CriticalCareNow

The Battle for Cor Pulmonale

Reading Time: 2 minutes
Matt Siuba
Zentensivist. ARDS, Mechanical Ventilation, RV, & Shock Enthusiast.
Brendan Riordan

Left-handed intensivist defending the right side of the heart. Often found ordering diuretics in the Cardiothoracic Surgery ICU or posting cat photos on twitter.

The Pre-brief

How does ARDS affect the right ventricle? Why should I care? Join two RV (aka #ThePeoplesVentricle) enthusiasts to learn more in this two-part video!

Timestamps:

  • 0:44 Right ventricular (RV) to pulmonary anatomy & physiology
  • 6:42 Defining acute cor pulmonale
  • 7:52 Understanding the relationship of lung volumes with pulmonary vascular resistance (PVR)
  • 10:24 How PVR affects RV performance
  • 11:16 Hypoxemic vasoconstriction
  • 15:57 Other factors affecting PVR
  • 18:36 Acute respiratory distress syndrome (ARDS) enters the chat
  • 25:21 Risk factors for acute cor pulmonale in ARDS
  • 30:00 The bottom line

The Debrief

  1. RV function is directly influenced by lung function
  2. Hypoxemia, hypercapnia and acidemia all worsen PVR
  3. ACP is RV dysfunction related to an acute rise in PVR, frequently this is due to ARDS or pulmonary embolism
  4. ACP is probably under-recognized 
  5. Risk factors for ACP in ARDS include pneumonia as an etiology for ARDS, hypoxemia, hypercapnia, and elevated driving pressure
  6. New hypotension in a patient with ARDS? Think about ACP!
  7. Of course, respect #ThePeoplesVentricle
  1. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75. doi: 10.1056/NEJMoa062200. Epub 2006 May 21. PMID: 16714767.
  2. Rosenberg AL, Dechert RE, Park PK, Bartlett RH; NIH NHLBI ARDS Network. Review of a large clinical series: association of cumulative fluid balance on outcome in acute lung injury: a retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med. 2009 Jan-Feb;24(1):35-46. doi: 10.1177/0885066608329850. Epub 2008 Dec 22. PMID: 19103612.
  3. Wanner PM, Filipovic M. The Right Ventricle-You May Forget it, but It Will Not Forget You. J Clin Med. 2020 Feb 5;9(2):432. doi: 10.3390/jcm9020432. PMID: 32033368; PMCID: PMC7074056.
  4. Andrew B. Lumb, Peter Slinger; Hypoxic Pulmonary Vasoconstriction: Physiology and Anesthetic Implications. Anesthesiology 2015; 122:932–946 doi: https://doi.org/10.1097/ALN.0000000000000569
  5. Ketabchi, F., Ghofrani, H.A., Schermuly, R.T. et al. Effects of hypercapnia and NO synthase inhibition in sustained hypoxic pulmonary vasoconstriction. Respir Res 13, 7 (2012). https://doi.org/10.1186/1465-9921-13-7
  6. Paternot A, Repessé X, Vieillard-Baron A. Rationale and Description of Right Ventricle-Protective Ventilation in ARDS. Respir Care. 2016 Oct;61(10):1391-6. doi: 10.4187/respcare.04943. Epub 2016 Aug 2. PMID: 27484108.
  7. Guérin, C., Matthay, M.A. Acute cor pulmonale and the acute respiratory distress syndrome. Intensive Care Med 42, 934–936 (2016). https://doi.org/10.1007/s00134-015-4197-z
  8. Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015 Feb 19;372(8):747-55. doi: 10.1056/NEJMsa1410639. PMID: 25693014.
  9. Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013 Jun 6;368(23):2159-68. doi: 10.1056/NEJMoa1214103. Epub 2013 May 20. PMID: 23688302.
  10. Bunge JJH, Caliskan K, Gommers D, Reis Miranda D. Right ventricular dysfunction during acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation. J Thorac Dis. 2018 Mar;10(Suppl 5):S674-S682. doi: 10.21037/jtd.2017.10.75. PMID: 29732186; PMCID: PMC5911554.
  11. de Asua, Ignacio, and Alex Rosenberg. “On the right side of the heart: Medical and mechanical support of the failing right ventricle.” Journal of the Intensive Care Society vol. 18,2 (2017): 113-120. doi:10.1177/1751143716684357
  12. Di Nicolò, P. The dark side of the kidney in cardio-renal syndrome: renal venous hypertension and congestive kidney failure. Heart Fail Rev 23, 291–302 (2018). https://doi.org/10.1007/s10741-018-9673-4
  13. https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20784/abnormal-central-venous-pressure-waveform-patterns
  14. https://derangedphysiology.com/main/cicm-primary-exam/required-reading/respiratory-system/Chapter%20064/factors-which-affect-pulmonary-vascular-resistance
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