Basic Hemodynamics

AZWAR
Eivon ARLIS
AKA Nor Shifak
iXRClinical
ClinicalApplication-IXR
Application Specialist
ASEAN Region, APAC
2012 asdasd,
The Heart

• Anatomy
• Circulatory
• Electrical

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The Heart… The Video

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The Heart

• Anatomy
• The heart is a muscular organ

• The heart of a human is about the

size of their closed fist.

• Located behind the lower part of the

breastbone, extending more to the left
of the midline.

• The heart is a four chambered

structure with two parallel
independent systems each consisting
of an atrium and ventricle

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Circulatory System
Head and arms
-Heart can be divided into Left and Right heart
venous
Left heart
arterial
Right low pressure high pressure

-Left = Oxygen rich blood (red) Vena cava superior

-Right = Deoxygenated blood

(blue) Aorta
Pulmonary
artery
-Each side has an atrium which
Pulmonary
receives blood and a ventricle LA vein

which pumps blood.

RA LV
-The walls of the ventricles are RV
more muscular, but in particular the
LV as this is the chamber of the
heart that has to pump blood to the Vena cava inferior Internal
rest of the body. organs

Legs

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Heart Chambers
The heart consists of four chambers:

- the upper two are the right – the lower two, the right
and left atria and left ventricles

LA
RA

LV
RV

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Heart Valves
The heart has four valves:
- .The mitral valve is between the
left atrium and left ventricle.
- The tricuspid valve is located
between the right atrium and right
ventricle.
– The pulmonary valve is
between the right ventricle
and the pulmonary artery.
– The aortic valve is
between the left ventricle
and the aorta.

AO
PA

LA
RA
Pulmonary
Mitral Valve Aortic
Valve Valve
LV LV
RV RV

Tricuspid
Valve

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Heart, Cardiac Cycle
Blood is pumped through the chambers, aided by four heart valves

Diastole

Atrial contraction

Ventricular contraction

Systole

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Circulatory and Important Anatomy

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What you see in the Xray/Fluouro…..

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Coronary Arteries

-Right and Left Coronary

-artery

-Supply the muscle of the

Heart

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The Heart

• Anatomy
• Circulatory
• Electrical

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The electrical conduction system of the heart

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The electrical conduction

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The electrical conduction system of the heart

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The Heart

Coronary Artery Disease (CAD)

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Coronary Artery Disease: Video

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 Coronary Artery Disease:
Risk factors for CAD
-Increasing age
-Male Sex (gender)
-Heredity (Race)
-Lifestyle
-Smoking
- High Cholesterol
- High BP
- Physical Inactivity
- Obesity/overweight
- Diabetes
- Stress
- Excess alcohol intake
Build up of a fatty substance
(plaque) within arteries.
Eventually can cause a heart attack!!
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What is a heart attack?

Lack of oxygenated blood to the

heart muscle due to narrowing
or closure of the coronary
arteries.

Symptoms:
Chest tightness
Shortness of breath
Pain radiating down the arm
Nausea and vomiting

What happens next?

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Patient is admitted to hospital:

The Cardiac Cath Lab.

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Hemodynamics, how it works
Introduction (cont’d)

What is hemodynamic monitoring?

– Hemodynamic monitoring directly measures
blood pressure from inside the veins, heart, and
arteries
– It also measures blood flow and how much
oxygen is in the blood
– It is a way to see how well your heart is working

Purposes of hemodynamic monitoring

– Monitoring of hemodynamic signals and How can you evaluate
diagnostics (measurements and calculations) to
Cardiovascular Functions?
determine pathology
• Early detection, identification and treatment of - Anatomy (Normal/Abnormal)
life-threatening conditions such as heart failure,
- Valve Functions
abnormal Anatomy and cardiac tampanade
- Shunts
• Evaluate the patients immediate response to
- Heart Functions
treatment such as drugs and mechanical support
(Systemic and Pulmonary blood flow;
• Evaluate the effectiveness of cardiovascular
Systemic and Pulmonary Resistance)
function such as Cardiac Output and Index

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Hemodynamics, how it works
Introduction (cont’d)

Vital Signs Monitoring (During all procedures)

• ECG, NIBP, Oxygen Saturation (SpO2) – Most important VS
• Respiration, End-tidal CO2 (EtCO2), Body surface
temperature (mostly for peadiatrics cases)

