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Cardiology Service, Department of Medicine, Unity Health Toronto, St. Joseph's Health Centre Site, Toronto, Ontario, CanadaDivision of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
Clinical assessment of right heart function and hemodynamics is relevant for many clinical states and may aid in quick clinical decision-making. With transcutaneous bidirectional Doppler, the jugular venous flow velocity patterns have been shown to reflect right heart hemodynamics and its derangement, irrespective of the underlying etiology. Given that the peaks in the forward flow velocities in the superior vena cava and the jugulars correspond to the falling slopes of pressure waves, namely the x, x', and y descents in the right atrium, the patterns of descents in the jugular venous pulse (JVP) become clinically useful for assessment of right heart function and right heart hemodynamics. Bedside assessment of the JVP has long been focused on the rise to the peaks of these physiological waveforms. However, these studies clearly show that the descents that represent the slopes of fall to the nadir (the lowest point) actually hold useful physiological correlates. The descents in the JVP are fast movements receding from the eye fields, and therefore they can be seen easily at the bedside. These studies and long-term clinical observations have shown that the normal JVP descent pattern is single x' or x'>y, and the descent patterns of x'=y, x'<y, and single y descent alone are abnormal. The focus of this paper is to discuss in detail these JVP descent patterns, both the normal and the abnormal, with emphasis on their clinical relevance. Clinical video recordings of JVP are presented to demonstrate the key points.
Résumé
L’évaluation clinique de l’hémodynamique et de la fonction du cœur droit est pertinente dans de nombreux cas cliniques et pourrait faciliter la prise de décisions cliniques. Il a été démontré que les fluctuations de la vitesse du flux sanguin dans la jugulaire, mesurée par une échographie de Doppler bidirectionnelle et transcutanée, reflètent l’hémodynamique du cœur droit et ses perturbations, quelle que soit l’étiologie sous-jacente. Comme les pics de vitesse du flux sanguin dans la veine cave supérieure et la jugulaire correspondent aux courbes descendantes des ondes de pression, nommément les courbes descendantes x, x’ et y dans l’oreillette droite, le schéma des courbes descendantes dans le pouls jugulaire devient utile sur le plan clinique pour évaluer l’hémodynamique et la fonction du cœur droit. De plus, l’évaluation du pouls jugulaire réalisée au chevet du patient se concentre depuis longtemps sur la montée et la pointe de ces ondes physiologiques. Par ailleurs, ces études révèlent que les courbes descendantes qui représentent la chute jusqu’au nadir (point le plus bas) présentent une corrélation physiologique utile. Les descentes du pouls jugulaire sont des mouvements rapides faisant en sorte que la veine devient moins visible, et sont donc facilement observables au chevet du patient. Ces études et les observations cliniques à long terme ont montré que le schéma normal de descente du pouls jugulaire est x’ seulement ou x’ > y, et que les schémas de descente x’ = y, x’ < y et descente y seulement sont anormaux. La présente publication vise à discuter en détail de ces schémas de descente du pouls jugulaire, tant normaux qu’anormaux, en soulignant leur pertinence clinique. Des enregistrements vidéo pris dans un contexte clinique du pouls jugulaire sont présentés pour illustrer les principaux éléments.
Mechanisms of venous return and right heart filling have been of interest to clinicians since the days of Harvey
Exercitatio anatomica de motu cordis et sanguinis in animalibus. Frankfurt: Gugliemi Fitzeri, 1628. English translation by Leake DC. [An anatomical exercise on the movement of the heart and blood in animals].
Uber die saugkraft des herzens. Ubbersicht der arbeiten und veranderungen der schlesischen gesellschaft fur vaterlanndische kultur im jahre [About the suction power of the heart, review of the works and changes of the Silesian society for patriotic culture in the year]..
