Management Of Right Ventricular Failure Research Articles

Ask the Expert: Management of Right Ventricular Failure in Acute Pulmonary Embolism

Ask the Expert: Management of Right Ventricular Failure in Acute Pulmonary Embolism

Pulmonary hypertension and its management in patients undergoing non-cardiac surgery.

Pulmonary hypertension is a complex disorder of the pulmonary vasculature that leads to increased peri-operative morbidity and mortality. Non-cardiac surgery constitutes a significant risk in patients with pulmonary hypertension. The management of right ventricular failure is inherently challenging and fraught with life-threatening consequences. A thorough understanding of the pathophysiology, the severity of the disease and its treatment modalities is required to deliver optimal peri-operative care. This review provides an evidence-based overview of the definition, classification, pathophysiology, diagnosis and treatment of pulmonary hypertension and focuses on the peri-operative management and treatment of pulmonary hypertensive crises in a non-cardiac setting.

Management of acute right ventricular failure in the intensive care unit.

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.

Management of Right Ventricular Failure in Pulmonary Hypertension (and After LVAD Implantation)

Right ventricular failure (RVF) is increasingly recognized as a complicating feature of a number of disease states, including pulmonary arterial hypertension (PAH) and advanced heart failure. It not only contributes to symptoms and complicates management, but also dramatically impacts prognosis. In PAH, early disease detection and institution of PAH therapy can prevent or delay RVF. Once established, therapy for RVF focuses on optimizing afterload reduction with PAH therapy, controlling volume, and judiciously using inotropic support when needed. In patients undergoing implantation of a LVAD, preoperative assessment and management of RVF is critical. Risk factors for the development of RVF after LVAD have been described, and may identify a population best managed with biventricular support. Postoperative management of RVF focuses on supportive therapy, judicious use of inotropes and volume management. Ongoing research may yield insights into specific therapies to prevent or reverse RVF.

Preoperative Evaluation and Perioperative Management of Right Ventricular Failure After Left Ventricular Assist Device Implantation

Right ventricular (RV) failure continues to be a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Preoperative evaluation of RV function with a variety of clinical, laboratory, echocardiographic, and hemodynamic variables is essential to ensure appropriate patient selection for LVAD therapy but remains imperfect. Therefore, clinicians involved in the care of these patients need to be prepared to manage RV failure after LVAD placement. Perioperative management of RV failure after LVAD implantation requires minimization of intraoperative RV ischemia, maintenance of appropriate filling pressure, supportive therapy with pulmonary vasodilators and inotropes, and surgical interventions such as RV assist devices in select cases. This article reviews the incidence of RV failure with LVAD implantation, preoperative predictors of RV failure, and perioperative management strategies.

Temporary right ventricular mechanical circulatory support for the management of right ventricular failure in critically ill patients

Management of right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is not evidence based. Temporary circulatory assistance has recently been reported to be of value for managing postoperative RV failure after LVAD implantation, but only in small series of patients or isolated case reports. We report here our experience with the use of temporary right ventricular assist devices (RVADs) in LVAD recipients. Forty-five of the 488 (9%) patients undergoing LVAD implantation between 2001 and 2011 at the Clinic for Thoracic and Cardiovascular Surgery in Bad Oeynhausen had RV failure requiring temporary RVAD. We analyzed preoperative data, complications, mortality at 6 months, and risk factors of death. The LVAD patients receiving temporary RVAD were younger than the 443 recipients of LVAD alone. They were more likely to have mechanical ventilation and haemofiltration and their Michigan right ventricular risk score was higher. The LVAD patients with temporary RVAD had a higher mortality at 6 months: 53%, versus 25% for patients receiving LVAD only (P<.001). The univariate risk factors for death were high blood urea nitrogen and C-reactive protein concentrations, preoperative mechanical ventilation, preoperative hemofiltration, destination therapy, the use of temporary RVAD, and the development of RV failure. Multivariate analyses did not identify predictors of death. The development of RV failure in LVAD recipients is a serious problem associated with high mortality. Temporary RV mechanical support is an acceptable way to manage postoperative RV failure in these severely ill LVAD recipients.

