B P3 C22 Invasive Hemodynamic Diagnosis of Cardiac Disease Flashcards
Give 3 indications for cardiac catheterization
- Suspected or known coronary artery disease
- Myocardial infarction
- SCD
- Valvular heart disease
- Congenital heart disease
- Aortic dissection
- Pericardial constriction or tamponade
- Cardiomyopathy
- Initial and follow up assessment for heart transplant
Major complications of cardiac catheterization
Major vascular complications 1%
Death 0.2%
Ventricular tachycardia, fibrillation, serious arrhythmia 0.5%
Cerebrovascular accident 0.07%
Myocardial infarction 0.05%
Relative complications to cardiac catheterization
Aortic dissection
Cardiac perforation, tamponade
Congestive heart failure
Contrast reaction (anaphylaxis, nephrotoxicity) Heart block, asystole
Hemorrhage (local, retroperitoneal, pelvic) Infection
Protamine reaction
Supraventricular tachyarrhythmia, atrial fibrillation
Thrombosis, embolus, air embolus
Vascular injury, pseudoaneurysm
Vasovagal reaction
Vascular complications occurred more often when the ____________ approach was used and least when the radial approach was used.
Brachial Artery
Compared with femoral artery access, transradial procedures have a lower _____________ and ________________, superior patient comfort, and improved efficiency in postprocedural care.
A. Lower risk of bleeding
B. Vascular complications
True or False
Documentation of adequate dual blood supply to the hand by either the Allen or the Barbeau test is no longer required in most patients.
True
The skin entry site for radial access
1 to 2 cm cranial to the bony prominence of the distal radius
Given to prevent postprocedural radial artery occlusion
5000 units of unfractionated heparin IV bolus or
UFH weight-adjusted (50 units per kg)
Measures to prevent arterial vasopasm during radial access
Adequate sedation
Avoidance of limb cooling
Vasodilators - Nitroglycerin (100 to 200 mcg) and Verapamil (2.5 mg)
Other approaches - SL NTG, and/or intra aterial Diltiazem or Nicardipine
The optimal puncture location during femoral vascular access is the __________________________
Common femoral artery (CFA)
Familiarity with the anatomy will assist in identifying the point of needle entry, usually 1 to 3 cm below the inguinal ligament, in line with the palpable course of the CFA
In femoral artery vascular access, point of needle entry ______________
Landmark to be identified prior to entry _____________________________
A. 1 to 3 cm below the inguinal ligament, in line with the palpable course of the CFA
B. Inferior edge of the femoral head by fluoroscopy
.Accidental cannulation of the _____ artery may result in limb ischemia or inability to accommodate vascular closure devices.
Superficial or profunda femoral artery
This occurs with puncture that are above the inferior epigastric artery
Retroperitoneal hematoma
Punctures below the profunda and superficial femoral artery bifurcation will result to these vascular complications
Pseudoaneursym
Arteriovenous fistula formation
Accidental cannulation of the superficial or profunda femoral artery may result in __________________ or ________________________
A. Limb ischemia
B. Inability to accommodate vascular closure devices
Femoral sheaths should not be removed until the activated clotting time (ACT) is _______________ unless a vascular closure device is being used.
Less than 160 to 180 seconds
Prosthetic peripheral vascular grafts are the most problematic vascular challenges because of the __________________ and potential for _________________________
A. Lack of adequate closure
B. Thrombotic occlusion
Femoral vein access
Using the femoral arterial pulse as a landmark, the femoral vein sits approximately _____________ to the femoral artery.
If a combined arterial and venous access is needed, the venous puncture site is ___________ and ______________ to the planned arterial entry site.
