This document discusses oximetry, a technique used to detect left-to-right and right-to-left cardiac shunts by measuring oxygen saturation levels in different chambers of the heart. It explains how to perform an oximetry run to collect blood samples and calculate pulmonary and systemic blood flows. A significant step up in oxygen saturation between chambers indicates the presence and location of a shunt. The document also discusses limitations of oximetry and alternative methods for detecting shunts like angiography and echocardiography.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
HEMODYNAMICS MONITORING IN CRITICALLY ILL PATIENTS: ASSESSMENT OF FLUID STATU...Bassel Ericsoussi, MD
Invasive methods are well accepted, but there is increasing evidence that these methods are neither accurate nor effective in guiding therapy
An accurate and non-invasive measurement of CO is the best method of cardiovascular assessment
Assessment of haemodynamics a critically ill patient and its management has always been a matter if debate. Over time a lot of studies and therapeutic interventions have been carried out. This presentation is a review of such interventions and their impact on the outcome.
Cardiac catheteriztion, Oximetery study in a patient with VSDPRAVEEN GUPTA
In this ppt i am going to discuss how to do cardiac catheterisation study, oximetry study and how to analyse its data in a patient with VSD who came to our hospital
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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oxymetery.pptx
1. Oximetry basic concept and it’s uses
in diagnosing various congenital
heart diseases
Speaker
Dr.Awdhesh
2. Introduction
Detection of LEFT to RIGHT SHUNT
Oximetry run
PBF calcualtion
SBF calculation
Left to right shunt Detection & Quantification
Flow Ratio (QP/QS)
Limitation of oximetry method
Other methods of left to right shunt
Detection of RIGHT to LEFT SHUNT
Bidirectional Shunt
3. INTRODUCTION
• Detection, localization and quantification of intracardiac
shunts is an integral part of the hemodynamic evaluation in
patients with CHD.
• Intracardiac shunting of blood results when there is an
opening between the right and left heart chambers and a
pressure difference between the connected chambers.
• Pressures on the left side of the heart are generally higher
than on the right side so most shunts are predominantly left
to right although right to left and bidirectional shunts are seen
(predominantly in Eisenmenger syndrome).
4. INTRODUCTION
• O2 CONTENT
Total amount of oxygen present in a blood
(O2 bound to Hb + Plasma Dissolved O2)
• O2 SATURATION
O2 bound to Hb
• O2 CARRYING CAPACITY OF Hb = 1.36 mL O2 PER GRAM OF HB
• DISSOLVED O2 = 0.03 x Partial Pressure of O2 in mm Hg
• RELATION BETWEEN O2 SATURATION AND CONTENT
O2 content =O2 carrying capacity of Hb x % Saturation +
Dissolved O2
5.
6.
7. When to suspect a shunt?
• Unexplained arterial desaturation(Sao2<95%)
(Rule out: Excessive sedation, COPD, Pulmonary
congestion/edema)
• Unexpectedly high Oxygen content in
pulmonary artery (>80%)
8. Any patient with cyanosis or arterial desaturation <95%
Supine position of the patient - Alveolar hypoventilation ,
Excessive sedation from the premedication
COPD or other pulmonary parenchymal disease
Pulmonary congestion secondary to the cardiac disease
Assume a more upright posture , take deep breaths , cough
Administer 100% oxygen
Persisting hypoxia indicates R – L cardiac
shunt
9. • Left to Right shunt:
Oxygenated blood that bypasses the systemic
vascular bed
• Right to left shunt:
Deoxygenated blood that bypasses the pulmonary
vascular bed
• Admixture lesion:
Anatomical defects facilitates the mixing of
oxygenated & deoxygenated blood
• Transposition physiology:
Anatomic abnormality preventing oxygenated blood
reaching the systemic vascular bed
10. Detection Of Left To Right Shunt
• L – RT SHUNT : Detection need “Significant O2 step up”
in blood oxygen saturation or content in one of the
right heart chamber/PA
• Significant Step up : Increase in blood O2 content or
saturation that exceeds the normal variability that
might be observed if multiple samples were drawn
from that cardiac chamber
11. Screening for Left To Right Shunt
• Take blood samples from SVC and PA if Δ O 2
saturation between these is ≥8% ,It means Left
to right shunt is there so do complete Oximetry
run to locate and to quantify the shunt
12. Catheter for Oximetry run
• End hole Catheter (Swan Ganz balloon flotation
catheter) or one with side hole near close to its tip
• Catheter tip position adjusted by pressure
measurement
• 2 ml blood should be taken from each site
13. OXYMETRY RUN: Sample Collection sites
• Left and/or Right PA
• MPA
• RVOT
• Mid RV
• RV near TV or Apex
• RA (low or near TV).
• Mid RA.
• High RA
• Low SVC (Near junction with
RA
• High SVC (Near junction with
innominate vein)
• IVC high (just at or below
diaphragm)
• IVC low (at L4- L5)
• LV
• Aorta (distal to insertion of
ductus)
.
