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A Little-Known Valve
DIAGNOSTIC DILEMMAS Paul S. Pagel, MD, PhD Section Editor
A Little-Known Valve Rebecca Moga, MD,† Donna Nicholson, MD, FRCPC,* Jordan K.C. Hudson, MD, FRCPC,* and Christopher C.C. Hudson, MD, FRCPC†
A
48-YEAR-OLD man underwent redo aortic valve replacement for severe symptomatic regurgitation of a bioprosthetic aortic valve. Three months postoperatively, he presented to the hospital with a second-degree atrioventricular block requiring insertion of a dual-chamber permanent pacemaker. He subsequently developed Peptostreptococcus endocarditis involving the newly implanted bioprosthetic aortic valve and required subsequent aortic valve re-replacement. Unfortunately, he required a total of 5 sternotomies because of further complications including the need for ascending aortic graft replacement and sternal debridement. A surface ultrasound used to guide right internal jugular vein catheter insertion during the fourth sternotomy revealed the following image (Fig 1). What is the diagnosis?
Fig 1.
From the *Department of Anesthesiology, University of Ottawa, Ottawa, Ontario, Canada; and †Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Address reprint requests to Christopher Hudson, MD, FRCPC, University of Ottawa Heart Institute, H2410, Ruskin Street, Ottawa, Ontario, Canada K1Y 4W7. E-mail: [email protected] © 2011 Elsevier Inc. All rights reserved. 1053-0770/2504-0024$36.00/0 doi:10.1053/j.jvca.2010.02.017 Key words: internal jugular vein valve, ultrasound
A surface ultrasound of the right neck before catheter insertion with a structure seen in the long axis.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 25, No 4 (August), 2011: pp 749-750
749
750
MOGA ET AL
DIAGNOSIS: INTERNAL JUGULAR VEIN VALVE
A differential diagnosis for the structure seen included an intimal tear in the vascular lumen from previous catheter insertion, intravascular vegetation, thrombus, or internal jugular vein valve (IJVV). Further images confirmed the diagnosis of internal jugular vein valve (Fig 2). IJVVs are present in 90% of the population.1-4 They are located in the distal portion of the internal jugular vein approximately 2 cm above the jugular-subclavian vein confluence.5 These valves usually are bilateral, bicuspid, and semilunar and may be seen to open and close rhythmically.5,6 Imai et al5 showed that these valves can be visualized easily with real-time ultrasound. Because it is the only valve between the heart and the brain,7 a competent valve has an important function in preventing retrograde blood flow within the internal jugular vein. Unlike an IJVV, endocarditis appears as a discrete, echo-
Fig 2. A surface ultrasound of the right neck with a structure in the short axis.
dense mass that typically adheres to the upstream surface of a valve leaflet; vegetations have never been reported in the internal jugular vein.8 Although a tear or dissection would have a similar appearance, this is unlikely to occur in a low-pressure circuit and would result in turbulent flow on color-flow Doppler imaging. Finally, thrombi typically appear as mobile echodense masses unlike the thin oscillatory structure seen here. The presence of IJVVs was first described in the 16th century, and the anatomy and pathology literature has made continued reference to these structures.1,3,9 Despite this, the present authors believe the existence of these valves is not common knowledge among anesthesiologists because there are few articles published on these valves in the anesthesia literature.3-5 The insufficiency of one or both IJVVs allows transmission of high intrathoracic pressure to the cerebral venous system, which can lead to transient increases in intracranial pressure and result in a decrease in cerebral blood flow. This has been implicated in playing a role in some patients with coughinduced syncope,10 transient global amnesia,7 and the mechanism of iatrogenic venous air embolism in the cerebral venous system.2 The transient increase in intracranial pressure in the presence of an incompetent IJVV associated with coughing and positive-pressure ventilation may be associated with compromised cerebral perfusion in patients after traumatic brain injury or neurosurgery.3 It is thought that these valves are crucial for the development of a transcranial blood pressure gradient during cardiopulmonary resuscitation with chest compressions.1 Cannulation and catheterization of the internal jugular vein frequently causes incompetence of the IJVV, either by direct puncture, abrasion of the fragile valve by the catheter, or the prevention of IJVV closure by the in situ catheter.4 The risk of valve incompetence cannot be eliminated by cannulating the internal jugular vein more proximally (above the cricoid level).4 It also has been proposed that chronically elevated central venous pressures may lead to valve incompetence.11 With the increasing use of ultrasound-guided central catheter insertion, it is likely that this valve will be visualized more frequently, and, thus, knowledge of the presence of this valve is important.
