Treatment of Right Ventricular Failure
The optimal management of right ventricular (RV) failure requires a standardized approach focusing on optimizing preload, enhancing contractility with vasopressors and inotropes, and reducing RV afterload with pulmonary vasodilators, while maintaining adequate systemic blood pressure. 1
Initial Assessment and Hemodynamic Stabilization
Volume Management
- Maintain euvolemia with central venous pressure of 8-12 mmHg 1
- Avoid excessive fluid loading which can worsen RV dilation and tricuspid regurgitation
- Cautious volume challenge (<500 mL) only if central venous pressure is low 1
- Diuresis if signs of ventricular dilation to improve biventricular coupling 1
Vasopressors and Inotropes
Norepinephrine (0.2-1.0 μg/kg/min) is the first-line vasopressor for RV failure with hypotension 1
- Improves RV inotropy and systemic blood pressure
- Promotes positive ventricular interactions
- Restores coronary perfusion gradient without increasing pulmonary vascular resistance
Dobutamine (2-20 μg/kg/min) for patients with low cardiac index and normal blood pressure 1
- Caution: May aggravate ventilation/perfusion mismatch
- May trigger or worsen arrhythmias if used alone
Vasopressin can be used to maintain RV perfusion during inodilator therapy 1
Pulmonary Vasodilators for RV Afterload Reduction
Inhaled Agents (Preferred)
Inhaled nitric oxide (5-40 ppm) 1
- Selective pulmonary vasodilation without systemic effects
- Monitor methemoglobin levels every 6 hours
Inhaled prostacyclin (10-50 ng/kg/min) 1
- Alternative to nitric oxide with similar efficacy
Oral/IV Agents
Sildenafil (20 mg TID) 1
- PDE-5 inhibitor that reduces pulmonary vascular resistance
Milrinone (0.25-0.75 μg/kg/min) 1
- Inodilator that improves RV contractility and reduces pulmonary vascular resistance
- May require concomitant vasopressor support to prevent systemic hypotension
IV prostacyclin (1-2 ng/kg/min) through central line 1
- Titrate to desired effect
- Monitor for systemic hypotension and other side effects
Ventilation Strategies
- Minimize positive pressure ventilation which can increase RV afterload 1
- Correct hypoxemia, acidosis, and hypercapnia which increase pulmonary vascular resistance 1
- Target PaCO₂ <48 mmHg to prevent worsening RV failure 1
- Limit driving pressure <18 cmH₂O to avoid RV overload 1
- Consider prone positioning in patients with ARDS to improve RV function 1
Advanced Therapies for Refractory RV Failure
Mechanical Circulatory Support
- Consider venoarterial ECMO or extracorporeal life support for patients with persistent RV failure refractory to medical therapy 1
- Options for RV mechanical support include:
Special Considerations
RV Failure in Pulmonary Hypertension
- Type V phosphodiesterase inhibitors, endothelin antagonists, and prostacyclin analogues may help by decreasing pulmonary arterial resistance 1
- Avoid diuretics and vasodilators that may reduce RV filling in acute RV failure secondary to pulmonary embolism 1
RV Failure Post-Cardiac Surgery
- Early and aggressive use of pulmonary vasodilators may prevent need for mechanical RV support 2
- Combined therapy with inhaled epoprostenol and inhaled milrinone may be effective 3
Pitfalls to Avoid
- Excessive volume loading can worsen RV function by causing RV distention and leftward interventricular septal shift 1
- Systemic vasodilators without pulmonary selectivity may worsen systemic hypotension 1
- Calcitropic agents alone may lead to progressive decline in RV function 1
- Abrupt discontinuation of inhaled pulmonary vasodilators can cause rebound pulmonary hypertension 1
- Failure to maintain adequate systemic blood pressure may compromise RV perfusion 1
By following this approach to RV failure management with appropriate hemodynamic monitoring, most patients can be successfully treated with improved outcomes and reduced mortality.