Low cardiac output due to acute right ventricular dysfunction in congenital heart disease
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Approach to right ventricular dysfunction in the immediate surgical period of patients with congenital heart disease.
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Low cardiac output due to acute right ventricular dysfunction in congenital heart disease
- 1. Bajo gasto cardíaco por disfunción ventricular derecha aguda en cardiopatía congénita Dr. Ricardo Poveda Jaramillo Fellow Anestesia Cardiovascular Universidad CES
- 3. Introducción Muchas cardiopatías congénitas se caracterizan por anomalías primarias de la estructura y función ventricular derecha, y mientras que la cirugía "correctiva" a menudo restaura el corazón a un circuito biventricular funcionalmente "normal", la hemodinámica ventricular derecha está a menudo lejos de lo normal. Redington AN. Low cardiac output due to acute right ventricular dysfunction and cardiopulmonary interactions in congenital heart disease (2013 Grover Conference series). Pulm Circ. 2014 Jun;4(2):191-9.
- 7. Redington AN, Rigby ML, Shinebourne EA, Oldershaw PJ. Changes in the pressure-volume relation of the right ventricle when its loading conditions are modified. Br Heart J 1990;63(1):45–49.
- 8. Redington AN, Rigby ML, Shinebourne EA, Oldershaw PJ. Changes in the pressure-volume relation of the right ventricle when its loading conditions are modified. Br Heart J 1990;63(1):45–49.
- 9. Redington AN, Rigby ML, Shinebourne EA, Oldershaw PJ. Changes in the pressure-volume relation of the right ventricle when its loading conditions are modified. Br Heart J 1990;63(1):45–49.
- 10. Redington AN, Rigby ML, Shinebourne EA, Oldershaw PJ. Changes in the pressure-volume relation of the right ventricle when its loading conditions are modified. Br Heart J 1990;63(1):45–49.
- 11. Interacciones derecha-izquierda “Neither the LV nor the RV can or should be considered as an isolated unit, because they function as an integrated system”. Redington AN. Low cardiac output due to acute right ventricular dysfunction and cardiopulmonary interactions in congenital heart disease (2013 Grover Conference series). Pulm Circ. 2014 Jun;4(2):191-9.
- 12. Damiano et all: Significant left ventricular contribution to right ventricular systolic function
- 13. Hay pruebas convincentes que la fuerza contráctil del ventrículo izquierdo contribuye a la función sistólica ventricular derecha de manera fundamental. Los autores concluyeron que aproximadamente el 40% del trabajo mecánico realizado por el RV es el resultado del acortamiento ventricular izquierdo. Damiano RJ Jr, La Follette P Jr, Cox JL, Lowe JE, Santamore WP. Significant left ventricular contribution to right ventricular systolic function. Am J Physiol Heart Circ Physiol 1991;261(5):H1514–H1524.
- 16. Ecocardiograma transesófagico que muestra un cambio en la posición septal durante la oclusión de RCA con pericardio intacto. Carl Brookes et al. Circulation. 1999;100:761-767
- 17. Cambio en la línea de base del gasto cardíaco (CO) en respuesta a la isquemia RCA. Carl Brookes et al. Circulation. 1999;100:761-767
- 18. Cambios en ESP y EDV en respuesta a la isquemia RCA. Carl Brookes et al. Circulation. 1999;100:761-767
- 19. Cambio en las pendientes de la PRSW y ESPVR desde la línea de base en respuesta a la isquemia RCA Carl Brookes et al. Circulation. 1999;100:761-767
- 21. Ciclos de presión-volumen del VI durante la oclusión de IVC antes y después de la oclusión de la RCA Carl Brookes et al. Circulation. 1999;100:761-767
- 22. Brookes C, Ravn H, White P, Moeldrup U, Oldershaw P, Redington A. Acute right ventricular dilatation in response to ischemia significantly impairs left ventricular systolic performance. Circulation 1999;100(7):761–767.
- 23. Manifestaciones de disfunción sistólica "aislada” del ventrículo derecho Dilatación del VD Reducción de la fracción de eyección del VD Hipertensión pulmonar Redington AN. Low cardiac output due to acute right ventricular dysfunction and cardiopulmonary interactions in congenital heart disease (2013 Grover Conference series). Pulm Circ. 2014 Jun;4(2):191-9
- 24. Tratamiento
- 26. El principio Dado que la RV es tan dependiente de una baja postcarga para una función óptima, debe hacerse todos los esfuerzos para minimizar la postcarga. Pero…la función contráctil ventricular derecha es parcialmente dependiente de la contractilidad del ventrículo izquierdo
- 27. …entonces: Redington AN. Low cardiac output due to acute right ventricular dysfunction and cardiopulmonary interactions in congenital heart disease (2013 Grover Conference series). Pulm Circ. 2014 Jun;4(2):191-9.
