disclosure: morton j. kern, md within the past 12 months ... · disclosure: morton j. kern, md...

Disclosure:

Morton J. Kern, MD

Within the past 12 months, the presenter or their spouse/partner have had a financial interest/arrangement or affiliation with the organization listed below.

Company Name RelationshipRadi Medical Inc. Speakers BureauMerrit Medical Inc. ConsultantBracco Inc. Consultant

LV hemodynamics

Morton J. Kern, MD

Associate Chief CardiologyDirector Clinical Affairs

University California IrvineOrange, California

Common Hemodynamic Problems involving LV pressure measurements

LV Compliance AssessmentMitral StenosisLow Gradient Aortic StenosisHOCMProsthetic Valve DysfunctionDiastolic CHFConstriction v Restriction

Potential Sources of Errors for Pressure Measurements

• Temporal delay of pressure transmission in fluid filled systems

• Nonsimultaneous pressure recordings

• Pressure damping

• Resonance artifact (underdamping)

• Calibration

• Flow dependence

• Effect of catheter across stenotic valve

Fusberg and Feldman T, Cath and CV Int 53:553;2001

Techniques for Aortic Valve Gradient Measurement

• Single Catheter LV-Ao pullback

• LV and Femoral Sheath

• LV and Long aortic sheath

• Bilateral femoral access

• Double-lumen pigtail catheter

• Transeptal LV access with ascending Ao

• Pressure Guidewire with ascending Ao

• Multi-transducer micromanometer catheters

Fusberg and Feldman T, Cath and CV Int 53:553;2001

BAMC Case #3117: Patient: 61 yo maleDx: 3V CAD filter: 50 Hz/ sample 250 Hz

Pre Contrast

Normal LV and Aortic Pressure, micromanometer transducers

Note normal impulse gradient

FA + AO

FA + LV

Most Common Approach to LV-Ao Gradient measurement

High Fidelity LV pressure can be measured with 0.014” pressure wire

Fusberg and Feldman T, Cath and CV Int 53:553;2001

Parham and Kern, Cath and CV Int 53:553;2001

Retrograde hemodynamic Assessment of Prosthetic Valves with a Pressure Wire

Damping and Resonance Artifacts

Abnormal LV Diastolic Relaxation

LV pressure changes with ValsavaManeuver

200mmHg

LV/RV diastolic waveforms reflect differences in compliance, timing of activation and function

100mmHg

40mmHg

LV/RV diastolic waveforms reflect differences in compliance, timing of activation and function

LV Puncture for 2 prosthetic valves

Pigtail

AV

MV

Pigtail

68yo W with 2 prosthetic valves

100mmHg

LVRV

Abnormal LV diastolic relaxation?

Abnormal LV diastolic relaxation?

The LV pressure wave reflects the appropriate or inappropriate transmission of blood

What caused gradient to increase in beat #2?P wave

What does the LV waveform tell us about this patient?

Wide PP, rapid diastolic upslope=AI Coarctation

200

Coarctation of Aorta

Rib Notching

Aortic Stenosis?

Aortic Regurgitation?

Wide Pulse Pressure

Upsloping LV diastolic pressure

Aortic Insufficiency

What is most likely diagnosis?

Aortic Insufficiency

LV/RV Diastolic elevation and equilibration

Constriction or Restriction?

RV/LV DiscordanceConstriction

RV/LV ConcordanceRestriction

Restrictive vs Constrictive?

Hemodynamics in the Cath Lab

•• Valuable diagnostic adjunctValuable diagnostic adjunct•• Confirm or establish many surgically correctableConfirm or establish many surgically correctable

etiologiesetiologies•• Confuse matters if data is poorly or inaccuratelyConfuse matters if data is poorly or inaccurately

collectedcollected•• Critical to teaching and understandingCritical to teaching and understanding

cardiovascular pathologycardiovascular pathology