CHAPTER 10 Hemodynamics—acquisition and presentation of data 274 The pressure curves display very minute deflections that reflect even the most minor pressure changes. With the proper connecting tubing, proper fluid in the column, meticulous flushing of all segments of the fluid column including that in the transducer, along with properly operating and accurately calibrated transducers, pres- sures recorded from fluid column systems are crisp, smooth and very accurate, and are comparable with the pressure curves obtained from catheter or wire tipped transducers, which are discussed later in this chapter. At the same time, this pressure measurement/recording systema with the long complex, interposed fluid column a does present the opportunity for many different types of artifacts or erroneous pressure waveforms. In order to transmit the pressure accurately, the entire length of tubing between the pressure source and the transducer (the catheter and connecting tubing) must be non-elastic (non-compliant) and have an adequate and fairly uniform diameter of its lumen. Most cardiac catheters themselves have fairly rigid walls, are very non- compliant and, in general, transmit pressures reliably. Usually the firmer the shaft of the catheter, the better the pressure transmission. There are, however, a few polyethylene catheters and catheters with very small lumens (< 4-French catheters) that transmit pressure poorly, and generally these should be avoided when very accurate pressures are required. There are many varieties of commercially available, flexible connecting tubing, which are very satisfactory for the connection between the proximal end of the catheter and the transducer. However, any tubing with soft or compliant walls, such as that which is often attached to the side ports of sheaths and back-bleed valves, attenuates the pressure transmission and is not satisfactory for use within the pressure system. Compliant or soft tubing dampens (smoothes or flattens) the pressure curves. However, very “elastic” tubing produces exactly the opposite effect. Because of the elastic recoil of the tubing, a marked “overshoot” (exaggeration) of the pressure curves is created. The entire fluid column within this tubing must be one continuous, intact column of a non-compressible liquid. It must be completely free of air, blood, clots or contrast material anywhere along the column. Many of the current plastic materials used in the connecting tubing/system are virtually “non wettable” and, as a consequence, tend to trap minute bubbles along their inner surfaces. As the fluids warm, the trapped gases within the fluid effervesce from the fluid into larger bubbles. There are usually multiple connectors or stopcocks between the catheter and the transducer including the manifold to which the transducer is attached. Each junc- tion in the system or stopcock represents a potential dis- ruption of the fluid column. A loose connection or, more commonly, a trapped micro-bubble of air at one of the junctions totally interrupts the transmission of the pres- sure wave through the fluid column. It is extremely important that all junctions and stopcocks along the course of the tubing are cleared of even minute bubbles to obtain accurate recordings. Each junction should be tapped vigorously with a hard instrument as the fluid system is flushed vigorously into a flush bowl on the table at the onset of the case and again anytime during the pro- cedure when the pressure curves change or deteriorate. Originally, pressure transducers were small and ex- tremely accurate Wheatstone bridges or “strain gauges”. The strain gauge transmitted infinitesimally small move- ments of a fluid column into small movements of a diaphragm in the transducer. The diaphragm movements changed the distances and, in turn, the electrical resist- ances between pairs of resistors. These changes were con- verted into variations in an electrical signal that was pass- ing through the resistors, which was displayed on the screen of a cathode ray tube (CRT) or other monitor as a pressure curve. These pressure curves were electronically attenuated from electrical interference so they were not “flingy” or ragged appearing. Modern transducers have much smaller and more rigid diaphragms, which move solid state crystals to produce the electrical signal of the pressure curve. These solid state transducers are equally as accurate, and more stable than, Wheatstone bridge transducers. At the same time, solid- state technology has allowed for a much less expensive manufacturing process for these transducers, making them essentially disposable. This allows for the easy replacement of the transducer if there is any question of its accuracy. The electrical signals from the transducers are transmitted and recorded as pressure curves in the physiologic recording apparatus, a tape or disk recording system and/or onto a paper record. A remote transducer is usually positioned on the rail of the catheterization table at one side of the patient, or occa- sionally, actually lying on the surface of the catheteriza- tion table itself near or on the patient’s feet or legs. In order to compensate for different patient sizes, the transducer itself or a reference, “zero point” of an open fluid column, connected directly to the transducer, is positioned at the “mid-chest” level, halfway between the front and back of the thorax 1 . The transducer is calibrated to zero electronic- ally with this zero fluid level opened to the room atmo- sphere at the mid-chest level. The transducer or “zero level” tubing is attached to the table at this level so that it moves up or down with the patient when the patient and table are moved up or down. This measured and fixed zero level does not take into account the differences in vertical height between various locations within the cardiac chambers and vascular sys- tem. Each difference of 2.5 cm in vertical height creates a CHAPTER 10 Hemodynamics—acquisition and presentation of data 275 1.9 mmHg difference in pressure; however, in the usual anatomy, and particularly in smaller patients, these inter- nal vertical distances and the resultant pressure differ- ences are negligible. In large patients, particularly where pressures are being recorded from the lower-pressure areas (for example the distance in a supine patient between the posterior of the left atrium and the anterior of the right atrium) the pressure difference due to the differ- ence in height between the two locations can lead to erro- neous “gradients”. When there is concern about this, the actual distances between the catheter tips are visualized and measured accurately using the lateral X-ray system in the straight lateral view. In the biplane pediatric catheter- ization laboratory, any significant discrepancy in these vertical distances becomes apparent very readily during the normal, intermittent use of the lateral fluoroscopy plane. In most catheterization procedures involving complex congenital heart lesions, at least two, if not more, catheters are used simultaneously. Two catheters with their tips positioned in the same location within the cardiovascular system offer the best opportunity to verify the accuracy of the entire pressure recording system. With properly func- tioning transducers and properly prepared and flushed fluid lines and