[HSF] RV failure management strategies

Fri Dec 1 20:13:21 EST 2006

Michael,
She was a case of severe calcific MS with LA clot severe TR with pretty 
bad RV function. She was on inotropes prior to surgery and was in low 
output. She had a TIA and so was taken semi-emergently. She could not 
lie down and was urgently intubated and required  rapid institution of 
CPB. Surgery was pretty uneventful (No clot was seen in the LA and I 
presume it had embolized during the TIA) and the heart was contracting 
well as long as not loaded. While loading  The situation was good LV 
contractility, RV poor EF (on Echo) . Low LAP and high transpulmonary 
gradient. We initially managed by giving pulmonary vasodilators etc and 
had to give systemic vasoconstrictors to maintain the SVR which was low 
Tried to use iNO - did not help . We could wean off CPB and she was 
pretty coagulopathic and after the usual burn and stitch for a couple of 
hours (ill advisedly) closed her and had to immediately open her due to 
tamponade due to a clot over the PA. Kept the chest open.
At present she is still on multiple inotropes. CI is wavering between 
2.4- 3.0. Bleeding seems to have stopped . I had opened up everything 
and washed the pericardium and sutured a plastic sheet back.
No evidence of sepsis.
I also like to "run em dry" and actually the patient is passing good 
urine and I have a PD catheter with mini-cycling to reduce edema.though 
she requires a CVP of around 12-14 to maintain hemodynamics. Her creat 
is pretty normal and her only abnormal parameter  are her platelets and 
bilirubn which is marginally high (probably going to keep rizing further!!)
I usually do not paralyze all open chests and keep them on Morphine and 
Ketamine infusions which usually deeply anesthetises them without the 
need to paralyze them. I have seen this been done with pediatric 
patients and they argue that "micromovements" is actually good in 
mobilizing tissue  edema by lymphatics.
(Patients actually do not move around when on the infusion but have 
preserved muscular tone if you get what I mean) though I do give them a 
relaxant if they breath spontaneously and this causes incoordination 
which they rarely do. One of my residents had lowered the drug infusion 
temporarily to see the CNS status !! That is how I know she was "awakable"
Did give her a shot of Methypred but no use.
RVAD in her is impractical for "practical" reasons. I have an IABP in 
place. I cannot do a bail out Glenn because her PVR is high.
At present following a wait and watch till edema comes down .
Prasanna

Michael Firstenberg wrote:
> Something does not quiet sound right with his hemodynamics - and maybe 
> I need to think about this more and look at the actual numbers.
> But, if your RV is failing - which it sounds like it is, then you 
> would have low preload delivered to the left heart and this should 
> (please all corrected me if I am wrong) result in a higher SVR as a 
> systemic compensatory measure.
>
> Coming into this a little late (missed some of the other comments)
> 1) Is your patient septic - and maybe the overall cardiac function can 
> not keep up enough
>     there may be a little zosyo-penia or the vanco receptors may not 
> be adequately saturated.
> 2) What is the renal function?
>     From what you are describing, probably poor - are you on CVVH yet?
>     If not - I am a firm believer of the voodoo of dialysis of "evil 
> humors"
>     If this is truly right heart failure - maybe getting volume off 
> acutely (even on tons of drugs) may bring you to a more favorable part 
> of the Starling curve
>     I have a little experience with acute ultra-filtration  (even with 
> "marginal urine output") is sucking some of these people dry which works!
>        May cause ARF (which should improve with time?) - but your 
> current path will most likely knock out the beans forever
>        (better to have a live patient on dialysis than a potential 
> kidney donor?)
> 3) You said "open chest" and patient actually woke up.
>      Is it correct to assume that he/she is pharm. paralyized?
>     I have also seen more than a few patients with "lap-pad" 
> tamponade.  Even though the chest is open, there are too many or a few 
> stratigically placed pads (particularly if they are placed for 
> bleeding) than compress the RV.
> 4) Fixed-dilated pupils?
>     Hmmm - no idea, but it aint over til its over
>    I am sure we have all seen comatose patients wake up quite contrary 
> to the Glascow data (which I am sure have a reprint somewhere knowing 
> you - read: compliment)
> 5) Acute adrenal insuff.  ->  when in doubt, steroids
>     I had a medical school professor who said that no one should die 
> without the benefits of steroids.
>
> There seems to be a lot going on with your very sick patient and I 
> tossed out a few "kitchen" sink ideas.
>      yes, a RVAD/Ecmo may help - but does not solve all of your problem
>     though with an open chest an RA-RV circuit with stuff you have 
> around may be enough.
>
> I have seen a few recent "mazes" in otherwise healthy hearts have 
> similar problems - not sure what to make of it - anyone else?
>
>
>
> Good luck - keep us up to date
>
>
> -michael
>
>
>
> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
>
>> Can the list members enumerate their management strategies for RV 
>> failure.
>> This is for two reasons. _ one for th3e Wiki and presently
>> I have  a patient who was in low output  and taken for a semi 
>> emergency MVR with maze with TV plasty. Patient had RV dysfunction 
>> and congestive hepatopathy. Had a difficult wean - LV good but RV 
>> function was pretty poor. Patient is in coagulopathy which seems to 
>> have decreased .No mechanical problem on epicardial echo.
>> Patient has an open chest and has adequate CI (PA cath with CCO) has 
>> a high PVR and low SVR and is requiring multiple inotropes (Dopa = 
>> Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one hand and 
>> multiple vasodilators on the other (getting constrictors via the 
>> central lumen of the IABP and dilators via the PA catheter) . I put 
>> the IABP as the patient has OK CI but low pressures due to a 
>> vasoplegic state and was worried that the coronary flow may not be 
>> adequate creating a vicious spiral 9and is helping in maintaining 
>> pressures).
>> Funny thing is patient has bilateral dilated and fixed pupils but has 
>> actually woken up once !! (On an infusion of morphine + Ketamine)
>> Prasanna
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