Dr. M. Brands – Dr. K. Buyck – Prof. Dr. S. Rex

Dienst anesthesiologie

Management van perioperatief

rechter ventrikelfalen

1. Rechter ventrikelfalen (RVF)

Inleiding

Fysiologie niet-falende RV

Etiologie en pathofysiologie RVF

Diagnose perioperatief RVF

2. Therapeutische maatregelen bij RVF

Inleiding: epidemiologie

RV falen = syndroom waarbij ejectie of vulling RV

onvoldoende is voor adequate CO

Incidentie = onbekend

Geen duidelijke diagnostische criteria

Cardiale heelkunde

- 42% van LCOS, mortaliteit 44% (Davila-Roman, Ann Thor Surg 1995)

Harttransplantatie

- 50% van de vroege complicaties

- 42% van de perioperatieve mortaliteit (Haddad, CanJcardiol 2008)

LVAD-implantatie

- Incidentie: 25-50%

- Mortaliteit: tot 50% (Matthews, JACC 2008; Kirklin JK, J of Heart and Lung Transplant, 2010)

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

Inleiding: outcome

Inleiding: outcome

Anne-Catherine M. Pouleur

Right Ventricular Systolic Dysfunction Assessed by Cardiac Magnetic Resonance Is a Strong Predictor of Cardiovascular Death After Coronary Bypass Grafting

The Annals of Thoracic Surgery, Volume 101, Issue 6, 2016, 2176–2184

Inleiding

Prognostisch belang RVF onderschat- Fontan-circulatie: patiënten zonder functionele RV en passieve

longcirculatie

- Dierenmodellen (1940): cauterisatie van RV laterale wand: geen

daling CO / stijging SVP

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

Fysiologie niet-falende RV

Addetia K. et al.

Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2016 May;17(5):564-75.

Fysiologie niet-falende RV

Addetia K. et al.

Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2016 May;17(5):564-75.

Rechter ventrikel Linker ventrikel

Volume-pomp Druk-pomp

Lage weerstand Hoge weerstand

Gevoelig aan

afterload ↑↑↑

Gevoelig aan

preload ↑↑↑

EF 45% - 60% EF 50% - 70%

Peristaltisch /

longitudinaal

Concentrisch /

radiaal

Fysiologie niet-falende RV

PRELOAD AFTERLOAD

Hrymak C. et al.

Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71

Fysiologie niet-falende RV

CORONAIRE PERFUSIE

Hrymak C. et al.

Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71

Fysiologie: ventriculaire interdependentie

“Concept that through direct mechanical interactions the size, shape, and

compliance of one ventricle may affect the size, shape, and pressure-volume

relationship of the other”

Serieel = antegrade vulling LV faalt

Parallel = transseptale verstoring diastole/systole functie LV

1. Shift van IVS naar links

2. Stretching pericard

CO

Harjola VP et al.

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of

the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.

Perioperatief RV Falen: etiologie

Afterload

Preload

Contractiliteit

Gemengd

Pulmonale hypertensie (Primair en

Secundair)

Longembolie

Pulmonalisstenose/RVOTO

HPV

Tricuspiedinsufficiëntie

ASD

Pulmonalisinsufficiëntie

PAPVU

RV infarct

Arrythmiën

Cardiomyopathie

Sepsis

Linker ventrikelfalen (chronisch en acuut)

Congenitale hartaandoeningen

Pathofysiologie

Afterload

Contractiliteit

Preload

Ventriculaire interdependentie

Inflammatie

Lahm T et al.

