Presentation on theme: "Jugular venous pressure and waveforms"— Presentation transcript:
1Jugular venous pressure and waveforms Dr Bijilesh
2Jugular venous pulse is the oscillating top of the the distended proximal portion of the internal jugular vein and represents volumetric changes that faithfully reflect the pressure cahnges in the right heart
3Right atrial pressure during systole and right ventricular filling pressure during diastole Window into the right heart, providing critical information regarding its hemodynamics.Right atrial pressure during systole and right ventricular filling pressure during diastole are producing pulsations and pressure waves in jugular veins .Evaluation of the jugular venous pulse offers a window into the right heart, providing critical information regarding its hemodynamics.
4“In the study of venous pulse we have often the direct means of observing the effects of systole and diastole of right auricle and systole and diastole of right ventricle.”James MackenzieGing back to a little bit of history.In 1902 james mc established jvp as an important part of cvs examination. According to him jvp provides a good opportunity to observe the effects of systole and diastole of right auricle and systole and diastole of right ventricle.”
5“Precise analysis of the cervical venous pulse and measurement of the height of each wave is not only possible at the bedside but highly desirable”PaulwoodDespite this ,analysis of jvp was lacking in the examination till 1950 wen paulwood reawakened the interest eplaining the hemodynamics
6AnatomyJV pressure measurementCauses of elevated JVPNormal wave patternAbnormal wave patternKussmaul s sign and hepatojugular refluxSpecific conditions
7Jugular veins Internal jugular vein External jugular vein Two jugular veins int and ext can be used 4 assessing jv pulse and pressure, though internal one is the preffered one
8The 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,. it joins the subclavian vein, to form r innominate which continue as superior vena cava and then into the right atrium.
9Lateral to carotid artery & deep to sternomastoid muscle. External jugular is superficial to sternomastoidThe internal jugular vein is
10Shows the vertical course of the ijv which psses inbetween the two heads of the st mastoid under the medial end of clavicle
11Examination of JVPRight IJV is usually assessed both for waveform and estimation of venous pressureTransmitted pulsations to overlying skin between two heads of sternocleidomastoidUnlike ejv pulsations it is not possible to see ijv pulsations directly as it is deep. We actually see the transmitted pulsations to the overlying skin b/w the two heads of st mast.
12Right IJV Preferred :Why? Straight line course through innominate vein to the svc and right atriumLess likely extrinsic compression from other structures in neckWhy not EJVNo or less numbers of valves in IJV than EJVUsually rijv s pref 4 jvp examination. RIJV is less likely affected by extrinsic compression from other structures in neck. Left inno compresssed by arch f aorta and presence of left svc can falsely elevate the jvp on left side. So in conditions with increased symp tone ejv pulsations less visible. Left IJV drains into left innominate vein, which is not in straight line from RA
13Differences between IJV and Carotid pulses Superficial and lateral in the neckBetter seen than feltHas two peaks and two troughsDescents >obvious than crestsDigital compression abolishes venous pulseJugular venous pressure falls during inspirationAbdominal compression elevates jugular pressureDeeper and medial in the neckBetter felt than seenHas single upstroke onlyUpstroke brisker and visibleDigital compression has no effectDo not change with respirationAbdominal compression has no effect on carotid pulse
14Estimation of Venous Pressure Measuring jugular venous pressureHepatojugular refluxExamining the veins on the dorsum of the handAssessment of jugular venous pressure at bed side reflect mean right atrial pressureVenous pressure can be roughly assessed
15Measurement of JV Pressure Sternal angle or angle of Louis - reference pointFound approximately 5 cm above the center of the right atriumSternal angle – RA Fixed relationshipSternal angle or angle of Louis is a surface anatomical mark reference point used for JVP measurementDistance between sternal angle and center of right atrium remains relatively constant regardless of position of the thorax
16In an adult with anatomically normal chestthe sternal angle is found to be 5 cm above the centre of ra in siiting supine or varios reclining angle inbetween. Since tha angle of louis has a fixed relationship with the centre of ra this landmark is used for measuresment os jvp.
