Right heart failure: Clinical sciences

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Introduction0:00–0:41

Right. Heart failure occurs when the right side of the heart cannot function properly, resulting in elevated central venous pressure and an impaired pulmonary circulation.
Assessing for right heart failure involves reviewing your patient's history and physical lab results performing an echocardiogram and evaluating right and left heart catheterization findings.
This helps to categorize it as right heart failure due to valvular disease, myocardial disease or pulmonary hypertension.
Keep in mind that right-sided heart failure, secondary to pulmonary hypertension is also called Cor Pulmonale. Now, if your patient presents with a chief concern, suggesting right heart failure, perform an ABCD E assessment to determine if they're unstable or stable, if unstable, stabilize their airway breathing and circulation, which might require endotracheal intubation and mechanical ventilation.

Unstable Patient0:41–2:16

Next, obtain IV access and put them on continuous vital sign monitoring, provide supplemental oxygen to maintain saturation above 90% and put your patient on cardiac monitoring.
Finally, in some cases, you might consider placing an indwelling pulmonary artery catheter, also known as a Swan Ganz catheter.
In order to obtain right-sided filling pressures. Next, obtain a focused history and physical examination.
Your patient may report shortness of breath and chest pain while physical exam might reveal hypertension, tachycardia, diaphoresis and cold extremities.
You might also notice jugular venous distension with hepatojugular reflux and lower extremity edema, cardiac exam typically reveals a right ventricular heave loud P two and right sided S3.
At this point, you should suspect cardiogenic or obstructive shock due to right heart failure. Here's a clinical pearl cardiogenic shock could be due to an acute right ventricular myocardial infarction, acute right-sided valvular dysfunction, severe myocarditis or cardiomyopathy.
On the other hand, obstructive shock could result from a massive pulmonary embolism or cardiac tamponade. Ok.

Unstable - Labs and Imaging2:16–4:12

Next, there is a variety of labs and imaging to obtain including A B NPA standard 12 lead E CG and right-sided ECG chest X ray echocardiogram.
And if necessary, a CT pulmonary angiogram labs will likely show an elevated BNP ECG. Findings could show various findings like ST elevation or depression, right, access deviation, right atrial enlargement, right ventricular hypertrophy and arrhythmias.
If there's acute right heart strain, an S one Q three T three pattern might be seen. Chest X ray often reveals a globular cardiac silhouette and potential rightward displacement.
And if there's also left heart failure, you might see pulmonary edema. Possible echocardiogram findings include right ventricular strain with hypertrophy or dilation tricuspid or pulmonary valve dysfunction and tamponade.
CT pulmonary angiogram might reveal a pulmonary embolism. These findings confirm the diagnosis of cardiogenic or obstructive shock due to right heart failure.
Here's a clinical pearl. Before diving into treatment, let's quickly review a little myocardial physiology.
When the right side of the heart is unable to pump enough blood to the lungs. It results in a build up of blood in the right ventricle leading to its overstretching.
This in turn reduces left ventricular filling and preload. You'll see this in the setting of right-sided myocardial infarction.
However, keep in mind other instances with high afterload, meaning the pressure, the right heart has to pump against like in pulmonary hypertension, pe valvular disease or CO PD.

Unstable - treatment4:12–5:50

Ok. First optimize RV preload.
This might require the administration of IV fluids. The amount of which is largely dependent on the underlying cause in the setting of a right sided myocardial infarction.
You need to maintain preload in order to prevent worsening ischemia. So in this case, increasing preload with IV fluids will increase cardiac output.
However, in other cases like a massive pe increasing preload with too much IV fluids will actually worsen the RV afterload.
Displacing the interventricular septum into the left ventricle causing immediate drop in cardiac output and cardiovascular collapse.
Use loop diuretics like furosemide. If diuresis is needed like in pulmonary hypertension or valvular disease where the afterload is high, you should also encourage sodium and fluid restriction.
And in some cases, you might even need to provide ultrafiltration. In order to help decrease pa afterload, you may also need to administer a pulmonary vasodilator such as inhaled nitrous oxide next to increase contractility and systemic BP.
Give inotropes like dobutamine and Milone and vasopressors like norepinephrine. Sometimes you may even need interventions like mechanical circulatory support like extracorporeal membrane oxygenation or ECMO.
Finally, you must treat the underlying cause like thrombolysis for massive pulmonary embolism or pericardiocentesis or tamponade.

Stable Patient5:50–6:42

Ok. Let's go back to the ABCD E assessment and now consider stable patients first obtain a focused history and physical exam.
Your patient may report dyspnea on exertion as well as abdominal fullness and early satiety. Physical exam typically reveals jugular venous distension, possibly with positive hepatojugular reflux.
You might also notice signs of fluid overload like bilateral lower extremity edema and even ascites cardiac exam will likely reveal a right ventricular heave loud P two and right sided S3 importantly, there will not be evidence of pulmonary edema.
Thus differentiating it from left heart failure at this point, you should suspect right heart failure. Ok.

