Right Ventricular Failure - Diagnosis and Management
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Description

Right Ventricular Failure - Diagnosis and Management

Right Ventricle Physiology

 • RV has thinner myocardium compared to LV->↑ compliance compared to LV, so it does not adapt well to acute increases in pressure

 • RV and LV are interdependent->failure of RV leads to failure of LV through several mechanisms: (a) decreased LV preload (because RV output = LV preload; (b) septal bowing into LV, causing diastolic impairment (“Bernheim effect”)

Acute Changes in RV Hemodynamics

 • ↑ RV afterload (e.g., PE), ↑ RV preload (e.g., L->R shunting through ASD/VSD), or ↓ RV contractility (e.g., MI) all lead to increased RV wall stress and resultant ischemia

 • RV CO subsequently ↓ and RV dilates, precipitating RV “death spiral”

Clinical Features and Workup

 • Exam: Elevated JVP, peripheral edema, RV heave, pulsatile liver. Less common: Split S2, new tricuspid regurgitation (loudest: RLSB)

 • Imaging: CXR->hard to evaluate RV 2/2 position, lateral film can help; CT->best for RV size/septum position

 • Echocardiography: measure RV size/function to elucidate underlying etiology. RVEF based on displacement of base towards apex (tricuspid annular plane systolic excursion [TAPSE], nl 2.4-2.7cm).

 • RHC: gold standard for measurement of ventricular filling pressures, CO, PA pressures

 • Labs: NT-proBNP and troponin are not specific but can indicate RV failure if no L-sided disease.

Management

 • Identify and treat triggers: infection, anemia, arrhythmia, PE, MI, hypoxia

 • Preload: Clinical assessment of optimal preload is challenging. Both hypo- and hypervolemia may ↓ CO.

     o Acute: consider volume loading in pts with acute RVMI or PE in absence of marked CVP elevation (“preload-dependent”)

     o Subacute/chronic: consider diuresis to reduce RV filling pressures and improve RV CO

 • Afterload - Systemic: if pt hypotensive, start systemic pressors; no clinical data regarding pressor of choice, but often choose or vasopressin or norepinephrine because it affects SVR>>PVR

 • Contractility: often use milrinone to enhance pulmonary vasodilation (vasodilates arteries in both systemic and pulmonary circulation)

Intubation and Mechanical Ventilation

Right Ventricular Myocardial Infarction 

 • EKG: Check R-sided EKG leads in pts with inferior STEMI (10-15% of pts with inf. STEMI have RV involvement)

 • Management: pts with RVMI are initially “preload-dependent” and often benefit from fluid bolus; caution w/ TNG (↓ preload) and BB (↓HR)



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