Weaning failure of cardiovascular origin: how to suspect, detect and treat—a review of the literature

Abstract

Among the multiple causes of weaning failure from mechanical ventilation, cardiovascular dysfunction is increasingly recognized as a quite frequent cause that can be treated successfully. In this review, we summarize the contemporary evidence of the most important clinical and diagnostic aspects of weaning failure of cardiovascular origin with special focus on treatment. Pathophysiological mechanisms are complex and mainly include increase in right and left ventricular preload and afterload and potentially induce myocardial ischemia. Patients at risk include those with preexisting cardiopulmonary disease either known or suspected. Clinically, cardiovascular etiology as a predominant cause or a contributor to weaning failure, though critical for early diagnosis and intervention, may be difficult to be recognized and distinguished from noncardiac causes suggesting the need of high suspicion. A cardiovascular diagnostic workup including bedside echocardiography, lung ultrasound, electrocardiogram and biomarkers of cardiovascular dysfunction or other adjunct techniques and, in selected cases, right heart catheterization and/or coronary angiography, should be obtained to confirm the diagnosis. Official clinical practice guidelines that address treatment of a confirmed weaning-induced cardiovascular dysfunction do not exist. As the etiologies of weaning-induced cardiovascular dysfunction are diverse, principles of management depend on the individual pathophysiological mechanisms, including preload optimization by fluid removal, guided by B-type natriuretic peptide measurement, nitrates administration in excessive afterload and/or myocardial ischemia, contractility improvement in severe systolic dysfunction as well as other rational treatment in specific indications in order to lead to successful weaning from mechanical ventilation.

Impact of the perioperative inotropic support in grown-up congenital heart patients undergoing cardiac surgery: a propensity score adjusted analysis

“…We could not infer any hypothesis about the pathophysiological pathways leading to this beneficial effect based on this retrospective data analysis. Literature contains several reports linking the use of levosimendan to successful weaning from mechanical ventilation, either due to recovery of myocardial dysfunction [42,43] or to recovery of diaphragmatic dysfunction [44][45][46]. We hypothesize that the beneficial effect is partly due to its pharmacological properties, since the concentration of the long-lasting active metabolite OR 1896 remains stable up to 8 days after a 24 h infusion, and enables to overcome the increase in the metabolic demand during ventilation weaning through a residual positive inotropic effect.…”

Postoperative pulmonary edema following vitrectomy in patients with ischemic heart disease and diastolic dysfunction in the post-anesthetic care unit

“…In a clinical setting, the shift from mechanical ventilation to spontaneous breathing may induce cardiac dysfunction and is a potential etiology underlying weaning-induced PE. [ 10 ] Weaning-induced acute hemodynamic effects may have detrimental consequences in patients with cardiovascular disease, particularly in patients with coronary artery disease. These effects may also induce localized myocardial ischemia or unmask areas of pre-existing marginal function.…”

“…[ 9 ] Myocardial ischemia could be the main mechanism of cardiac failure during weaning; effective management of this condition may improve the success of weaning in such cases. [ 10 ] Shifts in intravascular volume, significant operative pain, or withdrawal of anesthesia may contribute to cardiac events during the weaning period. [ 10 ] In the cases presented in this study, perioperative stress along with myocardial ischemia could have contributed to the development of acute PE.…”

“…[ 10 ] Shifts in intravascular volume, significant operative pain, or withdrawal of anesthesia may contribute to cardiac events during the weaning period. [ 10 ] In the cases presented in this study, perioperative stress along with myocardial ischemia could have contributed to the development of acute PE. Furthermore, diastolic dysfunction may aggravate myocardial ischemia in addition to the stress of weaning.…”

ERS International Congress, Madrid, 2019: highlights from the Respiratory Intensive Care Assembly

“…Longer duration of ventilation after the first separation attempt is associated with increased mortality and longer length of ICU stay [27,28]. Weaning is a costly and critical process that comprises numerous hurdles [29][30][31][32], and there is a remarkable lack of standardisation in definitions or evidence-based practices of what should be the best course to take [27,32,34].…”