Management of right heart failure in the critically ill

Perioperative management of the vulnerable and failing right ventricle

Under recognition combined with suboptimal management of right ventricular (RV) dysfunction and failure is associated with significant perioperative morbidity and mortality. The contemporary perioperative team must be prepared with an approach for early recognition and prompt treatment. In this review, a consensus-proposed scoring system is described to provide a pragmatic approach for expeditious decision-making for these complex patients with a vulnerable RV. Importantly, this proposed scoring system incorporates the context of the planned surgical intervention. Further, as the operating room (OR) represents a unique environment where patients are susceptible to numerous insults, a practical approach to anesthetic management and monitoring both in the OR and in the intensive care unit is detailed. Lastly, an escalating approach to the management of RV failure and options for mechanical circulatory support is provided.

Artificial Intelligence in the Intensive Care Unit: Present and Future in the COVID-19 Era

The development of artificial intelligence (AI) allows for the construction of technologies capable of implementing functions that represent the human mind, senses, and problem-solving skills, leading to automation, rapid data analysis, and acceleration of tasks. These solutions has been initially implemented in medical fields relying on image analysis; however, technological development and interdisciplinary collaboration allows for the introduction of AI-based enhancements to further medical specialties. During the COVID-19 pandemic, novel technologies established on big data analysis experienced a rapid expansion. Yet, despite the possibilities of advancements with these AI technologies, there are number of shortcomings that need to be resolved to assert the highest and the safest level of performance, especially in the setting of the intensive care unit (ICU). Within the ICU, numerous factors and data affect clinical decision making and work management that could be managed by AI-based technologies. Early detection of a patient's deterioration, identification of unknown prognostic parameters, or even improvement of work organization are a few of many areas where patients and medical personnel can benefit from solutions developed with AI.

Keep the Right in Mind-A Focused Approach to Right Ventricle-Predominant Cardiogenic Shock

Cardiogenic shock (CS) remains a highly lethal condition despite many efforts and new interventions. Patients presenting with a rapid onset of hemodynamic instability and subsequent collapse require prompt and appropriate multimodality treatment. Multiple etiologies can lead to heart failure and subsequent shock. As the case prevalence of heart failure increases worldwide, it is of great importance to explore all manners and protocols of presentation and treatment present. With research primarily focusing on CS due to cardiac left-sided pathology, few assessments of right-sided pathology and the subsequent clinical state and treatment have been conducted. This review aims to present an in-depth assessment of the currently available literature, assessing the pathophysiology, presentation and management of CS patients due to right heart failure.

Diuretics Versus Volume Expansion in the Initial Management of Acute Intermediate High-Risk Pulmonary Embolism

AIMS

The very early management of pulmonary embolism (PE), a part from antithrombotic treatment, has been little studied. Our aim was to compare the effects of diuretic therapy (DT) versus volume expansion (VE) in patients hospitalized for PE with RV dysfunction.

METHODS AND RESULTS

We conducted a randomized open-label multicentric study including patients with intermediate high-risk PE. Patients were randomized between diuretics or saline infusion. The primary endpoint was time to troponin (Tp) normalization. Secondary endpoints were time to normalization of B-type natriuretic peptide (BNP), changes in echocardiographic RV function parameters and treatment tolerance. Sixty patients presenting intermediate high-risk PE were randomized. Thirty received DT and 30 VE. We noted no changes in Tp kinetics between the two groups. In contrast, faster normalization of BNP was obtained in the DT group: 56 [28-120] vs 108 [48-144] h: p = 0.05, with a shorter time to 50%-decrease from peak value 36 [24-48] vs 54 [41-67] h, p = 0.003 and a higher rate of patients with a lower BNP concentration within the first 12 h (42% vs 12% p < 0.001). RV echocardiographic parameters were unchanged between the groups. One dose 40 mg furosemide was well-tolerated and not associated with any serious adverse events.

CONCLUSION

In the acute management of intermediate high-risk PE, initial therapy including diuretic treatment is well-tolerated and safe. Although changes in Tp kinetics and echocardiographic RV dysfunction parameters did not differ, normalization of BNP is achieved more quickly in the DT group. This finding, which need to be confirmed in trials with clinical end points, may reflects a rapid improvement in RV function using one dose 40 mg furosemide.

TRIAL REGISTRY

Clinical Trial Registration NCT02531581.

Analysis of extracorporeal membrane oxygenation in trauma patients with acute respiratory distress syndrome: A case series

BACKGROUND

Thoracic trauma is the most common injury in polytrauma patients. Often associated with the development of an acute respiratory distress syndrome (ARDS), conservative treatment options are very restricted and reach their limits quickly.

