Study of the Right Atrial Pressure Pulse in

Functional Tricuspid Regurgitation andNormal Sinus Rhythm

BY GEORGE A. RUBEIZ, M.D., MUNm E. NASSAfn, M.D.,AND IBRAHIM K. DAGHER, M.D.

IN spite of the loing interest in tricuspid valvedisease, review of the literature shows a

relatively small numl)er of reports about theincidence of functional trictuspid insuifficiency.Coelho 1 fouind tricuspid regurgitation in 20per cent of 620 patients with mitral valve dis-ease. Earlier, Mackenzie 2 and, later, Miillerand Shillingford 3 claimed that fu.nctional in-competence of the tricuspid valve appearsquite oftein, but organic incompetence is rare.4

Studies of the right atrial pressure-pulse inproved fuinctional tricuispid regurgitation andsinus rhythm are exceedingly scarce. Wood '

stated "good jugular or right atrial pressurepulse tracings in fuinctional tricuspid regurgi-tation and normal sinus rhythm are rare."

This paper presenits a study of the rightatrial pressure pulse in six patients havingfunctional tricuspid regurgitation and normalsinuis rhythm.

Materials and MethodsThis study was performed on six patien-ts with

rheumatic heart disease. Fouir were women andtwo were men. Their ages ranged between 16 and32 years. All were found to be in functional classIII.6 Twelve-lead electrocardiograms and completeroentgenoscopy and roentgenography were ob-tained. Phonocardiograms were recorded from theapex of the heart anid the fourth left intercostalspace with a Saniborn twini-beam phonocardio-graph (model 62). All the logarithmic phonocar-diograms were recorded during the inspiratory andthe expiratory phases of respiration. Five of the

From the Departmerut of Medicine and Surgery, andthe Cardiac Catheterization Laboratory of the Ameri-can University Hospital, American University of Beirut,Beirut, Lebanon.

Supported by Grant H-3671 from the National In-stitutes of Health, U. S. Puiblic Health Service, andGrant 61-G145 from the American Heart Association.

190

six patients had right lheart catheterizatioi by thetisual technic. The Haldane anid the Van Slyke anidNeill methods were ulsed for the gaseouis anialysisand for determination of oxygeni conitent in theblood, respectively. Cardiac ouitpuits were esti-mated according to Fick's prin-ciple. The zero ref-erenice point was takeni at the middle of the antero-posterior diameter of the chest. Pressures weremeasured by a Statham gage P23Gb manometeran.d xvere recorded oni ani Electroinics-for-Medicineapparatus.

All six patients hlad a right thoracotomy and theright atrial pressur-e-puilse tracings were obtainedwith a 20-gage nieedle, connected to the sameStatham gage and recording apparatus mentionedabove. This was followed by a digital explorationiof the tricuspid valve. Mitral commissurotomy wassuilbsequiently performed.

ResultsExamination of the six patients revealed a

regu.lar cardiac rlhythm anid the usual sigrns ofmitral stenosis. In all of the six patients a holo-systolic murmur, leard at the left lower sternalborder anid increasing in intenisity during in-spiration, vas confirmed by phoniocardiogram(fig. 1).

All electrocardiograms revealed a normal

Figure 1

Logarithmic phonocardiogram obtained at the leftlower sternal border showing the increase in the systolicmurmur withi inspiration (Insp.). 1, first hleart sound;2, second heart srond; SAL, systolic muirnmur; Exp.,expiration.

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RIGHT ATRIAL PRESSURE PULSE

Table 1

Restults of Right Cardiac Catheterization

RA

PAPC

cl

(L./min./M.2)PVR( dynes sec. )( cm.-5 )

S. 13.

m 386/0-3

86/45 m = 70ii 30

1.7

1360

E.A.

m = 381/0-3

81/34m 42in -262.36

PItitutTi.U.

m -3113 3

: 13/46 i- 78

352

miz.ni 7100/2-7

1.00/35 iii - 157 45/in - 35

2.8

429

RA, right atriuim; RV, right ventricle; PA, pulmoiiary arteiry; PC, paplmoiiiy capillary; CI, cairliae iud(lex; PVBI,pulmonary vascular resistance. Pressures are expressedi in mm. JIg.

Table 2

Right Atrial Pressure Pulse Components Expressedin tann. IIhg

4H1. nfl,

Patientw\ve S.13. E.A. II.11.

A 4 7 a

C 4v 0 4 3.3

M.Z. S.K. MN1.N.

