- Email: [email protected]
Unilateral pulsatile varicose veins from tricuspid regurgitation
4. Babbs CF, Paris RL, Tacker WA Jr, Bourland JD. Effects of myocardial infarction on catheter defibrillation threshold. Med Insrrum 1983;17:18-20. 5. Ruffy R, Schwartz DJ, Hieb BR. Influence of acute coronary occlusion on direct ventricular detibrillation in dogs. Med Instruni 1980;14:23-26. 6. Laman BB, Halpain HR, Tsitlik JE, Brin K, Clark CW, De& OC. Relationship between canine transthoracic impedance and defibrillation threshold: evidence for current-based d&briUation. J Clin Invest 1987;
80~797-803. 7. Winkle RA, Mead RH, Ruder MA, Smith NA, Buch WS, Gaudiani VA. Effect of duration of “enhicula fibrillation on defibrillation efficacy in humans. Circulation 1990$1:1477-1481. 8. Nademanee K. Refractory ventricular fibrillation in the electrophysiology laboratory: a nightmare from which we can awaken. J Am CoN Cardiol 1991;lS: 1285-1286. 9. Lmnan BB, Dale OC. Effect of epicardial patch
Unilateral Pulsatile Varicose Wns Tricuspid Regurgitation
electrodes on transtboracic defibiillation. Circulation 1990;81:1409-1414. 10. Walls JT, Schuder JC, Curtis JJ, Stephenson HE, McDaniel WC, Flaker GC. Adverse effects of permanent cardiac internal defibrillator patches on external defibrillation. Am J Cardiol 1989;64:1144-1147. 11. Ideker RE, Wolf PD, Alfemess C, Krassowska w, smith WM. cmmlt COnceDtSfor selectilx the location, size, and shape of defibrillation electrode. PACE 1991;14:227-240.
from
tolic pressure gradient of 25 mm Hg across the thickened tricuspid valve (Figure 3A). The right atrium and Herman 0. klein, MD, Dov Shachor, MD, Nina Schneider, MD, and Daniel ventricle were dilated; the inferior vena cava was dilated (2.7 cm) and David, MD, with the technical assistance of Osnat Sharoni expanded in systole (Figure 3B). evere tricuspid regurgitation proximally to the aortic btfurcation Color Doppler echocardiography (TR) has occasionally been without jmding any fistulous com- with the transducer placed over the known to lead to marked pnlsatility munication. liver documented the systolic reverThe sounds of the Starr-Edwards sal offlow toward the hepatic veins of varicose veins.‘” We present an unusual case in which the presence valve were normal. A 216 systolic (not shown) typical of TR. Thesereof unilateral venous varicosities in murmur that increased on deep inonly the right leg caused the ap- spiration was heard at the lower left pearanceof unilateral pulsations. sternal border. A rocking precordial A 70-year-old woman was eval- motion signalling severe TR was uated by the gynecologic servicefor present, accompanied by prominent metrorrhagia. The uterus was nor- systolic regurgitant v waves4 over mal in size; diagnostic curettage re- the jugular veins and the liver (Figvealed moderately dtrerentiated en- ures 2A and 3A). The true origin of dometrial adenocarcinoma and hys- the varicose vein pulsations was terectomy was planned. Fifteen thus jmally established when the years previously, mitral valve re- typical findings of TR were delinplacement had been pelformed for eated and the regurgitant waves mitral stenosis. traced in continuity down to the Prominent pulsatile varicose varices over the patella (Figure 2B). Two-dimensional and Doppler veins, which extendedfrom the right inguinal area where a surgical scar echocardiography (Aloka 870 syswas present (at the site of car- tem) showed severe TR with a sysdiopulmonary bypass 15 years previously) and down the entire saphenous vein system, including a large cavernous varix overlying the patella (Figure 1) were noted. A large, chronic, poorly healing superficial ulcer was present over the dorsum RGURE i. Venous puke recordings show mart+ systolic pulsations (v of the foot. These unilateral variwaves) over the liver (A) and over the cose pulsations were interpreted by large knee varix (B) after a delay that the surgeons as representing an iais appropriate to the time required for trogenic arteriovenous jistula. Aorretrograde pulse wave transmission from the right ventricle. A small c tography was therefore performed wave is still visible and a sharp deep y to establish the exact location of the descent is present. Pulsed Doppler sigpostulated fistula but none was nals recorded over.the liver (C) and demonstrated.Still suspecting a jLsthe knee varix (0) show reversed sy* tula, the surgeonsproceeded to extolic low-velocity venous flow toward the transducer and away from the plore the femoral artery at the time heart (arrows) ~multaneously with the of the scheduled hysterectomy,and systolic pulsation (v) recorded on the futilely extended the exploration venous pulse recordings. This is then
S
of Cardiology, Surgery 4 andYRadiology, Meir General Hospital, Sapir Medical Center, Kfar Saba 44281, Israel; and the Sackler Medical School, University of Tel-Aviv, Tel-Aviv, Israel. Manuscript received June 11, 1992; revised manuscript received and accepted August 21, 1992. From the Departments
622
FIGURE 1. Varicosities extending along the saphenous vein system to (and below) the right knee where a large, tortuous varix is present (arrows).
