CARDIOVASCULAR

BOARD REVIEW
FOR INITIAL CERTIFICATION AND RECERTIFICATION

August 21-26, 2021

©2021
©2021
Mayo
Mayo
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MedicalEducation
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and Research
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 HEMODYNAMICS
SUNIL MANKAD, MD, PROFESSOR OF MEDICINE
MACKRAM ELEID, MD, PROFESSOR OF MEDICINE
DEPARTMENT OF CARDIOVASCULAR MEDICINE
MAYO CLINIC, ROCHESTER, MN, USA

©2021
©2021
Mayo
Mayo
Foundation
Foundation
forfor
Medical
MedicalEducation
Educationand
and Research
Research | WF64680-2
 Disclosures

Relevant Financial Relationships

None

Off Label Usage

None

©2014 MFMER | Slide-3

Learning Objectives
•Describe the noninvasive and invasive
hemodynamics of valve, myocardial and
pericardial diseases
•Apply results of noninvasive and invasive
hemodynamics to clinical decision making in
cardiology in specific patient case scenarios

©2014 MFMER | Slide-4

 Case #1
•65 year old woman
•History of a murmur
•Exertional dyspnea x 2 months
•Walking several blocks or carrying
laundry upstairs
•Physical Exam
•BP = 150/90 mmHg
•Grade 3/6 late peaking SEM
•Single component S2
•No S3 or S4 or diastolic murmur
©2014 MFMER | Slide-5
 Echo/Doppler Data
LVOTTVI = 30 cm
AVTVI = 105 cm
Mean Gradient = 38 mmHg

LVOT = 2.4 cm

©2014 MFMER | Slide-6

 POLL

What is the Aortic Valve Area? OPEN

1. 0.8 cm2 AVTVI = 105 cm

2. 1.0 cm2 Mean Gradient = 38 mmHg
3. 1.3 cm2
LVOTTVI = 30
4. 1.6 cm2
LVOT = 2.4
LV EF = 60%

©2014 MFMER | Slide-8

 Simplified Bernoulli Equation
P = 4(V2)2
• To maintain flow continuity, flow speed
must increase through a stenosis
• In conjunction with this, the pressure
drops (the Bernoulli effect) in the stenosis

©2014 MFMER | Slide-9

 Continuity Equation
LVOT area LVOT TVI

AV area x
= AV TVI

©2014 MFMER | Slide-10

 Doppler Calculation of AVA
Continuity Equation

AVA = (LVOT diameter)2 x 0.785 x TVILVOT

TVIAV

AVA = (2.4)2 x 0.785 x 30

= 1.3 cm2
105

©2014 MFMER | Slide-11

 Severity of Aortic Stenosis
Echo/Doppler Mild Moderate Severe
Parameter
Velocity < 3.0 3.0 - 4.0 > 4.0

Mean Gradient < 25 25 - 40 > 40

(mmHg)
Valve Area > 1.5 1.0 - 1.5 < 1.0
(cm2)
Valve Area < 0.6
Index (cm2/m2)
ACC/AHA Valve Guidelines. Nishimura RA et al. JACC Vol. 63, No. 22, 2014

©2014 MFMER | Slide-12

 POLL

What would you recommend? OPEN

1. Aortic valve replacement

2. Coronary angiography and AVR

3. Invasive hemodynamic study

4. Medical therapy of hypertension

©2014 MFMER | Slide-13

Comprehensive Echo/Doppler
Assessment of Aortic Stenosis
• Valve morphology by 2D echo
• Peak and mean gradients
• Aortic valve area
• Continuity equation
• Planimetry

•Dimensionless index
• LVOT/aortic valve velocity ratio
©2014 MFMER | Slide-14
Pitfalls in Doppler Assessment Aortic
Stenosis: Doppler Angle

