What is the medical management of right ventricular failure?

Medical Management of Right Ventricular Failure

Diuretics are the primary treatment for fluid overload in right ventricular failure, with loop diuretics as first-line therapy, while vasopressors (norepinephrine) and inotropes (dobutamine or milrinone) are essential for hemodynamic support in acute decompensation. 1, 2

Initial Hemodynamic Stabilization

Volume Optimization

• Cautious fluid administration (≤500 mL over 15-30 minutes) may be considered only if central venous pressure is low, as assessed by ultrasound imaging of the IVC showing a small and/or collapsible IVC 1
• Aggressive volume expansion should be avoided as it can over-distend the RV, worsen ventricular interdependence by shifting the interventricular septum leftward, and ultimately reduce systemic cardiac output 1
• If signs of elevated central venous pressure are present (distended IVC, elevated JVP), further volume loading must be withheld 1

Vasopressor Support

• Norepinephrine (0.05-3.3 mcg/kg/min) is the vasopressor of choice for patients with RV failure and hypotension, as it improves systemic hemodynamics, ventricular systolic interaction, and coronary perfusion without increasing pulmonary vascular resistance 1
• Vasopressin is an alternative vasopressor option for maintaining coronary perfusion pressure 1
• Vasopressors are essential to restore systemic pressure and prevent RV ischemia in the setting of shock 3

Inotropic Support

• Dobutamine (2.5-5.0 mcg/kg/min) should be used for patients with low cardiac index and normal blood pressure, though higher doses may compromise RV filling time due to tachycardia 1
• Milrinone (0.25-0.75 mcg/kg/min) is an alternative inotrope and vasodilator that inhibits phosphodiesterase III, producing dose-related increases in myocardial contractility and forearm blood flow, though systemic hypotension is the most common side effect 1, 4
• Inotropic support may be used short-term for end-stage right heart failure 2

Afterload Reduction

Pulmonary Vasodilators

• Sildenafil (20 mg three times daily PO or via nasogastric tube) reduces pulmonary vascular resistance and is recommended for RV failure with pulmonary hypertension 1
• Inhaled nitric oxide (5-40 ppm) provides selective pulmonary vasodilation, with methemoglobin levels monitored every 6 hours and avoidance of abrupt discontinuation 1
• Inhaled prostacyclin (10-50 ng/kg/min) or intravenous prostacyclin (starting at 1-2 ng/kg/min via central line) are additional options for reducing pulmonary vascular resistance 1
• Hydralazine/nitrates may be used for RV failure and pulmonary hypertension 1

Blood Pressure Management

• Maintaining mean arterial pressure in the normal range is imperative to optimize forward flow and prevent adverse events 1
• Neurohormone-modifying agents (ACE inhibitors, ARBs, beta-blockers, mineralocorticoid receptor antagonists) decrease afterload and improve pump function 1

Diuretic Therapy

• Loop diuretics are first-line therapy for fluid overload, targeting elimination of jugular venous pressure elevation and peripheral edema 2
• Spironolactone may be added to enhance diuresis 2
• Target weight loss of 0.5-1.0 kg daily during active diuresis, even if mild hypotension or azotemia develops 2
• Sodium restriction to 2-3 grams daily enhances diuretic effectiveness 2
• Daily weight monitoring is essential for guiding therapy 2

Respiratory Management

Oxygenation

• Supplemental oxygen is indicated for patients with SaO2 <90% 1
• Oxygen therapy should maintain saturation above 90% in hypoxemic patients 2, 5
• High-flow nasal cannula or non-invasive ventilation should be preferred over intubation when feasible 1

Mechanical Ventilation Considerations

• Intubation should be performed only if the patient cannot tolerate non-invasive ventilation, as positive-pressure ventilation can reduce venous return and worsen low cardiac output 1
• Tidal volumes of approximately 6 mL/kg lean body weight should be used, keeping end-inspiratory plateau pressure <30 cm H2O 1
• Positive end-expiratory pressure should be applied with caution as it may reduce venous return and worsen RV failure 1
• Anaesthetic drugs prone to causing hypotension should be avoided during induction 1
• Hypoxia, acidosis, and hypercapnia must be avoided as they increase pulmonary vascular resistance and lead to further right heart failure 1

Treatment of Underlying Causes

• Anticoagulation is recommended for pulmonary embolism if present 2
• Antibiotics are indicated when pulmonary infection or endocarditis is the underlying cause 2
• Calcium channel blockers, nitric oxide, or prostaglandins should be used for pulmonary hypertension management when appropriate 2
• Identifying and treating triggers of RV failure (infection, PE, arrhythmias, unplanned withdrawal of PAH-targeted therapy) is essential 6

Common Pitfalls and Caveats

• The most critical error is aggressive fluid resuscitation, which worsens RV distension and compromises left ventricular filling through ventricular interdependence 1, 3
• Dobutamine may aggravate ventilation/perfusion mismatch by redistributing flow from obstructed to unobstructed vessels 1
• The RV is particularly sensitive to afterload changes compared to the LV, with steep declines in stroke volume when faced with pressure increases 2, 5
• Milrinone should not be used in severe obstructive aortic or pulmonic valvular disease and may aggravate outflow tract obstruction in hypertrophic subaortic stenosis 4
• Furosemide should not be administered in IV lines containing milrinone due to immediate chemical interaction and precipitate formation 4
• Hypokalemia from excessive diuresis may predispose digitalized patients to arrhythmias and should be corrected with potassium supplementation 4