Clinical presentation and management of right ventricular dysfunction

Ventricular Rupture With Pseudoaneurysm Causing Compression Effect on the Right Ventricular Cavity

Left ventricular pseudoaneurysm (LVPA) typically results from incomplete rupture of the ventricular wall. Here we describe the case of a 79-year--old patient who presented with acute chest pain, was found to have acute anterior and inferior ST-segment elevation myocardial infarction, and was accidentally discovered to have a subacute LVPA creating compression effect on the right-sided cardiac chambers. A multidisciplinary team promptly decided to proceed with surgical repair. This case highlights the varied presentations of LVPA, which can easily be overlooked during the initial evaluation. The use of multimodality imaging played a crucial role in the timely diagnosis and management of this condition.

Current insights on temporary mechanical circulatory support in adults with post-cardiotomy cardiogenic shock

Post-cardiotomy cardiogenic shock (PCCS) is a critical condition characterized by persistent low cardiac output syndrome (LCOS) that manifests either as an inability to wean from cardiopulmonary bypass (CPB) or as severe cardiac dysfunction in the immediate post-operative period despite optimal medical therapy. With an incidence of 2-20%, PCCS is associated with high morbidity, mortality, and healthcare resource utilization. This review explores the pathophysiology of PCCS while emphasizing mechanisms such as direct myocardial damage, ischaemia-reperfusion injury, and systemic effects of extracorporeal circulation. It also discusses key diagnostic tools for PCCS including echocardiography, pulmonary artery catheters, vasoactive inotropic scores (VIS), and lactate clearance, which facilitate early recognition and management. Treatment pathways centred on temporary mechanical circulatory support (tMCS), tailored to clinical scenarios such as the inability to wean from CPB or refractory LCOS. The pivotal role of the multi-disciplinary Heart Team in decision-making, collaboration, and patient-centred care is highlighted. Finally, weaning protocols and considerations for long-term outcomes are discussed, underscoring the need for timely interventions and a personalized approach. Advances in PCCS management continue to evolve, aiming to improve survival and long-term outcomes for this high-risk population.

Significance of Right Ventricular Dysfunction in Predicting Short-Term Survival Among Patients With Sepsis and Septic Shock: A Prognostic Analysis

Objective: This study sought to evaluate the association between right ventricular (RV) dysfunction and short-term in-hospital mortality among patients with sepsis and septic shock. Methods: A prospective cohort study was conducted on adult patients admitted at Burapha University Hospital for sepsis and septic shock from October 1, 2022, through June 30, 2023, who underwent echocardiography within 72 h after admission. RV dysfunction and other echocardiographic findings were analyzed and defined using the American Society of Echocardiography criteria. The primary outcome examined in this study was 28-day in-hospital mortality. Secondary outcomes included maximal blood lactate levels, length of intensive care unit (ICU) stay, and duration of mechanical ventilation. Results: A total of 104 patients (mean age: 69.54 ± 14.88 years) were enrolled in this study. Among the included patients, 32 (30.8%) developed septic shock whereas 20 (19.2%) exhibited RV dysfunction. Cox regression analysis showed that patients with RV dysfunction had a 28-day in-hospital mortality rate 5.53 times higher than that of patients with normal RV function (95% confidence intervals: 1.98-15.42; p=0.001). Regarding the secondary outcomes, patients with RV dysfunction exhibited a significantly higher mean serum lactate level (5.72 ± 4.96 vs. 3.74 ± 3.29 mmol/L; p=0.034) and length of ICU stay (6.50 ± 2.86 vs. 2.84 ± 1.56 days; p=0.020) than did those with normal RV function. Conclusions: RV dysfunction was associated with increased short-term mortality among patients with sepsis and septic shock. Assessing RV function among these patients facilitates precise prognostication and aids in guiding treatment strategies aimed at reducing mortality. Trial Registration: ClinicalTrials.gov identifier: NCT06193109.

Epidemiology of perioperative RV dysfunction: risk factors, incidence, and clinical implications