Appareilles et experiences cardiographiques per l’emploi des instruments enreistreures a indications continues [Cardiographic apparatus and experiments for the use of recording instruments with continuous indications].
at the beginning of the last century, introducing his classical polygraph method, studied extensively venous pulsations and helped define the wave forms, their terminology, and their origin. He recognized the main waves, calling them "a," "c," and "v" to denote the first letters of what he assumed to be their anatomic origins, namely the right atrium, the carotid pulse, and the right ventricle. He also described the abnormal venous pulse of tricuspid regurgitation as being dominated by a systolic "v" wave and termed this "ventricular type venous pulse." Since the days of Mackenzie, clinicians have studied venous pulse and pressure contour in a variety of clinical states.
Pathologic physiology and diagnostic significance of the pressure pulse tracings in the heart in patients with constrictive pericarditis and pericardial effusion.
Pathologic physiology and diagnostic significance of the pressure pulse tracings in the heart in patients with constrictive pericarditis and pericardial effusion.
The development of techniques to study blood flow velocity further substantially contributed to our understanding of the mechanisms of venous return and right heart filling.
Using the transcutaneous bidirectional Doppler technique, we had previously presented a systematic classification and correlation of jugular venous flow velocity patterns with both normal and abnormal states of right heart hemodynamics.
The application of these findings to clinical assessment and practice is the subject of this review. Three clinical video recordings of the jugular venous pulsations included in this paper are provided to assist in demonstrating the key points.
Normal Physiology of Right Atrial Pressure Pulse Waves
The pressure in the right atrium at the end of diastole before atrial contraction occurs is normally equal to the diastolic pressure in the right ventricle (in the absence of tricuspid stenosis, which is very rare). This pre-"a"-wave pressure sets the baseline over which the "a" wave and the "v" wave pressures rise in the right atrium. The pre-"a"-wave right ventricular diastolic pressure is influenced by the volume status of the patient, as well as by the diastolic compliance characteristics of the right ventricle and the surrounding pericardium (normally close to 0 to 2 mm Hg). In normal patients in sinus rhythm, the "a" wave is formed by right atrial contraction followed by atrial relaxation. Given that the descents in the right atrium (and by implication in the jugular venous pulse [JVP]) are all named, the falling slope of the "a" wave caused by active atrial relaxation has been termed the x descent (Fig. 1A). The next event in the cardiac cycle is the powerful ventricular systole. In most patients with intact tricuspid valve function, this event is associated with a steep slope of fall in right atrial pressure, termed the x prime (x') descent
It is due to the floor of the atrium formed by the closed tricuspid valve actively being pulled down, causing expansion of the right atrium and a rapid drop in right atrial pressure. One can see this active systolic downward movement of the base of the heart (the tricuspid and the mitral annular plane) in cine coronary angiogram of the right coronary artery. One can also see the tricuspid annular plane moving toward the apex actively during systole in the apical 4-chamber views of the 2-dimensional echocardiographic images, measured as triscupid annular plane systolic excursion (TAPSE)
Prognostic usefulness of the tricuspid annular plane systolic excursion in patients with congestiove heart failure secondary to idiopathic or ischemic dilated cardiomyopathy.
The right ventricular systolic function and its ejection output are mostly dependent on this longitudinal shortening from the base toward the apex.
Figure 1(A, B) Jugular venous pulse (JVP) recording in a patient with coronary artery disease and normal right heart function taken simultaneously with recording of right ventricular (RV) and right atrial (RA) pressures. The x descent in the JVP is due to atrial relaxation following the summit of the "a" wave formed by atrial contraction during sinus rhythm. The x' descent occurs during ventricular systole with rising RV pressure. (B) The diagram shows the closed tricuspid valve forming the floor of the right atrium being pulled down toward the apex during systole. Thick arrow represents the accelerating jugular venous flow velocity during systole. (C) Superior vena caval flow (SVC Fl) velocity recording is shown with simultaneous electrocardiogram (ECG), carotid pulse (CP), and RA pressures, with phonocardiogram at the bottom showing the second heart sound (S2). The systolic flow velocity peak (Sf) is more prominent than the diastolic flow (Df) peak in this adult patient with coronary artery disease with normal right heart function. The Sf peak corresponds to the nadir of the x' descent in the RA pressures occurring in the middle of systole. (D) is from the same patient with jugular venous flow (JVF) velocity recording obtained transcutaneously. The flow velocity patterns are similar to SVC Fl. The Sf in JVF peaks close to the end of systole due to the transmission delay to the neck almost synchronizing with the S2.
