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Giant “v” waves of tricuspid regurgitation

Posted Nov 06 2011 4:42am

V wave  is one of two positive  upstrokes   seen  in JVP.  Physiological  “v” wave is due to  atrial filling  and reaches the peak at late  systole , while pathological ” v” waves  are often  due to tricuspid regurgitation  . It is  a mid systolic wave .It is a fusion of  “c”and “v” waves .

Here is a patient  with dilated cardiomyopathy with severe tricuspid regurgitation  who presented with prominent neck veins.

there is no difficulty in identifying the  v wave . Careful acuity will reveal  a  sharp  “a”  wave as well !

JVP pressure wave form of tricuspid regurgitation showing classical systolic cv waves

How to measure the amplitude of  v waves ?

In JVP,  there is a baseline oscillating column . Individual wave  spikes  occur over and above this baseline . Hence  technically there  should be two measurements  , but we take only the  top most part of the oscillating  column.

What is the indirect evidence for tall  v waves ?

Physiologically “y” descend is  integral part of v wave (In fact ,  “y” descend  can be referred to as down stroke of  “v” wave )  .For every  tall “v” wave  there  must be  a prominent  “y”descent . (Probably  constrictive pericarditis is an important exception ! )

If  “y” descend is not rapid but shallow one can suspect two conditions

  • Tricuspid stenosis
  • Significant RV dysfunction

How to differentiate v waves from a waves ?

“V” wave  is a passive filling wave hence it raises  slowly , has  relatively   shallow summit and  occurs in   mid or late-systole  . “A”waves are  due to active contraction of atria . It is a  sharp pre-systolic wave . One practical way to recognise   “a” wave is ,  it  never stays in the eye , it just flickers.  If your eye sees a sustained wave for more than  a fraction of  moment it can not be  “a”  wave ! Another point that may be useful is  “a” is taller than “v” in  right atrium .

Reference

Click below to hear the murmur of TR (Courtesy of Texas heart institute )


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