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obtains blood samples from SVC, IVC, RA , RV, and PA
In cases of interatrial or interventricular shunts, it is recommended to
obtain multiple samples from the high, middle, and low RA or the RV
inflow tract, apex, and outflow tract to localize the level of the shunt
Another method of Oxymetric determination of intracardiac shunts uses
a balloon-tipped fiberoptic catheter that allows continuous registration of
oxygen saturation as it is withdrawn from the pulmonary artery through
the right-heart chambers into the SVC and IVC.
Shunt Detection & Measurement
Indications
Arterial desaturation (<95%)
Alveolar hypoventilation (Physiologic Shunt) corrects with deep
inspiration and/or O2
Sedation from medication
COPD / Pulmonary parenchymal disease
Pulmonary congestion
Anatomic shunt (RtLt) does not correct with O2
Unexpectedly high PA saturation (>80%) due to LtRt shunt
Shunt Detection & Measurement
Methods
Shunt Detection
Indocyanine green method
Oxymetric method
Shunt Measurement
Left-to-Right Shunt
Right-to-Left Shunt
Bidirectional Shunt
Shunt Detection & Measurement
Indocyanine Green
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Indocyanine green (1 cc) injected as a bolus into right side of circulation
(pulmonary artery)
Concentration
measured from
peripheral artery
Appearance and
washout of dye
produces initial 1st
pass curve followed
by recirculation in
normal adults
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Shunt Detection & Measurement
Right-to-Left Shunt
631
Shunt Detection & Measurement
Oxymetric Methods
Obtain O2 saturations in
sequential chambers,
identifying both step-up
and drop-off in O2 sat
Insensitive for small
shunts (< 1.3:1)
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Shunt Detection & Measurement
Oximetric Methods
Measurement of Shunt
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Shunt Detection & Measurement
Oximetric Methods
Lungs
Fick Principle: The total uptake or
release of any substance by an organ is RA (MV) LA (PV)
the product of blood flow to the organ
and the arteriovenous concentration
difference of the substance.
RV LV
Pulmonary circulation (Qp) utilizes
PA and PV saturations
PA Ao
O2 content = 1.36 x Hgb x O2 saturation
O2 consumption
PBF =
(PvO2 PaO2) x 10
PA Ao
O2 content = 1.36 x Hgb x O2 saturation
Body
O2 consumption
SBF =
(AoO2 MVO2) x 10
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Shunt Detection & Measurement
Oximetric Methods
Fick Principle: The total uptake or
release of any substance by an organ is RA (MV) LA (PV)
the product of blood flow to the organ
and the arteriovenous concentration
difference of the substance.
Pulmonary circulation (Qp) utilizes PA
and PV saturations
RV LV
Systemic circulation (Qs) utilizes MV and
Ao saturations
PA Ao
O2 content = 1.36 x Hgb x O2 saturation
O2 consumption O2 consumption
PBF = SBF =
(PvO2 PaO2) x 10 (AoO2 MVO2) x 10
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Left -Right Shunt
ASD
VSD
Coronary Cameral Fistula
Ruptured Sinus of Valsalva
Partial Anomalous Pulmonary Venous Return
Aorto Pulmonary Window
PDA
Aberrant Coronary Origin
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Shunt Detection & Measurement
Effective Pulmonary Blood Flow
Tetralogy of Fallot
Eisenmenger Syndrome
Pulmonary arteriovenous malformation
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Total anomalous pulmonary venous return (mixed)
If a PV is not sampled, systemic arterial oxygen content may be
substituted, assuming systemic arterial saturation is 95% or more.
if systemic arterial saturation is less than 93%, a R-L SHUNT may be
present.
If arterial desaturation is present but not secondary to a right-to-left
shunt, systemic arterial oxygen content is used.
If a R-L shunt is present, PV oxygen content is calculated as 98% of the
oxygen capacity
flow ratio PBF/SBF (or Qp/Qs) is used clinically to determine the
significance of the shunt.
A ratio of less than 1.5 indicates a small left-to-right shunt, and a ratio of
1.5 to 2.0, a moderate-sized shunt.
A ratio of 2.0 or more indicates a large left-to-right shunt and generally
requires percutaneous or surgical repair to prevent future pulmonary or
RV complications.
A flow ratio of less than 1.0 indicates a net R-L shunt.
If oxygen consumption is not measured, the pulmonic-to-systemic blood
flow ratio may be calculated as follows:
where SAO2, MVO2, PVO2, and PAO2 are systemic arterial, mixed venous, PV
, and PA blood oxygen saturations
Estimation of Vascular Resistance
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Vascular resistance calculations are based on hydraulic principles of
fluid flow, in which resistance is defined as the ratio of the decrease in
pressure between two points in a vascular segment and the blood flow
through the segment.
Vascular Resistance
Definitions
Normal reference values
Woods Units x 80 = Metric Units
Systemic vascular resistance
Ao - RA 10 20
SVR = 770 1500
Qs
Pulmonary vascular resistance
Baim DS and Grossman W. Cardiac Catheterization, Angiography, and Intervention. 5th Edition. Baltimore:
Williams and Wilkins, 1996.