12 12 8

12

8.4 6 6

The X (descent xx as leeper than the Y in all cases,except that in S.K. the X descent was equal to the Yde.Iscenit. In fouir catses the C wave xw as not identified.Patient MN.. had only tl-he right: atrial pressuire-puilsecolbtained at thoracotomy.

sinuls rhythm, atrial enlargemenlt, and rightventric011ar hypertroplhy. Results of the rightcardiac catheterization are presented in ta-ble 1.

Meas-urements of the different right atrialpressure-pulse components are fouind in ta-ble 2.The right atrial pressuire-pulse tracings re-

corded at surgery were found comparable tothose obtained at right lheart catheterizationi.The A wave was demnonstrated but the C wave

could be identified in only two cases. The Xdescent was well preserved. The V wave was

of normal configuiration and the Y descent was

not abrupt. The X descent was equal to the Yin one case but was deeper than the Y in theremaining five cases.

Examples of the right atrial pressure-pulsetracings obtained during right heart catheteri-zations and at tlhoracotomy are shown in fig-ures 2 and 3. At surgery, the right atriumn was

Circulation, Volauct XXX, Augit 1i964

Figure 2

1, righlt aItrial obtained in patient H.H.at righ,/t cardliac cathete rization. Ilihe X descent is well

preservedl. 2, the same ol)tained at thloracoton7nj.

LA

Figure 3

1, rig/ht atrial pr.es'sture-puilse obtained i11 patient E.A.at rig/it cardiac cathetr rizationt. T'lie X desentni is ivellprilKseo 2, the 5sa1 o)taiinedl (it f1ior,ae(,ototnil.

S.1K.

45/928 m 34

2.6

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RUBEIZ, NASSAR, DAGHER

found enlarged and digital exploration of thetricuspid valve performed on the six patientsrevealed moderate to severe tricuspid regurgi-tation. The regurgitant jet into the right atriumas assessed by the gloved finger remained allthrough the duration of ventricular systole.During ventricular systole, the tricuspid valveleaflets were found separated from each otherby a space measuring about 1 to 2 cm2. In allthese patients the leaflets of the tricuspid valvefelt normal and retained their pliability. Thecommissures were not fused, and the chordaetendineae were not shortened.

DiscussionGerhardt,7 in 1902, gave detailed descrip-

tions of the various forms of the positive sys-tolic wave seen in tricuspid incompetence.Later investigators including Mackenzie,2 Wig-gers,8 Bloomfield et al.,9 Little,10 Messer et al.,"1Muller and Shillingford,' Korner and Shilling-ford,'2 and Coelho l have all made similarobservations clinically and experimentally.

Messer et al.' noted the late occurrence ofthe S wave in systole in organic tricuspid re-gurgitation. Little '0 studied tricuspid insuffi-ciency with atrial fibrillation. He concludedthat the regurgitant jet of blood into the rightatrium is due to delayed closure of the atrio-ventricular cusps. Wood 5 pointed out the lackof accurate criteria for the diagnosis of func-tional tricuspid regurgitation, which as yethave to be firmly established, and also thescarcity of good jugular or right atrial pressure-pulse tracings in patients with proved func-tional tricuspid regurgitation and normal sinusrhythm.

In the six patients presented the diagnosisof functional tricuspid regurgitation was firmlyestablished by surgical exploration. The rightatrial pressure-pulse tracings at right heartcatheterization and at surgery were compa-rable. Furthermore, the tracings had a normalconfiguration. There was no exaggeration ofthe V waves in any of the curves. The X de-scent was well preserved. It became clear thatalthough there is unquestionable tricuspid in-competence in all six cases, the right atrial

pressure-pulse tracings were within normallimits.During ventricular systole, tricuspid regur-

gitation may alter the contour of the rightatrial pressure-pulse in either of two ways:impairment of the X descent and hence de-scent of the Y becomes more accentuated; ob-literation of the X descent by a positive systolicwave-the S wave.McMichael and Shillingford 13 found that

functional tricuspid incompetence often occursin congestive heart failure when the venouspressure is raised above 8 mm. Hg. Only oneof the six patients studied had a venous pres-sure of more than 8 mm. Hg.

Little's 14 in vivo and in vitro experimentscomparing the elastic properties of the rightand left atrium showed that for equal volumeincrements the walls of the right atrial systemis more distensible than the left. RecentlyBraunwald and Awe 1 reported the "syndromeof severe mitral regurgitation with normal leftatrial pressure," and they attributed the dis-crepancy between left atrial size and pressureto a disturbance in the compliance of the leftatrial wall. In seven of 10 patients studied theV-wave peaks were within normal limits butminimally elevated in only three patients.Thus the preservation of the right atrial pres-

sure-pulses in the cases studied here, in spiteof the presence of functional tricuspid regurgi-tation, is probably due to an increase in thecompliance of the walls of the right atrium andthe systemic veins.

