Beyond the left: Emerging paradigms in right ventricular failure management

The right ventricle (RV) is essential for sustaining pulmonary circulation and ensuring effective oxygenation of systemic blood. Once considered merely a passive passage, the RV is now understood to be a distinct chamber with specific structural and functional characteristics that set it apart from the left ventricle (LV). Its thin, crescent-shaped walls and lower afterload render it particularly vulnerable to changes in preload, afterload, and contractility. Increasingly, RV dysfunction is recognized as a major factor contributing to perioperative complications and mortality in cardiac surgeries, especially in procedures like coronary artery bypass grafting (CABG), valvular surgery, heart transplantation, and corrections of congenital heart defects.A comprehensive understanding of RV hemodynamics is crucial for enhancing perioperative care. Various diagnostic techniques, such as echocardiography, pulmonary artery catheterization, and cardiac MRI, offer valuable information regarding RV function and dysfunction. Perioperative conditions, including pulmonary hypertension, cardiopulmonary bypass, ischemia-reperfusion injury, mechanical ventilation, and fluid overload, can trigger RV failure, complicating surgical results. Effective management strategies include careful volume optimization, reduction of afterload, administration of inotropic agents, and, in critical situations, the use of mechanical circulatory support systems like extracorporeal membrane oxygenation (ECMO) or right ventricular assist devices (RVADs). This review explores RV hemodynamics, dysfunction mechanisms, and their implications in cardiac surgical patients, highlighting recent advancements in perioperative management and potential therapeutic interventions.