What are the characteristic sounds associated with right-sided heart failure?

Characteristic Sounds of Right-Sided Heart Failure

The hallmark auscultatory findings of right-sided heart failure include an accentuated pulmonary component of S2, a holosystolic murmur of tricuspid regurgitation that increases with inspiration, a right ventricular S3 gallop, and potentially a diastolic murmur of pulmonary regurgitation. 1

Primary Heart Sounds

Second Heart Sound (S2) Abnormalities

• Accentuated pulmonary component (P2) is the most characteristic finding, often audible even at the apex, reflecting increased force of pulmonary valve closure due to elevated pulmonary artery pressure 1
• Fixed splitting of S2 during both inspiration and expiration may suggest atrial septal defect with right heart volume overload 1
• The aortic component (A2) may be soft or absent in severe cases 1

Gallop Sounds

• Right ventricular S3 gallop occurs due to rapid ventricular filling in a dilated, failing right ventricle and is best heard at the lower left sternal border 2, 1
• Right ventricular S4 gallop results from forceful right atrial contraction against a stiff right ventricle and indicates diastolic dysfunction 1, 3
• When S3 is heard over the tricuspid area (lower left sternal border), it specifically suggests right ventricular dysfunction 3

Murmurs Associated with Right Heart Failure

Tricuspid Regurgitation

• Holosystolic murmur at the lower left sternal border is the characteristic murmur of tricuspid regurgitation, which occurs in approximately 80% of significant right heart failure cases due to annular dilation and leaflet tethering 2, 1
• This murmur increases in intensity with inspiration (Carvallo's sign), a key distinguishing feature from left-sided murmurs 2, 1
• The murmur may be inaudible even with severe tricuspid regurgitation, making jugular venous pulse examination critical 2

Pulmonary Regurgitation

• A low-pitched, early diastolic murmur of pulmonary regurgitation may be present in cases with pulmonary hypertension 2, 1
• This Graham Steell murmur reflects incompetence of the pulmonary valve due to elevated pulmonary artery pressures 2

Dynamic Auscultation Principles

Respiratory Variation

• Right-sided murmurs and sounds generally increase with inspiration due to increased venous return to the right heart 2, 1
• Left-sided murmurs are typically louder during expiration, providing a key differentiating feature 2, 1

Exercise Effects

• Murmurs caused by blood flow across stenotic valves (e.g., pulmonary stenosis) become louder with both isotonic and isometric exercise 2, 1
• This can help distinguish functional from organic murmurs in the clinical setting 2

Associated Physical Examination Findings

Jugular Venous Pulse

• Elevated jugular venous pressure with prominent "c-V" waves is often the most reliable clinical sign of advanced tricuspid regurgitation 2, 1
• Prominent jugular "a" wave suggests high right ventricular filling pressure and reduced compliance 1

Hepatic and Peripheral Signs

• Pulsatile liver edge (hepatojugular reflux) indicates significant tricuspid regurgitation with transmission of right ventricular systolic pressure to the hepatic veins 2, 1
• Peripheral edema and ascites indicate advanced right ventricular failure with systemic venous congestion 1

Clinical Pitfalls and Caveats

The absence of a murmur does not exclude severe tricuspid regurgitation—in many patients with advanced right heart failure, characteristic findings in the jugular venous pulse are the only clues, as the murmur may be inaudible 2. This occurs because severe tricuspid regurgitation with equalization of right atrial and ventricular pressures reduces the pressure gradient needed to generate an audible murmur.

The presence of these auscultatory findings should prompt immediate echocardiographic evaluation to assess right ventricular function, pulmonary artery pressure, tricuspid valve function, and the degree of right ventricular dilation 1. Careful auscultation during various respiratory phases and hemodynamic states is essential for proper characterization of right-sided heart sounds and differentiation from left-sided pathology 1.