Assault on the RV

Impact of Pulmonary Hypertension on

Heart-Lung Interactions

John Greenwood, MDUniversity of Pennsylvania

Department of Emergency MedicineDepartment of Anesthesiology & Critical Care

DISCLOSURES

NONE.

THE PATIENT

THE PATIENT

OBJECTIVES

• Understand clinical heart-lung interactions affected by pulmonary hypertension (PH)

• Identify patients at high risk for arrest from PH

• Discuss critical management strategies for the unstable patient with PH & RV dysfunction

CLASSIC DESCRIPTION OF PH

PROBLEMS IN THE ICU

CO2

O2

pH

Pneumonia PulmonaryEdema

ARDS

VENTILATOR AS A MURDER WEAPON

CARDIOVASCULAR CONSEQUENCES OF PH

RV MECHANICS

The Right Ventricle

Thin WallCompliantEfficient

VerticalMotion

Adapts to VOLUME

Fails under PRESSURE

MECHANICAL FAILURE

Mean PAP MAP

Right Ventricle Left Ventricle

Stro

ke v

olum

e (%

of c

ontro

l)

RCA

LCx

LAD

PREDICTABLE

Green EM et al. Curr Heart Failure Rep (2012) 9:228-235

EVALUATION & DIAGNOSTICS

TTE

24 y/o F with h/o PAH p/w acute SOB

24 y/o F with h/o PAH p/w acute SOB

CHRONIC DYSFUNCTION

24 y/o F with h/o PAH p/w acute SOB

66 y/o F with h/o COPD p/w acute SOB

TAPSE(TAP - SEE)

Tricuspid Valve

TAPSENormal > 1.6 cmMod: 1.0 - 1.6 cmSevere: < 1.0 cm

Resusthe

RV

PATIENT 2Mr. Blue

Tank Pump Pipes

Critical clinical questionWhat are my hemodynamic targets?

Tank

Pump

Pipes

• Volume Status• CVP

• ASSESS the RV• CPP & Squeeze

• PA Pressure• Targets: Reversible

treatable

The Tank

Add PPV video here

PITFALL: Looking to “Volume Responsiveness”

ABP

THE CVP IS NOT DEAD

10 - 14 mmHg

RCA

LCx

LAD

The Pump

CPP = -DBP(Ao)

CVP

VasopressinNorepinephrine

Epinephrine

TAPSE = 1.1 cm

Normal > 1.6 cmMod: 1.0 - 1.6 cmSevere: < 1.0 cm

Tank

Pump

Pipes

• Volume Status• CVP

• ASSESS the RV• CPP & Squeeze

• PA Pressure• Targets: Reversible

DROP THE AFTERLOAD PAP

O2 CO2 pH

Prostenoids iNO

THE TEST

Final Points• Acute PH is common• The RV is pressure sensitive• Practice TAPSE• Resuscitate wisely

QUESTIONS?

johncgreenwood@gmail.com

@JohnGreenwoodMD

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