•Goal: parallel to flow

•Skilled in non-guided
Right parasternal 19%

CW transducer
•Use multiple Apical 60%

transducer positions

©2014 MFMER | Slide-15

 Pitfalls in Doppler Assessment
Aortic Stenosis: LVOT Doppler

LVOTTVI = 30 cm

Error Correct

Increased LVOT TVI / velocity Correct LVOT TVI / velocity

Normal LVOT TVI: 18-22 cm

©2014 MFMER | Slide-16
 Indications for Hemodynamic
Catheterization in Aortic Stenosis
“When noninvasive data are
non-diagnostic
or if there is a discrepancy
between clinical and
echocardiographic evaluation,
cardiac catheterization for
determination of severity of AS
is recommended.”
ACC/AHA Valve Guidelines. Nishimura RA et al. JACC Vol. 63, No. 22, 2014
©2014 MFMER | Slide-17
 Indications for Cardiac
Catheterization in Aortic Stenosis
Symptomatic patient
3+ parvus, tardus
Late SEM

Echo → Moderate AS Echo → Severe AS

Hemodynamic Surgery
Cath

©2014 MFMER | Slide-18

Incorrect Correct Both

*Do not use femoral side arm as

surrogate for central aortic pressure

©2014 MFMER | Slide-19

 Gorlin formula
Forward flow rate
AVA =
44.3•C• mean grad
CO ÷ [SEP • HR]
=
44.3•C• mean grad

Hakki formula
CO
AVA =
Peak to peak gradient

*co-existent regurgitation → AVA underestimation

©2014 MFMER | Slide-20

 % of Aortic Stenosis Patients Undergoing
Invasive Hemodynamics, After Doppler Exam
Mayo Clinic

Pt undergoing invasive
100

hemodynamics (%)
95
80

60
54
40 40
35
29
20 23
13 13
0 Early
1990 91 92 93 94 98 99
1980s
Year
Roger V et al. Mayo Clinic Proc 1996;71:141-149

©2014 MFMER | Slide-21

 Take Home Points

•Echo/Doppler is very good for

assessment of aortic stenosis
•Pitfalls exist
•Consider invasive hemodynamic
assessment of aortic stenosis if
discordance between echo/Doppler
and clinical findings

©2014 MFMER | Slide-23

Case#2
48-year-old “Asymptomatic” Female
•General medical evaluation
•Left breast pain
•Headaches
•No cardiopulmonary symptoms
•“My valves leaked when I was young”
•PE
•BP:106/68 mmHg, Pulse:80 bpm
•Chest: Clear
•Heart: RRR without murmur, rubs, gallops
©2014 MFMER | Slide-24
48-year-old Asymptomatic Female

©2014 MFMER | Slide-25

48-year-old Asymptomatic Female

©2014 MFMER | Slide-26

48-year-old Asymptomatic Female

LV

LA

©2014 MFMER | Slide-27

48-year-old Asymptomatic Female

MG = 13 mmHg RVSP = 39 mmHg

MVA = 1.0 cm2
HR = 74 bpm
©2014 MFMER | Slide-28
 Pressure Half-time
220
MVA =
PHT
5
PHT = Deceleration Time x 0.29
Velocity
(m/s) 4
•the time required for the velocity to
3 drop to ½ the peak pressure
2

0
Hatle L et al. Br Med J 1978 (concept described by Libanoff and Rodbard in 1966)

©2014 MFMER | Slide-29

48-year-old Asymptomatic Female
Echo findings:
•Rheumatic mitral stenosis
•MG 13 mmHg (74bpm)
•MVA 1 cm2
•Mild mitral regurgitation
•Severe left atrial enlargement
•RVSP 39 mmHg

©2014 MFMER | Slide-30

48-year-old Asymptomatic Female
Physical Exam after the Echocardiogram:

•Heart: Loud S1, increased

intensity of P2, and an opening
snap with a tight P2-OS interval
perhaps 60 msec or so. There
very soft short rumble at rest.

