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Acute Right Heart Failure in the ICU Nicholas S. Hill MD Tufts Medical Center Boston, MA
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
Cardiac Echo in Acute Rt Heart Syndrome
Vieillard-Baron et al, AJRCCM 2002; 166:1310
PAcatheterhelpfulindiagnosis,assessingresponsetotherapy
PrinciplesofARHSManagement
RVFailure
ReversePrecipitatingEvent
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
GoalsofPulmonaryVasodilationinRightHeartFailure
�DecreasePVRandimpedancetoreduceRVafterload
GoalsofPulmonaryVasodilationinRightHeartFailure
�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput
GoalsofPulmonaryVasodilationinRightHeartFailure
�DecreasePVRandimpedancetoreduceRVafterload�IncreaseRVstrokevolumeandcardiacoutput�Avoidsystemichypotensionandmaintaincoronaryperfusion( PVR/SVR)
GoalsofPulmonaryVasodilationinRightHeartFailure
�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
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,