- 28. Efecto Anrep El efecto Anrep es un método de autorregulación en el que la contractilidad miocárdica aumenta con la poscarga. Se determinó experimentalmente que el aumento de la postcarga causa un aumento proporcionalmente lineal de la inotropía ventricular.
- 30. Cambios hemodinámicos y dimensionales observados después de poner una banda en la arteria pulmonar y aórtica Israel Belenkie et al. Circulation. 1995;92:546-554
- 31. Israel Belenkie et al. Circulation. 1995;92:546-554
- 32. Gráficos presión-longitud y presión-diámetro después de constreñir la arteria pulmonar y la aorta. Israel Belenkie et al. Circulation. 1995;92:546-554
- 33. Gráficos de presión transeptal-diámetro después de constreñir la arteria pulmonar y la aorta. Israel Belenkie et al. Circulation. 1995;92:546-554
- 34. Belenkie I, Horne SG, Dani R, Smith ER, Tyberg JV. Effects of aortic constriction during experimental acute right ventricular pressure loading: further insights into diastolic and systolic ventricular interaction. Circulation 1995;92:546–554
- 35. La respuesta
- 36. La diástole
- 39. Estrategias ① Mantener ritmo sinusal ② Bajar resistencias pulmonares ③ Administración de líquidos ④Creación de un foramen ovale permanentemente abierto
- 43. …entonces surge la hipótesis: Si la reducción del gasto cardíaco asociada con aumento de la presión media de las vías respiratorias es sólo un fenómeno de precarga, restaurar la precarga debe restaurar el gasto cardíaco. Henning RJ. Effects of positive end-expiratory pressure on the right ventricle. J Appl Physiol 1986;61(3):819–826.
- 44. El resultado Restaurar el volumen de fin de diástole a los niveles basales no restauró el gasto cardíaco a los niveles basales. Henning RJ. Effects of positive end-expiratory pressure on the right ventricle. J Appl Physiol 1986;61(3):819–826.
- 45. • Shekerdemian LS, Bush A, Lincoln C, Shore DF, Petros AJ, Redington AN. Cardiopulmonary interactions in healthy children and children after simple cardiac surgery: the effects of positive and negative pressure ventilation. Heart 1997;78(6):587–593. • Shekerdemian LS, Bush A, Shore DF, Lincoln C, Redington AN. Cardiorespiratory responses to negative pressure ventilation after tetralogy of Fallot repair: a hemodynamic tool for patients with a low-output state. J Am Coll Cardiol 1999;33(2):549–555.
- 50. Estrategias ① Bajar la presión media de la vía aérea ② Reducir PEEP ③ Disminuir el tiempo inspiratorio ④ Reducir al mínimo los tiempos de meseta
- 51. Gracias
Notas del editor
- Se está reconociendo cada vez más que la disfunción ventricular derecha desempeña un papel crucial en muchas enfermedades cardiovasculares.
- Many of the fundamental properties of the ventricle can be assessed from a simple Wiggers diagram.
- The hangout period: a delay between the onset of right ventricular pressure decline and pulmonary valve closure.
- In the chronically pressure-loaded RV, we have shown that the loops assume a “left ventricular” pattern Figure I A normal right ventricular pressure-volume diagram illustrating ejection during pressure development and decline. Figure 3 Right ventricular pressure-volume diagram from a patient with pulmonary stenosis. There are well-defined periods of isovolumic contraction and relaxation. Figure 2 Right ventricular pressure-volume diagram taken from a patient with tetralogy of Fallot. Ejection was occurring during pressure development but not during pressure decline. Maximum work and effective work are measured in mm Hg x ml
- In the chronically pressure-loaded RV, we have shown that the loops assume a “left ventricular” pattern Figure I A normal right ventricular pressure-volume diagram illustrating ejection during pressure development and decline. Figure 3 Right ventricular pressure-volume diagram from a patient with pulmonary stenosis. There are well-defined periods of isovolumic contraction and relaxation. Figure 2 Right ventricular pressure-volume diagram taken from a patient with tetralogy of Fallot. Ejection was occurring during pressure development but not during pressure decline. Maximum work and effective work are measured in mm Hg x ml
- - Figure 5 Right ventricular pressure-volume diagram from a patient with a large atrial septal defect. Ventricular volumes were increased but the overall shape of the loop was similar to that of the normal right ventricle - Figure 6 Right ventricular pressure-volume diagram from a patient after repair of tetralogy of Fallot. Ejection was occurring during pressure development and decline. - Figure 7 Left ventricular pressure-volume diagram obtained after Mustard repair of transposition of the great arteries. The left ventricle (ejecting into the pulmonary circulation had similar pressure-volume characteristics to the normal right ventricle
- Transesophageal echocardiogram showing change in septal position during RCA occlusion with intact pericardium.
