Hemodynamic

Hemodynamic Principles
The Fundamentals
Alan Keith Berger, MD
Divisions of Cardiology and Epidemiology
University of Minnesota
Minneapolis, MN
September 10, 2003

An Overview
• Pressure measurement
• Right and left heart catheterization
• Cardiac output measurement
– Fick-oxygen method
• Arterial-venous oxygen difference
– Indicator-dilution methods
• Indocyanine green
• Thermodilution
• Vascular resistance
• Shunt detection and measurement
• Gradients and valve stenoses

• Natural frequency
– Frequency at which fluid oscillates in a catheter when it is
tapped
– Frequency of an input pressure wave at which the ratio of
output/input amplitude of an undamaged system is maximal
Baim DS and Grossman W. Cardiac Catheterization, Angiography, and Intervention. 5th
Edition. Baltimore:
Williams and Wilkins, 1996.
Pressure Measurement
Terminology
Natural
frequency
catheter
radius
Catheter length x fluid density x π
= x Volume elasticity of transducer membrane
SHORTER catheter
LARGER catheter lumen
LIGHTER fluid
HIGHER natural frequency

• Damping
– Dissipation of the energy of oscillation of a pressure
management system, due to friction
Edition. Baltimore:
Terminology
Damping
Fluid density x (catheter radius)2
=
4 x viscosity of fluid
GREATER fluid viscosity
SMALLER catheter radius
LESS dense fluid
GREATER damping

• Damped natural frequency
– Frequency of oscillation in catheter system when the friction
losses are taken into account
Edition. Baltimore:
Terminology
Damped natural
frequency
=
Natural frequency = Damping  System critically damped
Natural frequency < Damping  OVERdamped
Natural frequency > Damping  UNDERdamped
(Natural frequency)2
– (Damping)2

Edition. Baltimore:
Terminology
UNDER damped OPTIMALLY damped OVER damped
Reverbrations
Less damping  greater
artifactual recorded pressure
overshoot above true
pressure when pressure
changes suddenly
More damping  less
responsive to rapid
alterations in pressure

• Frequency response profile
– Ratio of output amplitude to input amplitude over
a range of frequencies of the input pressure
– Frequency response of a catheter system is
dependent on catheter’s natural frequency
and amount of damping
– The higher the natural
frequency of the system,
the more accurate the
pressure measurement
at lower physiologic
frequencies
Edition. Baltimore:
Rotating
smoked
drum
Amplifying
lever arm
Fluid
filled
tubing
Sensing
membrane
Hürthle Manometer

Hürthle Manometer
Edition. Baltimore:
Rotating
smoked
drum
Amplifying
lever arm
Fluid
filled
tubing
Sensing
membrane
• Sensitivity
– Ratio of amplitude of the recorded
signal to the amplitude of the input
signal

Optimal Damping
0
0.5
1
1.5
2
2.5
3
0 20 40 60 80 100 120 140 160 180 200
Input Frequency as Percent of Natural Frequency
AmplitudeRatio(Output/Input)
D=0
(undamped)
D=0.20
(highly underdamped)
D=0.40
(underdamped)
D=0.64
(optimally
damped)
D=2
(over
damped)
Edition. Baltimore:

Harmonics
Hemodynamic
Pressure Curve
1st
Harmonic
2nd
Harmonic
3rd
Harmonic
4th
Harmonic
5th
Harmonic
6th
Harmonic
Amplitude
Cycle
Edition. Baltimore:

• Pressure wave: Complex periodic fluctuation
in force per unit area
• Fundamental frequency: number of times the
pressure wave cycles in 1 second
• Harmonic: multiple of fundamental frequency
• Fourier analysis: resolution of any complex
periodic wave into a series of simple sine
waves of differing amplitude and frequency
Terminology

• Essential physiologic information is
contained within the first 10 harmonics
– At pulse of 120, the fundamental frequency is 2
cycles/sec, and 10th
harmonic is 20 cycles/sec. A
pressure response system with a frequency
response range that is flat to 20 cycles/sec will be
adequate.
– Natural frequency should be 3 times as fast as the
10th
harmonic of the pressure measured.
– Fidelity of the recording drops with increasing HR.
Edition. Baltimore:
Terminology

• Fluid-filled catheter manometer
• Micromanomter (Catheter-tip pressure
manometer)
– High fidelity transducer catheter with miniaturized
transducer placed at tip (Millar Instruments)
– Improved frequency response characteristics and
reduced artifact
– Measurement of myocardial mechanics
(dP/dt of LV)
Edition. Baltimore:
Devices

Edition. Baltimore:
Reflected Waves
• Reflected waves: Both pressure and flow at any
given location are the geometric sum of the
forward and backward waves

Edition. Baltimore:
Reflected Waves
• Augmented pressure wave reflections
– Vasoconstriction
– Heart failure
– Hypertension
– Aortic / iliofemoral obstruction
– Post-valsalva release
• Diminished pressure wave reflections
– Vasodilation (physiologic / pharmacologic)
– Hypovolemia
– Hypotension
– Valsalva maneuver strain phase

Edition. Baltimore:
Wedge Pressure
• Wedge Pressure
– Pressure obtained when an end-hole catheter is
positioned in a “designated” blood vessel with its open
end-hole facing a capillary bed, with no connecting
vessels conducting flow into or away from the
“designated” blood vessel between the catheter’s tip
and the capillary bed
– True wedge pressure can be measured only in the
absence of flow, allowing pressure to equilibrate
across the capillary bed

Edition. Baltimore:
Wheatstone Bridge
• Strain-gauge pressure transducer
• Increased pressure on diaphragm stretches, and
increases resistance of G1 & G3 wires, while relaxing
G2 & G4 wires
• Voltage is applied
across the wires and
nnbalanced resistance
leads to current flow
across Wheatstone
bridge Diaphragm Vents to
atmospheric
pressure
G1 G2
G3 G4
P

Edition. Baltimore:
Balancing and Calibration
• Balancing a transducer
– Variable resistance is interpolated into circuit so that at
an arbitrary baseline pressure the voltage across the
output terminal can be reduced to zero
– Zero reference
• Midchest level
• Measure antero-posterior thoracic diameter at angle of
Louis
• Calibration
– Mercury manometer attached to free port with 100 mm
Hg of pressure transmitted through fluid-filled line
– Provides accurate scaling of pressure measurement

Edition. Baltimore:
Calibration
100
90
80
70
60
50
40
30
20
10
0
M
iscalibration

Edition. Baltimore:
Calibration
100
90
80
70
60
50
40
30
20
10
0

Edition. Baltimore:
Balancing
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0

Sources of Error
• Tachycardia
– If pulse is too fast for natural frequency of system, the
fidelity of the recording will drop.
– Pulse = 120  10th
harmonic = 20 Hz  Damped natural
frequency should be at least 60 Hz
• Deterioration in frequency response
• Catheter whip artifact
• End-pressure artifact
• Catheter impact artifact
• Systolic pressure amplification in the periphery
• Errors in zero level, balancing, calibration

Sources of Error
• Tachycardia
• Sudden changes in pressure
– Peak LV systole, trough early diastole, catheter bumping
against wall of valve
– Artifact seen due to underdamping

Sources of Error
• Tachycardia
– Introduction of air or stopcocks permits damping and
reduces natural frequency by serving as added compliance
– When natural frequency of pressure system falls, high
frequency components of the pressure waveform
(intraventricular pressure rise and fall) may set the system
into oscillation, producing “pressure overshoots”

Sources of Error
• Tachycardia
– Motion of the catheter within heart or large vessels
accelerates fluid in catheter and produces superimposed
waves of ± 10 mm Hg

Sources of Error
• Tachycardia
– Pressure from endhole catheter pointing upstream is
artifactually elevated. When blood flow is halted at tip of
catheter, kinetic energy is converted in part to pressure.
Added pressure may range 2-10 mm Hg.
– When endhole catheter is oriented into the stream of flow,
the “suction” can lower pressure by up to 5%

Sources of Error
• Tachycardia
– Pressure transient produced by impact on the fluid-filled
catheter by an adjacent structure (i.e. heart valve)
– Any frequency component of this transient that coincides
with the natural frequency of the catheter manometer system
will cause a superimposed oscillation on the recorded
pressure wave

Sources of Error
• Tachycardia
– Consequence of reflected wave
– Peripheral arterial systolic pressure commonly 20 mm Hg
higher than central aortic pressure (mean pressure same or
slightly lower)
– Masks pressure gradients in LV or across aortic valve

Sources of Error
• Tachycardia
– Zero level must be at mid chest level
– All manometers must be zeroed at same point
– Zero reference point must be changed if patient repositioned
– Transducers should be calibrated against standard mercury
reference (rather than electrical calibration signal) and
linearity of response should be verified using 25, 50, and 100
mm Hg

• Heart failure
• Acute MI
• Acute or chronic pulmonary disease
• Screening for unspecified respiratory disease
• Hypotension
• Valvular heart disease
• Mechanical complications
• Endomyocardial fibrosis
• Congenital heart disease
• Complications of transplanted heart
Right Heart Catheterization
Indications

• Heart failure
• Myocardial infarction
• Preoperative use
• Primary pulmonary hypertension
Indications for Bedside Placement
ACC Expert Consensus Document. JACC 1998; 32: 840-64.

