Giant a waves

Description

A 24-year-old man with a bioprosthetic tricuspid valve related to a history of infective endocarditis secondary to intravenous drug use was admitted to the hospital with fever and dyspnoea over the course of 2–3 weeks in the context of recidivism. On examination, the temperature was 38.0°C and the respiratory rate 24 breaths per minute. Qualitative analysis of the jugular venous waveform revealed the usual components, including two peaks, the a and v waves, and two troughs, the x and y descents. However, the first peak was more pronounced than usual, an abnormality known as a giant a wave. These waves coincided with a late diastolic murmur heard over the left lower sternal border that augmented with inspiration (see video 1). Blood cultures grew methicillin-sensitive Staphylococcus aureus. Transthoracic echocardiography demonstrated a large vegetation on the bioprosthetic tricuspid valve with an associated mean transtricuspid valve gradient of 17 mm Hg,...

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