Real and apparent apical impulse in tricuspid lesions

Real and Apparent Apical Impulse in Tricuspid Lesions Differentiation of Mitral and Tricuspid Murmurs and Sounds* J . M . RICERO-CARV .ALLO,

M .D .

and A

G .9RZr,

DE LOS

SANTOS, V .D .

Mexico City, Mexico

published in 1946 on the diagnosis of tricuspid regurgitation' it was concluded that : (1) tricuspid systolic murmurs are reinforced during postinspiratorv apnea while aortic and mitral systolic and diastolic murmurs decrease in intensity during this same phase . and (2) postexpiratory apnea increases aortic and mitral murmurs and decreases the intensity of the tricuspid murmurs . In 1one of uss described several physical data which are useful fur the diagnosis of tricuspid stenosis : increase during postinspiratory apnea of the diastolic and presystolic inurmura, of the opening snap of the tricuspid valve and of the first sound . In 1951-1952, other observations were published on [fie cardiac and peripheral phenomena associated with stenosis and regurgitation of the tricuspid valve .' =r In some patients, the tricuspid murmurs did not increase until after two or more inspirations and occasionally the murmurs decreased during inspiration . 'I he senior author and Ramirez Jaime' later ascertained that the reason for this was the presence of a large, degenerated and translucent right atrium, which they named "atrium papiraceoum ." In 1951 the senior author and his co-workers' described the relative stenosis of the tricuspid valve in patients with chronic cor pul'nonale due to pulmonary emphysema and mediastinal fii.,rosis' or idiopathic pulmonary hypertension, and in patients with rheumatic valvular disease without organic Iricuspid lesions . In all these cases, there was a remarkable dilatation of the right cardiac chamhers . They were furtherahle

I

to prove that the murmur audible at the apex was equally reinforced during postinspiratory apnea, a fact which led to the erroneous belief that some mitral murmurs acted as tricuspid murmurs . This fact was claimed to decrease the value of the previously described si,grns . Certain hemodynamic principles are basic and operate both in physiologic conditions and in clinical cases . Therefore, it does not seem logical for mitral murmurs to increase during postinspiratory apnea_ The analysis of this phenomenon and of it, mechanism led to the conclusion that there must have been an error of interpretation . A possibility was the fact that the "apes" beat was actually the impulse of the enlarged right ventricle . If this were true, then the murmurs heard in this area originated in the eri-

N A 11 . APER

cuspiid ualre and not in the initial cabre . MEtHOD AND MATERIAl

With this hypothesis and the previous studies of patients with tricuspid lesions, we tried to ascertain *.he real site of the cardiac apes i .e ., that area which belongs to the left ventricle . We proceeded to localize the apical heat in the left lateral position in patients with initial and tricuspid lesions and we made different auscultations in several points of the left precordiutn . In some patients, at this particular site. postinspiratorv apnea caused the murmurs and sounds to follow the general behavior of murmurs and sounds originating in the right .-" Significant differences cardiac chambers were noted Pay listening in the area between the apparent apes and the anterior or posterior

Prom the t arr] iovascular clinic, Is lcd eat School, University of Mexico . and the National Institute of Cardiology of t,texiro . Maxim C,iv . Mexico. Sst'TSmeea 1 9 .,9

367

36 8

Rivero-Carvallo and Garza de los Santos

Fm . 1, Method far the identification of the "apparent apex" in the recumbent position (left) ; and the "real apex" in the left lateral position (u'gh!) . axillary lines . Actually, a new auscultatory area was found at the anterior axillary line which we called the "real apex," where murmurs and sounds differed in quality from those found at the "apparent apex" and decreased during postinspiratory apnea, thus following the typical hemodynamic behavior of the left cardiac chambers . This was, therefore, the mitral area . Once this fact was ascertained, we sought for a new apical impulse in different positions ; it was discovered in the left lateral position (Pachon's method) . This was the solution to our problem . For statistical purposes, 200 patients with tricuspid lesions (a common complication in Mexico) were studied . In thirty of them, the diagnosis was confirmed at autopsy . In 12 per cent of the cases, the "true" and "apparent" apex phenomenon was present. All of them had advanced mitral and tricuspid lesions . The electrocardiogram, chest x-ray, phonocardiogram, apex cardiogram and autopsy records were studied,

