Advanced Heart Failure Management:

When to consider RHC

Tarek Kashour

King Saud University

Questions

• RHC should be performed routinely in advanced heart failure?

• RHC should not be considered in advanced heart failure?

• RHC is useful in some patients with advanced heart failure?

Questions

• Invasive evaluation is useful in patients with respiratory distress or impaired perfusion and undetermined filling pressures clinically?

• To guide therapy in patients who are not responding to treatment?

• Patients with persistent symptomatic hypotension?

• Worsening renal function with therapy?

• Patients who need vasoactive agents?

• Patients who are considered for MCS or transplantation?

• Patients with severe pulmonary hypertension?

Goals of medicine

• philosophers and ethicists identified four contemporary goals of medicine:1

1. Preventing disease and injury and promoting and maintaining health

2. Relieving pain and suffering caused by maladies

3. Caring for and curing those with a malady and caring for those who cannot be cured

4. Avoiding premature death and pursuing a peaceful death

1- Hastings Cent Rep 1996;26:S1-27

Does routine use of invasive hemodynamic monitoring useful in managing advanced heart

failure patients?

ESCAPE Trial

ESCAPE, JAMA 2005;294:1625-33

Increased adverse events with PAC

What guidelines say about Invasive evaluation in HF?

Invasive evaluation

Invasive evaluation

Invasive evaluation

Based on these guidelines, RHC can be considered in the following:

• Diagnostic dilemmas:– When other pathologies/abnormalities are present or

suspected; e.g. myocarditis, congenital heart disease

– Contribution of HF to current deterioration is uncertain

– Severe PH or RHF predominates the picture

• Therapeutic challenges:– Poor response to therapy

– When valve interventions are considered

– Need for MCS

– Transplantation

• Research

Heart Failure is a Hemodynamic Disorder

• Elevated filling pressures

• Reduced cardiac output

• Pulmonary hypertension

• Abnormal hemodynamic measures of systolic and

diastolic functions and ventriculo-arterial coupling

• Altered vascular compliance, resistance,

impedance

Pearls of Invasive Hemodynamic Assessment in HF

• Right operator and institution

• Proper set-up

• Right/suitable patient with the right goal

• Appropriate circumstances

• Proper execution of the procedure

Appropriate Circumstances

• Stable hemodynamics

• Special attention to volume status

• Stable metabolic status (e.g. acid-base balance)

• Avoidance of sedation

• If O2 therapy is required: pay special attention

Proper Study ExecutionGeneral

• Precision in obtaining and documentation of

measurements

• Continuous data acquisition and recording

• Understanding the implications of study findings

and preparedness to perform additional

measurements and testing when necessary

Proper Study ExecutionLeveling and zeroing the system

• Setting the transducer at the phlebosatic level

• Zeroing is performed by opening the system to air to establish

atmospheric pressure as zero

• Perform Zeroing:

– During initial set up

– If patient or transducer position changes, the system

has to be re-levelled and re-zeroed

– When suspecting inaccuracies with measurements

Balloon Pearls

• 1-1.5 cc used to wedge

• Wedge time <10-15 sec

• Never inject fluid into the balloon

• Avoid repeated inflations/ deflations

Proper Study ExecutionObtaining Good Quality Data

• Set the pressure scale at the optimal level

for proper pressure wave identification and

measurement

• Record waveform tracings at appropriate

speed

RA: Scale 50 & speed 25 RA: Scale 20 & speed 50

• Record pressures during normal breathing

and avoid straining or valsalva

• Measurements at the end expiration

• Current practice vary:

– End expiration

– Breath hold

– Machine derived numbers

• Take the average readings of 3 respiratory

cycles

Proper Study ExecutionObtaining Good Quality Data

PAWP pressure measurement

Machine reading artifacts

• Significant respiratory variations:

