Pathophysiology and management of right ventricular failure in critically ill patients: A narrative review

Right ventricular (RV) failure accounts for significant morbidity and mortality in critically ill patients. The RV is particularly vulnerable in conditions characterized by elevated pulmonary vascular afterload, which are commonly encountered in the intensive care unit (ICU). Conditions such as acute respiratory distress syndrome, pulmonary embolism, and decompensated pulmonary arterial hypertension are associated with acute and acute-on-chronic RV failure. In the ICU, RV failure may develop or worsen in patients with parenchymal pulmonary disease who acutely experience fluctuations in preload, excessive afterload, and/or insufficient myocardial contractility, often in addition to mechanical ventilation and circulatory compromise. This dynamic clinical scenario demands early recognition and intervention tailored to an individual patient's physiology. Distinguishing between acute and chronic RV failure in critical illness informs diagnostic workup, hemodynamic monitoring, and resuscitative efforts. This narrative review will provide an overview of common conditions associated with RV failure in critical illness, highlighting a practical, physiology-oriented approach to diagnosis and optimization of ventilator support, fluid resuscitation, vasopressor and inotrope use, and mechanical circulatory support. RV failure due to RV infarction or severe LV failure and decompensated congenital heart disease are distinct pathophysiologic entities. These conditions require distinct treatment approaches and are beyond the scope of this review.