Now we should be, we will be discussing about JVP. Right? JVP. JVP stands for what?
Yes, Dr. Sir. Jugular venous. Jugular venous? Pulse or pressure? For both.
For both. When we say check the JVP of the patient, we are supposed to see that can you really check what is the pressure in the jugular system and what are the pulse formation or waveform in the jugular system. So it stands for jugular venous.
pressure as well as jugular venous pulsations pulsations right now let's go to the fundamental concept related with jvp as you know that internal jugular vein is the mano is draining into superior vena cava which eventually drain into right atrium right and let's draw a diagram and see what is exactly there Now here is right heart, this is of course inferior vena cava, here is right atrium and here is right ventricle and this is spiro vena cava. Spiro vena cava has internal jugular vein draining into it. Right, let's suppose this is right internal jugular vein.
Internal jugular vein. Now you see that in the right atrium whatever the pressure of the blood is there it is very fatally communicated back into venous system. The reason being that there is no sphincter or valve between the right atrium and the cable system.
At this point there is no valve present between the right atrium and the cable system venous system due to that reason whatever pressure is present right atrium is very faithfully transmitted into venous system backward especially in and from the internal jugular vein it can be observed right now let's suppose this is the blood which is present in right atrium and this is the blood column in cable system Now this blood column is going up to internal jugular vein. Now normally the maximum pressure which is in the right atrium in normal circumstances is about 8 cm of water. The pressure is 8 cm of water in the right atrium. So it means if a person is sitting vertically, right, then the pressure will go up to what level? It will go how much up?
Up to 8 centimeter of water column above the mid of the mid of the right atrium. 8 centimeter above. This is the pressure here. So naturally this is the pressure with which you can say jugular pressure is maintained. So total blood column from the center of the right atrium up to internal jugular pulsation is 8 cm of water.
Now here I want to highlight one important thing that at the angle of Lewis, the distance of angle of Lewis from the you know sterno-minibrial junction right the distance from this point up to here is about roughly about depending upon the belt of the person is about 5 centimeter that is about 5 centimeter it means the vertical height of these pulsations above the sterno-manubrial junction above the sterno-manubrial junction should be how much attention please if you say from here center of the atrium right atrium it is going up to eight centimeter and we say from here up to your sterno manubria junction or angle of layers it is five centimeters so how much should be above it three centimeter it means that in a normal person usually we expect the jugular venous pressure should be around 3 cm. So exactly how we define jugular venous pressure? Jugular venous pressure is the vertical height of blood column present in jugular system, internal jugular system above the sterno-manubrial angle.
What is jugular venous pressure? Attention please, jugular venous pressure means that if you look at the vertical height of blood jugular venous pulsations vertical height of jugular venous pulsations above the angular fluids or sterno-manubial angle and usually it is about three centimeter and when it is more than four centimeter it is considered elevated. when it is more than 4 cm then it is considered elevated.
Is that right? Now why jugular venous pulsations and pressure is so important? The reason being that internal jugular vein is communicating through the superior vena cava up to the right atrial cavity and there is no valve in between.
So it means all the pressures and pulsations which are present in the right atrium they are very faithfully transmitted into internal jugular vein and if they are so faithfully transmitted to internal jugular vein it means this is a biological manometer internal jugular vein act as a biological manometer applied to the right heart or more truly speaking attached to the right atrium is that right it means that internal jugular pulsations here are all the time measuring the pressure changes and pulse patterns of the right atrium. Is that clear to everyone? Now, what is the normal waveform of the internal jugular system? Let's suppose hypothetically we are thinking, just to explain it to you hypothetically, let's suppose there's a ball present over here and this ball is floating at the upper end of the column of blood within internal jugular. when this ball is floating into that.
Now from this ball, from this ball if you bring out pointer here and their piece of paper, it is only hypothetical of course we don't do like this but just to explain it to you, there is a roll of paper which is moving in this direction and here is the pointer. Now what really happens? If ball is stationary right it will draw a straight line.
Let's start with the beginning of cardiac cycle. Acid node fires and first of all which part will contract? Atrium. When right atrium contracts, when the right atrium contracts what really happens?
That pressure in the right atrium increases. When right atrium contracts, pressure in the right atrium increases. Purpose of this increased pressure is to push the blood to right ventricle.
But actually because there is no valve between the right atrium and the internal jugular vein system, so there is a back pressure. Due to that reason, when right atrium contracts, this column moves slightly upward. When this column moves upward, it means this pointer will move upward and it will draw a wave like this.
And this is called A wave. So A wave is due to this is what that when right atrium contracts jugular venous pulsations move upward jugular venous pulsations move upward and this upward movement is A wave which is due to atrial contraction. Is that right? Now in the cardiac cycle what is the next point?
