Cardiovascular Hemodynamics for the Clinician

Title Page

Copyright Page

Contents

List of contributors

Part I Basics of hemodynamics

Chapter 1 Introduction to basic hemodynamic principles

1. Energy in the blood stream exists in three interchangeable forms: pressure arising from cardiac output and vascular resistance, “hydrostatic” pressure from gravitational forces, and kinetic energy of blood flow

2. Blood flow is a function of pressure gradient and resistance

3. Resistance to flow can be estimated using Poiseuille’s law

4. Reynold’s number can be used to determine whether flow is laminar or turbulent

5. Force developed by the ventricles is a function of preload or stretch—the Frank–Starling law

6. Wall tension is a function of pressure and radius divided by wall thickness—the Laplace relationship

7. The normal venous system is a low pressure, large volume reservoir of blood which enables rapid increases in cardiac output

8. The pressure and velocity of a fluid in a closed system are related

9. The velocity of blood increases and pressure decreases as the cross-sectional area of the blood vessel decreases

10. Resistance increases when blood vessels are connected in series and decreases when blood vessels are connected in parallel

Chapter 2 The nuts and bolts of right heart catheterization and PA catheter placement

The pulmonary artery catheter

Brief review of physiology relevant to right heart and pulmonary artery catheterization

Vascular access

Right heart catheterization and placement of a PA catheter

Ensuring that accurate data is obtained from a PA catheter

Cardiac output

Calculating systemic vascular resistance and pulmonary vascular resistance

SvO2 monitoring

Complications of pulmonary artery catheterization

References

Chapter 3 Normal hemodynamics

Cardiac chambers

Left ventricular function

Respiratory variation

Chapter 4 Arterial pressure

Aortic pressure

Mean arterial pressure

Pressure waveform

Effects of respiration on aortic pressure

Peripheral amplification

Noninvasive measurement of blood pressure

Oscillometric blood pressure devices

References

Chapter 5 The atrial waveform

The components of the atrial wave

Abnormalities in atrial pressures

Physical exam

Important points

References

Chapter 6 Cardiac output

Fick method

Thermodilution method

Doppler echocardiographic measurement of cardiac output

Cardiac output measurement in intensive care units

References

Chapter 7 Detection, localization, and quantification of intracardiac shunts

Detection of an intracardiac shunt

Oxygen saturation run

Limitations of using oximetry to detect and quantify intracardiac shunts

Diagnosis of intracardiac shunts at right heart catheterization

Quantifying a left-to-right shunt

Shunt management

Right-to-left shunting

References

Part II Valvular heart disease

Chapter 8 Aortic stenosis

Physical exam

Echocardiographic hemodynamics

Determination of severity of AS by echocardiography

Comparison between invasive and echocardiographic measurements of hemodynamics

Invasive hemodynamics

Common pitfalls

The challenge of low-gradient AS

The challenge of estimating aortic valve area in patients with AS and significant AR

Carabello’s sign

Subaortic membrane

References

Chapter 9 Hemodynamics of transcatheter and surgical aortic valve replacement

Selection of appropriate patients

Low flow–low-gradient aortic stenosis

Using hemodynamics to avoid pitfalls during TAVR

Assessing aortic insufficiency

Expected residual gradients after surgical valve replacement

Long term follow-up after valve replacement

References

Chapter 10 Mitral stenosis

Cardiac hemodynamics in patients with MS

Cardiac output

Quantification of severity of MS

Calculating mitral valve area

Physical examination in MS

Echocardiography

Hemodynamics of mitral valve surgery and percutaneous balloon mitral valvuloplasty (PBMV)

