right heart catheterization – basic right heart pressure tracings

Right Heart Catheterization – Right Heart Catheterization – basic right heart pressure basic right heart pressure

tracingstracingsUniversity of KansasUniversity of Kansas

August 20, 2004August 20, 2004Cardiac catheterization Cardiac catheterization

conferenceconference

The HeartThe Heart

Year 1 Year 1 Cardiology Cardiology FellowshipFellowship

Right heart catheterization and Right heart catheterization and the Swan Ganz catheterthe Swan Ganz catheter

The first to demonstrate that a The first to demonstrate that a catheter could be advanced safely into catheter could be advanced safely into the human heart was the German the human heart was the German surgeon Werner Forssmann (1904-surgeon Werner Forssmann (1904-1979) – who did the experiment on 1979) – who did the experiment on himself. A catheter similar to the himself. A catheter similar to the Swan-Ganz was originally developed in Swan-Ganz was originally developed in 1953 and used in dogs by the U.S. 1953 and used in dogs by the U.S. physiologists Michael Lategola and physiologists Michael Lategola and Hermann Rahn (1912-1990). Swan and Hermann Rahn (1912-1990). Swan and Ganz introduced their catheter into Ganz introduced their catheter into clinical practice in 1970.clinical practice in 1970.Bibliography:Bibliography:

W. Forssmann: W. Forssmann: Die Sondierung des Rechten Herzens.Die Sondierung des Rechten Herzens. Klinische Wochenschrift, Berlin, 1929, Klinische Wochenschrift, Berlin, 1929, 8: 2085.8: 2085.Experiments on myself.Experiments on myself. Translated by Translated by H. Davies. London, St. James Press, H. Davies. London, St. James Press, 1974.1974.

Right Heart CatheterizationRight Heart Catheterization IndicationsIndications

Diagnosis of shock states Diagnosis of shock states Differentiation of high- versus low-pressure pulmonary edema Differentiation of high- versus low-pressure pulmonary edema Diagnosis of primary pulmonary hypertension (PPH) Diagnosis of primary pulmonary hypertension (PPH) Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade, Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade,

and pulmonary embolus (PE) and pulmonary embolus (PE) Monitoring and management of complicated AMI Monitoring and management of complicated AMI Assessing hemodynamic response to therapies Assessing hemodynamic response to therapies Management of multiorgan system failure and/or severe burns Management of multiorgan system failure and/or severe burns Management of hemodynamic instability after cardiac surgery Management of hemodynamic instability after cardiac surgery Assessment of response to treatment in patients with PPH Assessment of response to treatment in patients with PPH

Contraindications Contraindications Tricuspid or pulmonary valve mechanical prosthesis Tricuspid or pulmonary valve mechanical prosthesis Right heart mass (thrombus and/or tumor) Right heart mass (thrombus and/or tumor) Tricuspid or pulmonary valve endocarditis Tricuspid or pulmonary valve endocarditis

Complications Complications AccessAccess

PneumonthoraxPneumonthorax HemothoraxHemothorax Tracheal perforationTracheal perforation

IntracardiacIntracardiac Stimulation of the RVOT – Stimulation of the RVOT –

ventricular arrhythmiasventricular arrhythmias AV block- be aware in AV block- be aware in

patients with a LBBB patients with a LBBB (consider a temporary (consider a temporary pacemaker prior to proceding)pacemaker prior to proceding)

Causing a RBBBCausing a RBBB Atrial arrhythmiasAtrial arrhythmias Pulmonary rupturePulmonary rupture Pulmonary infarctPulmonary infarct RV punctureRV puncture

Basics - InsertionBasics - Insertion The SGC is inserted percutaneously into a The SGC is inserted percutaneously into a

major vein (jugular, subclavian, femoral) via major vein (jugular, subclavian, femoral) via an introducer sheath. The predominance of an introducer sheath. The predominance of right heart catheterization is performed in right heart catheterization is performed in the invasive lab utilizing the femoral the invasive lab utilizing the femoral approach. Preference considerations for approach. Preference considerations for cannulation of the great veins are as follows: cannulation of the great veins are as follows:

