Christopher Lopez

He knows the drill: cut into the area behind the ears, find two small lymph nodes and incise them three or four times each. Check the nose and mouth for signs of disease — six to nine seconds to finish the inspection. Wash the gloves and sanitize the knives. One to two seconds to breathe.

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Tricuspid regurgitation (TR) is increasingly recognized as an important cause of right-sided heart failure and adverse clinical outcomes. Although severe TR typically presents with a holosystolic murmur, advanced disease may produce atypical findings that obscure the diagnosis. Lancisi’s sign, characterized by prominent systolic jugular venous pulsations, remains an important but underrecognized bedside clue to severe TR. We present the case of a 60-year-old man with a remote history of presumed infective endocarditis who presented with progressive dyspnea, anasarca, and peripheral edema. Physical examination revealed marked systolic jugular venous pulsations consistent with Lancisi’s sign but no audible cardiac murmur. Transthoracic echocardiography demonstrated complete degeneration of the tricuspid valve leaflets, torrential TR, massive right-sided chamber dilation, and right atrial ventricularization. Doppler interrogation confirmed rapid pressure equalization between the right atrium and right ventricle. Given the advanced right-sided remodeling and evidence of end-organ involvement, the patient was deemed unsuitable for surgical or transcatheter intervention and was managed medically. This case highlights the diagnostic value of careful physical examination and illustrates how severe TR may present without its classic auscultatory findings. Early recognition of bedside signs such as Lancisi’s sign may facilitate timely diagnosis before progression to irreversible right-sided heart failure.