In this edition of the journal, the Perioperative Quality Initiative (POQI) present three manuscripts describing the physiology, assessment, and management of right ventricular dysfunction (RVD) as pertains to the perioperative setting. This narrative review seeks to provide context for these manuscripts, discussing the epidemiology of perioperative RVD focussing on definition, risk factors, and clinical implications. Throughout the perioperative period, there are many potential risk factors/insults predisposing to perioperative RVD including pre-existing RVD, fluid overload, myocardial ischaemia, pulmonary embolism, lung injury, mechanical ventilation, hypoxia and hypercarbia, lung resection, medullary reaming and cement implantation, cardiac surgery, cardiopulmonary bypass, heart and lung transplantation, and left ventricular assist device implantation. There has however been little systematic attempt to quantify the incidence of perioperative RVD. What limited data exists has assessed perioperative RVD using echocardiography, cardiovascular magnetic resonance, and pulmonary artery catheterisation but is beset by challenges resulting from the inconsistencies in RVD definitions. Alongside differences in patient and surgical risk profile, this leads to wide variation in the incidence estimate. Data concerning the clinical implications of perioperative RVD is even more scarce, though there is evidence to suggest RVD is associated with atrial arrhythmias and prolonged length of critical care stay following thoracic surgery, increased need for inotropic support in revision orthopaedic surgery, and increased critical care requirement and mortality following cardiac surgery. Acute manifestations of RVD result from low cardiac output or systemic venous congestion, which are non-specific to the diagnosis of RVD. As such, RVD is easily overlooked, and the relative contribution of RV dysfunction to postoperative morbidity is likely to be underestimated.We applaud the POQI group for highlighting this important condition. There is undoubtedly a need for further study of the RV in the perioperative period in addition to solutions for perioperative risk prediction and management strategies. There is much to understand, study, and trial in this area, but importantly for our patients, we are increasingly recognising the importance of these uncertainties.

Study protocol for IMPRoVE: a multicentre prospective observational cohort study of the incidence, impact and mechanisms of perioperative right ventricular dysfunction in non-cardiac surgery

INTRODUCTION

Perioperative myocardial injury evidenced by elevated cardiac biomarkers (both natriuretic peptides and troponin) is common after major non-cardiac surgery. However, it is unclear if the rise in cardiac biomarkers represents global or more localised cardiac injury. We have previously shown isolated right ventricular (RV) dysfunction in patients following lung resection surgery, with no change in left ventricular (LV) function. Given that perioperative RV dysfunction (RVD) can manifest insidiously, we hypothesise there may be a substantial burden of covert yet clinically important perioperative RVD in other major non-cardiac surgical groups. The Incidence, impact and Mechanisms of Perioperative Right VEntricular dysfunction (IMPRoVE) study has been designed to address this knowledge gap.

METHODS AND ANALYSIS

A multicentre prospective observational cohort study across four centres in the West of Scotland and London. One hundred and seventy-five patients will be recruited from five surgical specialties: thoracic, upper gastrointestinal, vascular, colorectal and orthopaedic surgery (35 patients from each group). All patients will undergo preoperative and postoperative (day 2-4) echocardiography, with contemporaneous cardiac biomarker testing. Ten patients from each surgical specialty (50 patients in total) will undergo T1-cardiovascular magnetic resonance (CMR) imaging preoperatively and postoperatively. The coprimary outcomes are the incidence of perioperative RVD (diagnosed by RV speckle tracking echocardiography) and the effect that RVD has on days alive and at home at 30 days postoperatively. Secondary outcomes include LV dysfunction and clinical outcomes informed by Standardised Endpoints in Perioperative Medicine consensus definitions. T1 CMR will be used to investigate for imaging correlates of myocardial inflammation as a possible mechanism driving perioperative RVD.

ETHICS AND DISSEMINATION

Approval was gained from Oxford C Research Ethics Committee (REC reference 22/SC/0442). Findings will be disseminated by various methods including social media, international presentations and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05827315.

Feasibility of 2-dimensional speckle tracking echocardiography strain analysis of the right ventricle with trans-thoracic echocardiography in intensive care: a literature review and meta-analysis

OBJECTIVES

To identify variables that affect the feasibility of 2-dimensional right ventricular speckle tracking echocardiography (RV-STE) in the intensive care unit.

BACKGROUND

Trans-thoracic echocardiography (TTE) of the right ventricle is challenging. RV-STE is a novel echocardiography method thought to measure global RV function more fully than conventional TTE parameters. The feasibility of RV-STE in ICU populations has not been well described, and variables influencing RV-STE in ICU have not been investigated. This study aimed to address this.

METHODS

A literature review using Ovid MEDLINE(R) was undertaken. We performed meta-analysis with subgroup analysis of; RV-STE type (RV free-wall [RVFWLS] versus RV global longitudinal strain [RVGLS]), study design (prospective versus retrospective), coronavirus disease-19 (COVID-19) study or not, and strain software used. This was followed by meta-regression of proportion of invasive mechanical ventilation (IMV), with and without COVID-19 studies as a co-variate.

RESULTS

Eleven relevant studies from the literature search were identified, reporting an overall feasibility of RV-STE of 83.3% (95%CI 74.6-89.4%). Prospective study design was associated with higher feasibility compared with retrospective studies (p = 0.02). There were no statistical differences on univariate analysis between RVFWLS versus RVGLS, COVID-19 study or not, or strain software used. Meta-regression with COVID-19 study as a covariate demonstrated that higher proportions of IMV were significantly associated with worse feasibility (p = 0.04), as were COVID-19 studies (p < 0.01).

