International Perfusion Association

Acute Right Ventricular Heart Failure, ECMO, RVAD, Hemodynamic Support, Five Pillars Framework

Acute right ventricular heart failure (aRHF) has emerged as a critical focus in cardiology due to its unique pathophysiology, which demands a distinct therapeutic approach compared to left ventricular failure. This condition, long overshadowed by a left-ventricular-centric perspective, presents significant challenges due to the right ventricle’s heightened sensitivity to afterload changes and its interdependence with systemic venous return. This perspective outlines a five-pillar framework for managing aRHF, aiming to ensure clinical stability while addressing the condition’s multifaceted nature.

The first pillar, etiological or specific treatment, emphasizes the urgent need to identify and address the primary cause of aRHF. Whether the etiology involves acute pulmonary embolism, right myocardial infarction, acute respiratory distress syndrome, or cor pulmonale, rapid diagnostic measures are essential. Tools such as echocardiography, biomarkers like natriuretic peptides, and advanced imaging techniques play a pivotal role. Early intervention with therapies like anticoagulation, thrombolysis, or percutaneous catheter-directed treatments ensures that the underlying issue is resolved before irreversible right ventricular damage occurs.

The second pillar, hemodynamic support, focuses on maintaining coronary perfusion and systemic circulation. Vasopressors like norepinephrine and vasopressin stabilize systemic pressures, while inotropes such as dobutamine or levosimendan improve right ventricular contractility. Pulmonary vasodilators, including inhaled nitric oxide and prostacyclins, are used judiciously to reduce afterload and enhance right ventricular function. These therapies, while effective, must be balanced against risks like hypotension and pulmonary vascular resistance changes.

The third pillar, ventilation support, addresses the need for careful oxygenation strategies. While oxygen therapy is fundamental, positive pressure ventilation should be used cautiously due to its potential to increase intrathoracic pressure, reduce venous return, and exacerbate right ventricular dysfunction. High-flow nasal cannulas or non-invasive ventilation may offer safer alternatives, and mechanical ventilation, if necessary, should use ultraprotective settings. Prone positioning and advanced ventilatory strategies are particularly beneficial in cases of coexisting acute respiratory distress syndrome.

The fourth pillar, fluid optimization, highlights the delicate balance between preventing hypovolemia and avoiding systemic congestion. In most cases, fluid restriction or diuretic therapy is preferred to mitigate the effects of volume overload on right ventricular performance. Renal replacement therapy may be required in cases of severe fluid imbalance. Recent evidence suggests that dynamic markers of fluid responsiveness, such as pulse pressure variation, can guide treatment, but they must be interpreted carefully in the context of right ventricular dysfunction.

The fifth pillar, mechanical support, represents the most advanced therapeutic options for severe aRHF. Devices like venoarterial extracorporeal membrane oxygenation (VA-ECMO) or right ventricular assist devices (RVADs) such as Impella RP and ProtekDuo offer critical support in cases of refractory shock or severe pulmonary and cardiac failure. VA-ECMO is particularly effective when both cardiac and pulmonary support are needed, while RVADs may be preferred for isolated right ventricular failure. However, these devices carry risks, including vascular complications and hemolysis, and require a multidisciplinary team to optimize outcomes.

This five-pillar framework integrates etiological resolution, hemodynamic stabilization, respiratory management, volume control, and advanced mechanical support, providing a structured approach to aRHF management. By focusing on these interdependent pillars, clinicians can tailor treatment to individual patient needs, ensuring a comprehensive strategy that addresses both the acute and systemic effects of aRHF.

Future directions include leveraging artificial intelligence to enhance diagnostic accuracy and decision-making in aRHF. Emerging biomarkers, molecular imaging techniques, and hemodynamic indices may further refine our understanding of right ventricular function and facilitate earlier interventions. Additionally, repurposed therapies, such as sodium-glucose co-transporter-2 inhibitors (SGLT2i), show promise in improving right ventricular remodeling and reducing pulmonary pressures.

In conclusion, the five-pillar approach provides a robust and adaptable framework for managing the complexities of acute right ventricular heart failure. While ongoing research is needed to validate and expand these strategies, this model emphasizes the importance of personalized, multidisciplinary care in addressing this life-threatening condition.