From the Guidelines
Right heart failure is managed through a combination of medical and surgical interventions, with a focus on addressing the underlying cause of the condition and supporting optimal circulation.
Key Principles of Management
- The management of right heart failure (RHF) involves a comprehensive approach, including the assessment and evaluation of right ventricular (RV) function, as well as the epidemiology and prognosis of RHF 1.
- Medical management of RHF may involve the use of advanced pharmacology for managing pulmonary hypertension (PH), as well as other medications to support RV function and optimal circulation.
- Surgical management of RHF may involve the use of durable and temporary mechanical circulatory support (MCS) devices, as well as other surgical approaches to address underlying causes of RHF, such as congenital heart disease or valvular pathologies.
Assessment and Evaluation
- The assessment and evaluation of RV function is critical in the management of RHF, and may involve the use of novel imaging techniques and other diagnostic tools 1.
- RV dysfunction (RVD) is defined as evidence of abnormal RV structure or function, and is associated with poor clinical outcomes independently of the underlying mechanism of disease.
Medical and Surgical Management
- The medical and surgical management of acute (ARHF) and chronic RHF (CRHF) involves a range of strategies, including the use of medications to support RV function, as well as surgical interventions to address underlying causes of RHF 1.
- The recommendations and suggestions for management of RHF are evidence-based, and are guided by an extensive literature review and critical appraisal of the quality of study 1.
From the Research
Management of Right Heart Failure
The management of right heart failure (RHF) can be challenging due to its complex pathophysiology and the lack of guidelines. However, several studies have provided insights into the management of RHF:
- The primary goal of management is to alleviate any reversible cause of excessive load or right-ventricular contractile failure 2.
- Principles of treatment focus on reversal of the underlying cause, optimization of right ventricular preload and contractility, and reduction of right ventricular afterload 3.
- Medical therapies for RHF include optimization of volume status, hemodynamic and pharmacologic support, and rhythm control 4.
- For patients who are refractory to medical optimization, mechanical therapies such as venoarterial extracorporeal oxygenation and right ventricular assist devices may be warranted 4, 2, 3.
- Invasive monitoring can help guide therapy and determine the need for mechanical support 2, 3.
- Treatment options for RHF continue to evolve rapidly, with multiple options available, including different pharmacotherapies and mechanical circulatory support devices 5.
- Management of RHF in the intensive care unit requires tailored hemodynamic management, pharmacotherapy, and often mechanical circulatory support 6.
Mechanical Support Options
Mechanical support options for RHF include:
- Venoarterial extracorporeal oxygenation 4, 3
- Right ventricular assist devices, both surgical and percutaneous 4, 2, 3
- Veno-arterial extracorporeal membrane oxygenation 3
Importance of Understanding Pathophysiology
Understanding the normal right heart circulatory physiology, treatment, and support options for RHF patients is necessary to improve outcomes 5. The pathophysiology of RHF is complex and involves a feedforward spiral of decline, making management challenging 4. The right ventricle is embryologically distinct from the left ventricle and has unique morphologic and functional properties, requiring tailored management strategies 6.