What is the appropriate management for a patient presenting with right ventricular heave?

Management of Right Ventricular Heave

The appropriate management for a patient presenting with right ventricular heave requires immediate evaluation for underlying pulmonary hypertension, right ventricular dysfunction, or congenital heart disease, with treatment directed at the specific etiology while supporting right ventricular function.

Initial Assessment

• A right ventricular (RV) heave is a clinical sign of right ventricular enlargement or hypertrophy, indicating pressure or volume overload of the right ventricle 1, 2
• Comprehensive evaluation should include:
  • Electrocardiogram to assess for right ventricular hypertrophy, right axis deviation, and large S waves in left precordial leads 2
  • Chest X-ray to evaluate for cardiomegaly, right-sided chamber enlargement, and pulmonary vascular markings 3
  • Echocardiography as the first-line diagnostic test to assess right ventricular size, function, and potential causes 3, 1

Diagnostic Approach

• Echocardiography is the technique of choice for initial assessment, looking specifically for:
  • Right ventricular dilatation and dysfunction 1
  • Paradoxical septal motion 1
  • Pulmonary artery pressure estimation 4
  • Presence of congenital defects such as ventricular septal defect 5
• Consider cardiac MRI as the gold standard for anatomical and functional assessment of the right ventricle when available 6
• Pulmonary artery catheterization may be necessary for definitive diagnosis of pulmonary hypertension (defined as mean pulmonary artery pressure ≥25 mmHg at rest) 4

Management Based on Etiology

1. Pulmonary Embolism

• For suspected high-risk pulmonary embolism with shock or hypotension:
  • Immediate echocardiography to assess for RV overload 3
  • If RV overload is present and no other tests are available, PE-specific treatment is justified 3
  • Consider thrombolysis or embolectomy in hemodynamically unstable patients 3
• For non-high-risk pulmonary embolism:
  • Follow diagnostic algorithm with D-dimer testing and multidetector CT 3
  • Anticoagulation therapy when diagnosis is confirmed 3

2. Right Ventricular Infarction

• Maintain adequate right ventricular preload with fluid administration 3
• Avoid vasodilators (opioids, nitrates, diuretics, ACE-inhibitors/ARBs) which may worsen hypotension 3
• Consider dobutamine for inotropic support 3
• Direct percutaneous coronary intervention should be performed as soon as possible 3
• Correct any heart block with dual chamber pacing if needed 3

3. Pulmonary Arterial Hypertension

• ICU admission for critically ill patients with signs of right heart failure 3
• Central venous pressure monitoring and possibly pulmonary artery catheterization 3
• Maintain systemic vascular resistance greater than pulmonary vascular resistance to prevent right ventricular ischemia 3
• Consider inotropes with neutral or beneficial effects on pulmonary vascular resistance:
  • Dobutamine is preferred due to shorter half-life 3
  • Consider vasopressin to offset potential drop in systemic vascular resistance 3
• Inhaled nitric oxide may be used to acutely decrease pulmonary vascular resistance and improve cardiac output 3

4. Congenital Heart Disease

• For patients with tetralogy of Fallot and right ventricular dysfunction:
  • Monitor for ventricular arrhythmias, especially if QRS duration >180 ms 3
  • Consider electrophysiology study and possible implantable cardioverter defibrillator for high-risk patients 3
• For tricuspid valve abnormalities (e.g., Ebstein's anomaly):
  • Consider surgical repair when symptoms are present 3
  • Surgery may be reasonable in asymptomatic adolescent and young adult patients with severe tricuspid regurgitation if the valve appears repairable 3

Hemodynamic Support in Right Ventricular Failure

• Maintain adequate preload but avoid volume overload 4
• In hypotensive patients, use vasopressors and inotropes rather than excessive fluid boluses to avoid exacerbating right ventricular distension 4
• Maintain oxygenation and avoid hypercapnia, which can worsen pulmonary hypertension 4
• Avoid intubation if possible, as positive pressure ventilation can increase right ventricular afterload 4

Monitoring and Follow-up

• Serial echocardiography to assess response to treatment 1
• ECG monitoring for arrhythmias, particularly in patients with tetralogy of Fallot 3
• Consider early transfer to a tertiary care center with capabilities for advanced right ventricular support in severe cases 4
• Mechanical support with right ventricular assist device or extracorporeal membrane oxygenation may be necessary in refractory cases 6

Common Pitfalls to Avoid

• Excessive fluid administration in right ventricular failure can worsen ventricular distension and decrease cardiac output 4
• Vasodilators can precipitate hypotension in right ventricular infarction 3
• Failure to recognize right ventricular involvement in inferior myocardial infarction can lead to inappropriate management 3
• Discontinuation of pulmonary vasodilator medications in patients with pulmonary arterial hypertension can lead to rapid clinical deterioration 4