Right heart cath

1. Learning Objectives
• Identify normal hemodynamics
• Identify common conditions via their hemodynamics
• Understand Right Ventricular hemodynamics.
• Pitfalls in measuring hemodynamics
• Post Transplant Care
• Common Acute findings
• Biopsy schedule

2. “The Golden Hour”
• Sir R Adams Cowley “Father of Trauma
Medicine” 1975
• “There is a golden hour between life and
death. If a patient is critically injured he
has less than 60 minutes to survive. He
may not die right then: it may be a few
days, weeks, a month or a year later –
but something has happened in its body
that is irreparable”

3. Thiele H et al. IABP-SHOCK II Trial Investigators. Intraaortic balloon support for myocardial infarction with
cardiogenic shock. N Engl J Med. 2012 Oct 4;367(14):1287-96.
IABP-SHOCK II Trial Investigators IABP for cardiogenic
shock

4. Complete Reversal of Hypoperfusion in
30min of IABP from the SHOCK Registry
Ramanathan K, et al. Rapid complete reversal of systemic hypoperfusion after intra-aortic balloon pump counterpulsation and survival in
cardiogenic shock complicating an acute myocardial infarction. Am Heart J. 2011 Aug;162(2):268-75. doi: 10.1016/j.ahj.2011.04.025.

5. Pulmonary Artery Catheter Use and Mortality in the Cardiac
Intensive Care Unit
Kadosh B, Berg D, Bohula E, et al. Pulmonary Artery Catheter Use and Mortality in the Cardiac
Intensive Care Unit. J Am Coll Cardiol HF. 2023

6. Cardiovascular hemodynamics
• What we measure:
– Intracardiac pressures
– Oxygen Saturations
• What we calculate:
– Cardiac Output and Index
– Qp [pulmonary flow]
– Qs [systemic blood flow]
– PVR and TPG
– SVR
– Gradients across valves

7. Cardiovascular hemodynamics
• Fluid filled catheter which transmits pressure wave from the heart
• Pressure transducer which converts pressure to electrical impulse
• Amplifier converts small electrical impulse converted to a pressure wave

8. Right atrial pressure waveforms

10. Right Ventricle pressure waveforms
• Systolic pressure
• Diastolic pressure
• Right ventricular End Diastolic
Pressure

11. Formulas
• FICK CO = Oxygen Consumption / (Arterial Sat – Mixed Venous Sat)*1.36*10*Hgb
• CI = CO/BSA
• SVR = (MAP – CVP) /CO * 80
• PVR = (PCWP – PA mean) / CO *80
• CPO = (CO * MAP) / 451

12. Cardiac Power is the best predictor of mortality in cardiogenic shock
Rupert Fincke et al. JACC 2004;44:340-348
American College of Cardiology Foundation

14. Defintion of Pulmonary Hypertension
• 2018 World Symposium of Pulmonary Hypertension
– PH is currently defined by mPAP >20 mmHg.
– “Pre-capillary pulmonary hypertension” is considered, if mPAP is >20 mmHg, PAWP is ≤15 mmHg
and PVR is ≥3 WU.
– “Post-capillary pulmonary hypertension” is defined as mPAP >20 mmHg with PAWP >15 mmHg. In
the case of PVR <3 WU, we talk about “isolated post-capillary pulmonary hypertension”, while in
the case of PVR ≥3 WU the criteria for “combined pre- and post-capillary pulmonary hypertension”
are fulfilled.
– Exercise PH is currently not part of the haemodynamic definition of PH.
– The evidence for the beneficial effects of PAH therapies is exclusively based on therapeutic trials
with PAH patients (or non-operable chronic thromboembolic PH) with mPAP ≥25 mmHg.

15. Hemodynamic Definitions of Pulmonary Hypertension Based
on Right-Heart Catheterization
mPAP (mmHg) PCWP (mmHg) PVR (WU) Group
Precapillary
pulmonary
hypertension
mPAP ≥ 20 ≤15 ≥3 1, 3, 4, 5
Isolated postcapillary
pulmonary
hypertension
mPAP ≥ 20 >15 <3 2, 5
Combined pre- and
postcapillary
pulmonary
hypertension
mPAP ≥ 20 >15 ≥3 2, 5

16. Abnormal Hemodynamics
• 1. PCWP 12, PA 80/20/40, RV 78/5/8, RA 8, CO 4.5, CI 2.5
• 2. PCWP 25, PA 50/25/33, RV 50/10/23, RA 23, CO 4, CI 1.9
• 3. PCWP 20, PA 45/20/31, RV 46/2/5, RA 5, CO 5, CI 2.5
• 4. PCWP 12, PA 45/20/28, RV 45/10/22, RA 22, CO 3.6, CI 1.8
• 5. PCWP 35, PA 60/35/41, RV 58/5/10, RA 10, CO 3, CI 1.5
• 6. PCWP 14, PA 25/3/10, RV 42/2/5, RA 5, CO 5, CI 2.5
1. Group I Pulm HTN
2. Constriction
3. HFpEF
4. RV failure
5. LV failure

17. Pitfalls
• ZERO
• TD vs. FICK
• PA Cath position
• Air bubble and Catheter whip
• Deep inspirations/Respiration Variation for TD and pressure tracing
Source: Reynolds H, Hochman J; Circulation 2008;117(5):686-697

18. Right Ventricle
The Spectrum of Acute MCS Devices in 2017
Left Ventricle

19. Matching Patients and AMCS Pumps
The Tufts Cardiogenic Shock Algorithm
Kapur & Esposito. Curr Cardiol. 2016

20. Pulmonary Artery Pulsatility Index as a predictor of RV failure
after LVAD
J Card Fail. 2016 Feb;22(2):110-6. doi: 10.1016/j.cardfail.2015.10.019. Epub 2015 Nov 10.

22. Inference of the survival benefit of current destination therapy with current continuous-flow
left ventricular assist device (LVAD) compared with medical management from the REMATCH
trial.
Soon J. Park et al. Circ Heart Fail. 2012;5:241-248
Copyright © American Heart Association, Inc. All rights reserved.

23. Case
• CC: chest tightness
• 65 yr old man with PMhx of CAD with hx of PCI of LAD 2 yrs ago, HTN, DM, HLD,
obesity, OSA.
• BP 90/70 HR 120 RR 24 O2sat 90% on RA
• SOB, cool extremities, thready pulse
• EKG with anterior V1-V3 2mm Elevations
• Next step?

24. Case Cont
• Cath lab for emergent PCI
• Found to have occluded LAD
• BP 70/40 MAP 50, Confused, Lactate 5
• Next step?
• Inotropes, RHC, MCS, CABG?

25. Case Cont
Support then PCI,
coronary perfusion, end organ preservation
MCS? IABP, Impella, ECMO