Right Heart Failure

COURTNEY SCHILMILLER, APRN, MSN, ACNP-BCUNIVERSITY OF LOUISVILLE, DEPARTMENT OF

CARDIOVASCULAR AND THORACIC SURGERY

Disclosures:

None

Objectives:

1. Right Heart Hemodynamics

2. Recognizing Right Heart Problems

3. Differentiating Right Heart Failure

4. Treating Right Heart Failure

Why do we care?

Right Heart Failure accounts for 3 - 9% of acute heart failure admissions

In‐hospital mortality 5 - 17%

Mortality as high as LV Failure

75% of our patients have severe right ventricular dysfunction prior to LVAD implant

20-50% of patients post LVAD experience complications

Meineri. M., Rensburg, A., and Vegas. A. (2012). Right ventricular failure after LVAD implantation: prevention and treatment. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/22910091/

Causes of Right Ventricular Failure?

Acute Progressive

Pulmonary Embolism Pulmonary Hypertension

Right Sided MI Left Ventricular Failure

Right Heart Hemodynamics

Cardiac

OutputStroke Volume Heart Rate

Preload

Afterload

Contractility

Right

Heart Contractility

https://www.quizover.com/biology3/course/8-1-heart-anatomy-by-openstax-heart?page=3

Diagnosis of

Right Heart

Failure

Systemic Venous

Congestion

RUQ discomfort,

Epigastric

Fullness

Elevated Central Venous

Pressure

BNP, AST/ALT, T.bili, creatinine,

Elevated lactate

Echo

Echocardiogram

Echocardiogram

Assessing RV Function: TAPSE-

Tricuspid Annular Plane Systolic

Excursion

Bedside echo

Normal is > 2.0 cm

Correlates with RV systolic

functionSchmid, L., Hilbreth, J., Blumenstock.G, Shekar, P., King, S., Sherman. S., Rosenberger. P., & Nowak-Machen. M. (2015). Tricuspid annular plane systolic excursion (TAPSE) predicts poor outcome in patients undergoing acute

pulmonary embolectomy. Heart Lung And Vessels 7(2), 151–158. Retrieved from:https://ubpem.files.wordpress.com/2020/06/tapse.pdf

Assessing RV Function: Pulmonary

Artery Pulsatility Index (PAPi)

PAPi =systolic pulmonary artery pressure – diastolic

pulmonary artery pressure)/central venous pressure

The physiological basis for PAPi as an indicator of

right heart function is predicated on PASP as an

indirect indicator of RV contractile function against

a given afterload, and high CVP as a sign of failing

right ventricle

Normal PAPi is > 1

Guson. K., Richard. H., & Dipanjan., B. (2016). Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation. The Journal of Heart and Lung Transplantation

Three Types of Right Heart Failure

1. Preload problem – Volume overload

2. Contractility problem – RV failure with

normal afterload

3. Afterload problem – RV failure with

increased afterload

Ventetuolo C, Klinger J; Management of Acute Right Ventricular Failure in the Intensive Care Unit; Annals ATS; 2014;11:811-22

Treatment

Based on Which Problem??? Optimize

hemodynamics1. Preload problem – Volume overload-DIURESIS, Ultrafiltration

2. Contractility problem – RV failure with normal afterload-Inotropes

Milrinone + Vaso, Epinephrine

3. Afterload problem – RV failure with increased afterload. Correct

hypercapnia, acidosis, and hypoxia. Pulmonary vasodilators-iFlolan,

iNO

4. VA ECMO

Common Misconception: Volume

Administration RV can physiologically accommodate large variations in preload

Some patients with RV failure are preload dependent-be gentle!!

Delicate balance

A substantial amount RV failure is caused, associated with or aggravated by RV volume overload.

Volume administration → RV overdistention →Increased wall tension → Decreased RV contractility → Worsening tricuspid regurgitation → Decreased LV filling → Reduced systemic cardiac output → End organ malperfusion →Cardiogenic shock

Ventetuolo, C. & Klinger J. Management of Acute Right Ventricular Failure in the Intensive Care Unit. (2014). Annals ATS. June; 2014; 11 (5), 811-822.

