Management Of Right Ventricular Failure Research Articles

Pulmonary Hypertension and Right Ventricle: A Pathophysiological Insight.

Pulmonary hypertension (PH) is a pulmonary vascular disease characterized by elevated pulmonary vascular pressure. Long-term PH, irrespective of its etiology, leads to increased right ventricular (RV) pressure, RV hypertrophy, and ultimately, RV failure. Research indicates that RV failure secondary to hypertrophy remains the primary cause of mortality in pulmonary arterial hypertension (PAH). However, the impact of PH on RV structure and function under increased overload remains incompletely understood. Several mechanisms have been proposed, including extracellular remodeling, RV hypertrophy, metabolic disturbances, inflammation, apoptosis, autophagy, endothelial-to-mesenchymal transition, neurohormonal dysregulation, capillary rarefaction, and ischemia. Studies have demonstrated the significant role of oxidative stress in the development of RV failure. Understanding the interplay among these mechanisms is crucial for the prevention and management of RV failure in patients with PH.

Approach to the hospitalized patient with pulmonary arterial hypertension.

Hospitalization in pulmonary arterial hypertension (PAH) patients is an important clinical worsening event significantly associated with subsequent mortality. Furthermore, irrespective of the cause of hospitalization, the overall outcome is closely related to the severity of the right ventricular (RV) dysfunction. Therefore, understanding the pathophysiology of pulmonary hypertension and RV failure is paramount in successfully managing PAH patients requiring hospitalization. This review highlights diagnostic and therapeutic approaches in various clinical scenarios that might be encountered during hospitalization of the World Health Organization group I PAH patient. This article covers recent literature describing risk factors, predictors of outcome and state-of the art management approach to a hospitalized PAH patients with a special focus on management of RV failure and common complications in PAH requiring hospitalization. The review highlights the importance of multidisciplinary approach to a hospitalized PAH patient and highlight important implications in clinical practice and knowledge gaps for potential future research.

Haemodynamic Effects of Sildenafil on Subpulmonic Morphological Left Ventricle in Congenitally Corrected Transposition of Arteries After Left Ventricular Assist Device Implantation

Sildenafil can be used for the management of right ventricular failure after left ventricular assist device (LVAD) implantation. However, the usefulness of sildenafil on subpulmonic morphological left ventricle (pLV) has not been reported. This study reported the haemodynamic effects of sildenafil on pLV after LVAD implantation.

Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review.

Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.

Cohen’s Comprehensive Thoracic Anesthesia

Cohen’s Comprehensive Thoracic Anesthesia

A Different Perspective on the Intraoperative Management of Right Ventricular Failure During Left Ventricular Assist Device Implantation

A Different Perspective on the Intraoperative Management of Right Ventricular Failure During Left Ventricular Assist Device Implantation

Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 2-management of right ventricular failure).

The single most important factor in improving outcomes in right ventricular (RV) failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation, occurs, leading to cardiogenic shock, multi-organ failure, and death. RV dysfunction and failure theoretically can occur in three settings—increase in the pre-load; increase in after load; and decrease in contractility. For patients deemed low risk for the development of RV failure, when it occurs, the correction of underlying cause is the most important and effective treatment strategy. Therapy of RV failure must focus on improving the RV coronary perfusion, lowering pulmonary vascular resistance, and optimizing the pre-load. Pre-load and after-load optimization, ventilator adjustments, and improving the contractility of RV by inotropes are the first line of therapy and should be initiated early to prevent multi-organ damage. Mechanical assist device implantation or circulatory support with extracorporeal membrane oxygenation (ECMO) may be needed in refractory cases.

Evaluation of Inhaled Alprostadil in Hospitalized Adult Patients.

Intermittent inhaled alprostadil (iPGE1) may be a viable alternative to inhaled nitric oxide or epoprostenol for management of right ventricular failure, pulmonary hypertension (pHTN) or acute respiratory distress syndrome (ARDS). However, limited evidence exists regarding iPGE1 use in adults, ideal dosing strategies, or optimal use cases. To describe the clinical characteristics of patients receiving iPGE1 and identify specific sub-populations warranting further research. This was a single-center, retrospective, descriptive analysis of inpatients who received at least one dose of iPGE1. The primary outcome was to describe patient characteristics and alprostadil dosing strategies. Secondary outcomes included changes in respiratory support requirements, hemodynamics, and inotropic/vasoactive use. Outcomes were stratified and compared based on primary therapeutic indication (cardiac or pulmonary). Fifty-four patients received iPGE1 40 (75%) for pulmonary (pHTN or ARDS) and 14 (25%) for cardiac indications. There was no difference between indications in the number of patients de-escalated from level of respiratory (53% vs 57%, P = 0.76), inotropic (70% vs 57%, P = 0.39), or vasopressor support (78% vs 57%, P = 0.17). Furthermore, there was no significant improvement in cardiopulmonary parameters at multiple time intervals after iPGE1 initiation. This is the largest study to date on the use of intermittent iPGE1 in adults. Alprostadil was safely utilized in novel populations; however, efficacy as evaluated by clinical or surrogate endpoints could not be demonstrated and further investigation is needed to determine its potential and optimal place in therapy.

