Debating Volume Optimization in Acute Right Ventricular Failure – The Preload Paradox

Volume management in acute right ventricular failure presents a fundamental clinical paradox. Although the right ventricle is traditionally described as preload-dependent, contemporary evidence suggests that excessive volume loading may worsen cardiac output by promoting RV dilation, septal shift, and impaired left ventricular filling. Conversely, premature or aggressive diuresis may reduce preload below the threshold required to maintain forward flow, particularly in ischemic or preload-responsive states.

This debate session will examine the critical “when” and “how” of RV failure: when to administer fluids versus initiate decongestion, how to assess volume responsiveness, and how underlying etiology should influence management strategy. Expert debaters will present contrasting, evidence-informed perspectives on these unresolved controversies, supported by physiologic principles, hemodynamic data, and clinical experience. Case-based discussion will anchor the debate in real-world decision-making and highlight areas of consensus and ongoing uncertainty.

Learning Objectives

• Analyze the competing physiologic mechanisms that determine optimal preload in acute right ventricular failure to understand why both inadequate and excessive volume can impair cardiac output.
• Evaluate evidence-based criteria for identifying which patients with acute right ventricular failure may benefit from volume loading versus diuresis, considering underlying etiology, hemodynamic phenotype, and acuity of presentation.
• Apply invasive and noninvasive assessment techniques to guide individualized volume management decisions.