Percutaneous mechanical circulatory support for acute right heart failure: A practical approach

Abstract

Acute right heart failure (RHF) represents a critical entity with significant morbidity and mortality. This review examines the role of percutaneous right ventricular assist devices (pRVADs) as a cornerstone of therapy in cases refractory to conventional management. Devices such as the Impella RP and dual-lumen cannulas provide targeted haemodynamic support, with indications in various clinical scenarios, including acute myocardial infarction, post-cardiac surgery, myocarditis, and after left ventricular assist device (LVAD) implantation. Successful implementation requires meticulous haemodynamic assessment, including parameters derived from pulmonary artery catheterization and echocardiography, to guide patient selection, optimize device placement, and monitor therapeutic response. The manuscript highlights contemporary weaning strategies, emphasizing recovery of right ventricular function, stabilization of systemic haemodynamics, and restoration of end-organ perfusion. While no universal protocols exist, this review presents a pragmatic framework informed by available evidence and expert consensus. Furthermore, the potential complications of pRVAD use-ranging from thromboembolism and haemolysis to device-specific issues such as migration and tricuspid valve damage-are discussed alongside preventive and management strategies. Key challenges in RHF management, including the interplay between right and left ventricular function, the impact of pulmonary vascular resistance, and the use of adjunctive pulmonary vasodilators, are addressed. The review underscores the absence of durable right ventricular assist devices and the need for innovation to close this therapeutic gap. Multidisciplinary collaboration among intensivists, cardiologists, and cardiac surgeons is critical to optimizing outcomes. This review provides actionable insights to assist clinicians in navigating the complexities of acute RHF, fostering a tailored and evidence-based approach to this high-risk population.

Keywords: Cardiogenic shock; ECMO; Impella; pRVAD.

Figure 1

Potential use of pRVAD in a clinical scenario. Clinical scenarios refer to the clinical cases described in Table 3 . LV, left ventricle; RV, right ventricle.

Figure 2

Haemodynamic effects of pRVADs. LV, left ventricle; RV, right ventricle.

Figure 3

Suggested weaning protocol for pRVAD. CI, cardiac index; CVP, central venous pressure; HR, heart rate; IVS, interventricular septum; LVAD, left ventricular assist device; MAP, mean arterial pressure; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; RAP, right atrial pressure; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion; TR, tricuspid regurgitation.