Critically Appraised Critically Appraised Topic: Topic:

Fluid Loading in Right Ventricular Fluid Loading in Right Ventricular

InfarctionInfarction

MounirMounir BasalusBasalus

Critically Appraised Critically Appraised Topic: Topic:

Fluid Loading in Right Ventricular Fluid Loading in Right Ventricular

InfarctionInfarction

MounirMounir BasalusBasalus

Patient with acute chest pain Patient with acute chest pain Patient with acute chest pain Patient with acute chest pain

• 60 y/o patient presented with acute chest pain.

• No past medical history,

• Smoker, family history of CVD.

• A/

• Acute chest pain (since 1 hour).

• Nausea and diaphoresis.

PhyscialPhyscial examination examination PhyscialPhyscial examination examination

• P: 90/min, BP: 90/50 mmHg.

• Jugular vein not congested

• Heart: normal heart sounds no additional

sounds.

• Lung: Vesicular breath sounds. No additional

sounds

• No oedema.

ECG: STEMI ECG: STEMI inferior inferior infarctioninfarction and right and right ventricularventricular MI.MI.ECG: STEMI ECG: STEMI inferior inferior infarctioninfarction and right and right ventricularventricular MI.MI.

CAGCAGCAGCAG

prepre

PCIPCIPCIPCI

GPIIbIIIa inhibitor; thrombus aspiratie RCA: 1 stent (3.5/23mm @14 atm); postdilatationNC ballon (3.5mm @24atm)

Voor thrombusaspiratie

finalfinal

Clinical Clinical questionquestionClinical Clinical questionquestion

• Persistent hypotension.

• Fluid loading? Or not?

• What is the effect of “volume loading” on the

hemodynamics of patients suffering from

right ventricular myocardial infarction (RVMI).

PICOPICOPICOPICO

P: patients suffering from right ventricular

myocardial infarction and low cardiac

output/hypotension.

I : Volume loading.

C: no volume loading, dobutamine

O: improvement in hemodynamic parameter.

Search strategy Search strategy Search strategy Search strategy

• Search terms:

• Right ventricle infarction AND volume

loading/infusion

• Right ventricle infarction AND treatment

• Human studies

Search strategy Search strategy Search strategy Search strategy

Search strategy Search strategy Search strategy Search strategy

3 Reviews

` 7 Clinical studies

ESC

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984JACC 1984ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984JACC 1984

• 53 patients with acute inferior transmural

myocardial infarction were studied.

• To evaluate the potential occurrence of right

ventricular infarction.

• Cardiac output/index was measure before and

after volume loading in a Subpopulation (n=27).

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984 ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984

RVI

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984 ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1984 JACC 1984

RVI

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985

• 13 patients with RVMI randomly treated with volume

loading (200-800 ml); dobutamine, and nitroprusside.

Before NaCl

ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985ClinicalClinical studystudy: : Dell'italiaDell'italia JACC 1985JACC 1985

• 13 patients with RVMI randomly treated with volume

loading (200-800 ml); dobutamine, and nitroprusside.

Before NaCl

ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985

• 43 patients with acute inferior infarction and depressed

RVEF.

• Substudy 11 ptns effect of volume loading vs Dopamine

CI = cardiac index (liters/min per me): PCW = mean pulmonary capillary wedge pressure (mm Hg):

RA = mean right atrial pressure (mm Hg); SVI = stroke volume index

ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985ClinicalClinical studystudy: : ShahShah JACC 1985JACC 1985

• 43 patients with acute inferior infarction and depressed

RVEF.

• Substudy 11 ptns effect of volume loading vs Dopamine

CI = cardiac index (liters/min per me): PCW = mean pulmonary capillary wedge pressure (mm Hg):

RA = mean right atrial pressure (mm Hg); SVI = stroke volume index

ClinicalClinical studystudy: : DhainautDhainaut JACC 1990JACC 1990ClinicalClinical studystudy: : DhainautDhainaut JACC 1990JACC 1990

• 20 consecutive patients with RVI and low cardiac output

within 48 h of the onset of symptoms were prospectively

included. Evaluation after volume loading and Dobu.

