Critical Care Refresher Course 2016: Cardiovascular

Pulmonary Hypertension (Rothen)

Pulmonary circulation

  • High flow, low pressure, low vascular resistance
  • Determinant of vascular resistance
    • intra or extraluminal obstructions
    • autonomic tone
    • hypoxia, hypercapnia (acidosis)
    • circulating vasoactive substances
    • blood viscosity
  • Interdependence between RV and LV
    • RV dilatation causes septal shift
  • RV adaptation to large increases in pressure is limited

Management of pulmonary hypertension in the ICU

  • Avoid/treat exacerbating factors
    • hypoxaemia/hypercania
    • acidosis, hypothermia, hypotonia, hypervolaemia
  • Consider vasodilators
    • inhaled prostacyclin, nitric oxide
    • PDEi
    • Dobutamine, milrinone, levosimendan


ESC/ERS Guidelines –

Clinical management of pulmonary hypertension –

Doppler-defined pulmonary HTN in medical ICU patients: Retrospective investigation of risk factors & mortality

Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology –

Right heart failure (Vieillard-Baron)


Formal diagnosis of RV failure is difficult

  • Clinical signs – significant congestion, shock
  • Monitoring – Severe RV dilatation, Decreased CO, CVP>PAOP, pulse pressure variation
  • Biological markers – decreased S(c)VO2, Increased lactate, Increased AP

Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. –

ACUTE AND CHRONIC HEART FAILURE ESC Clinical Practice Guidelines –

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine –

Right ventricular function during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome. –

Echo–Doppler Demonstration of Acute Cor Pulmonale at the Bedside in the Medical Intensive Care Unit –

Is ARDS usually associated with RV dysfunction or failure –

Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation –

Outcome prediction in sepsis: Speckle tracking echo based assessment of myocardial function –

Valvular heart disease (Maggiorini)

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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease –

Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement –

4-Year Results of a RCT of Percutaneous Repair Versus Surgery for Mitral Regurgitation –