Rising Central venous pressure: Impending right-sided failure?
Monish S Raut1, Arun Maheshwari1, Vinayak Desurkar2, Rajesh Bhavsar3 1 Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi, India 2 Department of Cardiac Anesthesiology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India 3 Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
Central venous pressure generally indicates right sided cardiac filling pressure. Although it is a static hemodynamic parameter, however trend of CVP gives important information regarding the patient's management. Patient with left ventricular assist device is prone to develop right ventricular dysfunction which can easily be suspected by trend of CVP. However rising CVP does not always imply right heart dysfunction.
Keywords:Central venous pressure, localized tamponade, right heart dysfunction
How to cite this article: Raut MS, Maheshwari A, Desurkar V, Bhavsar R. Rising Central venous pressure: Impending right-sided failure?. Ann Card Anaesth 2017;20:440-1
How to cite this URL: Raut MS, Maheshwari A, Desurkar V, Bhavsar R. Rising Central venous pressure: Impending right-sided failure?. Ann Card Anaesth [serial online] 2017 [cited 2021 Sep 28];20:440-1. Available from: https://www.annals.in/text.asp?2017/20/4/440/216267
A 48-year-male patient presented with severe shortness of breath. He was diagnosed as dilated cardiomyopathy with severe left ventricular systolic dysfunction (left ventricular ejection fraction 20%) with severe mitral regurgitation. Tricuspid annular plane systolic excursion was 14 mm. He was put on heart transplant waiting list. Considering the progressive heart failure, HeartWare-left ventricular assist device (LVAD) was inserted as a bridge to transplant to maintain the hemodynamics and systemic perfusion. Intraoperatively, LVAD flow was adjusted using transesophageal echocardiography examination to maintain interventricular septum midline. Central venous pressure (CVP) was 10 mmHg and mean arterial pressure (MAP) was 64 mmHg at the heart rate of ~70/min. Six hours after the device implantation, CVP gradually started rising from 10 to 20 mm Hg with decline in MAP to 52 mmHg and tachycardia (heart rate - 96–110 mmHg). Failure of the right ventricle (RV) has been reported to occur in up to 44% of LVAD recipients postimplant. Considering the possibility of RV failure in the present case, inodilator milrinone intravenous infusion at a dose of 0.5 μg/kg/min was started to reduce pulmonary vascular resistance. Intravenous adrenaline infusion was escalated from 0.05 to 0.1 μg/kg/min to maintain systemic pressure. Caution was taken to avoid hypoxia, hypercapnia, and acidosis by adjusting mechanical ventilatory settings. LVAD flow also started decreasing, probably the reason, we believed, could be impaired RV systolic function giving low output to LV. Overall clinical parameters (rising CVP, decreasing LVAD flow, tachycardia, and falling MAP) were giving indication for RV assist device (RVAD) placement. Reported incidence of RVAD implantation is 23% after LVAD placement. Transthoracic echocardiography examination was inconclusive due to poor echo window. Hence, bedside transesophageal echocardiography was performed as the patient was already sedated and on mechanical ventilatory support. It revealed midline position of interventricular septum and no evidence of suction event by inflow cannula. However, large collection compressing right atrial free wall was observed [Figure 1] and Video 1. This localized tamponade on right atrium caused significant rise of CVP and diminished filling of RV and thereby reduced preload to LV. In operating room, chest was reopened and localized collection was drained and hemodynamics and LVAD flow improved thereafter [Figure 2] and Video 2. Due to continuous flow by LVAD, clinical sign such as pulsus paradoxus is not observed in such cases. Point-of-care bedside transesophageal echocardiographic examination rules out RV failure and thereby unnecessary RVAD implantation. It diagnosed the exact cause of hemodynamic deterioration.
Figure 1: Midesophageal four-chamber echocardiographic (transesophageal echocardiography) view showing large collection causing right atrial localized tamponade
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