Left Ventricular Failure

Left Ventricular Failure

Heart failure is the inability of the heart to fill with or eject blood at a rate appropriate to meet tissue requirments.1 Acute or decompensated heart failure accounts for approximately 1 million hospital admissions/year in the United States and is the leading cause for admission for adults older than 65. Heart failure can be classified based on the side of the heart involved (Right vs. Left) or according to the portion of cardiac cycle involved (diastolic vs. systolic). Left sided heart failure is typically synonymous with systolic heart failure, although there are some cases that may involve diastolic heart failure.2

Hemodynamic Alterations2 Left heart failure undergoes a 3 stage process where a series of hemodynamic changes occur. 1. Early stage of LV failure, there is an increase in cardiac filling pressures, where stroke volume (SV) is maintained. 2. Compensatory dilation as ejection fraction decreases, as well as compensatory increase in heart rate (HR) to maintain cardiac output. 3. Final stage, where cardiac output decreases, marking the transition from compensated to decompensated heart failure.

Symptoms1 1. Pulmonary edema (and subsequent hypoxemia) 2. Hypotension 3. Elevated right-sided pressures A high Left Ventricular End Diastolic Pressure (LVEDP) promotes pulmonary venous congestion and leads to symptoms, including: 1. dyspnea 2. orthopnea 3. paroxysmal nocturnal dyspnea

Etiology2 Common causes of acute heart failure include, but not limited to: 1. Supraventricular arrythmias 2. Pulmonary embolus 3. Myocardial ischemia from hypotension/anemia in CAD 4. Complete heart block 5. Tamponade 6. Severe hypertension/Aortic Dissection 7. Decompensated Chronic Heart Failure (Acute afterload increase) In the setting of the operating room, arrhythmias and myocardial ischemia from pre-existing coronary disease are the more common etiologies. Hypotension and anemia, independently or in association with the aforementioned factors can exacerbate left ventricular failure.

Treatment3 Management of LV failure is aimed at maintaining an adequate circulating volume for ventricular filling and forward flow. Treatment consists of pharmacologically reducing afterload followed by positive inotropic support. Mechanical assist devices are also available in more severe settings if deemed appropriate. Treatment algorithm for patients in LV failure with cardiogenic shock3

  • Perform TEE in intubated patient
  • Is the patient hypotensive?
    • No
      • SVR> 1600 or narrow pulse pressure
        • Give afterload reduction agents such as Fenoldopam, Nitroprusside, Nesiritide, or ACEi.
    • Yes
      • Decrease PEEP
      • Check CVP, SPV (systolic pressure variation) or PPV (pulse pressure variation)
      • CVP >22 or low SvO2, SPV/PPV >15%
        • Rule out tamponade or tension Pneumothorax
      • CVP < 12 mm Hg SPV/PPV >12%
        • Check Hgb
          • Hgb < 7.0 (or active bleeding)
            • transfuse
          • Hgb > 7.0 and not actively bleeding
            • plasma expander
      • CVP < 22 mm Hg and SPV/PPV <12%
        • Check SVR and pulse pressure
          • SVR <800 or wide pulse pressure
            • Start vasopressors such as Vasopressin, Norepinephrine, Epinephrine + Dobutamine, Phenylephrine (MAINTAIN SVR < 800)
          • SVR >100- or narrow pulse pressure
            • Start Dobutamine, Epinephrine, IntraAortic Balloon pump (IABP), Ventricular Assist device (VAD)


  1. Roberta L. Hines and Katherine E. Marschall. Stoelting’s Anesthesia and Co-Existing Disease, 5th Edition. Philadelphia, PA: Churchill Livingstone, 2008. pages 104-105.
  2. Paul L. Marino. The ICU Book, Third Edition. Philadelphia, PA: LWW, 2007. Pages 255-272.
  3. Moitra, V et al. Anesthesia Advanced Circulatory Life Support. Can J Anesth/J Can Anesth (2012) 59:586-603.