Tricuspid incompetence in cor pulmonale.

In a survey of the Sheffield Region, Stuart-Harris, Twidle, and Clifton (1959) found that cor pulmonale was the commonest cause of heart failure resulting in admission to hospital. The investigation to be described was initiated when a patient in heart failure due to cor pulmonale was found to have a systolic murmur suggesting tricuspid incompetence which radiated down below the diaphragm into the left and right lobes of the liver reaching maximum intensity some 3 inches from the heart. In this patient the murmur remained constant over 13 weeks of bedrest in hospital. The necropsy showed gross cor pulmonale with cardiac cirrhosis but no organic disease of the tricuspid valve. Tricuspid incompetence has been recognized since early in the last century. In a historical note, Muller and Shillingford (1954) referred to seven descriptions published before 1840. An early account of a tricuspid valve lesion in which a systolic murmur was audible below the diaphragm may be that of Stokes (1854) who described a patient with a ruptured tricuspid valve in whom a systolic murmur was audible deep to the sternum and "along the course of the aorta." Bramwell (1884) described the murmur of tricuspid incompetence as "soft and blowing; the site of maximum differential intensity is the lower end of the sternum or adjacent costal cartilages; and its direction of propagation upwards and to the right." Subsequent writers have confirmed this description adding that the murmur may be widespread and audible to the apex (Broadbent, 1897; Gibson, 1898; Mackenzie, 1913; Vhite, 1944; Wood, 1956; Levine and Harvey, 1959). An investigation was therefore undertaken in which patients with cor pulmonale and tricuspid incompetence were assessed clinically and with a phonocardiograph in order to determine the site of maximum intensity of the systolic murmur resulting from tricuspid incompetence. The radiation of the murmur was also investigated in a number of patients with chronic rheumatic carditis and tricuspid incompetence.