Cardiovascular Haemodynamics
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Transcript of Cardiovascular Haemodynamics
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