Left ventricular (LV) heave, also known as a left ventricular lift, is a palpable sustained forceful thrust of the left ventricle against the chest wall during systole. It signifies increased left ventricular workload and is a clinical sign indicative of underlying cardiac pathology. Unlike a thrill, which is a palpable vibration, a heave is a sustained, forceful impulse. Understanding the nuances of LV heave, differentiating it from other palpable cardiac phenomena, and appreciating its clinical significance are crucial for accurate diagnosis and management of cardiovascular diseases.
Left Ventricular Heave: A Detailed Examination
The characteristic "see-saw" pulsation described in the context of a dyskinetic apex in a left ventricular aneurysm provides a vivid illustration of the abnormal movement associated with LV heave. The aneurysm, a weakened area of the ventricular wall, causes paradoxical outward movement during systole (the see-saw portion) followed by the out-of-phase bulge above the lowest impulse. This out-of-phase movement further emphasizes the abnormal contractility and increased workload of the left ventricle. The location, intensity, and timing of the heave provide valuable diagnostic clues.
The forceful impulse of an LV heave is a direct consequence of increased left ventricular systolic pressure and/or increased myocardial contractility. Several conditions can lead to this increased workload, including:
* Hypertension: Sustained high blood pressure forces the left ventricle to work harder to pump blood against increased resistance. This increased workload can lead to LV hypertrophy (enlargement) and eventually a palpable heave.
* Aortic stenosis: Narrowing of the aortic valve increases the resistance against which the left ventricle must pump, leading to increased pressure and hypertrophy, resulting in a heave.
* Hypertrophic cardiomyopathy: This genetic condition causes thickening of the ventricular walls, reducing the chamber size and impairing diastolic filling. The increased muscle mass can lead to a prominent heave.
* Left ventricular aneurysm: As described earlier, the weakened and bulging ventricular wall can produce a characteristic see-saw pulsation and a palpable heave.
* Systemic hypertension with left ventricular hypertrophy: The combination of high blood pressure and resulting left ventricular enlargement frequently leads to a palpable heave.
* Severe mitral regurgitation: The backflow of blood into the left atrium during systole increases the left ventricular volume and workload, potentially causing a heave.
Thrill vs. Heave: Cardiac Palpation Differentiated
Understanding the difference between a thrill and a heave is fundamental to accurate cardiac examination. Both are palpable phenomena, but they differ significantly in their character:
* Thrill: A thrill is a palpable vibration felt on the chest wall, usually caused by turbulent blood flow through a narrowed or incompetent valve. It feels like a purring cat. Thrills are typically high-frequency vibrations, and their location helps pinpoint the affected valve.
* Heave: A heave, as discussed, is a sustained forceful impulse resulting from increased left ventricular contractility or hypertrophy. It's a lower-frequency, more forceful thrust, representing the increased workload of the ventricle.
The simultaneous presence of both a thrill and a heave can indicate severe valvular disease with significant left ventricular hypertrophy. For example, a thrill over the aortic area combined with a parasternal heave could suggest severe aortic stenosis.
Parasternal Heave vs. Thrill: A Comparative Analysis
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