Right-Sided Heart Failure

The lungs are clear, but the patient's belly is distended and their ankles are swollen to the knees. Right-sided heart failure backs up behind the right ventricle — into the body, not the lungs.

Right-sided heart failure (RHF) occurs when the right ventricle cannot effectively pump blood into the pulmonary vasculature, causing systemic venous congestion. The most common cause is left-sided heart failure — chronic pulmonary hypertension from left-sided backup eventually overwhelms the right ventricle. However, RHF can also arise independently from cor pulmonale (right ventricular failure secondary to lung disease), pulmonary embolism, or tricuspid/pulmonic valve disease. Blood dams up behind the failing right ventricle, engorging the systemic venous system. This produces the hallmark presentation: jugular venous distention (JVD), hepatomegaly with right upper quadrant tenderness, ascites, splenomegaly, and dependent peripheral edema — bilateral pitting edema in the ankles and sacrum in bedbound patients. Weight gain from fluid retention can exceed 2-3 lb overnight. On assessment, hepatojugular reflux is positive: applying sustained pressure over the liver for at least 10-15 seconds causes sustained JVD elevation. Unlike left-sided failure, lung sounds are typically clear unless biventricular failure is present.

Key Distinctions

Don't confuse RHF edema (peripheral, dependent, systemic) with left-sided HF congestion (pulmonary crackles, dyspnea, orthopnea) — RHF fills the body, LHF fills the lungs. Students commonly assume all heart failure causes crackles; isolated RHF has clear lungs. Cor pulmonale is RHF caused by chronic lung disease (COPD), not by left-sided failure — the mechanism matters because treatment targets the underlying pulmonary pathology.

Clinical Pearl

Right is peripheral — JVD, jaundice (hepatic congestion), jelly belly (ascites), and jiggly ankles. If the backup is behind the right ventricle, think everything below the neck swells.