how to best monitor right x and left ventricular function · 2019-11-21 · how to best monitor...
TRANSCRIPT
![Page 1: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/1.jpg)
How to Best Monitor Right and Left Ventricular Function
Saul Flores, MD, FAAP, FACCCardiac Intensivist and CardiologistTexas Children’s Hospital/Baylor College of MedicinePediatric Critical Care Summit of the Americas11/09/19
X
![Page 2: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/2.jpg)
Page 1
xxx00.#####.ppt 11/12/2019 2:35:26 PM
Disclosures•None
![Page 3: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/3.jpg)
Page 2
xxx00.#####.ppt 11/12/2019 2:35:26 PM
Learning Objectives•Review ventricular function assessment
•Apply technology for the assessment of ventricular function
•Apply principles of hemodynamic assessment of ventricular function
![Page 4: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/4.jpg)
Page 3
xxx00.#####.ppt 11/12/2019 2:35:27 PM
Sample Case•14 year old teenager comes to the ED with severe respiratory distress. Describes symptoms for las 7 days that worsened overnight. Patient has had a runny nose and also noticed that ”whole” body appears swollen. Initial vital signs demonstrate HR 130 bpm, RR 35 bpm, BP 88/35 48, O2Sat 93% on RA and temp 102 F. Initial CXR demonstrates diffuse bl alveolar infiltrates and cardiomegaly.
•What is the best next step in the management of this patient?
![Page 5: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/5.jpg)
Physiological Assessment of the Right Ventricle
![Page 6: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/6.jpg)
Page 5
xxx00.#####.ppt 11/12/2019 2:35:28 PM
Cardiac Performance•Pre load
•After load
•Contractile function
•Heart rhythm
•Ventricular interdependence
![Page 7: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/7.jpg)
Page 6
xxx00.#####.ppt 11/12/2019 2:35:28 PM
Pre Load•Filling of RV
‐ RV filling normally starts before and finishes after LV
‐ RV isovolumic relaxation time is shorter
‐ RV filling velocities (E and A) and the E/A ratio are lower
•RV can accommodate varying degrees of pre load while maintaining a stable cardiac output and normal filling pressures
•Two characteristics of RV:‐ Distensibility of its free wall
‐ Compliance-the ability to increase volume without significant changes in the wall surface area
![Page 8: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/8.jpg)
Page 7
xxx00.#####.ppt 11/12/2019 2:35:28 PM
Pre Load/Filling of RV•Dilation of the RV caused by volume overload is usually well tolerated
•However, two consequences lead to symptoms:‐Functional tricuspid regurgitation
‐Compression of LV by mechanism of ventricular interdependence – decreased cardiac output
![Page 9: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/9.jpg)
Page 8
xxx00.#####.ppt 11/12/2019 2:35:29 PM
After Load•Normal after load is minimal – low impedance, highly distensible pulmonary vascular system
•PVR is the most commonly used index of afterload, but may not reflect the complex nature of ventricular afterload
•Several factors modulate PVR, including:‐ Hypoxia
‐ Hypercarbia
‐ Cardiac output
‐ Pulmonary volume and pressure
‐ Specific molecular pathways: Nitric oxide, prostaglandin, endothelin
![Page 10: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/10.jpg)
Page 9
xxx00.#####.ppt 11/12/2019 2:35:29 PM
Ferguson, CCM 2008
![Page 11: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/11.jpg)
Page 10
xxx00.#####.ppt 11/12/2019 2:35:30 PM
Compared with the LV, the RV demonstrates a heightened sensitivity to afterload changes
![Page 12: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/12.jpg)
Page 11
xxx00.#####.ppt 11/12/2019 2:35:31 PM
RV Contraction•RV consist of:
‐ The superficial oblique myocardial fibers, in continuity with the LV fibers
‐ Deeper layer of longitudinally arranged
•LV has additional middle transverse fibers
•RV contraction begins at the inflow region and progresses toward the outflow tract (likened to a bellows)
•In distinction, the LV contracts by squeezing motion (likened a wringing a towel) from the LV apex to the outflow tract
![Page 13: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/13.jpg)
Page 12
xxx00.#####.ppt 11/12/2019 2:35:31 PM
Smith, API 1992
![Page 14: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/14.jpg)
Page 13
xxx00.#####.ppt 11/12/2019 2:35:32 PM
RV Pressure Volume Loop
• External mechanical work is lower in the RV
• RV pressure begins to decline before closure of the pulmonic valve- RV continues to eject blood because of high compliance and low resistance of the pulmonary vasculature
Dell’Italia, CCM 2002
