Pulsations of the Liver in Heart Disease* HOMOHONo B . CALLEJA, M .D .,
F. ROSENOW, Columbus, Ohio
HE clinical significance of a pulsating liver was emphasized by Mackenzie  in 1902 in relation to tricuspid stenosis . He thought that a presystolic pulsation of the liver was diagnostic of tricuspid stenosis . Subsequently, Turnbull and Weil  in 1911 recorded a trial liver pulsations in an eighteen year old patient with left-sided rheumatic lesion involving the mitral and aortic valves alone . In 1950 Grishman et al .  documented presystolic pulsations of the liver in patients with heart disease but with no tricuspid valvular lesion . The present report illustrates hepatic pulse tracings in eight patients with heart disease . These patients have (1) tricuspid stenosis, (2) tricuspid incompetence with stenosis, (3) Ebstein's anomaly, (4) cor pulmonale due to multiple pulmonary infarction, (5) pericardial effusion, (6) constrictive pericarditis, (7) atrial
M .D .
THOMAS E . CLARK, M .D .
septal defect and (8) myocarditis . The first three patients have tricuspid valve lesions and the last five are free from organic tricuspid valvular involvement .
METHOD OF RECORDING LIVER PULSATIONS Hepatic tracings were taken using a pulse wave attachment connected to the AC input jack of the general purpose amplifier of a Sanborn Twin Beam Cardiette . A funnel type cup was fitted to the other end of the pulse wave attachment . The cup was held over the liver area with a steady pressure . Care was taken to place the cup lateral to the right mid-clavic ular line to avoid epigastric pulsations transmitted from the right ventricle or abdominal aorta . A phonocardiogram was taken simultaneously for the purpose of timing the hepatic pulsations . In older patients, respiratory movements were minimized by taking the tracing during a temporary pause in inspiration or expiration . NORMAL HEPATIC PULSE
The normal liver pulse consists of an "a" and a "v" wave . (Fig . 1 .) The "a" wave is due to atrial contraction . During ventricular systole the normal hepatic pulse has a negative wave called "systolic collapse ." This is apparently due to a decrease in liver volume as the hepatic veins empty into the inferior vena cava during ventricular contraction . The "v" wave occurs in early diastole and represents increase in hepatic volume . The "a" and "v" waves occur 0 .02 and 0 .004 second later than the corresponding waves in the jugular pulse . The "c" wave normally found in jugular and in atrial pulse tracings is absent . According to Mackenzie the "c" wave of the jugular pulse is due to carotid pulsation . Grishman et al .  believe the impact of aortic pulsation on the superior vena cava during cardiac systole accounts for the "c" wave in the jugular pulse . The "c" wave in the atrial pulse tracing is attributed to the ballooning of the A-V valves into the atrium during ventricular systole .
a VIN WS PULSE ^ v LIVER PULE E
%\ ~ \,
Fin . 1 . Schematic drawing of the hepatic pulse in relation to the phonocardiogram, electrocardiogram, and the venous pulse .
* From the Cardiological Department, White Cross Hospital, Columbus, Ohio . t Fellow of the Central Ohio Heart Association in Clinical Cardiology, White Cross Hospital . Present address : Manila, Philippines . 202
AMERICAN JOURNAL OF MI' .DTCINE
Liver Pulsations in Heart Disease -Galleja et al .
