On the right side of the heart: Medical and mechanical support of the failing right ventricle

Comparison of diuretics and fluid expansion in the initial treatment of patients with normotensive acute pulmonary embolism: a systematic review and meta-analysis

BACKGROUND

Right ventricular (RV) dysfunction is the main cause of death in patients with normotensive acute pulmonary embolism (PE). The optimal management for this subset of patients remains uncertain. This systematic review and meta-analysis focused on the comparison of diuretics and fluid expansion in patients with acute PE presenting with RV dysfunction and haemodynamic stability.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines considering only RTCs. The authors searched the traditional and grey literature through 1 November 2022. Meta-analysis used open source packages in R. Inverse variance fixed-effects models with OR as the effect measure were used for primary analyses. The main outcomes defined in this review protocol included pulmonary arterial systolic pressure (PASP), creatinine value changes and N-terminal pro-B-type natriuretic peptide during the first 24 hours.

RESULTS

Four studies with a total of 452 patients met the inclusion criteria. The baseline characteristics of patients were similar across all studies. Overall, patients receiving diuretics had a significant 24 hours reduction in pro-B-type natriuretic peptide (standard mean difference of -41.97; 95% CI -65.79 to -18.15), and PASP (standard mean difference of -5.96; 95% CI -8.06 to -3.86). This group had significantly higher creatinine levels (standard mean difference of 7.74; 95% CI 5.04 to 10.45). The quality of the studies was heterogeneous; two had a low risk of bias, and the other two had a high risk of bias.

CONCLUSIONS

Very few studies have compared the efficacy and safety of diuretics and fluid expansion in normotensive patients with acute PE with RV failure. Overall, furosemide appears to reduce RV dysfunction in this subset of patients compared with fluid expansion. Further research is required to confirm these findings.

BRASH Syndrome: A Systematic Review of Reported Cases

The pathophysiology of Bradycardia-Renal Failure-Atrioventricular Nodal Blockade-Shock-Hyperkalemia (BRASH) syndrome involves acute renal injury leading to ineffective clearance of AV nodal agents and potassium. Theoretically, the synergy between AV nodal blockade and hyperkalemic cardiac dysconduction results in circulatory collapse at less-than-expected doses of both. Our study aims to characterize the presentation of BRASH and provide clinical evidence of its risk factors. This systematic review comprises all reported cases of BRASH until February 2022. The average age and Charleston Comorbidity Index at presentation was 69 years and 3.8 respectively - hypertension (71%) was most prevalent followed by diabetes mellitus (48%) and chronic kidney disease (44%). The most frequent presenting complaint was fatigue or syncope (49%). More than half of all patients presented with nonsevere hyperkalemia (less than 6.5 mmol/L) and the mean serum creatinine was 3.6 mg/dL. Beta-blockers (75%) were the most commonly implicated nodal agents. Presenting mean arterial pressure was 62 mm Hg and heart rate averaged 36 bpm; junctional escape rhythm (50%), sinus bradycardia (17.1%), and complete heart block (12.9%) were generally observed on EKG. While most patients responded to medical management, 20% of patients required renal replacement therapy and 33% required transvenous or transcutaneous pacing. No patients underwent permanent pacemaker placement and the in-hospital mortality of BRASH was 5.7%. The diagnosis of BRASH requires a high index of suspicion; its synergistic pathology results in a dramatic clinical presentation that can be easily overlooked. As hypothesized, the degree of renal failure and hyperkalemia are not congruent with the presenting circulatory shock. The significant mortality of this syndrome presents an opportunity for intervention with timely recognition.

The Therapeutic Use of Impella Device in Cardiogenic Shock: A Systematic Review

Impella (Abiomed, Danvers, MA) devices nowadays have been linked to cardiogenic shock (CS) due to the importance of their use as therapeutic instruments. This study aims to review pathophysiologic mechanisms of cardiogenic shock and the implementation of Impella to overcome this condition. To investigate several different types of studies and analyze the use of Impella device in cardiogenic shock and the outcomes of heart malfunctioning and determine its positive and negative impacts as a therapeutic tool in cardiac ischemia and use as a resource in critical patients, we conducted a systematic review through different databases (PubMed, ScienceDirect, and Google Scholar) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and used the Medical Subjects Heading (MeSH) search strategy to obtain significant articles. We found 883 papers in total, and after removing duplicates, applying inclusion/exclusion criteria, and finding the most significant information, we ended up with 30 articles that were reviewed containing information about the impact of Impella device in cardiogenic shock in different locations. The study strongly concludes that Impella device in the setting of cardiogenic shock has more advantages than disadvantages in terms of outcomes and complications as a non-pharmacologic tool. Improvements in left ventricular ejection fraction and signs and symptoms of cardiogenic shock criteria were determinants. Nevertheless, complications during the implementation and use of the device were established; in this manner, the evaluation and treatment of each patient separately are imperative. Consequently, more studies on this relevant topic are needed.

A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock

This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.

Critical Care Management of Decompensated Right Heart Failure in Pulmonary Arterial Hypertension Patients - An Ongoing Approach

Despite substantial advancements in diagnosis and specific medical therapy in pulmonary arterial hypertension patients’ management, this condition continues to represent a major cause of mortality worldwide. In pulmonary arterial hypertension, the continuous increase of pulmonary vascular resistance and rapid development of right heart failure determine a poor prognosis. Against targeted therapy, patients inexorable deteriorate over time. Pulmonary arterial hypertension patients with acute right heart failure who need intensive care unit admission present a complexity of the disease pathophysiology. Intensive care management challenges are multifaceted. Awareness of algorithms of right-sided heart failure monitoring in intensive care units, targeted pulmonary hypertension therapies, and recognition of precipitating factors, hemodynamic instability and progressive multisystem organ failure requires a multidisciplinary pulmonary hypertension team. This paper summarizes the management strategies of acute right-sided heart failure in pulmonary arterial hypertension adult cases based on recently available data.

Management of Right Ventricular Failure in Pulmonary Embolism

Acute right ventricular failure remains the leading cause of mortality associated with acute pulmonary embolism (PE). This article reviews the pathophysiology behind acute right ventricular failure and strategies for managing right ventricular failure in acute PE. Immediate clot reduction via systemic thrombolytics, catheter based procedures, or surgery is always advocated for unstable patients. While waiting to mobilize these resources, it often becomes necessary to support the RV with vasoactive medications. Clinicians should carefully assess volume status and use caution with volume resuscitation. Right ventricular assist devices may have an expanding role in the future.