Norepinephrine and dobutamine improve cardiac index equally by supporting opposite sides of the heart in an experimental model of chronic pulmonary hypertension

Right ventricle-pulmonary artery coupling in pulmonary artery hypertension its measurement and pharmacotherapy

The right ventricular (RV) function correlates with prognosis in severe pulmonary artery hypertension (PAH) but which metric of it is most clinically relevant is still uncertain. Clinical methods to estimate RV function from simplified pressure volume loops correlate with disease severity but the clinical relevance has not been assessed. Evaluation of right ventricle pulmonary artery coupling in pulmonary hypertensive patients may help to elucidate the mechanisms of right ventricular failure and may also help to identify patients at risk or guide the timing of therapeutic interventions in pulmonary hypertension. Complete evaluation of RV failure requires echocardiographic or magnetic resonance imaging, and right heart catheterization measurements. Treatment of RV failure in PAH relies on decreasing afterload with drugs targeting pulmonary circulation; fluid management to optimize ventricular diastolic interactions; and inotropic interventions to reverse cardiogenic shock. The ability to relate quantitative metrics of RV function in pulmonary artery hypertension to clinical outcomes can provide a powerful tool for management. Such metrics could also be utilized in the future as surrogate endpoints for outcomes and evaluation of response to therapies. This review of literature gives an insight on RV-PA coupling associated with PAH, its types of measurement and pharmacological treatment.

The use of point-of-care assessments and advanced hemodynamic monitoring in a patient with Eisenmenger syndrome for cesarean section: A case report

INTRODUCTION

Eisenmenger syndrome should be diagnosed before pregnancy and surgically corrected if possible. Cesarean section in a patient with Eisenmenger syndrome is high risk as morbidity and mortality are very high. Delivery in hospitals with intensive care units should be recommended. Use of point-of-care assessments and advanced monitors allow accurate management.

CASE PRESENTATION

A primigravid with congestive heart failure from a patent ductus arteriosus in Eisenmenger syndrome, presented with threatened preterm labor and uncontrolled hypertension prompting cesarean delivery under epidural anesthesia. Pre-induction focused echocardiography revealed normal right ventricular function and severe pulmonary hypertension. Intraoperatively, hemodynamics became unstable. The decision to use fluids, vasopressor and inotrope was guided by analyses of arterial pulse contour, central venous pressure waveform and blood exams. Hemodynamics improved and a live baby was delivered. Postoperative course was unremarkable.

DISCUSSION

The cause of hemodynamic instability must be accurately determined as inappropriate use of fluid or medication may be detrimental to a patient with Eisenmenger syndrome. In this case, advanced hemodynamic monitoring showed changes in central venous pressure, cardiac output and systemic vascular resistance which differentiated the causes of hypotension and desaturation. Point-of-care blood analysis showed acidosis and hypoxia which may have worsened the right-to-left shunt, contributing to the desaturation. Fluid and drug infusions to address identified problems were then guided by advanced monitors.

CONCLUSION

The use of point-of-care assessments and advanced hemodynamic monitoring allowed accurate diagnoses and goal-directed therapies leading to improved patient safety and outcomes. The need for prolonged intensive care in this case was prevented.