Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology

Highlights from the ERS International Congress 2018: Assembly 13 - Pulmonary Vascular Diseases

The 2018 European Respiratory Society (ERS) International Congress in Paris, France, highlighted the subject of pulmonary vascular disease (PVD). 2018 was an exciting year for the PVD community as it was the first ERS International Congress since the formation of Assembly 13, which is dedicated to PVD, pulmonary embolism and the right ventricle. This article aims to summarise the high-quality studies presented at the 2018 Congress into four subject areas: the use of risk stratification in pulmonary arterial hypertension, the molecular mechanisms and treatment of pulmonary hypertension (PH), understanding and improving the right ventricle in PH, and finally, advances in the field of acute pulmonary embolus.

Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension

Intensive care of patients with pulmonary hypertension (PH) and right-sided heart failure includes treatment of factors causing or contributing to heart failure, careful fluid management, and strategies to reduce ventricular afterload and improve cardiac function. Extracorporeal membrane oxygenation (ECMO) should be considered in distinct situations, especially in candidates for lung transplantation (bridge to transplant) or, occasionally, in patients with a reversible cause of right-sided heart failure (bridge to recovery). ECMO should not be used in patients with end-stage disease without a realistic chance for recovery or for transplantation. For patients with refractory disease, lung transplantation remains an important treatment option. Patients should be referred to a transplant centre when they remain in an intermediate- or high-risk category despite receiving optimised pulmonary arterial hypertension therapy. Meticulous peri-operative management including the intra-operative and post-operative use of ECMO effectively prevents graft failure. In experienced centres, the 1-year survival rates after lung transplantation for PH now exceed 90%.

Temporary assist device support for the right ventricle: pre-implant and post-implant challenges

Severe right ventricular (RV) failure is more likely reversible than similar magnitudes of left ventricular (LV) failure and, because reversal of both adaptive remodeling and impaired contractility require most often only short periods of support, the use of temporary RV assist devices (t-RVADs) can be a life-saving therapy option for many patients. Although increased experience with t-RVADs and progresses made in the development of safer devices with lower risk for complications has improved both recovery rate of RV function and patient survival, the mortality of t-RVAD recipients can still be high but it depends mainly on the primary cause of RV failure (RVF), the severity of end-organ dysfunction, and the timing of RVAD implantation, and much less on adverse events and complications related to RVAD implantation, support, or removal. Reduced survival of RVAD recipients should therefore not discourage appropriate application of RVADs because their underuse further reduces the chances for RV recovery and patient survival. The article reviews and discusses the challenges related to the pre-implant and post-implant decision-making processes aiming to get best possible therapeutic results. Special attention is focused on pre-implant RV assessment and prediction of RV improvement during mechanical unloading, patient selection for t-RVAD therapy, assessment of unloading-promoted RV recovery, and prediction of its stability after RVAD removal. Particular consideration is also given to prediction of RVF after LVAD implantation which is usually hampered by the complex interactions between the different risk factors related indirectly or directly to the RV potential for reverse remodeling and functional recovery.

Monoamine oxidase A inhibition protects the myocardium after experimental acute volume overload

Objective:

The molecular pathway leading to myocardial cellular destruction after acute volume overload (AVO) may include monoamine oxidases. The aim of the present study was to investigate whether moclobemide (Mo), a monoamine oxidase inhibitor, protects the myocardium after AVO.

Methods:

Sixty syngeneic Fischer rats underwent surgical abdominal aortocaval fistula to induce AVO. Eighteen rats were treated with Mo 10 mg/kg/day and were compared with 42 untreated rats with AVO without treatment. Myocardial recovery was analyzed using quantitative reverse transcription polymerase chain reaction for hypoxia-inducible factor 1-alpha, inducible nitric oxide synthase, interleukin 6, E-selectin, atrial natriuretic peptide (ANP), brain natriuretic peptide, vascular endothelial growth factor-alpha, matrix metalloproteinase 9, chitinase 3-like protein (YKL-40), and transforming growth factor-beta.