THE AMERICANJOURNALOF CARDIOLOGY VOLUME71
followed (C) by diastolic flow toward the heart (open arrowb). CC = closing click of the StarPEdwards valve; EC0 q electrocardiogram; CC q opening click; PR q phonocardiogram; VPR = indirect venous pulse pressure recorck ings obtained over the liver and the patellar varix.
versed flow signals also were the onset of pressure pulsations and recorded by pulsed Doppler over Doppler signals in the venous vat-ix the liver (Figure 28) and over the was in keeping with the time needlarge knee varix (Figure 20). The ed for retrograde transmission of time delay from the QRS complex to venous blood from the right ventri-
RGURE 3. A, continuous Doppler (DGP) recording across the tricuspid valve (lR) (arrows) with a peak velocity of 2.5 m/s (giving a peak instantaneous pressure gradient of 25 mm lig by the simplified Bernoulli equation). Simultaneous venous pulse recordings (VPR) of the jugular veins show large systolic Y waves, the “re gurgitant wave” (RW) described by Luisznla et aL4 5, Mmode echocardiogram of the inferior vena cava (IVC) shows systolic expansion (a~~ow/reads~. Other abbreviations as in Figure 2.
cle to the knee.4” The deep veins were patent and without evidenceof obstruction when examined with a 7.5 MHz high resolution transducer using an Aloka 650 system.The tortuosity of the knee varix was easily demonstrable (Figure 4) and a striking high-velocity systolic jet of 1.3’8 mls was recorded over it (Figure 4B, bottom). Previous case reports have discussed the occurrence of prominent peripheral varicose pulsations and even bruits or murmurs associated with severe TR.‘“T~ The indirect pulse tracings recorded in our case are quite typical of those described in severeTR,4,6as is the systolic reversal of flow seen in the hepatic veins and below. To our knowledge, the recording of reversed flow signals as far as the knee varicosities has not been previously reported, and serves to graphically illustrate the far reaching manifestations of severeTR, and, in this case, its adverse influence on healing of the foot ulcer. As attested by this report, the temptation to attribute local pulsations to local causespersists among the surgical community.2,3 This temptation is even greater when the varicose veins are unilateral and combine with the fortuitous pressence of an old surgical scar just proximal to the varicose pulsations, as was the case in this patient. This report should serve as a timely reminder that severeTR may be associated with impressive venous pulsations that may appear to be arterial in origin to the untrained eye and the unsuspectingmind. REFERENCES
PlGURE 4. A, 3 separate convolutions of the varix are visualized (arrows). 6, Doppler examination records a relatively himvelocity (VEL) jet of 1.35 m/s (fu+ tom tracing) in the varix (arrows). WP q Doppler signals.
1. Brickner PW, Scudda WT, W&rib M. Pulsating varicose veins in functional tricuspid insufficiency. Case report and venous pressure tracing. Circulation 1962;25:12f%l29. 2. Blacken RL, Heard GE. Pulsatile varicose veins. Br J Surg 1988;75:865. 3. Hollins GW, Engeset .I. Pulsatile varicose veins associated with tricuspid regurgitation [letter]. Br J Surg 1989;76:207. 4. Luisada AA, Singhal A, Robles R. Diagnosis of tricuspid insufficiency by noninvasive methods. Angiology 1984,35:139-147. 5. Amidi M, Irwin .JM, Salemi R, Lavine S, Zubabubler JR, Shaver JA, Leon DF. Venous systolic thrill and murmur in the neck: a consequence of severe ticuspid insufficiency. J Am CON Cardiol 1986;4:942945. 6. Scheck-Krejca H, Zijlstra F, Roelandt J, VlettmMcGhie J. Diagnosis of tricuspid regurgitation: cmparison of jugular venous and liver pulse tracings with combined two-dimensional and Doppler echocadiography. Eur Heart J 1986;7:973-978.
