Causes of Right Ventricular Failure
Right ventricular failure results from three primary mechanisms: pressure overload (most commonly from pulmonary hypertension of any cause, including left-sided heart disease), volume overload (from valvular or congenital heart lesions), and intrinsic myocardial dysfunction (from cardiomyopathies, ischemia, or infarction). 1
Pressure Overload Causes
The RV is poorly equipped to handle sustained pressure increases, making pressure overload the dominant pathway to RV failure:
Pulmonary hypertension - This represents the most critical cause, with RV failure being the principal cause of death in pulmonary arterial hypertension patients 1
- Left-sided heart disease (most common overall cause of pulmonary hypertension)
- Chronic lung disease
- Chronic thromboembolic disease
- Primary pulmonary arterial hypertension
Pulmonic stenosis - Direct obstruction to RV outflow 1
Acute respiratory distress syndrome (ARDS) - Acutely elevates pulmonary vascular resistance 2
Volume Overload Causes
Chronic volume loading leads to progressive RV dilation and dysfunction:
Valvular pathologies 1
- Tricuspid regurgitation
- Pulmonary regurgitation
Congenital heart disease - Structural lesions causing left-to-right shunting or direct RV volume loading 1
Intrinsic Myocardial Dysfunction
Direct RV myocardial injury or disease:
RV ischemia and infarction - Acute RV myocardial infarction is a primary cause of death in this setting, typically from right coronary artery occlusion 1, 2
Primary cardiomyopathies with RV involvement 1
- Dilated cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy
- Restrictive cardiomyopathies
Myocarditis - Inflammatory involvement of RV myocardium 3
Acute Precipitating Causes
These conditions cause rapid-onset RV failure with hemodynamic instability:
Massive pulmonary embolism - Primary cause of death in acute presentation 1, 2
Postcardiotomy shock - Associated with cardiac surgery 1
Sepsis - Through multiple mechanisms including increased pulmonary vascular resistance and direct myocardial depression 4, 5
Critical Clinical Context
Progressive RV dysfunction in all these disease states is associated with increased morbidity and mortality 1. The common final pathway involves the RV's inability to maintain systemic venous pressure sufficiently low, resulting in systemic venous hypertension, end-organ venous congestion, underperfusion, and progressive multi-organ damage 3, 6.
Important Pitfall
Do not overlook left-sided heart disease as the underlying cause—it is the most common etiology of pulmonary hypertension leading to RV failure. Virtually all myocardial diseases involving the left heart (coronary disease, hypertension, valvular disease, cardiomyopathies) may be responsible for RVF 3. The thin-walled RV, adapted for low-pressure circulation, decompensates rapidly when faced with elevated afterload from any cause 6.