The rapid fall in the right atrial pressure during systole (x' descent) leads to an accelerated flow velocity in the superior vena cava and the jugulars. The systolic venous flow into the right atrium leads to a slow build of normal "v" wave in the right atrial pressure. At the end of systole, when the right ventricle begins to actively relax and expand, dropping its pressure to almost zero, the tricuspid valve opens and the right atrium begins to empty, initially somewhat rapidly during the rapid filling phase, and slowly over the slow filling phase. This diastolic filling of the right ventricle is associated with a falling slope of the right atrial "v" wave, and it is termed the y descent. In normal subjects, although the y descent is often seen in the right atrial pressure pulse recordings, it may not be seen in the internal jugular venous pulsations. This finding is explained by the fact that the right atrium is a capacitance chamber. Owing to that capacitance function, as it empties in diastole into the right ventricle, it can accommodate that volume loss without transmitting the resultant pressure fluctuations to the superior vena cava and the jugulars. Therefore, in normal adult patients, the jugular contour is often just a single x' descent. At the end of diastole, the filling of the right ventricle is aided by active contraction of the right atrium during sinus rhythm. This active right atrial contraction leads to the rising slope of the normal "a" wave in the right atrium of the next cardiac cycle. The foregoing description of the normal physiology of right atrial pressure pulse waves indicates that during normal sinus rhythm, 3 descents in the right atrial pressure pulse occur, namely the x descent, the x' descent, and the y descent.
Jugular Venous Flow Velocity Patterns and Descents
Three previously reported pivotal studies of jugular venous flow velocity patterns using the transcutaneous bidirectional Doppler technique combined with long-term clinical observations form the basis of this paper.
The first of these 3 studies was carried out in 174 patients with a variety of cardiac conditions (54 with ischemic heart disease, 68 with valvular heart disease, 19 with congenital heart lesions, 17 with cardiomyopathy, 8 with pericardial disease, 5 with pulmonary hypertension, and 3 with myxoma). Of the 174 patients, 82 had hemodynamic measurements made during diagnostic cardiac catheterization with the Doppler jugular venous flow studies carried out within 24 hours of the diagnostic catheterization.
The 2 subsequent studies were designed to clarify the mechanisms underlying the alterations in flow patterns associated with pulmonary hypertension and open-heart surgery.
The pulmonary hypertension study consisted of 25 patients, with significant pulmonary hypertension confirmed by cardiac catheterization (severe in 15 patients with pulmonary systolic pressure > 80 mm Hg; moderate in 5 patients (60-79 mm Hg); and mild in 5 patients (40-59 mm Hg).
The study to characterize and assess the mechanism behind the changes in jugular venous flow velocity patterns associated with open heart surgery was carried out with 25 patients (19 men and 6 women, ages 29 to 71 years), all of whom underwent coronary artery bypass grafting surgery.
In each of these studies, all patterns of forward flow velocity toward the heart are depicted in the Doppler tracings as upward deflections above the zero baseline.
The initial study (with a variety of cardiac conditions and correlation to right heart hemodynamics) demonstrated clearly that the flow velocity patterns and their variations reflect right heart hemodynamics and its derangement, irrespective of the underlying etiology.
The peaks in the flow velocity in the superior vena cava as well as in the jugulars correspond to the falling slopes of pressure waves in the right atrium, namely the x, x' ,and y descents. The flow velocity curves are similar in the superior vena cava and the internal jugular veins in the neck, except for a slight transmission delay to the neck.
The steepness in the peak velocities of the jugular venous flow reflects the steepness of the descents of the pressure pulse. Jugular venous flow velocity in normal subjects is similar to flow velocity in the superior vena cava, with a dominant flow in systole, namely, systolic flow velocity (Sf) > the diastolic flow velocity (Df).
