Cardiology · Medical Literature
Pulsatile Liver in Severe Tricuspid Regurgitation
Abstract
New England Journal of Medicine, Volume 395, Issue 5, July 30, 2026.
Clinical relevance
In a patient with severe tricuspid regurgitation and right heart failure, what are the characteristic physical examination and clinical findings — specifically the pulsatile liver — and what is their diagnostic and pathophysiological significance? __SNAPSHOT__ {"studyDesign":"Clinical case report / Images in Clinical Medicine (single case description with video documentation)","setting":"Not reported; published in New England Journal of Medicine, Vol. 395, Issue 5, July 30, 2026","sampleSize":"n=1 (single patient case report)","population":"A 51-year-old woman with right heart failure presenting with worsening abdominal distention and leg swelling","intervention":"Clinical examination and diagnostic evaluation of a pulsatile liver in the context of severe tricuspid regurgitation; video documentation of the physical finding","comparator":"Not applicable (single-arm case report)","primaryOutcome":"Description and video demonstration of a pulsatile liver as a physical sign of severe tricuspid regurgitation","followUp":"Not reported","fundingSource":"Not reported"}
Key findings
A 51-year-old woman with known right heart failure presented with worsening abdominal distention and lower extremity swelling. Physical examination revealed ascites, leg edema, a grade 4/6 holosystolic murmur, and a visually demonstrable pulsatile liver, documented on video. The pulsatile liver is understood pathophysiologically to result from retrograde transmission of elevated right atrial systolic pressure through the inferior vena cava and hepatic veins into the hepatic parenchyma during ventricular systole — the same mechanism that produces the prominent v-wave in severe tricuspid regurgitation. No quantitative hemodynamic data, echocardiographic measurements, laboratory values, or treatment outcomes are reported in the abstract. No p-values, confidence intervals, effect sizes, or NNT/NNH are applicable or calculable from this single case report.
Practice implications
⚠ Only the abstract/summary listing is available for this publication; the full case report text, accompanying video, and any additional clinical data are not accessible for review — this is a critical limitation of this summary. This case illustrates a classical but underappreciated bedside physical sign: the pulsatile liver in severe tricuspid regurgitation. The finding arises when systolic regurgitant flow is transmitted backward through the right atrium, inferior vena cava, and hepatic veins into the liver, producing a palpable and, in severe cases, visible hepatic pulsation synchronous with the cardiac cycle. Clinically important considerations include: (1) a pulsatile liver is a marker of hemodynamically significant, severe tricuspid regurgitation and advanced right heart failure; (2) loss of hepatic pulsatility in a patient with longstanding disease may paradoxically signal progression to congestive hepatic fibrosis or cardiac cirrhosis, as the fibrotic liver becomes less compliant to pressure transmission; (3) the constellation of ascites, peripheral edema, hepatomegaly, a holosystolic murmur loudest at the left sternal border, and pulsatile liver should prompt urgent echocardiographic evaluation; (4) this case does not establish treatment efficacy, prognosis, or management algorithms — it is descriptive and educational in intent. The findings apply broadly to patients with severe primary or secondary tricuspid regurgitation but were not derived from a study population; generalizability beyond the teaching context cannot be formally assessed. __LIMITATIONS__ 1. Single case report: no inferential statistics, no control group, and no ability to generalize findings. 2. Only abstract/listing text available — full clinical details, echocardiographic parameters, laboratory data, and treatment course are not reviewable. 3. No quantitative hemodynamic or imaging data are reported, precluding correlation of pulsatility severity with echocardiographic grade of tricuspid regurgitation. 4. Selection bias is inherent: this case was selected for publication because of its illustrative value, not as a representative sample. 5. The report does not address management, outcomes, or whether intervention (surgical or transcatheter) was undertaken. 6. Funding source and institutional setting are not reported, limiting conflict-of-interest assessment. __BOTTOM_LINE_CATEGORY__ confirmatory __BOTTOM_LINE__ This NEJM Images in Clinical Medicine case report documents a pulsatile liver — a classic but clinically important physical sign of severe tricuspid regurgitation — in a 51-year-old woman with right heart failure, ascites, and a grade 4/6 holosystolic murmur. Clinicians should recognize hepatic pulsatility as a bedside indicator of hemodynamically significant tricuspid regurgitation, prompting urgent echocardiographic evaluation. Paradoxically, loss of pulsatility in chronic disease may signal progression to congestive hepatic fibrosis or cardiac cirrhosis rather than clinical improvement.