Ebook Practical cardiovascular hemodynamics: Part 1

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LibraryofCongressCataloging-in-PublicationData
Hanna,EliasB.
Practicalcardiovascularhemodynamics/EliasB.Hanna.
p.;cm.

Includesbibliographicalreferencesandindex.
ISBN978-1-936287-84-0(alk.paper)--ISBN978-1-61705-139-5(e-book)
I.Title.
[DNLM: 1. Hemodynamics. 2. Cardiovascular Diseases. 3. Heart Valve


Diseases.WG106]
616.1’25--dc23
2012025525
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TomymotherMarieandmysisterEliana,
fortheirinfinitelove,kindness,
andsupport.
Toallthosewhoarewillingtoappreciatethebeauty
ineverytracing,everyline…
EliasB.Hanna

Contents

Preface
Abbreviations
Acknowledgments

SECTIONA:BASICANDADVANCEDHEMODYNAMICS
EliasBechirHanna
I

Pressuretracings
I.1.Rightatrialpressuretracing
I.2.Rightventricularpressuretracing—Characterisiticsofrightventricular
failure
I.3.Pulmonaryarterypressuretracing
I.4.Pulmonarycapillarywedgepressure
I.5.LeftventricularpressuretracingandinterpretationofLVEDP-Left
ventricularfailure
I.6.Aorticpressure,peripheralarterialpressure,anddescriptionofdamping
andventricularizationofaorticpressureuponcoronaryengagement
I.7.Pressuredampingandothersourcesofpressureartifact
I.8.Establishthezeroreference
I.9.Effectofrespirationonintracardiacpressuresandconceptoftransmural
pressure

II

Measurementofcardiacoutputandvascularresistances

Evaluationofleft-to-rightandright-to-leftshuntsandcalculationofshunt


III

ratio

IV

Overviewofthestepsperformedduringastandardrightandleftheart
catheterization

V

Leftventricularfailure

VI

Valvulardisorders:Calculationofvalvulararea

VII

Valvulardisorders:Aorticstenosis

VIII Valvulardisorders:Mitralstenosis
IX

Othervalvulardisorders:Mitralregurgitation,aorticinsufficiency,tricuspid
regurgitation,pulmonicstenosis,andprostheticvalves
IX.1.Mitralregurgitation

IX.2.Aorticinsufficiency
IX.3.Tricuspidregurgitation
IX.4.Pulmonicstenosis
IX.5.Tricuspidstenosis
IX.6.Pulmonicinsufficiency
IX.7.Prostheticvalves

X

Assessmentofmixedvalvulardisorders

XI

Hypertrophicobstructivecardiomyopathy

XII

Constrictivepericarditisanddifferentiationofconstrictivepericarditisfrom
restrictivecardiomyopathyandventricularfailure

XIII Tamponade
XIV Pulmonaryhypertension
XV

Hemodynamicsinshockandfluidresponsiveness

XVI

Hemodynamicsofleftventricularsupportdevicesandleftventricular
pressure-volumeloopinvariouscardiacconditions

XVI.1.Intra-aorticballoonpump


XVI.1.Intra-aorticballoonpump
XVI.2.Transvalvularleftventricularassistdevice(Impella)andTandemHeart
XVI.3.Leftventricularpressure-volumeloopsandeffectofleftventricular
supportdevicesoncardiachemodynamics
XVII

Coronaryhemodynamics:Fractionalflowreserveconcept,pitfalls,andspecial
applications

SECTIONB:TRACINGSANDCASES:SELF-ASSESSMENT
PROBLEMS
EliasBechirHanna,DavidLukeGlancy
SectionB-I: Longcases:Self-assessmentproblems
Cases1–22
SectionB-II: Shortcases:Self-assessmentproblems
Cases

