6.3 - Right-Sided Heart Failure

right heart failure

caused by left-sided heart failure and increased pulmonary pressure burden / workload on right heart

• left heart failure causes pulmonary blood to back up, increasing pulmonary vascular pressure

  • right ventricle must pump against greater resistance, eventually causing right heart failure

• less commonly caused by severe pulmonary hypertension, COPD, emphysema, pulmonary/interstitial fibrosis, specific valve disease, congenital heart disease

• clinical and morphological features related to engorgement of systemic and portal venous systems

  • if caused by left heart failure, respective features would also be present

cor pulmonale

enlargement and failure of right ventricle, caused by high blood pressure in lungs

• results in right ventricular hypertrophy / dilation and right atrial dilation

• right heart receives systemic venous blood, so right heart failure causes systemic and portal venous congestion

  • LEFT = lungs

  • RIGHT = rest of body

hepatic / renal changes in right heart failure

• congestive hepatomegaly:

  • passive congestion → nutmeg liver

    • congested centrilobular areas surrounded by plater non-congested parenchyma

  • long-standing congestion → fibrotic changes / cardiac cirrhosis

    • chronic tissue injury leads to fibrosis

  • if left heart failure also present, hypoxia may cause centrilobular necrosis

• hepatic changes leads to increased pressure in portal venous system

  • portal hypertension → hepatosplenomegaly

    • elevated pressure in hepatic portal vein results in splenomegaly

    • may also cause congestion of bowel wall, disrupting absorption of nutrients and medications

• chronic liver dysfunction can decrease albumin production and cause bowel edema

  • decreases nutrient / protein absorption

  • less albumin available decreases oncotic pressure, causing more edema

effusion changes from right heart failure

• pleural effusion → occurs with combined right + left heart failure

  • develops with increased pulmonary venous and systemic venous pressures

  • can be severe enough to compress lung and cause atelectasis

• pericardial effusion → fluid around heart

  • limits cardiac filling and lead to cardiac failure

  • can be severe enough to cause cardiac tamponade

• peritoneal spaces → cause ascites

  • edema in abdominal region from hepatic congestion and portal hypertension

peripheral / subcutaneous changes in right heart failure

• distension of the jugular vein

• clubbing of the fingers

• edema of

  • ankle and pretibial regions

  • presacral area in bedridden patients

  • anasarca → generalized massive edema in severe cases

right vs left heart failure

because left-sided heart failure causes right-sided heart failure, many chronic heart failure patients have biventricular congestive heart failure

• display mixture of pulmonary congestion, dyspnea, systemic venous congestion, edema / jugular vein distension, liver changes

• left heart failure — backs up into lungs

  • causes pulmonary features, heart failure cells, poor systemic perfusion, kidney/brain hypoperfusion

  • can cause right heart failure

• right heart failure — backs up into systemic veins

  • causes peripheral edema, hepatomegaly, nutmeg liver, ascites, jugular vein distension, dependent edema, anasarca

  • most commonly caused by left heart failure