrillation; AF with RVR, atrial fibrillation with rapid ventricular response\u003c/p\u003e","description":"","filename":"Figure5Postoperativecomplications.png","url":"https://assets-eu.researchsquare.com/files/rs-7157970/v1/5444ef1f5615f0e195e30581.png"},{"id":89359675,"identity":"c5e5cb2e-bd91-4676-bdf6-42ae2cf0fc04","added_by":"auto","created_at":"2025-08-19 08:09:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5154021,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7157970/v1/d7563e06-3be9-489a-836b-6e53dfd6c0b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of FloTrac/EV1000-guided intraoperative hemodynamic optimization on postoperative outcomes in cardiac valve surgery: a randomized controlled trial","fulltext":[{"header":"Background","content":"\u003cp\u003eCardiac valve surgery elicits a more pronounced systemic inflammatory response, as evidenced by higher interleukin-6 (IL-6) levels compared to coronary artery bypass grafting (CABG) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and remains associated with considerable postoperative morbidity and mortality. The 30-day mortality is about 4–6%, nearly two-fold higher than CABG [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], with complications occurring in up to 0.7–3.5% per patient-year [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Major postoperative complications include atrial fibrillation (30–64%) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], acute kidney injury (10–30%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], respiratory complications (10–30%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and coagulopathy (5–15%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Specifically, post-valve surgery atrial fibrillation occurs in 30–50% of patients, potentially prolonging hospital stay and increasing healthcare costs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Acute kidney injury after valve surgery is associated with a 5-fold increase in mortality risk [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], while major bleeding complications necessitating reoperation occur in 2–8% of cases [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOptimal perioperative hemodynamic management is crucial for improving outcomes; however, standardized protocols remain a topic of debate. The increasing complexity of valve procedures, often combined with CABG, presents additional challenges for intraoperative hemodynamic stability [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGoal-directed therapy (GDT) using minimally invasive cardiac output monitoring has shown promise in reducing complications and length of stay in major surgery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, the unique physiological changes during cardiopulmonary bypass and the specific hemodynamic targets for different valve pathologies create uncertainty about optimal management strategies. Traditional monitoring approaches rely heavily on static parameters and clinical experience, which may not adequately reflect the dynamic nature of cardiac performance during and after valve surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCurrently, two commonly utilized systems for minimally invasive cardiac output monitoring are the FloTrac/EV1000 and PiCCO. Both systems have demonstrated comparable performance in predicting fluid responsiveness [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The FloTrac/EV1000 system is preferred due to its calibration-free operation, whereas the PiCCO system necessitates calibration via the thermodilution technique.\u003c/p\u003e\u003cp\u003eThe FloTrac/EV1000 system (Edwards Lifesciences, Irvine, CA, USA) provides continuous cardiac output monitoring and dynamic parameters through arterial waveform analysis, offering potential advantages for guiding fluid and vasoactive (inotropes/vasopressors/vasodilators) therapy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Stroke volume variation (SVV) was initially validated as a predictor of fluid responsiveness in closed-chest patients, leading to caution against its use in open-chest settings. However, more recent research has demonstrated that SVV, along with pulse pressure variation (PPV), remains a reliable tool for assessing fluid responsiveness even in patients undergoing open-chest or open-pericardial procedures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Recent studies have demonstrated its efficacy in coronary artery bypass grafting (CABG), where its use was associated with reduced vasoactive drug requirements and shorter intensive care unit (ICU) stays [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In off-pump CABG procedures, hemodynamic optimization guided by FloTrac/EV1000 was associated with a shorter ICU stay and reduced hospital length of stay compared to conventional monitoring [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. While these findings are promising for cardiac surgery in general, evidence specifically addressing its impact on valve surgery outcomes remains limited.\u003c/p\u003e\u003cp\u003eA recent meta-analysis suggests that protocol-driven hemodynamic optimization can reduce postoperative complications, particularly in high-risk cardiac surgical patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the optimal monitoring platform and specific intervention thresholds remain undefined. The FloTrac/EV1000 system's ability to provide real-time SVV, stroke volume (SV)/Stroke volume index (SVI), cardiac output (CO)/cardiac index (CI), and systemic vascular resistance (SVR)/systemic vascular resistance index (SVRI) measurements without pulmonary artery catheterization may offer advantages for guiding perioperative management.\u003c/p\u003e\u003cp\u003eThis randomized controlled trial evaluated the effects of FloTrac/EV1000-guided intraoperative hemodynamic optimization on postoperative outcomes in cardiac valve surgery. We hypothesized that a GDT approach, targeting SVV, CI, and SVRI, would reduce vasoactive drug requirements, shorten ICU length of stay, and decrease postoperative complications compared to conventional management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design and Patient Population\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This prospective randomized controlled trial was approved by the Khon Kaen University Ethics Committee in Human Research (IRB: HE611321, September 11, 2019) and registered at ClinicalTrials.gov (NCT04292951, March 1, 2020) before commencement. The study adhered to the Declaration of Helsinki, ICH GCP guidelines, and CONSORT reporting standards. Written informed consent was obtained from all participants.