Recent Updates in Management of Right Ventricular Failure with Pulmonary Hypertension in ICU Essay
Amany Abdel Hameid Gomaa;
Abstract
P
ulmonary arterial hypertension continues to cause significant morbidity and mortality. Although the right ventricle can adapt to an increase in after-load, progression of the pulmonary vasculopathy that characterize pulmonary arterial hypertension, causes many patients to develop progressive right ventricular failure. Right ventricular failure represents a high percent of cases admitted to ICU and its treatment represents a challenge to physicians.
Acute right ventricular failure develop from disorders that lead to pressure overload, volume overload, intrinsic myocardial disease, or pericardial constrain. Immediate clinical and diagnostic evaluation and care is required in order to select the type of treatment. Initial diagnostic assessment should include clinical examination supported by the patient’s history, ECG, chest X-ray, plasma BNP/nt-proBNP, biomarkers of myocardial injury and other ordinary laboratory tests. Echocardiography should be performed in all patients as soon as possible to provide diagnostic and prognostic information in patients with pulmonary hypertension.
Cardiac magnetic resonance imaging provides a direct evaluation of RV size, morphology and function. Also Swan-Ganze catheter, right heart catheterization, abdominal ultrasound scan, pulmonary function tests and arterial blood gases are done. Acute pulmonary embolism is a frequent cause of RVF and diagnostic CT-angiography is often required.
Fluid management and optimization of preload in these patients is difficult. Minimize fluid retention and diuretic therapy is often used. Most important interventions to reverse RV failure are to reduce RV after load by using of pulmonary vasodilators. Patients with PAH may benefit from phosphodiestrase inhibitors as sildenafil citrate as inotropic agent. Prostacycline derivatives are the initial treatment of choice in these patients. Inhaled nitric oxide is selective pulmonary vasodilator.
Maintenance of cardiac rhythm and using anti-arrhythmic drugs or even cardio-version are very important. Anticoagulant therapy is used if the risk of thrombo-embolic events in RV failure. Supplement oxygen and ventilation to keep peripheral oxygen saturation above 90% and correction of anemia if present.
Despite advances in medical therapy, lung or heart-lung transplantation remains an important treatment option for patients with progressive pulmonary hypertension with refractory RV failure.
A lot of complications occur with pulmonary hypertension and RV failure leading to sudden cardiac death such as arrhythmia, left main Coronary artery compression syndrome, dissection and Rupture of pulmonary artery, hemoptysis and syncope. Hepatic cirrhosis, renal failure, and multi organs failure are also fatal complications.
References
Ambardekar AV and Buttrick PM (2011): Reverse remodeling with left ventricular assist devices: a review of clinical, cellular, and molecular effects. Circ Heart Fail 4:224–233.
Arcasoy SM, Christie JD, Ferrari VA, et al. (2003): Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med 167: 735-740.
Baandrup JD, Markvardsen LH, Peters CD, Schou UK, Jensen JL, Magnusson NE, Orntoft TF, Kruhoffer M and Simonsen U (2011): Pressure load: the main factor for altered gene expression in right ventricular hypertrophy in chronic hypoxic rats. PLoS ONE 6:e158-159.
Badesch DB, Champion HC, Sanchez MA, et al. (2009): Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol 54:S55-66.
Badsch DB, Abmon SH, Simonneau G, Rubin LJ and Mclaughlin VV (2007): Medical therapy for arterial pulmonary hypertension: updated ACCP evidence-baswd clinical practiceguidlines. Chest 131: 1917-1928.
ulmonary arterial hypertension continues to cause significant morbidity and mortality. Although the right ventricle can adapt to an increase in after-load, progression of the pulmonary vasculopathy that characterize pulmonary arterial hypertension, causes many patients to develop progressive right ventricular failure. Right ventricular failure represents a high percent of cases admitted to ICU and its treatment represents a challenge to physicians.
Acute right ventricular failure develop from disorders that lead to pressure overload, volume overload, intrinsic myocardial disease, or pericardial constrain. Immediate clinical and diagnostic evaluation and care is required in order to select the type of treatment. Initial diagnostic assessment should include clinical examination supported by the patient’s history, ECG, chest X-ray, plasma BNP/nt-proBNP, biomarkers of myocardial injury and other ordinary laboratory tests. Echocardiography should be performed in all patients as soon as possible to provide diagnostic and prognostic information in patients with pulmonary hypertension.
Cardiac magnetic resonance imaging provides a direct evaluation of RV size, morphology and function. Also Swan-Ganze catheter, right heart catheterization, abdominal ultrasound scan, pulmonary function tests and arterial blood gases are done. Acute pulmonary embolism is a frequent cause of RVF and diagnostic CT-angiography is often required.
Fluid management and optimization of preload in these patients is difficult. Minimize fluid retention and diuretic therapy is often used. Most important interventions to reverse RV failure are to reduce RV after load by using of pulmonary vasodilators. Patients with PAH may benefit from phosphodiestrase inhibitors as sildenafil citrate as inotropic agent. Prostacycline derivatives are the initial treatment of choice in these patients. Inhaled nitric oxide is selective pulmonary vasodilator.
Maintenance of cardiac rhythm and using anti-arrhythmic drugs or even cardio-version are very important. Anticoagulant therapy is used if the risk of thrombo-embolic events in RV failure. Supplement oxygen and ventilation to keep peripheral oxygen saturation above 90% and correction of anemia if present.
Despite advances in medical therapy, lung or heart-lung transplantation remains an important treatment option for patients with progressive pulmonary hypertension with refractory RV failure.
A lot of complications occur with pulmonary hypertension and RV failure leading to sudden cardiac death such as arrhythmia, left main Coronary artery compression syndrome, dissection and Rupture of pulmonary artery, hemoptysis and syncope. Hepatic cirrhosis, renal failure, and multi organs failure are also fatal complications.
References
Ambardekar AV and Buttrick PM (2011): Reverse remodeling with left ventricular assist devices: a review of clinical, cellular, and molecular effects. Circ Heart Fail 4:224–233.
Arcasoy SM, Christie JD, Ferrari VA, et al. (2003): Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med 167: 735-740.
Baandrup JD, Markvardsen LH, Peters CD, Schou UK, Jensen JL, Magnusson NE, Orntoft TF, Kruhoffer M and Simonsen U (2011): Pressure load: the main factor for altered gene expression in right ventricular hypertrophy in chronic hypoxic rats. PLoS ONE 6:e158-159.
Badesch DB, Champion HC, Sanchez MA, et al. (2009): Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol 54:S55-66.
Badsch DB, Abmon SH, Simonneau G, Rubin LJ and Mclaughlin VV (2007): Medical therapy for arterial pulmonary hypertension: updated ACCP evidence-baswd clinical practiceguidlines. Chest 131: 1917-1928.
Other data
| Title | Recent Updates in Management of Right Ventricular Failure with Pulmonary Hypertension in ICU Essay | Other Titles | التحديثات الأخيرة في معالجة قصور البطين الأيمن مع ارتفاع ضغط الدم الرئوي في وحدة العناية المركزة | Authors | Amany Abdel Hameid Gomaa | Issue Date | 2014 |
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