RV Failure & Pulmonary Hypertension

• A decompensated RV produces jugular distention, edema, and hypotension with clear lungs; echo reveals a dilated hypokinetic RV with septal flattening.
• Avoid intubation if you can, since induction drops preload; if unavoidable, use ketamine/etomidate with pressors already running.
• Preserve RV perfusion with noradrenaline ± inotrope (dobutamine/milrinone), and AVOID overhydration; the failing RV drowns.
• Lower afterload by correcting hypoxia, hypercapnia, and acidosis, bridging with inhaled prostacyclin/NO.
• Pulmonary hypertension is now defined as mPAP >20 mm Hg at rest with PVR >2 WU.

Mechanisms of Decompensated Right Ventricular Failure

• Compensated RV + acute insult
• RV dilation: wall stress ↑ · tricuspid regurgitation and RV end-systolic volume ↑
• Hypotension (myocardial oxygen supply ↓) combined with tachycardia (myocardial oxygen demand ↑) → RV ischemia → RV ejection fraction ↓
• Septal displacement encroaching on the LV · coronary sinus pressure ↑ · myocardial (wall) congestion ↑ → LV compliance ↓, LV filling ↓
• Cardiac output ↓↓ → cardiogenic shock

Diagnostic Route in Suspected Right Ventricular (RV) Failure

• Suspected RV failure → first evaluation: chest x-ray / ECG / labs
• Transthoracic ECHO plus bubble study
• RV failure without elevated PA pressure
• RV infarction → follow acute coronary syndrome protocol · acute tricuspid regurgitation → surgery consideration
• RV failure with elevated PA pressure (DRVF)
• Pulmonary embolism — PASP <50 → anticoagulate and consider thrombolytics (→ Pathway 22.3)
• Chronic PAH: flare of chronic RV dysfunction → Pathway 22.3
• Primary respiratory or LV failure → treat the underlying cause
• Pericardial disease
• Tamponade → pericardiocentesis · constrictive pericarditis → right/left heart cath, consider surgery

Treatment of Decompensated Right Ventricular (RV) Failure

• Acute decompensated RV failure — look for precipitating causes
• Fix hypoxemia when possible: caution with positive pressure ventilation and PEEP · avoid hypercarbia and acidemia
• Reverse hypotension, restore circulation: dynamically assess volume status — echocardiography/IVC, passive leg raise, pulse-pressure variation (CVP/PCWP not recommended for guiding fluids) · assess organ perfusion — lactate, venous saturation >> early vasopressor use
• Boost RV contractility: dobutamine · milrinone
• Dilate the pulmonary bed with inhaled nitric oxide or inhaled epoprostenol · IV prostacyclin analog or sildenafil only if not hypotensive
• Once stable: remove excess volume · switch to chronic pulmonary vasodilator
• Refractory → consider atrial septostomy, Potts shunt, ECLS