Cardiac haemodynamics Flashcards
Describe the way a swan ganz trace should look, including basic pressure info
RA- should be 5 mmHg
RV- across tricuspid valve systolic 20-30 and diastolic should be same as RA if no tricuspid stenosis
PA- more M shaped. systolic pressure should be same as RV (low if pulmonary stenosis). Diastolic aboud half way up. If PR, PA trace looks like RV trace.
PCW- measuring the pressure transmitted back as a surrogate of left atrial pressure
What does the atrial waveform look like and what can you tell from it.
Double impulse with a wave, x descent, v wave, y descent.
a- atrial systole- not there in AF
x - atrial relaxation
v- ventricular contraction (less than a in RA and more than a in LA)
y- atrial emptying
M wave with prominent x and y descent?
Constrictive pericarditis
No a waves
AF
CHB
cannon a waves
Tricuspid regurg, RV failure
increase V wave
WHAT DOEs kussmaul’s sign mean?
Increased RA pressure with inspiration- should drop. As seen in constriction or RAV ischaemia
What does it mean if PCWP is greater than LVEDP?
mitral stenosis -severe espec if mean gradient over 10
What if LV pressure a lot higher than L atrial?
AS
Most common cause of intraventricular pressure gradient?
HOCM with obstruction
Treatment constrictive pericarditis vs restrictive cm?
Pericardial stripping
Medical therapy ?transplant
List 5 causes of constrictive pericarditis
Uraemia TB pericarditis Recurrent pericarditis Previous mediastinal RT CT disease
List 6 causes of restrictive cardiomyopathy
Sarcoidosis Amyloidosis Haemochromatosis Idiopathic Post radiation Endocardial fibroelastosis
MAIN THING you have to remember to distinguish CP from RC?
Constriction- LV-RV interdependence (ie constriction binds together) See increase RV pressure with inspiration
Restriction- Absent LV-RV interdependence. Do not see increase RV pressure with inspiration.
Define pulmonary hypertension
mean PAP over 25mmHg
List the five causes of pulmonary hypetension
- Small arterioles (idiopathic, HIV, congenital, drugs)
- Left heart
- Lung disease- hypoxaemia
- Thromboembolic
- Multifactorial
What is the formula for pressure?
pr=4 x velocitysquared
(Bernoulli law)
Pressure in RV = (Pressure RV-RA) + RA pressure
The first bit is estimated by TR
How is PCWP used to tell between L heart failure and primary cause of pulm hypertension?
LA cause PCWP will he high
Lung cause, will be low (under 15)
What is the use of vasodilator testing in R heart cath>
PRedict response to vasodilator therapy like Ca channel blocker
?closure of shunt feasible
How do you calculate mean pulmonary pressure?
systolic + 2 x diastolic all divided by three!!
How do you calculate pulmonary vascular resistance?
(PA-LA) divided by (pulmonary blood flow which is cardiac output in L)
Normal is less than 3-5
ie seeing if pt can be listed for cardiac transplant or are lungs stuffed as well?
Who gets oxygen in pulm hypertension?
Group 3 mortality benefit
Who gets anticoagulation for pulmonary hypertension?
Group 1 and 4
What improves your 6MWT more ?
Exercise training over advanced therapies
Who gets advanced therapy?
Group 1 yes
3 4 5 maybe
NOT group 2 -if vasodilate can put into pulm oedema
Where is the most evidence for use of advanced therapies?
Idiopathic and scleroderma
What are the types of advanced therapies?
Endothelin receptor antagonists eg bosentan, macitentan, ambrisentan (symptoms, 6MWT)
Phosophodiesterase inhibitors eg sildenafil, tadalafil (symptoms, 6MWT)
Guanylate cyclase inhibitors eg Riociguat
Prostacyclin (epoprostenol), inhaled iloprost, sc trepostinil
What is “shunt size”
Qp:Qs = (ratio aortic valve oxygen- mixed venous)/ (PV oxygen- PA)
USING SATURATIONS not pressures
When to close an ASD?
When haemodynamically significant shunt- with symptoms, RV enlargement, Qp:Qs over 1.5
When getting paradoxical embolism
Platypnea orthodeoxia syndrome
DO NOT Close when eisenmenger physiology - this would convert some one to primary pulmonary hypertension which has worse prognosis if dont kill in process (PAP over 2/3 systemic BP or PVR more than 2/3 SVR)
Most common type ASD?
Ostium secundum
primum more common in Downs
ASD loads the…
VSD loads the…
PDA loads the,…
ASD loads right heart
VSD loads left heart
PDA loads the LV
Most common type VSD
membranous - bordered by fibrous continuity of AV valve and aortic valve
Get aneurysm formation and AR
VSD in adults close spontaneously…
50%
Why close PDA?
Endocarditis risk
But don’t close if murmur inaudible and asymptomatic or if Eisenmengers
PDA is connection between aorta and pulmonary artery
DDx continuous murmur
Coronary fistula
PDA
Ruptured sinus of valsalva anuerysm
PDA with eisenmengers see?
May see clubbing in feet with cyanosis but not hands
How does eisenmengers syndrome happen?
Left to right shunt puts volume pressure on pulm circulation and shear stress–>increase PVR–>change to R to L shunt
Most common cause of Eisenmengers
Uncorrected PDA>VSD>ASD
BUT prognosis way better than PPAH
Treatment Eisenmengers?
AVOID iron def–>increase micro red cells–>increase viscosity
Avoid warfarin as bleed risk more than thrombus risk
Pulm vasodiliator therapy does work- bosentan, sildenafil
heart lung transplant if syncope, refractory RHF
Endocarditis prophylaxis
Phlebotomy for hyper-viscosity symptoms
What does Ebstein anomaly look like?
Tricuspid valve shifted right down towards apex- tiny LV
AND 80% have ASD or PFO
Usually normal PAP
What is in tetrallogy
VSD
Over riding aorta
RVH
RVOTO either subpulm stenosis or pulmonary atresia
What should you look for when following up Tetrallogy?
On cardiac MRI, size of RV is an indication to treat pulmonary regurg
More likley SCD post repair if LV EDP over 12, if NSVT, or QRS over 180
What tends to happen with peripartum CM?
50% improvement in LVEF at 6 months
High recurrence risk
see in last trimester, early PP
Bernoulli equation-
Change in pressure = 4 x PEAK NOT MEAN velocity squared
So can work out pressure difference without a catheter in the lungs
If know velocity across tricuspid valve. (70-100% people do have a bit of this) so can work out pressure difference RA and RV
RV pressure = 4 x (TR velocity)squared
Continuity equation for finding out valve area?
Flow = area of valve x velocity across valve
constrictive pericarditis vs tamponade
tamponade -prominent x and absent y descent
constrictive- prominent x and Y
