Cardiac cath diseases

Question 1

SAS

Answer 1

PG is btwn main portion of LV and LVOT
o ↑ systolic peak in body of LV
o PG as KT withdrawn from LV to subvalvular region (95mmHg)
o No systolic gradient at valve level

Question 2

Valvular AS

Answer 2

PG btwn LVOT and Ao

Question 3

Supravalvular AS

Answer 3

PG beyond AoV btwn proximal and distal Ao portion

Question 4

Carbello sign

Answer 4

↑ arterial BP during LV KT pullback with severe SAS
o Related to partial obstruction of already narrowed orifice and subsequent relief when KT is removed
o Seen with patients with AoV area <0.6cm2

Question 5

Subvalvular PAS

Answer 5

o Pullback 1: systolic P remains unchanged from PA → RVOT
 Fall in diastolic pressure indicates entered RV
o Pullback 2: PG with no change in diastolic pressure → intraventricular obstruction

Question 6

Valvular PS

Answer 6

o Normal PAP and mean RAP
o Abrupt ↑ pressure as KT withdrawn across PV into RV
 Systolic PG = 86mmHg
o Slight ↑ a wave secondary to RVH and ↓ RV compliance

Question 7

Supravalvular PS

Answer 7

o PG is observed when KT is pulled back into MPA
 ↑systolic pressure with stable diastolic pressure = KT remains in PA, distal to valve
o 2nd pullback: not other systolic gradient → RV

Question 8

MV stenosis

Answer 8

LAP
o ↑a wave → ↑ residual volume in LA at onset of atrial systole
 Can be very large, as high as 50 mmHg
o ↑v wave → ↑LA volume/pressure
 Any further ↑ volume in passive atrial filling → increases v wave
o Delayed y descent slope: delayed early/rapid ventricular filling

• PG bwn LA and LV from 5-25mmHg
  o ↑LA/PAWP to 20-25mmHg → can lead to
   Pulmonary edema
   Secondary PH: PVr can ↑ 25-30x normal
  o Normal or low LV end diastolic P
  o ↓CO secondary to ↓ blood flow across MV

Question 9

AI

Answer 9

• ↑ LV volume secondary to regurgitation
  o ↑SV → ↑ systolic pressure
  o Regurgitation during diastole: ↓ diastolic pressure
   Diastasis: equalization of diastolic Ao and LVP in severe AI
  o Wide pulse pressure
• LV workload: progressively ↑ according to magnitude of AI → LV dilation → ↑ wall stress
• Premature MV closure: blood flowing from AI + normal diastole through MV → rapid ↑ LV diastolic P → exceed rapidly LAP → early MV closure

Question 10

Acute vs chronic AI

Answer 10

o Acute: higher end diastolic LVP → inability to handle ↑ volume
o Chronic: ↑ end diastolic and systolic volume, ↑SV, ↑Ao systolic/mean P + widened pulse pressure

Question 11

Non restrictive VSD

Answer 11

o ↑RV and PAP equivalent to systemic circulation
o Diastolic/mean PAP remain lower until pulmonary vascular dz develop
o ↑LA/LV end diastolic P → volume overload

Question 12

MR

Answer 12

• ↑ v wave: reflux of blood in LA during ventricular systole
  o Abnormal MV leaflets coaptation
  o ↓LA compliance
  o Severe MR:
   Acute: v wave >2-3x mean LAP/PAWP
   Chronic: v wave can be normal as LAE is gradual and can accept enormous MR
• Steep y descent: ↑ volume in LA (regurgitant + normal)
• Absent or small a wave

Question 13

Causes of incr V waves

Answer 13

MR
 ↑LAP w/o MR
 LV failure with large, non compliant LA

Question 14

Cardiac tamponade

Answer 14

• Equalization of diastolic pressures across all cardiac chambers
  o ↑ of diastolic pressures in all chambers
• RA waveform:
  o ↑a=v waves
  o Blunted y descent → ↓ volume from RA/LA to fill RV/LV
  o Predominant x descent
  o ↑mean RAP = end diastolic PAW/LAP
• LV and RV systolic peak pressure out of phase
• Peak AoP varying >10-12mmHg → pulsus paradoxus with respiratory cycles

Question 15

RCM

Answer 15

• Severe diastolic dysfct with preserved systolic fct
  o Diastolic filling restricted by myocardium
  o Involves entire myocardium → including IVS
   ↓ septal shift towards L during inspiration
   LVP tracks RVP during systole w respiration (concordant)
  o Not associated with ventricular interdependence or intra thoracic/cardiac dissociation
• RA waveform: M/W shape
  o Rapid x and y descent
  o ↑RAP
• Ventricular waveform: RV/LV dip and plateau during diastole → rapid early filling with abrupt stop and ↑ end diastolic P
  o ↑ diastolic pressures: LV > RV
  o Concordant fall in RV and LVP with inspiration
• Kussmaul sign → ↑RAP during inspiration

Question 16

Constrictive pericarditis

Answer 16

• Ventricular interdependence: filling of 1 ventricle impairs filling of the other (mechanical constraint of pericardium)
  o Discordant changes in R/LV systolic pressures during inspiration
  o Respiratory fluctuations:
   Inspiration: ↓ intrathoracic pressures NOT communicated to heart chambers
• No respiratory changes in RAP
• Kussmaul sign: ↑RAP in severe cases
• Ventricular waveform:
  o RV/LV dip and plateau during diastole → rapid early filling with abrupt stop secondary to volume limit from stiff pericardium
  o ↑ end diastolic P: LV = RV
• RA waveform: M/W shape
  o ↑/rapid y descent → rapid filling in early diastole
  o Steep A wave
  o Blunted x decsent → atrium attempt to fill an overfilled/full ventricle

Question 17

Double chamber RV

Answer 17

• Aberrant hypertrophied muscular bands divide RV in 2 chambers:
  o Proximal high-pressure chamber
  o Distal low-pressure chamber
• PG is between the inflow and outflow portion of the RV
  o KT advanced from high-pressure chamber → low pressure chamber
  o P in distal chamber = PAP

Question 18

How would you estimate the effective orifice area of a stenotic lesion in the cath lab

Answer 18

• Requires simultaneous measurements of pressure and flow across valve
  o CO
  o Diastolic time if AV valve, systolic time if GA valve
  o HR
  o C is a constant
   MV: 0.85
   AoV, PV, TV: 1
  o PG across valve

Area= (CO/(diastolic or systolic time)(HR) )/(44.3C√PG)