Physical findings associated with Tricuspid Regurgitation (TR) and right-sided heart failure are often secondary to blood reflux from the heart and vena cava into the vascular system. Notable signs include an elevated Jugular Venous Pulse (JVP), lower extremity edema and a positive hepatojugular reflux maneuver.

      A 93-year-old patient known to suffer from pulmonary hypertension and obesity presented to the ER complaining of worsening dyspnea and abdominal distention. His evaluation revealed ascites with high Serum Ascites Albumin Gradient (SAAG) and an elevated JVP. Unusually, physical exam revealed venous pulsations of the angular vein (video 1, see supplementary file), more pronounced in the sitting position, likely reflecting a severely elevated JVP and TR. Echocardiography revealed dilation of the right ventricle with reduced systolic function, severe dilation of the right atria and severe tricuspid regurgitation. The patient was diagnosed with right-sided heart failure exacerbated by concomitant anemia. Patient was treated with diuretics, resulting in a significant improvement of his symptoms.

     In this patient TR and right-sided heart failure have produced, along with known physical exam findings, the unusual finding of venous distention of the smaller veins of the face. This finding sheds light on the underlying pathophysiology of the symptoms of fluid overload and right sided heart failure.