B P3 C22 Invasive Hemodynamic Diagnosis of Cardiac Disease

Question 1

Give 3 indications for cardiac catheterization

Answer 1

1. Suspected or known coronary artery disease
2. Myocardial infarction
3. SCD
4. Valvular heart disease
5. Congenital heart disease
6. Aortic dissection
7. Pericardial constriction or tamponade
8. Cardiomyopathy
9. Initial and follow up assessment for heart transplant

Question 2

Major complications of cardiac catheterization

Answer 2

Major vascular complications 1%
Death 0.2%
Ventricular tachycardia, fibrillation, serious arrhythmia 0.5%
Cerebrovascular accident 0.07%
Myocardial infarction 0.05%

Question 3

Relative complications to cardiac catheterization

Answer 3

Aortic dissection
Cardiac perforation, tamponade
Congestive heart failure
Contrast reaction (anaphylaxis, nephrotoxicity) Heart block, asystole
Hemorrhage (local, retroperitoneal, pelvic) Infection
Protamine reaction
Supraventricular tachyarrhythmia, atrial fibrillation
Thrombosis, embolus, air embolus
Vascular injury, pseudoaneurysm
Vasovagal reaction

Question 4

Vascular complications occurred more often when the ____________ approach was used and least when the radial approach was used.

Answer 4

Brachial Artery

Question 5

Compared with femoral artery access, transradial procedures have a lower _____________ and ________________, superior patient comfort, and improved efficiency in postprocedural care.

Answer 5

A. Lower risk of bleeding
B. Vascular complications

Question 6

True or False

Documentation of adequate dual blood supply to the hand by either the Allen or the Barbeau test is no longer required in most patients.

Answer 6

True

Question 7

The skin entry site for radial access

Answer 7

1 to 2 cm cranial to the bony prominence of the distal radius

Question 8

Given to prevent postprocedural radial artery occlusion

Answer 8

5000 units of unfractionated heparin IV bolus or
UFH weight-adjusted (50 units per kg)

Question 9

Measures to prevent arterial vasopasm during radial access

Answer 9

Adequate sedation
Avoidance of limb cooling
Vasodilators - Nitroglycerin (100 to 200 mcg) and Verapamil (2.5 mg)
Other approaches - SL NTG, and/or intra aterial Diltiazem or Nicardipine

Question 10

The optimal puncture location during femoral vascular access is the __________________________

Answer 10

Common femoral artery (CFA)

Familiarity with the anatomy will assist in identifying the point of needle entry, usually 1 to 3 cm below the inguinal ligament, in line with the palpable course of the CFA

Question 11

In femoral artery vascular access, point of needle entry ______________

Landmark to be identified prior to entry _____________________________

Answer 11

A. 1 to 3 cm below the inguinal ligament, in line with the palpable course of the CFA

B. Inferior edge of the femoral head by fluoroscopy

Question 12

.Accidental cannulation of the _____ artery may result in limb ischemia or inability to accommodate vascular closure devices.

Answer 12

Superficial or profunda femoral artery

Question 13

This occurs with puncture that are above the inferior epigastric artery

Answer 13

Retroperitoneal hematoma

Question 14

Punctures below the profunda and superficial femoral artery bifurcation will result to these vascular complications

Answer 14

Pseudoaneursym
Arteriovenous fistula formation

Question 15

Accidental cannulation of the superficial or profunda femoral artery may result in __________________ or ________________________

Answer 15

A. Limb ischemia
B. Inability to accommodate vascular closure devices

Question 16

Femoral sheaths should not be removed until the activated clotting time (ACT) is _______________ unless a vascular closure device is being used.

Answer 16

Less than 160 to 180 seconds

Question 17

Prosthetic peripheral vascular grafts are the most problematic vascular challenges because of the __________________ and potential for _________________________

Answer 17

A. Lack of adequate closure
B. Thrombotic occlusion

Question 18

Femoral vein access

Using the femoral arterial pulse as a landmark, the femoral vein sits approximately _____________ to the femoral artery.

If a combined arterial and venous access is needed, the venous puncture site is ___________ and ______________ to the planned arterial entry site.

