management van perioperatief rechter ventrikelfalen · 1. rechter ventrikelfalen (rvf) inleiding...
TRANSCRIPT
Dr. M. Brands – Dr. K. Buyck – Prof. Dr. S. Rex
Dienst anesthesiologie
Management van perioperatief
rechter ventrikelfalen
1. Rechter ventrikelfalen (RVF)
Inleiding
Fysiologie niet-falende RV
Etiologie en pathofysiologie RVF
Diagnose perioperatief RVF
2. Therapeutische maatregelen bij RVF
Inleiding: epidemiologie
RV falen = syndroom waarbij ejectie of vulling RV
onvoldoende is voor adequate CO
Incidentie = onbekend
Geen duidelijke diagnostische criteria
Cardiale heelkunde
- 42% van LCOS, mortaliteit 44% (Davila-Roman, Ann Thor Surg 1995)
Harttransplantatie
- 50% van de vroege complicaties
- 42% van de perioperatieve mortaliteit (Haddad, CanJcardiol 2008)
LVAD-implantatie
- Incidentie: 25-50%
- Mortaliteit: tot 50% (Matthews, JACC 2008; Kirklin JK, J of Heart and Lung Transplant, 2010)
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
Inleiding: outcome
Inleiding: outcome
Anne-Catherine M. Pouleur
Right Ventricular Systolic Dysfunction Assessed by Cardiac Magnetic Resonance Is a Strong Predictor of Cardiovascular Death After Coronary Bypass Grafting
The Annals of Thoracic Surgery, Volume 101, Issue 6, 2016, 2176–2184
Inleiding
Prognostisch belang RVF onderschat- Fontan-circulatie: patiënten zonder functionele RV en passieve
longcirculatie
- Dierenmodellen (1940): cauterisatie van RV laterale wand: geen
daling CO / stijging SVP
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
Fysiologie niet-falende RV
Addetia K. et al.
Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2016 May;17(5):564-75.
Fysiologie niet-falende RV
Addetia K. et al.
Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2016 May;17(5):564-75.
Rechter ventrikel Linker ventrikel
Volume-pomp Druk-pomp
Lage weerstand Hoge weerstand
Gevoelig aan
afterload ↑↑↑
Gevoelig aan
preload ↑↑↑
EF 45% - 60% EF 50% - 70%
Peristaltisch /
longitudinaal
Concentrisch /
radiaal
Fysiologie niet-falende RV
PRELOAD AFTERLOAD
Hrymak C. et al.
Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71
Fysiologie niet-falende RV
CORONAIRE PERFUSIE
Hrymak C. et al.
Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71
Fysiologie: ventriculaire interdependentie
“Concept that through direct mechanical interactions the size, shape, and
compliance of one ventricle may affect the size, shape, and pressure-volume
relationship of the other”
Serieel = antegrade vulling LV faalt
Parallel = transseptale verstoring diastole/systole functie LV
1. Shift van IVS naar links
2. Stretching pericard
CO
Harjola VP et al.
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of
the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.
Perioperatief RV Falen: etiologie
Afterload
Preload
Contractiliteit
Gemengd
Pulmonale hypertensie (Primair en
Secundair)
Longembolie
Pulmonalisstenose/RVOTO
HPV
Tricuspiedinsufficiëntie
ASD
Pulmonalisinsufficiëntie
PAPVU
RV infarct
Arrythmiën
Cardiomyopathie
Sepsis
Linker ventrikelfalen (chronisch en acuut)
Congenitale hartaandoeningen
Pathofysiologie
Afterload
Contractiliteit
Preload
Ventriculaire interdependentie
Inflammatie
Lahm T et al.