Results:

After 3 days, the relative number of ischemic intramyocardial arteries in the left ventricle was lower in AVO treated with Mo than in without [0.04 (0.02–0.07) vs. 0.09 (0.07–0.14), point score unit]. After 1 day, ANP was lower in AVO treated with Mo than in without [0.95 (0.37–1.84) vs. 2.40 (1.33–3.09), fold changes from the baseline (FC), p=0.044], whereas after 1 and 3 days, YKL-40 was higher in AVO treated with Mo than in without [22.66 (14.05–28.83) vs. 10.06 (6.23–15.02), FC, p=0.006 and 6.03 (4.72–7.18) vs. 3.70 (2.62–5.35), FC, p=0.025].

Conclusion:

Mo decreases intramyocardial arterial ischemia of the left ventricle after AVO while increases YKL-40, reflecting cellular protection during early cardiac remodeling. In the future, adding Mo may be a simple means for myocardial protection after AVO. (Anatol J Cardiol 2019; 21: 39-45)

Right coronary artery ligation in mice: a novel method to investigate right ventricular dysfunction and biventricular interaction

Right ventricular (RV) dysfunction can lead to complications after acute inferior myocardial infarction (MI). However, it is unclear how RV failure after MI contributes to left-sided dysfunction. The aim of the present study was to investigate the consequences of right coronary artery (RCA) ligation in mice. RCA ligation was performed in C57BL/6JRj mice ( n = 38). The cardiac phenotypes were characterized using high-resolution echocardiography performed up to 4 wk post-RCA ligation. Infarct size was measured using 2,3,5-triphenyltetrazolium chloride staining 24 h post-RCA ligation, and the extent of the fibrotic area was determined 4 wk after MI. RV dysfunction was confirmed 24 h post-RCA ligation by a decrease in the tricuspid annular plane systolic excursion ( P < 0.001) and RV longitudinal strain analysis ( P < 0.001). Infarct size measured ex vivo represented 45.1 ± 9.1% of the RV free wall. RCA permanent ligation increased the RV-to-left ventricular (LV) area ratio ( P < 0.01). Septum hypertrophy ( P < 0.01) was associated with diastolic septal flattening. During the 4-wk post-RCA ligation, LV ejection fraction was preserved, yet it was associated with impaired LV diastolic parameters ( E/ E', global strain rate during early diastole). Histological staining after 4 wk confirmed the remodeling process with a thin and fibrotic RV. This study validates that RCA ligation in mice is feasible and induces RV heart failure associated with the development of LV diastolic dysfunction. Our model offers a new opportunity to study mechanisms and treatments of RV/LV dysfunction after MI. NEW & NOTEWORTHY Right ventricular (RV) dysfunction frequently causes complications after acute inferior myocardial infarction. How RV failure contributes to left-sided dysfunction is elusive because of the lack of models to study molecular mechanisms. Here, we created a new model of myocardial infarction by permanently tying the right coronary artery in mice. This model offers a new opportunity to unravel mechanisms underlying RV/left ventricular dysfunction and evaluate drug therapy.

The Right Ventricle During Selective Lung Ventilation for Thoracic Surgery

The right ventricle (RV) has been an area of evolving interest after decades of being ignored and considered less important than the left ventricle. Right ventricular dysfunction/failure is an independent predictor of mortality and morbidity in cardiac surgery; however, very little is known about the incidence or impact of RV dysfunction/failure in thoracic surgery. The pathophysiology of RV dysfunction/failure has been studied in the context of acute respiratory distress syndrome (ARDS), cardiac surgery, pulmonary hypertension, and left ventricular failure, but limited data exist in literature addressing the issue of RV dysfunction/failure in the context of thoracic surgery and one-lung ventilation (OLV). Thoracic surgery and OLV present as a unique situation where the RV is faced with sudden changes in afterload, preload, and contractility throughout the perioperative period. The authors discuss the possible pathophysiologic mechanisms that can affect adversely the RV during OLV and introduce the term RV injury to the myocardium that is affected adversely by the various intraoperative factors, which then makes it predisposed to acute dysfunction. The most important of these mechanisms seems to be the role of intraoperative mechanical ventilation, which potentially could cause both ventilator-induced lung injury leading to ARDS and RV injury. Identification of at-risk patients in the perioperative period using focused imaging, particularly echocardiography, is paramount. The authors also discuss the various RV-protective strategies required to prevent RV dysfunction and management of established RV failure.

