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Right Ventricular Failure
56 Plays2 years ago
There is increased recognition of the right ventricle's pivotal role in health and disease. In this episode, we will discuss Right Ventricular Failure in the context of critical illness. Our guest is Dr. Ryan Tedford, a practicing cardiologist focusing on heart failure. Dr. Tedford is the Dr. Peter C. Gaze Endowed Chair in Heart Failure. He is a Professor of Medicine and Cardiology, Section Chief for Heart Failure, Medical Director of Cardiac Transplantation, and Director of the Advanced Heart Failure & Transplant Fellowship Training Program at the Medical University of South Carolina.
Additional Resources
Right Ventricular Failure. Houston B, Britain EL, and Tedford R. N Engl J of Med 2023: https://pubmed.ncbi.nlm.nih.gov/36947468/
Diuretic versus placebo in intermediate-risk acute pulmonary embolism: a randomized clinical trial. Lim P, et al. Eur Heart J Acute Cardiovasc Care 2022: https://pubmed.ncbi.nlm.nih.gov/34632490/
Multimodality Imaging of Right Heart Function. Hahn R, et al. JACC 2023: https://pubmed.ncbi.nlm.nih.gov/37164529/
Ventricular dilation is associated with improved cardiovascular performance and survival in sepsis. Zanotti, s et al. CHEST 2010: https://pubmed.ncbi.nlm.nih.gov/20651022/
Link to recent podcast on Acute Pulmonary Embolism: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1463000353
Books Mentioned in this Episode:
The Right Ventricle in Health and Disease. N Voelkel and D Schranz, Editors: https://bit.ly/436iROd
The Code Breaker: Jennifer Doudna, Gene Editing, and the Future of the Human Race. By W Isaacson: https://bit.ly/3IDUL5a
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Transcript
Introduction to the Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now, your host, Dr. Sergio Zanotti.
Understanding Right Ventricular Failure
00:00:32
Speaker
In today's episode of the podcast, we will discuss right ventricular failure.
00:00:37
Speaker
Right ventricular failure is a frequent occurrence in critically ill patients, and in many circumstances, it is underdiagnosed and mismanaged.
00:00:45
Speaker
Our guest is Dr. Ryan Tedford, a practicing cardiologist with a focus on heart failure.
00:00:49
Speaker
Dr. Tedford is Dr. Peter C. Gaze Endowed Chair in Heart Failure, a professor of medicine and cardiology.
00:00:56
Speaker
He's the section chief for heart failure, medical director of cardiac transplantation, and director of the Advanced Heart Failure and Transplant Fellowship Training Program at the Medical University of South Carolina.
00:01:07
Speaker
He's a recognized expert in the topic.
00:01:09
Speaker
It is a true honor and pleasure to have him today as our guest.
00:01:13
Speaker
Ryan, welcome to Critical Matters.
00:01:16
Speaker
Sergio, thank you very much for having me.
00:01:17
Speaker
Look forward to the discussion today.
Historical Perspective on Right Ventricular Research
00:01:19
Speaker
Well, it seems that the left ventricle gets a lot of attention all the time, and somehow the right ventricle is a little bit forgotten in the mind of many clinicians.
00:01:29
Speaker
So I thought this would be a great topic for our audience to hear from you and maybe explore right ventricular failure within the context of acute illness in the ICU.
00:01:41
Speaker
For sure.
00:01:41
Speaker
Yeah, the right ventricle has only recently gotten its due, so I look forward to any time I can talk about my favorite ventricle.
00:01:49
Speaker
Awesome.
00:01:50
Speaker
So maybe we can start with a little bit of a historical context.
00:01:53
Speaker
Just tell us, I mean, how initially a lot of people really disregarded the right ventricle's importance, and then why do you think today we should be paying attention to the right ventricle as critical care clinicians?
00:02:07
Speaker
Yeah.
Importance of the Right Ventricle in Various Diseases
00:02:08
Speaker
Sure.
00:02:08
Speaker
Well, you know, some of this goes back to early animal studies.
00:02:13
Speaker
One that I talk about in our recent review in the New England Journal was done by Isaac Starr, where they essentially ablated the right ventricle.
00:02:20
Speaker
And when they saw that there was not much change in pressures or cardiac output, you know, they really concluded that the right ventricle was less and less important.
00:02:31
Speaker
And then on top of that, we have the development of Fontance, which have been lifesaving therapies.
00:02:37
Speaker
And
00:02:38
Speaker
You know, it showed that people could live without a right ventricle.
00:02:41
Speaker
Yet, you know, what was missing there is that these folks did not have normal functional capacity.
00:02:47
Speaker
And those individuals do okay until the other ventricle starts to fail, and then they get into real trouble.
00:02:53
Speaker
And so, you know, I think because of observations like that, the right ventricle has been less well studied.
00:03:00
Speaker
But now we know that it is a critical determinative outcome in many different ways.
00:03:07
Speaker
diseases, not just pulmonary arterial hypertension, but certainly left heart failure and even COVID-19.
00:03:14
Speaker
So it really now is getting its due.
Clinical Significance of Right Ventricular Failure
00:03:20
Speaker
And in terms of acute critical illness, you did mention COVID-19.
00:03:25
Speaker
You mentioned, obviously, left heart failure, which is the most common cause of right ventricular failure.
00:03:31
Speaker
But there's also, I mean, a growing recognition that isolated or predominant right heart failure in different situations also has significant clinical implications.
00:03:42
Speaker
Why do you think it's so important for us as critical care clinicians to pay more attention to this today?
00:03:48
Speaker
Well, I think it's for the reason that you mentioned that we know it's a major, if not the most, certainly a major determinative outcome in a bunch of different conditions.
00:03:57
Speaker
You know, we can think about it as both acute and chronic, and there's a differential diagnosis for both of those.
00:04:05
Speaker
Certainly the one that we think about with acute right heart failure, the most common would be a pulmonary embolism.
00:04:10
Speaker
And we know the right heart doesn't tolerate acute increases in afterload well compared to its counterpart across the septum, which can tolerate increases in load much better.
00:04:21
Speaker
And there's a number of different reasons for that.
00:04:24
Speaker
But those individuals really struggle and require, you know, certainly anticoagulation and sometimes additional therapies to alleviate that clot burden so that the right ventricle doesn't fail.
00:04:36
Speaker
But even in the chronic setting, the RV remains afterload sensitive.
00:04:41
Speaker
And so there's a number of different ways we can think about that and target that when we're thinking about treating the right heart.
00:04:47
Speaker
And I guess the other category that we'll maybe talk a little bit about also is acute and chronic, right?
00:04:52
Speaker
I mean, we see...
00:04:53
Speaker
This and a lot of chronic diseases in the ICU where small changes can really decompensate patients with chronic problems, but understanding how to manage them, in particular with the right ventricular failure, is going to be important for critical care physicians.
00:05:09
Speaker
That's exactly right.
00:05:10
Speaker
You know, on a chronic basis, the RV is able to compensate up to a point where it lacks reserve.
00:05:17
Speaker
And at that point, any further increases in afterload or decreases in contractility really push you over the edge.
00:05:25
Speaker
And those patients obviously become very critically ill.