Tic . 2 . 'T all atrial (a) wave . Note the peak and the downstroke of (a) occur before the stain vibration of the first (1st) sound . There is normal systolic collapse . (sm) systolic murmur . CASE REPORTS CASE I . A three month old boy had intermittent cyanosis and a pulsating liver . There was no evidence of congestive heart failure . The electrocardiogram showed left axis deviation and left ventricular preponderance for age . The chest roentgenogram showed a "square-shaped" heart with a normal transverse diameter . The diagnosis of tricuspid stenosis was confirmed by eineangiocardiography . A hepatic pulse tracing showed a huge "a" wave occurring before the onset of the first sound . (Fig . 2 .) CASE ii . A fifty-six year old man with known rheumatic aortic stenosis was in severe congestive heart failure with 4 plus pitting pedal and pretibial edema and questionable ascites . The liver remained palpable and was noticed to pulsate despite improvement from congestive heart failure . The hepatic pulse tracing showed a systolic wave "en plateau" with a delayed and gradual rise and fall, occurring during ventricular systole . (Fig . 3 .) CASE in . An eighteen month old boy had cyanosis since the age of twelve months . The. liver was enlarged and pulsated . A quadruple rhythm was present . The electrocardiogram showed incomplete right bundle branch block with slurring of lead Win lead V, and a borderline prolongation of the P-R interval for age
IV FIR" AKl 1961
and rate . In the chest roentgenogram the heart was enlarged and the pulmonary vascularity was diminished . A hepatic pulse tracing showed a call "a" wave occurring before the onset of the first sound . (Fig . 4 .) CASE iv . An eight year old buy had had recurrent pulmonary emboli in the past year . The second pulmonic sound was loud, split and palpable . The liver was palpable and pulsated . There was no evidence of congestive heart failure . The electrocardiogram showed right ventricular hypertrophy . The chest roentgenogram revealed a prominent pulmonary courts, enlarged right ventricle, and soft infiltrate in both right and left upper lung fields . A prominent "a" wave was seen in the hepatic pulse tracing . (Fig . 5 .) Autopsy findings confirmed the clinical diagnosis of pulmonary infarction and right ventricular hypertrophy. CASE v . A five year old boy was admitted with fever and dyspnea. The liver was palpable with questionable pulsation. Congestive heart failure was absent. 'The electrocardiogram was diagnostic of acute pericarditis . The chest roentgenogram showed an enlarged cardiac silhouette with probable pericardial effusion . Pericardial tap produced 50 cc . of serosanguinous fluid . Culture of the pericardial fluid grew Salmonella choleraesuis . The hepatic tracing
Liver Pulsations in Heart Disease-Calleja et al.
Ftc . 3 . Arrows indicate the systolic wave "en plateau ." Note the delayed onset and the gradual rise and fall durin whole of systole . There is no atrial wave . Atrial fibrillation is present . Compare with Figure 2 .
Large atrial (a) wave . The peak occurs before the first (1st) sound . The phonocardiogram shows double atrial sound (3) and (4) . FIO . 4 .
AMERICAN JOIIRVAL OF MEDIOINR
Liver Pulsations in Heart Disease- Calleja et al .
Fto . 5 . Prominent atria) (a) wave. Compare with Figures 2 and 4 .
Fin . 6 . Top, atrial (a) wave is not as tall as in Figures 2, 4 and 5 but still quite prominent . "P" represents an early systolic wave "en plateau ." Functional tricuspid incompetence is present . Undulation of the baseline is due to respiration . Fm . 7 . Middle, note similarity of this tracing with Figure 6 above . The phonocardiogram shows an early diastolic sound (EDS) . This tracing was taken before pericardectomy . Bottom, Tracing taken one month after pericardectomy . Normal (a) wave and no systolic wave "en plateau ." The early diastolic sound is absent . showed tall "a" wave with early systolic wave "en plateau ." (Fig . 6 .) CASE vi . A fourteen year old girl complained of exertional dyspnea . The liver was not palpable . There was no evidence of congestive heart failure . The chest roentgenogram showed pericardial calcification . The hepatic pulse tracing demonstrated increased "a" wave and an early systolic wave "en plateau ." The patient had an uneventful pericardiectomy. One month later another liver pulse tracing was taken which showed normal "a" and "v" waves . (Fig . 7 .) FEBRUARY 1961
CASE vu . A four year old girl had a heart murmur since birth . A prominent "a" wave was seen in the jugular veins . The second pulmonic sound was widely split and accentuated . The liver was not palpable . There was no congestive heart failure . The electrocardiogram showed incomplete right bundle branch block . The chest roentgenogram revealed increased pulmonary vascularity and some degree of cardiac enlargement . The hepatic pulse tracing showed a tall "a" wave . (Fig . g.) A large atrial septal defect measuring about 2 by 3 cm . was found at surgery . CASE vctt. A three year old boy was admitted in
Liver Pulsatiolzs in Heart Disease
Calleja e( al .
Upper, jugular pulse tracing . Note a, c, and v waves . Lower, hepatic pulse tracing : Atrial (a) wave is prominent . Undulation of the baseline is due to respiration . FIG . 8 .
