Rengga_PPT GELOMBANG RHC dari FKUNAND.pptx

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1. BENTUK GELOMBANG DAN PENGUKURAN TEKANAN HEMODINAMIK PADA RIGHT AND LEFT HEART CHATETERIZATION Oleh Rengga Sebastian Pembimbing: dr. Kino Sp.JP (K) Dr. Harben Fernando Sp.JP

2. PENDAHULUAN

3. POTENTIAL SOURCE OF PRESSURE TRACING ARTEFACT Lose connection in the system Catheter “”filling” Air in the system End-hole artefact Inaccurate calibration or baseline drift Peripheral pulse wave amplification Partial catheter obstruction Catheter entrapment

4. RIGHT HEART PRESSURE TRACING Right atrium Right ventricle Pulmonary artery Pulmonary capillary wedge E ach horizontal line = 2 mmHg

5. RA WAVEFORMS Normal R A pressure : 2- 8 mmHg a wave : Contraction in atrial systole x descent : fall in RA pressure (atrial diastole) c wave : closure of tricuspid valve v wave : ventricular systole + passive atrial filling in atrial diastole y descent : fall in RA pressure following opening of the TV + passive filling of RV

6. RV WAVEFORMS Normal RV pressure: 20-30/2-8 mmHg Right ventricular systolic pressure is elevated in the presence of a large VSD, RVOT obstruction, and pulmonary hypertension. Recordings should be obtained in the apex and in RVOT to confirm the absence of any intracavitary gradient The contour of the RV pressure trace  may indicate the form of pathology present (pulmonary valve stenosis with IVS  systolic trace is triangular shape, VSD such as ToF  same contours as LV with a systolic plateau)

7. PA WAVEFORMS Normal PA Pressure: 15 - 30 /4- 1 2 mmHg Mean pulmonary pressure : 12-16 mmHg

8. PULLBACK PA RV

9. PCWP WAVEFORMS Normal PCWP: 2-12 mmHg Pulmonary artery wedge pressure is usually a good reflection of the LA and LVEDP because of the absence of valves in the pulmonary circulation The PCWP does not reflect the LVEDP when there is pulmonary vein stenosis, cor triatriatum, mitral stenosis, or anomalous PVR

10. Pressure Waveform of Left Heart Left atrium Left ventricle Aorta E ach horizontal line = 2 mmHg E ach horizontal line = 10 mmHg

11. LA PRESSURE LA Pressure: 5-12 mmHg a Wave Elevated : LA outflow obstruction (mitral stenosis) or impaired LV compliance. Dominant : ASD v Wave Elevated : Mitral Regurgitation LA mean Pressure Elevated : large left-to-tight shunts at ventricle or great vessels or LV failure

12. LV PRESSURE Normal LV Pressure: 90-140/5-12 mmHg The peak systolic pressure in the LV should be ≤ 5 mm Hg greater than the peak systolic pressure in the ascending aorta gradient between the LV and the aorta is present in dynamic left ventricular obstruction (as in hypertrophic cardiomyopathy), subaortic stenosis, or aortic valve stenosis

13. AORTIC PRESSURE The normal aortic pressure is a reflection of left ventricular stroke volume and systemic vascular resistance A gradient between the ascending and descending aorta suggests coarctation of the aorta Increased : Ruptured sinus of Valsava , Aortic Insufficiency Narrowed : Low Cardiac Output (AS, CHF), Pericardial Tamponade

14. PULLBACK LV AO LV

15. RHC PRESSURE WAVEFORMS

16. TERIMA KASIH

17. TIP FOR ACCURATE PRESSURE EVALUATION Check setup (transducer levelling, zeroing, and calibration ) Select appropriate fluid-filled catheter (short, large bore, stiff, with side holes, or end hole) Assure there are tight connection s between catheter(s) and transducer(s), avoid fluid leakage Remove all air bubbles in the circuit Perform assessment of wave configuration with close correlation to the ECG Check for artifacts that can distort waveform tracing (e.g., over- or under- damping) Check an arterial blood gas to confirm normocapnia and rule out respiratory pathology Measure at end expiration Obtain pressure waveform data before injecting contrast Step 1 Step 2

18. Derived Hemodynamic Variables

19. Oxygen Method for Calculation of CO Oxygen in the blood is carried in two forms: Attached to Hb or dissolved in plasma Oxygen content : sum of dissolved oxygen in the blood and bound oxygen to Hb Oxygen capacity : amount of oxygen that can be bound by fully saturated haemoglobin in blood (max oxygen capacity 1.36 mL O2/1 gram of Hb)

20. Oxygen Consumption (VO2)

21. VO2 Table by LaFarge and Miettinen

22. Sampling SVC The sample in the true SVC is taken in the mid-portion, superior to the entrance of the azygous vein and inferior to the innominate vein Sampling too high in the SVC, near the IJ vein  “falsely” low saturation , cerebral extraction High mid-SVC saturation: high-output state, partial or total anomalous pulmonary venous return to the SVC or innominate vein, or an arteriovenous fistula A low mid-SVC saturation: systemic arterial saturation is low (pulmonary venous desaturation, right-to-left shunt) or with a low cardiac output state (high tissue extraction) Sampling RA The RA sample should be obtained at the lateral midatrial wall to avoid the low saturation stream from the coronary sinus and to facilitate mixing from the inferior and superior venae cavae streams A step-up of >9% is highly suggestive of a left-to-right shunt

23. Sampling RV The RV saturation should be approximately equal to that in the RA; a step-up of >6% suggests a L-R shunt A step-up at the ventricular level may be seen with a low ASD (where the oxygenated blood preferentially streams into the RV ), a VSD, a ruptured sinus of Valsalva aneurysm, a coronary AV fistula draining into the RV, or a L-R shunt at the great vessel level with signicant pulmonary valve insufficiency Sampling PA A step-up of >6% at the PA level is seen with a high outlet VSD , PDA, AP window, coronary artery fistula into the pulmonary artery, anomalous origin of the coronary artery from the pulmonary artery also with fistula, or a surgical aortopulmonary communication

24. Pulmonary to Systemic Flow Ratio Calculation of the pulmonary to systemic flow ratio ( Qp : Qs) can estimate the magnitude of shunts using the following equation: Absent of a shunt Small L  R shunt Large L  R shunt R  L shunt Qp : Qs = 1 Qp : Qs = between 1 and < 1.5 Qp : Qs = > 1.8 : 1 Qp : Qs = < 1

25. Vascular Resistance Resistance in vascular circuit  difference in pressure between the two end of the circuit divide by the flow Mathematical assessment of vascular resistance is based on laws of Poiseuille and Ohm (which describes electrical resistance). The normal range for indexed pulmonary resistance is 1 - 3 Wood units·m2 The normal range for indexed systemic resistance is 20 - 28 Wood units·m2

26. Pulmonary Vasculature Reactivity Testing PVR is the recommended parameter for differentiating subtypes of PH (preferred over Trans-Pulmonary Gradient, TPG, and Diastolic Pulmonary Gradient, DPG) PH (mean PAP>20) subtypes are identified based on PVR & PCWP PCWP ≥ 15 PCWP < 15 PVR ≥ 2 WU Combined Post and Pre-capillary PH ( CpcPH ) I solated Pre-capillary PH PVR < 2 WU Isolated Postcapillary PH ( IpcPH ) Consider high flow state

27. Valve Area and Pressure Gradient