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Treatment of Right Heart Failure
Treatment of Right Heart Failure
Introduction
Right heart failure (RHF) syndrome is characterised by the inability of the right ventricle to generate
enough stroke volume, thereby resulting in systemic venous congestion, underfilling of the left
ventricle and, in the most advanced cases, cardiogenic shock. Right heart failure portends a poor
prognosis in almost every clinical scenario [1-3]. Although the aetiologies of right ventricular (RV)
failure are diverse, treatment often involves simultaneous and timely execution of multiple strategies
aimed at optimising RV preload, afterload, and contractility. Amelioration of the primary driver of
RV failure and reducing further RV insult when feasible are desirable. Timely institution of
mechanical circulatory support can offer a bridge to RV recovery or to definitive management of the
underlying cause (Figure 1).
Figure 1. Principles of managing right heart failure.
Although the general principles of managing RHF apply to both the acute and chronic settings, the
following discussion highlights the nuances and challenges of managing isolated RHF in the acute
setting (Figure 2). Management of the specific causes of right heart failure, such as pulmonary
hypertension, pulmonary embolism, RV infarction, left ventricular dysfunction, sepsis etc., is beyond
the scope of this article.
Figure 2. Management of isolated acute right heart failure.
Modified from Hadad et al [23] and Lahm et al [24].
CVP: central venous pressure; ECMO: extracorporeal membrane oxygenation; iNO: inhaled nitric
oxide; PE: pulmonary embolism; PEEP: positive end-expiratory pressure; PPLAT: plateau pressure;
RV: right ventricle; RVAD: right ventricular assist device; VT: tidal volume
Although a detailed discussion of the management of specific aetiologies of RV failure is beyond the
scope of this article, the identification and management of treatable causes of RV failure is an
important aspect of management strategy. Examples include thrombolytic or catheter-based
management for massive pulmonary embolism and early coronary reperfusion for RV infarction.
In cases refractory to medical therapy, timely deployment of mechanical circulatory support may
offer a bridge to recovery or to the definitive management of the underlying cause. Percutaneous
support options include extracorporeal membrane oxygenation (ECMO), which offers right- and left-
sided circulatory support. Currently available options for percutaneous right ventricular assist devices
include the Impella RP System (Abiomed, Danvers, MA, USA), and TandemLife (CardiacAssist,
Inc. Pittsburgh, PA, USA) using the PROTEK Duo cannula. Surgically cannulated pumps such as the
Levitronix CentriMag left ventricular assist system (Levitronix LLC, Waltham, MA, USA) can also
offer RV support when employed in a right atrial and pulmonary artery configuration. Although none
of the durable ventricular assist devices is currently approved for RV support, their use has been
reported. [22] Select patients with refractory RHF may be candidates for transplantation.
Conclusion
The management of isolated acute right heart failure remains more of an art than a science in the
absence of robust randomised data. In addition to treating the specific cause, RV preload
optimisation, the use of selective pulmonary vasodilators, RV inotropic support and temporary
mechanical circulatory device therapy form integral components of a comprehensive strategy to
support the failing right heart.
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