1

Dr. Dibbendhu Khanra, SR2

Interpretation of hemodynamics

data

2

The lost world

3

The wind of change

4

Tools of the trade

5

Numbers

Formulas

Graphs

Relations

ABC of interpretation

6

The systole & the diastole

7

The normals

8

The abnormals

PP>60

RVF

PAH

Impaired LV

compliance

Impaired LA

complianceMR

ARLow SVR

High output states

CI <2.2Cardiogenic

shock

>8

>8

= =>

>

= dPAP

RVSP= sPAPLVSP= SBP >

= pericardial pressure

9

Relations

PA systolic pressure = RV systolic pressure

mean PCWP = PA diastolic pressure (+5)Mean PCWP = LVEDPRVEDP = RA pressurePCWP>RA pressure

LVEDP>RVEDP

Pressure equalize in

CP, RVF, RCMP

Atrial Ventricular

Arterial

10

Atrial pressure

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)

11

Ventricular trace vs arterial trace

Ventricular Arterial Diastole Pr rises Pr falls

Baseline touch Yes No Dicrotic notch Absent Present

A bump Present AbsentShape Rectangular Triangular

12

Problem: SOB, edema, PSM LA LV RA RV PA

TR: ventricularization RAP = RVEDP

13

Problem: DOE LA LV RA RV PA

MR: tall vSevere PAH mPCWP =

dPAP

14

Tall V

V>mean PCWP+10decompensated LVFSevere 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

PCWPPC-PA hybrid pressure

15

Problem: DOE, normal EF

LVDD MS CP

16

LVEDPA bumpDiastolic slope

LVEDP normal/ low in MS LVEDP high in CP, AR, LVDD Absent A bump in MS, AF Prominent in HOCM, LVDD

LVEDP

LVEDP = mPCWPExcept1. MS2. MR3. PAH

Flat slope in chronic ARSharp slope in acute AR

17

Saturations

LA 95% RA 75%

LV 95% RV 75%

AO 95%

PA 75%SVO2/ MVO2

SVC 74%

SCVO2

IVC 78%

PV 98%

Normal: SVO2> SCVO2In shock relation reverses MVO2 sat< 65%

Low CO

18

Step upChambers 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 RVRV to PA >= 5% PDA, APWSVC to PA >= 8% L-R shuntRA 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

19

Problem

Qp/Qs = Ao – MVO2/ PV-PA = 96 – 78/ 98 – 83 = 18 / 15 = 1.2 (small L-R)

PDA (L-R)PAHCoA

TAPVC

20

Fick

Gold standardTrue FickO2 challenge

Not accurate in- Low output state- Shunt- Regurgitation lesion

Cardiac outputThermodilution

SV = CO/ HR CI = CO/ BSA SVI = SV/ BSA = CI/ HR

21

SVR

N: 0.5-1 woods unitHigh in PAH- <3: passive PAH- 3-5: mixed PAH- >5: reactive PAH• In shunt: Qp

Resistance = Pressure/ flowPVR

MAP = 1SBP+2DBP/3

N: <700 dyn cm /sec5

Low SVR in septic shock

High SVR in ionotrpsW (mmHg/ L/min) = 80 dyn cm /sec5

22

Shunts Bidirectional shunt

Eisenmenger’s systemic = pulmonary pr

PVR>SVR (PVR> 5)Qp<Qs (Qp/Qs <1)

23

Room O2

PA 70/40/50 PCWP 10

ASD: bidirectional shunt in EchoRepair or not?