• Heart Failure
– Differentiating between hemodynamic and permeability
pulmonary edema or dyspnea when trial of diuretic or
vasodilator has failed or is associated with high risk
– Differentiating between cardiogenic and noncardiogenic
shock when trial of intravascular volume expansion has
failed or is associated with high risk; guidance of
pharmacologic or mechanical therapy
– Guidance of therapy in patients with features of both
“forward” and “backward” heart failure
– Determination of pericardial tamponade when clinical
exam and echocardiography are inconclusive
– Perioperative management of patients with heart failure
undergoing intermediate or high risk surgery
– Detection of pulmonary HTN and guidance of therapy

• Myocardial Infarction
– Differentiating between cardiogenic and hypovolemic
shock when initial therapy with trial of intravascular
volume and low-dose inotropes has failed
– Management of cardiogenic shock with pharmacologic
and/or mechanical therapy
– Pharmacologic and/or mechanical management of acute
mitral regurgitation
– Pre-op assessment left-to-right shunt severity in VSD
– Management of RV infarction associated with
hypotension and/or signs of low cardiac output, not
responsive to intravascular volume, low dose inotropes,
and restoration of heart rate and AV synchrony
– Management of pulmonary edema not responsive to
diuretics, vasodilators, and low-dose inotropes

• Pre-operative Use
– Differentiating between causes of low cardiac output
(hypotension vs. LV dysfunction) when clinical and/or
echocardiographic assessment is inconclusive
– Differentiating between right and left ventricular
dysfunction and pericardial tamponade when clinical
and echocardiographic assessment is inconclusive
– Management of severe low cardiac output syndrome
– Management of pulmonary HTN in patients with
systemic hypotension and evidence of inadequate organ
perfusion

• Primary Pulmonary Hypertension
– Exclusion of post-capillary (elevated PAOP) causes of
pulmonary hypertension
– Diagnosis and assessment of severity of precapillary
(normal PAOP) pulmonary hypertension
– Selection of long-term vasodilator therapy based on
acute hemodynamic response
– Assesment of hemodynamic variables prior to lung
transplantation

Kern MJ. Right Heart Catheterization. CATHSAP II CD-ROM. Bethesda, American College of Cardiology,
2001.
Swan Ganz Catheter

Right Atrial Pressure
• “a” wave
– Atrial systole
• “c” wave
– Protrusion of TV into RA
• “a” wave
– Atrial systole
• “c” wave
• “x” descent
– Relaxation of RA
– Downward pulling of tricuspid
annulus by RV contraction
• “v” wave
– RV contraction
– Height related to atrial compliance & amount of blood return
– Smaller than a wave
• “a” wave
– Atrial systole
• “c” wave
• “x” descent
• “v” wave
– RV contraction
– Smaller than a wave
• “y” descent
– TV opening and RA emptying into RV
• “a” wave
– Atrial systole
• “c” wave
• “x” descent

2001.
Inspiratory Effect on Right Atrial Pressure
• Normal physiology
– Inhalation: Intrathoracic pressure falls  RA pressure falls
– Exhalation: Intrathoracic pressure increases  RA
pressure increases

Abnormalities in RA Tracing
• Low mean atrial pressure
– Hypovolemia
– Improper zeroing of the transducer
• Elevated mean atrial pressure
– Intravascular volume overload
– Right ventricular failure
• Valvular disease (TS, TR, PS, PR)
• Myocardial disease (RV ischemia, cardiomyopathy)
• Left heart failure (MS, MR, AS, AI, cardiomyopathy)
– Increased pulmonary vascular resistance
(PE, COPD, primary pulmonary HTN)
– Pericardial effusion with tamponade physiology
– Atrial myxoma
Davidson CJ, et al. Cardiac Catheterization. In: Heart Disease: A Textbook of Cardiovascular Medicine,
Edited by E. Braunwald, 5th
ed. Philadelphia: WB Saunders Company, 1997

• Elevated mean atrial pressure

• Elevated a wave
– Tricuspid stenosis
– Decreased RV compliance due to RV failure
• Cannon a wave
– A-V asynchrony (3rd
degree AVB, VT, V-pacer)
• Absent a wave
– Atrial flutter or fibrillation
• Elevated v wave
– TR
– RV failure
– Reduced atrial compliance (restrictive myopathy)
• Equal a and v waves
– Tamponade
– Constrictive physiology

• Prominent x descent
– Tamponade
– Subacute/chronic
constriction
– RV ischemia
• Prominent y descent
– TR
– Constrictive pericarditis
– Restrictive myopathy
• Blunted x descent
– Atrial fibrillation
– RA ischemia
• Blunted y descent
– TS
– RV ischemia
– Tamponade

• M or W waves
– Diagnostic for RV ischemia, pericardial constriction or CHF

• Kussmaul’s Sign
– Inspiratory rise or lack of decline in RA pressure
– Diagnostic for constrictive pericarditis or RV ischemia

• Equalization of pressures
– < 5 mm Hg difference between mean RA, RV diastolic, PA
diastolic, PCWP, and pericardial pressures
– Diagnostic for tamponade
RA and LV RV and LV PCW and LV

Right Ventricular Pressure
• Systole
– Isovolumetric contraction
• From TV closure to PV opening
– Ejection
• From PV opening to PV closure
• Diastole
– Isovolumetric relaxation
• From PV closure to TV opening
– Filling
• From TV opening to TV closure
• Early Rapid Phase
• Slow Phase
• Atrial Contraction (“a” wave”)
End diastolic
pressure
Peak systolic
pressure

Right & Left Heart Catheterization
Abnormalities in RV Tracing
• Systolic pressure overload
– Pulmonary HTN
– Pulmonary valve stenosis
– Right ventricular outflow obstruction
– Supravalvular obstruction
– Significant ASD or VSD

– Pulmonary HTN
– Pulmonary valve stenosis
– Right ventricular outflow obstruction
• Systolic pressure reduced
– Hypovolemia
– Cardiogenic shock
– Tamponade

• End-diastolic pressure overload
– Hypervolemia
– CHF
– Diminished compliance
– Hypertrophy
– Tamponade
– Tricuspid regurgitation
– Pericardial constriction

– Hypervolemia
– CHF
– Hypertrophy
– Tamponade
– Tricuspid regurgitation
• End-diastolic pressure reduced
– Hypovolemia

• Dip and plateau in diastolic waveform
– Restrictive cardiomyopathy
– RV ischemia

Restrictive Cardiomyopathy
• Normal respiratory
variation
• Square root sign
• RVSP > 55 mm Hg
• RVEDP / RVSP < 1/3
• LVED-RVED > 5 mm Hg
• RV-LV interdependence
absent
• Lack of variation in
early PCW-LV
gradient

Constrictive Pericarditis
• Prominent x and y
descents
• M wave morphology
• Square root sign
• RVSP < 55 mm Hg
• RVEDP / RVSP > 1/3
• LVED-RVED < 5 mm Hg
• RV-LV interdependence
• Variation in early
PCW-LV gradient

Right vs Left Ventricular Pressure
End diastolic pressure
equalization (LVED-RVED)
Pulmonary artery pressure
RVEDP / RVSP
Dip-plateau morphology
Kussmaul’s sign
Constrictive
Pericarditis
Restrictive
Cardiomyopathy
≤ 5 mm Hg
< 55 mm Hg
> 1/3
LV rapid filling
wave > 7 mm Hg
No respiratory
variation in
mean RAP
> 5 mm Hg
> 55 mm Hg
≤ 1/3
LV rapid filling
wave ≤ 7 mm Hg
Normal respiratory
variation in
mean RAP

Edition. Baltimore:
Pulmonary Artery Pressure
• Biphasic tracing
– Systole
– Diastole
• Pulmonary HTN
– Mild: PAP > 20 mm Hg
– Moderate: PAP > 35 mm Hg
– Severe: PAP > 45 mm Hg

Abnormalities in PA Tracing
• Elevated systolic
pressure
– Primary pulmonary HTN
– MS
– MR
– CHF
– Left-to-right shunt
– Pulmonary disease

• Elevated systolic
pressure
– Primary pulmonary HTN
– MS
– MR
– CHF
– Left-to-right shunt
• Reduced systolic
pressure
– Hypotension
– Pulmonary artery stenosis
– Pulmonic stenosis
– Supra or subvalvular
stenosis
– Ebstein’s anomaly
– Tricuspid atresia

• Reduced pulse pressure
– Right heart ischemia
– RV infarction
– Pulmonary embolism
– Tamponade

– Right heart ischemia
– RV infarction
– Tamponade
• PA diastolic pressure > PCW pressure
– Pulmonary embolus
– Tachycardia

2001.
Swan Ganz Catheter
PCWP

Edition. Baltimore:
Pulmonary Capillary Wedge Pressure
• “a” wave
– Atrial systole
• “c” wave
– Protrusion of MV into LA
• “x” descent
– Relaxation of LA
– Downward pulling of mitral
annulus by LV contraction
• “v” wave
– LV contraction
– Higher than a wave
• “y” descent
– MV opening and LA emptying into LV

2001.
Inspiratory Effect on Right Atrial Pressure
PCWP

Edition. Baltimore:
Left Atrial and PCW Pressure
• PCW tracing “approximates” actual LA tracing but
is slightly delayed since pressure wave is
transmitted retrograde through pulmonary veins

2001.
Right vs Left Atrial Pressure
• Normal LA pressure slightly higher than RA
pressure

Abnormalities in PCWP Tracing
• Low mean pressure
– Hypovolemia
– Improper zeroing of the transducer
• Elevated mean pressure
– Intravascular volume overload
– Left ventricular failure
• Valvular disease (MS, MR, AS, AR)
• Myocardial disease (LV ischemia, cardiomyopathy)
• Left heart failure secondary to HTN
– Pericardial effusion with tamponade
– Atrial myxoma

• Elevated a wave
– Mitral stenosis
– Decreased LV compliance due to LV failure / valve disease
• Cannon a wave
– A-V asynchrony (3rd
degree AVB, VT, V-pacer)
• Absent a wave
– Atrial flutter or fibrillation
• Elevated v wave
– MR
– LRV failure
– Ventricular septal defect
– Tamponade
– Constrictive physiology

• Prominent x descent
– Tamponade
– Subacute/chronic
constriction
– MR
• Blunted x descent
– Atrial fibrillation
– LA ischemia
• Blunted y descent
– MS
– LV ischemia
– Tamponade

• Severe Mitral Regurgitation

• PCWP not equal to LV end diastolic pressure
– Mitral stenosis
– Atrial myxoma
– Cor triatriatum
– Pulmonary venous obstruction
– Decreased ventricular compliance
– Increased pleural pressure

2001.
Left Heart Catheterization
Pigtail Catheter

Left Ventricular Pressure
• Systole
– Isovolumetric contraction
• From MV closure to AoV opening
– Ejection
• From AoV opening to AoV closure
• Diastole
– Isovolumetric relaxation
• From AoV closure to MV opening
– Filling
• From MV opening to MV closure
• Early Rapid Phase
• Slow Phase
• Atrial Contraction (“a” wave”)
End diastolic
pressure
Peak systolic
pressure

Right vs Left Ventricular Pressure
• Diastolic amplitude similar between RV and
LV tracings
• Systolic amplitude higher for LV than RV
• Duration of systole, isovolumetric
contraction, and isovolumetric relaxation is
are longer for LV compared to RV
• Duration of ejection is shorter for LV than
RV

Abnormalities in LV Tracing
– Systemic HTN
– Aortic valve stenosis
– Left ventricular outflow obstruction
• Systolic pressure reduced
– Hypovolemia
– Tamponade

• Severe Aortic Stenosis

– Hypervolemia
– CHF
– Hypertrophy
– Tamponade
– Mitral regurgitation
• End-diastolic pressure reduced
– Hypovolemia
– Mitral stenosis

Arterial Pressure Monitoring
Central Aortic and Peripheral Tracings
• Pulse pressure =
Systolic – Diastolic
• Mean aortic pressure
typically < 5 mm Hg
higher than mean
peripheral pressure
• Aortic waveform varies
along length of the aorta
– Systolic wave increases in amplitude while diastolic wave
decreases
– Mean aortic pressure constant
– Dicrotic notch less apparent in peripheral tracing

Abnormalities in Central Aortic Tracing
• Systolic pressure elevated
– Systemic hypertension
– Atherosclerosis
– Aortic insufficiency
• Systemic pressure reduced
– Hypovolemia
– Aortic stenosis
– Heart failure

• Widened pulse pressure
– Systemic hypertension
– Significant patent ductus arteriosus
– Ruptured sinus of valsalva aneurysm
– Tamponade
– Heart failure
– Aortic stenosis

• Pulsus bisferiens
– Hypertrophic obstructive cardiomyopathy
Marriott HJL. Bedside Cardiac Diagnosis. Philadelphia: JB Lippincott Company, 1993.

