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The jugular venous tracing
The Jugular
Venous
Il. Ilartman,
.\l.D.,
Tracing Lcidcn,
Ncthcrlunds
I’hottocardiog~~~~h~ needs reference tracings. A fe~v authors have published phottocardiograms without any reference tracing, but the interpretation ma)be difficult or impossible even for readers with great experience. The simultaneous recording ot two or three phonocardiograms with different filtering yields more iniormation alread),. The electrocardiogram is frequently used as a reference tracing; it enlarges the information obtained. Yet the electrocardiogram is not the ideal reference for the photlocarcliogram. First, the elec-trocardiographic information is confined to q,stole. Second, the electrical events do not cover cxactl!. the mechanical events in the heart qzcle; in fact, the relationship between the electrocardiogram and the movements of the heart is variable. Third. the electroc;lrdiogrnm does ttot enable one to distinguish between left heart and right heat-t events. ITor these reasons, the advantage of additional mechanical tracings is evident. To get information about q,stole and diastole from the left heat-t at~d from the right heart, various indirect pulse tracings are necessar!-. Valuable tracings for this purpose are the carotid tracing, the phlebogram, and the apex c-ardiogram ; the liver pulse and the femoral arteq. also ma>. be useful. The carotid tracing represents left vetttricular ejection; the apex beat furnishes additional information, concerning in particular the left ventricular diastole. The jugular venous tracing and the liver pulse reflect systolic and diastolic events in the right heart. ‘Therefore, by successively recording the pulsations of the carotid artcrl., the jugular vein, and the apex beat it is possible to stud)- the s?,stolic and diastolic part of the heart c>rcle in both the left and the right heart. Sometitnes, however. the apes beat is formed b\, the right rather than 1~~.the left heat-t, and it1 this case we fail to have informatiott about left-sided diastoliceveIlls. To distinguish between the apex bent from the left heart a11d that it-m the right heat-t, several methods are available. The two most important are the prec-ordial electroc;trdiogram taken exactl!. at the site of the apes beat, :III~ the cot-relation of the jugular venous and apex beat tracings, as shown in the exhibit of the I,eiden (‘ardiac (‘enter at the ‘Third World (‘ongress oi (‘ardiolog>- it1 Hrussels (see also Snelleii’“~“‘; det;iiletl I~itblic-atioti is being prepared 1. Iii order
to obt;lin s)-llchrollously an electroc~~rdio~r;Lm, two I)honocardiograms of different frequent)., antI a pulse tracing, the use of a four-channel apparatus is Ilcc-essar>.. Therefore, \\-e feel that for efficient I,hotloc.;Lrtliogr;lphic examination, cquiprne~~t c:ip:~ble of reproducillg four tracings siniultaneousl~is essential. The various pulse records are of value as ;t reference for the phonocardiogr;ml ;wcl because of the shape of the pulse tracing. Esam~~les of the latt-er use are the characteristic patterns of the carotid arter!. itI aortic stenosis and aortic insufficiency: the positive venous and liver pulse tracing in tricuspid insuticierlq.; the different forms of the apes cardiogram in mitral stenosis ;LII~ mitral insufticienc~., as well as iI1 atrial septal defect antI ventricular septal defect; anal the slow ascent of the esternal femoral arterial tracing ill coarctation of the aorta. The value of these pulse records as reference tracings for the I,honocartlioKranl is obvious il OII~ thinks of the relationship of the ejection sound anti of the tu-o components of the second sound with the carotid arter).; of the tricuspid opellillg snap and of the third sound from the right heart with the venous tracillg; antI finall>-, of the mitral opening snap ad the third sound from the left heart \vith the apex cardiogram. In fact, without pulse tracings it is impossible to m;~l;e ;L reliable diagnosis of the 15 various sounds presentI\. knon~n.* III 1957, (‘ossio and Huzzi” published ;LII interesting article about the clinical value of the venous pulse. The), paid full attention to the form of the venous pulse, but little to its value as a reference tracing for the I,holloc-~lrtliogram. During the Europeall (‘ongress of (‘a-dialog?in Stockholm (1956) antI the World (‘ongress of C’ardiolog\~ in Hrussels (195X), we demonstrated in a11exhibition room these combined tr~~cillgs.x.Y,lg.?‘l In this paper we will report our esperience \vith the venous tracing, although we want to stress that ;L stutl!. of a11 the various ~)ulsc tracings is necess;tr!- for a complete utlderst:lndillg of the hemotl~~narnics of the patient. This communication is based on ;L st LICIJ~ of about 10,000 I~hollocardiograms. Many. patients underwent right heart catheterization. Furthermore, surgeg. has allowed us to compare in a number of these pat icll ts the phollocartlio#r;lphic interpretations lvith the operative fintlinp and to st utl~, these patients before and after operation. ‘The records are made I,hotoclectric~Lll~. lvith a piezoelectric microphone. ‘The apparatus used is the five-channel Hell&e Multikardiotest Type 9900/S. The paper speed is 50 mm. per second, and the time between the small lines is 0.02 second. The q,nchronous electroc;~rdiogrnm is Lcxl I I ; the uppermost phonocardiogram is an intermediate-frequenq. tracing and the lowermost one is a high-frequency tracing, designated accorcling to Maass and M’eber as 70 Herz and 140 Ha-z, rcspectivel~..‘” The various pulse tracings are made with the same applicator, consisting of ;I small cup connected 1~~. an air-containing rubber tubing. to a linear cqxtal microphotlr. The cup is held by hand. The best place for taking a VC’IIOUStracing is close to the median line of the chest just above the right clavicle, in such :I WA>’ *Mitral and tricuspid rlosurr sound. aortir aortir and pulmonic closure sound, mitral and heart,. atrial sounds from left, and right heart, t,he A-V valvrs Iwforr ventricular contraction. possible in t hr tn 0 lattrr cases. 1
and pulmonic ejection sound, midsystolic extra sound. tricuspid opening snap, third sounds from left and right summation gallop sound, sound of transient closure of (So far, no distinction between left and right heart was
II.\IITMAS
that the membr;me of the cup fxes the diaphrqm the carotid artery aside, thus avoiding interference veuous pulse. Even in patients bvith strong xterial undistorted venous tracings iu this WA)-. The patient with complete muscular relaxatioll, ~LIKI the tracing apnea.
Am. Heart J. .&lay. 1960
dud the rim of the cup ~)ushcs of the cxotid pulse with the pulsatiolls, we have obtained is placed in 2~supine I)osition, is t-,zken iu normal espiratory
The venous tracing appears to be more vxiable thau other pulse tr&lgs. This is due partly to the fnct that the venous tracing is, lor t.he most part, ITcorcletl in &stole; it is well known that diastole varies more than does s),stolc.
Wig. 2.
Pig. l.-Complete W~OUS tracing. The a wave is the highest of the four positive waves. It. begins 0.06 sec. after the beginning of the P waive and reaches its summit 0.14 sec. after the beginning of the P wave. The x depression ends before the split, second sound and is deeper than the 2/ depression. The h wave occurs 0.80 sec. after the beginning of the main deflection of the electrocardiogram. Fig. 2.-Venous tracing in pulmonic skmosis. The atria1 sound, visible in the 70 Hz (second tracing from above) and the 140 Hz phonocardiogram (fourth tracing from above). coincides with the summit of the a wave. The pulmonary component of the second sound (visible in both phonocardiograms) is quite close to the summit of the v wave.