A. 1 cm medial to CFA
B. 0.5 to 1 cm medial
C. 0.5 to 1 cm caudal
After the procedure is completed, venous hemostasis can be achieved with light finger pressure applied over the vein as described for femoral artery sheath removal. Usually only _____ minutes of compression is needed to obtain adequate hemostasis. (Femoral vein access)
5-10 mins
Brachial vein access
The _____________________ is preferred to avoid the acute angulation of the cephalic vein system as it joins with the axillary vein
Medial antecubital vein
The internal jugular (IJ) vein, especially the right IJ, is the preferred venous access because of the ffg advantages:
Greater patient comfort and lower infectious risk vs femoral
Reduced risk of pneumothorax vs subclavian
The internal jugular vein is located _____. For access, the patient is instructed to lie supine with the head turned 30 degrees to the contralateral side. Patients with low venous pressure may require leg elevation to increase venous filling volume. Routine use of ultrasound imaging facilitates localization of the IJ and can verify its patency. The use of ultrasound is recommended by national guidelines and reduces the overall risk of complications (carotid artery puncture,in particular) by 70%
Lateral to the carotid artery in the anatomic triangle of the two heads of the sternocleidomastoid muscle and the clavicle
Left heart catheterization
_________________ to the left ventricle is commonly performed using a straight or angled pigtail-shaped catheter
What catheters/guidewire to use/preferred:
Dilated aortic roots or horizontally oriented hearts
Small aortic roots
Bicuspid aortic valve
Screlotic/stenotic AV
What pressure measurements needed for
Aortic stenosis
Mitral stenosis
A. Retrograde access
B. Guiewire/catheters:
Dilated aortic roots or horizontally oriented hearts - angled pigtail catheter
Small aortic roots - R Judkins then exchange with pigtail catheter
Bicuspid aortic valve - L Amplatz (useful also in AS)
Screlotic/stenotic AV - straight guidewire vs J-tipped (increased risk for dislodging material from AV/aorta)
AS - simultaneous LV and aortic pressures (dual or MP + high fidelity pressure sensor guidewire)
MS - simultaneous LV and PCWP/LA pressures with 2 transudcers
A __________________ is the cyclic force generated by cardiac muscle contraction
This is influenced by factors:
Force of the contracting chamber
Chamber ___________ (extrinsic and intrinsic)
Physiologic variables of _________ rate, ____________ cycle, and vascular resistance
A. Pressure wave
B. Compliance
C. Heart rate
D. Respiratory cycle
The most common technical artifacts of fluid filled systems:
1. ______________, also known as excessive resonant artifact or ringing
2. ______________, e.g., blunted waveforms
3. Improper calibrations or setting (i.e.,____________) the transducer to atmospheric pressure
An __________________ (a brief, very high-frequency signal) can be noted when the catheter is struck by the walls or valves of the cardiac chambers.
- Underdamping
- Over-dampening
- Zeroing
- Impact artifact
Another explanation for a damped signal may be catheter tip obstruction by small vessel orifices or by engagement against vessel walls or thrombus within a catheter
Key Points for Accurate Hemodynamics:
1. Poorly collected or inaccurately obtained hemodynamic data can confuse or obscure the diagnosis and lead to improper therapy.
2. Properly collected data requires simultaneous electrocardiogram (ECG) tracings, accurate leveling or zeroing, an appropriate pressure scale (e.g., 0 to 200 mm Hg), and appropriate time scale.
3. The most common pressure wave artifact of a fluid-filled system is damping from blood or contrast in the catheter, which is easily resolved with a saline flush.
4. Exaggerated resonance or ringing of an underdamped pressure system can also occur and is resolved by using short stiff pressure tubing, properly debubbled lines, and calibrated recordings.
5. Correct interpretation of hemodynamic waveforms requires review of individual pressure waves and their timing to the ECG.
6. Distorted pressure waveforms on the hemodynamic tracing may be caused by an arrhythmia or conduction defect.
_________________ utilizes the indicator-dilution method for flow assessment with the indicator being temperature change after injection of a saline bolus cooler than blood temperature
Less accurate in situations such as:
Enumerate 4
A. Thermodilution
B. Less accurate: significant tricuspid or pulmonic regurgitation, intracardiac shunts, low cardiac output, or irregular rhythms
Cardiac output c relates inversely with the area under the curve
Key points for accurate hemodynamics
- Poorly collected or inaccurately obtained hemodynamic data can confuse or obscure the diagnosis and lead to improper therapy.
- Properly collected data requires simultaneous electrocardiogram (ECG) tracings, accurate leveling or zeroing, an appropriate pressure scale (e.g., 0 to 200 mm Hg), and appropriate time scale.