CONCLUSIONS

We have identified three variables associated with poor feasibility; retrospective study design, COVID-19 studies, and proportion of IMV. A prospective study design should be viewed as gold standard to maximise RV-STE feasibility.

Anaesthetic management of a patient with Gerbode defect

Gerbode defect is a rare left ventricle to right atrium shunt that can be acquired or congenital. The incidence of acquired defects has been growing and is caused by previous cardiac surgery, endocarditis, trauma and myocardial infarct. It can be challenging and the anesthesiologist should maintain a suspicion when there is circulatory failure after a cardiac surgery. It can be diagnosed by trans-esophageal echocardiography. In this case we presented the anesthetic management and the successful surgical correction of an acquired ventricular-atrial defect secondary to a previous mitral valve replacement.

Pre-Existing Right Ventricular Dysfunction as an Independent Risk Factor for Post Intubation Cardiac Arrest and Hemodynamic Instability in Critically Ill Patients: A Retrospective Observational Study

BACKGROUND

Post intubation cardiac arrest and hemodynamic instability are serious adverse events encountered in critically ill patients. The association of pre-existing right ventricular (RV) dysfunction with post intubation cardiac arrest and hemodynamic instability in critically ill patients is unknown.

METHODS

This is a retrospective matched cohort study of adult critically ill patients who underwent intubation from July 2016 to December 2019. The study was conducted at a quaternary medical center in Houston, Texas. A total of 340 critically ill patients who underwent intubation in the intensive care units, wards, and the emergency room were included. The study cohort was categorized into 4 groups based on the pre-existing RV function: normal function, mild dysfunction, moderate dysfunction, and severe dysfunction. Cardiac arrest and/or hemodynamic instability within one hour post intubation were the primary study outcomes. Secondary outcomes included in hospital and 60-day mortality.

RESULTS

Study patients were of mean age of 61.95 ± 14.28 years, including 132 (39%) females and 208 (61%) males. The primary outcomes were significantly worse in mild, moderate, and severe RV dysfunction groups compared to the normal RV function group (34.12%-P = 0.014, 47.06%-P < 0.001, 51.67%-P < 0.001, vs. 17.56%). In a multivariable logistic regression analysis, pre-existing moderate (OR = 2.65, P = 0.013) and severe RV dysfunction groups (OR = 2.66, P = 0.015) were associated with statistically significant higher cardiac arrest and hemodynamic instability post intubation. Pre-existing severe RV dysfunction was associated with statistically significant higher in hospital mortality (62.35%-P < 0.001). The multivariable Cox-regression analysis showed that pre-existing severe RV dysfunction was associated with a statistically significant higher 60-day mortality (HR = 2.57, P = 0.001).

CONCLUSIONS

Pre-existing moderate and severe RV dysfunctions were independently associated with significantly higher cardiac arrest and/or hemodynamic instability post intubation in critically ill patients. Pre-existing RV function may serve as a mortality predictor in critically ill patients undergoing endotracheal intubation.

Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery: a narrative review

Although thoracic surgery is understood to confer a high risk of postoperative respiratory complications, the substantial haemodynamic challenges posed are less well appreciated. This review highlights the influence of cardiovascular comorbidity on outcome, reviews the complex pathophysiological changes inherent in one-lung ventilation and lung resection, and examines their influence on cardiovascular complications and postoperative functional limitation. There is now good evidence for the presence of right ventricular dysfunction postoperatively, a finding that persists to at least 3 months. This dysfunction results from increased right ventricular afterload occurring both intraoperatively and persisting postoperatively. Although many patients adapt well, those with reduced right ventricular contractile reserve and reduced pulmonary vascular flow reserve might struggle. Postoperative right ventricular dysfunction has been implicated in the aetiology of postoperative atrial fibrillation and perioperative myocardial injury, both common cardiovascular complications which are increasingly being appreciated to have impact long into the postoperative period. In response to the physiological demands of critical illness or exercise, contractile reserve, flow reserve, or both can be overwhelmed resulting in acute decompensation or impaired long-term functional capacity. Aiding adaptation to the unique perioperative physiology seen in patients undergoing thoracic surgery could provide a novel therapeutic avenue to prevent cardiovascular complications and improve long-term functional capacity after surgery.

