9. PA systolic pressure = RV systolic pressure
mean PCWP = PA diastolic pressure (+5)
Mean PCWP = LVEDP
RVEDP = RA pressure
PCWP>RA pressure
LVEDP>RVEDP
Pressure
equalize in
CP, RVF, RCMP9
Atrial Ventricular Arterial
10. TP
V A
Two peaks/ QRS
v=T; a=P
PCWP: v>a; CVP: a>v (ASD a=v)
rises in diastole
falls in systole
end expiration (on ventillation: substract half of PEEP) 10
12. 12
LA
LV
RA
RV
PA
TR: ventricularization
RAP = RVEDP
13. 13
LA
LV
RA
RV
PA
MR: tall v
Severe PAH mPCWP = dPAP
14. Tall V
V>mean PCWP+10
decompensated LVF
Severe MR (early diastole slow downslope)
Severe MS (early diastole sharp downslope)
A=P, V=T (PA peaks before T)
V-V horizontal (downsloping)
No dicrotic notch
PV sat >95%, PA sat 75%
Mean PCWP = diast PA pr (+5) < PASP
PC-PA hybrid pressure
14
16. LVEDP
A bump
Diastolic slope
LVEDP normal/ low in MS
LVEDP high in CP, AR, LVDD
Absent A bump in MS, AF
Prominent in HOCM, LVDD
LVEDP = mPCWP
Except
1. MS
2. MR
3. PAH
16
Flat slope in chronic ARSharp slope in acute AR
17. LA 95% RA 75%
LV 95% RV 75%
AO 95% PA 75%
SVO2/ MVO2
SVC 74%
SCVO2
IVC 78%
PV 98%
Normal: SVO2> SCVO2
In shock relation reverses
MVO2 sat< 65%
Low CO 17
18. Chambers Step up D/D
SVC/IVC to RA >= 7% OS ASD, TAPVC, RSOV, CMF to RA
RA to RV >= 5% VSD, OP ASD, CMF to RV
RV to PA >= 5% PDA, APW
SVC to PA >= 8% L-R shunt
RA to PA >= 6% L-R shunt
PV to arterial SO2 >5% R-L shunt
MVO2
= O2 saturation in chamber proximal to shunt
= ASD: 3SVC+1IVC/4 (=SVC O2)
= VSD: RA SO2
= PDA: RV SO2
18
20. Fick
Gold standard
True Fick
O2 challenge
Not accurate in
- Low output state
- Shunt
- Regurgitation lesion
Thermodilution
SV = CO/ HR CI = CO/ BSA SVI = SV/ BSA = CI/ HR 20
21. SVR
N: 0.5-1 woods unit
High in PAH
- <3: passive PAH
- 3-5: mixed PAH
- >5: reactive PAH
• In shunt: Qp
PVR
MAP = 1SBP+2DBP/3
N: <700 dyn cm /sec5
Low SVR in septic shock
High SVR in ionotrps
W (mmHg/ L/min) = 80 dyn cm /sec5 21
26. MVA in MS
AF: 10 sec…X6 (avg over 10 beats)
Hakki area = CO/√PG
Mean grad in MS, peak instantaneous grad in AS
not validated for tachycardia or bradycardia
AVA in AS
Peak to
peak PG
= mean PG
mean PG
= 70% of Peak
instantaneous
PG
26
Area α Q
Gradient α Q2
A = Q/ √PG
Area α 1/ √PG
28. AS HOCM
Always rule out error in zeroing
Peripheral artery
-Pressure elevated
-No dicrotic notch
- delayed
28
29. Vena Contracta
(Ao pr lesser)
Aortic root<3cm
Pressure reco ery
Echo gradient
Higher
AVA less
In aortic root<3cm
catheter gradient accurate
Downstream to valve
(Ao pr higher)
HTN, LVDD
catheter gradient
Lower
AVA high
HTN, LVDD
Echo gradient accurate
29
Area
= Q/ √PG
LV load
SBP+PG/ SVI
= SBP+PG/ CI (ml) X HR
(> 4.5 abnormal)
30. 30
EF 55% CO4 CI 2 HR 80 SBP 178 mPG22
EF 55% CO4 CI 2 HR 80 SBP 138 mPG42
total LV load 8
total LV load 4.51 week
True severe AS
32. 32
Gradient α Q2
EF <40%EF >40%
low volume status
RAP, LVEDP low
fluid load - gradient rises
uncontrolled HTN
total LV load>4.5
control HTN- gradient rises
severe MS or MR
low forward flow
PCWP>15
Pseudosevere AS
True severe AS
DCM+ AS
Dobutamine
stress test
fluid load
RAP, LVEDP low
33. 33
True severe
AS
Pseudosevere
AS
DCM+AS
SV increase >20% >20% <20%
PG increase >50% (>40) <50% (<40) <50% (<40)
AVA increase <0.3 (<1.2) >0.3 (>1.2) >0.3 (>1.2)
PG ++++
Area +
PG +
Area ++++
True
severe AS
Pseudo
severe AS
43. Acute AR Chronic
compensated AR
Chronic
decompensated AR
LV vol Normal Increased Increased
EF (SV) Normal Very high Falls
LVEDP Steep Rise Normal to high Flat rise
LV-LA gradient
(end of diastole)
Present
(Austin Flint murmer)
No No
Pulse pressure Normal Wide Wide
Q = 2 X CO (severe AR)
Area= Q/ √PG= 2CO/ √PG
Otherwise Gorlin AVA falsely low
43
Severe AR
- L/O dicrotic notch
- LVEDP = DBP
- Q = 2CO
- LVEDP elevated
- Flat rise of LVEDP
44. 44
EF 15%
LVEDD 75
CO 3.6
mPG 31
AVA 0.65
Area
= Q/ √PG
= 2CO/ √PG
= 1.3 cm2
chronic severe decompensated AR
L/O dicrotic notch
45. 45
Acute severe AR
chronic compensated AR
chronic decompensated AR
46. -Severe PAH
- large V wave
-High PCWP (>25)
- mitral prosthesis
Mild MS + Stress test (2/3)
- Gradient >15
- mPAP>60
- PCWP>25
Low PG
Low MVA
High PG
High MVA