14. SVC sample
• Taken at mid SVC level: below the innominate and above the
azygous vein
• A location that is too high may provide a sample from the
axillary (peripheral arm) vein and give an erroneously high O2
saturation and a sample from the internal jugular vein can
give an erroneously low saturation.
• A sample obtained too low in the SVC (at, or close to, the
superior vena cava–right atrial junction) may actually include
some blood refluxing into the SVC from the right atrium.
• 5- 10 % lower than IVC sample .
15. IVC Sample
• True IVC sample is taken below the hepatics.
• Slight catheter manipulation causes significant
change in values.
• Samples close to coronary sinus are as low as 25-
40%, from close to renal veins can be as high as 90%,
saturations from hepatic veins are intermediate
between CS and renal vein saturations.
16. Right Atrium
• Right atrial sample should be taken at lateral
mid atrial wall to avoid the low saturation
stream from coronary sinus and to facilitate
mixing from IVC and SVC streams .
• Moss and adams Heart disease in infants, children
and adolescent
17. Practical Errors
• To ensure the results are as accurate as possible, the
samples must be collected as close in time as good
technique permits
• Blood samples should not be withdrawn into the
syringe too rapidly, “rapid aspiration increased
oxygen saturations”
• Complete mixing of blood is assumed in all chambers
Matta et al. Anesthesiology 1997;86:806–808.
18. • In performing the Oximetry run, an end-hole catheter (e.g.
Swan Ganz balloon flotation catheter) or one with side hole
close to its tip (e.g., a Goodale-Lubin catheter) is positioned in
the right or left pulmonary artery.
• Cardiac output is measured by the Fick method.
• One operator manipulates catheter under fluoroscopic and
pressure control ,while assistant aspirates 2 mL blood
samples from each of the locations indicated.
• If a sample cannot be obtained from a specific site because of
ventricular premature beats, that site should be skipped until
the rest of the run has been completed.
• The entire procedure should take less than 7 minutes.
19. GUIDELINES FOR OPTIMUM USE OF OXIMETRIC METHOD FOR
SHUNT DETECTION AND QUANTIFICATION
• Blood samples at multiple sites should be obtained rapidly.
• Blood O2 saturation data rather than O2 content data are preferable
• Comparison of the mean of all values obtained in the respective chambers
is preferable to comparison of highest values in each chamber.
• Because of the important influence of SBF on shunt detection exercise
should be used in equivocal cases where a low SBF is present at rest.
20. GUIDELINES FOR OPTIMUM USE OF OXIMETRIC METHOD FOR
SHUNT DETECTION AND QUANTIFICATION conti . .
• The sampling to be done with the patient breathing room air or
a gas mixture containing no more than a maximum of 30%
oxygen
• Saturation data may be inaccurate in patients breathing more
than 30% oxygen, as a significant amount of oxygen may be
present in dissolved form in the pulmonary venous sample.
21. • Oxygen content
The technique of the oximetry run is based on the
pioneering studies of Dexter and his associates in 1947.
Oxygen content was measured by Van Slyke technique , and
other manometric studies.
It was found that multiple samples drawn from the right
atrium could vary in oxygen content by as much as 2%.
The maximal normal variation within right ventricle was
found to be 1%.
Because of more adequate mixing, a maximal variation
within the pulmonary artery was found to be only 0.5%.
22. Thus using Dexter Criteria a significant step up is
present
At the atrial level when highest oxygen content in blood
samples drawn from the right atrium exceeds the highest
content in the venae cavae by 2 vol %.
At the ventricular level, if the highest right ventricular sample
is 1 vol % higher than the highest right atrial sample.
At the level of the pulmonary artery if the pulmonary artery
oxygen content is more than 0.5% vol% higher than the
highest right ventricular sample.
1 vol% = 1ml O2/100ml blood or 10mlO2/l
24. Detection of Left to Right Shunt by Oximetry
Criteria for Significant Step up
Difference in Mean
between Distal and
Proximal chamber
samples
Difference in Highest value
between Proximal
and Distal chamber
Approximate Minimal
Qp/Qs required to Detection
( Assuming SBFI=3L/min/M2
O2 % sat O2 vol % O2 % sat O2 vol%
Atrial
(SVC/IVC to RA
≥ 7 ≥ 1.3 ≥11 ≥ 2 1.5-1.9
Ventricular
(RA to RV)
≥ 5 ≥ 1 ≥ 10 ≥1.7 1.3-1.5
Great
vessel
(RV to PA)
≥ 5 ≥ 1 ≥ 5 ≥ 1 ≥ 1.3
Any level ≥ 7 ≥ 1.3 ≥ 8 ≥1.5 ≥ 1.5
25. Causes of O2 Step up at various level
Atrial :
• ASD
• PAPVC
• RSOV to RA
• VSD with TR
• Coronary fistula to RA
Ventricular
• VSD
• PDA with PR
• Ostium Primum ASD
• Coronary fistula to RV
27. Pre tricuspid shunts
• Atrial septal defect (ASD)
• Interatrial communication
• Anomalous pulmonary venous drainage
• Systemic AV fistulae
• Ruptured sinus of Valsalva to right atrium
• Coronary AV fistulae to right atrium
• Gerbode defect
28. Post tricuspid shunts
• Ventricular septal defect (VSD)
• Aortopulmonary window (APW)
• Patent ductus arteriosus (PDA)
• Pulmonary AV fistulae
• Coronary AV fistulae
• RSOV to any structure beyond tricuspid valve
• Aorta to LV tunnel
• Aortopulmonary collaterals
29. What to do if significant step up
detected?
