Right Heart Failure in the Intensive Care Unit: Etiology, Pathogenesis, Diagnosis, and Treatment

Abstract

Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.

Approach to Decompensated Right Heart Failure in the Acute Setting

“…The right heart is distinct from the left heart, with the right heart's circulatory system consisting of the right atrium, tricuspid and pulmonary valves, the right ventricle (RV), and pulmonary vasculature [8]. It is known that all causes of left-heart failure will eventually lead to right-heart failure [9].…”

“…The function of the RV is influenced by preload, afterload, contractility, and relaxation. RV preload refers to the end diastolic volume/pressure, or the load prior to contraction [8]. RV afterload is influenced by the pulmonary vascular resistance (PVR) and the compliance of the chamber [8].…”

“…RV preload refers to the end diastolic volume/pressure, or the load prior to contraction [8]. RV afterload is influenced by the pulmonary vascular resistance (PVR) and the compliance of the chamber [8]. Excessive preload can be seen with regurgitant pulmonic or tricuspid valves, venous congestion, or left-to-right intracardiac shunts [2,3,5,8].…”

“…RV afterload is influenced by the pulmonary vascular resistance (PVR) and the compliance of the chamber [8]. Excessive preload can be seen with regurgitant pulmonic or tricuspid valves, venous congestion, or left-to-right intracardiac shunts [2,3,5,8]. Excessive afterload may be due to stenotic valvular diseases (pulmonary or mitral valve), obstructive pulmonary vascular diseases (PE, tumor emboli, etc.…”

“…ARHF can have many inciting incidents that impact the hemodynamics of the cardiopulmonary circulation. These include, but are not limited to, infections/sepsis, arrhythmias like supraventricular tachycardia (SVT), anemia, pregnancy, medication withdrawal, and acute cardiopulmonary events such as myocardial infarction (MI) or pulmonary embolism (PE) [3,4,7,8]. These etiologies are frequently seen in the emergency department; however, the management of patients with ARHF who present to the emergency department remains challenging.…”