Lancisi’s Sign: Giant C-V waves with Severe Tricuspid Regurgitation in
Isolated Tricuspid Valve Prolapse
Introduction
Tricuspid valve prolapse (TVP) is diagnosed if one or more leaflets
extend beyond the tricuspid annular plane into the right atrium in late
systole. TVP was present in 0.3% of individuals and most commonly
associated with concomitant mitral valve prolapse (1). Isolated TVP is a
rare finding on transthoracic echocardiography. Right atrial enlargement
or prominent ” v ” waves as a consequence of hemodynamic changes in
severe tricuspid regurgitation (TR) are rarely seen with isolated TVP
(2). Here is a case of isolated prolapse of anterior tricuspid leaflet
presenting with giant C-V waves also known as Lancisi’s sign.
Case Report
A 66-year-old male presented with increasing exercise limitation and
leg edema in recent months and was complaining about the persistent
pulsation at his neck. On physical examination, elevated jugular venous
pulse with prominent systolic pulsation that represents giant C-V waves,
also known as ‘Lancisi’s sign’ (Video-1) has detected. Cardiac
auscultation revealed a loud pulmonary component of the second heart
sound, and a holosystolic murmur at the left lower sternal border that
increased with inspiration. Peripheral pitting pedal edema, and ascites
were also noted. ECG showed 67 beats per minute with atrial fibrillation
and right bundle branch block. Two-dimensional echocardiography revealed
the presence of severe TR with isolated prolapse of the anterior leaflet
(Figure-1). Dilated right heart chambers with moderate to severe right
ventricular systolic dysfunction have also observed. He underwent
tricuspid valve replacement and the patients’ symptoms resolved
completely after surgery.
Discussion
TVP has been rarely found as an isolated finding and more frequently
found concomitantly with mitral valve prolapse. TVP is best defined at
parasternal short axis view with more than 2 mm atrial displacement (AD)
of leaflet/leaflets. TVP can also be detected from four chamber view
with more than 2 mm AD or in right ventricular inflow view with more
than 4 mm AD (1). The largest database of TVP from a single center,
retrospective study TVP was found to be associated with increased
severity of TR (1).
The physiological jugular venous waveform contains 3 peaks and 2
descents. It exhibits the pressure increase in the right atrium during
isovolumetric ventricular contraction as the c wave. Afterwards atrial
relaxation causes a decrease in the right atrial pressure during
mid-systole as we can see the x descent. The v wave occurs as a result
of atrial filling during late systole in healthy individuals. During
severe TR; retrograde blood flow through right atrium during ventricular
systole restrains x descent and produces a fusion of c and v waves that
appears as a large pulsation in physical examination called as
‘Lancisi’s sign’ (Video-1) (3-5).
Conclusion
‘Lancisi’s sign’ is defined as a large visible systolic neck pulsation
as a consequence of the c-v waves fusion by preventing x descent during
severe TR.
References
1- Lorinsky MK, Belanger MJ, Shen C, Markson LJ, Delling FN, Manning WJ,
Strom JB. Characteristics and Significance of Tricuspid Valve Prolapse
in a Large Multidecade Echocardiographic Study. J Am Soc Echocardiogr.
2021 Jan;34(1):30-37. doi: 10.1016/j.echo.2020.09.003. Epub 2020 Oct 16.
PMID: 33071045; PMCID: PMC7796941.
2- Brown AK, Anderson V. Two-dimensional echocardiography and the
tricuspid valve. Leaflet definition and prolapse. Br Heart J .
1983;49(5):495-500. doi:10.1136/hrt.49.5.495
3-Mansoor AM, Mansoor SE. IMAGES IN CLINICAL MEDICINE. Lancisi’s Sign. N
Engl J Med. 2016 Jan 14;374(2):e2. doi: 10.1056/NEJMicm1502066. PMID:
26760104.
4- Senguttuvan NB, Karthikeyan G. Jugular venous C-V wave in severe
tricuspid regurgitation. N Engl J Med 2012;2013:e5.
5-Vigo V, Lisi P, Galgano G, Lomonte C. Lancisi’s sign and central
venous catheter tip position: a case report. J Vasc Access. 2018
Jan;19(1):92-93. doi: 10.5301/jva.5000760. PMID: 28731490.