connections, the two separate pressure tracings from the two separate catheters positioned in the same location and displayed or recorded at the same pres- sure gain produce a single line (Figure 10.1). This almost single line tracing from the superimposed tracings from two separate catheters and two separate pressure systems/ transducers verifies the accuracy of the entire system! The lower the gain on the recording apparatus, the more accur- ate this comparison of the pressure curves will be. For example two venous pressures that are displayed at a maximum pressure gain of 10 mmHg, demonstrate very vividly even tiny differences between the two, sup- posedly identical pressure curves, while if the same pres- sure curves are displayed at a pressure gain of 100 mmHg, differences of 1–2 mmHg are easily missed. When more than two catheters are used during a catheterization, it is imperative to check the pressure curve from each additional catheter (and pressure system) against one of the other, already verified or corrected, pressure curves from one of the other catheters. Two, three, four or more simultaneous pressures generated from the same location, and displayed at the same gain, should display a single line pressure curve of all the super- imposed curves! This verifies the integrity of the entire pressure system and of each separate catheter/pressure system. When a pressure curve from any separate catheter or pressure system does not superimpose, the source of error is investigated and corrected before proceeding with any pressure measurements during the catheterization procedure. During the catheterization, when a pressure measure- ment or recording is made from any location, a separ- ate “reference pressure” is recorded simultaneously. The usual reference pressure is a peripheral arterial pressure tracing from the indwelling arterial line or catheter. The arterial pressure is displayed continuously and recorded simultaneously along with any other pressure being recorded. If this reference pressure is not always present, a difference in pressure between two locations that is recorded at different times and under different physio- logic conditions, can be interpreted erroneously as a “pressure gradient” between the two sites, even when no difference actually exists. The simultaneously recorded reference pressure clearly demonstrates changes in all of the pressures along with any changes in the patient’s “steady state”. As an example of the value of the reference pressure: At the beginning of the catheterization a patient with a suspected large ventricular septal defect has a right ven- tricular pressure of 70/0–3 while a simultaneous femoral arterial pressure of 80/45 mmHg is recorded. As the case progresses, the patient receives a bolus infusion of extra fluid, still more fluid from catheter flushes, and undergoes several right-sided angiograms. Somewhat later in the case, a pressure of 95/0–8 is recorded from the left ven- tricle. This, alone, suggests a 25 mm gradient between the two ventricles and, in turn, a restrictive VSD! In actuality, the femoral systemic pressure now is 105/60 with all of the intravascular/intracardiac pressures increased by the “volume expansion”. When rechecked against this systemic pressure, the right ventricular pressure also is 95/0–8! Without the reference arterial pressure, the over- all pressure rise in all of the chambers or vessels can go unrecognized and lead to erroneous conclusions. As with all pressure systems, the pressure tracing from the reference catheter/transducer must also be checked against another catheter/transducer system being used in the patient at the beginning of the case, as described previ- ously. If the arterial line itself is being used for pressure Figure 10.1 “Single” pressure curve from two separate catheters in the left atrium recorded through two separate pressure systems. CHAPTER 10 Hemodynamics—acquisition and presentation of data 276 recording (e.g. across an aortic valve or aortic obstruction) a pressure from another catheter, even in a right-sided site, is recorded as the reference for the arterial tracing. The new reference pressure from the catheter has already had its own “steady state” reference against the original arterial pressure recording and any changes in the patient’s steady state are reflected equally by changes in any second pressure. With a reference tracing always on the record- ing, pressures from all locations can be compared to the “original reference” and, in turn, to each other regardless of the differences in the patient’s “steady state” at the dif- ferent times of the actual recordings. When measuring the pressure difference (gradient) between two locations, two simultaneous pressures from two separate catheters are preferable to a “pull-back” pressure tracing using a single catheter. This of course assumes that the two pressure systems are balanced accurately and are identical. Two simultaneous pressure tracings measure and record the actual pressure differences, precisely, on a beat-to-beat basis, with no interposed artifact from catheter movement, hand motion on the catheter and/or respiratory variations to affect the actual gradient. A “pull-back” tracing, on the other hand, measures the pressures sequentially, not necessarily under the same hemodynamic conditions and always with superimposed catheter/operator’s hand motion artifact(s) on the tracing of the pressure waveforms. When pressures are measured sequentially, there are frequently significant fluctuations in the base-line pressures during the pull back due to the operator’s hand movements (tremors), the patient’s respi- rations, the patient’s movement due to straining from pain or from extra beats or true arrhythmias (Figure 10.2). When using a a pull-back tracing, the sequential pressures that are recorded must be adjusted to account for these artifacts before the gradient can be estimated rather than actually measured. When pull-back recordings are used, very long recordings before and after the catheter with- drawal must be recorded in order to visualize, and to be able to adjust for, all of the variations in the base-line pressures. This is particularly important when measuring pressures in low-pressure systems. Errors in pressure sensing/recording due to the fluid column when using remote transducers Errors in the mid-chest, zero level of the transducer or the open zero fluid column create a very common, but, at the same time, easy to recognize and easy to correct abnor- mality in the pressure tracings. When a cardiac catheter is first introduced into the venous system, a systemic venous (or right atrial) pressure can be obtained through the catheter. With knowledge of the patient’s clinical diagno- sis, the operator is immediately able to recognize whether the displayed venous pressure correlates with that partic- ular patient’s clinical status or is at least close to a “reason- able” value. An atrial mean or a ventricular end-diastolic pressure tracing which registers at or below the zero base- line on the monitor or the recorder, indicates that either the transducer or the zero reference is too high for the particular patient or the patient is extremely volume depleted. The same pressures registering well below the zero line definitely are the result of a transducer zero ref- erence