Right heart failure - NYSORA | NYSORA

Right heart failure

Learning objectives

  • Pathogenesis of right heart failure (RHF)
  • Treatment of RHF
  • Anesthetic management of RHF

Definition and mechanisms

  • Right heart failure (RHF) is defined as dysfunction of the right heart structures, predominantly the right ventricle (RV), but also the tricuspid valve and right atrium
  • Impaired vena cava flow, resulting in an impaired ability of the right heart to perfuse the lungs at normal central venous pressures, can also cause RHF
  • Ventricular interdependence, the phenomenon whereby the function, volume, or pressure in one ventricle can directly influence that of the other, contributes to right heart failure in case of left ventricular dysfunction
  • Vice versa, when RV pressure or volume overload occurs, the RV can affect LV performance and result in a decreased LV preload and contractility
  • Elevated filling pressures on the right side of the heart lead to backward failure and systemic venous congestion

Right Heart Failure, congestion, preload, afterload, inotropy

  • Backward failure: 
  • Fundamental management principles involve optimizing rate, rhythm, perfusion, and preload, whilst maintaining contractility and minimizing afterload

RV, tricuspid insufficiency, CVP, congestion, increased renal vein pressure, leftward septal shift, LVEDP, natriuretic peptides, blood pressure, glomerular pressure, vasodilation, stroke volume, cardiac output, RAAS, vasopressin, SNS, vasoconstriction, sodium and water restriction, renal perfusion, ischemia

Signs and symptoms

  • Breathlessness
  • Chest discomfort
  • Palpitations
  • Swelling
  • Elevated jugular venous pressure/jugular venous distention
  • Hepatojugular reflux
  • Peripheral edema
  • Bloating/early satiety/abdominal discomfort
  • Hepatosplenomegaly/hepatic pulsation
  • Ascites 
  • Pleural effusion
  • Prominent S2 (P2) (PH)    
  • Right-sided S3 gallop    
  • TR murmur    
  • RV heave
  • Paradoxical pulse


Decreased RV contractilityRV volume overloadRV pressure overload
LVAD supportHypoxia
MyocarditisAcute Respiratory Distress Syndrome
Perioperative injury/ischemia (postcardiotomy)Positive pressure ventilation
Mechanical ventilation
ChronicRight ventricular cardiomyopathyLeft heart disease
Arrhythmogenic right ventricular cardiomyopathySingle ventricle
Ebstein anomalyPericardial disease
Pulmonary regurgitationPulmonary hypertension (PH)
Transposition of the great arteriesChronic thromboembolic Pulmonary hypertension (PH)
Tricuspid regurgitation (TR)Pulmonary stenosis
Congenital heart disease with a shunt (ASD or anomalous pulmonary venous return)Left-sided valvular heart disease
Restrictive cardiomyopathy
Chronic obstructive pulmonary disease
Right ventricular outflow tract obstruction

Another important mechanism that leads to RHF is intrinsic RV myocardial disease:

RHF may be caused by impaired filling which is seen in the following conditions:


  • Chest X-ray
  • ECG
  • echocardiogram
  • Blood test (natriuretic peptides)
  • MRI/CT
  • Cardiac catheterization


Acute RHF

  • Volume management
    • Diuretics 
      • Loop diuretics + thiazide diuretic
      • Aldosterone antagonists
      • Carbonic anhydrase inhibitors
    • Renal replacement therapies
      • Veno-venous hemofiltration
      • Ultrafiltration
  • Vasoactive therapies
    • Afterload reduction
      • Non-selective vasodilators including intravenous nitroglycerin and sodium nitroprusside
      • Phosphodiesterase-5 inhibitors
    • fAugment contractility
      • Milrinone
      • Dobutamine
    • Maintain perfusion
      • Dopamine
      • Norepinephrine
      • Epinephrine
      • Arginine vasopressin
      • Phenylephrine

