Proactive Right Ventricular Failure Management Protocols Improve Patient Outcomes at Hackensack University Medical Center

RV shock care algorithm, early adoption of Impella RP Flex and innovative care team roles improve symptoms, length of stay and morbidity outcomes

Historically, the left ventricle reigned as the therapeutic focus for heart failure patients, but proactively addressing right ventricular (RV) failure brings outcomes success at Hackensack Meridian Hackensack University Medical Center.

During the COVID-19 pandemic, RV failure began receiving more focus, as physicians employed extracorporeal membrane oxygenation (ECMO) as an RV support device while administering oxygen, Kanika Mody, M.D., medical director, Hackensack University Medical Center Surgical VAD Program, said. Until recently the large, mobility-limiting ECMO device was the most advanced machine option for RV failure management.

Now, the much smaller Impella RP Flex can support the right side. Hackensack University Medical Center was a clinical trial site and early adopter of Impella RP Flex for RV failure, and has met success by anticipating RV issues and implementing support early.

“The appreciation we have for how the right side of the heart contributes to heart failure just continues to grow. Now we’re starting to understand how the two sides of the heart play off of one another and how treating just one side limits the patient’s recovery and symptom improvement,” Ryan Kaple, M.D., director of the Hackensack University Medical Center Structural and Congenital Heart Program, said.

At Hackensack University Medical Center, one of the first steps for RV failure is “chemical RVAD” or continuous dialysis for patients experiencing RV shock, Dr. Mody said. Many of these patients are already in LV shock and have an LVAD device in place. The team began, as protocol, upgrading to the Impella RP Flex in a short timeframe, granting the patient 3 to 5 days of support, which is generally sufficient for RV recovery, Dr. Mody said.

“We have found with this meticulous algorithm we are actually catching patients early. We’re already planning a pseudo elective machine procedure upfront,” Dr. Mody said.

Anticipating the right ventricular dysfunction that can occur after an LVAD is inserted is crucial, Scott Stewart, APN, mechanical circulatory device program supervisor, said, as many complications post-LVAD are due to RV dysfunction. The Hackensack University Medical Center team’s proactive approach decreases complications, length of stay and morbidity and improves general function. Using a smaller, jugular-approach device also allows for better patient mobility than past devices, Stewart said, which aids patient recovery and results in less post-op dialysis.

Another RV treatment angle addresses tricuspid valve leakage, which cause the RV to work even harder and fail further. Two newly FDA-approved devices addressing tricuspid valve leakage add to the team’s RV failure toolkit: TriClip tricuspid valve repair device and the Evoque tricuspid valve replacement , both of which are delivered using a catheter inserted through the blood vessels.

Looking ahead, Dr. Kaple is collaborating with a device maker to develop a better method for assessing tricuspid valve function. While a 2D echocardiogram measures valve movement at only one point, this new approach aims to assess CT scan data to track motion of the entire valve circumference.

In addition to embracing the latest technology and proactive protocols, better outcomes derive from an informed, empowered cardiac care team.

At Hackensack University Medical Center, when a new device such as Impella RP Flex comes online, the APNs, NPs, nurses, cardiac surgeons, cardiologists, engage in detailed training in the device, including how hemodynamics are affected, and what triggers and issues to watch for in patients, creating an empowered and knowledgeable care team. ICU APNs and NPs, for instance, are trained to read an echocardiogram and assess correct device placement, Stewart said.

While many institutions have a dedicated shock coordinator, Hackensack University Medical Center takes it a step further, with a dedicated mechanical circulatory device coordinator who provides boots-on-the-ground daily monitoring in addition to outcomes data analysis and care plan input.

Learn more about innovative cardiovascular care at Hackensack University Medical Center.