Assessment and treatment of right ventricular failure

Right ventricular (RV) failure is a complex problem with poor outcomes. Diagnosis requires a high degree of clinical suspicion, because many of the signs and symptoms of this condition are nonspecific and can be acute or chronic. Identification of the underlying aetiology, which can include pulmonary hypertension, cardiomyopathy, myocardial infarction, congenital or valvular heart disease, and sepsis, is essential. Echocardiography is the technique of choice for first-line assessment, but cardiac MRI is the current gold standard for anatomical and functional assessment of the right ventricle. Therapy for RV failure should be directed at the underlying cause, although management of symptoms is also important. Therapeutic options range from pharmacological treatment to mechanical RV support and heart transplantation. The complex 3D geometry of the right ventricle and its intricate interactions with the left ventricle have left many questions about RV failure unanswered. However, promising new targeted therapies are under development and mechanical support is becoming increasingly feasible. The next decade will be an exciting time for advances in our understanding and management of RV failure.

Perioperative right ventricular dysfunction

To evaluate new information on the importance of right ventricular function, diagnosis and management in cardiac surgical patients. There is growing evidence that right ventricular function is a key determinant in survival in cardiac surgery, particularly in patients with pulmonary hypertension. The diagnosis of this condition is helped by the use of specific hemodynamic parameters and echocardiography. In that regard, international consensus guidelines on the echocardiographic assessment of right ventricular function have been recently published. New monitoring modalities in cardiac surgery such as regional near-infrared spectroscopy can also assist management. Management of right ventricular failure will be influenced by the presence or absence of myocardial ischemia and left ventricular dysfunction. The differential diagnosis and management will be facilitated using a systematic approach. The use of right ventricular pressure monitoring and the publications of guidelines for the echocardiographic assessment of right ventricular anatomy and function allow the early identification of right ventricular failure. The treatment success will be associated by optimization of the hemodynamic, echocardiographic and near-infrared spectroscopy parameters.

Acute right ventricular failure

Acute right ventricular (RV) failure is a serious clinical challenge not only in cardiology intensive care but in adult critical care in general. It is related not only to left ventricular failure but also to a number of other causes of pulmonary vascular dysfunction and pulmonary hypertension (PH), for example, PH due to hypoxia, thromboembolism, mechanical ventilation or portopulmonary hypertension. Acute RV failure is often difficult to manage and it is associated with a worse prognosis. Mortality from cardiogenic shock due to RV infarction (&gt;50%) exceeds that due to left ventricular disease. Acute RV failure is also related to increased mortality after surgical procedures. The general principles of management include pre-load optimization, increase in RV inotropy and after-load reduction by lowering pulmonary vascular resistance. This review focuses on the principles of RV failure management including general measures, vasoactive substances, ventilation strategies, surgical as well as mechanical approaches.

Management of Acute Right Ventricular Failure in the Intensive Care Unit

Acute failure of the right ventricle is a common challenge in the intensive care unit that is associated with significant morbidity and mortality. Although often a complication of left ventricular failure, right ventricular failure is a distinct clinical entity, both in terms of its hemodynamic abnormalities and response to treatment. Effective management of right ventricular failure must consider the unique properties of the right ventricle and the pulmonary circulation, and their response to common pharmacologic and mechanical interventions. In this review, we present a contemporary approach to patients with acute failure of the right ventricle including strategies for mechanical ventilation, hemodynamic management, and mechanical circulatory support.

Right Ventricular Infarction

Right Ventricular Infarction

Pulmonary Hypertension and Right Ventricular Dysfunction: Physiology and Perioperative Management

PULMONARY HYPERTENSION (PH) is a life-threatening disease with a complex pathophysiology that if undiagnosed culminates in progressive increases in the pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR), which inevitably lead to right ventricular (RV) failure and death. 1 McLaughlin V. McGoon M. Pulmonary arterial hypertension. Circulation. 2006; 114: 1417-1431 Crossref PubMed Scopus (295) Google Scholar , 2 Farber H. Loscalzo J. Pulmonary arterial hypertension. N Engl J Med. 2004; 351 (655–166) Crossref PubMed Scopus (576) Google Scholar , 3 Fishman A.P. A century of pulmonary hemodynamics. Am J Respir Crit Care Med. 2004; 170: 109-113 Crossref PubMed Google Scholar , 4 Taichman D. Mandel J. Epidemiology of pulmonary hypertension. Clin Chest Med. 2007; 28: 1-22 Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar , 5 Dresdale D.T. Schultz M. Michtom R.J. Primary pulmonary hypertension I, clinical and hemodynamic study. Am J Med. 1951; 11: 686-705 Abstract Full Text PDF PubMed Google Scholar Unfortunately, significant delays in diagnosis and treatment occur because of nonspecific disease symptomatology, relative low incidence (2-5 persons/million/y in the United States), and general unfamiliarity with the disease. Role of Ketamine in the Management of Pulmonary Hypertension and Right Ventricular FailureJournal of Cardiothoracic and Vascular AnesthesiaVol. 26Issue 3PreviewWe read with interest the excellent review by Strumpher and Jacobsohn of pulmonary hypertension and right ventricular dysfunction.1 However, we take issue with the authors' statement during their discussion of the management of right ventricular failure that “ketamine … increase[s] [pulmonary vascular resistance] PVR and should be avoided.” We believe it is an overly negative and simplistic assessment of the role of ketamine in this context, and that it would lead readers to dismiss an agent that has significant potential benefits in this setting. Full-Text PDF

