Hemodynamics In The Cath Lab:
A Forgotten Art?
Jason Rogers, MD
Director, Interventional Cardiology
UC Davis Medical Center
Sacramento, California
What is Ths?
Pulsus Alternans
•  "Then he felt her pulse. There was a
strong stroke and a weak one, like a
sound and its echo. That was supposed
to betoken the end.”
•  D.H. Lawrence, “Sons and Lovers”
Basic Concepts
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Remember to flush and level
Know the deflections
Know the reference scale
Know the tracing speed
Know the underlying rhythm
Coronary Guide Maneuver
Ventricularization
Grossman’s Cardiac Cath
Right Heart Catheterization
Look at the Scale
Venous Pressure Tracing
•  a – atrial contraction
•  c – AV valve closure
•  v – venous filling of
atrium
•  x – atrial diastole
•  y – atrial emptying
Venous Waveform Variants
Hemodynamic
Assessment of Aortic Stenosis
Aortic Stenosis
most common
senile calcific (older
pts)
bicuspid (younger pts)
LVH
also congenital, rheumatic
Normal LV/Aorta Hemodynamics
EKG
Aortic
Pressure
LV
Pressure
Definitions
2014 ACC Valvular HD Guidelines
Richard
Gorlin
R.G.
1926 - 1997
Askenazi Circulation 1976
Torricelli’s Law
A
F = AVCc
Cc
V = (Cv) 2gh
CO/(HR)(DFP)
A=
(C)(44.3)
P
Flow-Gradient
Relationships in Aortic
Stenosis
HR = 88
HR = 68
With decreasing HR, the mean gradient increases for any
given CO (SV increases if CO unchanged--opposite effect of
mitral)
Hakki Formula
CO
A =
P
HR 65-100, Δ 0.07± 0.11 cm2
HR<65 >100, Δ 0.19 ± 0.28 cm2
Hillis LD, et al. Cath and Card Diagnosis
Hakki AH, et al. Circulation 1981;63:1050.
Femoral Artery vs. Ascending Aorta
Dobutamine in Low Output AS
No Dobu
CO/CI 4.37/2.01
Mean Gradient 32
AVA 0.77 cm2
Dobu 15 mcg/kg/min
CO/CI 6.63/3.14
Mean Gradient 45
AVA 0.96 cm2
Mitral Stenosis
Mitral Stenosis
LV
Pathophysiology:
LA
Pressure gradient
between LA and LV in
diastole
LA enlargement, small LV
Cardiac catheterization
Simultaneous pulmonary capillary wedge (PCW) and direct left atrial pressure. Sinus rhythm.
PCWP about 40-120 ms later and 2-4 mm Hg lower.
73
Mid Diastolic Rumble
Flow-Gradient
Relationships in Mitral
Stenosis
HR = 100
HR = 72
With decreasing HR, the mean gradient decreases for any
given CO (More diastolic filling time)
Aortic Regurgitation (AR)
Also called Aortic Insufficiency (AI)
Aortic Insufficiency
Mitral Regurgitation
LA Pressure Waveform
Large “V” wave in severe MR
PCW : mean 22, v wave 39
MitraClip Therapy for MR
PCW : mean 14, v wave 18
Hypertrophic Obstructive
Cardiomyopathy
Bach et al in Interventional Procedures for Adult Structural Heart Disease,
Rogers and Lasala eds
Systolic murmur w/ Valsalva
The BrockenbroughBraunwald-Morrow
Sign
Constrictive Pericarditis
Circulation
June 1, 1996 vol. 93 no. 11 2007-2013
Conclusions
•  Hemodynamics are a window into heart
physiology
•  Accurate waveform interpretation is
clinically important
•  Emerging structural heart therapies will
rely more heavily of real-time
assessment of hemodynamics
Thank You