5/30/2014. Pulmonary Hypertension PULMONARY HYPERTENSION. mean PAP > 25 mmhg at rest. Disclosure: none

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1 Disclosure: Pulmonary Hypertension none James Ramsay MD Medical Director, CV ICU, Moffitt Hospital, UCSF PULMONARY HYPERTENSION mean PAP > 25 mmhg at rest Pulmonary Hypertension and Right Ventricular Dysfunction: Physiology and Perioperative Management Johann Strumpher MBChB, FRCPC, and Eric Jacobsohn, MBChB, MHPE, FRCPC J Cardiothorac Vasc Anesth 25;2011:

McGlothlin et al Prog Cardiovasc Dis 2012 McGlothlin et al Prog Cardiovasc Dis

4 CO Pathophysiology Endothelial dysfunction and vascular remodeling Excess

proliferation Thrombus in situ Vasoconstriction In up to 20% of patients

2 McGlothlin et al Prog Cardiovasc Dis 2012 McGlothlin et al Prog Cardiovasc Dis 2012 * PVR > 3 WU * * TPG = MPAP-LAP * WU (PVR): MPAP LAP normal CO Pathophysiology Endothelial dysfunction and vascular remodeling Excess proliferation over apoptosis Small resistance vessels Inflammation Adventitial proliferation Thrombus in situ Vasoconstriction In up to 20% of patients Excess of constrictors (endothelin, thromboxane, serotonin) over dilators (prostacylins, NO) 2

3 Clinical Presentation of PH/RV failure ECG in Pulmonary Hypertension Dyspnea on exertion/fatigue Chest pain Syncope Palpitations Lower extremity edema Tachypnea Tachycardia Ascites Distended neck veins Strumpher and Jacobsohn 2011 In a monitored setting McLaughlin V et al. JACC 2009;53:1573 High CVP Low CO or surrogate markers (SVO2, lactate) High PAP (may be decreasing with RV failure) Echo evidence of poor RV function/dilatation 3

4 Acute worsening in the clinical setting Chronic disease state leads to slowly rising PAP, progressive RV dilatation and dysfunction Acute disease may cause decompensation Therapy may inadvertently result in decompensation Systemic hypotension from diuretic or medication Fluid overload Metabolic derangement (hypoxia/hypercarbia) Mechanical ventilation Clinical settings of RV dysfunction and failure Severe left sided heart disease Congenital disease with Left to Right shunt Known pulmonary vascular disease Chronic pulmonary disease ARDS and Sepsis Massive/chronic PE Post Cardiac Surgery RV infarction Known right heart disease independent of above PVR and Lung Volume Berne and Levy CV Mosby

The RV vs The LV Crescent shape 49-101 ml/m2 <35 gm/m2 EF 40-68% Elastance 1.

5 The RV vs The LV Crescent shape ml/m2 <35 gm/m2 EF 40-68% Elastance 1.3 mmhg/ml High compliance Ellipsoid shape ml/m2 <130 (M) <100 (F) EF 57-74% Elastance 5.5 mmhg/ml Lower compliance Haddad F, et al Anesth Analg 2009; 108: Haddad F et al; Circulation 2008;117:1717 Tahm et al, JACC 2010; 56:1435 5

6 Assessment of PH and RV Echocardiography Right heart catheterization (ECG, Chest XRAY) Price LC, et al: Crit Care 2010; 14:R169 6

7 Estimating RV/PA systolic pressure Fractional area change (vs EF) for RV Haddad F et al Anesth Analg 2009;108:407 7

8 Myocardial Performance Index (RV) TAPSE Haddad F et al Anesth Analg 2009;108:407 Treatment of RV Failure due to PH Hoeper and Granton Tahm et al, JACC 2010; 56:1435 8

9 Inotropic support for the RV Dobutamine Milrinone Isoproterenol Epinephrine Norepinephrine (Levosimendan) Treatment of systemic hypotension: Catechols vs vasopressin Low dose norepinephrine, epinephrine and vasopressin have little effect on PA pressures Phenylephrine causes dose-related increase PA pressure At high doses all of these drugs increase PA pressure Pulmonary Vascular and Right Ventricular Dysfunction: Systematic Review Price LC, et al: Crit Care 2010; 14:R169 Recommendations: Price LC, et al: Crit Care 2010; 14:R169 STRONG PDE III Inhibitors (ie, milrinone) Pulmonary dilators (ie, prostaglandins, ino) WEAK Monitor volume status Low dose NE and Vasopressin Low dose dobutamine Mechanical rescue therapy 9

venodilator) Intravenous: Epoprostanol Flolan) Milrinone (Isoproterenol) Oral: Sildenafil (PDE 5

10 From: Price, LC et al Crit Care 2010; 14:R169 Pulmonary vasodilators Inhaled: Nitric Oxide (cyclic GMP) Epoprostanol, Iloprost (adenylate cyclase) Milrinone (PDE 3 inhibitor) Nitrates (through NO; mostly venodilator) Intravenous: Epoprostanol Flolan) Milrinone (Isoproterenol) Oral: Sildenafil (PDE 5 inhibitor), others Bosentan (Endothelin receptor antagonist) Pulmonary Dilator Prostanoids Epoprostenol Iloprost Trepoprostinil 10

11 Devices/procedures IABP (RVAD) V-V vs V-A ECMO Atrial septostomy Lung transplantation 11

Pulmonary hypertension and right ventricular failure

Pulmonary hypertension and right ventricular failure Sven-Erik Ricksten Dept. Anaesthesiology and Intensive Care, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg,