LAKSHMI_2023_SPEED_24th_latest_the_final_version_31st_aug_2023.pptx

LAKSHMI_2023_SPEED_24th_latest_the_final_version_31st_aug_2023

1. Cardiac Catheterization Data Lakshmi Gopalakrishnan Railway Hospital Chennai

2. Systematic approach essential Comprehension of physiology underlying waveforms and changes Knowledge of technical aspects of recording, limitations and sources of error and artifacts Basic Requirements

3. Ability to identify chamber from which tracing is being recorded Recognize basic maneuvers – withdrawal from chambers, gradients etc Effect of “interventions” – ranging from respiratory changes, drug effect, procedures etc Basic Requirements

4. Data from different sites – physiologic events in different chambers Correlation with clinical data ECG correlation – do not be “electro-mechanically dissociated”!!! Oximetry data Relationship of flow volume, flow rate etc. Effect of maneuvers and medication Correlation of data

5. Baseline – is the zero level correct ? Scale factor – absolute level of pressure, equal for both chambers ? “Morphology” of waveforms – any abnormality Gradients – peak vs mean , flow correlates etc “Expected” phenomena – and variants Pay attention to

6. Inspection – raw data : correctness, validity etc. Inference – Converting raw data to hemodynamically meaningful information Integration – Correlation of the information into a diagnosis or explanation of an observation Steps in analysis

7. Right Atrial pressure waveform

8. RA Pressure Waveform X’ > Y schematic Systolic dominance

9. Respiratory variation

10. KUSSMAUL’S SIGN

11. CHARECTERISTIC M SHAPED APPEAREANCE IN CONSTRICTION X’ = Y giving the M pattern Increased V wave pressure with NO restriction to early rapid filling Sharp Y descent and deep Y trough

12. Dip and Plateau- SQUARE ROOT SIGN in early diastole Constrictive physiology

13. Cardiac tamponade – before and after pericardiocentesis Re appearance of the Y descent NO TAMPONADE ABSENT Y DESCENT TOTAL DIASTOLIC RESTRICTION – TAMPONADE

14. A -- Severe Tricuspid Regurgitation B -- Diastolic gradient indicating Tricuspid stenosis also

15. A ---- Severe Tricuspid Regurgitation Femoral vein

16. AV dissociation on the ECG ‘‘ Cannon ‘’ waves during AV dissociation, and small ‘ a ‘ waves during synchrony CANNON

17. ECG shows paced complexes on the left and on right sinus rhythm Cannon waves during pacing and normal “ a ” waves during av synchrony CANNON C

18. LA Pressure Waveform

19. Y dominant

20. X” Y DOMINANT Y DESCENT

21. Left ventricular diastolic pressure waveform

22. Ventricular pressure waveform -- Diastole

23. Varying severity of restriction to diastolic ventricular filling Line 3 dip and plateau - CP Line 5 Tamponade

24. Constrictive pericarditis simultaneous LV and RV pressures Equalization of high diastolic pressures Dip and Plateau 20mm Hg

25. Dip and Plateau - Square root sign in early diastole -- Constrictive physiology Dip and plateau

26. Great arteries

27. AORTIC PRESSURE PULSE WAVEFORM

28. Computer -derived forward and reflected pressure waves Central aortic pressure is Summation Reflected pressure wave La late systolic peaking due to reflected wave I incident wave

29. Valsalva maneuver Reduced pressure reflections Ee exagerated reflections Augmentation of pressure

30. Characteristic Waveform in hypovolemia After fluid bolus

31. Simultaneous RA, PERICARDIAL, and Aortic pressure trace After Pericardiocentesis PULSUS PARADOXUS NOPARADOXUS

32. Pulsus Alternans

33. Left - Pacing causes fall of systemic pressures – lack of atrial contribution Right - atrial synchrony and return of normal systemic pressures

34. PA pressure pulse trace

35. PCW trace PA trace what does the mark on PA trace denote ?

36. Technical aspects

37. Technical aspects – catheter position

38. Simultaneous LV and Femoral artery pressure trace in the same patient True AS gradient pigtail holes advanced across Aortic valve False low AS gradient sideholes in the Aorta

39. Pigtail catheter pullback from LV to Aorta Asterisk indicates falsely wide aortic pulse pressure Complete withdrawal of catheter to Aorta shows normal Aortic pressure

40. Simultaneous LV and Aortic pressure trace The LV pressure has come down below the aortic pressure on the right ‘ ’LOOSE CONNECTION ‘’ of tubing to catheter, manifold or transducer

41. Interactive Pressure Tracing Session - II

42. Pressure tracings – Interactive Session Comment on these two traces – What is the difference ?

43. Importance of compensatory mechanisms DIASTASIS between LV and AORTA CHRONIC ACUTE SEVERE AORTIC REGURGITATION WIDE PULSE PRESSURE

