What Is Right-Sided Heart Failure? 

Introduction

Right-Sided or Right-Ventricle Heart Failure (RHF) mainly occurs when the left ventricle loses the capacity to pump blood efficiently to other parts of the body. As a consequence, fluid gets pushed back through the lungs and impairs the right side of the heart, causing right-sided heart failure. This reverse flow causes fluid accumulation in the legs, ankles, digestive tract, and liver.¹

Right-sided heart failure occurs when the right ventricle of the heart is unable to pump sufficient blood to the lungs. It is usually a consequence of left-sided heart failure. When the left ventricle malfunctions and is unable to pump sufficient blood out, elevated fluid pressure is transferred back through the lungs. This harms the right side of the heart. 

When the right side of the heart loses pumping ability, the blood pools in the body’s veins. This buildup of blood increases the pressure in veins. This pressure pushes the fluid out of the veins and into the other tissues and the fluid accumulates in the legs and abdomen and this leads to swelling in patients.² 

Anatomy and function of the right heart

Overview of the heart's chambers

The heart consists of four chambers divided into two pumps, right and left, that provide blood supply to the systemic and pulmonary circulation. The four chambers of the heart are the right atrium, right ventricle, left atrium, and left ventricle. Through the superior and inferior vena cavae, the right atrium receives deoxygenated blood from the entire body, excluding the lungs.

Additionally, deoxygenated blood from the heart muscle drains via the coronary sinus into the right atrium. Therefore the right atrium serves as a reservoir for collecting deoxygenated blood. 

From here, blood travels via the tricuspid valve and fills the right ventricle, the right heart’s primary pumping chamber. The right ventricle circulates blood through the right ventricular outflow tract, throughout the pulmonic valve, and onto the pulmonary artery, which then oxygenates the blood and distributes it to the lungs. 

In the lungs, the blood is oxygenated as it travels through the capillaries, which are close enough to the oxygen in the alveoli. The four pulmonary veins, two from each lung, collect this oxygenated blood. These four veins connect to the left atrium, which serves as a collection chamber for oxygenated blood. 

Similar to the right atrium, the left atrium transfers blood to its ventricle both passively and actively. Thus, oxygenated blood enters the left ventricle via the mitral valve. 

The primary pumping chamber of the left heart is the left ventricle, which then pumps fresh oxygenated blood to the systemic circulation via the aortic valve. The cycle proceeds to continue with subsequent heartbeat.³ 

Pulmonary circulation

Pulmonary circulation is the circuit that transports deoxygenated blood from the heart to the lungs, where it is re-saturated with oxygen before being distributed into the systemic circulation. 

The inferior vena cava delivers deoxygenated blood from the lower part of the body to the heart, while the superior vena cava delivers deoxygenated blood from the upper part of the body to the heart. 

The superior and inferior venae cavae transport blood into the right atrium. Blood enters the right ventricle via the tricuspid valve. The blood then travels through the pulmonic valve and into the pulmonary artery before reaching the lung. 

The blood in the lungs then separates into a number of pulmonary capillaries where carbon dioxide is released and is resupplied with oxygen. Once the blood is thoroughly oxygenated, it is transported through the pulmonary vein and enters the left atrium, which then circulates the blood through the mitral valve and enters the left ventricle. The left ventricle releases blood rich in oxygen through the aortic valve and onto the aorta with vigorous contraction.⁴

Causes and risk factors for right-sided heart failure

Common underlying conditions

1. Left-Sided Heart Failure

Right-Sided Heart Failure is always caused by Left-Sided Heart Failure. When the left ventricle of the heart fails, excess fluid pressure travels back through the lungs, eventually causing damage to the heart’s right side. 

2. Pulmonary Hypertension

Right-Sided heart failure is frequently caused by persistent high blood pressure. 

Lifestyle factors

• Cocaine use
• Heavy alcohol use
• Tobacco use

Congenital heart defects

• Coronary artery disease
• Diabetes
• High blood pressure
• Obesity
• Pulmonary oedema
• Pulmonary embolism
• Pulmonary stenosis¹

Clinical presentation

Signs and symptoms 

• Waking up at night with shortness of breath
• Shortness of breath during exercise or when lying flat
• Coughing
• Wheezing 
• Difficulty concentrating
• Dizziness
• Fatigue
• Fluid retention causing swelling in the ankles, legs, feet, and abdomen
• Increased urge to urinate
• Lack of appetite and nausea
• Difficulty exercising
• Sudden weight gain¹
• Breathlessness
• Chest discomfort
• Palpitations
• Swelling⁵

Diagnostic methods

• Chest X-Ray: The right ventricle and proximal pulmonary artery would be enlarged on a chest X-ray in patients with right-sided heart failure.
• ECG: An electrocardiogram records the evidence of right ventricle hypertrophy. 
• Echocardiography: Echocardiography is able to measure right ventricle systolic pressure.
• MRI: May be useful for assessing cardiac chambers and function.⁶

Treatment and management

Medical management

Assessing the severity of the patient’s condition and deciding whether or not to admit the patient to the intensive care unit is the initial step in the management of right-sided heart failure. 

