The Acutely Failing Right Ventricle Disclosures I got a pen from Actelion once Satish K. Rajagopal, MD Director PCICU Benioff Children’s Hospital Associate Professor of Clinical Pediatrics UCSF 3/8/2019 1 3/8/2019 2 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 3/8/2019 3 3/8/2019 4 1
Unlike DT, RV’s approval rating is going up Causes of RV failure 1950 2000 2019 1000 800 Right 600 • Other • Elevated RV afterload Series1 400 – Myocarditis – PH 200 – Coronary ischemia – PS 0 – ARVC 69 67 65 63 61 59 57 55 53 51 49 47 45 43 41 39 37 35 33 31 29 27 25 23 21 19 17 15 13 11 9 7 5 3 1 – PA obstruction – TR, PR 2500 Left – PE – LVAD 2000 – PGD – Post-capillary left-sided disease 1500 – Congenital e.g. Ebstein’s Series1 1000 – Lung disease – Systemic RV 500 – Left heart failure 0 • L-tga, hlhs, atrial switch 69 67 65 63 61 59 57 55 53 51 49 47 45 43 41 39 37 35 33 31 29 27 25 23 21 19 17 15 13 11 9 7 5 3 1 3/8/2019 5 3/8/2019 6 Why the RV fails Why the RV fails • The RV changes over time from muscle that • Embryonic gene expression patterns are can handle high afterload to muscle that can’t partially maintained when RV afterload not doesn’t fall after birth – More afterload tolerant • Reversion to an embryonic-like phenotype is possible 3/8/2019 7 3/8/2019 8 2
RV afterload is the major determinant Three Clinical Scenarios of RV function • Acute PE in an adult • But, the LV has a • Baby with PS significant impact on RV function (ie up to • Teenager with CTEPH 50% of RV stroke work) 3/8/2019 9 3/8/2019 10 Why the RV fails What RV failure looks like? • Sudden death (aborted and not)/Cardiogenic Shock • Myocardial Perfusion • Exercise intolerance – RCA flow throughout the cardiac cycle is probably • Resp symptoms important for RV function • Systemic venous congestion • Acute increases in RVp decrease RCA flow in systole (ie – Ascites, belly pain, peripheral edema, renal and hepatic dysfxn more like the LV) and may be lead to subendocardial • Arrhythmia (usually atrial, MAT) ischemia • Symptoms related to underlying disease • The combination of high RVp and lower systemic BP • Isolated RV failure is rare maybe particularly bad – Left heart failure symptoms 3/8/2019 11 3/8/2019 12 3
Diagnosing RV failure Jeff Fineman likes videos • 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 Thanks Hythem 3/8/2019 13 3/8/2019 14 Principles of Rx for Acute RV failure 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 3/8/2019 15 3/8/2019 16 4
Despite major differences… The RV and the LV are Different Transcriptional Profiling of the Heart Reveals Chamber- Specific Gene Expression Patterns, Volume: 93, Issue: 12, Pages: 1193-1201 3/8/2019 17 3/8/2019 18 The RV and the LV are Different 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 3/8/2019 19 3/8/2019 20 5
Vasoactives for Acute RV failure • Hypotension is bad • If the BP is adequate – Dopamine – Milrinone – Epinephrine – Dobutamine – Norepinephrine • Combination therapy – Vasopressin – Dopa, epi, milrinone – Phenylephrine – Dopa + milrinone PCCM May 2016 SBP went up with all meds • Levosimendan ? AVP decreased PVR/SVR ratio Only epi increased CI 3/8/2019 21 3/8/2019 22 This is Cool Work 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 3/8/2019 23 3/8/2019 24 6
Thanks 3/8/2019 25 7
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