Acute peri-operative left heart failureleft heart failure

Alexandre Mebazaa, Hôpital Lariboisière, Université Paris 7p ,

U942 Inserm

Conflict of InterestConflict of Interest

Lecture fee: Orion

No other conflicts for this lectureNo other conflicts for this lecture

Acute peri-operative heart failureheart failure

Systolic heart failure, mostly after CPB

Diastolic heart failure: post-operativeDiastolic heart failure: post operative period of any surgery

Right ventricular failureg

Practical Recommendations On The Management of Perioperative Heart Failure g

In Cardiac Surgery

Chairpersons: F Follath, W Toller, A MebazaaMebazaa

Faculty: A Pitsis, A Rudiger, D Longrois, S-E Ricksten, I Bobek, SG De Hert, G Wieselthaler, U Schirmer, LK von Segesser, M Sander, D Poldermans, M Ranucci, P Wouters, M Seeberger, ER Schmid, W Weder

Mebazaa et al Crit Care 2010

Practical Recommendations On The Management of Perioperative Heart Failure g

In Cardiac Surgery

EpidemiologyRi k S ifi iRisk StratificationCardioprotective agentsCardioprotective agentsMonitoringPharmacological treatmentClinical scenariosClinical scenariosMechanical circulatory support

Mebazaa et al Crit Care 2010

« Medical » Cardiogenic Shock in ICU: EFICA t d S t Ad i iEFICA study, Symptoms on Admission

SBP H 93 139SBP mmHg 126 93 139 <0.0001DBP mmHg 71 54 77 <0.0001

Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

EFICA StudyP di ti F t f M t litPredictive Factors of Mortality

0.80.91.0

SBP >160 mm Hg% 17%

0.50.60.7

SBP <160 mm Hg

SBP >160 mm Hg

val R

ate,

38%No shock

0.20.30.4

Cardiogenic ShockSur

viv

68%

00.10.2

0 50 100 150 200 250 300 350 4000 50 100 150 200 250 300 350 400

Number of Days

Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

Survival rates of ICU-patients with different acute heart failure syndromes over timeacute ea t a u e sy d o es o e t e

Risk stratification in cardiac surgerycardiac surgery

Group recommendations:

‐Indicators of major clinical risk in the perioperative period are: unstable coronary syndromes, decompensated HF, significant arrhythmias and severe valvular diseasearrhythmias and severe valvular disease‐Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes p , , pmellitus, renal insufficiency and high‐risk surgery‐the EuroScore® predicts perioperative cardiovascular alteration 

llin cardiac surgery well‐BNP measure before surgery is an additional factor of risk stratificationstratification

Mebazaa et al Crit Care 2010

The cardioprotective agents in cardiac surgerycardiac surgery

G d tiGroup recommendation:

A i l i h t f ti d i di‐Aggressively preserving heart function during cardiac surgery is a major goalV l til th ti t b i i di t ti‐Volatile anesthetics seem to be promising cardioprotectiveagentsL i d th t i t d d tl l‐Levosimendan that was introduced more recently also seems to have cardioprotective propertiesL t i l till d d t th b t‐Large trials are still needed to assess the best cardioprotective agent(s) and the optimal protocol to use it

Mebazaa et al Crit Care 2010

Levosimendan Reduces Cardiac Troponin Release After Cardiac Surgery: A Meta-

analysis of Randomized Controlled Studies

Zangrillo et al J Cardiothoracic and Vasc Anesth 2009

Monitoring in cardiac surgeryMonitoring in cardiac surgeryGroup recommendation:p‐Monitoring is aimed to early detect and assess the mechanism(s) of perioperative cardiovascularmechanism(s) of perioperative cardiovascular dysfunction V l t t i id ll d b “d i ”‐Volume status is ideally assessed by “dynamic” measures of haemodynamic parameters before and after volume challenge rather than single measures ‐Heart function is first assessed by echocardiographyy g p yfollowed by PAC, especially in case of right heart dysfunctiondysfunction

Mebazaa et al Crit Care 2010

Echocardiography

Predominent rightventricular failure

Predominent leftventricular failure

Global heart failure

TAMPONADE ?

Yes

Massive mitral regurgitation ?

NoNo

Echocardiographic guided pericardiocentesis or surgical intervention

PA catheterLV dysfunction

Pulmonary hypertension?