This corresponds to the more dominant x' descent rather than the y descent in the right atrium (and in the jugulars) of normal subjects (Fig. 1C and D). Diagrammatic representation of the different flow velocity patterns and the corresponding JVP descent patterns are shown in Figure 2.
Figure 2Diagrammatic representation of different flow velocity patterns, both normal and abnormal, and their temporal relationship during the cardiac cycle shown, along with the corresponding descents pattern in the jugular venous pulse. In the patient with normal right heart function, the systolic flow (Sf) is more dominant than the diastolic flow (Df), and in the JVP, the descent pattern is x' > y. Ret Sf, retrograde flow into the jugulars during systole with significant tricuspid regurgitation. Ret Df, retrograde flow into the jugulars during diastole from strong right atrial contraction. ECG, electrocardiogram.
Although no controversy is associated with diastolic inflow occurring following the tricuspid valve opening, controversy and discussion have long centered around the cause of the more dominant systolic flow velocity in normal subjects.
and the descent of the base of the right ventricle (tricuspid valve ring with the closed tricuspid valve) during active ventricular systole, with the latter being the dominant factor.
In normal subjects, atrial relaxation flow is seen on Doppler tracings only as a notch on the upstroke of systolic flow velocity corresponding to the x descent (whereas the peak of Sf, as confirmed by internal pressure and flow recordings, always corresponds to the x' descent
(Fig. 1). The latter effect is due to the contracting ventricle. The drop in atrial pressure may be facilitated by the fall in pericardial pressures that occurs when the volume of the heart decreases during systole.
Alterations from this normal dominant systolic flow velocity (Sf > Df) pattern resulting from various pathologies include the flow velocity patterns of Sf = Df , Sf < Df , and Df alone. In the hemodynamic studies, they were all shown to be abnormal forward flow velocity patterns
(Fig. 2). They correspond to the descent patterns of x' = y or x' < y and single y descent in the contour of the right atrial pressures. The majority of patients with abnormal flow patterns and pulmonary hypertension had increased right atrial "v" wave pressures, implying that the Df velocity must be increased.
This increase was shown to be due to increased right ventricular early diastolic and pre-A wave pressures. Decreased Sf and Df alone patterns (corresponding respectively to x' < y and single y descent) were associated with congestive heart failure and appeared later in the course, in serial observations.
In most patients who have undergone cardiopulmonary bypass, however, the altered flow velocity patterns and descents are not associated with alterations in right heart hemodynamics.
Observations suggest that, postoperatively, the right atrium seems to behave like a conduit rather than as a capacitance chamber. Its capacitance function is likely attenuated in the early postoperative period, owing to edema, and later on owing probably to stiffness caused by scarring. The loss of buffering effect of the right atrium as a capacitance chamber leads to full reflection of the Df velocity at the tricuspid valve to the superior vena cava and the jugulars. When the flow pattern was Sf < Df, the right ventricular systolic dysfunction with decreased ejection fraction was demonstrated.
Generally, the clinical teaching is to look for the internal jugular venous pulsations transmitted to the surface of the neck overlying the region of the sterno-mastoid muscle, recognizing that the latter has 2 attachments—one to the clavicle, and the other to the sternum medially. They may be best seen in the small shallow space between the 2 heads of the sterno-mastoid. Use of a light source is recommended, preferably from the side to cast a shadow over this region, which brings the pulsations into clear view. The internal jugular venous pulsations can be recognized by the movement of the edge of the shadow. With practice, although most students and trainees will be able to identify the upper level of the pulsations and estimate the height of the venous pressure, many will be unable to describe the JVP contours in a way that will be useful clinically. This inability may be due to a lack of understanding of what is being observed. Stressing the usefulness of "the descents," which are the slopes of fall to the nadir (the lowest point), can be of help in this regard. All of the descents are named and have physiological correlates, as described earlier. Recognition of the descents and their patterns is not only the most useful approach clinically but also is the approach most easily accomplished. The descents are fast movements, and they recede from our eye image fields as we look at them and therefore are easily observed. On the other hand, the rises of the jugular "a" and "v" waves are slow, and the summits also are often not high, especially in normal subjects. They are therefore hard to recognize. The descents can also be easily timed to either systole or diastole by palpating the arterial pulse simultaneously. (We prefer using the radial arterial pulse, especially when teaching students, as it allows an unobstructed view of the whole neck region in looking for descents). In a normal subject, one should expect to see just a single x' descent (the fast receding movement of the venous pulse overlying the region of the sterno-mastoid). As this descent occurs with systolic contraction of the right ventricle, it will coincide with the arterial pulse. To check the timing with heart sounds, note that the x' descent will fall onto the second heart sound (S2). The sequence is "descent–S2." One can see the descent and almost immediately hear S2. The y descent, on the other hand, occurs in diastole and therefore will be asynchronous with the arterial pulse upstroke and occurs clearly after the S2 sound is heard. The sequence will be "S2–descent"—that is, one can hear the S2 and then see the descent following it.