REFERENCES 1. Lepori D, Capasso P, Fournier D, et al: High-resolution ultrasound evaluation of internal jugular venous valves. Eur Radiol 9:12221226, 1999 2. Nedelmann M, Pittermann P, Gast KK, et al: Involvement of jugular valve insufficiency in cerebral venous air embolism. J Neuroimaging 17:258-260, 2007 3. Sum-Ping ST: Internal jugular valves: Competent or incompetent? Anesth Analg 78:1039-1040, 1994 4. Wu X, Studer W, Erb T, et al: Competence of the internal jugular vein valve is damaged by cannulation and catheterization of the internal jugular vein. Anesthesiology 93:319-324, 2000 5. Imai M, Hanaoka Y, Kemmotsu O: Valve injury: A new complication of internal jugular vein cannulation. Anesth Analg 78:1041-1046, 1994 6. Darge K, Brandis U, Zieger B, et al: Internal jugular venous valves in children: High-resolution US findings. Eur Radiol 11:655658, 2001
7. Nedelmann M, Teschner D, Dieterich M: Analysis of internal jugular vein insufficiency—A comparison of two ultrasound methods. Ultrasound Med Biol 33:857-862, 2007 8. Sanfilipp AJ, Picard MH, Newell JB, et al: Echocardiographic assessment of patients with infectious endocarditis: Prediction of risk for complications. J Am Coll Cardiol 18:1191-1199, 1991 9. D’Cruz IA, Khouzam RN, Minderman DP, et al: Incompetence of the internal jugular venous valve: Spectrum of echo-Doppler appearances. Echocardiography 23:803-806, 2006 10. Styczynski G, Dobosiewicz A, Abramczyk P, et al: Internal jugular vein valve insufficiency in cough syncope. Neurology 70:812813, 2008 11. Doepp F, Bahr D, John M, et al: Internal jugular vein valve incompetence in COPD and primary pulmonary hypertension. J Clin Ultrasound 36:480-484, 2008
A Little-Known Valve Rebecca Moga, MD,† Donna Nicholson, MD, FRCPC,* Jordan K.C. Hudson, MD, FRCPC,* and Christopher C.C. Hudson, MD, FRCPC†
A
48-YEAR-OLD man underwent redo aortic valve replacement for severe symptomatic regurgitation of a bioprosthetic aortic valve. Three months postoperatively, he presented to the hospital with a second-degree atrioventricular block requiring insertion of a dual-chamber permanent pacemaker. He subsequently developed Peptostreptococcus endocarditis involving the newly implanted bioprosthetic aortic valve and required subsequent aortic valve re-replacement. Unfortunately, he required a total of 5 sternotomies because of further complications including the need for ascending aortic graft replacement and sternal debridement. A surface ultrasound used to guide right internal jugular vein catheter insertion during the fourth sternotomy revealed the following image (Fig 1). What is the diagnosis?
Fig 1.
From the *Department of Anesthesiology, University of Ottawa, Ottawa, Ontario, Canada; and †Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Address reprint requests to Christopher Hudson, MD, FRCPC, University of Ottawa Heart Institute, H2410, Ruskin Street, Ottawa, Ontario, Canada K1Y 4W7. E-mail: [email protected] © 2011 Elsevier Inc. All rights reserved. 1053-0770/2504-0024$36.00/0 doi:10.1053/j.jvca.2010.02.017 Key words: internal jugular vein valve, ultrasound
A surface ultrasound of the right neck before catheter insertion with a structure seen in the long axis.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 25, No 4 (August), 2011: pp 749-750
749
750
MOGA ET AL
DIAGNOSIS: INTERNAL JUGULAR VEIN VALVE
A differential diagnosis for the structure seen included an intimal tear in the vascular lumen from previous catheter insertion, intravascular vegetation, thrombus, or internal jugular vein valve (IJVV). Further images confirmed the diagnosis of internal jugular vein valve (Fig 2). IJVVs are present in 90% of the population.1-4 They are located in the distal portion of the internal jugular vein approximately 2 cm above the jugular-subclavian vein confluence.5 These valves usually are bilateral, bicuspid, and semilunar and may be seen to open and close rhythmically.5,6 Imai et al5 showed that these valves can be visualized easily with real-time ultrasound. Because it is the only valve between the heart and the brain,7 a competent valve has an important function in preventing retrograde blood flow within the internal jugular vein. Unlike an IJVV, endocarditis appears as a discrete, echo-
Fig 2. A surface ultrasound of the right neck with a structure in the short axis.
