What is the management approach for right ventricular (RV) support?

Management Approach for Right Ventricular Support

The management of right ventricular (RV) support should focus on optimizing preload, enhancing contractility, reducing afterload, and considering mechanical circulatory support in refractory cases. 1

Initial Assessment and Stabilization

• Identify the cause of RV dysfunction: Common etiologies include:

  • Acute: Pulmonary embolism, RV myocardial infarction, myocarditis
  • Chronic: Pulmonary hypertension, left heart disease, valvular disease 2

• Hemodynamic goals:

  • Maintain adequate RV preload
  • Optimize RV contractility
  • Reduce RV afterload
  • Preserve coronary perfusion pressure

Pharmacological Management

Volume Management

• Preload optimization:
  • For hypotensive patients with RV ischemia: Administer modest fluid challenge (500 mL) 2
  • Avoid aggressive volume expansion which can worsen RV function through mechanical overstretch 2
  • Avoid nitrates and diuretics in RV-dominant failure as they reduce preload 2

Vasopressors and Inotropes

• First-line vasopressor: Norepinephrine (0.05-3.3 μg/kg/min)

  • Improves RV function via direct positive inotropic effect
  • Enhances RV coronary perfusion through peripheral vascular alpha-receptor stimulation
  • Increases systemic blood pressure 2, 1

• Inotropic support:

  • Dobutamine (2.5-5.0 μg/kg/min) for patients with low cardiac index and normal BP 2, 1
  • Caution: Raising cardiac index above physiological values may worsen ventilation-perfusion mismatch 2
  • Milrinone (0.25-0.75 μg/kg/min) provides inotropic effect with pulmonary vasodilation 1

Pulmonary Vasodilators

• For RV failure with pulmonary hypertension:
  • Inhaled nitric oxide (5-40 ppm) 1
  • Inhaled prostacyclin (10-50 ng/kg/min) 1
  • Sildenafil (20 mg three times daily) 1
  • Caution with systemic vasodilators due to risk of hypotension 2

Respiratory Support

• Oxygen therapy: Correct hypoxemia to reverse hypoxic pulmonary vasoconstriction 2

• Mechanical ventilation considerations:

  • Use non-invasive ventilation when possible 1
  • If intubation necessary:
    • Establish arterial line monitoring before intubation
    • Use low tidal volumes (~6 mL/kg lean body weight)
    • Limit plateau pressure to <30 cmH2O
    • Apply minimal PEEP (≤10 cmH2O if oxygenation allows)
    • Avoid high intrathoracic pressures which can reduce venous return and worsen RV failure 2, 1

Mechanical Circulatory Support

• Indications for mechanical support:

  • Refractory RV failure despite optimal medical therapy
  • Cardiac power output <0.6W with right-dominant shock 2

• Device options:

  • RV-specific devices:

    • Impella RP
    • Protek Duo (allows addition of oxygenator if respiratory failure present) 2

  • ECMO:

    • Venoarterial ECMO for primary RV injury or concomitant LV failure 3
    • Veno-venous ECMO for isolated RV failure from acute hypoxemic respiratory failure 3
    • Consider in refractory cases as bridge to recovery or definitive therapy 1

• Caution: RV failure from progressive pulmonary hypertension may be poorly treated with RV-only support devices as forced perfusion may precipitate pulmonary hemorrhage 2

Special Considerations

RV Myocardial Infarction

• Maintain AV synchrony:

  • AV sequential pacing for symptomatic high-degree heart block
  • Prompt cardioversion for hemodynamically significant SVT 2

• Reperfusion strategies:

  • Thrombolytic agents
  • Primary PCI (preferred when available)
  • CABG in selected patients with multivessel disease 2

Pulmonary Embolism

• Anticoagulation: Immediate unless contraindicated 1
• Thrombolytic therapy: Consider in massive PE with hemodynamic instability 1
• Mechanical thrombectomy: Option for patients with contraindications to thrombolysis 1

Monitoring Parameters

• Hemodynamic monitoring:

  • Central venous pressure
  • Cardiac output
  • Pulmonary artery pressures
  • Consider pulmonary artery catheter in complex cases 1

• Imaging:

  • Echocardiography to assess RV size, function, and estimate pulmonary pressures 1

• Laboratory markers:

  • BNP/NT-proBNP
  • Troponins
  • Lactate levels 1

Pitfalls to Avoid

• Excessive volume loading causing RV distention
• Systemic hypotension reducing RV perfusion
• Excessive use of sedatives causing vasodilation
• Aggressive positive pressure ventilation worsening RV function
• Delayed recognition of RV failure in the setting of left heart disease

By following this structured approach to RV support, clinicians can optimize outcomes in patients with RV dysfunction across various clinical scenarios.