acute right heart failure in the icu - critical care...
TRANSCRIPT
Disclosures
Research Grants ActelionBayerGenzymeGileadNational Institutes of HealthNovartisPfizer United Therapeutics
AcuteRightHeartSyndrome
�IncreaseinRVafterload(orimpedance)precipitatingRVfailure�RVdilates,contractilefunctiondeteriorates�RightatrialandRVenddiastolicpressuresrise(>8mmHg)�Cardiacoutputandsystemicbloodpressurefall
Acute Right Heart Syndrome in ICU: Precipitating events
Acute or acute on chronic pulmonary embolism
Acute lung injury/ARDS/sepsisHeart, Lung, Liver Transplantation LV Failure, LV assist deviceCardiac Surgery (valve replacement)Lung Resection Deteriorating Chronic Pulmonary Arterial
Hypertension
ARHSinALI/ARDS
�Of502ptsinFACCT(FluidandCatheterTrial)ofARDSnet,73%hadtrans-pulmonarygradient(mPAP-PAW)>12mmHg– BullTetal,AJRCCM2010
�DecreaseinARDS-relatedcorpulmonalefrom60%in1985to20%in2001associatedwith useoflowVT– Vieillard-BaronAetal,CCM2001
Cardiac Echo in Acute Rt Heart Syndrome
Vieillard-Baron et al, AJRCCM 2002; 166:1310
PAcatheterhelpfulindiagnosis,assessingresponsetotherapy
PrinciplesofARHSManagement
RVFailure
ReversePrecipitatingEvent
ControlContributingFactors:Acidemia,anemia,infection,
arrhythmias
PrinciplesofARHSManagement
RVFailure
ReversePrecipitatingEvent
ControlContributingFactors:Acidemia,anemia,infection,
arrhythmias
Oxygenation,LungProtection
PrinciplesofARHSManagement
RVFailure
ReversePrecipitatingEvent
ControlContributingFactors:Acidemia,anemia,infection,
arrhythmias
MaintainPerfusionPressuremPAP>mSBP=
Oxygenation,LungProtection
PrinciplesofARHSManagement
RVFailure
ReversePrecipitatingEvent
ControlContributingFactors:Acidemia,anemia,infection,
arrhythmias
OptimizeFluidVolume
MaintainPerfusionPressuremPAP>mSBP=
Oxygenation,LungProtection
PrinciplesofARHSManagement
RVFailure
ReversePrecipitatingEvent
ControlContributingFactors:Acidemia,anemia,infection,
arrhythmias
OptimizeFluidVolume
MaintainPerfusionPressuremPAP>mSBP=
Oxygenation,LungProtection
Inotropy
PrinciplesofARHSManagement
RVFailure
ReversePrecipitatingEvent
ControlContributingFactors:Acidemia,anemia,infection,
arrhythmias
OptimizeFluidVolume
MaintainPerfusionPressuremPAP>mSBP=
Oxygenation,LungProtection
Inotropy PulmonaryVasodilators
Controlling predisposing factors
Optimize fluid balance– Ventricular interdependence– Cautious fluid administration – bolus and
observe response– Dilated IVC on echo, unlikely to respond– Consider cautious diuresis– Massive fluid overload, consider CVVH
Controlling predisposing factors
Optimize fluid balance– Ventricular interdependence– Cautious fluid administration – bolus and
observe response– Dilated IVC on echo, unlikely to respond– Consider cautious diuresis– Massive fluid overload, consider CVVH
PressorsinAcuteRightHeartSyndrome
�Norepinephrine,Dopamine,Epi– Totreatsystemichypotension(noclearwinner)– TomaintainRVcoronaryperfusionwithoutpulmonaryvasoconstrictionorimpairedmyocardialperformance– Effectsonrenalperfusionmayfavornorepi(indogmodelofpulmonaryembolism)
Inotropes
�Dobutamine(catechol),milrinone(PDE3I)– Systemicvasodilators;dobuttachy,mil BP,oftenneedpressors– Mildpulmonaryvasodilators– Maybeusedincombinationwithmorepotentpulmonaryvasodilators(likeinhaledNOorPGI2)toincreaseCOandfurtherlowerPApressure– NoclearwinnerBradfordetal,JCardiovascPharmacol2000;36:146
NewerInotrope• Levosimendan(notavailableinUS-canbegivenorally)– Ca++sensitizer,K+channelopener,noincreaseinmyocardialO2consumption– IndogswithpartialPAligation,increasesRVinotropy,decreasesRVafterload(betterpulmonaryvasodilatorthandobutamine)– SomefavorablecasereportsforPHaftersurgery