Practical management of concomitant acute heart failure and worsening renal function in the emergency department

Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as 'pseudo-WRF' and should not detract clinicians from targeting 'guideline-recommended' therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.

Fleckenstein's hypothesis revisited: excessive myocardial calcification after prolonged high dose catecholamine treatment: a case report

BACKGROUND

Myocardial calcification after prolonged highly dosed catecholamine treatment has been described experimentally. Here, we demonstrate myocardial calcifications by high-dose catecholamine treatment leading to chronic heart failure in patients.

CASE SUMMARY

A 62-year-old Caucasian woman presented with central pulmonary embolism, developing acute heart failure, and cardiogenic shock. Twenty-six days of high-dose norepinephrine treatment had to be administered to maintain circulation. After 74 days of intensive care treatment, the patient fortunately recovered but was readmitted to emergency ward because of dyspnoea and congestion. Computed tomography pulmonary angiography ruled out recurrence of pulmonary embolism, but depicted massive intramural cardiac calcifications, which were not present before treatment. Coronary angiography showed normal coronary arteries, and myocardial biopsy excluded infectious myocarditis. There was no evidence for sarcoidosis, thyroid disease, tuberculosis, or hyperparathyroidism. Oral heart failure treatment was initiated and at the 7 week follow-up the patient remained symptomatic with New York Heart Association functional Class III, while right and left ventricular function had recovered.

DISCUSSION

Prolonged activation of the heart by catecholamines leading to myocardial calcifications has first been examined experimentally by Fleckenstein et al. Herein, we are able to show, that this can occur in clinical situations. Careful dosing of catecholamines and early use of non-catecholamine-based haemodynamic support is recommended to avoid consecutive impairment of heart function and heart failure.

Chronic Right Heart Failure: Expanding Prevalence and Challenges in Outpatient Management

Right heart failure is caused by right heart dysfunction resulting in suboptimal stroke volume to supply the pulmonary circulation. Therapeutic developments mean that patients with acute right heart failure survive to hospital discharge and live with chronic right heart failure. Chronic right heart failure management aims to reduce afterload, optimize preload, and support contractility, with the best evidence available in vascular targeted therapy for pulmonary arterial hypertension. However, the management of chronic right heart failure relies on adapting therapies for left ventricular heart failure to the right. We review right heart failure management in the ambulatory setting and its challenges.

Concept, Evaluation, and Future Perspectives of PERKAT® RV-A Novel Right Ventricular Assist Device

Right heart failure (RHF) is a life-threatening condition. Mechanical right heart support offers an option for critically ill patients. The PERKAT® RV device is designed for percutaneous implantation in acute RHF. It consists of a nitinol chamber covered by foils containing inflow valves. An outlet tube is attached to its distal tip. Using an 18F sheath, it is implanted in the inferior vena cava while the tube bypasses the right heart with its tip in the pulmonary trunk. Then, an IABP balloon is inserted in the pump chamber. Balloon deflation generates blood inflow into the chamber; during inflation, blood is pumped into the pulmonary arteries. The device is capable of achieving flow rates of up to 3.5 l/min under in vitro conditions. In vivo, we were able to increase cardiac output by 59% in a sheep model of acute pulmonary embolism. Based on this, our further research will focus on first-in-human implants.