Management of Right Ventricular Failure in the Era of Ventricular Assist Device Therapy

The increasing incidence of patients with advanced heart failure, limited donor availability, and continued advancements in the field of mechanical circulatory support have made implantation of left ventricular assist device therapy (LVAD) an attractive option for patients with end-stage heart failure. Perioperative right ventricular failure (RVF) occurs frequently in patients undergoing LVAD implantation and is associated with significant morbidity and mortality. This review will discuss the pathophysiology of RVF, recent efforts to risk-stratify patients preoperatively, and current preoperative, perioperative, and postoperative management strategies.

New insights for the diagnosis and management of right ventricular failure, from molecular imaging to targeted right ventricular therapy

Despite the recognition of a critical role of the right ventricle (RV) in many aspects of cardiovascular medicine, there has been surprisingly little interest in right ventricular-targeted imaging and therapeutic approaches. Compared with the left ventricle, the RV has a different embryologic origin, undergoes a dramatic change during the transition from the fetal to the adult circulation and normally operates in a low resistance or impedance arterial system. Here, we review new insights on the pathophysiology, assessment and management of right ventricular failure. Our understanding of the mechanisms underlying right ventricular failure has improved. As in the left ventricle, decrease in alpha-myosin heavy chain and a switch towards glycolysis from fatty acid oxidation is observed in the stressed RV, but the key question remains unanswered: why is the RV so much more vulnerable to failure upon afterload increase compared with the left ventricle? In assessing the RV, it is becoming increasingly important to consider the RV and pulmonary artery as a unit. New therapies that could specifically target the RV, such as metabolic modulators and phosphodiesterase type 5 inhibitors, are now being considered. A better understanding of the molecular mechanisms of right ventricular failure will lead to the development of new strategies for the diagnosis and management of right ventricular failure. Right ventricular-targeted therapies are needed in a number of diseases in which only the RV fails.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management

The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in cardiac surgery and heart transplantation. In the first article of this review, key features of RV anatomy, physiology, and assessment were presented. In this second part, we review the pathophysiology, clinical importance, and management of RV failure in cardiac surgery.

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: I. Anatomy, Physiology, and Assessment

The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in heart failure, congenital heart disease, valvular disease, and cardiac surgery. In the first of our two articles, we will review key features of RV anatomy, physiology, and assessment. In the first article, the main discussion will be centered on the echographic assessment of RV structure and function. In the second review article, pathophysiology, clinical importance, and management of RV failure in cardiac surgery will be discussed.

Mitochondrial Medicine

Socrates: … And he who is most skilled in preventing or escaping from a disease is best able to create one? Polemarchus: True Socrates: And is he the best guard of a camp who is best able to steal a march upon the enemy? Polemarchus: Certainly Socrates: Then he who is a good keeper of everything is also a good thief? Polemarchus: That I suppose is to be inferred — —Plato, The Republic Reading Plato one might not be surprised by the apparent paradox in the ability of mitochondria to promote both life and death: On the one hand, they are the major producers of energy in the cell, and on the other hand, they can steal the life of their host “at will.” Mitochondria can sense the supply of fuel (they are important O2 sensors) and via the production of mediators (reactive O2 species [ROS]), communicate with critical effectors in the cell (like redox-sensitive ion channels in the membrane or the nucleus).1 In response to the needs of the cell, mitochondria produce both energy (ie, ATP) and heat, allowing the organism to work and keep a stable core temperature, facilitating optimal adaptation of eukaryotic cells to their environment. If the mitochondria cannot provide optimal adaptation to the metabolic needs and the environment, they have the ability to induce cell death (apoptosis). As strategic regulators of life and death, mitochondria are deeply involved in human disease, but the depth and breadth of mitochondria-based diseases is only now starting to be recognized.2 Article p 2492 Metabolism and apoptosis converge in mitochondria and are both recognized as playing a major role in disease. Primary metabolic abnormalities are now recognized in pulmonary and systemic vascular disease, and the apoptosis resistance seen in proliferative vascular remodeling might have a mitochondrial …

