In this episode of IM Basics, Dr. Eric Acker and co-host Dr. Tark take a deep dive into right ventricular (RV) failure—a high-risk but often under-recognized cause of clinical deterioration. The discussion frames RV failure as a problem of both forward flow limitation and backward congestion, emphasizing that a preserved left ventricular ejection fraction does not rule out severe cardiogenic pathology.

The hosts walk through the typical clinical presentation, highlighting early altered mental status, lactic acidosis, acute kidney injury, hepatic congestion, and gastropathy as hallmark features. Unlike left-sided failure, RV failure often causes early end-organ hypoperfusion despite relatively preserved blood pressure, making “normotensive shock” a key concept.

Etiologies are divided into chronic and acute causes. Chronic drivers include pulmonary hypertension (pre- and post-capillary), COPD, chronic thromboembolic disease, and longstanding left-sided heart disease. Acute causes most notably include massive or submassive pulmonary embolism and acute right coronary artery infarction. The conversation emphasizes distinguishing acute from chronic RV failure, as this distinction directly affects management decisions.

Diagnostic evaluation extends beyond routine labs. While BNP, lactate, CMP, and liver enzymes help identify congestion and hypoperfusion, bedside ultrasound plays a central role. The hosts caution against relying solely on IVC size, instead advocating for venous Doppler assessment (portal and femoral veins) and focused echocardiography. Key echo findings include RV dilation, septal flattening (“D-sign”), reduced TAPSE, tricuspid regurgitation velocity, and features suggesting chronic remodeling versus acute strain.

Management is framed around “RV-specific do’s and don’ts.” Core principles include aggressive but thoughtful diuresis—even in the presence of AKI—correction of hypoxia and acidosis, and avoidance of negative inotropes. The episode strongly cautions against premature intubation due to the risks of sedation, positive pressure ventilation, and increased RV afterload. When shock develops, vasopressin is favored for hemodynamic support, often combined with inotropes such as low-dose norepinephrine or dobutamine.

Finally, the hosts discuss escalation of care, including when to involve the ICU, consider mechanical circulatory support, or pursue advanced therapies such as Impella RP or ECMO in select patients. The episode closes with practical bedside pearls and reinforces the importance of early recognition and RV-specific management strategies to prevent rapid clinical collapse.

Academic References & Guidelines

• Echocardiography: ASE Guidelines for the Echocardiographic Assessment of the Right Heart in Adults (Standards for TAPSE <17 mm and RV diameter >4.2 cm).
• Pulmonary Hypertension: ESC/ERS Guidelines for PH (Defined by mPAP >20 mmHg).
• Cardiogenic Shock: SCAI Clinical Expert Consensus (SCAI/SKY SHOCK Criteria) for staging severity.
• Management: AHA Scientific Statement: Evaluation and Management of Right-Sided Heart Failure.

Content Reviewed by Dr. Alejandro Chapa-Rodriguez