[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [General pathology](https://durgical.com/en/general-pathology/) › [Heart](https://durgical.com/en/general-pathology/areas/heart/) › Left- vs right-sided heart failure

# Left- vs right-sided heart failure

- Lesion

A failing left heart backs blood into the lungs; a failing right heart backs it into the liver, legs and belly.

Updated Nov 12, 2026

## Key points

- Lungs in left failure: congestion, interstitial then alveolar edema, pleural effusions; hemosiderin-laden macrophages (‘heart-failure cells’).
- Kidneys: low perfusion activates renin–angiotensin–aldosterone; prerenal azotemia.
- Brain: hypoxic encephalopathy with irritability, confusion and, at worst, coma.
- Liver in right failure: ‘nutmeg’ liver from centrilobular congestion; severe cases have centrilobular necrosis and later cardiac sclerosis.
- Right failure also causes congestive splenomegaly, bowel wall edema, peripheral edema, ascites and pleural effusions.
- The commonest cause of right heart failure is left heart failure.

## What it is

Left-sided failure is most often caused by ischemic heart disease, hypertension, aortic and mitral valve disease and cardiomyopathies. Blood backs up into the pulmonary circulation, causing congestion and edema, while forward flow to the kidneys and brain falls. Right-sided failure is most often a consequence of left-sided failure; isolated right failure comes from pulmonary hypertension (cor pulmonale) and right-sided valve or congenital disease. It causes systemic venous congestion: liver, spleen, gut, legs and serous cavities.

## Structure

- Lung: engorged alveolar capillaries, pink edema fluid in alveoli, brown iron-laden macrophages (Prussian blue positive).
- Liver: dark red congested centrilobular zones alternating with paler periportal parenchyma (nutmeg pattern).

## What each organ shows in heart failure

| Organ | Left-sided failure | Right-sided failure |
| --- | --- | --- |
| Lungs | Congestion, edema, heart-failure cells, effusions; dyspnea, orthopnea, paroxysmal nocturnal dyspnea | Usually spared (lung disease may be the cause) |
| Liver | Spared unless right failure follows | Nutmeg liver, centrilobular necrosis, cardiac sclerosis |
| Kidneys | Low perfusion: salt and water retention, prerenal azotemia | Congestion; salt retention worsens edema |
| Brain | Hypoxic encephalopathy | Rarely affected |
| Spleen, gut, tissues | Little effect | Congestive splenomegaly, gut edema, ankle and sacral edema, ascites |

## Clinical notes

- Elevated jugular venous pressure, hepatomegaly and edema point to right-sided failure; crackles and orthopnea to left-sided failure.

## Memory aid

Left looks to the lungs, right runs to the rest: the back-up always goes upstream of the failing side.

## Test yourself

Think of the answer, then tap the question to see it.

## What are ‘heart-failure cells’?

Alveolar macrophages loaded with hemosiderin from red cells that leaked into alveoli during chronic pulmonary congestion.

## What gives the liver a nutmeg appearance in right heart failure?

Congested, dark centrilobular zones around central veins contrasting with paler periportal areas.

## What is the most common cause of right-sided heart failure?

Left-sided heart failure.

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## Elsewhere in DurgiPedia

- [Heart failure syndrome: left- and right-sided signs](https://durgical.com/en/clinical-exam/heart-failure-syndrome-left-and-right-sided-signs/)
- [Starling forces at the capillary](https://durgical.com/en/physiology/starling-forces-at-the-capillary/)
- [Jugular venous pressure and the venous pulse](https://durgical.com/en/clinical-exam/jugular-venous-pressure-and-the-venous-pulse/)

## Connections

## Related 6

- [Hyperemia and congestion (the nutmeg liver, heart-failure cells)](https://durgical.com/en/general-pathology/hyperemia-and-congestion/)
- [Edema and effusions: the four mechanisms](https://durgical.com/en/general-pathology/edema-and-effusions-the-four-mechanisms/)
- [Pulmonary edema: hemodynamic vs alveolar-capillary injury](https://durgical.com/en/general-pathology/pulmonary-edema-hemodynamic-vs-alveolar-capillary-injury/)
- [Hepatic venous outflow obstruction](https://durgical.com/en/general-pathology/hepatic-venous-outflow-obstruction/)
- [Heart failure: hypertrophy and remodelling](https://durgical.com/en/general-pathology/heart-failure-hypertrophy-and-remodelling/)
- [Splenomegaly and hypersplenism](https://durgical.com/en/general-pathology/splenomegaly-and-hypersplenism/)

## Related conditions 5

- [Heart failure](https://durgical.com/en/conditions/heart-failure/)
- [Pulmonary hypertension and cor pulmonale](https://durgical.com/en/conditions/pulmonary-hypertension-and-cor-pulmonale/)
- [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/)
- [Pleural effusion](https://durgical.com/en/conditions/pleural-effusion/)
- [Chronic obstructive pulmonary disease (COPD)](https://durgical.com/en/conditions/chronic-obstructive-pulmonary-disease/)

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Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.

Sources: [Heart Failure | Congestive Heart Failure | CHF | MedlinePlus](https://medlineplus.gov/heartfailure.html) (MedlinePlus, US National Library of Medicine, 2025).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/general-pathology/left-vs-right-sided-heart-failure/