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is a wellestablished therapy in cardio-thoracic surgery and internal medicine intensive care units. The purpose of this study is to analyse the potential benefit of ECMO therapy in ARDS treatment in polytrauma patients.

DESIGN

Retrospective case series.

SETTING

Level 1 trauma centre, Germany, 04/2011-04/2019.

PATIENTS

Nineteen patients with ARDS treated with a veno-venous ECMO system.

MAIN OUTCOME MEASURES

This study focused on the time leading to therapy initiation, the severity of thoracic and overall injury. The Sequential Organ Failure Assessment (SOFA) Score, the Murray Score, the Abbreviated Injury Scale (AIS) 2005 level and the Injury Severity Score (ISS) were analysed. The results were analysed regarding survival and death.

RESULTS

The survival rate was 53%. The ISS was the same for survivors and deceased patients (p = 0.604). Early initiation of ECMO therapy showed a significant trend for survivors (p = 0.071). The SOFA Score level before ECMO therapy was significantly lower in the survivors than in those who died (p = 0.035). The AISThorax level for survivors showed a significantly higher score level than the one for deceased patients (p = 0.05).

CONCLUSION

ECMO therapy in polytrauma patients is a safe and effective option, in particular when used early in ARDS treatment. The overall severity of organ failure determined the likelihood of survival rather than the thoracic trauma itself.

Management of reproductive health in patients with pulmonary hypertension

Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.

Right Ventricular Failure: Pathophysiology, Diagnosis and Treatment

The prognostic significance of the right ventricle (RV) has recently been recognised in several conditions, primarily those involving the left ventricle, the lungs and their vascular bed, or the right-sided chambers. Recent advances in imaging techniques have created new opportunities to study RV anatomy, physiology and pathophysiology, and contemporary research efforts have opened the doors to new treatment possibilities. Nevertheless, the treatment of RV failure remains challenging. Optimal management should consider the anatomical and physiological particularities of the RV and include appropriate imaging techniques to understand the underlying pathophysiological mechanisms. Treatment should include rapid optimisation of volume status, restoration of perfusion pressure and improvement of myocardial contractility and rhythm, and, in case of refractory RV failure, mechanical circulatory support.

Comparison of echocardiographic indices of right ventricular systolic function and ejection fraction obtained with continuous thermodilution in critically ill patients

Background

Though echocardiographic evaluation assesses the right ventricular systolic function, which of the existing parameters best reflects the right ventricular ejection fraction (RVEF) in the critically ill patients is still uncertain. We aimed to determine the relationship between echocardiographic indices of right ventricular systolic function and RVEF.

Methods

Prospective observational study was conducted in a mixed Surgical Intensive Care Unit (Hôpital Lariboisière, Paris, France) from November 2017 to November 2018. All critically ill patients monitored with a pulmonary artery catheter were assessed. We collected echocardiographic indices of right ventricular function (tricuspid annular plane systolic excursion, TAPSE; peak systolic velocity of pulsed tissue Doppler at lateral tricuspid annulus, S′; fractional area change, FAC; right ventricular index of myocardial performance, RIMP; isovolumic acceleration, IVA; end-diastolic diameter ratio, EDDr) and compared them with the RVEF obtained from continuous volumetric pulmonary artery catheter.

Results

Twenty-five patients were analyzed. Admission diagnosis was acute heart failure in 11 patients and septic shock in 14 patients. Median age was 70 years [57–80], norepinephrine median dose was 0.29 μg/kg/min [0.14–0.50], median Sequential Organ Failure Assessment score was 12 [10–14], and mortality at day 28 was 56%. When compared to RVEF, TAPSE had the highest correlation coefficient (rho = 0.78, 95% CI 0.52 to 0.89, p < 0.001). S′ was also correlated to RVEF (rho = 0.64, 95% CI 0.60 to 0.80, p = 0.001) whereas FAC, RIMP, IVA, and EDDr did not. TAPSE lower than 16 mm, S′ lower than 11 cm/s, and EDDr higher than 1 were always associated with a reduced RVEF.

Conclusions

We found that amongst indices of right ventricular systolic function, TAPSE and S′ were well correlated with thermodilution-derived RVEF in critically ill patients.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2582-7) contains supplementary material, which is available to authorized users.

