Chapter 26

• Right heart syndromes (RHS) as a cause of shock are less common than left heart dysfunction, but recognizing them requires a high level of vigilance.
• Clues to recognizing RHS as a cause of shock include a history of a condition that is associated with pulmonary hypertension, elevated neck veins, peripheral edema greater than pulmonary edema, or a right-sided third heart sound, in addition to electrocardiographic, radiographic, and echocardiographic findings.
• Echocardiography is extremely valuable, not only for demonstrating the presence of RHS, but also for guiding hemodynamic management.
• Progressive right heart shock can be worsened by excessive fluid infusion, concomitant left ventricular failure, inappropriate application of extrinsic positive end-expiratory pressure (PEEP) and hypoxia.
• The drug of choice for resuscitation of patients with acute RHS is dobutamine, initially infused at 5 μg/kg per minute. Systemically-active vasoconstrictors may provide additional benefit.
• Prostacyclin and nitric oxide are often beneficial in improving pulmonary hemodynamics and oxygenation, but may not improve survival.

In the majority of patients with shock due to “pump failure,” assessment is focused appropriately on the left ventricle. However, in a substantial minority of patients, right heart dysfunction is the cause of shock. Examples include acute pulmonary embolism (PE), other causes of acute right heart pressure overload (e.g., acute respiratory distress syndrome [ARDS] treated with positive pressure ventilation), acute deterioration in patients with chronic pulmonary hypertension, and right ventricular infarction. Although right ventricular infarction differs from the other right heart syndromes (RHS) in that the pulmonary artery pressure is not high, in many other regards right ventricular infarction resembles the other syndromes, so we will consider them together. Failure to consider the right heart in the differential diagnosis of shock risks incomplete or inappropriate treatment of the shock. It would be hard to overemphasize the importance of echocardiography, both in aiding the recognition of the right heart syndromes and in guiding management. In this chapter we review the notable features that distinguish the right heart from the left, describe the themes that unify the acute RHS and allow their recognition, discuss the pathophysiology and differential diagnosis of RHS, and review their management.

The right ventricle (RV) has long been considered the “forgotten ventricle,” because under normal pressure and volume loading conditions the RV is thought to function as a passive conduit for systemic venous return. When the pulmonary vasculature is normal, right ventricular performance has little impact on the maintenance of cardiac output. In animal models, complete ablation of the right ventricular free wall has little effect on venous pressures.

Despite the requirement for an equal, average cardiac output between the left and right ventricles, the bioenergetic requirement for RV ejection is approximately one fifth of the left ventricle (LV). This is in large part accounted for by the significant difference in downstream vascular resistance between the systemic and pulmonary circulations. In comparison with the LV, the RV ejects into a low-resistance circuit (normally only one tenth the resistance of the ...

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