Our patient's jugular venous pulse wave form is distinctly abnormal. Let's look together again using the cotton swab on the carotid vessel to identify systole and observe the movements in the neck. [Cut-away]
Now, that large wave is very aptly named, it is an "a" wave and it is very big, it is called a giant "a" wave. And what's the cause of that? When the right atrium goes to contract and push blood into the right ventricle, it finds resistance. That puts more stretch on the right atrium muscle, it enhances contraction and you get this reflected wave back into the neck called the giant "a" wave. This may be seen due to a number of causes, commonly, it's right ventricular hypertrophy.
Now, if that weren't clear enough, let's contrast this to what we would see in a normal patient, where the "a" wave is not giant, markedly enhanced, but is more subtle. Let's change to the normal patient, we can then put the carotid vessel impulse for timing before you by using the cotton swab and look at that vein. [Cut-away Totally different, a subtle "a" wave. Yes, a bit bigger than the second, or "v" wave, but much more subtle. This is a normal jugular venous impulse.]
Normal vs. giant "a" graphics
By comparing the graphic of a normal patient to our patient, we can appreciate that our patient's "a" wave is larger. An abnormally prominent, or giant, "a" wave is due to enhanced right atrial contraction against an increased resistance. This is most often due to right ventricular hypertrophy.