TO1 A complete venous tracing is obtained only with a slow heart rate, diastoie then being long. It is represented by four positive waves and two depressions (Fig. 1). The positive waves are: (1) the n wave produced by atria1 contraction; (2) the c wave clue to right ventricular contraction; (3) the ZQwave due to the completion of venous filling of the right atrium while the tricuspid valves are closed; and (4) the h wave, marking the end of complete filling of the right ventricle. There is general agreement that the systolic or s depression is caused I,>, atria1 diastoie and lowering of the bottom of the right atrium b,. right ventricular The diastolic or y depression is due to the emptying of the right contraction. atrium after opening of the tricuspid valves. Normaii~-, the s depression is deeper than the y depression. Paul M’ood’)’ gives the following t!picai figures for the height of the various waves: a = 0; x = -4; 21 = 0; y = -3; k = -1 (called 5 by 1Vood). Fowier, Westcott and Scott, fi from a large group of observations on normal subjects, quote the following average atria1 pressures for the various waves: a = 5.5; c = 3.5; ZJ= 4.5; .Y = 1.5; y = 2.5. The pressures are given in millimeters of mercury from a line 10 cm. anterior to the spine. These figures are in good agreement with the relative height of the waves as founci b\, us in the jugular venous tracings. They do not agree with the venous tracings published Aitmann registers the visible pulsations of the external jugular by Aitmann.‘,” vein bl. means of a beam of light crossing the vein and directed to a photocell. \1Te feel that these visible pulsations often are of combined venous and arteriai (carotid) origin, causing the c wave to be higher than the a and z’ waves, and the s depression to end 0.02 second after the second sound, as does the carotid catacrotic incisura. Zeh,” ernpio).ing the same method as Altmanll and Weber, states that the transmission from the right atrium to the jugular vein amounts to onI>, a few hundredths of a second for the different waves, except for the end of the x depression, which should have a deia!, of 0.24 second. In our opinion, this seemingi>, excessive delay of the x depression in the venous tracing is due to disturbance of the phiebogram b>- the carotid pulsations. Jn agreement with man)’ other workers in this field, we have found the end of the x depression in the phiebogram to occur before the second sound. The transmission from the right atrium to the jugular veins will be discussed further in the course of this arkle. The a wave in the venous tracing begins about 0.05 second after the beginning of the P xvave in the electrocardiogram and reaches its summit after another 0.11 second. The jugular venous c1 wave is thought to be due to regurgitation of blood from the atrium into the veins. If the resistance to ventricular filling is increased, the 11.waves are higher, because more blood is regurgitated. The tail tz wave ma\- be associated with an atria1 sound in the pholloc~~rdiogran1 if the increased resistance is caused b>, a higher ventricular end-diastolic pressure. This will be the case in puimonic stenosis and ill puimonar\~ hypertension from an)’ cause. If the increased resistance to vetltricuiar filling is clue to a narrowed tricuspid valve, an atrial systolic murmur ma\- appear. It must be noted, however, that there is no general agreement concerning the graphic definition of a heart sound as differentiated from a murmur , and it ma>. be doubtful in some cases whether the recorded vibrations represent a murmur or ;L sound. The venous
trac.ilq ma>. be of help then because an atrial sound from the right heart is s),ilchronous with the summit of the a wave, as ~vt‘ have fou~~tl in our venous tracings (Fig. 2), whereas the atria1 systolic murmur start.s before this summit. liuoi2 founct that in auricuiar gallop the gallop SOLIII~ occurred at the pe:\I; oi the atria1 n wave in the pressure curve. This has also t)een our experience. Sin(y \ve also have found the atrial sountl to he s!~nchronous with the pe;il; of the jugular a WIVC. little or no dela>. in transmission from thtx right atrium to the jugular vein is to be accepted. This is in contrast to the opinion of I., stated that the summit of the (I \ViLve in the I)hlelqqylrn aplwlrs O.OX set-ontl after the correst)ontling wave in the right atria1 prtssurt! wrw, ant1 the\lounci ;i de?a>, of the 4’ wave in the jugular vein as long as 0.t~ se~ontl. The l’uI,lished tracings in the last article, however. show distorted ;ltri;d pressure (‘urves and venous pulse wrves influenced b>. carotid pulsations. The point .s falls then after the second sound, and the recorded (false) ~1wave occurs too late. I I, indeed, the transmission from the right atrium to the jugular vein were as poor ;IS Kuo and I,agertiif and We&ii state, the venous tracing NTNII~ be worthless as ;I reference tracing for the phonocardiogram. Margolies and Q’otferth, Ifi however, stated atready in 1032, that the opening snap in mitral stenosis was q.nchronous with the top D of the venous tracing. Although the mitral openinK snap is a left-sided phenomenon, a tlela>. of 0.13 second for the jugular PI wave would be incompttible n;ith the st:Ltement of Margolies and Wolfcr~h. I3rttileman antI :tsso&tes” found in severXI su1,jec.t~ in I10 whom atria1 pressure curves were obtained during c-;u-tiiac c.;ltheterizatioi1, appreciable difference in time between the fall of the ;Ltrial pressure m1t1 the peak of the 11wave ill the jugular venous pulse. This agrees with our findings. L)uring cwtli;w catheterization we obtained s\~llchronoust!~1 pressure tracing from the right ;ltrium and an external jugular vwous tracing, mcl foLllltl collstallt I\. I10 ~~ppreciabte difference in time between the summits of the CL and the zl waves iI1 the right atria1 l~ressurc tracing and ill the jugular venous traciI~g.“l Furthermore. we recorded apex cardiograms in all of our patients. The ;~pes cardiogram shows no appreciable time kg. 1 ii several JM~ ients WC got an apes beat from the right hwrt. The correlation between the apes heat from the right heart ;u~tt the vwms ~)ulse tracing was manifest in all of OLII’ I)atients, showing that the dcla>, in lraiismissioii to the jugutar vein ilr csterllal traciiigs (xii be lleglectetl. Even ilr those cases in which onI!. a. left apes beat tracing was recorded, t hc ;E,>-Ic.hronism betwee the venous tracing and the apes heat llever rc;whetl such figures as Kuo and l,qp-liif and We&ii stated for the dela>. from the right atrium to the jugular vein. It must be conctuctetl from our observations that the 1:~ in time between the atria1 pressure tracing ant1 the external jugular venous tracing is negligible, and that the phtebogram is a suitable reference traciy for the I’honocarcliogram. In the presence of a long P-K interval a high-pitched SOUIIC~ rn;~>’ tw see11 ill the I~honocartlioRram 0.22 to 0.30 second after the onset of the I’ wave (Fig. 3). In the phlehogram this sound corresponds to the end of the deswnclin~ limb oi
the CL nxvc a11c1 l)robabl!, rqmsellts trallsiellt valves, caused 11~ a positive velrtricrll;tr-retrial me,,~,l,.12,1”,l”
closure pressure
d
the atriovelltricul;lr gradient at this mo-
The amplitude of the u wave is also related to the heart rh\?hm. Whell atria1 contraction occurs earl!- ill diastole before the rapid filling of the right ventricle is complctctt, the resistance to ventricular filling is small, atid little or no regurgitatim lakes place in the veins. This ma\. be found in tnch!~cxdi;~, or in complete
iO4 and illcomplete atriovelitl-icul;tr I)locli. Ill I he l~hlebogr~tni this is reHcc.tctl I,\. the fall of the m ~vave in the descending liml) of the ‘~1\vave, bvhich results in ;I small u wave (Figs. 4 and 5). Even in pulnioilic stenosis the a wave rn;~~’1,~ small when it appears early ill diastole. When atria1 and ventricular s),stole coillcide, ejection oi blood fro111 the atrium is only possible toward the veins, resulting ill Giant (I waves (Vellenpropfung; ventricular tamponade) (Fig. 5). ‘I’he c wave is due to right ventricular contrxtion a11tl occurs simu~t:~llcous~~ with the first heart sound and before the rise of the carotid tracing (Fig. 6). 111 man). tracings there is also a later appearing c wave, due to arterial interference; in fact, in some tracings this will be the onI>. c wave. The occurrence of the arterial c nxve is dependent U~OII the kind of heart disease, but still more upon the trailling of the investigator. That the real V~IIO~IS c wave is not a11 arterial inlp;lc-t may be co~~clutled from its being recordetl iI1 the right atrial pressure tracillg and in the liver pulse tracing. ITurthermore, it1 atrial fihrillation the c \V;LVC’iIt the phlebogram is often smaller after a long diastole thaII after a short otle; this is in contrast to the arterial tracing, which shows constantI>- higher waves after a long diastole thall after a short one. The location of the c wave with regard to the u wave is dependent on the P-R interval iI1 the electroc~trdiogranl. It appears commonly in the descending limb of the c1~v:tve, iI1 the first part of the .\: depression. ifThen the I’ \v;~ve in the electrocarcliogr~Im occurs tluring ventricular q.stole, the c wave appears before the a wave. or the c a11tl a xv;~ves merge into one wave (Fig. 5). During ventricular s\.stole, venous blood c-otltillues to How into the atrium. ‘Toward the end of ventricular s)xtole the atrium is tilled up and the venous curve starts to rise, thus forming the asrelltliltg limb of the 2)\vave. The descending limb of the 7~wave begins kith the ope1li11.q of the tricuspid valves, and the onset of this descending limb is termed the summit oi the v \vnve. It is possible that a slight descent of the 1’occurs before or at the seco1~1 sound, but the opening of the tricuspid valves is marked then by a11increasing speed of descent. In pulmanic stenosis the pulmonary component of the secolltl sound is quite close to the summit of the n wave (Fig. 2). ‘The same holds true in cases of atrial septal defect with normal pulmonary pressure (1;ig. 6). In pulmouic stenosis the time between the pulmonary part of the second sou1~1 and the summit of the 11wave is less than 0.04 second md ma>- be zero. This tillding ~vas so constant in our series of cases of pulmonic stenosis that it seemsteasollablc to assessthe degree of splitting of the second sound from the time elapsing between the aortic part of the second souutl and the summit of the jugular z’ wave in those patients with pulmonic stenosis in whom the pulmonar\~ l)art of the second sound could not be recorded in the pholloc;~rdiogram. 111atrial septal defect the time between the pulmonary component of the second sound and the summit of the TJwave ma> amount to 0.06 second, if the pulmon;~r~- pressure is Ilot appreciabl>- elevated. The some\\-hat higher pulmonary pressure in at ri;tl septal defect, as compared with the abnormall!~ low Ix-essure ill pulrno~~i~ stenosis, is thought to be the rexson that the distance between the pulmonar>~ part of the second sound ;md
705
and tall
Fig. 5.-The is low. In 0 WY&Yes.
the
first cycle following
sho\\s a normal ryclrs, atria1
(I RBW. contraction
In thr srcond cycle t,lle a appears in thf* c deswnt occurs during ventricular systolr. rrsulting in
Ipig. F.-Atria1 srptal defect. Atwvc is the pulsr tracing from thr carotid artery; belon- is 1,he jugular ~ewus tracing recorded on the same patient. The carotid artery tracing starts significantly later than the venous c wave. The pulmonary component of the second sound occws 0.05 SW. before the summit of the II wave: the mid-diastolic murmur starts after this summit. is maximal during the TVdescent, and stops with the end of rapid filling of the right ventricle (SW lowermost phonocardiogram).
706
H.\RTMAN
the summit of the 1~wave is slightly gregtter itt atrial septal defect that1 it1 l)ulmonk stenosis. However, if the atria1 septal defect is complicated by pulmonar~~ hypertension, the titne between the pulmonat-J. pat-t ol the secottd soutd at~d the summit of the ‘L’wave increases and, iti our cspericnce, ma>. he as much ;IS 0.12 second (Fig. 7). This holds true also for other casesof pulmottary h\-periettsion. The explanatiotl would seem to be that itt ~~tst’sof low pulmottary pressure the* closure of the pulmottar~~ valves precedes the tricuspid opening h>. 01t1\ some hundredths of a second or less,whereas in pulmonary+ hyl)ertcnsion the pulmon;u-!. valves close earlier, and the time between closure of the lxtlmonar~~ v;tlve atd opening of the tricuspid valve is increased. In the 1x1ter CYLSL’ the hemod> n;unic-s are more like those in the left heart, itt lvhic-h the c-losut-c oi the xx-tic valves precedes the opening of the mitral valves b>. ;~bout 0.10 swo~ttl.