Stable - Labs and Imaging6:42–8:07

Your next step is ordering labs and imaging labs include BNP and C MP. You should also obtain a 12 lead ECG and a chest X ray.
Likely you'll see elevated BNP. And in some cases, you'll find elevated ast A LT and bilirubin as well as B UN and creatinine ecg commonly shows signs of right heart overload like right axis deviation, right atrial enlargement and right ventricular hypertrophy.
Finally, chest X ray often shows a globular cardiac silhouette with rightward displacement. With these clinical findings diagnose right heart failure.
Here's a clinical pearl, the most common cause of right heart failure is left heart failure or LH F. Evidence of LH F includes left axis deviation, left atrial enlargement and left ventricular hypertrophy as well as pulmonary edema.
Next. Obtain an echocardiogram.
Your patient may also need a right heart catheterization or a cardiac MRI to confirm the diagnosis. Now, echocardiogram can confirm right ventricular dysfunction and it can help reveal the underlying cause such as structural abnormalities like valvular or myocardial disease.
First, let's discuss right heart failure due to valvular heart disease. Your patient may have a history of known valvular heart disease.

Valvular Heart Disease8:07–9:04

On physical exam, you might hear an ejection murmur over the pulmonary and tricuspid valve areas. It's classically a holosystolic diastolic or systolic ejection murmur.
Moving on the echocardiogram will reveal valvular dysfunction such as pulmonic valve regurgitation or stenosis, tricuspid valve regurgitation or stenosis or a combination of the two.
In this case, your patient's right heart failure is due to valvular heart disease. Initiate treatment with supplemental oxygen RV, preload reduction with loop diuretics like furosemide as well as sodium and fluid restriction.
Finally treat the underlying cause which may require valve repair or replacement. So consult the surgical team moving on to nonvalvular structural abnormalities, meaning rightsided heart failure due to myocardial disease.

Myocardial Disease9:04–10:31

These patients will typically present with a history of dyslipidemia, hypertension coronary artery disease or arrhythmia.
They may also have an infiltrative or connective tissue disease like sarcoidosis or systemic sclerosis. Additionally, they may have a family history of coronary artery disease or cardiomyopathy.
Now, ecg could show q waves in the inferior or right sided leads low QR S voltage or arrhythmia. The echocardiogram will likely show right ventricular systolic dysfunction and right ventricular dilation hypertrophy or hypokinesis.
Some patients may require cardiac MRI to more accurately measure decreased RV, ejection fraction and visualize myocardial fibrosis with these findings diagnose right heart failure due to myocardial disease.
Again, initiate treatment with supplemental oxygen optimize RV, preload with loop diuretics and sodium and fluid restriction and consider ultrafiltration to increase contractility.
Sometimes digoxin is used finally treat the underlying cause. In severe cases, may need mechanical circulatory support or even heart transplantation.

Pulmonary Hypertension10:31–11:52

Ok, let's go back to the echocardiogram. Suppose it shows elevated pulmonary artery systolic pressure or pa sp over 30 millimeters of mercury in these patients history often reveals chronic lung disease, obstructive sleep, apnea, venous thromboembolism or connective tissue disease.
Some may also have a family history of pulmonary hypertension. In addition to the elevated pa sp, the echocardiogram often shows enlargement of the right atrium and right ventricle as well as evidence of right ventricular strain.
Remember, the echocardiogram gives an estimate of pa sp that's not always accurate. So, consider right heart catheterization which directly measures the PA sp and is useful in determining the response to vasodilators.
These findings confirm the diagnosis of right heart failure due to pulmonary hypertension management also begins with supplemental oxygen decreasing RV, preload, decreasing the pulmonary afterload, increasing contractility and treating the underlying cause of pulmonary hypertension.
In some cases like in the setting of thromboembolism, thromboendarterectomy and anticoagulation may ultimately be needed.

Review11:52–13:10

All right, as a quick recap in right heart failure, unstable patients should be evaluated with ECG chest X ray, echocardiogram, and CT pulmonary angiogram to look for right ventricular myocardial infarction, valvular disease, cardiomyopathy, pulmonary embolism or tamponade optimize RV preload with either IV fluid or diuretics.
Increase contractility with inotropes and vasopressors and mechanical circulatory support if needed and treat the underlying cause for stable patients.
Echocardiogram will help distinguish between valvular disease or myocardial disease and pulmonary hypertension. In all cases, treat with supplemental oxygen and optimize preload for valvular disease.
Consult surgery for valve repair or replacement for myocardial disease. Treat underlying causes.
If severe, you may need to consider ultrafiltration, mechanical circulatory support or heart transplantation. Finally, for pulmonary hypertension, treat the underlying cause and if needed.
Consider ultrafiltration, mechanical circulatory support or lung transplantation.