Atlas of Hemodynamic Tracings
Atlas of Hemodynamic Tracings
The first human cardiac catheterization is credited to Werner Forssmann who performed a right heart self-catheterization in 1929. Over the next 50 years, invasive hemodynamic assessment in the cardiac catheterization laboratory provided critical clinical data for the management of patients with structural heart disease. During the 1980s, the improvement in two-dimensional echocardiography and Doppler echocardiography allowed for a noninvasive assessment of patients with structural heart disease and shifted the evaluation of these patients from the catheterization laboratory to the echocardiography laboratory. However, it is important to note that despite the advances in echocardiography, there are inherent limitations to noninvasive hemodynamic assessment. Current guideline recommendations suggest that hemodynamic assessment in the catheterization laboratory be performed when noninvasive assessment is inconclusive or when there is a discrepancy between the severity of a patient’s symptoms and noninvasive testing. With the evolution of structural heart disease percutaneous intervention in the catheterization laboratory (transcatheter aortic valve replacement [TAVR], percutaneous mitral valve repair, balloon valvuloplasty), there has been a resurgence in the need for careful hemodynamic assessment both before and following these complex interventions. This chapter will provide a careful overview of the typical waveform tracings encountered on both right and left heart catheterization as well as typical findings encountered during percutaneous structural interventions.
II. NORMAL HEMODYNAMIC PRESSURE WAVEFORMS
FIGURE 23.1 Normal right atrial (RA) waveform tracing.
FIGURE 23.2 Normal right ventricular (RV) waveform tracing.
FIGURE 23.3 Normal pulmonary artery (PA) waveform tracing.
FIGURE 23.4 Normal pulmonary capillary wedge pressure (PCWP) waveform tracing.
TABLE 23.1 Normal Values
Normal Values (mm Hg)
Pulmonary capillary wedge pressure
III. VALVULAR STENOSIS
A. Aortic stenosis.
Simultaneous left ventricular (LV) and ascending aorta (Ao) waveform analysis is the optimal technique to assess aortic stenosis (AS). Analysis of these waveforms allows for calculation of the peak-to-peak gradient as well as the mean transvalvular gradient. The mean gradient is the integrated gradient between the left ventricle and the Ao over the entire systolic period and is the recommended value to assess the severity of obstruction (Figs. 23.5
FIGURE 23.5 Aortic stenosis with simultaneous left ventricular (LV) and aorta (Ao) waveform tracing.
FIGURE 23.6 Aortic stenosis (AS) with simultaneous femoral artery (FA) and left ventricular (LV) waveform tracing. Note temporal delay in peak FA pressure, which may lead to false elevation in mean gradient and overestimation of AS severity.
FIGURE 23.7 Aortic stenosis with pullback method from left ventricle (LV) to aorta (Ao) to calculate peak-to-peak gradient.
B. Mitral stenosis.
Invasive assessment of mitral stenosis is typically performed with simultaneous LV and pulmonary capillary wedge pressure (PCWP) waveform analysis to calculate the mean transvalvular gradient. While the mean PCWP typically reflects the mean left atrial pressure, it is important to note the limitations of this approach (Figs. 23.8
FIGURE 23.8 Mitral stenosis with simultaneous left ventricular (LV) and pulmonary capillary wedge pressure (PCWP) waveform tracing.
Mitral stenosis with simultaneous left ventricular (LV) and left atrial (LA) waveform tracing. Note the difference between using pulmonary capillary wedge pressure and LA pressure in gradient calculation given the delay in transmission of the LA pressure across the pulmonary vasculature (shaded graphic in black seen in Figure 23.8)
. This can lead to a falsely elevated transvalvular gradient and overestimation of valve stenosis severity.
C. Pulmonic stenosis.
Two-dimensional echocardiography with continuous wave Doppler examination characterizes the severity and anatomic abnormalities in cases of pulmonary stenosis. Catheter-derived transvalvular gradients are typically obtained during pulmonary valvuloplasty; the pre- and post-catheter-derived peak-to-peak gradients are measured (Figs. 23.10
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