1.DR.NAVIN AGRAWAL

2. Right Heart Catheterization Left Ventricular Pressure Systole Isovolumetric contraction From MV closure to AoV opening Ejection Peak systolic pressureFrom AoV opening to AoV closure Diastole Isovolumetric relaxation From AoV closure to MV opening Filling From MV opening to MV closure Early Rapid Phase Slow Phase Atrial Contraction (a wave)End diastolic pressure 3. Peak systolic LV pressure 4. End diastolic LV pressure 5. Fixed aortic obstruction 6. Simultaneous pressure tracings from the left ventricle and the aorta in a patient with aortic stenosis.Brown J , Morgan-Hughes N J Contin Educ Anaesth Crit Care Pain 2005;5:1-4 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 1 2005 The Board of Management and Trustees of the British Journal of Anaesthesia 2005 7. ??? 8. Left ventricular(LV) catheter pullback to aorta in a patient with hyperrtrophic cardiomyopathy . There is a significant systolic gradient within the left ventricular cavity and the LV outflow tract and aortic pressure waveforms exhibit a spike-and dome contour. 9. Left ventricular (LV) and femoral artery (FA) presure tracings in a woman with hypertrophic cardiomyopathy and asymmertric septal hypertrophy illustration the increase in gradient and develop a spike-and dome configuration in the arterial pressure waveform following an extrasystolic beat . Arterial pulse pressure clearly narrows in postextrasystolic beat. The narrowing of pulse pressure is known as Brockenbrough-Braunwald sign 10. Left ventricular(LV) and femoral artery (FA) pressure tracings . Valsalva manuver producesa marked increase in the gradient , as well as a change in the femoral arterial pressure waveform to a spike-and dome configuration 11. Simultaneous left ventricular and aortic pressure tracings at rest and after provocation with intravenous isoprenaline.Serino W , Sigwart U Heart 1998;79:629-630Copyright BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved. 12. Left ventricular (LV) and left brachial artery(LBA) pressure tracings in a 64year-old woman with hypertrophic caridomyopathy . A: The effect of a spontaneous change from nodal rhythm to sinus rhythm. The short arrow showed LVEDP. With restoration of sinus shythm abd a presumed decrease in the obstruction. The loss of atrial kick in patients with a stiff ventricle leads to an acute reduction in cardiac output. 13. Left ventricular (LV) micromanometer ad aortic (Ao) pressure tracings in a 68-year-old woman with advanced dilated cardiomyopathy . Marked slowing of the rates of left ventricular pressure rise and fall give the LV pressure tracing a triangular appearance 14. Hemodynamic Principles PAW and LV Tracings during Inspiration and ExpirationRV and LV Tracings during Inspiration and Expiration 15. Hemodynamic Principles Which of the following is the most likely explanation for these findings? A. Chronic recurrent PE. B. Constrictive pericarditis. C. Atrial septal defect with a large shunt and right heart failure. D. Chronic pericarditis now presenting with tamponade. E. Chronic hepatitis with cirrhosis.PAW and LV Tracings during Inspiration and ExpirationRV and LV Tracings during Inspiration and Expiration 16. Hemodynamic Principles Which of the following is the most likely explanation for these findings? A. Chronic recurrent PE. B. Constrictive pericarditis. C. Atrial septal defect with a large shunt and right heart failure. D. Chronic pericarditis now presenting with tamponade. E. Chronic hepatitis with cirrhosis.PAW and LV Tracings during Inspiration and ExpirationRV and LV Tracings during Inspiration and Expiration 17. Hemodynamic PrinciplesA. B. C. D. E.She has valvular aortic stenosis. She has hypertrophic cardiomyopathy with obstruction. She has an intraventricular pressure gradient. She has a bicuspid aortic valve with mild stenosis. She has a pressure gradient but it is likely an artifact. 