Cardiac catheterization techniques: Normal hemodynamics
- Morton J Kern, MD, MSCAI, FAHA, FACC
Morton J Kern, MD, MSCAI, FAHA, FACC
- Professor of Medicine
- University of California, Irvine
Hemodynamic data have always been, and remain, an integral part of all cardiovascular observations. Significant advances in both surgical and nonsurgical techniques for heart disease have been established in the last decade, in large part due to innovations both within and outside the cardiac catheterization laboratory. Many difficult forms of heart disease can now be readily confirmed with the improvement in two-dimensional and Doppler echocardiographic techniques. However, given the nature of clinical testing, there will always be suboptimal noninvasive examinations or patients in whom such testing cannot be performed. Thus, the catheterization laboratory remains critical to accurate measurements and the establishment of diagnoses. The presence of coexisting hemodynamic abnormalities in patients with coronary artery disease, myocardial infarction, cardiomyopathy, or peripheral arterial disease cannot be established without direct information.
VASCULAR ACCESS AND SPECIAL CATHETERIZATION TECHNIQUES FOR OBTAINING HEMODYNAMIC DATA
Routine catheter access is obtained from either the femoral or radial artery and a convenient vein in most situations. The radial artery approach has gained wide acceptance and demonstrated reduced bleeding complications relative to femoral artery access. Many laboratories now use radial access as the default approach for routine cardiac catheterization [1-4].
●Transseptal access to the left atrium or ventricle is most often employed when prosthetic valves are located either in the aortic or mitral positions. Direct left atrial pressure measurement via the transseptal approach is also highly desirable, if not critical, to accurate decision making in conditions such as mitral stenosis (image 1), in which the pulmonary capillary wedge pressure is unreliable as a surrogate for the left atrial pressure. Under fluoroscopic guidance the transseptal access is obtained using a Brockenbrough catheter that is passed through the atrial septum over a long needle that is used to puncture the septum at the fossa ovalis. This technique is commonly used for accurate assessment of mitral valve disease and as access for mitral balloon valvuloplasty and a clip technique for percutaneous repair of secondary mitral regurgitation.
●Direct left ventricular puncture through the left ventricular apex via the fifth intercostal space using echo-guided needle positioning is rarely used, but needed in patients with both aortic and mitral prosthetic valves. This technique is rarely used for diagnostic purposes but is applied for transapical aortic valve replacement. This method carries significant risk of bleeding and potential coronary artery damage.
- Hemodynamic Rounds: Interpretation of Cardiac Pathophysiology from Pressure Waveform Analysis, 3rd ed, Kern MJ, Lim MJ, Goldstein JA. (Eds), Wiley-Blackwell, Hoboken 2009.
- The Cardiac Catheterization Handbook, 6th ed, Kern MJ. (Ed), Elsevier, Philadelphia 2015.
- Interventional cardiac catheterization handbook, 3rd ed, Kern MJ. (Ed), Mosby, St. Louis 2011.
- Moscucci M. Grossman and Baim’s Cardiac Catheterization, Angiography, and Intervention, 8th ed, Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia 2013. p.223.
- Cardiac Catheterization and Angiography, 3rd ed, Grossman, W (Ed) (Eds), Lea & Febiger, Philadelphia 1986.
- Diagnostic and Therapeutic Cardiac Catheterization, Pepine, CJ (Ed) (Eds), Williams & Wilkins, Baltimore 1989.
- Kern MJ, Feldman T, Bitar S. Hemodynamic Data. In: The Cardiac Catheterization Handbook, 5th ed, Kern MJ. (Ed), Mosby-Year Book, St. Louis 2011. p.126.
- Nishimura RA, Carabello BA. Hemodynamics in the cardiac catheterization laboratory of the 21st century. Circulation 2012; 125:2138.
- Morgan BC, Abel FL, Mullins GL, Guntheroth WG. Flow patterns in cavae, pulmonary artery, pulmonary vein, and aorta in intact dogs. Am J Physiol 1966; 210:903.
- BRECHER GA, HUBAY CA. Pulmonary blood flow and venous return during spontaneous respiration. Circ Res 1955; 3:210.
- Willems, J, Roelandt, J, Kesteloot, H. The jugular venous pulse tracing. Proc Vth European Cong Cardiol Sept 1968. p.433.
- Tavel ME. Normal sounds and pulses: Relationships and intervals between the various events. In: Clinical Phonocardiography and External Pulse Recording, 2nd, Year Book Medical Publishers, Chicago 1972. p.35.
- Kern MJ. Avoiding pitfalls in hemodynamic diagnosis. In: ACC Current Journal Review, Knoebel SB (Ed) (Ed), 1997.
- Lorell BH, Paulus WJ, Grossman W, et al. Improved diastolic function and systolic performance in hypertrophic cardiomyopathy after nifedipine. N Engl J Med 1980; 303:801.
- Hayward CS, Kelly RP. Gender-related differences in the central arterial pressure waveform. J Am Coll Cardiol 1997; 30:1863.
- Smulyan H, Marchais SJ, Pannier B, et al. Influence of body height on pulsatile arterial hemodynamic data. J Am Coll Cardiol 1998; 31:1103.
- Kannam JP, Levy D, Larson M, Wilson PW. Short stature and risk for mortality and cardiovascular disease events. The Framingham Heart Study. Circulation 1994; 90:2241.
- Parker JO, Ledwich JR, West RO, Case RB. Reversible cardiac failure during angina pectrois: hemodynamic effects of atrial pacing in coronary artery disease. Circulation 1969; 39:745.
- Kern MJ. Hemodynamic Rounds: Interpretation of Cardiac Pathophysiology from Pressure Waveform Analysis, Wiley-Liss, New York 1993. p.41.
- Hemodynamic Rounds: Interpretation of Pathophysiology from Pressure Waveform Analysis, 3rd ed, Kern MJ, Goldstein J, Lim M (Eds), Wiley-Liss, New York 2010.
- VASCULAR ACCESS AND SPECIAL CATHETERIZATION TECHNIQUES FOR OBTAINING HEMODYNAMIC DATA
- ROUTINE HEMODYNAMIC MEASUREMENTS
- NORMAL WAVEFORMS
- Right atrium
- Jugular venous pulsations
- Right ventricle
- Pulmonary artery
- Pulmonary capillary wedge and left atrium
- Left ventricle
- - Left ventricular end-diastolic pressure
- Abnormal LVEDP
- SIMULTANEOUS LEFT VENTRICULAR AND RIGHT VENTRICULAR END-DIASTOLIC PRESSURES
- LEFT VENTRICULAR COMPLIANCE
- PULMONARY CAPILLARY WEDGE PRESSURE
- PCWP fidelity
- TIMING OF HEMODYNAMICS WITH THE ECG
- INFORMATION FOR PATIENTS