References

Chapter 11 Aortic regurgitation

Hemodynamic changes of chronic aortic regurgitation

Aortic pressures

Left ventricular pressures

Hemodynamic changes detected by physical exam

Hemodynamic changes detected by echocardiography

Acute aortic regurgitation

Pharmacologic treatment of AR

Hemodynamic tracings of a patient with severe AR

References

Chapter 12 Mitral regurgitation

Pathology

Acute MR

Hemodynamic concepts in patients with chronic MR

Compensatory mechanisms in chronic MR

Cardiac catheterization and MR hemodynamics

Physical examination

Echocardiography

Important points

Hemodynamics of mitral regurgitation

Reference

Chapter 13 The tricuspid valve

Tricuspid regurgitation

Tricuspid stenosis

References

Chapter 14 Hemodynamic findings in pulmonic valve disease

Pulmonic valve stenosis

Non-invasive imaging

Cardiac catheterization and invasive hemodynamics

Treatment of PS

Pulmonic regurgitation

Hemodynamic changes in chronic PR

Right ventricular function in chronic PR

Hemodynamic changes detected by non-invasive imaging in chronic PR

Natural history of chronic PR

Pregnancy

References

Part III Cardiomyopathies

Chapter 15 Hypertrophic cardiomyopathy

Physical exam

Hemodynamics

Findings at cardiac catheterization

Left atrium or pulmonary capillary wedge pressure

LV pressure

Aortic pressure

Outflow tract gradient

Echocardiography

Septal reduction for refractory symptoms

References

Chapter 16 Heart failure

Directly measured intracardiac pressures

Derived parameters from measured intracardiac pressures

Important points: Hemodynamics in HF

References

Chapter 17 Restrictive cardiomyopathy

Hemodynamic principles

Differentiating restrictive cardiomyopathy from constrictive pericarditis

Echocardiography

References

Part IV Pericardial disease

Chapter 18 Constrictive pericarditis

Hemodynamics of constrictive pericarditis

Hemodynamic principles

Physical exam

Pericardial imaging techniques

Findings at cardiac catheterization

Sensitivity and specificity of various hemodynamic findings in constrictive pericarditis

Findings on echocardiography

Differentiation of constrictive pericarditis and restrictive cardiomyopathy

References

Chapter 19 Cardiac tamponade

Hemodynamic pathophysiology

Hemodynamic findings

Physical exam findings

Hemodynamics of cardiac tamponade as measured with echocardiography

References

Chapter 20 Effusive–constrictive pericarditis

Hemodynamics of effusive–constrictive pericarditis

Physical examination

Pericardial imaging techniques

Findings on echocardiography

References

Part V Hemodynamic support

Chapter 21 Hemodynamics of intra-aortic balloon counterpulsation

History and uses

Description

Hemodynamic effects

Intra-aortic balloon pump timing

Conclusion

References

Chapter 22 Hemodynamics of left ventricular assist device implantation

Initial evaluation

Early post-implantation period

The chronic LVAD patient

Conclusion

References

Part VI Coronary hemodynamics

Chapter 23 Coronary hemodynamics

Basic principles of coronary blood flow

Regulation of coronary blood flow

Clinical measurement of coronary hemodynamics in the cardiac catheterization laboratory: Doppler and pressure wires

Measurement of coronary blood flow

Doppler wire and coronary flow reserve

Pressure wire and fractional flow reserve

References

Chapter 24 Fractional flow reserve

Concept of fractional flow reserve

Key clinical studies of FFR

Limitations of FFR measurement

Instantaneous wave-free ratio

References

Part VII Miscellaneous

Chapter 25 Right ventricular myocardial infarction

The effects of ischemia on the right ventricle

Clinical presentation, ECG changes, and echocardiographic findings in RV infarction

Hemodynamics of RV infarction

Findings at cardiac catheterization

Diagnosis of RV infarction with hemodynamics

Management

References

Chapter 26 Pulmonary hypertension

Hemodynamic changes associated with pulmonary hypertension

Special population: Pulmonary hypertension in patients being evaluated for cardiac transplantation

Hemodynamic changes detected by history and physical exam

Two-dimensional echocardiography in pulmonary hypertension

Take-home message

References

Chapter 27 Hemodynamics of arrhythmias and pacemakers

Premature atrial and ventricular contractions

Heart block

Cannon A waves

Ventricular tachycardia

Junctional rhythm

Atrial fibrillation and atrial flutter

Sinus bradycardia or tachycardia

Cardiac pacing

Physiology and pathophysiology of AV synchrony

Pacemakers in specific patient populations

References

Chapter 28 Systematic evaluation of hemodynamic tracings

Unknowns

Reference

Index

EULA