Hemodynamic Rounds E-Book

Michael J. Lim

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 905

Veröffentlichungsjahr: 2011

Beschreibung

The essential resource on cardiac hemodynamics-now in a newedition Hemodynamic Rounds, Third Edition is intended to helpcardiologists and other members of the medical community enhancetheir understanding of cardiac physiology and its associatedhemodynamic presentations in health and disease, including thebasic principles of flow and pressure measurements; systemic aswell as coronary hemodynamics in normal and diseased states; andchanges in hemodynamics following interventional procedures rangingfrom valvuloplasty to stent placement. Like its popular predecessors, this new edition draws on casestudies to illustrate characteristic cardiac hemodynamic findingsand discuss the essential methods used in interpreting pressurewaveforms as a diagnostic and monitoring tool. The text is organized into chapters on specific areas of theheart, common cardiac anomalies, and hemodynamic situationsresulting from different therapeutic procedures, and includes bothnormal and abnormal pressure waveforms. This new edition includesthoroughly revised and updated chapters on specific topics,including: * Mitral stenosis and mitral valvuloplasty * Low-gradient aortic valve stenosis * Pitfalls of right heart hemodynamics * Aortic and pulmonary balloon valvuloplasty * Coronary hemodynamics for angioplasty and stenting * Hemodynamic evaluation of stenotic bioprosthetic mitralvalves * Evaluation of hypertrophic obstructive cardiomyopathies * Understanding cardiac pathophysiology from bedside hemodynamicstudy Hemodynamic Rounds, Third Edition, is the only book onthe market that specifically addresses comprehensive cardiachemodynamic findings, reviewing blood pressure tracings collectedfrom the cardiac catheterization lab on all aspects ofcardiovascular disease, as well as normal cardiac function. It isan indispensable tool for all physicians, nurses, and studentsmeasuring and interpreting cardiac waveforms in cardiac diagnosisand monitoring.

Leseprobe

CONTENTS

CONTRIBUTORS

PREFACE

INTRODUCTION

HISTORICAL REVIEW

APPROACH TO HEMODYNAMIC WAVEFORM INTERPRETATION

METHODOLOGIES INVOLVED IN HEMODYNAMIC DATA COLLECTION

EQUIPMENT FOR HEMODYNAMIC STUDIES

CARDIAC OUTPUT METHODOLOGY

REVIEWING WAVEFORMS

REFERENCES

SECTION I: FUNDAMENTALS AND CLINICAL APPLICATIONS OF HEMODYNAMICS

PART 1: HEMODYNAMIC WAVEFORMS: NORMAL AND PATHOPHYSIOLOGIC

1 Pressure Wave Artifacts: Measurement Systems and Artifacts

PRESSURE SYSTEM RESONANCE: THE UNDERAND OVERDAMPED WAVEFORM

CALIBRATION ERRORS: HIDDEN ARTIFACTS

A TRANSIENTLY WIDE PULSE PRESSURE: EPISODIC AORTIC INSUFFICIENCY?

