Review Article
The Right Ventricle During Selective Lung Ventilation for Thoracic Surgery

https://doi.org/10.1053/j.jvca.2018.11.030Get rights and content

The right ventricle (RV) has been an area of evolving interest after decades of being ignored and considered less important than the left ventricle. Right ventricular dysfunction/failure is an independent predictor of mortality and morbidity in cardiac surgery; however, very little is known about the incidence or impact of RV dysfunction/failure in thoracic surgery. The pathophysiology of RV dysfunction/failure has been studied in the context of acute respiratory distress syndrome (ARDS), cardiac surgery, pulmonary hypertension, and left ventricular failure, but limited data exist in literature addressing the issue of RV dysfunction/failure in the context of thoracic surgery and one-lung ventilation (OLV). Thoracic surgery and OLV present as a unique situation where the RV is faced with sudden changes in afterload, preload, and contractility throughout the perioperative period. The authors discuss the possible pathophysiologic mechanisms that can affect adversely the RV during OLV and introduce the term RV injury to the myocardium that is affected adversely by the various intraoperative factors, which then makes it predisposed to acute dysfunction. The most important of these mechanisms seems to be the role of intraoperative mechanical ventilation, which potentially could cause both ventilator-induced lung injury leading to ARDS and RV injury. Identification of at-risk patients in the perioperative period using focused imaging, particularly echocardiography, is paramount. The authors also discuss the various RV-protective strategies required to prevent RV dysfunction and management of established RV failure.

Section snippets

Pathophysiology of RV Injury During OLV

The historic controversy surrounding RV physiology based on animal research has led to newer insights into the role of the right ventricle.4, 5, 6, 7, 8 RV injury and dysfunction are poorly defined terms. There is more clarity about the definition of RV failure. The Heart Failure Association and the Working Group on Pulmonary Circulation & Right Ventricular Function of the European Society of Cardiology defines acute RV failure in the general population as a rapidly progressive syndrome with

Injurious Mechanical Ventilation

The RV is very sensitive to acute changes in afterload (Fig 3).10, 11, 13 Pulmonary vascular resistance (PVR) is affected by changes in lung volumes following a U-shaped curve with volumes both above and below the functional residual capacity (FRC) causing an increase in the PVR due to alveolar and extra-alveolar vessel collapse, respectively.15 One-lung ventilation therefore presents one of those unique situations where both the collapsed lung (always below the FRC) and the ventilated lung (if

Echocardiography

Echocardiography is a mainstay of diagnosing RV dysfunction/failure, and formal guidelines for the assessment of the RV using TTE assessment were published in 2010 by the American Society of Echocardiography.51 TEE now is being used increasingly in perioperative management of patients, and a consensus statement of the Society of Cardiovascular Anesthesiologists and the American Society of Echocardiography recommends echocardiographic assessment of the RV as a part of the basic perioperative TEE

Preoperative Period

The main preoperative goals here should be identification of patients at high risk for RV injury during and after thoracic surgery. The classical 3-pronged approach toward preanesthetic assessment of patients undergoing thoracic surgery is also relevant in this context. This includes assessment of the respiratory mechanics, pulmonary parenchymal function, and cardiopulmonary interaction.63 The assessment of cardiopulmonary reserve according to this model is undertaken on the basis of a simple

Vasoactives and Fluids

The hemodynamic goals in the treatment of established RV dysfunction/failure include optimization of RV preload, increase in RV contractility, and decreased RV afterload. Maintenance of sinus rhythm and prompt treatment of tachyarrhythmia or bradyarrhythmia is essential to prevent hypoperfusion, hypotension, and RV ischemia.10 There is ongoing clinical debate regarding fluid management in thoracic surgery, but current opinion weighs more toward goal-directed therapy and maintaining a “zero

Conclusion

The RV largely is understudied in the context of selective lung ventilation for thoracic surgery, and perioperative RV dysfunction could lead to adverse clinical outcomes. Clinical researchers should focus on (1) the epidemiology of RV dysfunction during OLV; (2) development and validation of risk-prediction models to identify patients at risk of developing RV dysfunction and enable clinicians to implement intraoperative RV-protective strategies early; and (3) utilization of observational data

Acknowledgments

The authors thank Dr. Andrew Roscoe for providing echocardiography images (anonymized and depersonalized) from his personal logbook.

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    V. Zochios is supported by an Academic Clinical Fellowship from the National Institute for Health Research (ACF-2016-09-011).

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