\u003c/p\u003e\u003cp\u003eThe trial included two groups of participants randomized in a 1:1 ratio to either the FloTrac/EV1000-guided hemodynamic management (EV1000 group) or the conventional management (Control group). The sample size was calculated to detect a 25% reduction in ICU length of stay after cardiac surgery, based on data from a previous study reporting a mean ICU stay of 4.9 ± 1.8 days [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Assuming a significance level (α) of 0.05, a power of 80%, and accounting for a 20% dropout rate, 40 patients per group were required. Randomization was performed using a computer-generated block-of-four sequence, with allocation concealment ensured via sealed opaque envelopes. Inclusion criteria were: age 18–80 years, elective cardiac valve surgery (with or without concomitant CABG) at Srinagarind Hospital or Queen Sirikit Heart Center of the Northeast, Khon Kaen University, Khon Kaen, Thailand, and American Society of Anesthesiologists (ASA) classification 2–4. Patients were excluded if they required emergency or redo surgery, preoperative intra-aortic balloon pump, or had severe pulmonary hypertension. Blinding of patients and outcome assessors was implemented.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnesthesia and Monitoring\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients received standardized anesthetic care in accordance with institutional protocols. Standard monitoring included electrocardiography, pulse oximetry, non-invasive blood pressure measurement, capnography, nasopharyngeal temperature monitoring, and urine output assessment. Radial artery cannulation was performed in all patients. In the Control group, the arterial line was connected to a standard pressure transducer for invasive blood pressure (IBP) monitoring. In the EV1000 group, a FloTrac transducer connected to the EV1000 monitor (Edwards Lifesciences, Irvine, CA, USA) was used to measure IBP, SVV, SVI, and CI. To ensure comparability, all measured values were normalized to the patient's body surface area using index values in this study. Internal jugular/subclavian vein cannulation was also performed in all patients. In the Control group, the catheter was connected to a standard pressure transducer for central venous pressure (CVP) measurement. In contrast, the EV1000 group utilized a pressure transducer integrated with the FloTrac/EV1000 system to monitor SVRI. During cardiopulmonary bypass (CPB), the absence of a pulsatile arterial waveform precludes FloTrac monitoring.\u003c/p\u003e\u003cp\u003eAnesthesia was induced with titrated propofol (1.5-2 mg/kg) or etomidate (0.2–0.3 mg/kg), and fentanyl (2–5 µg/kg) intravenously, followed by endotracheal intubation facilitated with cisatracurium (0.2 mg/kg) intravenously. Anesthesia was maintained with 50–60% oxygen in air and 1–2% sevoflurane or 3–6% desflurane, titrated to 0.7–0.8 minimum alveolar concentration (MAC). CPB was initiated after heparinization (3–4 mg/kg via the central venous catheter) with an activated clotting time (ACT) \u0026gt; 480 seconds, maintained above 400–480 seconds with supplemental heparin (0.5-1 mg/kg). Moderate hypothermia (32°C) was maintained during CPB. Cardioplegia was administered via an aortic root catheter, with supplemental doses as needed at the surgeon's discretion. Mean arterial pressure (MAP) was maintained between 50–75 mmHg during CPB. Protamine (0.7-1 mg per 1 mg of pre-CPB heparin) was slowly administered intravenously for heparin reversal after CPB weaning. Postoperatively, patients were transferred to the ICU and received standard ICU care. They were either mechanically ventilated or extubated for spontaneous ventilation. Extubation criteria included: adequate consciousness and motor strength, cardiovascular stability, a PaO\u003csub\u003e2\u003c/sub\u003e/FiO\u003csub\u003e2\u003c/sub\u003e ratio ≥ 250 mmHg, and a respiratory rate of 10–25 breaths/min. ICU discharge criteria were: adequate consciousness and neurological status, cardiovascular stability without inotropic or vasopressor support, stable respiratory status with \u0026lt; 60% oxygen requirement, and no need for ICU monitoring. Hospital discharge criteria included: cardiovascular and respiratory stability, removal of all drains and catheters, normal ambulation, absence of infection or serious complications, wound suture removal, and tolerance to a normal diet.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntraoperative Hemodynamic Management Protocol\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Control Group\u003c/b\u003e: Hemodynamic management was at the discretion of the attending anesthesiologists, who administered fluids, inotropes, and/or vasoactive medications as needed to maintain the following targets: MAP 65–90 mmHg, CVP 8–12 mmHg, urine output ≥ 0.5 mL/kg/h, SpO₂ ≥ 95%, and hematocrit 26–30% (22–25% during CPB). Hourly arterial blood gas analysis and electrolyte monitoring with appropriate correction were performed.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThe EV1000 Group\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eHemodynamic management in this group aimed to achieve similar targets \u003cb\u003e(\u003c/b\u003eMAP 65–90 mmHg, urine output ≥ 0.5 mL/kg/h, SpO₂ ≥ 95%, and hematocrit 26–30% [22–25% during CPB]\u003cb\u003e)\u003c/b\u003e but was guided by a structured algorithm utilizing FloTrac/EV1000-derived parameters (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cb\u003eStep 1: Preload assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePreload adequacy was initially assessed using SVV, with a threshold of 10–13%. If SVV \u0026gt; 10–13%, a fluid challenge with 50–100 mL of crystalloid over 5–10 minutes was administered. In patients with anemia or coagulopathy, blood or blood components were transfused as needed. For those with signs of volume overload, diuretic therapy was considered.\u003c/p\u003e\u003cp\u003eFollowing preload optimization (SVV \u0026lt; 10–13%), patients were classified based on MAP. If MAP ≥ 65 mmHg, the patient was considered purely hypovolemic. If MAP remained below 65 mmHg, further management was guided by assessments of afterload and contractility to determine the appropriate intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStep 2: Afterload assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor low SVRI (\u0026lt; 1,800 dynes/sec/cm\u003csup\u003e5\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e):\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIf systolic arterial pressure (SAP) \u0026lt; 90 mmHg or MAP \u0026lt; 65 mmHg with heart rate (HR) \u0026lt; 70 bpm, administer an intravenous ephedrine bolus of 3–6 mg.