Right internal jugular vein (RIJ) - Right internal jugular vein (RIJ) - Shortest and straightest path to the Shortest and straightest path to the heart heart

Left subclavian - Does not require the Left subclavian - Does not require the SGC to pass and course at an acute SGC to pass and course at an acute angle to enter the SVC (compared to angle to enter the SVC (compared to the right subclavian or left internal the right subclavian or left internal jugular [LIJ]) jugular [LIJ])

Femoral veins - These access points are Femoral veins - These access points are distant sites, from which passing a SGC distant sites, from which passing a SGC into the heart can be difficult, especially into the heart can be difficult, especially if the right-sided cardiac chambers are if the right-sided cardiac chambers are enlarged. Often, fluoroscopic assistance enlarged. Often, fluoroscopic assistance is necessary, but these sites are is necessary, but these sites are compressible and may be preferable if compressible and may be preferable if the risk of hemorrhage is high. the risk of hemorrhage is high.

Sheath InsertionSheath Insertion A. Puncture vessel by needleA. Puncture vessel by needle B. Flexible guidewire placed B. Flexible guidewire placed

into vessel via needleinto vessel via needle C. Needle removed and C. Needle removed and

guidewire left in place, hole in guidewire left in place, hole in skin is enlarged with a scalpelskin is enlarged with a scalpel

D. Sheath and dilator placed D. Sheath and dilator placed over the guidewireover the guidewire

E. Sheath and dilator advanced E. Sheath and dilator advanced into the vessselinto the vesssel

F. Dilator and sheath removed F. Dilator and sheath removed while sheath remains in the while sheath remains in the vesselvessel

Modified Seldinger’s technique

Right Heart Pressures Tracings

Advancing Your Right Heart Advancing Your Right Heart CatheterCatheter

Advance the SGC to Advance the SGC to about 20cm and inflate about 20cm and inflate the balloon tip.the balloon tip.

Initial chamber entered Initial chamber entered will be the right atrium will be the right atrium and the initial pressure and the initial pressure waveform will have 3 waveform will have 3 positive deflections, positive deflections, the a, c and v wavesthe a, c and v waves

There will be an x and There will be an x and y descenty descent

Right Atrial Pressure TracingRight Atrial Pressure Tracing a wave – results from a wave – results from

atrial systoleatrial systole c wave – occurs with c wave – occurs with

the closure of the the closure of the tricuspid valve and the tricuspid valve and the initiation of atrial fillinginitiation of atrial filling

v wave – occurs with v wave – occurs with blood filling the atrium blood filling the atrium while the tricuspid while the tricuspid valve is closedvalve is closed

Timing of the positive Timing of the positive deflectionsdeflections

a wave – occurs after a wave – occurs after the p wave during the p wave during the PR intervalthe PR interval

c wave – when c wave – when present occurs at the present occurs at the end of the QRS end of the QRS complex (RST complex (RST junction)junction)

v wave – occurs after v wave – occurs after the T wavethe T wave

Right Atrial ChamberRight Atrial Chamber Height of the v wave is Height of the v wave is

related to the atrial related to the atrial compliance and the compliance and the volume of blood volume of blood returning from the returning from the peripheryperiphery

Height of the a wave is Height of the a wave is related to the pressure related to the pressure needed to eject needed to eject forward blood flowforward blood flow The v wave is usually The v wave is usually

smaller than the a wave smaller than the a wave in the right atriumin the right atrium