CAUSES OF DELAYED OR LATE RISING CENTRAL AORTIC PRESSURE

DISEQUILIBRATION

REFERENCES

2 Pitfalls of Right-Heart Hemodynamics

EXAMINATION OF VENA CAVAL PRESSURE WAVEFORMS IN TRICUSPID REGURGITATION

CONCLUSIONS

REFERENCES

3 The Tricuspid Valve

NORMAL RIGHT ATRIAL WAVEFORM

“X” AND “Y” TROUGHS

CARDIAC RHYTHM AND RIGHT ATRIAL PRESSURE

SYSTOLIC REGURGITANT WAVES

PULSATILE VENOUS WAVES

RIGHT ATRIAL-RIGHT VENTRICULAR GRADIENTS

RIGHT ATRIAL PRESSURE ARTIFACTS

REFERENCES

4 The Left-Sided V Wave

WAVE ALTERNANS

NORMAL A AND V WAVE PATTERNS

CORRESPONDENCE OF PULMONARY CAPILLARY WEDGE AND LEFT VENTRICULAR END-DIASTOLIC PRESSURES

FACTORS INFLUENCING SIZE OF THE V WAVE

THE LARGE V WAVE AND MITRAL REGURGITATION

CONTRIBUTION OF ATRIAL SYSTOLE TO LEFT-SIDED V WAVES

V-WAVE MORPHOLOGY

THE DISPARATE PULMONARY CAPILLARY WEDGE AND LEFT ATRIAL PRESSURES

REFERENCES

5 The LVEDP

LVEDP: CLUES TO UNSUSPECTED CONDITIONS

FACTORS INFLUENCING LVEDP

REFERENCES

6 Simultaneous Left and Right Ventricular Pressure Measurements

HEMODYNAMIC MEASUREMENT TECHNIQUE

RIGHT AND LEFT VENTRICULAR PRESSURES IN A PATIENT WITH HYPERTENSION

EFFECTS OF CONDUCTION ON RIGHT AND LEFT VENTRICULAR PRESSURES

PACEMAKER PRESSURE RESPONSES

VENTRICULAR PRESSURES IN A PATIENT WITH MITRAL STENOSIS

REFERENCES

7 Effects of Nitroglycerin

NITROGLYCERIN AND VENTRICULAR UNLOADING

NITROGLYCERIN AND CORONARY BLOOD FLOW

NITROGLYCERIN, ANGINA, AND AORTIC STENOSIS

NITROGLYCERIN AND THE AORTIC PRESSURE WAVEFORM

SUMMARY

REFERENCES

8 Pulsus Alternans

CASE EXAMPLE

MECHANISMS OF PULSUS ALTERNANS

REFERENCES

PART 2: VALVULAR HEART DISEASE

9 Aortic Stenosis

CASE PRESENTATION

HEMODYNAMICS OF ECHOCARDIOGRAPHY

ROLE OF INVASIVE HEMODYNAMIC ASSESSMENT

CALCULATING AORTIC VALVE AREA

DISAPPEARING GRADIENTS DURING DATA COLLECTION

CARDIAC RHYTHMS AND AORTIC PRESSURE GRADIENTS

AORTIC STENOSIS WITH LOW AORTIC-LEFT VENTRICULAR GRADIENTS AND LOW AORTIC FLOW

AORTIC REGURGITATION COMPLICATING AORTIC STENOSIS

HEMODYNAMIC ARTIFACTS OF AORTIC AND LEFT VENTRICULAR PRESSURES

PERIPHERAL ARTERIAL WAVE SUMMATION AND ZERO DRIFT

REFERENCES

10 Aortic Regurgitation

PATHOPHYSIOLOGY

CHRONIC AORTIC INSUFFICIENCY

ACUTE AORTIC INSUFFICIENCY

REFERENCES

11 Aortic Regurgitation—Case Presentations

THREE PATIENTS WITH A DIASTOLIC MURMUR

SIGNS OF PERIPHERAL PRESSURE AMPLIFICATION IN AORTIC REGURGITATION (SEE TABLE 10.3)

PATHOPHYSIOLOGY OF AORTIC REGURGITATION

ACUTE AORTIC REGURGITATION

TRANSIENT ACUTE AORTIC REGURGITATION

REFERENCES

12 Abnormal Hemodynamics After Prosthetic Aortic Root Reconstruction: Aortic Stenosis or Insufficiency?

CASE REPORT

CASE DISCUSSION

REFERENCES

13 Acute Aortic Insufficiency—Case Presentation

PATIENT PRESENTATION

CASE DISCUSSION

REFERENCES

Commentary to Case of Acute Aortic Insufficiency by Godlewski KJ et al.*

REFERENCES

14 Multivalvular Regurgitant Lesions

MULTIPLE HEART MURMURS AFTER MITRAL VALVE REPLACEMENT

THE TRICUSPID VALVE

THE AORTIC VALVE

THE MITRAL VALVE

POSTSURGICAL HEMODYNAMICS

REFERENCES

15 The Hemodynamic Dilemma of Combined Mitral and Aortic Stenosis

CASE PRESENTATION

CASE DISCUSSION

REFERENCES

16 Determination of the Source and Severity of a Transvalvular Left Ventricular Outflow Tract Gradient in Patients with a Prosthetic Aortic Valve

INTRODUCTION

CASE #1

CASE #2

CASE DISCUSSION

REFERENCES

17 Mitral Valve Gradients—Section I

MITRAL STENOSIS WITH LARGE V WAVES

TECHNICAL NOTES FOR MITRAL VALVE AREA CALCULATION

PATHOPHYSIOLOGY OF MITRAL STENOSIS

MITRAL STENOSIS AND REGURGITATION

ALTERNATIVE METHODS FOR VALVE AREA CALCULATIONS

INFLUENCE OF HEART RATE ON DETERMINATION OF VALVE AREA

REFERENCES

18 Mitral Valve Gradients—Section II: Mitral Stenosis and Pulsus Alternans

CASE REPORT

DISCUSSION

REFERENCES

19 Mitral Valve Gradients—Section III

HEMODYNAMIC EVALUATION OF A STENOTIC BIOPROSTHETIC MITRAL VALVE

PROSTHETIC VALVES: NATURAL HISTORY

VALVE AREAS

MECHANISMS OF PROSTHETIC VALVE FAILURE

METHODS TO ASSESS VALVE DYSFUNCTION

HEMODYNAMIC ASSESSMENT OF PROSTHETIC VALVE DYSFUNCTION

PULMONARY CAPILLARY WEDGE VERSUS LEFT ATRIAL PRESSURE

EXERCISE HEMODYNAMICS

REFERENCES

20 Mitral Valve Gradients—Section IV: Left Ventricular Puncture for Hemodynamic Evaluation of Double Prosthetic Valve Stenosis

INTRODUCTION

CASE REPORT

DISCUSSION

COMPLICATIONS OF LV PUNCTURE

REFERENCES

21 Simplified Mitral Valve Gradient Calculation by Cui et al.

REFERENCES

22 Invasive Assessment of Mitral Regurgitation: Comparison of Hemodynamic Parameters

23 The Pulmonary Valve

PULMONARY STENOSIS: VALVULAR OR NONVALVULAR?

