Positive Carvallo sign

Specialty: Cardiovascular.

• sign of Rivero-Carvallo
• inspiratory accentuation of tricuspid murmurs

Why it occurs

• Functional tricuspid regurgitation or secondary to pulmonary hypertension
• Organic tricuspid insufficiency (rheumatic, endocarditis due to parenteral drugs, Ebstein's anomaly)
• Rheumatic tricuspid stenosis
• Myxoma of the right atrium protruding through the tricuspid valve

Initial workup

Color Doppler transthoracic echocardiogram to visualize the tricuspid valve, determine the mechanism of insufficiency (annular dilation, prolapse or leaflet restriction), measure the diameter of the inferior vena cava and its collapsibility, quantify the severity of regurgitation (EROA, regurgitant volume) and estimate the systolic pressure of the pulmonary artery; 12-lead electrocardiogram; Abdominal ultrasound to quantify liver congestion and the presence of ascites.

Standard management

• Furosemide — loop diuretic indicated to aggressively reduce right ventricular preload and relieve deep systemic venous congestion; 40 to 80 mg intravenously or orally in divided doses
• Spironolactone — aldosterone antagonist, indicated for the control of water retention and ascites secondary to hepatic congestion; 50 to 100 mg daily orally, monitoring renal function and serum potassium
• Ceftriaxone — antibiotic if the new murmur is associated with fever and suspicion of tricuspid endocarditis; 2 g intravenously every 12 hours after taking blood cultures
• Sildenafil (phosphodiesterase-5 inhibitor indicated if tricuspid regurgitation is functional secondary to severe precapillary pulmonary arterial hypertension; 20 mg three times a day orally).