Transcript Document 7110164

HEMODYNAMIC ASSESSMENT:
CARDIAC CATHETERIZATION
LABORATORY
William Hellenbrand MD
Director, Pediatric Cardiology
Morgan Stanley Children’s Hospital of New York - Presbyterian
Columbia University Medical Center
Komansky Center for Children’s Health
Cornell University Medical Center
CARDIAC
CATHETERIZATION
•
•
•
•
Cardiac output
Shunt & Resistance
Oxygen transport
Pressure-Volume loops
FICK PRINCIPLE
• The amount of flow through an organ or any circuit
may be determined if
• 1 - that organ consumes or secrets a given
substance
• 2 - the concentration of that substance can be
measured as it enters and leaves the organ
• 3 - The total amount of the substance consumed or
secreted can be measured per unit time
∆S/∆t
C2S – C1S
FICK PRINCIPLE
OXYGEN IN BLOOD
• When oxygen is exposed to blood it exists in 2
forms

Bound to hemoglobin
Each gram of Hgb is capable of binding 1.36
ml O2.
Therefore if the Hgb is 15 gm/100ml then the
maximal amount of oxygen(Capacity) that
can be taken up by Hgb is 20.4
ml/100ml(Vol%)
OXYGEN IN BLOOD
• When oxygen is exposed to blood it exists in 2
forms(cont)
• In solution in plasma –
At body temperature of 370 , there is .00003 ml of
O2 per one ml of plasma at a partial pressure of oxygen
of 1 mm Hg(1 torr)
Thus the solubility coefficient of oxygen in plasma
is 0.00003 ml/ml/mm Hg
Therefore the amount of dissolved oxygen in
plasma is equal to .003(PO2)
OXYGEN IN BLOOD
• Oxygen capacity = Hgb(gm/100ml)*1.36 ml O2/gm
= ml O2/100ml (Vol%)
• Oxygen saturation = proportion of O2 actually combined
with hemoglobin to the total capacity
• Oxygen content = Capacity*Saturation + .003*PO2
= ml/100ml (Vol%)
OXYGEN CONSUMPTION
• VO2 = VIFIO2 - VEFEO2
• If RER is 1 then VI = VE and all you need to
measure is VEFEO2
• RER = VCO2 / VO2
– RER is close to 1 with carbohydrate metabolism
– RER may be as low as 0.7 with mostly fat
metabolism
– Standard nomograms assume RER of 0.9
Oxygen Consumption
CARDIAC OUTPUT
SYSTEMIC BLOOD FLOW
Qs =
VO2
CaoO2 - CmvO2
Qp =
VO2
CpvO2 - CpaO2
If there is no shunt Qp = Qs
SHUNT CALCULATIONS
• Qs
=
VO2
CaoO2 - CmvO2
• Qp
=
VO2
CpvO2 - CpaO2
• Qep
=
VO2
CpvO2 - CmvO2
SHUNT CALCULATIONS
• SIMPLE SHUNT
– Ql-r = Qp - Qs
– Qr-l = Qs - Qp
• BIDIRECTIONAL SHUNT
– Ql-r = Qp - Qep
– Qr-l = Qs - Qep
RESISTANCE TO FLOW
• Poiseuille equation
Q = ∆Pπr4
8nl
1 = πr4
R
8nl
∆P = pressure drop
r
= radius
n
= viscosity
l
= length of tube
Q = ∆P
R
R = ∆P
Q
RESISTANCE
• SVR = AO(MEAN) - RA(MEAN)
Qs
• PVR = PA(MEAN) - LA(MEAN)
Qp
SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q
SOT = Q
X
X
OXYGEN CONTENT
[(1.36 X Hgb X O2 SAT) + (.003 X PO2)]
SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q
