Right Atrial Pressure Torsades de Pointes
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A 39-year-old man with non-ischemic cardiomyopathy presented for routine right heart catheterization. After fluoroscopic confirmation that the catheter tip was in the right atrium, the right atrial pressure was transduced and recorded. Torsades de Pointes of the right atrial pressure waveform was noted (Figure, Video).
The patient was asymptomatic and hemodynamically stable, and the electrocardiogram showed atrial and ventricular pacing and not ventricular fibrillation (Figure). Upon closer inspection, the “twisting” of the right atrial pressure waveform was noted to be related to the respiratory cycle, appearing larger and ventricularized during inspiration and smaller and atrialized during expiration (Figure, Video).
The likely explanation for this is the invasive hemodynamic manifestation of the Rivero-Carvallo sign, which is the inspiratory increase of intensity of the systolic murmur of tricuspid regurgitation (TR). However, inspiratory TR accentuation is not just an auscultatory phenomenon. Mechanistically, the hemodynamic accentuation of TR relates to the plasticity of the right-side ventriculo-valvular complex, whereby inspiration leads to widening of the right ventricle, an increase in the effective regurgitant orifice, and more than a 100% increase in TR volume.
To our knowledge, this is the first description of right atrial pressure Torsades de Pointes as a manifestation of the Rivero-Carvallo sign.
Affiliations and Disclosures
From the 1Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA; 2Texas Heart and Vascular Group and Texas Health Harris Methodist Fort Worth, Texas, USA.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Address for correspondence: Faris G. Araj, MD, Professional Office Bldg. 2 Suite 600, 5939 Harry Hines Blvd., Dallas, TX 75390-9252, USA. Email: faris.araj@utsouthwestern.edu
