The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Lindsey R. Baden, M.D., Editor

Lancisis Sign

cv
cv

y a y
a
Pressure

Patient

a a
c c
v v
x y x y

Schematic normal

Time

A
Andr M. Mansoor, M.D. 60-year-old man with nonischemic cardiomyopathy presented
Steven E. Mansoor, M.D., Ph.D. with progressive dyspnea and weight gain of approximately 9 kg that had
Oregon Health and Science University developed over a period of 2 to 3 weeks. On examination, a grade 2/6 holo-
Portland, OR systolic murmur that augmented with inspiration was noted at the left lower ster-
mansooan@ohsu.edu nal border. Examination of the neck revealed a palpable, monomorphic venous
pulsation, known as Lancisis sign (see video). Transthoracic echocardiography
revealed malcoaptation of the tricuspid-valve leaflets as a result of annular dilata-
tion, with resultant severe regurgitation. Lancisis sign is a physical finding of
A video showing severe tricuspid regurgitation. Normally, three peaks and two troughs characterize
Lancisis sign the venous waveform (the lower strip is a generic representation of normal find-
is available at
NEJM.org ings, for comparison). The first peak, called the a wave, results from atrial contrac-
tion during late diastole. Next, during early systole, isovolumetric ventricular
contraction triggers closure of the tricuspid valve, producing the c wave. In mid-
systole, given a competent tricuspid valve, a combination of atrial relaxation and
descent of the atrial floor during ventricular contraction results in the x descent.
The third peak, the v wave, occurs as a result of atrial filling during late systole.
Finally, passive ventricular filling in early diastole produces the y descent. In the
context of tricuspid regurgitation, retrograde blood flow into the right atrium dur-
ing ventricular systole results in loss of the x descent (the upper strip shows the
right atrial pressure tracing from this patient), creating a fused cv wave that ap-
pears as a large pulsation within the internal jugular vein that is often palpable.
This wave is typically followed by an augmented y descent, which is the conse-
quence of an increased pressure gradient between the right atrium and right ven-
tricle. In this patient, diuretic agents were used to normalize the volume status,
and the symptoms abated.
DOI: 10.1056/NEJMicm1502066
Copyright 2016 Massachusetts Medical Society.

e2 n engl j med 374;2 nejm.org January 14, 2016

The New England Journal of Medicine

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