The Battle for Cor Pulmonale (Part II)

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Matt Siuba
Matt Siuba
Zentensivist. ARDS, Mechanical Ventilation, RV, & Shock Enthusiast.
Brendan Riordan
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

Re-join #ThePeoplesVentricle Defense League for Part 2 of acute cor pulmonale in ARDS. If you missed Part 1, get caught up here.

 

In this segment we discuss diagnostic and therapeutic approaches to ACP management.

Timestamps:

  • 0:21 Introduction: Resistance is Futile

  • 1:15 Prevention of ACP

  • 9:09 Identifying ACP with invasive and non-invasive techniques (including POCUS)

  • 15:42 Treatment of ACP

  • 23:55 What about extracorporeal life support for ACP?

  • 27:33 The Bottom Line

The Debrief

  • ACP is best identified with POCUS, whether TTE or TEE. Invasive hemodynamic monitoring may play a role in select circumstances.
  • Targets to monitor response to therapy are not well defined
  • ACP prevention shares common ground with best practices for ARDS including lung-protective ventilation and prone position ventilation. This can be considered “RV-protective ventilation”.
  • Reduction of preload (via diuresis or ultrafiltration) should be considered
  • Afterload reduction is more challenging. Treat acid/base and gas exchange abnormalities as able. Inhaled pulmonary vasodilators are a physiologically appealing therapy for ACP but without strong evidence to support it.
  • Inotropic therapy may be attempted, but is a bridge at best.
  • Consider consultation with an experienced ARDS and extracorporeal life support center if the above was unsuccessful.
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  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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