Forgotten but Striking: Complete Tricuspid Valve Degeneration Unmasked by Lancisi’s Sign

Figures

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  Figure 1. Dynamic jugular venous distension during systole and diastole in severe TR Panel A shows an anterior view of the neck during diastole. The larger circle (blue arrow) identifies the external jugular vein, and the smaller oval (green arrow) identifies the anterior jugular vein, both demonstrating minimal venous distension. Panel B shows the same anterior view during systole. The larger circle (purple arrow) identifies the external jugular vein, and the smaller oval (red arrow) identifies the anterior jugular vein. Marked systolic distension of both veins is evident. Panel C shows a lateral view of the neck during diastole. The larger circle (blue arrow) identifies the external jugular vein, and the smaller circle (green arrow) identifies the anterior jugular vein, with only mild venous distension. Panel D shows the lateral view during systole. The larger circle (purple arrow) identifies the external jugular vein, and the smaller circle (red arrow) identifies the anterior jugular vein. Marked systolic distension of both veins is evident, consistent with giant c-v waves (Lancisi’s sign) secondary to severe TR. TR, tricuspid regurgitation

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  Figure 2. Lower-extremity manifestation of chronic right-sided heart failure Clinical photograph demonstrating bilateral lower-extremity edema, hyperpigmentation, and stasis dermatitis with scaling (red arrows), consistent with long-standing systemic venous hypertension secondary to severe TR and chronic right-sided heart failure. TR, tricuspid regurgitation

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  Figure 3. Chest radiograph showing cardiomegaly and pulmonary vascular congestion Portable anteroposterior chest radiograph obtained in the supine position, showing marked enlargement of the cardiac silhouette (red arrow), bilateral pulmonary vascular/interstitial congestion, and flattening of the diaphragms consistent with chronic hyperinflation (blue arrows). No focal air-space consolidation or pleural effusion is identified.

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  Figure 4. Echocardiographic findings in end-stage primary TR Panel A shows an apical four-chamber transthoracic echocardiogram with color Doppler demonstrating torrential TR. The red arrow highlights a broad systolic regurgitant jet extending from the right ventricle into the massively dilated right atrium. Panel B shows a parasternal short-axis view demonstrating severe right ventricular enlargement (red arrow). Panel C shows continuous-wave Doppler interrogation demonstrating a dense triangular regurgitant envelope with a peak velocity of 2.39 m/s (red arrow), consistent with severe TR and rapid right ventricular-right atrial pressure equalization during systole. TR, tricuspid regurgitation

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  Figure 5. Hemodynamic basis of Lancisi’s sign: right atrial pressure waveform in severe TR Right atrial pressure waveform in severe TR. Comparison of a normal right atrial pressure waveform (top) and severe TR (bottom). Severe TR is characterized by a giant systolic c-v wave resulting from regurgitant flow into the right atrium, with blunting or loss of the x descent. The prominent systolic venous pulsations produced by the giant c-v wave correspond clinically to Lancisi’s sign. TR, tricuspid regurgitation