The next point is that okay I will draw it here that A wave is due to what factor due to contraction of Yeah, atria. This is the contraction of atria which lead to the A wave. This is the contraction of atria which has led to the A wave. Is that clear to everyone? Now, what is the next point?
Once atria has completed its contraction, right, blood has been thrown from the atrium to the ventricle. Now there is onset of ventricular contraction. When right ventricle start contracting, right now listen carefully, as soon as atria has completed its contraction, it will start relaxing. When atria will start relaxing, this column will start moving downward.
This column will start moving downward. So from this point, what is, from this point onward, atria start relaxing. As soon as atria start relaxing, this column will start moving.
downward then suddenly ventricular contraction start. When ventricular contraction start right what happens that rising intraventricular pressure, rising intraventricular pressure closes the tricuspid valve right and rising intraventricular pressure transmits the increased pressure to atrium and especially when valve closes, listen here, look here, when valve closes, pressures are rising down, pressures have been transmitted up, yet blood has not gone up, right, and valve closes. As soon as valve closes, the column which was going down, it will have abrupt cessation. So there will be jerk here and this jerk is called C wave and this C wave is actually due to the onset of ventricular contraction.
So this is the onset of ventricular systole. This is the onset of ventricular systole. Now this valve is closed. Look here.
Now atria is a, this valve is closed and ventricle is contracting. Now for the time duration for which ventricle is contracting, the time duration for which the ventricle is contracting, atria keep on relaxing, right? And tricuspid valve is pulled downward.
So it keep on accommodating more blood due to this reason this column keep on falling. So pressure keep on falling. This descent is called X descent. So what is the cause of this descent?
Listen again. Recap up to this. In the beginning of the cardiac cycle right, acenode fired, atria contracted.
With the contraction of the atrium there was back pressure to the venous system. and A wave is produced in jugular venous JVP. What is this?
A wave is produced. Then, atria start relaxing and pressure start falling in jugular system. When pressure is falling, suddenly there is onset of ventricular contraction and there is rising intraventricular pressure, transmit pressure to the atrium as well as the sudden closure of tricuspid valve and this produces a little small wave which is usually not visible in the neck.
right, C wave right and after that communication between the atria and the ventricle is cut off due to closure of the tricuspid valve but atria keep on relaxing and tricuspid valve by the ventricular system is pulled downward so it atria can accommodate more, atrium can accommodate more blood so column comes down, is that right? Now once column of the, column has come down let's pose up to this level and look here please. When column has come down up to this level and atrium is completely relaxed.
Atrium is completely relaxed. Now it cannot further relax. Now atrium cannot further relax. Right? So now whatever more blood is coming back, coming, do you think it can be accommodated?
No. So now blood can start accumulating and this ball starts moving up. So now at this particular point, atria has been filled, right?
completely relaxed and now more venous return is leading to increased pressure in the jugular venous system right and this is called v wave what is it called v wave v wave is due to accumulation of venous return in the right atrium and cable system and jugular system am i clear now after this Suddenly there is onset of ventricular diastole. What is there? There is onset of ventricular diastole. With the onset of ventricular diastole the valve open. Which valve open?
Trichospid valve open. As soon as trichospid valve open blood from the atrium start falling into ventricle and jugular venous pressure start going again down and this is called y descent. Is it right? This during one cardiac cycle, this is the behavior of jugular venous pulsations in the neck. Right, first they will slightly go up due to atrial contraction, then they will start coming down due to atrium relaxation, but there will be little jerk due to tricuspid closure and then atrium keep on relaxing, so blood column keep on falling, pressure keep on falling in the jugular system.
And then once atrium is completely relaxed, further venous accumulation will lead to another wave formation which is called V wave. Right, so we can say during one cardiac cycle. Jugular venous JVP present three positive waves and two descents.
Positive waves are A wave, C wave and V wave. And descents are X descent and Y descent. Now let me explain it with further detail.
Now what's here? What is this? A wave which is due to atrial contraction.
What is this? C wave which is depicting the onset of ventricular. Cystole with closure of tricuspid valve and what is this V wave which is representing what venous accumulation in the jugular system. Now actually A wave represent what activity right A wave represents atrial contraction so we can make it like this that A wave represent atrial systole. up to this point what is this?
Atrial, yes please, systole. After that atria start relaxing. So what is there? Atrial, diastole. Now what is going on?
Here it is atrial, diastole. And atrium is still in diastole and blood is accumulating in jugular venous system. Is that right? So what is this? Atrial, diastole.
You know, ATI has systole of 0.1 second and diastole of maybe 0.7 second. One cardiac cycle is about 0.8 second if your heart rate happens to be 72 per minute. This is the relationship of JVP with atrial systole and atrial diastole.
