This document provides an overview of invasive hemodynamics techniques and measurements. It discusses when invasive hemodynamics are used, important measurements for the right and left heart, cardiac output determination methods, valvular lesions, and tips for provoked measurements. Key measurements include pressures, flows, gradients, valve areas, oxygen saturations for shunt calculations, and how values change in response to interventions.
This document discusses low cardiac output syndrome (LCOS), including its causes, assessment, and management. It defines LCOS as a cardiac index less than 2 L/min/m2 and left sided filling pressures greater than 20mmHg. The key determinants of cardiac output are reviewed as heart rate, stroke volume, preload, afterload, and contractility. Etiologies of LCOS are discussed including preoperative, intraoperative, and postoperative factors. Assessment involves bedside examination, hemodynamic measurements, labs, and imaging like echocardiogram. Management focuses on optimizing preload, contractility, afterload, oxygen delivery, and treating underlying causes.
Non-invasive methods can help identify patients at risk of fatal arrhythmias. Ambulatory ECG monitoring provides continuous cardiac rhythm monitoring over extended periods and is useful for evaluating arrhythmias, pacemaker function, and response to antiarrhythmic drugs. Transient VT on ambulatory ECG monitoring is the single best marker of high risk for sudden death in patients with hypertrophic cardiomyopathy. Non-invasive approaches include analyzing heart rate variation, late potentials, QT dispersion, and QRS fragmentation.
Cardiologist Chris Hayward talks about LVAD (Left ventricular assist devices) for the Sydney Intensive Network. The audio is found on www.intensivecarenetwork.com
This document discusses the evaluation of severity of aortic stenosis. It covers clinical evaluation including symptoms and signs of severity. Echocardiographic assessment including Doppler assessment of peak transvalvular velocity and mean gradient is discussed. Classification of severity is described based on guidelines. The continuity equation for calculating aortic valve area is explained. Low-flow low-gradient aortic stenosis is addressed. The roles of cardiac catheterization, CT, and MRI in further evaluating severity are also summarized.
hemodynamic in cath lab: aortic stenosis and hocmrahul arora
1) Cardiac catheterization can provide key information about aortic stenosis including transvalvular pressure gradients, the level of stenosis, and estimation of valve area.
2) Low-flow, low-gradient aortic stenosis can be further classified as either having a decreased ejection fraction or a paradoxically normal ejection fraction.
3) In hypertrophic cardiomyopathy, cardiac catheterization can identify dynamic intraventricular pressure gradients that may only be provoked with maneuvers like the Valsalva maneuver.
This document discusses trans-septal puncture, which involves puncturing the septum between the right and left atria to access the left side of the heart. It outlines the evolving indications for trans-septal puncture including interventions for mitral valve disease, closure of defects, left atrial procedures, and arrhythmia ablation. The key steps are reviewed - having the proper anatomical landmarks, hardware including sheaths and needles, and imaging guidance. Complications are discussed and how to successfully perform the puncture is summarized as being familiar with the anatomy, hardware, and vigilance for potential complications.
The document discusses the FloTrac system, which uses an existing arterial line to continuously monitor cardiac output (CO) and other hemodynamic values through advanced arterial waveform analysis. While the trends provided by FloTrac can be useful for estimating hemodynamic status, its specific CO and cardiac index values may not correlate exactly with pulmonary artery catheter measurements. FloTrac requires good arterial signal quality and its values could be affected by factors like arrhythmias, hemodynamic instability, or ventilator settings like PEEP. Clinical judgment is still needed to interpret the data from FloTrac.
This document discusses the use of transesophageal echocardiography (TEE) as a powerful diagnostic tool that can decrease morbidity and increase survival in anesthetized patients. It describes how TEE works and provides various views that can be obtained. It also outlines applications of TEE during cardiac surgery and in the intensive care unit to assess hemodynamics and guide treatment. Contraindications and precautions for TEE are also mentioned.
This document discusses low cardiac output syndrome (LCOS), including its causes, assessment, and management. It defines LCOS as a cardiac index less than 2 L/min/m2 and left sided filling pressures greater than 20mmHg. The key determinants of cardiac output are reviewed as heart rate, stroke volume, preload, afterload, and contractility. Etiologies of LCOS are discussed including preoperative, intraoperative, and postoperative factors. Assessment involves bedside examination, hemodynamic measurements, labs, and imaging like echocardiogram. Management focuses on optimizing preload, contractility, afterload, oxygen delivery, and treating underlying causes.
Non-invasive methods can help identify patients at risk of fatal arrhythmias. Ambulatory ECG monitoring provides continuous cardiac rhythm monitoring over extended periods and is useful for evaluating arrhythmias, pacemaker function, and response to antiarrhythmic drugs. Transient VT on ambulatory ECG monitoring is the single best marker of high risk for sudden death in patients with hypertrophic cardiomyopathy. Non-invasive approaches include analyzing heart rate variation, late potentials, QT dispersion, and QRS fragmentation.
Cardiologist Chris Hayward talks about LVAD (Left ventricular assist devices) for the Sydney Intensive Network. The audio is found on www.intensivecarenetwork.com
This document discusses the evaluation of severity of aortic stenosis. It covers clinical evaluation including symptoms and signs of severity. Echocardiographic assessment including Doppler assessment of peak transvalvular velocity and mean gradient is discussed. Classification of severity is described based on guidelines. The continuity equation for calculating aortic valve area is explained. Low-flow low-gradient aortic stenosis is addressed. The roles of cardiac catheterization, CT, and MRI in further evaluating severity are also summarized.
hemodynamic in cath lab: aortic stenosis and hocmrahul arora
1) Cardiac catheterization can provide key information about aortic stenosis including transvalvular pressure gradients, the level of stenosis, and estimation of valve area.
2) Low-flow, low-gradient aortic stenosis can be further classified as either having a decreased ejection fraction or a paradoxically normal ejection fraction.
3) In hypertrophic cardiomyopathy, cardiac catheterization can identify dynamic intraventricular pressure gradients that may only be provoked with maneuvers like the Valsalva maneuver.
This document discusses trans-septal puncture, which involves puncturing the septum between the right and left atria to access the left side of the heart. It outlines the evolving indications for trans-septal puncture including interventions for mitral valve disease, closure of defects, left atrial procedures, and arrhythmia ablation. The key steps are reviewed - having the proper anatomical landmarks, hardware including sheaths and needles, and imaging guidance. Complications are discussed and how to successfully perform the puncture is summarized as being familiar with the anatomy, hardware, and vigilance for potential complications.
The document discusses the FloTrac system, which uses an existing arterial line to continuously monitor cardiac output (CO) and other hemodynamic values through advanced arterial waveform analysis. While the trends provided by FloTrac can be useful for estimating hemodynamic status, its specific CO and cardiac index values may not correlate exactly with pulmonary artery catheter measurements. FloTrac requires good arterial signal quality and its values could be affected by factors like arrhythmias, hemodynamic instability, or ventilator settings like PEEP. Clinical judgment is still needed to interpret the data from FloTrac.
This document discusses the use of transesophageal echocardiography (TEE) as a powerful diagnostic tool that can decrease morbidity and increase survival in anesthetized patients. It describes how TEE works and provides various views that can be obtained. It also outlines applications of TEE during cardiac surgery and in the intensive care unit to assess hemodynamics and guide treatment. Contraindications and precautions for TEE are also mentioned.
