Diagnostic workup, etiologies and management of acute right ventricle failure

Abstract

The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.

Right ventricular failure in septic shock: characterization, incidence and impact on fluid responsiveness

“…However, RV failure is difficult to define in the critical care setting. A recent consensual definition proposed by different groups of experts characterizes RV failure as the association of a “significant” RV dilatation associated with systemic congestion [ 3 – 5 ]. This definition is mainly physiologically based, not strictly validated, and the experts did not propose any threshold for RV size or congestion using critical care echocardiography (CCE) and central venous pressure (CVP), respectively.…”

Performance of a capnodynamic method estimating cardiac output during respiratory failure - before and after lung recruitment

“…Lung protective mechanical ventilation commonly improves compliance and oxygenation. However, the accompanying high levels of PEEP can increase the right ventricular afterload with negative effect on the cardiac performance [2,3]. Hemodynamic monitoring is therefore of great importance to optimize blood perfusion to the injured lungs with least possible strain on the right ventricle.…”

Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome: A pilot study

“…Its development was reported to be related also to high pressures of ventilation, and consequently, an echo‐guided strategy for protection of the right ventricle was proposed, integrating echocardiographic assessment to the ventilation strategy Nowadays, in the era of protective ventilation, the incidence of acute cor pulmonale has dramatically reduced and the modified ventilatory strategy may have affected the panorama of echocardiographic abnormalities in ARDS. However, RV dilatation/dysfunction is one of the major determinant of hemodynamic instability in ARDS which is known to be associated with higher mortality …”

“…However, RV dilatation/dysfunction is one of the major determinant of hemodynamic instability in ARDS which is known to be associated with higher mortality. 1,8,9 Myocardial deformation (strain) imaging is a novel echocardiographic technique to assess RV myocardial function and, unlike other echo techniques, to define subtle RV dysfunction. 10,11 RV strain of the free wall has been reported to hold prognostic value in different disease conditions such as heart failure and pulmonary hypertension [12][13][14][15] while no data are so far available in patients with ARDS.…”