What is the clinical sign associated with a holo-systolic murmur that increases with inspiration, indicative of tricuspid regurgitation: Gallavardin Effect or Carvallo's sign?

Carvallo's Sign is the Clinical Sign Associated with a Holo-systolic Murmur that Increases with Inspiration

Carvallo's sign, not Gallavardin effect, is the correct clinical sign associated with a holo-systolic murmur that increases with inspiration, which is characteristic of tricuspid regurgitation. 1

Understanding Carvallo's Sign

Carvallo's sign refers specifically to the augmentation of a tricuspid regurgitation murmur during inspiration. This occurs because:

• During inspiration, there is increased venous return to the right side of the heart
• This increased blood volume in the right ventricle leads to greater regurgitation through an incompetent tricuspid valve
• The resulting murmur becomes louder during the inspiratory phase of respiration 1

According to the ACC/AHA guidelines, the clinical features of tricuspid regurgitation include:

• Abnormal systolic c and v waves in the jugular venous pulse
• A lower left parasternal systolic murmur (holosystolic or less than holosystolic) that increases on inspiration (Carvallo's sign)
• Middiastolic murmur in severe regurgitation
• Systolic hepatic pulsation 1

Differentiating from Gallavardin Effect

The Gallavardin effect is an entirely different phenomenon:

• It refers to the musical quality of the murmur of aortic stenosis
• It involves the transmission of the high-frequency components of an aortic stenosis murmur to the apex
• It can be mistaken for mitral regurgitation
• Unlike Carvallo's sign, it does not vary with respiration 1

Respiratory Variation in Heart Murmurs

The ACC/AHA guidelines clearly state that right-sided murmurs generally increase with inspiration, while left-sided murmurs are usually louder during expiration 1. This respiratory variation is a key diagnostic feature:

• Tricuspid regurgitation murmurs (right-sided) increase during inspiration (Carvallo's sign)
• Mitral regurgitation murmurs (left-sided) typically increase during expiration
• This distinction helps differentiate between right and left-sided valvular pathologies 1

Clinical Significance

Recognizing Carvallo's sign is important because:

• It helps identify tricuspid regurgitation, which may be primary or secondary
• Secondary tricuspid regurgitation is often due to right ventricular dilation, pulmonary hypertension, or left-sided heart disease 2
• Early identification allows for appropriate management before right ventricular dysfunction occurs 3
• Untreated isolated tricuspid regurgitation significantly worsens survival 4

Common Pitfalls in Diagnosis

• Moderate or severe tricuspid regurgitation may be present without classic clinical features 1
• Clinically insignificant tricuspid regurgitation is detected by color Doppler imaging in many normal persons 1
• Clinical correlation and judgment must accompany echocardiographic results
• Systolic pulmonary artery pressures greater than 55 mm Hg are likely to cause tricuspid regurgitation with anatomically normal tricuspid valves 1

In summary, a holo-systolic murmur that increases with inspiration is characteristic of tricuspid regurgitation, and this specific finding is known as Carvallo's sign, not the Gallavardin effect.