acute rv failure physiology to management
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ACUTE RV FAILUREPHYSIOLOGY TO MANAGEMENT
Dr. DEV PAHLAJANI MD,FACC,FSCAIHOD INTERVENTIONAL CARDIOLOGY BREACH CANDY HOSPITAL MUMBAI
Venous Return Physiology
• “Most People have a Cardiocentric view of the World.” – Michael O’Conner
• The Heart can only pump out, what comes in. Therefore the main job of the RV is to maintain a low right atrial pressure so that Venous Return is optimized.
Anatomy The RV is triangular in shape
Divided into three regions –Inlet–Apex–Infundibulum or Conus
Both Ventricles are composed of a 3D network of muscle fibers
Circulation 2008;117:1436-1448
In idiopathic PAH, the RV is characterized by increased end-diastolic volume, change of the
normal ventricular conformation tetrahedron to a crescentic trapezoid, and varying degrees of
right ventricle hypertrophy
Voelkel NF et al Circulation, Volume 114(17) 2006
The RV in severe idiopathic PAH assumes a spherical shape with a greater cross-sectional area than the LV, which is normally larger
Right ventricle in pulmonary hypertension /RVI
Mechanisms of RV Dysfunction in Critically Ill Patients
Lahm et al JACC Vol. 56, No. 18, 2010.
Effect of Ventricular Afterload• As a result of the lower pulmonary circuit pressures the period of
Iso volumic contraction is less compared to the LV (or Pressure loaded RV). This results in decreased Myocardial oxygen demand.
• Additionally the point of semi lunar valve closure is delayed leading to a prolonged ejection phase.
Normal pressures and vascular resistance in the pulmonary and systemic
circulationsSystolic Diastolic
Right ventricle 15- 25 1- 7 Pulmonary artery 8- 12 Left ventricle 90-140 5- 15 Aorta 60- 90 Pulmonary vascular resistance
150 – 250
Systemic vascular resistance
900-1400
Leo G. K and Barnard M CEACCP , Vol 7 (3) 2007
Aortic Pressure and Coronary Blood Flow
Frank-Starling Law of the Heart
• States that strength of ventricular contraction varies directly with EDV– Is an intrinsic property
of myocardium– As EDV increases,
myocardium is stretched more, causing greater contraction & SV
Hemodynamic effects of fluid loading in acute massive pulmonary embolism
Anatomy
In ≤10% of patients, the left circumflex CA supplies perfusion to a larger extent of the RV than usual, through posterior diagonal branches off the posterior descending CA and from acute marginal branches of an ongoing circumflex
after the crux.
Right ventricular infarction- Elsevier Health, 2006
RCA Distal
RVI Haemody
• Increased RV compliance
• Increased RVEDP and RA pressure
• Shift of IVS to left --LV interdependence
• Increased LVEDP
• Reduced stroke volume
Anatomical changes in RV infarction
Normal atrial size andanatomy
Enlargement of the right side of the heart as a consequence of RVinfarction.
Right ventricular infarction- Elsevier Health, 2006
RV infarction (RVI)
• RVI rarely isolated Associated with 30-50 % acute INF STEMI
• The syndrome of RVI is that of low output and hypotension.
• Responsible for some cardiogenic shock cases and a larger proportion of hypotensive inferior infarction cases.
Right ventricular infarction- Elsevier Health, 2006
Relationship to different infarcts
Infarct Location RV Dysfunction RV FACAnterior 16.7% 42.5 ± 10%
Inferior only 22.9% 40.1 ± 10%Anterior and inferior 26.9% 38.7 ± 11%
Any inferior 24.2% 39.5 ± 11%Other 11.8% 41.2 ± 8.5%
Right ventricular infarction- Elsevier Health, 2006
Clinical presentation • Hypotensive inferior infarction
• Inferior infarction, cardiogenic shock
• Inferior infarction with venous distention, Kussmaul sign
• Inferior infarction, BP intolerant of GTN
• Larger biomarker rise than anticipated from inferior infarction
• Greater amount of hypotension than expected from a first
infarct with a small or moderate creatine kinase rise
Right ventricular infarction- Elsevier Health, 2006
• TOP, ECG shows complete heart block with an irregular wide complex ventricular rhythm. There is no pacemaker capture due to RV infarction.
• MIDDLE, CXR shows normal-sized cardio pericardial silhouette, no pulmonary edema.
• BOTTOM, ECG on arrival shows asystole with ventricular escape beats.
CASE STUDY
• 49 yrs. male
• Chest pain few hours
• Persistent hypotension BP 80/60,hr 60
• Pale
• Lungs clear
• Raised troponins
CASE STUDY
• Post PPCI - pain free
• Persistent hypotension despite fluid load
• Adequate urine output
• Dopamin, nor ad.
