evaluation and management of right-sided heart failurehntmmttn.vn/upload/file/dvc 12/[cd1.04] pgs...
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Evaluation and Management of
Right-sided Heart FailurePGS. TS Phạm Nguyễn Vinh
Bệnh viện Tim Tâm Đức
Đại học Y khoa Phạm Ngọc Thạch
Đại học Y khoa Tân Tạo
Viện Tim Tp. HCM
1
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Khảo sát và điều trị Suy tim phải
Main points of RHF
❖Causes:‐ RV cardiomyopathy‐ RV myocardial ischemia/infarction‐ RV volume overload caused by CHD or VHD ‐ RV pressure overload caused by PS or PH
❖Acute RHF:‐ Unstable hemodynamics‐ Leading mortality cause of massive PE ‐ RV myocardial infarction‐ Shock after pericardiotomy/cardiac surgery
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Khảo sát và điều trị Suy tim phải
Main points of RHF (cont.)
❖Chronic RHF:
‐ Decreased functional capacity
‐ Exercise intolerance
‐ Decreased cardiac output
‐ Progressive injury of target organs
‐ Cachexia
‐ Increased systemic inflammation
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Khảo sát và điều trị Suy tim phải
Cardiac embryogenesis
4Konstam MA, et al. Circulation. 2018;137:e578–e622
▪ Primary heart field (from Mesoderm) → Heart tube
▪ Heart tube:
➢ Atria
➢ Ventricles
▪ Secondary heart field → arterial and venous poles
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Khảo sát và điều trị Suy tim phải
Right ventricular (RV) geometry
5Konstam MA, et al. Circulation. 2018;137:e578–e622
Normal subject Chronic volume or pressure overload
P: Pulmonary valveT: Tricuspid valve
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Khảo sát và điều trị Suy tim phải
Relationship of RV and LV stroke volumes to increases in afterload
6Konstam MA, et al. Circulation. 2018;137:e578–e622
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Khảo sát và điều trị Suy tim phải
RV pressure-volume loops
7
Konstam MA, et al. Circulation. 2018;137:e578–e622
ESPVR : End-systolic pressure volume relationshipEes: end-systolic elastance Loop C: decompensated hypertensive RV
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Khảo sát và điều trị Suy tim phải
Ventricular interdependence in right-sided heart failure
8Konstam MA, et al. Circulation. 2018;137:e578–e622
RV is constrained by the pericardium (arrows)
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Khảo sát và điều trị Suy tim phải
Pathophysiology of right-sided heart failure
9Konstam MA, et al. Circulation. 2018;137:e578–e622
LVEDP: left ventricular end-diastolic pressureRVEDD: right ventricular end-diastolic dimensionRAP: right atrial pressure
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Khảo sát và điều trị Suy tim phải
Hemodynamics in progressive pulmonary vascular disease
10Konstam MA, et al. Circulation. 2018;137:e578–e622
PAP: Pulmonary arterial pressure; CO: cardiac output; MPAP: mean PAP; PCWP: pulmonary artery capillary wedge pressure; PVR: pulmonary vascular resistance; RAP: right atrial pressure
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Khảo sát và điều trị Suy tim phải
Causes of RHF
11Konstam MA, et al. Circulation. 2018;137:e578–e622
ARDS: acute respiratory distress syndrome; ARVC: arrhythmogenic right ventricular cardiomyopathy; LH: leftsided heart disease; LVAD: left ventricular assist device; PAH: pulmonary arterial hypertension; PE: pulmonary embolism; PH: pulmonary hypertension; PR: pulmonary regurgitation; PS: pulmonary stenosis; RHF: right-sided heart failure; RV: right ventricular; RVMI: right ventricular myocardial infarction; TGA: transposition of the great arteries; TR: tricuspid regurgitation.
