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Hemodynamics for the Interventional Cardiologist
Gregory J. Dehmer, MD Professor of Medicine, Texas A&M College of Medicine Director, Cardiology Division Scott & White Clinic Hemodynamics: What invasive cardiologists did before stents were invented
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Gregory J. Dehmer, MD, FSCAI
I have no relevant financial disclosures to make.
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Must Know Hemodynamics for PCI
How to measure pressures Catheter behaviors Hypotension during PCI Tamponade
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Rules for Proper Pressure Recording
Use the same routine and (almost) never take a short cut Critically assess the fidelity of the waveforms and exclude artifact Time the events with the ECG Always know the transducer level and zero position Statham transducer Disposable transducer
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Balancing and Zeroing The “zero” position is:
Mid-chest level Uppermost blood level in the chamber being measured* For the LV -5 cm below the LSB at the 4th LICS Error for other chambers ± 0.8 mmHg for other chambers The transducer should be placed at the “zero” position Above zero = falsely low pressure Below zero = falsely high pressure * Courtois M, et al. Circulation 1995;92:
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Common Errors and Artifacts
Over-damped waveform Over-damped Properly damped Air bubble, clot or contrast in the line Soft compliant tubing Loose catheter connection
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Common Errors and Artifacts
Underdamped waveform (“ring artifact”) Tubing too stiff or too long Hyperdynamic state Catheter tip in turbulent jet
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Common Errors and Artifacts
Catheter whip or fling “Fling” caused by extra loop of Swan Ganz in RV. Same patient after removal of extra loop
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Common Errors and Artifacts
Catheter malposition RA catheter is near the TV and is periodically being “hit” by the valve creating high frequency noise What’s the problem? Loose connections, catheter kinks, faulty transducers
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Pitfalls in Pressure Recording
Stiffness of pressure tubing Stiffer = less dampening Softer = more dampening Length of pressure tubing Longer = more dampening Shorter = less dampening Viscosity of fluid in tubing Viscous fluid (e.g., contrast) increases dampening Elimination of gas bubbles Air in tubing dampens waveform With excessive high frequency waves, introduce a small air bubble to dampen “chatter”
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Catheter Behaviors Damping “Ventricularization”
Damping: loss of systolic and diastolic components Damping Occlusion of the catheter tip Clot, vessel wall Kink in body of catheter Balloon inflation within tip “Ventricularization” Occlusion of the coronary by the catheter Transmural myocardial pressure Guide too large, proximal spasm or proximal stenosis Ventricularization: loss of diastolic component Hybrid: FLP
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Ritzema-Carter JLT. Circ 2006;113:e705 - e706
Hypotension During PCI 81 y/o man with prior CABG and LVEF 24% Investigational percutaneous-implanted LA pressure monitoring system More Common Bleeding Low filling pressures Vagal reaction Bezold Jarisch reflex Overmedication Technical considerations Pressure miscalibration / display Loose connections Arrhythmia Shock Transient ischemic dysfunction Ritzema-Carter JLT. Circ 2006;113:e705 - e706 BJ reflex: A cardiovascular decompressor reflex involving a marked increase in vagal (parasympathetic) efferent discharge to the heart, elicited by stimulation of chemoreceptors, primarily in the left ventricle. This causes a slowing of the heart beat (bradycardia) and dilatation of the peripheral blood vessels with resulting lowering of the blood pressure. Baseline
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Hemodynamic Changes During PCI
With balloon inflation V waves to 80 mmHg Baseline After 3 min. During PCI Ritzema-Carter JLT. Circ 2006;113:e705 - e706
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Remember, you can always measure an LVEDP!!!
Hypotension During PCI More Common Less Common Bleeding Low filling pressures Vagal reaction Bezold Jarisch reflex Overmedication Technical considerations Pressure miscalibration / display Loose connections Arrhythmia Shock Transient ischemic dysfunction Tamponade Anaphylactoid rxn New or unsuspected valvular lesion Acute MR AS Remember, you can always measure an LVEDP!!!
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Hemodynamics of Tamponade
Incidence 0.12 – 0.6 % Increased with newer devices Atherectomy Hydrophilic wires GP IIb/IIIa inhibitors Influence outcome (death) Delayed presentation May be delayed in 50% Dx outside of the lab 2 – 36 hrs post PCI Fejka M, et al. Am J Cardiol 2002;90: Fasseas P, et al. Am Heart J 2004;147:
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Delayed Onset Tamponade
Symptoms Chest discomfort Tachypnea, dyspnea but clear lungs Restlessness, agitation or drowsiness Generalized weakness Postural weakness/syncope Signs heart rate Hypotension or relative hypotension urine output ± pericardial rub Inspiratory JVP prominent x descent attenuated y descent Electrical alternans Pulsus paradoxus
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Hemodynamics of Pulsus Paradoxus
Panel B shows simultaneous tracings of LV and PCWP from the same patient. The fall in pressure with inspiration is associated with decreased LV filling. Inspiration: pericardial pressure, augment right heart filling, shifting the septum to left further compressing the LV and systolic BP falls Expiration: augments left heart filling, shifting septum to the right, compressing the RV, but with an increase in BP.
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Pulsus Paradoxus Nonpericardial Causes
COPD Acute asthma Diastolic and systolic fall with inspiration Hemorrhagic shock Tension pneumothorax Tracheal compression RV infarction Massive pulmonary embolism Restrictive cardiomyopathy Mediastinal and cardiac compression by tumors Tamponade without pulsus paradoxus Marked LVH Severe left-sided CHF Severe aortic regurgitation Atrial septal defect Extreme hypotension Acute, large LV infarction Local cardiac compression Pericardial adhesions over the right heart Spodick DH. The Pericardium - A Comprehensive Textbook 1997
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Equalization of Diastolic Pressures
All diastolic pressures within 5 mmHg Absent y descent in RA pressure Pressure wave reflects blood flow Total heart volume is fixed, thus blood can only enter when blood is leaving y descent normally from a pressure drop at the opening of the TV during diastole. Blunted as no blood is leaving the heart in diastole X descent from atrial relaxation during systole is preserved, as blood is leaving the RV during systole Normal variation in terms of decreasing with inspiration. A wave, v wave, x, and y. You also know that overall pressure is elevated. Normal should be less than 8.
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Differential of Impaired Diastolic Filling
Constrictive pericarditis RV infarct Tamponade Restrictive cardiac disease Pulses paradoxus < 1/3 Occasional Frequent Rare RA waveforms Prominent y descent “M “ or “W” Insp. Prominent y descent x descent Insp. Variable Equalization of diastolic pressures “Square root” sign Absent
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Diagnostic Criteria for Constriction
Sensitivity Specificity PPV NPV LVEDP vs. RVEDP < 5 mmHg 60 38 4 57 RVEDP vs. RVSP > 1/3 93 52 89 PASP < 55 mmHg 24 47 25 RV free wall > 7 mm 61 92 Respiratory change in RA , 3 mmHg 48 58 PCWP vs. LV > 5 mmHg 81 78 94 LV/RV Interdependence 100 95 Traditional Dynamic respiratory factors From: Kern MJ. Editor SCAI Interventional Cardiology Board Review Book
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Ventricular Interdependence
Concordant pressures Discordant pressures Restrictive Constrictive
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