- The most common pressure wave artifact of a fluid-filled system is damping from blood or contrast in the catheter, which is easily resolved with a saline flush.
- Exaggerated resonance or ringing of an underdamped pressure system can also occur and is resolved by using short stiff pressure tubing, properly debubbled lines, and calibrated recordings.
- Correct interpretation of hemodynamic waveforms requires review of individual pressure waves and their timing to the ECG.
- Distorted pressure waveforms on the hemodynamic tracing may be caused by an arrhythmia or conduction defect.
The _______________ relies on this principle that blood flow (cardiac output) is inversely proportional to the extent of oxygen extraction (AV O2 difference)
Formula ________
Situations in which this should not be used:
Give 3
A. Fick method
B. Formula:
Cardiac output = O2 consumption (ml/min) / Arterial O2 sat - Mixed Venous O2 sat (PA) x 1.36 x Hgb x 10
C. Siginificant MR or AR, rapid changes in flow
No O2 su-port during determination
Common Hemodynamic Calculations:
BP = ________ x SVR
CO = HR x _______
CI = CO (ml/beat) / _______
SV = _________ (ml/min) / HR (bpm)
SVI = SV (ml/beat) / ________
SVR = _______ - ________ / CO (WU) x 80 (dynes)
PVR = _______ - ________ / CO (WU) x 8p (dynes)
TPR = _______ / CO
BP = CO x SVR
CO = HR x SV
CI = CO (ml/beat) / BSA
SV = CO (ml/min) / HR (bpm)
SVI = SV (ml/beat) / BSA
SVR = MAP - Mean RA / CO (WU) x 80 (dynes)
PVR = mean PA - mean PCWP/LA / CO (WU) x 8p (dynes)
TPR = mean PA / CO
List the Phases of Cardiac Cycle
Isovolumic contraction
Ejection
Isovolumic relaxation
Rapid inflow
Diastasis
Atrial systole
Give the pressure ranges of the different cardiac chambers (Mean)
RA
RV EDP
PA
PCWP
LA
LV EDP
Central Aorta MAP
SVR
RA - 1-5 mm Hg
RV EDP - 1-7 (systolic peak 15-30)
PA EDP - 4 -12 (systolic peak 15-30)
PCWP - 4-12
LA - 4-12
LV EDP - 5-12 (systolic peak 90-140)
Central Aorta MAP - 70-105 (systolic peak 90-140)
SVR - 700-1600 dynes
Characterize the ffg Atrial Pressures
a wave - ___________, _________ on ECG
c wave - ______________________ (isovolumic contraction; early systole)
x descent - ___________________
v wave - ______________________
y descent - ___________________
True or false:
_______The a wave is usually smaller than the v wave in the right atrium
_______A highly compliant atrium can accommodate large amount of volume and may produce large v waves
_______Stiff and noncompliant chambers may produce exaggerated v wave with normal filling pressures
a wave - reflects atrial c tion, and atrial contractility, follows P wave
c wave - atrioventricular (tricuspid or mitral) valve bulging into the atria during isovolumic ventricular contraction (early systole)
x descent - atrial relaxation and downward pulling of the tricuspid annulus as the right ventricle contracts
v wave - atrial filling, end of isovolumetric relaxation
y descent - drop in atrial pressure after AV opens
True - right atrium can easily decompress through the SVC and inferior vena cava (IVC), whereas the left atrium is constrained posteriorly by the pulmonary veins
False - small v waves
True - noncompliant atrium may produce large v waves
PCWP reflects the LA pressure through the __________________
To confirm PCWP is accurate and not dampened, check the ffg:
Identifying clear ___ and ____ waveforms timed against the ECG or LV pressure
Should note the time delay (i.e., phase shift) of the PCW v wave to match the __________________
Oxygen saturation ______ %
A. Pulmonary veins and capillaries
B. Accurate and not dampened PCWP tracing:
Clear a and v wave
LV downstroke, on or after
O2 sat >95%
Effects of over and under wedging of PCWP waveform:
Over wedging»_space; excessive damping: falsely ________; ________ waveform
Under wedging: falsely _______; appears to be a dampened __________ waveform
A. Low; FLAT waveform
B. High; Dampened PA waveform
PCWP may not reflect left atrial pressure as accurately as needed for mitral valve assessment.
