Acute peri-operative. Alexandre Mebazaa, Hôpital Lariboisière, Université Paris 7 U942 Inserm

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1 Acute peri-operative left heart failure Alexandre Mebazaa, Hôpital Lariboisière, Université Paris 7 U942 Inserm

2 Conflict of Interest Lecture fee: Orion No other conflicts for this lecture

3 Acute peri-operative heart failure Systolic heart failure, mostly after CPB Diastolic heart failure: post-operativeoperative period of any surgery Right ventricular failure

4 Practical Recommendations On The Management of Perioperative Heart Failure In Cardiac Surgery Chairpersons: F Follath, W Toller, A Mebazaa Faculty: A Pitsis, A Rudiger, D Longrois, S-E Ricksten, I Bobek, SG De Hert, G Wieselthaler, U Schirmer, LK von Segesser, M Sander, D Poldermans, M Ranucci, P Wouters, M Seeberger, ER Schmid, W Weder Mebazaa et al Crit Care 2010

5 Practical Recommendations On The Management of Perioperative Heart Failure In Cardiac Surgery Epidemiology Risk Stratification i Cardioprotective agents Monitoring Pharmacological treatment Clinical scenarios Mechanical circulatory support Mebazaa et al Crit Care 2010

6 «Medical» Cardiogenic Shock in ICU: EFICA study, Symptoms on Admission i SBP mmhg < DBP mmhg < Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

7 EFICA Study Predictive Factors of Mortality % Surviv val Rate, % 38% 68% Number of Days SBP >160 mm Hg SBP <160 mm Hg Cardiogenic Shock No shock Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

8 Survival rates of ICU-patients with different acute heart failure syndromes over time

9 Risk stratification in cardiac surgery Group recommendations: Indicators of major clinical risk in the perioperative period are: unstable coronary syndromes, decompensated HF, significant arrhythmias and severe valvular disease Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high risk surgery the EuroScore predicts perioperative cardiovascular alteration in cardiac surgery well BNP measure before surgery is an additional factor of risk stratification Mebazaa et al Crit Care 2010

10 The cardioprotective agents in cardiac surgery Group recommendation: Aggressively A i l preserving heart tfunction during cardiac surgery is a major goal Volatile Vltil anesthetics ti seem to be promising ii cardioprotective ti agents LevosimendanL i d that t was introduced dmore recently also seems to have cardioprotective properties Large L ti trials are still needed ddto assess the best cardioprotective agent(s) and the optimal protocol to use it Mebazaa et al Crit Care 2010

11 Levosimendan Reduces Cardiac Troponin Release After Cardiac Surgery: A Metaanalysis of Randomized Controlled Studies Zangrillo et al J Cardiothoracic and Vasc Anesth 2009

12 Monitoring in cardiac surgery Group recommendation: Monitoring is aimed to early detect and assess the mechanism(s) of perioperative cardiovascular dysfunction Volume Vl status tt is ideally assessed by dynamic measures of haemodynamic parameters before and after volume challenge rather than single measures Heart function is first assessed by echocardiography followed by PAC, especially in case of right heart dysfunction Mebazaa et al Crit Care 2010

13 Echocardiography Predominent right ventricular failure Global heart failure Predominent left ventricular failure TAMPONADE? Yes No Massive mitral regurgitation? No Echocardiographic guided pericardiocentesis or surgical intervention PA catheter LV dysfunction Pulmonary vasodilators Pulmonary hypertension? RV ischaemia? Reduce RV afterload, avoid excess volume, use inotropes if CO low Any CO monitoring, i ideally non invasive Optimise LV pre- and afterload, Inotropes if required Mebazaa et al. Intensive Care Med, 2004;30:185-96; Antonelli et al. Intensive Care Med, 2007;33:575-90

14 Intensive Care Medicine, 2006; 32:9-10

15 The «pyramid» of echocardiography skills in ICU Cholley,Vieillard-Baron, Mebazaa, ICM 2006

16 Management of post-operative hemodynamic failure SBP < 85mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion Heart rate Volemia Myocardial function Vessel tone

17 Pharmacologic treatment of cardiac dysfunction in the perioperative period of cardiac surgery (1) Group recommendation In case of myocardial dysfunction consider the following 3 options either alone or combined: 1)Milrinone decreases PCWP and SVR while stroke volume (SV) and heart rate (HR) increase less than with other inotropes 2)Dobutamine improves SV and HR while PCWP moderately decreases 3)Levosimendan increases SV and decreases SVR. It also reduces the time to extubation and ICU LOS compared to dobutamine Mebazaa et al Crit Care 2010

18 Pharmacologic treatment of cardiac dysfunction in the perioperative period of cardiac surgery (2) Norepinephrine should be used in case of low blood pressure due to vasoplegia, to maintain an adequate perfusion pressure. Volaemia should be repeatedly assessed to ensure that the patient is not hypovolaemic while under vasopressors Optimal use of inotropes or vasopressors in the perioperative period of cardiac surgery is still controversial and needs further large multinational studies Mebazaa et al Crit Care 2010