Answer 18

A. 1 cm medial to CFA
B. 0.5 to 1 cm medial
C. 0.5 to 1 cm caudal

Question 19

After the procedure is completed, venous hemostasis can be achieved with light finger pressure applied over the vein as described for femoral artery sheath removal. Usually only _____ minutes of compression is needed to obtain adequate hemostasis. (Femoral vein access)

Answer 19

5-10 mins

Question 20

Brachial vein access

The _____________________ is preferred to avoid the acute angulation of the cephalic vein system as it joins with the axillary vein

Answer 20

Medial antecubital vein

Question 21

The internal jugular (IJ) vein, especially the right IJ, is the preferred venous access because of the ffg advantages:

Answer 21

Greater patient comfort and lower infectious risk vs femoral
Reduced risk of pneumothorax vs subclavian

Question 22

The internal jugular vein is located _____. For access, the patient is instructed to lie supine with the head turned 30 degrees to the contralateral side. Patients with low venous pressure may require leg elevation to increase venous filling volume. Routine use of ultrasound imaging facilitates localization of the IJ and can verify its patency. The use of ultrasound is recommended by national guidelines and reduces the overall risk of complications (carotid artery puncture,in particular) by 70%

Answer 22

Lateral to the carotid artery in the anatomic triangle of the two heads of the sternocleidomastoid muscle and the clavicle

Question 23

Left heart catheterization
_________________ to the left ventricle is commonly performed using a straight or angled pigtail-shaped catheter

What catheters/guidewire to use/preferred:
Dilated aortic roots or horizontally oriented hearts
Small aortic roots
Bicuspid aortic valve
Screlotic/stenotic AV

What pressure measurements needed for
Aortic stenosis
Mitral stenosis

Answer 23

A. Retrograde access

B. Guiewire/catheters:
Dilated aortic roots or horizontally oriented hearts - angled pigtail catheter
Small aortic roots - R Judkins then exchange with pigtail catheter
Bicuspid aortic valve - L Amplatz (useful also in AS)
Screlotic/stenotic AV - straight guidewire vs J-tipped (increased risk for dislodging material from AV/aorta)

AS - simultaneous LV and aortic pressures (dual or MP + high fidelity pressure sensor guidewire)
MS - simultaneous LV and PCWP/LA pressures with 2 transudcers

Question 24

A __________________ is the cyclic force generated by cardiac muscle contraction

This is influenced by factors:
Force of the contracting chamber
Chamber ___________ (extrinsic and intrinsic)
Physiologic variables of _________ rate, ____________ cycle, and vascular resistance

Answer 24

A. Pressure wave
B. Compliance
C. Heart rate
D. Respiratory cycle

Question 25

The most common technical artifacts of fluid filled systems: 1. ______________, also known as excessive resonant artifact or ringing 2. ______________, e.g., blunted waveforms 3. Improper calibrations or setting (i.e.,____________) the transducer to atmospheric pressure An __________________ (a brief, very high-frequency signal) can be noted when the catheter is struck by the walls or valves of the cardiac chambers.

Answer 25

1. Underdamping 2. Over-dampening 3. Zeroing 4. Impact artifact Another explanation for a damped signal may be catheter tip obstruction by small vessel orifices or by engagement against vessel walls or thrombus within a catheter Key Points for Accurate Hemodynamics: 1. Poorly collected or inaccurately obtained hemodynamic data can confuse or obscure the diagnosis and lead to improper therapy. 2. Properly collected data requires simultaneous electrocardiogram (ECG) tracings, accurate leveling or zeroing, an appropriate pressure scale (e.g., 0 to 200 mm Hg), and appropriate time scale. 3. The most common pressure wave artifact of a fluid-filled system is **damping from blood or contrast in the catheter**, which is easily resolved with a saline flush. 4. Exaggerated resonance or ringing of an underdamped pressure system can also occur and is resolved by using short stiff pressure tubing, properly debubbled lines, and calibrated recordings. 5. Correct interpretation of hemodynamic waveforms requires review of individual pressure waves and their timing to the ECG. 6. Distorted pressure waveforms on the hemodynamic tracing may be caused by an arrhythmia or conduction defect.