Concept of Forward and Backward-traveling (reflected wave)
In the young and healthy subject on the left, the backward-traveling wave arrives at _________________ , contributing to closing the aortic valve and to increasing ________________ pressure
In the hypertensive subject on the right, the backward-traveling wave reaches the proximal aorta in ______________ and contributes to the _________________ in pressure.
A. Late systole»_space; diastolic perfusion pressure
B. Early systole»_space; late systolic peak
LV vs RV pressure waveforms
Magnitude of waveform
Duration of LV systole
Duration of isovolumic contraction
Duration of relaxation
Ejection period
LVEDP is taken _______________, _____ on ECG
PCWP correlates better with a _______________, which reflects the mean LV filling pressure.
Higher magnitude - LV
Longer LV systole, isovoumic cont and relaxation - LV
Shorter ejection period - LV
LVEDP taken after a wave, R wave on ECG
Pre-a LVEDP
In aortic stenosis
A ______________________ from the left ventricle into the aorta should only be used as a screening technique
True or false
The optimal way to measure the gradient in a patient with aortic stenosis is to use simultaneous LV and central aortic pressure
Single pressure pullback technique
True
In measuring transaortic gradient in AS
Use of a _________________ or _________________ eliminates any difference in pressure transmission time or effect of peripheral amplification.
Dual-lumen catheter or micromanometers
The ______________________ is the difference between the peak left ventricular and peak aortic pressures, which is a nonphysiological measurement because the peak pressures occur at different points in time.
Peak-to-peak gradient
The _______________________ (the integrated gradient between the left ventricular and aortic pressure throughout the entire systolic ejection period) should be used to determine the severity of the aortic stenosis
Mean pressure gradient
The mean integrated gradient between the left ventricle and aortic pressure waves over the systolic ejection period is the best measure of the stenosis severity
In aortic stenosis
The ejection of blood from the LV is forced through the fixed reduced aortic orifice area (i.e., the anatomic orifice area [AOA]). Energy is lost due to valvular resistance, resulting in a pressure drop and acceleration of flow.
After crossing the AV, (i.e., the effective orifice area [EOA]), part of the kinetic energy is reconverted back to potential energy, and the pressure increases, also called the ________________________________
Pressure Recovery
When the blood flow contracts to pass through a stenotic orifice (i.e., the anatomic orifice area [AOA]), a portion of the potential energy of the blood, namely, pressure, is converted into kinetic energy, namely, velocity, thus resulting in a pressure drop and acceleration of flow. Downstream of the vena contracta (i.e., the effective orifice area [EOA]), a large part of the kinetic energy is irreversibly dissipated as heat because of flow turbulences. The remaining portion of the kinetic energy that is reconverted back to potential energy is called the pressure recovery (PR).
The global hemodynamic load imposed on the left ventricle results from the summation of the valvular load and the arterial load. This global load can be estimated by calculating the valvuloarterial impedance.
Low-flow, low-gradient (LF/LG) severe aortic stenosis (AS) - valve area ________ but mean gradient ___________
In patients with LFLG AS with reduced EF, _________________ challenge will permit assessment of CO, valve gradient and area
True AS _______________
< 1.0 cm2
< 40 mm Hg
Dobutamine challenge
True AS - the valve gradient should increase with a higher cardiac output while the AV area will remain small.
Dobutamine also provides prognostic information, as patients without an adequate contractile reserve (e.g., stroke volume increase <20%) have poor outcomes irrespective of valve intervention.
In patients with low-gradient severe AS with a preserved ejection fraction (paradoxical LF/LG AS), cardiac output is limited by:
1.
2.
3.
- Relaxation abnormalities
- Low stroke volume
- Impaired ventriculovascular coupling
The dynamic obstruction in HOCM is affected by:
1.
2.
Ventricular loading conditions
Changes in contractility
The obstruction is dynamic, and worsens with reduced LV volume or increased LV contractility.