A 45 year old woman presented with shortness of breath on exertion. Echocardiography showed an atrial septal defect (ASD). ASDs are congenital heart defects where the wall separating the left and right atria is incomplete. The most common type is secundum ASD, which accounts for 70-75% of cases. ASDs allow blood to shunt from the left to the right atrium, overloading the right heart and lungs over time if not repaired. Echocardiography is the primary test to diagnose ASDs.
Hemodynamic monitoring has advanced with new equipment allowing continuous, non-invasive monitoring of key parameters. Pulse contour analysis uses an arterial catheter to provide beat-to-beat measurements used to calculate stroke volume, cardiac output, and contractility. Thermodilution techniques inject cold saline to measure parameters like intrathoracic blood volume, extravascular lung water, and ejection fraction. Echocardiography non-invasively assesses cardiac structure and function. These advances allow early detection and guided therapy for shock.
This document discusses the echocardiographic assessment of atrial septal defects (ASDs). It describes the main types of ASDs and notes that 80% are secundum defects. Echocardiography is used to identify and characterize ASDs, detect associated anomalies, diagnose complications, and guide treatment. Transthoracic echocardiography is the initial study, while transesophageal echocardiography provides better views of the atrial septum. Key measurements include ASD size, location, rim dimensions, and quantifying shunt severity with Qp/Qs. Echocardiography guides decisions about ASD device closure or surgery.
This document discusses the use of echocardiography in evaluating congenital heart diseases in adults. It outlines the indications for echocardiography and describes how to perform the examination and interpret findings. Key abnormalities that can be identified include atrial septal defects, ventricular septal defects, atrioventricular septal defects, anomalies of venous inflow, and abnormalities of ventricular morphology. Echocardiography is well-suited for diagnosing and monitoring these congenital heart conditions in adulthood.
This document discusses less invasive methods of advanced hemodynamic monitoring. It begins by explaining the key factors that affect hemodynamic conditions like cardiac output, including heart rate, intravascular volume, myocardial contraction, and vasoactivity. It then discusses several noninvasive and invasive monitoring methods and focuses on pulse wave contour analysis and transpulmonary thermodilution techniques. These techniques can provide continuous cardiac output measurements along with volumetric parameters through advanced analysis of arterial pressure waveforms and thermal dilution curves. The document concludes by outlining typical values of parameters measured and providing an example decision tree for fluid and drug therapy guided by hemodynamic monitoring.
A lecture on the echocardiographic evaluation of hypertrophic cardiomyopathy. Starts with an overview of the topic then a systematic approach to diagnosis and then a differential diagnosis followed by take-home messages and conclusion.
The document provides an overview of right ventricular assessment using echocardiography. It discusses normal RV anatomy, segmental nomenclature, and coronary supply. Key metrics for evaluating RV size, wall thickness, function, and pressures are outlined. Normal values and technical aspects of measuring RV dimensions, area/fractional area change, tricuspid annular plane systolic excursion, myocardial velocity, and diastolic function are summarized. Hemodynamic assessment of pulmonary pressures is also reviewed.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
This document provides an overview of echocardiographic evaluation of restrictive cardiomyopathy. Key points include:
- Restrictive cardiomyopathy is characterized by a nondilated left ventricle with abnormal diastolic function and typically normal systolic function.
- Causes include infiltrative diseases like amyloidosis and storage diseases. Echocardiography can help diagnose but it is more difficult than other cardiomyopathies.
- Findings include low diastolic volume, normal ejection fraction, diastolic dysfunction with rapid early mitral inflow. Echocardiography helps differentiate restrictive cardiomyopathy from constrictive pericarditis.
A cardiac shunt is a pattern of blood flow in the heart that deviates from the normal circuit of the circulatory system. It may be described as right-left, left-right or bidirectional, or as systemic-to-pulmonary or pulmonary-to-systemic.
This document provides an overview of the anatomy and assessment of the mitral valve using transesophageal echocardiography (TEE). It describes the components of the mitral valve complex including the annulus, leaflets, chordae tendineae, and papillary muscles. It outlines different TEE views used to evaluate the mitral valve and provides details on quantifying mitral stenosis and regurgitation. Causes of mitral valve dysfunction like rheumatic heart disease and ischemic mitral regurgitation are summarized. Assessment of mitral valve repair is also discussed, including complications like paravalvular leaks and systolic anterior motion.
The document discusses the history, anatomy, angiographic views, variations, and clinical relevance of coronary arteries. It provides a detailed overview of the typical anatomy and branches of the left main, left anterior descending, left circumflex, and right coronary arteries. It also describes common anatomical variations and anomalies seen in coronary arteries and their clinical implications. Angiographic classification methods for different coronary artery segments are presented.
Stress echocardiography combines echocardiography with physical, pharmacological, or electrical stress to effectively evaluate for myocardial ischemia. It is used to screen for coronary artery disease and identify affected coronary territories. Stress echocardiography can also differentiate viable myocardium from scarred tissue and provides important prognostic information after myocardial infarction and before noncardiac surgery. Dobutamine stress echocardiography is widely used to assess viable myocardium while exercise stress echocardiography is preferred when possible due to its safety. Stress echocardiography techniques are safe and relatively inexpensive options for evaluating myocardial ischemia and viability.
This document discusses the limitations and techniques for assessing right ventricular (RV) function using echocardiography. It is difficult to accurately evaluate RV volume, delineate borders, and image the entire RV using echocardiography due to its complex crescent shape. However, the document recommends using RV fractional area change, tricuspid annular plane systolic excursion, tissue Doppler S' velocity, and Tei index to quantitatively assess RV systolic function as they are reproducible methods. RV dimensions, wall thickness, and outflow tract size can also provide information on RV size and function. Assessment of RV diastolic function includes parameters like E/A ratio, E/E' ratio, and deceleration time.
1. Mitral stenosis is most commonly caused by rheumatic fever and results in thickening and calcification of the mitral valve, reducing the valve orifice area and obstructing blood flow from the left atrium to ventricle.
2. The pathophysiology involves elevated left atrial pressure, pulmonary hypertension, and reduced cardiac output. Symptoms range from easy fatigability to pulmonary edema.
3. Physical exam findings include an opening snap, rumbling diastolic murmur, and signs of right heart failure in severe cases. Severity is graded based on orifice area, pulmonary artery pressure, and NYHA functional
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
Echo assessment of aortic valve diseaseNizam Uddin
This document discusses the echocardiographic assessment of aortic valve diseases. It describes how aortic stenosis is classified based on its location as valvular, subvalvular, or supravalvular. It outlines the etiology of valvular aortic stenosis and discusses echocardiographic methods for assessing the severity of aortic stenosis including peak transvalvular velocity, mean transvalvular gradient, and aortic valve area using the continuity equation. The document also discusses the assessment of aortic regurgitation severity using measurements such as vena contracta width, regurgitant jet width and area, pressure half time, diastolic flow reversal, and regurgitant volume and fraction. Methods for
The document provides an overview of basic pacing concepts including:
- Types of pacemakers such as single chamber, dual chamber, and triple chamber systems.
