Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France Challenge in Right Heart Failure

1- In case of acute RV failure, fluid infusion may decrease CO 3- In case of MV with PEEP, fluid infusion may increase CO through an increase in systemic venous return (RV preload effect) 2- In case of acute RV failure, fluid infusion may increase CO 4- In case of MV with PEEP, fluid infusion may increase CO through a beneficial effect on PEEP-induced RV dysfunction (RV afterload effect)

Acute pulmonary embolism Major causes of acute RV failure in critically ill patients Sepsis-induced myocardial dysfunction RV failure secondary to ARDS Deleterious effects of MV

Challenge in acute RV failure Fluid administration and RV failure

preload responsiveness preload unresponsiveness Stroke Volume Ventricular preload If RV is dilated, fluid infusion → no increase in RV stroke volume

RV end diastolic volume RV end diastolic pressure A B C D If RV is dilated, fluid infusion → large increase in RV EDP

RVLV RVLV Biventricular interdependence → decrease in LV stroke volume If RV is dilated, fluid infusion → no increase in RV stroke volume If RV is dilated, fluid infusion → large increase in RV EDP Fluid infusion not only does not increase but can even decrease CO

1- Inadequate (low) RV preload can be responsible for low CO in case of acute RV failure such as pulmonary embolism Fluid infusion not only does not increase but can even decrease CO But

Hemodynamic effects of fluid loading in acute massive pulmonary embolism Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors Critical Care Medicine 1999; 27:

Hemodynamic effects of fluid loading in acute massive pulmonary embolism Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors Critical Care Medicine 1999; 27: r = 0.89 Fluid responders had lower RVEDI

RAP cannot be used for identifying pts who can benefit from fluid influsion Hemodynamic effects of fluid loading in acute massive pulmonary embolism Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors Critical Care Medicine 1999; 27:

1- Inadequate (low) RV preload can be responsible for low CO in case of acute RV failure such as pulmonary embolism Fluid infusion not only does not increase but can even decrease CO But 2- In case of MV, more complex relationships between the effects of fluid infusion and the right ventricle

Mechanical insufflation and the RV Mechanical ventilation and the right ventricle PEEP and the RV

Mechanical insufflation and venous return Mechanical insufflation and RV

 P abd  P RA  P ms  P RA – P ms  P alv  P it

P RA P ra1 P ra2 Effects of cyclic increase in intrathoracic pressure P ms1 P ms2 Increased P IT Increased P abd venous return Cardiac output or CO 1 CO 2

P RA P ra1 P ra2 Effects of cyclic increase in intrathoracic pressure P ms1 P ms2 Increased P IT Increased P abd venous return Cardiac output or CO 1 CO 2 P ms3 Fluids

Mechanical insufflation and RV ejection Mechanical insufflation and venous return Pulmonary vascular resistance and lung volume Mechanical insufflation and RV

extra-alveolar vessels intra-alveolar vessels high lung volume

 lung volume  Lung volume improves the RV ejection by decreasing resistance of extra-alveolar vessels

Lung volume RVFRCTLC PVR extra-alveolar vessels

 P alv  Lung volume improves the RV ejection by decreasing resistance of extra-alveolar vessels impedes the RV ejection by compressing the intra-alveolar vessels  Transpulmonary pressure  P it  P transpulm = P alv - P it

Lung volume RVFRCTLC PVR extra-alveolar vessels intra-alveolar vessels

Lung volume RVFRCTLC PVR

Mechanical insufflation and RV ejection Mechanical insufflation and venous return Pulmonary vascular resistance and lung volume Pulmonary vascular resistance and West’s zones Mechanical insufflation and RV

Zone 1 Zone 2 Zone 3 P alv P PA P PV Palv P alv > P PA > P PV P PA > P alv > P PV P PA > P PV > P alv PVR up bottom

Zone 3 Lung volumes RV FRC TLC PVR extra-alveolar vessels intra-alveolar vessels Zone 1 Zone 2 Zone 3 Zone 1 Zone 2