The primary focus of treatment is on optimising volume status, increasing right ventricle contractility and decreasing right ventricle afterload. Volume loading should be appropriate for hypotensive patients. As the right ventricle is preload-dependent, monitoring of central venous pressure is often beneficial. 

Volume loading may cause right ventricle dilation and an additional decrease in cardiac output. If volume overload has occurred and volume removal cannot be achieved with medication, intravenous diuresis or renal replacement therapy is indicated. Maintaining euvolemia requires sodium restrictions, daily weights, and strict monitoring of fluid intake and urine output. Considering the contribution of atrial contraction to cardiac output in right ventricle failure, efforts are to be made to restore sinus rhythm in atrial arrhythmia patients. 

In the presence of haemodynamic instability, vasopressors are recommended. Norepinephrine is the preferred pressor for restoring cerebral, cardiac, and end-organ perfusion. Inotropes such as Dobutamine, Levosimendan, and the phosphodiesterase-3 inhibitor milrinone, are also advantageous because they enhance contractility and cardiac output. 

Dobutamine is the preferred inotrope for right ventricle failure because it increases myocardial contractility via the beta receptor and causes vasodilation/reduced afterload via the beta receptor. Dobutamine or Milrinone may both reduce systemic pressure, so caution is advised when using them. If this occurs, it may be necessary to administer vasopressors.⁵

Medications that are mainly prescribed by physicians may include: 

• Beta Blockers 

These medications act by slowing down the heartbeat and thereby reducing the heart’s workload.

• Diuretics

These medications help to eliminate excess sodium and fluid.

• Pulmonary vasodilators

These drugs relax the blood vessels that connect the heart and lungs.

• Digoxin

This medication increases the pumping capacity of the heart

• Vasodilators

These medications work by relaxing the blood vessels¹

Surgical management 

For patients with reversible right ventricle failure who are unresponsive to medical treatment, surgical options as a bridge to recovery or transplantation are indicated. In the presence of valvular heart disease, congenital heart disease, and chronic thromboembolic pulmonary hypertension, surgery may be recommended for patients with right ventricle failure.⁵ When the medications are ineffective in treating right-sided heart failure, a ventricular-assist device or heart transplant may be required.

• Ventricular assist device

The implantation of a Ventricular Assist Device (VAD) can help a feeble heart to circulate more efficiently.

• Heart transplant surgery

Heart transplant surgery is performed when all other treatments for right-sided heart failure have failed. The weakened heart is removed surgically and replaced with a heart from a deceased donor who is in good health.

Lifestyle modifications 

It is essential to consume a diet minimal in sodium, lipids, and cholesterol. Additionally, light aerobic exercise is recommended.¹ 

Prognosis and complications

Prognosis 

The prognosis for right-sided heart failure differs according to the underlying cause and severity of symptoms. Several symptoms might improve with treatment and lifestyle modification. Cor pulmonale can be fatal for some individuals and very severe symptoms may necessitate a heart transplant or implantation of a ventricular assist device.¹

Potential complications

• Liver damage 

When the fluid accumulates in the abdomen, it can exert pressure on the blood vessels surrounding the liver. Eventually, this can cause fibrosis and tissue damage in the liver, interfering with its ability to function normally.

• Kidney damage

Changes in fluid and blood flow can result in chronic kidney disease or renal failure due to cardiac failure. Renal failure, if left untreated, can necessitate long-term dialysis.

• Malnutrition 

Heart failure can reduce appetite and level of energy, making it challenging to consume the necessary amount of food. A poor diet can result in substantial muscle and fat loss, and a vitamin and mineral deficiency. 

• Heart valve dysfunction

The heart’s valve ensures that blood flows in the correct direction. Weakened muscles and blood pooling may compromise these valves. In the case of weak cardiac valves, blood may flow and return through the valve instead of travelling forward.

• Cardiac arrest

Heart Failure raises the likelihood of cardiac arrest.⁷

Summary 

Right-Sided Heart Failure is a condition that affects the function of the right side of the heart, particularly the right ventricle. This condition is significant in terms of cardiac health because it is frequently associated with a number of underlying conditions, including left-sided heart failure and pulmonary hypertension. 

Clinical presentation of right-sided heart failure included oedema, breathing difficulty, and fatigue. Diagnosis involves various physical examinations as well as various imaging techniques which include echocardiography, and chest-x ray. 

Treatment and management for right-sided heart failure included beta-blockers, diuretics, lifestyle modifications, and surgical interventions such as heart transplantation and right ventricular assist devices when necessary. 

The prognosis of right-sided heart failure depends on the severity and underlying causes. Various complications include kidney damage, liver damage, and cardiac arrest.