level that is too high. A disproportionately high venous or ventricular end-diastolic pressure, on the other hand, suggests either severe right heart failure, or, more likely, that the zero reference level is too low. The mea- surement for the height of the transducer should be double checked against a radio-opaque marker posi- tioned at mid chest or even compared to the level of the tip of the catheter in the right atrium on the lateral fluoro- scope image. Other very common abnormalities in pressure trac- ings occur because of interruptions in the continuity or integrity of the fluid column between the tip of the catheter and the transducer. The interruption can be from inclusions of bubbles or clots within the fluid column or from a mixture of several fluids with different densities (e.g. saline with blood or contrast) within the fluid col- umn. A very tiny gas (usually air) bubble anywhere in the long, complex column of fluid causes a major overshoot or “spike” in the pressure tracing. These spikes result in an exaggeration of both the peak systolic and the ventricular end-systolic pressures (Figure 10.3). An immediate clue to the presence of this artifact is the sharp “spiky” appear- ance of the peak systolic pressure curve and the presence of end-systole ventricular pressure curves that pass well below the zero base-line. Physiologic pressure curves do not have sharp spikes! Any such pressure curves must be investigated and corrected before any recording is per- formed. The tiny bubbles accumulate from the efferves- cence of gas from the flush fluid itself as it warms within the tubing/transducers. These microbubbles can occur Figure 10.2 “Pull-back” pressure curve from left ventricle (LV) to left atrium (LA) with a simultaneous separate left atrial pressure tracing; LVed, left ventricular end diastolic. CHAPTER 10 Hemodynamics—acquisition and presentation of data 277 even if the system was flushed and completely cleared of bubbles previously. They are very elusive, “hiding” and clinging within the catheter, the plastic connecting tubing, in the junctions and stopcocks between the segments of tubing or even in the transducers themselves. The only valid solution to this “fling or spiking” artifact is to remove the offending bubble(s) from the fluid col- umn. The tubing system is first disconnected or diverted away from the catheter which is in the patient. In order to dislodge these “micro bubbles”, each of the segments and connections in the tubing/transducer fluid “column” throughout its entire length is tapped crisply and vigorously with a metal instrument while the system is flushed thor- oughly. Fluid is withdrawn from the separated catheter while the hub is tapped and then the catheter is hand flushed and reattached to the cleared fluid column. These “micro bubbles” can be very elusive and resistant to dis- lodging, particularly in the virtually non-wettable plastic materials of the tubing, connectors and transducers them- selves. If the artifact is not eliminated even after the fluid column (including the fluid in the transducer) is entirely free of bubbles, the transducer should be exchanged. The appearance of the “overshoot” can be erroneously eliminated by the introduction of contrast or blood into the fluid column. This much denser fluid dampens the “overshoot” and smoothes out the curve. However, this, in turn, superimposes a second artifact that obscures, but does not eliminate the original artifact, and produces a doubly erroneous pressure curve. Seldom do two wrongs make a right! This “remedy” may create smoother or “prettier” recordings, but certainly does not produce accurate pres- sure recordings. In contrast to the “micro bubbles”, a denser fluid, a large bubble of air, or a clot within the fluid column are all inclusions that flatten or “dampen” the pressure wave- form. Large gas bubbles create “air locks” which flatten (dampen) the pressure wave significantly. Fluids such as blood or contrast medium, which are significantly denser than physiologic flush solutions, “resonate” at a much lower frequency than the flush solution and dampen the waveform. Very small clots easily compromise or totally occlude the small lumen of a cardiac catheter and dampen or obliterate the pressure wave. Thrombi commonly form at the tips of catheters following wire exchanges through the catheter. Blood that refluxes back into a catheter and is not flushed out, thromboses and compromises or can occlude the lumen of the catheter. A smoothing, or “rounding-off” of both the top and bottom of the pressure curve indicates an artifact from one of these inclusions in the fluid column (Figure 10.4). In addition there will be no end systolic/diastolic deflections in the ventricular curve and no anacrotic or dicrotic notches on the arterial pressure curves. In addition to the rounding-off of the curve, there is a lowering of the peak systolic pressure and an elevation of the end-systolic and diastolic pressures. In extreme cases of this artifact, the pressure wave appears like a sine wave or even becomes a mechanical mean of the systolic and diastolic pressures. To correct these artifacts, all non-flush solution, bubbles or clots must be withdrawn from the catheter and flushed from the catheter tubing before the catheter and tubing are refilled with an uninterrupted column of clean flush solution. A segment of very compliant or soft connecting/flush tubing interposed as an extension tubing in the pres- sure/flush system will produce this same artifact of a dampened pressure curve. Similarly, a fluid column that is too narrow to transmit fluid waves also flattens or dampens the waveform of the pressure curve. This usu- ally is the result of using a catheter that is too small in diameter (e.g. 3-French or even some 4-French in some materials). The only solution to this problem is to replace Figure 10.3 The exaggeration of end-systolic and peak systolic left ventricular pressure tracing due to “microbubbles” within the fluid column giving a very “spiky” left ventricular pressure curve. Figure 10.4 Dampened left ventricular pressure curve with blunting and lowering of the peak systolic pressure and blunting and elevation of the end systolic /diastolic pressures. CHAPTER 10 Hemodynamics—acquisition and presentation of data 278 the catheter or tubing. A kink in the catheter or pressure line will also dampen or obliterate the pressure. Usually, however, a kink interrupts the pressure abruptly or inter- mittently as the catheter is maneuvered. A kink in the catheter is easy to identify by visualizing the course of the catheter under fluoroscopy. Some catheter materials (e.g. woven dacron) actually swell when exposed to “moisture” at body temperature, as a result of which the internal diameter of the lumen of a very small catheter can be reduced so much as to make it unusable. This problem is recognized by an initially good, crisp pressure curve when the small catheter is first introduced but in which, as the case progresses, the pressure gradually dampens. The “normal” appearance of the pressure may return transiently after the catheter is flushed, only to be re-dampened within minutes (sec- onds) after each flush. The only solution in order to obtain meaningful data in this circumstance is to exchange the catheter. A tiny thrombus at the end of the