PULMONIC STENOSIS AND ECG ABNORMALITIES

COMBINED PULMONARY STENOSIS AND INSUFFICIENCY

A DIASTOLIC MURMUR AND ELEVATED RIGHT VENTRICULAR END-DIASTOLIC PRESSURE

REFERENCES

24 Percutaneous Balloon Valvuloplasty

PERCUTANEOUS BALLOON AORTIC VALVULOPLASTY

PERCUTANEOUS BALLOON MITRAL VALVULOPLASTY

PULMONARY BALLOON VALVULOPLASTY (PBV)

REFERENCES

PART 3: VALVULOPLASTY

25 Mitral Valve Gradients and Valvuloplasty

MITRAL STENOSIS AND VALVULOPLASTY

MITRAL REGURGITATION AFTER BALLOON VALVULOPLASTY

USE OF THE PULMONARY CAPILLARY WEDGE DURING VALVULOPLASTY

REFERENCES

26 Reduction of Mitral Regurgitation After Aortic Valvuloplasty

HEMODYNAMIC TECHNIQUE

27 Aortic Valvuloplasty in a Very Elderly Woman

28 Mitral Valve Gradient with Dobutamine Stress Testing

29 Left-Heart Catheterization and Mitral Balloon Valvuloplasty in a Patient with a Mechanical Aortic Valve

CASE HISTORY

DISCUSSION

CONCLUSIONS

REFERENCES

PART 4: HEMODYNAMICS OF PERICARDIAL CONSTRAINT, MYOCARDIAL RESTRICTION, AND TAMPONADE

30 Constrictive Physiology

INFLUENCE OF RESPIRATORY DYNAMICS ON VENTRICULAR PRESSURES

DISCUSSION

NORMAL AND ABNORMAL VENTRICULAR FILLING PHYSIOLOGY

DOPPLER FLOW CRITERIA IN CONSTRICTIVE PHYSIOLOGY

RESPIRATORY HEMODYNAMIC CRITERIA

CATHETERIZATION TECHNIQUE FOR CONSTRICTIVE PHYSIOLOGY

CRITERIA OF CONSTRICTIVE PHYSIOLOGY

ADDITION CONSIDERATIONS FOR CONSTRICTIVE PHYSIOLOGY

REFERENCES

31 Post-Cardiac Surgical Constrictive Pericardial Disease

CASE REPORTS

DISCUSSION

REFERENCES

32 Pericardial Compressive Hemodynamics

PERICARDIAL CONSTRAINT IN A PATIENT WITH RENAL FAILURE

THE DIASTOLIC PLATEAU

LOW PRESSURE TAMPONADE

ATRIAL WAVEFORMS AND PERICARDIAL CONSTRAINT

MECHANISM OF THE “M” CONFIGURATION

KUSSMAUL’S SIGN

CONSTRICTIVE OR RESTRICTIVE PHYSIOLOGY

REFERENCES

33 Unusual Hemodynamics of Constrictive Physiology

THE EMPTY PERICARDIUM

TECHNICAL NOTES FOR PERICARDIOCENTESIS

THE EMPTY PERICARDIUM WITH ELEVATED RIGHT ATRIAL PRESSURE

INSPIRATORY AUGMENTATION OF A RIGHT-HEART MURMUR

REFERENCES

34 Cardiac Tamponade

PERICARDIAL FLUID AFTER CARDIAC TRANSPLANTATION AND EARLY TAMPONADE

THE THREE PHASES OF CARDIAC TAMPONADE

ROLE OF ECHOCARDIOGRAPHY IN CARDIAC TAMPONADE

PULSUS PARADOXUS

REFERENCES

35 Tamponade in a Patient with AIDS-Related Non-Hodgkin’s Lymphoma

CASE PRESENTATION

DISCUSSION

MALIGNANT PERICARDIAL EFFUSIONS

NON-HODGKIN’S LYMPHOMA

THERAPEUTIC APPROACHES

HEMODYNAMICS OF PERICARDIAL TAMPONADE

REFERENCES

36 A Novel Assessment for Constrictive Pericarditis in a Complex Patient

CASE REPORT

DISCUSSION

REFERENCES

37 Why Does Kussmal’s Sign and Pulsus Paradoxus Occur?

LOW-PRESSURE CARDIAC TAMPONADE

REFERENCE

PART 5: ARRYTHMIAS

38 Cardiac Arrhythmias

PREMATURE CONTRACTIONS

IRREGULAR RHYTHMS

MISLEADING ATRIAL WAVEFORMS DURING ARRHYTHMIAS

RHYTHM WITH WIDE QRS PATTERNS

REFERENCES

39 Pacemaker Hemodynamics

ATRIAL WAVES DURING PACEMAKER ACTIVITY

DISSOCIATED ATRIAL ACTIVITY AND HEMODYNAMIC FUNCTION

NORMAL AND PACED ATRIAL SYSTOLES AND LEFT VENTRICULAR PRESSURE

CLINICAL SIGNIFICANCE OF VENTRICULAR PACEMAKER HEMODYNAMICS

REFERENCES

PART 6: HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

40 Hypertrophic Cardiomyopathy

DISAPPEARING AORTIC STENOSIS

LEFT VENTRICULAR DIASTOLIC WAVEFORM ABNORMALITIES: RELAXATION IMPAIRMENT

HEMODYNAMICS OF DUAL-CHAMBER PACING AND VALSALVA MANEUVER IN A PATIENT WITH HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

