The FLARE Four
- Right ventricular dysfunction commonly occurs in critical illness, particularly in patients with sepsis and acute respiratory distress syndrome, and is associated with increased risk of death
- Case series suggest that RV failure can occur in COVID-19
- While echocardiogram is the preferred test to assess for RV dysfunction, point-of-care ultrasound, clinical exam, EKG and hemodynamic monitoring also have utility in confirming the diagnosis
- To date, there is no convincing evidence that critically ill patients with COVID-19 are more prone to developing RV dysfunction or failure than similar ICU patients without COVID-19
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The significance of right ventricular dysfunction in patients with COVID-19 has not yet been fully characterized, but case series have described acute RV failure in patients with severe COVID-19.
In a fast literature update posted on May 28, 2020, Alison Witkin, MD, associate director, Pulmonary Hypertension and Thromboendarterectomy Program at Massachusetts General Hospital, addresses the epidemiology and management of RV dysfunction in patients with COVID-19.
RV dysfunction has long been recognized in patients with acute respiratory distress syndrome (ARDS), with an estimated incidence of 25% to 50%. It is associated with increased mortality.
To date, no high-quality data indicate that patients with COVID-19 are at higher risk of RV dysfunction or failure than would be expected based on the underlying ARDS, or that RV dysfunction in this setting has novel features.
An echocardiogram is the test of choice for assessment of RV dysfunction. If an echocardiogram is not readily available, point-of-care ultrasound may allow bedside assessment. EKG findings such as complete or incomplete right bundle branch blocks, T-wave inversions in V1–V4 or the S1Q3T3 pattern should also raise concern for RV dysfunction.
Physical exam findings suggesting significant RV dysfunction include elevated jugular venous pressure, cool extremities, peripheral edema, a prominent P2, RV heave and/or a pulsatile liver.
Laboratory findings may include elevations in N-terminal pro-brain natriuretic peptide and evidence of end-organ dysfunction. In the ICU, an elevation in central venous pressure and low central or mixed venous oxygen saturations should increase concern for RV dysfunction.
Management of patients with COVID-19 who develop RV dysfunction should follow usual ICU procedures and protocols. This includes efforts to minimize pulmonary vascular resistance by correcting acidosis and hypoxia and ensuring the patient is not being ventilated at extremes of lung volume.
Inhaled pulmonary vasodilators can also be tried for lowering pulmonary vascular resistance. For patients with COVID-19, inhaled nitric oxide is preferred because of the risk of aerosolization with nebulized epoprostenol. Oral and parenteral pulmonary vasodilators are typically avoided in the ICU given risks of systemic hypotension.
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