- Components of a pacemaker system including the pulse generator, leads, and electrical concepts such as voltage, current, and impedance.
- Factors that can affect pacing thresholds and how to test the pacemaker circuit including identifying high and low impedance conditions.
Trans-esophageal echocardiography (TEE) uses ultrasound to obtain high-quality images of the heart and surrounding structures. It involves inserting a probe with an ultrasound transducer at the tip through the mouth and esophagus. TEE provides clearer images than transthoracic echocardiography as the esophagus is directly behind the heart. A TEE exam involves systematically imaging the heart in various planes as the transducer is advanced and manipulated. Standard views include the mid-esophageal four-chamber, two-chamber, aortic, and RV inflow-outflow views. Real-time 3D TEE can provide en face views of structures.
This document provides information about right heart catheterization including the equipment, technique, and pressure measurements involved. It describes how to insert a Swan-Ganz catheter into the internal jugular, subclavian, antecubital, or femoral vein using micropuncture technique. It explains how to advance the catheter to the right atrium, ventricle, and pulmonary artery while monitoring pressure waveforms. Precautions for the procedure and interpretations of different pressure waves are also summarized.
Swan-Ganz catheters are balloon-tipped catheters inserted into the heart to measure pressures and collect blood samples from the right atrium, right ventricle, and pulmonary artery. This allows clinicians to assess conditions like shock, respiratory distress, and complications of myocardial infarction. Measurements of pressures, oxygen saturations, and cardiac output can guide therapy for critical illnesses and help evaluate the effects of treatments. While useful for management, the procedure does carry risks of complications if not performed carefully.
1. Clinical examination alone is not sufficient to assess hemodynamic status in critically ill patients as individual vital signs do not reflect overall status.
2. Arterial lines can be used to monitor blood pressure, heart rate, and derive parameters like cardiac output but waveforms require interpretation and may be affected by various artifacts.
3. Pulmonary artery catheters can measure central venous and pulmonary artery pressures as well as cardiac output but have potential complications and their use remains controversial with no proven benefits shown in large trials.
A 45 year old woman presented with shortness of breath on exertion. Echocardiography showed an atrial septal defect (ASD). ASDs are congenital heart defects where the wall separating the left and right atria is incomplete. The most common type is secundum ASD, which accounts for 70-75% of cases. ASDs allow blood to shunt from the left to the right atrium, overloading the right heart and lungs over time if not repaired. Echocardiography is the primary test to diagnose ASDs.
Hemodynamic monitoring has advanced with new equipment allowing continuous, non-invasive monitoring of key parameters. Pulse contour analysis uses an arterial catheter to provide beat-to-beat measurements used to calculate stroke volume, cardiac output, and contractility. Thermodilution techniques inject cold saline to measure parameters like intrathoracic blood volume, extravascular lung water, and ejection fraction. Echocardiography non-invasively assesses cardiac structure and function. These advances allow early detection and guided therapy for shock.
This document discusses the echocardiographic assessment of atrial septal defects (ASDs). It describes the main types of ASDs and notes that 80% are secundum defects. Echocardiography is used to identify and characterize ASDs, detect associated anomalies, diagnose complications, and guide treatment. Transthoracic echocardiography is the initial study, while transesophageal echocardiography provides better views of the atrial septum. Key measurements include ASD size, location, rim dimensions, and quantifying shunt severity with Qp/Qs. Echocardiography guides decisions about ASD device closure or surgery.
This document discusses the use of echocardiography in evaluating congenital heart diseases in adults. It outlines the indications for echocardiography and describes how to perform the examination and interpret findings. Key abnormalities that can be identified include atrial septal defects, ventricular septal defects, atrioventricular septal defects, anomalies of venous inflow, and abnormalities of ventricular morphology. Echocardiography is well-suited for diagnosing and monitoring these congenital heart conditions in adulthood.
This document discusses less invasive methods of advanced hemodynamic monitoring. It begins by explaining the key factors that affect hemodynamic conditions like cardiac output, including heart rate, intravascular volume, myocardial contraction, and vasoactivity. It then discusses several noninvasive and invasive monitoring methods and focuses on pulse wave contour analysis and transpulmonary thermodilution techniques. These techniques can provide continuous cardiac output measurements along with volumetric parameters through advanced analysis of arterial pressure waveforms and thermal dilution curves. The document concludes by outlining typical values of parameters measured and providing an example decision tree for fluid and drug therapy guided by hemodynamic monitoring.
A lecture on the echocardiographic evaluation of hypertrophic cardiomyopathy. Starts with an overview of the topic then a systematic approach to diagnosis and then a differential diagnosis followed by take-home messages and conclusion.
The document provides an overview of right ventricular assessment using echocardiography. It discusses normal RV anatomy, segmental nomenclature, and coronary supply. Key metrics for evaluating RV size, wall thickness, function, and pressures are outlined. Normal values and technical aspects of measuring RV dimensions, area/fractional area change, tricuspid annular plane systolic excursion, myocardial velocity, and diastolic function are summarized. Hemodynamic assessment of pulmonary pressures is also reviewed.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
This document provides an overview of echocardiographic evaluation of restrictive cardiomyopathy. Key points include:
- Restrictive cardiomyopathy is characterized by a nondilated left ventricle with abnormal diastolic function and typically normal systolic function.
- Causes include infiltrative diseases like amyloidosis and storage diseases. Echocardiography can help diagnose but it is more difficult than other cardiomyopathies.
- Findings include low diastolic volume, normal ejection fraction, diastolic dysfunction with rapid early mitral inflow. Echocardiography helps differentiate restrictive cardiomyopathy from constrictive pericarditis.
A cardiac shunt is a pattern of blood flow in the heart that deviates from the normal circuit of the circulatory system. It may be described as right-left, left-right or bidirectional, or as systemic-to-pulmonary or pulmonary-to-systemic.
This document provides an overview of the anatomy and assessment of the mitral valve using transesophageal echocardiography (TEE). It describes the components of the mitral valve complex including the annulus, leaflets, chordae tendineae, and papillary muscles. It outlines different TEE views used to evaluate the mitral valve and provides details on quantifying mitral stenosis and regurgitation. Causes of mitral valve dysfunction like rheumatic heart disease and ischemic mitral regurgitation are summarized. Assessment of mitral valve repair is also discussed, including complications like paravalvular leaks and systolic anterior motion.
The document discusses the history, anatomy, angiographic views, variations, and clinical relevance of coronary arteries. It provides a detailed overview of the typical anatomy and branches of the left main, left anterior descending, left circumflex, and right coronary arteries. It also describes common anatomical variations and anomalies seen in coronary arteries and their clinical implications. Angiographic classification methods for different coronary artery segments are presented.
Stress echocardiography combines echocardiography with physical, pharmacological, or electrical stress to effectively evaluate for myocardial ischemia. It is used to screen for coronary artery disease and identify affected coronary territories. Stress echocardiography can also differentiate viable myocardium from scarred tissue and provides important prognostic information after myocardial infarction and before noncardiac surgery. Dobutamine stress echocardiography is widely used to assess viable myocardium while exercise stress echocardiography is preferred when possible due to its safety. Stress echocardiography techniques are safe and relatively inexpensive options for evaluating myocardial ischemia and viability.
