CARDIOVASCULAR CARDIOVASCULAR HAEMODYNAMICS HAEMODYNAMICS How Do I Deal With It? How Do I Deal With It? NHAM ASM 2009 PRE-CONGRESS WORKSHOP Dr Noorfaizan Saaidin MBBCh,BAO (Ireland), MRCP (UK), FNHAM Consultant Cardiologist KPJ Selangor Specialist Hospital Shah Alam
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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..
Look at saturationsLook at saturationsLook at pressuresLook at pressuresCalculate shuntCalculate shuntCalculate gradientCalculate gradientDiagnoses:Diagnoses:
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
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
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
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