Differential Diagnosis of Double Descents

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A schema for the differential diagnosis and the significance of the double descents is shown in Table 3, both in the presence and the absence of pulmonary hypertension.

Table 3

Differential Diagnosis of Double Descents in Jugular Venous Pulse

In pulmonary hypertension In the absence of pulmonary hypertension x'> y: Indicates good right ventricular (RV) function

Compensated RV function • Normal young adult

• Hypervolemia

• Increased sympathetic tone

• Early pericardial effusion

x' = y: Increased v wave pressure with NO restriction to rapid filling

Early RV decompensation • Pericardial effusion

• Constrictive pericarditis with good myocardial function

• Early or mild RV infarction

• Early cardiomyopathy

• Post-cardiac surgery resulting from decreased right atrial capacitance x' < y: Indicates decreased RV function

RV failure • Late stage of constriction

Mild tricuspid regurgitation • RV infarction

• Cardiomyopathy

• Post-cardiac surgery (RV damage)

ASD, Atrial septal defect.

With Pulmonary Hypertension

In patients with pulmonary hypertension, the jugular pulse showing only an x' or a dominant x' descent would imply a compensated RV function. In addition, if the wave preceding the x' descent is large and rising fast, this would indicate a strong atrial contraction causing reversal of flow in end-diastole implying decreased RV compliance (Figs. 8 and 24).

If the pulmonary hypertension is severe and of long duration, the jugular pulse will change to the pattern x' = y descent. This would imply raised RV pre-a wave pressure and a secondary rise in RA and jugular v wave pressure (Fig. 24).

With progression of pulmonary hypertension, the pattern x' < y will emerge (Fig. 12). At this stage, the RV contractility is significantly reduced and RV failure has begun (41). Eventually RV dilatation and tricuspid regurgitation together with RV failure lead to markedly diminished or even absent x' descent and emergence of single dominant y descent (Fig. 13 and Table 3).

If the wave preceding the y descent is large and its rate of rise is prominent (the "cv" wave) it would indicate systolic flow reversal of tricuspid regurgitation. During this progression, before significant tricuspid regurgitation develops, the prominent a wave may in fact disappear as a result of deteriorating right atrial function.

Pulmonary Hypertension x' = y, ta

Pulmonary Hypertension x' = y, ta

Fig. 24. Simultaneous recordings of electrocardiogram (ECG), jugular venous flow velocity (JVF), and right atrial (RA) pressure in a patient with pulmonary hypertension. Superimposed diagrams depict the altered pathophysiology at different phases of the cardiac cycle. The systolic and the diastolic flow peaks (Sf = Df) are equal with the corresponding RA pressure showing x' = y descents. While the right ventricular (RV) systolic function is still preserved (good x' descent), the raised diastolic pressures in the RV secondary to RV hypertrophy and decreased diastolic compliance cause elevated RA v wave pressure, which leads to a prominent y descent. The strong contraction of the RA causes also a prominent a wave (retrograde end-diastolic flow [Ret Df] in the JVF).

Fig. 24. Simultaneous recordings of electrocardiogram (ECG), jugular venous flow velocity (JVF), and right atrial (RA) pressure in a patient with pulmonary hypertension. Superimposed diagrams depict the altered pathophysiology at different phases of the cardiac cycle. The systolic and the diastolic flow peaks (Sf = Df) are equal with the corresponding RA pressure showing x' = y descents. While the right ventricular (RV) systolic function is still preserved (good x' descent), the raised diastolic pressures in the RV secondary to RV hypertrophy and decreased diastolic compliance cause elevated RA v wave pressure, which leads to a prominent y descent. The strong contraction of the RA causes also a prominent a wave (retrograde end-diastolic flow [Ret Df] in the JVF).

Without Pulmonary Hypertension

In the absence of pulmonary hypertension also, the pattern of x' > y implies normal right ventricular function. This can be seen in some of the conditions that lead to an exaggeration of the y descent such as the first four causes in Table 2.

In the absence of pulmonary hypertension x' = y can be seen in:

1. Pericardial effusion

2. Constrictive pericarditis with good myocardial function

3. Early and mild right ventricular infarction

4. Early cardiomyopathy

5. Some patients with atrial septal defect

6. This pattern is quite common in post-cardiac-surgery patients. It tends to develop quite early after the pump run and may persist for the life of the patient.

The dominant y descent (x' < y) pattern with or without pulmonary hypertension implies right ventricular dysfunction. In post-cardiac-surgery patients this pattern is less common and would imply right ventricular damage. The pattern, if noted in constrictive pericarditis, implies a late stage of constriction with myocardial dysfunction. In the presence of acute inferior infarction, this jugular pulse contour would imply right ventricular involvement (30). The dominant y descent pattern is not usually seen in pure LV failure of acute myocardial infarction (see JVP Videofiles 4, 5, 9, and 10 on the Companion CD).

Asr>

Fig. 25. Simultaneous recordings of electrocardiogram (ECG), carotid pulse (CP), phonocardio-gram (Phono), andjugular venous flow velocity (JVF) in a patient with atrial septal defect (ASD). Note the splitting of S2 (A2 and P2). The important fact is that the Sf > Df flow pattern is maintained in ASD despite increased venous return to the right heart (double source of blood — normal venous return plus shunt flow). (Reproduced with kind permission from ref. 47.)

Fig. 25. Simultaneous recordings of electrocardiogram (ECG), carotid pulse (CP), phonocardio-gram (Phono), andjugular venous flow velocity (JVF) in a patient with atrial septal defect (ASD). Note the splitting of S2 (A2 and P2). The important fact is that the Sf > Df flow pattern is maintained in ASD despite increased venous return to the right heart (double source of blood — normal venous return plus shunt flow). (Reproduced with kind permission from ref. 47.)

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