This document discusses the limitations and techniques for assessing right ventricular (RV) function using echocardiography. It is difficult to accurately evaluate RV volume, delineate borders, and image the entire RV using echocardiography due to its complex crescent shape. However, the document recommends using RV fractional area change, tricuspid annular plane systolic excursion, tissue Doppler S' velocity, and Tei index to quantitatively assess RV systolic function as they are reproducible methods. RV dimensions, wall thickness, and outflow tract size can also provide information on RV size and function. Assessment of RV diastolic function includes parameters like E/A ratio, E/E' ratio, and deceleration time.
1. Mitral stenosis is most commonly caused by rheumatic fever and results in thickening and calcification of the mitral valve, reducing the valve orifice area and obstructing blood flow from the left atrium to ventricle.
2. The pathophysiology involves elevated left atrial pressure, pulmonary hypertension, and reduced cardiac output. Symptoms range from easy fatigability to pulmonary edema.
3. Physical exam findings include an opening snap, rumbling diastolic murmur, and signs of right heart failure in severe cases. Severity is graded based on orifice area, pulmonary artery pressure, and NYHA functional
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
Echo assessment of aortic valve diseaseNizam Uddin
This document discusses the echocardiographic assessment of aortic valve diseases. It describes how aortic stenosis is classified based on its location as valvular, subvalvular, or supravalvular. It outlines the etiology of valvular aortic stenosis and discusses echocardiographic methods for assessing the severity of aortic stenosis including peak transvalvular velocity, mean transvalvular gradient, and aortic valve area using the continuity equation. The document also discusses the assessment of aortic regurgitation severity using measurements such as vena contracta width, regurgitant jet width and area, pressure half time, diastolic flow reversal, and regurgitant volume and fraction. Methods for
The document provides an overview of basic pacing concepts including:
- Types of pacemakers such as single chamber, dual chamber, and triple chamber systems.
- Components of a pacemaker system including the pulse generator, leads, and electrical concepts such as voltage, current, and impedance.
- Factors that can affect pacing thresholds and how to test the pacemaker circuit including identifying high and low impedance conditions.
Trans-esophageal echocardiography (TEE) uses ultrasound to obtain high-quality images of the heart and surrounding structures. It involves inserting a probe with an ultrasound transducer at the tip through the mouth and esophagus. TEE provides clearer images than transthoracic echocardiography as the esophagus is directly behind the heart. A TEE exam involves systematically imaging the heart in various planes as the transducer is advanced and manipulated. Standard views include the mid-esophageal four-chamber, two-chamber, aortic, and RV inflow-outflow views. Real-time 3D TEE can provide en face views of structures.
This document provides information about right heart catheterization including the equipment, technique, and pressure measurements involved. It describes how to insert a Swan-Ganz catheter into the internal jugular, subclavian, antecubital, or femoral vein using micropuncture technique. It explains how to advance the catheter to the right atrium, ventricle, and pulmonary artery while monitoring pressure waveforms. Precautions for the procedure and interpretations of different pressure waves are also summarized.
Swan-Ganz catheters are balloon-tipped catheters inserted into the heart to measure pressures and collect blood samples from the right atrium, right ventricle, and pulmonary artery. This allows clinicians to assess conditions like shock, respiratory distress, and complications of myocardial infarction. Measurements of pressures, oxygen saturations, and cardiac output can guide therapy for critical illnesses and help evaluate the effects of treatments. While useful for management, the procedure does carry risks of complications if not performed carefully.
1. Clinical examination alone is not sufficient to assess hemodynamic status in critically ill patients as individual vital signs do not reflect overall status.
2. Arterial lines can be used to monitor blood pressure, heart rate, and derive parameters like cardiac output but waveforms require interpretation and may be affected by various artifacts.
3. Pulmonary artery catheters can measure central venous and pulmonary artery pressures as well as cardiac output but have potential complications and their use remains controversial with no proven benefits shown in large trials.
This document discusses central venous pressure (CVP), including its indications, measurement sites, determinants, and limitations. Some key points:
- CVP is the pressure measured in central veins close to the heart and reflects right atrial pressure. It provides information about right ventricular preload but does not indicate blood volume.
- CVP can be measured through the internal jugular, femoral, or subclavian veins. Factors like cardiac function, vascular compliance, blood volume, and intrathoracic pressure determine CVP.
- While CVP provides data on circulatory equilibrium between the heart and veins, it does not predict fluid responsiveness or tissue perfusion. Dynamic variables obtained through fluid challenges or
This document summarizes different methods for measuring cardiac output, including clinical assessment, minimally invasive techniques, and invasive pulmonary artery catheterization. Clinical assessment involves evaluating end organ perfusion rather than direct cardiac output measurements. Minimally invasive techniques discussed include thoracic bioimpedance and esophageal Doppler. Invasive pulmonary artery catheterization provides direct cardiac output measurements via thermodilution but carries risks of complications. The document evaluates the advantages, limitations, and evidence for various cardiac output monitoring methods.
This document discusses various techniques for monitoring cardiac output (CO), including invasive and non-invasive options. It provides details on pulmonary artery catheters, the Fick principle, transesophageal echocardiography, esophageal Doppler, pulse contour analysis methods (PiCCO, LiDCO, Flowtrac), transthoracic bioimpedance, and transthoracic echocardiography. While some methods like pulmonary artery catheters and LiDCO are well-validated, the document notes that rigorous validation studies are still needed for newer non-invasive options like Flowtrac and transthoracic bioimpedance. Overall, it emphasizes understanding the limitations of different CO monitoring systems and using trends over
29624_Cardiac Output and hemodynamic measurement.pptraphaelyohana140
1) The document discusses various methods of measuring cardiac output, including the Fick principle which is considered the gold standard but is difficult to apply in critically ill patients.
2) Thermodilution, using a pulmonary artery catheter, is another common method where cardiac output is calculated based on how fast injected cold saline is mixed and diluted by flowing blood.
3) Non-invasive methods like Doppler ultrasound and impedance plethysmography can also estimate cardiac output by measuring aortic blood flow or chest impedance changes during the cardiac cycle.
This document discusses echocardiographic assessment of pulmonary arterial hypertension (PAH). It defines PAH and outlines how echocardiography can be used to estimate pulmonary artery pressure, assess right ventricular structure and function, and determine pulmonary vascular resistance. Key echocardiographic measures discussed include right atrial size, tricuspid regurgitation velocity, right ventricular size and function. The document also covers using echocardiography to screen for PAH in at-risk groups and outlines its limitations. Prognostic indicators by echocardiography in PAH are also reviewed.
This document discusses cardiac output and methods for monitoring it. It begins by defining cardiac output and factors that influence it, such as stroke volume, preload, afterload, and contractility. Both invasive and minimally invasive methods for monitoring cardiac output are described, including pulmonary artery catheters and techniques such as thermodilution that use temperature sensors. The principles behind various monitors that can measure cardiac output and its determinants using methods such as Fick's principle and thermodilution are explained. The document also discusses using echocardiography to monitor cardiac output and principles guiding fluid therapy.
