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Critically Appraised Critically Appraised Topic: Topic: Fluid Loading in Right Ventricular Fluid Loading in Right Ventricular Infarction Infarction Mounir Mounir Basalus Basalus Critically Appraised Critically Appraised Topic: Topic: Fluid Loading in Right Ventricular Fluid Loading in Right Ventricular Infarction Infarction Mounir Mounir Basalus Basalus
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Page 1: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Critically Appraised Critically Appraised Topic: Topic:

Fluid Loading in Right Ventricular Fluid Loading in Right Ventricular

InfarctionInfarction

MounirMounir BasalusBasalus

Critically Appraised Critically Appraised Topic: Topic:

Fluid Loading in Right Ventricular Fluid Loading in Right Ventricular

InfarctionInfarction

MounirMounir BasalusBasalus

Page 2: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Patient with acute chest pain Patient with acute chest pain Patient with acute chest pain Patient with acute chest pain

• 60 y/o patient presented with acute chest pain.

• No past medical history,

• Smoker, family history of CVD.

• A/

• Acute chest pain (since 1 hour).

• Nausea and diaphoresis.

Page 3: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

PhyscialPhyscial examination examination PhyscialPhyscial examination examination

• P: 90/min, BP: 90/50 mmHg.

• Jugular vein not congested

• Heart: normal heart sounds no additional

sounds.

• Lung: Vesicular breath sounds. No additional

sounds

• No oedema.

Page 4: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ECG: STEMI ECG: STEMI inferior inferior infarctioninfarction and right and right ventricularventricular MI.MI.ECG: STEMI ECG: STEMI inferior inferior infarctioninfarction and right and right ventricularventricular MI.MI.

Page 5: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

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Page 6: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

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Voor thrombusaspiratie

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Page 7: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Clinical Clinical questionquestionClinical Clinical questionquestion

• Persistent hypotension.

• Fluid loading? Or not?

• What is the effect of “volume loading” on the

hemodynamics of patients suffering from

right ventricular myocardial infarction (RVMI).

Page 8: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

PICOPICOPICOPICO

P: patients suffering from right ventricular

myocardial infarction and low cardiac

output/hypotension.

I : Volume loading.

C: no volume loading, dobutamine

O: improvement in hemodynamic parameter.

Page 9: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Search strategy Search strategy Search strategy Search strategy

• Search terms:

• Right ventricle infarction AND volume

loading/infusion

• Right ventricle infarction AND treatment

• Human studies

Page 10: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Search strategy Search strategy Search strategy Search strategy

Page 11: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Search strategy Search strategy Search strategy Search strategy

3 Reviews

` 7 Clinical studies

ESC

Page 12: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984JACC 1984ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984JACC 1984

• 53 patients with acute inferior transmural

myocardial infarction were studied.

• To evaluate the potential occurrence of right

ventricular infarction.

• Cardiac output/index was measure before and

after volume loading in a Subpopulation (n=27).

Page 13: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984 ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984

RVI

Page 14: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984 ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984

RVI

Page 15: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985

• 13 patients with RVMI randomly treated with volume

loading (200-800 ml); dobutamine, and nitroprusside.

Before NaCl

Page 16: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985

• 13 patients with RVMI randomly treated with volume

loading (200-800 ml); dobutamine, and nitroprusside.

Before NaCl

Page 17: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985

• 43 patients with acute inferior infarction and depressed

RVEF.

• Substudy 11 ptns effect of volume loading vs Dopamine

CI = cardiac index (liters/min per me): PCW = mean pulmonary capillary wedge pressure (mm Hg):

RA = mean right atrial pressure (mm Hg); SVI = stroke volume index

Page 18: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985

• 43 patients with acute inferior infarction and depressed

RVEF.

• Substudy 11 ptns effect of volume loading vs Dopamine

CI = cardiac index (liters/min per me): PCW = mean pulmonary capillary wedge pressure (mm Hg):

RA = mean right atrial pressure (mm Hg); SVI = stroke volume index

Page 19: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : DhainautDhainaut JACC 1990JACC 1990ClinicalClinical studystudy: : DhainautDhainaut JACC 1990JACC 1990

• 20 consecutive patients with RVI and low cardiac output

within 48 h of the onset of symptoms were prospectively

included. Evaluation after volume loading and Dobu.

