Right ventricular (RV) failure, or cor pulmonale leading to cardiogenic shock, is associated with high morbidity and mortality in both cardiac surgical units and nonsurgical ICUs. Early recognition and prompt intervention are critical for improving survival. As mechanical circulatory support (MCS) technologies advance, understanding the unique features of right-sided devices is essential for optimal patient selection.

Etiologies of RV failure align with the determinants of cardiac output: preload, afterload, and contractility. Excess preload may result from biventricular failure, valvular pathology, or left-to-right shunting. Reduced contractility can occur due to acute myocardial infarction, myocarditis, cardiac surgery, or acute-on-chronic RV dysfunction. Increased afterload is often secondary to pulmonary embolism, pulmonary hypertension, or ARDS.

Clinical evaluation focuses on signs of systemic congestion such as dyspnea, jugular venous distention, hypotension, and tachycardia, supported by elevated lactate, troponin, or brain natriuretic peptide levels. Bedside imaging with point-of-care ultrasound or an RV-focused echocardiogram, along with pulmonary artery catheterization, enables early diagnosis and monitoring. Hemodynamic findings typically include elevated pulmonary artery wedge pressure, central venous pressure, pulmonary artery systolic pressure, and pulmonary artery diastolic pressure, with a pulmonary artery pulsatility index < 0.9-1.5 and decreased tricuspid annular plane systolic excursion suggesting significant RV dysfunction. Immediate management includes inotropes, vasodilators, thrombolytics, and rapid activation of a multidisciplinary shock team.

Importantly, MCS should not be delayed until refractory shock ensues. Early initiation can prevent catastrophic cardiovascular collapse. MCS goals in RV failure include bridge to recovery, bridge to intervention (catheterization or surgery), or bridge to durable solutions such as a left ventricular assist device (LVAD) or heart transplantation.

Mechanical support options are classified by location (intracorporeal vs extracorporeal) and pump type (axial vs centrifugal flow). The Impella RP® remains the only available intracorporeal percutaneous axial flow pump. Extracorporeal devices utilize centrifugal pumps, with cannulation strategies determined by whether oxygenation support is needed.

In severe pulmonary vascular resistance states, such as pulmonary arterial hypertension, direct right atrium-to-pulmonary artery (RA → PA) bypass alone may be ineffective. Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) (RA → aorta), whether central or peripheral, provides a superior rescue option and can bridge patients to recovery or transplantation. VA-ECMO is also effective for massive pulmonary embolism and during cardiopulmonary resuscitation.

For isolated RV failure, as seen in postmyocardial infarction, postcardiac surgery, post-LVAD implantation, or posttransplantation, percutaneous RV assist devices can deliver 2 to 4 liters per minute of flow from the RA to the PA via single-lumen or dual-lumen cannulae. In cases of concurrent hypoxemia, such as ARDS, oxygenators can be incorporated into configurations like veno-PA or venovenous ECMO to provide both RV support and oxygenation.

In summary, successful management of RV failure relies on early detection, prompt escalation, and coordination across a multidisciplinary team. Intensivists are uniquely positioned to lead recognition, escalation, and management of these patients in the growing era of MCS critical care.

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