Jugular Valve Research Articles

INTERNAL JUGULAR VEIN VALVE INSUFFICIENCY IN COUGH SYNCOPE

A 53-year-old man with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea was admitted to the hospital for the evaluation of recurrent syncopal episodes induced by paroxysmal cough. Loss of consciousness was brief, and preceded by the sensation of “fullness in the head.” Syncope was provoked also by prolonged expiration during spirometry, which revealed severe bronchial obstruction. However, oxygen saturation on room air and blood gases were within normal limits. To reproduce reported symptoms, the Valsalva maneuver (VM) was performed with the patient in the supine position with noninvasive, continuous blood pressure monitoring (Finapres, Ohmeda) and finger pulse oximetry. This resulted in a brief loss of consciousness, although no desaturation, decrease in blood pressure, or bradycardia was noted. Transthoracic echocardiography revealed normal left and right ventricular function, mild tricuspid insufficiency, and no evidence of pulmonary hypertension. There was no right-to-left shunt detected on the bubble-contrast study. Neurologic assessment, MRI of the brain, and EEG were unremarkable. Duplex-Doppler examination of extracranial carotid and vertebral arteries showed no stenosis. However, evaluation of the internal jugular veins (IJVs) with the use of color Doppler revealed right internal jugular valve insufficiency with flow reversal during inspiration (figure …

Incompetence of Internal Jugular Valve in Patients with Primary Exertional Headache: A Risk Factor?

The pathophysiology of primary exertional headache (EH) is unknown. Physical exertion is associated with Valsalva-like manoeuvres (VM). VM leads to increased intrathoracic pressure and reduces cerebral venous drainage. Internal jugular vein valve incompetence (IJVVI) leads to retrograde venous flow during VM with transient increase of intracranial pressure. We analysed the prevalence of IJVVI in EH patients using duplex ultrasound. Bilateral measurements were performed at rest and during VM in 20 patients and 40 controls. Incompetence was concluded if retrograde venous flow could be seen in the jugular Doppler spectrum during repeated VM. Seventy percent of EH patients and 20% of controls demonstrated IJVVI, yielding a significant difference (P = 0.0004). IJVVI was always observed on the dominant venous drainage side. Our study suggests that intracranial venous congestion caused by retrograde jugular venous flow might play a role in the pathophysiology of EH with IJVVI as a risk factor.

Involvement of Jugular Valve Insufficiency in Cerebral Venous Air Embolism

Cerebral venous air entrapment is a rare finding on cranial computed tomography (CT) scan. Peripheral air embolism is discussed as a potential cause. However, the mechanism of retrograde passage through internal jugular valves and veins is unclear. The case of a patient is reported, who had air entrapment in the left cavernous sinus. Prior to CT scanning, a peripheral intravenous line had been placed. Ultrasound revealed excessive insufficiency of the left internal jugular valve. To further study the mechanism of embolism, an echo contrast agent was injected into the cubital vein. A Valsalva maneuver resulted in retrograde transition of microbubbles across the insufficient valve. Valvular function on the unaffected right side was intact. This case report gives insight into the mechanism of cerebral venous air embolism. This is the firstcase describing jugular valve insufficiency as the missing link between peripheral air embolism and cerebral venous air entrapment.

Three sisters covering the transient global amnesia spectrum

We report the case of an Italian family in which three sisters experienced transient global amnesia (TGA). Since its early description, this transitory pure memory deficit has attracted increasing interest, especially within the neurological community. In 1964 the term “TGA” was coined to identify the abrupt onset of anterograde amnesia, accompanied by repetitive queries lasting for hours and then gradually recovering, leaving an amnesic gap for the duration of the attack. Afterwards, many studies focused on TGA, and in 1990 clinical criteria were defined by Hodges and Warlow (1990). Further studies showed that meeting diagnostic criteria was a significant predictor for a better outcome than in other forms of transient amnesia, while amnesic patients who did not fulfil the TGA criteria had different outcomes. Precipitating and trigger events for TGA were identified and divided into physical and psychological factors (Inzitari et al., 1997; Quinette et al., 2006). Physical precipitants were found to be gardening, housework and sawing wood, contact with water and changes in body temperature occurring during hot baths or showers, or a cold swim at the swimming pool. Emotional trigger events included a major life or death event, emotional stress triggered by a gastric endoscopy, an exhausting work session, and anxiety resulting from conflicts at home or at work, health problems and money worries. Several hypotheses have been proposed for its pathogenesis such as psychogenic, venous dysfunction due to jugular venous valve incompetence, or ischemic aetiology, but the enigma of TGA still needs to be unravelled (Lewis, 1998; Akkawi et al., 2001).

