Where can a tricuspid murmur be best heard?

Tricuspid Murmur Auscultation Location

A tricuspid murmur is best heard at the lower left sternal border (4th-5th left intercostal space), and its intensity characteristically increases with inspiration. 1

Optimal Auscultation Site

• The lower left sternal border is the primary location for detecting tricuspid valve pathology, whether regurgitation or stenosis 1
• The murmur may also be audible at the left sternal edge, typically grade 3-4/6 in intensity when significant 2
• In some cases, particularly with severe tricuspid regurgitation, the murmur can be heard at the fourth left parasternal border 3

Key Distinguishing Features Using Dynamic Auscultation

Respiratory variation is the most reliable bedside maneuver to confirm tricuspid origin:

• Right-sided murmurs, including tricuspid murmurs, increase with inspiration (Carvallo's sign) due to increased venous return to the right heart 1
• Left-sided murmurs typically increase with expiration, providing clear differentiation 1

Additional bedside maneuvers to enhance detection:

• Manual pressure applied below the liver (hepatic pressure maneuver) can augment the tricuspid regurgitation murmur, providing an additional diagnostic tool beyond the Carvallo sign 4
• This maneuver is particularly useful when the standard inspiratory augmentation is subtle or equivocal 4

Timing and Character of Tricuspid Murmurs

Tricuspid regurgitation characteristics:

• Early to midsystolic timing at the lower left sternal border typically indicates tricuspid regurgitation without pulmonary hypertension 1
• May present as a holosystolic murmur when regurgitation is severe 3
• Late systolic murmurs preceded by clicks can occur with tricuspid valve apparatus interference 2

Tricuspid stenosis characteristics:

• Middiastolic or presystolic murmurs originating from the tricuspid valve 1
• These diastolic murmurs are less common than regurgitant murmurs 1

Common Pitfalls to Avoid

• Do not confuse with pulmonic area murmurs, which are heard at the left 2nd intercostal space (upper left sternal border), not the lower left sternal border 5
• Failing to use respiratory maneuvers is the most common error—always assess the murmur during both inspiration and expiration to confirm right-sided origin 1
• Venous hum can mimic tricuspid pathology but is heard at the upper sternal border (not lower), has diastolic accentuation, and disappears with jugular venous compression or supine positioning 5, 6

Associated Physical Findings

When a tricuspid murmur is identified, look for:

• Regurgitant cv waves in the jugular venous pulsation, which are indicative of tricuspid regurgitation and may be present even without an audible murmur 1
• Signs of right heart failure including elevated jugular venous pressure, hepatomegaly, and peripheral edema 7
• Absence of left heart failure signs when tricuspid pathology is isolated 7