100% o2

VO2 220Hb 15

45 mmH

g

80 mmH

g

450 mmH

g

100 mmH

gPA 55/32/39 PCWP 10

24

Rest

QpQs

QeffPVR

25

100% o2

Repair

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

Gorlin’sValve area

AVA in AS

Peak to peak PG = mean

PG

mean PG = 70% of

Peak instantaneo

us PG

Area α QGradient α Q2

A = Q/ √PG

Area α 1/ √PG

27

Problem:

AS HOCM technical error

28

AS

Aortic stenosisHOCM

Always rule out error in zeroing

Peripheral artery- Pressure

elevated- No dicrotic

notch- delayed

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LV – Aorta gradient: doppler vs catheter

Vena Contracta(Ao pr lesser)

Aortic root<3cm

Pressure reco ery

Echo gradientHigher

AVA less

In aortic root<3cmcatheter gradient

accurate

Downstream to valve

(Ao pr higher)HTN, LVDD

catheter gradientLower

AVA highHTN, LVDD

Echo gradient accurate

Area= Q/ √PG

LV loadSBP+PG/ SVI

= SBP+PG/ CI (ml) X HR

(> 4.5 abnormal)

30

Severe AS, mPG 27mmHg, AVA 0.9 cm2

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

31

Asympt, normal EF, PG 43, AVA 1.25

Echo gradient Higher

AVA less

Aortic root<3cmAR

AVA = Q/√PG

Pseudo severe AS

32

Low gradient (<40mmHg) severe AS (AVA<1 cm2)

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

Low gradient severe AS with low EFTrue

severe ASPseudoseve

re ASDCM+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

34

severe AS, mPG 26mmHg, AVA 0.85 cm2

CI 1.6 HR 55 EF 40% PA o2sat 55% BP 130/80

35

Dobutamine stress: mPG 45, AVA 1.1

CI 3 HR 78 EF 40% PA o2sat 73%

True severe AS

36

End holeWedge Wire manipulation- Pulmonary wedge

catheter

Pressure monitoring

Blood sampling- Berman catheter- Multipurpose

catheter- Pigtail catheter

Choosing Catheter Side hole

37

AS HOCM

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Problem: LV to aorta pull back

AS HOCM

39

HOCM• ASH (anterior)• LVOT narrows• increased velocity • SAM (MR)• LVOT further narrows• gradient increases- Low preload- high contractility (dobu CIed)- low afterload• gradient max in late systole• dicrotic pulse (Low CO)•early systolic pr peak in aorta• LV pressure peaks later

Spike and dome

40

Brokenborough sign

AS HOCMPAC: LV pr increase IncreasePAC: Ao Pr Increase Decrease (CO

low)PAC: LV-Ao grad low highAo: pr upslope Delay Rapid Dicrotic pulse - +LV/Ao pr peak discordant Concordant

41

Level of obstruction

vulvular AS supravulvular AS subvulvular AS CoA pressure recovery

Level of obstruction

CoA CoA +AS

CoA + AR

Gradient>20

mmHg

43

Acute AR Chronic compensated

AR

Chronic decompensated

ARLV 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

Aortic regurgiatation

Q = 2 X CO (severe AR) Area= Q/ √PG= 2CO/ √PG

Otherwise Gorlin AVA falsely low

Severe AR- L/O dicrotic notch

- LVEDP = DBP- Q = 2CO

- LVEDP elevated- Flat rise of LVEDP

44

Problem: Bicuspid AV, severe AR, LVF

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

Severe AR, sudden LVF

Acute severe AR chronic compensated AR chronic decompensated AR

46

Mitral stenosis [PCWP: high a, high v; LVEDP: low, absent A]

- Severe PAH- large V wave

- High PCWP (>25)- mitral prosthesis

Mild MS + Stress test (2/3)

- Gradient >15- mPAP>60- PCWP>25

Low PGLow MVA

High PGHigh MVA

MVA = 220/ PHT

- Impaired LV compliance

- severe AR

High gradientLow MVA

47

Rest

TVD, DOE, Echo: mild MS, EF =55%

Dobutamine stress

MVA 1.6mPG 3.8PCWP 18PAP 41

MVA 0.85mPG 13PCWP 22PAP 66

CABG + MVR

48

Echo - mean PG 15 mmHg - MVA 2.2 cm2 (PHT)

• Cath study - CO 4 ltr/ min - mean PG 16 mmHg - Gorlin MVA 4/√16 =

1 cm2

Problem: long mid diastolic mumer

Increased LVEDP

49

chambers?

wave?

diagnosis?