©2014 MFMER | Slide-31

 Grading the Severity of Mitral Stenosis
Stage Definition Anatomy Hemodynamics Consequences Symptoms
A At risk Doming Normal None None
B Progressive Doming, MVA >1.5cm2 Mild-mod LAE None
Commissural PHT <150ms
fusion
C Severe Doming, MVA ≤1.5cm2 Severe LAE None
Asymptomatic Commissural MVA ≤ 1cm2 (very RVSP > 30 mmHg
fusion severe)
PHT ≥ 150ms
PHT ≥ 220ms (very
severe)
*MG > 5-10mmHg
D Severe Doming, MVA ≤ 1.5cm2 Severe LAE Decrease
Symptomatic Commissural MVA ≤ 1cm2 (very RVSP > 30mmHg exercise
fusion severe) tolerance
PHT ≥ 150ms Dyspnea
PHT ≥ 220ms (very
severe)
*MG > 5-10mmHg

Nishimura RA et al. ACC/AHA Guidelines Circ 2014

©2014 MFMER | Slide-32
What would you recommend now?
1. Observe, she’s asymptomatic

2. Transesophageal echo

3. Exercise transthoracic echo

4. Cardiac catheterization

©2014 MFMER | Slide-33

 Mitral Stenosis:
Diagnosis and Follow-Up
Recommendations COR LOE
Exercise testing with Doppler or invasive
hemodynamic assessment is recommended to
evaluate the response of the mean mitral
gradient and pulmonary artery pressure in I C
patients with MS when there is a discrepancy
between resting Doppler echocardiographic
findings and clinical symptoms or signs

©2014 MFMER | Slide-34

Mitral Stenosis
•Symptoms and pulmonary hypertension
predict poor outcome
•Degree of stenosis at rest may not reflect
true severity of obstruction with exercise
•Pressure gradient function of flow and
diastolic filling period

©2014 MFMER | Slide-35

Supine Bike Hemodynamic Stress Test
Rest 10 mmHg 25W 25 mmHg

50W 33 mmHg 75W 37 mmHg

©2014 MFMER | Slide-36

Supine Bike Hemodynamic Stress Test
Rest 30 mmHg 25W 56 mmHg

50W 74 mmHg 75W 100 mmHg

©2014 MFMER | Slide-37

Supine Bike Stress Echo
Look for Development of Symptoms,
RV dysfunction, or Pulmonary HTN

©2014 MFMER | Slide-38

 2014 ACC/AHA Guidelines:
Class I
3. Exercise testing with Doppler or invasive
hemodynamic assessment is recommended to
evaluate the response of the mean mitral gradient
and pulmonary artery pressure in patients with
MS when there is a discrepancy between resting
Doppler echocardiographic findings and clinical
symptoms or signs. (Level of Evidence: C)
Nishimura RA et al. JACC Vol. 63, No. 22, 2014

©2014 MFMER | Slide-39

 Mitral Stenosis
LA/LV Gradient

Good Doppler Angle

©2014 MFMER | Slide-40

Limitation of PCWP in
Mitral Stenosis

©2014 MFMER | Slide-41

Problems with PCWP in MS
DOPP PCWP
20 20

15 15

10 10

5 5
R=0.96 R=0.77
0 0
0 5 10 0 5 10
LA/LV LA/LV

If no Doppler, you need direct LAP

Nishimura: JACC 1994
©2014 MFMER | Slide-42
 Take Home Points
• Doppler echocardiography is highly accurate
and better than LV-PCWP for measuring the
mitral gradient in mitral stenosis
• If Doppler unavailable, you need to directly
measure LA pressure
• Consider exercise testing, either non-invasive
or invasive, in patients in whom symptoms are
discordant with severity of mitral stenosis

©2014 MFMER | Slide-43

 Case #3
A 65 year-old man with severe exertional dyspnea
undergoes hemodynamic catheterization

Select the most likely diagnosis:

1. Severe Aortic Regurgitation

2. Hypertrophic Obstructive CM

3. Severe Aortic Stenosis

4. Constrictive Pericarditis

©2014 MFMER | Slide-45

 Look at the pulse pressure
change on the post-PVC beat
Aortic stenosis Obstructive HCM

Sorajja and Nishimura, The assessment and therapy of valvular heart disease in the
cardiac catheterization laboratory, Cardiovascular Medicine, 3rd Edition 2007
©2014 MFMER | Slide-46
 Post-PVC:
Look at the Aortic Pulse Pressure
Aortic stenosis Obstructive HCM

Ao Ao

©2014 MFMER | Slide-47

 Case #4
Which one is Aortic Regurgitation?