Fig. is recorded romponent
7.--.ktriat septal defect with pulmonary aftor a split first, sountt. The\ summit. of thv swond sound
systotir pressuw uf SO mm. Hg. An c!.icWion sound of thr r wave nt,pc’ars 0. I1 SW. aftrr bhr pulmonary
As published b>. Margolies and Wolferth, Iti thy mitral opening snap is simultaneous with the summit of the venous 2’W;LVC,if the right ad left heart events coincide. ‘This is in agreement \vith our findings, although we have to state that in mitral stenosis the openittg snq ma>. be found to occur shortI>- before the summit of the 21wave, even it1 cases in which splittiug of the second sound is not obvious. The tricuq)iti opening SII;I~ which occurs ill tricuspid stenosis, \tttt which is more frequetitl~- encountered in atrial septal defwl 1 n-;LS;dwa~~sfoutd 011the top of the vettous z \v;tve (F;ig. X). This olwtlin~ snal) \I’;LSoften not audible because of its vet-!. short tlistanc’c frotn the se~xttcl sout~tl ;tntl LV;LSrecorded in 15 out of 91 cases of atria1 sq)t;Ll defect. iti \Ihich olxxttiott r?ve:Llerl tt0rmd tricuspid and mitral valves. \Tic have to allon- for the possibilit)~ that the tricuspid opening snap is still more frequent iii ;\trial septal clefcc-t. lwcauw in 5 ndtlitiotial
c;tses the last vibtxtion of a broad, high-pitched pulmottaq- componettt of the second soutitl coincided xvith the sttmmit of the 21i~xvc and possihl\’ rqxeseti ted ;II~ opetiitt~ stt;q). ititlow itito The clescetiding limb oi the ‘iI \zxvc is itiscribctl during the r+d the right vent-rick. The end of the steep descent corresponds to an eventual third sound from the right heart (f;ig. 11). ,A third sound iron1 the left heart is often earlier and occurs commottl~ in the descending limb of tht ’ “1’leave. (‘onsequetitl~~, ;L third soutttl occurring before the iv depression is from the left heart; a thirtl sountl at the end of the a descent ma!- be either from the left heart. or from the right heat-t. If both third sounds at-e recorded, the determinatiotl is eas>’ (I;ig. 9). C‘;dn” tlescribecl ;Xfifth soutld, occurring later tha~t the third souttcl. 111our tr;icings an ~~ldition;tl diastolic sountl, occurring after a third sound, was alwa~~s s\‘ttc-hrotlous with the 3’ depression of the venous tracing anal was thought to be ;L
1%. X.-At rial stqdal dc*fwt. A t riruspid opening snap appews after a widrly split secorltl sound ant1 is synchronous wit.h the summit rrf thr o wave. _4 short. mitl-diastolic murmur occurs during the rapid filling of the right vrntrkln. The c wave is slight,ly higher than the (I wave. The summit of the u wave appears 0.04 SW. aftw thr pulmonary part, of the srvond sound, indicating normal pulmonary prcssurr, as was indrrd found by right, hrart, cathetwization. At operat,ion the atria1 septal defect measuretl 4 t)y 1 cm. : no tricuspid wgurgit aliorr was felt : Iricwspicl and mitral valves were normal.
third sountl from the right ventricle. Therefore, we suppose that the fifth sound mentioned b!- Cnlo is itlentiwl with the third sountl from the right heart. Because of the fact that ;L third sound from the left heart is much more frequent than one from the right heart, the gettcral statement found in the literature is that the third sound supervenes in the descent of the v wave. I6 The ph>.siologic third sound is probably nlwa~~s from the left heart. The difference in inc-idence between the third soutd from the left heart and that from the right heart is in agreement with the diastolic contour of the apes beat tracings, just as the rapid filling wave is more conspicuous it1 the left apex c;trdiogr;m~ than it is in the ri,ght apex
cartliogram. This is also ~II ;~c~ord;~nw \vith the venous trx.ing:, because aiter the steep descent, representing the rapid ati-i;l] outflow, the triwing oftell tlocs Ilot rise immediately, but before rising contiiiues clescenrliiig, \\-ith a smaller slope, indicating that the atria1 outflow illto the right ventric.le is still greater than the venous inflow into the right atrium. The transition from rapid to slow filling is apparently less abruJ)t in the right ventricle thalr in the left ventricle, ;~ntl this may allow for the greater inc-idence of a thirtl sou~~tl from the left heart thall from the right heart.
In atria1 septal defect ;i mid-diastolic murmur at t ributetl to relative tricuspid stenosis, aid a protodiastolic murmur referred to pulmonary incompetence, have been described by many authors. CZ:e have found a tliastolir murmur in X0 per cent of 91 cases of atria1 septal defect in which at operation the mitral and tricuspid valves were found to be normal. In m:ul)cases, however, it was
not possible to determine with certaint\~ whether the murmur was protodiastolic or mid-diastolic, because of the fact that the puhnonaq, component of the secolltl sound appeared very shortI>. before the opening of the tricuspid valves, occurring close to the summit of the 21WLVC (Figs. 6 and 8). In the left heart the difference between a protodiastolic and ;L mid-diastolic murmur is more apparent. The end of the diastolic murmur in ever!. patient with uncomplicated atria1 septal defect was reached at or ver\. short]!! after the y depression in the phlebo~ram.
Fig.
IO.-Vnnous
tracing in prrdomirrant or absemt. and both limbs
tricuspid stenosis. confirmed at operation. of the 1, rleprrkon haw a smaller slope than
The usual.
h WZ&W is late
Fig. 1 l.Venous baring in predominant tricuspid insufficirnry. This patient was operatvtl on for pulmonk st’enosis. Apart from thr pulmonic strwosis the swyeon found tricuspid regurgitat.ion. The Jdepression is ahsrwt,, a well-formed 11 depression is present. and in fhe int~ermediate phonocardiogram a third sound, probably from the right hrart and synchronous \\ith thv 2/ dqwrssion. is rrcordrd. The h wave appears 0.76 SW. aftw t Iw Q waw of’ t hr. rlrctroc.ar[lioirram. AS for the mid-diastolic murmur, due to augmented flow through normal tricuspid valves, it is acceptable that after the rapid filling the remaining flow is not s&icient to produce a murmur. In the same way, holvever, the Ixotodiastolic murmur of pulmonary insuficietxxstops at the y depression if the pulmonar). pressure is not raised, as we have noted it1 those patients \vho demonstrated pulmonaq~
itisufkietiq~ after operatiott for pulmottic stenosis. Ilvcti a loud protodktolic murmur did not reach be).ottd the y depression, :uitl the murmur was recorded itt the phonocardiogram in the shape of ;I short diamond. immediatel~~ iollo\vittg the pulmonary part nf the second sound, if present, or iollo\vittg the aot-tic part
Pig. IS.--Venous sion is present after the wnous tracin::
tracing in a patient wit,h tricuspid insulKciency the n w-avr. but is filled up after th
w-ith sinus thr patirnt,
rhythm. Thr wais rffnrtivrlg
x ti~restreated.
of the secottd sound after a silent gap. ‘The murmur ma)’ be thought to represent a mid-diastolic murmur when the pulmottar?component ol the secontl sound is absent. OnI>- itt the presence of pulmonary. h>.pet-tettsion ma>. the pttlmonar~~ protodiastolic murmur extend beyond the y depressiott, as does the aortic protodiastolic murmur in aortic insufficient>-. Also, the diastolic murmurs of tricuspid
and mitral insuficienq~ stop at or shortI)- after the y clepressioll, because the)are Dale to ;u1gmented flow in earl), diastole, whereas the diastolic murmurs of tricuspid atlcl mitral stenosis may pass distinctly beyoucl the y depression. ‘After the rapid ventricular filling the venous tracirlg either shows ;I slower clesce~lt Idore rising agail or rises immediatel\~. If the heart rate is slow, the
Fig.
1.5
y depression is followed by the h wave, marking the end of slow filling of the right: ventricle. This wave was first described by Hirschfelder,fl in July, 1907. He encountered in some venous tracings a wave which occurred after the collapse following the TJwave, and noted that the wave corresponded more or less to the time at which the cardiac plethysmograph showed that the main filling of the
Fig. 16.----A. Atria1 septal defect of tho primum type aftor operaLion without closure of the tlefrrl. The venous wacing was t,akrn 3 weeks after oprration and shows an indistinct a waw. a shallow z cl?pression after the c wave. and a deep ?, depression. The pulmonary component of the second sound is close to the summit of the D wave. In the phonocardiogram an rjrct,ion sound is recorded. H, The same patient 3 months after operation. The u wave is more pronounced than in A. C, The Sam? pat,ient 6 months after operat,ion. A dist,invt r( wave is presrnt,. The y dnpwssion is still somewhat deeper than the z depression.
ventricle had occurred. 111 the same ).ear, November, 1907, Gibson wrote: “ I II the course of a study of jugular pulses in normal persons I have noticed that in those whose pulse rate is slower than the average a wave between the “v” wave and the ” a” wave is often to be seen. It is conceivable that this extra wave ma>I)e due to the closure of the atrioventricular valves bq. natural tilling of the ventricle with blood.“7 Both authors suggested that this extra wave might coincide with the third heart sound, and Gibson even wrote to Einthovell, who had rec.ordcd the third heart sound, to ask for information about the location of this sountl.
The h wave ma). be present either as a distinct positive wave (Figs. 1 and 9) or onI>- as the onset of a horizontal line, the latter representing the base line of the phlebogram (Fig. 11). With increasing heart rate the h wave disappears, and the y depression is followed by the a wave of the next heart q,cle (Fig. 7). With still increasing heart rate, even the y depression may be absent, and zl and u merge into one single wave (Fig. 4). The usual location of the h wave is some 0.40 second after the second sound and 0.80 second after the Q wave of the electrocardiogram. In severe constrictive pericarditis the 11 wave occurs early. The ventricle is not able to dilate further after the rapid filling, and the rise after the y depression is abrupt, giving origin to a deep, narrow y-trough and an ecu-11 h wave (Fig. 9). In great contrast to the picture in constrictive pericarditis is the venous tracing in tricuspid stenosis. Here the y depression is shallow and the h wave is late or absent (Fig. lo), as alread>~ described b). Wood.?* The rapid and the slow filling through a narrowed tricuspid orifice are retarded, and the descending as well as the ascending limbs of the y depression show a decrease of their slope.
