Current Heart Failure Reports

, Volume 14, Issue 6, pp 519–528 | Cite as

Visceral Congestion in Heart Failure: Right Ventricular Dysfunction, Splanchnic Hemodynamics, and the Intestinal Microenvironment

  • Vincenzo B. Polsinelli
  • Arjun Sinha
  • Sanjiv J. ShahEmail author
Prevention of Heart Failure (M Sutton, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Prevention of Heart Failure


Purpose of Review

Visceral venous congestion of the gut may play a key role in the pathogenesis of right-sided heart failure (HF) and cardiorenal syndromes. Here, we review the role of right ventricular (RV) dysfunction, visceral congestion, splanchnic hemodynamics, and the intestinal microenvironment in the setting of right-sided HF. We review recent literature on this topic, outline possible mechanisms of disease pathogenesis, and discuss potential therapeutics.

Recent Findings

There are several mechanisms linking RV–gut interactions via visceral venous congestion which could result in (1) hypoxia and acidosis in enterocytes, which may lead to enhanced sodium–hydrogen exchanger 3 (NHE3) expression with increased sodium and fluid retention; (2) decreased luminal pH in the intestines, which could lead to alteration of the gut microbiome which could increase gut permeability and inflammation; (3) alteration of renal hemodynamics with triggering of the cardiorenal syndrome; and (4) altered phosphate metabolism resulting in increased pulmonary artery stiffening, thereby increasing RV afterload. A wide variety of therapeutic interventions that act on the RV, pulmonary vasculature, intestinal microenvironment, and the kidney could alter these pathways and should be tested in patients with right-sided HF.


The RV–gut axis is an important aspect of HF pathogenesis that deserves more attention. Modulation of the pathways interconnecting the right heart, visceral congestion, and the intestinal microenvironment could be a novel avenue of intervention for right-sided HF.


Heart failure Right ventricle Venous congestion Intestine Sodium–hydrogen exchanger 3 Microbiome 



National Institutes of Health R01 HL107577 and R01 HL 127028, and American Heart Association no. 16SFRN28780016 and no. 15CVGPSD27260148.

Compliance with Ethical Standards

Conflict of Interest

V.B.P. and A.S. each declare no potential conflicts of interest.

S.J.S. has received grant support from Actelion, AstraZeneca, Corvia, and Novartis; and consulting fees from Actelion, AstraZeneca, Bayer, Boehringer-Ingelheim, Cardiora, Ironwood, Merck, Novartis, Pfizer, and Sanofi.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Vincenzo B. Polsinelli
    • 1
  • Arjun Sinha
    • 1
  • Sanjiv J. Shah
    • 1
    Email author
  1. 1.Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoUSA

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