- Email: [email protected]
Coupled hepatic pulsations in tricuspid incompetence (a new physical sign)
Coupled (A
Hepatic
New Physical
R. Barratt
Terry,
Pulsutionr
in Tricuspid
Incompetence
Sign) M.D.,
Chicago, Ill.
Pulsation of the liver may be expansile, as in tricuspid incompetence, or may be transmitted from the abdominal aorta. In theory, the differentiation between expansile and transmitted pulsation is easy, but in practice it is frequently extremely difficult, and endless argument often ensues. This paper is concerned with an observation which has been found useful on several occasions in determining the character of hepatic pulsations. The E$ect of Ventricular Extrasystoles on Hepatic Pulsation.-A ventricular extrasystole usually results in contraction of the ventricles without ejection of significant amounts of blood into the aorta, as indicated by the absence both of the second heart sound and of a pulse wave in the peripheral arteries. In tricuspid incompetence, such a ventricular extrasystole also fails to create an arterial pulsation or a second heart sound, but it does cause substantial pulsation in the jugular veins; and, if the normal ventricular systoles are causing expansile hepatic pulsation, the ventricular extrasystoles will usually create an easily perceptible hepatic pulsation. If there is hepatic pulsation in the absence of tricuspid incompetence, it is transmitted from the abdominal aorta. In this instance, an extrasystole that fails to produce an arterial pulsation will also fail to prcduce hepatic pulsation. The Effect of Digitalis Coupling on Hepatic Pulsation.-Whereas determination of the relationship of hepatic pulsations to isolated ventricular extrasystoles requires patience and practice, this observation is rendered much simpler when ventricular extrasystoles alternate with normal systoles as in the coupling of digitalis intoxication. Under these circumstances, in tricuspid incompetence, each normal systole results in simultaneous palpable carotid pulsation, visible jugular pulsation, and palpable hepatic pulsation : each ventricular extrasystole results in simultaneous jugular and hepatic pulsation, but no arterial pulsation occurs and no second heart sound is produced. The persistent occurrence of two hepatic pulsations for each single arterial pulsation is a striking clinical phenomenon as well :as a useful physical sign. From the Departments of Medicine. Passavant :Medical School, and Cook County Hospital, Chicago, Received for publication Sept. 11, 1958.
Memodal Ill.
Hospital.
Northwestern
University
Volume Number
57 1
COI:PLED
HEPATIC
PCLSATIONS
IN
TRICC’SPID
INCOMPETENCE
159
If, in fact, the hepatic pulsation in a case of tricuspid incompetence is transmitted from the abdominal aorta, the alternate ventricular extrasystoles fail to produce hepatic pulsation. Timing of the Various Pulsations.-It is usually sufficient to palpate the liver with the right hand and the right carotid pulse with the left hand; at the same time, the pulsations are watched in the left jugular veins. In some instances of tricuspid incompetence, however, the marked pulsation of the jugular veins may confuse palpation of the carotid pulsation, and it is then easier to feel the brachial artery or the abdominal aorta, Simultaneous auscultation of the heart with the diaphragm of the stethoscope resting on the precordium helps to confirm the occurrence and timing of the ventricular extrasystoles as well as the failure of the extrasystole to produce a second heart sound. CLINICAL
EXPERIENCE
These observations were first made in 1956, in a patient in whom tricuspid incompetence was quite definite, but much argument centered around the expansile or transmitted character of the hepatic pulsations. Then, on one occasion, while I was trying to decide whether the hepatic pulse was synchronous with the carotid pulse, I noted that for every pulsation felt in the carotid artery, two pulsations were felt in the liver and two pulsations could be seen in the jugular veins. Auscultation of the heart revealed that there was coupling, and electrocardiography demonstrated digitalis intoxication with coupled ventricular extrasystoles. During the ensuing weeks, coupling due to digitalis intoxication recurred frequently, and the phenomenon of paired hepatic pulsations associated with single arterial pulsations was noted repeatedly. Coupled hepatic pulsations have since been noted in three additional cases of tricuspid incompetence in which digitalization had been too vigorous, although it may be noted that digitalis intoxication appears to occur very readily in these patients. SUMMARY
The coupling of the heart beats in digitalis intoxication may be used to demonstrate the expansile nature of the hepatic pulsation of tricuspid incompetence, since ventricular extrasystoles produce pulsations of the liver without corresponding arterial pulsation, with the result that two hepatic pulsations may be felt for each arterial pulsation.
