The jugular venous pulse (1957): Entire title

[Music] in 192 Sir James mckenzi published his classical work entitled the study of the pulse arterial venus and hepatic and the movements of the heart this superb book can still be obtained and makes exciting reading his investigations were made chiefly by means of the clinical polygraph a cup shaped rece was placed over the pulsating vein and connected pneumatically by way of a rubber tube to a tamber to the membran of this a lever was attached in McKenzie's original instrument the lever marked smoke paper covering a revolving drum but in this instrument Modified by Sir Thomas Lewis the lever carries a pen which writes on smooth white paper the polygraph has several drawbacks including time lag due to air transmission overshooting due to the mechanical inertia of amplifying levers and the Primitive method of recording in modern instruments developed from the polygraph the receiver is usually a carbon microphone electrical transmission eliminates time lag thermionic valves provide suitable amplification and the recording systems are similar to those used for electrocardiography the fogam may be timed against a simultaneous arteriogram and electrocardiogram as shown here on the sandborn polyiso as a matter of fact a phonocardiogram probably makes a better reference tracing the jugular pulse consists essentially of four main waves a x v and y a and v being crests red string high pressure X and Y being troughs or periods of low pressure the a-wave corresponds to right atrial Cally a fifth positive wave C May interrupt the X descent the X descent begins with atrial relaxation and is augmented during the earlier part of ventricular syy by displacement of the floor of the atrio ventricular septum towards the apex of the heart creating a negative pressure within the Atria the Venus pressure Rises later during ventricular syst to form the v-wave because at this time Al flow from the at is temporally obstructed the Y descent or the down slope of V begins as soon as the tricuspid valve opens when right atrial and ventricular pressures equalize rapidly and fall together to the truff Y after which they rise again before the onset of the next atrial contraction the nature of the seawave proper is controversial the large seawave recorded in the jugular fogam however is the cored pulse itself as shown by McKenzie no wave of similar amplitude and timing is seen in right atrial pressure tracings while taking full advantage of modern instrumental techniques it must be emphasized that accurate analysis of the wave form of the jugular pulse and reasonably precise measurement of the amplitude of each individual wave is usually possible at the bedside the patient should be placed supine if the pressure is below sternal angle level or propped up if the pressure is raised the correct position being that which favors maximum jugular of pulsation the most readily inspected pulsation is that of the internal jugular vein with normal Rhythm there are two main waves the a wave of atrial cyly the v-wave of ventricular Cy and two traps X and Y per cardiac cycle the movement is soft diffuse undulant and normally impalpable when timed against the koted pulse only the first trap X appears to coincide with Cy the a wave precedes it the V Peak is appreciably later and Y is clearly diastolic you can see the arterial pulse here clearly By the Light reflection on the red spot the Venus pressure Rises on expiration and falls with inspiration passively following the changes in inter thoracic pressure the amplitude of all the waves increases during inspiration cervical venous pulsation ceases when the jugular veins are compressed at the root of the neck light pressure of the finger against the root of the external jugular of vein distends the upper part of the vessel on removing the finger the vein collapses to the level of the mean jugul Venus pressure Sir Thomas Lewis pointed out that the most satisfactory reference point from which to measure the Venus pressure was the sternal angle because this was about 5 cm above the center of the right atum in both horizontal and vertical positions with reference to the sternal angle the Venus pressure swings around a mean level of about -2 cm in the horizontal position but the range is considerable indeed in this normal subject the maximum systolic level which happens to be a is plus 3.5 CM let us now look at some abnormalities of the Venus pulse a giant airwave abrupt and collapsing in quality and measuring between 6 and 15 mm of mercury above V is usual in tricuspid stenosis and at treia but is equally characteristic of severe py hypertension and severe py stenosis it is pable and transmitted to the liver and tends to be increased by inspiration here is a case of mitost stenosis with severe reactive py hypertension due to a high py vascular resistance the giant a is well seen in the right internal jugular pulse and measures about 6 cm above the internal angle on inspiration its amplitude increases even though the mean right atrial pressure may fall and here is a man with severe palmary valve stenosis with normal atic root it has a conspicuous a-wave the sinosis is due to reversed into atrial shunt also the slight claing of the fingers you see the Venus pulse is moving the lobe of the a that the large Venus wave is presystolic can be seen by timing it against the temporal arterial pulse which may be observed just in front of the ear it is shown very clearly there from this angle the height of the a-wave may be compared with the height of V which can also be seen just there in the super cicular fer you can see V just coming up the giant airwave also occurs in tricuspid treia particularly when associated with a forino rather than a large atrial SLE def such was the case in this sinos go the degree of clubbing emphasizes the low level of the arterial oxygen saturation the giant airwave is well seen timed against the cored pulse it is obviously presystolic the time relationship between the Venus and arterial pulses may be analyzed by inspection in