18. Hemodynamic PrinciplesA. B. C. D. E.She has valvular aortic stenosis. She has hypertrophic cardiomyopathy with obstruction. She has an intraventricular pressure gradient. She has a bicuspid aortic valve with mild stenosis. She has a pressure gradient but it is likely an artifact. 19. Dicrotic pressure changes 20. Dicrotic pressure changes this part here is the dicrotic notch 21. Arterial Pressure Monitoring Abnormalities in Central Aortic Tracing Spike and dome configuration Hypertrophic obstructive cardiomyopathySpikeDomeDavidson CJ, et al. Cardiac Catheterization. In: Heart Disease: A Textbook of Cardiovascular Medicine, Edited by E. Braunwald, 5th ed. Philadelphia: WB Saunders Company, 1997 22. Right Heart Catheterization Left Ventricular Pressure Systole Isovolumetric contraction From MV closure to AoV opening Ejection Peak systolic pressureFrom AoV opening to AoV closure Diastole Isovolumetric relaxation From AoV closure to MV opening Filling From MV opening to MV closure Early Rapid Phase Slow Phase Atrial Contraction (a wave)End diastolic pressure 23. Peak systolic LV pressure 24. End diastolic LV pressure 25. Fixed aortic obstruction 26. Simultaneous pressure tracings from the left ventricle and the aorta in a patient with aortic stenosis.Brown J , Morgan-Hughes N J Contin Educ Anaesth Crit Care Pain 2005;5:1-4 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 1 2005 The Board of Management and Trustees of the British Journal of Anaesthesia 2005 27. ??? 28. Left ventricular(LV) catheter pullback to aorta in a patient with hyperrtrophic cardiomyopathy . There is a significant systolic gradient within the left ventricular cavity and the LV outflow tract and aortic pressure waveforms exhibit a spike-and dome contour. 29. Arterial Pressure Monitoring Central Aortic and Peripheral Tracings Pulse pressure =Systolic Diastolic Mean aortic pressure typically < 5 mm Hg higher than mean peripheral pressure Aortic waveform varies along length of the aorta Systolic wave increases in amplitude while diastolic wavedecreases Mean aortic pressure constant Dicrotic notch less apparent in peripheral tracing Davidson CJ, et al. Cardiac Catheterization. In: Heart Disease: A Textbook of Cardiovascular Medicine, Edited by E. Braunwald, 5th ed. Philadelphia: WB Saunders Company, 1997 30. PWV stiffer arteries increased PWV earlier arrival of reflected waves augmentation of systolic rather than diastolic pressureincreased pulse pressure 31. Dehydration-Hypovolemia 32. Effects of respiration 33. ANACROTIC SHOULDER 34. Pulsus paradoxus 35. Pulsus alternans Pericardial effusion Cardiomyopathy CHF 36. Advancing Your Right Heart Catheter Advance the SGC toabout 20cm and inflate the balloon tip. Initial chamber the right atrium. Initial pressure waveform 3 positive deflections, the a, c and v waves There will be an x and y descent 37. Right Atrial Pressure Tracing a wave atrial systole c wave occurs with theclosure of the tricuspid valve and the initiation of atrial filling v wave occurs with blood filling the atrium while the tricuspid valve is closed 38. Timing of the positive deflections a wave occurs after the P wave (60-80 msec)during the PR interval c wave when present occurs at the end of the QRS complex (RST junction) v wave Peak occurs after the T wave 39. Right Atrial Chamber 1. Height of the v waveatrial compliance volume of blood returning 2. Height of the a wave The pressure needed to eject forward blood flow The v wave is usually smallerthan the a wave in the right atrium 40. Right Heart Pressures Tracings 41. Right Atrial Chamber 1. Height of the v waveatrial compliance volume of blood returning 2. Height of the a wave The pressure needed to eject forward blood flow The v wave is usually