Hepatic Pulsations in Tricuspid Insufficiency

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Adapted by: Jennifer Gue

In 1958 Dr. R. Barratt Terry described a physical sign to help determine whether palpable pulsation of the liver is due to tricuspid insufficiency, or to transmitted pulsations from the abdominal aorta.

The sign can be found in patients with sustained ventricular bigeminy.

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 insufficiency, such a ventricular extrasystole also fails to create an arterial pulsation or a second heart sound, but it does cause a visible 'CV' wave in the jugular veins.

If hepatic pulsation is due to transmitted pulsations from the abdominal aorta and there is no tricuspid insufficiency, an extrasystole that fails to produce an arterial pulsation will also fail to produce hepatic pulsation.

If the hepatic pulsation in a case of tricuspid insufficiency is transmitted from the abdominal aorta, the alternate ventricular extrasystoles will produce hepatic pulsation.

In a patient with tricuspid insufficiency in ventricular bigeminy:

Each normal systole results in:

Each ventricular extrasystole results in:

The examiner should 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. The stethoscope rests on the chest where the second heart sound can be heard.

If the marked jugular pulsation confuses palpation of the carotid pulsation, it may be easier to feel the brachial artery or the abdominal aorta. Simultaneous auscultation with the stethoscope resting on the precordium helps to confirm the occurrence and timing of the ventricular extrasystoles, as well as failure of the extrasystole to produce a second heart sound.

When ventricular extrasystoles produce pulsations in the liver without corresponding arterial pulsation, two hepatic pulsations will be felt for each arterial pulsation.

The persistent occurrence of two hepatic pulsations for each single arterial pulsation in the patient with bigeminy is a a useful physical sign.

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