catheter results in a similar intermittent dampening of the pressure. Flushing the catheter often improves the pressure curve for a few cardiac beats, only to have the dampening recur within a few seconds. This is a common occurrence after the withdrawal of a spring guide wire from the catheter where fibrin or actual thrombi are stripped off the wire and withdrawn into the tip of the catheter lumen as the wire is withdrawn into the catheter. In this circumstance, either the clot must be withdrawn completely from the catheter by strong, forceful suction on it or the catheter is exchanged. There are several logical and fairly quick steps to verify that there actually is an artifact in the pressure curve and then for determining the source of the error when the pressure curve is artifactual. The types of artifactual pressure recordingsaas described in the previous paragraphsaprovide clues to the source of the abnormal curve. The first step is to open the transducer and fluid line to air zero, flush the lines outside of the body thor- oughly, and then “rebalance” the transducer(s). Once these fundamentals have been performed, the pressure recording from the suspect catheter is checked against a pressure recording from the same location through a second catheter with a completely separate fluid tubing system and transducer. If the two curves are different in amplitude but identical in configuration, even though set to record at the same gain, usually the electronic calibration of one of the transducers is off. Each transducer comes with its own specific electronic calibration factor, which is electron- ically adjusted, in the recording apparatus. Occasionally this factor is off or drifts in value. The easiest check is to change the transducer for a new one. Modern electronics and manufacturing have allowed the production of very accurate, stable, yet relatively cheap and disposable trans- ducers. This allows for the frequent and easy replacement of transducers. A more time-consuming alternative to replacing the transducer is to re-calibrate it against a mercury manometer and then reset the calibration factor on the recording apparatus during the procedure. Although this re-calibration of transducers is performed routinely and on a regular basis, the procedure is time consuming and is usually performed by, or at least requires the assistance of, the biomedical engineer, and is performed more conveni- ently when the catheterization laboratory is not in use. When there is not only a different amplitude of the pressure curves obtained from the same location, but also a different configuration to the curves, the solution to the problem is a little more complicated. The first step is to electrically balance and calibrate both transducers against zero, while the suspect fluid system is flushed thoroughly. If there are still different pressures, the pressure tubing between the catheters and the transducers are switched at the catheter hubs. If the abnormal pressure curve “moves” to the other transducer, the catheter is at fault and needs further clearing, flushing or replacing. If the abnormal pressure curve remains with the original transducer, the original tubing and/or the transducer is/are at fault. The pressure tubing between the catheters and transducers is now switched at the connection to the transducers. If the abnormal pressure is now generated from the other trans- ducer, the connecting tubing is at fault and is replaced. If, on the other hand, the artifactual pressure remains with the same transducer, the original transducer is at fault. If a transducer is determined to be at fault, that trans- ducer is re-flushed, re-zeroed and its electrical connec- tions are checked. If the pressure tracing still is not correct, the electrical connections from the two transducers to the recording apparatus are switched. If the abnormal pres- sure “moves channels” with the transducer, the trans- ducer itself is at fault. When all other sources of artifacts in the pressure curves have been eliminated as the source of error, the transducer is replaced. A brand new trans- ducer should be checked against the pressure curve from another transducer, comparing a pressure curve from the new transducer with a curve that was obtained in the same location from another catheter/transducer system. Catheter and wire-tip micromanometers (transducers) The most accurate pressure recordings available in the catheterization laboratory are obtained with catheter or wire-tip micromanometers (transducers) (Millar Instru- ments Inc., Houston, TX). These micromanometers are actually tiny piezoelectric crystals which respond directly to changes in pressure, converting the changes into a CHAPTER 10 Hemodynamics—acquisition and presentation of data 279 proportionate electrical signal. The tiny pressure sen- sors (transducers) are embedded in, or near, the tip of a catheter or guide wire. The pressure is actually measured within the chamber or vessel by the micromanometer crystal, which is positioned in the chamber. The pressure is converted into an electrical signal and the electrical sig- nal from the catheter or wire-tip micromanometer is trans- mitted from the catheter tip to an amplifier, monitor and recorder. As a consequence, all of the common artifacts due to the interposed fluid column, which are a part of the system using remote transducers, are eliminated by the use of catheter-tipped pressure transducers. A high-quality, properly functioning catheter or wire- tip transducer provides pressure curves that are extremely sensitive and accurate. With these catheter/wire-tip transducers, there are no artificial pressures created by a difference in the height of the transducer relative to the chamber, however, catheter or wire-tip transducers are so sensitive that gradients can be recorded between two catheter or wire-tip transducers which are positioned at significantly different vertical heights from each other but are still within the same chamber! The transducers are small enough that two or more transducers can be mounted at different locations on a single catheter or they can be mounted with other additional sensors (flow meters). With more than one micromanometer or a flow meter on a catheter, simultaneous pressures with or without simultaneous flow measurements from different areas within the heart or vascular tree can be recorded using only one catheter. Catheter or wire-tip transducers are invaluable when extremely precise pressure measure- ments are required. They are useful, particularly, for recording high-fidelity pressure curves in low-pressure areas. When derivatives of the pressure curves (dP/dT) and actual analysis of the wave forms of the pressure are desired, catheter/wire-tip micromanometers are the only type of transducer that should be used. Pressure recordings from catheter/wire-tip micro- manometers are not without some problems. Artifacts in the high-fidelity pressure curves can, and do occur. Artifacts occur when the tip of the catheter/wire (with the transducer) is entrapped in either a trabecula or a small side branch vessel or when the catheter/wire-tip trans- ducer along with the catheter/wire is “bounced” against structures within the heart/vessel as the heart beats. As mentioned above, erroneous pressure gradients can also be recorded when there is a