44. SIMULTANEOUS LV AND PCW PRESSURE WHAT DOES THE ARROW DENOTE WHAT DOES THE ARROW DENOTE

45. ACUTE SEVERE AR - premature mitral valve closure The LVEDP exceeds PCW LVEDP exceeds PCW MITRAL VALVE CLOSURE premature

46. Aortic Stenosis Gradients WHAT ARE THESE GRADIENTS MARKED ?

47. PEAK INSTANTANEOUS GRADIENT ( 75 mm Hg) PEAK TO PEAK GRADIENT ( 35 mm Hg) MEAN GRADIENT Area /SEP 100 mm Hg Aortic Stenosis Gradients : Peak to Peak, Peak instantaneous and Mean Gradient

48. Pressure tracings – Interactive Session Left ventricular (LV) and femoral arterial (FA) traces during left heart hemodynamic study. What is the interpretation?

49. Pressure tracings – Interactive Session Rise in Femoral Art. pressure by approx. 20 mm Hg. on withdrawal of catheter across Aortic valve Carabello’s sign - seen only in patients with critical AS (AVA <0.6 cm 2 ) Carabello BA Am J Cardiol 44 :424;1979

50. Cardiac Catheterization Data Lakshmi Gopalakrishnan Railway Hospital Chennai

51. Pressure tracings – Interactive Session What is the diagnosis ? Why ?

52. Pressure tracings – Interactive Session HOCM - LV cavity to outflow gradient with no valvar gradient.

53. Pressure tracings – Interactive Session Why not discrete sub-aortic stenosis ?

54. Pressure tracings – Interactive Session Spike-and-dome Aortic trace rules out discrete sub-aortic stenosis .

55. Pressure tracings – Interactive Session What is your interpretation of this tracing ?

56. Pressure tracings – Interactive Session Brockenbrough –Braunwald sign narrow pulse pressure SPIKE AND DOME

57. Aortic stenosis Patient A Patient B AORTIC VALVAR FIXED STENOSIS DYNAMIC LVOTO

58. Simultaeneous LV and Aortic pressure traces from two patients Patient A Patient B Comment on the two traces

59. Simultaeneous LV and Aortic pressure traces from two patients Patient A Patient B HOCM dynamic LVOTO severe , Mid systolic obstruction , spike and dome Aortic valve stenosis Severe, late slow peaking ,

60. Pressure tracings – Interactive Session . COMMENT ON THE TRACE

61. Pressure tracings – Interactive Session HOCM -spontaneous change from nodal to sinus rhythm. With restoration of sinus there is an increase in LV stroke volume ( seen on LBA trace) and fall in gradient.

62. Please comment on the trace

63. Supra- Valvar Aortic stenosis Low Dicrotic Notch Wide Pulse pressure

64. Mitral stenosis PRE POST Comment on these two tracings

65. Mitral stenosis – contd. PRE POST More than just a gradient !

66. Pressure tracings – Interactive Session How severe is the stenosis? Mild Moderate Severe Mitral stenosis : LA and LV pressure traces : 50 mmHg

67. Pressure tracings – Interactive Session How severe is this stenosis? Mild Moderate Severe Mitral stenosis : LA and LV pressure traces : 50 mmHg

68. Pressure tracings – Interactive Session

69. Pressure tracings – Interactive Session Atropine Baseline What is the difference between trace A and B ? What is the significance of this ? A B

70. Pressure tracings – Interactive Session Atropine Baseline Mitral stenosis – effect of heart rate on gradient

71. Essentials of Hemodynamics and Oximetry What does the lower set of data represent ? What is the term used to characterize this ?

72. Essentials of Hemodynamics and Oximetry

73. LA – LV pressure crosover at a higher LA pressure-----S1 The DP/DT is already high by then in the LV S2—OS

74. Pressure tracings – Interactive Session What does the pressure tracing show ? (LV= left ventricle PC= pulmonary capillary wedge )

75. Pressure tracings – Interactive Session Acute severe MR - giant v wave due to regurgitation into a small and non-compliant LA

76. PCW trace PA trace what does the mark on PA trace denote ?

77. Pressure tracings – Interactive Session A B What is your interpretation of trace A ? What has caused the change in trace B ? Left ventricular and pulmonary wedge pressures

78. Pressure tracings – Interactive Session A B Severe MR with tall v waves . After nitroprusside infusion, LV systolic and after-load fall, with fall in v wave height .(Note patient has AF).

79. TWO PATIENTS WITH RESTRICTIVE PHYSIOLOGY LV AND RV SIMULTANEOUS PRESSURES 1 2 WHAT IS THE OBSERVATION ?

80. Constrictive pericarditis VS Restrictive cardiomyopathy LV - RV DISCORDANCE IN CONSTRICTION LV – RV CONCORDANCE IN RESTRICTION VENTRICULAR INTERDEPENDANCE

81. Pressure tracings – Interactive Session What is your interpretation of this tracing? RV and LV tracings in a patient with acute TR

82. Pressure tracings – Interactive Session RV and LVEDP elevated. Identical pressures throughout diastole. RV systolic minimally raised - so high RVEDP not due to PAH. Restrictive physiology due to restraining effect of pericardium with acute volume overload of RV .