Hemodynamic Analysis
– Invasive pressures, Cardiac Output
– Valve gradients, Saturations & Calculations

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Hemodynamics
Invasive Monitoring: Left Heart Study

Scientific explanation:
Aortic stenosis is characterized by the left
ventricular pressure being much greater than aortic
pressure during left ventricular ejection (see the
shaded gray in figure above). Normally, the
pressure gradient across the aortic valve is very
small (a few mmHg); however, the pressure
gradient can become quite high during severe
stenosis (>100 mmHg). The aortic valve gradient
results from both increased resistance (related to Pullback pressures (LVp and AOp)
narrowing of the valve opening) and turbulence
distal to the valve.

Layman’s interpretation:
In patients with aortic stenosis, the left ventricle
has to “work overtime” to compensate for the
constricted blood flow through the valve. The aortic
valve gradient increases as a result. Over time, this
can severely damage the patient’s left ventricle as it
thickens and dilates

Aortic Valve Gradient (AVG)

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Hemodynamics
Invasive Monitoring: Right Heart Study

RA RV PA PCW

Pullback Method
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Hemodynamics, how it works
The Swan-Ganz Pulmonary Artery Catheter (PAC) used for Right Heart

Measuring PW, PA, RV and RA pressures using the pullback method

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Hemodynamics
Cardiac Output – Cardiac Index

• Is the amount of blood

pumped by the heart in one
minute

• Calculated by multiplying heart

rate times stroke volume

• Cardiac Index is the Cardiac

Output adjusted for Body
Surface Area (BSA)

Using the Thermo dilution method for measuring CO

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Hemodynamics
Cardiac Output – Using the Thermodilution method

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Hemodynamics

• ECG
• Pressure traces
• Calculations

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ECG Monitoring

• Basically to Monitor the patients Pre Procedure, During Procedure and

Post Procedure.
• To ensure there is no changes Pre and Post procedures.
• Especially Interventional procedures.

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ECG Lead Placement
5 Lead

3 Lead

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NIBP, Temp, ETCO2, SpO2, Resp.
• NIBP: Non-invasive Blood Pressure

• Temp: Body Temp

• SpO2:

• ETCO2:

• Resp: ECG

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ECG Learning and Quiz

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Hemodynamics

• ECG
• Pressure traces
• Calculations

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In the lab:
P1
P2
Pressure Adapter
To fit standard transducer P3
cable provided by the
transducer company
P4

Pressure Ports
Usually only use 1 (most cases)
or 2 (during Lt & Rt Heart Study or
special Procedure)
- Each port correlate directly with the
pressure no on the monitoring monitor.
.
CUSTOMER IS RESPONSIBLE TO PROVIDE TRANSDUCER
CABLES WITH AMP 11/8 PLUG – MALE (206434-1)
CONNECTOR
Transducer cables to the front end can be ordered from the
tranducer company.
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Hemodynamics
Systole and Diastole

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Pressure, Sp02 and 02 - Volume

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Aorta Pressure - Ao

A
O

AP View

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Left Ventricle Pressure- LV

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Pressure traces – Pullback LV > AO

A
O A
O

Aortic
Valve
LV

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Pressure traces – Aortic Stenosis

A
O

Aortic
Valve
LV

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Pressure traces – Pulmonary Wedge

P
W

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Pressure traces – Mitral Stenosis

L
A Mitral
Valve

L
V

2 Catheters ( Lt Heart – LV; Rt Heart; PW)

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Hemodynamics

• ECG
• Pressure traces
• Calculations

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Cardiac Output (CO) – Measuring Methods

• CO Thermodilution
is measured with a Thermodilution device

• CO Fick
is calculated by the hemodynamic software using the
formula according to Fick

• CO Angio
is calculated by software using an image from the X-ray
system

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Cardiac Output (CO) Thermodilution
CO Thermo is measured with a thermodilution device

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Cardiac Output (CO) FICK

CO Fick is calculated by the hemodynamic software using the formula according to Fick

Needed values:
• Hemoglobin (Hb)
• Venous oxygen saturation (VO2)
• Oxygen saturation taken from aorta
• Oxygen saturation from pulmonary artery
• Body surface area (BSA)
• Weight
• Height
• Age
• Sex