It means A wave is the part of atrial systole and remaining C wave, X descent and Y descent and V wave. All these things occur during atrial diastole. Now let's correlate it with ventricular systole and diastole. Ventricular systole started from this point with the C wave.
So this is ventricular systole and it continues up to the, yeah this is ventricular systole. right that with the onset of the ventricular systole there is which wave? C wave right and at the end of the ventricular systole and onset of the ventricular? Yes?
Dastole. With onset of the ventricular? Dastole. There is opening of which valve? Tricuspid valve and this time duration is presenting ventricular?
diastole. So look, when there is ventricular systole, atrial diastole is there. Look here please in the diagram.
When ventricular, yes, systole occur, onset of the ventricular systole, there is already commencement of atrial diastole and due to atrial diastole, because atrium is relaxing, this is falling. But onset of ventricular systole and closure of the tricuspid valve produces little jerk. But after that, relationship between the ventricle and the atrium is lost.
Atrium remain relaxed, right, and ventricle is undergoing contraction. So until ventricle remains under contractive phase, right, tricuspid valve remain closed. So initially when atria was still relaxing, blood column, you can say jugular venous pressure were coming down until it came down as much it could.
After that further venous accumulation accumulated the blood within jugular system and that led to the V wave. But really at the peak of the V wave and suddenly there is a Y descent. Y descent is telling the onset of ventricular dastardly and opening of tricuspid valve.
And there is opening of tricuspid valve. Am I clear to everyone? Now again if you really continue.
what will happen here again there is a wave c wave and so under these circumstances it means here there is onset of atrial systole and then there is atrial dashley and here there was what was here ventricular systole is it clear to everyone Another way to explain JVP is, is that clear? That what are the exactly going in the heart when A wave is coming? When A wave is being formed, what really happens?
Right? This is A wave formation. What really happens?
Actually when A wave is being formed, what is really happening is that this valve is open right tricuspid valve is open and atria is yes please contracting and atrium is contracting and due to that reason there is some back pressure going on so main event is that this valve is open blood is moving from atrium to ventricle but because hm is squeezing some back pressure is there Right? Not only blood is moving towards forward, some back pressure there and this takes the JVP to A wave. Is it clear? Then after that there was this X descent. What really happening during the X descent?
During the X descent, what was happening? During the X descent, especially at this point C wave what is there that what has closed which valve is closed tricuspid valve and it has started there is outflow started during ventricular systole outflow started from the pulmonary system but there is no you can say communication between atrium and ventricle Now this is the time when there is onset of ventricular contraction. Here it was which contraction? Atrial contraction followed by relaxation of atrium. Atrium is now relaxing, opening up.
Right? It is relaxing. But as soon as ventricular contraction starts, it shuts down the tricuspid valve. And as soon as it closes, what is this? C wave.
Is that right? After that, atrium keep on relaxing and pressure keep on falling and this is due to continued atrial dysplasia. Now why the, what happens at the V wave time? When V wave is being formed at that very moment, actually tricuspid valve will be closed and what is this?
Ventricle is still contracting, is that right? when V wave is coming and now there is continued accumulation of blood in venous system right and because blood cannot move forward and atria cannot relax so further incoming blood takes the jugular venous pressure upward and which wave is formed? V wave.
V wave which form? V wave. Then at this particular moment what really happens?
There is onset of ventricular darsely. Right at this particular moment what really happens? Why there is y descent?
Because this onset of ventricular darsely. So the diagram which will go, it should go like this that now which valve is again opened? Trichospid valve.
And now what is relaxing? Ventricle. Ventricle. Because ventricle is relaxing or this is Going in.
diastole. Is that right? At this moment ventricle is going into diastole.
So accumulated blood, the blood which was accumulated in atrium, this will simply fall, you can say early passive filling of the ventricle. When passive filling is occurring, blood is moving from the venous system to now. What has happened? What is the cause of y descent? Why this pressure fall?
The reason being this valve is open and blood is rapidly entering into ventricle. So this column has to come down until it again contracts it will go up with a wave. Is that clear to everyone?
So this is what exactly is happening during the normal physiologically speaking JVP. What is the method to determine? the jugular venous pulsations and the pressure.
We will discuss here it very briefly. Mainly you will be learning how to take JVP in your clinical rotations through your wards. Right now just for basic concept when you are going to determine JVP you have to remember this is the vertical height of jugular venous pulsations.
The vertical height of jugular venous pulsations above the sterno-menubrial joint. Now Exactly first I should tell you just focus on me please not on that man with the big nose. Look what really happens that jugular venous, internal jugular vein when you are going to look for that bend the head of the person little bit and tilt to the opposite side and you should look for this remember neck should be little bit relaxed so that fascia should not compress the pulsations.