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Khảo sát và điều trị Suy tim phải
ECG in patients with right-sided heart disease
12Konstam MA, et al. Circulation. 2018;137:e578–e622
Arrhythmogenic right ventricular cardiomyopathy
• T(-) in V1→ V4• Prolongation of the terminal activation (nadir of S wave → end of QRS complex)
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Khảo sát và điều trị Suy tim phải
ECG in patients with right-sided heart disease
13Konstam MA, et al. Circulation. 2018;137:e578–e622
Right ventricular hypertrophy
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Khảo sát và điều trị Suy tim phải
Criteria for ECG diagnosis of ARVC
14Konstam MA, et al. Circulation. 2018;137:e578–e622
ARVC: arrhythmogenic right ventricular cardiomyopathy; SAECG: signal-averaged ECG
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Khảo sát và điều trị Suy tim phải
Criteria for ECG diagnosis of ARVC
15Konstam MA, et al. Circulation. 2018;137:e578–e622
ARVC: arrhythmogenic right ventricular cardiomyopathy; SAECG: signal-averaged ECGMũi tên: epsilon wave
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Khảo sát và điều trị Suy tim phải
Classification of PH
16Konstam MA, et al. Circulation. 2018;137:e578–e622
DPG: diastolic pulmonary gradient; MPAP: mean pulmonary artery pressure; PCWP: pulmonary capillary wedge pressure; PH: pulmonary hypertension; PVR: pulmonary vascular resistance; WHO, World Health Organization; WU: Woods units
DPG= PA diastolic pressure – PCWPChronic lung disease: precapillary PH
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Khảo sát và điều trị Suy tim phải
Classification of PH (1)
17
Group 1: Pulmonary Arterial Hypertension
Precapillary PH:- Idiopathic PAH- Hereditary PAH- Drugs, toxins- Connective tissue disease- Portal hypertension- HIV- CHD with persistent pulmonary to systemic shunt- Eisenmenger physiology- Schistosomiasis- Persistent PAH of the newborn- Pulmonary veno-occlusive disease- Pulmonary capillary hemangiomatosis
Konstam MA, et al. Circulation. 2018;137:e578–e622
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Khảo sát và điều trị Suy tim phải
Classification of PH (2)
18
Group 2: Left heart disease
• DPG ≥ 7 mmHg: pulmonary vascular disease superimposed on left-sided pressure elevation
• DPG < 7 mmHg: isolated postcapillary PH
Group 3: Chronic lung disease and Hypoxia
Group 4: Chronic Thromboembolic Disease
Group 5: Miscellanous
• Sarcoidosis; chronic hemolytic disorders; chronic kidney disease
• Myocardial depression during sepsis• ARDS; mechanical ventilation
Konstam MA, et al. Circulation. 2018;137:e578–e622
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Khảo sát và điều trị Suy tim phải
Manifestations of RHF (1)
19Konstam MA, et al. Circulation. 2018;137:e578–e622
Clinical manifestations of RHF
Increased mortality
Fatigue/decreased functional capacity
Cardiorenal abnormalities
Cardiohepatic abnormalities
Protein malnutrition
Coagulopathy
Cachexia
LLSB: left lower sternal border; PH: pulmonary hypertension; RHF: right-sided heart failure; RV: right ventricular; TR: tricuspid regurgitation
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Khảo sát và điều trị Suy tim phải
Manifestations of RHF (2)
20Konstam MA, et al. Circulation. 2018;137:e578–e622
LLSB: left lower sternal border; PH: pulmonary hypertension; RHF: right-sided heart failure; RV: right ventricular; TR: tricuspid regurgitation
Signs and symptoms
Elevated jugular venous pressure with prominent V wave
Peripheral edema
Bloating/early satiety/abdominal discomfort
Ascites and hepatomegaly
Pleural effusion
Prominent S2 (P2) (PH)
Right-sided S3 gallop
Holosystolic murmur LLSB (TR)
RV parasternal heave
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Khảo sát và điều trị Suy tim phải
Pathophysiology of cardiorenal
disease
21Kiernan MS, et al. UpToDate, January 30, 2018
CO: cardiac output; CVP: central venous pressure; LVEDP: left ventricular end-diastolic pressure; RAAS: renin-angiotensin-aldosterone system; SNS: sympathetic nervous system; SV: stroke volume
(Acute decompensated HF leading to kidney injury)
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Khảo sát và điều trị Suy tim phải
Clinical manifestation of RHF
❖Acute RHF:
‐ Acute RV dilatation
‐ Signs of hypoperfusion and hypotension (diaphoresis, listlessness, cyanosis, cool extremities, hypotension, and tachycardia)
