Τί κάνουμε όταν πάσχει η δεξιά κοιλία Οξεία πνευμονική εμβολή. Βασίλειος Σαχπεκίδης Επιμελητής Α Καρδιολογίας Γ.Ν.Θ. Παπαγεωργίου

Transcription

1 Τί κάνουμε όταν πάσχει η δεξιά κοιλία Οξεία πνευμονική εμβολή Βασίλειος Σαχπεκίδης Επιμελητής Α Καρδιολογίας Γ.Ν.Θ. Παπαγεωργίου

2 No conflicts of interest

3 RV anatomy Ho SY and Nihoyannopoulos P. Heart 2006;92 Suppl 1:i2-13.

4 RV anatomy and muscle orientation Ho SY and Nihoyannopoulos P. Heart 2006;92 Suppl 1:i2-13.

5 Pulmonary circulation = low pressure circulation

6 Assessment of RV size and function

7

8 RV is very sensitive to afterload change MacNee W. Am J Respir Crit Care Med 1994;150:

9 RV response to acute pressure overload Anrep s effect Greyson CR. Rev Esp Cardiol. 2010;63:81-95.

10 RV is not alone Haddad F et al. Circulation 2008;117:

11 Pathophysiology of acute RV failure Harjola VP et al. Eur J Heart Fail 2016;18: Begieneman MP et al. Heart 2008;94:

12 Case 79 y old female SOB commencing 24 h ago Colon cancer operated a year ago (+ chemotherapy) DM HTN on b-blocker No bleeding history BP=95/70 mmhg, HR=76 bpm, SatO2=92% on air with RR=25/min, oliguric Mild Trop elevation Hb=12,3 mg/dl

13 Echo

14 Echo

15 Echo

16 Echo PASP = 20 + RAP AcT = 72 ms

17 Sometimes the diagnosis is clear

18 In our case CTPA

19 Risk stratification Konstantinides SV et al. J Am Coll Cardiol 2016;67:

20 How to treat such patient? Improvement of haemodynamics and oxygenation Fluids Inotropes Oxygen PA thrombus dissolution reduction of RV afterload Anticoagulation Thrombolysis Surgical Embolectomy Percutaneous catheter directed techniques

21 Improvement of haemodynamics and oxygenation Close monitoring (CCU) arterial line for continuous BP monitoring and ABG analysis urine output Modest ( ml) fluid challenge may be helpful (also assess IVC) if no BP response seen stop as RV overstretching may have detrimental effects Inotropes: - Norepinephrine when hypotension present - Dobutamine/dopamine when CI is reduced and BP normal -?Levosimedan?NO. Oxygen when hypoxemia present Avoid mechanical ventilation if possible adverse effects on RV filling and function ECMO Konstantinides SV et al. Eur Heart J 2014;35: Harjola VP et al. Eur J Heart Fail 2016;18:

22 Anticoagulation UFH preferred when: - Primary reperfusion considered - CrCl < 30 ml/min - Severe obesity Advantages of UFH: - Short half life - Ease of monitoring? - Rapid reversal with protamine Konstantinides SV et al. Eur Heart J 2014;35:

23 NOACs??? Patients receiving thrombolysis excluded Safety and efficacy of NOACs in patients with intermediate-risk PE have not been systematically addressed thus far. Konstantinides SV et al. J Am Coll Cardiol 2016;67:

24 Thrombolysis Marti C et al. Eur Heart J 2015;36:

25 Thrombolysis in intermediate risk PE Meyer G et al. N Engl J Med 2014;370:

26 Konstantinides SV et al. Eur Heart J 2014;35:

27 Surgical embolectomy High risk PE when thrombolysis is contraindicated or failed Relatively simple operation Perioperative mortality rates of 6% or less have been reported Preoperative thrombolysis increases the risk of bleeding, but it is not an absolute contraindication Konstantinides SV et al. Eur Heart J 2014;35:

28 Catheter based therapies Jaber WA et al. J Am Coll Cardiol 2016;67:

29 Catheter directed thrombolysis Piazza G et al. J Am Coll Cardiol Intv 2015;8:

30 Back to our patient Patient transferred to ICU arterial line placed Oxygen 3 lt/min Judicious use of iv fluids b-blocker and HTN medication stopped UFH started Patient remained oliguric after 6 hours of FU, with borderline BP (~90 mmhg) Low dose noradrenaline + dobutamine iv started + rt-pa 100 mg administered within 2 hours Within hours after thrombolysis patient s haemodynamics improved and urine output increased next day inotropes stopped Uneventful recovery discharged day 8

31 Echo before discharge

32 Echo before discharge

33 Sometimes treatment decisions are 43 y male Metastatic melanoma (brain lesion with haemorrhage, bones, liver) with some response to treatment SOB last 4 days cardiac arrest intubated on high doses of inotropes Pulsus paradoxus not easy

34 Echo

35 Echo How would you treat this patient???

36 To sum up RV is very sensitive to acute increase of afterload (such as in acute PE) RV dysfunction on echo (or CT) esp when accompanied by increase of biomarkers (eg ctn) or hypotension carries a bad prognosis for acute PE pts Treatment goals: - Improvement of haemodynamics and oxygenation - thrombus dissolution reduction of RV afterload

37 To sum up Improvement of haemodynamics and oxygenation Fluids (judicious use) Inotropes (norepinephrine / dobutamine) Oxygen Avoid mechanical ventilation if possible PA thrombus dissolution reduction of RV afterload Anticoagulation (UFH / LMWH / Fondaparinux / NOACs?) Thrombolysis Surgical Embolectomy if thrombolysis is contraindicated or failed Percutaneous catheter directed techniques (experience needed)

38

39 ECG

40 Pulmonary Embolism Severity Index (PESI) Our patient s score: 109 (Class IV) Konstantinides SV et al. Eur Heart J 2014;35:

41 Areas of uncertainty Conclusions: Compared with the 100 mg/2 h regimen, the 50 mg/2 h rt-pa regimen exhibits similar efficacy and perhaps better safety in patients with acute PTE. Low dose thrombolysis Mobile right heart thrombi

42 Percutaneous catheter-directed treatment Absolute CI to thrombolysis Without absolute CI to thrombolysis Konstantinides SV et al. Eur Heart J 2014;35:

43 Vena Cava filters? Konstantinides SV et al. Eur Heart J 2014;35: Mismetti P et al. JAMA2015;313:

44 Echo before discharge