Pulmonary Embolism: Contemporary Medical Management and Future Perspectives

Pulmonary embolism (PE) contributes substantially to the global disease burden. A key determinant of early adverse outcomes is the presence (and severity) of right ventricular dysfunction. Consequently, risk-adapted management strategies continue to evolve, tailoring acute treatment to the patients' clinical presentation, hemodynamic status, imaging and biochemical markers, and comorbidity. For subjects with hemodynamic instability or 'high-risk' PE, immediate systemic reperfusion treatment with intravenous thrombolysis is indicated; emerging approaches such as catheter-directed pharmacomechanical reperfusion might help to minimize the bleeding risk. Currently, direct, non-vitamin K-dependent oral anticoagulants are the mainstay of treatment for acute PE. They have been shown to simplify initial and extended anticoagulation regimens while reducing the bleeding risk compared to vitamin K antagonists. (This is a review article based on the invited lecture of the 37th Annual Meeting of Japanese Society of Phlebology.).

Positive Pressure Ventilation in the Cardiac Intensive Care Unit

Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). PPV often plays an important role in the management of patients with cardiogenic pulmonary edema, cardiogenic shock, or cardiac arrest, and those undergoing mechanical circulatory support. Noninvasive PPV, when appropriately applied to selected patients, may reduce the need for invasive mechanical PPV and improve survival. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.

Right Ventricular Function in Left Heart Disease

Right ventricular (RV) function is an independent prognostic factor for short- and long-term outcomes in cardiac surgical patients. Patients with mitral valve (MV) disease are at increased risk of RV dysfunction before and after MV operations. Yet RV function is not part of criteria for decision making or risk stratification in this setting. The role of MV disease in the development of pulmonary hypertension (PHTN) and the ultimate impact of PHTN on RV function have been well described. Nonetheless, there are other mechanisms by which MV disease and MV surgery affect RV performance. Research suggests that PHTN may not be the most important determinant of RV dysfunction. Both RV dysfunction and PHTN have independent prognostic significance. This review explores the unique anatomic and functional features of the RV and the pathophysiologic and prognostic implications of RV dysfunction in patients with MV disease in the perioperative period.

Comparative Effectiveness and Safety Between Milrinone or Dobutamine as Initial Inotrope Therapy in Cardiogenic Shock

Inotropes are an integral component of the early stabilization of the patient presenting with cardiogenic shock. Despite years of clinical experience with the 2 most commonly used inotropes, dobutamine and milrinone, there remains limited data comparing outcomes between the two. We conducted a retrospective review to compare the effectiveness and safety of milrinone or dobutamine for the initial management of cardiogenic shock. Adult patients with cardiogenic shock regardless of etiology who received initial inotrope therapy with either milrinone (n = 50) or dobutamine (n = 50) and did not receive mechanical circulatory support were included. The primary end point was the time to resolution of cardiogenic shock. Changes in hemodynamic parameters from baseline and adverse events were also assessed. Resolution of shock was achieved in similar numbers in both the groups (milrinone 76% vs dobutamine 70%, P = .50). The median time to resolution of shock was 24 hours in both groups ( P = .75). There were no differences in hemodynamic changes during inotrope therapy, although dobutamine trended toward a greater increase in cardiac index. Arrhythmias were more common in patients treated with dobutamine than milrinone, respectively (62.9% vs 32.8%, P < .01), whereas hypotension occurred to a similar extent in both groups (milrinone 49.2% vs dobutamine 40.3%, P = .32). The use of concomitant vasoactive medications, dosage required, and duration of therapy did not differ between groups. There was no difference in the overall rate of discontinuation due to adverse event; however, milrinone was more commonly discontinued due to hypotension (13.1% vs 0%, P < .01) and dobutamine was more commonly discontinued due to arrhythmia (0% vs 11.3%, P < .01). Milrinone and dobutamine demonstrated similar effectiveness and safety profiles but with differences in adverse events. The choice of milrinone or dobutamine as initial inotrope therapy for cardiogenic shock may depend more on tolerability of adverse events.

Right heart dysfunction: from pathophysiologic insights to therapeutic options: a translational overview

: The right ventricle has become increasingly studied in cardiovascular research. In this article, we describe specific pathophysiological characteristics of the right ventricle, with special focus on functional and molecular modifications as well as therapeutic strategies in right ventricular dysfunction, underlining the differences with the left ventricle. Then we analyze the main imaging modalities to assess right ventricular function in different clinical settings. Finally, we acknowledge main therapeutic advances for treatment of right heart diseases.

