HEMODYNAMIC ASSESSMENT: CARDIAC CATHETERIZATION LABORATORY

1. HEMODYNAMIC ASSESSMENT: CARDIAC CATHETERIZATION LABORATORY William Hellenbrand MD Director, Pediatric Cardiology Morgan Stanley Children’s Hospital of New York - Presbyterian Columbia University Medical Center Komansky Center for Children’s Health Cornell University Medical Center

2. CARDIAC CATHETERIZATION • Cardiac output • Shunt & Resistance • Oxygen transport • Pressure-Volume loops

3. FICK PRINCIPLE • The amount of flow through an organ or any circuit may be determined if • 1 - that organ consumes or secrets a given substance • 2 - the concentration of that substance can be measured as it enters and leaves the organ • 3 - The total amount of the substance consumed or secreted can be measured per unit time ∆S/∆t C2S – C1S

4. FICK PRINCIPLE

5. OXYGEN IN BLOOD • When oxygen is exposed to blood it exists in 2 forms • Bound to hemoglobin Each gram of Hgb is capable of binding 1.36 ml O2. Therefore if the Hgb is 15 gm/100ml then the maximal amount of oxygen(Capacity) that can be taken up by Hgb is 20.4 ml/100ml(Vol%)

6. OXYGEN IN BLOOD • When oxygen is exposed to blood it exists in 2 forms(cont) • In solution in plasma – At body temperature of 370 , there is .00003 ml of O2 per one ml of plasma at a partial pressure of oxygen of 1 mm Hg(1 torr) Thus the solubility coefficient of oxygen in plasma is 0.00003 ml/ml/mm Hg Therefore the amount of dissolved oxygen in plasma is equal to .003(PO2)

7. OXYGEN IN BLOOD • Oxygen capacity = Hgb(gm/100ml)*1.36 ml O2/gm = ml O2/100ml (Vol%) • Oxygen saturation = proportion of O2 actually combined with hemoglobin to the total capacity • Oxygen content = Capacity*Saturation + .003*PO2 = ml/100ml (Vol%)

8. OXYGEN CONSUMPTION • VO2 = VIFIO2 - VEFEO2 • If RER is 1 then VI = VE and all you need to measure is VEFEO2 • RER = VCO2 /VO2 • RER is close to 1 with carbohydrate metabolism • RER may be as low as 0.7 with mostly fat metabolism • Standard nomograms assume RER of 0.9

9. Oxygen Consumption

10. CARDIAC OUTPUTSYSTEMIC BLOOD FLOW • Qp = VO2 • CpvO2 - CpaO2 • Qs = VO2 • CaoO2 - CmvO2 If there is no shunt Qp = Qs

11. SHUNT CALCULATIONS • Qs = VO2 CaoO2 - CmvO2 • Qp = VO2 CpvO2 - CpaO2 • Qep = VO2 CpvO2 - CmvO2

12. SHUNT CALCULATIONS • SIMPLE SHUNT • Ql-r = Qp - Qs • Qr-l = Qs - Qp • BIDIRECTIONAL SHUNT • Ql-r = Qp - Qep • Qr-l = Qs - Qep

25. RESISTANCE TO FLOW • Poiseuille equation Q = ∆Pπr4 1 = 8nl R ∆P = pressure drop r = radius Q = ∆P n = viscosity R l = length of tube πr4 8nl R = ∆P Q

26. RESISTANCE • SVR = AO(MEAN) - RA(MEAN) Qs • PVR = PA(MEAN) - LA(MEAN) Qp

27. SYSTEMIC OXYGEN TRANSPORT (SOT) SOT = Q X OXYGEN CONTENT SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)]

28. SYSTEMIC OXYGEN TRANSPORT (SOT) SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)] Anemic Hypoxia:  Hgb SOT  Acute compensation  Q SOT  Chronic compensation  Hgb SOT 

29. SYSTEMIC OXYGEN TRANSPORT (SOT) SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)] Hypoxic Hypoxia:  02 SAT SOT  Acute compensation  Q SOT  Chronic compensation Hgb,  Q SOT 

