This document provides guidelines for managing right heart failure in cardiac surgery patients. Pulmonary vasoconstriction due to factors like hypoxia, hypercarbia, and pulmonary hypertension can increase right ventricular afterload and precipitate right heart failure. Right ventricular dysfunction can be caused by systolic dysfunction, volume overload, or pressure overload. Right heart failure is manifested by elevated central venous pressure, decreased blood pressure, and decreased cardiac output. Echocardiography can evaluate right ventricular function and pressures. The goals of treatment are to ensure adequate preload, reduce pulmonary vascular resistance, and improve contractility. This involves optimizing ventilation to avoid hypoxemia and hypercarbia, using pulmonary vasodilators, and administer

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2. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Increased PVR during postop period:
• SIRS 20
to CPBP (pulmonary vasoconstriction)
• Protamine (pulmonary vasoconstriction)
• Hypoxia (pulmonary vasoconstriction)
• ↑ pCO2, acidemia (pulmonary vasoconstriction)
• PEEP, ventilator dysynchrony (pulmonary vasoconstriction)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.

3. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Pulmonary vasoconstriction:
• Hyperventilation counteracts hypoxic pulmonary vasoconstriction in man
• PAP increased (p < 0.001) with elevations in PaCO2
• Marked decrease in SVR with increasing PaCO2
• Blood pressure decreased (p < 0.001) with ↑ in PaCO2 up to 50 mmHg
Bindslev L, et al. Hypoxic pulmonary vasoconstriction in man: effects of hyperventilation. Acta Anesthesiol
Scand. 1985;29:547-551.
Avidan MS, et al. Mild hypercapnia after uncomplicated heart surgery is not associated with hemodynamic
compromise. J Cardiothorac Vasc Anesth 2007;21:371-374.

4. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Pulmonary vasoconstriction:
• Avoidance of hypercarbia seems advisable in the post-perfusion
stage because of a potential impedance to RV ejection
• Hypercarbia induced by alveolar hypoventilation after CPBP increased
PVR by 40 percent
• After hypothermic CPBP, pulmonary vasoconstriction would be
expected to occur and impair RV performance.
• Therefore, tight control of PaCO2 with appropriate adjustment of
ventilatory support is mandatory
Salmenpera M, et al. Pulmonary vascular responses to moderate changes in PaCO2 after
cardiopulmonary bypass. Anesthesiology 1986;64:311-315.
Viitanen A, et al. Pulmonary vascular resistance before and after cardiopulmonary bypass. The effect of
PaCO2. Chest 1989;95:773-778.

5. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Pulmonary vasoconstriction:
• Can precipitate acute right heart failure
• More frequent conditions: MVR, CHD with L → R shunt
• Heart Tx, Lung Tx
• Pneumonectomy
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

6. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Right Ventricular Perfusion Pressure:
RVPP = MAP – RVEDP
MAP decreases with ↓ CO
RVEDP increases with ↑ PVR and excess fluid
Low RVPP leads to RV systolic dysfunction and ↓ CO and eventually ↓ PAP
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

7. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Right ventricular dysfunction:
• Systolic dysfunction (myocardial stunning or ischemia)
• RV volume overload (acute: volume overload)
(chronic: PR, TR, ASD)
• RV pressure overload (acute: ↑ PVR, ↓ O2, ↑ pCO2, PEEP, massive PE)
(chronic: left heart disease, cor pulmonale, PS)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.

8. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Right ventricular failure:
• Manifested by ↑ CVP ↓ BP and ↓ CO
• Usually associated with ↑ PVR and pulmonary hypertension
• Progressive RV dilatation leads to ↑ CVP and ↓ RVSV
• Severe RV dilatation leads to functional TR
and leftward displacement of interventricular septum
• If CVP > LAP possible R→L shunt with unexplained hypoxemia
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.

9. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Evaluation of right ventricular function:
• Assessment of RV preload (CVP, TEE)
• Assessment of RV afterload (PVR)
• Response to volume administration (if CVP < 15 cm)
• If volume administration increases RA filling pressure without ↑ in CO,
further volume administration is not indicated
• Volume therapy is not indicated when there is combined arterial
hypotension and elevated right heart filling pressures
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

10. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Echocardiography:
• RV dilated & hypokinetic
• Severe RV dilatation leads to functional TR
• Leftward displacement of interventricular septum
• Leftward displacement of interatrial septum
• May reveal PFO with R→L shunt (worse with ↑ PEEP)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

11. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Goals of therapy:
• Prevention of LCOS
• Ensure adequate preload
• Reduction of ↑PVR (selective pulmonary vasodilatation)
• Increase myocardial oxygen supply
• Improve myocardial contractility (PDE III inhibitors)
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

12. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Treatment:
• Maintain adequate preload (if CVP < 15 cm)
• Augment contractility (dobutamine or milrinone + norepinephrine)
• Reduction of ↑PVR (avoidance of hypoxemia, hypercarbia & acidosis)
• Selective pulmonary vasodilatation (inhaled nitric oxide or prostacyclin)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

13. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Drug combinations:
• Dobutamine + norepinephrine
• Milrinone + norepinephrine (or phenylephrine)
• Milrinone + ephinephrine
• Milrinone + vasopressin
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

14. GUIDELINES FOR MANAGEMENT
OF RIGHT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Drug combinations:
Milrinone (Primacor):
• Standard Dilution: [50 mg/50 ml] [200 ml D5W or NS]
• Loading dosage: 50 mcg/kg over 10 min
• Usual dosage: 0.5 mcg/kg/min
Norepinephrine (Levophed):
• Standard Dilution: [8 mg] [250 ml D5W]
• Usual dosage: 0.01-0.1 mcg/kg/min
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.