Descents in JVP with normal right heart function
In patients with normal right heart function and pressures, one expects to see a single x' descent alone. If a y descent is also noted to be present, along with the x' descent, as may be seen in children, young adults, and pregnant patients, the x' descent will be dominant. In young children, the rapid circulatory state, with the relatively smaller atrial sizes, will allow buildup of the "v" wave, thereby exaggerating the y descent. The pattern, in patients with normal right heart hemodynamics, will therefore be either single x' or x' > y. A good x' descent means good right ventricular contraction and therefore normal right ventricular systolic function, regardless of the underlying condition (Video 1, view video online). The x descent, which occurs with right atrial relaxation in the presence of normal PR intervals, is often the initial part of the single systolic x' descent, and the 2 descents become merged. Sometimes, one may observe what looks like a minor hesitation as the systolic x' descent begins its fall, indicating the x and the x' components. Rarely, if the PR interval is significantly prolonged, one may actually see a separate x descent immediately preceding the dominant x' descent. The descent pattern will be x < x'. This patient was in sinus rhythm with a PR interval of 0.36 seconds. The descent pattern is clearly demonstrated in the video (Video 2, view video online). The pattern is easily distinguishable from a y descent, which should occur in diastole following the arterial pulse or the S2 and therefore following the systolic x' descent.
JVP with double descents
Double descents, whether x' > y, x' = y, or x' < y, generally arise because either the x' descent is decreased or the y descent is exaggerated, or both, similar to the corresponding flow velocity peaks (Fig. 2). If the jugular contour suggests equally prominent slopes of the fall of x' as well as y descents, the pattern is termed x' = y. The presence of the "v" wave is deduced when a dominant y descent is present, irrespective of whether the rise of the "v" wave is clearly visible or not. The pattern x' = y immediately indicates 2 things. The first is that the preserved and good x' descent means that the right ventricular systolic function is likely still good and that "no significant" tricuspid regurgitation is present. The second point is that the y descent is most likely exaggerated. The causes of decreased x' descent and exaggerated y descent are listed in Table 1. A decreased x' descent implies diminished right ventricular contraction. Exaggerated y descent requires increased right atrial "v" wave pressure without any restriction to ventricular filling during the rapid filling phase of diastole. Both of these conditions are met under the following circumstances (Table 1): (i) high sympathetic tone with rapid circulation, as in children and young adults; anxiety; anemia; pregnancy; and thyrotoxicosis; (ii) hypervolemia; (iii) an extra source of venous filling, as in atrial septal defect; (iv) pericardial effusion without tamponade but with some restriction; (v) constrictive pericarditis; (vi) pulmonary hypertension with elevated right ventricular diastolic pressures; (vii) ischemic or infarcted right ventricle; (viii) cardiomyopathy with elevated right ventricular diastolic pressures; (ix) in post-cardiac-surgery patients (in whom the y descent is exaggerated, but the "v" wave pressure is not usually elevated, most likely from the changes in the capacitance function of the right atrium, as pointed out earlier). Although the y descent may be exaggerated with higher "v" wave pressures in patients with pericardial effusion, if it is dominant or equally dominant (that is, the pattern is x' < y or x' = y), then one can immediately exclude cardiac tamponade at the time of the assessment. In cardiac tamponade, the 4 chambers of the heart are boxed in a pericardial sac with fluid or blood, with high intra-pericardial pressures. The blood can enter this boxed heart only when the blood leaves the box, namely, during systole. Diastolic filling of the ventricles from the atria is quite compromised and can occur only by passive transfer across the open tricuspid and mitral valves during diastole. Therefore, one will not expect to see any descents, let alone diastolic y descent. The jugular veins will be truly distended with very little pulsation, and the top of the column can be well above the neck region. With great difficulty, one may be able to record systolic flow in the jugulars or the superior vena cava toward the heart, and that too only during inspiration.
