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Collection of cath tracings by navin

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cardiac catheterisation tracings collection for cardiology viva and exams

cardiac catheterisation tracings collection for cardiology viva and exams

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  • 1. DR.NAVIN AGRAWAL
  • 2. Right Heart Catheterization Left Ventricular Pressure  Systole  Isovolumetric contraction  From MV closure to AoV opening  Ejection  Peak systolic pressure From 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;79:629-630 Copyright © 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 Expiration RV 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 Expiration RV 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 Expiration RV and LV Tracings during Inspiration and Expiration
  • 17. Hemodynamic Principles A. 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 Principles A. 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 cardiomyopathy Spike Dome 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
  • 22. Right Heart Catheterization Left Ventricular Pressure  Systole  Isovolumetric contraction  From MV closure to AoV opening  Ejection  Peak systolic pressure From 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 wave decreases  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 pressure→increased 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 to about 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 the closure 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 wave atrial compliance volume of blood returning 2. Height of the a wave The pressure needed to eject forward blood flow  The v wave is usually smaller than the a wave in the right atrium
  • 40. Right Heart Pressures Tracings
  • 41. Right Atrial Chamber 1. Height of the v wave atrial compliance volume of blood returning 2. Height of the a wave The pressure needed to eject forward blood flow  The v wave is usually smaller than the a wave in the right atrium
  • 42. Right atrial hemodynamic pathology  Elevated a wave  Tricuspid stenosis  Decreased RV compliance  e.g. pulm htn, pulmonic stenosis  Cannon a wave  AV asynchrony – atrium contracts against a closed tricuspid valve  e.g. AVB, Vtach X descent Prominent –Tamponade,RV ischemia,(ASD) Absent – Atrial arrhythmias,TR,RA ischemia  Absent a wave  Atrial fibrillation or standstill  Atrial flutter  Elevated v wave  Tricuspid regurgitation  RV failure  Reduced atrial compliance  e.g. restrictive myopathy Y descent Prominent –CCP/RCM/TR Absent – TS/Tamponade/RV ischemia
  • 43. Right atrial hemodynamic pathology Note 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 a waves 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 RA mean >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 ventricular pressure 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 wave a
  • 47. Normal RV waveform artifact  Note the notch on the top of RV pressure waveform  This represents “ringing” 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 indicating ventricular 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 gradient across the pulmonic valve during PA to RV pullback.  Notable extreme increases in RV systolic pressures and a damped PA pressure
  • 51. Right atrial hemodynamic pathology Note 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 a waves 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 RA mean >5 mmHg  Ration of V to RA mean>1.5
  • 54. Hemodynamic Pathology Mitral 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. peak 100 a 0 Dip NORMAL PRESSURE TRACING – Ventricle.
  • 74. Peak systolic end diastolic NORMAL ARTERIAL PRESSURE TRACINGS
  • 75. Kussmaul’s Sign CATHSAP6: 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 atrium 20 0
  • 79. 40 20 0 Right ventricle
  • 80. 40 20 0 Pulmonary artery
  • 81. 40 20 0 Pulmonary capillary wedge
  • 82. NORMAL PRESSURE TRACINGS – LA , LV , AORTA

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