Acute Heart Failure Management

Acute heart failure (AHF) is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. However, there are few evidence-based treatment methods. Interestingly, despite relatively similar ways of management of AHF throughout the globe, mid-term outcome in East Asia, including South Korea is more favorable than in Europe. Yet, most of the treatment methods are symptomatic. The cornerstone of AHF management is identifying precipitating factors and specific phenotype. Multidisciplinary approach is important in AHF, which can be caused or aggravated by both cardiac and non-cardiac causes. The main pathophysiological mechanism in AHF is congestion, both systemic and inside the organs (lung, kidney, or liver). Cardiac output is often preserved in AHF except in a few cases of advanced heart failure. This paper provides guidance on AHF management in a time-based approach. Treatment strategies, criteria for triage, admission to hospital and discharge are described.

Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association

Background and Purpose:

The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.

Methods:

The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.

Results:

Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.

Conclusions:

RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.

Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper

INTRODUCTION

This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors.

RESULTS

The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.

An Optical Method for the In-Vivo Characterization of the Biomechanical Response of the Right Ventricle

The intraoperative in-vivo mechanical function of the left ventricle has been studied thoroughly using echocardiography in the past. However, due to technical and anatomical issues, the ultrasound technology cannot easily be focused on the right side of the heart during open-heart surgery, and the function of the right ventricle during the intervention remains largely unexplored. We used optical imaging and digital image correlation for the characterization of the right ventricle motion and deformation during open-heart surgery. This work is a pilot study focusing on one patient only with the aim of establishing the framework for long term research. These experiments show that optical imaging and the analysis of the images can be used to obtain similar parameters, and partly at higher accuracy, for describing the mechanical functioning of the heart as the ultrasound technology. This work describes the optical imaging based method to characterize the mechanical response of the heart in-vivo, and offers new insight into the mechanical function of the right ventricle.

Acute Pulmonary Embolism: Focus on the Clinical Picture

Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.

Clinical experience with temporary right ventricular mechanical circulatory support

OBJECTIVES

This study sought to determine if indication for support affects the outcomes after temporary right ventricular mechanical circulatory support after postcardiotomy cardiogenic shock, cardiac transplant, or left ventricular assist device placement.

METHODS

A retrospective review was performed on 80 patients receiving a right ventricular assist device. Data were collected from a prospectively maintained database. Kaplan-Meier survival analysis was performed to compare survival between groups. Multivariate regression analysis was performed to identify risk factors for failure to wean from support.

RESULTS

The indication for support was postcardiotomy cardiogenic shock in 13 patients (16%), cardiac transplant in 25 patients (31%), and left ventricular assist device in 42 patients (53%). Median support time was 6 days. Device was successfully weaned in 6 postcardiotomy cardiogenic shock cases (46%), 21 cardiac transplant cases (84%), and 35 left ventricular assist device cases (83%). Survival was worse for patients with postcardiotomy cardiogenic shock compared with patients with a left ventricular assist device. Survival up to 3 months was better for patients who received immediate (n = 43) versus delayed (n = 37) support (79% vs 46%, P = .003). Weaning and survival remained static across implant era. Risk factor analysis identified postcardiotomy cardiogenic shock indication (odds ratio, 0.161; P = .007; confidence interval, 0.043-0.600) as an independent negative predictor of weaning from mechanical support.

CONCLUSIONS

Temporary right ventricular mechanical support remains an effective treatment strategy after left ventricular assist device placement with immediate support resulting in superior short-term survival. Caution should be applied in postcardiotomy cardiogenic shock when weaning and survival are poor. Overall survival outcomes have remained relatively static over time.

Optimal right heart filling pressure in acute respiratory distress syndrome determined by strain echocardiography

INTRODUCTION

Right ventricular (RV) systolic dysfunction is common in acute respiratory distress syndrome (ARDS). While preload optimization is crucial in its management, dynamic fluid responsiveness indices lack reliability, and there is no consensus on target central venous pressure (CVP). We analyzed the utility of RV free wall longitudinal strain (RVFWS) in the estimation of optimal RV filling pressure in ARDS.