Medical and Surgical Treatment of Acute Right Ventricular Failure J Am Coll Cardiol 2010;56:1435–46

Pathofysiologie

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

RV ischemiePulmonale hypertensie

RV dysfunctie

- Lung reperfusion injury

- Longembool

- Linker ventrikelfalen

- TRALI

- ARDS

- Luchtembolie

- Coronaire trombose

- Bypass graft failure

- Hypotensie

- Lange CPB-tijd

- LVAD

- Pre-op LV dysfunctie

- Slechte myocardprotectie

Pathofysiologie

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

RV ischemiePulmonale hypertensie

RV dysfunctie

- Lung reperfusion injury

- Longembool

- Linker ventrikelfalen

- TRALI

- ARDS

- Luchtembolie

- Coronaire trombose

- Bypass graft failure

- Hypotensie

- Lange CPB-tijd

- LVAD

- Pre-op LV dysfunctie

- Slechte myocardprotectie

Pre-op

Pathofysiologie

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

RV ischemiePulmonale hypertensie

RV dysfunctie

- Lung reperfusion injury

- Longembool

- Linker ventrikelfalen

- TRALI

- ARDS

- Luchtembolie

- Coronaire trombose

- Bypass graft failure

- Hypotensie

- Lange CPB-tijd

- LVAD

- Pre-op LV dysfunctie

- Slechte myocardprotectie

Per-op

Pathofysiologie

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

RV ischemiePulmonale hypertensie

RV dysfunctie

- Lung reperfusion injury

- Longembool

- Linker ventrikelfalen

- TRALI

- ARDS

- Luchtembolie

- Coronaire trombose

- Bypass graft failure

- Hypotensie

- Lange CPB-tijd

- LVAD

- Pre-op LV dysfunctie

- Slechte myocardprotectie

Post-op

Double-hit fenomeen

- Verminderde systeemperfusie tgv. CO daling

- Gestegen postcapillaire druk tgv. toegenomen

veneuze congestie

Orgaan perfusiedruk daalt

Evolutie naar multipel orgaan falen indicator slechte prognoseVerbrugge FH et al.

Abdominal contributions to cardiorenal dysfunction in congestive heart failure. J Am Coll Cardiol 2013;62:485–495.

Diagnose RV Falen: guidelines?

“No clinical signs, biochemical alterations or hemodynamic variables are specific

enough too allow an early differentation between RV, LV or biventricular failure”

Diagnose RV Falen: klinisch

- Hypoxemie

- Systemische congestie

- ECG: RV strain, S1Q3T3

- Arteriële curve: pulsus paradoxus

- Tekens LCOS: hypotensie / tachycardie / oligurie

Harjola VP et al.

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and

Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.

Diagnose RV Falen: echocardiografisch

Kwalitatief kwantitatief asessment RV

- FAC (G)

- TAPSE (E)

- Systolic S’ Velocity of the tricuspid

annulus (I)

- RIMP (K)

Harjola VP et al.

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and

Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.

Echocardiografisch: TEE

TEE Rounds November 2015 -- Right ventricular failure -- OpenAnesthesia.org

Echocardiografisch: TEE

TEE Rounds November 2015 -- Right ventricular failure -- OpenAnesthesia.org

Hemodynamisch: RV/ PA druk-meting

Whitener et al.

Pulmonary artery catheter Best Practice & Research Clinical Anaesthesiology Vol 28 (2014)

Hemodynamisch: RV/ PA druk-meting

Whitener et al.

Pulmonary artery catheter Best Practice & Research Clinical Anaesthesiology Vol 28 (2014)

RV/ PA druk-meting

Progressief RV Falen: CO PAP

Onbetrouwbaar hou rekening met graad van RVF en CO

Haddad F, Doyle R, Murphy DJ, Hunt SA.

Right ventricular function in cardiovascular disease. II. Pathophysiology, clinical importance, and management of right ventricular failure. Circulation 2008;117:1717–31

Therapie Rechter ventrikelfalen

Lahm T et al.

Medical and Surgical Treatment of Acute Right Ventricular Failure J Am Coll Cardiol 2010;56:1435–46

Therapie Rechter ventrikelfalen

Harjola VP et al.

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and

Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.

Therapie Rechter ventrikelfalen

1) Behandel uitlokkende factor

2) Behandel reversibele oorzaken

3) Optimaliseer vullingsstatus

4) Onderhoud MAP met vasopressie

5) Verlaag vullingsdrukken met inotropica

6) Farmacologische RV afterloadreductie

Harjola VP et al.

