Peri-operative right ventricular dysfunction—the anesthesiologist’s view

Recent years have seen an increasing number of adult and pediatric patients with right ventricular dysfunction (RVD) presenting for both cardiac and non-cardiac surgery. Right ventricular dysfunction is broadly defined as abnormal RV structure or function (1,2). Inclusive in this definition is consideration of the coupling between the RV and the pulmonary vascular bed. The etiologies of RVD are diverse with acute, acute-on-chronic and chronic subsets and can be summarized as follows (2): (I) RV pressure loading pathologies such as precapillary pulmonary hypertension (PH), moderate to severe RV outflow tract obstruction/pulmonary stenosis, acute lung injury/acute respiratory distress syndrome, massive pulmonary thromboembolism, postcapillary PH due to elevated left atrial pressure from left heart systolic or diastolic dysfunction, or valvular disease (mitral, aortic). (II) RV volume loading caused by congenital heart disease lesions or valvular pathologies such as large left to right intracardiac shunts (usually pre-tricuspid shunts such as large atrial septal defect), Epstein’s anomaly [tricuspid regurgitation (TR)], and repaired tetralogy of Fallot with free pulmonary regurgitation. (III) Impaired RV contracti l i ty associated with cardiomyopathies, ischemia, single ventricle physiology, left ventricular assist devices (LVAD) and post-cardiotomy states. Independent of the underlying pathophysiology, RVD is associated with poor clinical outcomes (2) and there is increasing recognition that peri-operative management of patients with RVD is challenging. With expanded therapies for PH and congenital heart disease and advanced technologies for mechanical support of the failing left ventricle (LV), anesthesiologists are likely to encounter more patients with RVD. This article highlights strategies to recognize, risk stratify, prevent and treat peri-operative RVD.