A low LVOT gradient at rest should be challenged with dynamic and provocative maneuvers (e.g., variation with respiration, post-PVC accentuation, isometric exercise) to identify the true obstructive nature of the disease and suitability for septal myectomy or percutaneous alcohol septal ablation
Significant gradient at rest ________ and after provocative measures __________
30 mm Hg
50 mm Hg
The location of the intraventricular gradient is defined by the _____________________ while still registering LV pressure
resolution point of the aortic-LV gradient
Hemodynamic findings in HOCM:
1. Rapid rise of the aortic pressure corresponding to the LV pressure at the onset of AV opening followed by blunted and rounded wave in late systole - ___________________
2. LV pressure proximal to the obstruction peaks late and has a late-peaking “_______________” shape
3. Increase in post-PVC _________ gradient
4. Diminished _________________ post PVC (_____________________ sign)
- Spike-and-dome contour
- Dagger shape
- LVOT gradient
- Aortic pulse pressure (Braunwald-Brockenbrough-Morrow sign)
Hanna:
1. Systolic aortic pressure has an early “spike” and a late “dome” (“spike and dome” appearance). In fact, LVOT obstruction is dynamic and is less severe in early systole when LV volume is largest, explaining the “peak” in aortic pressure. Obstruction is worst in mid and late systole when LV volume is reduced, explaining the low dome after the early spike (Figures XI.3-4).
- Because the LV obstruction is worse in late systole, LV pressure proximal to the obstruction peaks late and has a late-peaking “dagger” shape similar to the spectral Doppler dagger shape velocity across the LVOT.
- After a premature beat, LV volume increases leading to increased LV contractility and therefore increased LVOT obstruction. While LV pressure increases, the stroke volume decreases and thus the aortic pulse pressure decreases (Brockenbrough phenomenon); the aortic systolic pressure decreases as well. This is opposed to AS, wherein the LV pressure and the aortic pulse pressure both increase after a premature beat. In both HOCM and AS, the gradient and the murmur increase after a premature beat
Maneuvers that INCREASE LVOT gradient:
1.
2.
3.
Manuevers that INCREASE murmur of HOCM:
1.
2.
Manuevers that DECREASE murmur of HOCM:
1.
2.
Maneuvers that INCREASE LVOT gradient:
1. Valsava maneuver (dec preload)
2. Inhalation of amyl nitrite (dec afterload)
3. Dobutamine infusion (increase contractility)
4. Isoproterenol infusion (increase contractility)
Manuevers that INCREASE murmur of HOCM (decrease preload):
1. Valsalva
2. Standing
Manuevers that DECREASE murmur of HOCM (increase preload):
1. Squatting
2. Leg raise
*The gradient increases with decreased preload (Valsalva maneuver, hypovolemia, nitroglycerin), decreased afterload (vasodilators), or increased inotropism (exercise, inotropic drugs such as dobutamine)
Post PVC hemodynamic effects in
AS
1.
HOCM
1.
Aortic stenosis:
Increased gradient
Delayed aortic pressure upstroke (parvus and tardus upstroke)
Normal or widened pulse pressure
HOCM:
Increased gradient
Rapid aortic pressure upstroke
Reduced pulse pressure
In mitral stenosis
PCWP often __________________ LA pressure in patients with mitral stenosis or prosthetic mitral valves due to delayed and poor-quality pressure transmission
Most accurate method of determining transmitral gradient in patients suspected of MS?
A. Overestimates
B. For patients with elevated PCWP and suspected mitral valve abnormalities, direct measurement of the LA pressure by transseptal puncture is the most accurate method
Hemodynamic findings of mitral stenosis:
1.
2.
3.
- Large LA a wave
- Gradual y descent
- Low LV end diastolic pressure
The classic hemodynamic sign of mitral stenosis on left atrial pressure tracing is a markedly elevated a wave. Further, due to the stenosis of the mitral valve, the pressure only gradually decreases after opening and the y descent is gradual. The LV pressure waveform may show a lower end-diastolic pressure due to the impaired filling and a reduced atrial kick (i.e., a wave amplitude).
Hemodynamic findings of tricuspid stenosis:
1.
2.
3.
