Advertisement

Management of Decompensated Right Ventricular Failure in the Intensive Care Unit

  • Rana Lee Adawi Awdish
  • Michael P. MendezEmail author
Chapter

Abstract

Acute on chronic decompensation of right heart failure can present many challenges to the critical care practitioner that require an understanding of the effect of right heart failure on resuscitation endpoints and hemodynamic monitoring. In this chapter, we review principles of management of decompensated right heart failure using an illustrative case followed by a review of the evidence regarding monitoring, pharmacotherapy, and supportive care of these patients.

Keywords

Pulmonary hypertension Right ventricle Right ventricular failure Pulmonary Pulmonary vasculature Hemodynamics Pulmonary vasodilators RV failure RV decompensation Pulmonary artery pressure 

Supplementary material

Video 33.1

Parasternal short axis view demonstrating RV chamber dilation and D-shaped septum. (WMV 606 kb)

Video 33.2

View of the inferior vena cava demonstrating no collapse (WMV 843 kb)

References

  1. 1.
    Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119–41.CrossRefPubMedGoogle Scholar
  2. 2.
    Beaulieu Y. Bedside echocardiography in the assessment of the critically ill. Crit Care Med. 2007;35(5 Suppl):S235–49.CrossRefPubMedGoogle Scholar
  3. 3.
    Romero-Bermejo FJ, Ruiz-Bailen M, Guerrero-De-Mier M, Lopez-Alvaro J. Echocardiographic hemodynamic monitoring in the critically ill patient. Curr Cardiol Rev. 2011;7(3):146–56.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Sato T, Tsujino I, Ohira H, Oyama-Manabe N, Yamada A, Ito YM, et al. Validation study on the accuracy of echocardiographic measurements of right ventricular systolic function in pulmonary hypertension. J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr. 2012;25(3):280–6.CrossRefGoogle Scholar
  5. 5.
    Forfia PR, Fisher MR, Mathai SC, Housten-Harris T, Hemnes AR, Borlaug BA, et al. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med. 2006;174(9):1034–41.CrossRefPubMedGoogle Scholar
  6. 6.
    Batal O, Dardari Z, Costabile C, Gorcsan J, Arena VC, Mathier MA. Prognostic value of pericardial effusion on serial echocardiograms in pulmonary arterial hypertension. Echocardiography. 2015;32:1471–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Raymond RJ, Hinderliter AL, Willis PW, Ralph D, Caldwell EJ, Williams W, et al. Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. J Am Coll Cardiol. 2002;39(7):1214–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Arcasoy SM, Christie JD, Ferrari VA, Sutton MS, Zisman DA, Blumenthal NP, et al. Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med. 2003;167(5):735–40.CrossRefPubMedGoogle Scholar
  9. 9.
    Corson N, Armato 3rd SG, Labby ZE, Straus C, Starkey A, Gomberg-Maitland M. CT-based pulmonary artery measurements for the assessment of pulmonary hypertension. Acad Radiol. 2014;21(4):523–30.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Frazier AA, Burke AP. The imaging of pulmonary hypertension. Semin Ultrasound CT MR. 2012;33(6):535–51.CrossRefPubMedGoogle Scholar
  11. 11.
    Tan RT, Kuzo R, Goodman LR, Siegel R, Haasler GB, Presberg KW. Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Medical College of Wisconsin Lung Transplant Group. Chest. 1998;113(5):1250–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Rudolph AM, Yuan S. Response of the pulmonary vasculature to hypoxia and H+ ion concentration changes. J Clin Invest. 1966;45(3):399–411.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Walley KR. Use of central venous oxygen saturation to guide therapy. Am J Respir Crit Care Med. 2011;184(5):514–20.CrossRefPubMedGoogle Scholar
  14. 14.
    Beaulieu Y. Specific skill set and goals of focused echocardiography for critical care clinicians. Crit Care Med. 2007;35(5 Suppl):S144–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Pinsky MR. Functional haemodynamic monitoring. Curr Opin Crit Care. 2014;20(3):288–93.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Wyler von Ballmoos M, Takala J, Roeck M, Porta F, Tueller D, Ganter CC, et al. Pulse-pressure variation and hemodynamic response in patients with elevated pulmonary artery pressure: a clinical study. Crit Care. 2010;14(3):R111.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Mahjoub Y, Pila C, Friggeri A, Zogheib E, Lobjoie E, Tinturier F, et al. Assessing fluid responsiveness in critically ill patients: false-positive pulse pressure variation is detected by Doppler echocardiographic evaluation of the right ventricle. Crit Care Med. 2009;37(9):2570–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Ventetuolo CE, Klinger JR. Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc. 2014;11(5):811–22.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Gore JA, Alpert JS, Benntti JR, Kotilainen PR. Handbook of hemodynamic monitoring. Little Brown and Company, Boston, MA, USA; 1985.Google Scholar
  20. 20.
    Harvey RM, Enson Y, Betti R, Lewis ML, Rochester DF, Ferrer MI. Further observations on the effect of hydrogen ion on the pulmonary circulation. Circulation. 1967;35(6):1019–27.CrossRefPubMedGoogle Scholar
  21. 21.
    Viitanen A, Salmenpera M, Heinonen J. Right ventricular response to hypercarbia after cardiac surgery. Anesthesiology. 1990;73(3):393–400.CrossRefPubMedGoogle Scholar
