Treatment of right ventricular failure in acute high-risk pulmonary embolism

StrategyProperties and useCaveats
Volume optimization
 Cautious volume loading, saline, or Ringer's lactate, ≤500 mL over 15–30 minConsider in patients with normal–low central venous pressure (due, for example, to concomitant hypovolaemia)Volume loading can over-distend the RV, worsen ventricular interdependence, and reduce CO [239]
Vasopressors and inotropes
 Norepinephrine, 0.2–1.0 µg/kg/mina [240]Increases RV inotropy and systemic BP, promotes positive ventricular interactions, and restores coronary perfusion gradientExcessive vasoconstriction may worsen tissue perfusion
 Dobutamine, 2–20 µg/kg/min [241]Increases RV inotropy, lowers filling pressuresMay aggravate arterial hypotension if used alone, without a vasopressor; may trigger or aggravate arrhythmias
Mechanical circulatory support
 Veno–arterial ECMO/extracorporeal life support [251, 252, 258]Rapid short-term support combined with oxygenatorComplications with use over longer periods (>5–10 days), including bleeding and infections; no clinical benefit unless combined with surgical embolectomy; requires an experienced team

CO: cardiac output; BP: blood pressure; ECMO: extracorporeal membrane oxygenation; RV: right ventricle/ventricular. aEpinephrine is used in cardiac arrest.