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Hemodynamic Calculations
Aortic valve aperture area AVA
Cardiac Output acc. to Fick method

CO Fick = VO2x10/ {(AO O2 - PA O2) x Hb x 1,34} [l/min]

Stroke volume: SV=CO x 1000 / HR [ml]

Body surface: BSA = 71.84 x H0.725 x W0.425 / 104 [m2]

Oxygen consumption: VO2 = [138.1 - (11.49 x ln(age) +

0.378 x HR] x BSA
Female: 17.04

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Cardiac Output (CO) – Angio
CO Angio is calculated by software using an image
from the X-ray system

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Shunt calculation
Shunt

Qp/Qs in L/min - m2

Qp = VO2
(PV sat - PA sat)(Hgb)(1.36)(10)
Qs = VO2
(Ao sat - SVC sat)(Hgb)(1.36)(10)
Absolute shunt volumes

Q L to R = VO2
(PA sat - MV sat)(Hgb)(1.36)(10)
Q R to L = VO2
(PV sat - Ao sat)(Hgb)(1.36)(10)

Qp/Qs = Ao sat - MV sat*

PV sat - PA sat

VO2; oxygen consumption (ml/minutes)

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Qp/Qs

• Qp: pulmonary blood flow

• Qs: Systemic blood flow
• Normal ratio of Qp/Qs=1
• In left to right shunt, increase pulmonary blood flow the ratio
increase
• Should be interpreted with other clinical, ECG, CXR and
ECHO in making treatment decision

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O2 consumption calculation (VO2)
• Largest source of error
traditionally: using a hood & gas pump or commercial available system
 difficult to obtain satisfactory measurements
• Assumed: based on monogram age, sex & HR
• Normal < 3 months : 130 ml/min/m2
> older infant : 170 ml/min/m2
2-3 year : 180 ml/min/m2
2-5 year : 150-200 ml/min/m2
older children : 120-180 ml/min/m2
Poor correlation & wide discrepancies in individual

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Qp/Qs

Qp/Qs= Sat Ao – Sat MV/Sat PV – Sat PA

• PV ( Pulmonary vein) :
– assumed 98% or LA/LV/aortic if no R to L shunt

• MV (mixed vein): Need to get saturation for:

– (3 SVC + IVC )/4
Aorta
– (SVC + 2IVC) /3
IVC (high and low)
– SVC – (SVC-IVC)/4 SVC (high and low)
PA
LA or LV
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Resistance
• Pressure drop across the vascular bed by the indexed flow
• The higher the (R), the more pressure that will be needed to
maintain a constant flow
• In Woods unit (mmHg x min/L)
~ mean pressure
flow
• Systemic vascular resistance (SVR)
= (mean Ao pressure - mean RA pressure)
QS
• PAR = (mean PA pressure - mean LA pressure)
Qp
• Total PVR = mean PA pressure
Qp
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PVR and SVR

• R units are mmHg/l/min= Wood units=units=u

• Wood units x 80= dyne.sec.cm-5

PVR= (Normal PVR: 1-3 wood)

SVR= (Varies 15-30 unit.m2)

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Shunt Percentage
• Qep (effective pulmonary blood flow) is the amount of
desaturated systemic venous blood flow that actually
crosses the pulmonary vascular bed and picks up
oxygen
Qep = Qes = VO2
(PV sat - SVC)(Hgb)(1.36)(10)
• The absolute left to right shunt is =
Qp - Qep = (PA - SVC)
Qp (PV - SVC)
• Right to left = Qs - Qes = (PV - Ao)
Qs (PV - SVC)

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Valve Areas

Gorlin and Gorlin - formula to estimate the area across a

stenotic valve

For semilunar valve

= systolic flow (ml/sec)
(44.5)(square root of mean gradient)

Systolic flow (ml/sec)

= (CO)(R to R interval)
(60)(systolic ejection time)

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Valve Areas

For mitral or tricuspid valve

= diastolic flow (ml/sec)

(31.5)(square root of mean diastolic gradient)

Diastolic flow = (CO)(R - R interval)

(60)(diastolic filling time)

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Hemodynamic Calculations
Aortic valve

Aortic regurgitation

Grade Retrograde flow Regurgitation Fraction Symptoms

I Slightly regurgitation at the valve < 20% none

II Regurgitation of contrast medium- 20-40% with higher

not completely washed out in systole stress

II Aorta and left ventricle are 40-60% with light

contrasted simultaneously in the stress
same extend.

