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Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France

Challenge in Right Heart Failure. Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France. 1 - In case of acute RV failure , fluid infusion may decrease CO. 2 - In case of acute RV failure, fluid infusion may increase CO.

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Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France

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  1. Challengein Right Heart Failure Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France

  2. 1- In case of acute RV failure, fluid infusion may decrease CO 2- In case of acute RV failure, fluid infusion may increase CO 3- In case of MV with PEEP, fluid infusion may increase CO through an increase in systemic venous return (RV preload effect) 4- In case of MV with PEEP, fluid infusion may increase CO througha beneficial effect on PEEP-inducedRV dysfunction (RV afterload effect)

  3. Major causes of acute RV failure in critically ill patients • Sepsis-inducedmyocardial dysfunction • RV failure secondary to ARDS • Acute pulmonary embolism • Deleterious effects of MV

  4. Challenge in acute RV failure Fluid administration and RV failure

  5. If RV is dilated, fluid infusion→ no increase in RV stroke volume preload unresponsiveness preload responsiveness Stroke Volume Ventricular preload

  6. D If RV is dilated, fluid infusion → large increase in RV EDP C B A RV end diastolic pressure RV end diastolic volume

  7. If RV is dilated, fluid infusion→ no increase in RV stroke volume If RV is dilated, fluid infusion → large increase in RV EDP Biventricularinterdependence → decrease in LV stroke volume Fluid infusionnot only doesnot increasebut can evendecrease CO RV LV RV LV

  8. But 1- Inadequate (low) RV preload can be responsible for low CO in case of acute RV failure such as pulmonary embolism Fluid infusionnot only doesnot increasebut can evendecrease CO

  9. Hemodynamic effects of fluid loading in acute massive pulmonary embolism Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors Critical Care Medicine 1999; 27: 540-544

  10. Hemodynamic effects of fluid loading in acute massive pulmonary embolism Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors Critical Care Medicine 1999; 27: 540-544 Fluid responders had lower RVEDI r = 0.89

  11. Hemodynamic effects of fluid loading in acute massive pulmonary embolism Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors Critical Care Medicine 1999; 27: 540-544 RAP cannot be used for identifying pts who can benefit from fluid influsion

  12. But 1- Inadequate (low) RV preload can be responsible for low CO in case of acute RV failure such as pulmonary embolism 2- In case of MV,more complex relationships between the effects of fluid infusion and the right ventricle Fluid infusionnot only doesnot increasebut can evendecrease CO

  13. Mechanical ventilation and the right ventricle • Mechanical insufflation andthe RV • PEEP andthe RV

  14. Mechanical insufflation and RV Mechanical insufflationandvenous return

  15.  PRA  Pabd  Pms  Pit • Palv  PRA – Pms

  16. Effects of cyclic increase in intrathoracic pressure Cardiac output or venous return CO1 CO2 Pra1 Pra2 Pms1 Pms2 PRA Increased PIT Increased Pabd

  17. Effects of cyclic increase in intrathoracic pressure Cardiac output or venous return CO1 CO2 Pra1 Pra2 Pms1 Pms2 Pms3 PRA Increased PIT Increased Pabd Fluids

  18. Mechanical insufflation and RV Mechanical insufflation and venous return Mechanical insufflation andRV ejection • Pulmonary vascular resistance and lung volume

  19. high lung volume extra-alveolar vessels intra-alveolar vessels

  20.  Lung volume improves the RV ejection • lung volume by decreasing resistance of extra-alveolar vessels

  21. PVR extra-alveolar vessels RV FRC TLC Lung volume

  22.  Pit  Lung volume improves the RV ejection • Palv by decreasing resistance of extra-alveolar vessels • Ptranspulm  Transpulmonary pressure = Palv - Pit impedes the RV ejection by compressing the intra-alveolar vessels