Analysis of Internal Jugular Vein Insufficiency—A Comparison of Two Ultrasound Methods

Jugular venous valve insufficiency is a contributing factor to different pathologic conditions. For assessment of insufficiency, two ultrasound techniques have been developed, that are based on very different methodology (direct Doppler assessment versus air contrast ultrasound venography [ACUV]). This study was conducted to compare these two methods to improve comparability of existing studies and diagnostic accuracy in future studies. The function of 40 valves was determined in 20 individuals during a Valsalva maneuver. For direct Doppler assessment, valvular competence was assessed on basis of Doppler recordings, following recently established criteria. Valvular insufficiency in ACUV was diagnosed when reflux of an air-based echo contrast agent through the valve could be detected. With both methods, evaluation of 39 valves was accomplished (one exclusion due to hypoplasia of the corresponding vein). Both methods showed very high agreement in detection rates. All 18 valves being classified as insufficient by Doppler criteria were also insufficient in ACUV. Of 21 valves classified as competent (Doppler), one valve was rated as insufficient in ACUV due to discrete reflux of microbubbles. However, ACUV was inaccurate in evaluation of the left internal jugular vein after injection of the contrast agent into the right cubital vein. High detection rates could only be achieved when this was taken into account. This study shows that detection rates of internal jugular valve insufficiency are very similar with both methods. However, this high agreement required modification of the established protocol of ACUV. (E-mail: max.nedelmann@neuro.med.uni-giessen.de)

Histological/Biological Characterization of Decellularized Bovine Jugular Vein

Several deficiencies in currently available right ventricular valved conduits make them problematic for use in infants and children. A solution would be to develop a tissue-engineered valved conduit containing autologous cells. A method was devised to produce a decellularized bovine matrix scaffold for developing a tissue-engineered right ventricular valved conduit. Fresh bovine jugular veins were treated with sodium deoxycholate and Triton X-100. The major structural proteins of the fresh and decellularized jugular venous valves and vessel walls were detected by histological methods. Thickness, water absorption rate, water maintenance rate, disruption strength, and extensibility were determined. Circumferential and radial specimens of valves and vessel walls were subjected to tensile testing. Histological analysis showed that no cell fragments were retained within the decellularized matrix scaffold and the major structural proteins had been retained intact. There were no significant differences in thickness, rates of absorption and maintenance of water, disruption strength, and extensibility between the decellularized and fresh veins. It was concluded that this treatment can successfully remove cellular components while maintaining the major structural components and the histological and biological properties of bovine jugular veins.

Valved Bovine Jugular Vein Conduits for Right Ventricular Outflow Tract Reconstruction in Children: An Attractive Alternative to Pulmonary Homograft