Macro Fat Embolism After Gluteal Augmentation With Fat: First Survival Case Report

Gluteal augmentation with fat has become one of the most common cosmetic procedures worldwide. Gluteal augmentation is designed to increase the volume and contour of the gluteal region. Intramuscular lipoinjection has been linked to multiple reports of severe complications, including death due to macro fat embolism (MAFE). The authors present the first reported case of survival and successful recovery after MAFE secondary to gluteal augmentation with fat. A 41-year-old woman, ASA II, was scheduled for augmentation mammaplasty, liposuction, and gluteal augmentation with fat. The patient was operated under general anesthesia with a total intravenous anesthesia technique. A total of 3.5 liters of fat was liposuctioned with no complications. The patient was then positioned in a lateral decubitus position for gluteal augmentation with fat. Right after the last injection, the anesthesiologist noticed a sudden change in capnography followed by hypotension, bradycardia, and hypoxemia. The first reaction in the operating room was to consider that the patient was experiencing a severe episode of fat embolism. She was then resuscitated and transferred to a tertiary facility for intensive care management. To our knowledge, this is the first case report of successful resuscitation in a patient experiencing severe MAFE after gluteal augmentation with fat. We believe that this patient survived the event due to early detection, aggressive management, and proper transfer to an intensive care unit. Level of Evidence: 5.

Nonischemic Causes of Cardiogenic Shock

Although cardiogenic shock is uncommon in the emergency department, it is associated with high mortality. Most cardiogenic shock is caused by ischemia, but nonischemic etiologies are essential to recognize. Clinicians should optimize preload, contractility, and afterload. Volume-responsive patients should be resuscitated in small aliquots, although some patients may require diuresis to improve cardiac output. Vasopressors are important to restore end-organ perfusion, and inotropes improve contractility. Intubation and positive pressure ventilation impact hemodynamics, which, depending on volume status, may be beneficial or deleterious. Knowing indications for mechanical circulatory support is important for timely consultation or transfer as indicated.

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.

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.

Management of pulmonary hypertension from left heart disease in candidates for orthotopic heart transplantation

Pulmonary hypertension in left heart disease (PH-LHD) commonly complicates prolonged heart failure (HF). When advanced, the PH becomes fixed or out of proportion and is associated with increased morbidity and mortality in patients undergoing orthotopic heart transplant (OHT). To date, the only recommended treatment of out of proportion PH is the treatment of the underlying HF by reducing the pulmonary capillary wedge pressure (PCWP) with medications and often along with use of mechanical circulatory support. Medical therapies typically used in the treatment of World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH) have been employed off-label in the setting of PH-LHD with varying efficacy and often negative outcomes. We will discuss the current standard of care including treating HF and use of mechanical circulatory support. In addition, we will review the studies published to date assessing the efficacy and safety of PAH medications in patients with PH-LHD being considered for OHT.

Cardiac Support: Emphasis on Venoarterial ECMO

Major advances have been made in mechanical circulatory support in recent years. Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) provides both pulmonary and circulatory support for critically ill patients with hemodynamic compromise, serving as a bridge to recovery or definitive therapy in the form of transplant or a durable ventricular assist device. In the past, VA ECMO support was used in cases of cardiogenic shock or failure to wean from cardiopulmonary bypass; however, the technology is now being applied to an ever-expanding list of conditions, including massive pulmonary embolism, cardiac arrest, drug overdose, and hypothermia.

A rare cause of postoperative hypotension

A 62-year-old woman presented with a 3-month history of abdominal distension and decreased exercise tolerance. A chest radiograph showed a probable left pleural effusion (Fig 1). A CT scan of the abdomen revealed a solid ovarian mass with omental caking and a large volume of ascites; there was also confirmation of a left pleural effusion. Three days before surgery a CT pulmonary angiogram (CTPA) showed no evidence of pulmonary thromboembolism (PTE). The patient had some improvement in her symptoms after paracentesis and thoracentesis with drainage of 2,000 mL and 250 mL of fluid, respectively. She underwent total abdominal hysterectomy, bilateral oophorectomy, and partial sigmoid resection with an estimated blood loss of 850 mL. During the operation, she received 5 L of crystalloid and required phenylephrine at 40 to 80 μg/min to maintain a mean arterial pressure &gt; 65 mm Hg. She was extubated after surgery, but immediately after extubation, she became markedly hypotensive and hypoxemic with a BP of 50/20 mm Hg and an oxygen saturation of 70%. An ECG showed T-wave inversions from V1 to V5 and an S1Q3T3 pattern (Fig 2). A bedside echocardiogram showed an enlarged right ventricle (RV), septal dyskinesia, and obliteration of the left ventricle, all consistent with systolic and diastolic RV overload (Fig 3).