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIf SAP \u0026lt; 90 mmHg or MAP \u0026lt; 65 mmHg with HR \u0026gt; 70 bpm, administer norepinephrine (4–8 µg) or phenylephrine (50–100 µg) as an intravenous bolus.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003eFor high SVRI (\u0026gt; 2,500 dynes/sec/cm\u003csup\u003e5\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e):\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIf SAP \u0026gt; 140 mmHg or MAP \u0026gt; 90 mmHg with HR \u0026lt; 70 bpm, administer an intravenous nicardipine bolus (0.5-2 mg) or initiate a nitroglycerin infusion.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIf SAP \u0026gt; 140 mmHg or MAP \u0026gt; 90 mmHg with HR \u0026gt; 70 bpm, administer an intravenous diltiazem bolus of 2–5 mg.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003cb\u003eStep 3 Contractility assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor low CI (\u0026lt; 2.0-2.2 L/min/m\u003csup\u003e2\u003c/sup\u003e):\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIf SVRI \u0026gt; 2,500 dynes/sec/cm⁵/m² with SAP \u0026lt; 90 mmHg or MAP \u0026lt; 65 mmHg, administer an intravenous low-dose epinephrine bolus (5–10 µg) or initiate a dobutamine infusion.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIf SVRI \u0026lt; 1,500 dynes/sec/cm⁵/m² with SAP \u0026lt; 90 mmHg or MAP \u0026lt; 65 mmHg, administer an intravenous high-dose epinephrine infusion (\u0026gt; 0.2 µg/kg/min).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003eFor high CI (\u0026gt; 5.5-6.0 L/min/m²) indicating a hyperdynamic state in septic shock:\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIf SVRI \u0026lt; 1,200 dynes/sec/cm⁵/m² with SAP \u0026lt; 90 mmHg or MAP \u0026lt; 65 mmHg, initiate an intravenous infusion of norepinephrine or phenylephrine, along with treatment for the underlying cause of septic shock.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003cb\u003eData Collection and Outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCollected data included primary outcomes such as ICU length of stay, duration of mechanical ventilation, and total hospital length of stay. Secondary outcomes encompassed vasoactive drug requirements (types and number of drugs) at different phases—pre-CPB, post-CPB, transfer to the ICU, and in the ICU—along with fluid balance and postoperative complications.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe normality of continuous data was assessed using the Shapiro-Wilk test. Normally distributed data are presented as mean ± standard deviation (SD) and were compared using the unpaired Student's t-test. Non-normally distributed data are presented as median (interquartile range) and were compared using the Mann-Whitney U test. Categorical data are presented as number (%) and analyzed using the appropriate chi-squared (χ²) test or Fisher’s exact test. The primary outcome is reported as the mean difference with a 95% confidence interval (CI). Statistical significance was defined as P \u0026lt; 0.05. All analyses were conducted using SPSS 16.0 (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 82 patients were recruited between March 2021 and February 2022, with 42 patients in the EV1000 group and 40 in the Control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Baseline characteristics were generally comparable between the groups. The EV1000 group had a significantly higher baseline prevalence of congestive heart failure (a clinical syndrome in which the heart is unable to pump blood effectively to meet the body's demands and requires medical treatment) (23.8% vs. 2.5%, p\u0026thinsp;=\u0026thinsp;0.004) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003ePatient characteristics and perioperative clinical data (n\u0026thinsp;=\u0026thinsp;82)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEV1000\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e: male/female\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (66.7)/14 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (65.0)/14 (35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.872\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (y)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.397\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody weight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.701\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e161.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e163.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.339\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEjection fraction (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.411\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of operation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.442\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMV repair/MVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (11.9)/6 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (5.0)/1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMV repair\u0026thinsp;+\u0026thinsp;CABG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMVR \u0026amp; TVA/MVR \u0026amp; TVA\u0026thinsp;+\u0026thinsp;CABG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (9.5)/2 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (10.0)/1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAVR\u0026thinsp;+\u0026thinsp;CABG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (23.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAVR \u0026amp; MV repair\u0026thinsp;+\u0026thinsp;CABG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAVR \u0026amp; TVA/AVR \u0026amp; TVA\u0026thinsp;+\u0026thinsp;CABG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(2.4)/1 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)/1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAVR \u0026amp; ascending aortic graft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDVR \u0026amp; TVA\u0026thinsp;\u0026plusmn;\u0026thinsp;LAA Closure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDVR/DVR\u0026thinsp;+\u0026thinsp;CABG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.4)/2 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.5)/2 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTVA \u0026amp; maze procedure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTVA \u0026amp; ASD closer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTVA \u0026amp; ASD closer\u0026thinsp;+\u0026thinsp;CABG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFunctional class\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.846\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (62.