Slide 1

COLLECTION CATH TRACINGSDR VIRBHAN BALAI

Right Heart CatheterizationLeft Ventricular PressureSystoleIsovolumetric contractionFrom MV closure to AoV openingEjection From AoV opening to AoV closureDiastoleIsovolumetric relaxationFrom AoV closure to MV openingFillingFrom MV opening to MV closureEarly Rapid PhaseSlow PhaseAtrial Contraction (a wave)

End diastolic pressurePeak systolic pressure

Peak systolic LV pressure

End diastolic LV pressure

Fixed aortic obstruction

Simultaneous pressure tracings from the left ventricle and the aorta in a patient with aortic stenosis.

Brown J , Morgan-Hughes N J Contin Educ Anaesth Crit Care Pain 2005;5:1-4Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 1 2005 The Board of Management and Trustees of the British Journal of Anaesthesia 2005

Simultaneous pressure tracings from the left ventricle and the aorta in a patient with aortic stenosis. The relationship between the maximum gradient that can be measured by Doppler (solid arrow) and the peak-to-peak gradient that can be measured by cardiac catheterization (broken arrow) can be appreciated. The maximum gradient shown here is 100 mm Hg, which equates to a peak Doppler velocity of 5 m s1.

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Left ventricular(LV) catheter pullback to aorta in a patient with hyperrtrophic cardiomyopathy . There is a significant systolic gradient within the left ventricular cavity and the LV outflow tract and aortic pressure waveforms exhibit a spike-and dome contour.

Left ventricular (LV) and femoral artery (FA) presure tracings in a woman with hypertrophic cardiomyopathy and asymmertric septal hypertrophy illustration the increase in gradient and develop a spike-and dome configuration in the arterial pressure waveform following an extrasystolic beat . Arterial pulse pressure clearly narrows in postextrasystolic beat. The narrowing of pulse pressure is known as Brockenbrough-Braunwald sign

Left ventricular(LV) and femoral artery (FA) pressure tracings . Valsalva manuver producesa marked increase in the gradient , as well as a change in the femoral arterial pressure waveform to a spike-and dome configuration

Simultaneous left ventricular and aortic pressure tracings at rest and after provocation with intravenous isoprenaline.

Serino W , Sigwart U Heart 1998;79:629-630Copyright BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Simultaneous left ventricular and aortic pressure tracings at rest and after provocation with intravenous isoprenaline. The resting left ventricular outflow tract pressure gradient is completely abolished after the procedure, the very high pressure gradient after isoprenaline provocation is largely reduced following the procedure.

Left ventricular (LV) and left brachial artery(LBA) pressure tracings in a 64-year-old woman with hypertrophic caridomyopathy . A: The effect of a spontaneous change from nodal rhythm to sinus rhythm. The short arrow showed LVEDP. With restoration of sinus shythm abd a presumed decrease in the obstruction. The loss of atrial kick in patients with a stiff ventricle leads to an acute reduction in cardiac output.

Left ventricular (LV) micromanometer ad aortic (Ao) pressure tracings in a 68-year-old woman with advanced dilated cardiomyopathy . Marked slowing of the rates of left ventricular pressure rise and fall give the LV pressure tracing a triangular appearance

PAW and LV Tracings during Inspiration and ExpirationRV and LV Tracings during Inspiration and ExpirationHemodynamic Principles

PAW and LV Tracings during Inspiration and ExpirationRV and LV Tracings duringInspiration and ExpirationA. Chronic recurrent PE. B. Constrictive pericarditis. C. Atrial septal defect with a large shunt and right heart failure. D. Chronic pericarditis now presenting with tamponade. E. Chronic hepatitis with cirrhosis. Which of the following is the most likely explanation for these findings? Hemodynamic Principles

PAW and LV Tracings during Inspiration and ExpirationRV and LV Tracings duringInspiration and ExpirationA. Chronic recurrent PE. B. Constrictive pericarditis. C. Atrial septal defect with a large shunt and right heart failure. D. Chronic pericarditis now presenting with tamponade. E. Chronic hepatitis with cirrhosis. Which of the following is the most likely explanation for these findings? Hemodynamic Principles

Hemodynamic Principles

A. She has valvular aortic stenosis.B. She has hypertrophic cardiomyopathy with obstruction.C. She has an intraventricular pressure gradient.D. She has a bicuspid aortic valve with mild stenosis.E. She has a pressure gradient but it is likely an artifact.

