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Jugular Venous Pressure: DR - Sameer Ambar JNMC & Kles Hospital Belgaum
Jugular Venous Pressure: DR - Sameer Ambar JNMC & Kles Hospital Belgaum
The internal jugular vein begins just medial to the mastoid process at the base of the skull. The internal jugular vein runs directly inferior from the mastoid process, passing under the sternal end of the clavicle. Here it joins the subclavian vein, and then runs into the superior vena cava and then into the right atrium.
ANATOMY
jugular venous pulse) is the indirectly observed pressure over the venous system.
Classically three positive waves and two negative troughs have been
described.
The positive waves are
"a" (atrial contraction), "c" (due to bulging of tricuspid valve into the right atrium during isovolumic systole) and "v"= atrial venous filling.
The two negative troughs are
between the angle of Louis (manubrio sternal joint) and the highest level of jugular vein pulsation. A straight edge intersecting the ruler at a right angle may be helpful. Measure elevation of neck veins above the sternal angle (Lewis Method). Add 5 cm to measurement since right atrium is 5 cm below the sternal angle.
MEASUREMENT OF JVP
Causes of JVP
infarction.
2. Obstruction to RV inflow- TS, RA myxoma
Prominent a waves;
severe RVH- severe PS with intact IVS - severe Pulm HTN with intact IVS RV cardiomyopathy. Acute pulmonary embolism. Acute TR
Cannon a waves
Absent a waves
Regular- junctional rhythm - VT 1:1 retrograde conduction Irregular- CHB - VT - ventricular pacing - ventricular ectopy
Atrial fibrillation
Abnormal x wave. 1. Absent x descent- AF, TR. 2. Prominent x descent- constrictive pericarditis.
- cardiac tamponade.
Abnormal v waves.
1. Prominent- Tricuspid regurgitation ,RV failure,, ASD, ASD
Rapid- RV failure, TR, ASD, ASD with MR & constrictive pericarditis 2. Slow TS, pericardial tamponade & tension pneumothorax.
1.
x descent Normal
v wave
Normal
Obstruction to RA emptying.
a wave
Severe TR and small RA or acute TR Large wave with small RA & severe TR Mild TR with large RA or chronic TR rapid filling of RV Slow filling of RV
Normal
y descent Steep Slow with TS
x descent Normal or obliterated with severe TR v wave Normal or with RV failure y descent Normal or rapid with RV failure
a wave
x descent
v wave
Normal or absent
Normal or prominent Normal or Rapid or Slow
Absent AF , severe TR
RV failure TR
y descent
a wave
Prominent
Severe PAH with MR Severe PAH with TR IWMI + RVI with MR due to papillary muscle dysfunction MR with ASD PAH & RV failure Associated with TR Any of the above disease.
Level
a wave
x descent
Normal Elevated --- RVF secondary to LVF Associated MS + PAH + RVF Associated organic TV disease Prominent Severe AS- severe septal hypertrophy Mild AS- HOCM, MS+ PAH, TS or severe AS with LV dysfunction ( AS is underestimated) Normal -
v wave
y descent
Normal
Normal
a wave
JVP in ASD
Level Normal Elevated ----- Mitral valve disease LVF Severe PAH with RV failure Associated TAPVC Normal Prominent --- MS, PAH, PS Normal -
a wave
x descent
v wave
Prominent
Overfilling of RA vena cava & LA PAH with TR Associated MR Any of the above cause
y descent
Prominent
JVP in VSD
Level Normal Elevated -------Small VSD Large VSD + CCF VSD + MR/TR LV RA ( Gerbodes defect) Restrictive VSD with severe PS
a wave
x descent
v wave
CCF, TR,
y descent
TGA, TAPVC
a wave
N N
v wave
x, y descent
Cause
Anemia Systemic HTN
Mechanism
Volume load Non-compliant ventricle Biventricular failure AR,TR, Anemia, CRF Volume load Ventricular dysfunction Volume load Myocardial dysfunction
Infective endocarditis
AR Cardiomyopathy Associated PDA Adult tetrology
Tricuspid atresia PS intact IVS + RL atrial shunt TAPVC Pulmonary atresia with intact IVS TOF- Adult tetrology, HTN, Restrictive VSD, Cardiomyopathy
JVP in cardiomyopathy
DILATED RESTRICTIVE
Level
a wave x descent
N/
Normal Normal
N/
Prominent Normal
v wave
y descent
N / prominent
N / prominent
Normal
Normal
Kussmauls Sign This is a rise in the JVP seen with inspiration. It is the opposite of what is seen in normal people and this reflects the inability of the heart to compensate for a modest increase in venous return. This sign is classically seen in constrictive pericarditis in association with a raised JVP. This condition was originally described in tuberculous pericarditis and is rarely seen.
Kussmauls sign is also seen in right ventricular infarction, right heart failure.
Cardiac compression high intrapericardial pressure Atrial compression prevents atrial contraction Fall in atrial pressure ventricular contraction descent of atrioventricular septum Atrial filling is preserved Ventricular compression - high intrapericardial pressure Additional venous return not admissible - Cardiac compression
a wave x descent
Elevated severity Variable degree of cardiac - constriction compression. N N / exaggerated N / = a wave Rapid / steep Atrial constriction does not permit atrial contraction Constriction around AV groove excessive descent of AV septum. Venous return to RA unaffected Rapid ventricular filling active ventricular relaxation. Coincides with diastolic outward movement of pericardium & pericardial knock Additional venous return not admissible RV constriction
a wave x descent
v wave y descent
Kussmauls sign
+ve
MECHANISM
Ventricular/ Valvular dysfunction
Cardiac tamponade
RV infarction Acute pulmonary embolism Tension pneumo-thorax
Cardiac compression
RV failure & inadequate LV filling Pulmonary circulation obstruction. Cardio respiratory failure
& QRS complex in ECG. Normal sinus rhythm is characterized by sequential a & v waves. A wave occurring along 1st heart sound normal PR interval. Any disturbance in this wave form indicates rhythm abnormality.
Rhythm
Sinus I AV block
A-V sequence
a - v regular a precedes v regularly
Cannon waves
Absent Absent / rarely with extreme PR prolongation
Wenckebachs
Mobitz II block II AV block CHB VT Atrial tachycardia
Absent
Absent Absent Present & irregular Irregular Absent