Pulmonary homografts (PH) have been the preferred valved conduits for right ventricular outflow tract (RVOT) reconstruction in the US since the mid-1980s. Although PHs have worked well for Ross patients, many PH extracardiac conduits used for congenital heart surgery suffer from degeneration and develop regurgitation and obstruction within months after implantation and require replacement within 4 to 6 years. Recently a valve-containing bovine jugular vein (Contegra, Medtronic, Inc, Minneapolis, MN) was introduced for clinical trials for a variety of patients requiring RVOT reconstruction. The early results of RVOT reconstruction utilizing the Contegra conduit were retrospectively analyzed in 62 patients. This series consisted of 9 newborns with truncus arteriosus, 39 patients with failed PHs, 6 with pulmonary atresia and 2 with tetralogy of Fallot with absent pulmonary valve, 2 with transposition of great arteries with ventricular septal defect and pulmonary stenosis, and 4 undergoing a Ross procedure. The patients ages ranged from 2 weeks to 18 years (mean, 7.3 +/- 6.0 years) and weights were from 2 to 83 kg (mean, 28.1 +/- 22.3 kg). The Contegra conduit sizes varied in diameter between 12 and 22 mm (mean, 18.2 +/- 4.1 mm). There were two early (3%) and four (7%) late deaths and none of them was conduit related. There has been one conduit explantation, and seven patients have required reinterventions to relieve stenosis at or beyond the distal anastomosis of the conduit to pulmonary artery bifurcation (8 of 60; 13%). Six of the 7 patients had balloon dilatation of the branch pulmonary arteries for preexisting stenosis. One patient developed distal anastomotic stenosis that did not yield to balloon angioplasty and she underwent surgical patch arterioplasty of the distal anastomosis. The interval from conduit implantation to reintervention ranged from 3 to 27 months (mean, 11.1 +/- 7.8 months). Of these, three patients required placement of a stent in the left (n = 1) or both branch pulmonary arteries (n = 2). During the short to intermediate follow-up in our series we have not observed, on echocardiography, shrinkage of the Contegra as we and others have reported with PHs. The Contegra conduit offers a promising alternative for RVOT reconstruction. Early hemodynamic performance compares favorably with PHs. Clinical advantages are greater availability in sizes from 12 to 22 mm and natural continuity between the valve and conduit that allows proximal infundibular shaping without additional materials. The price of the bovine jugular venous valve is approximately one-half that of many PHs in the US. Short-term freedom from dysfunction is at least as good as PHs. Long-term durability must be determined for this new conduit. The Contegra conduit is currently our conduit of choice for RVOT reconstruction in infants, children, and young adults.

Incompetence of the Internal Jugular Venous Valve: Spectrum of Echo‐Doppler Appearances

The echocardiographic literature contains very scant reference to incompetence of the valve in the internal jugular vein. However, we found frequent Doppler evidence of such incompetence, especially in patients with congestive failure. This incompetence manifests as a variety of color Doppler and pulsed Doppler patterns, illustrated here in 3 patients.

Percutaneous pulmonary valve placement in a 10‐month‐old patient using a hand crafted stent‐mounted porcine valve

Percutaneous replacement of the pulmonary valve in a right ventricle to pulmonary artery (RV-PA) conduit using bovine jugular valves has recently been described as an alternative to surgical options in selected patients weighing >or=20 kg. We report the first case of transcatheter pulmonary valve implantation in an infant and the first use of "off the shelf" components. A 12-mm (Hancock) porcine valve was sutured into a predilated Genesis 2510b stent. The valved stent was manually crimped and mounted on a 12-mm balloon. Snare-assisted deployment in the middle of the RV-PA conduit was accomplished without the use of a long sheath. After the initial deployment, a 14-mm balloon was used to further approximate the stent to the walls of the conduit. Short-term (11 month) follow-up has demonstrated continued valve integrity, markedly decreased right ventricular size and improved function and symptomatic improvement. At 10 months of age, this case represents the youngest patient to undergo percutaneous valve placement and documents the technical feasibility of the procedure.

Percutaneous Pulmonary Valve Implantation

Percutaneous implantation of valves is a fast evolving field in interventional cardiology. Acquired pulmonary valve disease is uncommon; however, right ventricular outflow tract dysfunction is one of the common indications of reoperations during late follow-up of repaired congenital heart disease. The impact of pulmonary valvular dysfunction on right ventricular function during late follow-up of patients with adult congenital heart disease has led to earlier intervention. The importance of a technique with lower morbidity and mortality, good patient acceptance, and efficacy that is comparable with surgery cannot be underestimated. Percutaneous pulmonary valve implantation uses a valved-stent assembly implanted by means of a double balloon catheter delivery system. The device is a bovine jugular venous valve sutured inside a platinum-iridium. In a series of 58 consecutive patients, we implanted this valve successfully with good clinical and hemodynamic results and no mortality on long-term follow-up. Early device designs led to reintervention by surgical explantation in the early experience, and a second percutaneous pulmonary valve implantation during latter experience. This exciting new technique will lead to review of the current indications and timing of intervention for right ventricular outflow tract dysfunction in late follow-up of congenital heart disease.