- Elevated RA a wave
- Gradual y descent
- Reduced RV end diastolic pressure
With tricuspid stenosis, the obstruction of blood flow from the right atrium into the right ventricle, the volume of blood in the right atrium and the mean right atrial pressure are increased in diastole, generating a diastolic pressure gradient between these two chambers. This translates into a markedly elevated a wave. Opening of the stenotic tricuspid valve leads to a slow decrease in right atrial pressure and gradual y descent. Right ventricular pressure tracings show a reduced end-diastolic a wave amplitude secondary to the reduced atrial filling.
Hemodynamic findings in aortic regurgitation:
1.
2.
3.
Widened airtic pulse pressure
Rapid upstroke of LV diastolic filling pressure
Near equilibration of end-diastolic aortic and LV pressure
Hemodynamic findings in mitral regurgitation:
1.
2.
- Prominent v wave
- Postcapillary pulmonary hypertension
Acute MR - large v wave (may be present due to low compliance of the LA rather than MR)
A new large v wave after mitral balloon valvuloplasty, however, is usually a valid demonstration of acute MR.
Hemodynamic fincings of pulmonary regurgitation:
1.
2.
3.
Low pulmonary artery end-diastolic pressure
Wide pulmonary pulse pressure
Increased RV end-diastolic pressure
With severe degrees of regurgitation, PAP tracings may take on the appearance of an RV pressure tracing (“ventricularization”).
Hemodynamic findings of tricuspid regurgitation
1.
Elevated v wave
The characteristic hemodynamic finding is an elevated v wave generated by the open communication between the two chambers and the volume ejection from the right ventricle into the right atrium with the onset of systole
v wave amplitude and mean right atrial pressure may be very minimally elevated in relation to the chronicity of TR
Right atrial distension due to chronic volume expansion with evolving reduction in contractility also leads to a reduction in the a wave.
In intracardiac shunts
As a general rule, pulmonary artery oxygen saturations exceeding __________ hould raise the suspicion for a left-toright shunt. On the contrary, systemic, arterial oxygen saturations _____ that persist after several deep breaths to counteract alveolar hypoventilation should raise suspicion for a right-to-left shunt
PA O2 > 80%
SA O2 sat < 93%
Identify significant step up:
Between SVC and PA - ______
Inter-atrial and interventricular - _____
- > /= 8%
- > /= 5%
True or False
Oxygen saturation in the IVC is higher than in the SVC as oxygen extraction of the internal organs and lower extremity muscles is lower in a fasting and resting state than that of the brain
True
Give formula for PBF and SBF in computation of shunt
PBF = O2 consumption (ml/min) / PVO2 - PAO2 x Hgb x 1.36 x 10
SBF = O2 consumption (ml/min) / SAO2 - MVO2 x Hgb x 1.36 x 10
Normal subsidiary functions of the pericardium:
____________________ of intrathoracic cardiac motion
___________________________ through diastolic and systolic interactions
Limiting acute cardiac ___________
Minimizing ____________ between cardiac chambers and surrounding thoracic structures
Providing an anatomic __________ to infection from the lung and other contiguous structures
Stabilization
Balancing RV and LV cardiac output
Dilation
Friction
Barrier
Normal physiology:
On INSPIRATION:
______________ intrathoracic and intracardiac pressure (RV and LV)
______________ venous return through the SVC and IVC (extrathoracic)
Increase flow to the ________ and RV
______________ pulmonary venous pressure (PV are intrathoracic and extracardiac)
______________ LA-LV gradient
______________ LV filling/flow
- Decrease intrathoracic and intracardiac pressure (RV and LV)
- Increase venous return through the SVC and IVC
- Increase flow to the RA and RV
- Decrease pulmonary venous pressure (PV are intrathoracic and extracardiac)
- Unchanged/minimal change in LA-LV gradient (since there is a decrease pressure in PV and LA/LV)
- Minimal or no change LV filling/flow
Reverse in expiration
Constrictive physiology:
On INSPIRATION:
______________ intrathoracic pressure
______________ intracardiac pressure (RV and LV)
______________ SVC pressure, __________ IVC pressure
______________ SVC flow, __________ IVC flow
Increase flow to the ________ and __________ for a short period due to the flow from IVC in early diastole
______________ pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac)
______________ LA-LV gradient
______________ LV filling/preload and stroke volume
- Decrease intrathoracic pressure
- No change in intracardiac pressure (RV and LV)
- Decrease in SVC pressure, no change IVC pressure (extrathoracic)
- Decrease SVC flow, increase IVC flow (partly because of the positive intra-abdominal pressure)
- Increase flow to the RA and RV for a short period due to the flow from IVC in early diastole
- Decrease pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac)
- Decrease LA-LV gradient (PV/PCWP decreased pressure, but LA/LV unchanged)
- Decrease LV filling/preload and stroke volume
VENTRICULAR SYSTOLIC DISCORDANCE
Increase in ventricular interdependence, the reduced LV volume “sucks” the RV during inspiration; thus, the RV sucks flow from the RA, and the flow between the RA and RV increases.