The document discusses various techniques for hemodynamic monitoring. It covers electrocardiography (ECG), arterial pressure monitoring, cardiac filling pressures including central venous pressure and pulmonary arterial pressure, and cardiac output monitoring. Standards for clinical monitoring are outlined by organizations like the American Society of Anesthesiologists. Hemodynamic monitoring provides valuable information for detecting changes that may require therapeutic interventions through noninvasive and invasive methods. Invasive techniques like the pulmonary artery catheter allow for monitoring multiple pressures and cardiac output but also involve greater risks.
The Swan-Ganz catheter, also known as a pulmonary artery catheter, is a specialized catheter used to monitor a patient's hemodynamics. It is inserted into the internal jugular or subclavian vein and threaded through the heart into the pulmonary artery. This allows direct measurement of pressures in the right atrium, right ventricle, pulmonary artery, and indirect measurement of left-sided pressures. The catheter is useful for diagnosis and management of conditions affecting heart function or pulmonary circulation. However, randomized controlled trials found no improvement in outcomes with its use and increased risks, so the catheter's benefits must be weighed against risks for each individual patient.
Right heart cathterization AL-AMIN.pptxAlAmin837379
Werner Forssman first performed right heart catheterization on himself in 1929. Dr. Swan added a balloon tip to the catheter and Dr. Ganz added a thermistor, which helped develop right heart catheterization as a diagnostic tool. Right heart catheterization is used to measure pressures, cardiac output, oxygen saturation and evaluate conditions like intracardiac shunts and pulmonary hypertension. It provides important hemodynamic information to guide treatment for conditions like heart failure and shock. Complications can include arrhythmias, pulmonary infarction and bleeding.
This document provides an introduction to hemodynamic monitoring, which involves measuring factors that influence blood flow and pressure. It defines hemodynamic monitoring and outlines its purposes, which include diagnosing and managing shock states, determining fluid status, and measuring cardiac output. The document discusses indications for hemodynamic monitoring as well as contraindications for invasive pulmonary artery catheters. It also reviews important hemodynamic values and concepts, pulmonary artery catheter insertion and positioning, waveform analysis, and removal of pulmonary artery catheters.
I apologize, upon further review I do not feel comfortable providing medical advice or recommendations. Please consult your doctor for any medical questions or concerns.
Cardiovascular physiology REVISION NOTES TONY SCARIA
The document discusses cardiovascular physiology, specifically describing the cardiac cycle and regulation of blood pressure. It contains the following key points:
1. The cardiac cycle consists of ventricular systole and diastole. Systole includes isovolumic contraction, rapid ejection, and slow ejection phases. Diastole includes isovolumic relaxation and three filling phases.
2. Blood pressure is regulated rapidly by baroreceptor and chemoreceptor reflexes, and over longer periods by the renin-angiotensin-aldosterone system.
3. Factors like preload, contractility, and afterload influence stroke volume and thus cardiac output according to Frank-Starling's law.
The document discusses the pulmonary artery catheter, including its history, parts, specifications, insertion technique, measurements, complications, and indications. Some key points:
- The pulmonary artery catheter was introduced in the 1970s and can measure pressures in the right atrium, right ventricle, pulmonary artery, and pulmonary capillary wedge.
- It has multiple ports and a balloon at the tip that can be inflated to obtain pulmonary capillary wedge pressure measurements.
- Measurements include pressures, cardiac output via thermodilution, and derived parameters like stroke volume, vascular resistances, and oxygen transport values.
- Complications can include arrhythmias, infection, or pulmonary artery damage. Indications include
- The document discusses mitral stenosis and echocardiography. It describes the anatomy, etiology, pathophysiology and grading of severity of mitral stenosis.
- Echocardiography is outlined as the primary method for evaluating mitral stenosis, including 2D, Doppler and 3D imaging. Methods for measuring mitral valve area such as planimetry, pressure half-time and continuity equation are covered. Stress echocardiography is also discussed.
- Scoring systems for predicting outcomes of percutaneous mitral balloon valvuloplasty are presented, including the Wilkins, Padial and Cormier scores. Treatment options for mitral stenosis are mentioned.
This document discusses the definition, diagnosis, and assessment of cardiac shunts through catheterization. It defines different types of shunts and outlines steps to detect shunts through oximetry runs and hemodynamic measurements. Key points include determining shunt direction and magnitude, assessing pulmonary hypertension, and evaluating clinical signs of shunt operability versus inoperability. Reversibility testing with oxygen and vasodilators is described to help decide operability.
Ähnlich wie Invasive Hemodynamics: Assessment and interpretation (20)
This document discusses infective endocarditis (IE), including its changing epidemiology, pathogenesis, clinical manifestations, diagnosis, complications, and management. Some key points:
- The median age of IE patients has increased to over 60 years old. Rheumatic heart disease is less common while intracardiac devices and nosocomial sources have risen.
- Vegetations form from platelet-fibrin deposition on damaged heart valves, allowing bacterial colonization and abscess formation.
- Echocardiography is important for diagnosis. Findings include vegetations, abscesses, and valve dysfunction. Blood cultures help identify causative organisms.
- Complications include heart failure, embolization, and periannular
This document provides an overview of stress echocardiography including objectives, indications, protocols, interpretation, and complications. Key points include: stress echo can evaluate CAD using exercise or pharmacologic stress with dobutamine; it has good sensitivity and specificity for CAD compared to nuclear imaging; and provides prognostic information on cardiac events. Interpretation focuses on changes in wall motion, ejection fraction, and detection of ischemia. Stress echo helps evaluate multiple conditions including viability, valvular disease, and cardiomyopathies.
The document discusses exercise electrocardiogram (ECG) testing, including its value for diagnostic and prognostic purposes. It describes how the accuracy of exercise ECG testing depends on the pre-test probability of coronary artery disease. While exercise ECG has lower sensitivity than stress imaging tests, it has comparable specificity. For patients at intermediate pre-test probability who can exercise and have a normal ECG, exercise ECG is the initial recommended test rather than stress imaging due to its cost-effectiveness. The document provides details on exercise ECG testing protocols, interpretation, limitations, and pre-test instructions.
This document provides guidance on guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). It discusses initiation and titration of therapies including angiotensin receptor-neprilysin inhibitors, beta-blockers, sacubitril-valsartan, ivabradine, SGLT2 inhibitors, ACE inhibitors, ARBs, loop diuretics, and aldosterone antagonists. Key points include initiating therapies individually based on patient status, up-titrating doses every 2 weeks to maximize benefits, assessing for response using echocardiograms and biomarkers, and continuing GDMT even if ejection fraction improves to prevent heart failure events. Transcat
Atrial fibrillation is the most common cardiac arrhythmia. It occurs due to irregular electrical impulses in the atria that prevent coordinated atrial contraction. Risk factors include hypertension, heart disease, obesity, and sleep apnea. The pathophysiology involves triggers that initiate the arrhythmia as well as substrates in the atria that maintain it. Triggers commonly originate from the pulmonary veins. Substrates include atrial fibrosis and remodeling of ion channels. Once initiated, atrial fibrillation begets further fibrillation through mechanisms such as multiple wavelet reentry and focal drivers or rotors that sustain the irregular rhythm.