• Weaned off after 3 days
Why all patients do not respond to fluids?
• LV dysfunctio due to leftward shift of IVS
• Increased LVEDP
• Reduced LV compliance and cavity
• RV dilat. leads to increased int pericardial pressure
• Geometric deformity
In idiopathic PAH, the RV is characterized by increased end-diastolic volume, change of the
normal ventricular conformation tetrahedron to a crescentic trapezoid, and varying degrees of
right ventricle hypertrophy
Voelkel NF et al Circulation, Volume 114(17) 2006
The RV in severe idiopathic PAH assumes a spherical shape with a greater cross-sectional area than the LV, which is normally larger
Right ventricle in pulmonary hypertension /RVI
Venous return caves
PrognosisOutcome No RV Dysfunction RV Dysfunction
OR for RV Dysfunction (95%
CI)Death 14.5% 38.0% 3.6 (2.1–6.2)CVD 12.2% 32.9% 3.5 (2.0–6.3)HF 17.2% 30.4% 2.1 (1.2–3.7)
Death or HF 26.7% 50.6% 2.8 (1.7–4.7)Recurrent MI 13.3% 10.1% 0.7 (0.3–1.6)
Leonardo A.M. Zornoff, et al JACC,2002;39(9):1450-1455.
In Hospital Outcomes
• In hospital outcomes in patients with predominant RV and LV shock.
Jacobs KA et al , JACC, 2003;41(8):1273-1279.
1 month post infarction survival
• At 1 month after infarction, almost all survivors have normal RV systolic function, but few have normalized LV systolic function.
Right ventricular infarction- Elsevier Health, 2006
Treatment in RVI and LVI
LV INF.CLASS 3
• Modest diuresis
• IV NTG/nitropruss
• ACE inhibitors
• Volume restriction
• IABP+ PCI
RV INF.FAILURE
• Restrict diuretics
• No vasodilators
• No ACE inhibitors
• Volume++
• PPCI and IABP if LV failure
Therapy of different cases • Asymptomatic case Avoid diuretics and vasodilators that may precipitate low
output and hypotension• Symptomatic low-output state and normotensive with RA
pressure or pulmonary capillary wedge pressure <15 mm Hg– Add fluid to increase the PCWP to 15-18 mm Hg. – If cardiac output does not increase adequately, add a
vasodilator.– If the cardiac output still does not– increase adequately, add dobutamine or amrinone.– Reperfusion therapy should be considered.
Right ventricular infarction- Elsevier Health, 2006
• Symptomatic low-output state and normotensive with RA pressure or PCWP >15 mm Hg– Add intravenous dobutamine or amrinone.– Additional vasodilator with fluid therapy support may be
added.– Primary PCI with stent treatment of choice
• Cardiogenic shock– Sustain BP with dopamine; additional dobutamine may
increase cardiac output.– Consider RV assist or pulmonary artery counter pulsation for
select cases.– Primary PCI therapy is strongly recommended
Therapy of different cases
Right ventricular infarction- Elsevier Health, 2006
RV INFARCION PPCI-JACC 1995
RV INFARCTION PPCI-JACC 1995
In Hospital Survival
• Survival curves for patients with predominant RV and LV shock.
• In-hospital survival rates were 46.9% for patients with
predominant RV shock 39.2% for patients with
LV shock.
Jacobs KA et al , JACC, 2003;41(8):1273-1279.
Right Ventricle Recovery
The RV recovers more and faster than does the inferior wall of the LV
Right ventricular infarction- Elsevier Health, 2006
Transesophagealechocardiography
• Marked RA and RV dilation. The left-sided heart chambers are small• because of underloading. Interatrial septal bulging to the left side suggests that RA
pressure is greater than LA pressure. The right ventricular free wall is severely hypokinetic or akinetic, despite
• inotropic support. There is no pericardial effusion.
Differential diagnosis
• Under filling of the LV– Hypovolemia, may be from medications– RVinfarction
• • Vasodepression– Excessive effect of medications– Medication-induced anaphylaxis– Vagal vasodepressant state
• Tamponade• Ventricular septal rupture
Right ventricular infarction- Elsevier Health, 2006
V4R
Mortality
Mortality for patients with predominant RV and LV shock undergoing CABG and PTCA
Jacobs KA et al , JACC, 2003;41(8):1273-1279.
Auto-Aggravation: The Vicious Cycle
Leo G. K and Barnard M CEACCP , Vol 7 (3) 2007
Pressure–volume loops for the RV and LV.
Leo G. K and Barnard M CEACCP , Vol 7 (3) 2007
THANK YOU!!