Common Causes of Right Heart Failure
The most common cause of right heart failure is left-sided heart disease, followed by pulmonary hypertension from various etiologies, with other important causes including RV infarction, pulmonary embolism, and congenital heart disease. 1
Primary Categories of Right Heart Failure Etiology
Left-Sided Heart Disease (Most Common)
- Left-sided heart disease is the predominant cause of right heart failure in clinical practice, occurring through elevated left ventricular filling pressures that transmit backward into the pulmonary circulation 1
- Left ventricular systolic dysfunction from any cause (reduced ejection fraction heart failure) leads to pulmonary venous hypertension and subsequent RV pressure overload 2, 3
- Left ventricular diastolic dysfunction (preserved ejection fraction heart failure) causes elevated left atrial pressures that similarly burden the right ventricle 4
- Left-sided valvular disease, particularly mitral stenosis and mitral regurgitation, creates pulmonary venous congestion and secondary pulmonary hypertension 1, 4
Pulmonary Hypertension (Second Most Common)
- Pulmonary arterial hypertension from diverse causes represents a major pathway to right heart failure and is the principal cause of death in these patients 1
- Chronic obstructive pulmonary disease (COPD) is the most frequent cause of cor pulmonale, leading to chronic RV pressure overload 5
- Chronic thromboembolic disease from recurrent or unresolved pulmonary emboli causes persistent elevation in pulmonary vascular resistance 1
- Interstitial lung diseases and other chronic pulmonary parenchymal disorders elevate pulmonary pressures through vascular remodeling 1
- Idiopathic pulmonary arterial hypertension, though less common, causes severe RV dysfunction 5
Acute Right Ventricular Conditions
- Acute massive pulmonary embolism is a primary cause of death from acute right heart failure through sudden RV afterload increase 1
- Right ventricular myocardial infarction, typically from right coronary artery occlusion, causes acute RV contractile failure 1
- Postcardiotomy shock following cardiac surgery represents acute RV failure from surgical trauma or ischemia 1
Primary Cardiomyopathies with RV Involvement
- Dilated cardiomyopathy can involve the right ventricle either primarily or secondary to left ventricular disease 1
- Arrhythmogenic right ventricular cardiomyopathy specifically targets RV myocardium 1
- Infiltrative diseases (amyloidosis, sarcoidosis, hemochromatosis) can cause biventricular or isolated RV dysfunction 1
Volume Overload Conditions
- Congenital heart disease with left-to-right shunts (atrial septal defect, ventricular septal defect) causes chronic RV volume overload 1
- Tricuspid regurgitation, whether primary or secondary to RV dilation, perpetuates volume overload 1
- Pulmonary regurgitation from valvular disease or post-surgical states increases RV preload 1
Pressure Overload Without Pulmonary Hypertension
- Pulmonic stenosis, either congenital or acquired, directly increases RV afterload 1
Critical Clinical Pitfalls
A common error is failing to recognize that left heart disease is the underlying driver in most cases of right heart failure, leading to inappropriate treatment focused solely on the right ventricle 3, 4. The cascade begins with elevated left ventricular filling pressures transmitting backward through pulmonary capillaries, eventually causing pulmonary arterial hypertension and RV failure 4.
Ventricular interdependence must be understood: RV dilation causes leftward shift of the interventricular septum, which impairs LV filling and worsens overall cardiac output even when LV systolic function appears preserved 6, 7. This creates a vicious cycle where RV failure begets further hemodynamic compromise 2.
The right ventricle is exquisitely sensitive to afterload changes, unlike the left ventricle, with steep declines in stroke volume when faced with even modest pressure increases 6, 7. This explains why acute pulmonary embolism or sudden increases in pulmonary vascular resistance can rapidly precipitate RV failure 8.
Diagnostic Approach Algorithm
When evaluating right heart failure, systematically assess:
First, determine if left-sided heart disease is present through echocardiography evaluating LV systolic and diastolic function, and valvular pathology 6, 7
Second, assess for pulmonary hypertension using Doppler echocardiography to estimate pulmonary artery pressures and determine if pressures are elevated 5
Third, evaluate for acute causes including ECG for RV infarction patterns, CT angiography or V/Q scan for pulmonary embolism, and recent cardiac surgery 8
Fourth, consider chronic pulmonary disease through pulmonary function tests and chest imaging for COPD, interstitial lung disease, or chronic thromboembolic disease 5
Finally, evaluate for structural heart disease including congenital lesions and primary cardiomyopathies if above evaluations are unrevealing 1