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(BQ) Part 1 book Practical cardiovascular hemodynamics has contents: Pressure tracings, measurement of cardiac output and vascular resistances, overview of the steps performed during a standard right and left heart catheterization, overview of the steps performed during a standard right and left heart catheterization,.... and other contents.
Visit our website at www.demosmedpub.com ISBN: 978-1-936287-840 e-book ISBN: 9781617051395 Acquisitions Editor: Rich Winters Production Editor: Joseph Stubenrauch Compositor: Manila Typesetting Company © 2013 Demos Medical Publishing, LLC All rights reserved This book is protected by copyright No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher Medicine is an ever-changing science Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Library of Congress Cataloging-in-Publication Data Hanna, Elias B Practical cardiovascular hemodynamics / Elias B Hanna p ; cm Includes bibliographical references and index ISBN 978-1-936287-84-0 (alk paper) ISBN 978-1-61705-139-5 (e-book) I Title [DNLM: Hemodynamics Cardiovascular Diseases Heart Valve Diseases WG 106] 616.1’25 dc23 2012025525 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups For details, please contact: Special Sales Department Demos Medical Publishing, LLC 11 West 42nd Street, 15th Floor New York, NY 10036 Phone: 800-532-8663 or 212-683-0072 Fax: 212-941-7842 E-mail: rsantana@demosmedpub.com Printed in the United States of America by Bradford & Bigelow 12 13 14 15 / 5 4 3 2 1 To my mother Marie and my sister Eliana, for their infinite love, kindness, and support To all those who are willing to appreciate the beauty in every tracing, every line… Elias B Hanna Contents Preface Abbreviations Acknowledgments SECTION A: BASIC AND ADVANCED HEMODYNAMICS Elias Bechir Hanna I Pressure tracings I.1 Right atrial pressure tracing I.2 Right ventricular pressure tracing—Characterisitics of right ventricular failure I.3 Pulmonary artery pressure tracing I.4 Pulmonary capillary wedge pressure I.5 Left ventricular pressure tracing and interpretation of LVEDP-Left ventricular failure I.6 Aortic pressure, peripheral arterial pressure, and description of damping and ventricularization of aortic pressure upon coronary engagement I.7 Pressure damping and other sources of pressure artifact I.8 Establish the zero reference I.9 Effect of respiration on intracardiac pressures and concept of transmural pressure II Measurement of cardiac output and vascular resistances Evaluation of left-to-right and right-to-left shunts and calculation of shunt III ratio IV Overview of the steps performed during a standard right and left heart catheterization V Left ventricular failure VI Valvular disorders: Calculation of valvular area VII Valvular disorders: Aortic stenosis VIII Valvular disorders: Mitral stenosis IX Other valvular disorders: Mitral regurgitation, aortic insufficiency, tricuspid regurgitation, pulmonic stenosis, and prosthetic valves IX.1 Mitral regurgitation IX.2 Aortic insufficiency IX.3 Tricuspid regurgitation IX.4 Pulmonic stenosis IX.5 Tricuspid stenosis IX.6 Pulmonic insufficiency IX.7 Prosthetic valves X Assessment of mixed valvular disorders XI Hypertrophic obstructive cardiomyopathy XII Constrictive pericarditis and differentiation of constrictive pericarditis from restrictive cardiomyopathy and ventricular failure XIII Tamponade XIV Pulmonary hypertension XV Hemodynamics in shock and fluid responsiveness XVI Hemodynamics of left ventricular support devices and left ventricular pressure-volume loop in various cardiac conditions XVI.1 Intra-aortic balloon pump XVI.1 Intra-aortic balloon pump XVI.2 Transvalvular left ventricular assist device (Impella) and TandemHeart XVI.3 Left ventricular pressure-volume loops and effect of left ventricular support devices on cardiac hemodynamics XVII Coronary hemodynamics: Fractional flow reserve concept, pitfalls, and special applications SECTION B: TRACINGS AND CASES: SELF-ASSESSMENT PROBLEMS Elias Bechir Hanna, David Luke Glancy Section B-I: Long cases: Self-assessment problems Cases 1–22 Section B-II: Short cases: Self-assessment problems Cases Index Preface Despite the advances of imaging techniques, the understanding of invasive cardiovascular hemodynamics continues to be of critical importance in patients with conflicting or inconclusive noninvasive data Furthermore, invasive hemodynamics remain the backbone for in-depth understanding of cardiovascular physiology, physical examination, and echocardiographic hemodynamics Yet few manuals address cardiovascular hemodynamics in a practical and illustrated format or provide hemodynamic self-assessment problems to allow question-guided