Complications and Management of Right Heart Strain
Right heart strain leads to significant complications including tricuspid regurgitation, right heart thrombi formation with high mortality rates (80-100% if untreated), and atrial arrhythmias that require aggressive management targeting the underlying cause, hemodynamic support, and advanced therapies when indicated. 1
Complications of Right Heart Strain
Cardiovascular Complications
- Tricuspid regurgitation: Results from right ventricular dilation and dysfunction, leading to decreased cardiac output and increased mortality 1
- Right heart thrombi formation: Particularly mobile thrombi are associated with 80-100% mortality if untreated 1
- Atrial arrhythmias: Common especially in congenital heart disease with right heart strain 1
- RV dysfunction: Manifests as RV dilation and reduced contractility, associated with 30-day mortality and increased hospital length of stay 2
Hemodynamic Complications
- Decreased cardiac output: Due to RV failure and impaired LV filling
- Venous congestion: Leading to peripheral edema, ascites, and organ dysfunction
- Interventricular septal bowing: Impairs left ventricular filling and further reduces cardiac output 3
Diagnosis of Right Heart Strain
Imaging Assessment
- CT findings: RV:LV ratio ≥0.9 or interventricular septal bowing (88% sensitive but only 39% specific compared to TTE) 1, 3
- Echocardiographic findings:
- RV dilation (significantly associated with 30-day mortality) 2
- Tricuspid annular plane systolic excursion (TAPSE) <16 mm (associated with need for advanced therapy) 2
- McConnell's sign (regional RV dysfunction) 4
- Abnormal septal motion 4
- Tricuspid regurgitation 4
- Elevated pulmonary artery systolic pressure 4
- Cardiac MRI: Provides detailed assessment of RV function and strain, allowing for early detection 1, 5
Laboratory Assessment
- Elevated troponin and B-type natriuretic peptide values 2
- Daily monitoring of blood urea nitrogen, creatinine, and electrolytes 1
Management Approach
Treatment of Underlying Cause
- Pulmonary embolism: Anticoagulation, consider thrombolysis or surgical embolectomy for severe cases 1
- Right ventricular infarction: Maintain right ventricular preload 1
- Pulmonary hypertension: Medical therapies to reduce pulmonary artery pressures 1
Hemodynamic Support
- Volume optimization: Crucial for maintaining RV preload 1
- Avoid vasodilators: Can worsen RV failure, especially in RV infarction 1
- Inotropic support: For RV dysfunction with hemodynamic compromise
Specific Interventions
- Diuretics: For symptom management in severe tricuspid regurgitation 1
- Advanced therapies:
- Tricuspid valve surgery: Consider for patients with severe TR undergoing left-sided valve surgery 1
Monitoring and Follow-up
- Serial echocardiography: Essential for monitoring RV size, function, and response to therapy 1
- Hemodynamic monitoring: Guides therapy and prevents complications 1
- Laboratory monitoring: Daily assessment of renal function and electrolytes 1
Important Pitfalls and Considerations
- Excessive preload reduction: Vasodilators and aggressive diuresis can worsen RV failure in RV infarction 1
- Heparin-induced thrombocytopenia: Life-threatening complication that can worsen right heart strain; monitor platelet counts 1
- Delayed treatment of mobile right heart thrombi: Can lead to high mortality; immediate therapy is necessary 1
- Pregnancy considerations: Right heart strain may worsen during pregnancy due to increased blood volume and venous return 1
- Combined imaging approach: Patients with RV strain on both CT and TTE have higher risk (30%) of clinical deterioration compared to either modality alone 3
RV-Arterial Coupling Assessment
- CMR-derived RV strain correlates with RV-arterial uncoupling and RV diastolic dysfunction 5
- Long-axis RV radial strain is associated with RV-arterial uncoupling 5
- Long-axis RV longitudinal strain is associated with increased RV diastolic stiffness 5
- These non-invasive measurements can potentially replace invasive pressure-volume assessments in pulmonary hypertension 5