• Volume loading slight ↑in CI, marked ↑↑ in RAP .

• Dobu marked ↑↑ in CI.

ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994

• Evaluation of the effect of volume loading in 11 patient

with severe RVMI. Used volume loading aiming @ PWP

(18-24mmHg). Hemodynamics were measure before

and after volume loading

Hemodynamics Before volume loading After P value.

Right atrial pressure 12 ± 4 19 ± 5 mmHg (P<0.0001)

RV end-diastolic P 13 ± 4 20 ± 5 mmHg (P<0.0001)

PWP 14 ± 3 20 ± 6 (P<0.0001)

Mean PA pressure 20 ± 3 25 ± 6 (P<0.001)

PVR 117± 39 101 ± 49 dyn·s/cm5 P ns

RAP/PWP ratio 0. 85 ± 0.14 1.05 ± 0.07 (P<0.01)

End-diastolic RV volume 95 ± 26 113± 24ml. (P<0.001)

RV end-systolic volume 65 ± 28 83 ± 29 ml (P<0.01)

RV SV 30± 6 30± 8ml/beat (P ns)

RVEF 32± 11 28± 11% (P<0.001)

Cardiac output 2. 3 ± 0.42 2.4± 0.62 l/ min (P ns)

ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994ClinicalClinical studystudy: : SlniorakisSlniorakis EHJ 1994EHJ 1994

Conclusion: volume loading per se is not sufficient to

improve CO in patients with severe RVMI, despite the ↑↑

RV preload, LV preload does not increase, but PWP ↑↑

because of the limiting role of the pericardium.

Hemodynamics Before volume loading After P value.

Right atrial pressure 12 ± 4 19 ± 5 mmHg (P<0.0001)RV end-diastolic P 13 ± 4 20 ± 5 mmHg (P<0.0001)

PWP 14 ± 3 20 ± 6 (P<0.0001)

Mean PA pressure 20 ± 3 25 ± 6 (P<0.001)

PVR 117± 39 101 ± 49 dyn·s/cm5 P ns

RAP/PWP ratio 0. 85 ± 0.14 1.05 ± 0.07 (P<0.01)

End-diastolic RV volume 95 ± 26 113± 24ml. (P<0.001)

RV end-systolic volume 65 ± 28 83 ± 29 ml (P<0.01)

RV SV 30± 6 30± 8ml/beat (P ns)

RVEF 32± 11 28± 11% (P<0.001)

Cardiac index 2. 3 ± 0.42 2.4± 0.62 l/ min /m2 (P ns)

ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994

• 11 consecutive patients with RVI (and inferior infarction

with low cardiac output.

• After baseline measurements, patients were randomly

treated with

• dobutamine infusion, 5 µkg/min over 10 minutes,

followed by 10 p&kg/minover 10 minutes or,

• alternatively, by rapid intravascular administration of

normal saline solution in 200 ml increments over 5

minutes. Interruption of volume : mRAP> 20; mean

pulmonary capillary pressure >20 mm Hg, or ↓↓ CO

• After return of hemodynamics to baseline volume

loading & dobutamine were repeated in a crossover.

ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994ClinicalClinical studystudy: : FerrarioFerrario AJC 1994AJC 1994

• Volume loading(VL)↑↑RAP&PCWP BUT no change CI

• Dobutamine(d)no change RAP&PCWP BUT↑↑CI.

ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990

• 41 patients with RVMI

• What is the optimal filling pressure for the RV?

• Used volume loading or NTG to modify the right

ventricular filling pressure.

• Used right ventricular stroke work index (RVSWI) and CI

endpoints.

