Right Ventricular Failure in Pulmonary Embolism: The Forgotten Chamber—When in Trouble, Go Back to Basics

Abstract

Acute right heart syndrome complicates many critical illnesses but often goes undetected and is associated with high mortality. We present a case of acute right ventricular (RV) failure secondary to massive pulmonary embolism (PE) and outline its management based on a good understanding of heart-lung interactions and basic physiological principles.

A 65-year-old female presented with fever, dyspnoea and chest discomfort for 2 days. Her initial investigations confirmed severe pneumonia, complicated by septic shock, acute kidney injury and diabetic ketoacidosis. She developed refractory shock post-intubation. Echocardiogram revealed a severely dilated RV with flattening of the interventricular septum. Computed tomography confirmed bilateral PE. Despite definitive thrombolytic therapy, she remained hypotensive requiring high doses of vasopressors and inotropes. Pulmonary artery catheter was inserted to guide haemodynamic management. Further supportive treatment was focused on optimising RV preload, contractility and afterload. To reduce RV volume overload, she was commenced on controlled fluid removal with aquapheresis. To improve RV contractility, she was started on milrinone, which was later transited to levosimendan. To reduce RV afterload, she had “RV-protective” ventilatory strategy with low positive end-expiratory pressure and the use of pulmonary vasodilators such as iloprost and sildenafil. Her haemodynamics improved with resolution of the RV dysfunction.