MVA = 220/ PHT
-Impaired LV compliance
- severe AR
High gradient
Low MVA
46
50. Acute MR Chronic
compensated MR
Chronic decompensated
MR
v 3 x mPCWP Normal High
PCWP High Normal High (>10 + mean PCWP)
LV vol Normal High High
EF High High Lower
50
Q = 2 X CO (severe MR)
Q = 1.5 X CO (moderate MR)
Gorlin MVA false low
53. Chamber pressures are high & equalises in early diastole
M or W pattern RA pr = mPCWP LVEDP = RVEDP
Square root
(dip & plateu)
D/D
RVF
RCMP
RVEDP > LVEDP +5
PA pressure high
Better seen
in volume loading 53
54. Ventricular interdependance
Discordant systolic peak
CP
Concordant systolic peak
RCMP , RVF
Better seen in low
volume status
Also in COPD
RVEDP rises in inspiration
but not >LVEDP
RVEDP rises in inspiration
>LVEDP
54
55. Dissociation of intracardiac / intrathorasic pressure
>5
RAP does not decrease in
inspiration (kussmaul’s sign)
D/D COPD
Inspiration
Lack of transmission of
-ve intrathorasic pressure to LV
RV is sucked by LV
55
58. Tamponade Constriction
Early diastole
Later part of diastole
Compressed
Compressed (no Y)
Expands
Constrained (y)
Elevation & equalization of pressure + +
Dissociation of
intracardiac / intrathorasic pressure
- +
RAP Deep x flat y Deep x deep y
Early diastolic dip Abesnt Present
RAP decreases in inspiration Yes No
Kussmaul’s sign in JVP - +
Ventricular interdependance + (RV pushes LV) + (RV sucked by LV)
CO Low Maintained
Pulsus paradoxus
(Inspiratory decrease of SBP> 10 mmHg)
Present Absent usually
58
Pulsus paradoxus absent in
1. ASD
2. AR
59. Post capillary Pre capillary
Prevalence Common Less common
Mechanism Passive Reactive
Causes Mitral valve disease
LVF
Vascular dis (ASD, SSC)
Chr thromboembolism
Lung disease
Eisenmengers
PCWP >15 <15 (may be high)
Diast PA pr <5+ PCWP >5+ PCWP
PVR <3 >5
Transpulmonary gradient <12 >12
Chronic PAH
-PAP may be normal
-PVR>5
- >50 mmHg
59
Rule out shunt
Vasoreactivity
61. Positive when
- mean PAP drops by >10 (to a value<40)
- PVR drops by >20% (to a value <5)
- PCWP <15
-Role of CCB
- safety of CCB
- long term prognosis
- shunt reversibility
61
62. 62
CO 4
CI 1.9
mPCWP= 15
PVR = 55 – 15/ 4 = 10
mPAP – PCWP = 40
dPAP> mPCWP+5
SVC/IVC/PA 58/62/58 (5%): no o2 step up: no L-R shunt
Vasoreactivity test negative
63. Pulmonary embolism Cardiac tamponade
CVP High (>PCWP) High (=PCWP)
PAP High N
<700
Fluid response: leg rising
-CO increase by >10%
- IVC diameter >12mm
- pulse pressure >9%
Fluid challenge
Risky if PCWP>15
63
Mean BP<80
Dicrotic pulse
high PCWP (A)
High RAP
SVR >700
CI<2.2
PA sat <65%
SVO2< SCVO2
Septic
64. 64
CO 8; CI 3.3
PA o2sat 53%
SPO2 93%
Hb 11
High filling pressure
Dicrotic pulse
Normal CI
Low SVR
SVO2 53%
SVC SO2 63%
Cardiogenic shock on ionotrops
Septic shock
65. Normal and abnormals
Traces & relations
Shunt / o2 challenge/ resistance
Grdaient –area mismatch of severe AS
AS/ HOCM/ CoA
Severe MS/ stress test
Compensated/ decompensated AR/MR
RVF/ LVF
Contriction/ RVF/ tamponade
Passive/ reactive PAH/ vasoreactivity
Shock
65
Objective findings
Hemodynamics in paper
Decision making
At the cost of invasive procedure
Swan ganj cathter was first to be introduced for hemodynamic monitoring
Transducers transforms pressure signas to electrical signals
Importance of equalization of pressure to atmosphere to get a proper curve
Wiggers diagram
Once thought to be the best way to decipher hemodynamics
Understanding science is easier than understanding philosophy
Abnormal is more attractive and romantic than the naïve normal
Abnormal values
Normal relations
Equality
Inequals get equal (eisenmenger/ CP)// equal get inequal is a problem
Inequality
Pericardial pressure is measured by RAP
In CP, LVEDP is elevated..but if RAP is substacted..true transmural pressure will be obtained..and that wl be low due to low filling
Hakki area lesser than gorlin area
Hakki area: not validated for tachycardia or bradycardia
Hakki area: angel’s correction: <75 in MS, >90 in AS, multiply with 1.35
Hakki area: Mean grad in MS, peak instantaneous grad in AS
But not free of fallacies
Exams/ quiz
Mathemetical
Composite data f clin findings/ echo/ ecg