significant vertical dis- tance between the transducers within the heart. For ex- ample, in the supine patient, if one transducer is positioned anteriorly in the right atrium with the other transducer positioned posteriorly in the left atrium, an electrical adjustment for the difference in vertical distance often must be made to record accurate and comparable pres- sures. Each 2.5 cm in vertical distance within the heart results in a 1.9 mmHg difference in pressure. This height difference produces large “artifactual gradients” within the low-pressure (venous) system, particularly in very large hearts! The catheter tip transducer catheters themselves have some inherent disadvantages. Catheters containing catheter-tip transducers are difficult to maneuver com- pared to the usual diagnostic, cardiac catheters. In addi- tion, most of the catheters with transducers at the tip do not have a catheter lumen which would allow passage over a wire, deflection with a wire, or withdrawal of sam- ples or injections for angiograms through the catheter. These problems with the catheters themselves make them impractical for routine diagnostic catheterizations. Wire-tipped transducers overcome many of the tech- nical problems encountered with maneuvering catheters with tip transducers. The wires are small enough in dia- meter (0.014″) that they pass through the lumen of very small catheters. In this way, a small, standard, diagnostic, end-hole catheter can be maneuvered into, and through, difficult areas and then the wire with the transducer at the tip can be advanced beyond the catheter. The catheter along with the wire can be torqued in order to direct the wire selectively into very small or tortuous locations distal to the tip of the catheter. The crystals of the micromanometers on both the catheter and the wire-tip transducers are quite fragile. Before, and repeatedly during, measurements, they require precise and somewhat tedious calibration. Catheter and wire-tip transducers also are very expensive. The expense makes them hard to consider as disposable but, in the cur- rent catheterization laboratory environment, it is difficult, or, realistically, impossible, to re-sterilize and reuse them in patients. Because of these negative factors, catheter and wire-tip transducers are seldom used in the clinical car- diac catheterization laboratory. With their accuracy and in spite of their problems, the pressure tracings from catheter/wire-tip transducers serve as the “gold standard” for absolutely accurate pres- sure recordings of both amplitude and configuration of pressure curves. Physiologic artifacts in pressure tracings/recordings In addition to the previously described artifacts which originate from the catheters, fluid columns and transdu- cers, the intravascular pressures from the human vascular system generate a considerable variety of physiological variation. Significant changes in intravascular pressure tracings commonly occur during even normal respiration due to the physiologic changes in the intrathoracic pres- sure. These respiratory variations are greatly exaggerated when the patient experiences any respiratory difficulty during the catheterization. During normal respirations, CHAPTER 10 Hemodynamics—acquisition and presentation of data 280 there is a 3–8 mmHg negative pressure deflection with each inspiratory (active) respiratory effort. Because of this, pressure measurements from the recordings in a patient who is breathing normally, should be taken at the end expiratory (passive) phase of the respiratory cycle. This is particularly important when measuring the generally lower pressures in the pulmonary arterial, right ventricu- lar, all atrial and any capillary wedge positions. The most common and significant artifacts in the pres- sure curves are a result of ventilation problems related to upper airway obstruction, in which case the negative intrathoracic pressure during inspiration can be mag- nified greatly. Negative intrathoracic pressures greater than minus 50 mmHg can be generated with severe inspir- atory obstruction! Obviously, with such extreme sweeps in the base-line pressure, none of the intracardiac record- ings, either during inspiration or expiration, are valid. In such circumstances every effort is made at correcting or circumventing the airway obstruction. This type of obstruction is often due to large tonsils or adenoids or a congenitally small posterior pharynx (particularly in patients with Down’s syndrome). With such upper air- way obstruction, pulling the jaw forward and extending or bending the neck backward or to the side occasionally is sufficient to correct the problem. If not, then an oral- pharyngeal or nasopharyngeal airway is inserted gently in order to “bypass” the obstruction. A relatively large diameter, soft, rubber, nasal “trumpet” is very effective as a “splint” for the nasal airway and is tolerated very well once it is in place, though the patient may require some sup- plemental sedation in order to tolerate the introduction of any airway. Only in rare circumstances is endotracheal intubation necessary to overcome the effects of airway obstruction. However, if the intracardiac pressures are critical for the diagnosis and decisions are to be made from the pressures, then endotracheal intubation is neces- sary in order to record valid pressures. Another common, but often subtle, cause of artifacts in the pressure tracings is the result of the patient beginning to waken and becoming uncomfortable. The operator must be cognizant of a patient’s experiencing discomfort or pain, which can waken the patient from a deep sleep when apparently under good sedation or even under gen- eral anesthesia. Often, the first sign of a patient waking is an increasing heart rate as a result of the patient’s rising epinephrine level associated with a moving baseline of the pressure tracings as a result of their unconscious (or conscious) straining or movement. The patient with pulmonary edema or bronchospastic disease creates another and opposite respiratory artifact in the intravascular pressures. These patients actually generate a high or positive end expiratory pressure (PEEP) from their forceful expiratory effort. This abnor- mal respiratory effort is recognized on the displayed pressure curves by very high or positive swings in the base-line pressure curve with each expiratory phase of the patient’s respirations. If the forced expiration is persistent and cannot be corrected by treating the underlying cause, then the inspiratory phase of pressures is used as the pas- sive or base-line pressures. In severe cases, endotracheal intubation with total control of the respirations is usually necessary in order to manage the patient’s respiratory problem and to obtain valid pressure recordings. When a patient is on a respirator, the various effects of the respirator must be taken into consideration in inter- preting the pressure curves. The usual pressure or volume respirators apply positive pressure during the inflation of the lungs (inspiration) and have a passive expiratory phase. The intravascular pressures of a patient on a venti- lator are measured during the passive expiratory phase of the respiratory cycle. For very accurate recording of intracardiac pressures in patients on a respirator, the patient is detached from the respirator