Right Ventricular Function in Cardiovascular Disease, Part II

Right ventricular (RV) function may be impaired in pulmonary hypertension (PH), congenital heart disease (CHD), and coronary artery disease and in patients with left-sided heart failure (HF) or valvular heart disease. In recent years, many studies have demonstrated the prognostic value of RV function in cardiovascular disease. In the past, however, the importance of RV function has been underestimated. This perception originated from studies on open-pericardium dog models and from the observation that patients may survive without a functional subpulmonary RV (Fontan procedure). In the 1940s, studies using open-pericardium dog models showed that cauterization of the RV lateral wall did not result in a decrease in cardiac output or an increase in systemic venous pressure.1–3 As was later demonstrated, the open-pericardium model did not take into account the complex nature of ventricular interaction. In 1982, Goldstein and colleagues2 showed that RV myocardial infarction (RVMI) in a closed-chest dog model led to significant hemodynamic compromise. These findings were further supported by clinical studies demonstrating an increased risk of death, arrhythmia, and shock in patients with RVMI.4 The study of the RV is a relatively young field. In 2006, the National Heart, Lung, and Blood Institute identified RV physiology as a priority in cardiovascular research.5 The goal of this review is to present a clinical perspective on RV physiology and pathobiology. In the first article of the series, the anatomy, physiology, embryology, and assessment of the RV were discussed. In this second part, we discuss the pathophysiology, clinical importance, and management of RV failure. RV failure is a complex clinical syndrome that can result from any structural or functional cardiovascular disorder that impairs the ability of the RV to fill or to eject blood. The cardinal clinical manifestations of RV failure are (1) fluid retention, which may lead …

Right Ventricular Function in Cardiovascular Disease, Part I

In 1616, Sir William Harvey was the first to describe the importance of right ventricular (RV) function in his seminal treatise, De Motu Cordis : “Thus the right ventricle may be said to be made for the sake of transmitting blood through the lungs, not for nourishing them.”1,2 For many years that followed, emphasis in cardiology was placed on left ventricular (LV) physiology, overshadowing the study of the RV. In the first half of the 20th century, the study of RV function was limited to a small group of investigators who were intrigued by the hypothesis that human circulation could function adequately without RV contractile function.3 Their studies, however, were based on an open pericardial dog model, which failed to take into account the complex nature of ventricular interaction. In the early 1950s through the 1970s, cardiac surgeons recognized the importance of right-sided function as they evaluated procedures to palliate right-heart hypoplasia. Since then, the importance of RV function has been recognized in heart failure, RV myocardial infarction, congenital heart disease and pulmonary hypertension. More recently, advances in echocardiography and magnetic resonance imaging have created new opportunities for the study of RV anatomy and physiology. The goal of the present review is to offer a clinical perspective on RV structure and function. In the first part, we discuss the anatomy, physiology, aging, and assessment of the RV. In the second part, we discuss the pathophysiology, clinical importance, and management of RV failure. ### Macroscopic Anatomy of the RV In the normal heart, the RV is the most anteriorly situated cardiac chamber and lies immediately behind the sternum. In the absence of transposition of great arteries, the RV is delimited by the annulus of the tricuspid valve and by the pulmonary valve. As suggested by Goor and Lillehi,4 the RV can be described in …

Right ventricular failure complicating heart failure: Pathophysiology, significance, and management strategies

Right heart failure most commonly results from the complication of left heart failure (systolic or nonsystolic dysfunction) or pulmonary hypertension. Over the past decade, greater attention has been paid to the role of right ventricular failure in the morbidity and mortality associated with cardiomyopathy and pulmonary hypertension. The right ventricle is distinct from the left ventricle not only in its spatial localization, but also in its response to increased afterload and signaling mechanisms. This article discusses the role of right ventricular failure in the setting of heart failure as well as the clinical diagnosis and management of right ventricular failure.