![Page 15: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/15.jpg)
Page 14
xxx00.#####.ppt 11/12/2019 2:35:33 PM
RV Elastance
• Maximal RV elastance better reflects RV contractility than does the end-systolic elastance
• The normal maximal RV elastance is 1.3 +/-0.84 mmHg
Dell’Italia, CCM 2002
![Page 16: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/16.jpg)
Page 15
xxx00.#####.ppt 11/12/2019 2:35:33 PM
RV Pressure Tracing•RV pressure are lower than LV pressures
•Show early peaking and a rapidly decline in contrast to the rounded contour of LV pressure tracing
•RV isovolumic contraction time is shorter because RV systolic pressure rapidly exceeds the low pulmonary artery diastolic pressure
•End-systolic flow may continue in the presence of a negative ventricular-arterial pressure gradient (hangout interval)
![Page 17: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/17.jpg)
Page 16
xxx00.#####.ppt 11/12/2019 2:35:34 PM
Sinus Rhythm•Maintenance of sinus rhythm and AV synchrony is especially important in the presence of RV dysfunction
![Page 18: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/18.jpg)
Page 17
xxx00.#####.ppt 11/12/2019 2:35:34 PM
Ventricular Interdependence• The size, shape, and compliance of a ventricle may affect size, shape, and pressure-volume relationship of the other ventricle through direct mechanical interaction
• Systolic – mainly through the interventicular septum & continuity of muscle fibers
• Diastolic – mainly through the pericardium
Smith, API 2008
![Page 19: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/19.jpg)
Page 18
xxx00.#####.ppt 11/12/2019 2:35:35 PM
Acute RV pressure or volume overload states
Dilation of the RV
Shift of IVS towards LV
Alter LV geometry & increases pericardial constraint
LV diastolic pressure-volume curve shifts upward (decrease distensibility), decreased LV preload, an increased LV end-
diastolic pressure
Low cardiac output
![Page 20: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/20.jpg)
Page 19
xxx00.#####.ppt 11/12/2019 2:35:35 PM
Summary•Thin walled, more complaint, higher ED volumes
•Equal cardiac output at less energy expenditure
•Ejects equal amount of blood at lower RVEF
•Tolerates volume overload better
•More efficient work output
•Pre load and after load sensitive
•Ventricular interdependence
![Page 21: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/21.jpg)
Page 20
xxx00.#####.ppt 11/12/2019 2:35:36 PM
Evaluation of Right Ventricle•Chest X ray
•Echocardiogram
•Hemodynamic assessment
•Cardiac MRI
•Other studies
![Page 22: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/22.jpg)
Page 21
xxx00.#####.ppt 11/12/2019 2:35:36 PM
Chest X Ray
•Reasonable sensitivity but poor specificity
![Page 23: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/23.jpg)
Page 22
xxx00.#####.ppt 11/12/2019 2:35:37 PM
Echocardiogram
![Page 24: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/24.jpg)
Page 23
xxx00.#####.ppt 11/12/2019 2:35:37 PM
![Page 25: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/25.jpg)
Page 24
xxx00.#####.ppt 11/12/2019 2:35:38 PM
![Page 26: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/26.jpg)
Page 25
xxx00.#####.ppt 11/12/2019 2:35:39 PM
Ferguson, CCM 2008
![Page 27: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/27.jpg)
Page 26
xxx00.#####.ppt 11/12/2019 2:35:39 PM
![Page 28: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/28.jpg)
Page 27
xxx00.#####.ppt 11/12/2019 2:35:40 PM
5mm = 20% RVEF10mm = 30%15mm = 40%20mm = 50%
![Page 29: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/29.jpg)
Page 28
xxx00.#####.ppt 11/12/2019 2:35:40 PM
![Page 30: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/30.jpg)
Page 29
xxx00.#####.ppt 11/12/2019 2:35:41 PM
Volume assessmentCollapsibilityDistensibility
Fergurson, JASE 2008
![Page 31: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/31.jpg)
Page 30
xxx00.#####.ppt 11/12/2019 2:35:42 PM
![Page 32: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/32.jpg)
Page 31
xxx00.#####.ppt 11/12/2019 2:35:42 PM
Smith, API 2006
![Page 33: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/33.jpg)
Page 32
xxx00.#####.ppt 11/12/2019 2:35:43 PM
Myocardial Performance Index
Tei, JASE 2002
![Page 34: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/34.jpg)
Page 33
xxx00.#####.ppt 11/12/2019 2:35:43 PM
Strain Imaging and Speckle Tracking
McDermott, CMR 2008
![Page 35: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/35.jpg)
Cardinal Saturations
![Page 36: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/36.jpg)
Page 35
xxx00.#####.ppt 11/12/2019 2:35:44 PM
Cardinal Saturations•Pulmonary arterial = 67-86% mean 77%