Right atrial hemodynamic Right atrial hemodynamic pathologypathology

Elevated a waveElevated a wave Tricuspid stenosisTricuspid stenosis Decreased RV Decreased RV

compliancecompliance e.g. pulm htn, e.g. pulm htn,

pulmonic stenosispulmonic stenosis Cannon a waveCannon a wave

AV asynchrony – atrium AV asynchrony – atrium contracts against a contracts against a closed tricuspid valveclosed tricuspid valve

e.g. AVB, Vtache.g. AVB, Vtach

Absent a waveAbsent a wave Atrial fibrillation or Atrial fibrillation or

standstillstandstill Atrial flutterAtrial flutter

Elevated v waveElevated v wave Tricuspid regurgitationTricuspid regurgitation RV failureRV failure Reduced atrial Reduced atrial

compliancecompliance e.g. restrictive myopathye.g. restrictive myopathy

Right atrial hemodynamic Right atrial hemodynamic pathologypathology

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 PathologyHemodynamic Pathology Tricuspid StenosisTricuspid Stenosis

Large jugular venous Large jugular venous a waves on noted on a waves on noted on examexam

Notable elevated a Notable elevated a wave with the wave with the presence of a presence of a diastolic gradient - diastolic gradient - >5mmHg gradient is >5mmHg gradient is considered signficantconsidered signficant


Continue advancing the Continue advancing the catheter into the right catheter into the right ventricleventricle

The right and left ventricular The right and left ventricular pressure tracings are similar.pressure tracings are similar.

The right ventricular has a The right ventricular has a shorter duration of systoleshorter duration of systole

Diastolic pressure in the right Diastolic pressure in the right ventricle is characterized by ventricle is characterized by an early rapid filling phase, an early rapid filling phase, then slow filling phase then slow filling phase followed by the atrial kick or a followed by the atrial kick or a wavewave

a

Normal RV waveform Normal RV waveform artifactartifact

Note the notch on Note the notch on the top of RV the top of RV pressure waveformpressure waveform This represents This represents

“ringing” of a fluid-“ringing” of a fluid-filled catheterfilled catheter

Ringing can also be Ringing can also be noted on the noted on the diastolic portion of diastolic portion of the waveformthe waveform


Advancing out the RVOT to Advancing out the RVOT to the pulmonary arterythe pulmonary artery

There is a systolic wave There is a systolic wave indicating ventricular indicating ventricular contraction followed by contraction followed by closure of the pulmonic valve closure of the pulmonic valve and then a gradual decline in and then a gradual decline in pressure until the next pressure until the next systolic phase.systolic phase.

Closure of the pulmonic valve Closure of the pulmonic valve is indicated by the dicrotic is indicated by the dicrotic notchnotch

Timing of the PA pressureTiming of the PA pressure Peak systole Peak systole

correlates with the correlates with the T waveT wave

End diastole End diastole correlates with the correlates with the QRS complexQRS complex

Hemodynamic PathologyHemodynamic Pathology Pulmonic StenosisPulmonic Stenosis

Notable large Notable large gradient across the gradient across the pulmonic valve pulmonic valve during PA to RV during PA to RV pullback. pullback.

Notable extreme Notable extreme increases in RV increases in RV systolic pressures systolic pressures and a damped PA and a damped PA pressurepressure

Pulmonary artery Pulmonary artery hemodynamic pathologyhemodynamic pathology

Elevated systolic pressureElevated systolic pressure Primary pulmonary hypertensionPrimary pulmonary hypertension Mitral stenosis or regurgitationMitral stenosis or regurgitation Restrictive myopathiesRestrictive myopathies Significant L to R shuntSignificant L to R shunt Pulmonary diseasePulmonary disease

Reduced systolic pressureReduced systolic pressure Pulmonary artery stenosisPulmonary artery stenosis Ebstein’s anomalyEbstein’s anomaly Tricuspid stenosisTricuspid stenosis Tricuspid atresiaTricuspid atresia

Reduced pulse pressureReduced pulse pressure Right heart ischemiaRight heart ischemia Pulmonary embolusPulmonary embolus TamponadeTamponade

Bifid pulmonary artery Bifid pulmonary artery waveformwaveform

Large left atrial v wave Large left atrial v wave transmitted backwardtransmitted backward

Pulmonary artery diastolic Pulmonary artery diastolic pressure > pulmonary pressure > pulmonary capillary wedge pressurecapillary wedge pressure

Pulmonary diseasePulmonary disease Pulmonary embolusPulmonary embolus TachycardiaTachycardia