1. a

2. b

3. c

(a) (b) (c)

©2014 MFMER | Slide-49

Aortic regurgitation
160

Wide PP
Ao (except acute)
Pressure
(mm Hg)

Severe
Mild
LV EDP
0

CP1147395-20
Aortic Regurgitation Index after TAVR
[(DBP - LVEDP)/SBP] × 100

Sinning J-M et al. JACC Volume 59, Issue 13, 2012, 1134 - 1141

©2014 MFMER | Slide-51

Acute Severe Aortic Regurgitation
after Balloon Valvuloplasty

©2014 MFMER | Slide-52

Acute Severe Aortic Regurgitation
Pre-Valvuloplasty Post-Valvuloplasty

©2014 MFMER | Slide-53

Early Closure of the Mitral Valve:
Elevated LVEDP in Severe Aortic
Regurgitation

©2014 MFMER | Slide-54

 Take Home Points
•The post-PVC beat is most important in
identifying Brockenbrough-Braunwald Sign
•Decreased pulse pressure of post-PVC
beat with HOCM
•In the beat following a PVC, the carotid
impulse will be diminished and the
murmur will be louder in HOCM
•Recognize the hemodynamic of acute
severe aortic regurgitation (both invasive
and noninvasive)
©2014 MFMER | Slide-55
 Case # 5
•70 year old male
•PMH: CABG after Antero-apical MI
•NSVT, EF 30%, ICD placed
•Asymptomatic for 5 years
•Now presents with NYHA class III CHF
•Physical Exam:
•Grade 3/6 late peaking SEM
•Diminished, delayed carotid upstroke
•Single component S2

©2014 MFMER | Slide-56

2D Echo: Severe LV Dysfunction

EF: 20%

©2014 MFMER | Slide-57

 Aortic Valve

Parasternal Long-Axis Parasternal Short-Axis

©2014 MFMER | Slide-58

Aortic Valve Gradient

Pk Gr = 27 mmHg
Mn Gr = 14 mmHg
AVA = 0.8 cm2

©2014 MFMER | Slide-59

 Coronary Angiogram

Patent LIMA Patent SVG to OM1

• Occluded LAD
• 90% proximal Left Circumflex stenosis
• No significant disease in RCA
• Viability Study: Apical scar, all other areas viable
©2014 MFMER | Slide-60
 Question
What would you do next?
1. Aortic balloon valvuloplasty

2. Refer to CT Surgery for AVR

3. Dobutamine stress study

4. Prayer

©2014 MFMER | Slide-61

Dobutamine in Low Gradient-
Low EF Aortic Stenosis

• “True” severe AS
•  SV,  transvalvular gradient; No change in
calculated AVA
• remains in severe range
• “Pseudo” severe AS
•  SV and  AVA; No significant 
transvalvular gradient
©2014 MFMER | Slide-62
 Pseudo Aortic Stenosis
AVA
Baseline Dobutamine 0.8 cm2 → 1.3 cm2

Stroke volume
30 → 60 cc
TVI 8 cm TVI 16 cm

Mean gradient
13 → 19 mmHg
TVI 42 cm TVI 51 cm

Dimensionless Dimensionless
Index = 0.19 Index = 0.31 Eleid MF…Sorajja P. Heart Fail Rev. 2012 ©2014 MFMER | Slide-63
True Low Gradient/Low EF Aortic Stenosis
Baseline Dobutamine

Stroke volume
40 → 60 cc

Frederick-04-still.jpg

Mean gradient
25 → 40 mmHg
AVA = 0.7 cm2

Dimensionless Dimensionless
Index = 0.22 Index = 0.23 Eleid MF…Sorajja P. Heart Fail Rev. 2012 ©2014 MFMER | Slide-64
Low Gradient Aortic Stenosis