temporarily for a few seconds at a time while the pressure recording is being made. All of the normal and abnormal pressure waves in the heart are a direct consequence of the electrical stimulation of the cardiac chambers through the electrical conduction system of the heart. The contractility of the various cham- bers of the heart, and, as a result, each pressure wave have a temporal relationship to the ECG impulse. The atria are normally synchronized by this electrical activation to contract precisely as the adjoining ventricle is “relaxing”, and vice versaato “relax” as the ventricle contracts. This allows the atrio-ventricular or “outlet valve” of the atria to open freely into a zero, or even negative pressure in the ventricle as the atria contracts and to complete their empty- ing before the ventricle begins to contract. The degree of filling of the ventricle and the volume of the ventricular output are dependent upon this synchronization of con- tractions. As a consequence, the cardiac rhythm and the integrity of the conduction system have a marked in- fluence on the amplitude and configuration of the pres- sure waves, particularly of the atrial waves. Normal sinus rhythm is necessary for the generation of normal pressure waves in the heart and vascular system. Normal intravascular pressures Each chamber and vessel in the cardiovascular system has characteristic, “normal” pressure waves in both ampli- tude and configuration. The pressure waves are all related temporally to the electrocardiographic (ECG) events. The operator must be familiar with the normal and the variations in normal pressures and the variations in normal wave forms from each location in the cardiovascular system. The atria (and central veins) normally have characteris- tic, positive “a”, “c” and “v” waves. The “a” pressure CHAPTER 10 Hemodynamics—acquisition and presentation of data 281 wave corresponds to atrial contraction. It begins at the end of the electrical, “p” wave of the ECG complex. At the end of atrial contraction, the “a” wave begins to descend. Its descent is interrupted very early and transiently by the small “c” wave of atrioventricular valve closure. Often the “c” wave is so small and so close to the peak of the “a” wave that it is inseparable and included in the “a” wave amplitude. The “a” or “a-c” wave is followed by a drop in pressure, the “x” descent, which corresponds to atrial relaxation. This “x” descent is interrupted by first a slow and then a rapid rise in pressure, the “v” wave, which cor- responds to the filling of the atrium from the venous system against the closed atrioventricular valve. The “v” wave begins at the end of the QRS curve of the ECG and corresponds in time to ventricular systole. The “v” wave is followed by another drop in the pressure curve, the “y” descent, which corresponds to the atrial emptying into the ventricle (and ventricular filling!). Usually the “a” and “v” waves are of similar amplitude, although the right atrial “a” wave is normally slightly higher than the “v” wave and the left atrial “v” wave may be slightly higher than the “a” wave. The “normal” atrial pressures in childhood are slightly lower than those observed in the older or adult patient. These higher pres- sures in older patients may well represent a slight deterio- ration in cardiac function rather than an increase in the true normal pressures. In childhood, the normal right atrial “a” wave is 2–8 mmHg, the “v” wave is 2–7.5 mmHg, with a mean pressure in the right atrium of 1–5 mmHg. In the left atrium, the “a” wave is 3–12 mmHg, the “v” wave is 5–13 mmHg, with a mean in the left atrium of 2–10 mmHg (Figure 10.5). If there is no naturally occurring access to the left atrium and left atrial pressures are necessary, but the operator is unskilled in or uncomfortable with the atrial transseptal procedure, a pulmonary artery capillary “wedge pres- sure” can provide an adequate reflection of a left atrial pressure. The pulmonary veins have no venous valves, so a pressure from an end-hole catheter that is “wedged” in the pulmonary arterial capillary bed should reflect the venous pressure from “downstream” (i.e. from the pul- monary veins/left atrium). In order to obtain a pulmonary capillary wedge pres- sure, an end-hole catheter is advanced as far as possible into a peripheral distal pulmonary artery. This can be either one of numerous types of end-hole, torque- controlled catheters or a flow-directed, floating, “Swan™ Balloon” wedge catheter (Edwards Lifesciences, Irvine, CA). The torque-controlled catheter is pushed forward into the peripheral lung parenchyma as vigorously and as far as possible with the purpose of burying the tip of the catheter into the pulmonary capillary bed. In order to achieve a wedge position, it may be necessary to deliver the end-hole, torque-controlled catheter over a wire and even to record the pressure around the contained wire in order to maintain the tip of the catheter in the wedge posi- tion. A standard spring guide wire often fills the lumen of the catheter and does not allow recording of the pressure through the lumen and around the wire, and withdraw- ing the wire when the tip of the catheter is wedged often dislodges the catheter from the wedge position or leaves debris in the catheter lumen, which dampens the pres- sure. To overcome this problem of spring guide wires, a 0.017″ Mullins™ wire (Argon Medical Inc., Athens, TX) is used within the catheter through a wire back-bleed valve to help obtain a good wedge position. The fine stainless steel wire will add stiffness to and support the catheter without compromising its lumen. The end-hole, floating balloon catheter is floated as far as possible distally in the pulmonary artery, deflated slightly while still advancing the catheter, and finally par- tially reinflated. Either the shaft of the catheter itself or the inflated balloon occludes the pulmonary artery proximal to the tip of the catheter so that the pressure that is obtained is the “venous” pressure, which is reflected back through the capillary bed from the left atrium. Often it is necessary to deliver or support the floating balloon wedge catheter over a wire (similarly to torque-controlled catheters as described above). The adequacy of the wedge position and the validity of the wedge pressures are verified by several findings. The recorded pressure should be significantly lower than the pulmonary artery pressure and the pressure tracing should have an “atrial” configuration with distinct “a” and “v” waves. If the configuration of the displayed wave- form is not characteristic of an atrial pressure curve, a small “wedge angiogram” is performed. 