Intensive care management of right ventricular failure and pulmonary hypertension crises.

Pulmonary hypertension (PH), an often unrelenting disease that carries with it significant morbidity and mortality, affects not only the pulmonary vasculature but, in turn, the right ventricle as well. The survival of patients with PH is closely related to the right ventricular function. Therefore, having an understanding of how to manage right ventricular failure (RVF) and acute pulmonary hypertensive crises is imperative for clinicians who encounter these patients. This review addresses the management of these patients in detail, addressing: (a) the pathophysiology of RVF, (b) intensive care monitoring of these patients in the intensive care unit, (c) imaging of the right ventricle, (d) intubation and mechanical ventilation, (e) inotrope and vasopressor selection, (f) pulmonary vasodilator use, (g) interventional and surgical procedures for the acutely failing right ventricle, and (h) mechanical support for RVF.

Management of hospitalized patients with pulmonary arterial hypertension and COVID-19 infection.

Management of hospitalized patients with pulmonary arterial hypertension and COVID-19 infection.

Care for patients with ventricular assist devices and suspected COVID-19 infection.

Care for patients with ventricular assist devices and suspected COVID-19 infection.

Right Ventricular Failure.

Interest in the right ventricle has increased because of advances in pulmonary hypertension treatment, improved diagnostic technology, and increased implantation of left ventricular assist devices and other mechanical circulatory assist devices. Right ventricular dysfunction is an independent predictor of mortality in patients with chronic heart failure. The purpose of this article is to describe the normal structure and function of the right ventricle, causes of right ventricular dysfunction leading to right ventricular failure, diagnostic hemodynamic assessments, and management of right ventricular failure in the critical care unit.

Single Center Experience with a Percutaneous Right Ventricular Assist Device in the Management of Right Ventricular Failure

Purpose Right ventricular assist device (RVAD) support can be beneficial in a variety of clinical scenarios including post cardiotomy RV failure, cardiogenic shock, and severe acute hypoxemic respiratory failure with associated RV dysfunction. Reported mortality after RVAD insertion ranges from 37% to 46%. Percutaneous RVAD support via right internal jugular vein has emerged with the potential for enhanced weaning and ambulation strategies. However, the experience with such an approach remains limited. Methods A comprehensive retrospective review was completed for all patients receiving percutaneous RVAD support via a right internal jugular route at our institution between April 2017 and September 2018. Successful weaning from support, in-hospital mortality, and freedom from device related complications were assessed. Results Percutaneous RVAD support was instituted in 31 patients (22 men, 71%) with a median age of 58 years (19 to 77 years). Indications for implantation were divided into 3 groups. Group 1: Post cardiotomy support (n=18, 58%) including following LVAD insertion, pulmonary thromboendarterectomy, bilateral lung transplant, or cardiac transplantation, Group 2: Cardiogenic shock (n=7, 23%), and Group 3: Primary respiratory failure (n=6, 19 %). There were no failures to wean RVAD in Group 1, compared with 67% failure to wean in Group 2 and 33% in Group 3. Median duration of support in Group 1 was 16 (7-36) days, 5 (1-16) days in Group 2, and 13 (8-18) days in Group 3. All-cause mortality for the entire cohort was 29%. Mortality in Group 1 was 2/18 (11%), Group 2 was 4/7 (57%), and Group 3 was 3/6 (50%). Complications included postoperative bleeding requiring reoperation in 7 (23%) patients, device related superior vena cava obstruction in 3 patients (10%), and device migration in 2 (6%) patients. There were no device-related infections, DVT, valvular damage, or pulmonary emboli observed in this cohort. No patients required transition to implantable long-term RVAD. Conclusion Percutaneous RVAD support appears to be a versatile and effective tool for treating patients with severe RV failure, with best outcomes in the post cardiotomy group. The ability to ambulate these patients while on support and remove the device at the bedside without surgery may permit a more liberal use of this technology with improvements in outcomes in RV failure.

Mechanical Circulatory Support Devices for Acute Right Ventricular Failure.

Right ventricular (RV) failure remains a major cause of global morbidity and mortality for patients with advanced heart failure, pulmonary hypertension, or acute myocardial infarction and after major cardiac surgery. Over the past 2 decades, percutaneously delivered acute mechanical circulatory support pumps specifically designed to support RV failure have been introduced into clinical practice. RV acute mechanical circulatory support now represents an important step in the management of RV failure and provides an opportunity to rapidly stabilize patients with cardiogenic shock involving the RV. As experience with RV devices grows, their role as mechanical therapies for RV failure will depend less on the technical ability to place the device and more on improved algorithms for identifying RV failure, patient monitoring, and weaning protocols for both isolated RV failure and biventricular failure. In this review, we discuss the pathophysiology of acute RV failure and both the mechanism of action and clinical data exploring the utility of existing RV acute mechanical circulatory support devices.

On the right side of the heart: Medical and mechanical support of the failing right ventricle.

