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Acute Right Heart Failure in Pulmonary Hypertension

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The Right Heart

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Abstract

Right ventricular failure may occur in the course of pulmonary arterial hypertension (PAH) but can also occur, sometimes without pulmonary hypertension (PH) in conditions such as right ventricular infarction and others such as pulmonary embolism where the pressure may not be very high because the afterload increase was so rapid in onset. For patients with PAH, these episodes of right heart failure are severe and in-hospital mortality rates of up to 60 % in the most severe patients have been described but, no evidence based recommendations have been published to date and diagnostic and therapeutic strategies vary considerably between centres. Some prognostic factors have been identified from cohort studies: systemic arterial pressure, serum levels of sodium, creatinine and brain natriuretic peptide (BNP). Echocardiography also plays a role, though its utility overall remains uncertain. The advantages of right heart catheterization (RHC) have to be balanced with the potentially increased side effects of this tool in these fragile patients. Treatment goals should focus on addressing the pathophysiological components of right heart failure: preload balance, right ventricular afterload reduction, optimisation of cardiac contractility and systemic arterial pressure support. The identification and management of any underlying trigger of cardiac decompensation is very important. In patients with kidney failure, renal replacement therapy is feasible, though associated with a poor prognosis. Despite these treatments, some patients exhibit refractory heart failure and develop life threatening multi-organ failure. Lung or heart-lung transplantation may be considered as a rescue therapy in this setting, with extra corporeal life support a potentially lifesaving bridge to surgery in certain circumstances. However, the appropriate timing of this transplantation remains very challenging as no standardized monitoring protocol exists. More studies are needed to increase our knowledge of this devastating complication in PAH patients.

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Authors and Affiliations

  1. Intensive Care Unit, Antoine Béclère, 157 rue de la porte de Trivaux, Clamart, 92140, France

    Benjamin Sztrymf MD, PhD

  2. Respiratory and Intensive Care Department, Bicêtre, 78 avenue du général Leclerc, Le Kremlin Bicêtre, 94270, France

    Sven Günther MD & Marc Humbert MD, PhD

  3. Department of Respiratory medicine, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Dublin, 94270, Ireland

    Dermot S. O’Callaghan MD

Authors
  1. Benjamin Sztrymf MD, PhD
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  2. Sven Günther MD
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  3. Dermot S. O’Callaghan MD
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  4. Marc Humbert MD, PhD
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Correspondence to Benjamin Sztrymf MD, PhD .

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Editors and Affiliations

  1. National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland

    Sean P. Gaine

  2. Department of Cardiology, Erasme University Hospital, Brussels, Belgium

    Robert Naeije

  3. Scottish Pulmonary Vascular Unit, Regional Heart and Lung Centre, Glasgow, United Kingdom

    Andrew John Peacock

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Sztrymf, B., Günther, S., O’Callaghan, D.S., Humbert, M. (2014). Acute Right Heart Failure in Pulmonary Hypertension. In: Gaine, S., Naeije, R., Peacock, A. (eds) The Right Heart. Springer, London. https://doi.org/10.1007/978-1-4471-2398-9_16

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