Index


Preface

Despite the advances of imaging techniques, the understanding of invasive
cardiovascularhemodynamicscontinuestobeofcriticalimportanceinpatients
with conflicting or inconclusive noninvasive data. Furthermore, invasive
hemodynamics remain the backbone for in-depth understanding of
cardiovascular physiology, physical examination, and echocardiographic

hemodynamics. Yet few manuals address cardiovascular hemodynamics in a
practical and illustrated format or provide hemodynamic self-assessment
problems to allow question-guided learning, hence the reason why the topic
remainsconfusingtocardiologistsandtoourcardiologyfellows.
The purpose of this book is to provide an in-depth understanding of
waveformsandtracingsseenin variousdiseasestatesandthepathophysiology
behind those findings. This is highlighted throughout Section A of the book
where a thorough yet concise dynamic pathophysiology is used to explain
hemodynamicfindings.Oneexampleisthebook’sillustratedexplanationofthe
sequenceofeventstakingplaceinconstrictivepericarditisincontradictiontothe
seriesofeventsoccurringinrestrictivecardiomyopathy,ventricularfailure,and
obstructive lung disease. Practical issues that are rarely discussed or focused
upon in textbooks are highlighted in every part of Section A with detailed
waveformanalysis.Pitfallsinthehemodynamicassessmentofvalvulardiseases,
constrictive pericarditis, tamponade, pulmonary hypertension, shunt pathology,
coronary disease, and right and left ventricular failure are provided. Going
throughtheillustrationsandtheirdetailedlegendsmayprovidethereaderwith
mostoftherequiredinformation.
Section B of the book provides case-based and tracing-based selfassessment problems. The reader will learn to identify disease states and
waveform subtleties from single tracings or from case studies. The reader will
take the initiative to interpret tracings, understand notches, artifacts, and


formulateadiagnosis.
Despiteitsdepth,thebookisconciseandreliesonpracticalexplanations
andreal-lifeillustrationstosuccessfullybringaboutthehemodynamicconcepts.
Over 300 illustrations and 25 tables with detailed legends are used to allow
illustrated learning. I believe this book has a great educational value for
cardiology fellows, cardiologists, intensive care physicians, anesthesiologists,
andcatheterizationlaboratorypersonnelandnurses.

EliasB.Hanna


Abbreviations

A:

mitralinflowechocardiographicvelocityduringatrialcontraction

ACEinhibitor: angiotensinconvertingenzymeinhibitor
AF:

atrialfibrillation

AI:

aorticinsufficiency

AS:

aorticstenosis

ASD:

atrialseptaldefect

AT:

accelerationtime

AVA:

aorticvalvearea

BA:

brachialartery

BD:

pressureatthebeginningofdiastole(onventriculartracing)

BP:

bloodpressure

CABG:

coronaryarterybypassgrafting

Cathlab:

catheterizationlaboratory

CI:

cardiacindex

CO:

cardiacoutput

CP:

constrictivepericarditis

Dord:

diastolicpressureonarterialtracing



earlydiastolicpressureonventriculartracing(likeBD)



diastolicflowonpulmonaryvenousDoppler


DBP:

diastolicbloodpressure

DFP:

diastolicfillingperiod

DT:

mitralinflowdecelerationtime

E:

mitralinflowrapidfillingechocardiographicvelocity

"e"

ventricularend-diastolicpressureonventriculartracing(likeED)

E’:

annulartissuedopplervelocityduringearlydiastole

ECG:

electrocardiogramorelectrocardiographic

Echo:

echocardiogramorechocardiographic

ED:

end-diastolicpressureonventriculartracing

EF:

ejectionfraction

EOA:

effectiveorificearea

ESPVR:

end-systolicpressure-volumerelationship

FA:

femoralartery

Hb:

hemoglobin

HF:

heartfailure

HFNEF:

heartfailurewithnormalejectionfraction

HOCM:

hypertrophicobstructivecardiomyopathy

HR:

heartrate

HTN:

hypertension

IABP:

intra-aorticballoonpump

IVC:

inferiorvenacava

IVRT:

