Gaps and Knowledge in the Contemporary Management of Acute Right Ventricular Failure

Abstract

Acute right ventricular failure (ARVF) is commonly seen in the intensive care unit and constitutes a significant clinical challenge, with associated high in-hospital mortality. Recently, the treatment of ARVF has significantly changed, with the progressive implementation of mechanical circulatory support devices that now represent important tools for clinicians in treating this condition. However, despite recent advancements, the optimal approach for ARVF remains elusive, and precise treatment algorithms and comprehensive management protocols are still lacking. In the present review, we explore the pathophysiology of ARVF, highlighting the different mechanisms that may lead to this clinical entity and emphasizing the left and right heart's complex interplay. We analyze the different therapeutic options that are now available for short- and long-term management of ARVF, with a particular focus on the advantages and disadvantages of the mechanical circulatory support devices actually used. Furthermore, we propose future directions in the field and a possible flowchart for the treatment of this condition.

Keywords: heart; heart failure; hospital mortality; intensive care units; software design.

Figure 1.

Pathophysiological mechanisms in acute right ventricular failure. The figure provides a schematic overview of the development and impact of acute right ventricular failure (ARVF). It compares the pathways leading to ARVF under de novo conditions, which arise from direct acute injury, and acute on chronic scenarios, which develop due to a worsening of preexisting conditions. The diagram outlines the heart’s short-term and long-term adaptive responses to increased afterload, emphasizing the potential for right ventricular dilatation and the associated negative outcomes on systemic circulation and organ function. CO indicates cardiac output; CVP, central venous pressure; PA, pulmonary artery; and RV, right ventricular.

Figure 2.

Different causes and management of acute right ventricular failure. This figure depicts the causes and management of acute right ventricular failure (ARVF), resulting from acute or chronic stressors that affect preload, contractility, and afterload. Clinical manifestations include ascites, gastrointestinal congestion, peripheral edema, dyspnea, and jugular vein distension. Management strategies involve fluid control, addressing the underlying condition, and possible tricuspid valve repair. Hemodynamically unstable patients may require inotropes, vasopressors, or mechanical circulatory support (MCS), while stable patients undergo clinical follow-up and medical optimization. AMI indicates acute myocardial infarction; MAP, mean arterial pressure; PE, pulmonary embolism; PH, pulmonary hypertension; and TV, tricuspid valve.

Figure 3.

Temporary mechanical support devices for the treatment of acute right ventricular failure. The figure summarizes the characteristics, implantation techniques, and hemodynamic effects of the currently most adopted mechanical cardiac support devices for the treatment of acute right ventricular failure. LV indicates left ventricular; PA, pulmonary artery; RA, right atrium; RV, right ventricular; TH-RVAD, Tandem Heart right ventricular assist device; and VA-ECMO, venoarterial extracorporeal membrane oxygenation.

Figure 4.

Flowchart for the treatment of acute right ventricular failure. Hemodynamic instability=persistent hypotension (systolic blood pressure <90 mm Hg) requiring ≥1 inotrope/vasopressor to maintain with signs of organ hypoperfusion. ARVF indicates acute right ventricular failure; AV, atrioventricular; Bipella, simultaneous use of Impella RP/Impella RP flex with Impella CP; CVP, central venous pressure; HT, heart transplant; iNO, inhaled nitric oxide; MAP, mean arterial pressure; MCS, mechanical cardiac support; PAC, pulmonary artery catheterization; PAH, pulmonary arterial hypertension; PDE3, phosphodiesterase-3; PGI, prostacyclin; PVR, pulmonary vascular resistance; RV, right ventricular; RV-MCS, right ventricular mechanical cardiac support; TH-RVAD, Tandem Heart right ventricular assist device; and VA-ECMO, venoarterial extracorporeal membrane oxygenation.