IV Left ventricle is contrasted higher >60% in rest

than aorta

Retrograde flow = Regurgitation of contrast medium from the aorta into the left ventricle
Fraction = % of stroke volume

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Hemodynamic Calculations
Mitral valve

Mitral stenosis
Grad Mitral valve Gradient CI R CI S PCP R PCP S
e area MVA MVG mean Symptoms

I > 2,5 cm 2 5 – 10 mm HG > 2,5 >4 <12 <22 Dyspnea under

mm mm high stress
HG HG

II 1,0 – 2,5 cm 2 10 – 15 mm 2– 2,5 - <12 <22 Dyspnea under

HG 2,5 4 mm mm normal daily
HG HG stress

II < 1,0 cm 2 15 – 20 mm < 2,0 < 2,0 <12 >30 Dyspnea under
HG mm mm light stress
HG HG

IV < 0,8 cm 2 > 20 mm HG < 2,0 < 1,5 > 20 >40 Dyspnea in rest
mm mm
HG HG

Gradient = diastolic mean gradient of mitral valve (MVG mean)

Mitral valve area = opening area of mitral valve(MVA)
CI R = cardiac index in rest
CI S = cardiac index in stress
PCP R = pulmonary capillary pressure in rest
PCP S = pulmonary capillary pressure in stress

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Hemodynamic Calculations
Mitral valve
Mitral regurgitation

Grade Retrograde flow Regurgitatio PCP R PCP S Symptoms

n fraction

I Slightly regurgitation on the valve < 20% <12 <22 none

mm HG mm HG

II Contrasting of left atrium after several 20-40% <12 <22 none

injections mm HG mm HG

II Left atrium and left ventricle are 40-60% <12 >30 Dyspnea
contrasted simultaneously in the same mm HG mm HG under
extend. stress

IV Contrasting of left atrium till into the >60% > 20 >40 Dyspnea
pulmonary vein after the 1. systole mm HG mm HG under rest

Retrograde flow = Regurgitation of contrast medium from the left ventricle into the left atrium
Regurgitation fraction = % of stroke volume
PCP R = Pulmonary capillary pressure in rest
PCP S = Pulmonary capillary pressure in stress

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Hemodynamic formulas and equations
Formula Equation Normal Value

BSA Sq.Root {(Kg.)*(Cm.) / (3600)} 1.5-3.5 m^2 (adults)

Systemic Vascular Resistance (SVR) { (MAP-CVP)* 80 } / (CO) 800-1500 dynes*sec/cm^5

Pulmonary Vascular Resistance (PVR) { (PAP-CVP)* 80 } / (CO) 150-250 dynes*sec/cm^5

Mean Arterial Pressure SBP + 2 * DBP/3 70-105 mmHg

Cardiac Output (CO) HR * SV/1000 4-6 L/min

Cardiac Index CO/BSA 2.5-4 L/min/m^2

Stroke Volume CO/HR*1000 60-100 ml/beat

Left Ventricular Stroke Work (LVSW) SV * (MAP-PAWP) * 0.0136 58-104 gm-m/beat

Left Ventricular Stroke Work Index(LVSWI) SVI * (MAP-PAWP) * 0.0136 50-62 gm-m/beat

Right Ventricular Stroke Work (RVSW) SV * (MPAP-PAWP) * 0.0136 8-16 gm-m/beat

5-10 gm-m/bea
Right Ventricular Stroke Work Index(RVSWI) SVI * (MPAP-PAWP) * 0.0136

Coronary Artery Perfusion (CPP) Diastolic BP - PAWP 60-80 mmHg

Arterial Oxygen Content (CaO2) (0.0138 * Hgb * SaO2) + 0.0031 * PaO2 17-20 ml/dl

Venous Oxygen Content (CvO2) (0.0138 * Hgb * SvO2) + 0.0031 * PaO2 12-15 ml/dl

A-V Oxygen Content Difference {C(a-v)O2} CaO2-CvO2 4-6 ml/dl

Oxygen Consumption (VO2) {C(a-v)O2}*CO*10 200-250 ml/min

Oxygen Extraction Ration (O2ER) ((CaO2-CvO2)/CaO2) * 100 22-30 %

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