Overview
Right ventricular (RV) failure is a critical condition characterized by impaired RV function leading to hemodynamic instability, often observed perioperatively or in the context of severe pulmonary hypertension or myocardial infarction. 1Diagnosis
Clinical Presentation: Hemodynamic instability, including hypotension and elevated central venous pressure.
Echocardiography: Key tool for assessing RV function, identifying paradoxical ventricular septal motion (PVSM), and evaluating fractional area of contraction. 3
Liver Scintigraphy: May show focal defects mimicking hepatic metastases, indicative of RV failure. 5
Hemodynamic Monitoring: Essential for measuring central venous pressure, pulmonary artery pressure, and cardiac output. 46Management
Inotropic Support: Use of inotropic agents (e.g., phosphodiesterase inhibitors) to enhance RV contractility. 3
Vasopressors: Management of systemic hypotension, though careful monitoring is required to avoid prolonged vasopressor dependency. 3
Mechanical Support:
- PulseCath®: Temporary RV assist device for hemodynamic stabilization in acute RV failure post-cardiac surgery. 2
- Pulmonary Artery Balloon Counterpulsation (PABC): Effective in reducing RV preload and afterload, increasing cardiac output in experimental models and clinical settings. 67
Specific Interventions: Right atrial-pulmonary artery bypass (RA-PA) may be beneficial in acute RV ischemia models. 4Special Populations
Postoperative Patients: High risk for RV failure post-cardiac surgery, requiring vigilant monitoring and timely intervention. 24
Elderly: Increased vulnerability to RV dysfunction due to comorbid conditions and reduced physiological reserve. 1Key Recommendations
Early Identification and Monitoring: Implement comprehensive hemodynamic monitoring to promptly identify RV dysfunction. (Evidence: Strong 14)
Use of Mechanical Support Devices: Consider temporary mechanical support like PulseCath® or PABC for acute RV failure to stabilize hemodynamics. (Evidence: Moderate 267)
Tailored Pharmacological Support: Employ inotropic agents cautiously, balancing the need for RV support with the risk of systemic complications like prolonged vasopressor use. (Evidence: Moderate 3)References
1 Vandenheuvel MA, Bouchez S, Wouters PF, De Hert SG. A pathophysiological approach towards right ventricular function and failure. European journal of anaesthesiology 2013. link
2 Arrigoni SC, Kuijpers M, Mecozzi G, Mariani MA. PulseCath(R) as a right ventricular assist device. Interactive cardiovascular and thoracic surgery 2011. link
3 Maslow A, Schwartz C, Mahmood F, Singh A, Heerdt PM. Case report: paradoxical ventricular septal motion in the setting of primary right ventricular myocardial failure. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2009. link
4 Connolly MW, Lim KH, Rose DM, Tan IP, Grossi EA, Baumann GF et al.. Efficacy of right ventricular unloading during right coronary artery occlusion in an experimental model. Surgery 1986. link
5 Rossleigh MA, Uren RF, Bernstein L. Focal defects on liver scintigraphy due to right ventricular failure. Clinical nuclear medicine 1984. link
6 Opravil M, Gorman AJ, Krejcie TC, Michaelis LL, Moran JM. Pulmonary artery balloon counterpulsation for right ventricular failure: I. Experimental results. The Annals of thoracic surgery 1984. link62246-1)
7 Flege JB, Wright CB, Reisinger TJ. Successful balloon counterpulsation for right ventricular failure. The Annals of thoracic surgery 1984. link60309-8)