Gilberto Martinez

Cardiología clínica, Cardiología intervencionista

[Dr. Chacón-Lozsán F .'. @franciscojlk]

🫀The failing right ventricle:
the most misunderstood chamber in critical care

For years, we focused on the left ventricle.

But in the ICU, the real killer is often the right ventricle.

->What is acute RV failure?

👉 Not just “weak contraction”

It’s a hemodynamic collapse syndrome:

RV dilation

↓ LV preload

↓ cardiac output

↑ venous congestion

➡️ → multi-organ failure

->The key pathophysiology (the vicious cycle)

1. ↑ Afterload (PE, ARDS, PH)
2. → RV dilation
3. → Septal shift → LV underfilling
4. → ↓ CO → hypotension
5. → ↓ RCA perfusion
6. → RV ischemia

👉 And the cycle accelerates

->The most important concept

👉 The RV does NOT tolerate pressure

Handles preload very well

Fails rapidly with afterload

➡️ Even small ↑ PVR → collapse

->Main causes you MUST think first

🔴 Pulmonary embolism
🔴 RV myocardial infarction
🔴 ARDS / mechanical ventilation
🔴 Decompensated pulmonary hypertension
🔴 Post-cardiac surgery

->Diagnosis is NOT obvious

There is no single sign.

👉 It requires suspicion + integration:

Clinical: congestion + hypoperfusion

ECG + biomarkers

POCUS (your best friend 🤓)

Hemodynamics

->Echo mindset (fast ICU approach)

👉 Don’t overcomplicate

Look for:

✔ RV dilation
✔ Septal shift (D-sign)
✔ TAPSE ↓
✔ Venous congestion

The real ICU mistake

❌ Treating RV failure like LV failure

->Management principles

👉 Think in 4 pillars:

1. Preload — “not too much, not too little”

Hypovolemic → small fluid

Congested → REMOVE fluid

👉 CVP is not a target, it’s a warning

2. Afterload, THE key target

✔ Treat PE
✔ Optimize ventilation
✔ Reduce PVR

👉 If afterload stays high → RV will fail

3. Contractility
Dobutamine
Milrinone
Levosimendan

👉 Choose based on context

4. Perfusion pressure

👉 Norepinephrine is your anchor

✔ Maintains coronary perfusion
✔ Supports RV function

->Ventilation: the silent killer

⚠️ Positive pressure = ↑ PVR

👉 Over-ventilate → worsen RV failure

->When nothing works

👉 Think early:

VA-ECMO

RV assist devices

🤓Key insight

This is NOT just a cardiac problem.

👉 It is a ventriculo–arterial coupling failure

When:
Ees / Ea ↓ → RV collapses

🤓Bottom line

✔ RV failure is preload dependent BUT afterload sensitive
✔ Small mistakes → rapid collapse
✔ Early recognition + physiology-based treatment saves lives

->Clinical mindset

👉 Don’t ask:
“Is the RV failing?”

👉 Ask:
“Why is the RV failing and, what is driving the afterload?”

📃Reference
Giannakoulas G. et al. European Heart Journal (2025) 00, 1–16 https://t.co/gri8ZaHHsI

[Saad Ur Rahman @SaadUrRahman55]

Summary of all Late-Breaking Trials at #ACC2026 – take home points
@ACCinTouch @ACCmediacenter @JACCJournals

1. HI-PEITHO: Ultrasound-facilitated catheter-directed thrombolysis led to a lower risk of PE-related death, cardiopulmonary decompensation or collapse, or recurrence of PE. vs anticoagulation alone in intermediate-high risk PE.

[Dr. Martha Gulati ♥️🫀❤️‍🩹🇨🇦 @DrMarthaGulati]

Management of intermediate–high-risk PE remains a major clinical challenge.

🎷HI-PEITHO tests catheter-directed thrombolysis vs anticoagulation alone.

Will this change how we escalate therapy in PE?

➡️ Key results:
🎷544 patients randomized w/ intermediate Risk PE- 43% female, mean age 58
🎷Anti CoAg 🆚 thrombolysis
🎷outcome: PE mortality/PE recurrence
💥Favored Catheter directed thrombolysis for PE: Relative Risk 0.39
⤵️ Hospital stay
⤴️ Bleeding but no diff in major bleeding
#ACC26 #PulmonaryEmbolism #Cardiology

@NEJM
📎 https://t.co/wbrSDsVsXj

[Gilberto Martinez @drgilmtz]

@danicmartin Sugiero te hagas un ecocardiograma transesofagico para descartar Foramen oval permeable, causa frecuente de ictus en paciente joven! Saludos

[Gilberto Martinez @drgilmtz]

@Aeromexico No se puede facturar en su página ni en su app

[Gilberto Martinez @drgilmtz]

@mandeep_mayo Ivabradine + trimetazidine

[Gilberto Martinez @drgilmtz]

@Doc_pacomemo @paulinalm7

[Gilberto Martinez @drgilmtz]

Today’s case 👨🏻46 y/o heavy smoker, cardiogenic shock, IVUs guided pci TAP technique, AIBP for LV support. @cardiologiaj @umae34cathlab @jedicath @mirvatalasnag @mmamas1973 @evandrofilhobr @alexisbaor @JoseLuisBetanz3 @luis_arboine

[Dr.AsDeHis @DAsdehis]

Infarto explicado con un vaquita…🤣🫀⚡️

[Gilberto Martinez @drgilmtz]

@CardioMty Acaso un optigood???

[Gilberto Martinez @drgilmtz]

@scihubot 10.1001/jama.2022.0358

[Gilberto Martinez @drgilmtz]

@rafastarix @sulito3 Sanitas, gasas, papel lija, algodón de torunda sin alcohol, etc

[Gilberto Martinez @drgilmtz]

@miguelrompe Cath lab! ASAP

[Juan Manuel Cortés @Juanmacor5]

#struts
Preparándonos para el CADECI 2022!

[Gilberto Martinez @drgilmtz]

@mtzfcO @CyntiaMachain Qué dispositivo utilizaste viejon

[Gilberto Martinez @drgilmtz]

@AbrracionCulina @unatalulu para tus posts semanales

[Gilberto Martinez @drgilmtz]

@umae34cathlab @LabPemex @hcgfaa @INC_CathLab @HemoMacGregor @mornei2011 @SOCiME_ @smexcardiologia @mirvatalasnag @mmamas1973 @jedicath @duanepinto @Dr_Renteria @mtzfcO @miguelrompe @Abcsm74 @hecmnsxxi Cortez-barrera sign? 👀

[Gilberto Martinez @drgilmtz]

@miguelrompe @umae34cathlab Jajaja está buenísimo

[Gilberto Martinez @drgilmtz]

@alexisbaor @CarlosLoret @ClaudioOchoaH @latinus_us A huevo chismesitooooo

[Gilberto Martinez @drgilmtz]

@Albouaini @CardioWebinar @HRSonline @BSHeartFailure @BritishCardioSo @TheBJCA @BHRSociety @LHCHFT @ESC_Journals @escardio @luis_arboine mira el caso que metiste en la 34