Kerbaaletal,CritCareMedicine2006;34:2814
GoalsofPulmonaryVasodilationinRightHeartFailure
�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput
GoalsofPulmonaryVasodilationinRightHeartFailure
�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput�Avoidsystemichypotensionandmaintaincoronaryperfusion( PVR/SVR)
GoalsofPulmonaryVasodilationinRightHeartFailure
�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput�Avoidsystemichypotensionandmaintaincoronaryperfusion( PVR/SVR)�Avoidhypoxemia(fromworsenedventilation/perfusionrelationships)
SystemicVasodilators�CalciumChannelBlockers�α antagonists– Tolazoline
�Smoothmusclerelaxers– Hydralazine,nitroprusside
Notveryuseful,potentsystemicvasodilators,CCBsnegativelyinotropic,increaseshunt,maybedangerous
Prostacyclin(PGI2) �Potentvasodilator,plateletaggregation�Probablynotinotrope(Naeje,Chest07)�StrongevidenceforefficacyinClassIVPAH(functionalstatus,survival)�GivenascontinuousIVinfusionstartingat2-4ng/kg/min, astolerated�Systemicvasodilator,mayworsenhypoxemia�Inhaled,ismorespecificpulmonaryvasodilator(Kieler-Nielsenetal,JHeartLungTxplnt’93)
InhaledPGI2forARHS(offlabel)126pts-78s/pcardsurg,43s/plungTxplant, 5s/presectionmPA>30,P/F<150, orCVP>16mmHg,CI<2.2
DeWetetal,JThoracCardiovascSurg2004;127:1061
InhaledPGI2forARHS(offlabel)126pts-78s/pcardsurg,43s/plungTxplant, 5s/presectionmPA>30,P/F<150, orCVP>16mmHg,CI<2.2ContminiHeartneb30-50μg/min
DeWetetal,JThoracCardiovascSurg2004;127:1061
InhaledPGI2forARHS(offlabel)126pts-78s/pcardsurg,43s/plungTxplant, 5s/presectionmPA>30,P/F<150, orCVP>16mmHg,CI<2.2ContminiHeartneb30-50μg/min
BeforePGI2After4-6hPGI2MAP(mmHg) 77 78MPAP(mmHg)35 24*MPAP/MAP 0.47 0.32*CO(L/min) 4.6 5.3*P/Fratio 256 281 DeWetetal,JThoracCardiovascSurg2004;127:1061
InhaledIloprost(1/2life20min)
22ptsafterendarterectomywith“residual”PHfollowingsurgerygiven25mcginhalation
PVR iloprost(11)saline(11)Pre (dscm-5)503 41330min 328404*90min 352415*
Krammetal,EurJCardiothorSurg,2005
InhaledNOinAcuteRightHeartSyndrome
�Potentvasodilator-stimulatessolubleguanylatecyclaseinvascularsmoothmuscle,intracellularcGMP�UsuallyimprovesO2-byenhancingbloodflowtoventilatedareas�Virtuallynosystemicsideeffects;immediatelyinactivatedbyhemoglobin(formsmethemoglobin)�Givenbytitrationinconcentrationsof5-40ppm(littlegain>20ppm)
NOforAcuteRightHeart26ptswithmPA>30mmH,RVdilatationbyEcho
>20% CO, PVRResp Nonrespn 14(54%)12(46%)mPAP 40 39CO(L/min) 5.2 5.9PVR 512 361%onpressors 57 8Mortality(%) 79 50 Bhoradeetal,AJRCCM,1999150:571.
CaveatsreUseofiNOforARHS
�Withdrawalproblemsverycommon(2/3)– DropSBP,O2sats,increasePVR– ?RelatedtosuppressionofendogenouseNOS
�MethemoglobinandNO2mayaccumulate
�Veryexpensive!Upto$3000/dayinUS!
Phosphodiesterase5inhibitors
�PotentacutepulmonaryvasodilatorsbyslowingmetabolismofcGMP�PotentiatetheeffectofiNOorprostacyclin,reducerebound�Alsosystemicvasodilatorssomustbeusedwithgreatcautioninhypotensivepatients;prelimevidencesuggestsmoreselectivitybyinhaledroute
SildenafilasRescueTherapy
�Addedin20ptsfailingIVepoprostenolmonotherapy�ImprovedNYHAclass�FewersxofRtheartfailure�SmallerRVenddiastdiambyecho�2deathsafter2years– RuizMetal,JHeartLungTxplant2006
SildenafilasRescueTherapy
�Addedin20ptsfailingIVepoprostenolmonotherapy�ImprovedNYHAclass�FewersxofRtheartfailure�SmallerRVenddiastdiambyecho�2deathsafter2years– RuizMetal,JHeartLungTxplant2006If SPB, start at low dose (10-12.5 mg tid)