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

2. 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)

3. 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

4. Challenge in acute RV failure Fluid administration and RV failure

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

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

7. 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

8. 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

9. 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: 540-544

10. 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: 540-544 r = 0.89 Fluid responders had lower RVEDI

11. 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: 540-544

12. 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

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

14. Mechanical insufflation and venous return Mechanical insufflation and RV

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

16. 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

17. 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

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

19. extra-alveolar vessels intra-alveolar vessels high lung volume

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

21. Lung volume RVFRCTLC PVR extra-alveolar vessels

22.  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

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

24. Lung volume RVFRCTLC PVR

25. 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

26. 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

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

28. 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

29. * * * *

30. * * * *

31. RV RA LV ACP defined as RVEDA/LVEDA > 0.6 and septal dyskinesia Incidence of ACP: 25% Crit Care Med 2001, 29:1551-1555 ARDS with protective ventilation (Pplat < 30 cm H 2 O)

32. Definition of acute cor pulmonale mean PAP > 25 mmHg RAP > PAOP Stroke Index < 30 mL/m 2 145 ARDS pts with PAC with lung protective ventilation

33. 10% 90% ACP + ACP - 145 ARDS patients with lung protective ventilation

34. 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

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

37. 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

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

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

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

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

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

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

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

45. 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

46. 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°

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

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

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

50. CI L/min/m 2 *

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

52. RVEDA / LVEDA * Decrease in RV afterload with volume challenge

53. 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

54. 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)

55. 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