In conclusion, the demonstration of a nor-mally preserved right atrial pressure-pulse inpatients with normal sinus rhythm does notexclude the presence of functional tricuspidregurgitation.

SummarySix patients having mitral stenosis, func-

tional tricuspid regurgitation, and normal sinusrhythm were studied.

All patients had a systolic murmur at thelower left sternal border that increased withinspiration. Five patients had right heart cath-eterization while all six had right atrial pres-sure-pulses obtained by direct puncture of the

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RIGHT ATRIAL PRESSURE PULSE

right atrium with a 20-gage needle during rightthoracotomy. Functional tricuspid regurgita-tion was proved by subsequent digital explora-tion of the tricuspid valve. The right atrialpressure pulses obtained were analyzed. Thecurves taken with the needle-puncture of theright atrium were comparable to those ob-tained at right heart catheterization. The Xdescent was well preserved in all six cases. Infive patients the X descent was deeper thanthe Y descent, while in only one patient wasthe X descent equal to the Y descent. Therewas no exaggeration of the V wave in any ofthe curves. The role played by the complianceof the right atrium in preserving the normalcontour of the right atrial curve, in spite oftricuspid regurgitation, is discussed.

It is concluded that in functional tricuspidregurgitation with normal rhythm the normallypreserved X descent followed by a normal Vwave may persist in the right atrial curve. Theapplication of this finding to the clinical studyof the jugular venous pulse in functional tri-cuspid regurgitation and normal rhythm isevident.

References1. COELHO, E.: Physiopathologic study (clinical and

experimental) of the tricuspid valve. Am. J.Cardiol. 3: 517, 1959.

2. MACKENZIE, J.: Diseases of the Heart. London,Oxford University Press, 1908. Quoted by Miil-ler, 0., and Shillingford, J. P.: Tricuspid incom-petence. Brit. Heart J. 16: 195, 1954.

3. MULLER, 0., AND SHILLINGFORD, J. P.: Tricuspidincompetence. Brit. Heart J. 16: 195, 1954.

4. SALAZAR, E., AND LEVINE, H. D.: Rheumatic tri-cuspid regurgitation. The clinical spectrum. Am.J. Med. 33: 111, 1962.

5. WOOD, P. H.: Diseases of the Heart and Circula-tion. Ed. 2. London, Eyre & Spottiswoode, 1959,pp. 583; 588.

6. New York Heart Association Nomenclature andCriteria for the Diagnosis of the Heart andBlood Vessels. Ed. 6. New York Heart Associa-tion, 1962.

7. GERHARDT, D.: Einige Beobachten an Venenpul-sen. Naunyn-Schmiedebergs Arch. exper. Path.u. Pharmakol. 47: 250, 1902.

8. WIGGERS, C. J.: Circulation in Health and Disease.Philadelphia, Lea & Febiger 1915, pp. 138; 313.

9. BLOOMFIELD, R. A., LAUSON, H. D., COURNAND,A., BREED, E. S., AND RICHARDS, D. W., JR.: Re-cording of right heart pressures in normal sub-jects and in patients with chronic pulmonarydisease and various types of cardio-circulatorydisease. J. Clin. Invest. 25: 639, 1946.

10. LITTLE, R. C.: The cardiodynamics of tricuspidinsufficiency. Proc. Soc. Exper. Biol. & Med. 68:602,1948.

11. MESSER, E. L., HURST, J. W., RAPPAPORT, B. M.,AND SPRAGUE, B. H.: A study of the venouspulse in tricuspid valve disease. Circulation 1:388,1950.

12. KORNER, P., AND SHILLINGFORD, T.: The rightatrial pulse in congestive heart failure. Brit.Heart J. 16: 447, 1954.

13. MCMICHAEL, J., AND SHILLINGFORD, J. P.: Role ofvalvular incompetence in heart failure. Brit. M.J. 1: 537,1957.

14. LITTLE, R. C.: Volume elastic properties of theright and left atrium. Am. J. Physiol. 158: 237,1948.

15. BRAUNWALD, E., AND AWE, W. C.: The syndromeof severe mitral regurgitation with normal leftatrial pressure. Circulation 27: 29, 1963.

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GEORGE A. RUBEIZ, MUNIR E. NASSAR and IBRAHIM K. DAGHERand Normal Sinus Rhythm

Study of the Right Atrial Pressure Pulse in Functional Tricuspid Regurgitation

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1964 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/01.CIR.30.2.190

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