And from the ear lobe if you look downward somewhere between the sternoclavicular you can see heads there is clavicular head and this sternal sternum astride clavicular head and sternal head in between that point up to your lobule from the back of the angle of the jaw along this line you have to look for the jugular venous pulsations the best way to look for that is you look from the side from the tangent these are very fine pulsations uh initially it is really difficult to appreciate their presence but with practice as you keep on looking for more and more next in your clinical factor you will start look for the JVP. Now normally what happen that JVP can be determined either patient is sitting at 90 degree or patient is back is patient is reclining at 45 degree but in both methods you have a jugular venous pressure will be determined as vertical height taken from sterno-manubrial joint up to the pulsations. For example now this is a patient and he is sitting on the couch right with 45 angle. Now you are looking from the ear lobe up to the neck from the sides.
Let's suppose at this particular point you see there are some pulsations in the neck. Right? Now first of all you have to confirm are these venous pulsations or are these arterial pulsations? Let me explain the difference between venous pulsations and arterial pulsations.
Venous pulsations here are like suction pulse, they move up and down and carotid arterial pulsations move in and out. So we can say carotid pulsations are expensile pulsations but venous pulsations are yes, suction pulsations moving vertically. Another point which is important is during one cardiac cycle, arterial pulsation is one pulse but venous pulsations during one cardiac cycle you can see two pulses up and down.
Then another point which is important and that is very important that arterial pulsations are palpable but usually venous pulsations are not palpable until there is tricuspid regurgitation. Then another point to differentiate is that if you press at the root of the neck, if you press at the root of the neck, arterial pulsations will be still visible and palpable but if you compress at the root of the neck, venous pulsations will disappear, right? And they will start moving upward because when you press at the root of the neck then then this pressure may be enough to stop the pulse pattern from the right atrium to be projected to the internal jugular vein then another way to differentiate is that you press right upper hypo quadrant of the patient in the abdomen right and when you press it if there's an arterial pulse there won't be any change in that but if there's venous pulse with compression this will move Upward, is that right? So how many ways? Number one Number 1, arterial pulsations are Expansile pulsations, venous pulsations are suction pulsations.
Arterial pulsations are in and out, venous pulsations are up and down. Arterial pulsations are palpable, usually venous pulsations are not palpable. Arterial pulsations are not changed with posture, venous pulsations position in the neck is changed with posture.
Arterial pulsations are not altered with the pressure at the root of the neck. Venous pulsations pattern is altered when you press at the root of the neck, of course gently. arterial pulsations are not affected by pressure at the right upper quadrant of the abdomen right but venous pulsations may move upward is that right now if patient is at 45 angle how you really determine right the jugular venous pressure jugular venous pressure i told you this is the vertical height from angle of loess right and if patient is angulated then with one you can say what is this This may be a horizontally you put there a ruler right and then you measure the vertical height from the angle of this up to the horizontal ruler.
This should be ideally somewhere around three to four centimeter but if this length become more than four centimeter then it is considered pathologically elevated. So not only you have to look for where are jugular venous pulsations you have to also determine what is the pressure. it is three centimeter four centimeter or five centimeter then another very important point you have to look for the pulse pattern you have to look for the pulse pattern you know a wave is when atria contract this pulse goes upward then what happens atria start relaxing pulse will start going downward with a little uh only a very good clinician can judge when there's onset of ventricular systole there's c wave and there's x descent continuing eventually Then when further descent cannot continue, this venous accumulation leading to again elevation of this column. So what we can say, when atria contract, column moves upward, right?
Then when atria start relaxing, column start moving downward. Then venous accumulation lead to again column moving upward. And eventually when a tricuspid valve open with the onset of ventricular, that's the way column moves downward.
Is that clear? So you should be able to see that, A wave or V wave are the normal in their magnitude or there is some abnormality. Let's discuss few abnormalities related with jugular venous pulsations.
First I will draw the normal jugular venous pulsations. And then we'll see some patterns which are altered. Let's suppose here is a person.
and this is his normal jugular venous pattern. This is the normal jugular venous pattern. Right, of course this is A wave due to atrial contraction.
This is which descent? X descent, this is C wave and what is this wave? V wave and Y descent. Right, now X descent is this one and Y descent is this one.
and A wave is here and V wave is here. Is that clear to everyone? Now you understand this is atrial contraction, onset of atrial diastole. But here it is onset of ventricular systole and collier is the tricuspid valve. Then atrial diastole continues, maximum accumulation of blood in the atrial system.
