The presence of right ventricular (RV) injury in the context of acute respiratory distress syndrome (ARDS) is significantly associated with increased mortality posing a clinical challenge [1]. In a recent systematic review and meta-analysis of nine ARDS studies (n = 1861), RV injury defined as RV dysfunction, acute cor-pulmonale (ACP), RV dysfunction with hemodynamic compromise, or RV failure, was present in 21% of the cohort [1]. In this state-of-the-art concise article, we aim to discuss the potential mechanisms of abnormal RV biomechanics and the spectrum of RV injury phenotypes in ARDS. Understanding the pathophysiology and natural history of RV injury may inform the intensivist’s approach to diagnosis and RV monitoring, and application of personalized interventions with potential therapeutic relevance.