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Acute right ventricular failure: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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Isolated acute right ventricular failure is much less common than left ventricular acute heart failure. This is due to the fact that the right ventricle is more resistant to ischemic injury due to a more favorable ratio between its oxygen demand and the conditions of delivery to it. Therefore, most often, right ventricular failure occurs some time after the development of severe left ventricular failure.
In acute right ventricular failure, there is a sudden increase in central venous pressure (swelling of the veins of the neck, an increase in the level of pulsation of the internal jugular vein), tenderness and enlargement of the liver, pronounced dyspnea without orthopnea (patients usually prefer to lie), tachypnea, hypotension or a clinical picture of shock.
[What causes acute right ventricular failure?
Acute right ventricular failure is most often observed under the following conditions:
- myocardial infarction with right ventricular involvement,
- massive thromboembolism of the pulmonary artery,
- cardiac tamponade.
The clinical picture of right ventricular failure may develop with right ventricular infarction, interventricular septal rupture, pulmonary embolism, congenital and acquired heart defects.
Development of right ventricular failure with symptoms of stagnation can be due to pathology of the pulmonary artery and the right heart (exacerbation of chronic pulmonary disease with pulmonary hypertension, massive pneumonia, pulmonary embolism, dysfunction of the tricuspid valve as a result of trauma or infection).
Perhaps its development in acute or subacute disease of the pericardium, the progression of severe failure of the left heart with involvement of the right divisions, as well as decompensation of the long-term congenital heart disease.
The main non-cardiac causes are: nephritis, nephrotic syndrome, terminal stages of liver disease and tumors secreting vasoactive peptides.
As a rule, the development of right ventricular failure is due to increased pressure in the pulmonary artery and involvement of the right ventricular myocardium into the necrosis and peri-infarction lesion of the myocardium.
Symptoms of acute right ventricular failure
The main symptoms of acute right ventricular failure are pronounced venous congestion with a large circle (if there is no hypovolemia) and absence of stagnant phenomena in the lungs.
Clinically, right ventricular failure is manifested by an increase in the liver, swelling of the cervical veins, the appearance of peripheral and cavitary swelling. There is an increasing tachycardia, lowering of arterial pressure, cyanosis, dyspnea. There is a sharp increase in central venous pressure.
On an electrocardiogram, acute right ventricular failure may be manifested by a legalogram, an acute development of the blockade of the right leg of the bundle Guiss. "Gothic" P in II, III, aVF (P pulmonale), the predominance of the positive phase of the P wave in VI.
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Treatment of acute right ventricular failure
In all these cases, the use of diuretics and vasodilators is contraindicated. After the introduction of diuretics or vasodilators, there is always a decrease in blood pressure, down to pronounced hypotension or shock. With a decrease in blood pressure, intravenous fluids are introduced (plasma-substituting solutions at a rate that maintains BP at 90-100 mm Hg). When the effect is insufficient, dobutamine infusion is used. It is possible to use milrinone.
In cases of pronounced refractory hypotension - dopamine infusion, norepinephrine, intra-aortic counterpulsation, ancillary circulation.
The treatment uses diuretics, including spironolactone, sometimes a short course of dopamine in a low ("diuretic") dose.
When developing right ventricular failure, venous vasodilators are contraindicated, as they reduce the cardiac output by decreasing venous return.
For the correction of arterial hypotension in right ventricular failure, the introduction of plasma substitutes or plasma has been shown to increase preload on the right ventricle in combination with dobutamine and arterial vasodilators (hydralazine or phentolamine).
Dobutamine in combination with phentolamine causes vasodilation of peripheral arteries, reduces afterload on the left ventricle, pressure in the left atrium and pulmonary artery. This leads to a decrease in afterloading to the right ventricle and an increase in its ejection.
Shock ejection can be increased and by injecting fluid directly into the pulmonary artery.
With pulmonary infection and bacterial endocarditis, the use of antibiotics is indicated.
Treatment of primary pulmonary hypertension is performed by calcium antagonists, nitric oxide or prostaglandins.
With the development of thromboembolism of the pulmonary artery, thrombolytic therapy is performed and, according to indications, thrombectomy.
Acute right ventricular failure is treated based on the therapy of the underlying disease: with thromboembolism of the lungs - appointment of heparin and thrombolytic therapy, with tamponade - pericardiocentesis and drainage of the pericardial cavity, myocardial infarction - thrombolytic therapy or surgical treatment.