Right ventricular failure

Discuss heart failure in relationship to left ventricular failure, right ventricular failure, neurohormonal activity, and treatment options. 

Diseases that directly affect hepatic integrity include cirrhosis, viral infections, and collagen vascular diseases. Diseases that indirectly affect function include metabolic disorders (e.g., azotemia secondary to renal insufficiency) and cardiac disease. Although decreased left ventricular output can result in a decrease in hepatic arterial flow, right ventricular failure causes hepatic congestion, reducing the first-pass effect and delaying biotransformation. 

When given rapidly, protamine causes hypotension due to a decrease in vascular resistance, possibly linked to the release of nitric oxide from endothelium. Flypotension can be minimised by slow administration over 10-15 minutes. Protamine does not affect myocardial contractility. In some patients, systemic hypotension occurs in conjunction with pulmonary hypertension and, in severe cases, right ventricular failure. The mechanism is activation of the complement pathways by the heparin-protamine complex leading to release of thromboxane A2, which mediates pulmonary vasoconstriction. Unlike in anaphylaxis, plasma histamine concentrations are not increased. When this syndrome develops protamine administration should be stopped, and some have recommended giving heparin in an attempt to reduce the size of the heparin-protamine complex. 

Paraneoplastic syndrome Parasitic infections Parenteral nutrition Postoperative cholestasis Primary biliary cholangitis Primary sclerosing cholangitis Protoporphyria Right ventricular failure Sepsis... 

For obvious reasons, the use of dopamine may be dangerous in cases of coronary or peripheral vascular disorders. Dopamine used for hypotension during percutaneous transluminal angioplasty (PTCA) can be associated with diffuse coronary spasm, and it should therefore be used with caution, particularly if high doses are required. When dopamine aggravates pulmonary hypertension and right ventricular failure, isoprenaline should be considered as an alternative inotropic drug. 

When it is used in cardiac failure, furosemide acts in two ways besides its diuretic effect it produces an immediate fall in left ventricular filhng pressure, which is independent of and precedes diuresis. If furosemide is given intravenously in stable chronic heart failure (which it normally is not), this can be an unwanted effect, causing deterioration (SEDA-11, 199), particularly in patients with pure right ventricular failure. 

The authors concluded that after sudden withdrawal of inhaled nitric oxide rebound pulmonary hypertension had contributed to acute right ventricular failure and loss of left ventricular pre-load, with a fall in cardiac output leading to reduced coronary performance and near cardiac arrest. 

PAOP pulmonary artery occlusion pressure P-gp P-glycoprotein RAA renin-angiotensin-aldosterone RVF right ventricular failure SDC serum digoxin concentration S VR systemic vascular resistance TNF-a tumor necrosis factor-a TZD thiazolidinedione VAD ventricular assist device... 

Factors that decrease theophylline clearance and lead to reduced maintenance-dose requirements include advanced age, bacterial or viral pneumonia, left or right ventricular failure, liver dysfunction, hypoxemia from acute decompensation, and use of drugs such as cimetidine, macrolides, and fluoroquinolone antibiotics. Factors that may enhance theophylline clearance and result in the need for higher maintenance doses include tobacco and marijuana smoking, hyperthyroidism, and the use of such drugs as phenytoin, phenobarbital, and rifampin. 

Right ventricular failure can occur due to chronic lung disease, pulmonary valve disease and congenital defects. The symptoms are systemic oedema, particularly of the legs and ankles. 

Girard, C., Durand, P. G., Vedrinne, C., Pannetier, J. C., Estanove, S., Falke, K., Adnot, S., and Lemaire, F. (1993). Case conference Inhaled nitric oxide for right ventricular failure after heart transplantation./. Cardiothorac. Vase. Anesth. 7, 481-485. 

Elevated pulmonary vascular resistance is a risk factor prior to cardiac transplantation which is manifested by an increased risk of right ventricular failure postoperatively. " Nevertheless, patients with left atrial hypertension may have a reversible component to their pulmonary hypertension if the underlying cause can be relieved. Therefore, assessment of the degree of pulmonary vasoconstriction assumes importance prior to transplantation. The limited number of donor organs dictates that accurate assessment of pulmonary vascular disease be made in order to limit combined heart-lung transplantation and ensure more effective use of scarce resources. 

Skin A curious but non-serious local adverse reaction to iloprost, a linear erythematous facial rash, has been described in an 11-year-old boy with severe pulmonary hypertension associated with right ventricular failure, who was given iloprost by inhalation [32 ]. On one occasion, the child removed the mouthpiece and chamber lid and applied iloprost directly to his cheek. A few minutes later, he developed two erythematous linear skin lesions spreading over his face and neck, which resolved spontaneously within 3 days. 

Nearly 50% of patients requiring PMV or LTMV carry a preexisting diagnosis of coronary artery disease, left ventricular failure, or right ventricular failure (37). Therefore, impaired cardiovascular performance may contribute to ventilator dependence in many patients. So far, few case reports have shown that successful diuresis and weight loss may be... 

In the case of a 62-year-old woman with bilateral carotid body paraganglioma (19) and central alveolar hypoventilation—who received mechanical ventilation in 1990 with negative pressure through a poncho wrap and subsequently NIPPV through a nasal mask— two months after treatment symptoms, signs of right ventricular failure and daytime blood gases all improved. She has successfully been ventilated for 16 years. 

In most circumstances pharmacological therapy with pulmonary vasodilators and inotropic drugs can solve the problem. If not, a mechanical circulatory assist by external RVAD or ECMO should be considered. In recipients with high pulmonary vascular resistance as the principal cause of right ventricular failure, we prefer to use venoarterial ECMO support. 

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