Pulse-pressure variation and hemodynamic response in patients with elevated pulmonary artery pressure: a clinical study

Abstract

IntroductionPulse-pressure variation (PPV) due to increased right ventricular afterload and dysfunction may misleadingly suggest volume responsiveness. We aimed to assess prediction of volume responsiveness with PPV in patients with increased pulmonary artery pressure.MethodsFifteen cardiac surgery patients with a history of increased pulmonary artery pressure (mean pressure, 27 ± 5 mm Hg (mean ± SD) before fluid challenges) and seven septic shock patients (mean pulmonary artery pressure, 33 ± 10 mm Hg) were challenged with 200 ml hydroxyethyl starch boli ordered on clinical indication. PPV, right ventricular ejection fraction (EF) and end-diastolic volume (EDV), stroke volume (SV), and intravascular pressures were measured before and after volume challenges.ResultsOf 69 fluid challenges, 19 (28%) increased SV > 10%. PPV did not predict volume responsiveness (area under the receiver operating characteristic curve, 0.555; P = 0.485). PPV was ≥13% before 46 (67%) fluid challenges, and SV increased in 13 (28%). Right ventricular EF decreased in none of the fluid challenges, resulting in increased SV, and in 44% of those in which SV did not increase (P = 0.0003). EDV increased in 28% of fluid challenges, resulting in increased SV, and in 44% of those in which SV did not increase (P = 0.272).ConclusionsBoth early after cardiac surgery and in septic shock, patients with increased pulmonary artery pressure respond poorly to fluid administration. Under these conditions, PPV cannot be used to predict fluid responsiveness. The frequent reduction in right ventricular EF when SV did not increase suggests that right ventricular dysfunction contributed to the poor response to fluids.

Feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients

“…In this context it has been shown that concomitant tricuspid regurgitation is associated with underestimation of cardiac output measured by thermodilution [47]. In addition, clinically used parameters to estimate volume responsiveness seem to be unreliable in patients with right heart dysfunction [48,49]. Finally, hTEE monitoring was non-inferior to standard patient care in guiding norepinephrine treatment.…”

Radial–femoral concordance in time and frequency domain-based estimates of systemic arterial respiratory variation

“…Arterial respiratory variation is a promising clinical variable but has some shortcomings [19][20][21]. In particular, while there is a statistically significant relationship between respiratory variation and response to fluid loading, substantial individual variability limits the predictive capabilities of these metrics [22].…”

Management of Crashing Patients with Pulmonary Hypertension

“…Traditional methods of assessing fluid responsiveness, such as central venous pressure, pulse pressure variation, and stroke volume variation, are unreliable in patients with RV dysfunction. 62,63 Elevation in plasma atrial natriuretic peptide and BNP seems to increase proportionately to the extent of RV dysfunction in patients with PH. 54,64 The traditional gold standard for the diagnosis and management of PH and RV dysfunction is pulmonary artery catheterization (PAC).…”