With the balloon With the balloon inflated advance the inflated advance the catheter until the catheter until the pressure tip wedges pressure tip wedges into the distal into the distal pulmonary artery pulmonary artery (pulmonary capillary (pulmonary capillary wedge pressure)wedge pressure) Similar waveform to the Similar waveform to the

left atrial waveform left atrial waveform although dampedalthough damped

Pulmonary artery occlusive Pulmonary artery occlusive pressurepressure

A wave – represents A wave – represents left atrial contractionleft atrial contraction

C wave – represents C wave – represents closure of the mitral closure of the mitral valve although rarely valve although rarely actually seenactually seen

V wave – represents V wave – represents filling of the left filling of the left atrium while the atrium while the mitral valve is closedmitral valve is closed


PAOP or wedge PAOP or wedge represents a static represents a static column of blood from column of blood from the catheter tip – to the catheter tip – to the pulmonary v. – to the pulmonary v. – to the left atriumthe left atrium

Note the a wave is Note the a wave is now past the QRS now past the QRS complex and the V complex and the V wave is after the T wave is after the T wave (all delayed wave (all delayed pressure pressure transmission)transmission)


The mean PAOP or The mean PAOP or wedge pressure wedge pressure occurs at the QRS occurs at the QRS complex – can also complex – can also be derived from the be derived from the mean variance.mean variance.

Pulmonary capillary wedge Pulmonary capillary wedge pressure hemodynamic pressure hemodynamic

pathologypathology Elevated mean pressureElevated mean pressure

Increased volumeIncreased volume Left ventricular failureLeft ventricular failure TamponadeTamponade Obstructive atrial myxomaObstructive atrial myxoma

Elevated a waveElevated a wave Mitral stenosisMitral stenosis decreased LV compliancedecreased LV compliance

Cannon a waveCannon a wave AV dysynchronyAV dysynchrony

Elevated v waveElevated v wave Mitral regurgitationMitral regurgitation VSDVSD

PCWP does not = left PCWP does not = left ventricular end-diastolic ventricular end-diastolic

pressurepressure Mitral stenosisMitral stenosis Left atrial myxomaLeft atrial myxoma Cor triatriatumCor triatriatum Pulmonary venous obstructionPulmonary venous obstruction Decreased ventricular Decreased ventricular

compliancecompliance Increased pleural pressureIncreased pleural pressure

Hemodynamic PathologyHemodynamic Pathology Mitral StenosisMitral Stenosis

Simultaneous wedge and left Simultaneous wedge and left ventricular pressures are ventricular pressures are shown demonstrating a shown demonstrating a gradient at the end of diastole gradient at the end of diastole – this is consistent with mitral – this is consistent with mitral stenosis.stenosis.

A second tracing is shown A second tracing is shown demonstrating a simultaneous demonstrating a simultaneous left atrial and left ventricular left atrial and left ventricular pressure tracing – once again pressure tracing – once again note the gradient.note the gradient.

How does the wedge tracing How does the wedge tracing and LA tracing differ?and LA tracing differ?

Hemodynamic PathologyHemodynamic Pathology Severe mitral Severe mitral

RegurgitationRegurgitation Note the large CV waves – Note the large CV waves –

this is due to ventricular this is due to ventricular systolic pressures systolic pressures reflected through the reflected through the pulmonary circulationpulmonary circulation

This patient had severe This patient had severe MR from a ruptured MR from a ruptured papillary musclepapillary muscle


Not a good place to be during Not a good place to be during your right heart cath…your right heart cath…

Similar waveform to the right Similar waveform to the right atrial pressure tracing. atrial pressure tracing. Typically involves higher Typically involves higher pressures and the v wave is > pressures and the v wave is > a wavea wave

V wave is greater due to V wave is greater due to resistance from the resistance from the pulmonary veins whereas the pulmonary veins whereas the right atrium can decompress right atrium can decompress into the SVC and IVC.into the SVC and IVC.