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (40.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eASA classification\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.703\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (30.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (62.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (70.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUnderlying diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (47.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (45.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.812\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (27.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.567\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMyocardial ischemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (47.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.382\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDyslipidemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (11.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.784\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongestive heart failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (23.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtrial fibrillation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic kidney disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOld cardiovascular accident\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoagulopathy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.927\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.058\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSodium (mEq/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e139.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.245\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePotassium (mEq/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.261\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood sugar (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e122.1\u0026thinsp;\u0026plusmn;\u0026thinsp;50.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114.8\u0026thinsp;\u0026plusmn;\u0026thinsp;42.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.478\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.644\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.026*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlatelet (x10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e232.7\u0026thinsp;\u0026plusmn;\u0026thinsp;88.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e239.3\u0026thinsp;\u0026plusmn;\u0026thinsp;86.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.734\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eINR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.205\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLactate (mmol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.012*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnesthesia time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e380.5\u0026thinsp;\u0026plusmn;\u0026thinsp;88.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e362.4\u0026thinsp;\u0026plusmn;\u0026thinsp;101.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.386\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPB time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e145.5\u0026thinsp;\u0026plusmn;\u0026thinsp;42.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e139.5\u0026thinsp;\u0026plusmn;\u0026thinsp;50.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.552\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic cross-clamp (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98.3\u0026thinsp;\u0026plusmn;\u0026thinsp;27.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.5\u0026thinsp;\u0026plusmn;\u0026thinsp;35.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.258\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e318.5\u0026thinsp;\u0026plusmn;\u0026thinsp;83.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e310.4\u0026thinsp;\u0026plusmn;\u0026thinsp;98.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.683\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrystalloid intake (mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1,576.7\u0026thinsp;\u0026plusmn;\u0026thinsp;600.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1,538.2\u0026thinsp;\u0026plusmn;\u0026thinsp;663.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.784\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1,023.3\u0026thinsp;\u0026plusmn;\u0026thinsp;248.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1,056.6\u0026thinsp;\u0026plusmn;\u0026thinsp;293.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.574\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrine output (mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1,391.3\u0026thinsp;\u0026plusmn;\u0026thinsp;727.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e993.4\u0026thinsp;\u0026plusmn;\u0026thinsp;612.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.009*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n (%)\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e* \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eMV, mitral valve; MVR, mitral valve replacement; CABG, coronary artery bypass graft; TVA, tricuspid valve annuloplasty; AVR, aortic valve replacement; DVR, double valve replacement; LAA, left atrial appendage; ASD, atrial septal defect; INR, international normalized ratio; CPB, cardiopulmonary bypass\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePreoperative laboratory values were similar across groups, though the EV1000 group had higher albumin levels (4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 vs. 4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 mg/dL, p\u0026thinsp;=\u0026thinsp;0.026) and lower lactate levels (0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 vs. 