spaces . Without removing the right hand from this position, the patient is then made to turn to the left lateral recmmbent position (Fig . 1) . At this time a new apical impulse appears which was not previousk apparent or was doubtful ; this is caused by the "real" apex. It is felt from 6 to 12 cm . from the apparent apex, according to the age of the patient and the shape of the chest . The nmrmurs and sounds produced at the mitral valve are clearly heard in this area . The inspiratorc and expiratory changes noticed in this apical region behave according to the hemodynamic changes of the left heart . With the patient in the recumbent position, an increase of the intensity of the apical beat is generally felt ; it is displaced minimally giving the impression that it never disappears . and this is even more clearly perceptible it a thrill is present. On the contrary-, if there is a "real" and an "apparent" apex, a second apical heat appears under the tips of the fingers of the exploring hand .

CLINICAL OBSERVATIONS

ANATOMICAL DATA Enlargement of the right cardiac chambers displaces the cardiac apex outwards and posteriorly . This fact is particularly noticeable in patients with old tricuspid lesions . The consequent clockwise rotation of the heart around the longitudinal axis and the counterclockwise rotation around the transverse axis causes a considerable backward displacement of the left ventricle . The right atrium and

DESCRIPTION OF '1 'HE SIGN AND HOLY To DISCOVER II' When the apex beat is located in [tie recruitbent position, the palm of the right hand is ; this apical beat is the placed over this "apparent" one ;area the tips of the fingers will then he reaching the axillary lines somewhere between the fourth and sixth left intercostal

TIIL AMERICAN JOURNAL OF CARDIOLOGY

Apical Impulse in Tricuspid Lesions

369

Flc . 2 . Left . electrocardiogram ofa patient wit it Initial and tricuspid lesions with marknl right axis deviation . "I'he patterns in leads V, to V are those of the right ventricle ; 1('f centricnlar patterns appear only in V, . Right, circumferential chest leads recorded ti the level of lead V i ; the transitional zone is displaced to the Ieft (lead V,1 . (t'uurtesv tit Dr . Cisncros .) ventricle then loan the anterior aspect of the heart . _-Autopsies performed by Costero, Barroso, Chcvez, Monroe- and Contreraa have proved this fact . F:LECrw,l,ARDIO(3RAPHIG

FINDINGS

The electrocardiogram, through the pattern of the unipolar precordial leads, shows the area of the heart iv here the exploring electrode is placed . Since the classic work of Wilson et al . ." it is accepted that leads V t and V, correspond ill potential variations of the right ventricle : leads V ;, and V I to those of the ventricular septum (transitional zone) ; and leads V s and V e to those of the left ventricle . Ferrero et al ." have reached the same conclusions . A displacement of the transitional zone to the left indicates that the heart has rotated around it, longitudinal axis in a clockwise direction . SEPIEML£R Pig

Direct unipolar recordings made by Barbato's indicate that the right ventricle represents the greatest part of the anterior aspect of the heart in patients with mitral disease . Recent studies by Cisneros, Fishleder and Sodi-Pallares't on the electrocardiogram in rheumatic valvular disease further support this concept because right ventricular overload causes a marked clockwise rotation around the longitudinal axis and displacement of the transitional zone to the left . In patients with "real" and "apparent" apex, the transitional zone is displaced to lead V a or further, and the left ventricular pattern starts at leads V 5 or V s (Fig . 2i . RADIOLOGIC

FINDINGS

Dorbecker has given a demonstration of the site of the real apex (left ventricle) by means of fluoroscopy and with selective x-rays through