RV ischaemia?Any CO

it i

Reduce RV afterload, avoid excess volume use

monitoring,ideally non

invasive

Pulmonary vasodilators

avoid excess volume, use inotropes if CO low

Mebazaa et al. Intensive Care Med, 2004;30:185-96; Antonelli et al. Intensive Care Med, 2007;33:575-90

Optimise LV pre- and afterload,Inotropes if required

Intensive Care Medicine, 2006; 32:9-10

The « pyramid » of echocardiography skills in ICU

Cholley,Vieillard-Baron, Mebazaa, ICM 2006

Management of post-operative hemodynamic failure

SBP < 85mmHg

hemodynamic failureSBP < 85mmHg

Oliguria (<0.5ml/Kg/hour)Clinical signs of tissue hypoperfusion

Heart rate

Volemia VesseltoneMyocardial

functionfunction

Pharmacologic treatment of cardiac dysfunction in the perioperative period of

cardiac surgery (1)Group recommendation‐In case of myocardial dysfunction consider the following 3 options either alone or combined:1)Milrinone decreases PCWP and SVR while stroke volume (SV) and heart rate (HR) increase less than with other inotropes2)Dobutamine improves SV and HR while PCWP moderately decreases3)Levosimendan increases SV and decreases SVR. It also reduces the time to extubation and ICU LOS compared to dobutamine

Mebazaa et al Crit Care 2010

Pharmacologic treatment of cardiac dysfunction in the perioperative period of

‐ Norepinephrine should be used in case of low bloodcardiac surgery (2)

Norepinephrine should be used in case of low blood pressure due to vasoplegia, to maintain an adequate perfusion pressure Volaemia should be repeatedlyperfusion pressure. Volaemia should be repeatedly assessed to ensure that the patient is not h l i hil dhypovolaemic while under vasopressors

‐ Optimal use of inotropes or vasopressors in the perioperative period of cardiac surgery is still controversial and needs further large multinational controversial and needs further large multinational studies

Mebazaa et al Crit Care 2010

Clinical scenarios of cardiac dysfunctiondysfunction

Group recommendation :pThe classification of cardiac impairment in the perioperative period of cardiac surgery should be based 1) on the time of p g y )occurrence:‐precardiotomy (A)p y‐failure to wean (B)‐postcardiotomy (C)and 2) on the haemodynamic severity of the condition of the patient‐crash and burn (1)‐sliding fast (2)‐stable but inotrope dependent (3)

Mebazaa et al Crit Care 2010

Mechanical Circulatory Supporty

Cli i l i C l d d iClinical scenarios Commonly used devicesIABP

I ll 2 5/5A. precardiotomy CS Impella 2.5/5Percutaneous (tranfemoral) ECMO

TandemHeartIABP

B. failure to wean

IABPImpella 5ECMO

Centrifugal pumps as LVAD RVAD BVADCentrifugal pumps as LVAD, RVAD,BVADAbiomed BVS 5000, AB 5000, Thoratec PVAD

Long term implantable devicesIABP

C. postcardiotomy CS

IABPImpella 5ECMO

Centrifugal pumps* as LVAD, RVAD, BVADg p p , ,Percutaneous pulsatile devices** as LVAD, RVAD,BVADLong term implantable devices 1st, 2nd and 3rd generation

Mebazaa et al Crit Care 2010

Acute peri-operative heart failureheart failure

Systolic heart failure, mostly after CPB

Diastolic heart failure: post-operativeDiastolic heart failure: post operative period of any surgery

Right ventricular failureg

Patient’s historyPatient s history

• Men, 72 y.o.• smoker, quit 15 y ago• no diabetes• no diabetes• Admitted for knee surgery• major risk factor: father of an

anesthesiologist!anesthesiologist!

Before surgery 19 hours after surgeryBefore surgery 19 hours after surgeryECG: ischemia, TnI increased, LVEF 48%,

= diastolic dysfunction with a preserved systolic function

↑ Myocardial oxygen

consumption

↓ Coronary oxygen delivery

Increase in body temperature Anemia

MYOCARDIAL

+ +

MYOCARDIAL ISCHEMIA

↓diastolic coronary↓ filli i

TACHYCARDIA

↓ filling time

+

LEFT VENTRICULARDIASTOLIC DYSFUNCTION

Hypovolemia, Pain

Treatment by:diuretics morphine

blood transfusionβ-blockers

PULMONARY CONGESTION

β

Diastolic heart failure in anaesthesia and ICU

Pirracchio et al. Br. J. Anaesth.2007; 98: 707-721

Acute peri-operative heart failureheart failure

Systolic heart failure, mostly after CPB

Diastolic heart failure: post-operativeDiastolic heart failure: post operative period of any surgery

Right ventricular failureg

Right ventricular failure

following CPBfollowing CPB

Mechanims?

