[HSF] RV failure management strategies

Tea Acuff tacuff at swbell.net
Fri Dec 1 13:49:20 EST 2006 

I presume by morale that you mean conclusion. If so, then the morale is exactly the same that should be drawn if the patient survived for this series of one. That is, none. However, this experience raises a lot of potential questions. Would a short periods of RV "flow replacement" help patients with normal preop PA pressures and acute intaop RV failure of whatever cause. Is lethal arrythmia related to ventricular distention more than poor hemodynamics? Do those that place devices notice a decrease in VT and VF despite the retained presence of the electrophysiologists three ring circus that is declared the "cause" of such rhythms? Is volume reduction a more appropiate therapy than a rhythm box for some ischemically dilated ventricles? Should rescued ventricles have a longer stay in the ICU? etc
Tea 
ps Sorry for your and your patient's loss, Prasanna. Although we seldom get autopsies any more, as you may or may not know, autopsy means literally "see for oneself". So the discussion to see what happened probably makes us more physicans and less surgeons in the old sense of the monikers. Physicians discussed, and surgeons "autopsied"(or physically touched for that matter). Maybe we should rename autopsy, "pathopsy", since we rarely do "see". With HIPPA, third party imaging, standardization of H and P to fit billing, and discipline protocols and we are virtually back to John Hunter's Georgian days of medicine in "merry ol' England." Ironic how despite the drastic changes in our tools and knowledge and even outcomes, we tend to reorganize ourselves in the same limited ways.


----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, November 30, 2006 11:00:55 PM
Subject: Re: [HSF] RV failure management strategies


mmm...and the morale of the story????
  ----- Original Message ----- 
  From: Edward Bender<mailto:ebender001 at charter.net> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Thursday, November 30, 2006 11:11 PM
  Subject: Re: [HSF] RV failure management strategies


  I used the Amed pump for RV failure in a similar situation.  After 8  
  hours of RV support, everything improved, the pump was explanted, the  
  patient was transferred out of the ICU the next day and subsequently  
  went into V-fib and died.

  Ed Bender, MD


  On Nov 30, 2006, at 9:24 PM, Tea Acuff wrote:

  > It seems to me that proper treatment of RV failure likely depends  
  > on its etiology and is largely unrelated to RV effects itself. I am  
  > of the belief that acute ischemic RV failure is a contradiction for  
  > almost any indication of LV revascularization. The treatment is  
  > volume to the LV which is in turn deadly to the ischemic LV. I used  
  > the Amed device, which unfortunately got pushed into the Embolex  
  > venture for economic and ultimately fatal device reasons, for about  
  > 50 OPCABs and was impressed in its small size and 50-60cc internal  
  > volume in supporting CO in the contorted RV even when the LV was  
  > not working. RVs unlike LVs do seem to have the capacity to recover  
  > if LV filling can be maintained in the ischemic/ failing R  
  > ventricle. Fontan physiology seems to suggest the same argument. I  
  > don't know if models of primary RV failure exist as isolated RV and  
  > even RV valvular problems are rare. Almost all surgical treatments  
  > of the LV temporarily worsen the resistance to flow faced by
  >  the RV except if the LV can be markedly improved. In other words I  
  > think the question itself is largely misstated. Kind of like asking  
  > how can one get better pacing when the patients is in  
  > electromechanical dissociation (to use old descriptives.)
  > This kind of BS reasoning is one looking for counter arguments (and  
  > better understanding).
  > Tea
  >
  >
  > ----- Original Message ----
  > From: prasannasimha <prasannasimha at gmail.com<mailto:prasannasimha at gmail.com>>
  > To: "OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>" <OpenHeart- 
  > L at lists.hsforum.com<mailto:L at lists.hsforum.com>>; ccm <ccm-l at ccm-l.org<mailto:ccm-l at ccm-l.org>>
  > Sent: Thursday, November 30, 2006 8:40:26 PM
  > Subject: [HSF] RV failure management strategies
  >
  >
  > 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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