A Roadmap for Managing Right Ventricular Failure in PH

The management of critically ill patients with pulmonary hypertension is complicated, according to researchers, whose study offers guidance for managing these patients with right ventricular (RV) failure.

The researchers prefaced their study by highlighting that pulmonary arterial hypertension (PAH) and all forms of PH continue to be highly morbid and sometimes fatal, particularly in cases requiring hospitalization in the intensive care unit. The grim prognosis is usually due to RV failure with or without infection, tachyarrhythmias, or other forms of acute illness.

“Because management for the critically ill PH patient often is complex and challenging, involvement of PH specialists is highly advisable and transfer to [extracorporeal life support] and/or lung transplantation centers in select cases is appropriate,” commented the researchers.

According to the researchers, there are currently no randomized clinical trials or guidelines steering the management of RV failure, but the approach to managing the complication surrounds 3 factors:

• Optimizing RV preload: While some patients may require volume expansion of the RV, the majority have high right-sided filling pressures and volume removal using diuretics or hemofiltration is typically recommended in order to reduce RV distention and RV wall stress
• Reducing RV afterload: Characterized as a mainstay of RV failure treatment, the reduction of RV afterload is usually managed by pulmonary vasodilators, although hypoxemia, hypercapnia, acidemia, and mechanical ventilation can be leveraged
• Improving RV contractility: Using vasopressors, augmenting cardiac output, and oxygen delivery with inotropes can be used to avoid systemic hypotension and thus improve contractile function of the RV. Treating inciting factors, such as atrial tachyarrhythmias are also used. According to the researchers, transfusions should be considered for Hgb >10 g/dL

“In appropriate patients whose RV failure is refractory to treatment despite these management strategies, RV mechanical support and/ or lung transplantation should be considered,” noted the researchers. They added, “Critically ill PH patients who have evidence of hypoperfusion despite maximal medical therapy should be evaluated for extracorporeal life support (ECLS). Ideally, this should occur in parallel with medical optimization to avoid significant delays and additional end organ dysfunction.”

While understudied and likely underutilized, palliative care plays an integral role in these patients, with strategies including relief of distressing symptoms, discussing goals of care, and including the patient in the decision making. The researchers underscored the importance of palliative care, calling it essential to offering comprehensive care for patients.

Reference

Mullin C, Ventetuolo C. Critical care management of the patient with pulmonary hypertension. Clin Chest Med. 2021; 42(1): 155-165.