714 In predominant tricuspid insufficiency there is a deep y depressioll ;~nd ;I distinct h wave which may be earlier than t~sud (Fig. 11). These factors m;o. 1~ of interest even if the patient had a right heart catheterization. \Vc h;lv~ iolltd a diastolic pressure gradient betweeu the right atrium and the right \Jvlltriclc of 5 mm. Hg which was thought to be proof of tricuspid stellosis, whereas O~W;Itiou revealed tricuspid insutticienc~ without stenosis. The ve~~ous tracillg, however, presented distinct h waves. 111 recent !-ears we have beefy able to :lvoitf this mistake 1,~ appreciating the venous tracing while bringing down the heart rate if necessar!. in order to obtain suflicient dklstolic time for recording the k \V:IVC’. With is absent, 12).
atria1 fibrillation, the part and results iI1 a y depression
of the .L depression that is deeper thall
due to atri;ll tliastole the x depression (l-is.
In tricuspid insufficienq~ with sinus rhythm the regurgitant flow from the right ventricle to the right atrium may fill up more or less the .V depression ill the phlebogram, and the y depression ma\- be deeper than the .\: depression, ;IS in atria1 fibrillation without tricuspid insufficienq~. However, iI1 tricuspid insufficienq~ the x: depressiou after the u wave remains, and it is onI\- from the c wave on that the x depression is Hatteued out or lilled up (Fig. 13). This is ill contrast to the venous tracing in atria1 fibrillation without tricuspid illsutliciellc!~. wherein the x depression after the c wave is present (Fig. 12 1. If tricuspicl ins&iciency supervenes in a patient with atria1 fibrillatioll, the x depression ;litcArt hr c wave is absent, and c and z1 make one positive wave (Fig. 11). With atria1 flutter the venous tracing is quite different from that itI atriirl fibrillation. III atria1 flutter the multiple (1 waves are predominant (l;ig. 14), and it is not possible to use the tracing as ;I reference tracing insofar ;LS the zb wave is concerned. The venous tracing in atria1 septal defect is usually- within ~~ormal limits. In many cases the height of the v wave approaches that of the (I wave, or ma>. even be higher (Fig. 8). The high zf waves are suggestive of tricuspid iusufficicnc\--, but in only 2 out of 6 patients with v waves higher that1 (1 \IrCLves ill atria1 septal defect did the surgeoil feel a regurgitant flow. The phlebogram after operation for atria1 septal defect presents striking features. The a wave is small or absent, and the y depression is deeper than the x depression (Fig. 15). The x depression is onI>- Ixesent after the c WLVC‘. We believe that two maiu factors are to be considered responsible for this pntterll. One factor is that the stroke volume is now significautl~ smaller in the right heart than before surgery. The dilated right ventricle, which is apt to receive a great stroke output, easily takes up the atria1 blood. After the opening of the tricuspid valve the ventricular filling is “rapid” for a long time, and the y depression is deep and lasting. During atria1 s)stole the resistalice to ventricular filling is still small, as iu normal venous tracings when the u wave occurs before the end of rapid filling (Fig. 2), and there will be little or IIO regurgitation into the veins. This factor ma>’ be responsible for the small or absent vc~~ous a wave and the deep y depression.
.Another factor m;i)~ be the damage inflicted on the right atrium bg- the operation, which may cause an absent or small a wave and a shallow x depressiou, features imitating atria1 fibrillation. This possibility IV:LS demonstrated in ;I patient with atria1 septal defect who ~1s operated up011 in 1956. At that time we were ~101 yet able to distinguish before operation between the sewndum and the primum types of atria1 septal defect. At operation the defect proved to be of the primum type, and the surgeon closed the right atrium without further intervention. The venous tracings of this patient presented postoperativeI!. the same ieaturcs as described above and returned to about normal in half a )-ear (1:ix. 1644, R, C). The curves are strikingly similar to the WI~OLIS tracings in atria1 tibrillatiou : the y depression is deeper thau the .x depressioll, and the s depression is present after the c wave, but is absent after the a wave.
Pig. 17.-Atria1 segtal a small Q W‘BVP is present, insufficiency. Compatible I,honorar~lio~ram. rwordrd
defwt of the primum t,ype after rlosurr of the defect. III the wnous and t.he o, c, and u waws merge into one positive wave, indicating wit,h this diagnosis are the pansystolic and mid-diastolic murmurs at the fourt,h intercostal spacr! parasternally.
tracing tricuspid in thv
It is also possible that tricuspid iusufficienc), supervenes after operation for atria1 septal defect. The small or absent a wave and the absence of the .T depression ;Lfter the c wave are characteristic of this event (Fig. 17). After operation ior ventricular septal defect we observed the same changes in the venous pulse contour as were seen in atria.1 septal defect. Again the damage to the right atrium by surger>. and the changed hemodynnmic-s due to closure of the defect may bc the most important fnc-tors resporlsible for these changes iu the V~IJOUS puke colltour. The stroke output of the right heart is less than before operation, and the distensibilit>of the right ventricle is greater than normal.
716
Am. Heart J.
H;\KTMAN
May,
1961~
The shape of the venous tracing in various heart diseases is discussetl. 111 tricuspid stenosis the a waves are always tall. This is usually also the case ill pulmonic stenosis and in high pulmonar\arterial pressure. However, in these conditions the CL waves ma)’ be low if the!, happen to occur in earl>- diastole. This is due to the low resistance to ventricular filling during that phase of the cycle. For an appreciation of the height of the n wave it is important, therefore, to take the heart rate into account. \4Yth atria1 fibrillation the a Leave is absent, and the s depression is onI>. present after the c wave, whereas the y depression is deeper than the x depression. With sinus rh?.thm and tricuspid insuficiellcl. the x depression is present in a normal wa!’ after the n wave, but it is flattened after the c wave and may disappear if the tricuspid insufficienc~~ is severe ellough. In atrial fibrillation associated with tricuspid insufficiency the .I‘ depression ma>. fail to appear. In tricuspid insuficienc!. there is a deep y depression and a distinct earl>. 12 wave, whereas in tricuspid stenosis the y depression is shallow a11d the h wave is late or absent. In atrial septal defect the shape of the venous tracing is usuall\~ within normal limits, but shows constantl\~ abnormal features after operation. The a wave is small or absent, and the y depression is deeper than the .Y depression. Possible responsible factors are considered to be the smaller volume of blood entering the dilated right ventricle and the damage inflicted OII the right atrium by surgery’. Similar postoperative features are seen in ventricular septal defect. The venous tracing is useful as a reference tracing for the I~holiocat-tliogram. It reflects accurateI>. the changes in right atria1 pressure, without appreciable dela>.. Ever). venous tracing with the .Y depression elAing after the stxn~tl heart sound should be considered suspect as being disturbed by arterial pulsations, and is not reliable as a reference tracing for the pholioc~~rdiogr~lm, insofar as the summit of the u wave is concerned. ‘l-he right atria1 sound is s!,nchronous with the jugular a wave. The opening snap from the right heart is s>~nchronous with the summit of the z wave; the opening snap from the left heart often occurs before the summit. The third heart sound from the right heart is s>,nchrollous with the y depression, whereas the third heart sound from the left heart ma!. be s)xichronous with the y depression or occurs during the descending limb oi the 11 W’lVc’ <
.
l II pulmonaq. h\‘pertension the distance betweell the pulmollar!~ component of the second sound and the summit of the er wave is greater than in cases in which pulmonary pressure is normal or lower than normal. The mid-diastolic murmurs due to functional tricuspid and mitral insuflicienc)do not pass the y depression; the same applies to the protodiastolic murmur of pulmonary insufliciency in patients with normal or low pulmonar\. pressure. I II contrast, ever>- mid-diastolic murmur that continues distinctly beyond the y depression is due to an organic lesion of the tricuspid or mitral orifice. The
author
is much
indebted
to Prof.
Lk.
H. I\. Snellen
for his helpful
advice
and
criticism.