Right ventricular free wall longitudinal strain is independently associated with mortality in mechanically ventilated patients with COVID-19

BACKGROUND

Right ventricular (RV) dysfunction has been commonly reported in patients with Coronavirus disease 2019 (COVID-19), and is associated with mortality in mixed cohorts of patients requiring and not requiring invasive mechanical ventilation (IMV). Using RV-speckle tracking echocardiography (STE) strain analysis, we aimed to identify the prevalence of RV dysfunction (diagnosed by abnormal RV-STE) in patients with COVID-19 that are exclusively undergoing IMV, and assess association between RV dysfunction and 30 day mortality. We performed a prospective multicentre study across 10 ICUs in Scotland from 2/9/20 to 22/3/21. One-hundred-and-four echocardiography scans were obtained from adult patients at a single timepoint between 48 h after intubation, and day 14 of intensive care unit admission. We analysed RV-STE using RV free-wall longitudinal strain (RVFWLS), with an abnormal cutoff of  > -20%. We performed survival analysis using Kaplan-Meier, log rank, and multivariate cox-regression (prespecified covariates were age, gender, ethnicity, severity of illness, and time since intubation).

RESULTS

Ninety-four/one-hundred-and-four (90.4%) scans had images adequate for RVFWLS. Mean RVFWLS was -23.0% (5.2), 27/94 (28.7%) of patients had abnormal RVFWLS. Univariate analysis with Kaplan-Meier plot and log-rank demonstrated that patients with abnormal RVFWLS have a significant association with 30-day mortality (p = 0.047). Multivariate cox-regression demonstrated that abnormal RVFWLS is independently associated with 30-day mortality (Hazard-Ratio 2.22 [1.14-4.39], p = 0.020).

CONCLUSIONS

Abnormal RVFWLS (> -20%) is independently associated with 30-day mortality in patients with COVID-19 undergoing IMV. Strategies to prevent RV dysfunction, and treatment when identified by RVFWLS, may be of therapeutic benefit to these patients.

TRIAL REGISTRATION

Retrospectively registered 21st Feb 2021.

CLINICALTRIALS

gov Identifier: NCT04764032.

A Review of Anesthesia for Lung Transplantation

Lung transplantation is the only treatment option for patients with end-stage lung disease. Although more than 4,000 lung transplants are performed every year worldwide, the standardized protocols contain no guidelines for monitoring during lung transplantation. Specific anesthetic concerns are associated with lung transplantation, especially during critical periods, including anesthesia induction, the initiation of positive pressure ventilation, the establishment and maintenance of one-lung ventilation, pulmonary artery clamping, pulmonary artery unclamping, and reperfusion of the transplanted lung. Anesthetic management according to the special risks associated with a patient’s existing lung disease and surgical stage is the most important factor. Successful anesthesia in lung transplantation can improve hemodynamic stability, oxygenation, ventilation, and outcomes. Therefore, anesthesiologists must have expertise in transesophageal echocardiography, extracorporeal life support, and cardiopulmonary anesthesia and understand the pathophysiology of end-stage lung disease and the drugs administered. In addition, communication among anesthesiologists, surgeons, and perfusionists during surgery is important to achieve optimal patient results.

Study protocol for COVID-RV: a multicentre prospective observational cohort study of right ventricular dysfunction in ventilated patients with COVID-19

INTRODUCTION

COVID-19 can cause severe acute respiratory failure requiring management in intensive care unit with invasive ventilation and a 40% mortality rate. Cardiovascular manifestations are common and studies have shown an increase in right ventricular (RV) dysfunction associated with mortality. These studies, however, comprise heterogeneous patient groups with few requiring invasive ventilation. This study will investigate the prevalence and prognostic significance of RV dysfunction in ventilated patients with COVID-19 which may lead to targeted interventions to improve patient outcomes.

METHODS AND ANALYSIS

This prospective multicentre observational cohort study will perform transthoracic echocardiography (TTE) in 150 patients with COVID-19 requiring invasive ventilation for more than 48 hours. RV dysfunction will be defined as TTE evidence of RV dilatation along with the presence of septal flattening. Baseline demographics, disease severity data and clinical information relating to proposed aetiological mechanisms of RV dysfunction (acute respiratory distress syndrome (ARDS), disordered coagulation, direct myocardial injury and ventilation) will be collected and analysed.Primary outcome measures include the prevalence of RV dysfunction and its association with 30-day mortality. Exploratory outcome measures will investigate the association of the proposed aetiological mechanisms of RV dysfunction to the primary outcomes.Prevalence of RV dysfunction will be determined along with 95% Clopper-Pearson CIs and 30-day survival will be analysed using logistic regression adjusting for patient demographics, phase of disease and baseline severity of illness. The role of potential aetiological factors (ARDS, disordered coagulation, direct myocardial injury and ventilation) in relation to the primary outcomes will be analysed using logistic regression.

ETHICS AND DISSEMINATION

Approval was gained from Scotland A Research Ethics Committee (REC reference 20/SS/0059). Findings will be disseminated by various methods including webinars, international presentations and publication in peer-reviewed journals.