acute right heart failure in the icu - critical care...

Acute Right Heart Failure in the ICU

Nicholas S. Hill MDTufts Medical CenterBoston, MA

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

PathophysiologyofARHS

ARDS

RightHeartIntolerant

Afterload (mean pressure)

CO

40 150

RV LV

RightHeartIntolerant

Afterload (mean pressure)

CO

40 150

RV LV

Positive Inotrope

Cardiac Echo in Acute Rt Heart Syndrome

Vieillard-Baron et al, AJRCCM 2002; 166:1310

Cardiac Echo in Acute Rt Heart Syndrome

Vieillard-Baron et al, AJRCCM 2002; 166:1310

PAcatheterhelpfulindiagnosis,assessingresponsetotherapy

PrinciplesofARHSManagement

RVFailure

ReversePrecipitatingEvent


RVFailure


ControlContributingFactors:Acidemia,anemia,infection,

arrhythmias


RVFailure



arrhythmias

Oxygenation,LungProtection


RVFailure



arrhythmias

MaintainPerfusionPressuremPAP>mSBP=



RVFailure



arrhythmias

OptimizeFluidVolume




RVFailure



arrhythmias

OptimizeFluidVolume



Inotropy


RVFailure



arrhythmias

OptimizeFluidVolume



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

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


�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput


�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput�Avoidsystemichypotensionandmaintaincoronaryperfusion( PVR/SVR)


�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput�Avoidsystemichypotensionandmaintaincoronaryperfusion( PVR/SVR)�Avoidhypoxemia(fromworsenedventilation/perfusionrelationships)

SystemicVasodilators

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)

InhaledVasodilatorsmay

InhaledVasodilator

Alveoli

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!

iNO(20ppm)vsinhaledepoprostenol(50ng/kg/min)

Change PVR

Change PVR (%)

Shah A et al, ATS ‘11

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)

Summary:RtHeartFailureinICU�Highmorbidity,mortality�Importanttocharacterize,identifyandcorrectreversiblefactorspreoperatively�CardiacechoandPAcatheterhelpful�Keytomaintainperfusion,optimizefluidvolume,avoidhypoxemia�Prostacyclinsarepotentvasodilators,

acute right heart failure in the icu - critical care...

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