Question 26

_________________ utilizes the indicator-dilution method for flow assessment with the indicator being temperature change after injection of a saline bolus cooler than blood temperature Less accurate in situations such as: Enumerate 4

Answer 26

A. Thermodilution B. Less accurate: significant tricuspid or pulmonic regurgitation, intracardiac shunts, low cardiac output, or irregular rhythms Cardiac output c relates inversely with the area under the curve

Question 27

Key points for accurate hemodynamics

Answer 27

1. Poorly collected or inaccurately obtained hemodynamic data can confuse or obscure the diagnosis and lead to improper therapy. 2. Properly collected data requires simultaneous electrocardiogram (ECG) tracings, accurate leveling or zeroing, an appropriate pressure scale (e.g., 0 to 200 mm Hg), and appropriate time scale. 3. The most common pressure wave artifact of a fluid-filled system is damping from blood or contrast in the catheter, which is easily resolved with a saline flush. 4. Exaggerated resonance or ringing of an underdamped pressure system can also occur and is resolved by using short stiff pressure tubing, properly debubbled lines, and calibrated recordings. 5. Correct interpretation of hemodynamic waveforms requires review of individual pressure waves and their timing to the ECG. 6. Distorted pressure waveforms on the hemodynamic tracing may be caused by an arrhythmia or conduction defect.

Question 28

The _______________ relies on this principle that blood flow (cardiac output) is inversely proportional to the extent of oxygen extraction (AV O2 difference) Formula ________ Situations in which this should not be used: Give 3

Answer 28

A. Fick method B. Formula: Cardiac output = O2 consumption (ml/min) / Arterial O2 sat - Mixed Venous O2 sat (PA) x 1.36 x Hgb x 10 C. Siginificant MR or AR, rapid changes in flow No O2 su-port during determination

Question 29

Common Hemodynamic Calculations: BP = ________ x SVR CO = HR x _______ CI = CO (ml/beat) / _______ SV = _________ (ml/min) / HR (bpm) SVI = SV (ml/beat) / ________ SVR = _______ - ________ / CO (WU) x 80 (dynes) PVR = _______ - ________ / CO (WU) x 8p (dynes) TPR = _______ / CO

Answer 29

BP = CO x SVR CO = HR x SV CI = CO (ml/beat) / BSA SV = CO (ml/min) / HR (bpm) SVI = SV (ml/beat) / BSA SVR = MAP - Mean RA / CO (WU) x 80 (dynes) PVR = mean PA - mean PCWP/LA / CO (WU) x 8p (dynes) TPR = mean PA / CO

Question 30

List the Phases of Cardiac Cycle

Answer 30

Isovolumic contraction Ejection Isovolumic relaxation Rapid inflow Diastasis Atrial systole

Question 31

Give the pressure ranges of the different cardiac chambers (Mean) RA RV EDP PA PCWP LA LV EDP Central Aorta MAP SVR

Answer 31

RA - 1-5 mm Hg RV EDP - 1-7 (systolic peak 15-30) PA EDP - 4 -12 (systolic peak 15-30) PCWP - 4-12 LA - 4-12 LV EDP - 5-12 (systolic peak 90-140) Central Aorta MAP - 70-105 (systolic peak 90-140) SVR - 700-1600 dynes

Question 32

Characterize the ffg Atrial Pressures a wave - ___________, _________ on ECG c wave - ______________________ (isovolumic contraction; early systole) x descent - ___________________ v wave - ______________________ y descent - ___________________ True or false: _______The a wave is usually smaller than the v wave in the right atrium _______A highly compliant atrium can accommodate large amount of volume and may produce large v waves _______Stiff and noncompliant chambers may produce exaggerated v wave with normal filling pressures

Answer 32

**a wave** - reflects atrial c tion, and atrial contractility, follows P wave **c wave** - atrioventricular (tricuspid or mitral) valve bulging into the atria during isovolumic ventricular contraction (early systole) **x descent** - atrial relaxation and downward pulling of the tricuspid annulus as the right ventricle contracts **v wave** - atrial filling, end of isovolumetric relaxation **y descent** - drop in atrial pressure after AV opens True - right atrium can easily decompress through the SVC and inferior vena cava (IVC), whereas the left atrium is constrained posteriorly by the pulmonary veins False - small v waves True - noncompliant atrium may produce large v waves

Question 33

PCWP reflects the LA pressure through the __________________ To confirm PCWP is accurate and not dampened, check the ffg: Identifying clear ___ and ____ waveforms timed against the ECG or LV pressure Should note the time delay (i.e., phase shift) of the PCW v wave to match the __________________ Oxygen saturation ______ %

Answer 33

A. Pulmonary veins and capillaries B. Accurate and not dampened PCWP tracing: Clear a and v wave LV downstroke, on or after O2 sat >95%

Question 34

Effects of over and under wedging of PCWP waveform: Over wedging >> excessive damping: falsely ________; ________ waveform Under wedging: falsely _______; appears to be a dampened __________ waveform

Answer 34

A. Low; FLAT waveform B. High; Dampened PA waveform PCWP may not reflect left atrial pressure as accurately as needed for mitral valve assessment.

