What is the initial approach to managing right ventricular (RV) failure?

Initial Management of Right Ventricular Failure

The initial approach to RV failure centers on achieving euvolemia (CVP 8-12 mmHg), optimizing ventilation to minimize RV afterload, maintaining RV coronary perfusion pressure with vasopressors, and considering selective pulmonary vasodilators—avoiding the common pitfall of aggressive volume loading which worsens RV distention and outcomes. 1, 2

Volume Management: Euvolemia, Not Preload

The traditional teaching that "the RV is preload dependent" is dangerously misleading and leads to harmful volume overloading. 1

• Target euvolemia with CVP 8-12 mmHg, not aggressive fluid resuscitation 1, 2
• Modest fluid challenge (≤500 mL) may be considered only if CVP is low and IVC appears small/collapsible on ultrasound 1
• Volume loading beyond euvolemia worsens RV dilation, causes leftward septal shift, compromises LV filling, and reduces cardiac output 1
• Experimental studies demonstrate aggressive volume expansion provides no benefit and may worsen RV function 1
• Diuresis reduces ventricular dilation and improves biventricular coupling when volume overloaded 1, 2

Vasopressor and Inotropic Support

Maintain systemic arterial pressure higher than pulmonary arterial pressure to preserve RV coronary perfusion. 2

• Norepinephrine is the preferred vasopressor, improving RV function by restoring mean arterial pressure and RV blood supply without increasing pulmonary vascular resistance 1, 2
• Norepinephrine should be used in cardiogenic shock to maintain systemic vascular resistance greater than pulmonary vascular resistance (SVR > PVR) 1, 2
• Dobutamine may be considered for low cardiac index with normal blood pressure, though it can aggravate ventilation/perfusion mismatch 1
• Avoid calcitropic agents (like milrinone) as monotherapy as they cause systemic vasodilation and progressive RV function decline due to decreased RV perfusion pressures 1
• If inodilators are used, concomitant vasopressors (vasopressin or norepinephrine) are needed to maintain RV perfusion 1

Respiratory Management: Optimize Ventilation to Unload the RV

Ventilatory strategy aimed at unloading the RV is a cornerstone of hemodynamic management. 1

Oxygen and Ventilation Strategy

• Administer supplemental oxygen if SaO₂ <90% 1
• Prefer non-invasive ventilation or high-flow nasal cannula over intubation when feasible, as positive pressure ventilation worsens RV function 1
• If mechanical ventilation required: use tidal volumes ~6 mL/kg lean body weight, keep plateau pressure <30 cmH₂O 1

PEEP Optimization

• Optimize PEEP to avoid both lung derecruitment (too low) and overdistension (too high), as both worsen RV afterload 1, 2
• PEEP >15 cmH₂O promotes overdistension and dramatically worsens RV systolic dysfunction 1, 2
• Apply positive end-expiratory pressure cautiously as it reduces venous return and worsens low cardiac output 1

Avoid Risk Factors for RV Failure

• Target driving pressure <18 cmH₂O 1, 2
• Target PaCO₂ <48 mmHg by correcting acidosis and avoiding hypercapnic pulmonary vasoconstriction 1, 2
• Correct hypoxemia (target PaO₂/FiO₂ >150 mmHg) to avoid hypoxic pulmonary vasoconstriction 1
• Avoid vigorous spontaneous breathing efforts which increase transmicrovascular pressures 1

Afterload Reduction: Selective Pulmonary Vasodilators

Inhaled selective pulmonary vasodilators are preferred over systemic agents to avoid hypotension. 1, 2

• Inhaled nitric oxide (5-10 ppm) reduces pulmonary vascular resistance without systemic hypotension 1, 2
• Inhaled prostacyclin (20-30 ng/kg/min) has comparable efficacy to nitric oxide 1, 2
• Both agents improve ventilation/perfusion matching, though benefits may diminish after initial use 1
• Systemic vasodilators have not been shown beneficial and should be avoided 1

Hemodynamic Monitoring

• Pulmonary artery catheterization is recommended to measure pulmonary vascular resistance, cardiac output, and right atrial pressure 2
• Echocardiography to assess RV size, function, ventricular interdependence, and tricuspid regurgitation 2
• Assess IVC dimension and filling dynamics by ultrasound to guide volume status 1

Mechanical Circulatory Support for Refractory Cases

When medical therapies fail, mechanical circulatory support should be considered. 1, 2

• For isolated RV failure refractory to medical therapy, RV mechanical support (Impella RP, Protek Duo) may be indicated 1
• Venoarterial ECMO is preferred when the primary lesion is pulmonary vasculature (progressive pulmonary hypertension), as isolated RV support devices may precipitate pulmonary hemorrhage 1, 2
• VV-ECMO is appropriate for isolated RV failure from acute hypoxemic respiratory failure, even in shock 3

Critical Pitfalls to Avoid

• Do not aggressively volume load—this is the most common error and worsens outcomes 1
• Avoid intubation if possible—induction, positive pressure ventilation, and high PEEP all worsen RV function 1
• Do not use inodilators without vasopressor support—systemic vasodilation decreases RV perfusion 1
• Avoid high driving pressures, hypercapnia, and excessive PEEP—all increase RV afterload 1, 2