Management of Acute Right Ventricular Failure in the Intensive Care Unit

Abstract

Right ventricular (RV) failure occurs when the RV fails to maintain enough blood flow through the pulmonary circulation to achieve adequate left ventricular filling. This can occur suddenly in a previously healthy heart due to massive pulmonary embolism or right-sided myocardial infarction, but many cases encountered in the intensive care unit involve worsening of compensated RV failure in the setting of chronic heart and lung disease. Management of RV failure is directed at optimizing right-sided filling pressures and reducing afterload. Due to a lower level of vascular tone, vasoactive medications have less salient effects on reducing vascular resistance in the pulmonary than in the systemic circulation. Successful management requires reversal of any conditions that heighten pulmonary vascular tone and the use of selective pulmonary vasodilators at doses that do not induce systemic hypotension or worsening of oxygenation. Systemic systolic arterial pressure should be kept close to RV systolic pressure to maintain RV perfusion. When these efforts fail, the judicious use of inotropic agents may help improve RV contractility enough to maintain cardiac output. Extracorporeal life support is increasingly being used to support patients with acute RV failure who fail to respond to medical management while the underlying cause of their RV failure is addressed.

Extracorporeal Membrane Oxygenation for Post Cardiotomy Acute Right Ventricle Failure in Adults

“…Failure of these measures may entail judicious use of inotropy to enhance RV contractility. The use of extracorporeal life support is on a constant rise to help patients who have acute RV failure and are pessimistically responsive non surgical steps in addition to addressing the precipitant of RV failure [2]. Mechanical support in patient with fulminant RV dysfunction has been well addressed by using right ventricular assist device (RVAD) and ubiquitously reported [3].…”

“…The treatment strategies employed to offset RV failure include optimization of preload and afterload, rhythm control, possible reversal of the etiological factors, prudent inotropy, venoarterial ECMO, RV assist devices, atrial septostomy and cardiac transplant. Extracoporeal membrane oxygenation (ECMO) is a well-documented salvage for cardiac, respiratory and septic shock states [2]. However, limited data is at hands regarding ECMO use for post cardiotomy isolated right heart failure.…”

Pulmonary Embolism

“…19,20 The pulmonary circulation is a low pressure system, and the combined effect of mechanical obstruction and hypoxic vasoconstriction mediated by inflammatory markers results in an increase in pulmonary vascular resistance. 21 Increase in RV afterload is due to an increase in PVR. The right ventricle is a thin-wall chamber that cannot withstand sudden surges in pressure.…”

Is There a Role for Invasive Hemodynamic Monitoring in Acute Heart Failure Management?

“…Measurements of pulmonary artery pressure are particularly indicated in the cases of right ventricular dysfunction where evaluation of the right ventricular afterload is crucial for diagnosis as well as for guiding therapy [26]. Except with echocardiography, there is no other means to determine pulmonary artery pressure at bedside.…”