Video Corner

A Neonate With Precordial Pulsations

Jocelyn Ou, MD,* Akshaya J. Vachharajani, MD*
*Washington University School of Medicine, St Louis Children’s Hospital, St Louis, MO

QUESTION

Which of the following physical findings are demonstrated in the video (Video 1)?
a. Precordial bulge, suprasternal pulsations, and an apical impulse
b. Precordial bulge, suprasternal pulsations, and a right parasternal heave
c. Precordial bulge, suprasternal pulsations, a left parasternal heave, and epi-
gastric pulsations
d. Precordial bulge, suprasternal pulsations, a right parasternal heave, and an
apical impulse
e. Suprasternal pulsations, a left parasternal heave, epigastric pulsations, and an
apical impulse

Video 1. What findings are seen on this video?

FINDINGS

Suprasternal pulsations are pulsations that occur in the midline region above
the suprasternal notch; in Video 2, these pulsations are observed below the
infant’s neck. They can be found in a neonate with hyperdynamic circulation or
a dilated aortic arch. Both of these findings are seen in an infant with a patent
ductus arteriosus with a large left-to-right shunt causing volume overload of
the left ventricle. The left ventricle volume overload then increases the left

AUTHOR DISCLOSURE Drs Ou and

Vachharajani have disclosed no financial
relationships relevant to this article. This
commentary does not contain a discussion of
an unapproved/investigative use of a
commercial product/device. Video 2. Explanation of the findings seen in Video 1.

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 Figure 1. Chest radiograph showing cardiomegaly. Figure 2. Chest radiograph with landmarks used to diagnose
cardiomegaly.
ventricular stroke volume in the aorta, resulting in a
term PMI is a misnomer because it also describes the site on
dilated aortic arch, which can be diagnosed on physical
the chest wall where a murmur is loudest. The PMI can be
examination by identifying suprasternal pulsations. The
caused by maximum precordial pulsations because of a
increase in left ventricular stroke volume is explained by
dilated pulmonary artery, a large right ventricle, ventricular
the Frank-Starling law, which states that within physio-
aneurysm, or an aortic aneurysm. An apex beat refers to the
logic limits, the force of contraction of a muscle fiber is
apex of the left ventricle.
directly proportional to the initial length of the muscle fiber.
The neonate depicted in the videos has a double outlet
Hyperdynamic circulation also may be seen in infants
right ventricle with a large patent ductus arteriosus that
with anemia or thyrotoxicosis.
explains these physical findings. The accompanying chest
A left parasternal heave is a visible pulsation on the left side
radiograph (Fig 1) demonstrates an enlarged heart and
of the chest wall that may also be palpable. In Video 2, a left
increased pulmonary vascular markings. Cardiomegaly
parasternal heave is appreciated when a finger placed on the
can be evaluated by adding lines AB and CD and dividing
chest is moved by the chest wall. In adults, the classic method
by line CT (Fig 2). The infant was referred for coiling of the
of demonstrating this sign is observing a pencil rise and fall
patent ductus arteriosus to reduce the left-to-right shunting
when placed perpendicular to the costal cartilages. It can also
and relieve the heart failure.
be demonstrated by placing a piece of paper on the area and
The infant in the videos does not have a precordial bulge,
watching it rise and fall. A parasternal heave can occur in an
which is a marker of longstanding cardiac enlargement. It
infant with right ventricular hypertrophy; when the hyper-
would be seen as a prominence of the left chest wall area
trophied right ventricle contracts, the left lower costal carti-
overlying the heart.
lages become more elevated. A left parasternal heave can also
occur in a patient with an aneurysm of the descending aorta.
A right parasternal heave does not exist. Correct Response
Epigastric pulsations are pulsations that are seen below the e. Suprasternal pulsations, a left parasternal heave, epigas-
xiphoid process in the midline on the anterior abdominal tric pulsations, and an apical impulse
wall and can be visualized in Video 2. They are caused by a
dilated right ventricle, hepatic pulsations, and an aneurysm
of the descending aorta. A dilated right ventricle is diag- American Board of Pediatrics
nosed by feeling the pulsation on the tip of the finger in the Neonatal-Perinatal Content
epigastrium. A pulsating aortic aneurysm is felt on the pad of
Specification
the palpating finger. A pulsating left lobe of the liver is
• Recognize the clinical features of a neonate with a left-to-right
associated with hepatomegaly.
shunt lesion.
An apical impulse or apex beat is also known as a point of
maximum intensity (PMI) and is shown in Video 2. The

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ACKNOWLEDGMENT Suggested Reading
We wish to thank Bryan Camp from media services at St Constant J. Inspection and palpation of the chest. In: Essentials of
Louis Children’s Hospital for editing the videos. Bedside Cardiology. 2nd ed. Totowa, NJ: Humana Press; 2002;
chap 5:89–111

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 A Neonate With Precordial Pulsations
Jocelyn Ou and Akshaya J. Vachharajani
NeoReviews 2019;20;e761
DOI: 10.1542/neo.20-12-e761

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/20/12/e761
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 A Neonate With Precordial Pulsations
Jocelyn Ou and Akshaya J. Vachharajani
NeoReviews 2019;20;e761
DOI: 10.1542/neo.20-12-e761

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/20/12/e761

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