• Pulsus alternans
– Pericardial effusion
– Cardiomyopathy
– CHF
Marriott HJL. Bedside Cardiac Diagnosis. Philadelphia: JB Lippincott Company, 1993.

• Pulsus paradoxus
– Tamponade
– COPD

• Spike and dome configuration
– Hypertrophic obstructive cardiomyopathy
Spike Dome

• Pulsus parvus and tardus
– Aortic stenosis

Hemodynamic Parameters
Reference Values
Average Range Average Range
a wave
v wave
mean
Right ventricle
peak systolic
end diastolic
Pulmonary artery
peak systolic
Right atrium
end diastolic
mean
6
5
25
9
15
25
4
3
2 - 7
2 - 7
15 - 30
4-12
9-19
15-30
1 - 7
1 - 5
mean
Left atrium
a wave
v wave
mean
Left ventricle
peak systolic
end diastolic
PCWP
Central aorta
peak systolic
9
12
8
130
8
10
4 - 12
6 - 21
2 - 12
90 - 140
5 - 12
4 - 16
130 90 - 140
70 60 - 90end diastolic
mean 85 70 -105

Left Ventricular Diastole
x
y
MV
opensMV
closes
S1

Left Ventricular Systole
AoV
opens
AoV
closes
S2

1. A 76-year-old woman with shortness of breath and pulmonary
edema is admitted to the Coronary Care Unit. Blood pressure
on admission was 280/130 mmHg. With treatment, pulmonary
edema has resolved and the patient is stable. For which of the
following is right heart catheterization an indication?
A. Routine management of pulmonary edema even if endotracheal
intubation and mechanical ventilation has been necessary.
B. To differentiate cardiogenic from noncardiogenic shock before a
trial of intravascular volume expansion.
C. To treat patients with marked hemodynamic instability in whom
pericardial tamponade is probable by echo criteria.
D. To be used in the perioperative-managed patients with
compensated CHF undergoing low-risk, noncardiac surgery.
E. To facilitate titration of diuretic, vasodialator, or inotropic therapy
in patients with severe heart failure.

2. A patient with a chest pain syndrome comes to
cardiac catheterization. Previous history includes
angina pectoris, cigarette smoking, and
emphysema. Which of the following would be an
indication for right heart catheterization?
A. First-degree AV block.
B. Left bundle branch block.
C. Positive stress test.
D. Dyspnea at rest.
E. Right axis deviation on electrocardiogram.

3. You are performing a cardiac catheterization
procedure and need to be certain your pulmonary
capillary wedge pressure is correct. Which of the
following is the most reliable way to confirm that a
presumed wedge pressure is a correct wedge
pressure?
A. The catheter tip does not move with cardiac motion.
B. The waveform has classic A and V deflections.
C. Obtain a blood sample for oximetry from the catheter tip
when wedged.
D. The mean PA pressure exceeds mean PCW pressure.
E. The T wave on the electrocardiogram follows the V wave on
the wedge pressure tracing.

4. A 48 yo man is referred to you because of progressive edema, ascites, and
dyspnea developing over the past 6 months. He had been previously healthy,
but was treated recently for chronic venous insufficiency. In retrospect, he
has also noticed fatigue during the past 2 years. On exam, his BP was 105/85
mmHg without a pulsus paradoxus and his heart rate was 95 bpm and regular.
His JVP was elevated to the mandible while sitting upright with a prominent
y-descent. The 1st
and 2nd
heart sounds were normal, and an early diastolic
sound was heard at the apex. His lungs were clear, ascites was present
without hepatosplenomegaly, and there was severe peripheral edema. Mild
cardiomegaly and small bilateral pleural effusions were present on his CXR.
Blood chemistry revealed the following: hemoglobin 13.9 mg/dl, serum
creatinine 1.7 mg/dl, AST 40IU, total bilirubin 1.6 mg/dl, alkaline phosphatase
403 IU. His EKG showed NSR with nonspecific ST and T-wave changes. An
echocardiogram demonstrated normal LV size and function with an EF of 50%
to 55%. There was abnormal septal motion and mild MR and TR. Figure 4-1
and Figure 4-2 show hemodynamic results from his cardiac catheterization.
Coronary angiography showed no atherosclerosis in the major epicardial
arteries. Which of the following is the most likely explanation for these
findings?

PAW and LV Tracings during
Inspiration and Expiration
RV and LV Tracings during
Inspiration and Expiration

PAW and LV
Tracings during
Inspiration and
Expiration
RV and LV
Tracings during
Inspiration and
Expiration
A. Chronic recurrent PE.
B. Constrictive pericarditis.
C. Atrial septal defect with a large
shunt and right heart failure.
D. Chronic pericarditis now
presenting with tamponade.
E. Chronic hepatitis with cirrhosis.
Which of the following is
the most likely explanation
for these findings?

5. A 37-year-old man is referred for the evaluation of aortic
regurgitation. He has known of his condition since he was
rejected from military service at age 20. His only symptom is
mild, but now over the past year has been suffering from a
progressive decline in his ability to work as a brick mason. His
physical examination, chest x-ray, and echocardiogram are all
consistent with important aortic regurgitation. Cardiac
catheterization is performed. Which of the following is not
seen in severe aortic insufficiency?
A. Femoral artery systolic pressure exceeds central aortic systolic
pressure by 60 mmHg.
B. An early rapid rise in the left ventricular diastolic pressure.
C. Diastasis of left ventricular and aortic diastolic pressures.
D. A regurgitant fraction of 0.35.
E. An LV end-diastolic volume index of 230ml/m².

6. Which of the following is the best method of
differentiating constrictive pericarditis from
restrictive cardiomyopathy in patients undergoing
cardiac catheterization?
A. Enhanced ventricular interaction between left
ventricle and right ventricle.
B. End diastolic equalization of pressures less than 5
mmHg.
C. Pulmonary artery pressure less than 50 mmHg.
D. A different plateau pattern in the right ventricular and
left ventricular pressure curve.
E. Right ventricular diastolic pressure greater than one-
third of the right ventricular systolic pressure.

7. Which of the following is the best method of
differentiating constrictive pericarditis from
restrictive cardiomyopathy in patients undergoing
cardiac catheterization?
A. Enhanced ventricular interaction between left
ventricle and right ventricle.
B. End diastolic equalization of pressures less than 5
mmHg.
C. Pulmonary artery pressure less than 50 mmHg.
D. A different plateau pattern in the right ventricular and
left ventricular pressure curve.
E. Right ventricular diastolic pressure greater than one-
third of the right ventricular systolic pressure.

8. A patient comes to the cardiac catheterization laboratory for possible
constrictive pericarditis. This patient has had progressive edema and
ascites for the past year. The patient is currently taking large dosages
of diuretics to control his symptoms. When the patient comes to the
catheterization laboratory, the RA pressure is 5 mmHg, the RV pressure
is 30/5 mmHg, and the PA pressure is 30/10 mmHg. The PCWP is 10
mmHg. The aortic pressure is 100/70 mmHg. Which of the following is
true about the work-up for this patient?
A. This patient does not have constrictive pericarditis or restrictive
cardiomyopathy and no further evaluation is necessary.
B. This patient has a restrictive cardiomyopathy rather than constrictive
pericarditis due to the end equalization of PA and RA pressures.
C. This patient should undergo fluid loading and have another measurement of
pressures.
D. This patient should receive nitroprusside infusion and have remeasurement
of pressures.
E. This patient should have a RA angiogram to look for pericardial thickening.

9. A 32-year-old obese man with a dilated cardiomyopathy is
referred for hemodynamic assessment to determine if he is a
candidate for cardiac transplantation. His mean pulmonary
artery pressure is 45 mmHg, mean pulmonary capillary wedge
pressure is 30 mmHg, and cardiac output is 5.0 L/min. Which
of the following is the next step in management?
A. Based on the PVR, he can be listed for cardiac transplantation.
B. He should undergo further hemodynamic evaluations during the
infusion of nitroprusside.
C. Based on the pulmonary vascular resistance, he is not a
candidate for cardiac transplantation.
D. He should be considered for combination heart-lung
transplantation.
E. More information is required to determine the pulmonary
vascular resistance.

10. An obese 30-year-old woman with a murmur is referred for
evaluation. An echocardiogram was of poor-quality but is
interpreted as showing important aortic stenosis. Your
exam confirms the presence of a systolic ejection murmur
with radiation to the base but the exam is limited by her
obesity. Cardiac catheterization is performed and the
pullback pressure (shown in Figure 1-1) is recorded. Which
of the following is the correct interpretation of this pressure
recording?
A. She has valvular aortic stenosis.
B. She has hypertrophic cardiomyopathy with obstruction.
C. She has an intraventricular pressure gradient.
D. She has a bicuspid aortic valve with mild stenosis.
E. She has a pressure gradient but it is likely an artifact.

A. She has valvular aortic stenosis.
B. She has hypertrophic cardiomyopathy with obstruction.
C. She has an intraventricular pressure gradient.
D. She has a bicuspid aortic valve with mild stenosis.
E. She has a pressure gradient but it is likely an artifact.

11. Of the following criteria, which has the greatest
positive predictive value for diagnosing
constrictive pericarditis?
A. Left ventricular end-diastolic pressure minus right
ventricular end-diastolic pressure < 5 mmHg.
B. Right ventricular end-diastolic pressure divided by
right ventricular systolic pressure > 1/3.
C. Respiratory change in right atrial pressure < 3 mmHg.
D. Left ventricular/right ventricular interdependence.
E. Dip and plateau of left ventricular diastolic pressure.

12. In the diagnosis of restrictive physiology, what are
the criteria with the highest sensitivity?
A. Parallel increase in left and right ventricular end-
diastolic pressures.
B. Concordance of left and right ventricular systolic
pressures during normal respiration.
C. Dyssynchronous increase in right ventricular systolic
pressure with left ventricular pressure at end
inspiration.
D. Simultaneous increase in left ventricular, pulmonary
capillary wedge, and left ventricular systolic
pressures.
E. Dip and plateau of LV diastolic pressure.