dense mass that typically adheres to the upstream surface of a valve leaflet; vegetations have never been reported in the internal jugular vein.8 Although a tear or dissection would have a similar appearance, this is unlikely to occur in a low-pressure circuit and would result in turbulent flow on color-flow Doppler imaging. Finally, thrombi typically appear as mobile echodense masses unlike the thin oscillatory structure seen here. The presence of IJVVs was first described in the 16th century, and the anatomy and pathology literature has made continued reference to these structures.1,3,9 Despite this, the present authors believe the existence of these valves is not common knowledge among anesthesiologists because there are few articles published on these valves in the anesthesia literature.3-5 The insufficiency of one or both IJVVs allows transmission of high intrathoracic pressure to the cerebral venous system, which can lead to transient increases in intracranial pressure and result in a decrease in cerebral blood flow. This has been implicated in playing a role in some patients with coughinduced syncope,10 transient global amnesia,7 and the mechanism of iatrogenic venous air embolism in the cerebral venous system.2 The transient increase in intracranial pressure in the presence of an incompetent IJVV associated with coughing and positive-pressure ventilation may be associated with compromised cerebral perfusion in patients after traumatic brain injury or neurosurgery.3 It is thought that these valves are crucial for the development of a transcranial blood pressure gradient during cardiopulmonary resuscitation with chest compressions.1 Cannulation and catheterization of the internal jugular vein frequently causes incompetence of the IJVV, either by direct puncture, abrasion of the fragile valve by the catheter, or the prevention of IJVV closure by the in situ catheter.4 The risk of valve incompetence cannot be eliminated by cannulating the internal jugular vein more proximally (above the cricoid level).4 It also has been proposed that chronically elevated central venous pressures may lead to valve incompetence.11 With the increasing use of ultrasound-guided central catheter insertion, it is likely that this valve will be visualized more frequently, and, thus, knowledge of the presence of this valve is important.
REFERENCES 1. Lepori D, Capasso P, Fournier D, et al: High-resolution ultrasound evaluation of internal jugular venous valves. Eur Radiol 9:12221226, 1999 2. Nedelmann M, Pittermann P, Gast KK, et al: Involvement of jugular valve insufficiency in cerebral venous air embolism. J Neuroimaging 17:258-260, 2007 3. Sum-Ping ST: Internal jugular valves: Competent or incompetent? Anesth Analg 78:1039-1040, 1994 4. Wu X, Studer W, Erb T, et al: Competence of the internal jugular vein valve is damaged by cannulation and catheterization of the internal jugular vein. Anesthesiology 93:319-324, 2000 5. Imai M, Hanaoka Y, Kemmotsu O: Valve injury: A new complication of internal jugular vein cannulation. Anesth Analg 78:1041-1046, 1994 6. Darge K, Brandis U, Zieger B, et al: Internal jugular venous valves in children: High-resolution US findings. Eur Radiol 11:655658, 2001
7. Nedelmann M, Teschner D, Dieterich M: Analysis of internal jugular vein insufficiency—A comparison of two ultrasound methods. Ultrasound Med Biol 33:857-862, 2007 8. Sanfilipp AJ, Picard MH, Newell JB, et al: Echocardiographic assessment of patients with infectious endocarditis: Prediction of risk for complications. J Am Coll Cardiol 18:1191-1199, 1991 9. D’Cruz IA, Khouzam RN, Minderman DP, et al: Incompetence of the internal jugular venous valve: Spectrum of echo-Doppler appearances. Echocardiography 23:803-806, 2006 10. Styczynski G, Dobosiewicz A, Abramczyk P, et al: Internal jugular vein valve insufficiency in cough syncope. Neurology 70:812813, 2008 11. Doepp F, Bahr D, John M, et al: Internal jugular vein valve incompetence in COPD and primary pulmonary hypertension. J Clin Ultrasound 36:480-484, 2008