CASE REPORTS 623
80~797-803. 7. Winkle RA, Mead RH, Ruder MA, Smith NA, Buch WS, Gaudiani VA. Effect of duration of “enhicula fibrillation on defibrillation efficacy in humans. Circulation 1990$1:1477-1481. 8. Nademanee K. Refractory ventricular fibrillation in the electrophysiology laboratory: a nightmare from which we can awaken. J Am CoN Cardiol 1991;lS: 1285-1286. 9. Lmnan BB, Dale OC. Effect of epicardial patch
Unilateral Pulsatile Varicose Wns Tricuspid Regurgitation
electrodes on transtboracic defibiillation. Circulation 1990;81:1409-1414. 10. Walls JT, Schuder JC, Curtis JJ, Stephenson HE, McDaniel WC, Flaker GC. Adverse effects of permanent cardiac internal defibrillator patches on external defibrillation. Am J Cardiol 1989;64:1144-1147. 11. Ideker RE, Wolf PD, Alfemess C, Krassowska w, smith WM. cmmlt COnceDtSfor selectilx the location, size, and shape of defibrillation electrode. PACE 1991;14:227-240.
from
tolic pressure gradient of 25 mm Hg across the thickened tricuspid valve (Figure 3A). The right atrium and Herman 0. klein, MD, Dov Shachor, MD, Nina Schneider, MD, and Daniel ventricle were dilated; the inferior vena cava was dilated (2.7 cm) and David, MD, with the technical assistance of Osnat Sharoni expanded in systole (Figure 3B). evere tricuspid regurgitation proximally to the aortic btfurcation Color Doppler echocardiography (TR) has occasionally been without jmding any fistulous com- with the transducer placed over the known to lead to marked pnlsatility munication. liver documented the systolic reverThe sounds of the Starr-Edwards sal offlow toward the hepatic veins of varicose veins.‘” We present an unusual case in which the presence valve were normal. A 216 systolic (not shown) typical of TR. Thesereof unilateral venous varicosities in murmur that increased on deep inonly the right leg caused the ap- spiration was heard at the lower left pearanceof unilateral pulsations. sternal border. A rocking precordial A 70-year-old woman was eval- motion signalling severe TR was uated by the gynecologic servicefor present, accompanied by prominent metrorrhagia. The uterus was nor- systolic regurgitant v waves4 over mal in size; diagnostic curettage re- the jugular veins and the liver (Figvealed moderately dtrerentiated en- ures 2A and 3A). The true origin of dometrial adenocarcinoma and hys- the varicose vein pulsations was terectomy was planned. Fifteen thus jmally established when the years previously, mitral valve re- typical findings of TR were delinplacement had been pelformed for eated and the regurgitant waves mitral stenosis. traced in continuity down to the Prominent pulsatile varicose varices over the patella (Figure 2B). Two-dimensional and Doppler veins, which extendedfrom the right inguinal area where a surgical scar echocardiography (Aloka 870 syswas present (at the site of car- tem) showed severe TR with a sysdiopulmonary bypass 15 years previously) and down the entire saphenous vein system, including a large cavernous varix overlying the patella (Figure 1) were noted. A large, chronic, poorly healing superficial ulcer was present over the dorsum RGURE i. Venous puke recordings show mart+ systolic pulsations (v of the foot. These unilateral variwaves) over the liver (A) and over the cose pulsations were interpreted by large knee varix (B) after a delay that the surgeons as representing an iais appropriate to the time required for trogenic arteriovenous jistula. Aorretrograde pulse wave transmission from the right ventricle. A small c tography was therefore performed wave is still visible and a sharp deep y to establish the exact location of the descent is present. Pulsed Doppler sigpostulated fistula but none was nals recorded over.the liver (C) and demonstrated.Still suspecting a jLsthe knee varix (0) show reversed sy* tula, the surgeonsproceeded to extolic low-velocity venous flow toward the transducer and away from the plore the femoral artery at the time heart (arrows) ~multaneously with the of the scheduled hysterectomy,and systolic pulsation (v) recorded on the futilely extended the exploration venous pulse recordings. This is then
S
of Cardiology, Surgery 4 andYRadiology, Meir General Hospital, Sapir Medical Center, Kfar Saba 44281, Israel; and the Sackler Medical School, University of Tel-Aviv, Tel-Aviv, Israel. Manuscript received June 11, 1992; revised manuscript received and accepted August 21, 1992. From the Departments
622
FIGURE 1. Varicosities extending along the saphenous vein system to (and below) the right knee where a large, tortuous varix is present (arrows).
