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Cardiac Catheterisation

Hemodynamic Principles the Fundamentals


Shunt Determinations
Normally, pulmonary blood flow and systemic blood flow are equal
most commonly used method for shunt determination in the cardiac
catheterization laboratory is the Oxymetric method
unexplained PAO2 saturation exceeding 80% should raise suspicion of L-
R shunt
unexplained arterial desaturation (<93%) may indicate R-L shunt
Arterial desaturation commonly results from
1. alveolar hypoventilation
2. oversedation from premedication,
3. pulmonary disease,
4. pulmonary venous congestion,
5. pulmonary edema, and
6. cardiogenic shock.
If arterial desaturation persists after the patient takes several deep
breaths or after administration of 100% oxygen, a right-to-left shunt is
likely.
Oxymetric Method
Oxymetric method is based on blood sampling from various cardiac
chambers for the determination of oxygen saturation.
L-R shunt is detected when a significant increase in blood oxygen
saturation is found between two right-sided vessels or chambers.
screening oxygen saturation measurement for L-R shunt is performed by
sampling of blood in SVC and PA
If the difference in oxygen sat between these samples is 8% or more, a L-
R shunt may be present, and an oximetry run should be performed.

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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oxygen saturation as it is withdrawn from the pulmonary artery through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

Shunt Detection & Measurement


Left-to-Right Shunt

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Shunt Detection & Measurement
Right-to-Left Shunt

Shunt Detection & Measurement


Indocyanine Green Method

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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)

Shunt Detection & Measurement


Oximetry Run

MVO2 is the average oxygen content of the blood in the chamber


proximal to the shunt.

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Shunt Detection & Measurement
Oximetric Methods

RA receives blood from several sources


SVC: Saturation most closely approximates true
systemic venous saturation
IVC: Highly saturated because kidneys receive 25% of
CO and extract minimal oxygen
Coronary sinus: Markedly desaturated because heart
maximes O2 extraction
flamm Equation: Mixed venous saturation used to
normalize for differences in blood saturations that
enter RA
3 (SVC) + IVC
Mixed venous saturation =
4

Measurement of Shunt

Shunt Detection & Measurement


Detection of Left-to-Right Shunt
Mean
Level of Differential
O2
shunt diagnosis
% Sat

Atrial ASD, PAPVR, VSD with TR,


(SVC/IVC RA) 7 Ruptured sinus of Valsalva,
Coronary fistula to RA
Ventricular
(RA RV) 5 VSD, PDA with PR,
Coronary fistula to RV

Great vessel Aorto-pulmonary window,


(RV PA) 5 Aberrant coronary origin,
PDA
ANY LEVEL
(SVC PA) 7 All of the above

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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

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.

Systemic circulation (Qs) utilizes MV RV LV


and Ao saturations

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

Detection Effective Pulmonary Blood Flow

Shunt Detection & Measurement


Effective Pulmonary Blood Flow

Effective Pulmonary Blood


Flow: flow that would be
present if no shunt were
present
Requires
MV = PA saturation
PV PA = PV - MV PBF

Effective Pulmonary O2 consumption O2 consumption


= =
Blood Flow
(Pv MV O2) x 10 (Pv Pa O2) x 10

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Left -Right Shunt

Shunt Detection & Measurement


Left-to-Right Shunt
Left to right shunt results in step-
up in O2 between MV and PA
Shunt is the difference between
pulmonary flow measured and
what it would be in the absence of
shunt (EPBF)
Systemic Blood Flow = EPBF
Left-Right Shunt = Pulmonary Blood Flow Effective Blood Flow
O2 consumption O2 consumption
=
(PvO2 Pa O2) x 10 (PvO2 MVO2) x 10
(AoO2 MVO2)
Qp / Qs Ratio = PBF / SBF =
(PvO2 PaO2)

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

Effective Pulmonary Blood


Flow: flow that would be
present if no shunt were
present
Requires
PV = Ao saturation
PV MV = Ao - MV SBF