X
[(1.36 X Hgb X O2 SAT) + (.003 X PO2)]
Anemic Hypoxia:
 Hgb
Acute compensation  Q
Chronic compensation  Hgb
SOT 
SOT 
SOT 
SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q
X
[(1.36 X Hgb X O2 SAT) + (.003 X PO2)]
Hypoxic Hypoxia:
 02 SAT SOT 
Acute compensation  Q
SOT 
Chronic compensation Hgb,  Q SOT 
SYSTEMIC OXYGEN TRANSPORT
(SOT)
SOT = Q
X
[(1.36 X Hgb X O2 SAT) + (.003 X PO2)]
Stagnant Hypoxia:
Q
SOT 
 Hgb,  02 SAT
SOT 
(Low Cardiac Output)
Compensation
VSD
80/50
M=65
95
70
80/40
M=60
80
80 M=8
M=6
70
80/6
85
VSD
Room Air
• Hgb = 10.0 Vol%
• V02 = 150 ml/min/m2
• Saturations
–
–
–
–
–
Svc
Ra
Rv
Pa
Ao
= 70
= 70
= 85
= 80
= 95
• Pressures
–
–
–
–
–
Ra = 6(mean)
Rv = 80/6
Pa = 80/40 60(mean)
La = 8(mean)
Ao = 80/50 65(mean)
VSD
Room Air
• Capacity = 1.36*10 = 13.6
• Contents =
–
–
–
–
•
Ao =13.6*.95=12.9
Mv = 13.6*.70=9.5
Pa = 13.6*.80=10.9
Pv = 13.6*.95=12.9
S(a-v)02 difference
= 3.4
• P(a-v)02 difference = 2.0
• Qp = 150/2.0
– = 7.5 l/min/m2
• Qs = 150/3.4
– = 4.4 l/min/m2
• Ql-r = 7.5-4.4=3.1
• Qp/Qs = 7.5/4.4=1.7
• PVR =(60-8)/7.5 =6.9
• SVR =(65-6)/4.4=13.4
VSD
fI02 = 1.0
• Hgb = 10.0 Vol%
• V02 = 150 ml/min/m2
• Saturations
–
–
–
–
–
Svc
Ra
Rv
Pa
Ao
= 75 (45)
= 80
= 94
= 95 (85)
= 100 (600)
• Pressures
–
–
–
–
–
Ra = 6(mean)
Rv = 80/6
Pa = 80/40 60(mean)
La = 8(mean)
Ao = 80/50 65(mean)
VSD
fI02 = 1.0(PO2 not included)
• Capacity = 1.36*10 = 13.6
• Contents =
–
–
–
–
•
Ao =13.6*1.0=13.6
Mv = 13.6*.75=10.2
Pa = 13.6*.95=12.9
Pv = 13.6*1.0=13.6
S(a-v)02 difference
= 3.4
• P(a-v)02 difference = 0.7
• Qp = 150/0.7
– = 21.4 l/min/m2
• Qs = 150/3.4
– = 4.4 l/min/m2
• Ql-r = 21.4-4.4=17.0
• Qp/Qs =21.4/4.4=>4/1
• PVR =(60-8)/21.4 =2.4
• SVR =(65-6)/4.4=13.4
VSD
fI02 = 1.0(PO2 included)
• Capacity = 1.36*10 = 13.6
• Contents =
–
–
–
–
•
Ao =13.6*1.0+1.8=15.4
Mv = 13.6*.75+.15=10.4
Pa = 13.6*.95+.25=13.2
Pv = 13.6*1.0+1.8=15.4
S(a-v)02 difference
= 5.0
• P(a-v)02 difference = 2.2
• Qp = 150/2.2
– = 6.8 l/min/m2
• Qs = 150/5.0
– = 3.0 l/min/m2
• Ql-r = 6.8-3.0=3.8
• Qp/Qs = 6.8/3.0=2.3
• PVR =(60-8)/6.8 =7.6
• SVR =(65-6)/3.0=20.0
VSD
• P02 not included
• Qp = 150/0.7
– = 21.4 l/min/m2
• Qs = 150/3.4
– = 4.4 l/min/m2
• Ql-r = 21.4-4.4=17.0
• Qp/Qs =21.4/4.4=>4/1
• PVR =(60-8)/21.4 =2.4
• SVR =(65-6)/4.4=13.4
• P02 included
• Qp = 150/2.2
– = 6.8 l/min/m2
• Qs = 150/5.0
– = 3.0 l/min/m2
• Ql-r = 6.8-3.0=3.8
• Qp/Qs = 6.8/3.0=2.3
• PVR =(60-8)/6.8 =7.6
• SVR =(65-6)/3.0=20.0
VALVE AREA CALCULATION
VALVE AREA CALCULATION
VALVE AREA CALCULATION
OXYGEN DISSOCIATION
CURVE
OXYGEN DISSOCIATION
CURVE
OXYGEN DISSOCIATION
CURVE
PRESSURE-VOLUME
LOOPS
P-V LOOPS
P-V LOOPS
Pump Failure
P-V LOOPS
Pump Failure
P-V LOOPS