CARDIOVASCULAR CARDIOVASCULAR HAEMODYNAMICSHAEMODYNAMICSHow Do I Deal With It?How Do I Deal With It?

NHAM ASM 2009 PRE-CONGRESS WORKSHOP

Dr Noorfaizan SaaidinMBBCh,BAO (Ireland), MRCP (UK), FNHAM

Consultant Cardiologist KPJ Selangor Specialist Hospital

Shah Alam

Highlights Highlights

Indication Indication How is it done?How is it done?Several concepts on basic Several concepts on basic haemodynamicshaemodynamics –– CO, CI, SVR, PVRCO, CI, SVR, PVRWhat do the numbers mean?What do the numbers mean?How to come up with a diagnosis?How to come up with a diagnosis?Common heart conditions..Common heart conditions..

5

Dealing with PressuresDealing with Pressures

Rule of 5Rule of 5’’s : s : RA (CVP) ~ 5 mmHgRA (CVP) ~ 5 mmHgRV systolic/endRV systolic/end--diastolic ~ 25 / 5diastolic ~ 25 / 5PA ~ 25 / 10PA ~ 25 / 10LA pressure (PCWP) ~ 10 LA pressure (PCWP) ~ 10 LV systolic/endLV systolic/end--diastolic ~ 125 / 10diastolic ~ 125 / 10

More than 10 is significant More than 10 is significant PHT / AS / PHT / AS / CoarctationCoarctation / PS/ PS

55

255

2510 10

12510

Dealing with SaturationsDealing with Saturations

More than 5 out is significantMore than 5 out is significantShunt calculation :Shunt calculation :

Shunt fraction Shunt fraction QpQp/Qs = /Qs = AortaAorta--MVMVPVPV--PAPA

Dealing with SaturationsDealing with Saturations

More than 5 out is significantMore than 5 out is significantShunt calculation :Shunt calculation :

Shunt fraction Shunt fraction QpQp/Qs = /Qs = AortaAorta--MVMVPVPV--PAPA

Mixed Venous = Mixed Venous = 3xSVC + IVC3xSVC + IVC44

ShuntsShuntsNormalNormal: :

effective pulmonary blood flow = systemiceffective pulmonary blood flow = systemic

L L R shunt:R shunt:

pulmonary BF = systemic + shunt flowpulmonary BF = systemic + shunt flow

R R L shunt:L shunt:

pulmonary BF = systemic pulmonary BF = systemic –– shunt flowshunt flow

HAEMODYNAMICSHAEMODYNAMICS

Look at saturationsLook at saturationsLook at pressuresLook at pressuresCalculate shuntCalculate shuntCalculate gradientCalculate gradientDiagnoses:Diagnoses:

ASD/VSD/ASD/VSD/EisenmengerEisenmenger’’s/AS/PS/Coarctations/AS/PS/CoarctationFallotFallot’’ss (VSD/PS)(VSD/PS)

77--year old male with easy fatigue in year old male with easy fatigue in school gamesschool games

ChamberChamber Pressure (mmHg)Pressure (mmHg) Saturation (%)Saturation (%)SVCSVC 33 7575IVCIVC 33 7373RARA 44 8585RVRV 36/136/1 8686PAPA 36/1436/14 8484LALA 1212 9696LVLV 110/10110/10 9696FAFA 110/60110/60 9797

4

361

3614 12

11010

11060

96

75

73 86

85

97

84

96

QuestionsQuestions

1. What is the diagnosis?1. What is the diagnosis?

2. What is the size of the shunt?2. What is the size of the shunt?

3. What is the treatment?3. What is the treatment?

24 year old male with murmur from 24 year old male with murmur from childhoodchildhood--now now dyspnoeicdyspnoeic

ChamberChamber Pressure (mmHg)Pressure (mmHg) Saturation (%)Saturation (%)SVCSVC 55 7070IVCIVC 55 7070RARA 66 7373RVRV 120/12120/12 7676PAPA 125/50125/50 7575