17Position of PatientPatient should lie comfortably and trunk is inclined by an angleElevate chin and slightly rotate head to the leftNeck and trunk should be in same lineWhen neck muscles are relaxed ,shine the light tangentially over the skin and see pulsationsSimultaneous palpation of the left carotid artery or apical impulse aids in timing of the venous pulsations in cardiac cycle .Or at an angle which permits best view of the upperlevel of the venouspulsations
18Iclination is required as level go below mandible in high jvp or below clavi in low pr. So start with 45 then tilt pt appropriately up or down . In patients with low jugular pressure , a lesser (<30‘) inclination is desirableIn patients with high jugular pressure ,a greater (60-90‘) inclination is required to obtain visible pulsations
19Measurement of JVP Two scale method is commonly used Normally JV pressure does not exceed 3- 4 cm above the sternal angleSince RA is approximately 5 cm below the sternal angle , the jugular venous pressure corresponds to 9 cm =7mmhgElevated JVP : JVP of >4 cm above sternal angle .(9 cm column of water / 1.3 =6.9)
20.A horizontal scale at the top of the oscillating venous column in IJV cuts the vertical scale at the sternal angle gives JV pressure in cm of waterAdd 5 cm to measurement since right atrium is 5 cm below the sternal angle
23Kussmaul's signMean jugular venous pressure increases during inspirationConstrictive pericarditisSevere right heart failureRV infarctionRestrictive cardiomyopathyImpaired RV compliance.Normally mean jvp falls during insp ..as a result of impaired RV compliance, so the increased venous return cannot be accomodated by the rv, resulting in an elevated jvp
24Abdominal -Jugular Reflux Hepatojugular reflux – Rondot (1898)Apply firm pressure to periumbilical region secNormally JV pressure rises transiently to < 1cm while abdominal pressure is continuedIf JV pressure remains elevated >1cm until abdominal pressure is continued: Positive AJR.Apply firm pressure to periumbilical region for sec with patient lying comfortably and breathing quietly while observe JVP ABRAMS
25Abdominal compression forces venous blood into thorax. A failing/dilated RV not able to receive venous return without rise in mean venous pressure.Positive AJRIncipient and or compensated RVFTricuspid regurgitationCOPDCopd sudden disproportionate increase in intrathoracic pr due to altered intrathoracic pr relation ships in copd
27Gaertner's methodMeasurement of JVP by examining the veins on the dorsum of the handWhen patient sitting or lying at a 45‘ elevation , arm slowly and passively raised from dependant position until the vein collapsesHeight of the limb above the level of sternal angle at which vein collapses represents the venous pressureWhen venous pressure is normal , veins of hand collapse at the level of sternal angle
28Normal JVPNormal JVP reflects phasic pressure changes in RA during systole and RV during diastoleTwo visible positive waves ( a and v) and two negative troughs ( x and y)Two additional positive waves can be recorded C wave interrupts x descent and h waveand h wave precedes the next a wave
29Normal JVP Waveform Consists of 3 positive waves a,c & v And 3 descentsx, x'(x prime) and y
30a WaveFirst positive presystolic a wave is due to right atrial contractionEffective RA contraction is needed for visible a waveDominant wave in JVP and larger than vIt precedes upstroke of the carotid pulse and S1, but follow the P wave in ECGFirst positive presystolic a wave is due to right atrial contraction results in retrograde blood flow in to svc and jugulars
31x DescentSystolic x descent is due to atrial relaxation during atrial diastoleX descent is most prominent motion of normal JVP which begins during systole and ends just before S2It is larger than y descentX descent more prominent during inspiration
32C Wave Not usually visible. Two different causes - Transmitted carotid artery pulsations.- Upward bulge of closed Tricuspid valve inisovolumic systoleSecond positive wave recorded in JVP which interrupts the x descent
33x` Descent x`descent is systolic trough after c wave Due to Fall of right atrial pressure during early RV systoleDownward pulling of the TV by contracting right ventricleDescent of RA floor
34v Wave Begins in late systole ends in early diastole Rise in RA pressure due to continued RA filling during ventricular systole when tricuspid valve closedRoughly synchronous with carotid upstroke and corresponds S2 .Third positive wave in JVP which begins in late systole and ends in early diastole
35y Descent Diastolic collapse wave (down slope v wave) It begins and ends duringdiastole well after S2Decline of RA pressure due to RA emptying during early diastole when tricuspid valve opens
36h waveSmall brief positive wave following y descent just prior to a waveDescribed by Hieschfelder in 1907It usually seen when diastole is longWith increasing heart rate, y descent immediately followed by next a wave .Small brief positive wave following y descent just prior to a wave during period of diastasisIt usually seen when diastole is long (as in slow heart rates)
37Prominent a WaveForceful atrial contraction when there is resistance to RA emptying or increased resistance to ventricular fillingRV inflow obstruction:Tricuspid stenosis or atresiaRA mxyomaDecreased ventricular compliance:Pulmonary stenosisPulmonary hypertension of any causeRV infarctionRV cardiomyopathy (HOCM)Acute pulmonary embolism3. Increased RVEDP.RV infarction , Acute pulmonary embolism
39Cannon WavesWhenever RA contracts against closed TV valve during RV systoleRegular cannon waves:Junctional rhythmVT with 1:1 retrograde conductionIsorhythmic AV dissociationIrregular cannon waves :Complete heart blockVentricular tachycardiaVentricular pacing or ventricular ectopics .Venous corrigan by paul wood
41Absent a Wave When no effective atrial contraction as in atrial fibrillationIn sinus tachycardia , when a wave may fuse with preceding v wave , especially when the PR interval is prolonged .
