Hemodynamic Rounds

5/13/11

Hemodynamics
Equalization of diastolic pressures (RA, RV, LV, Wedge) and pericardial pressure Total intracardiac volume fixed, so flow into heart occurs mainly during systole; X-descent is the dominant wave Loss of Y-descent: No overall change in intracardiac volume in diastole

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.

Paradoxical Pulse and Interdependence

Hallmark of tamponade Inspiration causes increased venous return with fixed intracardiac volume RV size increases, septum shifts, LV size decreases (180 degrees out of phase)

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.

Tamponade
Critical point where effusion reduces volume of cardiac chambers Last Drop Phenomenon Decreases stroke volume in both left and right heart Primarily affects the right heart due to lower pressures Fixed total cardiac volume accentuates interdependence

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.

Hemodynamic Findings
High RA, RVEDP, LVEDP and intrapericardial pressure prior to tap Cardiac output reduced Low RA transmural pressure Post-tap, intrapericardial pressure dropped, RA transmural pressure increased, RA and RVEDP dropped slightly and LVEDP was unchanged CO increased slightly Y-descent returned Dip-plateau visible
Sagrista-Sauleda. NEJM 350: 2004.

Constriction Hemodynamics
Chief characteristic: Failure of transmission of intrathoracic pressure changes of respiration to the cardiac chambers Interdependence: Pressure changes continue to transmit to the pulmonary circulation, so inspiration decreases pulmonary venous pressure
Drops the PV-LA gradient, with reduced LA inflow and reduced transmitral flow Underfilled LV permits septal shift to left and increased RV filling

Hemodynamics
Equilibration of RA, RV diastolic, Wedge and LV diastolic pressures (less than 35mmHg difference) Atrial wave: Preserved X-descent, prominent Y-descent (M or W configuration)

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.

Hemodynamics
RV and LV show dip and plateau or square root sign Reflects lack of mid-to-late diastolic filling

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.

Constriction vs. Tamponade

Both restrict cardiac filling and raise systemic and pulmonary venous pressures Venous pressure waveforms differ

Zipes. Braunwalds Heart Disease, 7th ed. Ch. 64.

Vs. Restriction: Dissociation of Intrathoracic and Intracardiac Pressures

Hatle LK, et. al. Circ. 1989;79357-370

Ventricular Interdependence

Hatle LK, et. al. Circ. 1989;79357-370

Insp

Expir

Ventricular Pressures Are DISCORDANT

Little. Circulation 2006, 113: 1629.

Kussmauls Sign
Pericardial constriction Restrictive cardiomyopathy Congestive Heart Failure:RV failure
Right ventricular infarction

Acute pulmonary embolism COPD