1. Cath Lab Essentials: Basic Hemodynamics for the Cath Lab and ICU
Ailin Barseghian El-Farra, MD, FACC
Assistant Professor, Interventional Cardiology
University of California, Irvine
Department of Cardiology

2. First cardiac catheterization and pressure measurement performed on a living animal
English physiologist Stephen Hales
Early 1700s
“By accessing the internal jugular vein and carotid artery of a horse, Hales performed his experiments using a brass pipe as the catheter connected by a flexible goose trachea to a long glass column of fluid. The pressure in the white mare’s beating heart raised a column of fluid in the glass tube over 9 feet high.”
Reported in the book Haemastaticks in 1733; Hall WD. Clin. Cardiol. 1987:10;487-9.

3. Right Heart Catheterization

4. INDICATIONS Cause of shock Pulmonary hypertension
Guide fluid management
Left to right shunt
Pericardial tamponade vs constrictive and restrictive cardiomyopathy

5. CONTRAINDICATIONS ABSOLUTE CAUTION none pulmonary hypertension elderly
left bundle branch block

6. B C A EQUIPMENT Catheter
Fluid-filled tubing to connect the catheter to the transducer (A)
Transducer (B)
Physiologic recorder to display, analyze, store waveforms (C) B C A

7. EQUIPMENT

8. Systematic Hemodynamic Interpretation
1. Establish the zero level and balance transducer 2. Confirm the scale of the recording -40 mmHg for RHC, 200 mmHg for LHC 3. Collect hemodynamics in a systematic method using established protocols 4. Critically assess the pressure waveforms for proper fidelity 5. Carefully time pressure events with the ECG 6. Review the tracings for common artifacts

9. Components of a Right Heart Catheterization
Right atrium
Mean (1-5 mmHg)
Right ventricle
Phasic (25/5 mmHg)
Pulmonary capillary wedge
Mean (7-12 mmHg)
Pulmonary artery
Phasic and mean (25/10 mmHg; mean mmHg)
Definition of pulm htn is mean PA pressure > 25 mmHg with PCWP < 15 mmhg

10. PRECAUTIONS Always record pressures at end-expiration (unless on PEEP)
During inspiration, pressures will be lower due to decrease in intrathoracic pressure (assuming normal conditions)
Always zero and reference the system

11. Components of a Routine Complete Right- and Left-Heart Catheterization
1. Position pulmonary artery (PA) catheter. 2. Position aortic (AO) catheter. 3. Record PA and AO pressure 4. Measure thermodilution (x3) cardiac output. 5. Measure oxygen saturation in PA and AO blood samples to determine Fick output and screen for shunt. 6. Enter the left ventricle (LV) by retrograde crossing of the AO valve. 7. Advance PA catheter to pulmonary capillary wedge position (PCWP) 8. Measure simultaneous LV-PCWP (mitral valve assessment). 9. Pull back from PCWP to PA. 10. Pull back from PA to right ventricle (RV) (to screen for pulmonic stenosis) and record RV. 11. Record simultaneous LV-RV (constriction vs restriction). 12. Pull back from RV to right atrium (RA) (to screen for tricuspid stenosis) and record RA 13. Pull back from LV to AO (to screen for aortic stenosis).

12. “Once the catheter was in place, all lights in the room were turned off, and the Hamilton manometer (which focused a light on sensitive paper to record the pressure contour) was attached to the catheter and manipulated in absolute darkness so that its light output could be captured with a handheld mirror and adjusted to strike the paper. Researchers could then record intravascular pressures.”
Enson Y, Chamberlin MD. Cournand and Richards and the Bellevue Hospital Cardiopulmonary Laboratory. Columbia Magazine, Fall

13. CARDIAC CYCLE

14. Phase 1: atrial contraction Phase 2: isovolumic contraction
(TV/MV closure
to PV/AV opening)
Phase 3: rapid ejection
Phase 4: reduced ejection
(PV/AV opening to PV/AV closure)
Phase 5: isovolumic relaxation
(PV/AV closure to TV/MV opening)
Phase 6: rapid ventricular filling
Phase 7: reduced ventricular filling
(TV/MV opening to TV/MV closure)

15. PRESSURE WAVE INTERPRETATION

16. RIGHT ATRIUM

17. RIGHT VENTRICLE RV normal RV pulm HTN
PA normal – dicrotic notch (represents closure of the PV)
PA – respiratory variation
An increase in RV end-diastolic pressure is seen in many forms of cardiomyopathy, as well as in right ventricular ischemia, infarction, and cardiac constriction or tamponade.

18. PULMONARY ARTERY RV normal RV pulm HTN
PA normal – dicrotic notch (represents closure of the PV)
PA – respiratory variation
An increase in RV end-diastolic pressure is seen in many forms of cardiomyopathy, as well as in right ventricular ischemia, infarction, and cardiac constriction or tamponade.

19. PULMONARY CAPILLARY WEDGE PRESSURE

20. LEFT HEART CATHETERIZATION

21. AORTIC PRESSURE

22. LEFT VENTRICLE
Kern MJ. Right Heart Catheterization. CATHSAP II CD-ROM. Bethesda, ACC, 2001.

23. PITFALLS

25. ARTIFACTS “whip” artifacts seen in pts with hyperdynamic hearts
A- PA waveform unrecognizable
B excessive catheter whip from prominent loop in rt atrium
C removal of loop improved the appearance of waveform
D but, overshoot artifact remained
E filter resulted in further improvement in appearance of waveform

26. CARDIAC OUTPUT
Thermodilution
Fick Method

27. THERMODILUTION Bolus injection of liquid Saline Proximal port
Change in temperature is measured by thermistor in the distal portion of the catheter

28. FICK PRINCIPLE Described in 1870
Assumes rate of O2 consumption is a function of rate of blood flow times the rate of O2 pick up by the RBC
Oxygen consumption
-Direct Fick:
--Directly measured
-Indirect Fick:
--125 ml/min/m2 (avg)
--110 ml/min/m2 (elderly)
Cardiac Output
(L/min)

29. LIMITATIONS Thermodilution Fick
Not accurate in TR
Overestimated cardiac output at low output states
Oxygen consumption is often estimated by body weight (indirect method) rather than measured directly
Large errors possible with small differences in saturations and hemoglobin.
Measurements on room air

30. THANK YOU

31. Normal Pressures Site Normal Value (mmHg) Mean Pressure (mmHg)
Saturation
Right Atrium (or CVP)
0-5
75%
Right Ventricle
25/5
Pulmonary Artery
25/10
10-20
PCWP
7-12
95-100% LV
120/10
Aorta
120/80

32. Normal Values Site Value Sv02 0.60-0.75 Stroke Volume 60-100 ml/beat
Stroke Index
33-47 ml/beat/m2
Cardiac Output
4-8 L/min
Cardiac Index
L/min/m2
SVR
dynes sec/-cm5
PVR
<250 dynes sec/-cm5
MAP
mmHg

33. References
Bangalore and Bhatt. Right heart catheterization, coronary angiography and percutaneous coronary intervention. Circulation, 2011; 124: e428-e433.
Kern, Morton J. The Cardiac Catheterization Handbook. Philadelphia, PA: Saunders Elsevier, Print.
Ragosta, Michael. Textbook of Clinical Hemodynamics. Philadelphia, PA: Saunders/Elsevier, Print.