Monin et al - Circulation 2003; 108:319-24

• 136 AS pt - AVA 0.7, MG 29 mmHg

• LV contractile reserve assessed by DSE

• Present in 92 (Group I)
• Absent in 44 (Group II)

©2014 MFMER | Slide-65

Kaplan-Meier Survival Estimates by
Group and Treatment
100
Operative Mortality 5%
Group I
75 Valve replacement

Pt Operative Mortality 32%

survival 50 Group II
(%) Valve replacement
Group I
25 Medical treatment

Group II
0 Medical treatment
0 25 50 75 100

Follow-up (mo)
©2014 MFMER | Slide-66
 Case:
Results of Dobutamine Stress Echo
V1 V2 TVI AVA Peak/Mean
TVI
(cm) (cm2) AV Gradient
(cm)
(mmHg)
Baseline 13 47 0.86 25/14
5 mcg/kg/min 14 47 0.93 25/14
dobutamine
10 mcg/kg/min 15 53 0.88 31/16
dobutamine
20 mcg/kg/min 15 53 0.88 33/17
dobutamine
* No significant change in EF during study ©2014 MFMER | Slide-67
Change in LVEF after AVR
Severe AS with low EF
Contractile Reserve
80 No Contractile Reserve

60

% 40

20

0
Before AVR After AVR

Quere, J.-P. et al. Circulation 2006;113:1738-1744

©2014 MFMER | Slide-68

Influence of Contractile Reserve
in Low-gradient AS
• Absence of CR related to  operative mortality,
but it does not predict the absence of LVEF
recovery in patients surviving AVR

• These data further support the concept that

surgery should not be contraindicated on the
basis of absence of CR alone

Quere, J.-P. et al. Circulation 2006;113:1738-1744

©2014 MFMER | Slide-69
• TAVR Associated
with good
periprocedural
outcomes in LFLG
• 1/3 died at 2 years
• DSE failed to
predict outcome
of EF changes

©2014 MFMER | Slide-70

 Take Home Points
• Dobutamine stress testing is helpful
in low gradient-low EF AS
• Importance of contractile reserve
• “True AS” vs “Pseudo” AS
• Absence of contractile reserve
substantially increases operative
mortality with AVR in low EF-low
gradient AS
• But if patients survive, EF improves
and outcome good
©2014 MFMER | Slide-71
©2014 MFMER | Slide-72
Normal LVEF: 60%
Small LV Cavity
- LVEDD: 40 mm
- LVEDV: 70 ml
LA vol = 72 ml/m²

©2014 MFMER | Slide-73

Doppler Data

• AV Velocity 3.4 m/sec

• AV Mean Gr 27 mmHg
• AVA 0.85 cm2
• AVA index 0.43 cm2/m2
• LV Stroke Volume Index 24 cc/m2
• Cardiac Index 2.1 l/min/m2

©2014 MFMER | Slide-74

©2014 MFMER | Slide-75
Impact of AVR on Survival in “Paradoxcial”
Low Gradient Aortic Stenosis
Low Flow Low Gradient

Normal Flow Low Gradient

Dayan V et al. J Am Coll Cardiol 2015;166:2594-2603.

©2014 MFMER | Slide-76
 Case #6
• 45 yo woman with severe right-sided heart
failure for the past 6 months
• Mantle radiation for non-Hodgkins lymphoma
20 yrs ago
• Physical Exam
• JVP is elevated to 20 cm H20 with rapid x
and y descents
• 2/6 SEM and a 1/6 diastolic decrescendo
murmur at RUSB; no S3 or S4.
• 3+ pedal edema; ascites.
• Echo with Doppler performed
©2014 MFMER | Slide-77
Echo: 4 Chamber View