0.5 ml of contrast is introduced into the catheter and this small bolus of con- trast is flushed through the catheter by following it with Figure 10.5 Normal right (RA) and left atrial (LA) pressure curves: a, “a” wave; v, “v” wave; x, “x” descent; y, “y” descent. CHAPTER 10 Hemodynamics—acquisition and presentation of data 282 3–4 ml of flush solution. This should demonstrate the ade- quacy of the wedge position, as described in Chapter 11. Withdrawing blood back through the wedged catheter and acquiring fully saturated blood from the pulmonary veins has been advocated as a technique to confirm the wedge position. Usually it is not possible to withdraw the blood and even when possible, it has not proven very sat- isfactory for documenting the adequacy of the wedge pressure. If withdrawal of blood is possible, it must be done extremely slowly and even then, a partial vacuum may be created which draws air bubbles into the sample. Once blood has been withdrawn, it is often difficult to clear the catheter of the blood to obtain a satisfactory pres- sure tracing without forcing the tip of the catheter out of the wedge position. Pulmonary capillary wedge pressures can be useful when a very accurate wedge position is achieved, how- ever, the accuracy of the wedge pressure at reflecting the actual left atrial pressure cannot be verified unequivocally unless a simultaneous left atrial pressure is recordeda nullifying the need for the wedge pressure! The wedge values obtained must correlate with all of the other data and should never be taken as “gospel”. Even good wedge pressure waves are damped slightly in amplitude and the appearance and peak times of the various waves are always delayed compared to the actual pressures in the left atrium. This must be taken into account when calcu- lating a mitral valve area from the combined pulmonary capillary and left ventricular pressure waves. Ventricular pressure waves are generated by ventricu- lar contractility and relaxation, i.e. ventricular emptying and filling. The ventricular systolic wave begins near the end of the QRS complex on the ECG and continues until the end of the “T” wave. Ventricular contraction is nor- mally very rapid and, as a consequence, the upstroke of this ventricular curve is very steep (almost vertical). When the increasing ventricular pressure exceeds the corre- sponding arterial diastolic pressure, a small “anacrotic notch” occasionally appears on the upstroke of the ven- tricular (and arterial) pressure curve. This corresponds to the opening of the semilunar valve. The peak of the ven- tricular pressure corresponds to the end of ventricular contraction. The top of the pressure curve is smooth and rounded but slightly peaked. As ventricular contraction ends, the pressure rapidly begins to drop off. As the pressure curve descends, there is a distinct incisura or “dicrotic notch” in the descending limb of the curve as the ventricular pressure falls below the diastolic pressure in the artery and the semilunar valve closes. With continued ventricular relaxation, the ventricular pressure drops very steeply to zero and then rebounds to slightly above zero. As the atrioventricular valves open and the ventricle begins to fill during ventricular relax- ation, there is a slow, small rise in the ventricular pressure until the end of diastole. The slow gradual rise in pressure is interrupted by a very small positive deflection which is produced by the “a” wave “kick” of the atrial contraction (and pressure), which is reflected in the ventricle, just before the end of diastolic filling of the ventricle. The end- diastolic pressure of the ventricle is measured in the slight negative dip in the ventricular pressure curve after the “a” wave and just before the rapid upstroke of the ventricular curve. The upstroke and downstroke of the normal curves of the right ventricle are slightly less acute (vertical) than the comparable curves in the left ventricle, since the normal peak right ventricular pressure is so much lower while the ejection times of the ventricles are the same. The normal right ventricular pressures are between 15 and 30 mmHg peak systolic and 0 and 7 mmHg end diastolic. The normal left ventricular pressures are between 90 and 110 mmHg peak systolic and 4 and 10 mmHg end diastolic. As with the atrial pressures, the normal ventricular pressure val- ues increase slightly in adulthood. The arterial pressure curves correspond to the ejection and relaxation times of the ventricles. The arterial pres- sure curves begin to rise in systole as the ejection pressure of the corresponding ventricle exceeds the diastolic pres- sure of the arteries and opens the semilunar valves. The arterial pressures peak simultaneously with the end of ventricular contractions. The normal arterial pressure curves have the same peak systolic pressure amplitudes and the same peak systolic configurations as their respect- ive ventricles. At the end of the ventricular ejection time, as the ventricle begins to relax, the arterial pressure, like the ventricular pressure, begins to drop fairly rapidly. As the two pressures drop together, the semilunar valve closes, creating the dicrotic notch on the descending limb of the pressure curves. After the closure of the semilunar valve, the ventricular pressure continues to drop precipi- tously. The arterial pressure curve continues to decline, but at a much slower rate than the ventricular curve and only slightly further as the blood from the artery runs off slowly into the adjoining vascular bed. This results in a tailing-off or slow decline in the arterial pressure until no further blood runs off and the arterial pressure reaches its diastolic level (Figure 10.6). The normal systolic pressures in the central great arter- ies correspond in amplitude and configuration to the corresponding ventricular systolic pressures, with peak pressures of 15–30 mmHg for the pulmonary artery and 90–110 mmHg for the central aorta. The central aortic peak pressure and pressure waveforms are a combination of the forward flow and some reflected or retrograde flow generated from the elastic recoil of the long, elastic vascu- lar walls of the relatively large systemic arterial vascular system. Diastolic pressures in the great arteries are not as consistent from patient to patient, and depend a great deal CHAPTER 10 Hemodynamics—acquisition and presentation of data 283 on the patient’s circulating blood volume and the capacit- ance of the particular vascular bed. The diastolic pressure in the normal pulmonary artery ranges between 3 and 12 mmHg in the presence of normal pulmonary vascular resistance. The diastolic pressure in the pulmonary artery corresponds closely to the pulmonary capillary wedge pressure. The diastolic pressure in the aorta will range between 50 and 70 mmHg in the presence of normal sys- temic resistance. The peripheral systemic arterial pressures have a higher, and a slightly delayed, peak systolic pressure com- pared to the central aortic pressure. This is a result of pulse wave amplification of the systolic pressure from the cen- tral aorta to a peripheral artery (e.g. femoral artery) due to a summation of the reflected arterial waves along the rela- tively long, elastic, vascular walls. This pulse wave amplification is always present in a normal aorta and arte- rial system and can be as much as 15–20 mmHg. The delay in the build-up time and the peak systolic pressure in the more peripheral artery is a manifestation of the time and augmentation of the propagation of the pressure wave front through the fluid column (aorta) to the more periph- eral arterial site (Figure 10.7). Occasionally, in complex congenital lesions with pul- monary valve/artery atresia, the pulmonary artery or one or more of its branches cannot be entered, yet pressure information from the particular pulmonary artery is nec- essary to make a therapeutic decision. Inferential informa- tion about the pulmonary arterial pressure can be obtained from a pulmonary venous