Diagnosis of tricuspid regurgitation. Current status.

The most accepted diagnostic methods of tricuspid regurgitation (TR) are the physical examinations and the evaluation of right atrial pressure. However, these methods are not consistently diagnostic, and a "silent" form of TR has been recognized. The current status of noninvasive and invasive diagnostic techniques is reviewed.

Intracardiac phonocardiography in tricuspid regurgitation: relation to clinical and angiographic findings.

Intracardiac phonocardiograms were obtained from the right atrium in order to study the relation between the clinical signs of tricuspid regurgitation, intracardiac murmurs and the degree of regurgitation demonstrated on right ventriculography with use of a preshaped catheter. In five patients with no heart disease, right ventriculograms showed no evidence of tricuspid regurgitation and intracardiac phonocardiograms in the right atrium demonstrated no murmur. Among 35 patients with valvular heart disease, a Carvallo sign (increased intensity of systolic murmur during inspiration) was present in 19 and absent in 16. All 19 patients with a Carvallo sign had variable degrees of tricuspid regurgitation on right ventriculography, and intracardiac phonocardiograms were positive for tricuspid regurgitation in 18. Among 16 patients with an absent Carvallo sign, neither right ventriculography nor intracardiac phonocardiography was indicative of tricuspid regurgitation in 5. Five patients had 1+ regurgitation and the intracardiac phonocardiogram was positive in three of these five patients. The other six patients showed 3+ to 4+ regurgitation and the intracardiac phonocardiogram was positive for tricuspid regurgitation in all. In conclusion, (1) the Carvallo sign is a reliable indicator of tricuspid regurgitation but its absence does not rule it out, and (2) right ventriculography using a preshaped catheter and intracardiac phonocardiography are useful in detecting clinically unrecognized tricuspid regurgitation.

Diagnosis of severe tricuspid regurgitation.

Fifty-nine patients were studied who had severe tricuspid regurgitation which was confirmed by right ventriculography and during surgery in order to determine the incidence of clinical, radiologic, and hemodynamic clues of severe tricuspid regurgitation. Eighty-eight percent of patients had Carvallo sign alone or in combination with pulsatile liver or prominent jugular venous V waves, and the classic triad was present in 42 percent. Most patients had enlargement of the right atrium on chest x-ray film. The classical "ventricularization" pattern of right atrial pressure was seen in 30 percent, prominent V waves with rapid Y descents were present in 37 percent, and normal contour of right atrial waves with normal mean pressure was seen in 33 percent. The inspiratory maneuver was helpful to induce the ventricularization pattern or prominent V waves with rapid Y descents especially in patients with normal right atrial pressure waves. In conclusion, right ventriculography is a sensitive and accurate method for detecting and quantitating tricuspid regurgitation in the absence of the diagnostic physical findings.

The use of the hepatic pressure maneuver to identify the murmur of tricuspid regurgitation.

To enhance the bedside diagnosis of tricuspid regurgitation, the influence of manual pressure applied below the liver on lower left sternal border murmurs was determined in 23 patients. All 23 subjects had right ventriculograms and right atrial phonocardiograms. The sign was positive in 13 cases, including 3 who were without a Carvallo sign. The application of manual pressure below the liver is a simple and valid additional maneuver for identifying the murmur of tricuspid regurgitation.

Giant Lambl's excrescences of papillary muscle and aortic valve: echocardiographic, angiographic, and pathologic findings.

A 54-year-old female with rheumatic heart disease was found to have a mass in the left ventricle by echocardiography and angiography. Subsequently, giant Lambl's excrescences of papillary muscle and aortic valve were confirmed by operation and pathologic examination. Possible complication from cardiac catheterization could be avoided by the utilization of echocardiography prior to catheterization.

Exercise testing and portable ECG recording in arrhythmia-prone patients.

To detect transient arrhythmias or conduction disturbances, 200 patients with the symptoms of palpitations, syncope or dizziness, and patients with coronary heart disease, angina pectoris, arrhythmias or conduction disturbances on resting 12-lead electrocardiogram, were studied by submaximal treadmill exercise and portable Holter recording. Thirty-nine patients (19.5%) had arrhythmias on the resting 12-lead ECG, 136 patients (68%) showed arrhythmias either on treadmill or Holter recording or both. Eighty-nine patients (44.5%) showed arrhythmias on exercise, while 123 patients (61.5%) had rhythm or conduction disturbances on Holter recording. Twenty-two patients (11%) had arrhythmias only on treadmill walking, while 68 (34%) had arrhythmias only with the Holter. In six patients different arrhythmias was noted by each method. Although the Holter recording technique affords a higher yield of recording transient arrhythmias than did exercise testing, both methods are useful and complementary in evaluating the ambulatory patients suspected of having rhythm or conduction disturbances.

High-output congestive failure due to arteriovenous fistula resulting from lumbar disc surgery--a case report.

A patient is described who developed high-output congestive failure following surgery to a lumbar disc. Diagnosis of arteriovenous fistula was suggested by the signs of high-output state and a continuous bruit heard over the low back scar. Confirmation was demonstrated by abdominal aortography. Corrective surgery resulted in resolution of congestive failure.