The contour of this patient’s venous pulse gives us much information of the pathophysiology in this case. Using the carotid as a timing mechanism, we observe the venous pulse and we see a movement just before systole, that is, just before the carotid impulse, and then we see a very big movement during systole – a venous impulse, but systolic. Much information about this patient’s pathophysiology… observe it carefully. [Cut-away]
The very large systolic impulse in this patient’s jugular venous pulse sends us a message. There shouldn’t be a systolic impulse coming up at the same time as the carotid. It means that the venous pulse in the neck is ventricularized – when the right ventricle contracts, there must be tricuspid regurgitation to account for this, and then that pressure rises and the impulse comes up in the neck. This is telling us that this patient should have tricuspid regurgitation.
Graphic comparison
By comparing a graphic of a normal patient to our patient, we can appreciate that our patient's jugular venous wave form shows a small "a" wave and a systolic "cv" wave. Following the "a" wave that reflects right atrial contraction, there is positive systolic "cv" wave that reflects tricuspid regurgitation. The systolic regurgitant wave is transmitted from the right ventricle via the right atrium into the neck veins. Note that the "y" descent in prominent, as there is no obstruction to flow into the right ventricle during diastole. Note also that patients with systolic "cv" waves due to tricuspid regurgitation typically have an elevated central venous pressure.