• Volume loading slight ↑in CI, marked ↑↑ in RAP .

• Dobu marked ↑↑ in CI.

Page 20: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994

• Evaluation of the effect of volume loading in 11 patient

with severe RVMI. Used volume loading aiming @ PWP

(18-24mmHg). Hemodynamics were measure before

and after volume loading

Hemodynamics Before volume loading After P value.

Right atrial pressure 12 ± 4 19 ± 5 mmHg (P<0.0001)

RV end-diastolic P 13 ± 4 20 ± 5 mmHg (P<0.0001)

PWP 14 ± 3 20 ± 6 (P<0.0001)

Mean PA pressure 20 ± 3 25 ± 6 (P<0.001)

PVR 117± 39 101 ± 49 dyn·s/cm5 P ns

RAP/PWP ratio 0. 85 ± 0.14 1.05 ± 0.07 (P<0.01)

End-diastolic RV volume 95 ± 26 113± 24ml. (P<0.001)

RV end-systolic volume 65 ± 28 83 ± 29 ml (P<0.01)

RV SV 30± 6 30± 8ml/beat (P ns)

RVEF 32± 11 28± 11% (P<0.001)

Cardiac output 2. 3 ± 0.42 2.4± 0.62 l/ min (P ns)

Page 21: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994

Conclusion: volume loading per se is not sufficient to

improve CO in patients with severe RVMI, despite the ↑↑

RV preload, LV preload does not increase, but PWP ↑↑

because of the limiting role of the pericardium.

Hemodynamics Before volume loading After P value.

Right atrial pressure 12 ± 4 19 ± 5 mmHg (P<0.0001)RV end-diastolic P 13 ± 4 20 ± 5 mmHg (P<0.0001)

PWP 14 ± 3 20 ± 6 (P<0.0001)

Mean PA pressure 20 ± 3 25 ± 6 (P<0.001)

PVR 117± 39 101 ± 49 dyn·s/cm5 P ns

RAP/PWP ratio 0. 85 ± 0.14 1.05 ± 0.07 (P<0.01)

End-diastolic RV volume 95 ± 26 113± 24ml. (P<0.001)

RV end-systolic volume 65 ± 28 83 ± 29 ml (P<0.01)

RV SV 30± 6 30± 8ml/beat (P ns)

RVEF 32± 11 28± 11% (P<0.001)

Cardiac index 2. 3 ± 0.42 2.4± 0.62 l/ min /m2 (P ns)

Page 22: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994

• 11 consecutive patients with RVI (and inferior infarction

with low cardiac output.

• After baseline measurements, patients were randomly

treated with

• dobutamine infusion, 5 µkg/min over 10 minutes,

followed by 10 p&kg/minover 10 minutes or,

• alternatively, by rapid intravascular administration of

normal saline solution in 200 ml increments over 5

minutes. Interruption of volume : mRAP> 20; mean

pulmonary capillary pressure >20 mm Hg, or ↓↓ CO

• After return of hemodynamics to baseline volume

loading & dobutamine were repeated in a crossover.

Page 23: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994

• Volume loading(VL)↑↑RAP&PCWP BUT no change CI

• Dobutamine(d)no change RAP&PCWP BUT↑↑CI.

Page 24: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990

• 41 patients with RVMI

• What is the optimal filling pressure for the RV?

• Used volume loading or NTG to modify the right

ventricular filling pressure.

• Used right ventricular stroke work index (RVSWI) and CI

endpoints.

• RVSWI=0.0144*SVI*MPAP (the amount of work that

the right ventricle does during each contraction)

Page 25: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990

Baseline

mRAP<10mmHg <10mmHg 10-14mmHg 10-14mmHg >14mmHg

mRAP after

intervention10-14mmHg >14mmHg 10-14mmHg >14mmHg RA Perssure

lowered

• Similarly, optimal PWP 16 mmHg.

