Question 6

Outline the key issues in the management of acute right ventricular failure in an ICU patient with moderate to severe pulmonary hypertension.

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College Answer

Goal / Principle Additional detail to be provided
Treat triggering factors Infection, anaemia, arrhythmias, comorbidities, PE,
MI, acidosis
Maintain oxygenation Supplemental Oxygen to maintain sats >90%
Avoid Intubation if possible.
Consider Echo +/ - PA Catheter risks
Establish adequate
monitoring
ECG, Arterial line, Oxygen Sats, CVP,
Echocardiography vs PA Catheter
Kidney function: Urine Catheter, Serum Creatinine,
Liver congestion: AST, ALT, Bilirubin, Lactate
Optimise fluid balance Fluids if hypovolaemia is present , diuretics if excess fluid is
present
Reduce RV afterload IV Prostanoids: Epoprostinil, iloprost
IV or Oral PDE-5 inhibitors (sildenafil)
Inhaled vasodilators (nitric oxide)
Endothelin receptor antagonists (ERAs) eg bosantan
Optimise Cardiac output Milrinone, Levosimendan,
Optimise Systemic
perfusion pressure
Norepinephrine or Vasopressin
Liaison with Pulmonary
Hypertension Centre
Surgical options: Pulmonary thrombendarterectomy /
balloon atrial septostomy / ECMO / Ventricular assist device /
Heart/lung transplant / Palliation

Additional comments:
Candidates who scored well showed an in-depth understanding of the applied physiology and consequences of the various therapeutic options. Candidates who scored poorly omitted key points.
 

Discussion

A reader has pointed out an excellent review article by Hoeper et al (2018) which covers this in some detail. 

Management of preload

  • Diuretics
  • Fluid restriction
  • Venodilators
  • Aldosterone antagonists
  • Beta-blockers
  • Maintenance of sinus rhythm and atrial systolic contribution
  • Pacing to maintain AV synchrony

Management of afterload

  • Normoxia
  • Normocapnea
  • Normal acid-base balance (especially avoidance of acidosis)
  • Avoidance of excessive positive respiratory pressures
  • Pulmonary vasodilators
    • Nitric oxide
    • Prostacycline

Increase contractility

  • Inotropes
    • Digoxin
    • Dobutamine
    • Milrinone
    • Levosimendan
  • Cardiac resychronisation
  • Supportive hormones and micronutrients (cortisol, insulin, calcium, glucagon, thyroxine, thiamine etc)

Increase cardiac output by unnatural means:

  • LVAD
  • ECMO (eg. VA ECMO or PA-LA support)
  • Increase the pacemaker rate

Decrease the organism's demand for cardiac output

  • Hypothermia
  • Paralysis/sedation

References

Hoeper, Marius M., et al. "Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension." European Respiratory Journal 53.1 (2019).

Lahm, Tim, et al. "Medical and surgical treatment of acute right ventricular failure." Journal of the American College of Cardiology 56.18 (2010): 1435-1446.

Balanos, George M., et al. "Human pulmonary vascular response to 4 h of hypercapnia and hypocapnia measured using Doppler echocardiography." Journal of Applied Physiology 94.4 (2003): 1543-1551.

Griffiths, Mark JD, and Timothy W. Evans. "Inhaled nitric oxide therapy in adults." New England Journal of Medicine 353.25 (2005): 2683-2695.

Benedetto, Maria, et al. "Inhaled nitric oxide in cardiac surgery: Evidence or tradition?." Nitric Oxide 49 (2015): 67-79.