isovolumicrelaxationtime

LA:

leftatriumorleftatrial

LAD:

leftanteriordescendingartery

LCx:

leftcircumflexcoronaryartery

LM:

leftmain


LV:

leftventricleorleftventricular

LVEF:

leftventricularejectionfraction

LVEDP:

leftventricularend-diastolicpressure

LVH:

leftventricularhypertrophy

LVOT:

leftventricularoutflowtract

MR:

mitralregurgitation

MS:

mitralstenosis

MVA:

mitralvalvearea

MVO2:

mixedvenousO2saturation

PA:

pulmonaryartery

PAH:

pulmonaryarterialhypertension

PAO2:

pulmonaryarterialO2saturation

PDA:

patentductusarteriosus

PCWP:

pulmonarycapillarywedgepressure

PH:

pulmonaryhypertension

PHT:

pressurehalf-time

PISA:

proximalisovolumetricsurfacearea

PS:

pulmonicstenosis

PV:

pulmonaryveinorpulmonaryvenous

PVloop:

pressure-volumeloop

PVC:

prematureventricularcomplex

PVO2:

pulmonaryvenousO2saturation

RA:

rightatriumorrightatrial

RV:

rightventricleorrightventricular

RVEDP:

rightventricularend-diastolicpressure

RVOT:

rightventricularoutflowtract

S:

systolicpressureonarterialtracing




systolicflowonpulmonaryvenousDoppler

SBP:

systolicbloodpressure

SEP:

systolicejectionperiod

SV:

strokevolume

SVC:

superiorvenacava

SvO2:

mixedvenousO2saturation

SaO2,SAO2: arterialO2saturation
TR:

tricuspidregurgitation

VSD:

ventricularseptaldefect

VTI:

velocitytimeintegral

Acknowledgements

Deprived of meaningful work, humans lose their reason for existence; they go
stark,ravingmad…
FyodorDostoyevsky
…Andmaddestofallistoseelifeasitis,notasitshouldbe.
MigueldeCervantes,DonQuixote
This work would not have been possible without the inspiration of my former
mentors at Louisiana State University (LSU) and Oklahoma University. More
specifically,IwouldliketoacknowledgetheenlighteningDr.D.LukeGlancyat
LSUandalltheinterventionalcardiologistsatOklahomaUniversity,particularly
Dr.EliotSchechter,Dr.ThomasHennebrywithhiscommandingpersonalityand
catheterization style, and Dr. Mazen Abu-fadel. I am also appreciative of the
LSU and Oklahoma University catheterization laboratory’s nurses and
technicians, who allowed the recording of quality tracings fundamental to this
endeavor.
EliasB.Hanna


A


BASICAND
ADVANCED
HEMODYNAMICS
EliasB.Hanna

CONTENTS
I

PRESSURETRACINGS
I.1.

Rightatrialpressuretracing
Pressurecontour
TiminginrelationtotheECGandtheventriculartracing
Respiratoryvariations
CorrelationsbetweentheRApressuretracingandDopplertracingsof
theinferiorvenacava,hepaticveins,andtrans-tricuspidflow
Descriptionofsomeabnormalities

I.2.

Rightventricularpressuretracing—CharacteristicsofRVfailure

I.3.

Pulmonaryarterypressuretracing

I.4.

Pulmonarycapillarywedgepressure
DescriptionofPCWPwaves—CorrelationofPCWPwithLApressure
PitfallsininterpretingPCWP
KeypointsindifferentiatingPApressurefromPCWP
AbnormalitiesofPCWPtracing

I.5.

LeftventricularpressuretracingandinterpretationofLVED-left
ventricularfailure
LVsystolicpressure


LVdiastolicpressureandevaluationofLVfailure
CorrelationbetweenLVEDPandaproperlydonePCWP
HowtoaccuratelymeasureLVEDP?
PitfallsinLVEDPdetermination
I.6.

