By Debabrata Mukherjee, MD, MS, MSCAI, Eric Cantey, MD, MSc, FSCAI, Said Ashraf, MD, FSCAI, Daniel Burkhoff, MD

As interventional cardiologists, we have to deal with acute right heart failure (RHF) as a significant clinical challenge in the catheterization laboratory and in the intensive care setting. In this Tip of the Month, we focus on the role of percutaneous right ventricular assist devices (pRVADs) for management of acute RHF.

Indications and Device Selection for Percutaneous Right Ventricular Mechanical Circulatory Support (RV-MCS)

Percutaneous RV-MCS is indicated for patients with RHF or RV-predominant cardiogenic shock (CS) that is refractory to traditional medical therapy, such as volume optimization and inotropic drugs. Specifically, indications include acute right ventricular myocardial infarction (RVMI) — typically post-inferior MI — RV failure following left ventricular assist device (LVAD) implantation, myocarditis, post-cardiotomy shock (PCS), fulminant myocarditis, or massive acute pulmonary embolism. Important considerations at the time of device selection include urgency of deployment, need for oxygenation, pathophysiology of shock state, the need for RV-only or biventricular support, blood flow requirement, and ambulation. Patient factors to consider include medical history, hemodynamics, anatomic considerations (peripheral arterial disease, congenital heart disease, valvular heart disease), frailty, and recoverability. Device selection, the timing of initiation, and platforms are nuanced and best decided with a multidisciplinary Shock Team approach. The goal of therapy is to serve as a bridge to recovery (BTR) by reducing RV wall stress and oxygen demand, or bridge to decision/transplant in end-stage cases.

Table 1: Available Devices

Note: AI: aortic insufficiency; IVC: inferior vena cava; PA: pulmonary artery; RA: right atrium; VA-ECMO: venoarterial extracorporeal membrane oxygenation

Hemodynamic Monitoring

PA catheterization is central to evaluating patients with suspected RV failure (either in isolation or in combination with left ventricular [LV] failure) and determining when escalation to percutaneous MCS is warranted. Key measurements and cutoff values are listed in Table 2. RV failure is suggested by right atrial pressure (RAP) >15 mmHg, a disproportionately elevated RAP/pulmonary capillary wedge pressure (PCWP) ratio (>0.63 after LVAD or >0.86 in acute MI [AMI]), low pulmonary artery pulsatility index (PAPi) (≤1.0 in AMI‑CS or <1.85 in heart failure-related CS [HF‑CS]), and reduced cardiac index (<2.2 L/min/m²), particularly when accompanied by clinical hypoperfusion. Persistent RV dilation, low PA pulse pressure, and declining venous oxygen saturation (SvO₂) provide additional confirmation. These hemodynamic thresholds, especially when combined with rising lactate, worsening renal or hepatic function, or ECHO evidence of impaired RV contractility, should prompt early consideration of RV-MCS. Continuous pulmonary artery catheterization (PAC) monitoring guides therapeutic manipulation of volume status (e.g., volume infusion versus diuretics or some form of renal replacement therapy), afterload (e.g., inhaled nitric oxide [NO]), and inotropes (e.g., dobutamine or milrinone) and supports timely initiation of mechanical support before irreversible end‑organ dysfunction develops.¹

Table 2: Key Hemodynamic measurements and cutoff values for monitoring

Strategies for Weaning

Weaning right‑sided MCS should be considered once hemodynamics stabilize, end‑organ function improves, and the underlying cause of the acute RV failure has been corrected or is clearly recovering. Key readiness indicators include optimized volume status, reduced RAP (<10–15 mmHg), improving PAPi, mean arterial pressure (MAP) ≥65 mmHg with minimal vasoactive support, lactate normalization, and echocardiographic evidence of enhanced RV contractility. A structured, device‑specific, stepwise reduction in support — such as decreasing RVAD flow by 0.5 L/min increments or lowering Impella RP support to P2 while maintaining flows >1.5 L/min — allows careful assessment of RV adaptability. Throughout the process, continuous monitoring of invasive hemodynamics, perfusion markers, and clinical status is essential. If stability is maintained at minimal support, device explantation can be pursued; if deterioration occurs, the wean should be paused and contributing factors reassessed. Early involvement of an interdisciplinary shock team supports safe and timely decannulation.²
 

Complications Related to Device

Bleeding is the most common complication of percutaneous RV support, occurring in up to 60% microaxial flow pump (mAFP) devices and 35% of RA-PA catheters. The use of anticoagulation in a critically ill population to decrease the risk of device-related thrombosis likely accounts for a large percentage of bleeding-related events. Venous access site bleeding occurs in 3.5% of mAFP and 17.5% of RA-PA implantations. Hemolysis has been reported in 13.3% of mAFP cases and is minimal in RA-PA catheters, which use centrifugal pump configurations.^{3, 4}

Meticulous device positioning and repositioning with balloon-tipped catheters to navigate to the distal PA, supportive introducer wires, and fluoroscopic or echocardiographic guidance are critical to avoid both procedural and intensive care unit (ICU)-related valvular and pulmonary artery injury.

Clinical Pearls and Practical Pointers

• As with all CS care, the early involvement of a shock team is critical for the multidisciplinary management of RV failure. Prompt treatment of reversible etiologies of RV failure, such as catheter-based or lytic therapy for pulmonary embolism, is necessary to allow for RV recovery.
• The use of a PAC is essential for prompt identification, risk stratification, and phenotypic characterization of RV failure; tailored optimization of RV cardiac output; and assistance with device escalation or weaning.
• RV failure is suggested by RAP >15 mmHg, a disproportionately elevated RAP/PCWP ratio (>0.63 after LVAD or >0.86 in AMI), low PAPi (≤1.0 in AMI-CS or <1.85 in HF-CS), and reduced cardiac index (<2.2 L/min/m²).
• The type of percutaneous right ventricular support device depends on multiple patient-and center-specific variables. Concomitant biventricular failure, hypoxia, and the need to ambulate are critical to device selection. Direct RV support devices enhance LV preload and may worsen LV dysfunction if used in isolation for biventricular failure. The use of an oxygenator in indirect (VA-ECMO) and direct RV support (RA-PA catheters) can reduce the need for deleterious positive-pressure ventilation.
• RA-PA catheters typically provide a stable device position, enabling patient ambulation.
• Center-specific, protocol-based care promotes adherence to best practices and maintains active vigilance to reduce the risk of complications associated with RV support devices.

Summary

Prompt diagnosis of acute RHF with the decision to place a pRVAD with appropriate device selection will help successfully treat a failing RV refractory to maximal medical therapy and improve patient survival and outcome. It is critical that today’s interventional cardiologists be familiar with available pRVADs to provide state-of-the-art care to these critically ill patients.

References

1. Kapur NK, Esposito ML, Bader Y, et al. Mechanical Circulatory Support Devices for Acute Right Ventricular Failure. Circulation. 2017 Jul 18;136(3):314-326.

2. Geller BJ, Sinha SS, Kapur NK, et al. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2022 Aug 9;146(6):e50-e68.

3. Anderson MB, Goldstein J, Milano C, et al. Benefits of a novel percutaneous ventricular assist device for right heart failure: The prospective RECOVER RIGHT study of the Impella RP device. JHLT. 2015 Dec 8; 34(12):1549-1560.

4.  Ravichandran AK, Baran DA, Stelling K, et al. Outcomes with the Tandem Protek Duo Dual-Lumen Percutaneous Right Ventricular Assist Device. ASAIO J. 2018 Jul/Aug;64(4):570-572.