HEMODYNAMIC EFFECTS OF ALCOHOL- INDUCED SEPTAL INFARCTION FOR HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

ALTERNATIVES TO MEDICAL THERAPY

COMPLICATIONS OF ALCOHOL SEPTAL ABLATION

REFERENCES

PART 7: CORONARY HEMODYNAMICS

41 Coronary Hemodynamics

CORONARY CATHETERTIP PRESSURES

CORONARY HEMODYNAMICS: DOPPLER FLOW

CORONARY FLOW RESERVE AND HYPEREMIA

FFR

CLINICAL APPLICATION OF INTRACORONARY PRESSURE MEASUREMENTS

ROLE OF rCVR

REFERENCES

42 Hemodynamic and Intravascular Ultrasound Assessment of an Ambiguous Left Main Coronary Artery Stenosis

INTRODUCTION

METHODS

DISCUSSION

REFERENCES

43 Renal Hemodynamics: Theory and Practical Tips

INTRODUCTION

METHODS

DISCUSSION

REFERENCES

PART 8: ADULT CONGENITAL ANOMALIES

44 Adult Congenital Anomalies

INTRODUCTION

ATRIAL PRESSURE WITH A VENTRICULAR ELECTROGRAM

INTRACARDIAC SHUNTS

SUMMARY

REFERENCES

45 Case Studies in Congenital Cardiac Anomalies

ATRIAL SEPTAL DEFECT AND DIASTOLIC DYSFUNCTION OF THE LEFT VENTRICLE

PERSISTENT ARTERIAL DUCT ASSOCIATED WITH PREDUCTAL COARCTATION OF THE AORTA

VT ARREST NINE MONTHS AFTER SURGICAL VSD CLOSURE : MITRAL INSUFFICIENCY WITH SUBAORTIC STENOSIS

REFERENCES

PART 9: EXTRA HEARTS

46 Extra Hearts: Unusual Hemodynamics of Heterotopic Transplant and Ventricular Assist Devices

“EXTRA” ARTERIAL PRESSURE

LEFT VENTRICULAR ASSIST DEVICES

PORTABLE CARDIOPULMONARY BYPASS

REFERENCES

PART 10: RIGHT VENTRICULAR DYSFUNCTION

47 Hemodynamic Manifestations of Ischemic Right-Heart Dysfunction

ISCHEMIC RV DYSFUNCTION

DETERMINANTS OF RV PERFORMANCE WITH ACUTE RV DYSFUNCTION

COMPENSATORY CONTRIBUTIONS OF AUGMENTED RA CONTRACTION AND DELETERIOUS EFFECTS OF RA ISCHEMIC DYSFUNCTION

HEMODYNAMIC IMPACT OF RHYTHM DISORDERS AND REFLEXES ASSOCIATED WITH RVI

IMPACT OF REPERFUSION

MECHANICAL COMPLICATIONS ASSOCIATED WITH RVI

DIFFERENTIAL DIAGNOSIS OF HEMODYNAMICALLY SEVERE RV INFARCTION

CASE STUDIES

SUMMARY

REFERENCES

Commentary

EDITORIAL COMMENTS: HEMODYNAMIC MANIFESTATIONS OF ISCHEMIC RIGHT HEART DYSFUNCTION

SECTION II: CLINICAL AND BEDSIDE APPLICATIONS OF HEMODYNAMICS

CLINICAL-ANATOMIC-PATHOPHYSIOLOGIC CORRELATIONS TO SYMPTOM ASSESSMENT

CARDIAC ANATOMY, MECHANICAL FUNCTION AND HEMODYNAMICS

PERTINENT ASPECTS OF CARDIAC MECHANICS

SYSTOLIC PERFORMANCE

DIASTOLIC FUNCTION AND CARDIAC COMPLIANCE

PERTINENT ASPECTS OF NORMAL PRESSURE WAVEFORMS: RELATIONSHIP OF CARDIAC MECHANICS TO ATRIAL WAVEFORMS, VENOUS FLOW PATTERNS AND RESPIRATORY PHYSIOLOGY

PERTINENT ASPECTS OF VENTRICULAR AND ARTERIAL WAVEFORMS

ANATOMIC-PATHOPHYSIOLOGIC APPROACH TO DIFFERENTIAL DIAGNOSIS

PERICARDIAL ABNORMALITIES

MYOCARDIAL ABNORMALITIES

VALVULAR PATHOPHYSIOLOGY

BASICS OF THE GENERAL APPROACH TO CARDIOVASCULAR EXAM

BEDSIDE HEMODYNAMICS

48 Hemodynamic Evaluation of Dyspnea

DYSPNEA WITH ELEVATED PCW (>15–20 mm Hg)