13. A 65-year-old man presents with progressive dyspnea on exertion,
edema, and ascites. A history of coronary artery disease was present
and coronary artery bypass surgery had been performed several years
earlier. Echocardiography revealed normal left ventricular function with
small-to-moderate pericardial and pleural effusions. On examination,
there was jugular venous distention with rapid 'Y' descent, bilateral
lower extremity, and distant heart sounds. The electrocardiogram
showed sinus tachycardia. In examination of the hemodynamics of this
patient, which findings are most diagnostic of constrictive physiology?
A. Abrupt cessation of ventricular filling with simultaneous right and left
ventricular diastolic pressures.
B. Respiratory disconcordance of simultaneous right and left ventricular
systolic pressures.
C. Respiratory concordance of simultaneous right atrial and left ventricular
pressures.
D. Respiratory disconcordance of simultaneous pulmonary capillary wedge
and right atrial pressures.
E. Dip and plateau of left ventricular diastolic pressure.

14. A 70 yo woman with signs and symptoms of right and left
heart failure undergoes cardiac catheterization. Her study
shows no underlying coronary artery disease, but elevations
of her right and left ventricular diastolic pressures in the
range of 22-25 mmHg. Which of the following is more
commonly seen in patients with restrictive cardiomyopathy
than in patients with constrictive pericarditis?
A. Elevation and equilibration of right and left ventricular end
diastolic pressures.
B. Absence of rapid early diastolic filling (no dip and plateau
ventricular waveform).
C. Lower pulmonary artery systolic pressures typically in the
range of 35-45 mm Hg.
D. An increase in mean right atrial pressure with inspiration.
E. A normal left ventricular ejection fraction.

Cardiac Output Measurement
• Definition: Quantity of blood
delivered to the systemic circulation
per unit time
• Techniques
– Fick-Oxygen Method
– Indicator-Dilution Methods
• Indocyanine Green
• Thermodilution

Fick Oxygen Method
• Fick Principle: The total uptake or release of any
substance by an organ is the product of blood
flow to the organ and the arteriovenous
concentration difference of the substance.
• As applied to lungs, the substance released to
the blood is oxygen, oxygen consumption is the
product of arteriovenous difference of oxygen
across the lungs and pulmonary blood flow.
• In the absence of a shunt, systemic blood flow
(Qs) is estimated by pulmonary blood flow (Qp).
Qp =
Oxygen consumption
Arteriovenous O2 difference
Edition. Baltimore:

Vincent JL. Hemodynamic Monitoring, Pharmacologic Therapy, and Arrhythmia Management in Acute
Congestive Heart Failure. In: Congestive Heart Failure. Edited by Hosenpud JD and Greeenberg BH. New
York: Springer-Verlag, 1994.
O2 Consumption
0
1
2
3
4
5
0 10 20 30 40 50 60 70
CardiacIndex(L/min/m2)
Oxygen Extraction (%)
Serial VO2
Isopleths
Increasing VO2
Cardiac index =
VO2
Oxygen extractionAthlete
Heart Failure

Fick Oxygen Method: O2 Consumption
• Polarographic O2 Method
– Metabolic rate meter
– Device contains a polarographic oxygen
sensor cell, a hood, and a blower of variable
speed connected to a servocontrol loop with
an oxygen sensor.
– The MRM adjusts the variable-speed blower to
maintain a unidirectional flow of air from the
room through the hood and via a connecting
hose to the polarographic oxygen-sensing cell.
Edition. Baltimore:

VM = VR + VE - VI
VM = Blower Discharge Rate
VR = Room Air Entry Rate
VI = Patient Inhalation Rate
VE = Patient Exhalation Rate
VO2 = (FRO2 x VR) - (FMO2 x VM)
FRO2 = Fractional room air O2 content = 0.209
FMO2 = Fractional content of O2 flowing past polarographic cell
Edition. Baltimore:
VR VM
VE
VI

VO2 = (FRO2 x VR) - (FMO2 x VM)
VO2 = VM (0.209 - FMO2) + 0.209 (VI - VE)
Constant if
steady state
Servocontrolled system adjusts VM to keep
fractional O2 content of air moving past
polarographic sensor (FMO2) at 0.199
VO2 = 0.01 (VM) + 0.209 (VI - VE)
Respiratory quotient
RQ = VI / VE = 1.0
VO2 = 0.01 (VM)
Edition. Baltimore:

• Douglas Bag Method
– Volumetric technique for measuring O2
– Analyzes the collection of expired air
– Utilizes a special mouthpiece and nose clip so
that patient breathes only through mouth
– A 2-way valve permits entry of room air while
causing all expired air to be collected in the
Douglas bag
– Volume of air expired in a timed sample (3 min)
is measured with a Tissot spirometer
Edition. Baltimore:

Barometric pressure = _________ mm Hg
Barometric temperature = _________ º C
Corrected barometric pressure = _________ mm Hg
pO2 room air = _________ mm Hg
pO2 expired air = _________ mm Hg
Tissot: initial = _________ cm
Tissot: final = _________ cm
Sample volume (oxygen analysis) _________ L
Correction factor _________ (standard tables)
Collection time _________ min
Edition. Baltimore:

Step 1: Calculate oxygen difference
O2 content room air =
pO2 room air x 100
Corrected barometric pressure
O2 content expired air =
pO2 expired air x 100
Corrected barometric pressure
O2 room air - O2 expired air = ______ mL O2 consumed / L air
Oxygen difference =
Edition. Baltimore:

Step 2: Calculate minute ventilation
Tissot difference = Tissot initial – Tissot final = _____ cm
Total volume = Tissot volume + sample volume = _____ L
Ventilation volume (corrected to STP) =
Tissot volume = Tissot difference x correction factor = _____ L
Total volume expired air x correction factor = _____ L
Minute ventilation =
Ventilation volume
Collection time
Edition. Baltimore:

Step 3: Calculate oxygen consumption
O2 consumption = O2 difference x minute ventilation
O2 consumption
Body surface area
O2 consumption index =
Edition. Baltimore:

• Sampling technique
– Mixed venous sample
• Collect from pulmonary artery
• Collection from more proximal site may result in
error with left-right shunting
– Arterial sample
• Ideal source: pulmonary vein
• Alternative sites: LV, peripheral arterial
– If arterial dessaturation (SaO2 < 95%) present, right-to-
left shunt must be excluded
• Measurement
– Reflectance (optical absorbance) oximetry
Fick Oxygen Method: AV O2 Difference
Edition. Baltimore:

Fick Oxygen Method: AV O2 Difference
O2 carrying capacity (mL O2 / L blood) =
1.36 mL O2 / gm Hgb x 10 mL/dL x Hgb (gm/dL)
Step 1: Theoretical oxygen carrying capacity
Step 2: Determine arterial oxygen content
Arterial O2 content = Arterial saturation x O2 carrying capacity
Step 3: Determine mixed venous oxygen content
AV O2 difference = Arterial O2 content - Mixed venous O2 content
Step 3: Determine A-V O2 oxygen difference
Mixed venous O2 content = MV saturation x O2 carrying capacity
Edition. Baltimore:

Fick Oxygen Method
• Fick oxygen method total error ≈ 10%
– Error in O2 consumption ≈ 6%
– Error in AV O2 difference ≈ 5%. Narrow AV O2
differences more subject to error, and therefore Fick
method is most accurate in low cardiac output states
• Sources of Error
– Incomplete collection of expired air (Douglas bag)
• Underestimate O2 consumption and CO
– Respiratory quotient = 1
• Volume of CO2 expired is not equal to O2 inspired
• Leads to underestimation of O2 consumption and CO
– Incorrect timing of expired air collection (Douglas bag)
Edition. Baltimore:

Fick Oxygen Method
– Spectophotometric determination of blood oxygen
saturation
– Changes in mean pulmonary volume
• Douglas bag and MRM measure amount of O2 entering
lungs, not actual oxygen consumption
• Patient may progressively increase or decrease pulmonary
volume during sample collection. If patient relaxes and
breathes smaller volumes, CO is underestimated
– Improper collection of mixed venous blood sample
• Contamination with PCW blood
• Sampling from more proximal site
Edition. Baltimore:

Indicator Dilution Methods
• Requirements
– Bolus of indicator substance which mixes
completely with blood and whose
concentration can be measured
– Indicator is neither added nor subtracted from
blood during passage between injection and
sampling sites
– Most of sample must pass the sampling site
before recirculation occurs
– Indicator must go through a portion of
circulation where all the blood of the body
becomes mixed
Edition. Baltimore:

Indicator Dilution Methods
Edition. Baltimore:
CO = 
0
∞
Indicator amount
C (t) dt
C = concentration
of indicator
• Indicators
– Indocyanine Green
– Thermodilution (Indicator = Cold)
Stewart-Hamilton Equation
CO =
Indicator amount (mg) x 60 sec/min
mean indicator concentration (mg/mL) x curve duration

Indocyanine Green Method
Edition. Baltimore:
• Indocyanine green (volume and concentration
fixed) injected as a bolus into right side of
circulation (pulmonary artery)
• Samples taken from peripheral artery,
withdrawing continuously at a fixed rate
• Indocyanine green concentration measured by
densitometry
Concentration
Recirculation
Extrapolation
of plot
time
CO =
(C x t )
I
(C x t)
CO inversely
proportional
to area under
curve

Edition. Baltimore:
– Indocyanine green unstable over time and with
exposure to light
– Sample must be introduced rapidly as single bolus
– Bolus size must be exact
– Indicator must mix thoroughly with blood, and should
be injected just proximal or into cardiac chamber
– Dilution curve must have exponential downslope of
sufficient length to extrapolate curve. Invalid in Low
cardiac output states and shunts that lead to early
recirculation
– Withdrawal rate of arterial sample must be constant

Thermodilution Method
Edition. Baltimore:
CO =

0
∞
VI (TB-TI) (SI x CI / SB x CB ) x 60
∆ TB dt
VI = volume of injectate
SI, SB = specific gravity of injectate and blood
TI = temperature of injectate
CI, CB = specific heat of injectate and blood
∆ TB = change in temperature measured downstream

Edition. Baltimore:
• Advantages
– Withdrawal of blood not necessary
– Arterial puncture not required
– Indicator (saline or D5W)
– Virtually no recirculation, simplifying computer
analysis of primary curve sample

Edition. Baltimore:
• Sources of Error (± 15%)
– Unreliable in tricuspid regurgitation
– Baseline temperature of blood in pulmonary artery may
fluctuate with respiratory and cardiac cycles
– Loss of injectate with low cardiac output states
(CO < 3.5 L/min) due to warming of blood by walls of
cardiac chambers and surrounding tissues. The
reduction in ∆ TB at pulmonary arterial sampling site will
result in overestimation of cardiac output
– Empirical correction factor (0.825) corrects for catheter
warming but will not account for warming of injectate in
syringe by the hand

Edition. Baltimore:
• Stroke Volume
– Volume of blood ejected in a single contraction
– Volumetric analysis requires 3-dimensional
analysis to calculate end-diastolic and end-
systolic volume
– Estimation based on cardiac output
Stroke Volume
Stroke volume = End-diastolic volume – End-systolic volume
Stroke volume =
Heart rate
Cardiac output

1. In the cardiac catheterization laboratory, cardiac output
is measured using the Fick principle or thermodilution
technique. Which of the following statements is correct?
A. Using an assumed O2 consumption of 125 ml/m2
is
acceptable and results in minimal variability in cardiac output
compared with direct measurements of O2 consumption.
B. The thermodilution method underestimates cardiac output in
patients with low forward flows (cardiac outputs <3.5 L/min).
C. The thermodilution method underestimates cardiac output in
the presence of important tricuspid regurgitation.
D. O2 saturation measured in blood collected from a central line
in the right atrium is an acceptable substitute for a pulmonary
artery sample when calculating the AV O2 difference.
E. A high cardiac output will produce a large area under the
temperature-time curve in thermodilution determinations.