Aorticpressure,peripheralarterialpressure,anddescriptionof
dampingandventricularizationofaorticpressureuponcoronary
engagement
Aorticpressure
Peripheralarterialpressure:Reflectedwavesandsystolic
amplification
Dampingandventricularizationoftheaorticwaveformupon
coronaryengagement

I.7.

PressuredampingandOthersourcesofpressureartifact

I.8.

Establishthezeroreference

I.9.

Effectofrespirationonintracardiacpressuresandconceptof
transmuralpressure

References
II

MEASUREMENTOFCARDIACOUTPUTANDVASCULAR
RESISTANCES
References

III

EVALUATIONOFLEFT-TO-RIGHTANDRIGHT-TO-LEFTSHUNTS
ANDCALCULATIONOFSHUNTRATIO
III.1.

Shuntevaluation

III.2.

ShuntratiocalculationincaseofO2therapy

III.3.

Shuntandpulmonaryhypertension

III.4.

Examplesofoximetryruns

III.5.

Shuntcasewithpulmonaryhypertension


References
IV

OVERVIEWOFTHESTEPSPERFORMEDDURINGASTANDARD
RIGHTANDLEFTHEARTCATHETERIZATION

V

LEFTVENTRICULARFAILURE
V.1.

Overview

V.2.

HeartfailurewithnormalLVEDPandnormalPCWPatrest—Value
ofstresstesting

V.3.

AssessmentofLVcontractility

V.4.

EchocardiographicdeterminationofLVfillingpressures

References
VI

VALVULARDISORDERS:CALCULATIONOFVALVULARAREA
VI.1.

Overview

VI.2.

Calculationofvalvularareainatrialfibrillation

VI.3.

Calculationofvalvularareaincaseofcoexistingregurgitationofthe
samevalve

References
VII

VALVULARDISORDERS:AORTICSTENOSIS
VII.1.

Typesoftransaorticvalvegradients

VII.2.

MorphologyoftheaorticpressuretracinginsevereAS

VII.3.

Howtoobtainthetransaorticpressuregradient

VII.4.

CaseofAF

VII.5.

Caseoflow-gradientASwithAVA≤1cm2andlowEF<40%

VII.6.

Caseoflow-gradientASwithAVA≤1cm2butnormalEF

VII.7.

Pressurerecoveryphenomenon

VII.8.

LVOTobstructionandLVflowaccelerationinaorticstenosis
followingaorticvalvereplacement


References
VIII VALVULARDISORDERS:MITRALSTENOSIS
VIII.1. LApressurewaveformandtransmitralpressuregradientinMS
VIII.2. Howtoobtaintransmitralvalvegradient

VIII.3. NoteontheechocardiographicdeterminationofMSseverity
VIII.4. PulmonaryhypertensioninMS
VIII.5. CaseofAF
VIII.6. StresstestingforMS
VIII.7. Assessmentoftheresultsofmitralballoonvalvuloplasty
References
IX

OTHERVALVULARDISORDERS:MITRALREGURGITATION,
AORTICINSUFFICIENCY,TRICUSPIDREGURGITATION,PULMONIC
STENOSIS,ANDPROSTHETICVALVES
IX.1.

Mitralregurgitation

IX.2.

Aorticinsufficiency

IX.3.

Tricuspidregurgitation

IX.4.

Pulmonicstenosis

IX.5.

Tricuspidstenosis

IX.6.

Pulmonicinsufficiency

IX.7.

Prostheticvalves

References
X

ASSESSMENTOFMIXEDVALVULARDISORDERS
X.1.

Mixedsinglevalvedisease

X.2.

Multiplevalvularinvolvement(combinedstenosisorregurgitationof2
differentvalves)


XI

HYPERTROPHICOBSTRUCTIVECARDIOMYOPATHY
XI.1.

Overviewofhypertropicobstructivecardiomyopathy(HOCM)and
thehemodynamicfindingsinHOCM

XI.2.

