2. INTRODUCTION
• stenotic lesions start in anatomic LVOT extend upto the descending
portion of aortic arch.
• obstruction
• valvular,
• subvalvular
• Fixed
• dynamic
• supravalvular.
• impose increased afterload on LV and if severe and untreated lead
to hypertrophy, eventual dilation and failure of LV.
3. Role of cardiac catheterization in AS
What information can be obtained in AS ?
• measurement of pressure gradient
• level of stenosis
• analysis of the pressure waveforms
• estimation of valve area
• measurement of cardiac output
Discrepancy between echo findings and patient symptoms
4. Methods of measuring a transvalvular gradient in AS
1. retrograde approach
• AO catheter retrograde above AO valve, LV retrograde with pressure wire or pigtail.
• LV retrograde with pigtail, AO pressure from side arm of long sheath or femoral sheath.
• LV and AO retrograde with dual lumen pigtail
• LV retrograde with pigtail and ‘‘pullback’’ pressure from LV to AO
2. antegrade approach
• LV via transseptal, AO catheter retrograde above AO valve
5. CAVEAT: both measurement at same time with
direct measurement of aortic pressure is best
means of assessment.
METHOD EASE OF USE DISADVANTAGE
PULLBACK +++++ LEAST ACCURATE
FEMORAL SHEATH +++++ PRESSURE
AMPLIFICATION
ILIAC ARTERY STENOSIS
DOUBLE ARTERIAL
PUNCTURE
+++ EXTRA VASCULAR
ACCESS RISK
PIG TAIL- DOUBLE
LUMEN
+++ DAMPING
TRANSEPTAL ++ RISK
6.
7. Carabello Sign
rise in arterial blood pressure during left heart catheter pullback in
patients with severe aortic stenosis
Mechanism : related to partial obstruction of an already narrowed
aortic orifice by the retrograde catheter & relief of this
obstruction when the catheter is withdrawn
AVA<0.6cm2
8. Artifacts can result when a
multiple-side-hole pigtail catheter
is incompletely advanced into the
LV chamber
9. Simultaneous measurement of aortic and FA pressure demonstrating
peripheral amplification
Peripheral amplification
# increase in peak systolic pressure and pulse pressure in peripheral
arteries as compared to the central aorta
10. A. The tracings demonstrating the significant time delay for
the pressure waveform to reach the RFA.
B. Realignment using tracing paper.
11. THREE INVASIVE MEASUREMENTS
Mean gradient
• represents the area under the LV-Ao
pressure curve
• corresponds to echo mean gradient
Peak to peak gradient
• no true physiological meaning
• difference between maximum aortic
and max LV pressures
Peak instantaneous gradient
• maximum difference between LV &
aorta during systole.
• corresponds to maximum
instantaneous gradient by echo.
16. Low-Flow, Low-Gradient Aortic Stenosis
With Normal and Depressed LVEF
# Decreased EF (<40%) - Low Flow –Low Gradient AS
# Normal EF ( ≥ 50%) - Paradoxical Low Flow –Low Gradient AS
⇊ in gradient ➨ ⇊ in trans-valvular flow.
17. Low-flow, Low-Gradient severe AS with decreased LVEF
# valve area <1 cm2
# mean aortic valve gradient < 40 mm Hg
# ejection fraction <40%
# pseudo aortic stenosis ➨ medications that increase cardiac output
will usually increase the calculated AVA
# Intravenous dobutamine - 5 μg/kg/min ➔➔ 20 μg/kg/min
18. # true severe aortic stenosis
(1) a mean aortic valve gradient greater than 30 mm Hg
(2) an aortic valve area ≤ 1.2 cm2
Effects of dobutamine infusion in patients with and without valvular AS
# Pseudo severe As
Peak stress
- MG < 30 mm Hg
- EOA >1.0-1.2 cm2
- ab. in EOA> 0.3 cm2
19.
20.
21. Paradoxical Low flow –low Gradient Severe AS:
- indexed AVA < 0.6 cm2/m2
- Gradient < 40 mmHg
- EF > 50%
- Stroke volume index (SVi) : < 35 mL/m2
Paradoxical Low flow –low Gradient Severe AS:
22. Physiopathology : paradoxical LF- AS despite preserved EF
Pronounced concentric LV remodelling and smaller LV cavity size
≈ restrictive physiology
# Decrease in SV is due to deficient ventricular filling
# smaller LV cavity size
# deficient ventricular emptying
# Intrinsic myocardial dysfunction causing EF lower than expected (50-60%)
# Prevalence increases with
- older age
- female gender
- concomitant systemic HTN
23. ROLE OF CARDIAC CATHERIZATION IN TAVR
• pre TAVR evaluation
• to measure the gradient.
• for evaluation in case of
discrepancy between echo
and clinical symptoms.
• for evaluation of low flow
low gradient aortic
stenosis.
• post TAVR
• to measure the success of
procedure by measuring
residual stenosis.
• to look for complications in
form of aortic regurgitation.
24. Hypertrophic cardiomyopathy
dynamic intraventricular pressure gradient
may/ may not have systolic pressure gradient at rest
gradient - provoked with : Valsalva maneuver
: extra systole
: systemic vasodilator (amyl nitrate)
: inotropic stimulation
25.