Restrictive CMP vs Constrictive Pericarditis
Restrictive CMP
Decreased ventricular chamber ________________ due to increased myocardial ____________.
The steep compliance curve results in an abnormal increase in impedance throughout the ________________ and a reduced atrial filling component at end-diastole
Constrictive Pericarditis
The ventricular chamber compliance is __________ in ______ diastole, allowing for normal or rapid early filling.
In _____________, ventricular filling is abruptly decelerated as the intracardiac volume approaches the fixed limit of the constricting pericardium.
- Compliance
- Stiffness
- Entire diastolic period
- Normal, early diastole
- Mid-diastole
Common hemodynamics in RCMP and CP:
1.
2.
- Elevation and equalization of right and LV diastolic pressures
- Abrupt cessation of early ventricular filling, classically described as a “dip and plateau” waveform of the ventricular pressures
Give the 5 traditional hemodynamic criteria of CP
- End-diastolic pressure equalization (LV end-diastolic pressure minus RV end-diastolic pressure <5 mm Hg)
- PAP <55 mm Hg
- RV end-diastolic pressure divided by RV systolic pressure >1/3
- Dip and plateau diastolic pressure morphology as reflected by the height of the LV rapid filling wave (>7 mm Hg)
- Kussmaul’s sign
Neither sensitive or specific for CP
____________________________ (correspondence of LV-RV systolic pressures) exhibited during respiration is the most sensitive and specific hemodynamic finding differentiating constrictive pericarditis from restrictive physiology.
Dynamic ventricular interdependence (100% sensitive, 95% specific)
During peak inspiration, there was discordance between RV and LV function with an increase in RV systolic pressure and simultaneous decrease in LV systolic pressure.
This is the lack of an inspiratory fall in mean right atrial pressure
Kussmauls’ sign
The classic signs in cardiac tamponade (Beck’s triad)
Hypotension, jugular venous distension, and muffled heart sounds
This is an exaggerated decline (>10 mm Hg) in systemic arterial pressure during inspiration
Pulsus Paradoxus
Hemodynamic consequences of Cardiac Tamponade:
Elevation and equalization of atrial and ventricular diastolic pressures
Decreased transmural filling pressures
Loss of y descent (*x and y descents corresponds to periods when venous flow is increasing) - heart is compressed throughout all diastole in tamponade, including early diastole. RA-RV flow is impeded throughout diastole
Loss of RV diasolic dip
Deep x in early systole as RV annulus moves down and stretches out the compressed RA
respiratory changes of intrathoracic pressure are transmitted to the cardiac chambers in tamponade as oppose to CP
________________ exercise is the most physiologic way of challenging the heart to unmask cardiac pathology
Dynamic
Differences Supine vs Upright Exercise
Supine exercise:
Larger _______________ volumes
Lower _____ and __________ pressure
Higher pulmonary and _________ pressures
Increase in SV by ________ %
Increase in LV EDV, decrease in ________, hence higher _______
Larger ventricular volumes
Lower HR and diastolic pressure
Higher pulmonary and intracardiac pressures
Increase in SV by 20-50 %
Increase in LV EDV, decrease in LV ESV, hence higher EF
Under normal conditions,the increased oxygen demand induced by exercise is met by an increase in _______________ and _______________________
A. Cardiac output
B. Peripheral oxygen extraction
This is the ratio of the observed/measured to the predicted CI
Normal values ____
Exercise index/Dexter index
Value of ≥0.8 reflects a normal cardiac output response to exercise
This is computed - increase in cardiac output divided by the increase in oxygen consumption
Normal values _____
Exercise factor of ≥6 is normal; that is, for every 100 mL/min increase in oxygen consumption, cardiac output should increase by at least 600 mL/min with exercise.