00:05:29
Speaker
And so it's, you know, how do we recognize that?
00:05:32
Speaker
How do we prevent that tipping point when we're going to manage those patients?
Determinants of Right Ventricular Function
00:05:38
Speaker
Excellent.
00:05:38
Speaker
Well, let's dive into the topic.
00:05:40
Speaker
And I was mentioning before we started recording how much I appreciated your recent review article in the New England Journal of Medicine and the fact that you added a lot of pathophysiology in the appendix.
00:05:53
Speaker
And it just reminded me of my medical student days reading Gaitan and really enjoying Gaitan.
00:05:58
Speaker
learning about how the heart works and the hemodynamic factors that determine function.
00:06:05
Speaker
So why don't we start with pathophysiology, Ryan, and maybe we could start with the hemodynamic determinants of right ventricular function.
00:06:14
Speaker
Sure.
00:06:15
Speaker
You know, when we were writing this review, we initially got a little bit of pushback as we started talking about physiology.
00:06:23
Speaker
And, you know, they wanted it to be a very clinically approachable review.
00:06:28
Speaker
But the argument, of course, is that if you don't understand the physiology, you can't treat these patients because it's all about the physiology.
00:06:37
Speaker
And so we actually use that framework throughout the review when it comes to diagnosis as well as treatment.
00:06:44
Speaker
And so really understanding the physiology is key.
00:06:47
Speaker
And, you know, honestly, just like the left ventricle, the right ventricle has four main determinants of function.
00:06:52
Speaker
Preload.
00:06:54
Speaker
or essentially how much the ventricle is stretched, contractility or inotropy, afterload, the pressure or the impedance against the right ventricle must overcome to eject, and then something called lucidotropy or active relaxation.
00:07:13
Speaker
And it's really those four determinants of function that dictate how the right ventricle is going to do.
00:07:20
Speaker
You can either have too much or too little preload.
00:07:23
Speaker
You certainly can have a decrease in contractility.
00:07:26
Speaker
You can have too much afterload and then impaired lucidrophy.
00:07:31
Speaker
All of those will cause worsening RV function.
00:07:37
Speaker
And it's interesting, I mean, that obviously I think most of us have always thought at the bedside in terms of preload, afterload, and contractility, but lucitrophy is a function that really over more recent, let's say, years in research have really become more interesting for clinicians in general, both on the left and the right.
00:07:57
Speaker
And just as an anecdote,
00:08:00
Speaker
Back in the day when I was doing research, Ryan, I had an animal model of septic shock, and we did a serial echocardiography on septic mice.
00:08:11
Speaker
And what was super interesting is that the main determinant of survival was diastolic function, which I guess is a correlate of lucid trope.
Focus on Diastolic Function and Survival
00:08:21
Speaker
So the animals that could dilate their ventricles with fluid load were the ones who were survivors.
00:08:27
Speaker
Yeah.
00:08:29
Speaker
Yeah, you know, I think that makes a lot of sense, and you're right.
00:08:32
Speaker
You know, we talk about contractility and after a little lot in RVPA coupling, but there's increasing work and data from the groups in the Netherlands as well as Germany that suggest RV diastolic function may be, you know, just as important, if not more important.
00:08:50
Speaker
Now, a lot of times, you know, all of these factors coexist, right?
00:08:54
Speaker
If you have RV contractile deficits, you're likely going to have diastolic dysfunction as well.
00:08:58
Speaker
But there are certainly cases where you may have diastolic dysfunction and contractility may be normal.
00:09:04
Speaker
For example, in early heart failure with preserved ejection fraction, and both on the LV and RV side, there's some data to support that.
00:09:12
Speaker
So I think it's something that we're learning a lot more about.
00:09:14
Speaker
We don't have great ways to target that yet, but maybe we will in the future.
00:09:19
Speaker
And I agree with you 100%, especially as intensivist at the bedside.
00:09:24
Speaker
I think that having very firm understanding of basic physiology is going to be critical as we implement, obviously, evidence-based therapies, but in terms of trying to figure out how our patient, individual patient, is responding.
00:09:36
Speaker
And you're right.
00:09:37
Speaker
I mean, I don't see how we could talk about therapy later if we don't focus on preload, afterload, and contractility.
00:09:45
Speaker
I agree with you.
00:09:46
Speaker
Now,
00:09:47
Speaker
Before we go into more of the clinical aspect, I do think that, at least for me, it was a lot of interest, and obviously you are deep into this topic, so this is what you live every day, but you did talk a little bit more about cellular and molecular mechanisms, and I found that all very interesting because it's not something that I have read recently, and without nerding out too much, could you just give us maybe an overview of some of those mechanisms?
Cellular Mechanisms in Chronic Right Ventricular Failure
00:10:10
Speaker
And I believe those are going to be more important for chronic right ventricular failure, correct?
00:10:17
Speaker
That's right.
00:10:18
Speaker
You know, and I have to, one, give a shout out to my colleague, Evan Britton at Vanderbilt, who is really a leading expert in this and was really this section and the review was his focus and he was very helpful.
00:10:32
Speaker
But it is, you know, very interesting to look at the different aspects.
00:10:37
Speaker
cellular and molecular mechanisms that may contribute to right heart failure.
00:10:42
Speaker
You know, we think about hypertrophy that occurs, fibrosis that occurs, ischemia that occurs due to a number of different factors.
00:10:51
Speaker
When the right heart fails, the neurohormonal system gets activated.
00:10:56
Speaker
We see inflammation and there's shifts in the metabolic substrate from using fatty acid oxidization, the switch over to using glucose.
00:11:08
Speaker
So a lot of different mechanisms play a role.
00:11:11
Speaker
I think some of the other kind of fascinating and more recent findings is insulin resistance that may occur in these individuals and also the impacts of obesity.
00:11:27
Speaker
One of my former colleagues, Kavita Sharma, has shown us that in obese HEPP patients, for example, they have intrinsic ventricular dysfunction compared
00:11:35
Speaker
to their non-obese counterparts.
00:11:37
Speaker
So if you develop pulmonary hypertension, you're just not going to be able to tolerate that as well if you have a contractile deficit.
00:11:45
Speaker
So these are all very important factors when we think about the different mechanisms that are contributing to right heart failure.
00:11:54
Speaker
Many of these patients will have a sleep disorder of breathing, and that can cause hypoxia and also change the molecular phenotype that may be happening in the right ventricle.
00:12:07
Speaker
Excellent.
00:12:07
Speaker
And as we mentioned, these are probably very critical to understand in terms of chronic development, but also I would imagine that in terms of long-term therapy, these are all going to be targets of research of new maybe drugs in the future and of current drugs.
00:12:22
Speaker
So I feel that it's something that worthwhile discussing even if briefly.
00:12:27
Speaker
Yeah, we certainly, right now, a major element of need is a drug that targets the RV myocardial function, both systolic and diastolic.
00:12:41
Speaker
Most of our therapies are aimed at amelioration of afterloads.
00:12:45
Speaker
But, you know, that's only part of the story, as we've talked about.
00:12:48
Speaker
So the more we understand the pathophysiology here, the more we understand these molecular mechanisms, the more we should be able to target the myocardium itself and make advances forward.