• RVSWI=0.0144*SVI*MPAP (the amount of work that

the right ventricle does during each contraction)

ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990ClinicalClinical studystudy: : BerishaBerisha BMJ 1990BMJ 1990

Baseline

mRAP<10mmHg <10mmHg 10-14mmHg 10-14mmHg >14mmHg

mRAP after

intervention10-14mmHg >14mmHg 10-14mmHg >14mmHg RA Perssure

lowered

• Similarly, optimal PWP 16 mmHg.

summary summary clinicalclinical studies studies (n=7)(n=7)summary summary clinicalclinical studies studies (n=7)(n=7)

• Volume loading has no effect on CI : 5

• Volume loading has a modest effect on CI: 1

• Volume loading has an effect on CI within limits : 1

Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000

• Optimization of preload.

• Initial therapy of RVI (hypotension and no pulmonary

congestion) should start with volume expansion.

• If unresponsive to initial trial of fluids hemodynamic

monitoring, and subsequent volume challenge CVP < I5

mmHg.

• Any interventions that reduce the preload (diuretics,

nitrates, and vasodilators) should be avoided even in the

absence of hypotension.

Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000Review: Review: MovahedMovahed ClinClin. . CardiolCardiol. 2000. 2000

• When RVI is accompanied by severe LV dysfunction and

pulmonary congestion, the RV is further compromised by

increased afterload.

• In this circumstance, the use of afterload-reducing

agents such as sodium-nitroprusside or IABP is often

necessary to unload the LV and subsequently the RV.

Review: Review: GoldsteinGoldstein JACC 2002JACC 2002Review: Review: GoldsteinGoldstein JACC 2002JACC 2002

• Optimization of preload:

• RVI dilated noncompliant RV is exquisitely preload

dependent.

• factors that reducing preload tend to be detrimental,

• optimizing cardiac filling tend to be beneficial.

• Wide spectrum of initial volume status in acute RVI:

• relatively volume depleted benefiting from VL

• more replete flat response to fluid resuscitation.

Review: Review: GoldsteinGoldstein JACC 2002JACC 2002Review: Review: GoldsteinGoldstein JACC 2002JACC 2002

• An initial volume challenge is appropriate for patients

manifesting

• low output

• without pulmonary congestion,

• particularly if the estimated CVP <15 mm Hg.

• For those unresponsive to an initial trail of fluids,

• hemodynamically monitored volume challenge may

be appropriate.

• Avoid excessive volume administration (descending limb of starling curve).

Review: Review: InoharaInohara EHJEHJ--ACVC 2013ACVC 2013Review: Review: InoharaInohara EHJEHJ--ACVC 2013ACVC 2013

• Older (animal model) studies maintenance of the RV

preload with volume loading thought to resolve

accompanying hypotension.

• Later clinical studies variable responses to

aggressive fluid therapy.

• Some studies, showed that volume loading further

elevates right-sided filling pressure without improving CI

• Berisha et al: maximal RVSWI & CI @mRAP of 10–14

mmHg, and a mRAP of >14 mmHg ↓↓RVSWI/CI.

• Haemodynamics of RVI : extremely variable (influenced

by state of hydration and the degree of concomitant LV

involvement.)

GuidelinesGuidelines: ESC EHJ 2012: ESC EHJ 2012GuidelinesGuidelines: ESC EHJ 2012: ESC EHJ 2012

• Despite the jugular distension, fluid loading that

maintains right ventricular filling pressure is a key

therapy in avoiding or treating hypotension.*

• In addition, diuretics and vasodilators should be avoided,

as they may aggravate hypotension.*

* No references

ConslusionConslusionConslusionConslusion

• Patients suffering from RVMI appears to be very

sensitive for changes in volume status.

• In patients with RVMI and low cardiac

output/hypotension, low CVP, and no pulmonary

congestion it is prudent to administer boluses of

normal saline (200 cc) reaching a maximal of 1.5 ltr.

(voluven is frequently administered in the cathlab)

• This group of patients may be simply suffering from a

low circulating volume status.

ConslusionConslusionConslusionConslusion

• In case of no response on this initial “fluid challenge”,

invasive monitoring of CVP should be considered.

• CVP <10mmHg further volume loading.

• CVP 10-14Hg consider dobutamine/ LV unloading

devices.

• CVP >14mmHg modest dose

diuretics/±venodilators(beside dobu en LV

unloading).