Hemodynamic assessment in cardiology
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Transcript of Hemodynamic assessment in cardiology
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HEMODYNAMIC ASSESSMENT
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INTRODUCTION
Conventionally hemodynamics were obtained by cardiac catheterization.
It is possible to determine the same by echocardiography.
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MethodsM-mode & 2D echo alone can provide only indirect evidence of hemodynamic abnormalities.These signs are not highly specific / sensitive.Doppler echo is the best tool to assess intra cardiac hemodynamics.
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Doppler echo & the accuracy of doppler derived hemodynamic measurements has been validated by comparison with simultaneously derived catheterization data.
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Stroke volume & COFlow across a fixed orifice is equal to the product of the cross sectional area of the orifice & flow velocity.Velocities varies during ejection in a pulsatile system, individual velocities of the doppler spectrum need to be summed(TVI or VTI).Flow rate = CSA x FLOW VELOCITY
SV = CSA X TVI CO = SV X HR
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STROKE VOLUME
IS THE PRODUCT OF CROSS SECTIONAL AREA AND THE FLOW VELOCITY INTEGRAL.
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CSAThe CSA of orifices in the heart is usually assumed to be a circle and it is determined from measurement of the orifice diameter(D).
CSA = (D/2) ² X = D ² X 0.785
SV = D ² X 0.785 X TVI
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MEASUREMENT OF STROKE VOLUME & CARDIAC OUTPUT
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Regurgitant orifice area (ROA)
ESTIMATED BY PISA USING THE PRINCIPAL OF CONTINUITY EQUATION.
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PISA CALCULATION
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PISA CALCULATION
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PISA CALCULATION
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PISA CALCULATION
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PISA CALCULATION
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REGURGITANT ORIFICE AREA
CALCULATION
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REGURGITANT VOLUMEVOLUME OF BLOOD THAT REGURGITATES THROUGH AN INCOMPETANT ORIFICE WITH EACH HEART BEAT
TOTAL FORWARD FLOW (Q)
_ SYSTEMIC FLOW(Qs).
RV =
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An example of regurgitant volume
calculation in MR.
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REGURGITANT VOLUME CALCULATION BY PISA
REGURGITANTORIFICE AREA
INTEGRATED VELOCITY OF MR JET
XRV =
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REGURGITANT FRACTIONIt is simply the percentage of regurgitant volume compared to flow across the regurgitant valve.
REG VOLRegurgitant fraction =
Q valve flowX 100
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Pulmonary to systemic flow ratio (Qp/Qs)
In the presence of intracardiac shunt the flow ratio between the pulmonary & systemic circulation usually indicates the magnitude of shunt.Pulmonary flow (Qp) is calculated from the RVOT & systemic flow (Qs) , from the LVOT.
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RVOT TVI X RVOT CSA
LVOT TVI X LVOT CSA.
Qp/Qs =
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DOPPLER ESTIMATION OF INTRA-CARDIAC
PRESSURES
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RIGHT ATRIAL PRESURE
•IVC diameter measurement adjacent to right atrium
•Subcostal view
•During quite respiration & forced inspiration
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RV SYSTOLIC PRESSURE BY TR VELOCITY JET
•Reflects pressure difference between RV &RA
•TR present in 75% normal adults
•Normal velocity 2- 2.5m/sec
•Higher velocity –PS or PHT
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ESTIMATION OF SYSTOLIC PAP IN THE ABSENCE OF PS
PAP = 4( V TR)² + RAP systolic
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ESTIMATION OF SYSTOLIC PAP IN THE PRESENCE OF
PS
PAP = (4 (VTR)² + RAP ) – 4(V PS) ² systolic
PAP = RVSP – 4(V PS) ² systolic
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RVOT FLOW ACCELERATION TIME
•Pulse wave doppler
•Sample volume at valve annulus
•Ac T=Time between beginning of flow & peak velocity
•Normal 120 m Sec or higher
•PHT –Ac T Shortened
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Fig. 4-43. Pulmonary arteryflow in three patients with dif-fering pulmonary artery pres-sures. The acceleration time(AT) becomes shorter as thepulmonary artery pressurerises.
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ESTIMATION OF MEAN PAP FROM RVOT Ac T
MAHAN’S regression equation
MPAP = 79 - ( 0.45 X Ac T)
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PULMONARY REGURGITATION VELOCITY
•Reflects end diastolic pressure gradient between PA & RV
•At end diastole RV pressure = RAP
•Used to calculate PAEDP & mean PAP
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ESIMATION OF END DIASTOLIC PAP FROM PR VELOCITY
PAEDP – RVEDP = 4 X PR EDV ²
PAEDP = 4 X PR EDV ² + RVEDP
= 4 X PR EDV ² + RAP
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ESIMATION OF MEAN PAP FROM PR VELOCITY
According to Masuyama
Mean PAP = 4 X peak PR velocity ²
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LVEDPLVEDP & LV diastolic function are closely related phenomenon.Changes in mitral flow velocities in early & late diastole reflect changes in LVEDP.In presence of AR the LVEDP is easily calculated.AR velocity reflects the diastolic pressure difference between AO & LV.
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LA PRESSUREMR velocity represents the systolic pressure difference between the LV & the LA.In patients without LV outflow obstruction systolic BP is practically same as LV systolic pressure.LA pressure = SBP – 4 x MRV²
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Relation of PVF with LAP
LAP = 35 - 0.39 X ( SYSTOLIC FRACTION )
SYSTOLIC FRACTION = Si X 100
Si+Di
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PCWP by MITRAL & TISSUE DOPPLER
PCWP = 1.24 E 1.9
E’X +
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LVEDP by MITRAL & TISSUE DOPPLER
E
E’
> 15
LVEDP > 12 mmHg
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THANK YOU
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