Diagnosing Right Ventricular Failure in ICU
00:12:59
Speaker
Absolutely.
00:13:00
Speaker
So let's talk a little bit about diagnosis and evaluation in terms of, like we mentioned, there's chronic right heart failure, which is something that you encounter in the outpatient setting.
00:13:14
Speaker
But considering our audience, I want to focus on when should we be thinking and how should we work up a suspected right ventricular failure in acute situations or acute and chronic situations in the ICU?
00:13:27
Speaker
Okay.
00:13:30
Speaker
Well, you know, it starts, of course, with a thorough history and physical exam.
00:13:36
Speaker
Nothing really replaces that.
00:13:38
Speaker
You know, in history, in the ICU, it's going to be a little bit more apparent, but, you know, we're looking for signs that they've had, you know, exertional dyspnea for a period of time.
00:13:49
Speaker
They have abdominal fullness.
00:13:51
Speaker
They may be tachycardic.
00:13:52
Speaker
They may have early satiety.
00:13:54
Speaker
A lot of those type of symptoms can give you a hint that the right ventricle may be impaired.
00:14:01
Speaker
Your physical exam, though, is going to be very helpful, of course.
00:14:03
Speaker
The best physical exam tool that we have is to look at the jugular venous pressure.
00:14:07
Speaker
And we can do that either just by visualization or with a direct measurement if we're in the ICU.
00:14:14
Speaker
Listening to the heart for a loud second heart sound may suggest pulmonary hypertension.
00:14:18
Speaker
You know, having a palpable and pulsatile liver would suggest, again, right ventricular dysfunction or tricuspid regurgitation.
00:14:26
Speaker
And, of course, things like ascites and lower extremity edema.
00:14:30
Speaker
All of those can be very helpful.
00:14:32
Speaker
Our basic diagnostic tools then, looking at electrocardiograms, and then what's really the best screening tool we have, echocardiography.
00:14:43
Speaker
And that's really going to help describe to us how sick the right ventricle is and if it's involved.
00:14:50
Speaker
Before we talk a little bit more about echocardiography in the setting of the ICU, what are some biomarkers or EKG findings that we should be attentive to when we're evaluating these patients?
00:15:04
Speaker
Well, the EKG, if the right ventricle is very dilated, well, first and foremost, probably the most sensitive is just sinus tachycardia, you know.
00:15:14
Speaker
There was a colleague of mine who used to say sinus tachycardia scares me the most of any arrhythmias because I don't know what to do with it.
00:15:22
Speaker
it's usually a sign of something ominous.
00:15:24
Speaker
And so sinus tachycardia to begin with, we certainly can see right axis deviation, right atrial dilatation, or evidence of right ventricular hypertrophy.
00:15:33
Speaker
All of those may suggest that the right ventricle is in trouble.
00:15:38
Speaker
Now, completely perhaps separate would be, you know, a right-sided myocardial infarction.
00:15:43
Speaker
And there are
00:15:44
Speaker
you know, characteristic EKG findings of that.
00:15:46
Speaker
But if we're talking more just identifying in the sick shock patient is the right ventricle at play, those signs that I mentioned can be helpful.
00:15:56
Speaker
Biomarkers, we have, you know, brain enterotic peptide is a sensitive biomarker.
00:16:01
Speaker
It doesn't really differentiate between left and right-sided heart failure.
00:16:05
Speaker
But it's also not specific because other things can contribute either to levels that are higher, for example, in sepsis.
00:16:13
Speaker
As you probably know, Sergio, it can be elevated.
00:16:16
Speaker
But also other factors like obesity can actually cause a relative lower BNP for the degree of heart dysfunction that you have.
00:16:27
Speaker
Absolutely.
00:16:27
Speaker
And I think that also, obviously, like troponin could be helpful in the right context.
00:16:32
Speaker
Now, it's also nonspecific for the right ventricle.
00:16:35
Speaker
But if you're suspecting PE, any of these biomarkers, if elevated, should make you think that there might be RV dysfunction.
00:16:41
Speaker
Yeah, so troponin, of course, is not specific for acute coronary syndrome, and you're exactly right, in pulmonary embolism.
00:16:48
Speaker
One of my former colleagues, Tom Metkiss at Johns Hopkins, has done a lot of work in RV protective strategies in ARDS, and in fact, has shown that, of course, the higher the troponin, the worse your outcomes.
00:17:01
Speaker
And so a lot of that, we were actually related back to the right ventricle and how stressed it was.
00:17:06
Speaker
So
00:17:07
Speaker
Certainly a troponin can be helpful in terms of prognosis.
00:17:13
Speaker
And the other thing I wanted to ask you, Ryan, before we dive into echocardiography is, I know that in your review, you talk a lot about MRI a lot.
MRI's Role in Right Ventricular Dysfunction
00:17:23
Speaker
And it's kind of like the, it seems that there's a lot of amazing things you can measure with cardiac MRI these days, but I've never seen it used at the ICU.
00:17:31
Speaker
And that I presume is for logistical reasons.
00:17:36
Speaker
But is that something that you think might be coming to an ICU soon?
00:17:38
Speaker
Yeah.
00:17:41
Speaker
You know, the MRIs still take a lot of time, and they're excellent tools.
00:17:45
Speaker
We can certainly learn a lot from an MRI, but I think typically, you know, folks are critical in the ICU.
00:17:53
Speaker
They just don't tolerate, you know, the MRI problems.
00:17:57
Speaker
Don't tolerate being in the MRI suite that long for various reasons.
00:18:01
Speaker
We certainly do it, you know, thinking about in our left heart failure world for patients that are sick that we think may have, you know, active cardiac sarcoid, for example, or myocarditis will work to try to get an MRI.
00:18:13
Speaker
You can obviously do it when the patient's intubated, but they need to be somewhat stable.
00:18:18
Speaker
But, you know, some of the things we're finding on MRI is a little bit more subtle, and I think it's more useful in more of the outpatient evaluation, with a few exceptions, like I mentioned.
00:18:28
Speaker
But, you know, really for the inpatient, we're going to have our invasive hemodynamics, and we're going to have our echocardiography.
00:18:34
Speaker
We really didn't talk about the gold standard, which, of course, is pressure volume assessment, and, you know, a lot of my research has been in PV loops.
00:18:41
Speaker
These are really elegant,
00:18:44
Speaker
type of measurements that can be used to assess the right ventricle, and they can detect abnormalities that you wouldn't detect by MRI and echo.
00:18:52
Speaker
For example, we showed that in patients with systemic sclerosis, these individuals have RV dysfunction out of proportion to their afterload increases, and this was very different from idiopathic pulmonary arterial hypertension patients.
00:19:07
Speaker
We've also used these techniques to show that women tend to have better contractile function than men.
00:19:14
Speaker
But, you know, these are, again, a little bit more in a research setting.
00:19:19
Speaker
There are surrogates that are being developed, kind of less invasive approaches, single-beat approaches that might be used clinically down the road once those are a bit more standardized.
00:19:29
Speaker
But, you know, the question is how do we relate that gold standard then to our more clinically approachable metrics that we have with either echo MRI or invasive heme dynamics?
