What are the characteristic changes on a Wiggers diagram for the various cardiac pathologies (mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, tricuspid regurgitation, constrictive pericarditis, cardiac tamponade, and left‑ventricular failure)?

Wiggers Diagram Changes in Cardiac Pathologies

Mitral Stenosis

In mitral stenosis, the Wiggers diagram shows a prolonged pressure gradient between the left atrium and left ventricle during diastole, with elevated left atrial pressure throughout the cardiac cycle and a characteristic slow decline in the left atrial pressure curve. 1

• The left atrial pressure remains elevated with a prominent a-wave (if in sinus rhythm) due to forceful atrial contraction against the stenotic valve 1
• The v-wave is typically prominent, reflecting continued atrial filling during ventricular systole when the mitral valve is closed 2
• The y-descent (diastolic emptying of the left atrium) is slow and gradual due to restricted flow through the narrowed valve orifice 1
• Left ventricular end-diastolic pressure may be normal or low, creating a persistent diastolic pressure gradient across the mitral valve 1
• The mitral valve opening is delayed, and the E-wave velocity on Doppler is increased (>1.2-1.5 m/s) with prolonged pressure half-time 3

Mitral Regurgitation

Mitral regurgitation produces a large v-wave in the left atrial pressure tracing, with the height and morphology of the v-wave reflecting the severity of regurgitation. 2, 3

• The v-wave becomes markedly elevated and may merge with the systolic pressure curve in severe cases, as the left atrium receives both normal pulmonary venous return and regurgitant volume during systole 4, 2
• Left atrial pressure rises rapidly during systole, and the v-wave peak occurs earlier in systole with severe regurgitation 2
• Left ventricular end-diastolic volume and pressure are increased due to volume overload 1, 3
• The left ventricular pressure curve shows normal or increased systolic pressure, but the effective forward stroke volume is reduced 3
• In acute severe mitral regurgitation, the left atrial pressure curve shows a giant v-wave that may equal or exceed left ventricular systolic pressure 2

Aortic Stenosis

Aortic stenosis creates a characteristic pressure gradient between the left ventricle and aorta during systole, with delayed and reduced aortic pressure upstroke (pulsus parvus et tardus). 1

• The left ventricular systolic pressure is markedly elevated while aortic systolic pressure is reduced, creating a large systolic gradient 1
• The aortic pressure waveform shows a slow upstroke (delayed peak) and reduced pulse pressure 1
• Left ventricular end-diastolic pressure is often elevated due to concentric hypertrophy and diastolic dysfunction 1
• The a-wave in the left atrial pressure tracing is prominent, reflecting forceful atrial contraction to fill the hypertrophied, stiff left ventricle 1
• Ejection time is prolonged, and the aortic valve closure is delayed 1

Aortic Regurgitation

Aortic regurgitation shows a wide pulse pressure with rapid rise and fall of aortic pressure (Corrigan pulse), and elevated left ventricular end-diastolic pressure that may equal or exceed left atrial pressure. 1

• The aortic diastolic pressure falls rapidly and may reach very low levels due to regurgitant flow back into the left ventricle 1
• Left ventricular end-diastolic pressure is elevated and may approach or equal left atrial pressure, potentially causing premature mitral valve closure 1
• Left ventricular systolic pressure is increased due to the large stroke volume (forward flow plus regurgitant volume) 1
• The left ventricular pressure curve shows rapid early diastolic pressure rise as regurgitant blood fills the ventricle 1
• In chronic severe aortic regurgitation, left ventricular end-diastolic and end-systolic volumes are markedly increased (eccentric hypertrophy) 1

Tricuspid Regurgitation

Tricuspid regurgitation produces a prominent cv-wave (merged c and v waves) in the right atrial pressure tracing, with loss of the normal x-descent. 5, 1

• The right atrial pressure shows a large systolic wave as blood regurgitates backward during ventricular systole 5
• The normal x-descent (atrial relaxation during ventricular systole) is obliterated or reversed in severe tricuspid regurgitation 1, 5
• Right ventricular systolic pressure may be normal or elevated depending on the presence of pulmonary hypertension 1, 5
• The inferior vena cava is dilated with no respiratory collapse, reflecting elevated right atrial pressure 1, 5
• Right ventricular end-diastolic volume is increased due to volume overload 5

Constrictive Pericarditis

Constrictive pericarditis shows equalization of diastolic pressures across all cardiac chambers, with a characteristic "square root sign" (dip-and-plateau pattern) in the ventricular pressure tracings. 1

• Ventricular diastolic pressure shows rapid early filling (steep y-descent) followed by an abrupt plateau as the rigid pericardium limits further filling 1
• Right and left ventricular end-diastolic pressures are elevated and typically within 5 mmHg of each other 1
• The right atrial pressure shows prominent x and y descents, creating an "M" or "W" configuration 1
• Atrial pressures remain elevated throughout the cardiac cycle with minimal variation 1
• Ventricular interdependence is present, with reciprocal changes in right and left ventricular filling during respiration 1

Cardiac Tamponade

Cardiac tamponade produces elevation and equalization of diastolic pressures with loss of the normal y-descent in the atrial pressure tracings. 1

• Right atrial pressure is elevated with a prominent x-descent but absent or blunted y-descent, as pericardial pressure prevents normal early diastolic ventricular filling 1
• All cardiac chamber diastolic pressures are elevated and equalized (within 5 mmHg) 1
• The right atrial pressure curve shows a single descent per cardiac cycle (only x-descent) rather than the normal two descents 1
• Pulsus paradoxus is present, with exaggerated respiratory variation in systolic blood pressure (>10 mmHg decrease during inspiration) 1
• Ventricular filling is restricted throughout diastole, unlike constrictive pericarditis where early filling is rapid 1

Left Ventricular Failure

Left ventricular failure shows elevated left ventricular end-diastolic pressure, elevated left atrial pressure with prominent a and v waves, and reduced stroke volume with decreased aortic pulse pressure. 1, 2

• Left ventricular end-diastolic pressure is markedly elevated (>20 mmHg), reflecting impaired diastolic compliance and/or systolic dysfunction 1, 2
• The left atrial pressure is elevated throughout the cardiac cycle with prominent a and v waves 1, 2
• Pulmonary artery pressure is elevated (>50 mmHg systolic), with elevated pulmonary capillary wedge pressure reflecting backward transmission of left atrial pressure 1
• The aortic pressure curve shows reduced pulse pressure and may demonstrate pulsus alternans (beat-to-beat variation in systolic pressure amplitude) in severe failure 2
• Left ventricular systolic pressure may be normal or reduced depending on the degree of contractile dysfunction 1
• The left ventricular pressure-volume loop is shifted rightward and upward, with increased end-diastolic and end-systolic volumes 1

Common Pitfalls

• Do not confuse the timing of pressure waves: the c-wave occurs during isovolumetric contraction (ventricular systole), while the v-wave peaks in late systole before valve opening 2
• Avoid misinterpreting v-wave height in mitral regurgitation: the v-wave morphology reflects both regurgitant severity and left atrial compliance; a non-compliant left atrium may show giant v-waves even with moderate regurgitation 2
• Do not overlook v-wave alternans as a sign of severe left ventricular dysfunction and poor prognosis 2
• Recognize that pressure gradients must be measured simultaneously: sequential measurements can be misleading, especially in conditions with beat-to-beat variability 1
• In aortic stenosis with low gradient and reduced ejection fraction, perform dobutamine stress echocardiography to distinguish true severe stenosis from pseudo-stenosis 1