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 mmol/L, p\u0026thinsp;=\u0026thinsp;0.012) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe distribution of surgical procedures was similar between the groups (p\u0026thinsp;=\u0026thinsp;0.442). Duration of anesthesia, CPB time, and aortic cross-clamp time were also comparable. However, the EV1000 group exhibited significantly higher urine output (1,391.3\u0026thinsp;\u0026plusmn;\u0026thinsp;727.6 vs. 993.4\u0026thinsp;\u0026plusmn;\u0026thinsp;612.7 mL, p\u0026thinsp;=\u0026thinsp;0.009) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe EV1000 group had a significantly shorter ICU stay (44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 vs. 63.9\u0026thinsp;\u0026plusmn;\u0026thinsp;39.9 hours, mean difference: -19.3 hours, 95% CI: -31.8 to -6.8, p\u0026thinsp;=\u0026thinsp;0.002) and a shorter hospital stay (11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 vs. 13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0 days, mean difference: -1.8 days, 95% CI: -3.3 to -0.3, p\u0026thinsp;=\u0026thinsp;0.021). Ventilation time was comparable between groups (13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 vs. 13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1 hours, p\u0026thinsp;=\u0026thinsp;0.924) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003ePostoperative outcomes (n\u0026thinsp;=\u0026thinsp;82)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEV1000\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;42\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;40\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU stay (h)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e63.9\u0026thinsp;\u0026plusmn;\u0026thinsp;39.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-19.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-31.8 to -6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.002*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVentilator time (h)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-4.5 to 4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.924\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay (d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-3.3 to -0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.021*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e* \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eICU, intensive care unit\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding vasoactive drug requirements in the operating room, the EV1000 group required more concurrent drugs during the pre-bypass phase (p\u0026thinsp;=\u0026thinsp;0.018), showed no significant difference post-bypass (p\u0026thinsp;=\u0026thinsp;0.267), and required fewer drugs before ICU transfer (p\u0026thinsp;=\u0026thinsp;0.003) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Immediately upon ICU admission, the EV1000 group required significantly less epinephrine (p\u0026thinsp;=\u0026thinsp;0.001) and nitroglycerin (NTG) (p\u0026thinsp;=\u0026thinsp;0.044). Over the total ICU stay, the EV1000 group required significantly less epinephrine (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), dobutamine (p\u0026thinsp;=\u0026thinsp;0.039), NTG (p\u0026thinsp;=\u0026thinsp;0.033), and nicardipine (p\u0026thinsp;=\u0026thinsp;0.027) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe EV1000 group demonstrated a lower incidence of ventricular fibrillation (VF) (0% vs. 15.0%, p\u0026thinsp;=\u0026thinsp;0.011), bradycardia (11.9% vs. 35.0%, p\u0026thinsp;=\u0026thinsp;0.016), atrial fibrillation (AF) with rapid ventricular response (RVR) (14.3% vs. 25.0%, p\u0026thinsp;=\u0026thinsp;0.032), acute respiratory distress syndrome (ARDS) (0% vs. 5.0%, p\u0026thinsp;=\u0026thinsp;0.045), and acute kidney injury (AKI) (0% vs. 5.0%, p\u0026thinsp;=\u0026thinsp;0.045). Other complications, including supraventricular tachycardia, temporary pacemaker use, thrombocytopenia, AF with slow ventricular response, complete heart block, reintubation, and coagulopathy, showed no significant differences between groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis randomized controlled trial demonstrated that GDT using FloTrac/EV1000-guided hemodynamic management in cardiac valve surgery resulted in shorter ICU and hospital stays, reduced vasoactive drug requirements, and fewer postoperative complications compared to conventional management. The 19.3-hour reduction in ICU stay and 1.8-day decrease in hospital stay represent clinically significant findings.\u003c/p\u003e\u003cp\u003eThe pattern of vasoactive drug use varied notably between groups. While the EV1000 group required more vasoactive support during the pre-bypass period, they needed significantly fewer drugs before ICU transfer and throughout their ICU stay. This suggests that early hemodynamic optimization during the pre-bypass period may enhance cardiovascular stability in the postoperative period. The reduced vasoactive drug requirements in the ICU indicate better hemodynamic stability, likely contributing to the shorter ICU and hospital stays.\u003c/p\u003e\u003cp\u003eRegarding postoperative complications, VF is an uncommon complication, with a reported incidence of 0.95%. The underlying mechanism of VF remains unclear, though elevated catecholamine levels and autonomic imbalance during the early recovery period of surgery may contribute to the initiation of dysrhythmias [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Postoperative bradycardia occurred in 5.25% of patients, with half requiring temporary cardiac pacing. Risk factors for postoperative bradycardia include the adequacy of intraoperative myocardial perfusion [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The lower incidence of postoperative arrhythmias (VF, bradycardia, and AF with RVR) in the EV1000 group is particularly noteworthy. The reduced incidence of postoperative AF with RVR (14.3% vs 25.0%) was consistent with the findings of Tribuddharat et al., which showed that GDT using FloTrac/EV1000 reduced the incidence of AF with RVR in patients undergoing CABG and off-pump coronary artery bypass (OPCAB) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This reduction may be attributed to better perioperative hemodynamic optimization, as unstable hemodynamics and suboptimal tissue perfusion are well-recognized risk factors for postoperative arrhythmias [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The greater postoperative use of epinephrine in the Control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), may have increased beta-adrenergic stimulation, potentially contributing to the higher incidence of ventricular fibrillation (15% vs. 0%) and atrial fibrillation with rapid ventricular response (25% vs. 14.3%) observed. This difference, possibly due to discretionary management, highlights the need for standardized postoperative protocols.