Acute Right Ventricular Failure

2. The Forgotten Ventricle
(Acute Right Ventricular Failure)
Awad Youssef Zeid, MSc
Professional member of ESC, ACCA and HFA
Young National Ambassdor for ACCA/ESC in Egypt
Cardiologist, El-Maamoura Chest Hospital

3. Aknowledgment

5. Right Ventricle

6. Agenda
• Definition of acute right ventricular failure(RVF).
• Anatomy and mechanics of right ventricular
function.
• Aetiology and pathogenesis of RVF.
• Consequences of right ventricular failure.
• Clinical presentation and assessment.
• Clinical management.
• Cases presentation.
• Conclusions and take home message.

7. Definition of acute right ventricular failure
(RVF)
• Acute right ventricular (RV) failure can be
defined as a rapidly progressive syndrome with
systemic congestion resulting from impaired RV
filling and/or reduced RV flow output.
• Most often it is associated with increased RV
afterload or preload and consequent RV
chamber dilatation and tricuspid regurgitation.

8. • The prevalence of acute RV failure is difficult to
estimate, but its predominant causes [i.e. left-
sided heart failure, acute pulmonary embolism
(PE), acute myocardial ischaemia] are common.
• It is observed in 3–9% of acute heart failure
admissions, and the in-hospital mortality of
patients with acute RV failure ranges from 5-
17%.

9. Anatomy and mechanics of right ventricular function

10. Causes and differential diagnosis of acute
RVF

11. Pathophysiology of right ventricular failure

12. Organs dysfunctions in RVF

13. The spiral of RV overload and
decompensation

14. Ventricular interdependence in right ventricular
failure

15. Clinical signs and biochemical markers of acute right
ventricular (RV) failure

16. Acute RV failure on echo: diagnosis

17. Clinical managment
• Volume optimization
• Vasopressor and inotrope treatment
• Mechanical circulatory support
• Clinical management in specific clinical scenarios (PE,
RV infarction, pulmonary HTN,Tamponade,Valvular
diseases,Surgery)

18. Clinical management cont’
• Effective treatment of RV failure requires a skilled
multidisciplinary team to rapidly assess and triage the patient to
the appropriate environment.
• The ongoing monitoring varies according to the clinical scenario, but its
focus is on supporting the RV, managing the consequences of
failure, and alleviating distressing physical (e.g. breathlessness,
pain) and emotional (e.g. anxiety) symptoms.

19. Clinical management cont’

20. Volume optimization
• As RV failure is often caused, associated with, or
aggravated by RV volume overload, diuretics are
often the first option for most patients with RV
failure who present with signs of venous
congestion along with maintained arterial blood
pressure.
• Volume redistribution in the venous system under
diuretic treatment can contribute to rapid clinical
improvement.

21. Volume optimization cont’

22. Vasopressor and inotrope treatment
• Vasopressors and/or inotropes are indicated in acute
RV failure with haemodynamic instability.

23. Mechanical circulatory support
• Acute mechanical circulatory support of the right ventricle may
be required in certain clinical situations such as RV myocardial
infarction (MI), acute PE, following left ventricular assist device
implantation, or primary graft failure after hear transplantation.
• The most important determinant of success is the correct timing
of implantation to avoid significant, potentially irreversible end-
organ injury. Multi organ failure is the leading cause of death in
unsuccessful cases. Early transfer of the patient to an
appropriate centre is essential for success. Device selection
depends on the anticipated duration of mechanical support.
• ECMO/RVADs/Cardiac transplant.

24. Mechanical circulatory support cont’

25. Case presentation
• 65 M
• No DM, no HTN, Smoker
• Fracture lower 1/3 tibia and below knee cast
2weeks
• Presented at ER with acute rapid progressive
dyspnea
• BEAE + mild bilateral expiratory wheezes
• + D dimer
• ECG/Screen Echo. at ER were done.

26. ECG

27. Screen TTE

28. Rapidly deteriorated….Shocked
after CTPA

29. Managment
• Reperfusion therapy (SK)
• Shock resolved after …………….. and sent
home safely on OAC.
• We lost the follow up………

30. Conclusions and take home message
1) Acute RV failure is a diagnosis based on history (search for
causes/triggers) and clinical examination.
2) Echocardiography and biomarker tests are necessary for accurate
assessment and severity-adapted management.
3) Management of acute RV failure demands BOTH general supportive
measures and cause-specific treatment, particularly relief of afterload.
4) Decompensated chronic PH must be identified and its triggers treated.
5) Possible “acute-on-chronic” PE is first treated like acute PE; search for
CTEPH is warranted later, after 3 months of therapeutic
anticoagulation.

31. Dr. Ragab El Sharkawy Cardiology Department