[HSF] RV failure management strategies

[Rwmfglycar at aol.com]

Sorry about your case Prasanna. A few random comments:
I documented a case once in which R coronary air embolism occurred (in the  
days before we worked out how to prevent that).
The RV dilated and started to contract poorly. Tric Regurg appeared. The  
Cardiac output and the RV systolic pressure fell substantially (and  
simultaneously). Return to bypass and using high aortic pressure to drive the  air through 
while the RV was being supported produced complete recovery. 
I think you said you saw LA thrombus preoperatively but it had disappeared.  
Could the thrombus that disappeared from the LA have embolized the RCA?
Tom Salerno mentioned RCA obstruction in conjunction with aortic valve  
repl.as a mechanism.
The paradoxical rise in PA resistance that we have all seen in these cases  
has many more pharmacological remedies than it once had. In one young patient 
in  whom the preop  systemic level PA pressures went to suprasystemic post op I 
 was able to manage without ever closing the chest  by keeping the  patient 
on bypass for 9 further hours, checking hourly on the level of PA  resistance 
until it dropped to a tolerable level. She was wide awake the  next day. At 
that time we had none of the modern agents.
In my experience any time there is Tric. Regurg. preop there is reduced RV  
function already.
Fixing the Tric will help but in the patients with sick ventricles the  
function does not necessarily and certainly not immediately recover; this means  
that intense concentration on RV function in the bypass weaning process is  
essential, with great attention paid to titrating the R ventricular filling  
pressures, the R ventricular dimensions and contractility and the cardiac  output. 
There are times when the RV performance will determine outcome. I  am sure 
this does not apply to you but I have seen the systemic pressure being  used as 
the mark of satisfactory performance the inevitable consequence  being RV 
collapse a while later.
Yours
Bob.