New Treatments for Right Ventricular Failure Show Promise

The assessment of right ventricular functions is challenging, according to investigators of a review published in The New England Journal of Medicine.

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However, they call for better surrogates for right ventricular-pulmonary arterial coupling and better ways to identify the at-risk right ventricle.

Many long-term therapies rely solely on load amelioration, but therapies that target the right ventricular are needed, investigators said.

Additionally, the right ventricle should be considered in clinical trial designs as part of inclusion criteria, as well as endpoints and stratification, according to investigators.

The initial evaluation of individuals with right ventricular failure includes a detailed medical history and physical examination. The symptoms can include abdominal fullness, dyspnea, early satiety, exertional intolerance, fatigue, lower-extremity edema, and right-upper-quadrant tenderness.

The historical features that physicians look for include chronic lung disease, left heart failure, presence of coronary artery disease, and more. Additionally, they look into family history, illicit or prescribed use of anorexigens, and tobacco use.

Physical symptoms include elevated jugular venous pressure, prominent pulmonic component of the second heart sound, and right ventricular heave on palpation.

An electrocardiogram may also be used to determine right atrial dilatation, right-axis deviation, or right ventricular hypertrophy. Confirmation of right ventricular failure includes imaging and invasive hemodynamic techniques.

In terms of treatment, individuals who are in shock because of an acute increase in right ventricular afterload or an acute reduction in contractility could benefit from volume loading and increased transpulmonary blood transit, investigators said.

However, not all individuals with acute right ventricular failure require aggressive volume loading, and it could be harmful, they said.

Individuals who initially have volume depletion and right ventricular infarction could benefit from volume loading, but patients with normal intravascular volume could negatively affect the cardiac output through a decrease in left ventricular transmural filling pressure and increased pericardial constraint.

Additionally, afterload reduction is beneficial for individuals who have elevated right ventricular afterload and right ventricular failure.

The specific cause of elevated right ventricular afterload could affix the relative benefit of afterload-reducing therapies, investigators said.

However, there are several new therapies that target different pathway that show promise. For those with pulmonary hypertension related to lung disease, investigators have found that inhaled Treprostinil improved exercise capacity. Surgical pulmonary endarterectomy for those with pulmonary hypertension related to chronic thromboembolic disease or percutaneous balloon pulmonary angioplasty for patients who are inoperable could be considered with an anticoagulation therapy.

Additionally, those who have acute right ventricular failure and chronically elevated precapillary right ventricular after load found immediate improvement from inhaled pulmonary vasodilators, such as epoprostenol or nitric oxide.

Finally, for those with intractable right ventricular failure, a long or heart-lung transplant could be considered for select patients.

Investigators also noted that direct pulmonary vasodilators have proven to not be largely beneficial in individuals with pulmonary hypertension because of the left heart disease and could be harmful.

Furthermore, sleep disorders should be considered for individuals with pulmonary hypertension, including pulmonary arterial hypertension, according to investigators.

Reference

Houston BA, Brittain EL, Tedford RJ. Right ventricular failure. N Engl J Med. 2023;388(12):1111-1125. doi:10.1056/NEJMra2207410