PAWPPAWP 99 --LVLV 120/12120/12 8686FAFA 120/60120/60 8686

6

12012

12550 9

12012

12060

70

70 76

73

86

75

86

Questions Questions

1.1. What is the diagnosis?What is the diagnosis?

2.2. What is the treatment option?What is the treatment option?

8 year old with a murmur8 year old with a murmur

ChamberChamber Pressure (mmHg)Pressure (mmHg) Saturation (%)Saturation (%)SVCSVC 22 6565IVCIVC 11 6666RARA 55 6666RVRV 37/337/3 7676PAPA 40/2040/20 7777

PAWPPAWP 1212 --LVLV 130/10130/10 9090FAFA 130/60130/60 8686

5

373

4020 12

13010

13060

65

66 76

66

86

77

90

QuestionsQuestions

1. What is the diagnosis?1. What is the diagnosis?-- EbsteinsEbsteins-- VSDVSD-- PDAPDA-- FallotFallot’’ss-- CoarctationCoarctation

2. What is the most 2. What is the most serious complication?serious complication?-- arrhythmiasarrhythmias-- EisenmengersEisenmengers

syndromesyndrome-- endocarditisendocarditis-- MitralMitral regurgitationregurgitation-- PulmonaryPulmonary

regurgitationregurgitation

GP sees 33 year old woman with GP sees 33 year old woman with anginaangina--has a murmurhas a murmur

ChamberChamber Pressure (mmHg)Pressure (mmHg) Saturation (%)Saturation (%)SVCSVC 44 6464IVCIVC 33 6262RARA 77 8787RVRV 70/570/5 8484PAPA 25/1025/10 8484

PAWPPAWP 99 --LVLV 110/10110/10 9595FAFA 112/60112/60 9292

7

705

2510 9

11010

11260

96

64

62 84

87

92

84

95

Pressures and Pressures and satssats data from cardiac data from cardiac cathcathof a 22of a 22--year old womanyear old woman

SiteSite Pressure mmHgPressure mmHg satssats %%SVCSVC -- 6868RARA 66 7878RVRV 25/025/0--66 7979PAPA 25/825/8 8080LALA 66 9797LVLV 110/0110/0--55 9696AoAo 110/70110/70 9595

6

256

258 6

1105

11070

97

68

79

78

95

80

96

Questions Questions

1.1. What is the diagnosis?What is the diagnosis?

2.2. What would your advice be?What would your advice be?

Cardiac Cardiac cathcath of a 52 y.o woman with of a 52 y.o woman with hxhxof rheumatic fever and now c/o severe of rheumatic fever and now c/o severe

dyspnoeadyspnoea at rest and on exertionat rest and on exertion

SiteSite pressure mmHgpressure mmHg satssats%%RARA mean 13mean 13 6565RVRV 88/088/0--1212 6464PAPA 85/40 mean 5085/40 mean 50 6666LALA mean 15mean 15 9292LVLV 120/0120/0--66 9191AoAo 120/90120/90 9090

Cardiac output is measured at 3.4L/minCardiac output is measured at 3.4L/min

13

8012

8540 15

1206

12090

92

64

65

90

66

91

Questions Questions

1.1. What is the diagnosis?What is the diagnosis?

2.2. What complication has arisen?What complication has arisen?

3.3. Is this lady a suitable surgical candidate?Is this lady a suitable surgical candidate?

A 25 y.o man with a systolic murmur A 25 y.o man with a systolic murmur noted at an insurance medicalnoted at an insurance medical

SiteSite Pressure mmHgPressure mmHgRARA mean 0mean 0RVRV 24/024/0--33PAPA 24/12 mean 1524/12 mean 15LALA mean 7mean 7LVLV 220/0220/0--88AoAo 170/90170/90FAFA 90/6090/60

0

243

2412 7

2208

17090

9060

Questions Questions

1.1. What is the diagnosis?What is the diagnosis?

2.2. What associated lesion is present?What associated lesion is present?

After an acute inferior MI in a 67 y.o After an acute inferior MI in a 67 y.o female the following female the following intracardiacintracardiac

pressures were recorded with a Swanpressures were recorded with a Swan--GanzGanz cathetercatheter

SiteSite Pressure mmHgPressure mmHgRARA mean 8mean 8RV RV 20/420/4--1212PAPA 18/5 mean 1018/5 mean 10PA wedgePA wedge mean 4mean 4FAFA 100/60100/60

What is the explanation for this result?What is the explanation for this result?