©2014 MFMER | Slide-78

 Subcostal Views

Inferior Vena Cava Ascites

©2014 MFMER | Slide-79

Transmitral Doppler

©2014 MFMER | Slide-80

Hepatic Vein Doppler

©2014 MFMER | Slide-81

SVC Doppler

©2014 MFMER | Slide-82

Tissue Doppler of Mitral Annulus

©2014 MFMER | Slide-83

 Surgical Specimen:
Constrictive Pericarditis

©2014 MFMER | Slide-84

Doppler Findings in Constriction

Oh JK, Seward J, Tajik AJ. Echo Manual, 2nd edition

©2014 MFMER | Slide-85

Hepatic Vein Doppler in
Constrictive Pericarditis

©2014 MFMER | Slide-86

 Abnormal Septal Motion:
Increased Interventricular Dependence

Image Courtesy of Dr. Raul Espinosa ©2014 MFMER | Slide-87

Effusive Constrictive Pericarditis

Images Courtesy of Dr. Paul Mckie

©2014 MFMER | Slide-88

Effusive Constrictive Pericarditis
•After pericardiocentesis, there is
persistent modest elevation of right
atrial pressure and the development of
the classic “constrictive” waveform

©2014 MFMER | Slide-89

Mitral Annular Velocity

Courtesy of Drs. Jae K. Oh and Raul Espinosa

©2014 MFMER | Slide-90
©2014 MFMER | Slide-91
Evaluation of Diastolic Function
Mitral Inflow and Annulus Velocity
Normal Ab Relax Pseudo Restrictive
Grade 1 Grade 2 Grade 3
Mitral flow

Mitral annulus
Preload dependent
velocity

Less Preload independent

Sohn et al: JACC, 1997 CP1254003-30
©2014 MFMER | Slide-92
Estimation of LV Filling Pressures
E/e’ (Medial MV annulus)
40
35 EF >50%

LV filling pressure
30 EF <50%
25
20
15
10
5
0
E/E <8 E/E 8-15 E/E >15
Ommen SR et al: Circulation 102:1788, 2000

©2014 MFMER | Slide-93

 Annulus Paradoxus in
Constrictive Pericarditis

©2014 MFMER | Slide-94

 Annulus Reversus
Constrictive Pericarditis

lateral

RA
LA E’ = 9

medial
Lateral is frequently, but not
always, less than medial
E’ = 14
annular velocity

©2014 MFMER | Slide-95

Importance of
Superior Vena Caval
Doppler Velocities
Boonyaratavej S, Oh JK, Tajik AJ, Appleton CP, Seward JB
J Am Coll Cardiol 1998; 32(7): 2043-8

Inspiratory-Expiratory Forward SVC Velocities

©2014 MFMER | Slide-96

A 45 year-old woman presents fatigue and lower extremity
edema. She previously underwent mantle chest radiation
therapy for Hodgkin’s lymphoma 18 years ago. Her symptoms
have been refractory to high-dose diuretics. She undergoes
cardiac catheterization (see below).

Select the most appropriate treatment for

this patient:
1. pericardiectomy

2. cardiac transplant evaluation

3. balloon aortic valvuloplasty

©2014 MFMER | Slide-98

 (A)

Constriction

(B)
No
Constriction

©2014 MFMER | Slide-99

 Constriction vs Restriction
Hemodynamic Criteria
mm Hg C R Wood P:
AJC, 1961
LVEDP-RVEDP <5 >5
RVP systolic <50 >50 Yu et al:
Circ, 1953
RVEDP/RVSP >0.3 <0.3
LVEDP- RVEDP Systolic RVP RVEDP/RV
30
30 100
100 0.8
0.8
20
20 80
80 0.6
0.6
mm Hg

mm Hg

Ratio
60
60
10
10 0.4
0.4
40
40
00 20 0.2
0.2
20
-10
-10 00 00
CP RCM CP RCM CP RCM
Vaitkus, Kussmaul: AHJ, 1991
Dynamic Criteria
Restriction Constriction

Concordance Discordance

©2014 MFMER | Slide-101

 Early rapid filling

Intracavitary and
intrathoracic
dissociation

©2014 MFMER | Slide-102

 Take Home Points
•Doppler echocardiography is very
useful for diagnosing constrictive
pericarditis
•In certain scenarios, cath
confirmation may not be necessary
•Know how to differentiate constriction
from restriction using the LV and RV
tracings