00:19:39
Speaker
And
00:19:40
Speaker
You know, I think the other in the ICU, typically it's not subtle, right?
00:19:45
Speaker
So the RV is really blown out.
00:19:46
Speaker
So I think some of these other metrics are better for detecting kind of subacute or kind of hidden right ventricular failure rather than if you have a huge dilated right ventricle.
00:19:59
Speaker
The diagnosis is not in question at that point.
00:20:01
Speaker
Awesome.
00:20:02
Speaker
From an echo perspective, what are the things that people should be paying attention to or what are the things that you're looking at in an acute setting?
00:20:11
Speaker
Sure.
00:20:11
Speaker
Well, you know, I think it is your overall gestalt when you look at the echo, right?
00:20:16
Speaker
So just the RV size and the overall squeeze.
00:20:20
Speaker
You know, we do have some limitations when it comes to imaging the right ventricle.
00:20:26
Speaker
You know, sometimes, especially if a patient is acutely ill on a ventilator, it may be difficult to actually visualize.
00:20:31
Speaker
There's a really nice review out by Rebecca Hahn in Jack Journals where she kind of goes through imaging the right ventricle via echo.
00:20:40
Speaker
But just looking at the RV size, right, if the RV size is bigger than the LV, you know that you have a right ventricle that's in trouble.
00:20:50
Speaker
The TAPC, or the tricuspid annular plant systolic excursion, is a good measure of right ventricular function.
00:20:57
Speaker
We know that the right ventricle, about 80% of its function is contraction occurs in a longitudinal motion.
00:21:05
Speaker
And so seeing how that tricuspid annulus moves towards the apex gives us a good sense of right ventricular function.
00:21:13
Speaker
We can also look at the tissue Doppler velocity at the lateral tricuspid annulus.
00:21:18
Speaker
It's called S prime.
00:21:19
Speaker
It can be helpful.
00:21:21
Speaker
And we can't really get an RV ejection fraction when we use echo, at least 2D echo.
00:21:27
Speaker
So we look at the fractional area change, but all of those can be helpful.
Echocardiographic Assessment Techniques
00:21:31
Speaker
The metric that what I think is, well, maybe the two metrics that I think are the best, one is the ratio of TAPC to the pulmonary artery systolic pressure, that ratio, and of course the pulmonary artery systolic pressure being estimated.
00:21:48
Speaker
But that ratio is at least, has been shown to modestly correlate with
00:21:53
Speaker
the gold standard that we talked about earlier, that RVPA coupling from conductance catheters and pressure volume analysis.
00:22:01
Speaker
It's not a perfect surrogate.
00:22:02
Speaker
Certainly TAPC has some low dependence, and so to some extent you're kind of maybe overcorrecting for afterload, but this metric has been shown to be prognostic in left heart disease and pulmonary hypertension, and we actually have some cut points now that can be used clinically.
00:22:18
Speaker
So I think that that's a pretty good metric.
00:22:20
Speaker
We have a paper out in JACE just a couple days ago, and that's one of the factors that we use in a multimodality risk assessment for acute pulmonary embolism.
00:22:31
Speaker
The other is, you know, RV strain.
00:22:35
Speaker
And, you know, I do want people to realize that strain is actually not a measure of contractility.
00:22:40
Speaker
In fact, it's probably
00:22:41
Speaker
better correlated to afterload than contractility.
00:22:44
Speaker
Nonetheless, it's still quite prognostic and it's probably also, well, it is also more closely associated with RVPA coupling than some of our other metrics.
00:22:55
Speaker
And so I think that, you know, in more subtle cases, strain can be helpful.
00:22:59
Speaker
But as we go back to the ICU setting, usually it's not subtle, right?
00:23:04
Speaker
It's the ventricular size.
00:23:06
Speaker
It's the flattening of the intraventricular septum that can suggest either volume or pressure overload.
00:23:12
Speaker
We can quantify this by looking at the eccentricity index, which is essentially the ratio of the anterior-posterior dimension
00:23:22
Speaker
to the septolateral dimension.
00:23:24
Speaker
And if the value is more than one, this, you know, suggests ventricular overload.
00:23:28
Speaker
And these are patients that, you know, when you see this, this is obviously something we want to target when we're trying to improve these patients.
00:23:36
Speaker
Absolutely.
Pulmonary Artery Catheters in Management
00:23:37
Speaker
And I think that the other thing I wanted to ask you about, obviously, the well-done echocardiogram can give you, like you said, a lot of measurements and new measurements being developed.
00:23:48
Speaker
So it's worth it.
00:23:49
Speaker
But like you said, in the acute setting, a fast POCUS exam or even a CT scan can show you that the RV is dilated.
00:23:58
Speaker
That's a starting point, right?
00:24:00
Speaker
And in the right clinical context, you can start making the story together.
00:24:05
Speaker
But the other thing I wanted to ask you, Brian, is the right heart catheterization, right, which in your world is going to the cath lab and doing all these fancy measurements.
00:24:15
Speaker
But in the critical care world, it used to be our bread and butter, a PAC catheter, which now is almost gone.
00:24:22
Speaker
However, this might be a population where perhaps we should reconsider that.
00:24:28
Speaker
You know, unfortunately, or maybe fortunately, right, there were a number of studies in the
00:24:35
Speaker
non-cardiology literature, critical care literature that suggested therapy guided by pulmonary artery catheters was not beneficial, and in fact, in some studies, perhaps harmful.
00:24:48
Speaker
You know, I think on the cardiology side, it's been more neutral, although arguably the design of those studies weren't perhaps ideal.
00:24:56
Speaker
You know, for most patients, though, right, PA catheter guided therapy is not necessary.
00:25:01
Speaker
I think it's
00:25:02
Speaker
It's one of those things where you don't need it until you actually need it.
00:25:05
Speaker
But I think, you know, sometimes people interpret those studies as suggesting that an invasive hemodynamic evaluation is not needed or useful, and I think that's wrong.
00:25:18
Speaker
Whether or not a PA catheter needs to be left in for days or a week to, you know, titrate therapy, I think that is a point you could argue, but I never think it's wrong to be able to understand hemodynamics.
00:25:30
Speaker
And, you know,
00:25:31
Speaker
And I think with all of our non-invasive tools, it's easy to be misled.
00:25:38
Speaker
You know, I think about an example is patients with left ventricular assist devices.
00:25:43
Speaker
And, you know, the unloading characteristics of our new devices are very different than the other devices.
00:25:49
Speaker
And you can't tell by echo.
00:25:52
Speaker
if someone has adequate LV unloading.
00:25:54
Speaker
You might have an eight centimeter ventricle, a very globular septum or a very globular LV and a septum that protrudes into the RV, yet their wedge pressure or their left atrial pressure could be one.
00:26:06
Speaker
And so again, I think it's never wrong to get a right heart catheterization because it's always gonna be, as long as you're doing it right, it's gonna give you important information.
00:26:17
Speaker
You know, we can estimate, of course, what preload is.
00:26:21
Speaker
Now, I want to be careful and remind everybody that pressure does not always equal volume, but you certainly can determine if pressure on the right side of the heart is elevated.