New insights in minimally invasive valve replacement: description of a cooperative approach for the off-pump replacement of mitral valves

The aim of the present study was to evaluate whether off-pump mini-invasive mitral valve replacement is possible after prior bioprosthetic mitral valve replacement in animals. To validate this concept for off-pump redo mitral valve insertion, we first replaced surgically mitral valves of six sheep under extracorporeal circulation using a Mosaïc valve. Prior to its insertion, we added a radio-opaque ring on its base to enhance its visualization under fluoroscopy. A bovine jugular valve mounted into a stent was then inserted off-pump through an opening of the atrial wall. Mitral valves were replaced successfully in all animals. Following the surgical valve insertion, mean left atrium and left ventricular end-diastolic pressures were 38 (22-42) and 18.8 mmHg (13-22), respectively. Angiography showed perfectly functioning valves, no subaortic valve obstruction, and a mild paravalvular leak in one animal. In one animal, we were unable to control the bleeding from the atrial opening. In this case, trans-atrial valvulation was not attempted. The off-pump valvular implantation was successful in the other five sheep. Haemodynamic data did not change after the insertion of valved stents. Implanted valves were all competent. The animal with the better haemodynamics was kept alive and is still alive 3 months after implantation. Surgically implanted bioprosthetic valves provide excellent support for off-pump insertion of a valved stent. Further experiments are necessary, in particular with appropriate valve size, before considering this approach for percutaneous mitral valvular replacement in patients with a dysfunctional bioprosthesis.

Increased incidence of jugular valve insufficiency in patients with transient global amnesia

While transient global amnesia (TGA) is a clinically well defined disorder, its etiology is poorly understood. Cerebral venous hypertension and subsequent damage to hippocampal and diencephalic structures are among the discussed hypothetical causes. Using a direct method for the study of retrograde flow during a Valsalva maneuver, we determined whether jugular valve insufficiency contributes to cerebral venous hypertension in patients with TGA. Jugular valve closure was assessed by duplex sonography in 20 patients with TGA and 20 age and gender matched controls. The diagnosis of valvular insufficiency was made on the basis of recently established criteria. Valvular insufficiency (either left or right-sided, or bilateral) was identified in 85% of patients with TGA,and in 45% of controls (p = 0.008). All patients with involuntary Valsalva episodes immediately prior to TGA developed valvular insufficiency (n = 8; p = 0.13 compared with patients who did not recall such an event). The mean duration of the insufficiency jet did not differ significantly between patients with TGA (3.26 s) and controls (2.78 s; p = 0.315). However, patients with TGA who experienced a trigger event were characterized by significantly longer insufficiency reflux times (3.84 s) than those without (2.55 s; p = 0.03). TGA is associated with an increase in the prevalence of jugular insufficiency. Valvular insufficiency may lead to increased venous pressure transmission during a Valsalva maneuver and thus contribute to venous ischemia in TGA. The association of valvular insufficiency and longer reflux times with the occurrence of a trigger event further suggests that cerebral venous congestion is an important etiological factor in transient global amnesia.

Cough Headache and Thoracic Inlet Valvular Competence in Uremia

Cough headache is a transient headache upon coughing, bending, stooping, or lifting in the absence of intracranial lesions. Reports show that incompetent jugular venous valve and cerebrospinal fluid hypervolemia are contributing factors. Headache is a common complaint of uremia patients. We conducted a clinical-radiological correlation study on 15 uremia patients with headache and central venous thrombosis. Thirteen patients were diagnosed to have benign cough headache (BCH); the others were diagnosed with chronic tension type headache. Venogram disclosed either internal jugular or vertebral venous regurgitation in the BCH group. Acquired thoracic inlet valvular incompetence might contribute to BCH.

Functional and Morphological Criteria of Internal Jugular Valve Insufficiency as Assessed by Ultrasound