‐ Shortness of breath, atrial and ventricular arrhythmias
❖Chronic RHF:
‐ Cardiorenal syndrome
‐ Cardiohepatic syndrome
‐ Gastrointestinal involvement
22
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Khảo sát và điều trị Suy tim phải
Evaluation of RHF
❖Physical examination
❖ECG
❖Serum markers:‐ Transaminases‐ ↓ Albumin‐ ↑ INR‐ ↑ Bilirubin
❖Echocardiography
❖Cardiac MRI
❖MSCT
❖Radionuclide Imaging
❖Chest X-ray
❖Biomarkers/RV function: NT-ProBNP, BNP
23
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Khảo sát và điều trị Suy tim phải
Hemodynamic Assessment of RH Function
24Konstam MA, et al. Circulation. 2018;137:e578–e622
Hemodynamic Parameters Associated With RV Function
Variable Calculation Thresholds associated with Clinical Events in Specific Populations
RAP RAP (or CVP) > 15 mmHg (RHF after LVAD)
Right-to-left discordance of filling pressures
RAP:PCWP > 0.63 (RHF after LVAD)> 0.86 (RHF in acute MI)
PA pulsatility index (PASP−PADP)/RAP <1.0 (RHF in acute MI)203 <1.85 (RHF after LVAD)
RV stroke work index
(MPAP−CVP)×SVI <0.25–0.30 mm Hg·L/m2 (RHF after LVAD)
PVR (MPAP−PCWP)/CO >3.6 WU (RHF after LVAD)
PA compliance SV/(PASP−PADP) <2.5 mL/mm Hg (RHF in chronic HF, RV-PA coupling in PAH)
LVAD: left ventricle assist device; CVP: central venous pressure
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Khảo sát và điều trị Suy tim phải
Management of acute right-sided HF
25Konstam MA, et al. Circulation. 2018;137:e578–e622
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Khảo sát và điều trị Suy tim phải
Stepped Pharmacological Care (1)
26Konstam MA, et al. Circulation. 2018;137:e578–e622
LVAD: left ventricular assist device; UO: urine output
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Khảo sát và điều trị Suy tim phải
Stepped Pharmacological Care (2)
27Konstam MA, et al. Circulation. 2018;137:e578–e622
LVAD: left ventricular assist device; UO: urine output
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Khảo sát và điều trị Suy tim phải
Medical management of ARHF
❖Volume management‐ Diuretics‐ Renal Replacement Therapies
❖Vasoactive Therapies‐ Afterload Reduction‐ Augment Contractility
❖Maintain Perfusion
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Khảo sát và điều trị Suy tim phải
Medical management of CRHF
❖Diuretics and Sodium Restriction
❖RAAS inhibitors, β-Blockers, Hydralazine
❖Digoxin
❖Pulmonary Vasodilators‐ Prostacyclin Analogs‐ PDE-5 inhibitors‐ Endothelin Receptor Antagonists
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Khảo sát và điều trị Suy tim phải
Management of CRHF in Congenital Heart Disease (CHD)
❖Standard HF drugs: non-efficacy in single RV,
systemic RV or pulmonary RV ( eg. after TOF surgery)
❖Individualized treatment by specialist in CHD and HF
❖Heart or lung transplantation
30Konstam MA, et al. Circulation. 2018;137:e578–e622
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Khảo sát và điều trị Suy tim phải
MCS and Transplantation
for RHF
31Konstam MA, et al. Circulation. 2018;137:e578–e622
MCS: Mechanical circulatory support; BiVAD: biventricular assist device; ECMO: extracorporeal membrane support; LVAD: left ventricular assist device; RVAD: right ventricular assist device
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Khảo sát và điều trị Suy tim phải
MCS options for acute RV support
32Konstam MA, et al. Circulation. 2018;137:e578–e622
RVAD: right ventricular assist device; VAECMO: veno-arterial extracorporeal membrane oxygenation
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Khảo sát và điều trị Suy tim phải
Indications for surgery for TR
33Nishimura et al. 2014 AHA/ACC Valvular Heart Disease Guideline. JACC Vol. 63(22):e57–185 2014
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Khảo sát và điều trị Suy tim phải
Conclusion (1)
❖Diagnosis of RHF:
‐ Clinical manifestation, biomarkers, echocardiography, CT, MRI, angiography.
❖Management of ARHF:
‐ Volume control: diuretics, renal replacement therapies.
‐ Afterload reduction; augment contractility
‐ Maintain organs perfusion
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Khảo sát và điều trị Suy tim phải
Conclusion (2)
❖Management of CRHF:
‐ Drugs:
• Diuretics; RAAS inhibitors; beta blockers; hydralazine
• Digoxin
• Pulmonary vasodilators: PDE-5 inhibitors, Prostacyclin analogs, Endothelin receptor antagonists
‐ Heart or Heart Lung transplantation
‐ Tricuspid valve surgery
35