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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
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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.
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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.
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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.
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CAGCAGCAGCAG
prepre
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PCIPCIPCIPCI
GPIIbIIIa inhibitor; thrombus aspiratie RCA: 1 stent (3.5/23mm @14 atm); postdilatationNC ballon (3.5mm @24atm)
Voor thrombusaspiratie
finalfinal
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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).
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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.
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Search strategy Search strategy Search strategy Search strategy
• Search terms:
• Right ventricle infarction AND volume
loading/infusion
• Right ventricle infarction AND treatment
• Human studies
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Search strategy Search strategy Search strategy Search strategy
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Search strategy Search strategy Search strategy Search strategy
3 Reviews
` 7 Clinical studies
ESC
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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).
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ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984 ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984
RVI
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ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984 ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984
RVI
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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
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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
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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
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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
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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.
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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)
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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)
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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.
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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.
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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)
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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.
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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
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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.
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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.
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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.
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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).
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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.)
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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
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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.
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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).