Acute RV Failure Management in Pulmonary Embolism

Acute right ventricular (RV) failure significantly influences mortality rates in patients experiencing pulmonary embolism (PE). This condition arises from an abrupt increase in RV afterload triggered by clot burden, neurohormonal activation, and hypoxia-mediated feedback mechanisms. The ensuing pathological cascade results in RV dilation, decreased stroke volume, and compromised left ventricular (LV) filling due to interventricular dependence, which can lead to hemodynamic collapse. This paper elucidates management strategies focusing on preload optimization, early clot removal through thrombolytic therapy or thrombectomy, and the judicious use of vasopressors and inotropes to sustain systemic blood pressure, enhance coronary perfusion, and maintain RV-LV coupling. In cases of respiratory failure, mechanical ventilation must be utilized with caution. At the same time, advanced interventions such as extracorporeal membrane oxygenation (ECMO) or RV assist devices are reserved for more severe scenarios. A comprehensive understanding of RV physiology and the pathophysiology of PE is essential for devising early interventions aimed at averting the "RV death spiral" and enhancing patient outcomes. Timely recognition and aggressive management are foundational to treating acute RV failure in PE effectively. Acute right ventricular failure is a critical pathology observed in patients suffering from pulmonary embolism. The significance of understanding the underlying mechanisms of RV failure, particularly concerning PE, cannot be overstated, as it is a crucial determinant of morbidity and mortality. The development of acute RV failure is primarily precipitated by a sudden escalation in RV afterload, a consequence of the obstruction of pulmonary arteries by embolic material. This obstruction induces neurohormonal activation and triggers feedback mechanisms associated with hypoxia, leading to the aforementioned detrimental cascade. The resultant RV dilation and diminished stroke volume adversely affect LV filling due to the phenomenon of interventricular dependence, ultimately paving the way for hemodynamic instability. A nuanced understanding of RV physiology alongside the pathophysiological mechanisms underlying pulmonary embolism is imperative for developing and implementing timely interventions. Early recognition and an aggressive management approach are vital to prevent the "RV death spiral" and improve clinical outcomes for patients confronting acute RV failure in the context of pulmonary embolism. Tech Vasc Interventional Rad 28:101039 (c) 2025 Published by Elsevier Inc.