From the Guidelines
The V wave is a venous wave that represents atrial filling against a closed tricuspid valve, typically indicating tricuspid regurgitation when prominent or large, as seen in conditions like right ventricular failure, pulmonary hypertension, or primary tricuspid valve disease 1.
Clinical Features of Tricuspid Regurgitation
The clinical features of tricuspid regurgitation (TR) include abnormal systolic c and v waves in the jugular venous pulse, which can be observed by positioning the patient at a 45-degree angle and looking for pulsations in the internal jugular vein.
- A lower left parasternal systolic murmur that may increase on inspiration (Carvallo’s sign)
- A middiastolic murmur in severe regurgitation
- Systolic hepatic pulsation
- In rare instances, severe TR may produce systolic propulsion of the eyeballs, pulsatile varicose veins, or a venous systolic thrill and murmur in the neck
Diagnosis and Assessment
Echocardiography is valuable in assessing tricuspid valve structure and motion, measuring annular size, and identifying other cardiac abnormalities that might influence tricuspid valve function, as stated in the acc/aha 2006 guidelines for the management of patients with valvular heart disease 1.
- Doppler echocardiography permits estimation of the severity of TR, RV systolic pressure, and the tricuspid valve diastolic gradient
- Although echocardiography is a valuable diagnostic tool, clinically insignificant TR is detected by color Doppler imaging in many normal persons, which is not an indication for either routine follow-up or prophylaxis against bacterial endocarditis
- Clinical correlation and judgment must accompany the echocardiographic results
Severity of Tricuspid Regurgitation
The height of the V wave correlates with the severity of tricuspid regurgitation, and systolic pulmonary artery pressures greater than 55 mm Hg are likely to cause TR with anatomically normal tricuspid valves, whereas TR occurring with systolic pulmonary artery pressures less than 40 mm Hg is likely to reflect a structural abnormality of the valve apparatus, as noted in the guidelines 1.
- Systolic pulmonary artery pressure estimation combined with information about annular circumference will further improve the accuracy of clinical assessment
- Understanding V waves is important for bedside cardiovascular assessment as they provide valuable information about right heart function and tricuspid valve competence without requiring advanced imaging techniques.
From the Research
Definition of V Wave
- A V wave is a prominent wave in the right atrial pressure tracing that occurs during ventricular systole, specifically when the tricuspid valve is closed 2.
- It is one of the hemodynamic changes in right atrial pressures seen in severe tricuspid regurgitation, along with elevated mean pressures, a large systolic wave called an "s" wave, a prominent 'Y' descent, and a blunted 'X' descent 2.
Relationship with Tricuspid Regurgitation
- The V wave is related to tricuspid regurgitation, but its correlation with the severity of tricuspid regurgitation is poor, as shown in a study where the right atrial V wave correlated poorly with the severity of tricuspid regurgitation intraoperatively, both before and after cardiopulmonary bypass 3.
- Other echocardiographic parameters, such as vena contracta width, proximal iso-velocity surface area-derived regurgitant volume, and effective regurgitant orifice area, are more reliable in assessing the severity of tricuspid regurgitation 4, 5.
Clinical Significance
- Severe tricuspid regurgitation can lead to significant morbidity and mortality if left untreated, and the V wave is one of the hemodynamic findings that can be seen in these patients 6, 2.
- Accurate assessment of tricuspid regurgitation severity is crucial in determining the best course of treatment, and echocardiography plays a key role in this assessment 3, 4, 5.