Right ventricular failure across load and myocardial phenotypes: anatomy, plasticity and therapeutic implications

Abstract The right ventricle (RV) is a load-dependent chamber whose performance reflects myocardial reserve, loading conditions and ventricular interdependence. Volume overload, pressure overload and intrinsic myocardial dysfunction produce distinct, often overlapping remodelling trajectories and therapeutic targets. This review integrates contemporary imaging and prognostic evidence into a mechanism-to-decision framework. Its clinical contribution is to explain how deformation and chamber geometry should be interpreted with regurgitant burden and forward flow in volume overload, vascular load and coupling in pressure overload, and regional motion and tissue injury in intrinsic disease. Echocardiography combines these measurements with valve assessment, pulmonary outflow Doppler, left-heart filling phenotype and systemic venous congestion. Cardiovascular magnetic resonance, computed tomography, right heart catheterisation and stress testing resolve selected anatomical or physiological uncertainty. Automated measurements can support serial phenotyping but require image and contour review. Reverse remodelling describes favourable structural change; meaningful recovery additionally requires preserved or restored effective forward performance and improvement in clinical or venous consequences after treatment of the causal load, lesion or myocardial substrate. This framework helps recognise discordant findings, select further assessment and judge treatment response without equating a single load-dependent index with myocardial recovery.