Supportive organ management in acute right ventricular failure secondary to pulmonary embolism: a narrative review

Abstract

Background. Pulmonary embolism (PE) is among the most common cardiovascular syndromes and a leading cause of acute right ventricular failure (ARVF), which drives haemodynamic and respiratory deterioration and high mortality. While causal treatment removes the thrombus, supportive organ management keeps patients alive until it takes effect, yet clear algorithms are lacking. Aim. To review the pathophysiology of ARVF in PE and available supportive (haemodynamic, oxygenation, ventilation) strategies, appraising their efficacy, safety and evidence quality. Material and methods. Narrative review of PubMed and Google Scholar (2016–2026, with justified exceptions), using Boolean combinations of terms on right ventricular failure, PE and organ support. 36 studies were narratively synthesised, each assessed for design, sample size and methodology. Results. ARVF in PE stems from RV pressure overload uncoupling contractility from afterload, causing RV dilatation, septal shift, LV underfilling and ischaemia. Supportive care targets preload, afterload and contractility. High-flow oxygen therapy appears superior to low-flow and possibly comparable to non-invasive ventilation; positive-pressure ventilation risks haemodynamic harm. Fluids require cautious titration guided by CVP and VExUS. Noradrenaline and dobutamine are preferred; levosimendan and milrinone reduce pulmonary vascular resistance but risk hypotension. Inhaled vasodilators (notably nitric oxide) and oxygen show promise but unproven benefit. Mechanical circulatory support (mainly VA-ECMO) is a bridging option, best combined with embolectomy. Conclusions. Management of ARVF in PE demands combined causal and supportive treatment, but much supportive care rests on extrapolated or low-quality evidence; PE-specific studies are needed.