83. Pressure tracings – Interactive Session Comment on these two traces – what is the difference ?

84. Pressure tracings – Interactive Session Ventricular interdependence in Constrictive Pericarditis Contrast with Restrictive Cardiomyopathy

85. Pressure tracings – Interactive Session Severe AR in a patient with a prosthetic aortic valve. Diastasis between LV and Aorta . LVEDP exceeds PCWP.

86. Oximetry – Interactive session

87. Oximetry Data Always interpret in light of clinical data Hemodynamic data usually also provided Correlation of clinical, hemodynamic and oximetry data essential

88. Cyanosis in the new born A 5 day old with profound cyanosis. No cardiomegaly, single S2, no murmur. ABG: pO2 18mmHg, SaO2 40% and acidosis.

89. CATH DATA

90. Diagnosis LV and PA saturations and pressures are same indicating that they are connected to each other Diagnosis: Transposition of great arteries with restrictive inter-atrial communication

91. Management Balloon septostomy / Prostaglandin E1 as emergency measure Arterial switch operation at 4 to 5 weeks

92. Clinical data 35 day old child Increased precordial activity Cyanosis

93. SO2 Pressure SVC 66.0 RA 90.0 12 RV 92.4 58 PA 92.0 50/32 LA 90.5 12 LV 91.6 110 Ao 90.5 110/70 Cath data

94. Cardiac type TAPVC Saturations of all the chambers of the heart are same - diagnostic of TAPVC Here the SVC saturation was normal and hence the TAPVC is of cardiac type In supracardiac TAPVC, the SVC saturation also would be high

95. CHF in the newborn A 5 day old baby presents with severe respiratory distress and shock Chest x-ray - No cardiomegaly , pulmonary odema

96. Chamber O 2 Saturation Pressure SVC 65 - IVC 90 - RA 90 a 6 v 8 (6) RV 89 70/10 PA 88 70/30 (45) LA 86 a 7 v 7 (6) LV 89 80/9 FA 88 80/50 (62)

97. Infradiaphragmatic TAPVC Saturations in all chambers are nearly the same Here the IVC saturation is also high and hence infradiaphragmatic TAPVC All four pulmonary veins form a confluence draining to portal system via a descending vertical vein Obstruction invariable , when ductus venosus closes Treatment – Emergency surgery

98. 9 month old child who underwent a palliative procedure on day 40 of life

99. Cath data

100. TOF with BT shunt

101. 18 year old boy,Class II effort intolerance , recently detected heart disease

102. Cath data

103. PDA Eisenmenger

104. Clinical data 10 year old boy with no cardiac symptoms No cardiomegaly, single loud S2, constant pulmonary ejection click X-ray – no cardiomegaly, dilated central pulmonary arteries, peripheral pruning ECG – RVH

105. Cath data Oximetry % Pressures Post O2 (mmHg) SVC 71 IVC 77 PA 87 95/62 (77) 102/62 (82) Aorta 97 98/72 (82) 102/72 (86) PA wedge 6 PVR 14.1 SVR 27.7 Qp /Qs 5.1/2.7

106. Recommendation Inoperable No clinical signs of shunt No cardiomegaly / vascularity on x-ray No LV on ECG Near identical PA and aortic mean pressures No response of PA pressures to oxygen PVR 14

107. Assessment of operability

108. Pulmonary vascular disease in CHD CRITERIA FOR OPERABILITY RESISTANCE RATIO = PVR/SVR NORMAL < 0.25 Ratio factors in neural, hormonal and blood viscosity influences 0.25 TO 0.50 MODERATE PULM VASCULAR DISEASE SURGERY LIMITED TO NET SHUNT L>R RESISTANCE RATIO <0.5 >0.75 indicates SEVERE PVD AND CONTRAINDICATION TO SURGERY

109. 8 months infant , 6.5 kg Downs syndrome

110. Chamber O 2 Sat Pressure O 2 Sat Pressure SVC 53 - 56 - RA 80 a10-v12 (8) RV 79 82/9 PA 75 80/42 (55) 85 80/30 (47) PAW 91 a12-v9 (7) (10) LA 90 a10-v12 (8) LV 90 84/11 FA 90 84/46 (59) 99 84/50 (61) Qp Qs Qp /Qs PVR In room air 5.0 2.8 1.8 9.1 On 10 lit O2 11.7 2.8 4.2 3.2 On 10’ of O 2

111. Diagnosis ? Management ?

112. Diagnosis and Management AV septal defect Surgical repair Significant increase in L>R shunt with inhaled oxygen Fall in PVR to operable range with oxygen

113. 23 year old lady Recent onset palpitations and dyspnea