Chronic RHF

  • Diuretics and sodium restriction
    • Combination therapy: loop diuretics with thiazides
  • Renin-angiotensin-aldosterone system inhibitors, beta-blockers, and hydralazine
  • Digoxin
  • Pulmonary vasodilators
    • Prostacyclin analogs
      • Epoprostenol
      • Treprostinil
      • Iloprost
    • Phosphodiesterase-5 inhibitors
    • Endothelin receptor antagonists
  • Mechanical circulatory support
    • ECMO
    • RVAD
    • LVAD
  • Transplantation

ClassificationDose (i.v. unless stated)EffectsAdvantagesDisadvantages
NoradrenalineVasopressor0.02-0.2 µg/kg/minVasoconstriction, ↑SVR, ↑myocardial O2 delivery, ↑PVRCheap, easy to titrate, familiarityArrhythmias, ↑PVR in higher doses
VasopressinVasopressor1-4 units/minVasoconstriction, ↑SVR, pulmonary vasodilatation at low doses via endothelial nitric oxide pathway, ↑myocardial O2 deliveryCatecholamine-sparing, less ↑PVR than noradrenaline, easy to titrateExpensive, bradycardia, splanchnic ischemia
DobutamineInodilator2.5-10 µg/kg/minInotropy, ↑contractility, ↓SVR, PVREasy to titrate, cheap↑O2 demand, tachyarrhythmias, systemic hypotension
MilrinoneInodilator0.75-0.75 µg/kg/minInotropy, ↑contractility, ↓SVR, PVRPulmonary vasodilatationSystemic hypotension
LevosimendanInodilatorLoading dose: 6-12 µg/kg/min over 10 min followed by infusion of 0.1 µg/kg/min↑ContractilityNo effect on myocardial oxygen demandExpensive, tachycardia, hypotension, headache
SildenafilPulmonaryvasodilator10 mg t.d.s.
Oral: 20-100 mg t.d.s
↓PVR, ↑ContractilityOral administration for patients with chronic diseaseLong terminal half-life (4e18 h), ↓SVR
EpoprostenolPulmonaryvasodilator1-2 ng/kg/min
Nebulized: 0.2-0.3 ml/min of a 10-20 µg/mil solution
↓PVR, ↑V/QmismatchAs efficient as nitric oxideSystemic hypotension with i.v. administration, flushing, headaches

Anesthetic management

Right heart failure, afterload, preload, contractility, nitrates, diuretics, inotropes, oxygen, central venous pressure, etomidate, propofol

Suggested reading

  • Houston BA, Brittain EL, Tedford RJ. Right, Ventricular Failure. N Engl J Med. 2023;388(12):1111-1125.
  • Price LC, Martinez G, Brame A, et al. Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. Br J Anaesth. 2021;126(4):774-790.
  • Murphy, E., Shelley, B., 2019. Clinical presentation and management of right ventricular dysfunction. BJA Education 19, 183–190.
  • Cops J, Mullens W, Verbrugge FH, et al. Selective abdominal venous congestion induces adverse renal and hepatic morphological and functional alterations despite a preserved cardiac function. Sci Rep. 2018;8(1):17757.
  • Cops J, Mullens W, Verbrugge FH, et al. Selective abdominal venous congestion to investigate cardiorenal interactions in a rat model. PLoS One. 2018;13(5):e0197687. Published 2018 May 29.
  • Konstam MA, Kiernan MS, Bernstein D, et al. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association. Circulation. 2018;137(20):e578-e622.
  • Murphy, E., Shelley, B., 2018. The right ventricle—structural and functional importance for anaesthesia and intensive care. BJA Education 18, 239–245.
  • Gorter TM, van Veldhuisen DJ, Bauersachs J, et al. Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2018;20(1):16-37.
  • Kevin LG. 2007. Right ventricular failure. Continuing Education in Anaesthesia Critical Care & Pain. 7;3:89-94.

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