Intensive Care Unit Management of Patients with Severe Pulmonary Hypertension and Right Heart Failure

Abstract

Despite advances in medical therapies, pulmonary arterial hypertension (PAH) continues to cause significant morbidity and mortality. Although the right ventricle (RV) can adapt to an increase in afterload, progression of the pulmonary vasculopathy that characterizes PAH causes many patients to develop progressive right ventricular failure. Furthermore, acute right ventricular decompensation may develop from disorders that lead to either an acute increase in cardiac demand, such as sepsis, or to an increase in ventricular afterload, including interruptions in medical therapy, arrhythmia, or pulmonary embolism. The poor reserve of the right ventricle, RV ischemia, and adverse right ventricular influence on left ventricular filling may lead to a global reduction in oxygen delivery and multiorgan failure. There is a paucity of data to guide clinicians caring for acute right heart failure in PAH. Treatment recommendations are frequently based on animal models of acute right heart failure or case series in humans with other causes of pulmonary hypertension. Successful treatment often requires that invasive hemodynamics be used to monitor the effect of strategies that are based primarily on biological plausibility. Herein we have developed an approach based on the current understanding of RV failure in PAH and have attempted to develop a treatment paradigm based on physiological principles and available evidence.

2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension

“…The basic principles of ICU management of patients with PH and RV failure include the treatment of triggering factors (such as anaemia, arrhythmias, infections or other co-morbidities), optimization of fluid balance (usually with i.v. diuretics), reduction of RV afterload (usually with parenteral prostacyclin analogues, but sometimes also with other PAH drugs), improvement of CO with inotropes (with dobutamine being the preferred inotrope to treat RV failure) and maintenance of systemic blood pressure with vasopressors, if necessary [258][259][260]. Intubation should be avoided in patients with RV failure, as it frequently results in haemodynamic collapse.…”

Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey

“…More recently, PRICE et al [10] reported on another retrospective series of 28 patients (20 PAH and eight chronic thromboembolic PH) undergoing noncardiothoracic nonobstetric surgery between 2000 and 2007, with a mortality rate of 7%. It is possible that with contemporary PAH treatment [6,11], modern anaesthesia [4,7,12,13] and modern intensive care management [14,15], surgery may be associated with better outcomes in this patient population [16].…”

Advanced pulmonary arterial hypertension: mechanical support and lung transplantation

“…These procedures are described in more detail below. In patients with end-stage PAH for whom all available treatment options have been exhausted, palliative care should be considered [35]. Current or a history of non-compliance to medical therapy Psychiatric or psychological conditions associated with inability to adhere to medical therapy Substance abuse or dependence Absence of an adequate or reliable social support system Severely limited functional status with poor rehabilitation potential # : unless combined organ transplantation can be performed, except in the case of chronic renal impairment due to venous congestion which is often reversible following lung transplantation [15].…”