Collection of cath tracings by navin

Right Heart Catheterization
Left Ventricular Pressure
 Systole
 Isovolumetric contraction


From MV closure to AoV opening

 Ejection


Peak systolic
pressure

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

Simultaneous pressure tracings from the left ventricle and the aorta in a patient with aortic
stenosis.

Brown J , Morgan-Hughes N J Contin Educ Anaesth Crit
Care Pain 2005;5:1-4
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 1 2005 © The
Board of Management and Trustees of the British Journal of Anaesthesia 2005

Left ventricular(LV) catheter pullback to aorta in a patient with hyperrtrophic
cardiomyopathy . There is a significant systolic gradient within the left ventricular
cavity and the LV outflow tract and aortic pressure waveforms exhibit a spike-and –
dome contour.

Left ventricular (LV) and femoral artery (FA) presure tracings in a woman with
hypertrophic cardiomyopathy and asymmertric septal hypertrophy illustration
the increase in gradient and develop a spike-and –dome configuration in the
arterial pressure waveform following an extrasystolic beat . Arterial pulse
pressure clearly narrows in postextrasystolic beat. The narrowing of pulse
pressure is known as Brockenbrough-Braunwald sign

Left ventricular(LV) and femoral artery (FA) pressure tracings . Valsalva
manuver producesa marked increase in the gradient , as well as a change in
the femoral arterial pressure waveform to a spike-and –dome configuration

Simultaneous left ventricular and aortic pressure tracings at rest and after provocation with
intravenous isoprenaline.

Serino W , Sigwart U Heart 1998;79:629-630

Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Left ventricular (LV) and left brachial artery(LBA) pressure tracings in a 64year-old woman with hypertrophic caridomyopathy . A: The effect of a
spontaneous change from nodal rhythm to sinus rhythm. The short arrow
showed LVEDP. With restoration of sinus shythm abd a presumed decrease in
the obstruction. The loss of atrial kick in patients with a stiff ventricle leads to
an acute reduction in cardiac output.

Left ventricular (LV) micromanometer ad aortic (Ao) pressure tracings in a
68-year-old woman with advanced dilated cardiomyopathy . Marked
slowing of the rates of left ventricular pressure rise and fall give the LV
pressure tracing a triangular appearance

Hemodynamic Principles
PAW and LV Tracings during
Inspiration and Expiration

RV and LV Tracings during
Inspiration and Expiration

Which of the following is the
most likely explanation for
these findings?
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.

PAW and LV
Tracings during
Inspiration and
Expiration

RV and LV
Tracings during
Inspiration and
Expiration


A.
B.
C.
D.
E.

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

Dicrotic pressure changes
this part here is the dicrotic notch

Arterial Pressure Monitoring
Abnormalities in Central Aortic Tracing
 Spike and dome configuration
 Hypertrophic obstructive cardiomyopathy

Spike

Dome

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

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
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

PWV
stiffer arteries → increased PWV
→ earlier arrival of reflected waves →
augmentation of systolic rather than
diastolic pressure→increased pulse pressure

Pulsus alternans
Pericardial effusion
Cardiomyopathy
CHF

Advancing Your Right Heart
Catheter
 Advance the SGC to

about 20cm and inflate
the balloon tip.
 Initial chamber  the
right atrium.
 Initial pressure waveform
3 positive deflections, the
a, c and v waves
 There will be an x and y
descent

Right Atrial Pressure Tracing
 a wave –atrial systole
 c wave – occurs with the

closure of the tricuspid
valve and the initiation of
atrial filling
 v wave – occurs with
blood filling the atrium
while the tricuspid valve
is closed

Timing of the positive deflections
 a wave – occurs after
the P wave (60-80
msec)during the PR
interval
 c wave – when present
occurs at the end of the
QRS complex (RST
junction)
 v wave – Peak occurs
after the T wave

Right Atrial Chamber
1. Height of the v wave

atrial compliance
volume of blood returning
2. Height of the a wave
The pressure needed to
eject forward blood flow

 The v wave is usually smaller

than the a wave in the right
atrium

Right Heart Pressures Tracings

Right atrial hemodynamic pathology
 Elevated a wave
 Tricuspid stenosis
 Decreased RV

compliance


e.g. pulm htn, pulmonic
stenosis

 Cannon a wave
 AV asynchrony –

atrium contracts against
a closed tricuspid valve


e.g. AVB, Vtach

X descent
Prominent –Tamponade,RV
ischemia,(ASD)
Absent – Atrial
arrhythmias,TR,RA ischemia

 Absent a wave

 Atrial fibrillation or

standstill
 Atrial flutter

 Elevated v wave
 Tricuspid regurgitation
 RV failure
 Reduced atrial compliance


e.g. restrictive myopathy

Y descent
Prominent –CCP/RCM/TR
Absent – TS/Tamponade/RV
ischemia

Right atrial hemodynamic pathology

Note the Cannon a wave that is
occurring during AV dysynchrony
– atrial contraction is occurring
against a closed tricuspid valve.

Note the large V wave that
occurs with Tricuspid
regurgitation

Hemodynamic Pathology
 Tricuspid Stenosis
 Large jugular venous a

waves on noted on
exam
 Notable elevated a
wave with the presence
of a diastolic gradient >5mmHg gradient is
considered signficant

Prominent Rt V wave
 V> 15 mmHg
 Difference of V and RA

mean >5 mmHg
 Ration of V to RA
mean>1.5

Catheter
 Continue advancing the catheter
into the right ventricle
 The right and left ventricular

pressure tracings are similar.
 The right ventricular has a shorter
duration of systole
 Diastolic pressure in the right
ventricle is characterized by an
early rapid filling phase, then slow
filling phase followed by the atrial
kick or a wave

a

Normal RV waveform artifact
 Note the notch on the
top of RV pressure
waveform
 This represents

“ringing” of a fluid-filled
catheter
 Ringing can also be
noted on the diastolic
portion of the waveform

Catheter
 Advancing out the RVOT to the
pulmonary artery
 There is a systolic wave indicating

ventricular contraction followed by
closure of the pulmonic valve and
then a gradual decline in pressure
until the next systolic phase.
 Closure of the pulmonic valve is
indicated by the dicrotic notch

Timing of the PA pressure
 Peak systole correlates
with the T wave
 End diastole correlates
with the QRS complex

 Pulmonic Stenosis
 Notable large gradient

across the pulmonic
valve during PA to RV
pullback.
 Notable extreme
increases in RV systolic
pressures and a
damped PA pressure


Mitral Stenosis
This patient underwent mitral valvuloplasty resulting in a reduction of
the resting gradient by 10mmHg and an increase in CO from 3.7 to
5.5LPM and a valve area from about 1.1 to 2.9 cm2

NORMAL PRESSURE TRESSINGS – RA, RV , PA, PCWP

peak

100

a

0
Dip

NORMAL PRESSURE TRACING – Ventricle.

Peak systolic

end diastolic

NORMAL ARTERIAL PRESSURE TRACINGS

Kussmaul’s Sign

CATHSAP6: Coronary Angiography and Intervention

Mitral stenosis with 20 mm
gradient. Atrial fibrillation.
Note slow “y” descent and lack
of “a” waves (atrial fib.).

Name this pathology.
97

Probable Mitral
Regurgitation.
Large “v” waves, which could also
be due to atrial fibrillation or
CHF.

Name this pathology.
98

40

20

0

Pulmonary capillary wedge

NORMAL PRESSURE
TRACINGS – LA , LV ,
AORTA

Collection of cath tracings by navin

Collection of cath tracings by navin

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Collection of cath tracings by navin