THE AMERICANJOURNALOF CARDIOLOGY VOLUME71
followed (C) by diastolic flow toward the heart (open arrowb). CC = closing click of the StarPEdwards valve; EC0 q electrocardiogram; CC q opening click; PR q phonocardiogram; VPR = indirect venous pulse pressure recorck ings obtained over the liver and the patellar varix.
versed flow signals also were the onset of pressure pulsations and recorded by pulsed Doppler over Doppler signals in the venous vat-ix the liver (Figure 28) and over the was in keeping with the time needlarge knee varix (Figure 20). The ed for retrograde transmission of time delay from the QRS complex to venous blood from the right ventri-
RGURE 3. A, continuous Doppler (DGP) recording across the tricuspid valve (lR) (arrows) with a peak velocity of 2.5 m/s (giving a peak instantaneous pressure gradient of 25 mm lig by the simplified Bernoulli equation). Simultaneous venous pulse recordings (VPR) of the jugular veins show large systolic Y waves, the “re gurgitant wave” (RW) described by Luisznla et aL4 5, Mmode echocardiogram of the inferior vena cava (IVC) shows systolic expansion (a~~ow/reads~. Other abbreviations as in Figure 2.
cle to the knee.4” The deep veins were patent and without evidenceof obstruction when examined with a 7.5 MHz high resolution transducer using an Aloka 650 system.The tortuosity of the knee varix was easily demonstrable (Figure 4) and a striking high-velocity systolic jet of 1.3’8 mls was recorded over it (Figure 4B, bottom). Previous case reports have discussed the occurrence of prominent peripheral varicose pulsations and even bruits or murmurs associated with severe TR.‘“T~ The indirect pulse tracings recorded in our case are quite typical of those described in severeTR,4,6as is the systolic reversal of flow seen in the hepatic veins and below. To our knowledge, the recording of reversed flow signals as far as the knee varicosities has not been previously reported, and serves to graphically illustrate the far reaching manifestations of severeTR, and, in this case, its adverse influence on healing of the foot ulcer. As attested by this report, the temptation to attribute local pulsations to local causespersists among the surgical community.2,3 This temptation is even greater when the varicose veins are unilateral and combine with the fortuitous pressence of an old surgical scar just proximal to the varicose pulsations, as was the case in this patient. This report should serve as a timely reminder that severeTR may be associated with impressive venous pulsations that may appear to be arterial in origin to the untrained eye and the unsuspectingmind. REFERENCES
PlGURE 4. A, 3 separate convolutions of the varix are visualized (arrows). 6, Doppler examination records a relatively himvelocity (VEL) jet of 1.35 m/s (fu+ tom tracing) in the varix (arrows). WP q Doppler signals.
1. Brickner PW, Scudda WT, W&rib M. Pulsating varicose veins in functional tricuspid insufficiency. Case report and venous pressure tracing. Circulation 1962;25:12f%l29. 2. Blacken RL, Heard GE. Pulsatile varicose veins. Br J Surg 1988;75:865. 3. Hollins GW, Engeset .I. Pulsatile varicose veins associated with tricuspid regurgitation [letter]. Br J Surg 1989;76:207. 4. Luisada AA, Singhal A, Robles R. Diagnosis of tricuspid insufficiency by noninvasive methods. Angiology 1984,35:139-147. 5. Amidi M, Irwin .JM, Salemi R, Lavine S, Zubabubler JR, Shaver JA, Leon DF. Venous systolic thrill and murmur in the neck: a consequence of severe ticuspid insufficiency. J Am CON Cardiol 1986;4:942945. 6. Scheck-Krejca H, Zijlstra F, Roelandt J, VlettmMcGhie J. Diagnosis of tricuspid regurgitation: cmparison of jugular venous and liver pulse tracings with combined two-dimensional and Doppler echocadiography. Eur Heart J 1986;7:973-978.
CASE REPORTS 623