- Change in cardiac output (CO) from baseline in response to RCA ischemia.
- Changes in ESP and EDV from baseline in response to RCA ischemia.
- Change in slopes of the PRSW and ESPVR from baseline in response to RCA ischemia. End-systolic pressure volume relationship (ESPVR), Preload recruitable stroke work (PRSW)
- Change in slopes of the PRSW and ESPVR from baseline in response to RCA ischemia. End-systolic pressure volume relationship (ESPVR), Preload recruitable stroke work (PRSW)
- Example of LV pressure-volume cycles during IVC occlusion before and after occlusion of the pRCA.
- Con catéteres de conductancia biventricular utilizados para evaluar los cambios instantáneos en el ventrículo derecho e izquierdo
- Dilatación y reducción de la fracción de eyección del VD es una manifestación común de la cardiopatía congénita en fase terminal, y la disfunción ventricular derecha en ausencia de hipertensión pulmonar es relativamente inusual.
- Left ventricular Anrep effect (increasing myocardial contractility in response to increased afterload), a phenomenon discovered by Gleb von Anrep in 1912 (Russian physiologist)
- We instrumented nine dogs with ultrasonic dimension crystals to measure RV segment length, septum–to–RV free wall and septum–to–LV free wall diameters, and LV antero-posterior diameter
- Plots of hemodynamic and dimension changes observed during interventions. Values are mean±SEM and are normalized to percent, 100% being the control value. SV indicates stroke volume; SWalv, left ventricular area stroke work; TSG, transseptal pressure gradient; ED, end diastole; Drv, septal position; SWlrv, right ventricular segment length stroke work; CONT, control; ISCH, ischemia; PAC, pulmonary artery constriction; AOC, aortic constriction; and ↑Q, increased coronary flow. *P<.05 vs immediately before intervention.
- End-diastolic cross-sectional echocardiographic views showing changes in left ventricular (LV) size and shape during control, during severe pulmonary artery (PA) constriction, when LV size was reduced with septal flattening, and during pulmonary constriction and aortic constriction, when LV size was increased and septal shape was similar to that observed during control. RV indicates right ventricle.
- Graphs of right ventricular (RV) pressure–segment length and pressure-diameter loops during severe pulmonary artery (PA) and aortic constriction. A, RV pressure–segment length relations during control, severe PA constriction, and when aortic constriction was added. PA constriction shifted the loop to the right and upward, but the loop was still positive, which suggests that ischemia is not an important factor. Aortic constriction caused further changes in the loop, reflecting an increase in RV pressure, but also reduced systolic segment length shortening. B, Respective changes in the RV pressure–RV diameter loops. PA constriction caused a rightward shift in the loop and a negative loop. These changes were reversed by aortic constriction. A positive loop during aortic constriction was observed in the seven animals in which the control loop was normal. Prv indicates RV pressure; Lrv, RV segment length; Dsrvfw, septum–to–RV free wall diameter; ED, end diastole; PAC, PA constriction; and AOC, aortic constriction.
- Graphs of transseptal pressure gradient (TSG)–diameter relations during control and severe pulmonary artery (PA) constriction plus aortic constriction. During severe PA constriction, the TSG was close to 0 mm Hg throughout the cardiac cycle. Positive loops with respect to the right ventricular (RV) diameter and septal position were reestablished during aortic constriction; positive loops were present in the seven animals with normal control loops. DRV indicates septum–to–RV free wall diameter/septum–to–RV free wall plus left ventricular free wall diameters. See Fig 5 for other abbreviations.
- - If the impedance to right ventricular filling is greater than the impedance to flow provided by the pulmonary vascular bed, then such transtricuspid flow is translated through the ventricle into the pulmonary artery (the RV acting as a “conduit” at end diastole). - The presence of antegrade diastolic flow in the pulmonary artery in late diastole can be a useful marker, albeit qualitative, of abnormal right ventricular compliance.
- Debido a la naturaleza altamente adaptable de la aurícula derecha, cambios en la presión intratorácica se reflejan fácilmente como cambios en la presión de la aurícula derecha André Cournand demostró que un aumento relativamente modesto de la presión media de las vías aéreas (5-10 cm de agua) impuesto por la ventilación con mascarilla, reducía el gasto cardíaco 10% -15% en estudiantes de medicina voluntarios