Problem: SOB, PSM

LV/ PCWPAbsent A, tall VAF, severe MR

50

Mitral regurgiatation 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

Q = 2 X CO (severe MR) Q = 1.5 X CO (moderate

MR)Gorlin MVA false low

51

Left ventricular failure

LVEDP >16

Impaired LA

compliance

Myocardial disease

Aortic valve diseaseLVDD

MS, MR High

PCWPTall V

DCMCI low

High PCWP Tall A

Dicrotic aortic tracing

LVDDLVEDP >20Prominent A

bumpSteep diastolic

slopePCWP normal

AR Flat diastole

Wide PPL/O dicrotic

notch

52

Problem: SOB, swelling, raised JVP

RCMP RVF CP

53

Chamber pressures are high & equalises in early diastole

Constriction

M or W pattern RA pr = mPCWP

LVEDP = RVEDP

Square root(dip & plateu)

D/DRVF

RCMPRVEDP > LVEDP

+5PA pressure high

Better seen in volume loading

54

Ventricular interdependance

Constriction

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

55

Dissociation of intracardiac / intrathorasic pressure

Constriction

>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

56

Problem: Anasacrca, LVF, RVF, normal EF

W pattern

Severe RVF

57

Problem: SOB, low BP, elevated JVP

Tamponade

v

a

x

58

Tamponade Tamponade Constriction

Early diastole Later part of diastole

CompressedCompressed

(no Y)

ExpandsConstrained (y)

Elevation & equalization of pressure

+ +

Dissociation of intracardiac / intrathorasic

pressure

- +

RAP Deep x flat y Deep x deep yEarly 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

Pulsus paradoxus absent in1. ASD2. AR

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PAH (mPAP>25 in rest, >30 in exercise)

Post capillary Pre capillary Prevalence Common Less commonMechanism Passive Reactive Causes Mitral valve

diseaseLVF

Vascular dis (ASD, SSC)Chr thromboembolismLung diseaseEisenmengers

PCWP >15 <15 (may be high)Diast PA pr <5+ PCWP >5+ PCWPPVR <3 >5Transpulmonary gradient

<12 >12

Chronic PAH-PAP may be

normal- PVR>5

- >50 mmHg

Rule out shunt Vasoreactivity

60

Severe PAH

CO 4CI 1.9

mPCWP= 15PVR = 55 – 15/ 4 =

10mPAP – PCWP = 40dPAP> mPCWP+5

Money.Monster.2016.720p.BluRay.x264.YIFY

Severe precapillary PAH

61

Positive when - mean PAP drops by >10 (to a value<40)

- PVR drops by >20% (to a value <5)- PCWP <15

Vasoreactivity test

- Role of CCB- safety of CCB

- long term prognosis- shunt

reversibility

Precapillary /reactive PAH

62

Severe PAH

CO 4CI 1.9

mPCWP= 15PVR = 55 – 15/ 4 =

10mPAP – PCWP = 40dPAP> 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

ShockMAP<60, SBP<90, SBP decrease by >40

<700

Fluid response: leg rising- CO increase by >10%- IVC diameter >12mm- pulse pressure >9%

Fluid challengeRisky if PCWP>15

Mean BP<80 Dicrotic

pulse high PCWP

(A) High RAP

SVR >700 CI<2.2

PA sat <65% SVO2<

SCVO2

Septic

64

Post PTCA, CA stomach, DCM (EF 20%), refractory shock, on ionotrops,

on ventillation

CO 8; CI 3.3 PA

o2sat 53% SPO2 93%

Hb 11High filling pressure

Dicrotic pulseNormal CILow SVR

SVO2 53%SVC SO2

63%Cardiogenic shock on ionotrops

Septic shock

65

Normal and abnormalsTraces & relations Shunt / o2 challenge/ resistanceGrdaient –area mismatch of severe ASAS/ HOCM/ CoASevere MS/ stress testCompensated/ decompensated AR/MRRVF/ LVFContriction/ RVF/ tamponade Passive/ reactive PAH/ vasoreactivity Shock

Summary

66

The legend of fall

67Misguided faith in catheter

68

Then & Now

69

no subjective error

hemodynamics in paper

decision making

70Thank you