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and

Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.

Therapie: reversibele oorzaken

Long-protectieve ventilatie

Pplat < 30mmHg, VT 4-6ml/kg, PEEP

HYPOXIE – HYPERCARBIE – ACIDOSE

Ventilatie

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

Therapie: reversibele oorzaken

Ritme-Rate

Behoud sinusaal ritme essentieelCave verlies atriale kick bij niet-compliante RV RVF

Cardioversie aritmie = essentieel

Atriale PM-draden zo risico op post-operatief RVF

I.g.v. RVF: preferentieel hoger HR

Cave toename TI bij HR < 80 ppm

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

Therapie: optimalisatie vullingsstatus

Falend RV: Sterk afgevlakte Frank-Starling curve

Optimal filling of the RV is essential.

A failing RV will not tolerate

under- or overfilling.

Hrymak C. et al.

Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71

Volume overload

RV dilatatie wandspanning (VO2)

Tricuspiedinsufficiëntie

Shift interventriculair septum LV vulling

Optimaliseer vullingsstatus

1. IV diuretica

2. CVVH indien onvoldoende (snel) effect

Op geleide van CO-meting en TEE

Hrymak C. et al.

Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71

Therapie: optimalisatie vullingsstatus

Therapie: afterload - vasopressie

MAP >> RVsys druk

Hrymak C. et al.

Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71

CORONAIRE PERFUSIEDRUK

SEPTALE SHIFT VOORKOMEN

Therapie: afterload - vasopressie

“Ideale vasopressor”

Toename MAP zonder toename PVR

Ventetuolo CE1, Klinger JR.

Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc. 2014 Jun;11(5):811-22.

1) Behandel uitlokkende factor

2) Behandel reversibele oorzaken

3) Optimaliseer vullingsstatus

4) Onderhoud MAP met vasopressie

5) Verlaag vullingsdrukken met inotropica

6) Farmacologische RV afterloadreductie

Harjola VP et al.

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and

Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.

Therapie: contractiliteit – inotropie

Therapie: contractiliteit – inotropie

Cathecholamines

PDEIs IIIGlycosiden

Levosimendan

Fellahi J-L et al.

Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

Therapie: contractiliteit – inotropie

Fellahi J-L et al.

Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

Therapie: contractiliteit – inotropie

Fellahi J-L et al.

Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

Potentieel gevaarlijke effecten inotropica

• Cardiotoxiciteit

• Ca2+ overload

• Toename ischemie-reperfusie schade

• Toename stunning

• Pro-apoptotische effecten in (myocardiale) myocyten

• Intramyocardiale vrijzet van pro-inflammatoire cytokines

• Arrhythmogeen (toename intracellular Ca2+)

• Tachyphylaxie

• Onevenwicht tussen O2-aanbod en O2-verbruik

Gemakkelijke titratie, snel “on/off effect

Myocardiaal O2 aanbod/verbruik evenwicht

Steady-state in de tijd (geen tachyfylaxie)

Direct positief inotroop effect

Weinig tot niet arrythmogeen

Geen toename in intracellulair Ca2+ overload

Behoud van de coronaire perfusiedruk

Positief effect op regionale vaatbedden (renaal, splanchnisch)

Aanvaardbare risico/baten verhouding

Fellahi J-L et al.

Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

“Ideaal inotropicum”

Therapie: contractiliteit – inotropie

Therapie: contractiliteit – inotropie

Catecholamines = Ca2+ mobilizer

Fellahi J-L et al.

Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

Therapie: contractiliteit – inotropie

PDEI 3 inhibitors = Ca2+ mobilizer

Fellahi J-L et al.

Positive Inotropic Agents in Myocardial Ischemia–Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

• Milrinone / Enoximone

– Toename cAMP onafhankelijk van adrenerge receptoren

– Myocardweefsel: toename contractiliteit

– Vasculair gladde spier: relaxatie en vasodilatatie

• Geen/weinig tachycardie

• Vaak associatie met vasopressor noodzakelijk

Therapie: contractiliteit – inotropie

Felker et al.