to . 9 . Tall atrial (a) wave. The peak and downstroke of (a) occur with the first (1st) sound and early systole. "P" represents an early systolic wave "en plateau" fused with the (a) wave. Functional tricuspid incompetence is present . Compare with Figures 2, 4, 5, 6 and 7 . severe congestive heart failure . The liver was palpable with questionable pulsations . The electrocardiogram showed S-T and T changes consistent with myocarditis . The chest roentgenogram showed hilar congestion and an enlarged heart . The etiology of the myocarditis remains unknown . A huge "a" wave fused with an early systolic wave was present in the hepatic pulse tracing. (Fig . 9 .) COMMENTS
Abnormal pulsations of the liver are either presystolic (atrial) or systolic in time in relation to the cardiac cycle . The accentuation of the normal "a" wave gives rise to a large presystolic or atrial liver pulse . With a normal sinus rhythm the term "presystolic" is correct . When the atria and the ventricles contract simultaneously or
almost simultaneously, as in certain types of arrhythmias, the "a" wave of the hepatic pulse may occur during ventricular systole . In the presence of atrial fibrillation, a situation in which an effective and strong atrial contraction is wanting, the "a" wave is absent . For these reasons, "atrial" is preferable to "presystolic" in describing the "a" wave of the hepatic pulse . A positive systolic wave in the liver pulse is always abnormal . It represents tricuspid incompetence if an "a" wave produced by an arrhythemia is excluded . This positive wave is called systolic wave "en plateau ." It is due to retrograde transmission of a pulse wave resulting from right ventricular contraction . The extra load on the right atrium and the great veins provided by AMERICAN JOURNAL OF MEDICINE
I .ivci Pulsatioun ill Hcait lliseasc the regurgitant blood may be an additional factor in the genesis of this wave . AtrialPulsations . Conditions producing prominent atrial pulsation of the liver may be due to systolic or to diastolic overloading of the right atrium or both . (Table 1 .) The entrance of both superior and inferior venae cavae into the right atrium is not protected by any competent valve structure . Refiux of dye into the great veins during the rapid injection of dye into the right atrium is commonly seen in angiocardiograms or cineangiocardiograms . The retrograde transmission of the pressure wave from a strong right atrial contraction (or from the contraction of the left atrium transmitted through an atrial septal defect) down the inferior vena cava to the liver produces the prominent "a" wave in these conditions. Clinically, anatomic obstruction to right atrial outflow is seen in congenital tricuspid atresia in its complete form . An atrial septal defect must exist to sustain life . Partial obstruction is found in tricuspid stenosis, commonly acquired and rarely congenital (Case I) . Usually acquired tricuspid stenosis is part of a multivalvular rheumatic involvement . Differentiation between congenital tricuspid stenosis and atresia is now possible during life by cineangiocardiography ]4] . Since both these conditions show prominent "a" waves, the hepatic tracing adds no further help in the differential diagnosis . However, a hepatic pulse tracing may be helpful in ruling out congenital tricuspid incompetence . Certain disturbances in cardiac rhythm give rise to a prominent "a" wave in thejugular pulse as well as in the hepatic pulse tracing . Examples of such arrhythemias are complete A-V block or A-V dissociation, atrial flutter or atrial tachycardia with A-V block, double tachvcardias and some types of nodal rhythm . Large "a" waves are produced when atrial contraction occurs simultaneously with ventricular systole . In this instance the A-V valves are closed temporarily because of ventricular contraction . The force of atrial contraction therefore can he propagated only retrograde to the jugulars and to the liver . In pure pulmonic stenosis (ventricular septum intact) prominent "a" waves are commonly seen in the jugular pulse . In fact if pulmonary stenosis is suspected and no prominent "a" wave is visible in the jugular vein an associated ventricular septal defect must he considered . FEURUARY
Calleja el a! .
rAELE I CONDITIONS PRODUCING INCREASED ATRIAL LIVER PULSATIONS
Systolic overloading of the right atrium A . Obstruction to right atrial outflow 1 . Anatomic Tricuspid atresia-congenital Tricuspid stenosis-acquired or congenital 2 . Physiologic Disturbances of rhythm -complete A-V block, etc. B . Obstruction to right ventricular outflow 1 . Pulmonary artery atresia--congenital Pulmonic stenosis -valvular, infundibular or both 2. Pulmonary hypertension-primary or secondary C . Restriction of right ventricular filling 1 . Pericardial effusion, constrictive pericarditis 2 . Ebstein's anomaly n . Diastolic overloading of the right atrium A . Left to right shunt at the atrial level-atrial septal defect, patent foramen ovate . Lutembacher syndrome, rupture of sinus of Valsalva into the right atrium anomalous pulmonary veins In . Combination of I and n A . Congestive heart failure complicating conditions in land ii B . Primary myocardial disease with congestive heart failure 1 . Myocarditis-specific or non-specific I.
