Acute Right Ventricular (RV) Failure in the ICU

• Failure occurs when the RV fails to maintain enough perfusion through pulmonary circulation to achieve adequate left ventricular filling
• This occur suddenly in a previously healthy heart (massive PE, right sided MI) or worsening of compensated RV failure in setting of chronic heart/lung disease
• When RVEDP > LVEDP, septum flattens and “D” shape is seen on cross section of ultrasound
• Management:
  • Reverse the underlying cause and any condition that increase pulmonary vascular tone
  • Optimize right sided filling pressures and reduce after-load (i.e., elevated pulmonary pressures)
  • Use selective pulmonary vasodilators at doses that do not induce systemic hypotension and worsening of oxygenation
  • Use inotropic agents to help improve RV contractility enough to maintain cardiac output
  • Consider ECMO if all else fails while underlying cause of RV failure is being addressed

References

• Ventetuolo CE, Klinger JR. Management of Acute Right Ventricular Failure in the Intensive Care Unit. Ann Am Thorac Soc Vol 11, No 5, pp 811–822, Jun 2014