Provocativemaneuvers

XI.3.

OthercausesofLVOTobstruction

XI.4.

OthercausesofsevereLVhypertrophy

XI.5.

CorrectionofHOCM

References
XII

CONSTRICTIVEPERICARDITISANDDIFFERENTIATIONOF
CONSTRICTIVEPERICARDITISFROMRESTRICTIVE
CARDIOMYOPATHYANDVENTRICULARFAILURE
XII.1.

Overviewofthehemodynamicsofconstrictivepericarditis

XII.2.

DifferentiationbetweenCP,restrictivecardiomyopathy,andany

decompensatedventricularfailure

XII.3.

EchocardiographicdifferentiationbetweenCPandrestrictive
cardiomyopathy

XII.4.

DifferentiatingCPfromparticularcasesofsevereRVfailurethat
simulateconstriction

XII.5.

COPDandothercausesofRV-LVrespiratorydiscordance

XII.6.

EffectofrespirationonRVandLVfillinginnormalindividuals

XII.7.

DifferentiationbetweenCOPDandconstriction

XII.8.

TransientCP

XII.9.

PracticalperformanceofahemodynamicstudywhenCPissuspected

References
XIII TAMPONADE
XIII.1. Overviewofthehemodynamicsoftamponade
XIII.2. Summaryofthehemodynamicfindingsintamponade


XIII.3. Low-pressuretamponade
XIII.4.

CasesofunderlyingRVorLVfailureandcausesofabsentpulsus
paradoxus

XIII.5. Regionaltamponade
XIII.6. Effusive-constrictivepericarditis
XIII.7.

COPDandothercausesofpulsusparadoxusandRV-LVrespiratory
discordance

References
XIV PULMONARYHYPERTENSION
XIV.1. Definition
XIV.2. Categoriesofpulmonaryhypertension
XIV.3. Twotipsontheevaluationofpulmonaryhypertension
XIV.4. Rightandleftheartcatheterizationforpulmonaryhypertension
References
XV

HEMODYNAMICSINSHOCKANDFLUIDRESPONSIVENESS
XV.1.

Shock

XV.2.

Fluidresponsiveness

References
HEMODYNAMICSOFLEFTVENTRICULARSUPPORTDEVICESAND
XVI LEFTVENTRICULARPRESSURE-VOLUMELOOPINVARIOUS
CARDIACCONDITIONS
XVI.1. Intra-aorticballoonpump
OverviewofIABP
Triggeringandtiming
Contraindications


Troubleshootingandlackofappropriateaugmentation
XVI.2.

Transvalvularleftventricularassistdevice(Impella)and
TandemHeart
Transvalvularassistdevice
Impellacontraindications
TandemHeart

XVI.3.

Leftventricularpressure-volumeloopsandeffectofleftventricular
supportdevicesoncardiachemodynamics
Definitionofafterload
CoronarybloodflowandmyocardialO2demands
Pressure-volumeloop

References
XVII

CORONARYHEMODYNAMICS:FRACTIONALFLOWRESERVE
CONCEPT,PITFALLS,ANDSPECIALAPPLICATIONS
XVII.1. Myocardialbloodflowandconceptoffractionalflowreserve
XVII.2. PracticalperformanceofFFR
XVII.3. Fractionalflowreserveinspecialsituations
Serialstenoses
Diffusedisease
Bifurcationdisease
Ostialdisease
Acutecoronarysyndrome
MicrocirculatorydysfunctionandLVhypertrophy
Arterysupplyinganoldinfarctedmyocardium—ValueofFFRin
assessingischemiaandviability
FFRvsnuclearperfusionimaginginmultivesseldisease


FFRandbypassgrafts
XVII.4. TricksandpitfallsinFFRperformance
XVII.5. EvidencesupportingtheuseofFFR
Overview
ComparisonwithIVUS

FFRassessmentafterPCI
Caseofleftmaindisease
References