19 Clinical scenarios of cardiac dysfunction Group recommendation : The classification of cardiac impairment in the perioperative period of cardiac surgery should be based 1) on the time of occurrence: precardiotomy p y(a) failure to wean (B) postcardiotomy (C) and 2) on the haemodynamic severity of the condition of the patient crash and burn (1) sliding fast (2) stable but inotrope dependent (3) Mebazaa et al Crit Care 2010

20 Mechanical Circulatory Support Clinical i l scenarios Commonly used ddevices A. precardiotomy CS B. failure to wean C. postcardiotomy CS IABP Impella 2.5/5 Percutaneous (tranfemoral) ECMO TandemHeart IABP Impella 5 ECMO Centrifugal pumps as LVAD, RVAD,BVAD Abiomed BVS 5000, AB 5000, Thoratec PVAD Long term implantable devices IABP Impella 5 ECMO Centrifugal pumps* p as LVAD, RVAD, BVAD Percutaneous pulsatile devices** as LVAD, RVAD,BVAD Long term implantable devices 1 st, 2 nd and 3 rd generation Mebazaa et al Crit Care 2010

21 Acute peri-operative heart failure Systolic heart failure, mostly after CPB Diastolic heart failure: post-operativeoperative period of any surgery Right ventricular failure

22 Patient s history Men, 72 y.o. smoker, quit 15 y ago no diabetes Admitted for knee surgery major risk factor: father of an anesthesiologist!

23 Before surgery 19 hours after surgery ECG: ischemia, TnI increased, LVEF 48%, = diastolic dysfunction with a preserved systolic function

24 Increase in body temperature Myocardial oxygen consumption Coronary oxygen delivery Anemia + + MYOCARDIAL ISCHEMIA diastolic coronary filling time + TACHYCARDIA diuretics Hypovolemia, Pain LEFT VENTRICULAR DIASTOLIC DYSFUNCTION PULMONARY CONGESTION Treatment by: morphine blood transfusion β-blockersβ

25 Diastolic heart failure in anaesthesia and ICU Pirracchio et al. Br. J. Anaesth.2007; 98:

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27 Acute peri-operative heart failure Systolic heart failure, mostly after CPB Diastolic heart failure: post-operativeoperative period of any surgery Right ventricular failure

28 Right ventricular failure following CPB Mechanims? Mebazaa et al. Intensive Care Med, 2004;30:185-96

29 Pulmonary stenosis

30 Right coronary stenosis

31 Pulmonary stenosis and RC stenosis 1971

32 Dilated Right Ventricle! TR

33 Auto-aggravation of CO decrease in ARVF Right Ventricular Failure Reduction in CO + RV dilatation + reduction in LV preload tricuspid regurgitation hypotension decrease in RCPP organ's hypoperfusion + congestion (acidosis,...) greater reduction in CO Mebazaa et al. Intensive Care Med, 2004;30:185-96

34 DANGER Volume loading can be harmful It may worsen liver and kidney congestion if RV function is not previously restored

35 volume loading PA CO is often unchanged RAP TR ARVF RV CONGESTION Increase in AP, transaminases and creatinine

36 In AHF-induced liver congestion What is/are the mechanism(s) of: Increased transaminases? Increased alkaline phosphatase?

37 The cardio-hepatic syndrome AHF-induced d liver congestion (increased BNP) Normal Bile duct compression (increased AP) Bile duct compression (increased AP) and cytolysis (increased transaminases)

38 In case of RVF, «tailored therapy» is recommended d Low BP: NE is needed to improve right coronary perfusion pressure and organ perfusion pressure High PAP: Inhaled NO Low CO/cardioprotection: levosimendan is an option

39 Acute Heart Failure: Global Survey of Standard Treatment The ALARM-HF Study F Follath et al. Intensive Care Med (in press) A Mebazaa Intensive Care Med (in press)

40 All iv inotropes F Follath et al. Intensive Care Med (in press)

41 ty 0.6 Epinephrine In-hos spital mortali Norepinephrine Dopamine Dobutamine Whole cohort 0.1 Diuretics 0.0 Levosimendan Vasodilatators Days A Mebazaa Intensive Care Med (in press)

42 SBP < 100 mmhg SBP mmhg SBP mmhg SBP > 160 mmhg A Mebazaa Intensive Care Med (in press)

43 Does post-discharge treatment influence short- and dlong-term outcome?

44 All-Cause Mortality by Beta-Blocker Use at Baseline and Discharge (n=1000+ patients) 1.0 Prob bability of surviv val Baseline Discharge Yes / Yes No / Yes No / No Yes / No Days since start of study drug infusion

45 Effects of beta-blockers on patients admitted for acute respiratory failure (n=300+ patients) CARDIAC CAUSES NON-CARDIAC CAUSES No/Yes Yes/Yes No/No Yes/Yes No/Yes No/No Yes/No Yes/No Noveanu et al Crit Care 2010

46 In summary In case of low CO in post-operative CPB period: Understand the mechanism (echo, PAC) Give an appropriate treatment Do not forget to give a post-discharge treatment