Hemodynamics II … When The Waves Don’t Look Right … Chris Pan, MD. MBA. MS. Interventional Cardiology University of California, Irvine

Disclosures None

Content Valvular heart disease Pericardial disease Intracardiac shunt Aortic disease Mimicker of aortic stenosis Mitral disease Pericardial disease Constrictive vs Restrictive Intracardiac shunt

LHC + RHC measurement RHC: chamber pressure, cardiac output, valve area LVEDP: Fluid status / HF LV-Ao measurement: Aortic disease LV-PCWP measurement: Mitral disease LV-RV response: Pericardial disease Saturations: intracardiac shunt

Case 1 70M presented with shortness of breath Diastolic murmur along sternal border Visible strong carotid pulse Head bobbing

Ren X , Banki N M Circulation 2012;126:e28-e29

Wide Pulse Pressure Aortic tracing LV tracing Ren X , Banki N M Circulation 2012;126:e28-e29

Rapid Rise of LV Diastolic Pressure Aortic tracing LV tracing Ren X , Banki N M Circulation 2012;126:e28-e29

Near Equalization of Diastolic LV and Ao Aortic tracing LV tracing Ren X , Banki N M Circulation 2012;126:e28-e29

Aortic Regurgitation Key Hemodynamic Findings: Wide pulse pressure: High systolic +Low diastolic AO Rapid rise in LV diastolic pressure LVEDP ~ AOEDP LVEDP is much higher than PCWP (esp. in acute AR)

Case 2 70M presented with shortness of breath Cath findings: Normal coronary arteries LVgram: EF ~ 30%

WWYD? 70M with SOB, normal coronary arteries, depressed EF, and aortic stenosis with aortic gradient ~ 30mmHg Right heart catheterization Re-cross aortic valve to measure gradient with a Langston dual lumen catheter Determine the true severity of the aortic stenosis Pseudo aortic stenosis (2/t low flow or gradient) vs True fixed aortic stenosis

AoV Area Formula Gorlin Formula: Hakki Formula

Moderate or Severe AS? Valve Replacement? P-P gradient 30mmHg CO = 3.2l/m Fick AVA = 0.7cm2

Dobutamine Challenge True fixed stenosis vs Pseudo variable stenosis In patients in whom there is a low-output, low-gradient (Grad) state, it may be necessary to perform dobutamine stimulation to normalize cardiac output. This can be used to differentiate between patients with true aortic (Ao) stenosis and those with pseudo–aortic stenosis. A, With dobutamine stimulation, the gradient increases from 28 to 42 mm Hg and the valve area remains small at 0.7 cm2. This indicates that there is severe fixed valvular stenosis in this patient. B, In this patient with similar resting hemodynamics, dobutamine infusion does not change the gradient remaining at 24 mm Hg. The valve area increases to 1.2 cm2. This is an example of pseudo–aortic stenosis in which the valve area is small at baseline owing to the lack of momentum from a ventricle to fully open a mildly stenotic aortic valve. AVA indicates aortic valve area; LV, left ventricle; RV, right ventricle; and LA, left atrium. True fixed stenosis vs Pseudo variable stenosis Nishimura R A , Carabello B A Circulation 2012;125:2138-2150

Dobutamine Challenge Base 10 Dob+Pace 80 20 Dob + Pace 95

S/p Aortic valvuloplasty … What happened? AR

Case 3 70M presented with shortness of breath Cath findings: Normal coronary arteries Normal ejection fraction

Aortic Stenosis?

Still Aortic Stenosis? Distal LV Sub-Aortic

Spike & Dome

Hypertrophic Cardiomyopathy A visual assessment of the contour of the aortic (Ao) and left ventricular (LV) pressures is important during cardiac catheterization. Left, Patients with fixed obstruction (either valvular stenosis or fixed subvalvular stenosis) will demonstrate a parvus and a tardus in the upstroke of the aortic pressure, beginning at the time of aortic valve opening. Right, In patients with a dynamic obstruction (such as that found in hypertrophic cardiomyopathy), the aortic pressure will rise rapidly at the onset of aortic valve opening and then develop a spike-and-dome contour as the obstruction occurs in late systole. The left ventricular pressure also has a late peak because of the mechanism of this dynamic obstruction. LA indicates left atrium. Nishimura R A , Carabello B A Circulation 2012;125:2138-2150

Brockenbrough-Braunwald-Morrow Sign AS 1. Decreased arterial pulse pressure 2. Increased systolic peak gradient 3. Spike and Dome HCM The decrease in pulse pressure after a premature ventricular contraction is due to reduced stroke volume caused by increased dynamic obstruction, which is due, in turn, to post-extrasystolic potentiation. Nishimura R A , Carabello B A Circulation 2012;125:2138-2150

Case 4 70M evaluated for shortness of breath Admitted for inferior STEMI s/p DES to mid RCA Developed acute HF symptoms and new systolic murmur 24hrs after PCI

Large V wave

Large V wave Definition: Peak V wave > 40mmHg Peak V wave – PCWP > 10mmHg Peak V wave : PCWP > 2 Etiologies: Sudden increase of LA pressure/volume Acute MR (from ruptured chordae): 3x > normal Septal defects Hypervolemia Atrial infarction

Case 5 70M evaluated for shortness of breath Cath findings: Normal coronary arteries Normal ejection fraction

Mitral Stenosis

Mitral Stenosis Commonly measured by simultaneous LV and PCWP pressures Often overestimate the true transmitral gradient Delay in transmission of the change in pressure contour Phase shift Heart rate

Overestimate Mitral Stenosis Nishimura R A , Carabello B A Circulation 2012;125:2138-2150

Overestimate Mitral Stenosis Rogers, J. “Hemodynamics in the Cath Lab: A Forgotten Art?”

Case 6 70M evaluated for shortness of breath Lung cancer on chemo-radiation therapy Recurrent pericardial effusion

Which Tracing Requires Pericardiocentesis? B. https://thoracickey.com/5-the-atrial-waveform/

Tampondade vs Constrictive Pericarditis B. http://www.brown.edu/Courses/Bio_281-cardio/cardio/handout6c.htm

Constrictive Restrictive LV RV

Schematic representation of transvalvular and central venous flow velocities in constrictive pericarditis. During inspiration the decrease in left ventricular filling results in a leftward septal shift allowing augmented flow into the right ventricle. The opposite occurs during expiration. D = diastolic venous flow; EA = mitral inflow; HV = hepatic vein; LA = left atrium; LV = left ventricle; PV = pulmonary venous flow; RA = right atrium; RV = right ventricle; S = systolic venous flow.

Does he need ASD repair ? Case 7 70M evaluated for shortness of breath Known ASD Saturations: SVC: 68% IVC: 63% RA: 65% RV: 87% PA: 87% FA: 100% PV: 100%

LR shunt: ASD VSD PDA RV failure RL shunt: ToF Eisenmenger’s Transposition Hypoxia

Shunt Calculation Qp (Ao sat – Mv sat) (Pv sat – Pa sat) Qs Mv sat = (3 SVC + IVC) / 4 Pulm vein sat = LV O2 sat if shunt exists Qp/Qs > 2 = severe shunt = repair Qp/Qs < 1 = R  L shunt = irreversible = no repair

Qp (100% – 66.75%*) Qs (100% – 87%) SVC: 68% IVC: 63% RA: 65% RV: 87% PA: 87% FA: 100% PV: 100% 2.56 * MV sat = (3 x 68% + 63%) / 4 = 66.75%

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