Therefore, in following patients with pericardial effusion, the presence of a good y descent is a very helpful and easily assessable clinical bedside sign that logically favours the absence of cardiac tamponade. This sign becomes useful clinically for follow-up of patients with pericardial effusion.
Table 1Causes of decreased x' descent and exaggerated y descent
Decreased x' descent
1.
Diminished RV contraction, e.g.,
RV failure in pulmonary hypertension
Post-cardiac-surgery RV damage
RV infarction
2.
Atrial fibrillation due to loss of Starling effect
Given that double descents in the jugulars (x' > y, x' = y, and x' < y), as mentioned above, also may be noted in patients with pulmonary hypertension, one needs to look for clinical signs of pulmonary hypertension. If the patient were to have clinical signs of pulmonary hypertension (palpable P2 in the 2nd left intercostal space near the left sternal margin, sustained right ventricular impulse felt by sub-xiphoid palpation together with electrocardiographic evidence of right axis deviation or right ventricular hypertrophy), the presence of x' = y descent pattern in the jugulars will correlate with significant pulmonary hypertension with pulmonary arterial systolic pressure of 75 mm Hg or more
(Video 3, view video online). Furthermore, the preserved x' descent will indicate preserved right ventricular systolic function with no or only mild tricuspid regurgitation. The exaggerated y descent, however, would imply elevated right ventricular pre "a" wave and early diastolic pressures. Patients with double descents with the x' = y pattern and elevated venous pressures, with no clear cut clinical signs of pulmonary hypertension, warrant imaging assessment including Doppler assessment with 2-dimensional echocardiography to rule out pulmonary hypertension. If double descents are noted and the pattern happens to be x' < y, this indicates decreased right ventricular systolic function with possible tricuspid regurgitation. Mild tricuspid regurgitation will not totally eliminate the systolic x' descent. However, significant tricuspid regurgitation will do so and will result in a large, actively rising wave, termed the "cv" wave, during systole, followed by a single y descent. The jugular pulsations with this pattern will be visible from several feet away from the patient with the patient sitting up. In the presence of significant pulmonary hypertension, serial observations of JVP descent patterns reflect the progression from a compensated state to decompensation with right ventricular failure.
In the early compensated state with right ventricular hypertrophy and preserved systolic function, the JVP descents will be dominant (x' > y); this pattern will eventually change to x' = y with further elevation of the right ventricular diastolic pressures. With further progression and onset of right ventricular systolic dysfunction, the dominant y descent pattern will emerge (x' < y), and eventually, with further deterioration and right ventricular dilatation, the contour will change to large "cv" waves with a single y descent.
Very rarely, in some patients with severe mitral regurgitation, the jet of regurgitation directed toward the inter-atrial septum may result in inter-atrial septal bulge into the right atrium during systole. This bulge may diminish the full effect of the descent of the base on the right atrium, resulting in decreased x' descent. This decrease in x' descent is explained by a "Bernheim" type effect on the atrial septum.
In such patients, the y descent may be exaggerated as well, without significant elevation of the v wave pressure by the sudden emptying of the left atrium and reversal of the systolic bulge of the inter-atrial septum.
Differential diagnosis of JVP with double descents in adult patients therefore requires consideration of the various conditions listed in Table 1, both with and without the presence of pulmonary hypertension.