Edition. Baltimore:
Vascular Resistance
Poiseuille’s Law
Q =
π (Pi – Po) r 4
8 η L
Pi
r
PoPi
LPi – Po = inflow – outflow pressure
r = radius of tube
η = viscosity of the fluid
L = length of tube
Q = volume flow
Resistance =
8 η L∆ P
Q
=
π r 4
In vascular system,
key factor is radius
of vessel

Edition. Baltimore:
SVR =
Vascular Resistance
Definitions
Ao - RA
Qs
PVR =
PA - LA
Qp
Normal reference values
Woods Units x 80 = Metric Units
10 – 20 770 – 1500
0.25 – 1.5 20 – 120
Systemic vascular resistance
Pulmonary vascular resistance

Edition. Baltimore:
Vascular Resistance
Systemic Vascular Resistance
• Increased
– Systemic HTN
– Cardiogenic shock with compensatory arteriolar
constriction
• Decreased
– Inappropriately high cardiac output
• Arteriovenous fistula
• Severe anemia
• High fever
• Sepsis
• Thyrotoxicosis

Edition. Baltimore:
Vascular Resistance
Pulmonary Vascular Resistance
• Increased
– Primary lung disease
– Eisenmenger syndrome
– Elevated pulmonary venous pressure
• Left-sided myocardial dysfunction
• Mitral / Aortic valve disease
• Decreased

A. He would be a candidate for cardiac transplantation based
upon the calculated pulmonary arteriorlar resistance.
B. He should undergo further evaluation with infusion of
nitrprusside.
C. He would not be a candidate for cardiac transplantation
based upon pulmonary arteriorlar resistance.
transplanation.
arteriorlar resistance.
1. An obese patient with a dilated cardiomyopathy comes to the
cardiac catheterization laboratory to determine whether or not
he might be a candidate for cardiac transplantation. The
pulmonary artery pressure is 40 mmHg, the pulmonary artery
wedge pressure is 25 mmHg, and the cardiac output is 5 L/min.
Which of the following statements is true?

1. An obese patient with a dilated cardiomyopathy comes to the
cardiac catheterization laboratory to determine whether or not
he might be a candidate for cardiac transplantation. The
pulmonary artery pressure is 40 mmHg, the pulmonary artery
wedge pressure is 25 mmHg, and the cardiac output is 5 L/min.
Which of the following statements is true?
A. He would be a candidate for cardiac transplantation based
upon the calculated pulmonary arteriorlar resistance.
B. He should undergo further evaluation with infusion of
nitrprusside.
C. He would not be a candidate for cardiac transplantation
based upon pulmonary arteriorlar resistance.
transplanation.
arteriorlar resistance.

2. The patient is a 55-yo woman who was diagnosed with severe
pulmonary hypertension 2 months ago. She has had evidence of
RVH by ECG dating back 6 years, but remained asymptomatic until
recently. A daughter died at the age of 8 years from primary
pulmonary hypertension. She was referred for right heart
catheterization to exclude an intracardiac shunt and to perform an
intravenous prostacyclin challenge to assess her pulmonary
vasoreactivity. Her pulmonary artery hydrogen curve appearance
time was 12 seconds.
The hydrogen curve technique is performed by having the patient
inhale one breath of hydrogen and record the time to downward drift of
the electrocardiographic baseline recorded from the tip of an electrode
catheter placed in the main pulmonary artery. A short appearance
time of the ECG drift (1-2 seconds) confirms the presence of a left-to-
right intracardiac shunt. The 12 second recorded in this patient is
normal and excludes a left-to-right shunt. The hydrogen curve
technique is very sensitive compared to oximetry, but is not useful in
quantifying the magnitude of the shunt nor in detecting a right to left
shunt.
?

A Flolan (IV prostacyclin) infusion was begun. At a dose of 8
ngm/kg/minute, she had moderate cutaneous flushing and her
systemic arterial pressure was reduced from the baseline of 107/81
(mean 90 mmHg) with a heart rate of 136bpm to 86/61 (mean 67
mmHg) with a heart rate of 137 bpm. Thermodilution cardiac output
was 2.50 L/min at baseline and 4.20 L/min during the maximum
prostacyclin infusion. The pressure tracing below was recorded
before prostacyclin was initiated.

The pressure tracing below was recorded after prostacyclin was
initiated.

A. Further reductions in pulmonary artery pressure can likely
be achieved at higher dose of this prostaglandin.
B. The hydrogen curve result suggests there is an intracardiac
left-to-right shunt.
C. At baseline, the pulmonary resistance is elevated at 20
Wood units.
D. At baseline, the pulmonary resistance is elevated at 20
dyne/sec/cm-5.
E. Primary pulmonary hypertension has no genetic
determinants.
Which of the following correctly describes these data or the
management of this patient?

3. The patient is a 42-year-old woman who presents with mild
dyspnea. She has gained considerable weight and feels that
it is the primary reason for the new symptoms. Her initial
exam suggests no CHF, but a pulmonic flow murmur is
heard. The second heart sound is clearly widely split. She
has a right bundle branch block on her ECG. An
echocardiogram is obtained that reveals an enlarged RA
and RV. By Doppler/echocardiogram, a left-to-right shunt is
noted across the atrial septum. Using saline contrast a few
microcavitations appear on the left side of the heart. A
cardiac catheterization is performed to assess size of shunt
and pulmonary pressures.

3. The cardiac catheterization revealed:
Pressures (mmHg): RA: mean 7, RV: 45/6, PA: 45/25, mean 33, PCW: mean
10, LV: 120/5, Aortic: 120/80, mean 95.
Saturations (%): SVC: 60, IVC: 65, (Mixed Venous 62), RA: 80, RV: 75, PA:
75, PV: 95, Aortic: 95.
Hemoglobin: 13 mg/dl, Oxygen consumption: 250 ml/min.
LA angiogram: Consistent with secundum atrial septal defect.
Using these data, the pulmonary blood flow was determined to be 7.1
liters/min and the systemic blood flow was found to be 4.3 liters/min.
Select the correct answer based on the findings at cardiac catheterization.
A. The QP/QS suggests that no therapy is required at this time.
B. The PVR/SVR ratio suggests the elevated PA pressure is due to
Eisenmenger’s syndrome, and it is too late to consider ASD closure.
C. The PVR/SVR ratio is low enough that she would be a candidate for ASD
closure at this time.
D. There are inadequate data to decide the patient’s operability.
E. Endocarditis prophylaxis is highly recommended to prevent endocarditis
given these hemodynamics.

4. A 48-year-old patient with pulmonary hypertension is
admitted with profound cyanosis and clubbing. Her workup
reveals primary pulmonary hypertension with a patent
foramen ovale and right-to-left shunt. Given the following
information, calculate her pulmonary vascular resistance.

4. At catheterization, the SVC oxygen saturation is 43%, the
IVC oxygen saturation is 50%, the RA saturation is 45%, the
PA oxygen saturation is 45%, the PV saturation is 90%, the
aortic oxygen saturation is 80%. Oxygen consumption is 275
ml/min. The hemoglobin is 15gm%. The RA pressure mean
is 15, the RV pressure is 90/15, the PA pressure is 90/60 with
a mean of 75, the pulmonary wedge pressure is 10, the LV
pressure is 110/10, the aortic pressure is 110/80 with a mean
of 95 mmHg.
A. There is inadequate information to calculate the PVR.
B. The PVR is 21.7 Wood units.
C. The PVR is 16.2 Wood units.
D. The PVR is 10.3 Wood units.
E. The PVR is 8.8 Wood units.

Edition. Baltimore:
• Arterial desaturation (<95%)
– Alveolar hypoventilation (Physiologic Shunt)
corrects with deep inspiration and/or O2
• Sedation from medication
• COPD / Pulmonary parenchymal disease
• Pulmonary congestion
– Anatomic shunt (RtLf) does not correct with O2
• Unexpectedly high PA saturation (>80%) due
to LfRt shunt
Shunt Detection & Measurement
Indications

Edition. Baltimore:
• Shunt Detection
– Indocyanine green method
– Oximetric method
• Shunt Measurement
– Left-to-Right Shunt
– Right-to-Left Shunt
– Bidirectional Shunt
Methods

Edition. Baltimore:
• Indocyanine green (1 cc) injected as a bolus into
right side of circulation (pulmonary artery)
• Concentration
measured from
peripheral artery
• Appearance and
washout of dye
produces initial 1st
pass curve followed
by recirculation in
normal adults

Edition. Baltimore:
Left-to-Right Shunt

Edition. Baltimore:
Right-to-Left Shunt

Bashore, TM. Congenital Heart Disease in Adults. The Measurement of Intracardiac Shunts. In: CATHSAP
II. Bethesda: American College of Cardiology, 2001.

