The Etiology and Management of Critical Acute Right Heart Failure

Right ventricular failure contributes to the morbidity and mortality of acute myocardial function, massive pulmonary embolism, and chronic pulmonary hypertension. Understanding how the normal physiology of the right ventricle (RV) is disrupted is integral to managing patients who present with RV decompensation. Therapeutic advances in mechanical circulatory support, pharmacotherapies to reduce afterload, mechanical and chemical lytic therapies for acute pulmonary embolism have improved outcomes of patients by offloading the RV. In this report we provide an overview of the physiology of the RV, medical management (volume optimization, hemodynamic targets, rhythm management), along with critical care-specific topics (induction with mechanical ventilation, sedation strategies, and mechanical circulatory support) and provide a framework for managing patients who present with leveraging principles of preload, contractility, and afterload. Last, because of the complexity of right ventricular failure management, and the complexity of presentation, we also discuss the role of team-based approach (cardiogenic shock and pulmonary embolism response teams), and highlight its benefits at improving outcomes.