This document provides guidelines for pre-operative evaluation and risk assessment. It discusses evaluating patients' medication use, medical conditions, functional status, and surgery-specific risk. Key factors that increase cardiac risk include recent heart attack, heart failure, diabetes, and poor functional status. Testing may be warranted for intermediate-high risk surgery or patients with a predicted >1% risk of major cardiac events. Continuation of most medications is reasonable. Statins, aspirin, and beta-blockers in selected patients can reduce risk. Timing of elective surgery depends on prior stenting or heart attack. The goal is to identify and optimize modifiable risks to reduce complications.
The document provides guidelines for cholesterol management and cardiovascular disease (CVD) risk assessment. It discusses guidelines for measuring cholesterol and lipid levels, calculating LDL and VLDL values, and assessing CVD risk. It recommends starting moderate- or high-intensity statin therapy for most adults aged 40-75 years with diabetes or LDL ≥70 mg/dL. For those without diabetes but with a CVD risk of 7.5% or higher, it recommends discussing statin therapy. The guidelines also provide recommendations for managing statin side effects, evaluating risk factors, and refining risk assessment using coronary artery calcium scoring. The main messages are to emphasize lifestyle changes, use high-intensity statins for high-risk patients, and consider patient risk
Among 19,114 healthy elderly patients without cardiovascular disease who were randomized to low-dose aspirin or placebo, aspirin did not reduce the primary composite outcome of death, dementia or persistent physical disability compared to placebo after a median follow-up of 4.7 years. Aspirin was associated with a higher risk of major hemorrhage. Similar recent trials found no benefit of aspirin for primary prevention in diabetic patients or those at moderate cardiovascular risk without increasing bleeding risk. Guidelines do not recommend routine aspirin use for primary prevention in adults over 70 years old due to lack of benefit and risk of bleeding.
This document provides a comprehensive overview of EKG interpretation. It defines the various EKG waves, intervals, segments and complexes. It describes normal values as well as abnormalities related to conditions like myocardial infarction, hypertrophy, conduction blocks, electrolyte imbalances, hypothermia and more. Causes of variations in waves, intervals and complexes are discussed in detail. Commonly seen arrhythmias and their mechanisms are also explained.
Evaluation of Chest Pain in the Ambulatory SettingKerolus Shehata
This document discusses the evaluation of chest pain in an outpatient setting. It begins by stating that the initial goals are to rule out acute coronary syndrome (ACS) and other life-threatening conditions. Common causes of chest pain in an outpatient setting include chest wall pain, gastroesophageal reflux disease (GERD), and costochondritis. More serious potential causes include ACS, pulmonary embolism, aortic dissection, and pneumonia. The document reviews the likelihood ratios and characteristics for diagnosing various potential causes of chest pain. It also discusses appropriate use of stress testing and who should be urgently referred to the emergency department for evaluation.
This document provides guidance on the management of hypertension. It begins with educational objectives and a case study example. It then reviews the magnitude of hypertension, definitions of true hypertension versus white coat hypertension, and the role of ambulatory blood pressure monitoring. Guidelines for diagnosing and staging hypertension from ACC/AHA and JNC-8 are presented. Non-pharmacologic and pharmacologic treatment options are discussed, including diuretics, ACE inhibitors, ARBs, beta blockers, calcium channel blockers, and vasodilators. Resistant hypertension, hypertensive crises, and hypertension management in specific clinical contexts like stroke are also addressed. Recommendations are provided for evaluating and managing different patient cases.
- The 44-year-old man presented with an unprovoked left proximal leg deep venous thrombosis 3 months ago and has since been stable on warfarin therapy with therapeutic INR levels. For unprovoked proximal DVT, guidelines recommend extended anticoagulation therapy indefinitely due to the risk of recurrence, unless the patient has a high bleeding risk. Therefore, the most appropriate management would be to continue anticoagulation indefinitely (Option A).
This document discusses the management of hyperglycemic crises including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It provides guidelines on the identification and treatment of these conditions. It presents a case study of a patient with vomiting and elevated blood glucose and ketones who is diagnosed with DKA. It covers the diagnostic criteria, precipitants, signs and symptoms, pathophysiology, treatment including fluid resuscitation and insulin therapy, complications, and discharge planning for DKA and HHS. Hypoglycemia is also discussed including causes, outcomes, and treatment approaches.
- Left bundle branch block (LBBB) is caused by conditions that damage the left bundle branch, such as hypertension, dilated cardiomyopathy, and ischemic heart disease.
- LBBB is diagnosed based on criteria including a QRS duration of over 120ms and abnormal ST segment and T wave patterns.
- The prognosis of LBBB depends on any underlying heart conditions, with LBBB increasing the risk of mortality. LBBB may resolve temporarily following a premature ventricular contraction due to resetting of the conduction system.
Non-atherosclerotic spontaneous coronary artery dissection (NA-SCAD) is a rare cause of acute coronary syndrome where the coronary arterial wall separates, creating a false lumen without evidence of trauma or atherosclerosis. It often presents in young women and can be difficult to diagnose without advanced imaging. While management differs from atherosclerotic coronary artery disease, prognosis is generally better for NA-SCAD than other forms of SCAD. Further research is still needed to understand triggers, management options, and long-term outcomes of this condition.
First aid course focusing on management of burns, wounds of different types, disturbed conscious level and chemical intoxication whether by inhalation, ingestion or skin exposure.
This document appears to contain the name of an individual, Kerolus E. Shehata. No other details are provided about this person in the single line of text. In summary, the document states an name without any other contextual information about the individual named.
This document provides an overview of general toxicology. It discusses factors affecting the toxic response, including factors related to the poison and patient. It describes various types of toxins based on origin, site of action, and organ specificity. It also summarizes approaches to managing the poisoned patient, including stabilization, decontamination, and enhanced elimination techniques like activated charcoal, gastric lavage, forced diuresis, and dialysis. Complications and contraindications of different management strategies are also outlined.
Provides a simple organized way for ABG analysis with special emphasis on Acid-base balance interpretation & its crucial rule in clinical toxicology practice.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
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In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
3. When Do We Use Invasive Hemodynamics
• When non-invasive assessments are non-diagnostic.
• When there is a discrepancy between clinical and echocardiographic
assessments.
• To evaluate effects of percutaneous therapies intra-procedurally (e.g.
change in LA pressures after TEER; LV-Ao gradient after TAVR).
4. Tips and Tricks
• Pressure may not reflect true flow if vascular impedance is abnormal.
• Meticulous technique for hemodynamic system.
• Balance and calibrate.
• Systolic pressure amplification, mean pressure may be more accurate.
• Recording artifacts Underdamping & Overdamping.
• Respiratory variation, PEEP, Mechanical ventilation.
• We measure: Pressures, saturations, blood gases.
• We calculated: Flows, resistances and gradients.
5. Cath Lab Math – Practical tips
• Eliminate technical errors in set up (Damping, bubbles).
• Understand vagaries of CO determinations.
• Understand what flows to use for valve area calculations.
• Understand low output/low gradient AS hemodynamics.
• Recall significant stenotic valve gradients.
• Use Hakki formula for quick valve area calculations.
• Use shunt shortcuts for Qp/Qs calculations.