Oximetric Methods
Edition. Baltimore:
• Obtain O2 saturations in
sequential chambers,
identifying both step-up
and drop-off in O2 sat
• Insensitive for small
shunts (< 1.3:1)

Oximetry Run
Edition. Baltimore:
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
• IVC, L4-5 level
• IVC, above diaphragm
• SVC, innominate
• SVC, at RA
• RA, high
• RA, mid
• RA, low
• RV, mid
• RV, apex
• RV, outflow tract
• PA, main
• PA, right or left
• Left ventricle
• Aorta, distal to ductus

Oximetric Methods
Edition. Baltimore:
• RA receives blood from several sources
– SVC: Saturation most closely approximates true
systemic venous saturation
– IVC: Highly saturated because kidneys receive 25% of
CO and extract minimal oxygen
– Coronary sinus: Markedly desaturated because heart
maximes O2 extraction
• Phlamm Equation: Mixed venous saturation used
to normalize for differences in blood saturations
that enter RA
Mixed venous saturation =
3 (SVC) + IVC
4

Detection of Left-to-Right Shunt
Edition. Baltimore:
Atrial
(SVC/IVC  RA)
Ventricular
(RA  RV)
Great vessel
(RV  PA)
ANY LEVEL
(SVC  PA)
Mean
∆ O2
% Sat
Mean
∆ O2
Vol %
Minimal
QpQs
detected
≥ 7
≥ 5
≥ 5
≥ 7
≥ 1.3
≥ 1.0
≥ 1.0
≥ 1.3
1.5 – 1.9
1.3 – 1.5
1.3
1.3
Differential
diagnosis
ASD, PAPVR, VSD with TR,
Ruptured sinus of Valsalva,
Coronary fistula to RA
VSD, PDA with PR,
Coronary fistula to RV
Aorto-pulmonary window,
Aberrant coronary origin,
PDA
All of the above
Level of
shunt

Oximetric Methods
• Fick Principle: The total uptake or
release of any substance by an organ is
the product of blood flow to the organ
and the arteriovenous concentration
difference of the substance.
– Pulmonary circulation (Qp) utilizes PA
and PV saturations
PBF =
O2 consumption
(PvO2 – PaO2) x 10
O2 content = 1.36 x Hgb x O2 saturation
RA (MV)
RV
LA (PV)
LV
PA Ao
Lungs

Oximetric Methods
– Systemic circulation (Qs) utilizes MV and
Ao saturations
SBF =
O2 consumption
(AoO2 – MVO2) x 10
RA (MV)
RV
LA (PV)
LV
Body
PA Ao

Oximetric Methods
– Pulmonary circulation (Qp) utilizes PA
and PV saturations
– Systemic circulation (Qs) utilizes MV and
Ao saturations
PBF =
O2 consumption
(PvO2 – PaO2) x 10
RA (MV)
RV
LA (PV)
LV
PA Ao
SBF =
O2 consumption
(AoO2 – MVO2) x 10

Effective Pulmonary Blood Flow
• Effective Pulmonary Blood
Flow: flow that would be
present if no shunt were
present
• Requires
– MV = PA saturation
– PV – PA = PV - MV
Effective Pulmonary
Blood Flow
O2 consumption
(Pv – MV O2) x 10
=
O2 consumption
(Pv – Pa O2) x 10
=
PBF

Left-to-Right Shunt
• Left to right shunt results in step-
up in O2 between MV and PA
• Shunt is the difference between
pulmonary flow measured and
what it would be in the absence
of shunt (EPBF)
• Systemic Blood Flow = EPBF
Left-Right Shunt = Pulmonary Blood Flow – Effective Blood Flow
O2 consumption
(PvO2 – Pa O2) x 10
=
O2 consumption
(PvO2 – MVO2) x 10
–
Qp / Qs Ratio = PBF / SBF =
(PvO2 – PaO2)
(AoO2 – MVO2)

Left-to-Right Shunt
Edition. Baltimore:
• ASD
• VSD
• Coronary Cameral Fistula
• Ruptured Sinus of Valsalva
• Partial Anomalous Pulmonary Venous Return
• Aorto Pulmonary Window
• PDA
• Aberrant Coronary Origin

Effective Pulmonary Blood Flow
• Effective Pulmonary Blood
Flow: flow that would be
present if no shunt were
present
• Requires
– PV = Ao saturation
– PV – MV = Ao - MV
Effective
Pulmonary Flow
O2 consumption
(Pv – MV O2) x 10
=
O2 consumption
(Ao – MV O2) x 10
=
SBF

Right-to-Left Shunt
• Left to right shunt results in step-
down in O2 between PV and Ao
• Shunt is the difference between
systemic flow measured and what
it would be in the absence of
shunt (EPBF)
• Pulmonary Blood Flow = EPBF
Right-Left Shunt = Systemic Blood Flow – Effective Blood Flow
O2 consumption
(AoO2 – MVO2) x 10
=
O2 consumption
(PvO2 – MVO2) x 10
–
Qp / Qs Ratio = PBF / SBF =
(PvO2 – PaO2)
(AoO2 – MVO2)

Right-to-Left Shunt
Edition. Baltimore:
• Tetralogy of Fallot
• Eisenmenger Syndrome
• Pulmonary arteriovenous malformation
• Total anomalous pulmonary venous return
(mixed)

Edition. Baltimore:
Bidirectional Shunts
• Left-to-Right Shunt
Qp (MV O2 content – PA O2 content)
=
(MV O2 content – PV O2 content)
• Right-to-Left Shunt
Qp (PV O2 content – SA O2 content) (PA O2 content – PV O2 content)
=
(SA O2 content – PV O2 content) (MV O2 content – PV O2 content)
* If pulmonary vein not entered, use 98% x O2 capacity.

Bidrectional Shunt
• Transposition of Great Arteries
• Tricuspid atresia
• Total anomalous pulmonary venous return
• Truncus arteriosus
• Common atrium (AV canal)
• Single ventricle

Edition. Baltimore:
Limitations of Oximetric Method
• Requires steady state with rapid collection of O2
samples
• Insensitive to small shunts
• Flow dependent
– Normal variability of blood oxygen saturation in the right
heart chambers is influenced by magnitude of SBF
– High flow state may simulate a left-to-right shunt
• When O2 content is utilized (as opposed to O2 sat),
the step-up is dependent on hemoglobin.

1. A patient undergoes right and left heart catheterization. The
patient is breathing room air, hemoglobin is 13.6 gm/dl, and
measured oxygen consumption is 250 ml/minute. The systemic
arterial oxygen content is 195 ml/liter and the mixed venous
oxygen content is 145 ml/liter. Which of the following is the
correct cardiac output?
A. 5.0 liters/minute.
B. 5.3 liters/minute.
C. 5.8 liters/minute.
D. 6.2 liters/minute.
E. 6.5 liters/minute.

2. The following oxygen saturations were obtained during cardiac
catheterization from a patient with a suspected shunt. The
saturations shown are the means of multiple values.
Superior vena cava 55% High right atrium 70%
Mid-right atrium 79% Low right atrium 83%
Inferior vena cava 75% Right ventricle 78%
Pulmonary artery 80% Left atrium 98%
Pulmonary vein 99% Aorta 98%
Which of the following is the correct location and QP/QS ratio?
A. 3-to-1 shunt at the atrial level.
B. 2-to-1 shunt at the ventricular level.
C. Bidirectional shunting at the atrial level with a 1.8-to-1 left to right
shunt and 1.2-to-1 right-to-left shunt.
D. 2-to-1 at the atrial level.
E. 3-to-1 at the ventricular level.

3. A 40-year-old obese woman is admitted to the hospital with
shortness of breath and you are asked to consult. She has
ruddy cheeks and perhaps mild cyanosis, but there is no
clubbing. Her jugular venous pulse is not elevated and lungs are
clear. A right ventricular heave is palpated, as is the second
heart sound along the left sternal border. Her left ventricular
apex is not displaced. Auscultation shows a soft systolic
murmur along the left sternal border that radiates slightly
toward the left with an S3 present, but you cannot distinguish
whether it is a left or right-sided S3. The pulmonary component
of her second heart sound is loud. There is no hepatomegaly or
edema. Her echocardiogram is of marginal quality, but there is
marked enlargement of the right atrium and right ventricle.
Agitated saline injection results in filling of the left heart
structures immediately through what appears to be a secundum
atrial septal defect (ASD).

3. Cardiac catheterization shows the following hemodynamics
and oxygen saturations:
Pressures (mmHg): Saturations:
RA: a=15, v=13, mean=14 SVC: 60%
RV: 50/15 IVC: 70%
PA: 50/25 mean= 32 RA: 80%
PCW: mean=10 RV: 79%
LV: 130/10 PA: 79%
Aorta: 115/60 mean=78 Ao: 97%
LA: 97%
Oxygen consumption: 275 ml/min PV: 98%
Hemoglobin: 15.0 gm%
Which of the following is the most appropriate assessment and
management of this patient?

A. The patient has excessively high pulmonary vascular resistance and
irreversible pulmonary hypertension, thus it is too late to consider
surgical closure of her ASD.
B. Her pulmonary hypertension is primarily due to the increased
pulmonary blood flow with a mild increase in pulmonary vascular
resistance. Her PVR/SVR ratio falls within the acceptable range, and
surgical closure of the ASD is appropriate.
C. Although her pulmonary hypertension is mostly due to increased
pulmonary blood flow, the elevated right atrial pressure indicates
right heart failure and thus she would not benefit from surgical
closure.
D. The patient has a balanced shunt (Qp/Qs = 1.1) and should undergo
surgery to prevent further deterioration in her condition and
progressive cyanosis in the future.
E. None of the above is correct.

A. The patient has excessively high pulmonary vascular resistance and
irreversible pulmonary hypertension, thus it is too late to consider
surgical closure of her ASD.
B. Her pulmonary hypertension is primarily due to the increased
pulmonary blood flow with a mild increase in pulmonary vascular
resistance. Her PVR/SVR ratio falls within the acceptable range, and
surgical closure of the ASD is appropriate.
C. Although her pulmonary hypertension is mostly due to increased
pulmonary blood flow, the elevated right atrial pressure indicates
right heart failure and thus she would not benefit from surgical
closure.
D. The patient has a balanced shunt (Qp/Qs = 1.1) and should undergo
surgery to prevent further deterioration in her condition and
progressive cyanosis in the future.
E. None of the above is correct.
Calculate PVR / SVR
> 0.5 Risk of surgery increased
> 0.7 No benefit from surgery

4. A 52-year-old man undergoes catheterization for unexplained
right ventricular dilatation seen on echocardiography. His spiral
CT scan and a radionuclide ventilation perfusion scan are
normal. Oximetry is performed during right and left heart
catheterization. The following saturations are noted:
Left ventricle 96%
Aorta 96%
Main pulmonary artery 80%
Right ventricular outflow tract 80%
Right ventricular apex 79%
High-right atrium 74%
Mid-right atrium 84%
Low-right atrium 79%
SVC 64%
IVC 70%

A. Partial anamolous pulmonary venous return with a
QPQS less than 1.5.
B. Atrial septal defect with a QPQS between 1.5 and 2.0.
C. Patent ductus arteriosus.
D. Bi-directional shunt.
E. Atrial septal defect with a QPQS greater than 2.0.
4. Which of the following is the most likely diagnosis?

5. Given the following information, calculate the
approximate left-to-right shunt in a patient with a
secundum ASD: SVC oxygen saturation= 55%, IVC
oxygen saturation= 65%, RA oxygen saturation=
78%, PA oxygen saturation= 75%, aortic oxygen
saturation= 95%, oxygen consumption= 280 ml/min,
hemoglobin= 13.0. Assume a PV oxygen saturation
of 95%.
A. The left-to-right shunt is 3.7 liters/min.
B. The left-to-right shunt is 2.8 liters/min.
C. The left-to-right shunt is 2.4 liters/min.
D. The left-to-right shunt is 3.0 liters/min.

