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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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Albulushi A, Giannopoulos A, Kafkas N, Dragasis S, Pavlides G, Chatzizisis YS. Acute right ventricular myocardial infarction. Expert Rev Cardiovasc Ther 2018; 16:455-464. [PMID: 29902098 DOI: 10.1080/14779072.2018.1489234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Acute right ventricular myocardial infarction (RVMI) is observed in 30-50% of patients presenting with inferior wall myocardial infarction (MI) and, occasionally, with anterior wall MI. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Areas covered: The pathophysiological mechanisms, diagnostic steps, and novel therapeutic approaches of acute RVMI are described. Expert commentary: Diagnosis of acute RVMI is based on physical examination, cardiac biomarkers, electrocardiography, and coronary angiography, whereas noninvasive imaging modalities (echocardiography, cardiac magnetic resonance imaging) play a complementary role. Early revascularization, percutaneous or pharmacological, represents key step in the management of RMVI. Maintenance of reasonable heart rate and atrioventricular synchrony is essential to sustain adequate cardiac output in these patients. When conventional treatment is not successful, mechanical circulatory support, including right ventricle assist devices, percutaneous cardiopulmonary support, and intra-aortic balloon pump, might be considered. The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.
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Affiliation(s)
- Arif Albulushi
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
| | - Andreas Giannopoulos
- b Cardiac Imaging, Department of Nuclear Medicine , University Hospital Zurich , Zurich , Switzerland
| | - Nikolaos Kafkas
- c Cardiology Department , General Hospital KAT , Athens , Greece
| | | | - Gregory Pavlides
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
| | - Yiannis S Chatzizisis
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
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Abstract
PURPOSE OF REVIEW For the past 15 years, there has been a strong push to use goal-directed protocols for resuscitating critically ill patients and to manage perioperative patients. However, recent large clinical trials have failed to find evidence of improved outcome with this approach. RECENT FINDINGS A striking feature in the recent three large prospective randomized trials of septic patients and the one in high-risk perioperative patients is that outcomes in the control groups have markedly improved. This implies improvement in care and clinical acumen. Perhaps the clinical approach should be more toward further helping clinicians with their clinical choices. A good example is cardiac output. The objective of most hemodynamic interventions is to increase cardiac output. It would thus make sense to assess what happened to cardiac output after the intervention to determine if the intervention actually increased cardiac output. If it did not, another therapy should be chosen. I call this a flow-directed responsive protocol. SUMMARY A clinical approach that uses monitored values such as cardiac output as a feedback tool to evaluate the response to therapeutic interventions in individual patients may be better than protocols that set fixed targets for all study participants.
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Magder S. Right Atrial Pressure in the Critically Ill: How to Measure, What Is the Value, What Are the Limitations? Chest 2016; 151:908-916. [PMID: 27815151 DOI: 10.1016/j.chest.2016.10.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/17/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022] Open
Abstract
Right atrial pressure (Pra) is determined by the interaction of the function of the heart as a pump, which is called cardiac function, and the factors that determine the return of blood to the heart, which is called return function. Thus, monitoring Pra or its surrogate, central venous pressure (CVP), can give important insights into mechanisms behind changes in hemodynamic status, responses to interventions, and the likelihood of diagnoses. Examination of the components of the Pra tracing, especially during the ventilator cycle, can also give information about right-sided cardiac diastolic function, the status of the tricuspid valve, volume responsiveness, and the cardiac rhythm. Importantly, the pressure difference from the large venous reservoir to the heart is small, and thus great care must be taken with technical factors that affect the measurement.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, McGill University Health Centre, Montreal, QC, Canada.
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Marx G, Schindler AW, Mosch C, Albers J, Bauer M, Gnass I, Hobohm C, Janssens U, Kluge S, Kranke P, Maurer T, Merz W, Neugebauer E, Quintel M, Senninger N, Trampisch HJ, Waydhas C, Wildenauer R, Zacharowski K, Eikermann M. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33:488-521. [PMID: 27043493 PMCID: PMC4890839 DOI: 10.1097/eja.0000000000000447] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gernot Marx
- From the Department of Cardiothoracic and Vascular Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz (JA); Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena (MB); Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne (ME); Institute of Nursing Science and Practice, Paracelsus Private Medical University, Salzburg, Austria (IG); Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Leibzig (CH); Department of Cardiology, St Antonius Hospital, Eschweiler (UJ); Centre for Intensive Care Medicine, Universitätsklinikum, Hamburg-Eppendorf (SK); Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Würzburg (PK); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (GM); Urological Unit and Outpatient Clinic, University Hospital rechts der Isar, Munich (TM); Department of Obstetrics and Gynaecology, Bonn University Hospital, Bonn (WM); Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne (CM, EN); Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen (MQ); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (AWS); Department of General and Visceral Surgery, Münster University Hospital, Münster (NS); Department of Health Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum (HJT); Department of Trauma Surgery, Essen University Hospital, Essen (CW); Department of General Surgery, University Hospital of Würzburg, Würzburg (RW); and Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany (KZ)
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Perel A, Saugel B, Teboul JL, Malbrain MLNG, Belda FJ, Fernández-Mondéjar E, Kirov M, Wendon J, Lussmann R, Maggiorini M. The effects of advanced monitoring on hemodynamic management in critically ill patients: a pre and post questionnaire study. J Clin Monit Comput 2015; 30:511-8. [DOI: 10.1007/s10877-015-9811-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/26/2015] [Indexed: 11/28/2022]
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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Bloechlinger S, Berger D, Bryner J, Roost E, Jakob S, Dünser MW, Takala J. Changes in Left Ventricular Torsion Early Postoperatively After Aortic Valve Replacement and at Long-Term Follow-up. J Cardiothorac Vasc Anesth 2015; 29:860-7. [DOI: 10.1053/j.jvca.2015.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Indexed: 12/16/2022]
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Abstract
Although invasive hemodynamic monitoring requires considerable skill, studies have shown a striking lack of knowledge of the measurements obtained with the pulmonary artery catheter (PAC). This article reviews monitoring using a PAC. Issues addressed include basic physiology that determines cardiac output and blood pressure; methodology in the measurement of data obtained from a PAC; use of the PAC in making a diagnosis and for patient management, with emphasis on a responsive approach to management; and uses of the PAC that are not indications by themselves for placing the catheter, but can provide useful information when a PAC is in place.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, Royal Victoria Hospital, McGill University Health Centre, 687 Pine Avenue West, Montreal, Quebec H3A 1A1, Canada.
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Abstract
PURPOSE OF REVIEW Many devices are currently available for measuring cardiac output and function. Understanding the utility of these devices requires an understanding of the determinants of cardiac output and cardiac function, and the use of these parameters in the management of critically ill patients. This review stresses the meaning of the physiological measures that are obtained with these devices and how these values can be used. RECENT FINDINGS Evaluation of devices for haemodynamic monitoring can include just measurement of cardiac output, the potential to track spontaneous changes in cardiac output or changes produced by volume infusions or vasoactive drugs, or the ability to assess cardiac function. Each of these puts different demands on the need for accuracy, precision, and reliability of the devices, and thus devices must be evaluated based on the clinical need. SUMMARY Evaluation of cardiac function is useful when first dealing with an unstable patient, but for ongoing management measurement of cardiac output itself is key and even more so the trend in relationship to the patient's overall condition. This evaluation would be greatly benefited by the addition of objective measures of tissue perfusion.
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