Pulmonary embolism (PE) is the third most common cause of cardiovascular death. With over a fourth of PE patients progressing to acute right ventricular (RV) failure, it is imperative to have an in-depth appreciation for the complex physiology of the right heart circuit and its relationship with the left heart. Ventricular interdependence, pulmonary vascular resistance, RV preload, and right ventricular systolic function are greatly affected by the acute increase in RV afterload that occurs with large obstructive pulmonary embolism. Laboratory markers and radiographic indicators of right heart strain can provide early prognostic information useful for identifying patients who are at elevated risk of hemodynamic compromise. When acute RV failure is evident, cautious volume resuscitation, or even preload reduction may be necessary to maintain end organ perfusion. If vasopressors use is warranted, it is important to consider agents that improve right ventricular systolic function without increasing the pulmonary vascular resistance. Invasive hemodynamic assessment can be a useful tool in critically ill patients with PE-related RV failure where accurate filling pressures are needed for fine titration of pharmacologic therapies. In refractory cases of cardiogenic shock due to acute PE, right ventricular mechanical circulatory support has shown promise for short term use in patients with high probability of recovery.