Management of acute right ventricular failure

Management of acute right ventricular failure

Large pulmonary emboli are an important cause of acute right ventricular failure due to acute increase in afterload. Reduction in RV contraction is another cause, as in right ventricular infarction. Perioperative RV injury is another cause of acute right ventricular failure.

Treatment of underlying condition and hemodynamic support are the sheet anchor of management of acute right ventricular failure. Volume administration is one of the key issues in management of acute right ventricular failure. Volume administration should be guided by central venous pressure measurements. Inodilators, like milrinone may be useful by decreasing the pulmonary vascular resistance along with inotropic support. Dobutamine is also useful since it dilates the pulmonary vasculature. If mechanical ventilation is needed, use minimal PEEP and have higher oxygen levels which can dilate the pulmonary vasculature.

Fibrinolytic therapy is useful in pulmonary embolism. Fibrinolytic therapy has a longer window of utility in pulmonary embolism compared to that in acute myocardial infarction. Sometimes catheter embolectomy may be needed. Special catheters are needed for catheter pulmonary embolectomy. Rotational pigtail has been used for fragmenting the thrombus. Thrombus aspiration catheters are also there. Surgical pulmonary embolectomy is needed in massive pulmonary embolism who have a high risk.

Right ventricular infarction is an important and common cause of acute right ventricular failure. Acute dilatation of right ventricle can lead to a constrictive physiology by compressing the left ventricle. Volume restoration and establishment of a physiological rhythm using AV sequential pacing in complete heart block are useful. Inotropic support is also useful in the management of acute right ventricular failure. Percutaneous coronary intervention can reverse the RV failure in some cases, even after some delay, possibly because RV can recover later as well due to some blood supply reaching the RV muscle directly from the cavity, maintaining its viability.