42Prominent x descentPresence of atrial relaxation with intact tricuspid valve and good RV contractionCauses :Cardiac tamponadeConstrictive pericarditisis needed for prominent x descent.
43Reduced x descent Moderate to severe TR: early sign Atrial fibriillationObliteration of x descent with early large systolic wave
44Prominent v wave Increased RA volume during ventricular systole produce prominent v waveSevere TR : giant v waveGiant v wave sometimes causes :systolic movement of ear lobehead bobbing with each systolesystolic pulsation of liverpulsatile exophthalmos(Lanci sign) – ventricularization of atrial / jugular pressure
46PROMINENT V WAVE ASD with mitral regurgitation VSD of LV to RA shunt (Gerbode's defect)RV failure
47Rapid y Descent Severe TR C .Pericarditis (Friedreich's sign): Early rapid ventricular fillingSevere RV failureASD with mitral regurgitationElevated venous pressure from any cause.Constrictive pericarditis,(Friedreich’s sign)Severe TR, Severe RVF Severe RV infarction
49Slow y DescentWhen RA emptying and RV filling are impaired y descent is slow and gradualTricuspid stenosisRight atrial tumoursPericardial tamponade( y descent may even be absent).
50Respiratory influences Inspiration – increased visibility of venous pulse.Mean venous pressure falls , but the wave forms are accentuated during inspiration.
51Waves more prominent during inspiration X descent more briskIncreased venous return augment RA contraction and hence relaxation >> brisk xAlso increased venous return augment RV volume and contraction > increased systolic descent of floor of RA>>brisk x’
52JUGULAR VENOUS PULSE IN ARRHYTHMIAS ‘a’ & ‘v’/c (carotid pulse correlates with P & QRS complex in ECG.Normal sinus rhythm is characterized by sequential a & v waves.Any disturbance in this wave form indicates rhythm abnormality.A wave occurring along 1st heart sound – normal PR interval.
53Rhythm Cannon waves Sinus a - v regular Absent I AV block Pr0longed AC intervalWenckebach’sGradual prolongation of A-C intervalMobitz II blockConstant AC interval followed by sudden skipping of carotid pulseCHBVariablePresent & irregularVPC JPCEarly cyclePresentAPCVTAtrial tachycardiaNormal
54Cardiac tamponade JVP is usually elevated y descent is diminished or absentx wave is normalKussmaul's signusually negative
55Constrictive pericarditis JVP is elevateda wave is usually normalv wave is usually equal to a wavex descent –prominenty descent – rapid descentKussmauls sign is usually positive
56Restrictive cardiomyopathy JVP is usually elevatedBoth a and v wave equalKussmaul s may be positive
57Pulmonary Hypertension Early RV decompensation :JVP may be elevateda wave is prominentDecompensated RVF:a and v wave prominent ,v wave larger than a wavex descent is diminished or absentRapid y descent due to TR
58JVP in ASD JVP is normal and equal a and v waves Elevated JVP may seen in severe PAH and in RVFProminent a wave with PS and MSProminent v wave with PAH and RVF with TRRapid y descent with RVF or TR
59JVP in VSD Elevated JVP with CHF Prominent v wave with Gerbode's shunt In Eisenmenger complex :JV Pressure usually normalNormal a and v waves
60Ebstein Anomaly JVP is usually normal Attenuated x descent and systolic v wave are not reflected in jugular pulse despite appreciable TRDamping effect of large capacitance RA and thin, toneless atrialized RVUnimpressive JVP is attributed to