The Diagnosis and Treatment of Postoperative Right Heart Failure

Abstract

Background: Acute right heart failure is a life-threatening condition that can arise postoperatively. The options for symptomatic treatment have been markedly expanded in recent years through the introduction of percutaneously implantable mechanical cardiac support systems.

Methods: This review is based on publications retrieved by a selective literature search in PubMed as well as on guidelines from Germany and abroad.

Results: The diagnostic evaluation of right heart failure is chiefly based on echocardiography and pulmonary arterial catheteri - zation and is intended to lead to immediate treatment. Alongside treatment of the cause of the condition, supportive management is crucial to patient survival. A variety of ventilation strategies depending on the situation, catecholamine therapies, inhaled selective pulmonary vasodilators, and cardiac support systems are available for this purpose. The in-hospital mortality of postoperative right heart failure is 5-17 %. The results of the use of cardiac support systems reported in case series are dis - appointing, but nonetheless good compared to what these critically ill patients would face without such treatment. In one observational study, the 30-day survival rate was 73.3%.

Conclusion: Survival is aided by the rapid recognition of right heart failure, targeted multidisciplinary treatment, and contact with an extracorporeal life support (ECLS) center for additional supportive treatment measures. Further studies on the use of pharmacological and mechanical cardiac support systems must be carried out to provide stronger evidence on which treatment recommendations can be based.

Figure 1

Etiology and pathogenesis of acute postoperative right heart failure. Causes of acute right heart failure include (1) decreased right ventricular preload, especially in a patient with preexisting dysfunction, (2) acute increase in right ventricular preload, and (3) increase in right ventricular afterload with subsequent acute tricuspid regurgitation with venous backflow to the liver, intestines, and kidneys. Reduced right ventricular contractility (4) and a mixture of all pathogenetic causes (5) further lead to acute right heart failure (red panels). ARDS, acute respiratory distress syndrome; PAWP, pulmonary capillary wedge pressure; RCA, right coronary artery; RCX, left circumflex artery; RV, right ventricular; SIRS, systemic inflammatory response syndrome; CVP, central venous pressure

Figure 2

ECLS, extracorporal life support; iNO, inhaled nitric oxide; LoE, level of evidence; PAC, pulmonary artery catheter; PiCCO, pulse contour cardiac output; CVP, central venous pressure

Figure 3

Chest radiographs of a patient with a left ventricular assist device (LVAD) (*) and a temporary right ventricular assist device. a) The inflow cannula (white arrows), implanted via the femoral vein, and the outflow cannula (black arrows), which is placed over a tube anastomosed onto the pulmonary trunk, create a right heart bypass. b) Temporary transvenously placed axial pump (*). The inlet is located in the right atrium, or in this image the inferior vena cava; the outlet is placed in the pulmonary artery distal to the pulmonary valve (insets, arrows).

Figure 4

Patient with temporary right heart strain with a large extracorporeal system.