370

Rivero-Carvallo and Garza de los Santos

Pre . 3 . Left, rhest Ioeutgcnograrn in the frontal view . The space of clear limp held between the chest wall and the heart is resonant to percussion, a fact which permits an accurate location of the apex . Centre, left oblique view at 60 degrees . '['he letter .4 corresponds to the anterolateral aspect of the right ventricle and to the site found by palpation ('apparent" apex) . The letter F is at the site of the "real" apex (left ventricle) . These facts arc eonlh-med Nuoroseopically . Right, the chest of the same patient . The letter d corresponds to the "apparc rt" apex ; the Inter R to the "real'' apex found clinically . ((toortcsq of Drs . Dorbeeker, Cornminas and Ambia .)

Fen . 4 . Phonoeardiograms and apex cardiogrunrs . fhc rraclngs on the /oft are recorded over the xiphoid area ; those in the erntc,, over the "apparent' apex ; those on the ri,ghe user the '`real" ape,. lop : phonocardiogranrs during pus'texpiratory apnea ; 34a(dler phonocardiograms during postinspiratory apnea ; Bottom : low frqucncv apex tracings (cardiograms). Notice the reinforcement of tricuspid murmurs during Posh uspuat"'v apnea (middle) at the xiphoid and apparent apex, and their decrease at the real apex . In the upper records (top), taken during pratcxpiratory apnea, the murmurs decrease over the xiphoid and "apparent" apex areas (left and center) while they itie -ruse at rh e "real" apex (right) . (Courtesy of Drs . Fishieder and Avila Cos-) the use of markers . The site of the apex at fluoroscopy coincided with that found clinically (Fig . 3) . Cineangiocardiograpitic studies by Dorbecker show that, in these cases, the right ventricle occupies the anterior aspect of the heart including the area normally filled by the left ventricle. .

Roentgenolo), has also proved that the heart, in the left lateral position, displaces the margins of the left tong, thus permitting the left ventricle to come in contact with the chest wall at one of the axillary lines . PIIONUCARDIOGRAPIRC FINDINGS Fishlederry has given proof that rnurmurs and rue.AMERICAN lourv Al .otr CAan101 .00Y



Apical Irnpulsc in Tricuspid Lesions sounds of the real apex originate in the mitral valve, since the' decrease in postinspiratory apnea and increase in postexpiratory apnea . On the contrary . over the apparent apex, the nturmursancl soundsongirate in the tricuspid valve and increase during inspiration (Fig . 41 . At tin cam . extraneous acoustic phenomena originatiug in different valves invade these areas . Thus, a high-pitched mitral systolic murmur may appear during postexpira Tory apnea in the tricuspid area . 'I his phenomenon is at tines seen in greatkc dilated hearts with considerable rotation . I n these cases, diflerentiation is made specially be comparing the auseultatory data in the phases of postiuspiratorv and pastexpiratnry apnea .' The a/)ical cardiogram, studied by Avila Cos' , under the direction of Fishleder, also indicates the patterns of the right and left entricular in, pukes . The cardiogram recorded at the xiphoid (tricuspid area) shows a large positive in sc,tole (Fig . 4) . On the contra-N, the tracing obtained in the seventh left intercostal space at the mid-axillarv line shows fundamentally a systolic depression with a small positive wave at the beginning of ejection_ The cardiogram registered at the fifth left intercostal space and the mid-clavicular line shows a dipha, ic (minus-plus) wave during role . 'I` lie cardiograms suggest that, during ejection, the heart oscillates clockwise around its longitudinal axis causing the right ventricle to move forward and the left ventricle backward . This is commonly seen in predominant rightsidocl enlaigernents . At the fifth left intercostal space and the mid-elavicular line, the prerordial motions art- influenced by hoth ventricles, although more so En- the right . The presence of a positive wave at the beginning of ejection in the cardiogram at the seventh left intercostal space and the mid-axillarv line suggests that, although right ventricular enlargentent predominates, there is also a certain degree of leftsided enlargement. The systolic murmur and the loud third sound . coinciding with a large third wave in the cardiogram, reveals the existence of significant nlitr;tl re+gurgitation associated with the stenosis of the mitral and tricuspid valves. Fig 4 i . C ;ou sttrTs 'Ihe morphologic changes occurring in the heart when greater or lesser dilatation of the right cardiac ehamhers occurs have been the 1tPJF V3Eus

