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

2. Disclosures
None

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

4. 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

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

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

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

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

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

10. 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)

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

12. 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

13. AoV Area Formula
Gorlin Formula: Hakki Formula

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

15. 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:

16. Dobutamine Challenge
Base Dob+Pace Dob + Pace 95

17. S/p Aortic valvuloplasty … What happened?AR

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

19. Aortic Stenosis?

20. Still Aortic Stenosis?
Distal LV
Sub-Aortic

21. Spike & Dome

22. 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:

23. Brockenbrough-Braunwald-Morrow SignAS
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:

24. 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

25. Large V wave

26. 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

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

28. Mitral Stenosis

29. 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

30. Overestimate Mitral Stenosis
Nishimura R A , Carabello B A Circulation 2012;125:

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

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

33. Which Tracing Requires Pericardiocentesis?B.

34. Tampondade vs Constrictive PericarditisB.

35. Constrictive
Restrictive LV RV

36. 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.

37. 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%

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

39. 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

40. 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%

41. Questions & Comments
THANK YOU