\u003c/p\u003e\u003cp\u003eThe incidence of ARDS in the perioperative period of cardiac surgery has been reported to range from 0.4\u0026ndash;8.1% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The complete absence of ARDS in the EV1000 group in this study highlights the potential benefit of hemodynamic optimization using FloTrac/EV1000.\u003c/p\u003e\u003cp\u003eDespite similar fluid administration between groups, the significantly higher urine output observed in the EV1000 group suggests better renal perfusion, which may explain the lower incidence of postoperative AKI. Our study showed a more substantial reduction in AKI (0% vs 5%) compared to the previous report by Meersch et al. (55.1% vs 71.7%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This improved renal outcome might be attributed to our strict adherence to hemodynamic optimization protocols and the higher urine output observed in the EV1000 group. This finding supports the idea that optimized hemodynamic management can help preserve organ function, particularly during the vulnerable perioperative period [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInterestingly, despite the higher incidence of preoperative congestive heart failure in the EV1000 group, these patients demonstrated better outcomes. This finding suggests that FloTrac/EV1000-guided management may be particularly beneficial for cardiac surgery patients.\u003c/p\u003e\u003cp\u003eAlthough the EV1000 group showed statistically significant differences in higher albumin levels (4.3 vs. 4.1 g/dL, p\u0026thinsp;=\u0026thinsp;0.026) and lower lactate levels (0.9 vs. 1.1 mmol/L, p\u0026thinsp;=\u0026thinsp;0.012), both values remain within the normal physiological range and therefore are not considered clinically significant to influence the study outcomes.\u003c/p\u003e\u003cp\u003eSince the FloTrac/EV1000 system derives hemodynamic information from the arterial waveform, it is limited during the CPB period, as the absence of an arterial waveform prevents the system from displaying any data.\u003c/p\u003e\u003cp\u003eOur findings have important clinical implications for perioperative management in cardiac valve surgery. They align with several recent studies on minimally invasive cardiac output monitoring in cardiac surgery. GDT using FloTrac/EV1000 reduced ICU stay and the use of vasopressor or inotropic drugs in patients undergoing cardiac, including CABG and OPCAB surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The 19.3-hour reduction in ICU stay observed in our study was comparable to the findings of Kapoor et al. who reported a mean reduction of 2.3 days in moderate to high-risk cardiac surgery patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In patients undergoing CABG and OPCAB, Kapoor et at. reported a reduction in ICU stay of 0.33 and 1.7 days [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], while Tribuddharat et al. reported a reduction of 29.5 hours and 1.3 days, respectively [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Our structured GDT algorithm provided a systematic approach to hemodynamic management through a stepwise assessment of preload, contractility, and afterload (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). By incorporating specific intervention thresholds, including HR and SVRI for drug selection, the algorithm enabled precise hemodynamic optimization. This approach differs from a previous expert review that relied on more generalized hemodynamic targets, such as pulse pressure variation, pleth variability index, and changes in stroke volume during a mini-fluid challenge or passive leg raising [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The observed pattern of vasoactive drug use\u0026mdash;with more intensive optimization pre-bypass followed by reduced postoperative requirements\u0026mdash;reflects the structured nature of the algorithm. The higher initial vasoactive requirements in the EV1000 group likely resulted from strict adherence to specific hemodynamic thresholds, including MAP\u0026thinsp;\u0026gt;\u0026thinsp;65 mmHg, CI\u0026thinsp;\u0026gt;\u0026thinsp;2.2 L/min/m\u0026sup2;, and SVV\u0026thinsp;\u0026lt;\u0026thinsp;10\u0026ndash;13%. We prefer to give vasoactive drugs as titrated bolus doses when indicated to restore the deviated parameters to normal ranges as soon as possible. Our principle of \u0026ldquo;\u003cb\u003eidentify the right causes, give the right drugs, at the right time\u003c/b\u003e\u0026rdquo; ensures optimal organ perfusion throughout the perioperative period, thereby minimizing postoperative vasoactive drug requirements and reducing complications. This proactive approach to hemodynamic management may explain the observed improvements in postoperative stability and the reduction in complications\u003c/p\u003e\u003cp\u003eThe investment in advanced hemodynamic monitoring technology appears justified by the reduction in complications and length of stay, which likely leads to lower healthcare costs and improved patient outcomes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The implementation of FloTrac/EV1000-guided management protocols could be particularly beneficial for high-risk cardiac surgical patients, where precise hemodynamic optimization is crucial.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe main limitation of this study is its single-center nature and relatively small sample size. Additionally, the inability to blind the anesthesiologists to group allocation may have introduced some bias. Future multicenter studies with larger populations are needed to confirm these findings and establish optimal hemodynamic targets for specific valve pathologies. Given the demonstrated intraoperative benefits of the FloTrac/EV1000 system, its application in postoperative ICU monitoring warrants consideration. However, advanced systems such as PiCCO, which provide measurements of extravascular lung water and global end-diastolic volume, may offer complementary data for optimizing fluid management and addressing respiratory complications in the ICU. Future studies are needed to compare the performance and clinical utility of these monitoring systems in the postoperative setting.