JUGULAR VENOUS PRESSURE

DR.SAMEER AMBAR JNMC & KLES HOSPITAL BELGAUM drsameerambar@rediffmail.com

The 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, passing under the sternal end of the clavicle. Here it joins the subclavian vein, and then runs into the superior vena cava and then into the right atrium.

ANATOMY

 The jugular venous pressure (JVP, sometimes referred to as

jugular venous pulse) is the indirectly observed pressure over the venous system.
Classically three positive waves and two negative troughs have been

described.
The positive waves are

"a" (atrial contraction), "c" (due to bulging of tricuspid valve into the right atrium during isovolumic systole) and "v"= atrial venous filling.
The two negative troughs are

"x (due to atrium relaxation and downward displacement of

tricuspid valve) and

"y" descent (rapid filling of ventricle after tricuspid opening).

The technique for examination of JVP (jugular venous pressure)

Patient reclining at 45 with head elevated.

Light should be tangentially illuminated.

Neck should not be sharply flexed. Using a centimeter ruler, measure the vertical distance

between the angle of Louis (manubrio sternal joint) and the highest level of jugular vein pulsation. A straight edge intersecting the ruler at a right angle may be helpful. Measure elevation of neck veins above the sternal angle (Lewis Method). Add 5 cm to measurement since right atrium is 5 cm below the sternal angle.

MEASUREMENT OF JVP

Normal JVP 4-11cm H2O

Causes of JVP

1. RV pressure- PS, Pulm HTN, RV failure, or RV

infarction.
2. Obstruction to RV inflow- TS, RA myxoma

constrictive pericardial disease.

3. Superior vena caval obstruction.

4. Circulatory overload- renal failure.

5. ASD with mitral valve disease.

Abnormality of wave pattern

Prominent a waves;

1. Tricuspid level- TS, RA tumours. 2. RV level-

severe RVH- severe PS with intact IVS - severe Pulm HTN with intact IVS RV cardiomyopathy. Acute pulmonary embolism. Acute TR

 Cannon a waves

Absent a waves

Regular- junctional rhythm - VT 1:1 retrograde conduction Irregular- CHB - VT - ventricular pacing - ventricular ectopy

Atrial fibrillation

 Abnormal x wave. 1. Absent x descent- AF, TR. 2. Prominent x descent- constrictive pericarditis.

- cardiac tamponade.
Abnormal v waves.
1. Prominent- Tricuspid regurgitation ,RV failure,, ASD, ASD

with MR. 2. Diminished hypovolemia.

Abnormal y descent

Rapid- RV failure, TR, ASD, ASD with MR & constrictive pericarditis 2. Slow TS, pericardial tamponade & tension pneumothorax.
1.

JVP in Tricuspid stenosis

Level
a wave

Elevated or normal Prominent( giant a wave)

Obstruction to Tricuspid Valve Obstruction to presystolic atrial emptying

Obliterated with AF

x descent Normal

v wave

Normal
Obstruction to RA emptying.

y descent Slow y descent

JVP in Tricuspid regurgitation

Level Normal or elevated RV failure

a wave

Prominent with PAH or acute TR a wave merges with v wave in severe TR

Severe PAH with non-compliant RV

x descent Obliterated with severe TR and small RA or acute TR v wave Prominent

Severe TR and small RA or acute TR Large wave with small RA & severe TR Mild TR with large RA or chronic TR rapid filling of RV Slow filling of RV

Normal
y descent Steep Slow with TS

JVP in pulmonary stenosis

Level a wave Normal with RV failure Prominent in severe PS RV systolic dysfunction Favors intact IVS Hypertrophied & non-compliant RV Severe TR results in early filling of RA Increased atrial filling

x descent Normal or obliterated with severe TR v wave Normal or with RV failure y descent Normal or rapid with RV failure

JVP in mitral stenosis

Level Normal or elevated RV failure. Associated organic TS/ TR. Associated ASD. Prominent Severe MS with severe PAH Associated TS Associated ASD

a wave

x descent
v wave

Normal or absent
Normal or prominent Normal or Rapid or Slow

Absent AF , severe TR
RV failure TR

y descent

Rapid- RVF, TR Slow- TS

JVP in mitral regurgitation

Level Elevated PAH with RV failure Associated organic TS/ TR. Associated ASD. RV infarct with MR in CAD Secondary MR with myocardial dysfunction in cardiomyopathy or CAD

a wave

Prominent

x descent v wave y descent

Obliterated Prominent Rapid

Severe PAH with MR Severe PAH with TR IWMI + RVI with MR due to papillary muscle dysfunction MR with ASD PAH & RV failure Associated with TR Any of the above disease.

