Download Equalization of diastolic pressures

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
2007 SCAI Interventional Cardiology Fellows Course
Gregory J. Dehmer, MD, FSCAI
I have no relevant financial disclosures to make.
Must Know Hemodynamics for PCI
• How to measure pressures
• Catheter behaviors
• Hypotension during PCI
• Tamponade
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
Statham transducer
•
Time the events with the ECG
•
Always know the transducer
level and zero position
Disposable transducer
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;92:1994-2000.
Common Errors and Artifacts
•
Over-damped waveform
Over-damped
Air bubble, clot or contrast in the line
Soft compliant tubing
Loose catheter connection
Properly damped
Common Errors and Artifacts
•
Underdamped waveform (“ring artifact”)
Tubing too stiff or too long
Hyperdynamic state
Catheter tip in turbulent jet
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
Common Errors and Artifacts
•
Catheter malposition
What’s the problem?
•
Loose connections, catheter kinks,
faulty transducers
RA catheter
is near the
TV and is
periodically
being “hit” by
the valve
creating high
frequency
noise
Catheter Behaviors
•
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: loss of
diastolic component
“Ventricularization”
– Occlusion of the coronary by the
catheter
– Transmural myocardial pressure
– Guide too large, proximal spasm or
proximal stenosis
Hybrid: FLP
Hypotension During PCI
More Common
•
Bleeding
•
Vagal reaction
•
•
Overmedication
Technical considerations
•
•
•
Arrhythmia
Shock
Transient ischemic
dysfunction
– Low filling pressures
81 y/o man with prior CABG and LVEF 24%
Investigational percutaneous-implanted LA
pressure monitoring system
Ritzema-Carter JLT. Circ 2006;113:e705 - e706
– Bezold Jarisch reflex
– Pressure miscalibration /
display
– Loose connections
Baseline
Hemodynamic Changes During PCI
Baseline
After 3 min.
With balloon inflation
V waves to 80 mmHg
During PCI
Ritzema-Carter JLT. Circ 2006;113:e705 - e706
Hypotension During PCI
•
More Common
Bleeding
– Low filling pressures
•
Vagal reaction
•
•
Overmedication
Technical considerations
•
•
•
Arrhythmia
Shock
Transient ischemic
dysfunction
– Bezold Jarisch reflex
– Pressure miscalibration /
display
– Loose connections
Less Common
•
•
•
Tamponade
Anaphylactoid rxn
New or unsuspected
valvular lesion
– Acute MR
– AS
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;90:1183-86
Fasseas P, et al. Am Heart J 2004;147:140-45.
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
Hemodynamics of Pulsus Paradoxus
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.
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
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
Differential of Impaired Diastolic Filling
Constrictive
pericarditis
RV infarct
Tamponade
Restrictive
cardiac
disease
< 1/3
Occasional
Frequent
Rare
Prominent
y descent
“M “ or “W”
Insp. 
Prominent
y descent
Prominent
x descent
Variable
y descent
Equalization
of diastolic
pressures
Frequent
Frequent
Frequent
Rare
“Square
root” sign
Frequent
Frequent
Absent
Variable
Pulses
paradoxus
RA
waveforms
Insp. 
Diagnostic Criteria for Constriction
Dynamic
respiratory
factors
Traditional
Criteria
Sensitivity
Specificity
PPV
NPV
LVEDP vs. RVEDP
< 5 mmHg
60
38
4
57
RVEDP vs. RVSP
> 1/3
93
38
52
89
PASP < 55 mmHg
93
24
47
25
RV free wall
> 7 mm
93
57
61
92
Respiratory change
in RA , 3 mmHg
93
48
58
92
PCWP vs. LV
> 5 mmHg
93
81
78
94
100
95
94
100
LV/RV
Interdependence
From: Kern MJ. Editor SCAI Interventional Cardiology Board Review Book
Ventricular Interdependence
Concordant pressures
Restrictive
Discordant pressures
Constrictive