1. 7 5: 4. 3. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Altmann,
R. : Die Bedeutung der graphischen Venenpulsregistrierung fiir die Beurteilung Herzkrankheiten, Ztschr. Kreislaufforsch. 41:751, 1952. Altmann, R.: Der Venenpuls, Berlin, 1956, Urban & Schwarzenberg. Calo, A4.: La phase de &action ventriculaire 61astique et le cinqui$me bruit du coeur, Cardiologia 18:112, 1951. Cossio, P., and Buzzi, A.: Clinical Value of the Venous Pulse, .4~. HEART J. 54:127, 1957. Eddleman, E. E., Jr., et al: Relationship of the Physiologic Third Heart Sound to the Jugular Venous Pulse. Am. I. Med. 17:15. 1954. Fowler, X. O., Westcott, N.: and Scott, Fi. C.: Normal Piessure in the Right Heart and Pulmonary Artery, .%M. HEART J. 4( 6:264, 195.3. Gibson, A. G., Oxon, XI. B., and Land, :M.R.C.P.: The Signihcance of a Hitherto Undescribed Wave in the Jugular P&e, Lancer 58:1380, 1907. Hartman, H.: The Diagnosis of Sub; xortic Stenosis, Third World Congress of Cardiology, 1955, Abstracts of Conm.. Innirations. ~~_. .~. ~. D. . 267. Hartman, H.: Differentiation Between the Influence of the Right and the Left Ventricle in the Phonocardiogram, With the Aid of Pulsation Cur\-es, Second European Congress of Cardiology, 1956, Abstracts of Papers, p. 127. Hartman. II.. and Snellen. H. ,I.: Die Klinische Redcutunr II des Venenuulses. Forsch. . I Arztl. 13:ho‘L 1959. Hirschfelder,‘A. D.: Some Variations in the Form of the Venous Pulse, 13ull. Johns Hopkins Hosp. 18:265, 1907. Kuo, P. T.: Symposium on Cardiovascular Sound, Circulation 16:270, 1957. Lagerltif, H., and &‘erkii, L.: Studies on the Circulation in Man, Cardiologia 13:241, 1948. Little, K.: Effect of Atria1 Systole on Ventricular Pressure and Closure of A-V Valves, Am. I. Phvsiol. 166:289. 19.51. Maassy H, jnd t;t’eber, .A.: Herzschallregistrierung mittels differenzierender Filter, Cardiologla 21:773, 1952. Margolies, A., and Wolferth, C.: The Opening Snap in Mitral Stenosis, Its Characteristics, Mechanism of Production and Diagnostic Importance, XX HEART J. ‘7:443, 1932. Schlitter, J. G., and Schiilmerick, P.: Die frequenzanalytische Differentialdiagnose der diastojischen Estratijne, Cardiologia 26:272, 1955. Siecke, H.: ITber den Einflusz der PQ Zeit auf die Amplitude des I Herztones ins besondere beim Kompletten X-V Block, Ztschr. Kreislaufforsch. 44:109, 1955. Snellen, H. =\.: The Clinical Criteria of Operability in Acquired Valvular Disease, Third U’orld Congress of Cardiology. 1958, Abstracts of Symposia, p. 671. Snellen, H. A.: Methodes destinCes A remplacer le cath&&-isme et B faire la pr&tlection, des cas pour le cathbterisme, Semaine hOp. 17/18:1281, 1958. Wood, P.: Diseases of the Heart and Circulation, ed. 2, London, 1956, Eyre & Spotliswoode; Philadelphia, J B. Lippincott Company. Zch, IX.: Die Diagnose des ‘I’rikuspidalinsufizienz, .-Xrch. Kreislaufforsrh. 30:175, 1959. van
Venous
Il. Ilartman,
.\l.D.,
Tracing Lcidcn,
Ncthcrlunds
I’hottocardiog~~~~h~ needs reference tracings. A fe~v authors have published phottocardiograms without any reference tracing, but the interpretation ma)be difficult or impossible even for readers with great experience. The simultaneous recording ot two or three phonocardiograms with different filtering yields more iniormation alread),. The electrocardiogram is frequently used as a reference tracing; it enlarges the information obtained. Yet the electrocardiogram is not the ideal reference for the photlocarcliogram. First, the elec-trocardiographic information is confined to q,stole. Second, the electrical events do not cover cxactl!. the mechanical events in the heart qzcle; in fact, the relationship between the electrocardiogram and the movements of the heart is variable. Third. the electroc;lrdiogrnm does ttot enable one to distinguish between left heart and right heat-t events. ITor these reasons, the advantage of additional mechanical tracings is evident. To get information about q,stole and diastole from the left heat-t at~d from the right heart, various indirect pulse tracings are necessar!-. Valuable tracings for this purpose are the carotid tracing, the phlebogram, and the apex c-ardiogram ; the liver pulse and the femoral arteq. also ma>. be useful. The carotid tracing represents left vetttricular ejection; the apex beat furnishes additional information, concerning in particular the left ventricular diastole. The jugular venous tracing and the liver pulse reflect systolic and diastolic events in the right heart. ‘Therefore, by successively recording the pulsations of the carotid artcrl., the jugular vein, and the apex beat it is possible to stud)- the s?,stolic and diastolic part of the heart c>rcle in both the left and the right heart. Sometitnes, however. the apes beat is formed b\, the right rather than 1~~.the left heat-t, and it1 this case we fail to have informatiott about left-sided diastoliceveIlls. To distinguish between the apex bent from the left heart a11d that it-m the right heat-t, several methods are available. The two most important are the prec-ordial electroc;trdiogram taken exactl!. at the site of the apes beat, :III~ the cot-relation of the jugular venous and apex beat tracings, as shown in the exhibit of the I,eiden (‘ardiac (‘enter at the ‘Third World (‘ongress oi (‘ardiolog>- it1 Hrussels (see also Snelleii’“~“‘; det;iiletl I~itblic-atioti is being prepared 1. Iii order
to obt;lin s)-llchrollously an electroc~~rdio~r;Lm, two I)honocardiograms of different frequent)., antI a pulse tracing, the use of a four-channel apparatus is Ilcc-essar>.. Therefore, \\-e feel that for efficient I,hotloc.;Lrtliogr;lphic examination, cquiprne~~t c:ip:~ble of reproducillg four tracings siniultaneousl~is essential. The various pulse records are of value as ;t reference for the phonocardiogr;ml ;wcl because of the shape of the pulse tracing. Esam~~les of the latt-er use are the characteristic patterns of the carotid arter!. itI aortic stenosis and aortic insufficiency: the positive venous and liver pulse tracing in tricuspid insuticierlq.; the different forms of the apes cardiogram in mitral stenosis ;LII~ mitral insufticienc~., as well as iI1 atrial septal defect antI ventricular septal defect; anal the slow ascent of the esternal femoral arterial tracing ill coarctation of the aorta. The value of these pulse records as reference tracings for the I,honocartlioKranl is obvious il OII~ thinks of the relationship of the ejection sound anti of the tu-o components of the second sound with the carotid arter).; of the tricuspid opellillg snap and of the third sound from the right heart with the venous tracillg; antI finall>-, of the mitral opening snap ad the third sound from the left heart \vith the apex cardiogram. In fact, without pulse tracings it is impossible to m;~l;e ;L reliable diagnosis of the 15 various sounds presentI\. knon~n.* III 1957, (‘ossio and Huzzi” published ;LII interesting article about the clinical value of the venous pulse. The), paid full attention to the form of the venous pulse, but little to its value as a reference tracing for the I,holloc-~lrtliogram. During the Europeall (‘ongress of (‘a-dialog?in Stockholm (1956) antI the World (‘ongress of C’ardiolog\~ in Hrussels (195X), we demonstrated in a11exhibition room these combined tr~~cillgs.x.Y,lg.?‘l In this paper we will report our esperience \vith the venous tracing, although we want to stress that ;L stutl!. of a11 the various ~)ulsc tracings is necess;tr!- for a complete utlderst:lndillg of the hemotl~~narnics of the patient. This communication is based on ;L st LICIJ~ of about 10,000 I~hollocardiograms. Many. patients underwent right heart catheterization. Furthermore, surgeg. has allowed us to compare in a number of these pat icll ts the phollocartlio#r;lphic interpretations lvith the operative fintlinp and to st utl~, these patients before and after operation. ‘The records are made I,hotoclectric~Lll~. lvith a piezoelectric microphone. ‘The apparatus used is the five-channel Hell&e Multikardiotest Type 9900/S. The paper speed is 50 mm. per second, and the time between the small lines is 0.02 second. The q,nchronous electroc;~rdiogrnm is Lcxl I I ; the uppermost phonocardiogram is an intermediate-frequenq. tracing and the lowermost one is a high-frequency tracing, designated accorcling to Maass and M’eber as 70 Herz and 140 Ha-z, rcspectivel~..‘” The various pulse tracings are made with the same applicator, consisting of ;I small cup connected 1~~. an air-containing rubber tubing. to a linear cqxtal microphotlr. The cup is held by hand. The best place for taking a VC’IIOUStracing is close to the median line of the chest just above the right clavicle, in such :I WA>’ *Mitral and tricuspid rlosurr sound. aortir aortir and pulmonic closure sound, mitral and heart,. atrial sounds from left, and right heart, t,he A-V valvrs Iwforr ventricular contraction. possible in t hr tn 0 lattrr cases. 1
and pulmonic ejection sound, midsystolic extra sound. tricuspid opening snap, third sounds from left and right summation gallop sound, sound of transient closure of (So far, no distinction between left and right heart was
II.\IITMAS
that the membr;me of the cup fxes the diaphrqm the carotid artery aside, thus avoiding interference veuous pulse. Even in patients bvith strong xterial undistorted venous tracings iu this WA)-. The patient with complete muscular relaxatioll, ~LIKI the tracing apnea.
Am. Heart J. .&lay. 1960
dud the rim of the cup ~)ushcs of the cxotid pulse with the pulsatiolls, we have obtained is placed in 2~supine I)osition, is t-,zken iu normal espiratory
The venous tracing appears to be more vxiable thau other pulse tr&lgs. This is due partly to the fnct that the venous tracing is, lor t.he most part, ITcorcletl in &stole; it is well known that diastole varies more than does s),stolc.
Wig. 2.
Pig. l.-Complete W~OUS tracing. The a wave is the highest of the four positive waves. It. begins 0.06 sec. after the beginning of the P waive and reaches its summit 0.14 sec. after the beginning of the P wave. The x depression ends before the split, second sound and is deeper than the 2/ depression. The h wave occurs 0.80 sec. after the beginning of the main deflection of the electrocardiogram. Fig. 2.-Venous tracing in pulmonic skmosis. The atria1 sound, visible in the 70 Hz (second tracing from above) and the 140 Hz phonocardiogram (fourth tracing from above). coincides with the summit of the a wave. The pulmonary component of the second sound (visible in both phonocardiograms) is quite close to the summit of the v wave.