Examples of diseases where exercise testing is beneficial
- HFpEF
- VHD - MS, valvular regurgitation
__________________ consists of skeletal muscle contraction without shortening
Isometric exercise
In patients with CAD, isometric exercise rarely precipitates ischemia but may induce ______________________, a decrease in ________________, and an increase in ________ with no change in diastolic volume. SV and CO may decline during isometric exercise.
In patients with CHF, HR and systemic pressure may rise appropriately with a _______________, resulting in an increase in LVEDV and PA pressure.
- New LV wall motion abnormalities
- LV ejection fraction
- LV ESV
- Fall in SV and CO
Effect of Valsalva maneuver in HCM:
1.
Effects of PVC in HCM:
1.
2.
3.
Effect of rapid volume loading in CP:
1.
2.
Effect of Valsalva maneuver in HCM:
1. Decreases venous return and thus LV preload, which increases the systolic LV outflow tract pressure gradient
Effects of PVC in HCM:
1. Decrease in pulse pressure/aortic pressure
2. Accentuates spike and dome
3. Increase LVOT gradient
Effect of rapid volume loading in CP:
1. Exaggerated ventricular interdependence
2. Volume loading can cause equalized diastolic pressures between the two ventricles to differ in the setting of constriction.
Pharmacologic challenges
Effect of Dobutamine on LFLG AS
Effect of Isoproterenol, Nitroglycerin and Amyl nitrite on HCM gradient
Effect of Phenylephrim]ne on HCM gradient
- Severe AS - increase in CO, mean gradient > 30 mm Hg, AVA remains <1.2cm2
- Isoproterenol increase HCM gradient (inc chrono and inotropy), NTG increase (reduce preload). Amyl nitrite increase (reduce afterload)
- Phenylephrine reduces HCM gradient - increase in afterload/SVR
Criteria for PAH
Mean PAP
PCWP
PVR
Mean PAP >25 mm Hg
PCWP <15
PVR > 3 WU
Vasodilator testing with e prostenol, adenosine, nitroprusside, or nitric oxide is used to identify potential responders to therapy with calcium channel blockers and to establish prognosis.
Vasodilator testing - orthotopic heart transplantation (OHTx). Relative contraindications to OHTx include a PVR ≥5, a pulmonary vascular resistance index (PVRI) ≥6, and a transpulmonary gradient (TPG) ≥16
Criteria for a positive vasodilator testing
Decrease in mean PAP >/= _______ to an
Absolute mean PAP of </= ________ without
________ cardiac output
- 10 mm Hg
- 40 mm Hg
- A decrease in CO
Use of NO in patients with elevated PCWP at baseline
Inhaled nitric oxide can reduce PVR leading to pulmonary edema. The mechanism is increased forward flow through the pulmonary vasculature with increased filling of left-sided heart chambers that have already reached their maximum compliance, precipitating further increase in PCWP and pulmonary congestion.
Positive response to nitroprusside in patients with PH and elevated PCWP
Drop in PVR of at least _____ %
20%
In patients with an elevated PCWP, sodium nitroprusside is preferred to document if reduction in afterload and LV filling pressure also lowers PAP and improves cardiac output. This holds true in cases of MR, dilated cardiomyopathy, and HFpEF. A typical protocol is to commence the infusion at 0.25 to 0.5 μg/kg/min following acquisition of baseline hemodynamic data and to up-titrate at the same dose range in 2- to 5-minute intervals until PCWP is <18 mm Hg, systemic blood pressure <90 mm Hg, or development of symptoms (e.g., lightheadedness).24 , 25 On reaching those hemodynamic endpoints, a positive response is usually defined as a drop in PVR of at least 20%.