Calculate
• PBF
• SBF
• Magnitude shunt
30. MVO2 Calculation
• The mixed venous oxygen content is the average
oxygen content of the blood in the chamber proximal
to the left to right shunt
• MVO2 ( At Rest) = 3 SVC O2 + 1 IVC O2
4
• MVO2 ( At Exercise) = 1 SVC O2 + 2 IVC O2
3
31. Calculation of Pulmonary Blood flow
(QP )
PV O2 = Pulmonary venous O2 concentration
PA O2 = Pulmonary artery O2 concentration
VALUES
PULMONARY VEIN = 95% If systemic saturation ≥95%
If systemic saturation <95% check whether intra cardiac
shunt present or not. If not there take value as 98% if
there take the arterial saturation as pulmonary vein
saturation
33. Magnitude of shunt
• Expressed in terms of either Absolute blood flow across
the shunt in L/mt or as a ratio of the PBF to SBF.
• Left to right shunt = Q p – Q S or QP/QS
34. Flow ratio
QP/QS Ratio
< 1 means Right to Left shunt
< 1.5 but >1 means Small left to right shunt
≥2 Large left to Right shunt
Use O2 % saturation
35. Limitation of oximetry method
• Absence of steady state during the collection of blood sample
• Elevated SBF will cause mixed venous oxygen saturation to be higher than
normal and inter chamber variability will be blunted.
• If oxygen content is used for calculating the shunt rather than O2
saturation Hb concentration will effect the result
• Small shunts or in the presence of high cardiac output (which decreases
AVO2 difference) oximetry data loses its accuracy
36. • The magnitude of the step-up varies with the oxygen-carrying
capacity of blood and the cardiac output.
• The relationship between the magnitude of step-up and the shunt
flow is nonlinear and with increasing left-to-right shunting, a given
change in shunt flow produces less of a change in the saturation step-
up.
37. Other method of shunt detection
• Indocyanine green curve
• Radionuclide technique
• Contrast angiography
• Echocardiography
38. Indocyanine green curve
• It can detect shunts too small to be detected by
the oxygen step-up method
• IF negative , no need to perform an complete
oximetry run.
39. Procedure
• Dye injection: Proximal chamber and a sample is taken from a distal
chamber.
• Using a densitometer, the density of dye is displayed over time distal
chamber
• L- RT shunt : Injected to PA sampling done at brachial artery
Finding: Early recirculation on the downslope of the dye
curve
• Rt - Lt shunt :
Injected into the right side of the heart proximal to the
location of the suspected shunt and blood samples
obtained from a BA
Findings: Distinct, early peak present on the upslope of the
curve
42. Angiography
• Selective angiography done for visualizing and
locating the site of left to right shunt
View
• LAO Cranial View: IV Septum, Sinus of Valsalva
, AT Aorta , DT Aorta
43. Detection Of Right To Left Shunt
• R-L shunt suspected if cyanosis or arterial
desaturation is there (<95%)
• If hypoxemia present aim is to find out the
location and magnitude of the shunt
44. Oximetry :
• Take Oximetry sampling from PV, LA, LV and Aorta
• First chamber which shows desaturation is the site
of shunt
• Disadvantage: In adults PV & LA entry difficult
45. Bidirectional flow
• Left to Right shunt = QP – Q eff
• Right to left shunt = QS − Q eff
Effective Blood Flow (EBF) is the fraction of mixed venous
return received by the lungs without contamination by the
shunt flow or the oxygenated blood reaching the systemic
circulation without the shunt blood
47. 6 years old asymptomatic child, acyanotic,
S2 wide split, 3/6 ESM at base
Chamber O2 Saturation
SVC 72
IVC 76
RA 85
RV 88
PA 89
PAW 100
LV 98
Ao 97
FA 98
49. • To say Significant step in O2 saturation difference
between Mean of distal chamber and proximal
chamber samples in SVC/IVC to RA, RA to RV, RV to
PA are
• a) ≥8, ≥4, ≥3
• b) ≥7, ≥5, ≥5.
• c) ≥9, ≥8, ≥4.
• d) ≥1.3, ≥1, ≥1.