Right Heart Failure Patient Identification: Medical Science Office Discussion

William Lowe, Manager Advance Training at Johnson & Johnson MedTech, leads this discussion on identifying patients with right heart failure. Bobbi Chapman, MD, contributes from the perspective of managing patients with chronic heart failure; Andy Shaw, MD, adds his perspective from managing primarily post-cardiotomy RV dysfunction and failure; and Navin Kapur, MD, provides the acute myocardial infarction (AMI) setting perspective.

When asked what hemodynamic and clinical parameters she looks for when trying to identify right heart failure, Dr. Chapman highlights rising central venous pressure (CVP) as a prompt to initiate use of intropes, and escalating use of inotropes as a prompt to consider a mechanical device, such as Impella RP Flex^TM with SmartAssist^TM, to prevent right ventricular (RV) shock. Dr. Shaw, noting that he has the advantage of actually being able to see the right ventricle in the OR, explains that he also relies on pulmonary artery (PA) catheter measurements integrated with transesophageal echo (TEE) assessment of the right ventricle. Dr. Kapur adds that right heart failure can become apparent when suction events or low flow occurs when using an Impella CP® with SmartAssist® to support the left side of the heart.

The physicians discuss preassessment for placement of a right-side hemodynamic support device and concerns regarding thrombus burden. Dr. Kapur emphasizes that heart team discussions are vital, especially in patients with profound right heart failure, noting, “it all comes down to risk-benefit calculations for the patient.” The physicians also emphasize the importance of putting in a fresh PA catheter, a fresh dialysis catheter, or replacing other central lines before placing an Impella RP Flex to help mitigate thrombus risk.

The physicians conclude with a discussion of the terms ‘RV dysfunction’ and ‘RV failure.’ “I think about RV dysfunction as more of a physiologic dysfunction,” Dr. Chapman states. “But when you start talking about RV failure, it’s a clinical scenario, where patients are having clinical signs and symptoms of failure, so its often associated with abnormal hemodynamics, an elevated CVP, a low cardiac output. And patients start to have hypoperfusion and signs of end-organ dysfunction. So I’d say, all patients with RV failure have RV dysfunction, but not all patients with RV dysfunction have RV failure.”