Outline the key issues in the management of acute right ventricular failure in an ICU patient with moderate to severe pulmonary hypertension.
| 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.
A reader has pointed out an excellent review article by Hoeper et al (2018) which covers this in some detail.
Management of preload
Management of afterload
Increase contractility
Increase cardiac output by unnatural means:
Decrease the organism's demand for cardiac output
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.