EVALUATION OF DYSPNEA: KEYS OF PHYSICAL EXAMINATION

EVALUATION OF DYSPNEA: FOCUS ON THE CAROTID WAVEFORM

INVASIVE HEMODYNAMIC EVALUATION OF DYSPNEA

49 Bedside Evaluation of Low-Output Hypotension

EVALUATION OF LOW-CARDIAC-OUTPUT HYPOTENSION

REDUCED CARDIAC PRELOAD DUE TO DECREASED TOTAL BLOOD VOLUME

DECREASED CARDIAC PRELOAD DESPITE INCREASED TOTAL BLOOD VOLUME RIGHT-HEART INFLOW OBSTRUCTION

DECREASED RV OUTFLOW

LEFT-HEART INFLOW OBSTRUCTION

LOW OUTPUT DUE TO DIMINISHED LV OUTFLOW

ALGORITHM FOCUSED ON THE CAROTID WAVEFORM

50 Hemodynamic Evaluation of Right-Heart Failure

PHYSICAL EXAMINATION OF THE JUGULAR VENOUS PRESSURE AND RA WAVEFORM

ALGORITHMIC EVALUATION OF RIGHTHEART FAILURE: FOCUS ON THE JVP

DIFFERENTIAL DIAGNOSIS OF PULMONARY HYPERTENSION

INVASIVE HEMODYNAMIC ASSESSMENT OF RIGHT-HEART FAILURE

INDEX

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To Margaret and Anna Rose, the systole of my life. MJK

To Amy, Parker, and Taylor – the essential pieces to my life. MJL

To my wife Cindy, who keeps life fun while I am working. JAG

HEMODYNAMIC ROUNDS 2007

The following citations have been used in the chapters identified by chapter number. These chapters were originally published in Catheterization and Cardiovascular Diagnosis and comprise the basis for most of the chapters in Hemodynamic Rounds, Third Edition.

