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Management of Decompensated Right Ventricular Failure in the Intensive Care Unit

  • Matthew K. Hensley
  • Michael P. MendezEmail author
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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 

References

  1. 1.
    Murray MJ, Cowen J, DeBlock H, Erstad B, Gray AW, Tescher AN, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2002;30(1):142–56.PubMedCrossRefGoogle Scholar
  2. 2.
    Beaulieu Y. Bedside echocardiography in the assessment of the critically ill. Crit Care Med. 2007;35(5 Suppl):S235–49.PubMedCrossRefGoogle 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.PubMedPubMedCentralCrossRefGoogle 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. 2012;25(3):280–6.PubMedCrossRefGoogle 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.PubMedCrossRefGoogle 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(10):1471–6.PubMedCrossRefGoogle 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.PubMedCrossRefGoogle Scholar
  8. 8.
    Arcasoy SM, Christie JD, Ferrari VA, Sutton MSJ, 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.PubMedCrossRefGoogle Scholar
  9. 9.
    Corson N, Armato 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.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Frazier AA, Burke AP. The imaging of pulmonary hypertension. Semin Ultrasound CT MR. 2012;33(6):535–51.PubMedCrossRefGoogle 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.PubMedCrossRefGoogle 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.PubMedPubMedCentralCrossRefGoogle 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.PubMedCrossRefGoogle 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.PubMedCrossRefGoogle Scholar
  15. 15.
    Pinsky MR. Functional haemodynamic monitoring. Curr Opin Crit Care. 2014;20(3):288–93.PubMedPubMedCentralCrossRefGoogle 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.PubMedPubMedCentralCrossRefGoogle 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.PubMedCrossRefGoogle 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.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Dunham-Snary KJ, Wu D, Sykes EA, Thakrar A, Parlow LRG, Mewburn JD, et al. Hypoxic pulmonary vasoconstriction: from molecular mechanisms to medicine. Chest. 2017;151(1):181–92.PubMedCrossRefGoogle Scholar
  20. 20.
    Viitanen A, Salmenperä M, Heinonen J. Right ventricular response to hypercarbia after cardiac surgery. Anesthesiology. 1990;73(3):393–400.PubMedCrossRefGoogle Scholar
  21. 21.
    Brimioulle S, Lejeune P, Vachiery JL, Leeman M, Melot C, Naeije R. Effects of acidosis and alkalosis on hypoxic pulmonary vasoconstriction in dogs. Am J Phys. 1990;258(2 Pt 2):H347–53.Google Scholar
  22. 22.
    Viitanen A, Salmenperä M, Heinonen J, Hynynen M. Pulmonary vascular resistance before and after cardiopulmonary bypass. The effect of PaCO2. Chest. 1989;95(4):773–8.PubMedCrossRefGoogle 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.PubMedGoogle 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.PubMedCrossRefGoogle Scholar
  25. 25.
    Roca O, Hernández G, Díaz-Lobato S, Carratalá JM, Gutiérrez RM, Masclans JR, et al. Current evidence for the effectiveness of heated and humidified high flow nasal cannula supportive therapy in adult patients with respiratory failure. Crit Care. 2016;20(1):109.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    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.PubMedCrossRefGoogle Scholar
  27. 27.
    Legras A, Caille A, Begot E, Lhéritier G, Lherm T, Mathonnet A, et al. Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study. Crit Care. 2015;19:174.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Lhéritier G, Legras A, Caille A, Lherm T, Mathonnet A, Frat J-P, et al. Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study. Intensive Care Med. 2013;39(10):1734–42.PubMedCrossRefGoogle Scholar
  29. 29.
    Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med. 2019;47(1):3–14.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet. 2005;366(9484):472–7.PubMedCrossRefGoogle Scholar
  31. 31.
    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.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Chan CM, Klinger JR. The right ventricle in sepsis. Clin Chest Med. 2008;29(4):661–76. ixPubMedCrossRefGoogle Scholar
  33. 33.
    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.PubMedCrossRefGoogle Scholar
  34. 34.
    Martin C, Perrin G, Saux P, Papazian L, Gouin F. Effects of norepinephrine on right ventricular function in septic shock patients. Intensive Care Med. 1994;20(6):444–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Kerbaul F, Rondelet B, Motte S, Fesler P, Hubloue I, Ewalenko P, et al. Effects of norepinephrine and dobutamine on pressure load-induced right ventricular failure. Crit Care Med. 2004;32(4):1035–40.PubMedCrossRefGoogle Scholar
  36. 36.
    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.PubMedCrossRefGoogle Scholar
  37. 37.
    Kwak YL, Lee CS, Park YH, Hong YW. The effect of phenylephrine and norepinephrine in patients with chronic pulmonary hypertension∗. Anaesthesia. 2002;57(1):9–14.PubMedCrossRefGoogle Scholar
  38. 38.
    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.PubMedCrossRefGoogle Scholar
  39. 39.
    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.PubMedCrossRefGoogle Scholar
  40. 40.
    Holloway EL, Polumbo RA, Harrison DC. Acute circulatory effects of dopamine in patients with pulmonary hypertension. Br Heart J. 1975;37(5):482–5.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    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.PubMedCrossRefGoogle Scholar
  42. 42.
    Chen EP, Bittner HB, Davis RD, Van Trigt P. Milrinone improves pulmonary hemodynamics and right ventricular function in chronic pulmonary hypertension. Ann Thorac Surg. 1997;63(3):814–21.PubMedCrossRefGoogle Scholar
  43. 43.
    Jentzer JC, Mathier MA. Pulmonary hypertension in the intensive care unit. J Intensive Care Med. 2016;31(6):369–85.PubMedCrossRefGoogle Scholar
  44. 44.
    Vachiéry J-L, Adir Y, Barberà 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.PubMedCrossRefGoogle Scholar
  45. 45.
    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.PubMedCrossRefGoogle Scholar
  46. 46.
    Afshari A, Brok J, Møller AM, Wetterslev J. Aerosolized prostacyclin for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev. 2010;8:CD007733.Google Scholar
  47. 47.
    Vachiery J-L, 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.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8.CrossRefGoogle Scholar
  49. 49.
    Repessé X, Charron C, Vieillard-Baron A. Acute cor pulmonale in ARDS: rationale for protecting the right ventricle. Chest. 2015;147(1):259–65.PubMedCrossRefGoogle Scholar
  50. 50.
    Jozwiak M, Teboul J-L, 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.PubMedCrossRefGoogle Scholar
  51. 51.
    Varpula T, Valta P, Niemi R, Takkunen O, Hynynen M, Pettilä VV. Airway pressure release ventilation as a primary ventilatory mode in acute respiratory distress syndrome. Acta Anaesthesiol Scand. 2004;48(6):722–31.PubMedCrossRefGoogle Scholar
  52. 52.
    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 Transplant. 2010;10(9):2173–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical Care, Department of Internal MedicineUniversity of MichiganAnn ArborUSA

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