Carvallo Sign of Tricuspid Insufficiency

The Carvallo sign is found during cardiac auscultation.

It is named after Mexican cardiologist José Manuel Rivero Carvallo.

He described an increase in the intensity of the systolic murmur of tricuspid insufficiency during inspiration. This distinguishes it from left sided murmurs such as mitral insufficiency, which do not change with respiration.

It may be difficult to hear the change in murmur intensity during normal respiration. In that case, auscultation is performed during postinspiratory apnea and the loudness of the systolic murmur is compared to its loudness during postexpiratory apnea.

The murmur of tricuspid insufficiency increases in intensity during held, deep inspiration. The murmur may also become higher pitched.

In contrast, the murmur of mitral insufficiency does not increase during held, deep inspiration. It may actually decrease in intensity. One explanation for the decreased intensity is the inspiratory interposition of the pulmonary appendage between the apex of the heart and the chest wall.

Rivero Carvallo JM
Signo para el diagnostico de las insuficiencias tricuspideas
Archivos del Instituto de Cardiologia de Mexico, Mexico, 1946, 16: 531.

Rivero Carvallo JM
Comunicacion a la Sociedad Mexicana de Cardiologia
August, 1946.

Am J Cardiol. 1981 Sep;48(3):578-83.
Intracardiac phonocardiography in tricuspid regurgitation: relation to clinical and angiographic findings.
Cha SD, Gooch AS, Maranhao V.

Intracardiac phonocardiograms were obtained from the right atrium in order to study the relation between the clinical signs of tricuspid regurgitation, intracardiac murmurs and the degree of regurgitation demonstrated on right ventriculography with use of a preshaped catheter. In five patients with no heart disease, right ventriculograms showed no evidence of tricuspid regurgitation and intracardiac phonocardiograms in the right atrium demonstrated no murmur. Among 35 patients with valvular heart disease, a Carvallo sign (increased intensity of systolic murmur during inspiration) was present in 19 and absent in 16. All 19 patients with a Carvallo sign had variable degrees of tricuspid regurgitation on right ventriculography, and intracardiac phonocardiograms were positive for tricuspid regurgitation in 18. Among 16 patients with an absent Carvallo sign, neither right ventriculography nor intracardiac phonocardiography was indicative of tricuspid regurgitation in 5. Five patients had 1+ regurgitation and the intracardiac phonocardiogram was positive in three of these five patients. The other six patients showed 3+ to 4+ regurgitation and the intracardiac phonocardiogram was positive for tricuspid regurgitation in all. In conclusion, (1) the Carvallo sign is a reliable indicator of tricuspid regurgitation but its absence does not rule it out, and (2) right ventriculography using a preshaped catheter and intracardiac phonocardiography are useful in detecting clinically unrecognized tricuspid regurgitation.

Clin Cardiol. 1984 May;7(5):299-306.
Chronic traumatic tricuspid insufficiency.
Sheikhzadeh A, Langbehn AF, Ghabusi P, Hakim C, Wendler G, Tarbiat S.

Isolated tricuspid insufficiency (TI) is relatively uncommon and mostly of traumatic origin. We report clinical noninvasive and invasive findings and surgical results in 5 cases. All patients had complete clinical, noninvasive and invasive studies including right and left catheterization, and coronary angiographies in 3 patients. All but 1 patient had nonpenetrating trauma. All had large jugular V waves, right precordial impulse, systolic liver pulse, positive Carvallo sign documented also by noninvasive techniques. Right heart failure was present in 3 patients. Chest x-ray showed prominent right atrium and distended vena cavae. Electrocardiogram showed normal sinus rhythm in 4 patients and atrial fibrillation in 1. Two patients had right bundle-branch block, and 2 presented RSR'-pattern. Echocardiogram showed large right atrium (RA) (6-10 cm), floppy tricuspid valve (TV) in all, dilated right ventricle (RV) in 2 patients. Findings of left heart were normal in all. Three patients had right-to-left shunt. In RA A waves were 4-8, Y waves 1-3, and V waves 12-22 mmHg, respectively (mean RV and PA pressures were 23/3 and 23/10 mmHg, respectively). Four patients had anuloplasty, 2 of them repair of valve and chordae. Surgical results were good in 2 patients with valve repair, satisfactory in 1; there was significant TI resistance in 1 case. We conclude that TI has distinctive clinical findings and must be ruled out in all patients with chest trauma. Surgery must include not only anuloplasty, but, cusps and chordae must also be evaluated and reconstructed if necessary.

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