Hepatic
New Physical
R. Barratt
Terry,
Pulsutionr
in Tricuspid
Incompetence
Sign) M.D.,
Chicago, Ill.
Pulsation of the liver may be expansile, as in tricuspid incompetence, or may be transmitted from the abdominal aorta. In theory, the differentiation between expansile and transmitted pulsation is easy, but in practice it is frequently extremely difficult, and endless argument often ensues. This paper is concerned with an observation which has been found useful on several occasions in determining the character of hepatic pulsations. The E$ect of Ventricular Extrasystoles on Hepatic Pulsation.-A ventricular extrasystole usually results in contraction of the ventricles without ejection of significant amounts of blood into the aorta, as indicated by the absence both of the second heart sound and of a pulse wave in the peripheral arteries. In tricuspid incompetence, such a ventricular extrasystole also fails to create an arterial pulsation or a second heart sound, but it does cause substantial pulsation in the jugular veins; and, if the normal ventricular systoles are causing expansile hepatic pulsation, the ventricular extrasystoles will usually create an easily perceptible hepatic pulsation. If there is hepatic pulsation in the absence of tricuspid incompetence, it is transmitted from the abdominal aorta. In this instance, an extrasystole that fails to produce an arterial pulsation will also fail to prcduce hepatic pulsation. The Effect of Digitalis Coupling on Hepatic Pulsation.-Whereas determination of the relationship of hepatic pulsations to isolated ventricular extrasystoles requires patience and practice, this observation is rendered much simpler when ventricular extrasystoles alternate with normal systoles as in the coupling of digitalis intoxication. Under these circumstances, in tricuspid incompetence, each normal systole results in simultaneous palpable carotid pulsation, visible jugular pulsation, and palpable hepatic pulsation : each ventricular extrasystole results in simultaneous jugular and hepatic pulsation, but no arterial pulsation occurs and no second heart sound is produced. The persistent occurrence of two hepatic pulsations for each single arterial pulsation is a striking clinical phenomenon as well :as a useful physical sign. From the Departments of Medicine. Passavant :Medical School, and Cook County Hospital, Chicago, Received for publication Sept. 11, 1958.
Memodal Ill.
Hospital.
Northwestern
University
Volume Number
57 1
COI:PLED
HEPATIC
PCLSATIONS
IN
TRICC’SPID
INCOMPETENCE
159
If, in fact, the hepatic pulsation in a case of tricuspid incompetence is transmitted from the abdominal aorta, the alternate ventricular extrasystoles fail to produce hepatic pulsation. Timing of the Various Pulsations.-It is usually sufficient to palpate the liver with the right hand and the right carotid pulse with the left hand; at the same time, the pulsations are watched in the left jugular veins. In some instances of tricuspid incompetence, however, the marked pulsation of the jugular veins may confuse palpation of the carotid pulsation, and it is then easier to feel the brachial artery or the abdominal aorta, Simultaneous auscultation of the heart with the diaphragm of the stethoscope resting on the precordium helps to confirm the occurrence and timing of the ventricular extrasystoles as well as the failure of the extrasystole to produce a second heart sound. CLINICAL
EXPERIENCE
These observations were first made in 1956, in a patient in whom tricuspid incompetence was quite definite, but much argument centered around the expansile or transmitted character of the hepatic pulsations. Then, on one occasion, while I was trying to decide whether the hepatic pulse was synchronous with the carotid pulse, I noted that for every pulsation felt in the carotid artery, two pulsations were felt in the liver and two pulsations could be seen in the jugular veins. Auscultation of the heart revealed that there was coupling, and electrocardiography demonstrated digitalis intoxication with coupled ventricular extrasystoles. During the ensuing weeks, coupling due to digitalis intoxication recurred frequently, and the phenomenon of paired hepatic pulsations associated with single arterial pulsations was noted repeatedly. Coupled hepatic pulsations have since been noted in three additional cases of tricuspid incompetence in which digitalization had been too vigorous, although it may be noted that digitalis intoxication appears to occur very readily in these patients. SUMMARY
The coupling of the heart beats in digitalis intoxication may be used to demonstrate the expansile nature of the hepatic pulsation of tricuspid incompetence, since ventricular extrasystoles produce pulsations of the liver without corresponding arterial pulsation, with the result that two hepatic pulsations may be felt for each arterial pulsation.