CVP & PCWP MONITORING

Sultan Qaboos University Hospital, Muscat

 AGENDA
Cardiac cycle
CVP
PAP
 Cardiac Cycle
The series of electrical and mechanical events that
constitute a single heart beat
Cardiac Cycle
 Cardiac Cycle

• 1 - Atrial Contraction
• 2 - Isovolumetric Contraction
• 3 - Rapid Ejection
• 4 - Reduced Ejection
• 5 - Isovolumetric Relaxation
• 6 - Rapid Filling
• 7 - Reduced Filling
 Central Venous Pressure
Venous pressure is a term that represents the average
blood pressure within the venous compartment.

The term "central venous pressure" (CVP) describes

the pressure in the thoracic vena cava near the right
atrium
therefore CVP and right atrial pressure are essentially the
same
 Central Venous Pressure
CVP is a major determinant of the filling pressure and
therefore the preload of the right ventricle, which
regulates stroke volume
Central Venous Pressure
 Central Venous Pressure
Factors increasing CVP
Raised intrathoracic pressure
• Eg, IPPV, coughing, expiration in spont
ventilation
Circulatory overload; Venoconstriction

Impaired cardiac function

• Eg, outlet obstruction, cardiac failure, cardiac
tamponade
Superior vena cava obstruction
 Central Venous Pressure
Factors decreasing CVP

Reduced intrathoracic pressure

• Eg, inpiration in spont ventilation

Hypovolemia

Venodilatation
• Eg, septic shock
 CVP monitoring
In CVP monitoring, a catheter is inserted
through a vein and advanced until its tip lies in
or near the right atrium
Because no major valves lie at the junction of
the vena cava and right atrium, pressure at
end diastole reflects back to the catheter
 CVP monitoring
When connected to a manometer, the catheter
measures central venous pressure (CVP), an index of
right ventricular function
CVP monitoring helps to assess cardiac function, to
evaluate venous return to the heart, and to indirectly
gauge how well the heart is pumping
 The phlebostatic axis is the reference point for zeroing
the hemodynamic monitoring device. This reference
point is important because it helps to ensure the
accuracy of the various pressure readings.

4th intercostal space, mid-axillary line

Level of the atria

Central venous
catheterisation
Central venous
catheterisation
CVP monitoring
CVP monitoring
CVP waves

Waveform Phase of cardiac Mechanism

cycle
a wave End diastole Atrial contraction
c wave Early systole Isometric ventricular contraction;
Tricuspid motion towards RA
x descent Mid systole Atrial relaxation; descent of base
v wave Late systole Systolic filling of atrium
y descent Early diastole Early ventricular filling
h wave Mid- to late diastole Diastolic plateau
CVP waves
CVP waves
 CVP abnormalities
Condition Characteristics
Atrial fibrillation Loss of a wave
Prominent c wave
AV dissociation Cannon a wave
Tricuspid regurgitation Tall systolic c-v wave
Loss of x descent
Tricuspid stenosis Tall a wave
Attenuation of y descent
Pericardial constriction Tall a and v waves; Steep x and y descents M
or W configuration
Cardiac tamponade Dominant x descent
Attenuated y descent
Respiratory variations Measure pressure at end-expiration
CVP – Atrial fibrillation

absence of the a wave

prominent c wave

preserved v wave and y

descent
 CVP – AV dissociation

Retrograde conduction of the nodal impulse throughout the atrium

causes atrial contraction to occur during ventricular systole while the
tricuspid valve is closed

Early systolic Cannon a

wave
CVP – Tricuspid regurgitation

Tall systolic c-v wave

Loss of x descent

In this example, the a wave is not seen because of atrial fibrillation

 CVP – Tricuspid stenosis

End-diastolic a wave is
prominent

Diastolic y descent is
attenuated

Tricuspid stenosis increases mean CVP

CVP & Intrathoracic pressure
CVP measurement is influenced by
changes in intrathoracic pressure.
It fluctuates with respiration.
Decreases in spontaneous
inspiration.