Jugular venous valve insufficiency may play a role in different neurological diseases. This study describes the methodology to detect internal jugular valve insufficiency and establishes functional and morphological criteria to discriminate retrograde flow during valve closure from retro grade insufficiency flow. Valve closure was assessed in 100 valves (50 healthy volunteers). The valves were visualized in B-mode. During a pressure-controlled Valsalva maneuver, valve closure was monitored by color duplex. The duration and the peak velocity of retrograde flow were determined. Backward flow during valve closure in competent valves was visually clearly discernible from a retrograde flow jet through insufficient valves. Insufficiency was found in 29% of valves. The duration of backward flow in competent valves was between 0.22 and 0.78 seconds (mean = 0.46 +/- 0.14 seconds on Doppler measurements) and in insufficient valves between 1.23 and 6.15 seconds (mean = 2.66 +/- 1.28; P < .0001). Peak velocity of retrograde flow in competent valves was between 12 and 65 cm/s (mean = 26.2 +/- 11.1 cm/s) and between 25 and 160 cm/s (mean = 89.5 +/- 39.3 cm/s; P < .0001) in insufficient valves. On B-mode imaging, the "typical" aspect of an immobile, frozen valve was seen only in 5 cases of insufficient valves; 21 insufficient valves did not display this aspect. The duration of retrograde flow clearly discriminates competent and incompetent valves. On the basis of our results, we provide cut off values that help differentiate between physiological and insufficiency reflux. The differences in peak velocity and morphology criteria are helpful but not reliable to predict insufficiency of the valve.

Functional and Morphological Criteria of Internal Jugular Valve Insufficiency as Assessed by Ultrasound

Functional and Morphological Criteria of Internal Jugular Valve Insufficiency as Assessed by Ultrasound

Brain glucose and lactate gradient versus pressure gradient across the internal jugular valve during ECC

Brain glucose and lactate gradient versus pressure gradient across the internal jugular valve during ECC

Importance of Jugular Valve Incompetence in Contrast Transcranial Doppler Ultrasonography for the Diagnosis of Patent Foramen Ovale

Transcranial Doppler (TCD) ultrasound with the intravenous injection of agitated saline as contrast (cTCD) is an effective method for detecting right-to-left intracardiac and extracardiac shunt (RLS); however, the sensitivity of cTCD in the diagnosis of RLS remains slightly less than that of transesophageal echocardiography, even in patients with adequate transtemporal ultrasonic bone windows. The authors present a case with cTCD underestimating RLS because of jugular valve incompetence in a 42-year-old man presenting with an episode of transient aphasia. Three weeks after transcatheter closure of a patent foramen ovale associated with an atrial septal aneurysm, he experienced 2 episodes of amaurosis fugax. Following a negative 45-minute embolus detection study with power M-mode TCD, the patient underwent a cTCD study with monitoring of the left middle cerebral artery (MCA), the anterior cerebral artery, and the submandibular extracranial internal carotid artery. A single microbubble (MB) was detected in the left MCA in only 1 of 5 studies; the remaining runs all failed to detect an RLS. Significant MB reflux was noted in the left internal jugular vein because of jugular valve incompetence. The authors conclude that incompetence of the jugular vein valve can result in a false negative cTCD study for RLS detection.

Importance of Jugular Valve Incompetence in Contrast Transcranial Doppler Ultrasonography for the Diagnosis of Patent Foramen Ovale

Importance of Jugular Valve Incompetence in Contrast Transcranial Doppler Ultrasonography for the Diagnosis of Patent Foramen Ovale

Role of the internal jugular venous valve during an increase in intrathoracic pressure

Role of the internal jugular venous valve during an increase in intrathoracic pressure

Transient Global Amnesia: A Clinical and Sonographic Study

Background: The aetiology of transient global amnesia (TGA) is still unknown. The aim of this study was to identify potential risk factors for TGA, vascular risk factors, the role of patent foramen ovale (PFO) and of retrograde jugular venous flow. Methods: 138 subjects entered the study, including 48 patients with TGA, 42 age-matched patients with transient ischaemic attack (TIA) and 48 controls. PFO was studied by contrast transcranial duplex sonography. Retrograde jugular venous flow was tested with air contrast ultrasound venography (ACUV). Results: TGA patients and controls showed a lower prevalence for vascular risk factors than TIA patients. No statistical difference was found between the 3 groups with regard to PFO. ACUV detected jugular valve incompetence in 72.9% TGA, 35.7% TIA and 39.5% controls (TGA vs. TIA and TGA vs. controls p < 0.01). Conclusions: TGA patients have fewer vascular risk factors than TIA patients. Paradoxical embolism due to PFO as a cause of TGA is not confirmed in our study. Cerebral venous hypertension due to incompetence of the internal jugular valve may play a role in the pathogenesis of TGA.