Effective O2 consumption O2 consumption


= =
Pulmonary Flow
(Pv MV O2) x 10 (Ao MV O2) x 10

Right- Left Shunt

Shunt Detection & Measurement


Right-to-Left Shunt
Rt to lt shunt results in step-down
in O2 between PV and Ao
Shunt is the difference between
systemic flow measured and what
it would be in the absence of
shunt (EPBF)
Pulmonary Blood Flow = EPBF
Right-Left Shunt = Systemic Blood Flow Effective Blood Flow
O2 consumption O2 consumption
=
(AoO2 MVO2) x 10 (PvO2 MVO2) x 10
(AoO2 MVO2)
Qp / Qs Ratio = PBF / SBF =
(PvO2 PaO2)

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

PA - LA 0.25 1.5 20 120


PVR =
Qp

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

Right atrium PCWP


a wave 6 2-7 mean 9 4 - 12
v wave 5 2-7 Left atrium
mean 3 1-5 a wave 10 4 - 16
Right ventricle v wave 12 6 - 21
peak systolic 25 15 - 30 mean 8 2 - 12
end diastolic 4 1-7 Left ventricle
Pulmonary artery peak systolic 130 90 - 140
peak systolic 25 15-30 end diastolic 8 5 - 12
end diastolic 9 4-12 Central aorta
mean 15 9-19 peak systolic 130 90 - 140
end diastolic 70 60 - 90
mean 85 70 -105
Davidson CJ, et al. Cardiac Catheterization. In: Heart Disease: A Textbook of Cardiovascular Medicine,
Edited by E. Braunwald, 5th ed. Philadelphia: WB Saunders Company, 1997

Fick Oxygen Method: O2 Consumption


Polarographic O2 Method
Metabolic rate meter
Device contains a polarographic oxygen sensor cell, a hood, and a
blower of variable speed connected to a servocontrol loop with an
oxygen sensor.
The MRM adjusts the variable-speed blower to maintain a unidirectional
flow of air from the room through the hood and via a connecting hose to the
polarographic oxygen-sensing cell.

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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

VO2 = (FRO2 x VR) - (FMO2 x VM)


FRO2 = Fractional room air O2 content = 0.209
FMO2 = Fractional content of O2 flowing past polarographic cell

Fick Oxygen Method: O2 ConsumptionDouglas Bag Method


Volumetric technique for measuring O2
Analyzes the collection of expired air
Utilizes a special mouthpiece and nose clip so that patient
breathes only through mouth
A 2-way valve permits entry of room air while causing all expired
air to be collected in the Douglas bag
Volume of air expired in a timed sample (3 min) is measured with a
Tissot spirometer

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Fick Oxygen Method: O2 Consumption

Douglas Bag Method


Barometric pressure = _________ mm Hg
Barometric temperature = _________ C
Corrected barometric pressure = _________ mm Hg
pO2 room air = _________ mm Hg
pO2 expired air = _________ mm Hg
Tissot: initial = _________ cm
Tissot: final = _________ cm
Sample volume (oxygen analysis) _________ L
Correction factor _________ (standard tables)
Collection time _________ min

Fick Oxygen Method: O2 Consumption

Fick Oxygen Method: O2 Consumption

Douglas Bag Method


Step 1: Calculate oxygen difference
pO2 room air x 100
O2 content room air =
Corrected barometric pressure

pO2 expired air x 100


O2 content expired air =
Corrected barometric pressure

Oxygen difference =
O2 room air - O2 expired air = ______ mL O2 consumed / L air

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Fick Oxygen Method: O2 Consumption

Douglas Bag Method


Step 2: Calculate minute ventilation
Tissot difference = Tissot initial Tissot final = _____ cm
Tissot volume = Tissot difference x correction factor = _____ L

Total volume = Tissot volume + sample volume = _____ L

Ventilation volume (corrected to STP) =


Total volume expired air x correction factor = _____ L
Ventilation volume
Minute ventilation =
Collection time

Fick Oxygen Method: O2 Consumption

Douglas Bag Method


Step 3: Calculate oxygen consumption
O2 consumption = O2 difference x minute ventilation

O2 consumption
O2 consumption index =
Body surface area

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Commonly used Formulas

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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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