Further accumulation of blood lead to V wave. Now number one sometimes pattern remains the same but pressure goes up. For example, this was the pressure here 3 centimeter. Here it is suppose 7 centimeters or 6 centimeter. Someone has the normal pattern but someone has the normal pattern but with elevated pressures, what could be the cause of it?
fluid overloading for example, yes congestive cardiac failure. In this case, pattern will remain normal but what will happen? Pressure will go up. Another example, let's suppose we see another patient in which jugular venous pulsations are like this. Pressure has gone very high, right?
But there's no clear-cut waveform. This type of situation is seen, this type of Situation is seen when there is sphenoid venous cable obstruction. When there is sphenoid venous cable obstruction by any mass, Leon, then what happens that pulsations from the right atrium cannot be transmitted to the jugular system.
Blood accumulates into jugular system, venous, jugular venous pressure goes up, right, but pulsations are not coming, so it becomes almost static. Raised jugular venous pressure without pulsations. Is that right?
Then we can come to another unusual situation. Let's suppose you have another person. Overall jugular venous system is normal.
Look. But in this particular person there's pathology that A wave which was supposed to be like this, it has gone like this. Okay let me change it.
This is the normal A wave. and C wave and V wave. Now if someone has A wave going moderately high right it means the right atrium is contracting more strongly with more strength to push the blood into ventricle.
It means right atrium has some degree of resistance right. It may be due to these are large A wave what we call it large A wave. Large A wave may be seen in which conditions? pulmonary stenosis, pulmonary hypertension or right ventricular hypertrophy or tricuspid stenosis.
Let me explain these four reasons of large A-weave graphically. Right, if anyone has number one tricuspid stenosis, atria has to contract very forcefully to push the blood into ventricle or someone has hypertrophy of right atrium, right again it has to push the blood with unusual force with the ventricle because there is forward resistance or someone who has what is this stenosis of pulmonary valve so either there is stenosis of tricuspid or there is right ventricular hypertrophy or there is pulmonary stenosis or there is pulmonary hypertension right any one of these condition or any combination of these condition will make the atria to contract more forcefully than normal to push the blood from atrium to the ventricle so naturally backfire to produce a wave will be also stronger so you will get larger a waves right now another situation which I would like to explain right and that explain that situation is in which a waves become very large very very large we can say extremely large for example someone has an a wave which is going like this. This is very big A wave.
It's like we call it cannon A waves. Cannon waves. Now what is the cause of cannon waves?
Why A waves will be so large? Mechanism is very simple. Whenever atrium contracts against a closed valve, tricuspid valve.
Whenever atrium contracts against a closed tricuspid valve, then all the blood will be shot backward and there will be extremely large A wave or we call it cannon waves. Now what could be the reasons for the cannon waves? Number one, number one condition may be look here if a patient has complete heart block. Complete heart block means that no impulse from the atrium can go to the ventricle. AV node is completely inhibited and from the atrium if no impulse can go to ventricle let's suppose this was your yeah what is this av node if it is completely blocked whatever the reason it may be extreme vagal stimulation or it may be due to excessive dose of beta blockers or calcium channel blockers or adenosine whatever now if you have a navy or av node has undergone function whatever the reason if av node is unable to transmit the atrial impulses to the ventricle then atria will be beating according to the sinus control SA node and ventricles will develop their own ectopic focus.
If atria are beating according to the SA node control, maybe atria are beating at the rate of 80 beats per minute but ventricle may follow the stimulation from a ectopic focus and that may be 40 beats per minute. Now it means atrium, atria and ventricle are contracting at independent rate. So, H we are contracting at the rate of 80 and what is this? ventricle is contracting at the rate of 40. so they are dissociated their contraction normally what happen there is a special relationship between the atrial and ventricular contraction that first is atrial contraction and then it is followed by ventricular contraction but under these circumstances by random chance it is possible that atria and ventricle contract simultaneously if by random chance atria and ventricle contract simultaneously at that very moment atria will contract against the closed tricuspid valve because simultaneous ventricular contraction will keep the tricuspid valve shut so when atria will contract against a closed tricuspid valve right because they cannot open the tricuspid valve there will be very big cannon wave going backward into jugular system am i clear so one causes third degree heart block another mechanism in which atrial ventricular contractions become dissociated is when there is ventricular tachycardia when there is yes please ventricular tachycardia if someone has ventricular tachycardia it means there is this tachycardia focus may be driving the ventricle at the rate of 160 per minute and as you know atrium is following what is this 80 beats per minute if this patient has ventricular tachycardia It means ventricular focus is over driving the ventricle V-tach.