Chapter 1Kern MJ, Aguirre FV, Donohue TJ. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Pressure wave artifacts. Cathet Cardiovasc Diagn 27:147–154, 1992.Chapter 2Kern MJ. Pitfalls of right heart hemodynamics. Cathet Cardiovasc Diagn 43:90–94, 1998.Chapter 3Kern MJ, Deligonul U. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. II. The tricuspid valve. Cathet Cardiovasc Diagn 21:278–286, 1990.Chapter 4Kern MJ. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. The left-side V wave. Cathet Cardiovasc Diagn 23:211–218, 1991.Chapter 5Kern MJ. The LVEDP. Cathet Cardiovasc Diagn 44:70–74, 1998.Chapter 6Kern MJ, Donohue TJ, Bach R, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Simultaneous left and right ventricular pressure measurements. Cathet Cardiovasc Diagn 28:51–55, 1992.Chapter 7Kern MJ, Aguirre FV, Hilton TC. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. The effects of nitroglycerin. Cathet Cardiovasc Diagn 25:241–248, 1992.Chapter 8Schoen WJ, Talley JD, Kern MJ. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Pulsus alternans. Cathet Cardiovasc Diagn 24:315–319, 1991.Chapter 9Kern MJ. Editorial comments for hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Acute aortic insufficiency. Cathet Cardiovasc Diagn 28:244–249, 1993.Chapter 10Kern MJ, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Aortic regurgitation. Cathet Cardiovasc Diagn 26:232–240, 1992.Chapter 11Kern MJ, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: aortic regurgitation. Cathet Cardiovasc Diagn 26:232–240, 1992.Chapter 12Kern MJ, Aguirre FV, Guerrero M. Abnormal hemodynamics after prosthetic aortic root reconstruction: Aortic stenosis or insufficiency? Cathet Cardiovasc Diagn 44:336–340, 1998.Chapter 13Godlewski KJ, Talley JD, Morris GT. Interpretation of cardiac pathophysiology from pressure waveform analysis: Acute aortic insufficiency. Cathet Cardiovasc Diagn 28:244–248, 1993.Chapter 14Kern MJ, Aguirre FV, Donohue TJ, Bach RG. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Multivalvular regurgitant lesions. Cathet Cardiovasc Diagn 28:167–172, 1993.Chapter 15Suh WM, Kern MJ. Modified and reproduced from Cathet Cardiovasc Intervent 71: 944–949, 2008.Chapter 17Kern MJ, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Mitral valve gradients, part I. Cathet Cardiovasc Diagn 26:308–315, 1992.Chapter 18Kern MJ. Mitral stenosis and pulsus alternans. Cathet Cardiovasc Diagn 43:313–317, 1998.Chapter 19Azrak E, Kern MJ, Bach RG, Donohue TJ, Hemodynamic evaluation of a stenotic bioprosthetic mitral valve. Cathet Cardiovasc Diagn 45:70–75, 1998.Chapter 20Kern MJ. Left ventricular puncture for hemodynamic evaluation of double prosthetic valve stenosis. Cathet Cardiovasc Diagn 43:466–471, 1998.Chapter 22Freihage JH, Joyal D, Arab D, Dieter RS, Loeb HS, Steen L, Lewis B, Liu JC, Leya F, et al. Invasive assessment of mitral regurgitation: Comparison of hemodynamic parameters. Cathet Cardiovasc Intervent 69:303–312, 2007.Chapter 23Kern MJ. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. The pulmonary valve. Cathet Cardiovasc Diagn 24:209–213, 1991.Chapter 24Kern MJ, Bach RG. Pulmonic balloon valvuloplasty. Cathet Cardiovasc Diagn 44:227–234, 1998.Chapter 25Kern MJ, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Mitral valve gradients, part II. Cathet Cardiovasc Diagn 27:52–56, 1992.Chapter 29Kosmicki L, Michaels AD. Cathet Cardiovasc Intervent 2008, in press.Chapter 30Higano ST, Azrak E, Tahirkheli NK, Kern MJ. Hemodynamics of constrictive physiology: Influence of respiratory dynamics on ventricular pressures. Cathet Cardiovasc Intervent 46:473–486, 1999.Chapter 32Kern MJ, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Pericardial compressive hemodynamics. Part II, Cathet Cardiovasc Diagn 26:34–40, 1992.Chapter 33Kern MJ, Aguirre FV. Hemodynamics rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Pericardial compressive hemodynamics. Part III. Cathet Cardiovasc Diagn 26:152–158, 1992.Chapter 34Kern MJ, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Pericardial compressive hemodynamics. Part I. Cathet Cardiovasc Diagn 25:336–342, 1992.Chapter 35Azrak EC, Kern MJ, Bach RG. Hemodynamics of cardiac tamponade in a patient with AIDS-related non-Hodgkin’s lymphoma. Cathet Cardiovasc Diagn 45:287–291, 1998.Chapter 36Strote JA, Dean LS, Goldberg SL, Krieger EV, Stewart DK. A novel assessment for a constrictive pericarditis. In press. 2008.Chapter 38Kern MJ, Donohue TJ, Bach RG, Aguirre FV. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: Cardiac arrhythmias. Cathet Cardiovasc Diagn 27:223–227, 1992.Chapter 39Kern MJ, Deligonul U. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. Pacemaker hemodynamics. Cathet Cardiovasc Diagan 24:22–27, 1991.Chapter 40Kern MJ, Puri S, Donohue TJ, Bach RG. Hemodynamics of dual-chamber pacing and Valsalva maneuver in a patient with hypertrophic obstructive cardiomyopathy. Cathet Cardiovasc Diagn 44:438–442, 1998.Kern MJ, H, Bach RG. Hemodynamics effects of alcohol-induced septal infarction for hypertrophic obstructive cardiomyopathy. Cathet Cardiovasc Intervent 47:221–228, 1999.Chapter 41Kern MJ. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. Coronary hemodynamics: I. Coronary catheter pressures. Cathet Cardiovasc Diagn 25:57–60, 1992.Kern MJ. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. Coronary hemodynamics part II. Patterns of coronary flow velocity. Cathet Cardiovasc Diagn 25:154–160, 1992.Kern MJ, Aguirre FV, Donohue TJ, Bach RG. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. Coronary hemodynamics part III: Coronary hyperemia. Cathet Cardiovasc Diagn 26:204–211, 1992.Kern MJ, Puri S, Craig WR, Bach RG, Donohue TJ. Coronary hemodynamics for angioplasty and stenting after myocardial infarction: Use of absolute, relative coronary velocity and fractional flow reserve. Cathet Cardiovasc Diagn 45:174–182, 1998.Chapter 44Kern MJ, Aguirre FV, Donohue TJ, Bach RG. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis: adult congenital anomalies. Cathet Cardiovasc Diagn 27:291–297, 1992.Chapter 46Kern MJ, Deligonul U, Miller L. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. IV. Extra hearts: Part I. Cathet Cardiovasc Diagn 22:197–201, 1990.Kern MJ, Deligonul U. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. IV. Extra hearts: Part II. Cathet Cardiovasc Diagn 22:302–306, 1990.Kern MJ, Deligonul U. Hemodynamic rounds: Interpretation of cardiac pathophysiology from pressure waveform analysis. IV. Extra hearts: Part III. Cathet Cardiovasc Diagn.

CONTRIBUTORS

Robin Abdelmalik, MD, Resident Internal Medicine, University California Irvine, 101 The City Drive, Orange, CA 92868

Elie Azrak, MD, Cardiology Consultants, St. Louis, MO 63110

Frank V. Aguirre, MD, Prarire Cardiovascular Associates Spramfield, Illinois

Steven Appleby, MD, Fellow in Cardiology, University California Irvine, 101 The City Drive, Orange, CA 92868

Richard G. Bach, MD, Washington University, St. Louis, MO

James Bergin, MD, Cardiovascular Division, University of Virginia Health System, Cardiovascular Division, Box 800158, Charlottesville, Virginia, 22908

Jeff Ciaramita, MD, Fellow in Cardiology, St. Louis University, 1325 S. Grand Ave. St. Louis, Missouri 63110

Larry S. Dean, MD, Professor of Medicine, Director, UW Regional Heart Center, Division of Cardiology, University of Washington, 1959 NE Pacific Ave, Box 356422, Seattle, WA 98195

Ubeydullah Deligonul, MD, Cardiovascular Consultants, St. Louis, MO

Thomas J. Donohue, MD, St. Raphael’s Hospital, New Havern, CT

Ziad Elghoul, MD, Division of Cardiology, University of Louisville, 323 E. Chestnut St., Louisville, KY 40292

Ted Feldman, MD, Director Invasive Cardiology, Evanston Hospital, 2650 Ridge Avenue, Evanston, IL 60201

