Hemodynamic Rounds

1
Hemodynamic Rounds

• 5/13/11

2
(No Transcript)
3
Hemodynamics

• Equalization of diastolic pressures (RA, RV, LV,
  Wedge) and pericardial pressure
• Total intracardiac volume fixed, so flow into
  heart occurs mainly during systoleX-descent is
  the dominant wave
• Loss of Y-descent No overall change in
  intracardiac volume in diastole

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.
4
(No Transcript)
5
Paradoxical Pulse and Interdependence

• Hallmark of tamponade
• Inspiration causes increased venous return with
  fixed intracardiac volume
• RV size increases, septum shifts, LV size
  decreases (180 degrees out of phase)

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.
6
Tamponade

• Critical point where effusion reduces volume of
  cardiac chambers Last Drop Phenomenon
• Decreases stroke volume in both left and right
  heart
• Primarily affects the right heart due to lower
  pressures
• Fixed total cardiac volume accentuates
  interdependence

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.
7
Hemodynamic Findings

• High RA, RVEDP, LVEDP and intrapericardial
  pressure prior to tap
• Cardiac output reduced
• Low RA transmural pressure
• Post-tap, intrapericardial pressure dropped, RA
  transmural pressure increased, RA and RVEDP
  dropped slightly and LVEDP was unchanged
• CO increased slightly
• Y-descent returned
• Dip-plateau visible

Sagrista-Sauleda. NEJM 350 2004.
8
Constriction Hemodynamics

• Chief characteristic Failure of transmission of
  intrathoracic pressure changes of respiration to
  the cardiac chambers
• Interdependence Pressure changes continue to
  transmit to the pulmonary circulation, so
  inspiration decreases pulmonary venous pressure
• Drops the PV-LA gradient, with reduced LA inflow
  and reduced transmitral flow
• Underfilled LV permits septal shift to left and
  increased RV filling

9
Hemodynamics

• Equilibration of RA, RV diastolic, Wedge and LV
  diastolic pressures (less than 3-5mmHg
  difference)
• Atrial wave Preserved X-descent, prominent
  Y-descent (M or W configuration)

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.
10
Hemodynamics

• RV and LV show dip and plateau or square root
  sign
• Reflects lack of mid-to-late diastolic filling

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.
11
Constriction vs. Tamponade

• Both restrict cardiac filling and raise systemic
  and pulmonary venous pressures
• Venous pressure waveforms differ

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.
12
Vs. Restriction Dissociation of Intrathoracic
and Intracardiac Pressures
Hatle LK, et. al. Circ. 198979357-370
13
Ventricular Interdependence
Hatle LK, et. al. Circ. 198979357-370
Ventricular Pressures Are DISCORDANT
Insp
Expir
14
Little. Circulation 2006, 113 1629.
15
Kussmauls Sign

• Pericardial constriction
• Restrictive cardiomyopathy
• Congestive Heart FailureRV failure
• Right ventricular infarction
• Acute pulmonary embolism
• COPD