The venous waveforms include several distinct peaks (a, c, and v; see Fig. 12-2).

The a wave reflects RA presystolic contraction, occurs just after the electrocardiographic P wave, and precedes the first heart sound (S1). A prominent a wave indicates reduced right ventricular (RV) compliance. A cannon a wave occurs with A-V dissociation and RA contraction against a closed tricuspid valve (TV; Fig. 123). The presence of cannon a waves in a patient with

wide complex tachycardia identifies the rhythm as ventricular in origin. The a wave is absent with AF. The x descent reflects the fall in RA pressure after the a wave peak. The c wave interrupts this descent as ventricular systole pushes the closed TV into the RA. In the neck, the carotid pulse may also contribute to the c wave. The x descent follows because of atrial diastolic suction created by ventricular systole pulling the TV downward. In normal individuals, the x descent is the

predominant waveform in the jugular venous pulse. The v wave represents atrial filling, occurs at the end of ventricular systole, and follows just after S2. Its height is determined by RA compliance and by the volume of blood returning to the RA, either antegrade from the vena cavae and/or retrograde through an incompetent TV. The v wave is smaller than the a wave because of the normally compliant RA. In patients with ASD, the a and v waves may be of equal height; in TR, the v

wave is accentuated. With TR, the v wave will merge with the c wave because retrograde flow and antegrade right atrial filling occur simultaneously (see Fig. 12-3). The y descent follows the v wave peak and reflects the fall in RA pressure after TV opening. Resistance to ventricular filling in early diastole blunts the y descent, as is the case with pericardial tamponade or tricuspid stenosis (TS). The y descent will be steep when ventricular diastolic filling occurs early and rapidly, as with

pericardial constriction or isolated severe TR. The normal venous pressure should fall by at least 3 mm Hg with inspiration. A rise in venous pressure (or its failure to decrease) with inspiration (the Kussmaul sign) is associated with constrictive pericarditis and also with restrictive cardiomyopathy, pulmonary embolism, RV infarction, and advanced systolic heart failure. A Kussmaul sign occurs with right-sided volume overload and reduced right ventricular compliance. Normally, the inspiratory increase in right-sided venous return is

accommodated by increased right ventricular ejection, facilitated by an increase in the capacitance of the pulmonary vascular bed. In states of RV diastolic dysfunction and volume overload, the right ventricle cannot accommodate the enhanced volume and the pressure rises.

The normal CVP waveform consists of three upwards deflections (a, c, & v waves) and two downward

defections (x and y descents). These waves are produced as follows: 1. The a wave is produced by right atrial contraction and occurs just after the P wave on the ECG. 2. The c wave occurs due to isovolumic ventricular contraction forcing the tricuspid valve to bulge upward into the right atrium. (RA) 3. The pressure within the RA then decreases as the tricuspid valve is pulled away from the atrium during right ventricular ejection, forming the X descent.

4. The RA continues to fill during late ventricular systole, forming the V wave The Y descent occurs when the tricuspid valve opens and blood from the RA empties rapidly into the RV during early diastole.(