Treatment of right ventricular failure in acute high-risk pulmonary embolism
| Strategy | Properties and use | Caveats |
| Volume optimization | ||
| Cautious volume loading, saline, or Ringer's lactate, ≤500 mL over 15–30 min | Consider 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 gradient | Excessive vasoconstriction may worsen tissue perfusion |
| Dobutamine, 2–20 µg/kg/min [241] | Increases RV inotropy, lowers filling pressures | May 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 oxygenator | Complications 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.