Hemodynamic Principles

A. She has valvular aortic stenosis.B. She has hypertrophic cardiomyopathy with obstruction.C. She has an intraventricular pressure gradient.D. She has a bicuspid aortic valve with mild stenosis.E. She has a pressure gradient but it is likely an artifact.

Dicrotic pressure changes

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Dicrotic pressure changes

this part here is the dicrotic notch

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Arterial Pressure MonitoringAbnormalities in Central Aortic TracingSpike and dome configurationHypertrophic obstructive cardiomyopathy

Davidson CJ, et al. Cardiac Catheterization. In: Heart Disease: A Textbook of Cardiovascular Medicine,Edited by E. Braunwald, 5th ed. Philadelphia: WB Saunders Company, 1997

SpikeDome

Right Heart CatheterizationLeft Ventricular PressureSystoleIsovolumetric contractionFrom MV closure to AoV openingEjection From AoV opening to AoV closureDiastoleIsovolumetric relaxationFrom AoV closure to MV openingFillingFrom MV opening to MV closureEarly Rapid PhaseSlow PhaseAtrial Contraction (a wave)

End diastolic pressurePeak systolic pressure

Peak systolic LV pressure

End diastolic LV pressure

Fixed aortic obstruction

Simultaneous pressure tracings from the left ventricle and the aorta in a patient with aortic stenosis.

Brown J , Morgan-Hughes N J Contin Educ Anaesth Crit Care Pain 2005;5:1-4Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 1 2005 The Board of Management and Trustees of the British Journal of Anaesthesia 2005

Simultaneous pressure tracings from the left ventricle and the aorta in a patient with aortic stenosis. The relationship between the maximum gradient that can be measured by Doppler (solid arrow) and the peak-to-peak gradient that can be measured by cardiac catheterization (broken arrow) can be appreciated. The maximum gradient shown here is 100 mm Hg, which equates to a peak Doppler velocity of 5 m s1.

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Left ventricular(LV) catheter pullback to aorta in a patient with hyperrtrophic cardiomyopathy . There is a significant systolic gradient within the left ventricular cavity and the LV outflow tract and aortic pressure waveforms exhibit a spike-and dome contour.

Arterial pulse

Arterial Pressure MonitoringCentral Aortic and Peripheral TracingsPulse pressure = Systolic DiastolicMean aortic pressure typically < 5 mm Hg higher than mean peripheral pressureAortic waveform variesalong length of the aortaSystolic wave increases in amplitude while diastolic wave decreasesMean aortic pressure constantDicrotic notch less apparent in peripheral tracing

Davidson CJ, et al. Cardiac Catheterization. In: Heart Disease: A Textbook of Cardiovascular Medicine,Edited by E. Braunwald, 5th ed. Philadelphia: WB Saunders Company, 1997

PWV

stiffer arteries increased PWV earlier arrival of reflected waves augmentation of systolic rather thandiastolic pressureincreased pulse pressure

Dehydration-Hypovolemia

Effects of respiration

ANACROTIC SHOULDER

Pulsus paradoxus

Pulsus alternansPericardial effusionCardiomyopathyCHF

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Advancing Your Right Heart CatheterAdvance the SGC to about 20cm and inflate the balloon tip.Initial chamber the right atrium.Initial pressure waveform 3 positive deflections, the a, c and v wavesThere will be an x and y descent

Right Atrial Pressure Tracinga wave atrial systolec wave occurs with the closure of the tricuspid valve and the initiation of atrial fillingv wave occurs with blood filling the atrium while the tricuspid valve is closed

Timing of the positive deflectionsa wave occurs after the P wave (60-80 msec)during the PR intervalc wave when present occurs at the end of the QRS complex (RST junction)v wave Peak occurs after the T wave

Right Atrial ChamberHeight of the v wave atrial compliance volume of blood returningHeight of the a wave The pressure needed to eject forward blood flowThe v wave is usually smaller than the a wave in the right atrium

43Can briefly overview anatomy-with mechanical ventilation the intrathoracic pressrues are increased and right atrial pressures would increase.