Question 35

Concept of Forward and Backward-traveling (reflected wave) In the young and healthy subject on the left, the backward-traveling wave arrives at _________________ , contributing to closing the aortic valve and to increasing ________________ pressure In the hypertensive subject on the right, the backward-traveling wave reaches the proximal aorta in ______________ and contributes to the _________________ in pressure.

Answer 35

A. Late systole >> diastolic perfusion pressure B. Early systole >> late systolic peak

Question 36

LV vs RV pressure waveforms Magnitude of waveform Duration of LV systole Duration of isovolumic contraction Duration of relaxation Ejection period LVEDP is taken _______________, _____ on ECG PCWP correlates better with a _______________, which reflects the mean LV filling pressure.

Answer 36

Higher magnitude - LV Longer LV systole, isovoumic cont and relaxation - LV Shorter ejection period - LV LVEDP taken after a wave, R wave on ECG Pre-a LVEDP

Question 37

In aortic stenosis A ______________________ from the left ventricle into the aorta should only be used as a screening technique True or false The optimal way to measure the gradient in a patient with aortic stenosis is to use simultaneous LV and central aortic pressure

Answer 37

Single pressure pullback technique True

Question 38

In measuring transaortic gradient in AS Use of a _________________ or _________________ eliminates any difference in pressure transmission time or effect of peripheral amplification.

Answer 38

Dual-lumen catheter or micromanometers

Question 39

The ______________________ is the difference between the peak left ventricular and peak aortic pressures, which is a nonphysiological measurement because the peak pressures occur at different points in time.

Answer 39

Peak-to-peak gradient

Question 40

The _______________________ (the integrated gradient between the left ventricular and aortic pressure throughout the entire systolic ejection period) should be used to determine the severity of the aortic stenosis

Answer 40

Mean pressure gradient The mean integrated gradient between the left ventricle and aortic pressure waves over the systolic ejection period is the best measure of the stenosis severity

Question 41

In aortic stenosis The ejection of blood from the LV is forced through the fixed reduced aortic orifice area (i.e., the anatomic orifice area [AOA]). Energy is lost due to valvular resistance, resulting in a pressure drop and acceleration of flow. After crossing the AV, (i.e., the effective orifice area [EOA]), part of the kinetic energy is reconverted back to potential energy, and the pressure increases, also called the ________________________________

Answer 41

Pressure Recovery When the blood flow contracts to pass through a stenotic orifice (i.e., the anatomic orifice area [AOA]), a portion of the potential energy of the blood, namely, pressure, is converted into kinetic energy, namely, velocity, thus resulting in a pressure drop and acceleration of flow. Downstream of the vena contracta (i.e., the effective orifice area [EOA]), a large part of the kinetic energy is irreversibly dissipated as heat because of flow turbulences. The remaining portion of the kinetic energy that is reconverted back to potential energy is called the **pressure recovery (PR)**. The global hemodynamic load imposed on the left ventricle results from the summation of the valvular load and the arterial load. This global load can be estimated by calculating the valvuloarterial impedance.

Question 42

Low-flow, low-gradient (LF/LG) severe aortic stenosis (AS) - valve area ________ but mean gradient ___________ In patients with LFLG AS with reduced EF, _________________ challenge will permit assessment of CO, valve gradient and area True AS _______________

Answer 42

< 1.0 cm2 < 40 mm Hg Dobutamine challenge True AS - the valve gradient should increase with a higher cardiac output while the AV area will remain small. Dobutamine also provides prognostic information, as patients without an adequate contractile reserve (e.g., stroke volume increase <20%) have poor outcomes irrespective of valve intervention.

Question 43

In patients with low-gradient severe AS with a preserved ejection fraction (paradoxical LF/LG AS), cardiac output is limited by: 1. 2. 3.

Answer 43

1. Relaxation abnormalities 2. Low stroke volume 3. Impaired ventriculovascular coupling

Question 44

The dynamic obstruction in HOCM is affected by: 1. 2.

