Treatment of Right Heart Failure
The treatment of right heart failure should focus on addressing the underlying cause, managing fluid overload with diuretics, optimizing cardiac function with inotropes when necessary, and providing supportive care to improve morbidity, mortality, and quality of life. 1
Initial Assessment and Management
- Identify the underlying etiology of right heart failure (e.g., pulmonary embolism, right ventricular infarction, pulmonary hypertension, left heart disease) 2
- Assess severity through clinical signs: elevated jugular venous pressure, peripheral edema, congestive hepatomegaly, and ascites 2
- Monitor heart rate, rhythm, blood pressure, and oxygen saturation continuously for at least the first 24 hours of admission 1
- Maintain oxygen saturation above 90% at all times 1
Pharmacological Management
Diuretics
- Diuretics are essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 1
- Loop diuretics (e.g., furosemide) are first-line therapy for managing fluid retention 1, 3
- Consider doubling the dose of loop diuretic up to equivalent of furosemide 500 mg if no initial response (doses of 250 mg and above should be given by infusion over 4 hours) 1
- If diuretic resistance develops, consider combination therapy with different classes of diuretics or venovenous isolated ultrafiltration 1, 3
Inotropic Support
- For patients with cardiac decompensation due to depressed contractility, intravenous dobutamine is indicated for short-term inotropic support (not to exceed 48 hours) 4
- Dobutamine at 2.5-5.0 μg/kg/min can improve right ventricular output 1
- Consider milrinone (0.25-0.75 μg/kg/min) as an alternative inotrope, particularly for its additional pulmonary vasodilatory effects, but monitor for hypotension 1, 5
- In patients with persistent hypotension despite inotropes, consider vasopressors such as norepinephrine or vasopressin 1
Pulmonary Vasodilators
- For right heart failure associated with pulmonary hypertension, consider:
Other Pharmacological Therapies
- Digoxin may be considered for patients with refractory right heart failure, though evidence is limited 1
- Calcium channel blockers should only be used in selected patients with pulmonary arterial hypertension who demonstrate vasoreactivity 1
- ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular systolic function who also have right heart failure 1
Mechanical Support
- Consider intra-aortic balloon pump or other mechanical circulatory support in patients without contraindications 1
- For patients with severe right heart failure not responding to pharmacological therapy, ventricular assist devices may be used as a "bridge to decision" or longer-term support in selected patients 1, 6
Hemodynamic Monitoring
- Pulmonary artery catheterization should be considered in patients who are:
- Refractory to pharmacological treatment
- Persistently hypotensive
- Have uncertain left ventricular filling pressure
- Being considered for cardiac surgery 1
- Right heart catheterization can help optimize right ventricular function, particularly in patients with mechanical circulatory support 6
Ventilatory Support
- Consider CPAP or non-invasive positive pressure ventilation in patients without contraindications 1
- Endotracheal intubation and invasive ventilation may be necessary with worsening hypoxemia, failing respiratory effort, or increasing confusion 1
Monitoring After Stabilization
- Daily assessment of fluid intake and output, weight, jugular venous pressure, and extent of pulmonary and peripheral edema 1
- Monitor blood urea nitrogen, creatinine, potassium, and sodium daily during intravenous therapy 1
- Continue to evaluate right ventricular function throughout follow-up, as late right heart failure is associated with worse outcomes 6
Special Considerations
- In right ventricular infarction, volume loading with normal saline (500-ml bolus, followed by 500 ml/h) is recommended unless there are signs of left heart volume overload 1
- Avoid excessive fluid administration in patients with a massively dilated right ventricle as this may increase right ventricular distention and compromise left ventricular filling 1
- For patients with right heart failure following left ventricular assist device implantation, a multidimensional assessment approach is needed 6