This document contains descriptions of 30 hemodynamic slides showing various cardiac pathologies. It provides the problems or pathologies seen in each slide and explanations. Some of the pathologies described include constrictive pericarditis, pulmonary valvular stenosis, ventricularization, hypertrophic obstructive cardiomyopathy, coarctation of the aorta, cardiac tamponade, and trigeminy. The document tests the reader's ability to interpret cardiac catheterization images and understand different cardiac pressures, waveforms and pathophysiology.

1. Cardiac Pressure I Image identification Identify the 30 hemodynamic slides, with the artifacts, problems, and pathology shown. After you identify the problem, explanations are provided. By Wes Todd

2. . What 3 hemodynamic problems are seen during this coronary injection? Transient hypotension, bradycardia & ST depression characteristic of right coronary injection using old style high osmolar contrast. LCA injection causes ST elevation.

3. Con . Name this pathology. Constrictive pericarditis. Note the diastolic pressure equality along with a square root sign. The systolic pressure variation varies by 20 mmHg = Pulsus Paradoxus.

4. Same Pt. as previous slide . What are the negative LV spikes? LV LV “ y” waves or square root sign. There is diastolic pressure equality of all pressures (even with positive intrathoracic pressure shown at left). This is Constrictive Pericarditis.

5. . Read this RV (List 3 numbers). Read at plateau 40/ 11, 13. Computer reading grossly underestimates these pressure. They should never be negative. RV with marked respiratory variation.

6. . What pressure is this? PA with respiratory variation. Distinct dicrotic notch. Disregard premature beat. (AF ?) Read as 33/19, 23 mmHg.

7. . Name this pathology. Pulmonary Valvular Stenosis. PA pressure grossly distorted with systolic vibrations possibly due to turbulence in PA. 50 mm PP gradient.

8. . Name this congenital pathology. AS with PDA. Catheter pulls back from LV-AO (with35 mm gradient) then through PDA, into PA (with 13 mm gradient) and finally into RV.

9. . Name this pathology. V waves on wedge suggest Mitral Regurgitation. Note how the PA dicrotic notch is exaggerated by V waves. Severe MR waves may be transmitted all the way back into the lung bed, and through it into the PA.

10. . Name this pathology, seen during coronary angiography. Ventricularization. Shows characteristic diastolic upsloping with occasional “a” waves. Probable widowmaker lesion in Main LCA.

11. . What causes this problem? Reverse aortic gradient. (normal) Peripheral amplification in AO.

12. . Name this pathology. HOCM. Hypertrophic Obstructive Cardiomyopathy (old term IHSS) Subvalvular LV gradient 100 mmHg.

13. . Name the 3 chambers seen in this pullback. PA, RV & wedge. Pulmonary hypertension with systolic RV of 42 mmHg. (Average out resonant peak) PA systolic is 36 mmHg. Could be PS, or more likely just respiratory variation. Same as previous patient. 30 60

14. . Name the congenital pathology seen in this Rt. Ht. pullback. PA-RV pullback showing pulmonary valve stenosis. RV hypertension of 70 mmHg. Probable peripheral edema with RV edp of 20 mmHg.

15. . Why is #2 higher than #1? AO & peripheral aorta (femoral sheath) showing peripheral amplification of 20 mmHg. Do not use this spiked peripheral artery when measuring critical pressures like AS gadient.

16. . This type of arterial pulse is termed pulsus ______. Pulsus Tardus. Tardus means slow or delayed upstroke. Also, note the anacrotic notch on upstroke, characteristic of AS. 44 mmHg peak-peak gradient. If the pulse were reduced in amplitude it would also be termed “Pulsus Parvus.”

17. Aortic Regurgitation. Corrigan’s wide pulse pressure (low diastole). . Name this pathology.

18. . Name this pathology. Coarctation of aorta with 30 mmHg peak-peak gradient. Slow pullback across coarct. Shows typical systolic gradient only.

19. Ventricularized pressure above. Note flat diastole with prominent “a” wave. Probable Left-Main coronary lesion. During LCA angiography . What is the probable diagnosis?

20. . Name this pathology. Pulsus Bigeminus. Bigeminy on ECG with alternating hi – low ventricular beats.

21. . Why is the arterial pressure imroved? Bradycardia & hypotension, corrected with ventricular pacemaker. Note small ventricular spikes on ECG in last tracing.

22. . Name this pathology. Brockenbraugh’s sign of HOCM. Post PVC compensatory pause causes increased filling, and increased preload. Frank-Starling law causes post PVC increased LV contraction with characteristically increased gradient.

23. . In order of their appearance, list the 4 chambers through which this Swan-Ganz passes. RA, RV, PA, wedge Swan-Ganz rapid float through. Not usually this concise.

24. . The BP (off screen) varies markedly with respiration. Name this pathology. Cardiac Tamponade. Diastolic equality of all pressures (except arterial). Arterial respiratory variation of more than 10 mmHg is Pulsus Paradoxus. No square root sign in PT.

25. . What is this procedure? Pericardial centesis or “tap”, for pericardial tamponade. Here blood is drawn off from hemo-pericardium due to possible trauma or catheter rupture of RV. Centesis is now usually done by placing a soft pigtail catheter in pericardium first.

26. . Name the atrial waves seen. Biphasic atrial “c” waves due to atrial fibrillation. Computer miss-reads them thinking them to be “a” waves. Spiked “v” waves. Wedge mean is elevated at 25 mmHg. RV hypertension 50 mmHg.

27. . Name this ECG pathology. Trigeminy. (Pulsus Trigeminus) Every 3 rd beat is a PVC with reduced arterial pressure.

28. Damped coronary pressure. Catheter “deep throat” in RCA. Diastole flat with pres-systolic dip. During RCA angiography . What’s wrong with this coronary pressure?

29. Resolution of VF into atrial fib. Hypotensive BP returning towards normal. . Name this ECG pathology.

30. Ventricularized / damped pressure above. Reduced systole with decreased diastolic slope. Probable Left-Main coronary lesion. . What’s wrong with the 1 st coronary pressure above?

31. The End How did you do? Developed & copyright by Wes Todd 2004 Additional pressure games found in Todd’s CV Review CD version 4 www.westodd.com