Answer 44

Ventricular loading conditions Changes in contractility **The obstruction is dynamic, and worsens with reduced LV volume or increased LV contractility.**

Question 45

A low LVOT gradient at rest should be challenged with dynamic and provocative maneuvers (e.g., variation with respiration, post-PVC accentuation, isometric exercise) to identify the true obstructive nature of the disease and suitability for septal myectomy or percutaneous alcohol septal ablation Significant gradient at rest ________ and after provocative measures __________

Answer 45

30 mm Hg 50 mm Hg

Question 46

The location of the intraventricular gradient is defined by the _____________________ while still registering LV pressure

Answer 46

resolution point of the aortic-LV gradient

Question 47

Hemodynamic findings in HOCM: 1. Rapid rise of the aortic pressure corresponding to the LV pressure at the onset of AV opening followed by blunted and rounded wave in late systole - ___________________ 2. LV pressure proximal to the obstruction peaks late and has a late-peaking “_______________” shape 3. Increase in post-PVC _________ gradient 4. Diminished _________________ post PVC (_____________________ sign)

Answer 47

1. Spike-and-dome contour 2. Dagger shape 3. LVOT gradient 4. Aortic pulse pressure (Braunwald-Brockenbrough-Morrow sign) Hanna: 1. Systolic aortic pressure has an early “spike” and a late “dome” (“spike and dome” appearance). In fact, LVOT obstruction is dynamic and is less severe in early systole when LV volume is largest, explaining the “peak” in aortic pressure. Obstruction is worst in mid and late systole when LV volume is reduced, explaining the low dome after the early spike (Figures XI.3-4). 2. Because the LV obstruction is worse in late systole, LV pressure proximal to the obstruction peaks late and has a late-peaking “dagger” shape similar to the spectral Doppler dagger shape velocity across the LVOT. 3. After a premature beat, LV volume increases leading to increased LV contractility and therefore increased LVOT obstruction. While LV pressure increases, the stroke volume decreases and thus the aortic pulse pressure decreases (Brockenbrough phenomenon); the aortic systolic pressure decreases as well. This is opposed to AS, wherein the LV pressure and the aortic pulse pressure both increase after a premature beat. In both HOCM and AS, the gradient and the murmur increase after a premature beat

Question 48

Maneuvers that INCREASE LVOT gradient: 1. 2. 3. Manuevers that INCREASE murmur of HOCM: 1. 2. Manuevers that DECREASE murmur of HOCM: 1. 2.

Answer 48

Maneuvers that INCREASE LVOT gradient: 1. Valsava maneuver (dec preload) 2. Inhalation of amyl nitrite (dec afterload) 3. Dobutamine infusion (increase contractility) 4. Isoproterenol infusion (increase contractility) Manuevers that INCREASE murmur of HOCM (decrease preload): 1. Valsalva 2. Standing Manuevers that DECREASE murmur of HOCM (increase preload): 1. Squatting 2. Leg raise *The gradient increases with **decreased preload** (Valsalva maneuver, hypovolemia, nitroglycerin), **decreased afterload** (vasodilators), or **increased inotropism** (exercise, inotropic drugs such as dobutamine)

Question 49

Post PVC hemodynamic effects in AS 1. HOCM 1.

Answer 49

Aortic stenosis: Increased gradient Delayed aortic pressure upstroke (parvus and tardus upstroke) Normal or widened pulse pressure HOCM: Increased gradient Rapid aortic pressure upstroke Reduced pulse pressure

Question 50

In mitral stenosis PCWP often __________________ LA pressure in patients with mitral stenosis or prosthetic mitral valves due to delayed and poor-quality pressure transmission Most accurate method of determining transmitral gradient in patients suspected of MS?

Answer 50

A. Overestimates B. For patients with elevated PCWP and suspected mitral valve abnormalities, **direct measurement of the LA pressure** by transseptal puncture is the most accurate method

Question 51

Hemodynamic findings of mitral stenosis: 1. 2. 3.

Answer 51

1. Large LA a wave 2. Gradual y descent 3. Low LV end diastolic pressure The classic hemodynamic sign of mitral stenosis on left atrial pressure tracing is a markedly elevated a wave. Further, due to the stenosis of the mitral valve, the pressure only gradually decreases after opening and the y descent is gradual. The LV pressure waveform may show a lower end-diastolic pressure due to the impaired filling and a reduced atrial kick (i.e., a wave amplitude).

Question 52

Hemodynamic findings of tricuspid stenosis: 1. 2. 3.

Answer 52

1. Elevated RA a wave 2. Gradual y descent 3. Reduced RV end diastolic pressure With tricuspid stenosis, the obstruction of blood flow from the right atrium into the right ventricle, the volume of blood in the right atrium and the mean right atrial pressure are increased in diastole, generating a diastolic pressure gradient between these two chambers. This translates into a markedly elevated a wave. Opening of the stenotic tricuspid valve leads to a slow decrease in right atrial pressure and gradual y descent. Right ventricular pressure tracings show a reduced end-diastolic a wave amplitude secondary to the reduced atrial filling.

Question 53

Hemodynamic findings in aortic regurgitation: 1. 2. 3.

Answer 53

Widened airtic pulse pressure Rapid upstroke of LV diastolic filling pressure Near equilibration of end-diastolic aortic and LV pressure

Question 54

Hemodynamic findings in mitral regurgitation: 1. 2.

Answer 54

1. Prominent v wave 2. Postcapillary pulmonary hypertension Acute MR - large v wave (may be present due to low compliance of the LA rather than MR) A new large v wave after mitral balloon valvuloplasty, however, is usually a valid demonstration of acute MR.

Question 55

Hemodynamic fincings of pulmonary regurgitation: 1. 2. 3.

Answer 55

Low pulmonary artery end-diastolic pressure Wide pulmonary pulse pressure Increased RV end-diastolic pressure With severe degrees of regurgitation, PAP tracings may take on the appearance of an RV pressure tracing (“ventricularization”).

Question 56

Hemodynamic findings of tricuspid regurgitation 1.

Answer 56

Elevated v wave The characteristic hemodynamic finding is an elevated v wave generated by the open communication between the two chambers and the volume ejection from the right ventricle into the right atrium with the onset of systole v wave amplitude and mean right atrial pressure may be very minimally elevated in relation to the chronicity of TR Right atrial distension due to chronic volume expansion with evolving reduction in contractility also leads to a reduction in the a wave.

Question 57

In intracardiac shunts As a general rule, pulmonary artery oxygen saturations exceeding __________ hould raise the suspicion for a left-toright shunt. On the contrary, systemic, arterial oxygen saturations _____ that persist after several deep breaths to counteract alveolar hypoventilation should raise suspicion for a right-to-left shunt

Answer 57

PA O2 > 80% SA O2 sat < 93%

Question 58

Identify significant step up: Between SVC and PA - ______ Inter-atrial and interventricular - _____

Answer 58

1. >/= 8% 2. >/= 5%

Question 59

True or False Oxygen saturation in the IVC is higher than in the SVC as oxygen extraction of the internal organs and lower extremity muscles is lower in a fasting and resting state than that of the brain

Answer 59

True

Question 60

Give formula for PBF and SBF in computation of shunt

Answer 60

PBF = O2 consumption (ml/min) / PVO2 - PAO2 x Hgb x 1.36 x 10 SBF = O2 consumption (ml/min) / SAO2 - MVO2 x Hgb x 1.36 x 10

Question 61

Normal subsidiary functions of the pericardium: ____________________ of intrathoracic cardiac motion ___________________________ through diastolic and systolic interactions Limiting acute cardiac ___________ Minimizing ____________ between cardiac chambers and surrounding thoracic structures Providing an anatomic __________ to infection from the lung and other contiguous structures

Answer 61

Stabilization Balancing RV and LV cardiac output Dilation Friction Barrier

Question 62

Normal physiology: On INSPIRATION: ______________ intrathoracic and intracardiac pressure (RV and LV) ______________ venous return through the SVC and IVC (extrathoracic) Increase flow to the ________ and RV ______________ pulmonary venous pressure (PV are intrathoracic and extracardiac) ______________ LA-LV gradient ______________ LV filling/flow

Answer 62

1. Decrease intrathoracic and intracardiac pressure (RV and LV) 2. Increase venous return through the SVC and IVC 3. Increase flow to the RA and RV 4. Decrease pulmonary venous pressure (PV are intrathoracic and extracardiac) 5. Unchanged/minimal change in LA-LV gradient (since there is a decrease pressure in PV and LA/LV) 6. Minimal or no change LV filling/flow Reverse in expiration

Question 63

Constrictive physiology: On INSPIRATION: ______________ intrathoracic pressure ______________ intracardiac pressure (RV and LV) ______________ SVC pressure, __________ IVC pressure ______________ SVC flow, __________ IVC flow Increase flow to the ________ and __________ for a short period due to the flow from IVC in early diastole ______________ pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac) ______________ LA-LV gradient ______________ LV filling/preload and stroke volume