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGoal-directed hemodynamic management using FloTrac/EV1000 monitoring in cardiac valve surgery reduced ICU and hospital length of stay, postoperative vasoactive drug requirements, and major complications. The structured algorithm incorporating SVV, CI, SVRI, and HR parameters provided an effective framework for optimizing hemodynamic stability. This approach was particularly beneficial in reducing postoperative arrhythmias and organ dysfunction. Future multicenter studies should focus on refining hemodynamic targets for specific valve pathologies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Activated clotting time\u003c/p\u003e\n\u003cp\u003eAF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Atrial fibrillation\u003c/p\u003e\n\u003cp\u003eAKI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Acute kidney injury\u003c/p\u003e\n\u003cp\u003eARDS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acute respiratory distress syndrome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eASA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003eCABG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Coronary artery bypass grafting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Cardiac index\u003c/p\u003e\n\u003cp\u003eCO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cardiac output\u003c/p\u003e\n\u003cp\u003eCPB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cardiopulmonary bypass\u003c/p\u003e\n\u003cp\u003eCVP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Central venous pressure\u003c/p\u003e\n\u003cp\u003eGDT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; Goal-directed therapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Heart rate\u003c/p\u003e\n\u003cp\u003eIBP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Invasive blood pressure\u003c/p\u003e\n\u003cp\u003eICU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intensive care unit\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMAC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Minimum alveolar concentration\u003c/p\u003e\n\u003cp\u003eMAP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Mean arterial pressure\u003c/p\u003e\n\u003cp\u003eNTG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Nitroglycerine\u003c/p\u003e\n\u003cp\u003eOPCAB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Off-pump coronary artery bypass\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePPV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pulse pressure variation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRVR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Rapid ventricular response\u003c/p\u003e\n\u003cp\u003eSAP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Systolic blood pressure\u003c/p\u003e\n\u003cp\u003eSV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Stroke volume\u003c/p\u003e\n\u003cp\u003eSVI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Stroke volume index\u003c/p\u003e\n\u003cp\u003eSVR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Systemic vascular resistance\u003c/p\u003e\n\u003cp\u003eSVRI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Systemic vascular resistance index\u003c/p\u003e\n\u003cp\u003eSVV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Stroke volume variation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ventricular fibrillation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by\u0026nbsp;The Khon Kaen University Ethics Committee in Human Research\u0026nbsp;(HE611321; approved on September 11, 2019). Written informed consent was obtained from all participants prior to enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026quot; in this section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: ST, PR, and TS. Registration of clinical trial: TS. Data collection: ST, NC, LP, and PM. Analysis and interpretation of the data: ST, PR, and TS. Writing the manuscript: ST, PR, and TS. All authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTakayama H, Soltow LO, Chandler WL, Vocelka CR, Aldea GS. Does the type of surgery effect systemic response following cardiopulmonary bypass? J Card Surg. 2007;22:307-13.\u003c/li\u003e\n\u003cli\u003eLiu Y, Xiao J, Duan X, Lu X, Gong X, Chen J, et al. The multivariable prognostic models for severe complications after heart valve surgery. BMC Cardiovasc Disord. 2021;21:491.\u003c/li\u003e\n\u003cli\u003eMisawa Y. Valve-related complications after mechanical heart valve implantation. Surg Today. 2015;45:1205-9.\u003c/li\u003e\n\u003cli\u003eRho RW. The management of atrial fibrillation after cardiac surgery. Heart. 2009;95:422-9.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Neal JB, Shaw AD, Billings FTt. Acute kidney injury following cardiac surgery: current understanding and future directions. Crit Care. 2016;20:187.\u003c/li\u003e\n\u003cli\u003eMohamed MA, Cheng C, Wei X. Incidence of postoperative pulmonary complications in patients undergoing minimally invasive versus median sternotomy valve surgery: propensity score matching. J Cardiothorac Surg. 2021;16:287.\u003c/li\u003e\n\u003cli\u003eBolliger D, Tanaka KA. Coagulation Management Strategies in Cardiac Surgery. Curr Anesthesiol Rep. 2017;7:265-72.\u003c/li\u003e\n\u003cli\u003eKalra R, Patel N, Doshi R, Arora G, Arora P. Evaluation of the Incidence of New-Onset Atrial Fibrillation After Aortic Valve Replacement. JAMA Intern Med. 2019;179:1122-30.\u003c/li\u003e\n\u003cli\u003eBolliger D, Tanaka KA. Point-of-Care Coagulation Testing in Cardiac Surgery. Semin Thromb Hemost. 2017;43:386-96.\u003c/li\u003e\n\u003cli\u003ePotestio C, Xu X. Intraoperative Hemodynamic Monitoring for the Cardiac Surgery Patient. In: Awad MDMBAAS, editor. Cardiac Anesthesia: The Basics of Evaluation and Management. Cham: Springer International Publishing; 2021. p. 155-79.\u003c/li\u003e\n\u003cli\u003eGiglio M, Biancofiore G, Corriero A, Romagnoli S, Tritapepe L, Brienza N, et al. Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis. J Anesth Analg Crit Care. 2021;1:26.\u003c/li\u003e\n\u003cli\u003eKapoor PM, Kakani M, Chowdhury U, Choudhury M, Lakshmy, Kiran U. Early goal-directed therapy in moderate to high-risk cardiac surgery patients. Ann Card Anaesth. 2008;11:27-34.\u003c/li\u003e\n\u003cli\u003eHofer CK, Senn A, Weibel L, Zollinger A. Assessment of stroke volume variation for prediction of fluid responsiveness using the modified FloTrac and PiCCOplus system. Crit Care. 2008;12:R82.\u003c/li\u003e\n\u003cli\u003eTribuddharat S, Sathitkarnmanee T, Ngamsangsirisup K, Nongnuang K. Efficacy of Intraoperative Hemodynamic Optimization Using FloTrac/EV1000 Platform for Early Goal-Directed Therapy to Improve Postoperative Outcomes in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Randomized Controlled Trial. Med Devices (Auckl). 2021;14:201-9.