learning, hence the reason why the topic remains confusing to cardiologists and to our cardiology fellows The purpose of this book is to provide an in-depth understanding of waveforms and tracings seen in various disease states and the pathophysiology behind those findings This is highlighted throughout Section A of the book where a thorough yet concise dynamic pathophysiology is used to explain hemodynamic findings One example is the book’s illustrated explanation of the sequence of events taking place in constrictive pericarditis in contradiction to the series of events occurring in restrictive cardiomyopathy, ventricular failure, and obstructive lung disease Practical issues that are rarely discussed or focused upon in textbooks are highlighted in every part of Section A with detailed waveform analysis Pitfalls in the hemodynamic assessment of valvular diseases, constrictive pericarditis, tamponade, pulmonary hypertension, shunt pathology, coronary disease, and right and left ventricular failure are provided Going through the illustrations and their detailed legends may provide the reader with most of the required information Section B of the book provides case-based and tracing-based selfassessment problems The reader will learn to identify disease states and waveform subtleties from single tracings or from case studies The reader will take the initiative to interpret tracings, understand notches, artifacts, and FIGURE XII.9 Sequence of events occurring during inspiration in COPD (−) sign adjacent to a structure signifies there is transmission of the negative intrathoracic pressure to this structure, whereas (0) corresponds to the lack of transmission of the intrathoracic pressure to this structure Gray block arrows signify increased flow between 2 chambers, whereas the blue block arrows signify reduced flow between 2 chambers During inspiration, the negative pressure is transmitted to PV and SVC and to the intracardiac chambers (this is different from constriction) This increases flow between both IVC and SVC on the one hand and the RA then RV on the other hand Because the pericardium is not constrictive, the RV will expand laterally and will not or will only minimally push the LV The septal position changes minimally LV filling is reduced because of reduced leftsided driving pressure and increased afterload (see text for details) The main difference from constriction (Figure XII.1) is the inspiratory decrease of RA pressure and the inspiratory increase of SVC to RA flow The IVC and hepatic flow increases similarly in COPD and in constriction Other differences not portrayed by this figure are the lack of equalization of diastolic pressures, the lack of deep X/deep Y on the RA tracing, and the lack of the dip-plateau pattern on the ventricular tracings On echocardiography, SVC flow may be used to differentiate COPD from constriction In constriction, SVC flow does not increase during inspiration (Kussmaul’s sign), whereas in COPD, SVC flow increases during inspiration.12,21,22 The IVC and hepatic flow increases during inspiration and is reduced and partially reversed in expiration in both COPD and constriction XII.8 TRANSIENT CP Up to 17% of patients with CP may have transient CP This may be seen with idiopathic, postsurgical, traumatic, infectious, or collagen vascular diseaseassociated CP, particularly when the onset of symptoms is acute Radiationinduced CP is not transient A pericardial effusion is often present, sometimes large, and 50% of cases of idiopathic effusive-constrictive pericarditis are transient In contrast with persistent CP, transient CP is associated with elevated markers of inflammation (C-reactive protein) Constrictive physiology resolves with observation and anti-inflammatory therapy within months (mean, 2.1 months).23 XII.9 PRACTICAL PERFORMANCE OF HEMODYNAMIC STUDIES WHEN CP IS SUSPECTED The 3 most important recordings to obtain are the following: RA pressure recorded during quiet breathing: look for deep X and deep Y descents and the lack of inspiratory decrease in pressure LV and RV simultaneous recording during quiet and deep breathing: Analyze diastole for (1) dip and plateau pattern and (2) equalization of LVRV end-diastolic pressures Also, compare LVEDP and RVEDP outside the part of the respiratory cycle where they are equal RVEDP>LVEDP suggests RV failure, whereas LVEDP>RVEDP suggests constriction or restrictive cardiomyopathy Analyze systole during deep breathing to assess discordance vs concordance of LV and RV systolic pressure peaks LV and PCWP simultaneous recording: in CP, the gradient between PCWP and early diastolic LV pressure does not change with respiration When CP is suspected clinically and the RA mean pressure is