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Ventilation according to the open lung concept (OLC) consists of recruitment maneuvers, followed by low tidal volume and elevated positive end-expiratory pressure (PEEP). Elevated PEEP is associated with an increased right ventricular afterload. We investigated the effect of OLC ventilation on right ventricular outflow impedance during inspiration and expiration in patients after cardiac surgery using transesophageal echo-Doppler.A prospective, single-center, crossover, randomized, controlled clinical study.Cardiothoracic intensive care unit of a university hospital.Twenty-eight patients scheduled for elective cardiac surgery with cardiopulmonary bypass.In the intensive care unit, each patient was ventilated for approximately 30 mins according to both OLC and conventional ventilation. During OLC ventilation, recruitment maneuvers were applied until Pao2/Fio2 was >375 torr (50 kPa); during conventional ventilation no recruitment maneuvers were performed.Transesophageal echo-Doppler measurements were performed at end-inspiration and end-expiration in a steady-state condition, 20 mins after initiation of a ventilation strategy. Mean acceleration of flow was determined in the long axis of the pulmonary artery in a transverse axis view. During OLC ventilation, a total PEEP of 14 ± 4 cm H2O was applied vs. 5 cm H2O during conventional ventilation. Mean acceleration during expiration was comparable between groups. During inspiration, OLC ventilation did not cause a decrease of mean acceleration compared with expiration, whereas this did occur during conventional ventilation.Despite the use of elevated PEEP levels, ventilation according to OLC does not change right ventricular outflow impedance during expiration and decreases right ventricular outflow impedance during inspiration.