  22. 22.
    Viitanen A, Salmenpera M, Heinonen J, Hynynen M. Pulmonary vascular resistance before and after cardiopulmonary bypass. The effect of PaCO2. Chest. 1989;95(4):773–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Dambrosio M, Fiore G, Brienza N, Cinnella G, Marucci M, Ranieri VM, et al. Right ventricular myocardial function in ARF patients. PEEP as a challenge for the right heart. Intensive Care Med. 1996;22(8):772–80.CrossRefPubMedGoogle Scholar
  24. 24.
    Hoeper MM, Granton J. Intensive care unit management of patients with severe pulmonary hypertension and right heart failure. Am J Respir Crit Care Med. 2011;184(10):1114–24.CrossRefPubMedGoogle Scholar
  25. 25.
    Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17–20.CrossRefPubMedGoogle Scholar
  26. 26.
    Pandharipande P, Banerjee A, McGrane S, Ely EW. Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care. Crit Care. 2010;14(3):157.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Hadian M, Pinsky MR. Evidence-based review of the use of the pulmonary artery catheter: impact data and complications. Crit Care. 2006;10 Suppl 3:S8.CrossRefPubMedGoogle Scholar
  28. 28.
    Chan CM, Klinger JR. The right ventricle in sepsis. Clin Chest Med. 2008;29(4):661–76. ix.CrossRefPubMedGoogle Scholar
  29. 29.
    Schreuder WO, Schneider AJ, Groeneveld AB, Thijs LG. Effect of dopamine vs norepinephrine on hemodynamics in septic shock. Emphasis on right ventricular performance. Chest. 1989;95(6):1282–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Rich S, Gubin S, Hart K. The effects of phenylephrine on right ventricular performance in patients with pulmonary hypertension. Chest. 1990;98(5):1102–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Le Tulzo Y, Seguin P, Gacouin A, Camus C, Suprin E, Jouannic I, et al. Effects of epinephrine on right ventricular function in patients with severe septic shock and right ventricular failure: a preliminary descriptive study. Intensive Care Med. 1997;23(6):664–70.CrossRefPubMedGoogle Scholar
  32. 32.
    Leather HA, Segers P, Berends N, Vandermeersch E, Wouters PF. Effects of vasopressin on right ventricular function in an experimental model of acute pulmonary hypertension. Crit Care Med. 2002;30(11):2548–52.CrossRefPubMedGoogle Scholar
  33. 33.
    Holloway EL, Polumbo RA, Harrison DC. Acute circulatory effects of dopamine in patients with pulmonary hypertension. Br Heart J. 1975;37(5):482–5.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Acosta F, Sansano T, Palenciano CG, Falcon L, Domenech P, Robles R, et al. Effects of dobutamine on right ventricular function and pulmonary circulation in pulmonary hypertension during liver transplantation. Transplant Proc. 2005;37(9):3869–70.CrossRefPubMedGoogle Scholar
  35. 35.
    Chen EP, Bittner HB, Davis Jr RD, Van Trigt 3rd P. Milrinone improves pulmonary hemodynamics and right ventricular function in chronic pulmonary hypertension. Ann Thorac Surg. 1997;63(3):814–21.CrossRefPubMedGoogle Scholar
  36. 36.
    Vachiery JL, Adir Y, Barbera JA, Champion H, Coghlan JG, Cottin V, et al. Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol. 2013;62(25 Suppl):D100–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Bhorade S, Christenson J, O’Connor M, Lavoie A, Pohlman A, Hall JB. Response to inhaled nitric oxide in patients with acute right heart syndrome. Am J Respir Crit Care Med. 1999;159(2):571–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Nagendran J, Archer SL, Soliman D, Gurtu V, Moudgil R, Haromy A, et al. Phosphodiesterase type 5 is highly expressed in the hypertrophied human right ventricle, and acute inhibition of phosphodiesterase type 5 improves contractility. Circulation. 2007;116(3):238–48.CrossRefPubMedGoogle Scholar
  39. 39.
    Vachiery JL, Huez S, Gillies H, Layton G, Hayashi N, Gao X, et al. Safety, tolerability and pharmacokinetics of an intravenous bolus of sildenafil in patients with pulmonary arterial hypertension. Br J Clin Pharmacol. 2011;71(2):289–92.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301–8.Google Scholar
  41. 41.
    Repesse X, Charron C, Vieillard-Baron A. Acute cor pulmonale in ARDS: rationale for protecting the right ventricle. Chest. 2015;147(1):259–65.CrossRefPubMedGoogle Scholar
  42. 42.
    Jozwiak M, Teboul JL, Anguel N, Persichini R, Silva S, Chemla D, et al. Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2013;188(12):1428–33.CrossRefPubMedGoogle Scholar
  43. 43.
    Varpula T, Valta P, Niemi R, Takkunen O, Hynynen M, Pettila VV. Airway pressure release ventilation as a primary ventilatory mode in acute respiratory distress syndrome. Acta Anaesthesiol Scand. 2004;48(6):722–31.CrossRefPubMedGoogle Scholar
  44. 44.
    Olsson KM, Simon A, Strueber M, Hadem J, Wiesner O, Gottlieb J, et al. Extracorporeal membrane oxygenation in nonintubated patients as bridge to lung transplantation. Am J Transpl Off J Am Soc Transpl Am Soc Transpl Surg. 2010;10(9):2173–8.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of Pulmonary and Critical Care MedicineHenry Ford Health SystemDetroitUSA
  2. 2.Division of Pulmonary and Critical Care MedicineUniversity of MichiganAnn ArborUSA

Personalised recommendations