8

2012

185 4

10060

EXTRASEXTRAS

Left side anatomyLeft side anatomyStroke volume, stroke volume indexStroke volume, stroke volume indexEjection fractionEjection fractionCardiac output, cardiac indexCardiac output, cardiac indexPreloadPreloadAfterloadAfterloadContractilityContractility

STROKE VOLUMESTROKE VOLUME

The volume of blood ejected by the The volume of blood ejected by the ventricle with each heartbeatventricle with each heartbeat

Normal value Normal value 6060--70 70 mLmL

STROKE VOLUME INDEX STROKE VOLUME INDEX (SVI)(SVI)

Stroke volume indexed to BSAStroke volume indexed to BSA

Formula Formula SVI = Stroke Volume / Body Surface AreaSVI = Stroke Volume / Body Surface Area

Normal valueNormal value25 25 –– 45 mL/m45 mL/m²²

Ejection FractionEjection Fraction

EF = EF = endend--diastolic volume diastolic volume –– endend--systolic volumesystolic volumeendend--diastolic volumediastolic volume

Normal range = 60 Normal range = 60 –– 75 % 75 % of endof end--diastolic volumediastolic volume

Cardiac Output (CO)Cardiac Output (CO)

DefinitionDefinitionThe volume of blood ejected from theThe volume of blood ejected from theventricle over 1 minute.ventricle over 1 minute.

FormulaFormulaCO = heart rate x stroke volumeCO = heart rate x stroke volumeCO = HR x SVCO = HR x SV

Normal ValueNormal Value4 4 -- 6 6 LitersLiters / min/ min

Cardiac Index (CI)Cardiac Index (CI)

DefinitionDefinitionCO indexed against body sizeCO indexed against body size

FormulaFormulaCI = Cardiac Output / Body Surface CI = Cardiac Output / Body Surface

AreaAreaCI = CO / BSACI = CO / BSA

Normal ValueNormal Value2.5 2.5 -- 4.0 4.0 LitersLiters / min / m2/ min / m2

Decrease CO/CIDecrease CO/CI

Causes:Causes:MIMIShockShock↓↓ HRHR↓↓ SVSV((--) ) inotropesinotropeshigh PEEPhigh PEEP

↑↑ vascular vascular resistanceresistanceCardiac Cardiac tamponadetamponadeHypovolemiaHypovolemiaValvularValvular heart heart diseasedisease

Increase CO/CIIncrease CO/CI

Causes:Causes:HypertensionHypertension↓↓ vascular resistancevascular resistance

Pulmonary Pulmonary edemaedema↑↑ Metabolic stateMetabolic state

Positive Positive inotropesinotropes

Cardiac Output = HR x SVCardiac Output = HR x SV

Myocardial OxygenMyocardial Oxygen

PREPRE--LOADLOAD

Definition: Definition: Volume in ventricle at end Volume in ventricle at end diastole.diastole.

ORORPressure exerted onPressure exerted onwalls of ventricle atwalls of ventricle atend diastoleend diastole

PREPRE--LOADLOAD

Clinical Significance:Clinical Significance:Represents fluid returning to heartRepresents fluid returning to heartAlso known as Also known as ““filling pressurefilling pressure””

↑↑ preload, preload, ↑↑ MVO2 demandMVO2 demand

Preload is assessed by measuring thePreload is assessed by measuring thefilling pressure of each ventricle:filling pressure of each ventricle:

Right ventricle preload Right ventricle preload CVPCVPL ft t i l l dLeft ventricle preload PAOPPAOP

AFTERAFTER--LOADLOAD

Definition:Definition:Amount of pressure the ventricle must Amount of pressure the ventricle must

work against during systole to open the work against during systole to open the valvevalve