Mebazaa et al. Intensive Care Med, 2004;30:185-96

Pulmonary stenosis

Right coronary stenosis

Pulmonary stenosis and RC stenosis

1971

Dilated Right Ventricle !

TR

Auto-aggravation of CO decrease in ARVFRight Ventricular Failure

Reduction in CO + RV dilatation + reduction in LV preloadp

tricuspid regurgitation hypotensiontricuspid regurgitation hypotension

decrease in RCPPdecrease in RCPPorgan's hypoperfusion

+ congestion (acidosis )

greater reduction in CO

+ congestion (acidosis, ...)

greater reduction in CO

Mebazaa et al. Intensive Care Med, 2004;30:185-96

DANGER

Volume loading can be harmfulVolume loading can be harmful

It may worsen liver and kidneyti if RV f ti i tcongestion if RV function is not

previously restoredpreviously restored

volume loading CO is oftenPA

g CO is oftenunchanged

ARVFRAP

RVTR

Increase in AP

CONGESTION

Increase in AP,transaminases and

creatinine

CONGESTION

In AHF-induced liver congestion

• What is/are the mechanism(s) of:

– Increased transaminases?

– Increased alkaline phosphatase ?

AHF i d d li ti

The cardio-hepatic syndromeAHF-induced liver congestion

(increased BNP)

Bile ductcompression

Bile ductcompression

Normalcompression(increased AP)

compression(increased AP)

+++++

+ +++++

and cytolysis(increased transaminases)

In case of RVF, « tailored therapy » i d dis recommended

Low BP: NE is needed to improve right coronary perfusion pressure and organ perfusion pressureHigh PAP: Inhaled NOLow CO/cardioprotection: levosimendan is an optionp

Acute Heart Failure: Global Survey of Standard Treatment

The ALARM-HF StudyThe ALARM-HF Study

F Follath et al. Intensive Care Med (in press) A Mebazaa Intensive Care Med (in press)

All iv inotropes

F Follath et al. Intensive Care Med (in press)

0.6

ty Epinephrine4

0.5

mor

tali Epinephrine

Norepinephrine

0.3

0.4

spita

l m0.

20

In-h

os

Whole cohort

Dopamine

Dobutamine

0.1

Whole cohort

Diuretics

0 5 10 15 20 25 30

0.0 Levosimendan

Diuretics

Vasodilatators0 5 10 15 20 25 30

DaysA Mebazaa Intensive Care Med (in press)

SBP < 100 mmHg SBP 100-119 mmHg

SBP 120-159 mmHg SBP > 160 mmHg

A Mebazaa Intensive Care Med (in press)

Does post-discharge treatment influence short-

d l t t ?and long-term outcome ?

All-Cause Mortality by Beta-Blocker Useat Baseline and Discharge

All-Cause Mortality by Beta-Blocker Useat Baseline and Discharge (n=1000+ patients)at Baseline and Discharge

1.0

at Baseline and Discharge

1.0

( p )va

l 0.9Baseline

Discharge

val 0.9

Baseline

Discharge

of s

urvi

v

0.8 No / Yes

Yes / Yes

of s

urvi

v

0.8 No / Yes

Yes / Yes

babi

lity

o

0.7No / No

Yes / No

babi

lity

o

0.7No / No

Yes / No

0.6Prob

0.6Prob

0.00 30 60 90 120 150 180

0.00 30 60 90 120 150 1800 30

Days since start of study drug infusion60 90 120 150 1800 30

Days since start of study drug infusion60 90 120 150 180

Effects of beta-blockers on patients admitted for acute respiratory failure (n=300+ patients)for acute respiratory failure (n 300+ patients)

No/YesYes/Yes

No/Yes

CARDIAC CAUSES NON-CARDIAC CAUSES

No/No

Yes/YesNo/Yes

No/No

Yes/No

Yes/No

Noveanu et al Crit Care 2010

In summaryIn summary

• In case of low CO in post-operative CPB period:p– Understand the mechanism (echo, PAC)

Give an appropriate treatment– Give an appropriate treatment

• Do not forget to give a post-discharge treatmenttreatment