Yoğun Bakım ve Akut Sağ Kalp Yetmezliği
Özet
Akut dekompanse pulmoner hipertansiyon (PHT), akut sağ ventrikül (RV) disfonksiyonu ve multiorgan disfonksiyonu gelişme riski olan; mortalitesi yüksek seyreden bir klinik durumdur. Artmış pulmoner vasküler rezistansın (PVR) ilerlemesiyle gelişen RV disfonksiyonu patofizyolojideki esas sebep olmakla birlikte, hastalarda sıklıkla akut dekompanzasyonu başlatan tetikleyici bir mekanizma da mevcuttur. Prognoz direkt olarak RV performansı ile ilişkili olup, hastaların takibinde de esas olarak kardiyak debi ve sistemik dolaşım ön planda olmalıdır. Multidisipliner olarak takip edilmesi gereken bu tabloda, hastaların sıvı dengesinin sağlanması, kardiyak kontraktilitenin artırılması, gerekli hastalarda sistemik perfüzyonun devamı için vazopressör tedavi verilmesi ve altta yatan PHT'ye yönelik art yük azaltıcı tedavi verilmesi klinik yönetimin temel taşlarıdır. Geliştirilen birçok tedavi ve takip yöntemine rağmen refrakter RV disfonksiyonu olan hastalarda zaman kaybetmeden ekstrakorporeal yaşam desteği (ECLS) sağlanması ve organ nakline hazırlık yapılması hastaların yaşam şansını artırır.
Acute decompensated pulmonary hypertension (PH) is a clinical condition associated with a high risk of acute right ventricular (RV) dysfunction and multiorgan dysfunction, and it follows a course with high mortality. Although RV dysfunction that develops with the progression of increased pulmonary vascular resistance (PVR) is the principal underlying pathophysiological mechanism, a triggering factor that precipitates acute decompensation is also frequently present. Prognosis is directly related to RV performance; therefore, cardiac output and systemic circulation should be the primary focus during patient monitoring. In this condition, which must be managed by a multidisciplinary team, the cornerstones of clinical management are the optimization of the patient's fluid balance, augmentation of cardiac contractility, administration of vasopressor therapy to maintain systemic perfusion in patients who require it, and afterload-reducing therapy directed at the underlying PH. Despite the many therapeutic and monitoring methods that have been developed, in patients with refractory RV dysfunction, providing extracorporeal life support (ECLS) without delay and preparing for organ transplantation increase the patients' chance of survival.
Referanslar
Vonk-Noordegraaf A, Haddad F, Chin KM, Forfia PR, Kawut SM, Lumens J, et al. [Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology]. Turk Kardiyol Dern Ars. 2014;42 Suppl 1:29-44.
Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618-731.
Vonk Noordegraaf A, Westerhof BE, Westerhof N. The Relationship Between the Right Ventricle and its Load in Pulmonary Hypertension. J Am Coll Cardiol. 2017;69(2):236-43.
Savale L, Weatherald J, Jais X, Vuillard C, Boucly A, Jevnikar M, et al. Acute decompensated pulmonary hypertension. Eur Respir Rev. 2017;26(146).
Haddad F, Peterson T, Fuh E, Kudelko KT, de Jesus Perez V, Skhiri M, et al. Characteristics and outcome after hospitalization for acute right heart failure in patients with pulmonary arterial hypertension. Circ Heart Fail. 2011;4(6):692-9.
Kurzyna M, Zylkowska J, Fijalkowska A, Florczyk M, Wieteska M, Kacprzak A, et al. Characteristics and prognosis of patients with decompensated right ventricular failure during the course of pulmonary hypertension. Kardiol Pol. 2008;66(10):1033-9; discussion 40-1.
Masih R, Paudyal V, Basnet YM, Sunesara S, Sharma M, Surani S. Revisiting Acute Decompensated Right Ventricle Failure in Pulmonary Arterial Hypertension. Open Respir Med J. 2025;19:e18743064359315.