– Obesity

– COPD, OSA and interstitial lung disease

• Computer-based measurements average the mean pressure

throughout the respiratory cycle giving an underestimated value for

the PAWP

Snapshot reading given by the machine of

PCW : 15/18/14

Improper machine displayed pressure

Correct mean

PAWP Measurement Errors Due to Use of Digitized Readings

Ryan et al, Am Heart J 2012

Other Common Pitfalls with PAWP

Measurements

Over-wedging of the balloon catheter

After proper wedging

Other Common Pitfalls with PAWP Measurements

• Partial occlusion pressure (falsely high PAWP)

– Gives hybrid waveform with overestimated PAWP

– Timing of v wave helps

– PAWP higher than dPAP

– Oxymetry of wedge blood sample

Mathier, 2011 Adv Pulm Htn

What parameters should be evaluated

• RAP

• PSP

• PAWP

• TPG and DPG

• CO/CI

• Mixed venous O2 sats

• PVR and SVR

• Vasoreactivity testing

Safety of RHC

• Contraindications:

– Absolute: Right-sided thrombus or mass, right-sided

endocarditis

• Complications:

– Hematoma, vasovagal episodes, arrhythmias, hypotension

Pulmonary hemorrhage

• Safety: Complication rate 1.1%. Most of these are access site

related and vasovagal episodes. Procedure related death

0.06%1

Hoeper M et al, JACC 2006;48:2546-52

Hemodynamic assessment in transplantation candidates

• A severely increased risk of right heart failure and mortality after heart transplantation is thought to be present:

– When the PVR is >5 WU or the PVRI is >6 WU.m2 in children, or the TPG exceeds 16 to 20 mmHg.

– If the systolic PAP exceeds 60 mmHg in conjunction with any one of the preceding three variables.

– If the PVR can be reduced to <2.5 with a vasodilator only at the cost of a fall in arterial systolic blood pressure <85 mmHg.

Mehra M et al, J Heart lung Trans 2006;25:1024-42

Hemodynamic assessment in transplantation candidates

• A vasodilator challenge: should be administered when the pulmonary artery systolic pressure is ≥50 mmHg and either the transpulmonary gradient (TPG) is ≥15 mmHg or the PVR is >3 WU and With SBP> 85 mmHg

• Agents: Nitroprusside, NTG, NO, epoprostenol, PG-E1 and iloprost, milrinone can be used

• Goal: PVR< 2.5-3 WU and TPG< 12 with maintenance of SBP> 85 mmHg

Mehra M et al, J Heart lung Trans 2006;25:1024-42

Back to the case• A 28-year-old male has familial dilated cardiomyopathy. He was NYHA

class I in 2016 but slowly deteriorated to functional class II. In January 2017, he refused CRTD due to a panic episode on the table. A month later he decompensated rapidly after febrile illness but was ambulatory on the ward and no dyspnea with limited movement. He was on milrinone 0.375 mcg/kg/min, dopamine 4 mcg/min, spironolactone 25 mg daily, digoxin 0.125 mg daily, Lasix infusion 20 mg/hr, metolazone 5 mg daily. Two attempts at weaning from dopamine resulted in symptomatic hypotension.

• His HR 120/min, BP 85/50, JVP 7 cm ASA, warm to touch, mild edema

• ECG sinus tachycardia, HR 110/min, LBBB QRS 150 ms

• WBC 8, HB 9, creatinine unchanged at 180 (eGFR 30), Na 127, K 3.7, NT-pBNP 5000

• Echo: LVEDD 80 mm, LVEF 15%, moderate RV systolic dysfunction, PASP 55 mmHg

Back to the case

The following statements are true except

A. The patient’s status is best described as INTERMACS level 3

B. Right heart catheterization is indicated

C. CRTD has limited role for such a patient

D. Guidelines on inotrope therapy in cardiogenic shock are strongly evidence-driven

E. No additional functional assessment is necessary

Take home Message

• Routine RHC in advanced heart failure is not recommended

• RHC plays an important role in the management of select

patients with advanced HF

• RHC is recommended inpatients considered for transplant or

MCS

• RHC is safe if performed by trained operators

Thank you

Use of PAC over time

Kahwash R et al, 2009 Heart F Clinic;5: 241-48