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Left parasternal heave

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Here is a structured, textbook-referenced overview of the left parasternal heave:

Left Parasternal Heave (Right Ventricular Heave / Lift)

Definition and Mechanism

A left parasternal heave is a palpable, sustained outward thrust felt at the lower left sternal border (left parasternal area), produced by an enlarged or hypertrophied right ventricle (RV) pushing the chest wall forward with each systole. Because the RV lies directly behind this region, any significant pressure or volume overload causing RV enlargement can be felt here.
  • Goldman-Cecil Medicine: "A palpable left parasternal heave may be caused by the hypertrophied, pressure-overloaded right ventricle."
There is also a second mechanism: massive left atrial (LA) enlargement can push the RV anteriorly against the chest wall, producing a parasternal heave even in the absence of intrinsic RV hypertrophy (classically seen in mitral regurgitation).

How to Elicit It

  • Place the heel of the hand (or fingertips) flat over the lower left sternal border / left parasternal region (3rd-5th intercostal spaces).
  • A heave is a sustained systolic lift that pushes the hand/fingers upward and outward.
  • Distinguish from a normal RV impulse or a hyperdynamic (volume) tap - a true heave is forceful and sustained throughout systole.

Causes

CategorySpecific Conditions
Pressure overload of RVPulmonary arterial hypertension (PAH), pulmonary stenosis, cor pulmonale (COPD, IPF, PE)
Volume overload of RVAtrial septal defect (ASD), total anomalous pulmonary venous return (TAPVR), tricuspid regurgitation, pulmonary regurgitation
Left atrial enlargement pushing RV forwardSevere mitral regurgitation, mitral stenosis
Complex congenital heart diseaseEisenmenger syndrome, VSD with pulmonary hypertension

Associated Clinical Findings by Condition

Pulmonary Hypertension (most classic cause):
  • Left parasternal heave (pressure-loaded RV)
  • Loud/palpable P2 (loud pulmonary component of S2)
  • RV S4 (stiff, hypertrophied RV)
  • Jugular venous distension with prominent v-waves (if TR present)
  • Holosystolic murmur of tricuspid regurgitation (augments with inspiration)
  • RV S3 = advanced disease/right heart failure
  • Hepatomegaly, peripheral edema, ascites (right heart failure) (Goldman-Cecil Medicine)
Atrial Septal Defect (ASD):
  • Parasternal heave from RV volume overload
  • Fixed, widely split S2 (hallmark)
  • Ejection systolic murmur (relative pulmonary stenosis) at upper left sternal border
  • May also have a diastolic rumble (relative tricuspid stenosis) (Fuster and Hurst's The Heart)
Pulmonary Stenosis (severe):
  • Prominent a-wave in JVP (non-compliant RV)
  • RV heave
  • Precordial thrill
  • Ejection systolic murmur, radiating to the back (Fuster and Hurst's The Heart)
Pulmonary Regurgitation (post-repair of pulmonary stenosis):
  • RV heave
  • Single S2
  • Ejection systolic murmur + early diastolic murmur (shorter with severe PR) (Fuster and Hurst's The Heart)
Eisenmenger Syndrome:
  • Central cyanosis and digital clubbing
  • Right parasternal heave or lift
  • Loud P2
  • S3 or S4
  • High-pitched diastolic murmur (pulmonary regurgitation) (Braunwald's Heart Disease)
Cor Pulmonale / Pulmonary fibrosis:
  • Accentuated P2, right ventricular heave
  • Lower extremity edema (Textbook of Family Medicine, Goldman-Cecil Medicine)

Grading / Severity

  • A palpable heave always indicates significant RV hypertrophy/dilatation - it is not a normal finding.
  • The stronger the lift, the more severe the RV pressure/volume overload.
  • In advanced right heart failure, the heave may paradoxically decrease as the failing RV dilates and loses contractile force.

Differential for Parasternal Pulsation

FindingCause
Sustained heaveRV pressure overload (pulmonary hypertension, PS)
Tapping/diffuse heaveRV volume overload (ASD, TR)
Parasternal pulsation without true heaveLeft atrial expansion (MR) pushing RV anteriorly
Absent RV liftSignificant tricuspid stenosis (TS) - RV cannot fill adequately
(Braunwald's Heart Disease notes "absent right ventricular lift" as a feature of tricuspid stenosis)

Key Associations to Remember

  • Loud P2 + left parasternal heave = pulmonary hypertension until proven otherwise
  • Fixed split S2 + parasternal heave = ASD
  • Parasternal heave + opening snap + mid-diastolic rumble = mitral stenosis with RV involvement
  • Parasternal heave + cyanosis + clubbing = Eisenmenger syndrome or cyanotic congenital heart disease
  • RV S3 + parasternal heave = advanced right heart failure
Sources: Goldman-Cecil Medicine (p. 818), Braunwald's Heart Disease, Fuster and Hurst's The Heart (15th ed.)
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