Krystof J. Godlewski, MD, University of Louisville, Louisville, KY

Steven L. Goldberg, MD, Clinical Associate Professor, Director, Cardiac Catheterization Laboratory, Division of Cardiology, University of Washington, 1959 NE Pacific Ave, Box 356422, Seattle, WA 98195

James A. Goldstein, MD, Director, Cardiovascular Research, William Beaumont Hospital, 3601 W. Thirteen Mile Rd Royal Oak, MI 48073

Marco Guerrero, MD, Fellow in Cardiology, St. Louis University, St. Louis, MO 63110

Stuart T. Higano, MD, Cardiovascular Consultants, St. Louis, MO

Ziyad M. Hijazi, MD, FSCAI, Director, Rush Center for Congenital & Structural Heart Disease, Professor of Pediatrics & Internal Medicine, Chief, Section of Pediatric Cardiology, Rush University Medical Center, Suite 770 Jones 1653 W. Congress Parkway, Chicago, IL 60612

Ralf J. Holzer, MD, MSc. Assistant Director, Cardiac Catheterization & Interventional Therapy, Assistant Professor of Pediatrics, Cardiology Division, The Ohio State University, The Heart Center, Columbus Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205

John Kern, MD, Department of Cardiothoracic Surgery, University of Virginia Health System, Cardiovascular Division, Box 800158, Charlottesville, VA 22908

Morton J. Kern, MD, Professor of Medicine, Associate Chief of Cardiology, University of California, Irvine, CA 90803

Douglas L. Kosmicki, MD, Fellow in Cardiology, University of Utah, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132–2401

Eric V. Krieger, MD, Cardiology Fellow, Division of Cardiology, University of Washington, 1959 NE Pacific Ave, Box 356422, Seattle, WA 98195

Abhay Laddu, MD, Resident Internal Medicine, St. Louis University, 1325 S. Grand Ave. St. Louis, MO 63110

Massoud A. Leesar, MD, Division of Cardiology, University of Louisville, 323 E. Chestnut St., Louisville, KY 40292

D. Scott Lim, MD, Cardiovascular Division, University of Virginia Health System, Cardiovascular Division, Box 800158, Charlottesville, VA 22908

Michael J. Lim, MD, Director Interventional Cardiology, St. Louis University, 1325 S. Grand Ave. St. Louis, MO 63110

Andrew D. Michaels, MD, Associate Professor of Medicine, Director, Cardiac Catheterization Laboratory and Interventional Cardiology, University of Utah, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132

Leslie Miller, MD, Washington Hospital, Washington, DC

Robert H. Neumayr, St. Louis University, St. Louis, MO

Gary S. Mintz, MD, Chief Medical Officer, Cardiovascular Research Foundation, 111 E 59th St, 11th Floor, New York, NY 10022 212 851 9395

Glenn T. Morris, MD, University of Louisville, Louisville, KY

Michael Ragosta, MD, Director, Cardiac Cath Lab, Cardiovascular Division, Associate Professor of Medicine, Director, Cardiac Catheterization Laboratories, University of Virginia Health System, Cardiovascular Division, Box 800158, Charlottesville, VA 22908

Syed T. Reza, MD, Division of Cardiology, University of Louisville, 323 E. Chestnut St., Louisville, KY 40292

Tariq S. Siddiqui, MD, Division of Cardiology, University of Louisville, 323 E. Chestnut St., Louisville, KY 40292

Douglas K. Stewart, MD, Professor, University of Washington Medical Center, Director, Interventional Cardiology Fellowship, Division of Cardiology, University of Washington, 1959 NE Pacific Ave, Box 356422, Seattle, WA 98195

George A. Stouffer, MD, Professor of Medicine, Director of Interventional Cardiology, CB 7075, University of North Carolina, Chapel Hill, NC 27599

Justin A. Strote, MD, Interventional Cardiology Fellow, Division of Cardiology, University of Washington, 1959 NE Pacific Ave, Box 356422, Seattle, WA 98195

Williams M. Suh, MD, Fellow in Cardiology, University California Irvine, 101 The City Drive, Orange, CA 92868

Naeem K. Tahirkheli, MD, Fellow in Cardiology, Mayo Clinic Rochester, MN

J. David Talley, MD, University of Louisville, Louisville, KY

Joshua W. Todd, MD, Fellow, Division of Cardiology, CB 7075, University of North Carolina, Chapel Hill, NC 27599

Zoltan Turi, MD, Professor of Medicine, Robert Wood Johnson Medical School, Director, Structural Heart Disease Program, Cooper University Hospital, D-427, One Cooper Plaza, Camden, NJ 08103

PREFACE

As noted in the textbooks of cardiology, hemodynamics continue to be an integral part of the training experience and comprise validation for much of the pathophysiology obtained from clinical examination, echocardiographic study, and new imaging modalities. With the increased attention to visual medicine and angiography, the graphics of hemodynamics have been in decline. However, hemodynamics remain useful for diagnosis and treatment of the multitude of various and unusual cardiovascular conditions. It remains true that in today’s modern cardiology, hemodynamics are still critical to the diagnosis of valvular disorders and unusual cardiomyopathic conditions contributing to cardiac disability.

