1. Valvular Hemodynamics Morton J. Kern, MD Professor of Medicine Chief of Cardiology Associate Chief Cardiology University California Irvine Orange, California

2. Hemodynamic Problems for the Cath Lab Valvular heart disease: Aortic stenosis/insufficiency Mitral stenosis/insufficiency Intraventricular gradients Pericardial effusion/tamponade Constrictive/restrictive physiology Coronary Hemodynamics Intracardiac Shunts

3. Tri/MV valves open Pa/Ao valves are closed Pa/Ao valves open Tri/MV valves close Pa/Ao valves close Tri/MV valves open systole =Valve action

4. BAMC Case #3117: Patient: 61 yo male Dx: 3V CAD filter: 50 Hz/ sample 250 Hz Pre Contrast Normal LV and Aortic Pressure Fluid-filled system micromanometer transducers Fluid filled, FA sheath

5. Normal aortic valve Congenital bicuspid aortic stenosis Aortic Stenosis

6. Mechanism of AS: LV-Ao Gradient Consequences of LV-Ao Gradient: 1.late peaking Systolic murmur 2.Single A2 3.Slow pulse upstroke

7. LV Fusmann and Feldman T, Cath and CV Int 53:553;2001 Hemodynamics of AS Peak to peak pressure gradients differ between ECHO and CATH Peak instantaneous P-P Unshifted=larger Grad

11. Parham and Kern, Cath and CV Int 53:553;2001 Retrograde hemodynamic Assessment of Prosthetic Valves with a Pressure Wire

12. Low Gradient AS. EF 25%, no CAD. Valve replacement? P-P gradient 30mmHg CO = 3.2l/m Fick AVA = 0.7cm 2

13. Base 10 Dob+Pace 8020 Dob + Pace 95 Dobutamine challenge for LG AS P-P = 50mmHg CO = 4.2l/m AVA = 0.6cm 2

14. Grayburn, P. A. Circulation 2006;113:604-606 What should you do with Symptomatic AS patient, low gradient, low flow? The Dobutamine Challenge AVA = 0.7cm 2 AVA = 1.0cm 2 AVA = 1.5cm 2 Fixed area

17. AVP after 20 x 60mm Balloon. What happened? AS+AI

18. Hemodynamics of Aortic Insufficiency Greatest Diastolic Gradient early Volume filling LV is rapid LVEDP will be high unless compensated

21. Normal LA and LV diastolic pressures LA-LV Diastolic Gradient

26. Pressure Waves are related Chamber compliance (p/v)

27. Hemodynamics for the Cath Lab Low Gradient AS Complications of AVP – AI AS vs. HOCM Mitral Regurgitation after MVP for MS Diastolic CHF – constrictive v Restrictive Tamponade Intracardiac Shunts