Hemodynamic PathologyHemodynamic Pathology Mitral RegurgitationMitral Regurgitation

Simultaneous left atrial and Simultaneous left atrial and left ventricular pressures left ventricular pressures demonstrate huge v waves demonstrate huge v waves present.present.

The PCWP has a slight delay The PCWP has a slight delay in the pressure tracingin the pressure tracing

Will increase the PCWP and in Will increase the PCWP and in acute setting triggers acute setting triggers pulmonary edema from the pulmonary edema from the increase osmotic forcesincrease osmotic forces

Bad to have happen during Bad to have happen during valvuloplastyvalvuloplasty

Hemodynamic PathologyHemodynamic Pathology

Mitral StenosisThis 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

Left Ventricular Pressure Left Ventricular Pressure TracingTracing

Typically obtained by Typically obtained by passing a pigtail passing a pigtail catheter across the catheter across the aortic valveaortic valve Gives information Gives information

regarding pressure regarding pressure changes across the changes across the aortic valve as well as aortic valve as well as the end diastolic the end diastolic pressurespressures

Aortic Pressure waveformAortic Pressure waveform Waveform appears Waveform appears

similar to the PA similar to the PA waveform with a waveform with a smooth rounded peaksmooth rounded peak

Dicrotic notch noted – Dicrotic notch noted – represents sudden represents sudden closure of the aortic closure of the aortic valvevalve

Remainder represents Remainder represents smooth run-off in smooth run-off in diastolediastole

Hemodynamic PathologyHemodynamic Pathology Aortic StenosisAortic Stenosis

This reflects a This reflects a pullback while pullback while continuously continuously recording. recording.

The presence of The presence of significant aortic significant aortic stenosis is reflected stenosis is reflected by the pressure by the pressure gradientgradient

Hemodynamic PathologyHemodynamic Pathology Aortic Aortic

RegurgitationRegurgitation Note the rapidly increasing Note the rapidly increasing

left ventricular end-left ventricular end-diastolic pressure and diastolic pressure and equilibration of aortic and equilibration of aortic and LV pressures at end-LV pressures at end-diastolediastole

Measuring Cardiac OutputMeasuring Cardiac Output Most commonly used methods are Most commonly used methods are

Thermodilution method Thermodilution method Fick methodFick method

There is no completely accurate way to There is no completely accurate way to assess cardiac outputassess cardiac output

ThermodilutionThermodilution Requires bolus injection of Requires bolus injection of

liquid – commonly saline - liquid – commonly saline - into the proximal port. into the proximal port.

The change in temperature The change in temperature is measured by a is measured by a thermistor mounted in the thermistor mounted in the distal portion of the distal portion of the cathetercatheter PitfallsPitfalls

Not accurate with TRNot accurate with TR Overestimates cardiac Overestimates cardiac

output at low output output at low output statesstates

Birkbeck injection

Fick MethodFick Method Fick Principle – first Fick Principle – first

described by Adolph Fick in described by Adolph Fick in 1870…1870… Assumes the rate at Assumes the rate at

which O2 is consumed is a which O2 is consumed is a function of the rate of function of the rate of blood flow times the rate blood flow times the rate of O2 pick up by the red of O2 pick up by the red blood cellsblood cells

Fick MethodFick Method So cardiac output is So cardiac output is

expressed in the equation expressed in the equation to the rightto the right

Measurements should be Measurements should be made in the steady state.made in the steady state. O2 consumption can be O2 consumption can be

estimatedestimated 3ml O2/kg or 3ml O2/kg or

125ml/min/m2125ml/min/m2 AV O2 difference is arterial AV O2 difference is arterial

– venous O2 content– venous O2 content = saturation X1.36 X Hgb= saturation X1.36 X Hgb

e.g. AO sat 95%, PA sat 65%Patient wght 70kg and Hgb 13.0

210________(0.95-0.65) X 1.36 X 13.0 X 10

=3.96 L/min

I -PCWP tracing I -PCWP tracing

J -PCWPJ -PCWP

right heart catheterization – basic right heart pressure tracings

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