Cardiorenal syndrome

In patients with RV dysfunction, you

have decreased arterial perfusion to

kidneys, compounded by increased

venous congestion, which further

decreases renal blood flow.

Both partially responsible for AKI in

decompensated heart failure

Fundamentals of Veno-Venous

(VV) and Veno-Arterial (VA)

Extracorporeal Membrane

Oxygenation (ECMO)

Objectives:

1. List the indications for ECMO in

management of severe respiratory or

circulatory failure.

2. Basics of cannulation techniques and sites

3. Describe basic physiology during ECMO

4. Common complications of the patient on

ECMO

What is ECMO?

ECMO is a form of cardiopulmonary life-

support, where blood is drained from the

vascular system, circulated outside the

body by a mechanical pump, and then

returned into the circulation.

Brief History

1916-Heparin discovered

1944-discovered that blood became oxygenated as it passed through the cellophane chambers of an artificial kidney

1953-Gibbon used artificial oxygenation and perfusion support (cardiopulmonary bypass) for the first successful open-heart operation

1972- Long-term ECMO as support for severe respiratory failure in an adult patient with post-traumatic respiratory failure

1989-ELSO Founded-Best Practices

2009-H1N1 flu pandemic and CESAR Trial-clearly showed an improvement in the death rate and severe disability 6 months after randomization of patients with severe respiratory failure treated with ECMO in an expert high-case-volume center compared with no specialized hospital care.

Makdisi, G. & Wang, I. (2015). Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. Journal of Thoracic Disease, Jul; 7(7): E166–E176

Jewish Hospital Data-2020

Multi-disciplinary Team-Surgeon, Cardiologists, Pulmonologists, Perfusionists, Intensivists, APPs, RNs, RTs.

Higher success rate in weaning patients from VV ECMO verses VA ECMO

In 2020 we placed a total of 50 patients on ECMO.

56% patients were successfully weaned off

44% patients were discharged from the facility

ECMO Indications for cardiac support (VA ECMO only)

1. Cardiogenic shock: Severe cardiac failure due to almost any cause:

▪ acute coronary syndrome

▪ cardiac arrhythmic storm refractory to other measures

▪ sepsis with profound cardiac depression

▪ drug overdose/toxicity with profound cardiac depression

▪ myocarditis

▪ pulmonary embolism

▪ isolated cardiac trauma

▪ acute anaphylaxis

2. Post cardiotomy: inability to wean from cardiopulmonary bypass after cardiac surgery

3. Post heart transplant: primary graft failure after heart or heart-lung transplantation

4. Chronic cardiomyopathy:

▪ as a bridge to longer term VAD support

▪ or as a bridge to decision

5. Periprocedural support for high-risk percutaneous cardiac interventions

6. Bridge to transplant

Makdisi, G. & Wang, I. (2015). Extra Corporeal Membrane

Oxygenation (ECMO) review of a lifesaving technology.

Journal of Thoracic Disease, Jul; 7(7): E166–E176

ECMO indications for respiratory support

1. Acute respiratory distress syndrome:

▪ severe bacterial or viral pneumonia

▪ aspiration syndromes

▪ alveolar proteinosis

2. Extracorporeal assistance to provide lung rest:

▪ airway obstruction

▪ pulmonary contusion

▪ smoke inhalation

3. Lung transplant:

▪ primary graft failure after lung transplantation

▪ bridge to lung transplant

▪ intaroperative ECMO

4. Lung hyperinflation:

▪ status asthmaticus

5. Pulmonary hemorrhage or massive hemoptysis

Makdisi, G. & Wang, I. (2015). Extra Corporeal Membrane

Oxygenation (ECMO) review of a lifesaving technology.

