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Q. Parasternal Heave in Differentiating Volume Overload and Pressure Load on Right Ventricle
Explanation by Prof. Patnaik
With each ventricular systole the left lower costal cartilages along with the attached part of sternum get elevated due to the hypertrophied and dilated right ventricle. The inspection and palpation of this phenomenon in supine position has become a standard method of clinical cardiac evaluation.  Appreciation of this lift/heave at the left parasternal area is not as precise as the cardiac apex however, clinicians have learned to roughly quantify the right ventricular systolic pressure and volume changes.
It is most conveniently graded (All India Institute of Medical Sciences [AIIMS] gradation) as follows:
1/3 (Grade 1): visible but not palpable
2/3 (Grade 2): visible and palpable but obliterable
3/3 (Grade 3): visible and palpable but not obliterable
In the presence of significant right ventricular pressure overload the palpation of the left parasternal area will reveal a sustained left parasternal lift.  There may be associated prominent “a” wave in jugular venous pressure (JVP) and abnormal epigastric and subxiphoid pulsations. Common causes of raised right ventricle (RV) pressure are pulmonary hypertension and severe pulmonary stenosis. In RV volume overloaded states, the left parasternal impulse is appreciable but not sustained. Atrial septal defect (ASD) with significant left to right shunt can have an associated tricuspid mid-diastolic flow murmur. The ASD or severe tricuspid or pulmonary regurgitation cause RV volume overload.
Large left atrial enlargement in severe mitral regurgitation sometimes produces left parasternal lift but it is mostly confined to late systole. Similarly, a dilated left ventricle (LV) that is rotated counterclockwise in severe AR can also cause parasternal lift. In children and thin adults, a parasternal heave (PSH)–like chest motion may be appreciated without any heart disease.
Explanation by Prof. Dayasagar Rao
Parasternal Pulsations (Left)—Clinical Implications
In situs solitus state the most anterior structure of the heart is the right ventricle which is just below the anterior chest wall.
In patients with RV volume overload like ostium secundum ASD with large L–R shunt (and no pulmonary hypertension [PH]) or low pressure tricuspid regurgitation (TR) there will be vigorous pulsation in intercostal spaces (3rd, 4th, and 5th) of left parasternal region consequent to dilation of RV. These pulsations are present over RV inflow (5th space) and RV outflow (3rd and 4th interspace) but no significant, sustained lift of precordium.
In some clinical situations RV outflow pulsations without inflow pulsation are seen, classically in Ebstein’s anomaly of tricuspid valve (TV) where the inflow of RV is atrialized and in patients with RV and in endomyocardial fibrosis (EMF) where inflow is fibrosed plastering the posterior leaflet to TV.
In parasternal heave, unlike in the parasternal pulsation, precordium is lifted above the chest wall and sustained for significant time (>50% systole) and is characteristically seen in pressure overloaded RV, like in pulmonary hypertension and right ventricular outflow tract (RVOT) obstruction. The parasternal heave is graded (arbitrarily) as follows:.
Grade I: visible, barely palpable
Grade II: visible, palpable, but can be obliterated by counter-pressure of hand
Grade III: parasternal heave that cannot be obliterated by counter-pressure (mild)
Occasionally in severe mitral regurgitation systolic expansile impulse of LA can be felt over left parasternal area even though LA is the most posterior structure (parasternal heave is a transmitted pulsation). This LA lift is better palpated in the upper parasternal area and occurs in later part of systole in contrast to early systolic lift of RV pressure overload.
09 April 2021 (online)
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