Page 26: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

summary summary clinicalclinical studies studies (n=7)(n=7)summary summary clinicalclinical studies studies (n=7)(n=7)

• Volume loading has no effect on CI : 5

• Volume loading has a modest effect on CI: 1

• Volume loading has an effect on CI within limits : 1

Page 27: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000

• Optimization of preload.

• Initial therapy of RVI (hypotension and no pulmonary

congestion) should start with volume expansion.

• If unresponsive to initial trial of fluids hemodynamic

monitoring, and subsequent volume challenge CVP < I5

mmHg.

• Any interventions that reduce the preload (diuretics,

nitrates, and vasodilators) should be avoided even in the

absence of hypotension.

Page 28: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000

• When RVI is accompanied by severe LV dysfunction and

pulmonary congestion, the RV is further compromised by

increased afterload.

• In this circumstance, the use of afterload-reducing

agents such as sodium-nitroprusside or IABP is often

necessary to unload the LV and subsequently the RV.

Page 29: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Review: Review: GoldsteinGoldstein JACC 2002JACC 2002Review: Review: GoldsteinGoldstein JACC 2002JACC 2002

• Optimization of preload:

• RVI dilated noncompliant RV is exquisitely preload

dependent.

• factors that reducing preload tend to be detrimental,

• optimizing cardiac filling tend to be beneficial.

• Wide spectrum of initial volume status in acute RVI:

• relatively volume depleted benefiting from VL

• more replete flat response to fluid resuscitation.

Page 30: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Review: Review: GoldsteinGoldstein JACC 2002JACC 2002Review: Review: GoldsteinGoldstein JACC 2002JACC 2002

• An initial volume challenge is appropriate for patients

manifesting

• low output

• without pulmonary congestion,

• particularly if the estimated CVP <15 mm Hg.

• For those unresponsive to an initial trail of fluids,

• hemodynamically monitored volume challenge may

be appropriate.

• Avoid excessive volume administration (descending limb of starling curve).

Page 31: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

Review: Review: InoharaInohara EHJEHJ--ACVC 2013ACVC 2013Review: Review: InoharaInohara EHJEHJ--ACVC 2013ACVC 2013

• Older (animal model) studies maintenance of the RV

preload with volume loading thought to resolve

accompanying hypotension.

• Later clinical studies variable responses to

aggressive fluid therapy.

• Some studies, showed that volume loading further

elevates right-sided filling pressure without improving CI

• Berisha et al: maximal RVSWI & CI @mRAP of 10–14

mmHg, and a mRAP of >14 mmHg ↓↓RVSWI/CI.

• Haemodynamics of RVI : extremely variable (influenced

by state of hydration and the degree of concomitant LV

involvement.)

Page 32: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

GuidelinesGuidelines: ESC EHJ 2012: ESC EHJ 2012GuidelinesGuidelines: ESC EHJ 2012: ESC EHJ 2012

• Despite the jugular distension, fluid loading that

maintains right ventricular filling pressure is a key

therapy in avoiding or treating hypotension.*

• In addition, diuretics and vasodilators should be avoided,

as they may aggravate hypotension.*

* No references

Page 33: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ConslusionConslusionConslusionConslusion

• Patients suffering from RVMI appears to be very

sensitive for changes in volume status.

• In patients with RVMI and low cardiac

output/hypotension, low CVP, and no pulmonary

congestion it is prudent to administer boluses of

normal saline (200 cc) reaching a maximal of 1.5 ltr.

(voluven is frequently administered in the cathlab)

• This group of patients may be simply suffering from a

low circulating volume status.

Page 34: Critically Appraised Topic: Fluid Loading in Right Ventricular Infarction

ConslusionConslusionConslusionConslusion

• In case of no response on this initial “fluid challenge”,

invasive monitoring of CVP should be considered.

• CVP <10mmHg further volume loading.

• CVP 10-14Hg consider dobutamine/ LV unloading

devices.

• CVP >14mmHg modest dose

diuretics/±venodilators(beside dobu en LV

unloading).