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Acute Right Ventricular Failure

Professor of Cardiology Democritus University of Thrace, Greece skonst@med.duth.gr

Stavros V. Konstantinides, MD, PhD, FESC Professor, Clinical Trials in Antithrombotic Therapy, and Medical Director Center for Thrombosis und Hemostasis, University of Mainz, Germany stavros.konstantinides@unimedizin-mainz.de

Conflict of Interest - Disclosures

below. Affiliation/Financial Relationship Company 1. Honoraria for lectures: Bayer HealthCare,

Boehringer Ingelheim, MSD, Pfizer – Bristol-Myers Squibb, Servier, BTG

2. Honoraria for advisory board activities: Bayer HealthCare, Daiichi Sankyo, Boehringer Ingelheim, Actelion

3. Participation in clinical trials: United Therapeutics, Actelion, Janssen

4. Research funding (institutional grants): Bayer HealthCare, Actelion, Boehringer Ingelheim, Pfizer

1) Right ventricular failure in acute pressure overload a) RV versus LV dynamics b) Causes and pathophysiology c) Diagnosis d) Risk stratification e) General and specific therapy

2) Chronic RV failure, acute decompensation a) Distinguishing between acute and chronic RV overload b) Echo for suspicion and follow-up of PH c) Identifying and treating the decompensation trigger

Acute right ventricular failure

1) Right ventricular failure in acute pressure overload a) RV versus LV dynamics b) Causes and pathophysiology c) Diagnosis d) Risk stratification e) General and specific therapy

2) Chronic RV failure, acute decompensation a) Distinguishing between acute and chronic RV overload b) Echo for suspicion and follow-up of PH c) Identifying and treating the decompensation trigger

Acute right ventricular failure

RV LVElastance (Emax), mm Hg/ml

1.30+0.84 5.48+1.23

PVR vs. SVR, dyn.s.cm-5 70 (20-130) 1100 (700-1600)

End-diastolic compliance high low

EF, % 61+7 (47-76) 67+5 (57-78)

Stroke work index, g/m²/beat

8+2 (1/6 of LV) 50+20

Resistance to ischaemia high low

Adaptation to disease Better for volume overload

Better for pressure overload

RV vs. LV physiology

Haddad F, et al. Circulation 2008;117:1436-1448

• Secondary to acute LV failure • RV ischaemia/infarction • Acute pulmonary embolism • Exacerbation of chronic lung disease/hypoxia • Acute lung injury or ARDS • Decompensated chronic pulmonary hypertension • Pericardial disease (tamponade) • Arrhythmias • Congenital heart disease (ASD, VSD, Ebstein‘s

anomaly) • Valvulopathies • Cardiomyopathies (e.g. ARVD) • Myocarditis or other inflammatory disease • Cardiac surgery • Haematological disorders (e.g. sickle cell disease)

Implications for causes & pathogenesis of RV failure

PRESSURE

PRESSURE

PRESSURE

PRESSURE

PRESSURE

PRESSURE

PRESSURE

PRESSURE

Pathophysiology of acute RV failure

Harjola VP, …, Konstantinides S. Eur J Heart Fail 2016;18:226-241

European Heart Journal (2014):doi:10.1093/eurheartj/ehu283

Increased RV afterload

Cardiogenicshock

Death

RV O2 delivery

RV coronaryperfusion

Systemic BP

Low CO

LV pre-load

RV output RV contractility

RV ischaemia

RV O2 demand

Myocardialinflammation

Neurohormonalactivation

RV wall tension

TV insufficiency

RV dilatation

The spiral of RV overload and decompensation

Courtesy Prof. A. Torbicki, Warsaw, PL

Severity spectrum of acute RV failure

Further determinants of prognosis (PE)

European Heart Journal (2014):doi:10.1093/eurheartj/ehu283

Clinical presentation of acute RV failure

Harjola VP, …, Konstantinides S. Eur J Heart Fail 2016;18:226-241

Harjola VP, …, Konstantinides S. Eur J Heart Fail 2016;18:226-241

Acute RV failure on echo: diagnosis

RV enlargement, paradoxical septum, LV eccentricity

Pulmonary hypertension

RV dysfunction, global and regional

RV enlargement -> paradoxical septal wall

RV enlargement -> septal shift -> LV eccentricity

Eccentricity index of LV >1.0 ➔ RV overload

RV basal systolic function: TAPSE

Upper reference limit (URL) TAPSE: 16 mm

Schulman S, Ageno W, Konstantinides S. Thromb Haemost 20176;in press Photos: Courtesy K F Kreitner, University Medical Center Mainz, DE

Diagnosing the cause/trigger of acute RV failure

Becattini C, …., Konstantinides S. Eur Respir J 2016;48(3):780-786

Early mortality risk

Risk parameters and scores

Death at 30 days PESI class

III-V or sPESI >1

RV dysfunction

(imaging)

Cardiac laboratory markers

High + + (+) 23/105 22% (14-29.8%)

