D ont L ook R ight Chris Pan MD MBA MS Interventional Cardiology University of California Irvine Disclosures None Content Valvular heart disease Aortic disease Mimicker of aortic stenosis ID: 1036789
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1. Hemodynamics II… When The Waves Don’t Look Right … Chris Pan, MD. MBA. MS.Interventional CardiologyUniversity of California, Irvine
2. DisclosuresNone
3. ContentValvular heart diseaseAortic diseaseMimicker of aortic stenosisMitral diseasePericardial diseaseConstrictive vs RestrictiveIntracardiac shunt
4. LHC + RHC measurementRHC: chamber pressure, cardiac output, valve areaLVEDP: Fluid status / HFLV-Ao measurement: Aortic diseaseLV-PCWP measurement: Mitral diseaseLV-RV response: Pericardial disease Saturations: intracardiac shunt
5. Case 170M presented with shortness of breathDiastolic murmur along sternal borderVisible strong carotid pulseHead bobbing
6. Ren X , Banki N M Circulation 2012;126:e28-e29
7. Wide Pulse PressureAortic tracingLV tracingRen X , Banki N M Circulation 2012;126:e28-e29
8. Rapid Rise of LV Diastolic PressureAortic tracingLV tracingRen X , Banki N M Circulation 2012;126:e28-e29
9. Near Equalization of Diastolic LV and Ao Aortic tracingLV tracingRen X , Banki N M Circulation 2012;126:e28-e29
10. Aortic RegurgitationKey Hemodynamic Findings:Wide pulse pressure: High systolic +Low diastolic AORapid rise in LV diastolic pressureLVEDP ~ AOEDPLVEDP is much higher than PCWP (esp. in acute AR)
11. Case 270M presented with shortness of breathCath findings:Normal coronary arteriesLVgram: EF ~ 30%
12. WWYD?70M with SOB, normal coronary arteries, depressed EF, and aortic stenosis with aortic gradient ~ 30mmHgRight heart catheterizationRe-cross aortic valve to measure gradient with a Langston dual lumen catheterDetermine the true severity of the aortic stenosisPseudo aortic stenosis (2/t low flow or gradient) vsTrue fixed aortic stenosis
13. AoV Area FormulaGorlin Formula:Hakki Formula
14. Moderate or Severe AS? Valve Replacement?P-P gradient 30mmHgCO = 3.2l/m FickAVA = 0.7cm2
15. Dobutamine ChallengeNishimura R A , Carabello B A Circulation 2012;125:2138-2150 True fixed stenosis vs Pseudo variable stenosis
16. Dobutamine ChallengeBase 10 Dob+Pace 80 20 Dob + Pace 95
17. S/p Aortic valvuloplasty … What happened?ASAR
18. Case 370M presented with shortness of breathCath findings:Normal coronary arteriesNormal ejection fraction
19. Aortic Stenosis?
20. Still Aortic Stenosis?Distal LVSub-Aortic
21. Spike & Dome
22. Hypertrophic CardiomyopathyNishimura R A , Carabello B A Circulation 2012;125:2138-2150
23. Brockenbrough-Braunwald-Morrow SignNishimura R A , Carabello B A Circulation 2012;125:2138-2150HCMAS1. Decreased arterial pulse pressure2. Increased systolic peak gradient3. Spike and Dome
24. Case 470M evaluated for shortness of breathAdmitted for inferior STEMI s/p DES to mid RCADeveloped acute HF symptoms and new systolic murmur 24hrs after PCI
25. Large V wave
26. Large V waveDefinition:Peak V wave > 40mmHgPeak V wave – PCWP > 10mmHgPeak V wave : PCWP > 2Etiologies:Sudden increase of LA pressure/volumeAcute MR (from ruptured chordae): 3x > normalSeptal defectsHypervolemiaAtrial infarction
27. Case 570M evaluated for shortness of breathCath findings:Normal coronary arteriesNormal ejection fraction
28. Mitral Stenosis
29. Mitral StenosisCommonly measured by simultaneous LV and PCWP pressuresOften overestimate the true transmitral gradientDelay in transmission of the change in pressure contourPhase shiftHeart rate
30. Overestimate Mitral StenosisNishimura R A , Carabello B A Circulation 2012;125:2138-2150
31. Overestimate Mitral StenosisRogers, J. “Hemodynamics in the Cath Lab: A Forgotten Art?”
32. Case 670M evaluated for shortness of breathLung cancer on chemo-radiation therapyRecurrent pericardial effusion
33. Which Tracing Requires Pericardiocentesis?A.B.https://thoracickey.com/5-the-atrial-waveform/
34. Tampondade vs Constrictive PericarditisB.http://www.brown.edu/Courses/Bio_281-cardio/cardio/handout6c.htm
35. ConstrictiveLVRVRestrictive
36.
37. Case 770M evaluated for shortness of breathKnown ASDSaturations: SVC: 68% IVC: 63% RA: 65% RV: 87% PA: 87% FA: 100% PV: 100%Does he need ASD repair ?
38. LR shunt:ASD VSD PDARV failureRL shunt:ToF Eisenmenger’s TranspositionHypoxia
39. Shunt CalculationMv sat = (3 SVC + IVC) / 4Pulm vein sat = LV O2 sat if shunt existsQp/Qs > 2 = severe shunt = repairQp/Qs < 1 = R L shunt = irreversible = no repair (Ao sat – Mv sat) Qp (Pv sat – Pa sat) Qs
40. * MV sat = (3 x 68% + 63%) / 4 = 66.75% (100% – 66.75%*) Qp (100% – 87%) Qs2.56SVC: 68% IVC: 63%RA: 65%RV: 87%PA: 87%FA: 100%PV: 100%
41. Questions & CommentsTHANK YOU