6. Important Hemodynamics - RIGHT HEART
• RAP +/or CVP (0-8 mmHg)
• RV Systolic/Diastolic (15-30/0-8 mmHg)
• PA Systolic/Diastolic (15-30/8-12 mmHg)
• SVO2 (70-75%)
• Right heart pumps against PVR (120-250 dynes*sec/cm-5) =
80*(mean PA-PCWP)/CO
• PAPi (>0.9) = (PASP-PADP)/CVP
7. Important Hemodynamics - LEFT HEART
• PCWP = 5. Left atrial Pressure (8-12 mmHg)
• LVEDP (5-12 mmHg)
• CO (4-7 L/min) via thermodilution (TD) or CCO PA Catheter
• Blood Pressure (100-140/60-90 mmHg)
• MAP (70-100 mmHg)=2/3*Diastolic Pressure + 1/3*Systolic Pressure
• CO (4-7L/min)= FICK equation = (BSA ×120)/ 0.1 × 1.36 × (SaO2-SvO2) × Hgb
• CI (2.5-4.5L/min/m²) = CO/BSA
• L Heart pumps against the SVR (SVR 800-1200dynes*sec/cm-5) = 80* (MAP-
CVP)/CO
• CPO (>1.0 Watts) = (CO x MAP)/451
8. Cardiac Output
• Cardiac Output = Heart Rate x Stroke Volume (L/min).
• The volume of blood ejected by the heart in a minute.
• Can be measured in several ways: Thermodilution, Fick Method or CMR.
9. Fick principle
• Described in 1870
• Assumes rate of O2 consumption is a function of rate of blood flow x rate of O2 pick up by RBC
• CO = [MVO2 ] / [AV O2 difference]
• AV O2 difference = Arterial O2 content- Venous O2 content
• O2 content= Hgb x 1.36 x 10 x %O2 sat
• Most accurate at low outputs, steady state
• Large errors possible with small differences in saturations and hemoglobin
• Total error ~ 10-15%
• A-V O2 difference = Arterial O2 content- Venous O2 content
• O2 content= Hgb x 13.6 x %O2 sat
• A-V O2 difference = [O2 content] x [Art sat- Venous sat]
• The larger the A-V O2 difference, the lower the CO
• Normal CO: PA sat 70-80%
• Low CO: PA sat < 65%
• High CO (or L-R shunt): PA sat >80%
10. Oxygen consumption (VO2)
• Measure of the volume of oxygen used by the body in a minute
• Dependent on the product of oxygen delivery and extraction
• Direct measurement requires mass spectrometry of exhaled air or
a breath-by-breath analysis with a metabolic cart
• Estimated value assumes HR, oxygen delivery and extraction are
stable
• Significant variance in smaller or obese individuals
11. Thermodilution
• Indicator dilution methods (dye, temperature).
• Most accurate in high output states.
• Less accurate in low output states.
• Inaccurate with TR, AF.
• Variability 15-20%.
12. Cardiac Power Output (CPO)
• Assesses left heart contractility (flow and SVR)
• CPO = MAP x CO/451
• CPO (normal) = (93x5)/451 = approximately 1.0 Watts
• CPO < 0.6 Watts (0.53) associated with increased mortality
13. Pulmonary Arterial Pulsatility Index (PAPi)
• Assesses right heart function
• PAPi = PA(systolic) – PA(diastolic)/RA
• PAPi (normal) (25-8)/4 = approx. 4.0
• PAPi < 0.9 associated with RV compromise and need for RV support
• Right Heart Dysfunction: PAPi < 0.9, CVP > 15 mmHg, CVP/PCWP >
0.63, CI < 2.2 L/min/M2 with Left support
14. Cardiogenic Shock Criteria
• SBP < 90 mmHg for > 30 minutes (or inotropes/vasopressors
to maintain SBP >90)
• Evidence of end-organ hypoperfusion
• Lactate > 2 mmol/L
• Fick CI < 1.8 L/min/m2 w/o inotropes/vasopressors or <2.2
with inotropes/vasopressors
• PCWP > 15 mmHg (18); RVEDP > 10-15 mmHg
• Cardiac Power Output (CPO) < 0.6 Watts
• Pulmonary Arterial Pulsatility Index (PAPi) < 0.9
15. RA/LA Pressure Wave Forms
• a=atrial contraction; x descent
• c=systolic bulge of TV into RA
• v=atrial filling; y descent
• Measure mean Pressure
• Right-sided: a>v, Left-sided: v>a
26. Vascular Resistance
• Resistance = ΔP/CO
• SVR = (mAP - mRAP) x 80/CO. Normal range 700-1600 dynes-sec/cm5
• PVR = (mPA - mPCW) x 80/CO. Normal range 20-130 dynes-sec/cm5
• For Woods Units, divide metric units by 80
28. When is A Step-Up Significant?
Location Max Step-up Mean Step-up Shunt Detection
• VC to RA >11 >7 1.5-1.9
• RA to RV >10 >5 1.3-1.5
• RV to PA >5 >5 1.3-1.5
29. Basics of shunt studies
• No L-R shunt: mixed venous = PA sat
• With L-R shunt, mixed venous O2 sat = O2 sat in chamber proximal to shunt
• For ASD, mixed venous = caval O2 sat = (3xSVC +1xIVC)/4
• No R-L shunt: PV O2 sat= FA O2 sat
• Shunt calculation depends on ratio of total pulmonary blood flow to total
systemic blood flow
• Shunt ratio = Qp /Qs
• Blood flows (pulmonary and systemic) are determined using the Fick equations
31. Bidirectional shunts
• Effective blood flow = Qeff = O2 consumption/(PV O2- MVO2)
• Left to right shunt: Qp-Qeff
• Right to left shunt: Qs-Qeff
32. Can I close this shunt?
• Take away “pop-off” to force full cardiac output across stenotic
valve and/or stiff ventricle
• PA/IVS with antegrade blood flow and ASD: Evaluate TS, RV
compliance, cardiac output
• MS, small left heart sided structures and ASD: Evaluate MS, LV
compliance, LVOT. Be mindful of LA HTN
• Technique: Two venous lines are ideal. Monitor atrium, ventricle,
cardiac output and systemic BP.
33. AS - Methods of Invasive Evaluation
Method Consideration
• Single catheter LV-aortic pullback Qualitative only; Does not allow for
quantitative calculations
• LV catheter through arterial sheath Use longest sheath possible due to delay
between central and peripheral pressures
• Double arterial access with 2 pigtails Double arterial access
• Double-lumen pigtail catheter Hard to find
• Mother-child aortic guide catheter with smaller pigtail to LV Consider 2Fr system difference or sidehole
guide to avoid dampening of pressure
• Transseptal puncture to access LV with second catheter in aorta Only consider for mechanical AVR
• Guide catheter in aorta with 0.014 pressure wire in LV Cost is higher
• Dual sensor pressure guidewire Cost is even higher
34. AS hemodynamics
• Aortic Pressure: Delayed
rise in aortic pressure
compared with LV
pressure. Loss of dicrotic
notch
• LV Pressure: LVEDP
commonly elevated. May
see prominent “a” wave
during diastole.
35. Aortic Valve Area
• Mean AV Gradient: Requires simultaneous LV-Ao pressures
• Aortic Valve Area: Requires LV-Ao gradient and Cardiac Output (e.g. RHC)
• Gorlin equation: AVA = Cardiac output ÷ (44.3 x Heart rate x Systolic ejection period
x Sq rt mean systolic pressure gradient)
• Assumes steady state and fixed orifice
• Not accurate with concomitant regurgitation
• Not accurate at low output
• Not accurate at low or high HR
• For both Aortic and Mitral Valve Area calculations, it’s fine to use the Hakki formula.
