Jugular Venous Pulse (1957) Pt. 4 of 4

the Y descent was first recognized in 1846 by fredri who drew attention to what he called diastolic collapse of the Venus pulse in chronic constrictive pericarditis in other words a sharp wide descent and deep wide truff followed by a sharp Ascent as in this tracing from a typical case of pix disease this wave form signifies increased rapid ventricular filling followed by resistance to further filling here is the X-ray showing the calcific pericardium at the bedside the Venus pulse shows two crests and two troughs the Rhythm being normal the Y descent is rapid and the Y Tru conspicuous as in all cases of pix disease it may be noticed that the first trap or X descent is also unusually sharp and this is frequently so in this condition for it is easier for the ventricles to pull the base of the heart towards the Apex then it is for them to pull in the calcified pericardium the Steep wide descent and deep wide Tru though characteristic of pix disease may be observed in any condition with a sufficiently High Venus filling pressure provided there is no obstruction of the tricuspid orifice this is shown in this case of isolated myocarditis which had been previously diagnosed as pix disease the chief wave here is a truff and represents a steep wide descent followed by a rapid return to the zero point the dominant movement being diastolic cyly may be recognized by the movement of the thumb which has been placed over the kotd the diagnosis in this case was proved a thorocotomy since a rapid y descent and deep wi truff imply rapid ventricular filling such a waveform categorically denies tricuspid stenosis or any other obstruction at the tricuspid orifice in contrast a slow wide Ascent an absent wide truff a virtually diagnostic of Tri aspid stenosis provided the Venus pressure is high both features are seen in this patient the Venus wave here is systolic and the irregularity is due to atrial fibrillation the white escent is relatively slow and no truff can be seen some experience is necessary to estimate the speed of the wide descent but the absent truff is not difficult to detect the appearances are very different from those of piix disease and heart failure they are not incompatible with a moderate degree of tricuspid incompetence as well but they do mean sufficient obstruction of the tricuspid orifice to prevent Equalization of right atrial and right ventricular pressures throughout the major part of diast in differential diagnosis some attention has been paid to kmol sign a paradoxical rise of Venus pressure on inspiration well seen in this tracing this was first recognized in pix dis disase when it was attributed to an increase of pericardial tension caused by the scent of the diaphragm and this explanation still holds Good whilst it is agreed that kmos sign is characteristic of chronic constrictive pericarditis it is not at all uncommon in any form of heart failure perhaps because Descent of the diaphragm increases the tension of the pericardium when the heart is grossly distended here for example is a case of primary primary hypertension the Venus pressure is obviously raised and a giant a wve is well seen on inspiration not only is the amplitude of the a wve increased but the Venus pressure Rises as a whole perhaps we may conclude now with a case for diagnosis this patient was sent to the clinic with a diagnosis of aortic and mital stenosis Complicated by heart failure looking at the neck the High Venus pressure is obvious it will be seen that there is only one Venus pulse wave per cardiac cycle and that the rhythm is irregular certainly then she has atrial fibrillation when the single Venus p is timed against kotd it is found to be a systolic event or if you like a large v-wave is this simply heart failure or is it organic tricuspid incompetence looking at the way form more critically the relatively slow wide descent is impressive and if you look closely you will see that there is no visible wi truff in diast the wide descent subsiding to a flat Plateau this means that there must be some obstruction of the tricuspid valve in fact she had organic tricuspid valve disease with both stenosis and incompetence the stenosis has put a break on the speed of the wide descent and has abolished the wide Tru the incompetence has increased the amplitude of the v-wave and caused the wide descent to be less sluggish than one might expect in severe stenosis