26. HOCM : SPIKE-AND- DOME CONFIGURATION OF PULSE WAVE
dynamic outflow obstruction ➨
characteristic arterial pressure
waveform “spike-and-dome
configuration
• early spike ➨ rapid lv ejection by
the hypercontractile myocardium
• pressure dip & doming ➨ reflect
the dynamic outflow obstruction
27. Valsalva maneuver : produces a marked increase in the gradient
: change in the FA pressure waveform to a spike-and-
dome configuration.
LV and FA pressure tracings in HCM
28.
29. Brokenbrough-Braunwald-Morrow sign
Post PVC potentiation in HOCM
PVC ➨⇈in intracavitary gradient ➨⇈ed contractility (⇈ed Ca2+)
# Post PVC beat is associated with a reduction in aortic systolic
pressure and pulse pressure ≈ B-B-M sign
31. • NO OBSTRUCTION AT ONSET OF VENTRICULAR EJECTION.
• BRISK, INITIAL UPSTROKE- PEAK SYSTOLIC PRESSURE.
• OBSTRUCTION PROGRESSIVELY DURING SYSTOLE AS THE CONTRACTILE
FORCE OF THE LV BUILDS.
• WHEN OBSTRUCTION REACHES A MAXIMUM ,AORTIC PRESSURE DROPS.
32. MECHANISM
• NORMALLY AFTER A PVC, COMPENSATORY PAUSE
• DIASTOLIC FILLING TIME & DIASTOLIC VOLUME
• INCREASED STRETCH
• SV AND CONTRACTILITY (FRANK STARLING LAW)
• ARTERIAL SYSTOLIC PRESSURE TO RISE
• IN HCM PARADOXICAL DECREASE IN SV DUE INCREASED CONTRACTILITY CALCIUM LEADING
TO DECREASED ORIFICE SIZE AND INCREASED GRADIENT
• DIMINISHED PULSE PRESSURE
• REDUCED SV CAUSED BY INCREASED DYNAMIC OBSTRUCTION
33.
34. 1. Torricelli's law:
flow across a round orifice F = AV CC
F = flow rate A = orifice area
V = velocity of flow CC = coefficient of orifice contraction
GORLIN FORMULA:
2. relates pressure gradient and velocity of flow - Torricelli's law
V = velocity of flow
Cv = coefficient of velocity - correcting for energy loss as pressure energy is converted to
kinetic or velocity energy
h = pressure gradient in cm H2O
g = gravitational constant (980 cm/sec2) for converting cm H2O to units of pressure
A = F
VCC
Calculation of stenotic valve area
35. C = empirical constant accounting for CV and CC
h = mm Hg (rather than cm H2O)
GORLIN FORMULA:
C - empirical constant ( 0.85 for mitral valve, 1.0 for Aortic valve)
36. Flow (F) = is the total cardiac output expressed in terms of the seconds
per minute during which there is actually forward flow across the valve.
F= CO (ml or cm3/min)
SEP (sec/min) x HR
cm3 x min
Min x Sec
cm3 /sec
Editor's Notes
In a study published in Lancet, 22 of 101 pts (22%) had MRI abnormalities c/w acute cerebreal embolic events after crossing AV valve for AS assessment.3 of these pts (3%) had clinically apparent neurologic deficits.
n patients with AS, Carrabello’s sign is defined as a rise in peak aortic systolic pressure by greater than 5 mm Hg when a catheter is removed from theleft ventricle (Figure 8.8). This phenomenon occurs in the setting of a highlystenosed valve because the additional occlusive effect of the catheter across thevalve is enough to further decrease aortic pressure. Carrabello and colleaguesfound this sign in 15 of 20 patients with AVA < 0.6 cm2 and in none of 22patients with AVA > 0.7 cm2. (Am J Cardiol 1979;44:424)
There is a temporal delay in the peripheral pressure. There is also a pressure “overshoot”These will lead to problems with aortic valve gradient.
In an invasive hemodynamic AS study, why should the mean gradient be used instead of the peak to peak gradient?
The peak to peak gradient is not simultaneous and is therefore not physiologic.
Hakki is valid only for 60-100/min
Co estimation
Ficks – oxygen consumption
Thermodilution method- low output state, tr
Another major challenge is accurate calculation of aortic valve area in patientswith concurrent aortic regurgitation (AR). The problem lies in the numeratorof the Gorlin equation, namely, the accurate determination of flow across theaortic valve. Commonly used ways to estimate cardiac output such as Fick andthermodilution measure effective and right-sided cardiac output, respectively,and thus will underestimate the flow across the aortic valve (flow across theaortic valve = cardiac output + regurgitant volume) and thus overestimate theseverity of AS.
If there is co-existent regurgitation, the AVA will be underestimated. Therefore, if you see a pt with both AS and AR, the AVA will be underestimated
Post AVR : lower peri-operative mortality (5% v/s 32%) ( n=136)
In contrast the patients with pseudo AS will not have contractile reserve,will not significantly increase their LV–aortic pressure gradient, and will oftenhave an increase in calculated aortic valve area with dobutamine. These latterpatients typically have myocardial disease as their primary lesion and “incidental” AS. They do not respond favorably to aortic valve replacement
Poor prognosis if treated medically rather than treated surgically