JVP in aortic stenosis

Elevated JVP in AS usually occurs in late stages and carries poor prognosis

Level

a wave

x descent

Normal Elevated --- RVF secondary to LVF Associated MS + PAH + RVF Associated organic TV disease Prominent Severe AS- severe septal hypertrophy Mild AS- HOCM, MS+ PAH, TS or severe AS with LV dysfunction ( AS is underestimated) Normal -

v wave
y descent

Normal
Normal

JVP in aortic regurgitation

Level Normal Elevated --- RVF secondary to LVF Associated TVD Normal Prominent - Associated TS Associated MS + PAH Depend on presence of RV failure -

a wave

x descent v wave y descent -

JVP in ASD
Level Normal Elevated ----- Mitral valve disease LVF Severe PAH with RV failure Associated TAPVC Normal Prominent --- MS, PAH, PS Normal -

a wave

x descent

v wave

Prominent

Overfilling of RA vena cava & LA PAH with TR Associated MR Any of the above cause

y descent

Prominent

JVP in VSD
Level Normal Elevated -------Small VSD Large VSD + CCF VSD + MR/TR LV RA ( Gerbodes defect) Restrictive VSD with severe PS

a wave

Normal Prominent -----Normal Obliterated ----Normal Prominent ------Normal Prominent ------

x descent

TR, LVRA defect

v wave

CCF, TR,

y descent

With v wave prominence

JVP in Eisenmenger syndrome

ASD Level- VSD N N N PDA Prominent Prominent with CCF/ TR

a wave-- N v wave-- Prominent with CCF/ TR

JVP in Cyanotic CHD

TOF
Level

PS + intact IVS + RL atrial shunt Elevated

Tricuspid atresia With restrictive ASD Prominent Prominent With MR -

TGA, TAPVC

a wave

N N

Prominent Normal Elevated with TR -

Prominent Prominent with CCF+ TR -

v wave

x, y descent

ELEVATED JVP IN TOF- CAUSES

Cause
Anemia Systemic HTN

Mechanism
Volume load Non-compliant ventricle Biventricular failure AR,TR, Anemia, CRF Volume load Ventricular dysfunction Volume load Myocardial dysfunction

Infective endocarditis
AR Cardiomyopathy Associated PDA Adult tetrology

Bronchopulmonary collatrells Volume load Pulmonary flow

Cyanotic CHD & prominent a waves

Tricuspid atresia PS intact IVS + RL atrial shunt TAPVC Pulmonary atresia with intact IVS TOF- Adult tetrology, HTN, Restrictive VSD, Cardiomyopathy

JVP in cardiomyopathy
DILATED RESTRICTIVE

Level
a wave x descent

N/
Normal Normal

N/
Prominent Normal

v wave
y descent

N / prominent
N / prominent

Normal
Normal

 Kussmauls Sign This is a rise in the JVP seen with inspiration. It is the opposite of what is seen in normal people and this reflects the inability of the heart to compensate for a modest increase in venous return. This sign is classically seen in constrictive pericarditis in association with a raised JVP. This condition was originally described in tuberculous pericarditis and is rarely seen.

Kussmauls sign is also seen in right ventricular infarction, right heart failure.

JVP IN PERICARDIAL TAMPONADE

Level

Elevated above the angel of mandible Normal Normal

Cardiac compression high intrapericardial pressure Atrial compression prevents atrial contraction Fall in atrial pressure ventricular contraction descent of atrioventricular septum Atrial filling is preserved Ventricular compression - high intrapericardial pressure Additional venous return not admissible - Cardiac compression

a wave x descent

v wave y descent Kussmauls sign

Normal Obliterated/ absent +/-

JVP IN CONSTRICTIVE PERICARDITIS

Level

Elevated severity Variable degree of cardiac - constriction compression. N N / exaggerated N / = a wave Rapid / steep Atrial constriction does not permit atrial contraction Constriction around AV groove excessive descent of AV septum. Venous return to RA unaffected Rapid ventricular filling active ventricular relaxation. Coincides with diastolic outward movement of pericardium & pericardial knock Additional venous return not admissible RV constriction

a wave x descent

v wave y descent

Kussmauls sign

+ve

Elevated JVP with shock

CAUSES
Heart failure

MECHANISM
Ventricular/ Valvular dysfunction

Cardiac tamponade
RV infarction Acute pulmonary embolism Tension pneumo-thorax

Cardiac compression
RV failure & inadequate LV filling Pulmonary circulation obstruction. Cardio respiratory failure

Massive pleural effusion

Cardio respiratory failure

JUGULAR VENOUS PULSE IN ARRHYTHMIAS

The a & v waves in JVP correlates with P

& QRS complex in ECG. Normal sinus rhythm is characterized by sequential a & v waves. A wave occurring along 1st heart sound normal PR interval. Any disturbance in this wave form indicates rhythm abnormality.

Rhythm
Sinus I AV block

A-V sequence
a - v regular a precedes v regularly

Cannon waves
Absent Absent / rarely with extreme PR prolongation

Wenckebachs
Mobitz II block II AV block CHB VT Atrial tachycardia

Gradual prolongation of a-v interval

Constant a not followed by v wave 2:1 a:v wave Variable; Variable Normal

Absent
Absent Absent Present & irregular Irregular Absent