TO1 A complete venous tracing is obtained only with a slow heart rate, diastoie then being long. It is represented by four positive waves and two depressions (Fig. 1). The positive waves are: (1) the n wave produced by atria1 contraction; (2) the c wave clue to right ventricular contraction; (3) the ZQwave due to the completion of venous filling of the right atrium while the tricuspid valves are closed; and (4) the h wave, marking the end of complete filling of the right ventricle. There is general agreement that the systolic or s depression is caused I,>, atria1 diastoie and lowering of the bottom of the right atrium b,. right ventricular The diastolic or y depression is due to the emptying of the right contraction. atrium after opening of the tricuspid valves. Normaii~-, the s depression is deeper than the y depression. Paul M’ood’)’ gives the following t!picai figures for the height of the various waves: a = 0; x = -4; 21 = 0; y = -3; k = -1 (called 5 by 1Vood). Fowier, Westcott and Scott, fi from a large group of observations on normal subjects, quote the following average atria1 pressures for the various waves: a = 5.5; c = 3.5; ZJ= 4.5; .Y = 1.5; y = 2.5. The pressures are given in millimeters of mercury from a line 10 cm. anterior to the spine. These figures are in good agreement with the relative height of the waves as founci b\, us in the jugular venous tracings. They do not agree with the venous tracings published Aitmann registers the visible pulsations of the external jugular by Aitmann.‘,” vein bl. means of a beam of light crossing the vein and directed to a photocell. \1Te feel that these visible pulsations often are of combined venous and arteriai (carotid) origin, causing the c wave to be higher than the a and z’ waves, and the s depression to end 0.02 second after the second sound, as does the carotid catacrotic incisura. Zeh,” ernpio).ing the same method as Altmanll and Weber, states that the transmission from the right atrium to the jugular vein amounts to onI>, a few hundredths of a second for the different waves, except for the end of the x depression, which should have a deia!, of 0.24 second. In our opinion, this seemingi>, excessive delay of the x depression in the venous tracing is due to disturbance of the phiebogram b>- the carotid pulsations. Jn agreement with man)’ other workers in this field, we have found the end of the x depression in the phiebogram to occur before the second sound. The transmission from the right atrium to the jugular veins will be discussed further in the course of this arkle. The a wave in the venous tracing begins about 0.05 second after the beginning of the P xvave in the electrocardiogram and reaches its summit after another 0.11 second. The jugular venous c1 wave is thought to be due to regurgitation of blood from the atrium into the veins. If the resistance to ventricular filling is increased, the 11.waves are higher, because more blood is regurgitated. The tail tz wave ma\- be associated with an atria1 sound in the pholloc~~rdiogran1 if the increased resistance is caused b>, a higher ventricular end-diastolic pressure. This will be the case in puimonic stenosis and ill puimonar\~ hypertension from an)’ cause. If the increased resistance to vetltricuiar filling is clue to a narrowed tricuspid valve, an atrial systolic murmur ma\- appear. It must be noted, however, that there is no general agreement concerning the graphic definition of a heart sound as differentiated from a murmur , and it ma>. be doubtful in some cases whether the recorded vibrations represent a murmur or ;L sound. The venous
trac.ilq ma>. be of help then because an atrial sound from the right heart is s),ilchronous with the summit of the a wave, as ~vt‘ have fou~~tl in our venous tracings (Fig. 2), whereas the atria1 systolic murmur start.s before this summit. liuoi2 founct that in auricuiar gallop the gallop SOLIII~ occurred at the pe:\I; oi the atria1 n wave in the pressure curve. This has also t)een our experience. Sin(y \ve also have found the atrial sountl to he s!~nchronous with the pe;il; of the jugular a WIVC. little or no dela>. in transmission from thtx right atrium to the jugular vein is to be accepted. This is in contrast to the opinion of I
the CL nxvc a11c1 l)robabl!, rqmsellts trallsiellt valves, caused 11~ a positive velrtricrll;tr-retrial me,,~,l,.12,1”,l”
closure pressure
d
the atriovelltricul;lr gradient at this mo-
The amplitude of the u wave is also related to the heart rh\?hm. Whell atria1 contraction occurs earl!- ill diastole before the rapid filling of the right ventricle is complctctt, the resistance to ventricular filling is small, atid little or no regurgitatim lakes place in the veins. This ma\. be found in tnch!~cxdi;~, or in complete
iO4 and illcomplete atriovelitl-icul;tr I)locli. Ill I he l~hlebogr~tni this is reHcc.tctl I,\. the fall of the m ~vave in the descending liml) of the ‘~1\vave, bvhich results in ;I small u wave (Figs. 4 and 5). Even in pulnioilic stenosis the a wave rn;~~’1,~ small when it appears early ill diastole. When atria1 and ventricular s),stole coillcide, ejection oi blood fro111 the atrium is only possible toward the veins, resulting ill Giant (I waves (Vellenpropfung; ventricular tamponade) (Fig. 5). ‘I’he c wave is due to right ventricular contrxtion a11tl occurs simu~t:~llcous~~ with the first heart sound and before the rise of the carotid tracing (Fig. 6). 111 man). tracings there is also a later appearing c wave, due to arterial interference; in fact, in some tracings this will be the onI>. c wave. The occurrence of the arterial c nxve is dependent U~OII the kind of heart disease, but still more upon the trailling of the investigator. That the real V~IIO~IS c wave is not a11 arterial inlp;lc-t may be co~~clutled from its being recordetl iI1 the right atrial pressure tracillg and in the liver pulse tracing. ITurthermore, it1 atrial fihrillation the c \V;LVC’iIt the phlebogram is often smaller after a long diastole thaII after a short otle; this is in contrast to the arterial tracing, which shows constantI>- higher waves after a long diastole thall after a short one. The location of the c wave with regard to the u wave is dependent on the P-R interval iI1 the electroc~trdiogranl. It appears commonly in the descending limb of the c1~v:tve, iI1 the first part of the .\: depression. ifThen the I’ \v;~ve in the electrocarcliogr~Im occurs tluring ventricular q.stole, the c wave appears before the a wave. or the c a11tl a xv;~ves merge into one wave (Fig. 5). During ventricular s\.stole, venous blood c-otltillues to How into the atrium. ‘Toward the end of ventricular s)xtole the atrium is tilled up and the venous curve starts to rise, thus forming the asrelltliltg limb of the 2)\vave. The descending limb of the 7~wave begins kith the ope1li11.q of the tricuspid valves, and the onset of this descending limb is termed the summit oi the v \vnve. It is possible that a slight descent of the 1’occurs before or at the seco1~1 sound, but the opening of the tricuspid valves is marked then by a11increasing speed of descent. In pulmanic stenosis the pulmonary component of the secolltl sound is quite close to the summit of the n wave (Fig. 2). ‘The same holds true in cases of atrial septal defect with normal pulmonary pressure (1;ig. 6). In pulmouic stenosis the time between the pulmonary part of the second sou1~1 and the summit of the 11wave is less than 0.04 second md ma>- be zero. This tillding ~vas so constant in our series of cases of pulmonic stenosis that it seemsteasollablc to assessthe degree of splitting of the second sound from the time elapsing between the aortic part of the second souutl and the summit of the jugular z’ wave in those patients with pulmonic stenosis in whom the pulmonar\~ l)art of the second sound could not be recorded in the pholloc;~rdiogram. 111atrial septal defect the time between the pulmonary component of the second sound and the summit of the TJwave ma> amount to 0.06 second, if the pulmon;~r~- pressure is Ilot appreciabl>- elevated. The some\\-hat higher pulmonary pressure in at ri;tl septal defect, as compared with the abnormall!~ low Ix-essure ill pulrno~~i~ stenosis, is thought to be the rexson that the distance between the pulmonar>~ part of the second sound ;md
705
and tall
Fig. 5.-The is low. In 0 WY&Yes.
the
first cycle following
sho\\s a normal ryclrs, atria1
(I RBW. contraction
In thr srcond cycle t,lle a appears in thf* c deswnt occurs during ventricular systolr. rrsulting in
Ipig. F.-Atria1 srptal defect. Atwvc is the pulsr tracing from thr carotid artery; belon- is 1,he jugular ~ewus tracing recorded on the same patient. The carotid artery tracing starts significantly later than the venous c wave. The pulmonary component of the second sound occws 0.05 SW. before the summit of the II wave: the mid-diastolic murmur starts after this summit. is maximal during the TVdescent, and stops with the end of rapid filling of the right ventricle (SW lowermost phonocardiogram).
706
H.\RTMAN
the summit of the 1~wave is slightly gregtter itt atrial septal defect that1 it1 l)ulmonk stenosis. However, if the atria1 septal defect is complicated by pulmonar~~ hypertension, the titne between the pulmonat-J. pat-t ol the secottd soutd at~d the summit of the ‘L’wave increases and, iti our cspericnce, ma>. he as much ;IS 0.12 second (Fig. 7). This holds true also for other casesof pulmottary h\-periettsion. The explanatiotl would seem to be that itt ~~tst’sof low pulmottary pressure the* closure of the pulmottar~~ valves precedes the tricuspid opening h>. 01t1\ some hundredths of a second or less,whereas in pulmonary+ hyl)ertcnsion the pulmon;u-!. valves close earlier, and the time between closure of the lxtlmonar~~ v;tlve atd opening of the tricuspid valve is increased. In the 1x1ter CYLSL’ the hemod> n;unic-s are more like those in the left heart, itt lvhic-h the c-losut-c oi the xx-tic valves precedes the opening of the mitral valves b>. ;~bout 0.10 swo~ttl.
Fig. is recorded romponent
7.--.ktriat septal defect with pulmonary aftor a split first, sountt. The\ summit. of thv swond sound
systotir pressuw uf SO mm. Hg. An c!.icWion sound of thr r wave nt,pc’ars 0. I1 SW. aftrr bhr pulmonary
As published b>. Margolies and Wolferth, Iti thy mitral opening snap is simultaneous with the summit of the venous 2’W;LVC,if the right ad left heart events coincide. ‘This is in agreement \vith our findings, although we have to state that in mitral stenosis the openittg snq ma>. be found to occur shortI>- before the summit of the 21wave, even it1 cases in which splittiug of the second sound is not obvious. The tricuq)iti opening SII;I~ which occurs ill tricuspid stenosis, \tttt which is more frequetitl~- encountered in atrial septal defwl 1 n-;LS;dwa~~sfoutd 011the top of the vettous z \v;tve (F;ig. X). This olwtlin~ snal) \I’;LSoften not audible because of its vet-!. short tlistanc’c frotn the se~xttcl sout~tl ;tntl LV;LSrecorded in 15 out of 91 cases of atria1 sq)t;Ll defect. iti \Ihich olxxttiott r?ve:Llerl tt0rmd tricuspid and mitral valves. \Tic have to allon- for the possibilit)~ that the tricuspid opening snap is still more frequent iii ;\trial septal clefcc-t. lwcauw in 5 ndtlitiotial
c;tses the last vibtxtion of a broad, high-pitched pulmottaq- componettt of the second soutitl coincided xvith the sttmmit of the 21i~xvc and possihl\’ rqxeseti ted ;II~ opetiitt~ stt;q). ititlow itito The clescetiding limb oi the ‘iI \zxvc is itiscribctl during the r+d the right vent-rick. The end of the steep descent corresponds to an eventual third sound from the right heart (f;ig. 11). ,A third sound iron1 the left heart is often earlier and occurs commottl~ in the descending limb of tht ’ “1’leave. (‘onsequetitl~~, ;L third soutttl occurring before the iv depression is from the left heart; a thirtl sountl at the end of the a descent ma!- be either from the left heart. or from the right heat-t. If both third sounds at-e recorded, the determinatiotl is eas>’ (I;ig. 9). C‘;dn” tlescribecl ;Xfifth soutld, occurring later tha~t the third souttcl. 111our tr;icings an ~~ldition;tl diastolic sountl, occurring after a third sound, was alwa~~s s\‘ttc-hrotlous with the 3’ depression of the venous tracing anal was thought to be ;L
1%. X.-At rial stqdal dc*fwt. A t riruspid opening snap appews after a widrly split secorltl sound ant1 is synchronous wit.h the summit rrf thr o wave. _4 short. mitl-diastolic murmur occurs during the rapid filling of the right vrntrkln. The c wave is slight,ly higher than the (I wave. The summit of the u wave appears 0.04 SW. aftw thr pulmonary part, of the srvond sound, indicating normal pulmonary prcssurr, as was indrrd found by right, hrart, cathetwization. At operat,ion the atria1 septal defect measuretl 4 t)y 1 cm. : no tricuspid wgurgit aliorr was felt : Iricwspicl and mitral valves were normal.