30. SYSTEMIC OXYGEN TRANSPORT (SOT) SOT = Q X [(1.36 X Hgb X O2 SAT) + (.003 X PO2)] Stagnant Hypoxia:  Q SOT  (Low Cardiac Output) Compensation  Hgb,  02 SAT SOT 

31. VSD 80/50 M=65 95 80 80/40 M=60 70 80 M=8 M=6 70 80/6 85

32. Hgb = 10.0 Vol% V02 = 150 ml/min/m2 Saturations Svc = 70 Ra = 70 Rv = 85 Pa = 80 Ao = 95 Pressures Ra = 6(mean) Rv = 80/6 Pa = 80/40 60(mean) La = 8(mean) Ao = 80/50 65(mean) VSDRoom Air

33. Capacity = 1.36*10 = 13.6 Contents = Ao =13.6*.95=12.9 Mv = 13.6*.70=9.5 Pa = 13.6*.80=10.9 Pv = 13.6*.95=12.9 S(a-v)02 difference = 3.4 P(a-v)02 difference = 2.0 Qp = 150/2.0 = 7.5 l/min/m2 Qs = 150/3.4 = 4.4 l/min/m2 Ql-r = 7.5-4.4=3.1 Qp/Qs = 7.5/4.4=1.7 PVR =(60-8)/7.5 =6.9 SVR =(65-6)/4.4=13.4 VSDRoom Air

34. Hgb = 10.0 Vol% V02 = 150 ml/min/m2 Saturations Svc = 75 (45) Ra = 80 Rv = 94 Pa = 95 (85) Ao = 100 (600) Pressures Ra = 6(mean) Rv = 80/6 Pa = 80/40 60(mean) La = 8(mean) Ao = 80/50 65(mean) VSDfI02 = 1.0

35. Capacity = 1.36*10 = 13.6 Contents = Ao =13.6*1.0=13.6 Mv = 13.6*.75=10.2 Pa = 13.6*.95=12.9 Pv = 13.6*1.0=13.6 S(a-v)02 difference = 3.4 P(a-v)02 difference = 0.7 Qp = 150/0.7 = 21.4 l/min/m2 Qs = 150/3.4 = 4.4 l/min/m2 Ql-r = 21.4-4.4=17.0 Qp/Qs =21.4/4.4=>4/1 PVR =(60-8)/21.4 =2.4 SVR =(65-6)/4.4=13.4 VSDfI02 = 1.0(PO2 not included)

36. Capacity = 1.36*10 = 13.6 Contents = Ao =13.6*1.0+1.8=15.4 Mv = 13.6*.75+.15=10.4 Pa = 13.6*.95+.25=13.2 Pv = 13.6*1.0+1.8=15.4 S(a-v)02 difference = 5.0 P(a-v)02 difference = 2.2 Qp = 150/2.2 = 6.8 l/min/m2 Qs = 150/5.0 = 3.0 l/min/m2 Ql-r = 6.8-3.0=3.8 Qp/Qs = 6.8/3.0=2.3 PVR =(60-8)/6.8 =7.6 SVR =(65-6)/3.0=20.0 VSDfI02 = 1.0(PO2 included)

37. P02 not included Qp = 150/0.7 = 21.4 l/min/m2 Qs = 150/3.4 = 4.4 l/min/m2 Ql-r = 21.4-4.4=17.0 Qp/Qs =21.4/4.4=>4/1 PVR =(60-8)/21.4 =2.4 SVR =(65-6)/4.4=13.4 P02 included Qp = 150/2.2 = 6.8 l/min/m2 Qs = 150/5.0 = 3.0 l/min/m2 Ql-r = 6.8-3.0=3.8 Qp/Qs = 6.8/3.0=2.3 PVR =(60-8)/6.8 =7.6 SVR =(65-6)/3.0=20.0 VSD

38. VALVE AREA CALCULATION

39. VALVE AREA CALCULATION

40. VALVE AREA CALCULATION

41. OXYGEN DISSOCIATION CURVE

42. OXYGEN DISSOCIATION CURVE

43. OXYGEN DISSOCIATION CURVE

44. PRESSURE-VOLUME LOOPS

45. P-V LOOPS

46. P-V LOOPSPump Failure

47. P-V LOOPSPump Failure

48. P-V LOOPS