Right Heart Failure

Background

• Right heart failure is a clinical syndrome resulting from impaired right ventricular filling and/or reduced right ventricular flow output due to a variety of causes, including structural or functional cardiovascular disorders.
• Patients usually present with exercise limitation and fatigue.
• Findings on exam include elevated jugular venous pressure, peripheral edema, and/or hepatomegaly.

Evaluation

• Perform a transthoracic echocardiography (TTE) to evaluate right ventricular size and function in patients with suspected right ventricular dysfunction (Strong recommendation).
• For patients suspected of having right heart failure due to constrictive pericarditis:
  • Perform a TTE with Doppler assessment of ventricular filling to confirm the presence of constrictive physiology (Strong recommendation).
  • Use cardiac magnetic resonance (CMR) imaging or computed tomography (CT) imaging to assess for pericardial thickening (Strong recommendation).
• Use CMR to evaluate patients suspected of having arrhythmogenic right ventricular dysplasia (Strong recommendation).
• Use right heart catheterization to evaluate patients with refractory right heart failure or if diagnosis cannot be made using other testing (Strong recommendation).

Management

• Identify and treat the underlying etiology of right heart failure, if possible.
• Optimize fluid status; use IV diuretics if there is volume overload, and exercise caution and avoid fluid overfilling if there is low central venous pressure (CVP).
• For patients who are hypotensive despite optimizing fluid status, maintain arterial pressure with vasopressors and/or inotropic agents.
• Consider mechanical circulatory support and/or cardiac transplantation for patients with refractory right heart failure requiring prolonged inotropic support.
• Consider management options based on the specific etiology or right heart failure.
• Offer an annual flu shot to all patients with right heart failure (Strong recommendation).