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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Intensive Care Medicine

The Step-by-Step Plan to Strengthen the Right Heart

At a Glance

Treatment for right ventricular failure after heart surgery requires a carefully balanced step-by-step approach in the ICU. Doctors use a combination of fluid management, vasopressors, inotropes, and inhaled medications to support the right ventricle and lower lung pressure.

Treating a right heart that is struggling after surgery is a delicate “balancing act.” Because the right ventricle (RV) is thinner and more sensitive than the left side, the medical team cannot simply give a single medicine and wait. Instead, they use a stepwise approach—a series of carefully timed adjustments to help the heart “find its rhythm” again [1].

Think of this process like trying to get a heavy, stalled truck moving up a hill. You have to manage the fuel (fluids), the engine power (heart strength), and the steepness of the hill (lung pressure) all at once.

Step 1: Optimizing the “Fuel” (Fluid Balance)

The first step is managing preload, which is the amount of blood filling the heart before it squeezes [2]. You can read about how doctors track this by checking the CVP in Decoding the ICU: Monitors and Metrics for the Right Heart.

  • The Goldilocks Rule: The RV needs just enough fluid to stretch the muscle and trigger a good squeeze. However, if there is too much fluid, the RV over-stretches like an old rubber band and becomes even weaker [3].
  • The Strategy: Doctors may give small “fluid boluses” (quick doses of IV fluid) to see if the heart responds, or use diuretics (water pills) to remove extra fluid if the heart is getting overwhelmed [4].

Step 2: Protecting the “Engine” (Vasopressors)

The RV needs blood flow to its own muscle to stay strong. This is called coronary perfusion pressure.

  • Maintaining Pressure: Doctors use medications called vasopressors (like norepinephrine or vasopressin) to keep the overall blood pressure high enough [5][6].
  • Why it Matters: If the blood pressure in the body drops too low, the RV muscle itself doesn’t get enough “food” (oxygenated blood), causing it to fail even further [1][7].

Step 3: Boosting the “Horsepower” (Inotropes)

Once the fluids and pressure are stable, the team may add inotropes. These drugs tell the heart muscle to squeeze harder [8].

  • Common Meds: You may hear names like milrinone, dobutamine, or levosimendan [9][10].
  • Individual Fit: Each of these works slightly differently. Some may also help lower lung pressure, while others might increase the heart rate. The team chooses the one that best fits your loved one’s specific needs [11].

Step 4: Leveling the “Hill” (Inhaled Therapies)

The final step is to make the “hill” (the pressure in the lungs) easier to climb. This is done by lowering pulmonary vascular resistance (PVR) [12].

  • Inhaled Medications: Doctors often use inhaled nitric oxide (a gas) or prostacyclins (a nebulized liquid mist) [13][14].
  • The Advantage: Because these are breathed in, they go straight to the lungs to “open up” the blood vessels there [12]. This helps the RV push blood through without affecting the rest of the body’s blood pressure [13].

A Dynamic Process

This treatment isn’t “one-and-done.” The ICU team is constantly “tuning” these medications. As the heart gets stronger, they will slowly “wean” or decrease the doses [12]. This process can take time, and it is common to see doses go up and down as the heart finds its footing [15].

If the heart does not respond well to these medications, the next step involves mechanical support, detailed in When the Heart Needs a Machine: Mechanical Support Options.

Common questions in this guide

How do doctors treat right heart failure after surgery?
Doctors use a stepwise approach that carefully balances fluids, medications to maintain blood pressure, drugs to strengthen the heart's squeeze, and inhaled treatments to reduce pressure in the lungs. This combination is constantly adjusted as the heart recovers.
Why does the right heart need vasopressors?
Vasopressors maintain adequate blood pressure throughout the body. This ensures that the right ventricle muscle itself receives enough oxygen-rich blood, which is crucial to keep it pumping effectively.
What are inotropes and how do they help the right heart?
Inotropes, such as milrinone or dobutamine, are medications that tell the heart muscle to squeeze harder. They act as a power boost for a weakened right ventricle, helping it push blood more efficiently.
Why are inhaled medications used for right heart failure?
Inhaled medications, like nitric oxide or prostacyclins, go directly to the lungs to open up blood vessels and lower resistance. This makes it easier for the right heart to pump blood into the lungs without dropping blood pressure in the rest of the body.
Why do the medication doses keep changing in the ICU?
Because the right ventricle is thin and sensitive, its recovery takes time and constant adjustments. It is very common for medication doses to go up and down as the intensive care team helps the heart slowly find its rhythm again.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What is the current 'step' on the treatment ladder we are on today?
  2. 2.Are we using inhaled nitric oxide or prostacyclins to help lower the pressure in the lungs?
  3. 3.How are we balancing the need for blood pressure (vasopressors) with the need for heart strength (inotropes)?
  4. 4.Is the patient's 'coronary perfusion pressure' high enough to keep the right heart muscle healthy?
  5. 5.What specific 'milestone' needs to be met before we can start weaning the inhaled medications?

Questions For You

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References

References (15)
  1. 1

    Medical and Mechanical Circulatory Support of the Failing Right Ventricle.