METHODS

A retrospective cross-sectional analysis of clinical data and echocardiograms of patients with ARDS was performed. Tricuspid annular plane systolic excursion (TAPSE), tricuspid peak systolic velocity (S'), RV fractional area change (RVFAC), RVFWS, CVP, systolic pulmonary artery pressure (SPAP), and left ventricular ejection fraction (LVEF) were measured.

RESULTS

Fifty-one patients with moderate-severe ARDS were included. There were inverse correlations between CVP and TAPSE, S', RVFAC, RVFWS, and LVEF. The most significant was with RVFWS (r:.74, R² :.55, P:.00001). Direct correlations with creatinine and lactate were noted. Receiver operating characteristic analysis showed that RVFWS -21% (normal reference value) was associated with CVP: 13 mm Hg (AUC: 0.92, 95% CI: 0.83-1.00). Regression model analysis of CVP, and RVFWS interactions established an RVFWS range from -18% to -24%. RVFWS -24% corresponded to CVP: 11 mm Hg and RVFWS -18% to CVP: 15 mm Hg. Beyond a CVP of 15 mm Hg, biventricular systolic dysfunction rapidly ensues.

CONCLUSIONS

Our data are the first to show that an RV filling pressure of 13±2 mm Hg-as by CVP-correlates with optimal RV mechanics as evaluated by strain echocardiography in patients with moderate-severe ARDS.

PERKAT RV: first in vivo data of a novel right heart assist device

AIMS

Mechanical right ventricular (RV) support offers a treatment option for critically ill patients with RV failure (RVF). We developed an assist device for rapid percutaneous implantation. The aim of the present study was to investigate the implantation procedure, haemodynamic performance and possible side effects of the novel right ventricular assist device - PERKAT RV - in an animal model.

METHODS AND RESULTS

The PERkutane KATheterpumptechnologie RV (PERKAT RV) device consists of a nitinol chamber covered by foil containing inflow valves. An outlet tube is attached to its distal part. The system is designed for 18 Fr percutaneous implantation. The chamber is unfolded in the inferior vena cava while the outlet tube bypasses the right heart with the tip in the pulmonary trunk. An IABP balloon is placed inside. Balloon deflation generates blood flow into the chamber; during inflation, blood is guided into the pulmonary arteries. Acute RVF was induced by venous injection of Sephadex in seven sheep for evaluation of the device. The PERKAT RV was able to improve haemodynamics immediately generating a median increase in cardiac output of 59%. Longer pump support was evaluated in a second study. Four sheep were supported for eight hours without any problems.

CONCLUSIONS

The percutaneous implantation and explantation of the PERKAT RV device was possible in the designed way. The sheep studies proved beneficial haemodynamic effects in acute RVF. The system offers easy and safe treatment in acute RVF.

Monitorage hémodynamique dans le SDRA : que savoir en 2018

Environ deux tiers des patients atteints de syndrome de détresse respiratoire aiguë (SDRA) présenteront une instabilité hémodynamique avec recours aux vasopresseurs. Sous ventilation mécanique, la diminution de précharge du ventricule droit (VD) suite à l’augmentation de la pression pleurale et l’augmentation de la postcharge du VD secondaire à l’élévation de la pression transpulmonaire seront des phénomènes exacerbés en cas de SDRA. Les risques encourus sont une diminution du débit cardiaque global et l’évolution vers un cœur pulmonaire aigu (CPA). Le contrôle de la pression motrice, de la pression expiratoire positive et la lutte contre l’hypoxémie et l’hypercapnie auront un impact autant respiratoire qu’hémodynamique. L’échographie cardiaque tient un rôle central au sein du monitorage hémodynamique au cours du SDRA, à travers l’évaluation du débit cardiaque, des différentes pressions de remplissage intracardiaques et le diagnostic de CPA. Le cathéter artériel pulmonaire est un outil de monitorage complet, indiqué en cas de défaillance cardiaque droite ou hypertension artérielle pulmonaire sévère ; mais le risque d’effets indésirables est élevé. Les moniteurs utilisant la thermodilution transpulmonaire permettent un monitorage du débit cardiaque en temps réel et sont d’une aide précieuse dans l’évaluation du statut volumique. L’évaluation de la précharge dépendance ne doit pas s’effectuer sur les variabilités respiratoires de la pression pulsée ou du diamètre des veines caves, mais à travers l’épreuve de lever de jambe passif, le test d’occlusion télé-expiratoire ou encore les épreuves de remplissage titrées.

