B. Stobierska-dzierzek et al., The evolving management of acute right-sided heart failure in cardiac transplant recipients, J AM COL C, 38(4), 2001, pp. 923-931
Citations number
56
Categorie Soggetti
Cardiovascular & Respiratory Systems","Cardiovascular & Hematology Research
Avoidance of the clinical syndrome of acute right-sided heart failure after
heart transplantation is, unfortunately, not possible. Clinical experience
and the literature certainly suggest that a significant factor in the succ
essful management of right ventricular (RV) failure is recipient selection.
Moreover, threshold hemodynamic values beyond which RV failure is certain
to occur and heart transplantation is contraindicated do not exist. Nor are
there values below which RV failure is always avoidable. Acute RV failure
will remain a difficult and ever-present clinical syndrome in the transplan
t recipient. Goals in the treatment of this clinical problem include:
1. Preserving coronary perfusion through maintenance of systemic blood pres
sure.
2. Optimizing RV preload.
3. Reducing RV afterload by decreasing pulmonary vascular resistance (PVR).
4. Limiting pulmonary vasoconstriction through ventilation with high inspir
ed oxygen concentrations (100% FiO(2)), increased tidal volume and optimal
positive end expiratory pressure ventilation.
Inhaled nitric oxide is recommended before leaving the operating room in ca
ses where the initial therapies have had little impact. Intra-aortic balloo
n counterpulsation is employed in patients with impaired left ventricular (
LV) function and may be of benefit in patients with RV dysfunction resultin
g from ischemia, preservation injury or reperfusion injury. Optimal LV func
tion reduces RV afterload and PVR. A proactive decision regarding RV assist
device implantation is made before leaving the operating room and is highl
y dependent upon overall hemodynamics, size and function of the ventricles
as seen on transesophageal echocardiography, renal function and surgical bl
eeding. Only through careful preoperative planning can this life-threatenin
g condition be managed in the postoperative period. (C) 2001 by the America
n College of Cardiology.