6. Calculation of the QP
/QS
(pulmonary blood flow/systemic blood
flow) ratio provides information regarding relative shunt size.
In a patient with an atrial septal defect and a left-to-right
shunt, but no right-to-left shunt, select the minimal amount of
information required to determine the QP
/QS
ratio.
A. The SVC (superior vena cava) oxygen saturation, the PV (pulmonary
venous) oxygen saturation, and the oxygen consumption.
B. The PA (pulmonary artery) oxygen saturation, the AO (aortic)
oxygen saturation, and the MV (mixed venous) oxygen saturation.
C. The PA oxygen saturation, the AO oxygen saturation, and the
oxygen consumption.
D. The MV oxygen saturation, the PV oxygen saturation, and the
oxygen consumption.
E. The MV oxygen saturation, the PA oxygen saturation, and the
oxygen consumption.

7. A 45-year-old woman presents with a murmur heard by her
gynecologist. She is asymptomatic. On exam she has wide
splitting of the second heart sound and a pulmonic flow
murmur. On echocardiography, she has evidence for an
enlarged right atrium and right ventricle. Injecting agitated
saline contrast, a small number of "bubbles" are seen in
the left atrium. The septum is well seen, and there is no
secundum atrial septal defect. Pulmonary pressure is
estimated to be normal. A sinus venosus ASD is suspected
and flow through an anomalous pulmonary vein to the SVC
is suggested.

7. Select the correct answer given the following information.
The high SVC oxygen saturation is 60%; the IVC oxygen
saturation is 70%. The PA saturation is 80%; the AO
saturation is 95%. Assume a PV saturation of 95%. The
oxygen consumption is 250 ml/min.
A. The QP
/QS
ratio is about 2.2.
B. The QP
/QS
ratio is about 1.8.
C. The QP
/QS
ratio is about 1.6.
D. The QP
/QS
ratio is about 2.0.
E. There is inadequate information to determine the shunt
ratio.

8. Because of advances in therapy, many children with
congenital heart disease are living longer and well into
adulthood. Therefore, the recognition and treatment of
congenital heart disease in adults is becoming important
for adult cardiologists. Which of the following conditions
is associated with a left-to-right shunt?
A. Scimitar syndrome
B. Persistent left superior vena cava syndrome
C. IVC interruption with azygous continuation
D. Shone syndrome
E. Williams Syndrome

Valve Stenoses
Gorlin Formula Derivation
Hydraulic Principle # 1
(Toricelli’s Law)
F = A • V • C
F = flow rate
A = area of orifice
Cc = coefficient of orifice
contraction
V = velocity of flow
Hydraulic Principle # 2
V2
= Cv
2
• 2 g h
V = velocity of flow
Cv = coefficient of velocity
h = pressure gradient in cm H2O
g = acceleration gravity constant
Flow
Cc Cv • 2 g h
A = =
Flow
C • 44.3 h

Valve Stenoses
Two Catheter Technique

Valve Stenoses
Gorlin Formula Derivation
A =
Flow
C • 44.3 h
Flow has to be corrected for the time
during which there is cardiac output
across the valve.
Aortic
Pulmonic
Tricuspid
Mitral
Systolic Flow
(SEP)
Diastolic Flow
(DFP)
A =
CO / (DFP or SEP) • HR
C • 44.3 ∆P
Gorlin Formula:
Aortic, Tricuspid, Pulmonic: C = 1.0
Mitral: C = 0.85
VSD, PDA: C = 1.0
Constant:

Valve Stenoses
The “Quick Valve Area” Formula
A =
CO / (DFP or SEP) • HR
C • 44.3 ∆P
Gorlin Formula:
Quick Valve Area Formula (Hakki Formula):
Determine peak gradient across valve.
A =
CO
Peak gradient

Aortic Valve Stenosis
Calculating Valve Area
SEP
Step 1: Planimeter area and calculate SEP
Gradient
Deflection
Length
of SEPArea of gradient
(mm2
) (mm) (mm)
#1
#2
#3
#4
#5
Average deflection = mm

Step 2: Calculate mean gradient
Mean gradient = Average deflection x Scale Factor
(mm deflection) (mm Hg / mm deflection)(mm Hg)
Step 3: Calculate average systolic period
Average SEP =
(sec / beat)
Average SEP (mm)
Paper speed (mm / sec)
Step 4: Calculate valve area
Valve area =
(cm2
)
Q (cm3
/ min) / [Average SEP (sec / beat) x HR (beat / min)]
44.3 x mean gradient
.
Aortic Valve Stenosis

Aortic Stenosis
Reference Values
Aortic valve area
Normal
Mild stenosis
Moderate stenosis
3.0 cm2
0.7 – 1.0 cm2
> 1.0 cm2
Moderate-severe stenosis 0.5 – 0.7 cm2
Severe stenosis ≤ 0.5 cm2
Edition. Baltimore:

• Hydraulic principles
– Gorlin formula substitutes pressure for
velocity
• Low cardiac output
• Mixed valvular disease
• Pullback hemodynamics
• Improper alignment
Aortic Stenosis
Pitfalls in Gorlin Formula

– Distinguish true anatomic stenosis from
aortic psuedostenosis, a physiologic
state in which there is insufficient flow
through the valve secondary to decreased
LV pressure (valve partially opens)
– Nitroprusside or dobutamine to
distinguish conditions
Aortic Stenosis

• 75 consecutive patients with isolated AS
• Compare Gorlin AVA and continuity
equation (Doppler) AVA
• Doppler AVA systematically larger than
Gorlin AVA (0.10 ± 0.17 cm2
, p<0.0001)
• AVA difference was accentuated at low
flow states (cardiac index < 2.5 L/min/m2
)
Aortic Stenosis
Burwash JG, et al. Aortic valve discrepancy by Gorlin equation and Doppler echocardiography continuity
equation: relationship to flow in patients with valvular AS. Can J of Cardiol 2000; 16: 985-92.

Aortic Stenosis
Gorlin Conundrum
Symptomatic low-gradient, low-output AS
● AVA < 0.5 cm2
● Mean gradient ≤ 30 mm Hg
● LVEF ≤ 0.45
deFilippi CR, et al. Am J Cardiol 1995; 75: 191-4.
Fixed AS
Dobutamine induced
increases in peak
velocity, mean gradient,
and valve resistance
with no change in AVA
Relative AS
Dobutamine induced
increases in AVA
(≥ 0.3 cm2
) without
significant change
in peak velocity, mean
gradient, or valve
resistance
No Contractile Reserve
Dobutamine induced no
change in any hemodynamic
variable

• 32 patients with low-output, low-gradient AS and
an EF < 40% received dobutamine infusion in cath
lab
• Dobutamine continued until:
• Peak dose 40 ug/kg/min
• Mean gradient > 40 mm Hg
• HR > 140
• 50% increase in CO
• 21 patients had AVR at discretion of MD
• All patients with final AVR ≤ 1.2 cm2
at peak
dobutamine infusion and a mean gradient > 30 mm
Hg were found to have severe AS at time of surgery
• 15 patients showed contractile reserve (SV > 20%),
1 died perioperatively and 12 were alive in Class I
or II at median 32 month follow-up
Aortic Stenosis
Gorlin Conundrum
Nishimura R, et al. Circulation 2002; 106: 809-13.

• Low-Gradient
– Mean gradient < 30 mm Hg
– AVA < 1.0 cm2
• Low-Flow
• Diminished forward stroke volume
• Not necessarily diminished LVEF
Aortic Stenosis
Low-Flow, Low-Gradient AS
Grayburn RA and Eichhorn EJ. Editorial. Circulation 2002; 106: 763-5.

– AS & AI: CO underestimates transvalvular flow
 Gorlin underestimates AVA
– AS & MR: CO overestimates forward stroke
volume  Gorlin overestimates AVA
Aortic Stenosis

– Peak-to-peak gradient
larger than mean gradient
– Large (≥ 7 Fr) catheter
may obstruct lumen and
overestimate severity
– Pullback of catheter may
reduce severity
– Augmentation in peripheral systolic pressure by
> 5 mm Hg during pullback  AVA ≤ 0.5 cm2
Aortic Stenosis
Peak-to-peak

Aortic Stenosis
Test Question
• Right heart catheterization
– RA (a, v, mean): 7, 6, 5
– RV: 25 / 5
– PA: 25 / 11, mean 15; Sat = 76%
– PCW (a, v, mean): 12, 11, 10
• Left heart catheterization
– LV: 176 / 16; Sat = 96%
– Ao: 100 / 66, mean 84; Sat = 96%
• O2 consumption: 225 mL/min
• BSA = 1.87 m2
• Hgb = 14.7 g/dL
• Pulse = 70 bpm
• LVEF = 69% • Paper speed = 25 mm/sec
• Paper scale = 20 mm Hg / 10 mm Hg
8.75
mm
12.68 mm
21.43 mm
238 mm2

LV-Aortic Unaltered LV-FA Aligned LV-FA
Gradient
Area (cm2
)
31 37 22
1.07 1.01 1.24
Aortic Stenosis

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
Aortic Stenosis
Increasing Cardiac Output
Mean Gradient Across Valve
CardiacOutput(L/min)
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.02.04.0
HR = 80Area =
CO / (SEP x HR)
44.3 x gradient

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
Aortic Stenosis
Increasing Gradient
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.02.04.0
HR = 80Area =
CO / (SEP x HR)
44.3 x gradient

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
Aortic Stenosis
Increasing Pulse
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.0AVA = 2.04.0
HR = 60
0.9
Area =
CO / (SEP x HR)
44.3 x gradient

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
Aortic Stenosis
Increasing Pulse
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.02.04.0
HR = 80
0.7
Area =
CO / (SEP x HR)
44.3 x gradient

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
Aortic Stenosis
Increasing Pulse
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.02.04.0
HR = 100
0.5
Area =
CO / (SEP x HR)
44.3 x gradient

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
Aortic Stenosis
Impact of Bradycardia on Fixed Stenosis
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.02.04.0
HR = 100
∆ P = 25 Mean Gradient Across Valve (mm Hg)
Area =
CO / (SEP x HR)
44.3 x gradient

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.02.04.0
HR = 80
∆ P = 40 Mean Gradient Across Valve (mm Hg)
Area =
CO / (SEP x HR)
44.3 x gradient
Aortic Stenosis

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 50 100 150 200 250 300
Mean Gradient Across Valve (mm Hg)
AVA = 0.5
AVA = 0.3
AVA = 0.7AVA = 1.0AVA = 2.04.0
HR = 60
∆ P = 70
Area =
CO / (SEP x HR)
44.3 x gradient
Aortic Stenosis

Mitral Stenosis
DFP
Step 1: Planimeter area and calculate DFP
Gradient
DeflectionDFPArea of gradient
(mm2
) (mm) (mm)
#1
#2
#3
#4
#5
Average gradient = mm

