What is the treatment for right ventricular (RV) failure?

Treatment of Right Ventricular Failure

The cornerstone of RV failure management is avoiding aggressive fluid resuscitation, optimizing preload to maintain CVP at 8-12 mmHg, reducing RV afterload with pulmonary vasodilators, and maintaining systemic perfusion pressure with norepinephrine when hypotensive. 1, 2

Volume Management

The RV prefers euvolemia, not aggressive volume loading. 1

• Administer cautious fluid boluses (≤500 mL over 15-30 minutes) only if CVP is low, confirmed by ultrasound showing a small and/or collapsible IVC 2
• Avoid aggressive volume expansion as it over-distends the RV, shifts the interventricular septum leftward, compromises LV filling, and reduces cardiac output 1, 2
• Use loop diuretics as first-line therapy when fluid overload is present, targeting elimination of elevated jugular venous pressure and peripheral edema 2
• Target CVP of 8-12 mmHg, as the traditional concept that "the RV is preload dependent" leads to detrimental volume loading 1

Vasopressor and Inotropic Support

Norepinephrine is the vasopressor of choice for hypotensive RV failure. 2

• Start norepinephrine at 0.05-3.3 mcg/kg/min for hypotension, as it improves systemic hemodynamics, ventricular systolic interaction, and coronary perfusion without increasing pulmonary vascular resistance 2
• Maintain adequate systemic perfusion pressure to ensure RV coronary perfusion, particularly when using inodilators like milrinone that cause systemic vasodilation 1
• Consider vasopressin as an alternative pressor that increases systemic afterload without increasing pulmonary vascular resistance 1
• Use inotropes cautiously, as calcitropic agents have been associated with progressive decline in RV function, possibly due to systemic vasodilation and decreased right-sided perfusion pressures 1

Afterload Reduction

Pulmonary vasodilators are essential for reducing RV afterload when pulmonary hypertension is present. 2

• Administer sildenafil 20 mg three times daily (PO or via nasogastric tube) to reduce pulmonary vascular resistance in RV failure with pulmonary hypertension 2
• Use inhaled nitric oxide (5-40 ppm) for selective pulmonary vasodilation, monitoring methemoglobin levels every 6 hours and avoiding abrupt discontinuation 2
• Consider intravenous or inhaled pulmonary vasodilators for pulmonary arterial hypertension and RV failure 1

Respiratory Management

Optimize oxygenation and minimize factors that increase pulmonary vascular resistance. 1, 2

• Provide supplemental oxygen for SaO2 <90%, maintaining saturation above 90% 2
• Minimize intrathoracic positive pressure ventilation, as it increases RV afterload 1
• Correct acidosis, which increases pulmonary vascular resistance 1
• Improve hypoxic pulmonary vasoconstriction to reduce RV afterload 1

Medication Adjustments

Discontinue medications that worsen RV hemodynamics. 2

• Stop or significantly reduce calcium channel blockers (e.g., diltiazem), as they worsen hemodynamics in heart failure and should not be restarted 2
• Cautiously decrease diuretics if no signs of congestion are present, as overdiuresis worsens preload and cardiac output 2
• Monitor natriuretic peptide levels serially during diuretic reduction to ensure congestion does not worsen 2

Mechanical Circulatory Support

Consider RV mechanical support for refractory isolated RV failure. 1

• Use Impella RP or Protek Duo platforms to bypass the failing RV in select patients with persistent isolated RV failure refractory to medical therapy 1
• Choose Protek Duo with centrifugal pump when concomitant respiratory insufficiency exists, as it allows splicing of an oxygenator 1
• Use venoarterial extracorporeal membrane oxygenation for RV failure from progressive pulmonary hypertension, as devices providing only RV support may precipitate pulmonary hemorrhage with forced perfusion 1

Treatment of Underlying Causes

Address the specific etiology of RV failure. 2, 3

• Initiate anticoagulation for pulmonary embolism if present 2
• Evaluate and treat left-sided heart disease, as it is the predominant cause of RV failure in clinical practice 3
• Assess for pulmonary arterial hypertension, which is the principal cause of death in these patients 3

Critical Pitfalls to Avoid

The most critical error is aggressive fluid resuscitation, which worsens RV distension and compromises LV filling through ventricular interdependence. 2

• Avoid excessive fluid administration, as it worsens RV distention and further compromises cardiac output 4
• Do not delay appropriate RV failure-specific therapies while focusing only on symptomatic treatment 4
• Recognize that RV failure from progressive pulmonary hypertension is poorly treated with devices that only provide RV support 1