©2014 MFMER | Slide-103

 Case #7
A 55 yo woman undergoes percutaneous
mitral balloon valvuloplasty. LV and LA
pressure tracings before and after the
procedure are shown:

©2014 MFMER | Slide-104

 Select the most appropriate next step:
1. phenylephrine

2. dobutamine

3. pericardiocentesis

4. diuresis

©2014 MFMER | Slide-106

A Favorite Board Question

Tamponade Constriction

©2014 MFMER | Slide-107

Pericardial Tamponade

©2014 MFMER | Slide-108

 Take Home Points
•Clinical history, hemodynamic
tracings and echocardiography
are paramount to diagnosing
pericardial tamponade
•Pulsus Paradoxus is a cardinal
feature of pericardial tamponade
•Originally described by
Kussmaul in 1873

©2014 MFMER | Slide-109

 Case #8
Calculate the Qp/Qs from these data:
O2 sats:High SVC: 67%
Low SVC: 88%
Select the correct
IVC: 75% answer:
RA: 87% 1. 2.0

RV: 88% 2. 2.5

PA: 89%
3. 3.0
PCWP: 99%
C.O. = 5 l/min 4. 4.0

Hgb = 12 g/dl

©2014 MFMER | Slide-111

 Flamm Formula:
Pulmonary flow
Qp/Qs = MVO2= 3*SVC + 1*IVC
Systemic flow 4

VO2
[PVO2 – PAO2 ] • Hgb • 10
=
VO2
[PVO2 – MVO2] • Hgb • 10

PVO2 – MVO2 99-69

= = = 3.0
PVO2 – PAO2 99-89

©2014 MFMER | Slide-112

Ventricular Septal Defect

• Blood flows from LV

(higher pressure chamber)
to RV (lower pressure
chamber)
• What can you solve for?
•RV Systolic pressure
•Shunt Fraction

©2014 MFMER | Slide-113

Ventricular Septal Defect

5 m/sec

©2014 MFMER | Slide-114

 Ventricular Septal Defect:
What is the RV Systolic Pressure?

• Simplified Bernoulli Equation:

P = 4V2
140 • RVSP = LVSP – 4x(VSD)2
• Example:
80

•SBP = 140 mm Hg
140 •VSD velocity = 5.0 m/sec

40
• RVSP = 140 - 4(5.0)2
• RVSP = 140 - 100
• RVSP = 40 mm Hg

©2014 MFMER | Slide-115

 Shunt Ratio (Qp/Qs)

• What goes in (the pulmonary circulation),

must go out (the systemic circulation)
• RV stroke volume = LV stroke volume

©2014 MFMER | Slide-116

Calculation of Stroke Volume (Qs)

SV = LVOT diameter2 x 0.785 x LVOT TVI

SV = x 0.785 x

©2014 MFMER | Slide-117

Calculation of Stroke Volume (Qp)
SV = RVOT diameter2 x 0.785 x RVOT TVI

©2014 MFMER | Slide-118

Qp/Qs Calculation Example
• LVOT diameter 2.0 cm
• LVOT TVI 20 cm
• RVOT diameter 2.2 cm
• RVOT TVI 23 cm

• Calculate the Qp/Qs

©2014 MFMER | Slide-119

 Calculate Shunt Flow
Shunt ratio = Qp = SV Qp site
Qs = SV Qs site

Shunt ratio = (RVOT diameter)2 x 0.785 x RVOT TVI

(LVOT diameter)2 x 0.785 x LVOT TVI

Shunt ratio = (2.2 cm)2 x 0.785 x 23 = 87 = 1.38

2.0 cm)2 x 0.785 x 20 63

©2014 MFMER | Slide-120

 Take Home Points
•Know how to calculate Qp/Qs using
invasively derived oxygen saturations
•Know how to non-invasively calculate
RV systolic pressure in a VSD if given
systolic BP and VSD velocity
•Know how to non-invasively calculate
QP/QS