1959

371

=uhject of anatomic studies with or without postmortem filling of the chambers . - I'hese were confirmed by electrocardiographic and cincangiocardiographic studies in Taro . Pathologic, clectrocardiographic, roentecnologic and clinical studies reseal that the right ventricle occupies the anterolateral aspect of the chest, while the left ventricle is pushed backwards . Electrocardio,graphv reveals that these chances are clue to clockwise rotation around the longitudinal axis and counmrclockwise rotation around the transverse axis . These rotations explain why there is an " apparent' apex heat clue to impul,c of the dilated right ventricle, which has come into close contact with tire chest wall_ The left ventricle . On tile other hand, comes in contact with the chest wall near the anterior atillarv line by displacing the margin of the hung. In chronic cases of cur puluonale preciously studied,° .s these rotations were also present ; there were s} nolic and diastolic murmurs at the tricuspid area, the latter being clue to relative stenosis. In these patients, a "Ical" and an ''apparent" apical impulse Were also found . In some cases of congenital heart disease with right ventricular enlargement, the same phenornenon may he observed . The test described permits clear differentiation between mitral and tricuspid phenomena at the correct corresponding areas, clinical evaluation of the enlargement of the right ventricle, and estimation of the rotation of the heart around its axis . StnaiIARY

AND

CovcccstoNs

While studying patients with tricuspid lesions it was discovered that some showed a reinforcement of the murmurs during postinspiratory apnea at the mitral area apparent apical impulse t, This seemed to decrease the importance_ of signs which had been previously described by- one of us (R . C .) for the diagnosis of tricuspid vaIre lesions . The present study ascertained the following facts : 1 . When there is right ventricular enlargement. the heart presents a clockwise rotation around its longitudinal axis and a counterclockwise rotation around its transverse axis ; then, the- left ventricle is displaced backwards while the right occupies the anterolateral aspects of the heart . 3 . This extreme rotation is confirmed radiolot,icalh .

372

Rivero-Carvallo

3.

The electrocardiogram shows a right ven-

tricular pattern over the anterior aspect heart and that lead

and Garza

Vs

4.

of

of

the

the left ventricle only from

on .

The phonocardiogram shows that the

acoustic phenomena corresponding to the mitral valve occur at the left axillary line ("real" apex) while those corresponding to the tricuspid valve are found over the area

of

the ",apparent"

apex .

S. of

The apical cardiogram records the pattern

the right ventricle over the "apparent' apex

and that

of

the left ventricle over the "real"

apex .

6. A

method is described which permits the

differentiation between the "real" apex and the "apparent" apex

by

careful palpation of the

apical and adjacent areas in the left lateral decubitus .

7.

