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Assault on the RV Impact of Pulmonary Hypertension on Heart-Lung Interactions John Greenwood, MD University of Pennsylvania Department of Emergency Medicine Department of Anesthesiology & Critical Care
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Assault on the RV – Pulmonary Hypertension and Heart-Lung Interactions - John Greenwood

Apr 16, 2017

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Page 1: Assault on the RV – Pulmonary Hypertension and Heart-Lung Interactions - John Greenwood

Assault on the RV

Impact of Pulmonary Hypertension on

Heart-Lung Interactions

John Greenwood, MDUniversity of Pennsylvania

Department of Emergency MedicineDepartment of Anesthesiology & Critical Care

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DISCLOSURES

NONE.

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THE PATIENT

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THE PATIENT

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OBJECTIVES

• Understand clinical heart-lung interactions affected by pulmonary hypertension (PH)

• Identify patients at high risk for arrest from PH

• Discuss critical management strategies for the unstable patient with PH & RV dysfunction

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CLASSIC DESCRIPTION OF PH

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PROBLEMS IN THE ICU

CO2

O2

pH

Pneumonia PulmonaryEdema

ARDS

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VENTILATOR AS A MURDER WEAPON

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CARDIOVASCULAR CONSEQUENCES OF PH

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RV MECHANICS

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The Right Ventricle

Thin WallCompliantEfficient

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VerticalMotion

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Adapts to VOLUME

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Fails under PRESSURE

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MECHANICAL FAILURE

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Mean PAP MAP

Right Ventricle Left Ventricle

Stro

ke v

olum

e (%

of c

ontro

l)

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RCA

LCx

LAD

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PREDICTABLE

Green EM et al. Curr Heart Failure Rep (2012) 9:228-235

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EVALUATION & DIAGNOSTICS

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TTE

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24 y/o F with h/o PAH p/w acute SOB

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24 y/o F with h/o PAH p/w acute SOB

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CHRONIC DYSFUNCTION

24 y/o F with h/o PAH p/w acute SOB

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66 y/o F with h/o COPD p/w acute SOB

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TAPSE(TAP - SEE)

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Tricuspid Valve

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TAPSENormal > 1.6 cmMod: 1.0 - 1.6 cmSevere: < 1.0 cm

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Resusthe

RV

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PATIENT 2Mr. Blue

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Tank Pump Pipes

Critical clinical questionWhat are my hemodynamic targets?

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Tank

Pump

Pipes

• Volume Status• CVP

• ASSESS the RV• CPP & Squeeze

• PA Pressure• Targets: Reversible

treatable

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The Tank

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Add PPV video here

PITFALL: Looking to “Volume Responsiveness”

ABP

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THE CVP IS NOT DEAD

10 - 14 mmHg

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RCA

LCx

LAD

The Pump

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CPP = -DBP(Ao)

CVP

VasopressinNorepinephrine

Epinephrine

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TAPSE = 1.1 cm

Normal > 1.6 cmMod: 1.0 - 1.6 cmSevere: < 1.0 cm

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Tank

Pump

Pipes

• Volume Status• CVP

• ASSESS the RV• CPP & Squeeze

• PA Pressure• Targets: Reversible

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DROP THE AFTERLOAD PAP

O2 CO2 pH

Prostenoids iNO

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THE TEST

Final Points• Acute PH is common• The RV is pressure sensitive• Practice TAPSE• Resuscitate wisely

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QUESTIONS?

[email protected]

@JohnGreenwoodMD

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SELECTED REFERENCES

1. Barbosa EJ, Jr., Gupta NK, Torigian DA, Gefter WB. Current role of imaging in the diagnosis and management of pulmonary hypertension. AJR American journal of roentgenology 2012;198:1320-31.

2. Barst RJ, Gibbs JS, Ghofrani HA, et al. Updated evidence-based treatment algorithm in pulmonary arterial hypertension. Journal of the American College of Cardiology 2009;54:S78-84.

3. Bogaard HJ, Abe K, Vonk Noordegraaf A, Voelkel NF. The right ventricle under pressure: cellular and molecular mechanisms of right-heart failure in pulmonary hypertension. Chest 2009;135:794-804.

4. Chin KM, Rubin LJ. Pulmonary arterial hypertension. Journal of the American College of Cardiology 2008;51:1527-38. 5. Goldstein JA. Pathophysiology and management of right heart ischemia. Journal of the American College of Cardiology 2002;40:841-53. 6. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance,

and management of right ventricular failure. Circulation 2008;117:1717-31. 7. 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;184:1114-24. 8. Kopec G, Tyrka A, Miszalski-Jamka T, et al. Electrocardiogram for the diagnosis of right ventricular hypertrophy and dilation in idiopathic

pulmonary arterial hypertension. Circulation journal : official journal of the Japanese Circulation Society 2012;76:1744-9. 9. Ling Y, Johnson MK, Kiely DG, et al. Changing demographics, epidemiology, and survival of incident pulmonary arterial hypertension:

results from the pulmonary hypertension registry of the United kingdom and ireland. Am J Respir Crit Care Med 2012;186:790-6. 10. McGoon M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-

based clinical practice guidelines. Chest 2004;126:14S- 34S. 11. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the

American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation 2009;119:2250-94.

12. Segers VF, Brutsaert DL, De Keulenaer GW. Pulmonary hypertension and right heart failure in heart failure with preserved left ventricular ejection fraction: pathophysiology and natural history. Current opinion in cardiology 2012;27:273-80.

13. van Wolferen SA, Marcus JT, Westerhof N, et al. Right coronary artery flow impairment in patients with pulmonary hypertension. European heart journal 2008;29:120-7.

14. Williams L, Frenneaux M. Diastolic ventricular interaction: from physiology to clinical practice. Nature clinical practice Cardiovascular medicine 2006;3:368-76.