•Pulmonary venous = >95%
•Systemic Arterial = >95%, except IAA, TGA + PAH
•Systemic venous = Used to infer potential shunting
![Page 37: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/37.jpg)
Page 36
xxx00.#####.ppt 11/12/2019 2:35:45 PM
Oximetric Detection of Shunts in ChildrenChamber sampled Minimum difference Multiple samples
SVC – RA 9% 7%
RA ‐ RV 5% 4%
RV ‐ PA 6% 4%
![Page 38: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/38.jpg)
Page 37
xxx00.#####.ppt 11/12/2019 2:35:45 PM
Hemodynamic Assessment•General rules
•Description of cardinal saturations
•Description of pressure measurements
•Overview of cardiac ouput measurement
•Description of vascular resistance
![Page 39: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/39.jpg)
Page 38
xxx00.#####.ppt 11/12/2019 2:35:46 PM
RA Pressure•Normals:
‐ a, c, v Waves
‐ a wave < 8 mmHg
‐ v wave < 7 mmHg
‐ Mean < 6 mmHg
•a wave = atrial systole; first wave after P
•c wave = early V systole transmitted through AV valve
•v wave – end of systole – continued atrial filling against closed TV
![Page 40: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/40.jpg)
Page 39
xxx00.#####.ppt 11/12/2019 2:35:46 PM
RA Pressure•Increased a Wave
‐Ventricular hypertrophy
‐Atrial hypertrophy
•Increased v Wave‐Dilated RA
‐Large ASD
‐Severe TR
![Page 41: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/41.jpg)
Page 40
xxx00.#####.ppt 11/12/2019 2:35:47 PM
RA wave form
Smith, API 1992
![Page 42: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/42.jpg)
Page 41
xxx00.#####.ppt 11/12/2019 2:35:47 PM
Cannon “a” wave
Carter, JACC 2006
![Page 43: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/43.jpg)
Page 42
xxx00.#####.ppt 11/12/2019 2:35:48 PM
RV Pressure•Normals:
‐15-30 / 5-8 mmHg
•Increased‐PS, PAH, VSD
•Increased RVEDP‐RV Failure
‐Decreased compliance
‐Hypertrophy
![Page 44: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/44.jpg)
Page 43
xxx00.#####.ppt 11/12/2019 2:35:48 PM
RV Pressure Waveform
Smith, API 1992
![Page 45: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/45.jpg)
Page 44
xxx00.#####.ppt 11/12/2019 2:35:49 PM
Pulmonary Pressures•Normals:
‐ 15-25 / 8-12 mmHg
• Increased ‐ L -> R shunt
•VSD, PDA
‐ Pulmonary venous return resistance
•Obstructed veins: congenital or post-op
•Mitral disease: stenosis or severe regurgitation
•Elevated LVEDP
‐ Thromboemboli
•PVOD -> Eisenmenger physiology
•Primary pulmonary hypertension
![Page 46: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/46.jpg)
Page 45
xxx00.#####.ppt 11/12/2019 2:35:49 PM
Pressure Measurements Ventricles
Pierre,Circ 2004
![Page 47: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/47.jpg)
Cardiac Output Measurement
![Page 48: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/48.jpg)
Page 47
xxx00.#####.ppt 11/12/2019 2:35:50 PM
Methods of Cardiac Output Measurement
•Fick principle
•Thermodilution
•Dye dilution curves
![Page 49: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/49.jpg)
Vascular Resistance Measurement
![Page 50: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/50.jpg)
Page 49
xxx00.#####.ppt 11/12/2019 2:35:51 PM
Vascular Resistance•Poiseuille’s Law
![Page 51: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/51.jpg)
Page 50
xxx00.#####.ppt 11/12/2019 2:35:51 PM
Resistance•Resistance = Drop in pressure across a vascular bed/Volume of blood flowing through the vessels
•Vascular Resistance = Mean arterial – mean venous pressure/Flow
•PVR = Mean PAP – Mean PVP/Qp
•Wood unit = mmHg/L/min = mmHg x min/L
•Indexed for BSA = Wood U x m2
![Page 52: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/52.jpg)
Page 51
xxx00.#####.ppt 11/12/2019 2:35:51 PM
Pulmonary Vascular Resistance•Rp = Mean PA - Mean PV / Qp
•Normal PVR:‐First week life = 8-10 U x m2
‐ Infants and children = 1-3 U x m2
•Measurement unreliable if:‐Discontinuous or stenotic PA’s
‐Ao-PA shunt: differential flow to each lung
‐Multiple sources of Qp with different O2 sats
![Page 53: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/53.jpg)
Page 52
xxx00.#####.ppt 11/12/2019 2:35:52 PM
Summary•The importance of clear understanding of ventricular mechanics
•Exposure to current and novel technologies for ventricular function assessment
•Clear hemodynamic assessment of ventricular function
![Page 54: How to Best Monitor Right X and Left Ventricular Function · 2019-11-21 · How to Best Monitor Right and Left Ventricular Function. Saul Flores, MD, FAAP, FACC. Cardiac Intensivist](https://reader030.vdocument.in/reader030/viewer/2022040510/5e57693ab15d69723854e200/html5/thumbnails/54.jpg)
Page 53
xxx00.#####.ppt 11/12/2019 2:35:52 PM