smallerthan the a wave in the right atrium 42. Right atrial hemodynamic pathology Elevated a wave Tricuspid stenosis Decreased RVcompliance e.g. pulm htn, pulmonic stenosis Cannon a wave AV asynchrony atrium contracts against a closed tricuspid valve e.g. AVB, VtachX descent Prominent Tamponade,RV ischemia,(ASD) Absent Atrial arrhythmias,TR,RA ischemia Absent a wave Atrial fibrillation orstandstill Atrial flutter Elevated v wave Tricuspid regurgitation RV failure Reduced atrial compliance e.g. restrictive myopathyY descent Prominent CCP/RCM/TR Absent TS/Tamponade/RV ischemia 43. Right atrial hemodynamic pathologyNote the Cannon a wave that is occurring during AV dysynchrony atrial contraction is occurring against a closed tricuspid valve.Note the large V wave that occurs with Tricuspid regurgitation 44. Hemodynamic Pathology Tricuspid Stenosis Large jugular venous awaves on noted on exam Notable elevated a wave with the presence of a diastolic gradient >5mmHg gradient is considered signficant 45. Prominent Rt V wave V> 15 mmHg Difference of V and RAmean >5 mmHg Ration of V to RA mean>1.5 46. Advancing Your Right Heart Catheter Continue advancing the catheter into the right ventricle The right and left ventricularpressure tracings are similar. The right ventricular has a shorter duration of systole Diastolic pressure in the right ventricle is characterized by an early rapid filling phase, then slow filling phase followed by the atrial kick or a wavea 47. Normal RV waveform artifact Note the notch on the top of RV pressure waveform This representsringing of a fluid-filled catheter Ringing can also be noted on the diastolic portion of the waveform 48. Advancing Your Right Heart Catheter Advancing out the RVOT to the pulmonary artery There is a systolic wave indicatingventricular contraction followed by closure of the pulmonic valve and then a gradual decline in pressure until the next systolic phase. Closure of the pulmonic valve is indicated by the dicrotic notch 49. Timing of the PA pressure Peak systole correlates with the T wave End diastole correlates with the QRS complex 50. Hemodynamic Pathology Pulmonic Stenosis Notable large gradientacross the pulmonic valve during PA to RV pullback. Notable extreme increases in RV systolic pressures and a damped PA pressure 51. Right atrial hemodynamic pathologyNote the Cannon a wave that is occurring during AV dysynchrony atrial contraction is occurring against a closed tricuspid valve.Note the large V wave that occurs with Tricuspid regurgitation 52. Hemodynamic Pathology Tricuspid Stenosis Large jugular venous awaves on noted on exam Notable elevated a wave with the presence of a diastolic gradient >5mmHg gradient is considered signficant 53. Prominent Rt V wave V> 15 mmHg Difference of V and RAmean >5 mmHg Ration of V to RA mean>1.5 54. Hemodynamic PathologyMitral Stenosis This patient underwent mitral valvuloplasty resulting in a reduction of the resting gradient by 10mmHg and an increase in CO from 3.7 to 5.5LPM and a valve area from about 1.1 to 2.9 cm2 55. E 56. F 57. G 58. A 59. B 60. C 61. D 62. E 63. F 64. G 65. H 66. I-PCWP tracing 67. J-PCWP 68. K 69. L 70. M 71. N 72. NORMAL PRESSURE TRESSINGS RA, RV , PA, PCWP 73. peak100a0 DipNORMAL PRESSURE TRACING Ventricle. 74. Peak systolicend diastolicNORMAL ARTERIAL PRESSURE TRACINGS 75. Kussmauls SignCATHSAP6: Coronary Angiography and Intervention 76. Mitral stenosis with 20 mm gradient. Atrial fibrillation. Note slow y descent and lack of a waves (atrial fib.).Name this pathology. 97 77. Probable Mitral Regurgitation. Large v waves, which could also be due to atrial fibrillation or CHF.Name this pathology. 98 78. 40 Right atrium200 79. 40200Right ventricle 80. 40200Pulmonary artery 81. 40200Pulmonary capillary wedge 82. NORMAL PRESSURE TRACINGS LA , LV , AORTA