Summary by Erik Manninen, MD
*Pulmonary hypertension is found in the majority of patients with ARDS or COPD
*pulmonary edema, ARDS, hypoxemia, and acidemia can worsen pulmonary HTN
*intubation and high mean airway pressures can cause significant RV strain
*LV is designed to overcome arterial HTN, but the RV is designed to work efficiently against a low resistance system and can fail with acute elevations in pulmonary artery pressure
*RV overload can impede LV performance if shifting of the septum occurs and impedes LV filing as the pericardium is a closed space
*D-sign is a sign of pressure overload with the interventricular septum moving into the LV in diastole
*Because the RCA has a lower vascular density compared to the LCA, RV stretch can disproportionately increase RV oxygen demand, causing RV ischemia. RV ischemia worsens RV failure, causing further dilatation, propagating a vicious cycle.
*In tachydysrhythmias like atrial fibrillation, the ability of early rhythm control to restore atrial kick may be more beneficial than rate control
*using TTE to measure TAPSE is a great screening test for RV failure:
1-1.6cm = mild-moderate RV dysfunction
<1cm = severe RV dysfunction
*pulmonary artery catheters may assist in managing RV failure
*CVP trend may be helpful with CVP >10-14 likely needing unloading
*pulse-pressure variation is present with RV failure, but more fluids is not the answer
*inhaled epoprostenol can reduce PVR, as will correcting hypoxemia and acidemia
*early paralysis can lower pulmonary artery pressures and assist with vent dyssynchrony
*targeting a higher MAP to increase diastolic pressure may help improve coronary perfusion pressure
*milrinone, epinephrine, or dobutamine may help CO and lower CVP, thereby improving coronary perfusion pressure, but beware of hypotension with dobutamine and milrinone, which may decrease coronary perfusion pressure
- Cecconi M, et al. Intensive Care Med. 2014; 40:1795-815
- Chin KM, et al. Coron Artery Dis. 2005; 16:13-8
- Green EM, et al. Curr Heart Failure Rep. 2012; 9:228-35
