1. HEMODYNAMIC ASSESSMENT: CARDIAC CATHETERIZATION LABORATORY
William Hellenbrand MD
Director, Pediatric Cardiology
Morgan Stanley Children’s Hospital of New York - Presbyterian
Columbia University Medical Center
Komansky Center for Children’s Health
Cornell University Medical Center

2. CARDIAC CATHETERIZATION
Cardiac output
Shunt & Resistance
Oxygen transport
Pressure-Volume loops

3. FICK PRINCIPLE
The amount of flow through an organ or any circuit may be determined if
1 - that organ consumes or secrets a given substance
2 - the concentration of that substance can be measured as it enters and leaves the organ
3 - The total amount of the substance consumed or secreted can be measured per unit time
∆S/∆t
C2S – C1S

4. FICK PRINCIPLE

5. OXYGEN IN BLOOD When oxygen is exposed to blood it exists in 2 forms
Bound to hemoglobin
Each gram of Hgb is capable of binding 1.36 ml O2.
Therefore if the Hgb is 15 gm/100ml then the maximal amount of oxygen(Capacity) that can be taken up by Hgb is 20.4 ml/100ml(Vol%)

6. OXYGEN IN BLOOD
When oxygen is exposed to blood it exists in 2 forms(cont)
In solution in plasma –
At body temperature of 370 , there is ml of O2 per one ml of plasma at a partial pressure of oxygen of 1 mm Hg(1 torr)
Thus the solubility coefficient of oxygen in plasma is ml/ml/mm Hg
Therefore the amount of dissolved oxygen in plasma is equal to .003(PO2)

7. OXYGEN IN BLOOD
Oxygen capacity = Hgb(gm/100ml)*1.36 ml O2/gm = ml O2/100ml (Vol%)
Oxygen saturation = proportion of O2 actually combined with hemoglobin to the total capacity
Oxygen content = Capacity*Saturation *PO2
= ml/100ml (Vol%)

8. OXYGEN CONSUMPTION VO2 = VIFIO2 - VEFEO2
If RER is 1 then VI = VE and all you need to measure is VEFEO2
RER = VCO2 / VO2
RER is close to 1 with carbohydrate metabolism
RER may be as low as 0.7 with mostly fat metabolism
Standard nomograms assume RER of 0.9

9. Oxygen Consumption

10. CARDIAC OUTPUT SYSTEMIC BLOOD FLOW
Qp = VO2
CpvO2 - CpaO2
Qs = VO2
CaoO2 - CmvO2
If there is no shunt Qp = Qs

11. SHUNT CALCULATIONS Qs = VO2 CaoO2 - CmvO2 Qp = VO2 CpvO2 - CpaO2
Qep = VO2
CpvO2 - CmvO2

12. SHUNT CALCULATIONS SIMPLE SHUNT BIDIRECTIONAL SHUNT Ql-r = Qp - Qs
Qr-l = Qs - Qp
BIDIRECTIONAL SHUNT
Ql-r = Qp - Qep
Qr-l = Qs - Qep

25. RESISTANCE TO FLOW Q Q = ∆Pπr4 1 = 8nl R πr4 8nl R = ∆P
Poiseuille equation
Q = ∆Pπr = nl R
∆P = pressure drop
r = radius Q = ∆P
n = viscosity R
l = length of tube
πr4
8nl
R = ∆P Q

26. RESISTANCE
SVR = AO(MEAN) - RA(MEAN) Qs
PVR = PA(MEAN) - LA(MEAN) Qp

27. SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q X OXYGEN CONTENT
SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)]

28. SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)]
Anemic Hypoxia:  Hgb SOT 
Acute compensation  Q SOT 
Chronic compensation  Hgb SOT 

29. SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)]
Hypoxic Hypoxia:  02 SAT SOT 
Acute compensation  Q SOT 
Chronic compensation Hgb,  Q SOT 

30. SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)]
Stagnant Hypoxia:  Q SOT 
(Low Cardiac Output)
Compensation  Hgb,  02 SAT SOT 