00:26:31
Speaker
You can determine if you have pulmonary hypertension, if that pulmonary hypertension also has a precapillary component with elevated pulmonary vascular resistance, and then what's happening on the left side of the heart as well.
00:26:44
Speaker
And so, again, I think it's always useful information to have.
00:26:49
Speaker
And then we do have, you know, some hemodynamic measurements that can give us a sense of how the RV is doing.
00:26:56
Speaker
One of the ones that we use a lot is the Pulmonary Artery Pulsitility Index, or PAPI.
00:27:01
Speaker
This is the pulmonary artery pulse pressure divided by the right atrial pressure.
00:27:06
Speaker
And we think about what determines pulmonary artery pulse pressure.
00:27:09
Speaker
Well, it's really two things.
00:27:10
Speaker
One is stroke volume.
00:27:11
Speaker
and the other is the compliance of the pulmonary artery.
00:27:15
Speaker
And so this can be a good surrogate of right ventricular function.
00:27:20
Speaker
And in fact, one of my colleagues, Stephen Su, was able to isolate individual myocytes from patients with heart failure and reduced ejection fraction and RV dysfunction.
00:27:33
Speaker
And when he compared the different hemodynamic measurements to isolated myocyte function, he found PAPI
00:27:40
Speaker
was really the most closely associated with that individual myocyte function.
00:27:44
Speaker
So PAPI can be very helpful.
00:27:47
Speaker
I do want to point out, because the denominator of PAPI is right atrial pressure, there is a point where it may be less useful.
00:27:54
Speaker
For example, if your right atrial pressure is two versus four, that ventricle probably is about the same in terms of their filling pressures, yet this could lead to very different PAPI
00:28:07
Speaker
calculations.
00:28:08
Speaker
But if your right atrial pressure is elevated, I think PAPI is a good one that can help determine how sick the right ventricle is.
00:28:15
Speaker
You can also look at more simple things, just stroke volume, stroke volume index.
00:28:20
Speaker
We know both of those are very prognostic in pulmonary arterial hypertension.
00:28:24
Speaker
The ratio of right atrial pressure to wedge pressure may also be useful.
00:28:30
Speaker
So again, I think it's always helpful to have a hemodynamic assessment.
00:28:35
Speaker
It doesn't mean that a catheter has to be left in place for a week to get infected, but I think it'll give the physician taking care of the patients more information.
00:28:45
Speaker
Excellent.
00:28:46
Speaker
And one more question I had before we move on to a different area is what are some signs that help differentiate between truly acute right ventricular failure versus acute on chronic?
00:29:05
Speaker
It's a good question.
00:29:06
Speaker
You know, I think it goes back to the history and
00:29:09
Speaker
you know, what was the time course?
00:29:12
Speaker
Was this something that, you know, developed all of a sudden, or was it, you know, something that was a little bit more progressive?
00:29:18
Speaker
And that can be somewhat difficult to tease out, and particularly in young patients.
00:29:25
Speaker
You know, I think that when you look at
00:29:28
Speaker
The echocardiogram, if you see signs of, you know, left heart failure, for example, valvular abnormalities, this would suggest, you know, some chronicity to the right-sided failure usually.
00:29:42
Speaker
But it can be difficult to determine.
00:29:44
Speaker
I think the main thing goes back to your history to determine timing there.
00:29:49
Speaker
Perfect.
Causes of Right Ventricular Failure in ICU
00:29:51
Speaker
Let's talk a little bit about causes of right ventricular affair in the setting of the ICU.
00:29:56
Speaker
And I really think that a great framework to talk about this is through preload, afterload, and contractility.
00:30:06
Speaker
Sure.
00:30:07
Speaker
Yeah, so we can start by talking about disorders of excessive preload.
00:30:12
Speaker
And then again, I kind of always break this down into acute versus chronic preloads.
00:30:17
Speaker
And so excessive preload acutely, the one that we think about, although it's not very common, would be tricuspid regurgitation.
00:30:25
Speaker
That could occur if you have endocarditis and a valvular involvement there, or if you had some damage to that tricuspid valve during an intervention.
00:30:39
Speaker
Usually that is tolerated well, as long as you have
00:30:44
Speaker
normal right ventricular function and you have a normal left ventricular function.
00:30:50
Speaker
And so, you know, again, normally that's going to be tolerated well.
00:30:54
Speaker
When you have another condition and you develop worsening TR, that's a separate issue.
00:31:01
Speaker
When we think about more chronic RV preload abnormalities,
00:31:06
Speaker
You know, again, we think about worsening tricuspid insufficiency.
00:31:09
Speaker
We think about shunts, intracardiac left to right shunts, or extracardiac shunts.
00:31:15
Speaker
Extracardiac shunts, for example, being AV fistulas, right?
00:31:18
Speaker
So if we think back many decades ago, these AV fistulas for dialysis patients were put in the forearm, and that was...
00:31:27
Speaker
problematic a bit for our renal colleagues because they tended to close more often.
00:31:33
Speaker
They were more difficult to dialyze patients with, and so they moved them up to the upper extremities, and it works great for dialysis.
00:31:40
Speaker
Unfortunately, these fistulas can grow, and we've seen some of these grow to an excessive stint where there is liters and liters of flow going through these fistulas,
00:31:54
Speaker
And there's been elegant work from Barry Borlaug and Yogesh Reddy that have shown us that over time, the right heart dilates and becomes dysfunctional in these patients with very large fistulas.
00:32:04
Speaker
And so one of my favorite quotes or one of the things I always tell my colleagues and fellows is that I've never met a fistula.
00:32:12
Speaker
I didn't want to revise or close.
00:32:14
Speaker
Now, I do realize that they're a necessary evil for patients who have incision renal disease, but
00:32:20
Speaker
They do have a decrement.
00:32:21
Speaker
They can lead to problems with the right ventricle, particularly if they're high flow.
00:32:26
Speaker
And if they have underlying cardiac dysfunction, you know, I think that's going to be exacerbated.
00:32:32
Speaker
So that's something that I'm always kind of looking out for there.
00:32:37
Speaker
Not to mention that, as we talked earlier, a lot of now recognized risk factors for RV dysfunction, obesity, insulin resistance, are probably going to be more prevalent in some of these populations with fistulas.
00:32:51
Speaker
You bet.
00:32:51
Speaker
Absolutely.
00:32:55
Speaker
What about... Go ahead.
00:32:58
Speaker
Yeah, so then if we think about excessive afterload, again, breaking it down to acute and chronic, so acute...
00:33:05
Speaker
The classic example, of course, is the pulmonary embolism.
00:33:11
Speaker
Patients don't tolerate these big increases in afterload acutely because of the thin-walled nature of the RV that's used to ejecting into a low afterload circuit.
00:33:23
Speaker
And so that obviously is not tolerated well.
00:33:27
Speaker
Chronic increases in afterload, we really think about the development of pulmonary hypertension.
00:33:32
Speaker
And when we think about pulmonary hypertension, we really have five categories, right?
00:33:37
Speaker
We have group one pulmonary arterial hypertension, which is either idiopathic or connective tissue disease related or a couple of other causes.