JVP with prominent rises of waves
Unlike normal "a" and "v" waves which have low pressures and relatively slow rises, and are therefore often not seen in the neck, abnormal “a” and “v” waves have higher pressures and sharp rises, and so one may be able to see them. Marked tricuspid regurgitation with large tall "cv" waves was referred to previously. Such waves are associated with retrograde systolic flow away from the right atrium toward the superior vena cava and the internal jugulars. The large tall "cv" wave will rise with the arterial pulse, followed by a single y descent, which will fall in diastole after the arterial pulse is no longer felt by the palpating hand. The descent therefore will fall after S2 and its timing will be asynchronous with the arterial pulse. Unlike the "cv" waves with longer duration, prominent "a" waves often have sharp quick rises due to the short duration of the atrial systole. They may be noted in the presence of atrioventricular dissociation as in complete A-V block due to atrial contraction against the closed tricuspid valve secondary to simultaneous ventricular contraction. In this instance, they will be irregular. The sharp rises will attract the eyes and are associated with retrograde flow in the superior vena cava and the jugulars. They are termed "cannon waves," and typically, they have short duration. Rarely, in patients with severe pulmonary stenosis and patients with early stages of significant pulmonary hypertension with preserved right atrial function, one also may see regular prominent "a" waves with retrograde flow from the right atrium to the jugulars. Typically, these have sharp rises and short durations and are followed immediately by good x' descent indicating preserved right ventricular systolic function (Fig. 2).
JVP descents in atrial fibrillation
Atrial fibrillation is a fairly common arrhythmia encountered in clinical practice. The atrial contraction acts as a boost to the ventricular contraction and sometimes may contribute up to one fourth of the ventricular output. The atrial kick will be lost in atrial fibrillation irrespective of the background cardiac condition and its etiology. The arrhythmia is well known to produce an irregularly irregular peripheral pulse. If the underlying right ventricular function is relatively normal, the rhythm by itself will not lead to elimination of the x' descent. The varying diastolic intervals with resultant variations in the diastolic filling will affect the systolic outputs, making them vary from beat to beat. If the right ventricular function is preserved, one may still see a preserved x' descent in the context of irregular pulse. However, more often, atrial fibrillation will develop in patients with underlying heart disease with compromised biventricular function. In such patients, the irregular pulse will be accompanied by a single y descent. It will be clearly discerned in beats followed by a long diastolic pause.
Conclusion
Proper clinical assessment of the JVP requires a clear focus on the descents and their patterns, as described here. Such assessment provides much more useful information about the right heart function than simply assessing the patient's volume status by looking at only the height of the jugular venous pressure. Such assessment is easy to do and easy to teach, even to beginners. Also important to note is that the relationship between the x' and the y descents in patients with double descents does not alter, even when the volume status is altered by either diuretics or by volume infusion.
This lack of alteration is an added clinical advantage. In addition, the descent patterns provide a quick glimpse into the state of right ventricular function and are helpful in making a clinical diagnosis. A classic example of this usefulness is the ability to diagnose constrictive pericarditis at the bedside in patients presenting with congestive symptoms. Other examples include patients presenting with acute inferior infarction or with acute myocardial infarction with heart failure symptoms. Finally, when the jugular descent pattern is abnormal, consideration of the causes of both decreased x' descent and exaggerated y descent, as discussed in this paper, will help in the reaching the proper clinical evaluation of the patient at hand.
Acknowledgements
We express our sincere thanks to our colleague and friend Mr. Roger Harris, exchief of the audio-visual department of St. Joseph' Health Centre of Unity Health Toronto (30, The Queensway, Toronto, Ontario, Canada), for his help in the preparation of the illustrations.
Funding Sources
The authors have no funding sources to declare.
Disclosures
The authors have no conflicts of interest to disclose.