The first edition of Hemodynamic Rounds emphasized the interpretation of hemodynamic waveforms for clinical decision-making as presented from a series of cases published in the journal of “Catheterization and Cardiovascular Diagnosis” now renamed “Catheterization and Cardiovascular Intervention.” The case-based format limited itself to description of individual hemodynamic tracings, but was not presented in a formalized textbook fashion. The second edition of Hemodynamic Rounds extended this work and enlarged and reorganized it into new sections providing a more logical approach to the study of pressure waveforms and the associated pathology.

In the present edition of Hemodynamic Rounds, a further thematic approached to the understanding of pathophysiologic waveforms is provided. The text has been divided into 10 major parts (comprising Section I of this edition) incorporating the previously published works with new and dynamic tracings and incorporating the latest publications regarding hemodynamic topics as they have evolved into our modern practice.

Part 1 describes normal and pathophysiologic hemodynamic waveforms and is organized to the study of pressure wave measurement systems, artifacts, and normal waveforms. The hemodynamics of the tricuspid valve, the mitral valve, and left-sided V waves are reviewed. LV end-diastolic pressure, simultaneous right- and left-heart pressures, and effects of nitroglycerin and pulsus alternans are also discussed.

Parts 2 and 3 cover valvular and valvuloplasty hemodynamics. In Part 4, constrictive and restrictive physiologic waveforms are described in detail. Cardiac arrhythmias are dealt with in Part 5. Hypertrophic obstructive cardiomyopathy is presented in Part 6. Coronary hemodynamics in Part 7 has also been expanded. The new concepts involving absolute and relative coronary reserve and pressure-derived fractional flow reserve are compared with the intent to help the practitioner understand practice in the laboratory on a daily basis. These findings can be used for decision-making during coronary angiography.

Parts 8 and 9 deal with particularly unusual hemodynamic problems involving adult congenital anomalies and hemodynamics, extra hearts and transplants, intra-aortic balloon pumps, and circulatory assist devices. Finally, in Part 10, right ventricular infarction is described by one of the world’s experts, Dr. Goldstein.

As a new and important aspect of hemodynamic rounds, Dr. Goldstein (in Section II of this edition) has undertaken the compilation of clinical and bedside applications of hemodynamics describing the correlation between the anatomic and pathophysiologic presentations of dyspnea, edema and Anasarca, syncope, hypotension, and low cardiac output in four distinct blocks, presenting correlative findings between anatomy, hemodynamics, and clinical manifestations.

It is the hope of the authors that this work will be of lasting value to students, trainees, practicing physicians, and all related health-care personnel dealing with the important subject of cardiac hemodynamics. I continue to thank Dr. Frank Hildner, first editor and founder of Catheterization and Cardiovascular Interventions, formerly Catheterization and Cardiovascular Diagnosis for his involvement with this work, without whom this book would never have been published.

I would like to thank Margaret and Anna Rose, the continuing systole of my life as noted in our first edition, and I would like to extend my deepest appreciation to my co-editors and contributors to this work and to my fellows in training without them, there would be no point in these exercises.

MORTON J. KERN, MD

Professor of Medicine

Associate Chief Cardiology

University of California, Irvine

INTRODUCTION

MORTON J. KERN, MD, AND FRANK J. HILDNER, MD

HISTORICAL REVIEW

On February 28, 1733, the president of the Council of the Royal Society, Sir Hans Sloane, requested that Stephen Hales, one of the counselors, present his information on the mechanics of blood circulation from a previous presentation of a series of hemodynamic experiments reported in his book Haemastaticks [1]. Mr. Hales took his place in medical history next to William Harvey with regard to studies of the human and animal circulation. De Motu Cordis [2] and Haemastaticks stimulated scientists interested in the newly developed principles and mathematical computations of fluid mechanics as applied to circulatory physiologic events. The simple measurement of blood pressure now became a subject of great scientific interest.

From such basic interests, experimental physiologists at Oxford University in the 1800s, investigating the physiology of the circulation, began estimating the output of ventricular contraction and velocity of blood flow in the aorta based on relatively primitive measurements of cardiovascular structures. These data remain valid and correspond to currently accepted data obtained by computerized quantitative techniques. Cardiologists interested in hemodynamics should continue to emulate Stephen Hales, who relied on direct measurements and observations repeatedly checked and applied on simple and repeatedly confirmed computations. The numerous original achievements in hemodynamics provided to us by Hales are remarkable even by today’s standards and included the first direct and accurate measurement of blood pressure in different animals (see Figure) under different physiologic conditions such as hemorrhage and respiration; cardiac output estimated by left ventricular systolic stroke volume measured from the diastolic volume after death of the animal; calculations of pressure measured on the internal surface of the left ventricular at the beginning of systole; and determination of blood flow velocity in the aorta approximating 0.5 m/sec. Stephen Hales introduced the concept of the wind castle or capacitance effect in the transformation of pulsatile flow in large vessels to continuous flow in smaller vessels. Hales also made the first direct measurement of venous blood pressure and correct interpretation of venous return on cardiac output in relation to contraction and respirations. Since recording equipment documenting the observations of Hales was lacking, understanding the unique collection of data depends on interpreting descriptive material.