Then what really happens? Again atrial and ventricular you can say normal pattern of sequence of contraction is dissociated and again by random chance it's quite possible sometimes the atrium may contract simultaneously with ventricle then right atrium may be contracting against a closed tricuspid valve and that very contraction will send a cannon wave backward. So, in these cases either there is third degree heart block or there is V-tach in both cases atrioventricular sequence of contraction is disrupted and dissociated by random chance whenever atria contract simultaneously with the ventricle it will throw back a cannon wave in jugular pattern.
Another situation which can also produce regular cannons not off and on cannons regular cannons is that when every jugular venous pulsation in every cardiac cycle one canon will come this condition is when AV node is pacing the heart there's nodal rhythm what we call there is nodal rhythm sometimes it happen SA node has failed and AV node is controlling the current to the atria as well as ventricle so AV node is source of current to ventricle as well as to atria and if AV node is simultaneously leading to contraction of atria and ventricles then every time atria contracts against a closed tricuspid valve and patient will develop regular cannon waves. Is it clear to everyone? Now let's compare it here. If I say that this is the normal pattern, this is normal, suddenly person develops larger A wave, larger A wave.
This may be due to what could be the larger A wave, what could be the reason? Pulmonary hypertension or tricuspid stenosis or there may be pulmonary stenosis or there may be pulmonary hypertension. But if there is another patient, this was the patient number one, this was the patient number two. In third patient, what you really see is entirely different.
You find what is this? Canons, if they are coming regularly it means nodal rhythm. If they are coming off and on it may be dissociated atrial ventricular contraction which may occur due to ventricular tachycardia or third degree heart block. Right? Now you have learnt, if I asked you what is the cause of elevated jugular venous pressure without pulsations, this is spirovenous cable obstruction.
If I say pulse pattern is normal, it is simply pressure has taken up, fluid overload conditions. like ingestive cardiophilia or intravenous lesion, you are loading the patient with excessive fluid. Or if I say that pulse pattern is normal and pressure is normal, what does it mean?
Patient as far as jugular venous pulse is concerned, it is normal. Right? If I say the large A waves, it means the atria find extreme difficulty in pushing the blood into ventricles. And if I say there are very large cannon A waves, it means the atria and ventricular contracting simultaneously or atrium is contracting against closed.
Tracker speed, valve. Is that clear to everyone? Any question?
Now we come to another type of situation. We have already discussed, okay, let me draw one more pattern, normal pattern. For example, there is a person who has regurgitation of tricuspid valve. A patient who has regurgitation of tricuspid valve.
What will happen there? Normally what happens? Look.
We say after the A wave there is X descent and this jerk C wave is coming due to onset of ventricular contraction where tricuspid valve is slightly pushed upward and but there is no regurgitation. Let's suppose there is regurgitation look here now if there is regurgitation then blood from the ventricle where C wave should come will directly enter into atrium. and C and V wave will be fused. What is the pattern?
Look here. First I will make the normal patterns. Now these are three cycles.
One cycle from atria to next cycle and this is next cycle. Right. Now if someone has, look here, this pattern is going normal up to here after that C and V wave fuse.
Then it go like this, normal pattern in C wave and V wave fuse. Normal pattern, okay from here. C-V fuse.
It means real abnormality is this area that C wave and V wave they are fused. This is the abnormal area. This is called fuse C-V wave.
It means when tricuspid valve was supposed to close, suddenly pressure in the atrium became very high. It means Blood is regurgitating from the ventricle to the atrium. Is that right? And this is seen in tricuspid regurgitation. Right?
So this is a patient who has tricuspid regurgitation. As soon as what has started? Left ventricular contraction.
Blood has regurgitated into? Yes. Into where?
Atrium, so this will push a back pressure and the moment when C wave was supposed to be here blood will directly move back and take the C wave directly fuse with the A wave. Is that right? We call it fused C-V wave. Fused C-V wave. Right this is called fused C-V wave.
Now here I want to highlight one more point. You remember that in a normal jugular venous pressure. C wave tells you the onset of ventricular systole. It means if you are looking for the wave pattern here, if you are looking the wave pattern, if you are looking the wave pattern in the neck, right? Venus, which wave pattern?
Venus pulsations, right? You should observe here, don't touch here, observe here and feel the carotid on the opposite side. Now any wave which comes before the carotid pulse should be A wave because Here is the onset of ventricular, what is this?
Cystole, it means C wave, just with the C wave what comes? Ventricular Cystole, it means there is carotid pulse. So if you are feeling the carotid pulse on other side and one side you are looking for the pulse pattern in the JVP system, then what you really see? If you see a wave just before you feel you observe when you see a wave before you feel the carotid then it is A wave. If you see a wave just after feeling the carotid then it is yes V wave and if you see a wave venous wave with the arterial wave then what is C-V wave.
So what we can say that You have to simultaneously look at the venous pulse and feel the arterial pulse. Right? If venous pulse is before the arterial pulse, then it is A wave.
