Management van perioperatief rechter ventrikelfalen. Dr. M. Brands Dr. K. Buyck Prof. Dr. S. Rex Dienst anesthesiologie

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1 Management van perioperatief rechter ventrikelfalen Dr. M. Brands Dr. K. Buyck Prof. Dr. S. Rex Dienst anesthesiologie

2 1. Rechter ventrikelfalen (RVF) Inleiding Fysiologie niet-falende RV Etiologie en pathofysiologie RVF Diagnose perioperatief RVF 2. Therapeutische maatregelen bij RVF

3 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)

4 Inleiding: outcome Haddad et al. The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422 33

5 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,

6 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

7 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 May;17(5):

8 Fysiologie niet-falende RV Rechter ventrikel Volume-pomp Lage weerstand Gevoelig aan afterload Linker ventrikel Druk-pomp Hoge weerstand Gevoelig aan preload EF 45% - 60% EF 50% - 70% Peristaltisch / longitudinaal Concentrisch / radiaal Addetia K. et al. Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging May;17(5):

9 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

10 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

11 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 Parallel = antegrade vulling LV faalt = 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,

12 Perioperatief RV Falen: etiologie Afterload Preload Contractiliteit Pulmonale hypertensie (Primair en Secundair) Longembolie Pulmonalisstenose/RVOTO HPV Tricuspiedinsufficiëntie ASD Pulmonalisinsufficiëntie PAPVU RV infarct Arrythmiën Cardiomyopathie Sepsis Gemengd Linker ventrikelfalen (chronisch en acuut) Congenitale hartaandoeningen

13 Pathofysiologie Ventriculaire interdependentie Afterload Inflammatie Preload Contractiliteit Lahm T et al. Medical and Surgical Treatment of Acute Right Ventricular Failure J Am Coll Cardiol 2010;56:

14 Pathofysiologie - Lung reperfusion injury - Longembool - Linker ventrikelfalen - TRALI - ARDS - Luchtembolie - Coronaire trombose - Bypass graft failure - Hypotensie Pulmonale hypertensie RV ischemie RV dysfunctie - Lange CPB-tijd - LVAD - Pre-op LV dysfunctie - Slechte myocardprotectie Haddad et al. The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422 33

15 Pathofysiologie Pre-op - Lung reperfusion injury - Longembool - Linker ventrikelfalen - TRALI - ARDS - Luchtembolie - Coronaire trombose - Bypass graft failure - Hypotensie Pulmonale hypertensie RV dysfunctie RV ischemie - Lange CPB-tijd - LVAD - Pre-op LV dysfunctie - Slechte myocardprotectie Haddad et al. The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422 33

16 Pathofysiologie - Lung reperfusion injury - Longembool - Linker ventrikelfalen - TRALI - ARDS - Luchtembolie - Coronaire trombose - Bypass graft failure - Hypotensie Pulmonale hypertensie RV ischemie RV dysfunctie Per-op - Lange CPB-tijd - LVAD - Pre-op LV dysfunctie - Slechte myocardprotectie Haddad et al. The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422 33

17 Pathofysiologie - Lung reperfusion injury - Longembool - Linker ventrikelfalen - TRALI - ARDS - Luchtembolie - Coronaire trombose - Bypass graft failure - Hypotensie Pulmonale hypertensie RV ischemie RV dysfunctie Post-op - Lange CPB-tijd - LVAD - Pre-op LV dysfunctie - Slechte myocardprotectie Haddad et al. The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422 33

18 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 prognose Verbrugge FH et al. Abdominal contributions to cardiorenal dysfunction in congestive heart failure. J Am Coll Cardiol 2013;62:

19 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

20 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,

21 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,

22 Echocardiografisch: TEE TEE Rounds November Right ventricular failure -- OpenAnesthesia.org

23 Echocardiografisch: TEE TEE Rounds November Right ventricular failure -- OpenAnesthesia.org

24 Hemodynamisch: RV/ PA druk-meting Whitener et al. Pulmonary artery catheter Best Practice & Research Clinical Anaesthesiology Vol 28 (2014)

25 Hemodynamisch: RV/ PA druk-meting Whitener et al. Pulmonary artery catheter Best Practice & Research Clinical Anaesthesiology Vol 28 (2014)

26 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:

27 Therapie Rechter ventrikelfalen Lahm T et al. Medical and Surgical Treatment of Acute Right Ventricular Failure J Am Coll Cardiol 2010;56:

