W Sign
The normal jugular venous waveform contains two descents, x and y. Under normal conditions, the x descent is more prominent than the y descent. In constrictive pericarditis, the unyielding pericardium causes elevated atrial pressure and limits ventricular filling to the early diastolic period, resulting in a sharp and deep y descent, known as Friedreich’s sign. In some patients, the prominent y descent occurs in combination with a prominent x descent, creating two steep troughs known as the “W” sign. This finding is helpful in distinguishing constrictive pericarditis from restrictive cardiomyopathy, in which the x descent is typically diminished.
Patient 1:
This patient developed constrictive pericarditis many years after orthotopic heart transplantation, a rare sequala of that procedure. These videos demonstrate sharp and deep x and y descents of the jugular venous waveform. The astute observer will also note the presence of Kussmaul’s sign.
Video courtesy of BMJ case reports: “Jugular venous pulse in constrictive pericarditis”
*It may be easier to appreciate this video by slowing it down to half speed (click the gear icon in the bottom right corner of the video)
W sign
Annotated