Pathophysiology and management of right ventricular failure in critically ill patients: A narrative review

Table 1 Selected conditions and their associated impact on preload, afterload, and contractility

Factor	Pre-load (↑ or ↓)	Afterload (↑ or ↓)	Contractility (↑ or ↓)
Pulmonary embolism	↓ (In RV failure and venous return impairment)	↑↑ (Vascular obstruction with vasoconstriction)	↓ (In RV ischemia from pressure overload and failure)
Decompensated PAH	Variable (however, often ↑ due to volume overload)	↑↑ (Chronic ↑ PVR + inciting event)	↓ (RV dysfunction with progression)
Septic shock (w/RV dysfunction)	↑ (Aggressive fluid resuscitation → RV over-distension)	↑ (Microvascular changes, ARDS-related ↑ PA pressures)	↓ (Septic cardiomyopathy)
ARDS (and mechanical ventilatory support)	↓ (↑ Intrathoracic pressure → ↓ venous return)	↑ (Hypoxic vasoconstriction, microthrombi, high airway pressure)	↓ (Secondary to RV strain/failure)
Mechanical ventilation (High PEEP or tidal volume)	↓ (↑ Intrathoracic pressure → ↓ venous return)	↑ (Overdistension → ↑ PVR)	↓ (If RV ischemia/strain occurs)
Hypoxemia/hypercapnia		↑ (Vasoconstriction→ ↑ PVR)	↓ (If prolonged → RV dysfunction)
Arrhythmia (in PAH)	↓ (Ineffective filling)	-	↓ (Loss of coordinated contraction)
Fluid loading in sepsis	↑ (Aggressive fluids → RV over-distension)

PA: Pulmonary artery; PVR: Pulmonary vascular resistance; RV: Right ventricle; PAH: Pulmonary arterial hypertension; PEEP: Positive end-expiratory pressure; ARDS: Acute respiratory distress syndrome.

Table 2 Echocardiographic findings suggestive of right ventricular failure, as compared with normal parameters

	Normal	Suggestive of RV failure
Tricuspid annular plane systolic excursion	≥ 17 mm	< 17 mm
RV fractional area change	≥ 35%	< 35%
Tricuspid annular systolic S’ tissue doppler velocity	≥ 10 cm/second	< 10 cm/second
RV: LV end-diastolic diameter ratio	≤ 1.0	> 1.0
IVC measurement	≤ 2.1 cm diameter, > 50% inspiratory collapse	> 2.1 cm diameter, < 50 % inspiratory collapse
Tricuspid regurgitant jet velocity	≤ 2.8 m/second	> 2.8 m/second
McConnell’s sign	Absent	Present
“D Sign”	Absent	Present

RV: Right ventricle; LV: Left ventricle; IVC: Inferior vena cava.