Review

Managing right ventricular failure in the setting of pulmonary embolism

Sharmeen Sorathia, MD, Anibelky Almanzar, MD, Abhishek Bhandiwad, MD and Phoo Pwint Nandar, MD
Cleveland Clinic Journal of Medicine May 2025, 92 (5) 301-309; DOI: https://doi.org/10.3949/ccjm.92a.24069

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Illustration of the pathophysiology and development of right ventricular (RV) failure in the setting of acute increase in afterload caused by pulmonary embolism.

    LV = left ventricular

    Based on information from references 2 and 4.

  • Figure 2
    Figure 2

    (A) Computed tomography and (B) echocardiogram showing an increased right ventricle–to–left ventricle ratio, which is used to assess right ventricular strain and dysfunction for risk stratification of pulmonary embolism.

  • Figure 3
    Figure 3

    Algorithm of our initial assessment and risk stratification of pulmonary embolism based on Pulmonary Embolism Severity Index (PESI) score, cardiac markers (troponin or brain natriuretic peptide), right ventricular strain on imaging (transthoracic echocardiography or computed tomography pulmonary angiography), and hemodynamic instability (cardiac arrest, obstructive shock, or persistent hypotension). Note the addition of a subcategory of high-risk pulmonary embolism, termed catastrophic pulmonary embolism (those with hemodynamic collapse).

    Based on information from references 1 and 7.

Tables

  • TABLE 1

    Principles of management options of right ventricular failure in pulmonary embolism

    Management of the thrombusManagement of the preloadPharmacologic supportMechanical support
    High-risk pulmonary embolism: intravenous thrombolytics vs surgical embolectomyVolume assessmentFirst line: norepinephrineVenoarterial extracorporeal membrane oxygenation
    Intermediate-risk pulmonary embolism: catheter-guided therapies (thrombolysis or thrombectomy) vs anticoagulation aloneFluid challenge vs intravenous furesomideSecond line: dobutamineRight ventricular assist device
    Inferior caval vein filter placement as an adjunct to above, especially if contraindications to anticoagulation

    • Based on information from references 7 and 10.

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