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Physiology

  • Perfused in systole and diastole
  • RV dilation causes IV septum shifting/Functional TR
  • RV Systolic Perfusion Pressure = Systolic BP * Pulmonary Artery Systolic Pressure

Etiology3

  1. Pulmonary Hypertension
    • Acute
      • PE, Any lung Disease, Alpha-agonists
    • Chronic
      • WHO Groups 1-5
  2. RV Myocardial dysfunction/decompensation
    • Negative Inotropes:
      • Beta-Blockers
      • Diltiazem, Verapamil
    • Arrhythmia
      • Atrial Fibrillation
      • Bradycardia
    • Septic Cardiomyopathy
    • Post-Cardiac Arrest MI
    • Right Ventricular MI
    • S/p Cardiac Surgery
    • Rare
      • Myocarditis
      • ARVC
      • Sarcoidosis
  3. Excessive Preload
    • Hypervolemia
    • TR
    • AV Shunts/fistulas
  4. Increased Cardiac Demand (Systemic Vasodilation)
    • Shock
    • Medications
    • Liver Failure
    • Thiamine Deficiency
    • Adrenal Crisis/Thyroid Storm

Failure

  • Forward Failure
    • RV fails to generate CO, causing Cardiogenic Shock
    • Rare in isolation
  • Backwards Failure
    • RV fails to decongest the systemic venous system, leading to high CVP with systemic congestion

Stages

  1. Systemic Congestion
  2. Hypoperfusion w/o Frank Hypotension
    • Congestive Encephalopathy
    • Congestive Nephropathy
  3. Frank Hypotension with shock

Diagnostics

  • EKG
    • Acute
      • RBBB
      • Terminal Right-axis Deviation
      • T-wave Inversion
      • ST changes
    • Chronic
      • Tall R-wave in V1
      • Terminal Right-axis Deviation
      • RV Strain pattern: ST depression +/* T-wave inversion in V1-V4
  • TTE
    • RV Dilation
      • Normal: <~60% of LV
      • Moderate RVD: RV ~60-100% of LV
      • Severe RVD: RV > LV
    • RV Septal flattening ("D" sign)
    • Tricuspid Annular Plane Systolic Excursion (TAPSE)
      • Measure of displacement of the lateral tricuspid annulus toward the apex during systole
      • Apical 4-Chamber view with an M-mode
      • Low values mean RV systolic dysfunction
      • Single best indicator of RV systolic function at bedside
      • Normal TAPSE: >17mm1
      • Mild RV dysfunction: 10-17mm
      • Moderate RV dysfunction: 5-10mm
      • Severe RV dysfunction: <5mm>
    • CVP
      • IVC >2cm with lack of respirophasic variation suggests CVP is elevated
      • IVC <2cm with respirophasic variation suggests CVP is ~0-5mm (normal)
    • Pulmonary Artery Systolic Pressure (PASP)
      • PASP = CVP + 4(Max TR jet in m/s)^2 2

      • 35mm suggests PHTN

Management

  • Correct Precipitating Factors
    • Stop BBs/Vasodilators
    • Manage Electrolytes
    • Manage Primary Problem
    • Manage Afib/Aflutter
  • Aggressive Oxygenation
  • Volume Management
  • Perfuse (Map >65)
  • "Squeeze and Diurese"
    • For PHTN and Borderline MAP
      • MAP = 60, CVP = 25, No UOP
        • Add Vasopressor
      • MAP = 75, CVP = 25, Good UOP
        • Continue Pressor, Remove Fluid with Diuretics
      • MAP = 75, CVP = 12, Good UOP
        • Stop diuretic and pressors
      • MAP = 65, CVP = 12, Good UOP
        • Done
    • Vasopressors

      • 1: Vasopressin4

      • 2: Epinephrine

      • 3: Norepinephrine

        • May increase PVR 5
  • Refractory
    • Inhaled Pulmonary Vasodilators
    • Inotropes
      • Indications to consider
        1. RV Systolic Failure
        2. Inadequate systemic perfusion
        3. BRadycardia
      • Epinephrine
      • Dobutamine
    • VA ECMO