Right ventricular (RV) injury is a frequent complication in patients with acute respiratory distress syndrome (ARDS), yet its prevalence and prognostic significance remain uncertain. The main objective of this systematic review and meta-analysis was to evaluate the association between RV injury and mortality in patients with ARDS. The secondary objectives were to determine the prevalence of RV injury and to assess the impact of both COVID-19 status and the definition of RV injury on mortality.

From January 2013 to December 2024, we searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials for all studies including adult patients with ARDS according to the Berlin definition, which reported mortality according to the presence or absence of RV injury.

Twenty-three studies including 3,977 patients with ARDS were analyzed. The pooled prevalence of RV injury was 30% (95% confidence intervals (CI) 23-38%), ranging from 6% to 56% across studies depending on the definition used, and did not differ between COVID-19 (33%, 95%CI 22-47%) and non-COVID-19 (25%, 95%CI 21-29%) patients. RV injury was associated with increased ICU mortality in unadjusted analyses (random-effects odds ratio (OR) 2.49, 95%CI 1.81–3.42; I² = 56%) and in adjusted analyses (aOR 2.37, 95%CI 1.24-4.51, I ²  = 42%; adjusted hazard ratio (aHR) 2.64, 95%CI 1.60-4.37, I ²  = 24%). This association remained consistent across subgroups based on COVID-19 status and RV injury definition, and across sensitivity analyses excluding patients receiving venovenous extracorporeal membrane oxygenation and low to moderate quality studies.

RV injury is common in patients with ARDS and is consistently associated with increased mortality, irrespective of the definition used. Further studies enrolling consecutive patients, with standardized and repeated echocardiographic assessment of RV function, are needed to establish causal inference.

CRD42024568063 and date of registration: 22/07/2024