00:33:46
Speaker
We have group two or pulmonary hypertension due to left heart disease, which is by far the most common cause of pulmonary hypertension in the world.
00:33:54
Speaker
We have group three, which is pulmonary hypertension due to lung disease or hypoxia.
00:33:59
Speaker
We have group four, which is pulmonary hypertension due to arterial obstructions, the most common there being chronic lung block disease.
00:34:10
Speaker
And then we have group five, which is multifactorial conditions like sarcoid, for example.
00:34:16
Speaker
And so those are going to be your more chronic disorders of excessive afterload.
00:34:23
Speaker
And then, you know, moving on to contractility, acutely, the big one is myocardial infarction.
00:34:30
Speaker
And so you can either have a, you can have an isolated right ventricular infarction or a more global involvement of LV and RV myocardium with a myocardial infarction.
00:34:47
Speaker
These patients are typically very, very sick.
00:34:50
Speaker
They can be bradycardic.
00:34:52
Speaker
They can go into complete heart block.
00:34:54
Speaker
and they can be very difficult to manage, often requiring additional support.
00:34:58
Speaker
And then more chronic disorders of contractility, you know, if we think about left heart failure, for example, the same entities that impact the left heart can also impact the right heart.
00:35:11
Speaker
So, for example, cardiac sarcoid or amyloid, all of these things can impact right heart.
00:35:18
Speaker
myocardial function in the right heart.
00:35:22
Speaker
The other one that we think about is after cardiac surgery.
00:35:28
Speaker
Patients can come, have difficulty weaning from bypass.
00:35:31
Speaker
After a left ventricular assist device, these individuals lose a lot of their RV function for various reasons, and they can be indeed very sick and lose that function.
00:35:44
Speaker
So those are, you know, the kind of the big categories that I think about when it comes to the causes of right ventricular failure.
00:35:55
Speaker
With that framework, then I move into how we best treat those individuals.
00:35:59
Speaker
Absolutely.
00:36:00
Speaker
And before we jump into treatment, just a comment.
00:36:04
Speaker
Obviously, acute contractility issues, post-cardiac surgery is a growing challenge, I think, in many ICUs as we continue to expand.
00:36:15
Speaker
indications and procedures and we're taking care of sicker and sicker patients like you said even the increased use of assist devices in the left ventricle has now created new new paradigms right or new problems on the on the right so clearly something that a lot of our intensivists probably interact with in their daily day the last thing i wanted to ask you about causes just because it's not something that i have seen or very familiar with but it caught my eye just out of interest
00:36:41
Speaker
was ARVC, or Arrhythmogenic Right Ventricular Cardiomyopathy.
00:36:46
Speaker
Is that something that we're seeing more now?
00:36:48
Speaker
You know, I think we are increasingly recognizing it.
00:36:54
Speaker
It's actually not specific to the RV anymore.
00:36:58
Speaker
A lot of people now just call it AVC, arrhythmogenic ventricular cardiomyopathy, because biventricular involvement certainly is common.
00:37:08
Speaker
But it is certainly becoming more recognized as an important cause of heart failure and certainly a sudden cardiac death and ventricular arrhythmias.
00:37:18
Speaker
But when I think about somebody who has isolated RV failure, particularly in the absence of pressure overload,
00:37:25
Speaker
Right.
00:37:25
Speaker
That that differential is somewhat narrow.
00:37:28
Speaker
And so ARVC is certainly one of them.
00:37:30
Speaker
There's the 2010 revised task force criteria that provides a framework for diagnosis.
00:37:36
Speaker
There are ARVC centers.
00:37:39
Speaker
One of my former centers in Johns Hopkins is one of the leaders in this regard.
00:37:45
Speaker
You know, you think about, I still remember one of my favorite patients that got a transplant for isolated RV failure, and he had cardiac sarcoid that was really isolated to the right ventricle.
00:37:56
Speaker
Myocarditis can be isolated to the right ventricle, although it's more common to have biventricular involvement.
00:38:01
Speaker
But those are the three things that I think about when I see kind of isolated right ventricular failure, yet no pulmonary hypertension or pressure overload.
00:38:15
Speaker
Perfect.
00:38:16
Speaker
Thanks.
Preload Management Strategies
00:38:17
Speaker
Can we now talk about treatment?
00:38:19
Speaker
And I guess you would take probably a very similar approach, right?
00:38:23
Speaker
You have to kind of break it up into obviously different clinical conditions, but what are the things that you can do for preload, afterload, and contractility?
00:38:33
Speaker
Sure.
00:38:35
Speaker
Well, preload.
00:38:36
Speaker
And, you know, I think we go back a couple decades when
00:38:42
Speaker
people had RV failure.
00:38:43
Speaker
The answer was, well, they're preload dependent.
00:38:45
Speaker
We need to give them volume.
00:38:47
Speaker
And if you remember nothing else from the podcast today, please remember that that is almost always not true.
00:38:54
Speaker
There are rare instances, for example, in an acute RV infarct, if you have a relatively preload, a low preload state due to kind of distributive shock, then in those situations, small fluid challenges might be very reasonable.
00:39:15
Speaker
But in almost every other situation, either acute or chronic, volume loading is almost never the answer and will make patients worse.
00:39:23
Speaker
There was a study that was out recently that I really liked in acute PE where they actually randomized patients to receive a single dose of furosemide versus placebo in those who had an intermediate risk pulmonary embolism.
00:39:38
Speaker
And those who actually got Lasix were more likely to meet the combined endpoint.
00:39:44
Speaker
And so, which was a positive endpoint.
00:39:47
Speaker
And so, you know, very few situations would volume loading be the right answer.
00:39:51
Speaker
In fact, many times it may be harmful because we know as the RV gets volume overloaded, it becomes more dysfunctional.
00:39:58
Speaker
The septum flattens.
00:39:59
Speaker
We know that the septum is responsible for the lion's share of right ventricular function.
00:40:06
Speaker
We can develop pericardial restraint, which further reduces LV preload.
00:40:11
Speaker
And so most of the time, particularly and certainly in chronic RV failure, the answer is actually volume removal to optimize preload.
00:40:19
Speaker
And we do that through diuretics.
00:40:21
Speaker
Some situations may call for ultrafiltration or dialysis.
00:40:26
Speaker
There's even some novel therapies now that are looking at ways to reduce LV preload through devices or, for example, splintening nerve deinnervation.
00:40:36
Speaker
So maybe that's something that's coming down the pike.
00:40:37
Speaker
But normalization of preload is something that's really key to managing patients with right ventricular failure.
00:40:47
Speaker
And I think it's worth reemphasizing, as you mentioned, there's one thing people should take home today is this old dogma of preload augmentation to help these patients is really not based on evidence and probably more harmful.
00:41:04
Speaker
We want to optimize preload, but like you said, in most clinical circumstances, that's probably preload reduction and removal of fluid.
00:41:12
Speaker
Right, and you hear all the time, well, the patient's hypotensive.
00:41:15
Speaker
How could I possibly give them Lasix or diurese them?
00:41:19
Speaker
And, of course, we have to.
00:41:20
Speaker
We've got to support their blood pressure with other means, but certainly giving fluid is not the answer, and it's just going to start this RV death cycle that is occurring if you give them fluid.
