To better understand portal vein pulsatility in congestive heart failure, the authors compared portal vein spectral patterns to right atrial pressures measured with a Swan-Ganz catheter in 17 adult patients suspected of having congestive heart failure. Portal vein pulsatility was also evaluated in 17 healthy adults. A pulsatility score (scale, 1-5) based on a ratio of minimum to peak portal vein velocity was assigned. A score of 1 indicated continuous, monophasic flow, while a score of 5 indicated that flow reversal was observed with each cardiac cycle. All 17 healthy volunteers had portal vein pulsatility scores of 2 or less. Among the 17 patients suspected of having congestive heart failure, seven had normal right atrial pressure (less than 10 mm Hg) and pulsatility scores of 2 or less. Among the 10 patients with a right atrial pressure of 10 mm Hg or greater, six had pulsatility scores of 3 or greater (sensitivity, 60%; specificity, 100%). Greater than 50% of the variation in portal vein score is explained by changes in right atrial pressure. Review of echocardiograms in 13 of 17 patients showed no significant correlation between the degree of tricuspid regurgitation and portal vein score. Portal vein pulsatility is a sign of elevated systemic venous pressure.