Ronco C, House AA, Haapio M. Cardiorenal syndrome: refining the definition of a complex symbiosis gone wrong. Intensive Care Med. 2008;34(5):957-62.
Sztrymf B, Souza R, Bertoletti L, Jais X, Sitbon O, Price LC, et al. Prognostic factors of acute heart failure in patients with pulmonary arterial hypertension. Eur Respir J. 2010;35(6):1286-93.
Hoeper MM, Granton J. Intensive care unit management of patients with severe pulmonary hypertension and right heart failure. Am J Respir Crit Care Med. 2011;184(10):1114-24.
Humbert M, Sitbon O, Chaouat A, Bertocchi M, Habib G, Gressin V, et al. Survival in patients with idiopathic, familial, and anorexigen-associated pulmonary arterial hypertension in the modern management era. Circulation. 2010;122(2):156-63.
Inampudi C, Tedford RJ, Hemnes AR, Hansmann G, Bogaard HJ, Koestenberger M, et al. Treatment of right ventricular dysfunction and heart failure in pulmonary arterial hypertension. Cardiovasc Diagn Ther. 2020;10(5):1659-74.
Kerbaul F, Rondelet B, Motte S, Fesler P, Hubloue I, Ewalenko P, et al. Effects of norepinephrine and dobutamine on pressure load-induced right ventricular failure. Crit Care Med. 2004;32(4):1035-40.
Chen EP, Bittner HB, Davis RD, Jr., Van Trigt P, 3rd. Milrinone improves pulmonary hemodynamics and right ventricular function in chronic pulmonary hypertension. Ann Thorac Surg. 1997;63(3):814-21.
Kerbaul F, Rondelet B, Demester JP, Fesler P, Huez S, Naeije R, et al. Effects of levosimendan versus dobutamine on pressure load-induced right ventricular failure. Crit Care Med. 2006;34(11):2814-9.
Jardin F, Vieillard-Baron A. Right ventricular function and positive pressure ventilation in clinical practice: from hemodynamic subsets to respirator settings. Intensive Care Med. 2003;29(9):1426-34.
Sitbon O, Jais X, Savale L, Cottin V, Bergot E, Macari EA, et al. Upfront triple combination therapy in pulmonary arterial hypertension: a pilot study. Eur Respir J. 2014;43(6):1691-7.
Jais X, Launay D, Yaici A, Le Pavec J, Tcherakian C, Sitbon O, et al. Immunosuppressive therapy in lupus- and mixed connective tissue disease-associated pulmonary arterial hypertension: a retrospective analysis of twenty-three cases. Arthritis Rheum. 2008;58(2):521-31.
Javidfar J, Brodie D, Iribarne A, Jurado J, Lavelle M, Brenner K, et al. Extracorporeal membrane oxygenation as a bridge to lung transplantation and recovery. J Thorac Cardiovasc Surg. 2012;144(3):716-21.
Ius F, Tudorache I, Warnecke G. Extracorporeal support, during and after lung transplantation: the history of an idea. J Thorac Dis. 2018;10(8):5131-48.
Strueber M, Hoeper MM, Fischer S, Cypel M, Warnecke G, Gottlieb J, et al. Bridge to thoracic organ transplantation in patients with pulmonary arterial hypertension using a pumpless lung assist device. Am J Transplant. 2009;9(4):853-7.
Campo A, Mathai SC, Le Pavec J, Zaiman AL, Hummers LK, Boyce D, et al. Outcomes of hospitalisation for right heart failure in pulmonary arterial hypertension. Eur Respir J. 2011;38(2):359-67.
Teboul JL, Saugel B, Cecconi M, De Backer D, Hofer CK, Monnet X, et al. Less invasive hemodynamic monitoring in critically ill patients. Intensive Care Med. 2016;42(9):1350-9.
