Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension

Abstract

Intensive care of patients with pulmonary hypertension (PH) and right-sided heart failure includes treatment of factors causing or contributing to heart failure, careful fluid management, and strategies to reduce ventricular afterload and improve cardiac function. Extracorporeal membrane oxygenation (ECMO) should be considered in distinct situations, especially in candidates for lung transplantation (bridge to transplant) or, occasionally, in patients with a reversible cause of right-sided heart failure (bridge to recovery). ECMO should not be used in patients with end-stage disease without a realistic chance for recovery or for transplantation. For patients with refractory disease, lung transplantation remains an important treatment option. Patients should be referred to a transplant centre when they remain in an intermediate- or high-risk category despite receiving optimised pulmonary arterial hypertension therapy. Meticulous peri-operative management including the intra-operative and post-operative use of ECMO effectively prevents graft failure. In experienced centres, the 1-year survival rates after lung transplantation for PH now exceed 90%.

Care of patients with pulmonary arterial hypertension during the coronavirus (COVID‐19) pandemic

“…The focus of this manuscript is on the general management of COVID-19 infection in PAH, as opposed to the other etiologies responsible for decompensation of PAH, which have been addressed elsewhere. 8 The incubation period for COVID-19 is estimated to be four days (interquartile range: 2-7 days). Frequentlyreported symptoms of patients admitted to the hospital with COVID-19 infection include fever, cough, myalgia, fatigue, and shortness of breath (3-31%) at illness onset.…”

“…23 Although ECMO is used in some COVID-19 patients with refractory hypoxemia, in the cases that we have seen to date involving PAH, this modality is particularly challenging and decisions about utilizing this resource-intensive option during a pandemic have to be closely scrutinized, especially in the absence of bridging to transplantation during these difficult times. 8,11,24 Society finds itself in an unenviable position and increasingly will have to make difficult decisions about health care delivery and resource utilization, including the use of precious and intensive interventions such as invasive ventilation and ECMO. In particular, PAH patients will have great difficulty surviving these types of interventions which poses a significant opportunity cost during a pandemic that is stretching the health care system.…”

Acute Respiratory Failure in Interstitial Lung Disease Complicated by Pulmonary Hypertension

“…The RV is normally thin-walled and unable to compensate for acute changes in afterload [43]. Rising RV afterload results in increased RV wall stress, impaired myocardial contractility, and progressive tricuspid regurgitation with distention of the RV [44]. Increases in the resistance of the pulmonary circuit will also contribute to an increase in RV afterload and a decrease in RV stroke volume [45].…”

“…Oxygenation management is largely based on anecdotal experience and individual hospital preference. Supplemental oxygenation should target a peripheral oxygenation saturation >90% [44]. There is little evidence in ILD-ARF to guide which oxygenation strategy is superior when comparing noninvasive positive pressure ventilation (NIPPV) to high flow oxygenation (HFO) delivered by mask or nasal cannula.…”

“…Lung or heart-lung transplantation remain the only definitive treatment option for advanced ILD or ILD-PH in suitable candidates. When maximum medical therapy has failed to improve RV function, oxygenation, and/or ventilation, the next step may be to consider extracorporeal membrane oxygenation (ECMO) candidacy as a bridge transplant or in patients with a reversible cause of RVF [44]. Trudzinski et al (2016) retrospectively studied ECMO outcomes of patients with ILD-ARF.…”