If it is after the arterial pulse, then it is V wave. And if it is with the arterial pulse, it is C-V wave. Am I clear to everyone?
Is there any question up to here? Now we will talk about some very special features related with the JVP and pericarditis. In constrictive pericarditis, constrictive constrictive pericarditis. JVP develops a very unique pattern, right? We will discuss that but before that we must know what is constrictive pericarditis.
Constrictive pericarditis is a condition in which there is severe and prolonged inflammation of pericardium leading to fibrosis of the pericardium and pericardial sac is obliterated and what really happens in constrictive pericarditis that pericardial sac becomes fibrotic mass and it becomes total unyielding it become and it constrict it like a constriction band on the ventricles so it does not allow the ventricle during the diastole to relax properly. Is that right? Now let's see first normal JVP and then how what are the changes in JVP in a patient with constrictive pericarditis.
We have already discussed the normal pattern of GVP is like this during one cardiac cycle. Now in this particular pattern already you know this A wave is due to yes due to atrial contraction C wave is the onset of ventricular systole leading to closure of tricuspid valve and then this is a descent which is called X descent and X descent is due to yes now at this point what was closed? tricuspid valve.
Now, HA is relaxing and blood is filling into relaxing HM and there's a descent which is called X descent. And during that, then continuous venous return to the right heart develops another wave which is called V wave, right? Now, you must be knowing that from here, from here, there's onset of ventricular systole and ventricular systole continues up to this point. This is ventricular systole. It means the ventricular systole in the JVP is presented by the just after the A wave, atrial contraction or synchronous with the C wave and then relationship of the ventricular atrium is lost at this point and this is simple, simple first of all filling of the right atrium when it is undergoing further relaxation.
and eventually here it has completely relaxed and further venous accumulation lead to V wave. But why there is another descent here? You know this descent is called? Yes, this descent is called Y descent and cause of this Y descent is onset of ventricular diastole, onset of ventricular diastole.
This is ventricular you can say diastole. Now this is a normal pattern. Now what really happens in a patient with constrictive pericarditis? There are two things which happen.
First I will talk about an important sign which is called Frederick sign. What is Frederick sign? Actually in case of constrictive pericarditis right when this valve opens during diastole what is the name of this valve? tricuspid valve.
When this valve opens, there is a very rapid ventricular filling. But why it is so rapid? Because there was already very high, you can say, right atrial pressure. And high atrial pressure pushed the blood very rapidly into ventricular chamber.
Is that right? And when blood rapidly moves from right atrium to the right ventricle, jugular venous pulse pattern drops. this pulse drops rapidly. It means this y descent in which normally the y descent which is normally produced by the gradual filling of the ventricle because it is rapid ventricular filling so y descent become very steep.
So in these patients what really happens that this y descent becomes very very steep right this is one point. Secondly Once it is rapidly filling and ventricles rapidly start expanding but progressive ventricular filling lead to progressive expansion of the ventricle but that is suddenly interrupted further expansion by the constricting band of pericardial fibrotic system. So again let me repeat it. These patients when there is rapid ventricular filling due to high atrial pressure there is very steep y descent.
This is very steep. Why? descent right and not only there is very steep y descent there is one more problem that Due to rapid ventricular filling as ventricle is rapidly expanding there is sudden cessation of further expansion abrupt cessation of further expansion of the ventricle due to pericardial fibrotic pericardium due to that particular reason suddenly again pressure start rising right and again here is A wave so this is you can say very steep rise fall and rise now this steep fall and rise of JVP is called Friedrich sign.
Again let me recap what is Friedrich sign. We can say in the JVP pulse what really happens in patient typically in the patients with just constrictive pericarditis there is very steep fall of the y descent and steep rise. Right?
What is the reason for that? It's very simple to explain. Number one Why there is steep fall? Because due to previous over accumulation of fluid within atrium right atrial pressures are above normal. So as soon as ventricle relaxes very rapidly fluid move from the right atrium to the ventricle.
Due to that reason veins rapidly empty and when JVP rapidly empty there is steep y descent. But this y descent which is very steep does not remain continuous because a little bit more expansion of the right atrium. ventricle due to incoming blood is suddenly stopped by the constrictive pericardial area right sac and that will lead to abrupt stoppage of further fall in the yes fall in the jvp and then there will be steep rise in jvp right so steep fall and rise in jvp this combination is called frederick sign now let me draw it properly for you only look here this is suppose first of all normal jvp pattern right now i will show you the altered right yes steep fall of the y right and steep rise and then steep fall and steep rise and then there is steep fall and steep rise.
So this is the basic change. But there is one more change. Right here y wave has been, y descent was very steep.
