Department of internal disease propedeutics, gastroenterology, hepatology 1

PERCUSSION OF THE HEART

review of the topic for the class
Percussion is used to determine the size, position and shape of
the heart and the vascular bundle.

The right contour of dullness of the heart and the vascular

bundle is formed (from top to bottom) by the superior vena cava to the
upper edge of the 3rd rib and by the right atrium at the bottom.

The left contour is formed by the left part of the aortic arch at the
top, then by the pulmonary trunk, by the auricle of the left atrium at
the level of the 3rd rib and downward by a narrow strip of the left
ventricle.

The anterior surface of the heart is formed by the right ventricle.

Being an airless organ, the heart gives a dull percussion sound.

But since it is partly covered on its sides by the lungs, dullness is dual in
its character, i.e. it is relative (deep) and absolute (superficial).

The relative cardiac dullness is the projection of its anterior

surface onto the chest. It corresponds to the true borders of the heart,
while the absolute dullness corresponds to the anterior surface of the
heart that is not covered by the lungs.

Percussion can be done with the patient in both erect and lying
position. It should, however, be remembered that the area of cardiac
dullness in the vertical position is smaller than in the horizontal. This is
due to mobility of the heart and the displacement of the diaphragm as
the patient changes his posture.

Determining relative cardiac dullness. When determining the borders

of relative cardiac dullness, interspaces should be percussed in order to
avoid lateral distribution of vibrations along the ribs. The percussion

PERCUSSION OF THE HEART

Department of internal disease propedeutics, gastroenterology, hepatology 2

stroke should be of medium strength. The pleximeter-finger should be

tightly pressed against the chest so that the percussion vibration might
penetrate deeper regions.

When determining the border of relative dullness, the remotest

points of the cardiac contour are first found on the right, then on the
left, and finally at the top.

The right border of the relative

cardiac dullness. Since the border of
cardiac dullness depends on the
position of the diaphragm, the lower
border of the right lung is first
determined in the midclavicular line; its
normal position is at the level of the
6th rib. The position of the lower
border of the lung indicates the level of
the diaphragm. The pleximeter-finger is
then moved one interspace above the
lower border of the right lung and
placed parallel to the right border of
the heart being determined (normally, in the 4th costal interspace).
Percussion is continued by moving the pleximeter-finger gradually
along the interspace toward the heart until the percussion sound dulls.
The right border of the heart is marked by the outer edge of the finger
directed toward a clear resonant sound. Its normal position is 1 cm
laterally of the right edge of the sternum.

The left border of the relative cardiac dullness is determined in

the interspace, where the apex beat is present. The apex beat is
therefore first determined by palpation, and the pleximeter-finger is
then placed laterally of this point, parallel to the sought border, and the
interspace is percussed toward the sternum. If the apex beat cannot be

PERCUSSION OF THE HEART

Department of internal disease propedeutics, gastroenterology, hepatology 3

determined, the heart should be percussed in the 5th interspace from

the anterior axillary line toward the sternum. The left border of
relative cardiac dullness is located 1-2 cm medially of left
midclavicular line; it coincides with the apex beat.

The upper border of the relative

cardiac dullness is determined 1 cm to
the left of the left sternal line. To that
end, the pleximeter-finger is placed
perpendicularly to the sternum, near its
left margin, and then moved downward
until dullness appears. The normal
upper border of the relative cardiac
dullness is in the 3rd interspace.

Once the area of relative cardiac

dullness of the heart has been
established, its transverse length is
measured by a measuring tape, from
the extreme points of the relative dullness to the anterior median line.
The normal distance from the right border of relative cardiac dullness
(usually in the 4th interspace) to the anterior median line is 3 or 4 cm,
while the distance from the left border of relative cardiac dullness
(usually in the 5th interspace) to the same line is 8 or 9 cm. The sum
of these lengths is the transverse length of relative cardiac dullness
(normally 11-13 cm).

The shape of the heart can be determined by percussion of the

borders of the vascular bundle in the 2nd intercostal space on the right
and left, and of relative cardiac dullness in the 4th or 3rd interspace on
the right, and in the 5th, 4th, or 3rd interspace on the left. The
pleximeter-finger is moved parallel to the borders of expected dullness
and the elicited points of dullness are marked on the patient's skin. The

PERCUSSION OF THE HEART

Department of internal disease propedeutics, gastroenterology, hepatology 4

points are then connected by a line to mark the contours of the relative
cardiac dullness. Normally, an obtuse angle is formed by the lines of
the left heart contour between the vascular bundle and the left
ventricle. The heart is of normal configuration in such cases. In
pathological conditions, when the chambers of the heart are dilated,
mitral and aortal configurations are distinguished.

Position of the pleximeter-finger during outlining the upper, right, and

left borders of relative cardiac dullness.

Determining absolute (superficial) cardiac dullness. The anterior

wall of the heart is not covered by the lungs and the area of absolute
cardiac dullness corresponds to the area of the heart. Percussion of this
area gives dullness. To determine absolute dullness of the heart, light
percussion strokes are needed. The right border of absolute cardiac
dullness is first elicited. The pleximeter-finger is placed on the right
border of relative (deep) cardiac dullness, parallel to the sternum, and
then moved medially, to the left, to dullness. The border is marked by
the outer edge of the finger directed toward resonance. In normal
subjects this border passes along the left edge of the sternum.

To outline the left border of absolute cardiac dullness, the

pleximeter-finger is placed slightly outside the border of relative
cardiac dullness, and then moved medially to dullness. The left border
of absolute cardiac dullness is normally 1—2 cm medially of the
border of relative cardiac dullness.

To elicit the upper border of absolute cardiac dullness, the

pleximeter-finger is placed on the upper border of relative cardiac
dullness and then moved downward to dullness. The superior border
of absolute cardiac dullness is normally at the level of the 4th rib.

The borders of the vascular bundle are determined by light

percussion in the second intercostal space, to the right and left from
the midclavicular line, toward the sternum. When the percussion sound
PERCUSSION OF THE HEART
Department of internal disease propedeutics, gastroenterology, hepatology 5

dulls, a mark should be made by the outer edge of the finger. The right
and left borders of vascular dullness are normally found along the
edges of the sternum; the transverse length of dullness is 5—6 cm.

The area of cardiac dullness can be modified by extracardiac

factors. At high position of the diaphragm, the heart assumes a
horizontal position and its transverse dimensions thus increase. When
the diaphragm is low, the heart assumes the vertical position and its
transverse diameter is thus diminished.

Accumulation of liquid or air in one pleural cavity displaces cardiac

dullness toward the healthy side; in atelectasis and pneumosclerosis, or
in the presence of pleuropericardial adhesion the borders of cardiac
dullness are displaced to the affected side.

The area of absolute cardiac dullness markedly diminishes or

disappears in pulmonary emphysema, while it increases in
pneumosclerosis.

The area of absolute dullness is also enlarged in the anterior

displacement of the heart (e.g. by a mediastinal tumour, due to
accumulation of fluid in the pericardium, or in dilatation of the right
ventricle).

The borders of relative dullness are displaced in the presence of

enlarged heart chambers. Displacement to the right is due to dilatation
of the right atrium and the right ventricle.

If the left atrium or the conus of the pulmonary trunk is enlarged,

the area of relative dullness is displaced upwards.

Dilatation of the left ventricle displaces the area of relative

dullness to the left. It should be remembered that a markedly enlarged
and hypertrophied right ventricle displaces the left ventricle and can
also displace the border of relative dullness to the left. Aortic dilatation
increases the dullness area in the second interspace.
PERCUSSION OF THE HEART