Journal of Thoracic Disease, Jul; 7(7): E166–E176

Contrain

dications

to ECMO

Absolute: among these futile treatment without exit strategy in case

of

-Unrecoverable heart and not a candidate for transplant or

destination therapy of VAD support

-Disseminated malignancy

-Known severe brain injury

-Unwitnessed cardiac arrest

-Prolonged CPR without adequate tissue perfusion

-Unrepaired aortic dissection

-Severe aortic regurgitation

-Severe chronic organ dysfunction (emphysema, cirrhosis, renal

failure)

-Compliance (financial, cognitive, psychiatric, or social limitations

in patient without social support)

-Peripheral vascular disease is contraindicated in peripheral VA

ECMO

-VV ECMO is contraindicated in cardiogenic failure and in Severe

chronic pulmonary hypertension (mean pulmonary artery pressure

>50 mmHg)

Relative: contraindication for anticoagulation, advanced age,

obesityAnnich, G., Lynch, W., MacLaren, G., Wilson, J., and Bartlett, R. (2012). Extracorporeal Cardiopulmonary Support in Critical Care 4th Ed

ECMO Physiology-What is going

On? ECMO support is initiated when the patient is

connected to the ECMO circuit. The deoxygenated blood will be drained from the patient through a drainage cannula under negative pressure created by a centrifugal pump, then entering the oxygenator, where gas exchange occurs. Then, blood is returned back to the patient through the return cannula.

Goal is to supply oxygenated blood to meet the metabolic requirements and remove metabolic waste.

Oxygenator Specification: Provides oxygenation AND ventilation

Flow in Oxygenation controlled by FiO2

Ventilation controlled inversely by “Sweep Rate”

Sweep rate is analogous to minute ventilation

Max Blood flow: 7 LPM

Minimum Sweep rate: 1 LPM, unless weaning

Max Sweep rate: 15 LPM

VV ECMO Goals:

1. Support oxygenation and ventilation (gas exchange)

when lungs can’t

2. Lung Protective Ventilation “10/10/10”

• Rate: 10 BPM

• FiO2 : 40-60%

• Inspiratory Pressure 10

• PEEP: preferably 10 cmH2O

• Tidal Volume: 6-8 mL/kg of ideal body weight

HEART FUNCTION MUST BE PRESERVED!!

Must Monitor for Right Ventricular Failure

VV ECMO Cannulation Dual Lumen Bicaval cannulation

Right Internal Jugular

Both drainage and return lumens in one cannula

Requires precise placement. Drainage ports in SVC/IVC and return to

tricuspid valve and returns oxygenated blood to right ventricle

Two separate cannulas

Femoral Vein/Femoral Vein

Drainage cannula tip at IVC/RA junction

Right Internal Jugular Vein/Femoral Vein

Return cannula tip at SVC/RA junction

Hirose, H., Yamane, K., Marhefka, G. and Cavarocchi, N. (2012). Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation. Retrieved from https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-7-36

Dual Lumen Bicaval cannulation in patient with femorally inserted

Impella + Pulmonary Artery Catheter

Image from MC3 Cardiopulmonary. The ECMO Company.

VV ECMO-

Bicaval,

dual-lumen

cannula

Hypercapnic Respiratory Failure

VV ECMO support due to

hypercapnic respiratory failure, avoid

rapid corrections of hypercapnia

when initiating ECMO support. Failing

to do so might promote alkalemia, as

well as cerebral vasoconstriction.

Annich, G., Lynch, W., MacLaren, G., Wilson, J., and Bartlett, R. (2012). Extracorporeal Cardiopulmonary Support in Critical Care 4th Ed.

Troubleshooting Problems encountered

with VV ECMO: Recirculation

Recirculation- reinfused oxygenated blood is withdrawn through the

drainage cannula without passing through the systemic circulation

Decreases level of support provided

Identification: Increase in pre-oxygenator saturation and arterial

saturations, notice similar blood color in cannulas

Causes:

Cannula position are too close together

Higher flow rate and cannula size

Changes in intrathoracic pressure

Ptx, tamponade, anything that impedes venous return

Annich, G., Lynch, W., MacLaren, G., Wilson, J., and Bartlett, R. (2012). Extracorporeal Cardiopulmonary Support in Critical Care 4th Ed.