31. VSD
80/50
M=65 95
80/40
M=60 80 70 80
M=8
M=6 70
80/6 85

32. VSD Room Air Hgb = 10.0 Vol% V02 = 150 ml/min/m2 Saturations Pressures
Svc = 70
Ra = 70
Rv = 85
Pa = 80
Ao = 95
Pressures
Ra = 6(mean)
Rv = 80/6
Pa = 80/40 60(mean)
La = 8(mean)
Ao = 80/50 65(mean)

33. VSD Room Air S(a-v)02 difference = 3.4
Capacity = 1.36*10 = 13.6
Contents =
Ao =13.6*.95=12.9
Mv = 13.6*.70=9.5
Pa = 13.6*.80=10.9
Pv = 13.6*.95=12.9
S(a-v)02 difference = 3.4
P(a-v)02 difference = 2.0
Qp = 150/2.0
= 7.5 l/min/m2
Qs = 150/3.4
= l/min/m2
Ql-r = =3.1
Qp/Qs = 7.5/4.4=1.7
PVR =(60-8)/7.5 =6.9
SVR =(65-6)/4.4=13.4

34. VSD fI02 = 1.0 Hgb = 10.0 Vol% V02 = 150 ml/min/m2 Saturations
Svc = 75 (45)
Ra = 80
Rv = 94
Pa = 95 (85)
Ao = 100 (600)
Pressures
Ra = 6(mean)
Rv = 80/6
Pa = 80/40 60(mean)
La = 8(mean)
Ao = 80/50 65(mean)

35. VSD fI02 = 1.0(PO2 not included)
Capacity = 1.36*10 = 13.6
Contents =
Ao =13.6*1.0=13.6
Mv = 13.6*.75=10.2
Pa = 13.6*.95=12.9
Pv = 13.6*1.0=13.6
S(a-v)02 difference = 3.4
P(a-v)02 difference = 0.7
Qp = 150/0.7
= 21.4 l/min/m2
Qs = 150/3.4
= 4.4 l/min/m2
Ql-r = =17.0
Qp/Qs =21.4/4.4=>4/1
PVR =(60-8)/21.4 =2.4
SVR =(65-6)/4.4=13.4

36. VSD fI02 = 1.0(PO2 included) S(a-v)02 difference = 5.0
Capacity = 1.36*10 = 13.6
Contents =
Ao =13.6* =15.4
Mv = 13.6* =10.4
Pa = 13.6* =13.2
Pv = 13.6* =15.4
S(a-v)02 difference = 5.0
P(a-v)02 difference = 2.2
Qp = 150/2.2
= 6.8 l/min/m2
Qs = 150/5.0
= l/min/m2
Ql-r = =3.8
Qp/Qs = 6.8/3.0=2.3
PVR =(60-8)/6.8 =7.6
SVR =(65-6)/3.0=20.0

37. VSD P02 not included Qp = 150/0.7 = 21.4 l/min/m2 Qs = 150/3.4
Ql-r = =17.0
Qp/Qs =21.4/4.4=>4/1
PVR =(60-8)/21.4 =2.4
SVR =(65-6)/4.4=13.4
P02 included
Qp = 150/2.2
= 6.8 l/min/m2
Qs = 150/5.0
= l/min/m2
Ql-r = =3.8
Qp/Qs = 6.8/3.0=2.3
PVR =(60-8)/6.8 =7.6
SVR =(65-6)/3.0=20.0

38. VALVE AREA CALCULATION

39. VALVE AREA CALCULATION

40. VALVE AREA CALCULATION

41. OXYGEN DISSOCIATION CURVE

42. OXYGEN DISSOCIATION CURVE

43. OXYGEN DISSOCIATION CURVE

44. PRESSURE-VOLUME LOOPS

45. P-V LOOPS

46. P-V LOOPS Pump Failure

47. P-V LOOPS Pump Failure

48. P-V LOOPS