The video of the jugular venous pulsations (JVP) in the neck with simultaneously recorded audio of the heart sounds from the 2nd left inter-costal space near the left sternal border from a 65 year old man with mild obstructive coronary artery disease with risk factors of hypertension and dyslipidemia, during a recent routine follow up visit. The second heart sound (S2) is well heard and the first heart sound is not audible. A single decent in the venous pulsation clearly seen synchronous with the S2 showing thereby that it is the normal x' descent. JVPcontour is indicative of normal right ventricular systolic function and normal right heart hemodynamics.
This JVP video is from a 67 years old gentleman with known bicuspid aortic valve with dilated aortic root and ascending aorta with moderate aortic regurgitation, who has been clinically stable. The recording is made recently during routine follow up visit. The simultaneous audio of the phono recording is taken from the 3rd left intercostal space near the left sternal border. The S2 is clearly heard. The first heart sound was quite soft and not heard on this recording. The JVP clearly shows two descents. The dominant descent is seen to occur synchronously with the S2, confirming that it is the x' descent indicating normal right ventricular systolic function. In addition to this x' descent, another descent not as deep as the x' is also seen. It does not occur after S2 thereby indicating that it is not a y descent. This extra descent is seen to immediately precede the dominant x' descent. Therefore it is an x descent due to atrial relaxation. The rhythm is regular. The fact that the x descent is clearly seen separated from the x' descent implies that the PR interval in this patient must be prolonged. In fact, the patient had first degree AV block on the electrocardiogram during this visit (PR interval measured 0.36 sec).
This JVP video is from a 58 years old man with risk factor of hypertension with clinical evidence of mitral stenosis with significant calcification in the mitral valve in the 2D-Echocardiographic images. The JVP video is shown with simultaneous recording of carotid arterial flow audio signals from the opposite side of the neck to indicate the timing of systole. Two descents are seen clearly equally dominant in the JVP. One is systolic and coincides with the Doppler arterial flow signals and the second descent is diastolic. JVP contour is therefore "double descents" with the pattern of x'=y. While one can deduce that there must be "a" and "v" wave each preceding respectively the x' and the y descents, their slopes of rise are not prominent. This x'=y JVP pattern in this patient with mitral stenosis, is most likely indicative of the associated pulmonary hypertension. This pattern in the presence of pulmonary hypertension is usually associated with significant pulmonary hypertension in excess of 75 mmHg.
At cardiac catheterization, this patient had pulmonary arterial pressure of over 100 mmHg. The preserved x' descent means normal right ventricular systolic function with no more than mild tricuspid regurgitation. The exaggerated y descent implies elevated right ventricular pre "a" wave diastolic pressures due to right ventricular diastolic dysfunction.
References
Harvey W.
Exercitatio anatomica de motu cordis et sanguinis in animalibus. Frankfurt: Gugliemi Fitzeri, 1628. English translation by Leake DC. [An anatomical exercise on the movement of the heart and blood in animals].
Uber die saugkraft des herzens. Ubbersicht der arbeiten und veranderungen der schlesischen gesellschaft fur vaterlanndische kultur im jahre [About the suction power of the heart, review of the works and changes of the Silesian society for patriotic culture in the year]..
Appareilles et experiences cardiographiques per l’emploi des instruments enreistreures a indications continues [Cardiographic apparatus and experiments for the use of recording instruments with continuous indications].
Pathologic physiology and diagnostic significance of the pressure pulse tracings in the heart in patients with constrictive pericarditis and pericardial effusion.
Prognostic usefulness of the tricuspid annular plane systolic excursion in patients with congestiove heart failure secondary to idiopathic or ischemic dilated cardiomyopathy.
view video online). The x descent, which occurs with right atrial relaxation in the presence of normal PR intervals, is often the initial part of the single systolic x' descent, and the 2 descents become merged. Sometimes, one may observe what looks like a minor hesitation as the systolic x' descent begins its fall, indicating the x and the x' components. Rarely, if the PR interval is significantly prolonged, one may actually see a separate x descent immediately preceding the dominant x' descent. The descent pattern will be x < x'. This patient was in sinus rhythm with a PR interval of 0.36 seconds. The descent pattern is clearly demonstrated in the video (Video 2, 
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