Vascular Resistance
Systemic Vascular Resistance
Increased
Systemic HTN
Cardiogenic shock with compensatory arteriolar constriction
Decreased
Inappropriately high cardiac output
Arteriovenous fistula
Severe anemia
High fever
Sepsis
Thyrotoxicosis
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Vascular Resistance
Pulmonary Vascular Resistance
Increased
Primary lung disease
Eisenmenger syndrome
Elevated pulmonary venous pressure
Left-sided myocardial dysfunction
Mitral / Aortic valve disease
Volume flows are expressed in liters per minute,
Pressures are expressed in (mm Hg).
Resistance in - resistance units (R units) expressed in mm Hg per liter per
minute, also called hybrid resistance units (HRUs).
These HRUs are sometimes referred to as Wood units
They may be converted to metric resistance units expressed in dynes-
sec-cm-5 by use of the conversion factor 80.
In pediatric practice, it is conventional to normalize vascular resistances
for body surface area (BSA), thus giving a resistance index.
SVRI equals SVR multiplied by BSA
PVRI equals PVR multiplied by BSA
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Hemodynamic Parameters
Reference Values
Hemodynamic Parameters
Reference Values
Average Range Average Range
641
Fick Oxygen Method: O2 Consumption
Polarographic O2 Method
VM = VR + VE - VI VE
VM = Blower Discharge Rate VI
VR = Room Air Entry Rate
VI = Patient Inhalation Rate VR VM
VE = Patient Exhalation Rate
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Fick Oxygen Method: O2 Consumption
Oxygen difference =
O2 room air - O2 expired air = ______ mL O2 consumed / L air
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Fick Oxygen Method: O2 Consumption
O2 consumption
O2 consumption index =
Body surface area
644
Commonly used Formulas
645
Calculation with Example
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TYPICAL ANGIOGRAPHIC PROJECTIONS AND LESIONS BEST IMAGED
Projection Degrees Vessel/Chamber Lesion(s)
Imaged
Long axial oblique 70 LAO, LV Membranous VSD,
30 cranial conotruncal VSD, LVOT
obstruction
Hepatoclavicular 45 LAO, LV AV canal defect, midmuscular
45 cranial VSD
Four chambers LV-RA connections
PS/PPS/TGA/DORV
Coarctation/PDA
Lateral 90 RV/branch PAs Coarctation/aortic valve
Descending aorta disease
LAO 6070 Aorta TOF/PA stenoses
LAO
LAO-cranial 15 LAO, MPA-branch origins ASD, PFO
30 cranial
Steep LAO-cranial 60 LAO, Atrial septum TOF/PS/DORV
15 cranial
AP-cranial 0 LAO, RV/conduits TGA/DORV/ anomalous CA
30 cranial origins
AP-caudal 0 LAO, Ascending TGA/DORV/peripheral PS
45 caudal aorta/coronary artery
origins
AP 0 RV, peripheral PAs Pulmonary vein
Pulmonary veins stenoses/anomalies of
origin/connection
RAO 30 RAO LV Anterior VSD, mitral valve
disease
Ao, aorta; ASD, atrial septal defect; AV, atrioventricular; CA, coronary artery; DORV,
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double-outlet right ventricle; LAO, left anterior oblique; LV, left ventricle; LVOT, left
ventricular outflow tract; PA, pulmonary artery; PDA, patent ductus arteriosus; PFO, patent
foramen ovale; (P) PS, (peripheral) pulmonary stenosis; RAO, right anterior oblique; RV, right
ventricle; TGA, transposition of the great arteries (L, left; D, right); TOF, tetralogy of Fallot;
VSD, ventricular septal defect.
Common Operations
ASD OS closure
Under GA & Supine position. Parts are painted &Draped. Chest opened
through Median sternotomy. Hemostasis achieved. Thymus removed.
Pericardium opened towards the rt. Side & stays put. Anatomy assessed.
Looked for LSVC & Rt. PAPVC.Systemic heparinisation done with 3-5mg/Kg
Heparin.Aortic & caval purstrings taken.Cardioplegia purstrings
taken.Cannulated with Aortic & two caval cannulae. Once ACT crossed 480
seconds went on CPB. Cardioplegia cannula put. Cavae looped & SVC snugged.
Aorta was cross clamped. Patient was cooled to 28 degree centigrade. Cold
blood antegrade cardioplegia used (20ml/kg). IVC snugged & RA opened
obliquely. Stays put on RA. Anatomy assessed. Mitral & tricuspid valve
checked for regurgitation. Pericardium was harvested as per the size of ASD. 4-
0/5-0 Polypropylene suture taken & 1st suture passed through the septum at
the 50 clock position & suturing was done towards the surgeon till upper edge
of the ASD. Reawarming started. Now the other end of the suture is used &
closure of the remaining part of the ASD done. Deairing of the left heart done
by asking anaesthetist to ventilate & hold the breath. Root vent connected,
trendlenberg position put. Cross clamped released. RA closed with 5-0
polypropylene suture. Right heart deaired after clamping the IVC cannulae&
releasing the snugger. Heart started beating into SR spontaneously. Came off
CPB gradually.Decannulated.Protamine given. Hemostasis achieved.
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