Step 2: Calculate mean gradient
Mean gradient = Average deflection x Scale Factor
(mm deflection) (mm Hg / mm deflection)(mm Hg)
Step 3: Calculate average systolic period
Average SEP =
(sec / beat)
Average DFP (mm)
Paper speed (mm / sec)
Step 4: Calculate valve area
Valve area =
(cm2
)
Q (cm3
/ min) / [Average DFP (sec / beat) x HR (beat / min)]
37.7 x mean gradient
.
Mitral Stenosis

Mitral Stenosis
Reference Values
Mitral valve area
Normal
Mild stenosis
Moderate stenosis
4.0 – 6.0 cm2
1.0 – 2.0 cm2
> 2.0 cm2
Severe stenosis < 1.0 cm2
Edition. Baltimore:

• Pulmonary capillary wedge tracing
– Mean PCWP < mean PAP
– PCW O2 sat > 95% or > Art O2 sat
• Alignment mismatch
• Calibration errors
• Cardiac output determination
• Early diastasis
Mitral Stenosis

– LV & PCW traces do not match LV & LA traces
because transmission of LA pressure back thru
PV and capillary bed delayed 50-70 msec
– Realign tracings
• Shift PCW tracing leftward by 50-70 msec
• V wave should peak immediately before LV
downslope
• Early diastasis
Mitral Stenosis

– Errors in calibration and zero
– Quick check: switch transducers between
catheters and see if gradient identical
• Early diastasis
Mitral Stenosis

– Measure CO at same time gradient measured
– Fick and thermodilution measure “forward”
flow but Gorlin formula relies on total flow
(antegrade and retrograde) across valve
– In setting of MR, Gorlin formula will
underestimate actual anatomic stenosis
• Early diastasis
Mitral Stenosis

• Early diastasis
– If PCWP and LV diastolic pressures equalize
early, the “gradient” will appear to disappear
early in diastole. The diastolic filling period
(DFP) used in the calculation should include all
of the nonisovolumic diastole.
Mitral Stenosis

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
Mitral Stenosis
Increasing Cardiac Output
MVA = 0.5
MVA = 0.3
MVA = 0.7
MVA = 1.0MVA = 2.0MVA = 4.0
Area =
CO / (SEP x HR)
37.7 x gradientHR = 80

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
Mitral Stenosis
Increasing Mean Gradient
HR = 80
MVA = 0.5
MVA = 0.3
MVA = 0.7
MVA = 1.0MVA = 2.0MVA = 4.0
Area =
CO / (SEP x HR)
37.7 x gradient

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
Mitral Stenosis
Increasing Pulse
MVA = 0.5
MVA = 0.3
MVA = 0.7MVA = 1.0MVA = 2.0MVA = 4.0
1.0
Area =
CO / (SEP x HR)

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
Mitral Stenosis
Increasing Pulse
MVA = 0.5
MVA = 0.3
MVA = 0.7
MVA = 1.0MVA = 2.0MVA = 4.0
1.2
Area =
CO / (SEP x HR)

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
Mitral Stenosis
Increasing Pulse
MVA = 0.5
MVA = 0.3
MVA = 0.7
MVA = 1.0
MVA = 2.0MVA = 4.0
1.6
Area =
CO / (SEP x HR)

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
HR = 60
∆ P = 12
MVA = 0.5
MVA = 0.3
MVA = 0.7MVA = 1.0MVA = 2.0MVA = 4.0
Mitral Stenosis
Impact of Tachycardia on Fixed Stenosis

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
HR = 80
MVA = 0.5
MVA = 0.3
MVA = 0.7
MVA = 1.0MVA = 2.0MVA = 4.0
∆ P = 16
Mitral Stenosis

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 10 20 30 40 50 60
MVA = 0.5
MVA = 0.3
MVA = 0.7
MVA = 1.0
MVA = 2.0MVA = 4.0
HR = 100
Mean Gradient Across Valve (mm Hg)∆ P = 20
Mitral Stenosis

1. A 71 yo woman is referred for cardiac catheterization to evaluate
her aortic valve. She complains of progressive DOE but denies
chest pain. She has a history of 2 prior MIs and has inferior Q-
waves on her ECG. A murmur of aortic stenosis was first noted
about 14 years ago, and 3 years ago a soft diastolic murmur
consistent with aortic insufficiency was detected. Her echo shows
moderate LV enlargement with inferior akinesis and decreased LV
function. By echo the aortic valve gradient is 20 mmHg, and the
valve area is calculated to be 1.3 cm². She has mild to moderate
aortic regurgitation and no mitral regurgitation by echo. Because
her referring physician is concerned about the severity of her aortic
valve disease as a potential cause for her symptoms and left
ventricular dysfunction, she is referred for cardiac catheterization.
During the catheterization, her cardiac output measured by the Fick
method is 5.0 L/min and her mean aortic valve gradient is 16 mmHg.
Biplane left ventriculography and coronary angiography are
performed.

1. Which of the following is the most appropriate step in the analysis
of these hemodynamic data?
A. The Gorlin formula should not be used to calculate valve
area because it is less accurate when a low gradient is
present.
B. Using the Fick cardiac output in the Gorlin formula will
overestimate her actual valve area.
C. She should receive a dobutamine infusion and then
recalculate the valve area with the new hemodynamics.
D. The Gorlin formula can be used to calculate her aortic valve
area, but the angiographic output determined from the left
ventriculogram should be used.
E. The correct valve area is calculated using the Gorlin formula
and the difference between the angiographic output and
forward output.

2. A patient with hypertrophic obtrusive cardiomyopathy
has a premature ventricular contraction during cardiac
catheterization. Which one of the following responses
would be seen on the beat after the premature
ventricular contraction which would not be seen in a
patient with valvular aortic stenosis?
A. An increase in the peak-to-peak gradient between the
aorta and left ventricle.
B. An increase in the maximum instantaneous gradient
between the aorta and left ventricle.
C. A decrease in the pulse pressure of the aortic pressure.
D. An increase in the left ventricular systolic pressure.
E. An increase in the aortic systolic pressure.

3. In patients in whom low cardiac output and low
ejection fraction are associated with aortic
stenosis, which calculation provides the strongest
confirmation of fixed valvular obstruction?
A. Aortic valve area, Gorlin formula.
B. Planimetry of orifice area.
C. Aortic valve resistance.
D. Peak-to-peak left-ventricular-to-aortic gradient.
E. Aortic valve area, Hakki formula.

3. In patients in whom low cardiac output and low
ejection fraction are associated with aortic
stenosis, which calculation provides the strongest
confirmation of fixed valvular obstruction?
A. Aortic valve area, Gorlin formula.
B. Planimetry of orifice area.
C. Aortic valve resistance (Mean gradient / CO) > 250
D. Peak-to-peak left-ventricular-to-aortic gradient.
E. Aortic valve area, Hakki formula.

4. To secure the diagnosis of aortic stenosis, what is
the best technique to obtain the most accurate
hemodynamic data?
A. Left ventricular and femoral artery pressures.
B. Left ventricular and ascending aortic pressures.
C. Aortic and left atrial pressures.
D. Left ventricular pressure at the apex and left
ventricular pressure at the outflow tract.
E. Left ventricular and right ventricular pressures.

5. A 78-year-old woman has increasing shortness of breath, DOE, and mild
pedal edema. Physical examination demonstrates irregular pulse with
moderate neck vein distension, a diastolic murmur over the left sternal
border radiating to the apex, a brief systolic murmur at the apex, a quiet
left precordium, and +1 pitting edema. Echocardiography suggests
restricted transmitral flow and marked mitral annular calcification with a
nondilated ventricle. Which of the following data sets most accurately
characterizes the hemodynamics of this patient's mitral valve disease?
A. RA pressure = 10 mmHg; RV pressure = 60/12 mmHg; PA pressure = 30/16
mmHg; LVEDP = 16 mmHg.
B. RA pressure = 5 mmHg; RV pressure = 30/6 mmHg; PA pressure = 30/12
C. RA pressure = 15 mmHg; RV pressure = 80/16 mmHg; PA pressure = 80/40
D. RA pressure = 20 mmHg; RV pressure = 36/20 mmHg; PA pressure = 36/20
E. RA pressure = 5 mmHg; RV pressure = 60/6 mmHg; PA pressure = 20/10

6. Excluding coronary artery disease, which of the
following additional conditions may be present and
obscure the presumptive diagnosis of aortic
stenosis?
A. Mitral regurgitation.
B. Mitral stenosis.
C. Bilateral iliac stenoses.
D. Right ventricular pressure overload.
E. Hypertrophic obstructive cardiomyopathy.

7. A symptomatic 35-year-old woman with congenital aortic stenosis
undergoes echocardiography and cardiac catheterization. Her
echocardiogram shows an aortic valve gradient of 54 mmHg.
However, at catheterization the mean gradient recorded by
simultaneous pressures is only 25 mmHg. Which of the following
is not an explanation for the discrepancy between the gradient
values?
A. A femoral artery pressure was used instead of a central aortic
pressure during the catheterization.
B. The physiological recorder's internal calibration was used to
standardize the pressure transducers.
C. The left ventricular catheter was positioned in the left
ventricular outflow tract.
D. There was a difference in physiologic conditions during the
two determinations.
E. Echocardiography is inaccurate in estimating aortic valve
gradients at high flow.

8. Carabello’s sign refers to:
A. The reduced peripheral arterial pressure compared to
the LV systolic pressure
B. An increment of 5 mm Hg or more in the peripheral
pressure associated with the pullback of catheter from
LV into aorta
C. A narrowing of the pulse pressure observed with
simultaneous LV and Ao tracings following a PVC
D. The change in pulse pressure observed in patients with
aortic stenosis during inspiration

9. A patient with aortic stenosis is referred to you for a second
opinion to see if aortic valve replacement is warranted.
Specifically, you must compare the risk of the operation with
the potential benefit.
A. A 68 year old patient with CHF, LVEF=20%, an AVA of 0.6 cm2,
an mean transvalvular gradient of 60 mm Hg.
B. A 67 year old patient with CHF, LVEF=20%, an AVA of 0.6 cm2,
an mean transvalvular gradient of 25 mm Hg in whom
dobutamine doubles his CO and increases the valve gradient
such that the calculated AVA remains 0.6 cm2.
C. A 66 year old patient with CHF, LVEF=20%, an AVA of 0.6 cm2,
an mean transvalvular gradient of 25 mm Hg in whom
dobutamine doubles his CO with little change in the gradient.
D. A 74 year old man who is symptomatic with normal LV
function, a valve area of 0.9 cm2, and a mean transvalvular
gradient of 70 mm Hg.
E. An 80 year old otherwise healthy man, asymptomatic, with a
valve area of 0.7 cm2 and a mean transvalvular gradient of 70
mm Hg.

Edition. Baltimore:
10. What accounts for the change in the patient’s hemodynamics
between the left and right frame?
40

Hemodynamic

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