Right Heart Pressures Tracings

44Can discuss the rule of 5sRA 5, RV 25/5, the PA 25/10, PCWP 10-15, LA 10, LV 120/10

Right Atrial ChamberHeight of the v wave atrial compliance volume of blood returningHeight of the a wave The pressure needed to eject forward blood flowThe v wave is usually smaller than the a wave in the right atrium

46Can briefly overview anatomy-with mechanical ventilation the intrathoracic pressrues are increased and right atrial pressures would increase.

Right atrial hemodynamic pathologyElevated a waveTricuspid stenosisDecreased RV compliancee.g. pulm htn, pulmonic stenosisCannon a waveAV asynchrony atrium contracts against a closed tricuspid valvee.g. AVB, Vtach

Absent a waveAtrial fibrillation or standstillAtrial flutterElevated v waveTricuspid regurgitationRV failureReduced atrial compliancee.g. restrictive myopathy

X descentProminent Tamponade,RV ischemia,(ASD)Absent Atrial arrhythmias,TR,RA ischemiaY descentProminent CCP/RCM/TRAbsent TS/Tamponade/RV ischemia

Right atrial hemodynamic pathology

Note the Cannon a wave that is occurring during AV dysynchrony atrial contraction is occurring against a closed tricuspid valve.Note the large V wave that occurs with Tricuspid regurgitation

Hemodynamic PathologyTricuspid StenosisLarge jugular venous a waves on noted on examNotable elevated a wave with the presence of a diastolic gradient - >5mmHg gradient is considered signficant

Prominent Rt V waveV> 15 mmHgDifference of V and RA mean >5 mmHgRation of V to RA mean>1.5

Advancing Your Right Heart CatheterContinue advancing the catheter into the right ventricleThe right and left ventricular pressure tracings are similar.The right ventricular has a shorter duration of systoleDiastolic pressure in the right ventricle is characterized by an early rapid filling phase, then slow filling phase followed by the atrial kick or a wave

a

Normal RV waveform artifactNote the notch on the top of RV pressure waveformThis represents ringing of a fluid-filled catheterRinging can also be noted on the diastolic portion of the waveform

Advancing Your Right Heart CatheterAdvancing out the RVOT to the pulmonary arteryThere is a systolic wave indicating ventricular contraction followed by closure of the pulmonic valve and then a gradual decline in pressure until the next systolic phase.Closure of the pulmonic valve is indicated by the dicrotic notch

Timing of the PA pressurePeak systole correlates with the T waveEnd diastole correlates with the QRS complex

Hemodynamic PathologyPulmonic StenosisNotable large gradient across the pulmonic valve during PA to RV pullback. Notable extreme increases in RV systolic pressures and a damped PA pressure

Right atrial hemodynamic pathology

Note the Cannon a wave that is occurring during AV dysynchrony atrial contraction is occurring against a closed tricuspid valve.Note the large V wave that occurs with Tricuspid regurgitation

Hemodynamic PathologyTricuspid StenosisLarge jugular venous a waves on noted on examNotable elevated a wave with the presence of a diastolic gradient - >5mmHg gradient is considered signficant

Prominent Rt V waveV> 15 mmHgDifference of V and RA mean >5 mmHgRation of V to RA mean>1.5

Hemodynamic Pathology

Mitral StenosisThis patient underwent mitral valvuloplasty resulting in a reduction of the resting gradient by 10mmHg and an increase in CO from 3.7 to 5.5LPM and a valve area from about 1.1 to 2.9 cm2

E

F

G

A

B

C

D

E

F

G

H

I -PCWP tracing

J -PCWP

K

L

M

N

NORMAL PRESSURE TRESSINGS RA, RV , PA, PCWP

NORMAL PRESSURE TRACING Ventricle.

peakaDip0100

NORMAL ARTERIAL PRESSURE TRACINGS

Peak systolic end diastolic

Kussmauls SignCATHSAP6: Coronary Angiography and Intervention

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97

Name this pathology.Mitral stenosis with 20 mm gradient. Atrial fibrillation.Note slow y descent and lack of a waves (atrial fib.).

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Name this pathology.Probable Mitral Regurgitation.Large v waves, which could also be due to atrial fibrillation or CHF.

Right atrium02040

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Right ventricle20040

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Pulmonary artery20040

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Pulmonary capillary wedge20040

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NORMAL PRESSURE TRACINGS LA , LV , AORTA

LA , LV ,AORTA Pressure Tracing