This was the normal descent, this is steep descent. Right this was normal rising, this was steep and sudden rising. But again a wave will come at its own time. So they have to be drawn at the same point in the end.
Another point which is there is that you must know what normally happens to jugular venous pressure during inspiration and expiration. You know when we are taking inspiration chest is sucking not only air in but also pulling the blood in. It means during inspiration right ventricular filling or right heart venous return is increased. Again let me draw a diagram so that we can see it more clearly here's your right heart now what really happens during inspiration okay shouldn't be that global globular because it will remind you right ventricular failure okay now listen during inspiration what happened diaphragm is going down when diaphragm is going down you and chest is expanding, there is negative interstitial pressure.
Negative interstitial pressure not only pulls the air in but also pulls the blood to the chest. So we can say during inspiration Venus return to the right heart is increased. It means if there is increased Venus return to the right heart, it means that JVP will have low value during inspiration. But during expiration what really happens that pressure in the chest is more and if pressure in the chest is more it means the venous return to the chest is reduced and GVP is slightly elevated during the aspiration as compared to inspiration we can show this graphically in this fashion this is suppose GV pattern GVP pattern and in this particular pattern this is suppose during what is this suppose this is the during inspiration right this JVP pattern during Inspiration during expiration same pattern will become slightly elevated then again it is during and then again during expiration. So what we really see that during inspiration JVP is.
Inspiration and here it is yes Expiration right so what we really see in this diagram is that during inspiration because chest is this is the you can say pressure jugular venous pressure during wave pattern during inspiration expiration and normal but overall pressure goes down in the jugular system during inspiration and slightly goes up during expiration. Now what really happens in a patient with constrictive pericarditis? What really goes wrong in a patient with constrictive pericarditis is that when there is a constrictive band, fibrotic band around the pericardium and here is your diaphragm.
Now listen carefully what really happens. If this is you can say fibrotic band right and during inspiration when diaphragm descends down fibrotic band of pericardium is also pulled along with it and when this is pulled along with it during inspiration it will put unusual pressure on the both sides of the ventricle because pressure in the right ventricle the less so right ventricle is under more pressure of the constructive band again let me repeat it During what happens during inspiration when diaphragm descends down what really happens fibrotic band of the constrictive pericarditis compresses both ventricle but more so the right ventricle because that has less pressure as compared to the left. So it means during inspiration you can see as it descends down right this fibrotic band as it descends down what it is doing. this is fibrotic band all right it is having a special you can say pressure on what is this right ventricle so it means right heart filling in constrictive pericarditis is reduced during inspiration rather than increase is that right again let me repeat it during inspiration fibrotic band compresses the right ventricle strongly due to that reason normal venous filling of right ventricle which should be increased during inspiration is paradoxically reduced and when venous return to the right ventricle of filling to the right ventricle is reduced during inspiration then it means unexpectedly or surprisingly or you can say paradoxically during inspiration jvp goes up right so if we draw a patient here constrictive pericarditis the jvp pattern black is the normal pattern and now red i will show you constrictive pericarditis that during inspiration it is up and during expiration it is down is that clear this feature that normally jugular venous pressures come down during Inspiration in constrictive pericarditis, this usually go up during inspiration.
This paradoxical movement is called Kussmaul's sign. What is it called? What are the spellings? Yes, please. K-U-S-S-M-A-U-L as Kussmaul's sign.
So in relation to the constrictive pericarditis, you have to remember two things. Number one is what is Kussmaul's sign? And number two, you have to remember what is?
Frederick's sign, we have already discussed both. Kussmaul's sign is that during aspiration, JVP rather than falling in constrictive pericarditis, it goes up. And what is Frederick's sign? That during, in a patient with constrictive pericarditis, why descent is very steep and followed by a steep rise. The steep fall and rise of the jugular venous pulsations is called Frederick's sign in constrictive pericarditis.
Now the last point. There is a procedure called hepatodegular reflux. In hepatodegular reflux what you do in right upper quadrant of abdomen you apply a pressure right of course when you apply a pressure the venous return to the heart is increased and jvp will become slightly elevated but in some patients who have right ventricular stiffness or who have pathologically high central venous pressure if you apply pressure on the right on the right upper abdominal quadrant there is significant sustained elevation of jvp significant elevation mean elevation should be more than one centimeter and sustained mean it should be more than 200 seconds right so when you apply when you perform hepatocicular reflux in a patient when there is right ventricular hypertrophy or failure or there is excessive central venous pressures when you perform the jugular hepato jugular reflux there is an unusual finding in such patients remember in normal hepato jugular reflux of course jvp goes up but in these conditions jvp will go up too much more than one centimeter and jvp will move up for longer time that is more than 200 second and that's all for today