    Yuriditsky E, Chonde M, Friedman O, Horowitz JM

    Current cardiology reports 2024; (26(2)):23-34 doi:10.1007/s11886-023-02012-3.

    PMID: 38108956
  2. 2

    Cardiogenic shock in Takotsubo syndrome: Insights into phenotype-tailored management.

    Tomasino M, González-Santorum F, Admella L, Uribarri A

    Medicina intensiva 2026; 502517 doi:10.1016/j.medine.2026.502517.

    PMID: 42251021
  3. 3

    Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 2-management of right ventricular failure).

    Varma PK, Srimurugan B, Jose RL, et al.

    Indian journal of thoracic and cardiovascular surgery 2022; (38(2)):157-166 doi:10.1007/s12055-021-01226-w.

    PMID: 34751203
  4. 4

    Management of Right Ventricular Failure in Pulmonary Embolism.

    Zhao S, Friedman O

    Critical care clinics 2020; (36(3)):505-515 doi:10.1016/j.ccc.2020.02.006.

    PMID: 32473695
  5. 5

    Vasopressor use in cardiogenic shock.

    Levy B, Klein T, Kimmoun A

    Current opinion in critical care 2020; (26(4)):411-416 doi:10.1097/MCC.0000000000000743.

    PMID: 32487842
  6. 6

    Narrative Review of Controversies Involving Vasopressin Use in Septic Shock and Practical Considerations.

    Der-Nigoghossian C, Hammond DA, Ammar MA

    The Annals of pharmacotherapy 2020; (54(7)):706-714 doi:10.1177/1060028020901521.

    PMID: 31958982
  7. 7

    Intravenous Levosimendan and Vasopressin in New-Onset Acute Pulmonary Hypertension After Weaning from Cardiopulmonary Bypass.

    Poidinger B, Kotzinger O, Rützler K, et al.

    Journal of cardiothoracic and vascular anesthesia 2019; (33(2)):328-333 doi:10.1053/j.jvca.2018.07.013.

    PMID: 30122612
  8. 8

    Right Heart Failure in Pulmonary Hypertension.

    Cassady SJ, Ramani GV

    Cardiology clinics 2020; (38(2)):243-255 doi:10.1016/j.ccl.2020.02.001.

    PMID: 32284101
  9. 9

    Boosting the Beat: A Critical Showdown of Levosimendan and Milrinone in Surgical and Non-Surgical Scenarios: A Narrative Review.

    Quintero-Altare A, Flórez-Navas C, Robayo-Amortegui H, et al.

    Journal of cardiovascular pharmacology and therapeutics 2024; (29()):10742484241276431 doi:10.1177/10742484241276431.

    PMID: 39246279
  10. 10

    Intravenous Levosimendan versus Inhalational Milrinone in the Management of Pulmonary Hypertension during Adult Cardiac Surgery: A Randomized Clinical Trial.

    Ftikos P, Gkantinas G, Karageorgos V, et al.

    Life (Basel, Switzerland) 2024; (14(9)) doi:10.3390/life14091164.

    PMID: 39337947
  11. 11

    Comparative Effectiveness and Safety Between Milrinone or Dobutamine as Initial Inotrope Therapy in Cardiogenic Shock.

    Lewis TC, Aberle C, Altshuler D, et al.

    Journal of cardiovascular pharmacology and therapeutics 2019; (24(2)):130-138 doi:10.1177/1074248418797357.

    PMID: 30175599
  12. 12

    Phase 2 Study to Evaluate the Efficacy and Safety of Inhaled Nitric Oxide Therapy in Patients With Severe Right Heart Failure Associated With Pulmonary Hypertension　- Protocol for the PHiNO Study.

    Ueda J, Tsuji A, Aoki T, et al.

    Circulation reports 2025; (7(4)):308-312 doi:10.1253/circrep.CR-24-0125.

    PMID: 40213794
  13. 13

    Utility of inhaled nitric oxide for pulmonary hypertension in cyanotic congenital heart disease: a cohort study with propensity score matching.

    Wang X, Li C, Wang S, et al.

    Medical gas research 2026; (16(2)):93-97 doi:10.4103/mgr.MEDGASRES-D-25-00062.

    PMID: 40826929
  14. 14

    Successful Management of Right Ventricular Failure After Emergent Transcatheter Mitral Valve Edge-to-Edge Repair With Inhaled Nitric Oxide: A Case Report.

    Sato Y, Yanagi A, Kakumoto S, Miyawaki H

    Cureus 2023; (15(9)):e45469 doi:10.7759/cureus.45469.

    PMID: 37859894
  15. 15

    Life-Threatening Extreme Methemoglobinemia during Standard Dose Nitric Oxide Therapy.

    Centorrino R, Shankar-Aguilera S, Foligno S, De Luca D

    Neonatology 2019; (116(3)):295-298 doi:10.1159/000501462.

    PMID: 31454813

This page explains ICU treatment strategies for right ventricular failure for educational purposes only. Always consult the intensive care team for specific updates on your loved one's condition and treatment plan.

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