8 Feb 2017

Scheffler Right Heart

Threat: acute perioperative RV failure.

Good: maintain homeostasis

Bad pHTN resembles AoS

Leading cause: LV ischemic failure.

Echo: best screening
Right heart cath: gold standard diagnosis
Normal PAP: 25/10. pHTN: mean >25. PASP >70 = severe. (all numbers at rest)
3x normal PVR: normal = 80, pHTN = 240 dyne
transpulmonary gradient: …

old patient on ortho list with pHTN due to LV problems: don’t be afraid, they got old for a
reason- they are compensated.
Usually on dig / Lasix, not specific pHTN drugs.

Patients with primary PAH: rarer, underdiagnosed, usually on specific Rx.

Sx
Dyspnea
Edema
Syncope
Angina
Cough
Hemoptysis
Hematosplenomegaly
Worst sx: rest dyspnea, rest angina, hypoxemia (cyanosis), syncope.

PE
Jug distension
Lung crackles
Periph edema
RV heave
S3, S4
Fixed split S2
Loud P2
TR murmur
Labs / Ix
Clinical assessment:
6 min walk
Borg dyspnea scale

EKG: RVH, ischemic changes, RBBB, RAD, p-pulmonale (esp if COPD)

CXR: cardiomegaly, prominent PAs
pulm edema, esp if MS

ABG: hypoxemia, low CO2 (hyperventilating). IF severe: metabolic acidosis.

EC
Echo: TR, PR, elevated Right pressures.
Cath:

Medical Therapy:
CCB
Dig
Diuretic
Warfarin. [need to bridge] LMWH. PE very deadly.

Specific therapy: usually for Group 1 / PAH patients.

Prostaglandin gtt or inhaled (neb).
Sildenafil
ERB (bocentin)

General approach:
Identify pHTN patients.
Specific therapy must be continued.
Assess / discuss risk.
Monitor patients well.

Surgical Rx PAH: double lung Tx.

RV Facts:
RV has 1/6 muscle mass vs. LV
Response to increased afterload = dilation. Bad.
RV coronary perfusion is pressure dependent during diastole and systole.
RV does not like bradycardia. Different vs. AoS. Mechanism uncertain / poorly discussed.
Cavity dilation increases afterload regardless of PVR / SVR. Physics of cavity dimension vs. wall
stress.
Chronic Dilation = hypertrophy - > pressure overload.

Anesthetic Drugs and pHTN:

OK:
Ketamine: increases PVR with spon vent, NOT controlled vent. Good for pHTN
Fenta / sufenta: no effect
Propofol, midaz, etomidate: no effect.

Propably bad:
N20: increase PVR in adults, not children under anesthesia.
Thiopental: increased PVR.

What matters: don’t stop ventilating patients. BMV very important before ETT at induction.
Don’t let this happen: hypoxia-hypercarbia-acidosis-elevated PVR + drop in SVR from anesthesia
drugs. CPP down, PVR up, RV fails.
RV fails- LV worse due to interventricular dependence-RV perfusion drops- viscious cycle.

Volatiles: good. HPV blunting can be helpful. Preconditioning is helpful.

Nitric oxide: subtle effects.

Helpful: Norepi. CPP up much more important than detriment of small increase in PVR.
Dobutamine, vasopressin, Milrinone.

RV response to inotropy is limited. CPP up and PVR down is mainstay.

NTG: can dilate PVR. But SVR drop will need to be compensated for.

Dyspnea / hypoxemia in clinic:

ABG & TTE helpful; can be done in clinic.

Risk Stratification:

30 day mortality post-op if PASP>68 is 7%

RV performance predicts mortality.

Complications worse with 1) duration of anesthetic 2) extent of OR.

Invasiveness predicts morbidity.
Swan: no evidence to benefit. Can be considered. Caution with PA rupture / arrhythmia risk.
RV failure watch for:
1. Watch baseline.
2. PA pressure rise
3. PA pressure then dropping
4. CVP rising.

TEE: likely more helpful and less risk than Swan.

RV failure Watch for:
1. septal flattening / bowing,
2. decreased TV excursion (TAPSE),
3. free wall contractility.
4. RV dilation
5. paradoxical movement (RV strain, or pacing, or RBBB)

Start case:
Drugs ready: Norepi, Vasopressin, Epi on triple pump.
If sick:
1. norepi infusion pre-induction 10-50mcg/min titrate to visible BP rise (via solid PIV or
CVC)
2. Then consider HD addressed, focus on ventilation.

If evidence of RV failure, must ACT:

Optimize ventilation
Start drugs
Norepi bolus + infusion
Milrinone bolus 0.5mcg / kg +/- gtt.

Cases:

pHTN and Pregnancy:

Contraindicated.
Counsel on termination.
PVR will rise with increase in CO / increased plasma volume.
Will push into RV failure.

If carrying pregnancy:
CSx ICU
Both acceptable:
i. Epidural + Aline / CVC
ii. GA with Aline / CVC / TEE / full control of ventilation, hemodynamics,
metabolic parameters.
PE
Massive vs submassive: SBP < 90mmHg.
Full term fetal demise:
Heparin bolus, infusion
Dopamine
Thrombolysis.

4 hours post partum:

risk of bleeding with thrombolysis
consider surgical embolectomy (much more successful if done on-pump)

TTE for PE:

Massive RV dilation
McConnell sign: free wall hypokinesia with normal RV apex motion.
60/60 sign

Patient with sub-massive PE for pilon fracture ORIF:

Heparinize
HD stable
Compression ultrasound of entire leg veins to rule out residual clot burden
Take to OR. (vs wait more weeks with ex-fix at peril of ankle)
Intra op Plan in case of HD instability:
TEE probe in to confirm dx
tourniquet to protect operative site
Thrombolysis ready to give in OR.