Answer 63

1. Decrease intrathoracic pressure 2. **No change** in intracardiac pressure (RV and LV) 3. Decrease in SVC pressure, **no change** IVC pressure (extrathoracic) 4. Decrease SVC flow, increase IVC flow (partly because of the positive intra-abdominal pressure) 5. Increase flow to the RA and RV for a short period due to the flow from IVC in early diastole 6. Decrease pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac) 7. Decrease LA-LV gradient (PV/PCWP decreased pressure, but LA/LV unchanged) 8. Decrease LV filling/preload and stroke volume **VENTRICULAR SYSTOLIC DISCORDANCE** Increase in ventricular interdependence, the reduced LV volume “sucks” the RV during inspiration; thus, the RV sucks flow from the RA, and the flow between the RA and RV increases.

Question 64

Restrictive CMP vs Constrictive Pericarditis Restrictive CMP Decreased ventricular chamber ________________ due to increased myocardial ____________. The steep compliance curve results in an abnormal increase in impedance throughout the ________________ and a reduced atrial filling component at end-diastole Constrictive Pericarditis The ventricular chamber compliance is __________ in ______ diastole, allowing for normal or rapid early filling. In _____________, ventricular filling is abruptly decelerated as the intracardiac volume approaches the fixed limit of the constricting pericardium.

Answer 64

1. Compliance 2. Stiffness 3. Entire diastolic period 4. Normal, early diastole 5. Mid-diastole

Question 65

Common hemodynamics in RCMP and CP: 1. 2.

Answer 65

1. Elevation and equalization of right and LV diastolic pressures 2. Abrupt cessation of early ventricular filling, classically described as a **“dip and plateau”** waveform of the ventricular pressures

Question 66

Give the 5 traditional hemodynamic criteria of CP

Answer 66

1. End-diastolic pressure equalization (LV end-diastolic pressure minus RV end-diastolic pressure <5 mm Hg) 2. PAP <55 mm Hg 3. RV end-diastolic pressure divided by RV systolic pressure >1/3 4. Dip and plateau diastolic pressure morphology as reflected by the height of the LV rapid filling wave (>7 mm Hg) 5. Kussmaul’s sign Neither sensitive or specific for CP

Question 67

____________________________ (correspondence of LV-RV systolic pressures) exhibited during respiration is the most sensitive and specific hemodynamic finding differentiating constrictive pericarditis from restrictive physiology.

Answer 67

Dynamic ventricular interdependence (100% sensitive, 95% specific) During peak inspiration, there was discordance between RV and LV function with an increase in RV systolic pressure and simultaneous decrease in LV systolic pressure.

Question 68

This is the lack of an inspiratory fall in mean right atrial pressure

Answer 68

Kussmauls’ sign

Question 69

The classic signs in cardiac tamponade (Beck’s triad)

Answer 69

Hypotension, jugular venous distension, and muffled heart sounds

Question 70

This is an exaggerated decline (>10 mm Hg) in systemic arterial pressure during inspiration

Answer 70

Pulsus Paradoxus

Question 71

Hemodynamic consequences of Cardiac Tamponade:

Answer 71

Elevation and equalization of atrial and ventricular diastolic pressures Decreased transmural filling pressures Loss of y descent (*x and y descents corresponds to periods when venous flow is increasing) - heart is compressed throughout all diastole in tamponade, including early diastole. RA-RV flow is impeded throughout diastole Loss of RV diasolic dip Deep x in early systole as RV annulus moves down and stretches out the compressed RA **respiratory changes of intrathoracic pressure are transmitted to the cardiac chambers in tamponade as oppose to CP**

Question 72

________________ exercise is the most physiologic way of challenging the heart to unmask cardiac pathology

Answer 72

Dynamic

Question 73

Differences Supine vs Upright Exercise Supine exercise: Larger _______________ volumes Lower _____ and __________ pressure Higher pulmonary and _________ pressures Increase in SV by ________ % Increase in LV EDV, decrease in ________, hence higher _______

Answer 73

Larger ventricular volumes Lower HR and diastolic pressure Higher pulmonary and intracardiac pressures Increase in SV by 20-50 % Increase in LV EDV, decrease in LV ESV, hence higher EF

Question 74

Under normal conditions,the increased oxygen demand induced by exercise is met by an increase in _______________ and _______________________

Answer 74

A. Cardiac output B. Peripheral oxygen extraction

Question 75

This is the ratio of the observed/measured to the predicted CI Normal values ____

Answer 75

Exercise index/Dexter index Value of ≥0.8 reflects a normal cardiac output response to exercise

Question 76

This is computed - increase in cardiac output divided by the increase in oxygen consumption Normal values _____

Answer 76

Exercise factor of ≥6 is normal; that is, for every 100 mL/min increase in oxygen consumption, cardiac output should increase by at least 600 mL/min with exercise.