Right ventricular pressure is increased in pulmonary stenosis and pulmonary hypertension (Case iv) . This increase in right ventricular pressure raises the resistance to outflow of the right atrium . Figure 10 shows a jugular pulse tracing in a patient with pure pulmonic stenosis . Catheterization data did not reveal any evidence of a shunt . The diastolic filling of the right ventricle is restricted in pericardial effusion (Case v) and in constrictive pericarditis (Case vi) . It is possible that extracardiac masses pressing on the ventricular chambers may produce the same effect . The third sound called "protodiastolic knock" heard in some cases of constrictive pericarditis has been related to the early diastolic check to ventricular filling by the calcified pericardial shell . The third heart sound coincides with the early diastolic dip in a ventricular pressure tracing . Figure 6 shows the third sound in the phonocardiogram above the hepatic pulse curve before operation . After pericardiectomy the third sound disappeared and the hepatic pulse tracing returned to normal . Ebstein's anomaly (Case 3) presents an interesting congenital malformation of the tricuspid valve . The anterior and posterior leaflets are
Liver Pulsations in Heart Disease--Calleja et al .
FIG . 10 . Jugular pulse tracing : Tall atrial (a) wave . The phonocardiogram shows a systolic murmur (sm) termination clearly before the pulmonic (P) component of the second sound . (A) aortic component of the second sound .
fused and displaced downward into the cavity of the right ventricle . The right atrium becomes greatly enlarged at the expense of the right ventricular chamber . Frequently there is an associated atrial septal defect or a patent foramen ovale . The reduction in size of the cavity of the right ventricle limits ventricular filling in this condition . The shunt at the atrial level may he bidirectional, hence the absence of cyanosis does not rule out the diagnosis of Ebstein's anomaly . Diastolic overloading of the right atrium as a result of a left to right shunt at the atrial level (Case vii) increases the work load of the right atrium . This produces a strong atrial contraction . Myocardial weakness due to myocarditis (Case vnt) imposes a condition of relative diastolic overloading of the ventricles . The right ventricle, being the weaker ventricle, may fail earlier than the left . The decreased output of the former may spare the latter . When right ventricular failure develops, the end diastolic pressure in the right ventricle becomes elevated and the right atrial pressure also rises . In combined left and right ventricular failure the situation is more complex . A combination of
factors, including increase in circulating blood volume, may be at work . Half of the patients reported by Grishman et al .  were in congestive heart failure of moderate to severe degree . In this report severe congestive heart failure was present in Cases n and vin . Systolic Pulsations. Systolic pulsation of the liver is classically found in tricuspid incompetence, functional or organic . Lottenhach and Shillingford  have verified tricuspid incompetence at autopsy in ten patients with congestive heart failure whose mean venous pressure during life was greater than 8 mm . Hg . They postulated that tricuspid incompetence was produced first, by the dilated right ventricle pulling down the chordae attached to the edge of the valve, and second by the general dilatation of the valve ring . According to Hellman  the tricuspid valve is anatomically prone to incompetence in comparison with the mitral valve . It is probably true that functional tricuspid incompetence does occur in most cases of frank congestive heart failure . Organic tricuspid incompetence is usually due to rheumatic valvulitis . Incompetence almost always accompanies rheumatic tricuspid AMERICAN JOURNAL OF MEDICINE
Liver Pulsations in Heart Disease-Calleja et al .
Fta . 11 . Top and middle arejugular pulse tracings taken at 25 mm . and 75 turn . per second, respectively . Bottom, hepatic pulse tracing taken at 25 nit. . per second . Arrows indicate systolic wave "en plateau ." Aerial wave (a) is present . Compare with Figure 3 . (See text.) stenosis (Case n) . Congenital tricuspid incompetence is rare  . Both organic and functional tricuspid incompetence are characterized by a systolic wave "en plateau" in the hepatic pulse tracing . The differentiation between the two may prove difficult at times . Usually in functional tricuspid incompetence the plateau wave comes early in systole ; it may fuse with the downstroke of the "a" wave . In organic tricuspid incornpetence the "en plateau" wave has a delayed onset with a gradual rise and fall . The reason for this is the fact that acquired organic tricuspid incompetence usually accompanies stenosis of the valve as well . Figure 3 shows the hepatic FEBRUARY 1961
pulse tracing obtained in Case n . Typically, the plateau wave is delayed in onset ; the rise is gradual and the fall is slow . Recently, Terry  described a new physical sign in tricuspid incompetence called "coupled hepatic pulsation ." He found that ventricular extrasystoles may be helpful in distinguishing intrinsic hepatic pulsations due to tricuspid incompetence from hepatic pulsations transmitted from the abdominal aorta . By holding one hand over the liver and the other over a peripheral artery one will notice that in the presence of a ventricular extrasystole no pulse will he felt in the peripheral artery . However, a pulsation will be felt over the liver if tricuspid
Liver Pulsations in Heart Disease-Galleja et al .