Increases in positive pressure

ventilation.
CVP & Intrathoracic pressure
CVP should be taken at the end expiration.
PEEP applied to the airway at the end of exhalation,
may be partially transmitted to the intrathoracic
structures ► measured CVP will be higher.
CVP as hemodynamic
monitor
CVP & PEEP
 PA catheterisation
The pulmonary artery (PA) catheter (or Swan- Ganz
catheter) was introduced into routine practice in
operating rooms and intensive care units in the 1970s
The catheter provides measurements of both CO and
PA occlusion pressures and was used to guide
hemodynamic therapy, especially when patients
became unstable
 PA catheterisation
The pulmonary artery (PA) catheter (or Swan- Ganz
catheter) was introduced into routine practice in
operating rooms and intensive care units in the 1970s
The catheter provides measurements of both CO and
PA occlusion pressures and was used to guide
hemodynamic therapy, especially when patients
became unstable
Perioperative intensive care; Cardiac anesthesia
 Reduced SVR

Stroke Volume

Vasopressors
PAWP / LVEDP

Inotropes Volume admin

 PA catheter
PA catheter can be used to
guide goal-directed
hemodynamic therapy to
ensure organ perfusion in
shock states

7 - 9 FR catheter

4 lumens

110-cm long

Polyvinylchloride body
Pressure guidance is used to ascertain the localization of
the PA catheter in the venous circulation and the heart

Upon entry into the right atrium, the central venous pressure
tracing is noted
Higher systolic pressure than
seen in the right atrium,
although the end-diastolic
pressures are equal

Passing through the tricuspid valve right ventricular

pressures are detected
 A diastolic step-up compared
with ventricular pressure

At 35 to 50 cm depending upon patient size, the catheter will

pass from the right ventricle through the pulmonic valve into
the pulmonary artery
 Similar morphology to right atrial pressure, although the a-c and v
waves appear later in the cardiac cycle relative to ECG

When indicated the balloon- tipped catheter will wedge or

occlude a pulmonary artery branch.
PA pressure equilibrates with that of the left atrium which,
barring any mitral valve pathology, should be a reflection of
left ventricular end-diastolic pressure
From a right internal jugular vein puncture site, the right atrium
should be reached when the PAC is inserted 20 to 25 cm, the right
ventricle at 30 to 35 cm, the pulmonary artery at 40 to 45 cm, and the
wedge position at 45 to 55 cm.
30

0
 120

PAWP a-c and v waves appear to occur later in the cardiac cycle
compared with CVP trace
 PA catheter: Uses
There is no consensus on standards for PA catheter
use

PA catheters should only be used when a specific

clinical question regarding a patient’s hemodynamic
status can not be satisfactorily investigated by clinical
or noninvasive assessments
…. when the clinician is in need of knowing an in-depth
and continuous assessment of hemodynamics in order
to properly guide changes in the management of a
patient
 PA catheter: Measurements
Parameter Normal range Relevance

CVP 0-6mmHg Volume status & RV function;

correlates with RVEDP

RVP 20-30 / 0-6mmHg RV function and volume

PAP 20-30 / 6-10 mmHg State of PVR and RV function

PAWP 4-12mmHg LV function; correlates with LVEDP

Stroke vol. 60-80ml

SV index 33-47ml/beat/m2 SV adjusted to body surface area

(BSA)
 PA catheter: Measurements
Parameter Normal range

Cardiac Output 4 – 8 L/min

Cardiac Index 2.5 – 4 L/min/m2

Pulmonary Vascular Resistance 20-120 dynes/sec/cm5

Systemic Vascular Resistance 750-1500 dynes/sec/cm5

RV stroke work

LV stroke work

SvO2 (Mixed Venous O2 60 -75%

saturation)
PA catheter: Contraindications
• Known pulmonary hypertension

• Unstable arrhythmias

• Anticoagulation therapy

• Bleeding disorder

• Prior pneumonectomy

• Pacemakers

• Prosthetic heart valves

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