The Acutely Failing Right Ventricle Disclosures I got a pen from - - PowerPoint PPT Presentation

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The Acutely Failing Right Ventricle

Satish K. Rajagopal, MD Director PCICU Benioff Children’s Hospital Associate Professor of Clinical Pediatrics UCSF

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Disclosures

I got a pen from Actelion once

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Objectives

• Have each person learn at least 1 thing from the

following

– What causes the to RV fail – Why the RV fails – What RV failure looks like – How to diagnose it – How to treat it

• But first, start off with a good joke

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Unlike DT, RV’s approval rating is going up

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200 400 600 800 1000 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 Series1 500 1000 1500 2000 2500 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 Series1

1950 2000 2019 Left Right

Causes of RV failure

• Elevated RV afterload

– PH – PS – PA obstruction – PE – Post-capillary left-sided disease – Lung disease – Left heart failure

• Other

– Myocarditis – Coronary ischemia – ARVC – TR, PR – LVAD – PGD – Congenital e.g. Ebstein’s – Systemic RV

• L-tga, hlhs, atrial switch

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Why the RV fails

• The RV changes over time from muscle that

can handle high afterload to muscle that can’t not

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Why the RV fails

• Embryonic gene expression patterns are

partially maintained when RV afterload doesn’t fall after birth

– More afterload tolerant

• Reversion to an embryonic-like phenotype is

possible

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Three Clinical Scenarios

• Acute PE in an adult
• Baby with PS
• Teenager with CTEPH

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RV afterload is the major determinant

• f RV function
• But, the LV has a

significant impact on RV function (ie up to 50% of RV stroke work)

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Why the RV fails

• Myocardial Perfusion

– RCA flow throughout the cardiac cycle is probably important for RV function

• Acute increases in RVp decrease RCA flow in systole (ie

more like the LV) and may be lead to subendocardial ischemia

• The combination of high RVp and lower systemic BP

maybe particularly bad

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What RV failure looks like?

• Sudden death (aborted and not)/Cardiogenic Shock
• Exercise intolerance
• Resp symptoms
• Systemic venous congestion

– Ascites, belly pain, peripheral edema, renal and hepatic dysfxn

• Arrhythmia (usually atrial, MAT)
• Symptoms related to underlying disease
• Isolated RV failure is rare

– Left heart failure symptoms

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Diagnosing RV failure

• cMRI – objective, quantitative, reproducible, hard
• Single Photon CT - objective, quantitative,

reproducible, hard

• Cath – physiology, radiation, risk
• ECHO

– Qualitative RV function – TAPSE, TAV, FAC, MPI, 3D RVEF, Strain, Tissue doppler, Speckle, – TR, IVC dimensions, Anatomy, PE, left heart

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Jeff Fineman likes videos

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Thanks Hythem

Principles of Rx for Acute RV failure

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Principles of Rx for Acute RV failure

• No therapeutic interventions are substantiated by > level 3

evidence

• Trial and error, based on underlying physiology

– The literature will justify whatever you want to do

• Step-wise escalation based on risk of Rx & SOI
• Attempt to objectively assess effect of Rx

– Step up monitoring depending on SOI – Non-invasive, SVO2, PAC – Demonstrate lack of worsening

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Despite major differences…

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The RV and the LV are Different

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Transcriptional Profiling of the Heart Reveals Chamber- Specific Gene Expression Patterns, Volume: 93, Issue: 12, Pages: 1193-1201

The RV and the LV are Different

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Treating Acute RV failure

• Identify and treat underlying cause

– eg. Lytic therapy, PCI

• PH meds

– Care in post-capillary elevation in PAp

• Fix acidosis, mod to severe anemia
• Diuretics unless shock
• Minimize effects of mech ventilation

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Vasoactives for Acute RV failure

• Hypotension is bad

– Dopamine – Epinephrine – Norepinephrine – Vasopressin – Phenylephrine

• If the BP is adequate

– Milrinone – Dobutamine

• Combination therapy

– Dopa, epi, milrinone – Dopa + milrinone

• Levosimendan ?

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PCCM May 2016

SBP went up with all meds AVP decreased PVR/SVR ratio Only epi increased CI

This is Cool Work

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Tier 2 Rx for Acute RV failure

• Tricuspid surgery
• Rvot optimization
• Left heart optimization
• MCS
• Pott’s
• BAS
• Heart, Heart/lung, lung transplant
• We didn’t even mention RV diastolic dysfunction

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Thanks

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