HF Etiology and Response to Milrinone J Am Coll Cardiol. 2003 Mar 19;41(6):997-1003

Tacon et al.

Dobutamine for patients with severe heart failure: a systematic review and meta-analysis of randomised controlled trials. Intensive Care Med. 2012 Mar;38(3):359-67.

Therapie: contractiliteit – inotropie

Nielsen et al.

Health Outcomes with and without Use of Inotropic Therapy in Cardiac Surgery. Anesthesiology. 2014 May;120(5):1098-108

Therapie: contractiliteit – inotropie

PDEI 3 inhibitors = Ca2+ mobilizer

Nielsen DV, Algotssonb L

Outcome of inotropic therapy: is less always more? Curr Opin Anaesthesiol. 2015 Apr;28(2):159-64

Therapie: contractiliteit – inotropie

Levosimendan = Ca2+ sensitizer

RV/LV contractility

without increased

myocardial oxygen

Consumption

Mortality

Preconditioning and

anti-stunning effectsDimitrios Farmakis. Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. International

Journal of Cardiology Volume 222, Pages 303-312 (November 2016)

RV afterload

Coronary perfusion

LV afterload

Systemic hypotension

Levosimendan: mortaliteit

Pollesello P. et al.

Levosimendan meta-analyses: Is there a pattern in the effect on mortality? International Journal of Cardiology 209 (2016) 77–83

- Alle meta-analyses tot nu toe gepubliceerd

- N=25, n > 6000 patients

- Tonen allemaal voordeel in mortaliteit

(22/25 significant)

- Onafhankelijk van klinische setting /comparator

- 10 studies cardiale heelkunde, waarvan

8 verminderde mortaliteit aantonen.

Clinical practice: Recommended use of

levosimendan in cardiac surgery

Pisano A et al. Levosimendan: new indications and evidence for reduction in perioperative mortality?. Curr Opin Anesthesiol 2016, 29:454–461

Therapie: contractiliteit – inotropie

Nielsen DV, Algotssonb L

Outcome of inotropic therapy: is less always more? Curr Opin Anaesthesiol. 2015 Apr;28(2):159-64

Key points

Beschikbare inotropica verhogen cardiac output MAAR

ten koste van potentieel toegenomen mortaliteit

Juiste indicatiestelling is essentieel

Beperkte contractiele reserve vs. “potential harm”

Inotropie zou voornamelijk als rescue therapie moeten

gebruikt worden in geval van eind-orgaan hypoperfusie

1) Behandel uitlokkende factor

2) Behandel reversibele oorzaken

3) Optimaliseer vullingsstatus

4) Onderhoud MAP met vasopressie

5) Verlaag vullingsdrukken met inotropica

6) Farmacologische RV afterloadreductie

Harjola VP et al.

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and

Right Ventricular Function of the European Society of Cardiology. European Journal of Heart Failure (2016) 18, 226–241.

Therapie: contractiliteit – inotropie

Therapie:

Farmacologische RV afterloadreductie

Vermijd intraveneuze vasodilatatorenCoronaire hypoperfusie

Shift interventriculair septum

Inhibitie HPV V/P mismatch en hypoxie

Selectieve pulmonale vasodilatatoren1. iNO synthese c-GMP

2. Prostacyclines synthese c-AMP

3. PDE-III inhibitor inhibitie c-AMP degradatie

4. PDE-V inhibitor inhibitie c-GMP/c-AMP degradatie

Reductie PVR in goed-geventileerde gebieden V/P matching

Hrymak C. et al.

Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 2017 vol 33 61-71

Therapie: circulatoire support

Refractair RVF Survivalrate = 25-30%

Haddad et al.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422–33

Conclusie

Ventetuolo CE1, Klinger JR.

Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc. 2014 Jun;11(5):811-22.