Medical and Surgical Treatment of Acute Right Ventricular Failure J Am Coll Cardiol 2010;56:1435–46
Pathofysiologie
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
RV ischemiePulmonale hypertensie
RV dysfunctie
- Lung reperfusion injury
- Longembool
- Linker ventrikelfalen
- TRALI
- ARDS
- Luchtembolie
- Coronaire trombose
- Bypass graft failure
- Hypotensie
- Lange CPB-tijd
- LVAD
- Pre-op LV dysfunctie
- Slechte myocardprotectie
Pathofysiologie
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
RV ischemiePulmonale hypertensie
RV dysfunctie
- Lung reperfusion injury
- Longembool
- Linker ventrikelfalen
- TRALI
- ARDS
- Luchtembolie
- Coronaire trombose
- Bypass graft failure
- Hypotensie
- Lange CPB-tijd
- LVAD
- Pre-op LV dysfunctie
- Slechte myocardprotectie
Pre-op
Pathofysiologie
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
RV ischemiePulmonale hypertensie
RV dysfunctie
- Lung reperfusion injury
- Longembool
- Linker ventrikelfalen
- TRALI
- ARDS
- Luchtembolie
- Coronaire trombose
- Bypass graft failure
- Hypotensie
- Lange CPB-tijd
- LVAD
- Pre-op LV dysfunctie
- Slechte myocardprotectie
Per-op
Pathofysiologie
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
RV ischemiePulmonale hypertensie
RV dysfunctie
- Lung reperfusion injury
- Longembool
- Linker ventrikelfalen
- TRALI
- ARDS
- Luchtembolie
- Coronaire trombose
- Bypass graft failure
- Hypotensie
- Lange CPB-tijd
- LVAD
- Pre-op LV dysfunctie
- Slechte myocardprotectie
Post-op
Double-hit fenomeen
- Verminderde systeemperfusie tgv. CO daling
- Gestegen postcapillaire druk tgv. toegenomen
veneuze congestie
Orgaan perfusiedruk daalt
Evolutie naar multipel orgaan falen indicator slechte prognoseVerbrugge FH et al.
Abdominal contributions to cardiorenal dysfunction in congestive heart failure. J Am Coll Cardiol 2013;62:485–495.
Diagnose RV Falen: guidelines?
“No clinical signs, biochemical alterations or hemodynamic variables are specific
enough too allow an early differentation between RV, LV or biventricular failure”
Diagnose RV Falen: klinisch
- Hypoxemie
- Systemische congestie
- ECG: RV strain, S1Q3T3
- Arteriële curve: pulsus paradoxus
- Tekens LCOS: hypotensie / tachycardie / oligurie
Harjola VP et al.
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and
Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.
Diagnose RV Falen: echocardiografisch
Kwalitatief kwantitatief asessment RV
- FAC (G)
- TAPSE (E)
- Systolic S’ Velocity of the tricuspid
annulus (I)
- RIMP (K)
Harjola VP et al.
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and
Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.
Echocardiografisch: TEE
TEE Rounds November 2015 -- Right ventricular failure -- OpenAnesthesia.org
Echocardiografisch: TEE
TEE Rounds November 2015 -- Right ventricular failure -- OpenAnesthesia.org
Hemodynamisch: RV/ PA druk-meting
Whitener et al.
Pulmonary artery catheter Best Practice & Research Clinical Anaesthesiology Vol 28 (2014)
Hemodynamisch: RV/ PA druk-meting
Whitener et al.
Pulmonary artery catheter Best Practice & Research Clinical Anaesthesiology Vol 28 (2014)
RV/ PA druk-meting
Progressief RV Falen: CO PAP
Onbetrouwbaar hou rekening met graad van RVF en CO
Haddad F, Doyle R, Murphy DJ, Hunt SA.
Right ventricular function in cardiovascular disease. II. Pathophysiology, clinical importance, and management of right ventricular failure. Circulation 2008;117:1717–31
Therapie Rechter ventrikelfalen
Lahm T et al.
Medical and Surgical Treatment of Acute Right Ventricular Failure J Am Coll Cardiol 2010;56:1435–46
Therapie Rechter ventrikelfalen
Harjola VP et al.
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and
Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.