00:41:31
Speaker
So do everything you can not to forget that age-old adage of preload dependence of the RV.
00:41:42
Speaker
Perfect.
00:41:43
Speaker
Let's talk about contractility.
00:41:47
Speaker
Sure.
00:41:47
Speaker
So, you know, as we think about optimizing contractility, I think of a few things.
00:41:52
Speaker
So one, and again, I'm going to take you back to preload is, is as we normalize preload, the RV is actually going to contract better, right?
00:42:02
Speaker
Because the septal function will be better.
00:42:04
Speaker
So first and foremost, again, to augment contractility, we've got to optimize a preload in situations where,
00:42:12
Speaker
where you have ischemia, obviously large vessel ischemia from an acute infarct, we're going to want to try to open that artery and reperfuse the right ventricle.
00:42:23
Speaker
But then, you know, the rest of contractility augmentation is going to occur via two, really two mechanisms.
00:42:31
Speaker
One is to adequately support the systemic blood pressure.
00:42:33
Speaker
So as we get hypotensive, a couple of different things occur.
00:42:37
Speaker
One is the LV actually becomes less contractile as you become hypotensive.
00:42:44
Speaker
And we know that the RV depends on the LV for a significant amount of its contractile function.
00:42:51
Speaker
somewhere between 30 to 50%, and probably even more in pathologic states.
00:42:56
Speaker
And so as that LV becomes less contractile, we know the RV is also going to contract less.
00:43:02
Speaker
As the patient becomes hypotensive, there's also going to be more decreased blood flow down the right coronary artery, and the RV is going to become more ischemic as well, and that's going to further decrease contractility.
00:43:16
Speaker
So we want to support the systemic blood pressure.
00:43:20
Speaker
And then, of course, we can use direct inotropic medications like dobutamine, like epinephrine, perhaps milarnone, although we have to be careful with milarnone because of the systemic vasodilatation.
00:43:33
Speaker
I use milarnone a lot in patients with left heart failure, but certainly in patients with pulmonary arterial hypertension, you're probably just going to get a lot of systemic vasodilatation, and that may worsen RV function.
00:43:45
Speaker
So we can use those medications at least temporarily,
00:43:49
Speaker
to support the right heart, to optimize preload, to optimize afterload, like we're going to talk about in a minute, and support you through that acute state.
00:43:58
Speaker
But that's really, you know, how we're going to think about automating contractility.
Afterload Reduction Techniques
00:44:03
Speaker
Perfect.
00:44:04
Speaker
And I guess last but not least would be afterload reduction, which is going to be something that we're going to be thinking, I think, in a lot of our patients in the ICU.
00:44:14
Speaker
Absolutely.
00:44:15
Speaker
And, you know, so...
00:44:17
Speaker
Again, going back to the construct of acute versus chronic in patients with acute pulmonary embolism, right, we have to make a decision.
00:44:24
Speaker
Is anticoagulation going to be enough?
00:44:26
Speaker
Do we need some type of either catheter-directed or systemic thrombolysis?
00:44:30
Speaker
And, you know, that's still a topic that has a lot of debate.
00:44:36
Speaker
But certainly in critically ill patients with significant pressure overload, it's something that needs to be carefully considered.
00:44:44
Speaker
And then, you know, in more chronic afterload states, for example, and the easier one is pulmonary arterial hypertension,
00:44:53
Speaker
we are going to want to try to reduce afterload, right?
00:44:55
Speaker
And we have a number of different medications that can do that, both oral and IV, and that's really going to be in collaboration with your PH colleagues to how best to do that.
00:45:06
Speaker
In the ICU, many times that's going to be IV prostacycline in our critically ill patients.
00:45:13
Speaker
There is also sometimes an indication for inhaled
00:45:18
Speaker
therapies like inhaled nitric oxide, particularly in short term, which may help reduce RV afterload.
00:45:29
Speaker
In patients with left heart failure, it's a little bit less simple.
00:45:34
Speaker
Many of our drugs that we use to treat pulmonary hypertension have not shown to be helpful in pH to left heart disease, and in fact, there's some suggestion that they can be harmful.
00:45:46
Speaker
So in those individuals, we're going to try to reduce RV afterload by optimizing LV function, optimizing LV preload, and eventually work on getting these patients on the guideline-directed medical therapy with our four drug pillars.
00:46:02
Speaker
But they're a little bit more difficult to afterload reduce outside of optimizing LV preload.
00:46:10
Speaker
Perfect.
00:46:11
Speaker
The other question I had, Ryan, in terms of the use of inhaled basal dieters like nitric oxide in the acute setting, any thoughts on that?
Inhaled Vasodilators: Use and Misuse
00:46:23
Speaker
I think it's still an area of a lot of mismanagement in the ICU.
00:46:28
Speaker
And obviously, I'm talking about a mixed bag here.
00:46:31
Speaker
Sometimes it's utilized for pulmonary hypertension issues, other times just for hypoxemia.
00:46:37
Speaker
But any comments from your perspective?
00:46:40
Speaker
Yeah, you know, the data with nitric oxide is mixed at best.
00:46:45
Speaker
But, you know, the argument, of course, is, well, you can't really study the patients who need it.
00:46:49
Speaker
So that's a bit of a challenge.
00:46:51
Speaker
I think the thing that I always go back to is, well, what is the physiology?
00:46:58
Speaker
You know, if somebody has an elevated pulmonary vascular resistance and they're hypoxic, I think it's reasonable if the RV is struggling to,
00:47:07
Speaker
The nice thing about it is you can turn it on acutely and turn it off acutely, and it goes away.
00:47:11
Speaker
So it's, you know, each patient can kind of be their own.
00:47:17
Speaker
You can look at the response in the individual patients, but I do agree with you.
00:47:21
Speaker
I think it can be misused.
00:47:23
Speaker
I think it can be overused.
00:47:25
Speaker
And if somebody doesn't have, you know, elevated RV afterload, it probably isn't going to do very much.
00:47:31
Speaker
The other area I wanted to ask about, Ryan, is in terms of afterload in the context of PE, we're seeing a rapid increase in the utilization of catheter-directed therapies for acute pulmonary embolism with RV dysfunction.
00:47:48
Speaker
And obviously, there's really no good mortality data that I have seen, but a lot of the arguments are hemodynamic and afterload reduction arguments.
00:47:58
Speaker
whether that be catheter-directed TPA or catheter-directed thrombectomy.
00:48:03
Speaker
Any comments on this?
00:48:06
Speaker
Yeah, you know, and this is not my area of expertise, but physiologically, right, you would think that it would make sense, whether that translates into
00:48:17
Speaker
real improvements in clinical outcomes, I think is less clear.
00:48:20
Speaker
And, you know, all of these have some complication rates associated with them as well.
00:48:24
Speaker
So I think, thankfully, there are a number of clinical trials that should be coming out that will help give us that answer and define that population better.
00:48:32
Speaker
You know, I think one of the major advances, though, when it comes to dealing with the QPEs is the development of the PERT team, which many hospitals have, including ours.
