What are the management and treatment options for evidence of right ventricular dysfunction?

Management of Right Ventricular Dysfunction

The management of right ventricular dysfunction requires targeted therapies addressing the underlying cause, optimizing preload, reducing afterload, and enhancing contractility to improve mortality and quality of life outcomes. 1, 2

Diagnosis and Assessment

Right ventricular dysfunction (RVD) is defined as evidence of abnormal RV structure or function, while right-sided heart failure (RHF) is a clinical syndrome with signs and symptoms resulting from RVD 1. Assessment should include:

• Echocardiography: First-line assessment tool to evaluate RV size, function, and estimate pulmonary pressures 1, 3
• Cardiac MRI: Gold standard for anatomical and functional assessment of the right ventricle 4
• Hemodynamic parameters: Central venous pressure, cardiac output, and pulmonary artery pressures 1
• Biomarkers: Brain natriuretic peptide (BNP) and troponins to assess severity 1

Pharmacological Management

Vasopressors and Inotropes

• Norepinephrine (0.05-3.3 μg/kg/min): First-line vasopressor to maintain systemic arterial pressure and coronary perfusion 2
• Dobutamine (2.5-5.0 μg/kg/min): Improves RV contractility but may worsen ventilation/perfusion mismatch 2
• Milrinone (0.25-0.75 μg/kg/min): Provides inotropic support with pulmonary vasodilatory effects 2

Pulmonary Vasodilators

• Inhaled nitric oxide (5-40 ppm): Selective pulmonary vasodilator that reduces RV afterload without systemic effects 2
• Inhaled prostacyclin (10-50 ng/kg/min): Alternative pulmonary vasodilator for reducing RV afterload 2
• Sildenafil (20 mg three times daily): Oral phosphodiesterase-5 inhibitor for sustained pulmonary vasodilation 2

Volume Management

• Cautious fluid administration: Give limited fluid challenge (≤500 mL) only if central venous pressure is low 2
• Avoid volume overload: Excessive fluids can overdistend the RV and worsen ventricular interdependence 2
• Diuretics: Consider in volume-overloaded states to reduce RV preload 1

Ventilation Strategies

• Non-invasive ventilation: Should be attempted first whenever possible 2
• Low tidal volumes (~6 mL/kg): Maintain plateau pressure <30 cmH2O to minimize lung injury 2
• Minimal PEEP (≤10 cmH2O): Avoid overdistension that can worsen RV function 2
• Maintain adequate oxygenation: Keep SaO₂ >90% to prevent hypoxic pulmonary vasoconstriction 2
• Avoid hypercapnia: Acidosis increases pulmonary vascular resistance 2

Management Based on Etiology

Pulmonary Embolism

• Anticoagulation: Immediate therapeutic anticoagulation unless contraindicated 1
• Thrombolytic therapy: Consider in massive PE with hemodynamic instability 1
• Mechanical thrombectomy: Option for patients with contraindications to thrombolysis 1

Right Ventricular Myocardial Infarction

• Revascularization: Successful primary PCI leads to hemodynamic improvement and recovery of RV function 1
• Avoid nitrates and diuretics: Can worsen RV preload dependency 1

Pulmonary Hypertension

• Pulmonary vasodilators: Targeted therapy based on PH classification 1
• Combination therapy: May provide additional benefit in selected patients 1

Mechanical Support

• Intra-aortic balloon pump (IABP): Not routinely recommended but may be considered as a bridge to surgery in mechanical complications 1
• Percutaneous mechanical circulatory support: Superior hemodynamic support compared to IABP but with increased risk of adverse events 1
• LVAD therapy: Consider as bridge to transplantation in younger patients without contraindications 1
• ECMO: Consider in refractory cases as bridge to recovery or definitive therapy 1

Monitoring and Follow-up

• Daily weight monitoring: Track fluid status 2
• Medication adherence: Provide clear schedules and visual aids 2
• Regular follow-up: Assess response to therapy and adjust treatment as needed 2

Special Considerations

• Avoid medications that increase pulmonary vascular resistance: Including certain anesthetics, vasoconstrictors, and beta-blockers 1
• Treat underlying conditions: Address sleep apnea, COPD exacerbations, or other comorbidities that may worsen RV function 1
• Heart transplantation: Consider for patients with RV failure refractory to medical or surgical therapy 2

Right ventricular dysfunction remains a challenging clinical entity with significant impact on morbidity and mortality. Early recognition and targeted therapy addressing the underlying cause while optimizing preload, reducing afterload, and enhancing contractility are essential for improving outcomes.