28 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,

29 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,

30 Therapie: reversibele oorzaken Ventilatie Long-protectieve ventilatie Pplat < 30mmHg, VT 4-6ml/kg, PEEP HYPOXIE HYPERCARBIE ACIDOSE Haddad et al. The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management. Anesth Analg 2009;108:422 33

31 Therapie: reversibele oorzaken Ritme-Rate Behoud sinusaal ritme essentieel Cave 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

32 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

33 Therapie: optimalisatie vullingsstatus Op geleide van CO-meting en TEE Volume overload RV dilatatie wandspanning (VO 2 ) Tricuspiedinsufficiëntie Shift interventriculair septum LV vulling Optimaliseer vullingsstatus 1. IV diuretica 2. CVVH indien onvoldoende (snel) effect Hrymak C. et al. Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71

34 Therapie: afterload - vasopressie MAP >> RV sys druk CORONAIRE PERFUSIEDRUK SEPTALE SHIFT VOORKOMEN Hrymak C. et al. Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Canadian Journal of Cardiology 33 (2017) 61-71

35 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 Jun;11(5):

36 Therapie: contractiliteit inotropie 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,

37 Therapie: contractiliteit inotropie Levosimendan Cathecholamines Glycosiden PDEIs III Fellahi J-L et al. Positive Inotropic Agents in Myocardial Ischemia Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

38 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

39 Therapie: contractiliteit inotropie Potentieel gevaarlijke effecten inotropica Cardiotoxiciteit Ca 2+ overload Toename ischemie-reperfusie schade Toename stunning Pro-apoptotische effecten in (myocardiale) myocyten Intramyocardiale vrijzet van pro-inflammatoire cytokines Arrhythmogeen (toename intracellular Ca 2+ ) Tachyphylaxie Onevenwicht tussen O2-aanbod en O2-verbruik Fellahi J-L et al. Positive Inotropic Agents in Myocardial Ischemia Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

40 Therapie: contractiliteit inotropie Ideaal inotropicum Gemakkelijke titratie, snel on/off effect Myocardiaal O 2 aanbod/verbruik evenwicht Steady-state in de tijd (geen tachyfylaxie) Direct positief inotroop effect Weinig tot niet arrythmogeen Geen toename in intracellulair Ca 2+ 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

41 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

42 Therapie: contractiliteit inotropie PDEI 3 inhibitors = Ca2+ mobilizer 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 Fellahi J-L et al. Positive Inotropic Agents in Myocardial Ischemia Reperfusion Injury A Benefit/Risk Analysis. Anesthesiology 2013; 118:1460-5

43 Therapie: contractiliteit inotropie Felker et al. HF Etiology and Response to Milrinone J Am Coll Cardiol Mar 19;41(6): Tacon et al. Dobutamine for patients with severe heart failure: a systematic review and meta-analysis of randomised controlled trials. Intensive Care Med Mar;38(3):

44 Therapie: contractiliteit inotropie Nielsen et al. Health Outcomes with and without Use of Inotropic Therapy in Cardiac Surgery. Anesthesiology May;120(5):

45 Therapie: contractiliteit inotropie PDEI 3 inhibitors = Ca2+ mobilizer Nielsen DV, Algotssonb L Outcome of inotropic therapy: is less always more? Curr Opin Anaesthesiol Apr;28(2):159-64

46 Therapie: contractiliteit inotropie Levosimendan = Ca2+ sensitizer RV/LV contractility without increased myocardial oxygen Consumption Mortality RV afterload Coronary perfusion LV afterload Systemic hypotension Preconditioning and anti-stunning effects Dimitrios 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 (November 2016)

47 Levosimendan: mortaliteit - 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. Pollesello P. et al. Levosimendan meta-analyses: Is there a pattern in the effect on mortality? International Journal of Cardiology 209 (2016) 77 83

48 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:

49 Therapie: contractiliteit inotropie 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 Nielsen DV, Algotssonb L Outcome of inotropic therapy: is less always more? Curr Opin Anaesthesiol Apr;28(2):159-64

50 Therapie: contractiliteit inotropie 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,

51 Therapie: Farmacologische RV afterloadreductie Vermijd intraveneuze vasodilatatoren Coronaire hypoperfusie Shift interventriculair septum Inhibitie HPV V/P mismatch en hypoxie Selectieve pulmonale vasodilatatoren 1. 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

52 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

53 Conclusie Ventetuolo CE1, Klinger JR. Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc Jun;11(5):