00:48:41
Speaker
And I think
00:48:42
Speaker
You know, they're having a multidisciplinary approach from critical care doctors, cardiologists, interventional radiologists, pulmonologists, anesthesia critical care, just like a cardiogenic shock team, can really improve patient outcomes.
00:48:57
Speaker
So,
00:48:58
Speaker
Whether those devices need to be used more or less, I think that remains to be seen.
00:49:03
Speaker
But I think what we have learned is a multidisciplinary approach when it comes to treating these sick patients and determining how best to care for them is a clear winner.
00:49:14
Speaker
Perfect.
Mechanical Support Options in RV Failure
00:49:15
Speaker
The last question I have regarding treatment as we wrap up is any comments on mechanical support?
00:49:24
Speaker
Sure.
00:49:25
Speaker
Sure.
00:49:26
Speaker
Thankfully, we do have more mechanical support options than we used to for the right heart.
00:49:35
Speaker
There's a couple of temporary MCS devices that are axial flow devices that are available now, although usually these are used in patients with concomitant left heart failure or in postcardotomy shock.
00:49:53
Speaker
These devices, again,
00:49:55
Speaker
or not without complications, so they shouldn't be used unless they're truly indicated, but they certainly can restore blood flow, improve LB filling, and provide RV support.
00:50:08
Speaker
You know, I think that what we still really don't have a good sense of is what to do if these devices
00:50:19
Speaker
can safely be used in pulmonary arterial hypertension.
00:50:21
Speaker
One nice thing about them is you can adjust the flow, right?
00:50:24
Speaker
So I think traditionally when you've thought about support devices for the RV and pulmonary arterial hypertension, we worry about pulmonary hemorrhage and that's still a worry, but if you have a device that could give you a liter, liter and a half of flow, maybe that's enough in the acute setting to allow someone to get more compensated to better treat the cause of their RV dysfunction.
00:50:46
Speaker
ECMO certainly is a mechanical support platform that can be used to bridge patients if there is a destination.
00:50:56
Speaker
So I think whenever we're going to use these devices, whether it's a temporary MCS device or ECMO, we need to make sure that we have a destination.
00:51:04
Speaker
And maybe that's just a bridging to a decision, but we want to make sure what is the long-term outcome here?
00:51:13
Speaker
Are we going to try to
00:51:14
Speaker
recover the patient?
00:51:16
Speaker
Are we going to move on to a lung, heart or heart lung transplant?
00:51:20
Speaker
You know, we always have to have these in mind when we use these, you know, very expensive therapies.
00:51:24
Speaker
And it becomes very difficult if we don't have a destination in the patient, then we have to have the conversation with the patient and the family, you know, now what do you want us to do?
00:51:33
Speaker
We're going to have to stop using the device.
00:51:36
Speaker
And that can be very difficult.
00:51:37
Speaker
So I think it's, again, speaks the importance of a multidisciplinary team,
00:51:42
Speaker
that can help make those decisions when these devices may be used.
00:51:46
Speaker
But again, the good news is we do have some potential devices now that may help with these complicated issues.
00:51:54
Speaker
Absolutely.
00:51:54
Speaker
And I think that clearly a lot that we've learned over the last, I would say, couple decades and a lot still ahead that we don't know.
00:52:03
Speaker
But definitely, I think, a very relevant clinical topic.
00:52:07
Speaker
And thanks again for sharing your expertise.
00:52:10
Speaker
Obviously, this is something that you live every day and you see it from every angle.
00:52:15
Speaker
But I do believe it's something our critical care audience needs to be more aware of and
00:52:22
Speaker
With that, we usually like to close the podcast, Ryan, with a couple of questions unrelated to the clinical topic.
00:52:28
Speaker
Would that be okay?
00:52:30
Speaker
You bet.
00:52:31
Speaker
So the first question relates to books.
00:52:33
Speaker
Are there any books or book that has influenced you significantly or that you have gifted often to others?
00:52:41
Speaker
Well, you know, I guess I would start by saying a book called The Right Ventricle in Health and Disease.
00:52:47
Speaker
That's one that I typically...
00:52:49
Speaker
like to gift to my mentees and colleagues.
00:52:53
Speaker
I've been fortunate enough to participate in the writing of several of those editions.
00:52:56
Speaker
And, you know, it really goes back to a lot of the physiology, even more sophisticated physiology than we talked about in ventricular assessment.
00:53:04
Speaker
And I just find we can learn so much by the history of medicine and understanding physiology.
00:53:10
Speaker
Um,
00:53:11
Speaker
you know, kind of maybe outside my expertise, I recently read The Codebreaker, which was the story of Jennifer Adudna, who helped develop CRISPR-Case9 and gene editing, and I found that to be a really nice read, and her journey as a woman in science, and I really enjoyed that book.
00:53:34
Speaker
Excellent.
00:53:35
Speaker
And we'll definitely link both of these in the show notes.
00:53:38
Speaker
The second question relates to something you believe to be true in medicine or life that most other people don't believe, or at least they don't act as if they believe it.
00:53:50
Speaker
Um,
00:53:51
Speaker
Yeah, that's a good question.
00:53:53
Speaker
The one that immediately comes to mind is that medicine is the easy part.
00:53:59
Speaker
One of my former mentors, Charlie Weiner, used to say that all the time, and I found that to be more and more true.
00:54:07
Speaker
It's more, the difficult part can be managing personalities, managing patients, managing patients' families, managing your colleagues, getting everyone on the same page.
00:54:22
Speaker
But typically when, you know, the actual physiology, the actual knowing what to do is the easy part.
00:54:31
Speaker
It's making that plan happen in a complex environment that can be more challenging.
00:54:36
Speaker
I agree.
00:54:37
Speaker
And I've heard a similar thought in the terms of managing, right?
00:54:43
Speaker
Because management is easy.
00:54:44
Speaker
It's the people part that's hard.
00:54:46
Speaker
But I think at the end of the day, that's exactly what's happening at the bedside.
00:54:49
Speaker
That's exactly right.
00:54:51
Speaker
It's important to have a great team, right?
00:54:54
Speaker
For sure.
00:54:55
Speaker
I agree.
00:54:55
Speaker
And the last question relates to what would you want every listener, all our critical care clinicians listening to us to know could be a quote, a fact, or just a thought?
00:55:07
Speaker
Don't forget the RV.
00:55:09
Speaker
Hopefully it's clear now that the RV is critically important in almost every disease.
00:55:16
Speaker
And so we need better ways to assess it.
00:55:19
Speaker
We need better ways to identify dysfunction and then certainly better ways to treat it.
00:55:26
Speaker
So don't forget the RV and the RV is rarely preload dependent.
00:55:32
Speaker
So don't give fluid.
00:55:34
Speaker
I love that.
00:55:36
Speaker
Well, Ryan, thank you so much for sharing your expertise and for giving us your time.
00:55:39
Speaker
I hope to have you back on the podcast to talk about more about the RV or maybe some other topics related to heart failure.
00:55:46
Speaker
Very good, Sergio.
00:55:47
Speaker
Thank you for having me.
00:55:48
Speaker
Thank you.
00:55:51
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:55:55
Speaker
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00:56:01
Speaker
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00:56:05
Speaker
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