this closer view you can see the arterial pulse in in that shadow there just below the lobe of the a the powerful right agal contraction responsible for the giant a wve is due to increased resistance to right ventricular filling acting over a long period of time it serves to increase the contractile force of the right ventricle in accordance with starling's law which states that within certain limits the force of cardiac contraction varies directly with the length of the muscle fibers at the end of diast the giant a wave rarely occurs in poundy hypertension when there is free communication between the ventricles as in fist try on the left there and Isam Mangus complex on the right here is the child with fogy and you see very little in the neck just a very small a-wave here is the patient with Eisen Mangus complex and in these circumstances the right ventricular systolic pressure never rises above systemic level and the right ventricle is able to adapt itself to this ceiling with Little Help from its Atrium the braal artery pressure per artery pressure and right ventricular pressure are all around 100 mm of mercury the right atrial tracing shown on the right shows a only slightly higher than V both around zero the length of the PR interval can be roughly estimated by noting the time interval between the jugular a w and the koted pulse with experience it is not difficult to decide clinically whether the AC interval is more or less normal around 0.16 second or obviously prolonged 0.24 seconds or more as in the tracing the jugular fogam is the middle tracing shown a Canon wave is a particular form of giant airwave and occurs when all the energy released by right atrial contraction is translated into pressure because forward flow is impossible o to simultaneous closure of the tricuspid valve this happens regularly in nodal Rhythm and partial heart block noal rhythm in this case was probably caused by digitalis there is very marked sagging of the ST segment in lead V4 in the electrocardiogram there immediately following the slow arterial pulse there is a large systolic Cannon wave in the jugular pulse this might well be mistaken for truspa incompetence but the rhythm is regular and the absence of a presystolic wave should prevent error independent a waves can also be seen in many cases of complete heart block any type of ectopic beat may cause a cannon wave if the necessary conditions are fulfilled regular Cannon waves also occur in parisal nodal tachic cardia in this boy with parisal tachic cardia rapid Cannon wave are conspicuous suggesting that it is nodal in origin in fact it proved to be atrial with 2 to1 atrio ventricular block alternate atrial contractions coinciding with ventricular syy the speed here is about 180 the a wve disappears of course in atal fibrillation it should be noticed that the X descent is also inconspicuous since this is commonly so it is logical to conclude that the X descent depends more on atrial relaxation than on Descent of the base the jugular pulse is characterized by a single systolic wave this appearance of the X descent in Tri cusped Inc competence with atrial fibrillation is characterized by much larger V waves all the more apparent because of the deep wi truff which follows giant B waves from tricuspid incompetence are well seen in this patient that the Venus pal is systolic can be recognized by observing its time relationship to the kateed pulse which is lifting the pointer and the hand is moving up with it in this case the Venus valves have become incompetent and the J V wve is transmitted to the extremities the pulsation can be seen most easily when the legs are raised to a critical height just as posture must be used to bring out maximum Venus pulsation in the neck when there is normal rhythm in tusp incompetence a small X descent is often present but is overshadowed by the giant v the Y descent was first recognized in 1846 by fredri who drew attention to what he called dioic collapse of the Venus pulse in chronic constrictive pericarditis in other words a sharp wide descent and deep wide trough 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 the X-ray showing the calcific pericardium at the bedside the Venus P shows two crests and two troughs the Rhythm being normal the Y descent is rapid and the Y truff conspicuous as in all cases of pix disease it may be noticed that the first truff or X descent is also unusually sharp and this is fre frequently so in this condition for it is easier for the ventricles to pull the base of the heart towards the Apex than 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 madius 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 Cy 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 y truff imply rapid ventricular filling such a wave form 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 tricuspid stenosis provided the Venus pressure is high both features are seen in this patient the Venus wave here is systolic and the irregularities due to atrial fibrillation the wide descent 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 pix 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 disease when it was attributed to an increase of pericardial tension caused by the center of the diaphragm and this explanation still holds good whil it is agreed that Kosmos sign is characteristic of chronic constrictive pericarditis it is not at all uncommon in any form of heart failure perhaps because The 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 air wve is well seen on inspiration not only is the amplitude of the a wave 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 pulse 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 wave form more critically the relatively slow wi descent is impressive and if you look closely you will see that there is no visible wide 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 wi is scent and has abolished the wide truck the incompetence has increased the amplitude of the v-wave and cause the wi descent to be less sluggish than one might expect in severe stenosis