Once the "real" and "apparent" apex arc

identified, the behavior

of

the tricuspid valve

is

of

murmur=- and sounds

recognized as in other,

more common, cases . RErERENt:ES 1 . Rrvnxo-CARvILLo, J . M. Signo para el diagnhslieu de las insnficiencias tricuspideas . Arch. but. cardiol . 14vrico, 16 : 231, 1946 . 2 . RrvFRO-CARVALLO, J . M . El diagnhstico de la estenosis tricospidra . Arch . Lnst medial. dlezica, 20 : 1, 1950 . 3 . RIVFRO-CARVALL s . .J . M . Semiologia do ]as lesinnes tricuspideas . Arch . last . cordial. Alesico, 21 :567, 1951 ; Arch . mat . coeur, 2 : 1329, 1952 . 4 . RIVFRO-CARVALL0 . J . M„CARRAL. R . and RAMIREZ JAIME, M . H . Lslenosis I clativa de Is tricuspide. Arch. Iru7 . 'aids,! . Wixico, 21 : 47, 1951 . 5 . RrvtRO-CARCALLo, .J . M . and RAMIREZ JAIME, M . H . LI diagnostico do la auricula papiracea . To be published . 6 . RIVLRO-CARVAI .1 O, J . M ., CARRAL, R . and RAMIRFZ JAIME, M . H . LI diagndstico do la estcnosisrelatha de la tricuspide . Arch . In.rt . cardiol . lexico . '['a be published .

do los

Santos

7 . RIVERO-CutVAL1 .0. .1 . M . and PERRIN (Alto, SI . Las mediastinitis reum`aticas . Arch . Latino . am . de Cardio1 ) hemat., 13 :'171, 1943 8 . COIIRNAND, 11 . Recent observations on the dvnamics of the pulmonary circulation . Bull. No, ., .49,d Ysrk Acad . 23 : 51, 1947 . 9 . LALSON, H . D ., COuRNAND, A . and BLOOMEIELD, R. A . Influence of respiration on circulation in man, with special reference to pressures in the right auricle, right ventricle, femoral artery and peripheral veins . Am .1 . :Nrd., 1 :315, 1946 . 11) . COURNAND, A . . RILEY, R . L ., Burro, E . S ., BALDwiN, E . and RICnARD, D . W' ., JR. Measurement of cardiac output in man using the techniqur of catheterization of the right auricle or ventricle . ot. 17,, . InosE . . 24 : 106, 1945 . 11 . HAMR,ioN, W . F . Pressure relations in the pulmonmy- circuit . Proc . Sac . Ado . Sc ., 13 :324, 1940 . 12 . CARRAL ., R . Variaciones respiraturias do Ins soplos cardiacos . Arch . Gut . cordial, adecico, 17 : 478, 1947 . 13 . CONDORLLLL L- . .Atria e ventricolotensiografia . Riforasa nod. Rmoq 16-17 : 1, 1931 . 14 . Wnsos, F . N ., JOHNSTON, F . . D . COTRIM, N . and RosrNRAeM, F . F . Relation between the potential variations of the venhicular electrocardiograms in leads front the precordium and the extremitics . [sns . .4 . Am . Physicians, 16 : 258 . 1941 . 15 . FERRERO, G, DUCITOS L, P. W ., DORET, J . P ., GROSGLERIN, J . and MASTRANCRLO, E . A. Comparisones entre derivationes epicardiaques et precordiales . Presented at the First World Congress of Cardiology, Paris, 1950, 16 . BARDA'10 . E . I :studio electrocardiogr :Sfico da activaeao ventricular normal o patol6gico . Sea importancia na interpretacao das chamadas curvas de hipcrtrofia . Thesis, Sao Paulo, 1952 . 17 . CISNFROs F ., F1suLLDsR, B . and SOn1-PALLARES, D . Electrocardiograma co alpunas lesiones val. Mexico, vulares reumaticas . Arch . ho. cardio 28 : 63, 1958 . 18, AVILA Cus, L . Apex real y aparenre en valvulopatias ii icuspideas . (Maniobra de Rivero-Carvallo y Garza do Ins Santos .) Thesis, 1958 . 19 . FISHLFDFR, B . L. Auscultation v 1'onocardiografia en la estenosis mitral . Prioripio Grdiol . :Ilex . . 2 : 142, 1955_

Parts I and II of the Symposium on Phonocardiography (Aldo A . Luisada, Guest Editor) appeared in the July and August issues, respectively . Part IV will appear in the October issue and Part V in the November issue,

THf. AMERICAN JOURNAL OF ( :\RDIOLOGY