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Acute right ventricular failure—from pathophysiology to new treatments

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Abstract

The right ventricle (RV) provides sustained low-pressure perfusion of the pulmonary vasculature, but is sensitive to changes in loading conditions and intrinsic contractility. Factors that affect right ventricular preload, afterload or left ventricular function can adversely influence the functioning of the RV, causing ischaemia and right ventricular failure (RVF). As RVF progresses, a pronounced tricuspid regurgitation further decreases cardiac output and worsens organ congestion. This can degenerate into an irreversible vicious cycle.

The effective diagnosis of RVF is optimally performed by a combination of techniques including echocardiography and catheterisation, which can also be used to monitor treatment efficacy. Treatment of RVF focuses on alleviating congestion, improving right ventricular contractility and right coronary artery perfusion and reducing right ventricular afterload. As part of the treatment, inhaled nitric oxide or prostacyclin effectively reduces afterload by vasodilating the pulmonary vasculature. Traditional positive inotropic drugs enhance contractility by increasing the intracellular calcium concentration and oxygen consumption of cardiac myocytes, while vasopressors such as norepinephrine increase arterial blood pressure, which improves cardiac perfusion but increases afterload. A new treatment, the calcium sensitiser, levosimendan, increases cardiac contractility without increasing myocardial oxygen demand, while preserving myocardial relaxation. Furthermore, it increases coronary perfusion and decreases afterload. Conversely, traditional treatments of circulatory failure, such as mechanical ventilation and volume loading, could be harmful in the case of RVF. This review outlines the pathophysiology, diagnosis and treatment of RVF, illustrated with clinical case studies.

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Acknowledgements

We would like to acknowledge Professor Didier Payen for his critical review of the paper, Drs. Jan Eskilsson and Ulf Thilèn who performed the echocardiography shown in the ESM at the University Hospital in Lund, Sweden, and Professor Rymer and Dr Boudiaf, who performed the CT scan in Fig. S1 in the ESM.

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Authors and Affiliations

  1. Department of Anaesthesiology and Critical Care Medicine, Hopital Lariboisière, 2 Rue Ambroise Pare, 75475 , Paris Cedex 10, France

    Alexandre Mebazaa, Peter Karpati & Estelle Renaud

  2. Department of Anaesthesiology—Heart-Lung Division, University Hospital of Lund, 22185, Lund, Sweden

    Lars Algotsson

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  1. Alexandre Mebazaa
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  2. Peter Karpati
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Correspondence to Alexandre Mebazaa.

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Mebazaa, A., Karpati, P., Renaud, E. et al. Acute right ventricular failure—from pathophysiology to new treatments. Intensive Care Med 30, 185–196 (2004). https://doi.org/10.1007/s00134-003-2025-3

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