incompetence exists . This sign becomes more obvious in coupled rhythm due to ventricular extrasystoles . Correct timing of hepatic pulsations may be difficult by palpation and/or inspection alone . In the presence of a tachycardia the difficulty is magnified . In addition, the weaker atrial (presystolic) pulsation may not be appreciated by the palpating hand as a pulse wave separate from the usually stronger systolic pulsation, even with a normal sinus rhythm . In atrial fibrillation the "a" wave is absent and the systolic wave "en plateau" becomes more pronounced because tricuspid incompetence is increased . In Figure 3 the "a" wave is absent because the tracing was taken when the patient was in atrial fibrillation . Figure 11 is a tracing obtained from another patient with tricuspid stenosis with incompetence . Sinus rhythm and the "a" wave are present . Again the systolic wave "en plateau" is delayed in onset . By taking a hepatic pulse tracing, timing of liver pulsations is rendered easy and accurate . Recent advances in tricuspid valve surgery [9,10] have made correct timing of hepatic pulsations of more than academic interest . Consideration of a patient for possible surgery
of the tricuspid valve demands precise diagnosis of the valvular lesion-stenosis, incompetence, or both . In this regard, a hepatic pulse tracing may be helpful in corroborating the findings in the catheterization of the right heart and in cineangiocardiography  . A palpable liver is one of the cardinal signs of congestive heart failure . Mechanical obstruction to venous return of the right heart, as found in tricuspid valvular disease and in pericarditis, may produce hepatic enlargement with or without palpable or visible pulsation, edema or ascites in the absence of actual failure of the myocardium . Experimental studies [11,12] have demonstrated increased secretion of aldosterone in dogs with thoracic inferior vena cava constriction . An increase in aldosterone secretion may well be a factor in the production of liver engorgement, edema and ascites in tricuspid and pericardial disease . It is clinically important that the mere presence of these signs should not be construed hurriedly as evidence of congestive
heart failure and, therefore, an indication for digitalization . Conversely, in a patient (usually a female) with known rheumatic heart disease involving the mitral and/or aortic valve, persistence of signs of right-sided heart failure should call attention to tricuspid valvular involvement . SUMMARY
The clinical importance of pulsations of the liver in different heart conditions is summarized and the pathogenesis of these pulsations is explained . Eight case reports illustrating abnormal liver pulsations are presented . The value of correct timing of liver pulsations by taking hepatic pulse tracings is emphasized in the light of recent advances in tricuspid valve surgery REFERENCES
1 . MACKENZIE, J . Quoted by TURNBULL, H . H. and WEIL, H . T . 2 . TURNRm.L, H . H, and WELL, H. T . The auricular form of liver pulsation and its relation to tricuspid stenosis . Heart . 3 : 243, 1911 .p 3 . GRISHMAN, A., KRooP . 1 . G ., STEINBERG . M . F. and DACK, S . Presystolic pulsations of the liver in the absence of tricuspid disease. Am . Heart J., 40 : 731, 1950 . 4. CALLEJA, H . B., HosIER, D. M . and KISSASE, R . W . Congenital tricuspid stenosis : the diagnostic value of cineangiocardiography and hepatic pulse tracing . Am . ,I. Cordial ., in press . 5 . LorraNaACH, C . and SHTLLINGFORD, J . Functional tricuspid incompetence in relation to the venous pressure . Brit. Heart J., 19 : 395, 1957 . 6 . HELLMAN, A. The anatomical appearance of rheumatic tricuspid valve disease . Brit. Heart J., 19 : 211, 1957 . 7, BARRITT, D . W, and Untcri, H . Congenital tricuspid incompetence . Brit . Heart J., 18 : 133, 1956 . S . TERRY, R. B . Coupled hepatic pulsations in tricuspid incompetence . Am . Heart J., 57 : 158, 1959 . 9 . DERRA, E ., GRO5SE-BROCKHOFF, F . and LOGAN, F . Quoted by PYORALA, K . et al . Solitary tricuspid stenosis . Arta Cardiologica, 14 : 627, 1959 . 10. PANTRIDCE, J . F. and MARSHAI.r., R . J . Tricuspid stenosis, Lancet, 1 : 1319, 1957 . 11 . DAVIS, J . 0 ., PECHET, M . M., BALL, W. C. and GOODKIND, M . J . Increased aldosterone secretion in dogs with right-sided congestive heart failure and in dogs with thoracic inferior vena cava constriction. J. Clin . Invest ., 36 : 689, 1957 . 12 . DAVIS, J . C ., KLIMAN, B ., YANKOPOULos, N . A. and PETERSON, R . E . Increased aldosterone secretion following acute constriction of the inferior vena cava . J. Clin. Invest ., 37 : 1783, 1958 .
AMERICAN JOURNAL OF MEDICINE