The Opening Snap of the Tricuspid Valve: A Physical Sign of Tricuspid Stenosis

In two patients with rheumatic heart disease a short, loud, high pitched, early diastolic, snapping sound was heard at or below and to the right of the xiphisternum. Except for the different area of audibility it was similar on auscultation to the opening snap of the mitral valve. Both patients showed clinical evidence of tricuspid as well as mitral and aortic valvular disease. There was hemodynamic evidence of tricuspid disease in one, and the other displayed tricuspid stenosis at necropsy. The abnormal sound was regarded as the opening snap of the tricuspid valve. THE precise clinical localization of struc-tural valvular defects in the heart, and an exact estimation of the dynamic al-terations caused by them have assumed con-siderable practical importance with the advent of surgical procedures for the correction of such defects. Among the more difficult of these to diagnose clinically is tricuspid steno-sis. Since surgical treatment of it can be, and has been, successfully achieved,1 ' 23 any addi-tional aid in its preoperative detection should be of more than academic interest. Neither the normal mitral valve or the normal tricuspid valve make any sound on opening at the termination of isometric relaxa-tion of the ventricles. Luisada4 ' 5 has recorded a single vibration in normal subjects in early diastole which he regards as originating from the opening of the atrioventricular valves, but unlike the sound arising from pathological valves it is of low frequency. Disturbing, too, is that it may occur before the peak of the V wave in the jugular phlebogram. By contrast, the structurally deformed mitral valve was believed as early as 18726 to make a sound which has come to be known as the opening snap of the mitral valve.7 It is short, of snap-ping quality, and occurs anywhere from 0.03 to 0.014 second after the beginning of th