Right Ventricular Failure

Heart failure is the inability of the heart to fill with or eject blood at a rate appropriate to meet tissue requirments.1 Acute or decompensated heart failure accounts for approximately 1million hospital admissions/year in the United States and is the leading cause for admission for adults older than 65. Heart failure can be classified based on the side of the heart involved (Right vs. Left) or according to the portion of cardiac cycle involved (diastolic vs. systolic). Right Ventricular failure, like LV failure is predominantly systolic failure of the ventricle.


Failure of the Right Ventricle results in systemic venous hypertension, and can lead to the following signs/symptoms:

  1. Peripheral edema
  2. Anorexia, nausea, and abdominal pain related to congestion hepatomegaly
  3. Fatigue, dypnea (related to inadequate Cardiac Output)

Right Ventricular failure in the operating room could be associated with the following signs/symptoms:

  1. Hypotension
  2. Increased PCWP (in setting of PA catheter), although it may decrease as it worsens3
  3. Tachycardia
  4. New Right bundle branch block4
  5. RV third heart sound, Tricuspid regurgitation4


The pathophysiology of RV failure is similar in most cases, sharing elevated pulmonary vascular resistance, with the exception of RV infarction. The most common causes of RV failure include:

  1. Chronic Obstructive Pulmonary Disease (COPD) and Chronic Bronchitis
  2. Obstructive Sleep Apnea
  3. Morbid Obesity
  4. Massive Pulmonary Embolus
  5. Recurrent Thromboembolism
  6. Pulmonary Hypertension (Primary and secondary)

In the operating room, RV failure is exacerbated by and can be caused by:

  1. Hypercarbia- increases pulmonary vascular resistance
  2. Acute Pulmonary embolus/Air embolus/Fat embolus
  3. Elevated PEEP- decreased preload and cardiac output
  4. Hypoxemia
  5. Volume overload- leading to tricuspid regurgitation


Pulmonary vasodilators and positive inotropic agents are the best methods for improving RV function in RV failure. Unlike LV failure, systemic vasoconstrictors (increase LV afterload) can improve end-organ perfusion and cardiac output in RV failure.

Treatment algorithm for patients in RV failure with cardiogenic shock2

  • (Hypotensive)Perform Echo/TEE in intubated patient
  • Give Oxygen, decrease PEEP
  • Hypovolemic? Fluid Responsive? (ie: PPV > 12%))
    • Yes
      • Check Hgb
        • Hgb < 7.0 or actively bleeding
          • Transfuse pRBC
        • Hgb > 7.0 and not actively bleeding
          • Give plasma expanders
    • No
      • CVP >20, SvO2 < 65%
        • r/o tamponade/tension pneumothorax
        • Known or suspected Increased PVR?
          • Give Oxygen, consider pulmonary vasodilators such as milrinone +/- vasopressin, inhaled Nitric oxide
        • Decreased coronary perfusion?
          • Start vasopressin (less alpha-agonism than phenylephrine and NE, thus less of an increase in PVR
        • Diminished RV contractility?
          • Start inotropes such as: Dobutamine, milrinone, low dose epinephrine (0.005 – 0.02 ucg/kg/min)


  1. Roberta L. Hines and Katherine E. Marschall. Stoelting’s Anesthesia and Co-Existing Disease, 5th Edition. Philadelphia, PA: Churchill Livingstone, 2008. pages 104-105


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Anesthesia advanced circulatory life support.
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François Haddad, Ramona Doyle, Daniel J Murphy, Sharon A Hunt
Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure.
Circulation: 2008, 117(13);1717-31
[PubMed:18378625] [WorldCat.org] [DOI] (I p)

Gregory Piazza, Samuel Z Goldhaber
The acutely decompensated right ventricle: pathways for diagnosis and management.
Chest: 2005, 128(3);1836-52
[PubMed:16162794] [WorldCat.org] [DOI] (P p)