Zone 1 Zone 2 Zone 3 P alv P PA P PV P alv P alv > P PA > P PV P PA > P alv > P PV P PA > P PV > P alv PVR bottom up Hypovolemia favors zones 1 and 2 by reducing intravascular pressures Hypovolemia favors zones 1 and 2 by reducing intravascular pressures Reduced central blood volume should amplify the deleterious impact of MV on RV afterload and RV function

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RV RA LV ACP defined as RVEDA/LVEDA > 0.6 and septal dyskinesia Incidence of ACP: 25% Crit Care Med 2001, 29: ARDS with protective ventilation (Pplat < 30 cm H 2 O)

Definition of acute cor pulmonale mean PAP > 25 mmHg RAP > PAOP Stroke Index < 30 mL/m ARDS pts with PAC with lung protective ventilation

10% 90% ACP + ACP ARDS patients with lung protective ventilation

Reduction of transpulmonary pressure using ventilatory strategies aimed at limiting plateau pressure, is associated with high reduction of incidence and severity of acute cor pulmonale during ARDS

Mechanical insufflation and RV PEEP and RV  PEEP and venous return Mechanical ventilation and the right ventricle

P RA Venous return P ra1 P ra2 P ms P ms2 Increased P IT Increased P abd By increasing ITP PEEP should decrease venous return and thus cardiac output CO 1 CO 2

Mechanical insufflation and RV PEEP and RV  PEEP and venous return  PEEP and RV ejection Mechanical ventilation and the right ventricle

Lung volume RVFRCTLC PVR If PEEP overdistends lung and increases the end-expiratory volume above theoretical FRC, PVR should increase

Lung volume RVFRCTLC PVR If PEEP recruits lung units and increases the end-expiratory lung volume toward theoretical FRC, PVR should decrease

Lung volume RVFRCTLC PVR If the resultant effect is overdistension PVR should increase

Lung volume RVFRCTLC PVR In this case, tidal insufflation further increases PVR to a high value

Lung volume RVFRCTLC PVR If the resultant effect is lung recruitment, PVR should decrease

Lung volume RVFRCTLC PVR In this cas, mechanical insufflation induces little change in PVR

Mechanical insufflation and RV PEEP and RV  PEEP and venous return  PEEP and RV ejection The hemodynamic effects of PEEP are variable, depending on:  its capacity of recruiting or overdistending lungs  its capacity of improving arterial oxygenation  degree of airway pressure transmission  adaptative mechanisms  volume status Mechanical ventilation and the right ventricle

TV 6 mL/kg Low PEEP High PEEP 13 cmH 2 O TV 6 mL/kg 5 cmH 2 O Pplat : 30 cmH 2 O Passive Leg Raising 45°

CI L/min/m 2 Decrease in RV preload? Increase in RV afterload? *

PVR dynes.s.m 2 /cm 2 Decrease in RV preload Increase in RV afterload *

RVEDA / LVEDA * Decrease in RV preload Increase in RV afterload

CI L/min/m 2 *

PVR dynes.s.m 2 /cm 2 * Decrease in RV afterload with volume challenge

RVEDA / LVEDA * Decrease in RV afterload with volume challenge

Zone 1 Zone 2 Zone 3 P alv P PA P PV P alv P alv > P PA > P PV P PA > P alv > P PV P PA > P PV > P alv PVR up bottom Volume loading may favor zones 3 Volume loading may favor zones 3  P PA > P PV > P alv Zone 3

1- In case of acute RV failure, fluid infusion may decrease CO 3- In case of MV with PEEP, fluid infusion may increase CO through an increase in systemic venous return (RV preload effect) 2- In case of acute RV failure, fluid infusion may increase CO 4- In case of MV with PEEP, fluid infusion may increase CO through a beneficial effect on PEEP-induced RV dysfunction (RV afterload effect)

1- Inadequate (low) RV preload can be responsible for low CO in case of acute RV failure such as pulmonary embolism In case of acute RV failure, fluid infusion not only does not increase but can even decrease CO 2- In case of MV with PEEP, increase in central blood volume with fluid may improve PEEP-induced RV dysfunction However Conclusion Conclusion Thank you