Right ventricular (RV) failure is an often undertreated entity due to its multifactorial and complex pathophysiology. In contrast to the muscular high-pressure generating left ventricle, the thinwalled crescend-shaped RV optimizes venous return and enables continuous ejection of blood into a low-resistance, highly compliant pulmonary vascular system. RV dysfunction leads to impaired RV filling with increased right atrial pressures and venous congestion. Additionally, progressive RV overload will cause leftward shifting of the intraventricular septum with reduced LV filling, low cardiac output and multi organ failure. Besides treatment of major potentially reversible precipitants, supportive treatment remains the cornerstone in the management of RV failure and comprises 1. optimizing RV preload and cardiac output and 2) reducing RV afterload. This review presents a comprehensive approach of patients with RV failure in the ICU. © 2018, Netherlands Society of Intensive Care. All rights reserved.