Pulmonary Vascular Dysfunction and Cor Pulmonale During Acute Respiratory Distress Syndrome in Sicklers

BACKGROUND

Acute chest syndrome (ACS) is the most common cause of death among sickle cell disease (SCD) adult patients. Pulmonary vascular dysfunction (PVD) and acute cor pulmonale (ACP) are common during acute respiratory distress syndrome (ARDS) and their prevalence may be even more important during ARDS related to ACS (ACS-ARDS). The objective of this study was to evaluate the prevalence and prognosis of PVD and ACP during ACS-ARDS.

PATIENTS AND METHODS

This was a retrospective analysis over a 10-year period of patients with moderate-to-severe ARDS. PVD and ACP were assessed by echocardiography. ARDS episodes were assigned to ACS-ARDS or nonACS-ARDS group according to whether the clinical insult was ACS or not, respectively. To evaluate independent factors associated with ACP, significant univariable risk factors were examined using logistic regression and propensity score analyses.

RESULTS

A total of 362 patients were analyzed, including 24 ACS-ARDS. PVD and ACP were identified, respectively, in 24 (100%) and 20 (83%) ACS-ARDS patients, as compared with 204 (60%) and 68 (20%) nonACS-ARDS patients (P < 0.0001). The mortality did not differ between ACS-ARDS and nonACS-ARDS patients. Both the crude (odds ratio [OR], 19.9; 95% confidence interval [CI], 6.6-60; P < 0.0001), multivariable adjustment (OR, 27.4; 95% CI, 8.2-91.5; P < 0.001), and propensity-matched (OR, 11.7; 95% CI, 1.2-110.8; P = 0.03) analyses found a significant association between ACS-ARDS and ACP.

CONCLUSIONS

All SCD patients presenting with moderate-to-severe ARDS as a consequence of ACS experienced PVD and more than 80% of them exhibited ACP. These results suggest a predominant role for PVD in the pathogenesis of severe forms of ACS.

[Sonographic Evaluation Algorithm for Acute Dyspnea]

The goal in emergency medicine is to provide a patient with dyspnea with the optimal therapy without delay, even when the definitive diagnosis has not yet been ascertained. The focused lung and heart ultrasound is a diagnostic resource that can be deployed immediately and repeatedly, and which rapidly provides the treating physician with essential information for providing therapy. Certain diagnoses (pneumothorax, pleural effusion, pericardial effusion) can be identified based on ultrasound. Other findings, including patient interview and physical exam, must also be considered in order to assess the clinical relevance. Further diagnoses can be made only after combining all findings (lung embolism, cardiac insufficiency with lung edema).

Indications and practical approach to non-invasive ventilation in acute heart failure

In acute heart failure (AHF) syndromes significant respiratory failure (RF) is essentially seen in patients with acute cardiogenic pulmonary oedema (ACPE) or cardiogenic shock (CS). Non-invasive ventilation (NIV), the application of positive intrathoracic pressure through an interface, has shown to be useful in the treatment of moderate to severe RF in several scenarios. There are two main modalities of NIV: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV) with positive end expiratory pressure. Appropriate equipment and experience is needed for NIPSV, whereas CPAP may be administered without a ventilator, not requiring special training. Both modalities have shown to be effective in ACPE, by a reduction of respiratory distress and the endotracheal intubation rate compared to conventional oxygen therapy, but the impact on mortality is less conclusive. Non-invasive ventilation is also indicated in patients with AHF associated to pulmonary disease and may be considered, after haemodynamic stabilization, in some patients with CS. There are no differences in the outcomes in the studies comparing both techniques, but CPAP is a simpler technique that may be preferred in low-equipped areas like the pre-hospital setting, while NIPSV may be preferable in patients with significant hypercapnia. The new modality 'high-flow nasal cannula' seems promising in cases of AHF with less severe RF. The correct selection of patients and interfaces, early application of the technique, the achievement of a good synchrony between patients and the ventilator avoiding excessive leakage, close monitoring, proactive management, and in some cases mild sedation, may warrant the success of the technique.

Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism

OBJECTIVES

Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow's performance of goal-directed echocardiograms and intensivists' interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism.

DESIGN

Prospective observational study and retrospective chart review.

SETTING

Four hundred fifty bed urban teaching hospital.

PATIENTS

Adult in/outpatients diagnosed with acute pulmonary embolism.

INTERVENTIONS

Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date.

MEASUREMENTS AND MAIN RESULTS

Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow's area under the curve for size and function was 0.83 (95% CI, 0.75-0.90) and 0.83 (95% CI, 0.75-0.90), respectively. Intensivists' 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82-0.94), (1) 0.87 (95% CI, 0.80-0.93) and (2) 0.88 (95% CI, 0.82-0.95), (2) 0.88 (95% CI, 0.82-0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes.

CONCLUSIONS

This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.

Management of thromboembolism-in-transit with pulmonary embolism

We present a rare complication of deep venous thrombosis with pulmonary embolism that threatened the patient with systemic embolization. A 36-year-old female was referred to the hospital after five days of progressive shortness of breath and chest pain. Preceding onset of symptoms, she had undergone surgery leading to reduced physical activity and had just returned from vacation by a long flight. Investigations with transthoracic and transesophageal echocardiography revealed a thromboembolism-in-transit across a patent foramen ovale. Thoracic CT showed submassive bilateral pulmonary embolism. Hemodynamic parameters were stable. The patient was treated surgically with extraction of the thrombus, closure of the foramen ovale and removal of the bilateral pulmonary emboli. She was discharged after an uneventful hospital stay.

LEARNING POINTS

Thromboembolism-in-transit across a patent foramen ovale usually occurs in the presence of deep venous thrombosis with pulmonary embolism. The abrupt rise in pulmonary arterial pressure may contribute to the migration of the thrombus across the atrial septum to the systemic circulation.If any abnormal structures are seen in the left atrium by TTE in a patient with pulmonary embolism, a TEE should be performed to rule out an embolus entrapped in a patent foramen ovale.When acute pulmonary hypertension cannot be assessed by conventional methods, additional parameters such as shortened right ventricular outflow tract acceleration time and a mid-systolic notching of the pulse wave Doppler profile in the right ventricular outflow tract may be useful.Mortality is highest during the initial 24 h after onset of chest symptoms; thus, optimal treatment must commence urgently.The choice of treatment in each individual patient must be made after a thorough discussion in a multidisciplinary heart team.

Management of the Critically Ill Adult With Congenital Heart Disease

Survival of adults with congenital heart disease (CHD) has improved significantly over the last 2 decades, leading to an increase in hospital and intensive care unit (ICU) admissions of these patients. Whereas most of the ICU admissions in the past were related to perioperative management, the incidence of medical emergencies from long-term sequelae of palliative or corrective surgical treatment of these patients is rising. Intensivists now are confronted with patients who not only have complex anatomy after congenital cardiac surgery, but also complex pathophysiology due to decades of living with abnormal cardiac anatomy and diseases of advanced age. Comorbidities affect all organ systems, including cognitive function, pulmonary and cardiovascular systems, liver, and kidneys. Critical care management requires an in-depth understanding of underlying anatomy and pathophysiology in order to apply contemporary concepts of adult ICU care to this population and optimize patient outcomes. In this review, the main CHD lesions and their common surgical management approaches are described, and the sequelae of CHD physiology are discussed. In addition, the effects of chronic comorbidities on the management of critically ill adults are explored, and the adjustments of current ICU management modalities and pharmacology to optimize care are discussed.