IntermediateInterm-high + Both positive 21/272

7.7% (4.5-10.9%)

Interm-low + One (or none) positive 20/333 6.0% (3.4-8.6%)

Low − Assessment optional;if assessed, both negative

1/196 0.5% (0-1.5%)

Acute RV failure: basis for risk stratification

Acute RV failure: general management

Haemodynamic monitoring, support

(ICU)

Assess severity

☞ Clinical, biochemical, imaging, invasive parameters

Identify triggering factors

☞ Ensure cause-specific management

Optimize fluid status

☞ IV diuretics, RRT; cautious fluid filling if CVP↑

Maintain arterial pressure

☞ Norepinephrine

Consider inotropes reducing filling pressures

☞ Levosimendan, dobutamine, PDE-III inhibitors

Further measures for afterload reduction

☞ Inhaled NO, prostacyclins

Consider transfer for ECMO, mechanical

support

Harjola VP, et al. Eur J Heart Fail 2016;18:226-241

Indications • Cardiac arrest • Severe haemodynamic compromise • Contraindication(s) to systemic

thrombolysis • Failed systemic thrombolysis • Failed catheter-based clot extraction • Patient too unstable for catheter-based

clot extraction or thrombolysis • Severe hypoxaemia

Weinberg A, Tapson VF, Ramzy D. Semin Respir Crit Care Med 2017;38:66-72

Mechanical circulatory and respiratory support

Image source: CardiacAssist

Need for multidisciplinary approach (PE)

Jaber WA, et al. J Am Coll Cardiol 2016;67:991-1002

1) Right ventricular failure in acute pressure overload a) RV versus LV dynamics b) Causes and pathophysiology c) Diagnosis d) Risk stratification e) General and specific therapy

2) Chronic RV failure, acute decompensation a) Distinguishing between acute and chronic RV overload b) Echo for suspicion and follow-up of PH c) Identifying and treating the decompensation trigger

Acute right ventricular failure

Chronic pulmonary hypertension

● COPD ● ILD ● Other pulmonary

diseases with mixed restrictive and obstructive pattern

● Sleep-disordered breathing

● Alveolar hypoventilation disorders

● Chronic exposure to high altitude

● Developmental abnormalities

WHO Group 3 Lung/hypoxia related

Pulmonary hypertension

● IPAH ● Heritable ● Drug- and toxin-

induced ● APAH: ● CTD ● HIV infection ● Portal hypertension ● CHD ● Schistosomiasis

WHO Group 1′ ● PVOD ● Pulmonary capillary

hemangiomatosis WHO Group I′′

● PPHN

● Systolic dysfunction ● Diastolic dysfunction ● Valvular disease ● Congenital/acquired left

heart inflow/ outflow tract obstruction

Chronic thromboembolic

pulmonary hypertension

PH with unclear multifactorial mechanisms

WHO Group 1 PAH

WHO Group 2 Left heart related

WHO Group 4 CTEPH

WHO Group 5 Other

modified from Simonneau G et al. J Am Coll Cardiol 2013;62(25 Suppl):D34–41

RV

RV

RV

LV

LV

LV

Normal

Compensatory Hypertrophy

Failure

From adaptation to failure of the RV

Courtesy Prof. S. Gibbs, London, UK

Chronic, preexisting RV failure on echo

TR >3.4 m/s

Harjola VP, …, Konstantinides S. Eur J Heart Fail 2016;18:226-241

DD on echo: acute PE or CTEPH??

Konstantinides S, et al. Eur Heart J 2014; doi:10.1093/eurheartj/ehu283 Kim NH, et al. J Am Coll Cardiol 2013;62(25 Suppl):D92–9

Management of “acute-on-chronic” RV failure, i.e. acute PE and suspected pre-existing CTEPH: (1) General measures of RV

failure management! (2) Treate acute PE, dissolve the

fresh thrombus! (3) After stabilization,

anticoagulate for at least 3 months

(4) Then initiate diagnostic workup for CTEPH

Galiè N, et al. European Heart Journal 2016;37:67-119

Echo in the diagnosis of PH

Galiè N, et al. European Heart Journal 2016;37:67-119

RV-based risk stratification of PH

Decompensation triggers of chronic PH

Triggering factors • Infection / sepsis • Supraventricular arrhythmias • Anaemia • Non-adherence to treatment • Hypoxia, hypercapnia

Galiè N, et al. European Heart Journal 2016;37:67-119

RV functional status before…

…and after recompensation!!

1) Acute RV failure is a diagnosis based on history (search for causes/triggers) and clinical examination.

2) Echocardiography and biomarker tests are necessary for accurate assessment and severity-adapted management.

3) Management of acute RV failure demands BOTH general supportive measures and cause-specific treatment, particularly relief of afterload.

4) Decompensated chronic PH must be identified and its triggers treated.

5) Possible “acute-on-chronic” PE is first treated like acute PE; search for CTEPH is warranted later, after 3 months of therapeutic anticoagulation.

Acute RV failure: Conclusions