The document discusses left ventricular pressure tracings and their components during systole and diastole. It also discusses simultaneous pressure tracings from the left ventricle and aorta in a patient with aortic stenosis that show a fixed aortic obstruction. Finally, it examines left ventricular and left brachial artery pressure tracings in a patient with hypertrophic cardiomyopathy that show an increased gradient and spike-and-dome configuration in the arterial pressure waveform following an extrasystolic beat.

1. DR VIRBHAN BALAI

2. 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

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 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.

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
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

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

24. Peak systolic LV pressure

25. End diastolic LV pressure

26. Fixed aortic obstruction

27. 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

28. ???

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.

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

34. Dehydration-Hypovolemia

35. Effects of respiration

36. ANACROTIC
SHOULDER

37. Pulsus paradoxus

38. Pulsus alternans
Pericardial effusion
Cardiomyopathy
CHF

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

44. Right Heart Pressures Tracings

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

60. E

61. F

62. G

64. A

65. B

66. C

67. D

68. E

69. F

70. G

71. H

72. I -PCWP tracing

73. J -PCWP

74. K

75. L

76. M

77. N

78. NORMAL PRESSURE TRESSINGS – RA, RV , PA, PCWP

90. NORMAL PRESSURE TRACING – Ventricle.
peak
a
Dip
0
100

91. NORMAL ARTERIAL PRESSURE TRACINGS
Peak systolic
end diastolic

92. Kussmaul’s Sign
CATHSAP6: Coronary Angiography and Intervention

97. 97
Name this pathology.
Mitral stenosis with 20 mm
gradient. Atrial fibrillation.
Note slow “y” descent and lack
of “a” waves (atrial fib.).

98. 98
Name this pathology.
Probable Mitral
Regurgitation.
Large “v” waves, which could also
be due to atrial fibrillation or
CHF.

103. Right atrium
0
20
40

104. Right ventricle
20
0
40

105. Pulmonary artery
20
0
40

106. Pulmonary capillary wedge
20
0
40

108. NORMAL PRESSURE
TRACINGS – LA , LV ,
AORTA