capillary wedge pressure. Analogous to the pulmonary artery wedge pressures, a torque-controlled, end-hole (only!) catheter is advanced from the left atrium and into a pulmonary vein. The catheter tip is advanced as far as possible into the pul- monary vein and the tip wedged forcefully into the pulmonary parenchyma in order to record a pulmonary arterial pressure. The circumference of the shaft of the catheter in the vein occludes any pressure transmission from the vein while the pulmonary arterial pressure is transmitted through the pulmonary capillary bed to the tip of the catheter. In order to force the catheter tip into the wedge position, it is often necessary to provide extra stiffness to the shaft of the catheter. Similarly to the pul- monary arterial wedge position, this is accomplished with a straight 0.017″ or 0.020″ (depending on the size of the catheter) Mullins Deflector Wire™ (Argon Medical Inc., Athens, TX) introduced through a Tuohy™ wire back- bleed/flush device and advanced to a position just prox- imal to the tip of the catheter. A proper pulmonary vein wedge position and resultant pressure curve are suggested by the appearance of a higher peak pressure than recorded in the pulmonary vein and the presence of an arterial configuration to the waveform. The pulmonary vein wedge pressure is less reliable even than the pulmonary artery wedge pressure, but may give some idea about the pressure in that seg- ment of the lung. Even a “good” pulmonary vein wedge pressure is usually somewhat damped compared to the actual pulmonary arterial pressure. Pulmonary vein wedge pressures are more reliable when there are low pressures in the pulmonary arteries. A pulmonary vein wedge pressure that is less than 15 mmHg with a good arterial configuration is almost always consistent with a pulmonary arterial pressure of less than 20 mmHg. The contrary reliability in accurately determining higher pressures does not hold true in the presence of high pul- monary vein wedge pressures. Pulmonary vein wedge angiograms provide some additional direct and some indirect information about the adequacy of the wedge position and about the pulmon- ary arterial pressure and anatomy. The angiographic Figure 10.6 Simultaneous left ventricular (LV), ascending aorta (Asc Ao) and femoral arterial (FA) pressure curves. Figure 10.7 Severe aortic stenosis: simultaneous left ventricle (LV), ascending aortic (Asc Ao) and femoral artery (FA) pressure curves showing the left ventricle to aortic gradient and the significant delay and augmentation of the femoral arterial pulse curve compared to the ascending aorta. [...]... hemolyzed in order to eliminate the light scattering due to the intact red cells themselves The co-oximeter then performs the 296 spectrophotometric analysis on the free hemoglobin alone Co-oximeters measure total hemoglobin, oxy-hemoglobin, deoxy-hemoglobin, carboxy-hemoglobin and methemoglobin However, the various co-oximeter apparatuses are expensive and they require special hemolyzing and cleaning solutions... sides (pumps) within the heart, there is a constant and equal flow of blood into and out of each side of the heart Thus the flow into and out of either side of the heart is equivalent to the net flow into and out of the entire heart • There must be complete and uniform distribution within the flowing blood of any indicator substance that is introduced into the bloodstream at the proximal site in the circulation... the slightest hint of an irregularity in the values being obtained or expected In the current scheme for the determination of oxygen saturations, there are significant potential errors that can occur during the handling of the samples as well as during the displaying and recording of the results from the oxygen analyzer Handling, display and recording of oxygen saturation data in the catheterization. .. (in ml O2/min) by the difference between the in ow and outflow saturations (in ml O2/100 ml) of the blood across the pulmonary bed In pediatric and congenital patients this value is “indexed to” (multiplied by) the patient’s body surface area and the denominator is multiplied by 10 in order to express the result as liters/min/m2 The formulas and calculations used in the determination of flow, shunts and. .. exponential increase in viscosity The diameter and length of the vascular system is not uniform throughout any part of the circulation The blood flow is pulsatile not constant and, in the elastic vessels, the vessel diameters in any single location are continually changing In addition, the muscular walls of many of the vessels tend to contract against increased flow, reducing the luminal diameter and increasing... quantitative determination of flow in the fields of hydraulic engineering and physiologic fluid dynamics for over a century When using an indicator dilution technique for quantitative determinations of flow, a specific amount of an indicator substance is introduced into an in ow or “upstream” location in a constantly flowing fluid within a closed system Assuming that the substance is uniformly distributed within the... while the catheter is still in the same location or certainly during the catheterization procedure Once the catheter is removed, there is no means of checking unusual saturations which could result in all of the oxygen data being invalid In the absence of any right to left shunting from intracardiac or intravascular communications, left-sided samples throughout the heart and into the aorta are fully saturated... determination The detection and quantitating of shunts as well as the quantitative determination of flow in the cardiac catheterization laboratory, are based on the principals of indicator dilution techniques2 Indicator dilution techniques depend upon the detection and quantification of indicator substances that have been introduced into flowing fluids Indicator dilution techniques have been used and validated... solutions and a considerable amount of maintenance to maintain their accuracy As a consequence, co-oximeters are now used very infrequently in clinical cardiac catheterization laboratories The oxygen analyzers used most commonly in the current clinical cardiac catheterization laboratory are “wholeblood” oximeters These analyzers, as the name indicates, analyze whole-blood samples for percentage of oxygen in. .. substance in an abnormal location is sufficient to document the presence of the shunt Oxygen content (saturation) in the circulating blood and several exogenous indicatorsa including cold solutions, indigo-cyanine (Cardio-Green) dye and hydrogen ionsaare used for the detection and/ or quantification of total flow and shunts Oxygen, measured as oxygen content of the blood, is the principal indicator used in the . severe inspir- atory obstruction! Obviously, with such extreme sweeps in the base-line pressure, none of the intracardiac record- ings, either during inspiration or expiration, are valid. In such. within the heart, there is a constant and equal flow of blood into and out of each side of the heart. Thus the flow into and out of either side of the heart is equivalent to the net flow into and. principal indicator used in the determination of flow and the calculation of the magnitude of shunts in the cardiac catheterization labor- atory; exogenous indicators are discussed later in