  23. PVR intra-alveolar vessels extra-alveolar vessels RV FRC TLC Lung volume

  24. PVR RV FRC TLC Lung volume

  25. Mechanical insufflation and RV Mechanical insufflation and venous return Mechanical insufflation andRV ejection • Pulmonary vascular resistance and lung volume • Pulmonary vascular resistance and West’s zones

  26. up Palv Zone 1 Palv>PPA> PPV PPA PPV Palv PVR PPA>Palv> PPV Zone 2 PPA PPV Palv PPA>PPV>Palv Zone 3 PPA PPV bottom

  27. PVR Zone 1 Zone 2 Zone 1 Zone 3 Zone 2 Zone 3 intra-alveolar vessels extra-alveolar vessels FRC RV TLC Lung volumes

  28. Reduced central blood volume should amplify the deleterious impact of MV on RV afterload and RV function Hypovolemia favors zones 1 and 2 by reducing intravascular pressures up Palv Zone 1 Palv>PPA> PPV PPA PPV Palv PVR PPA>Palv> PPV Zone 2 PPA PPV Palv PPA>PPV>Palv Zone 3 PPA PPV bottom

  29. * * * *

  30. * * * *

  31. Crit Care Med 2001, 29:1551-1555 ACP defined as RVEDA/LVEDA > 0.6 and septal dyskinesia RV LV RA ARDS with protective ventilation (Pplat < 30 cm H2O) Incidence of ACP:25%

  32. Definition of acute cor pulmonale • mean PAP > 25 mmHg • RAP > PAOP • Stroke Index < 30 mL/m2 145ARDSpts withPAC with lung protective ventilation

  33. 10% 145 ARDS patients with lung protective ventilation ACP + ACP - 90%

  34. Reduction of transpulmonary pressure using ventilatory strategies aimed at limiting plateau pressure, is associated with high reductionof incidence and severity ofacute cor pulmonaleduring ARDS

  35. Mechanical ventilation and the right ventricle • Mechanical insufflation and RV • PEEP and RV • PEEP and venous return

  36. By increasing ITP PEEP should decrease venous return and thus cardiac output Venous return CO1 CO2 Pra1 Pra2 Pms Pms2 PRA Increased PIT Increased Pabd

  37. Mechanical ventilation and the right ventricle • Mechanical insufflation and RV • PEEP and RV • PEEP and venous return • PEEP and RV ejection

  38. If PEEP overdistends lung and increases the end-expiratory volume above theoretical FRC, PVR should increase PVR RV FRC TLC Lung volume

  39. If PEEP recruits lung units and increases the end-expiratory lung volume toward theoretical FRC, PVR should decrease PVR RV FRC TLC Lung volume

  40. If the resultant effect is overdistensionPVR should increase PVR RV FRC TLC Lung volume

  41. In this case, tidal insufflation further increases PVR to a high value PVR RV FRC TLC Lung volume

  42. If the resultant effect is lung recruitment,PVR should decrease PVR RV FRC TLC Lung volume

  43. In this cas, mechanical insufflation induces little change in PVR PVR RV FRC TLC Lung volume

  44. Mechanical ventilation and the right ventricle • Mechanical insufflation and RV • PEEP and RV • PEEP and venous return The hemodynamic effects of PEEP are variable, depending on: • its capacity of recruiting or overdistending lungs • its capacity of improving arterial oxygenation • degree of airway pressure transmission • adaptative mechanisms • volume status • PEEP and RV ejection

  45. TV 6 mL/kg High PEEP 45° Passive Leg Raising Low PEEP Pplat : 30 cmH2O TV 6 mL/kg 13 cmH2O 5 cmH2O

  46. CI L/min/m2 • Decrease in RV preload? • Increase in RV afterload? *

  47. PVR dynes.s.m2/cm2 • Decrease in RV preload • Increase in RV afterload *

  48. * • Decrease in RV preload • Increase in RV afterload RVEDA / LVEDA

  49. CI L/min/m2 *

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