Question 77

Examples of diseases where exercise testing is beneficial

Answer 77

1. HFpEF 2. VHD - MS, valvular regurgitation

Question 78

__________________ consists of skeletal muscle contraction without shortening

Answer 78

Isometric exercise

Question 79

In patients with CAD, isometric exercise rarely precipitates ischemia but may induce ______________________, a decrease in ________________, and an increase in ________ with no change in diastolic volume. SV and CO may decline during isometric exercise. In patients with CHF, HR and systemic pressure may rise appropriately with a _______________, resulting in an increase in LVEDV and PA pressure.

Answer 79

1. New LV wall motion abnormalities 2. LV ejection fraction 3. LV ESV 4. Fall in SV and CO

Question 80

Effect of Valsalva maneuver in HCM: 1. Effects of PVC in HCM: 1. 2. 3. Effect of rapid volume loading in CP: 1. 2.

Answer 80

Effect of Valsalva maneuver in HCM: 1. Decreases venous return and thus LV preload, which increases the systolic LV outflow tract pressure gradient Effects of PVC in HCM: 1. Decrease in pulse pressure/aortic pressure 2. Accentuates spike and dome 3. Increase LVOT gradient Effect of rapid volume loading in CP: 1. Exaggerated ventricular interdependence 2. Volume loading can cause equalized diastolic pressures between the two ventricles to differ in the setting of constriction.

Question 81

Pharmacologic challenges Effect of Dobutamine on LFLG AS Effect of Isoproterenol, Nitroglycerin and Amyl nitrite on HCM gradient Effect of Phenylephrim]ne on HCM gradient

Answer 81

1. Severe AS - increase in CO, mean gradient > 30 mm Hg, AVA remains <1.2cm2 2. Isoproterenol increase HCM gradient (inc chrono and inotropy), NTG increase (reduce preload). Amyl nitrite increase (reduce afterload) 3. Phenylephrine reduces HCM gradient - increase in afterload/SVR

Question 82

Criteria for PAH Mean PAP PCWP PVR

Answer 82

Mean PAP >25 mm Hg PCWP <15 PVR > 3 WU Vasodilator testing with e prostenol, adenosine, nitroprusside, or nitric oxide is used to identify potential responders to therapy with calcium channel blockers and to establish prognosis. Vasodilator testing - orthotopic heart transplantation (OHTx). Relative contraindications to OHTx include a PVR ≥5, a pulmonary vascular resistance index (PVRI) ≥6, and a transpulmonary gradient (TPG) ≥16

Question 83

Criteria for a positive vasodilator testing Decrease in mean PAP >/= _______ to an Absolute mean PAP of

Answer 83

1. 10 mm Hg 2. 40 mm Hg 3. A decrease in CO Use of NO in patients with elevated PCWP at baseline Inhaled nitric oxide can reduce PVR leading to pulmonary edema. The mechanism is increased forward flow through the pulmonary vasculature with increased filling of left-sided heart chambers that have already reached their maximum compliance, precipitating further increase in PCWP and pulmonary congestion.

Question 84

Positive response to nitroprusside in patients with PH and elevated PCWP Drop in PVR of at least _____ %

Answer 84

20% In patients with an elevated PCWP, sodium nitroprusside is preferred to document if reduction in afterload and LV filling pressure also lowers PAP and improves cardiac output. This holds true in cases of MR, dilated cardiomyopathy, and HFpEF. A typical protocol is to commence the infusion at 0.25 to 0.5 μg/kg/min following acquisition of baseline hemodynamic data and to up-titrate at the same dose range in 2- to 5-minute intervals until PCWP is <18 mm Hg, systemic blood pressure <90 mm Hg, or development of symptoms (e.g., lightheadedness).24 , 25 On reaching those hemodynamic endpoints, a positive response is usually defined as a drop in PVR of at least 20%.