\u003c/li\u003e\n\u003cli\u003eTribuddharat S, Sathitkarnmanee T, Ngamsaengsirisup K, Sornpirom S. Efficacy of early goal-directed therapy using FloTrac/EV1000 to improve postoperative outcomes in patients undergoing off-pump coronary artery bypass surgery: a randomized controlled trial. J Cardiothorac Surg. 2022;17:196.\u003c/li\u003e\n\u003cli\u003eReuter DA, Goepfert MS, Goresch T, Schmoeckel M, Kilger E, Goetz AE. Assessing fluid responsiveness during open chest conditions. Br J Anaesth. 2005;94:318-23.\u003c/li\u003e\n\u003cli\u003eSander M, Spies CD, Berger K, Grubitzsch H, Foer A, Kramer M, et al. Prediction of volume response under open-chest conditions during coronary artery bypass surgery. Crit Care. 2007;11:R121.\u003c/li\u003e\n\u003cli\u003eAya HD, Cecconi M, Hamilton M, Rhodes A. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth. 2013;110:510-7.\u003c/li\u003e\n\u003cli\u003eYeung-Lai-Wah JA, Qi A, McNeill E, Abel JG, Tung S, Humphries KH, et al. New-onset sustained ventricular tachycardia and fibrillation early after cardiac operations. Ann Thorac Surg. 2004;77:2083-8.\u003c/li\u003e\n\u003cli\u003eUdzik J, Sienkiewicz S, Biskupski A, Szylinska A, Kowalska Z, Biskupski P. Cardiac Complications Following Cardiac Surgery Procedures. J Clin Med. 2020;9:3347.\u003c/li\u003e\n\u003cli\u003eVincent JL, Pelosi P, Pearse R, Payen D, Perel A, Hoeft A, et al. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. Crit Care. 2015;19:224.\u003c/li\u003e\n\u003cli\u003eSanfilippo F, Palumbo GJ, Bignami E, Pavesi M, Ranucci M, Scolletta S, et al. Acute Respiratory Distress Syndrome in the Perioperative Period of Cardiac Surgery: Predictors, Diagnosis, Prognosis, Management Options, and Future Directions. J Cardiothorac Vasc Anesth. 2022;36:1169-79.\u003c/li\u003e\n\u003cli\u003eMeersch M, Zarbock A. Prevention of cardiac surgery-associated acute kidney injury. Curr Opin Anaesthesiol. 2017;30:76-83.\u003c/li\u003e\n\u003cli\u003eXiao C, Yang M, Cao L, Chen F, Jing S, Tan Y, et al. The impact of intraoperative hypotension on postoperative acute kidney injury, mortality and length of stay following off-pump coronary artery bypass grafting surgery: a single-center retrospective cohort study. BMC Anesthesiol. 2024;24:224.\u003c/li\u003e\n\u003cli\u003eKapoor PM, Magoon R, Rawat R, Mehta Y. Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: \u0026quot;A clinical outcome and biomarker-based study\u0026quot;. Ann Card Anaesth. 2016;19:638-82.\u003c/li\u003e\n\u003cli\u003eKapoor PM, Magoon R, Rawat RS, Mehta Y, Taneja S, Ravi R, et al. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth. 2017;20:83-9.\u003c/li\u003e\n\u003cli\u003eFellahi JL, Futier E, Vaisse C, Collange O, Huet O, Loriau J, et al. Perioperative hemodynamic optimization: from guidelines to implementation-an experts\u0026apos; opinion paper. Ann Intensive Care. 2021;11:58.\u003c/li\u003e\n\u003cli\u003eSornpirom S, Tribuddharat S, Sathitkarnmanee T. Cost-Effectiveness of Early Goal-Directed Therapy Using the FloTrac/EV1000 Platform in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Retrospective Analysis. J Med Assoc Thai. 2023;106:1015-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cardiac valve surgery, Hemodynamic optimization, FloTrac, EV1000, Postoperative outcomes, Goal-directed therapy","lastPublishedDoi":"10.21203/rs.3.rs-7157970/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7157970/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCardiac valve surgery is associated with significant postoperative morbidity and mortality. This study evaluated the impact of intraoperative hemodynamic optimization using FloTrac/EV1000 on postoperative outcomes in patients undergoing cardiac valve surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this single-center, prospective, randomized controlled trial, 82 patients undergoing elective cardiac valve surgery were randomly allocated to either FloTrac/EV1000 management (EV1000 group, n\u0026thinsp;=\u0026thinsp;42) or conventional management (Control group, n\u0026thinsp;=\u0026thinsp;40). The primary outcomes were ICU length of stay, duration of mechanical ventilation, and hospital length of stay. Secondary outcomes included vasoactive drug requirements, fluid balance, and postoperative complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe EV1000 group had significantly shorter ICU stay (44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 vs. 63.9\u0026thinsp;\u0026plusmn;\u0026thinsp;39.9 hours, p\u0026thinsp;=\u0026thinsp;0.002) and hospital stay (11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 vs 13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0 days, p\u0026thinsp;=\u0026thinsp;0.021) compared to the Control group. The EV1000 group required more vasoactive drugs during pre-bypass (p\u0026thinsp;=\u0026thinsp;0.018) but fewer before ICU transfer (p\u0026thinsp;=\u0026thinsp;0.003) and during their ICU stay (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The incidence of postoperative ventricular fibrillation (0% vs 15.0%, p\u0026thinsp;=\u0026thinsp;0.011), bradycardia (11.9% vs. 35.0%, p\u0026thinsp;=\u0026thinsp;0.016), atrial fibrillation with rapid ventricular response (14.3% vs. 25.0%, p\u0026thinsp;=\u0026thinsp;0.032), acute respiratory distress syndrome (0% vs. 5.0%, p\u0026thinsp;=\u0026thinsp;0.045), and acute kidney injury (0% vs. 5.0%, p\u0026thinsp;=\u0026thinsp;0.045) was lower in the EV1000 group.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFloTrac/EV1000-guided hemodynamic optimization in cardiac valve surgery resulted in shorter ICU and hospital stays, reduced postoperative vasoactive drug requirements, and fewer postoperative complications compared to conventional management.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eNCT04292951 (The full date of first registration on ClinicalTrials.gov: March 1, 2020)\u003c/p\u003e","manuscriptTitle":"Impact of FloTrac/EV1000-guided intraoperative hemodynamic optimization on postoperative outcomes in cardiac valve surgery: a randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 01:12:59","doi":"10.21203/rs.3.rs-7157970/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"22cfe8e8-86de-4a26-aca5-66379109b0ea","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-21T14:53:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 01:12:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7157970","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7157970","identity":"rs-7157970","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}