From the Guidelines
The correct statement about right heart failure is that a positive Kussmaul sign may be observed. Kussmaul sign refers to a paradoxical increase in jugular venous pressure (JVP) during inspiration, which occurs in right heart failure due to impaired right ventricular filling, as discussed in the evaluation and management of right-sided heart failure by the American Heart Association 1. This happens because the failing right ventricle cannot accommodate the increased venous return during inspiration, causing the JVP to rise rather than fall. The other statements are incorrect:
- in right heart failure, the CVP waveform typically shows a prominent V wave (not flat), as right ventricular dysfunction leads to altered hemodynamics 1
- mitral valve regurgitation is associated with left heart failure (not right), as it affects the left ventricle's ability to pump blood effectively
- and lower extremity edema in right heart failure is characteristically pitting (not non-pitting) due to fluid accumulation in the interstitial spaces, resulting from systemic venous congestion. Right heart failure commonly presents with peripheral edema, hepatomegaly, ascites, and elevated JVP as the right ventricle fails to effectively pump blood to the lungs, leading to systemic venous congestion, as outlined in the scientific statement from the American Heart Association 1.
From the Research
Right Heart Failure Characteristics
- A positive Kussmaul Sign may be observed in right heart failure, as it is associated with a paradoxical inspiratory rise in right atrial pressure 2, 3.
- Kussmaul's sign is specific for acute right ventricular myocardial infarction and may serve as an important clinical sign of right ventricular dysfunction requiring preload preserving management 3.
- Right heart failure is a major cause of morbidity and mortality in pulmonary hypertension, and its pathophysiology involves both adaptive and maladaptive patterns of right ventricular change 4.
- The presence of a high jugular venous pressure (JVP) at rest or with inspiration is associated with a higher incidence of adverse outcomes in patients with heart failure 5.
Clinical Signs and Diagnosis
- Kussmaul physiology is common in patients with congestive heart failure referred for heart transplantation and is associated with adverse cardiopulmonary hemodynamics 2.
- Noninvasive imaging such as echocardiography is useful in the diagnosis and risk assessment of right heart failure 4.
- Simplified methods have been proposed for assessment of right ventricular function and RV-arterial coupling, including echocardiographic and cardiac MRI approaches 6.
Treatment and Management
- Management of right heart failure focuses on optimizing preload, reducing afterload, and supporting the function of the right ventricle with vasopressors and inotropes, if necessary 4.
- Mechanical support is increasingly used to facilitate recovery or as a bridge to transplant in patients with right heart failure 4.