Clinical significance:Clinical significance:↑↑ afterloadafterload↑↑ work of the heartwork of the heart↑↑ MVO2 demandMVO2 demand

AFTERAFTER--LOADLOAD

Factors that Factors that increaseincrease afterloadafterload::VasoconstrictionVasoconstrictionValvularValvular stenosisstenosis↑↑ blood volumeblood volume

Factors that Factors that decreasedecrease afterloadafterloadVasodilationVasodilation

AFTERAFTER--LOADLOAD

MeasurementMeasurementAfterloadAfterload is assessed by measuring theis assessed by measuring theresistance in the ventricle duringresistance in the ventricle duringsystolic ejectionsystolic ejection

Right ventricle Right ventricle afterloadafterload PVRPVRLeft ventricle Left ventricle afterloadafterload SVRSVR

SYSTEMIC VASCULAR SYSTEMIC VASCULAR RESISTANCE ( SVR)RESISTANCE ( SVR)

DefinitionDefinitionThe resistance the left ventricleThe resistance the left ventriclemust pump against to eject its volume.must pump against to eject its volume.

This resistance is created by the systemic This resistance is created by the systemic arteries and arteriolesarteries and arterioles

FormulaFormula[ (MAP [ (MAP –– CVP) / CO ] x 80CVP) / CO ] x 80

Normal ValueNormal Value

SYSTEMIC VASCULAR SYSTEMIC VASCULAR RESISTANCE (SVR)RESISTANCE (SVR)

Clinical SignificanceClinical SignificanceSVR represents left ventricle SVR represents left ventricle afterloadafterload

↑↑ SVR, SVR, ↑↑ MVO2 demandMVO2 demand↑↑ SVR, SVR, ↓↓ Cardiac OutputCardiac Output↓↓ SVR, SVR, ↑↑ Cardiac OutputCardiac Output

↑↑ SVRSVR

Causes:Causes:

VasoconstrictionVasoconstrictionCatacholamineCatacholamine releasereleaseHypertensionHypertensionCardiogenicCardiogenic shockshockCardiac Cardiac tamponadetamponade

↓↓ SVRSVR

Causes:Causes:

VasodilationVasodilationVasodilator therapyVasodilator therapySeptic shock (Septic shock (hyperdynamichyperdynamic))

PULMONARY VASCULAR PULMONARY VASCULAR RESISTANCERESISTANCE

DefinitionDefinitionThe resistance the right ventricle must The resistance the right ventricle must pump against to eject its volume.pump against to eject its volume.

This resistance is created by theThis resistance is created by thepulmonary arteries and arteriolespulmonary arteries and arterioles

FormulaFormula[ (PAM [ (PAM –– PAOP ) / CO ] x 80PAOP ) / CO ] x 80

Normal ValueNormal Value100100--250 dynes/sec/cm250 dynes/sec/cm--55

f S

PULMONARY VASCULAR PULMONARY VASCULAR RESISTANCERESISTANCE

Clinical SignificanceClinical SignificancePVR represents right ventricle PVR represents right ventricle afterloadafterload

Causes of Causes of ↑↑ PVRPVRPulmonary vessel constriction due toPulmonary vessel constriction due to↓↓ PaO2PaO2↑↑ PaCO2PaCO2

Pulmonary embolusPulmonary embolus

CONTRACTILITYCONTRACTILITY

DefinitionDefinitionThe heartThe heart’’s contractile force or muscle s contractile force or muscle strengthstrength

Factors that influence contractility:Factors that influence contractility:StarlingStarling’’s Laws LawSympathetic nervous systemSympathetic nervous systemPharmacologic agents: +Pharmacologic agents: +ve/ve/--veve inotropyinotropy

StarlingStarling’’s s LawLaw

Positive Positive InotropesInotropes

digoxindigoxinepinephrineepinephrinedopaminedopaminedobutaminedobutamineinamrinoneinamrinonemilrinonemilrinone

Negative Negative InotropesInotropes

lopressorlopressoramiodaroneamiodaronediltiazemdiltiazemverapamilverapamilprocainamideprocainamide

THE END THE END