Rivero-Carvallo sign

Description

Rivero-Carvallo sign: Accentuation of the murmur of tricuspid regurgitation and tricuspid stenosis with inspiration. Auscultation is performed during post-inspiratory apnoea and the loudness of the systolic murmur is compared to its loudness during post-expiratory apnoea.

The murmur of tricuspid insufficiency increases in intensity during held, deep inspiration. The murmur may also become higher pitched. This, as well as the location of the murmur, helps to distinguish tricuspid regurgitation from mitral regurgitation.

Rivero-Carvallo manouver: With the patient in a seated position, they are requested take a deep inspiration and hold breath (inspiratory apnoea) whilst the examiner listens over the tricuspid area (left lower sternal border)

** Reversed Rivero-Carvallo sign: inspiratory reduction in murmur intensity—reported in patients with right sided hypertrophic obstructive cardiomyopathy and straight back syndrome

History of the Rivero-Carvallo sign

1946 – Rivero-Carvallo described an increase in the intensity of the systolic murmur of tricuspid insufficiency with deep inspiration and hold an inspiratory apnoea, whilst in a seated position. This distinguished it from left sided murmurs such as mitral insufficiency, which do not change with respiration.

Rivero-Carvallo applied his newly described maneuver to 4 groups of patients:

• clinically evident tricuspid insufficiency
• clinically evident mitral lesions (no tricuspid pathology)
• tricuspid rheumatic heart disease and arrhythmias
• patients with heart failure or arrhythmia without rheumatic heart disease

Results showed as increase in the intensity of tricuspid murmurs with maximum intensity over the tricuspid region and with radiation toward the mesocardium or the hepatic zone. The sign’s positivity was independent of heart rhythm or frequency. Rivero-Carvallo postulated that:

• tricuspid systolic murmurs are increased during a maneuver of inspiratory apnoea, and that systolic mitral murmurs diminish its intensity during such a maneuver, which differentiates them clearly
• the second was that post-expiratory apnoea increases aortic and mitral murmurs and decreases the intensity of tricuspid murmurs.

Validation studies:

• Sensitivity ranging from 61-100%
• 1981 – Cha SD et al using intracardiac phonocardiograms determined that the Rivero-Carvallo sign is a reliable indicator of tricuspid regurgitation but its absence does not rule it out [Am J Cardiol. 1981]

Associated Persons

• José Manuel Rivero-Carvallo (1905 – 1993)

Alternative names

• Rivero-Carvallo maneuver; Rivero-Carvallo sign
• Carvallo maneuver; Carvallo’s sign

References

Historical publications

• Rivero-Carvallo JM. Signo para el diagnóstico de las insuficiencias tricuspídeas [A sign for the diagnosis of tricuspid insufficiency]. Arch Inst Cardiol Mex. 1946; 16: 531–540.
• Rivero-Carvallo JM. Un nuovo segno diagnostico della insufficienza tricuspidale [A new diagnostic sign of tricuspid insufficiency]. Cuore e circolazione. 1947; 31(3-4): 54

Review publications

• Müller O, Shillingford J. Tricuspid incompetence. Br Heart J. 1954 Apr; 16(2): 195–207.
• Sepulveda G, Lukas DS. The diagnosis of tricuspid insufficiency; clinical features in 60 cases with associated mitral valve disease. Circulation. 1955; 11(4): 552-563.
• Killip T 3rd, Lukas DS. Tricuspid stenosis; physiologic criteria for diagnosis and hemodynamic abnormalities. Circulation. 1957; 16(1): 3-13
• Toso M, Innocenti P. [The Rivero-Carvallo maneuver in the diagnosis of tricuspid insufficiency. Conventional and intracavitary phonocardiographic study]. Cuore Circ. 1966; 50(2): 94-102.
• Cha SD, Gooch AS, Maranhao V. Intracardiac phonocardiography in tricuspid regurgitation: relation to clinical and angiographic findings. Am J Cardiol. 1981; 48(3): 578-583.
• Matsuo H, Morita H et al. Detection and visualization of regurgitant flow in valvular diseases by pulsed Doppler technique. Jpn Circ J. 1982; 46(4): 377-388
• Ishikawa K, Hirata F, Hirata S, Ishikawa M. Reversed Rivero-Carvallo’s sign in right-sided hypertrophic obstructive cardiomyopathy. Chest. 1983; 83(4): 694-6.
• Lembo NJ, Dell’Italia LJ, Crawford MH, O’Rourke RA. Bedside diagnosis of systolic murmurs. NEJM. 1988; 318(24): 1572-1578
• Suto M et al. Reversed Rivero-Carvallo’s sign confirmed by blood flow analysis using cardiac magnetic resonance imaging in a patient with straight back syndrome. Echocardiography. 2017 Oct 29.
• Robbins A, Zhang G, Cadogan M. Name that murmur. LITFL 2022
• Cadogan M. Rivero Calvallo sign. Eponym A Day. Instagram

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