|Year : 2020 | Volume
| Issue : 4 | Page : 281-283
Manar Fawaz Fallouh, Abdulrahman Arabi
Department of Cardiology and Cardiovascular Surgery, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
|Date of Submission||12-Mar-2020|
|Date of Acceptance||12-Mar-2020|
|Date of Web Publication||14-Jan-2021|
Dr. Manar Fawaz Fallouh
Department of Cardiology, Heart Hospital, Hamad Medical Corporation, P. O. Box 3050, Doha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Fallouh MF, Arabi A. Hemodynamic Corner. Heart Views 2020;21:281-3
Invasive hemodynamics measurement used to be the cornerstone of understanding the pathophysiology of patients with cardiovascular diseases. Cardiologist and Cardiology Fellows were very familiar with performing invasive hemodynamic measurements and interpretation. The advancement of cardiac imaging enabled cardiologist to obtain accurate and reliable information without the need of invasive procedure, subsequently invasive hemodynamics became increasingly less relevant in the daily practice or in training programs. It became not unusual to see a cardiology fellow who finished three years of training without being exposed to performing full hemodynamic study.
The role of invasive hemodynamics became limited to cases where there is a discrepancy between the clinical presentation and findings on noninvasive imaging. Ironically, it is in such difficult and challenging scenarios, fellows with limited experience are requested to perform an accurate and advanced hemodynamic study.
With the advancement of cardiogenic shock management, mechanical circulatory devices, coronary physiology and structural heart disease interventions in past 10 years, invasive hemodynamic became a part of the daily practice in any advanced heart center. Cardiology Fellows in the cardiac intensive care unit, cardiac customization catheterization laboratory and advanced heart failure units need to be familiar with the performing and interpretation of right heart catheterization and other forms of invasive cardiac hemodynamics which can provide instantaneous information about the heart function and the circulatory system.
The purpose of this hemodynamic corner is to provide Cardiology Felloe's with the tools to understand invasive hemodynamic tracings and their interpretations using cases from the daily practice. We welcome-to this corner- submissions of invasive hemodynamic tracing or cases that carry educational value.
- Abdulrahman Arabi, MD, FACC
| A Hemodynamic Quiz|| |
The following arterial tracing was angiography in a 56 years-old male. obtained during a pre-operative coronary
Based on the analysis of this tracing, which of the following statements is correct about this patient?
A. Cardiac auscultation reveals a late peaking systolic murmur
B. This tracing was obtained from the femoral artery
C. There is an air bubble in the pressure line which makes the tracing uninterpretable
D. The patient has Hypertrophic Obstructive Cardiomyopathy.
| Answer|| |
The correct answer is A.
The following findings can be detected on this arterial pressure tracing:
- The arterial pressure upstroke starts immediately after the QRS complex (red line). This suggests that the tip of the catheter is in the central aorta. In contrast, the peripheral arterial pressure tracing (femoral, radial or brachial) waveform is delayed after QRS with higher systolic peak, late dicrotic notch and lower end diastolic runoff when compared to central aortic waveform 
- The peak of arterial pressure is delayed (blue line), it coincides with the end of T-wave. This is suggestive of pulsus tardus and it correlates with the late peaking murmur of aortic valve stenosis on physical examination
- There is a prominent anarcotic notch on the systolic upstroke (blue arrow), which is another finding suggestive of aortic valve stenosis. In severe aortic valve stenosis, the systolic upstroke starts normally then, it is sharply impeded as the aortic valve stops opening leading to this deflection called anarcotic notch
- Widened pulse pressure: Wide pulse pressure is defined as pulse pressure greater than 60mmHg or half of systolic pressure. In this case the pulse pressure is 65mmHg (>60mmHg and >½ Systolic pressure) which is suggestive of concomitant Aortic valve regurgitation
- The arterial waveform is not damped. A Damped wave form refers to the loss of pressure amplitude and dicrotic notch, it may result from contrast, blood or air bubbles in the tubing. In this case the contour of the arterial wave is well defined with a clear anacrotic and dicrotic notches (blue and red arrows respectively) thus, the presence of an air bubble is unlikely
- In hypertrophic obstructive cardiomyopathy, aortic upstroke is usually rapid. There may be a spike and dome-like pattern in the aortic pressure, reflecting the interventricular obstruction and transient reduction in stroke volume that occurs during LV systole, none of these findings is seen in this tracing.
| In Summary|| |
The tracing shows a late peaking aortic pressure systolic upstroke with a prominent anacrotic notch and widened pulse pressure.
The angiogram was performed prior to aortic valve replacement in the setting of sub-acute infective endocarditis and root abscess of a bicuspid aortic valve with severe aortic valve stenosis and aortic regurgitation.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hana, E. B. (2013). Practical Cardiovascular Hemodynamics.
New York: Demos Medical Publishing.