©2014 MFMER | Slide-121

Case #9
Patient with dilated cardiomyopathy being considered
for cardiac transplantation.
Body surface area: 2.0 m2
Right atrium: 12 mmHg
Right ventricle: 70/13 mmHg
PA systolic pressure: 70 mmHg
Mean PA pressure: 50 mmHg
Wedge pressure: 20 mmHg
Cardiac output : 5.0 L/min
Calculate the pulmonary arteriolar resistance.
1. 12 Wood units

2. 2 Wood units

3. 4 Wood units

4. 6 Wood units

©2014 MFMER | Slide-123

Pulmonary Resistance
PAR = (Mean PA pressure – mean LA pressure)/CO
PAR = (50 mmHg – 20 mmHg) ÷ 5.0 l/min
PAR = 6 Wood units
To obtain PAR in dyness/cm-5, take Wood units x 80

Transpulmonary Gradient (TPG) =

Mean PA pressure - PCWP

*confirm wedge pressure with saturation

*CO measurement is critical
*give vasodilators if PAR >4 Wood units

©2014 MFMER | Slide-124

Take Home Points

•Know how to calculate pulmonary arteriolar

resistance
•Know when to give vasodilators

©2014 MFMER | Slide-125

 Case #10
Calculate the regurgitant fraction:
BP (mmHg): 140/90
HR (bpm) 80
End-diastolic volume (ml): 100
End-systolic volume (ml): 20
Cardiac output: 4.8 L/min
1. 10%

2. 25%

3. 50%

4. 75%
©2014 MFMER | Slide-127
 Regurgitant Fraction
RF = regurgitant volume/total volume
RF = (total volume - forward volume)/total volume
= (TV - CO/HR)/TV
=(80 - 4800/80)/80
= (80 – 60)/80
=25%
*remember that forward volume is derived
from cardiac output and heart rate

©2014 MFMER | Slide-128

 Conclusions

“Before I came here I

was confused about
this subject. Having
listened to your lecture
I am still confused.
But on a higher level”

-Enrico Fermi

©2014 MFMER | Slide-129

 Thank You!
and
Good Luck!
[email protected]
[email protected]

©2014 MFMER | Slide-130

 Hemodynamics: Board Pearls
#1
•Consider invasive hemodynamic
assessment of aortic stenosis if
discordance between
echo/Doppler and clinical findings

©2014 MFMER | Slide-131

 #2
•Doppler echocardiography is highly
accurate and better than LV-PCWP for
measuring the mitral gradient in mitral
stenosis → If Doppler unavailable, you
need to directly measure LA pressure
• Consider exercise testing, either non-
invasive or invasive, in patients with
symptoms out of proportion to severity of
mitral stenosis
©2014 MFMER | Slide-132
 #3
•The post-PVC beat is most important in
identifying Brockenbrough-Braunwald-
Morrow Sign
•Decreased pulse pressure of post-
PVC beat with HOCM
•In the beat following a PVC, the
carotid impulse will be diminished and
the murmur will be louder in HOCM

©2014 MFMER | Slide-133

 #4
• Dobutamine stress testing is
helpful in low gradient-low EF AS
• Importance of contractile reserve
• “True AS” vs “Pseudo” AS
• Absence of contractile reserve
substantially increases operative
mortality with AVR in low EF-low
gradient AS
• But if patients survive, EF improves and
outcome good

©2014 MFMER | Slide-134

 #5
• In patients with constrictive pericarditis, there is
enhanced ventricular interaction, which is reflected in a
discordance of the left and right ventricular pressures.
• During peak inspiration, the left ventricular pressure
decreases because there are decreases in the
intrathoracic pressure and the filling of the left ventricle.
As a result, the peak systolic pressure in the left ventricle
decreases and there is an overall change in the contour
of the curve, with a shortening of the width and a
decrease in the entire area during systolic contraction.
• The enhanced ventricular interaction causes a
compensatory increase in the filling of the right ventricle
and an increase in the right sided stroke volume. During
peak inspiration, this is seen as an increase in the peak
pressure and systolic width of the right ventricular
pressure curve.
©2014 MFMER | Slide-135