Acute right ventricular failure remains an immensely challenging clinical condition associated with a high mortality rate. In this narrative review, we highlight the pathophysiological mechanisms underlying right ventricular failure and suggest an initial diagnostic approach to this critically ill group of patients. Based on the best available evidence and our cumulative clinical experience as a national cardiothoracic centre, we summarize the basic principles of medical management and mechanical salvage therapy, finalizing with a series of recommendations for the management of right ventricular failure in specific clinical scenarios.

Ventricular Assist Devices in Pediatric Cardiac Intensive Care.

The objectives of this review are to discuss the process of patient and mechanical device selection, operative management, and postoperative care with a focus on the management of right ventricular failure, anticoagulation strategies, device-related infections and neurologic sequelae. MEDLINE, PubMed. The number of patients with advanced heart failure due to either acquired or congenital heart disease continues to increase, necessitating in some mechanical circulatory support and in others cardiac transplantation. With a limited cardiac donor pool, mechanical circulatory support is playing a greater role in the management of this population. The perioperative morbidity associated with mechanical circulatory support has lessened with improved postoperative management strategies.

Pulmonary Hypertension in the Intensive Care Unit.

Pulmonary hypertension occurs as the result of disease processes increasing pressure within the pulmonary circulation, eventually leading to right ventricular failure. Patients may become critically ill from complications of pulmonary hypertension and right ventricular failure or may develop pulmonary hypertension as the result of critical illness. Diagnostic testing should evaluate for common causes such as left heart failure, hypoxemic lung disease and pulmonary embolism. Relatively few patients with pulmonary hypertension encountered in clinical practice require specific pharmacologic treatment of pulmonary hypertension targeting the pulmonary vasculature. Management of right ventricular failure involves optimization of preload, maintenance of systemic blood pressure and augmentation of inotropy to restore systemic perfusion. Selected patients may require pharmacologic therapy to reduce right ventricular afterload by directly targeting the pulmonary vasculature, but only after excluding elevated left heart filling pressures and confirming increased pulmonary vascular resistance. Critically-ill patients with pulmonary hypertension remain at high risk of adverse outcomes, requiring a diligent and thoughtful approach to diagnosis and treatment.

Management of pulmonary hypertension and right heart failure in the intensive care unit.

Management of acute right ventricular failure, both with and without coexisting pulmonary hypertension, is a common challenge encountered in the intensive care setting. Both right ventricular dysfunction and pulmonary hypertension portend a poor prognosis, regardless of the underlying cause and are associated with significant morbidity and mortality. The right ventricle is embryologically distinct from the left ventricle and has unique morphologic and functional properties. Management of right ventricular failure and pulmonary hypertension in the intensive care setting requires tailored hemodynamic management, pharmacotherapy, and often mechanical circulatory support. Unfortunately, our understanding of the management of right ventricular failure lags behind that of the left ventricle. In this review, we will explore the underlying pathophysiology of the failing right ventricle and pulmonary vasculature in patients with and without pulmonary hypertension and discuss management strategies based on evidence-based studies as well as our current understanding of the underlying physiology.

Initial clinical experience with a miniaturized transesophageal echocardiography probe in a cardiac intensive care unit.

To investigate the safety of a novel, miniaturized, monoplane transesophageal echocardiography probe (mTEE) and its potential as a hemodynamic monitoring tool. This was a retrospective analysis of the clinical evaluation of a disposable mTEE in ventilated patients with severe cardiogenic shock requiring hemodynamic support. mTEE assessment was performed by operators with mixed levels of TEE training. Information on hemodynamic interventions based on mTEE findings was recorded. A tertiary university cardiac critical care unit. Male and female critical care patients admitted to the unit with severe hemodynamic instability. Insertion of miniaturized disposable TEE probe and hemodynamic and other critical care interventions based on this and conventional monitoring. In 41 patients (51.2% female, 73.2% after cardiac surgery), hemodynamic support probe insertion was accomplished without major complications. A total of 195 mTEE studies were performed, resulting in changes in therapy in 37 (90.2%) patients based on mTEE findings, leading to an improvement in hemodynamic parameters in 33 (80.5%) patients. Right ventricular (RV) failure was diagnosed in 25 patients (67.6%) and mTEE had a direct therapeutic impact on management of RV failure in 17 patients (68 %). Insertion and operation of a novel, miniaturized transoesophageal echocardiography probe can be performed for up to 72 hours without major complications. Repeated assessment using this device provides complementary information to invasive monitoring in the majority of patients and has an impact on hemodynamic management.

Assessment and management of right ventricular failure in left ventricular assist device patients.

Mechanical circulatory support devices, including ventricular assist devices (VADs) and the total artificial heart, have evolved to become accepted therapeutic options for patients with severe congestive heart failure. Continuous-flow left VADs are the most prevalent option for mechanical circulatory assistance and reliably provide years of support. However, problems related to acute and chronic right heart failure in patients with left VADs continue to cause important mortality and morbidity. This review discusses the assessment and management of right ventricular failure in left VAD patients. The goal is to summarize current knowledge and suggest new approaches to managing this problem.