third sountl from the right ventricle. Therefore, we suppose that the fifth sound mentioned b!- Cnlo is itlentiwl with the third sountl from the right heart. Because of the fact that ;L third sound from the left heart is much more frequent than one from the right heart, the gettcral statement found in the literature is that the third sound supervenes in the descent of the v wave. I6 The ph>.siologic third sound is probably nlwa~~s from the left heart. The difference in inc-idence between the third soutd from the left heart and that from the right heart is in agreement with the diastolic contour of the apes beat tracings, just as the rapid filling wave is more conspicuous it1 the left apex c;trdiogr;m~ than it is in the ri,ght apex
cartliogram. This is also ~II ;~c~ord;~nw \vith the venous trx.ing:, because aiter the steep descent, representing the rapid ati-i;l] outflow, the triwing oftell tlocs Ilot rise immediately, but before rising contiiiues clescenrliiig, \\-ith a smaller slope, indicating that the atria1 outflow illto the right ventric.le is still greater than the venous inflow into the right atrium. The transition from rapid to slow filling is apparently less abruJ)t in the right ventricle thalr in the left ventricle, ;~ntl this may allow for the greater inc-idence of a thirtl sou~~tl from the left heart thall from the right heart.
In atria1 septal defect ;i mid-diastolic murmur at t ributetl to relative tricuspid stenosis, aid a protodiastolic murmur referred to pulmonary incompetence, have been described by many authors. CZ:e have found a tliastolir murmur in X0 per cent of 91 cases of atria1 septal defect in which at operation the mitral and tricuspid valves were found to be normal. In m:ul)cases, however, it was
not possible to determine with certaint\~ whether the murmur was protodiastolic or mid-diastolic, because of the fact that the puhnonaq, component of the secolltl sound appeared very shortI>. before the opening of the tricuspid valves, occurring close to the summit of the 21WLVC (Figs. 6 and 8). In the left heart the difference between a protodiastolic and ;L mid-diastolic murmur is more apparent. The end of the diastolic murmur in ever!. patient with uncomplicated atria1 septal defect was reached at or ver\. short]!! after the y depression in the phlebo~ram.
Fig.
IO.-Vnnous
tracing in prrdomirrant or absemt. and both limbs
tricuspid stenosis. confirmed at operation. of the 1, rleprrkon haw a smaller slope than
The usual.
h WZ&W is late
Fig. 1 l.Venous baring in predominant tricuspid insufficirnry. This patient was operatvtl on for pulmonk st’enosis. Apart from thr pulmonic strwosis the swyeon found tricuspid regurgitat.ion. The Jdepression is ahsrwt,, a well-formed 11 depression is present. and in fhe int~ermediate phonocardiogram a third sound, probably from the right hrart and synchronous \\ith thv 2/ dqwrssion. is rrcordrd. The h wave appears 0.76 SW. aftw t Iw Q waw of’ t hr. rlrctroc.ar[lioirram. AS for the mid-diastolic murmur, due to augmented flow through normal tricuspid valves, it is acceptable that after the rapid filling the remaining flow is not s&icient to produce a murmur. In the same way, holvever, the Ixotodiastolic murmur of pulmonary insuficietxxstops at the y depression if the pulmonar). pressure is not raised, as we have noted it1 those patients \vho demonstrated pulmonaq~
itisufkietiq~ after operatiott for pulmottic stenosis. Ilvcti a loud protodktolic murmur did not reach be).ottd the y depression, :uitl the murmur was recorded itt the phonocardiogram in the shape of ;I short diamond. immediatel~~ iollo\vittg the pulmonary part nf the second sound, if present, or iollo\vittg the aot-tic part
Pig. IS.--Venous sion is present after the wnous tracin::
tracing in a patient wit,h tricuspid insulKciency the n w-avr. but is filled up after th
w-ith sinus thr patirnt,
rhythm. Thr wais rffnrtivrlg
x ti~restreated.
of the secottd sound after a silent gap. ‘The murmur ma)’ be thought to represent a mid-diastolic murmur when the pulmottar?component ol the secontl sound is absent. OnI>- itt the presence of pulmonary. h>.pet-tettsion ma>. the pttlmonar~~ protodiastolic murmur extend beyond the y depressiott, as does the aortic protodiastolic murmur in aortic insufficient>-. Also, the diastolic murmurs of tricuspid
and mitral insuficienq~ stop at or shortI)- after the y clepressioll, because the)are Dale to ;u1gmented flow in earl), diastole, whereas the diastolic murmurs of tricuspid atlcl mitral stenosis may pass distinctly beyoucl the y depression. ‘After the rapid ventricular filling the venous tracirlg either shows ;I slower clesce~lt Idore rising agail or rises immediatel\~. If the heart rate is slow, the
Fig.
1.5
y depression is followed by the h wave, marking the end of slow filling of the right: ventricle. This wave was first described by Hirschfelder,fl in July, 1907. He encountered in some venous tracings a wave which occurred after the collapse following the TJwave, and noted that the wave corresponded more or less to the time at which the cardiac plethysmograph showed that the main filling of the
Fig. 16.----A. Atria1 septal defect of tho primum type aftor operaLion without closure of the tlefrrl. The venous wacing was t,akrn 3 weeks after oprration and shows an indistinct a waw. a shallow z cl?pression after the c wave. and a deep ?, depression. The pulmonary component of the second sound is close to the summit of the D wave. In the phonocardiogram an rjrct,ion sound is recorded. H, The same patient 3 months after operation. The u wave is more pronounced than in A. C, The Sam? pat,ient 6 months after operat,ion. A dist,invt r( wave is presrnt,. The y dnpwssion is still somewhat deeper than the z depression.
ventricle had occurred. 111 the same ).ear, November, 1907, Gibson wrote: “ I II the course of a study of jugular pulses in normal persons I have noticed that in those whose pulse rate is slower than the average a wave between the “v” wave and the ” a” wave is often to be seen. It is conceivable that this extra wave ma>I)e due to the closure of the atrioventricular valves bq. natural tilling of the ventricle with blood.“7 Both authors suggested that this extra wave might coincide with the third heart sound, and Gibson even wrote to Einthovell, who had rec.ordcd the third heart sound, to ask for information about the location of this sountl.
The h wave ma). be present either as a distinct positive wave (Figs. 1 and 9) or onI>- as the onset of a horizontal line, the latter representing the base line of the phlebogram (Fig. 11). With increasing heart rate the h wave disappears, and the y depression is followed by the a wave of the next heart q,cle (Fig. 7). With still increasing heart rate, even the y depression may be absent, and zl and u merge into one single wave (Fig. 4). The usual location of the h wave is some 0.40 second after the second sound and 0.80 second after the Q wave of the electrocardiogram. In severe constrictive pericarditis the 11 wave occurs early. The ventricle is not able to dilate further after the rapid filling, and the rise after the y depression is abrupt, giving origin to a deep, narrow y-trough and an ecu-11 h wave (Fig. 9). In great contrast to the picture in constrictive pericarditis is the venous tracing in tricuspid stenosis. Here the y depression is shallow and the h wave is late or absent (Fig. lo), as alread>~ described b). Wood.?* The rapid and the slow filling through a narrowed tricuspid orifice are retarded, and the descending as well as the ascending limbs of the y depression show a decrease of their slope.
714 In predominant tricuspid insufficiency there is a deep y depressioll ;~nd ;I distinct h wave which may be earlier than t~sud (Fig. 11). These factors m;o. 1~ of interest even if the patient had a right heart catheterization. \Vc h;lv~ iolltd a diastolic pressure gradient betweeu the right atrium and the right \Jvlltriclc of 5 mm. Hg which was thought to be proof of tricuspid stellosis, whereas O~W;Itiou revealed tricuspid insutticienc~ without stenosis. The ve~~ous tracillg, however, presented distinct h waves. 111 recent !-ears we have beefy able to :lvoitf this mistake 1,~ appreciating the venous tracing while bringing down the heart rate if necessar!. in order to obtain suflicient dklstolic time for recording the k \V:IVC’. With is absent, 12).
atria1 fibrillation, the part and results iI1 a y depression
of the .L depression that is deeper thall
due to atri;ll tliastole the x depression (l-is.