Therapie Rechter ventrikelfalen
1) Behandel uitlokkende factor
2) Behandel reversibele oorzaken
3) Optimaliseer vullingsstatus
4) Onderhoud MAP met vasopressie
5) Verlaag vullingsdrukken met inotropica
6) Farmacologische RV afterloadreductie
Harjola VP et al.
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and
Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.
Therapie: reversibele oorzaken
Long-protectieve ventilatie
Pplat < 30mmHg, VT 4-6ml/kg, PEEP
HYPOXIE – HYPERCARBIE – ACIDOSE
Ventilatie
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
Therapie: reversibele oorzaken
Ritme-Rate
Behoud sinusaal ritme essentieelCave verlies atriale kick bij niet-compliante RV RVF
Cardioversie aritmie = essentieel
Atriale PM-draden zo risico op post-operatief RVF
I.g.v. RVF: preferentieel hoger HR
Cave toename TI bij HR < 80 ppm
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
Therapie: optimalisatie vullingsstatus
Falend RV: Sterk afgevlakte Frank-Starling curve
Optimal filling of the RV is essential.
A failing RV will not tolerate
under- or overfilling.
Hrymak C. et al.
Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71
Volume overload
RV dilatatie wandspanning (VO2)
Tricuspiedinsufficiëntie
Shift interventriculair septum LV vulling
Optimaliseer vullingsstatus
1. IV diuretica
2. CVVH indien onvoldoende (snel) effect
Op geleide van CO-meting en TEE
Hrymak C. et al.
Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71
Therapie: optimalisatie vullingsstatus
Therapie: afterload - vasopressie
MAP >> RVsys druk
Hrymak C. et al.
Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71
CORONAIRE PERFUSIEDRUK
SEPTALE SHIFT VOORKOMEN
Therapie: afterload - vasopressie
“Ideale vasopressor”
Toename MAP zonder toename PVR
Ventetuolo CE1, Klinger JR.
Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc. 2014 Jun;11(5):811-22.
1) Behandel uitlokkende factor
2) Behandel reversibele oorzaken
3) Optimaliseer vullingsstatus
4) Onderhoud MAP met vasopressie
5) Verlaag vullingsdrukken met inotropica
6) Farmacologische RV afterloadreductie
Harjola VP et al.
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and
Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.
Therapie: contractiliteit – inotropie
Therapie: contractiliteit – inotropie
Cathecholamines
PDEIs IIIGlycosiden
Levosimendan
Fellahi J-L et al.
Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5
Therapie: contractiliteit – inotropie
Fellahi J-L et al.
Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5
Therapie: contractiliteit – inotropie
Fellahi J-L et al.
Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5
Potentieel gevaarlijke effecten inotropica
• Cardiotoxiciteit
• Ca2+ overload
• Toename ischemie-reperfusie schade
• Toename stunning
• Pro-apoptotische effecten in (myocardiale) myocyten
• Intramyocardiale vrijzet van pro-inflammatoire cytokines
• Arrhythmogeen (toename intracellular Ca2+)
• Tachyphylaxie
• Onevenwicht tussen O2-aanbod en O2-verbruik
Gemakkelijke titratie, snel “on/off effect
Myocardiaal O2 aanbod/verbruik evenwicht
Steady-state in de tijd (geen tachyfylaxie)
Direct positief inotroop effect
Weinig tot niet arrythmogeen
Geen toename in intracellulair Ca2+ overload
Behoud van de coronaire perfusiedruk
Positief effect op regionale vaatbedden (renaal, splanchnisch)
Aanvaardbare risico/baten verhouding
Fellahi J-L et al.
Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5
“Ideaal inotropicum”
Therapie: contractiliteit – inotropie
Therapie: contractiliteit – inotropie
Catecholamines = Ca2+ mobilizer
Fellahi J-L et al.
Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5
Therapie: contractiliteit – inotropie
PDEI 3 inhibitors = Ca2+ mobilizer
Fellahi J-L et al.
Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5
• Milrinone / Enoximone
– Toename cAMP onafhankelijk van adrenerge receptoren
– Myocardweefsel: toename contractiliteit
– Vasculair gladde spier: relaxatie en vasodilatatie
• Geen/weinig tachycardie
• Vaak associatie met vasopressor noodzakelijk
Therapie: contractiliteit – inotropie
Felker et al.
HF Etiology and Response to Milrinone J Am Coll Cardiol. 2003 Mar 19;41(6):997-1003
Tacon et al.
Dobutamine for patients with severe heart failure: a systematic review and meta-analysis of randomised controlled trials. Intensive Care Med. 2012 Mar;38(3):359-67.
Therapie: contractiliteit – inotropie
Nielsen et al.
Health Outcomes with and without Use of Inotropic Therapy in Cardiac Surgery. Anesthesiology. 2014 May;120(5):1098-108
Therapie: contractiliteit – inotropie
PDEI 3 inhibitors = Ca2+ mobilizer
Nielsen DV, Algotssonb L
Outcome of inotropic therapy: is less always more? Curr Opin Anaesthesiol. 2015 Apr;28(2):159-64
Therapie: contractiliteit – inotropie
Levosimendan = Ca2+ sensitizer
RV/LV contractility
without increased
myocardial oxygen
Consumption
Mortality
Preconditioning and
anti-stunning effectsDimitrios Farmakis. Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. International
Journal of Cardiology Volume 222, Pages 303-312 (November 2016)
RV afterload
Coronary perfusion
LV afterload
Systemic hypotension
Levosimendan: mortaliteit
Pollesello P. et al.
Levosimendan meta-analyses: Is there a pattern in the effect on mortality? International Journal of Cardiology 209 (2016) 77–83
- Alle meta-analyses tot nu toe gepubliceerd
- N=25, n > 6000 patients
- Tonen allemaal voordeel in mortaliteit
(22/25 significant)
- Onafhankelijk van klinische setting /comparator
- 10 studies cardiale heelkunde, waarvan
8 verminderde mortaliteit aantonen.
Clinical practice: Recommended use of
levosimendan in cardiac surgery
Pisano A et al. Levosimendan: new indications and evidence for reduction in perioperative mortality?. Curr Opin Anesthesiol 2016, 29:454–461
Therapie: contractiliteit – inotropie
Nielsen DV, Algotssonb L
Outcome of inotropic therapy: is less always more? Curr Opin Anaesthesiol. 2015 Apr;28(2):159-64
Key points
Beschikbare inotropica verhogen cardiac output MAAR
ten koste van potentieel toegenomen mortaliteit
Juiste indicatiestelling is essentieel
Beperkte contractiele reserve vs. “potential harm”
Inotropie zou voornamelijk als rescue therapie moeten
gebruikt worden in geval van eind-orgaan hypoperfusie
1) Behandel uitlokkende factor
2) Behandel reversibele oorzaken
3) Optimaliseer vullingsstatus
4) Onderhoud MAP met vasopressie
5) Verlaag vullingsdrukken met inotropica
6) Farmacologische RV afterloadreductie
Harjola VP et al.
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and
Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.
Therapie: contractiliteit – inotropie
Therapie:
Farmacologische RV afterloadreductie
Vermijd intraveneuze vasodilatatorenCoronaire hypoperfusie
Shift interventriculair septum
Inhibitie HPV V/P mismatch en hypoxie
Selectieve pulmonale vasodilatatoren1. iNO synthese c-GMP
2. Prostacyclines synthese c-AMP
3. PDE-III inhibitor inhibitie c-AMP degradatie
4. PDE-V inhibitor inhibitie c-GMP/c-AMP degradatie
Reductie PVR in goed-geventileerde gebieden V/P matching
Hrymak C. et al.
Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 2017 vol 33 61-71
Therapie: circulatoire support
Refractair RVF Survivalrate = 25-30%
Haddad et al.
The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33
Conclusie
Ventetuolo CE1, Klinger JR.
Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc. 2014 Jun;11(5):811-22.