• Valve Area= CO/√(mean gradient)
40. AS Vs HOCM
Valsalva After VPB
Gradient Pulse pressure Gradient Pulse pressure
• AS Decrease Decrease Increase Increase
• HOCM Increase Decrease Increase Decrease
• Fixed Valvular AS: Parvus et Tardus in Aortic pressure upstroke.
• HCM: Aortic pressure rises rapidly and then develops spike-and-
dome contour, Late peak of LV Pressure.
41. Distinguishing AS from HCM: Post-PVC Waveforms
• Post-PVC potentiation increases LV contractility
• AS: Increase in pulse pressure
• HCM: Decrease in pulse pressure due to increase in SAM and outflow
obstruction (Brockenbrough-Braunwald-Morrow Sign).
44. Mitral Stenosis
What Information Are We Looking For?
• Mean MV Gradient: Requires simultaneous LA-LV pressures
• MVG simplified=mean LAP −(LVEDP/2)
• Remember that MVG is dependent on heart rate
• Higher HR = less LA emptying = Higher MVG
• Mean MVG measured during diastole by the simultaneous
comparison of LV pressure and LA pressure.
• Simple MVG equation doesn’t require simultaneous
recording of LV/LA diastolic pressures. But this method is
limited if pt is tachycardic, which can reduce accuracy of
LVEDP estimate and overestimate the gradient. And this
makes sense.
• HR effect on MVG is important and the gradient will be
higher with a faster heart rate because there is less time
available for left atrial emptying with a reduced diastolic
period.
45. Mitral Stenosis
• Gorlin formula best applied to patients in sinus rhythm with normal LV function, no MR, and no other
concomitant valve lesions
• CO=4.2L/min, HR 70, DFP 0.42, Mean Gradient 25, MVA ~4/5 ~ 0.8cm2
46. PCW does not always equal LA
Usually use PCWP in place of direct LA pressure. And although mean PCWP will usually reflect the mean LAP, the PCWP/LV
pressure gradient frequently overestimates the true severity of mitral stenosis due to phase shift in the PCWP and a delay in
transmission of the change in pressure contour through the pulmonary circulation. So, you can get a 30-50% overestimation
of the true gradient when conventional catheters are used even if you correct for phase shift. You can reduce this
overestimation by confirming that the catheter is truly wedged by checking oxygen sats in the PCWP blood. Direct LA
pressure can be obtained via a transseptal approach. So really you have to decide what therapeutic decision is being made
based on this data and thus how accurate it needs to be.
48. Aortic Regurgitation Waveforms
• Ao: rapid upstroke due to augmented LV
contractility and increased systolic pressure
due to increased stroke volume. Rapid fall in
pressure results from regurgitation – results
in widened pulse pressure
• LV: near equalization of Ao and LV pressures
because of continuous leaking of blood back
into the LV producing a rapid rise in LV
pressure across diastole.
49. Provoked Hemodynamics Tips
• Test occlude everything.
• Second venous line is helpful.
• Think about the rhythm (get into routine of checking before/during
hemodynamics) and pacemaker (if applicable).
50. Vasodilator testing for pulmonary hypertension
• Indication: Known PH or pulmonary vascular resistance ≥ 3 iWU or Single
ventricles with transpulmonary gradient > 6 mmHg.
• Therapies: Oxygen, inhaled nitric oxide, epoprostenol, iloprost.
• Reactivity: Mean PAP decrease at least 10 and to a value of less than 40 with
increased or unchanged cardiac output and no significant change in systemic
blood pressure. Reduction in PVR by 20%. ID those who may respond to
calcium channel blockers.
• Caution: May cause pulmonary edema in those with LA HTN (or occult PVOD).
51. Fontan Fenestration test occlusion
• Indication: Electively after fenestrated Fontan or if cyanosis, particularly with
exercise.
• Technique: Doable with one venous access, easier with two.
• Measurements: SvO2, AO sat, Fontan pressure, systemic blood pressure.
• One access: test occlude with Berman or balloon with long sheath in baffle.
• Two access: test occlude with anything, 2nd line measures pressure/obtains
true SvO2.
• Interpretation: Ok to close if no more than 15% change in Fontan pressure,
cardiac output, systemic blood pressure.
58. Chronic Mitral Regurgitation Waveforms
• Left Atrium (or PCWP): Tall V wave. Sensitive, but not
specific marker. Mean pressure may be normal in setting
of compliant LA
• Left Ventricle: Systolic/diastolic pressures often normal
or only slightly increased.
• V waves frequently associated with VSD, or other
disorders associated with altered compliance and
pressure/volume relationships within atrial/ventricular
chambers
• Chronic MR LA: LV and LA directly communicate during
systole, but mean LAP may be normal/slightly increased
due to compliant LA, which dilates in response to
volume overload. Thus, amplitude of V wave is less
than LV systole
• LV pressure: LV is volume overloaded, but LV
compliancy increases so pressures remain normal
59. Acute Mitral Regurgitation Waveforms
• LA (or PCWP): Tall V wave with amplitude nearly equivalent to
LV systolic pressure
• LV : Diastolic pressures increased due to non-compliance of LV
• In contrast, in acute MR, LV and LA have not had time to adapt
to volume overload. Compliance in both chambers is low. So,
with onset of systole and large volume of regurgitant blood
flow, LAP rises abruptly, and you get a very tall V wave. The
pressure gradient between A ad LV declines by end of systole
so amplitude of V wave and that of LV systole are nearly
equivalent. LVEDP is also elevated because of increase in EDV
within un-dilated and non-compliant chamber
60. A 70 y/o man with MR
LV gram EDV 120 cc, ESV 30 cc, CO 6.0 L/m, HR 100 bpm
• Total volume: EDV – ESV 120-30=90cc
• Forward volume: Fick CO/HR 6000/100 = 60 cc
• RV = TV – FV = 90 – 60 cc = 30 cc
• RF = RV/TV = 30cc/90cc = 33%
65. PV loop – Combined systolic and Diastolic dysfunction
66. 65-year-old woman with multi-valvular heart
disease and rapid AF
FA % sat 96%
PA % sat 55%
Thermodilution CO 5.0 L/min
What is the true cardiac output?
A. Normal
B. Low
C. High
D. Cannot tell
67. What is the likely cause of this finding?
A. Constriction
B. Restriction
C. Tamponade
D. TR
68. What is the PVR in Wood Units?
Mean RAP = 10 mmHg
mPA= 40 mm Hg
mPCWP = 20 mmHg
FA = 130/82 mmHg
CO = 4.0 L/min
A. Cannot calculate
B. 250
C. 5
D. 3
73. Interpret the post-TAVR findings
• Ao-LV gradient reduction.
• Improved Ao upslope.
• Widened Ao pulse pressure.
• Rapid LV diastolic filling.
• High LVEDP.
• Matching LVEDP with Ao diastolic
= Acute AI post-TAVR
• Rapid pacing for stabilization
then valve in valve implantation.
74. What was the procedure?
• No LVOT gradient
• No spike/dome Ao
• RBBB
• LVEDP elevation