In tricuspid insufficienq~ with sinus rhythm the regurgitant flow from the right ventricle to the right atrium may fill up more or less the .V depression ill the phlebogram, and the y depression ma\- be deeper than the .\: depression, ;IS in atria1 fibrillation without tricuspid insufficienq~. However, iI1 tricuspid insufficienq~ the x: depressiou after the u wave remains, and it is onI\- from the c wave on that the x depression is Hatteued out or lilled up (Fig. 13). This is ill contrast to the venous tracing in atria1 fibrillation without tricuspid illsutliciellc!~. wherein the x depression after the c wave is present (Fig. 12 1. If tricuspicl ins&iciency supervenes in a patient with atria1 fibrillatioll, the x depression ;litcArt hr c wave is absent, and c and z1 make one positive wave (Fig. 11). With atria1 flutter the venous tracing is quite different from that itI atriirl fibrillation. III atria1 flutter the multiple (1 waves are predominant (l;ig. 14), and it is not possible to use the tracing as ;I reference tracing insofar ;LS the zb wave is concerned. The venous tracing in atria1 septal defect is usually- within ~~ormal limits. In many cases the height of the v wave approaches that of the (I wave, or ma>. even be higher (Fig. 8). The high zf waves are suggestive of tricuspid iusufficicnc\--, but in only 2 out of 6 patients with v waves higher that1 (1 \IrCLves ill atria1 septal defect did the surgeoil feel a regurgitant flow. The phlebogram after operation for atria1 septal defect presents striking features. The a wave is small or absent, and the y depression is deeper than the x depression (Fig. 15). The x depression is onI>- Ixesent after the c WLVC‘. We believe that two maiu factors are to be considered responsible for this pntterll. One factor is that the stroke volume is now significautl~ smaller in the right heart than before surgery. The dilated right ventricle, which is apt to receive a great stroke output, easily takes up the atria1 blood. After the opening of the tricuspid valve the ventricular filling is “rapid” for a long time, and the y depression is deep and lasting. During atria1 s)stole the resistalice to ventricular filling is still small, as iu normal venous tracings when the u wave occurs before the end of rapid filling (Fig. 2), and there will be little or IIO regurgitation into the veins. This factor ma>’ be responsible for the small or absent vc~~ous a wave and the deep y depression.
.Another factor m;i)~ be the damage inflicted on the right atrium bg- the operation, which may cause an absent or small a wave and a shallow x depressiou, features imitating atria1 fibrillation. This possibility IV:LS demonstrated in ;I patient with atria1 septal defect who ~1s operated up011 in 1956. At that time we were ~101 yet able to distinguish before operation between the sewndum and the primum types of atria1 septal defect. At operation the defect proved to be of the primum type, and the surgeon closed the right atrium without further intervention. The venous tracings of this patient presented postoperativeI!. the same ieaturcs as described above and returned to about normal in half a )-ear (1:ix. 1644, R, C). The curves are strikingly similar to the WI~OLIS tracings in atria1 tibrillatiou : the y depression is deeper thau the .x depressioll, and the s depression is present after the c wave, but is absent after the a wave.
Pig. 17.-Atria1 segtal a small Q W‘BVP is present, insufficiency. Compatible I,honorar~lio~ram. rwordrd
defwt of the primum t,ype after rlosurr of the defect. III the wnous and t.he o, c, and u waws merge into one positive wave, indicating wit,h this diagnosis are the pansystolic and mid-diastolic murmurs at the fourt,h intercostal spacr! parasternally.
tracing tricuspid in thv
It is also possible that tricuspid iusufficienc), supervenes after operation for atria1 septal defect. The small or absent a wave and the absence of the .T depression ;Lfter the c wave are characteristic of this event (Fig. 17). After operation ior ventricular septal defect we observed the same changes in the venous pulse contour as were seen in atria.1 septal defect. Again the damage to the right atrium by surger>. and the changed hemodynnmic-s due to closure of the defect may bc the most important fnc-tors resporlsible for these changes iu the V~IJOUS puke colltour. The stroke output of the right heart is less than before operation, and the distensibilit>of the right ventricle is greater than normal.
716
Am. Heart J.
H;\KTMAN
May,
1961~
The shape of the venous tracing in various heart diseases is discussetl. 111 tricuspid stenosis the a waves are always tall. This is usually also the case ill pulmonic stenosis and in high pulmonar\arterial pressure. However, in these conditions the CL waves ma)’ be low if the!, happen to occur in earl>- diastole. This is due to the low resistance to ventricular filling during that phase of the cycle. For an appreciation of the height of the n wave it is important, therefore, to take the heart rate into account. \4Yth atria1 fibrillation the a Leave is absent, and the s depression is onI>. present after the c wave, whereas the y depression is deeper than the x depression. With sinus rh?.thm and tricuspid insuficiellcl. the x depression is present in a normal wa!’ after the n wave, but it is flattened after the c wave and may disappear if the tricuspid insufficienc~~ is severe ellough. In atrial fibrillation associated with tricuspid insufficiency the .I‘ depression ma>. fail to appear. In tricuspid insuficienc!. there is a deep y depression and a distinct earl>. 12 wave, whereas in tricuspid stenosis the y depression is shallow a11d the h wave is late or absent. In atrial septal defect the shape of the venous tracing is usuall\~ within normal limits, but shows constantl\~ abnormal features after operation. The a wave is small or absent, and the y depression is deeper than the .Y depression. Possible responsible factors are considered to be the smaller volume of blood entering the dilated right ventricle and the damage inflicted OII the right atrium by surgery’. Similar postoperative features are seen in ventricular septal defect. The venous tracing is useful as a reference tracing for the I~holiocat-tliogram. It reflects accurateI>. the changes in right atria1 pressure, without appreciable dela>.. Ever). venous tracing with the .Y depression elAing after the stxn~tl heart sound should be considered suspect as being disturbed by arterial pulsations, and is not reliable as a reference tracing for the pholioc~~rdiogr~lm, insofar as the summit of the u wave is concerned. ‘l-he right atria1 sound is s!,nchronous with the jugular a wave. The opening snap from the right heart is s>~nchronous with the summit of the z wave; the opening snap from the left heart often occurs before the summit. The third heart sound from the right heart is s>,nchrollous with the y depression, whereas the third heart sound from the left heart ma!. be s)xichronous with the y depression or occurs during the descending limb oi the 11 W’lVc’ <
.
l II pulmonaq. h\‘pertension the distance betweell the pulmollar!~ component of the second sound and the summit of the er wave is greater than in cases in which pulmonary pressure is normal or lower than normal. The mid-diastolic murmurs due to functional tricuspid and mitral insuflicienc)do not pass the y depression; the same applies to the protodiastolic murmur of pulmonary insufliciency in patients with normal or low pulmonar\. pressure. I II contrast, ever>- mid-diastolic murmur that continues distinctly beyond the y depression is due to an organic lesion of the tricuspid or mitral orifice. The
author
is much
indebted
to Prof.
Lk.
H. I\. Snellen
for his helpful
advice
and
criticism.
1. 7 5: 4. 3. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Altmann,
R. : Die Bedeutung der graphischen Venenpulsregistrierung fiir die Beurteilung Herzkrankheiten, Ztschr. Kreislaufforsch. 41:751, 1952. Altmann, R.: Der Venenpuls, Berlin, 1956, Urban & Schwarzenberg. Calo, A4.: La phase de &action ventriculaire 61astique et le cinqui$me bruit du coeur, Cardiologia 18:112, 1951. Cossio, P., and Buzzi, A.: Clinical Value of the Venous Pulse, .4~. HEART J. 54:127, 1957. Eddleman, E. E., Jr., et al: Relationship of the Physiologic Third Heart Sound to the Jugular Venous Pulse. Am. I. Med. 17:15. 1954. Fowler, X. O., Westcott, N.: and Scott, Fi. C.: Normal Piessure in the Right Heart and Pulmonary Artery, .%M. HEART J. 4( 6:264, 195.3. Gibson, A. G., Oxon, XI. B., and Land, :M.R.C.P.: The Signihcance of a Hitherto Undescribed Wave in the Jugular P&e, Lancer 58:1380, 1907. Hartman, H.: The Diagnosis of Sub; xortic Stenosis, Third World Congress of Cardiology, 1955, Abstracts of Conm.. Innirations. ~~_. .~. ~. D. . 267. Hartman, H.: Differentiation Between the Influence of the Right and the Left Ventricle in the Phonocardiogram, With the Aid of Pulsation Cur\-es, Second European Congress of Cardiology, 1956, Abstracts of Papers, p. 127. Hartman. II.. and Snellen. H. ,I.: Die Klinische Redcutunr II des Venenuulses. Forsch. . I Arztl. 13:ho‘L 1959. Hirschfelder,‘A. D.: Some Variations in the Form of the Venous Pulse, 13ull. Johns Hopkins Hosp. 18:265, 1907. Kuo, P. T.: Symposium on Cardiovascular Sound, Circulation 16:270, 1957. Lagerltif, H., and &‘erkii, L.: Studies on the Circulation in Man, Cardiologia 13:241, 1948. Little, K.: Effect of Atria1 Systole on Ventricular Pressure and Closure of A-V Valves, Am. I. Phvsiol. 166:289. 19.51. Maassy H, jnd t;t’eber, .A.: Herzschallregistrierung mittels differenzierender Filter, Cardiologla 21:773, 1952. Margolies, A., and Wolferth, C.: The Opening Snap in Mitral Stenosis, Its Characteristics, Mechanism of Production and Diagnostic Importance, XX HEART J. ‘7:443, 1932. Schlitter, J. G., and Schiilmerick, P.: Die frequenzanalytische Differentialdiagnose der diastojischen Estratijne, Cardiologia 26:272, 1955. Siecke, H.: ITber den Einflusz der PQ Zeit auf die Amplitude des I Herztones ins besondere beim Kompletten X-V Block, Ztschr. Kreislaufforsch. 44:109, 1955. Snellen, H. =\.: The Clinical Criteria of Operability in Acquired Valvular Disease, Third U’orld Congress of Cardiology. 1958, Abstracts of Symposia, p. 671. Snellen, H. A.: Methodes destinCes A remplacer le cath&&-isme et B faire la pr&tlection, des cas pour le cathbterisme, Semaine hOp. 17/18:1281, 1958. Wood, P.: Diseases of the Heart and Circulation, ed. 2, London, 1956, Eyre & Spotliswoode; Philadelphia, J B. Lippincott Company. Zch, IX.: Die Diagnose des ‘I’rikuspidalinsufizienz, .-Xrch. Kreislaufforsrh. 30:175, 1959. van