Equally prominent “a” and “v” waves usually occur as a result of an enhanced “v” wave reflecting increased right atrial filling. This is typically seen in mild-to-moderate tricuspid regurgitation and atrial septal defects. In the video below, note that the normal “a” wave occurs just before the carotid impulse and the equally prominent “v” wave occurs just after the carotid impulse. The cotton swab reflects the carotid impulse.