It is a condition characterized by inability of the right ventricle to propel blood forwards resulting in engorgement of right atrium, systemic veins with enlargement of liver and dependent oedema.
The term ‘Congestive failure’ is applicable to conditions associated with venous congestion, whether systemic or pulmonary. Thus it denotes left or right sided heart failure.
CAUSES OF RIGHT VENTRICULAR FAILURE
- Mitral stenosis-commonest cause.
- Secondary to left ventricular failure.
- Chronic lung diseases, e.g., emphysema and fibrosis of lungs.
- Pulmonary embolism.
- Congenital heart diseases, e.g., pulmonary stenosis and others.
- Ventricular tachyarrhythmia.
SYMPTOMS OF RIGHT VENTRICULAR FAILURE
- Palpitation due to tachycardia or cardiac arrhythmia.
- Heaviness of the precordium.
- Breathlessness or Dyspnoea-Theoretically speaking this should not be a feature of right heart failure, but as majority of the cases are secondary to left heart failure or from pulmonary diseases, dyspnoea becomes an invariable accompaniment of this condition. Associated hydrothorax, ascites, hydropericardium, etc. are also added factors.
- Cough and sputum may also be present.
Cerebral symptom (due to cerebral congestion)
Insomnia, blurring of vision, lack of concentration, forgetfulness, lack of personality, restlessness, drowsiness, etc. may be present.
- Due to hepatic congestion-Pain in the right hypochondriac region, particularly after meals, tightness of the upper abdomen due to stretching of the hepatic capsule.
- Due to gastrointestinal congestion as a result of portal congestion-Anorexia, nausea, vomiting, flatulence, constipation, swelling of the abdomen (ascites), tightness of the abdomen (due to enlarged liver and ascites).
- Oliguria-This is due to factors mentioned before.
- Nocturia-When the patient takes rest at night the oedema fluid is reabsorbed and this leads to increased urine volume at night.
Swelling of the body
This at first appears around the ankle (dependent oedema) and is particularly noticed by the patient at the end of day’s work. Tightness of the socks or shoes may be complained of. Gradually not only the lower limbs but also the abdomen and remaining part of the body become distinctly oedematous. This oedema is chiefly due to the following factors:
- Less renal blood flow and more tubular reabsorption of and chloride from the proximal tubule.
- Increased venous pressure.
- Anoxaemic damage to the capillary wall leading to increased permeability.
- Increased aldosterone and antidiuretic hormone as these are not detoxicated by the congested liver.
- Low colloidal osmotic pressure of blood from anorexia, congested liver, albuminuria, malabsorption from congested intestine, protein loss in transudates in serous sacs.
- Decubitus-propped up.
- Respiration rate hurried.
- Pulse shows tachycardia, this is due to Bainbridge auricular reflex.
- Cyanosis is present which is partly central and partly peripheral.
- Neck veins are engorged sometimes there may be prominent pulsations due to functional tricuspid incompetence. There may be giant ‘a’ waves due to right atrial failure. When the neck veins are just full hepatojugular reflux or Pasteur-Rondot reflex is present.
- Oedema is present, pitting in type. In ambulatory cases it is best observed over the ankles but in non-ambulatory cases it becomes prominent over the sacrum.
Examination of Heart
It may show evidences of different valve diseases and enlargement of different chambers of the heart. On inspection there may be right ventricular palsation and parasternal lift. Sa and S4 may be audible leading to triple rhythm and at times gallop rhythm which may be distinctly heard over left lower sternal region or epigastric region.
Examination of Abdomen
Liver is enlargd, soft in feel, tender (due to stretching of the capsule), margin is rounded, surface is smooth and sometimes it is pulsatile (systolic) which is due to functional tricuspid incompetence. In early stages, however, when the liver is just palpable it remains soft but in later stages or when there is recurrent failure, liver becomes permanently enlarged and firm in feel due to cardiac cirrhosis.
Spleen is not usually palpable but rarely it may be enlarged from cardiac cirrhosis.
Ascites may be seen in some cases which disappears with recovery from failure.
- Venous pressure is high (normal 9-12 cm of water at the antecubital vein at the level of the heart).
- Arm to lung circulation time is increased (normal 6 secs).
- ECG may show evidences of right ventricular enlargement and strain pattern or ischaemia. There may be associated RBBB pattern in later stages.
- Skiagram of chest shows enlargement of heart, particularly affecting the right ventricle. There may be emphysematous changes in the lungs.
- Radionuclide study and Echocardiogram will also help.
- Rest in bed in propped up position on a back rest inclined at an angle of 45° with the bed.
- O2 inhalation 4-6 litres per minute by nasal catheter method but ventimask is best. In chronic cor pulmonale O, inhalation should be given intermittently (for every 8 hours-5 hours oxygen and 3 hours gap) if required and should be guarded as it may precipitate CO2 narcosis.
- Sedative: Usually it is not required and is contraindicated in chronic cor pulmonale but it may be required in cases secondary to left ventricular failure. Morphine or Pethidine may be given in usual doses in such cases.
- Digitalisation: When the pulse rate is near about 120/minute digoxin 1 mg or and then 0.5 mg of Digoxin or 0.2 mg of Digitoxin to be given every 6 hourly until full digitalization occurs which usually takes place in 24 hours time and then a maintenance dose of 0.25 mg to 0.5 mg of Digoxin or 0.1 mg to 0.2 mg of Digitoxin may be given daily. Digitalis may also be given by IV route if necessity arises when it may be given taking all precautions. During digitalization heart rate and pulse rate must be watched carefully to keep the rate at 80 beats per minute. Although the pulse rate is high in chronic cor pulmonale Digitalis is not usually given because the response is poor as there is high output failure. Headache, vomiting, bradycardia, pulsus bigeminus from ventricular ectopics are early features of Digitalis intoxication.
- Diuretics: Thiazide diuretics or Loop diuretics are commonly choiced. Oral route is usually preferred unlike in left ventricular failure. In long standing cases there may be hyperaldosteronism and so aldosterone antagonists such as Aldactone may be given 25 mg-30 mg 4-6 times a day. In cases of chronic cor pulmonale carbonic anhydrase inhibitor like Acetazolamide may be used 500 mg once or twice daily. As diuretics are to be continued for a time one should be cautious for the side effects, particularly hypokalaemia, hyponatremia, etc….
- Diet: It should be preferably salt free for first few days and gradually salt-poor diet may be given. Our daily intake of salt is 10 gm. If table salt and salty foods are avoided it becomes 5 gm and if no salt is added during cooking it becomes 2 gm. In refractory cases 0.5-1 gm salt in diet may be given provided there is patient’s compliance.
- Vasodilators: These are used in refractory cases which may reduce after load and preload. Sodium nitroprusside, Isosorbide dinitrate, Hydralazine, Nitroglycerine etc. may be used.
- Sympathomimetic amines: In severe heart failure sometimes these are required. Dopamine 2 ug per kg per minute may be given. They increase renal blood flow, cardiac contractility, cardiac output with no change in heart rate.
- Paracentesis thoracis or abdominis may be required at times when there is huge collection of fluid and patient is having symptoms out of that.
- The underlying cause should be treated as far as practicable.
- Cardiac transplantation is to be considered in advanced cardiac failure if facilities are available.