VA ECMO

Goal:

To restore organ blood flow and

prevent end organ mal-perfusion

VA ECMO Cannulation Sites

Central Cannulation

Open chest-Post cardiotomy failure

Drainage cannula directly in right atrium

Return cannula in ascending aorta

Peripheral

Femoral Vein-Drainage tip at level of RA

Opposite Femoral Artery-Return tip in common iliac artery

Provides flow down opposite extremity and retrograde flow

up the aorta

Distal perfusion cannula to provide

Troubleshooting: Harlequin

Syndrome VA ECMO-perfusate blood from ECMO mixes in the aorta with the

blood ejected from the left ventricle

Content of oxygen and carbon dioxide in the patient’s arterial

blood represents a combination of blood from the above sources

Severe myocardial dysfunction

Mixing zone will be in proximal ascending aorta or aortic root

As myocardial function improves the mixing point moves distally into

the descending aorta

With significant pulmonary edema, hypoxic blood will perfuse the upper body. Thus, the patient’s upper body will appear blue, while

the lower body will appear pink

Short, B. and Williams, L. (2010). ECMO Specialist Training Manual 3rd Ed.

Left Ventricular Unloading in VA-

ECMO

LV Distention: LV Thrombus, Pulmonary

hemorrhage

Preload Reduction-Impella in conjunction

with VA ECMO

Afterload Reduction with Intra Aortic

Balloon Pump

Therapeutic anti-coagulation is essential

Bleeding and Thrombotic

Considerations & Complications

-Inflammatory Response

-Procoagulant mechanisms are activated

-Consumptive coagulopathy

-ECMO therapy leads to thrombocytopenia,

factor XIII and fibrinogen deficiency as well as

acquired von Willebrand syndrome.

Quantitative and qualitative platelet

dysfunction due to activation and

consumption

Anti-coagulation

ECMO circuit contains heparin

Requires systemic anti-coagulation with Heparin or Argatroban.

10% and 33% of patients on ECMO support experience thrombotic or bleeding events.

Fibrin/Clot identification

check pre/post oxygenator

Trend ABGs

Pressures in lines

APP Roles & Responsibilities Patient Preparation:

All necessary lines should be inserted prior to ECMO cannulation

Right Radial Aline-preferable for peripheral VA ECMO

“Prep” patient appropriately

Ensure the patient is adequately sedated and paralyzed

Have inotropes and vasopressor infusions

4 units of blood ordered to maintain a “post-ECMO initiation” Hgb of 8.0 g/L

Notify Blood Bank to keep 4 units pRBC on hold at all times during ECMO

Have anestheisa with TEE ready to ensure correct guidewire and cannula

placement

“ECMO” Bed with mapping system (pre-ECMO, time permitting)

Ethical Considerations:

“Just because we can, doesn’t mean we should”

Discussions with family

Time frame

Realistic Expectations

Palliative (Family Support Team) Care

Up and Coming

ECMO Transport Team

References: Annich, G., Lynch, W., MacLaren, G., Wilson, J., and Bartlett, R. (2012). Extracorporeal Cardiopulmonary Support in Critical Care 4th Ed.

Cresent cannula image from mc3corp.com

Guson. K., Richard. H., & Dipanjan., B. (2016). Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation. The Journal of Heart and Lung Transplantation. January; 35(1), 67-73. Retrieved July 1, 2021 from Science Direct database.

Hirose, H., Yamane, K., Marhefka, G. and Cavarocchi, N. (2012). Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation. Retrieved from https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-7-36

Makdisi, G. & Wang, I. (2015). Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. Journal of Thoracic Disease,

July; 7(7): E166–E176. Retrieved June 20, 2021.

Meineri. M., Rensburg, A., and Vegas. A. (2012). Right ventricular failure after LVAD implantation: prevention and treatment. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/22910091/.

Schmid, L., Hilbreth, J., Blumenstock.G, Shekar, P., King, S., Sherman. S., Rosenberger. P., & Nowak-Machen. M. (2015). Tricuspid annular plane

systolic excursion (TAPSE) predicts poor outcome in patients undergoing acute pulmonary embolectomy. Heart Lung And Vessels 7(2), 151–

158. Retrieved from: https://ubpem.files.wordpress.com/2020/06/tapse.pdf

Short, B. and Williams, L. (2010). ECMO Specialist Training Manual 3rd Ed.

Ventetuolo, C. & Klinger J. Management of Acute Right Ventricular Failure in the Intensive Care Unit. (2014). Annals ATS. June; 2014; 11 (5), 811-822.