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
12. Left ventricular (LV) and left brachial artery(LBA) pressure tracings in a 64-
year-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. PAW and LV Tracings during
Inspiration and Expiration
RV and LV Tracings during
Inspiration and Expiration
Hemodynamic Principles
15. PAW and LV
Tracings during
Inspiration and
Expiration
RV and LV
Tracings during
Inspiration and
Expiration
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.
Which of the following is the
most likely explanation for
these findings?
Hemodynamic Principles
16. PAW and LV
Tracings during
Inspiration and
Expiration
RV and LV
Tracings during
Inspiration and
Expiration
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.
Which of the following is the
most likely explanation for
these findings?
Hemodynamic Principles
17. Hemodynamic Principles
A. She has valvular aortic stenosis.
B. She has hypertrophic cardiomyopathy with obstruction.
C. She has an intraventricular pressure gradient.
D. She has a bicuspid aortic valve with mild stenosis.
E. She has a pressure gradient but it is likely an artifact.
18. Hemodynamic Principles
A. She has valvular aortic stenosis.
B. She has hypertrophic cardiomyopathy with obstruction.
C. She has an intraventricular pressure gradient.
D. She has a bicuspid aortic valve with mild stenosis.
E. She has a pressure gradient but it is likely an artifact.
21. Arterial Pressure Monitoring
Abnormalities in Central Aortic Tracing
Spike and dome configuration
Hypertrophic obstructive cardiomyopathy
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
Spike Dome
22.
23. Right Heart Catheterization
Left Ventricular Pressure
Systole
Isovolumetric contraction
From MV closure to AoV opening
Ejection
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
Peak systolic
pressure
29. 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.
30.
31.
32. 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
33. PWV
stiffer arteries → increased PWV
→ earlier arrival of reflected waves →
augmentation of systolic rather than
diastolic pressure→increased pulse pressure
40. 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
41. 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
42. 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
43. 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
46. 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
47. 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
Absent a wave
Atrial fibrillation or
standstill
Atrial flutter
Elevated v wave
Tricuspid regurgitation
RV failure
Reduced atrial compliance
e.g. restrictive myopathy
X descent
Prominent –Tamponade,RV
ischemia,(ASD)
Absent – Atrial
arrhythmias,TR,RA ischemia
Y descent
Prominent –CCP/RCM/TR
Absent – TS/Tamponade/RV
ischemia
48. 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
49. 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
50. Prominent Rt V wave
V> 15 mmHg
Difference of V and RA
mean >5 mmHg
Ration of V to RA
mean>1.5
51. 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
52. 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
53. 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
54. Timing of the PA pressure
Peak systole correlates
with the T wave
End diastole correlates
with the QRS complex
55. 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
56. 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
57. 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
58. Prominent Rt V wave
V> 15 mmHg
Difference of V and RA
mean >5 mmHg
Ration of V to RA
mean>1.5
59. 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