Cardiovascular Critical Care I

Etiologies of RV failure

Box 5. Etiologies of RV Failure (Exp Clin Cardiol 2013;18:27-30; J Am Coll Cardiol 2010;56:1435-46)

ARDS

Arrhythmias

Cardiac tamponade

Congenital heart disease

Heart transplantation (particularly if prolonged ischemic time)

Hypovolemia

Hypoxia

LV dysfunction

Mitral valve disease

Post-cardiac surgery

Pulmonary embolism

Pulmonary hypertension

Pulmonary regurgitation

Right coronary artery infarction/ischemia

RV overload

Sepsis

Tricuspid regurgitation/stenosis

testing may include:

Liver function tests (may be indicative of congestive hepatopathy, if elevated)

Troponin

Left heart catheterization if suspected new ischemic contribution

BNP or N-terminal pro-brain natriuretic peptide (elevations may help in the diagnosis of acutely

decompensated HF in scenarios of uncertainty)

Transthoracic or transesophageal ECHO

Invasive hemodynamic monitoring (to guide volume optimization and dosing response to inotropes or

vasopressors)

For less common cardiomyopathies, noninvasive imaging (i.e., cardiac magnetic resonance imaging

[MRI]) and/or myocardial biopsy may be required.

Assess volume status.

In selected cases of hypotension where HF is not known to be the exclusive culprit, small volume

fluid challenges (250–500 mL intravenous fluid bolus) or passive leg raising (PLR) maneuvers may

help show whether a patient is volume responsive.

PLR is a reliable and alternative way of evaluating volume status, without the need to administer a

Physical examination will generally guide fluid status decision.

Jugular venous distension, hepatojugular reflux, lower extremity edema, rales on auscultation,

dyspnea, paroxysmal nocturnal dyspnea

pressure greater than 18 mm Hg, pulmonary artery diastolic greater than 15 mm Hg, right atrial

greater than 10 mm Hg