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1 30 July 2016 เอกราช อร ยะช ยพาณ ชย Heart Failure and Transplant Cardiology Disclosure Speaker, CME service: Merck, Otsuka, Servier Consultant, non-cme service: Novartis, Menarini 1

2 Agenda: Right heart cath How to perform Measuring pressure and CO Common calculations Common mistakes and pitfalls PA guided therapy Cardiac Catheterization: The use of a catheter(tube) into the heart. Right heart catheterization 1. Measure hemodynamics Pressure Cardiac outputs Resistant 2. Shunt study (step up O2Sat) 3. Vasoreactivity test 4. Others Drug / treatment delivery Trans-septal approach Hepatic wedge Comprehensive RHC+LHC Circulation. 2012;125:

3 Right heart cath : Indication DDx types of shock DDx type of pulmonary edema Dx PH Dx PAH, evaluate response to CCB Dx L R shunt Hemodynamic tailored therapy in HF Prognosticate severe HF and transplant candidacy No benefit shown in RCTs and should not be routinely use Multiple studies confirmed no benefit (survival or days in hospital) from PACs in any medical or surgical population. Am J Med , 449 3

4 Planning Pre-procedure Indication, contraindication Consent Procedure Technique Position/ Site Equipment Imaging guide Anesthesiology Post-procedure Care Complication Vascular access (+/- ultrasound guide) Right IJ, left SubCl, Fem, brachial Swann-Ganz cath, MPA wire + wedge cath (Berman) Fluoroscopy, echo Local PA cath placement Femoral approach The cardiac catheterization handbook / edited by Morton J. Kern. -- 5th ed 2011 Cardiac catheterization : an atlas and DVD / Michael Ragosta. -- 1st ed

5 Right heart cath : PA Catheter or Swan Ganz Catheter A 120-cm long, multi-lumen, balloon-tipped catheter Usually 7.5 fr Connected to a pressure transducer and temperature sensor Fluid-filled catheter 1.5 ml air syringe 4-5 lumens Transducer Catheter tip Changing mechanical to electrical signal Pressure bag 5

6 Micromanometer (Catheter-tip pressure manometer) High fidelity transducer catheter frequency response, artifact Research setting Measurement of myocardial mechanics (e.g. dp/dt) Pressure wire Obtaining sloppy, poor-quality information or misinterpreting waveforms can lead to major errors in diagnosis and management. 6

7 Zero and Level Zero: Open transducer to air and zero Physiologic measurements are made relative to atmosphere Make the transducer to read zero while exposed to the atmosphere Level: adjust transducer to Phlebostasis axis Intracardiac measurements are referenced to mid chest position Mid-chest from sternal angle (or Mid axillary line x 4th ICS) 7

8 Time the wave with the ECG. Pressure increase if Chamber size Volume compliance Pressure RA (6 mmhg) RV (24/6 mmhg) PA (24/12 mmhg) PCWP (12 mmhg) Rapid upstroke followed by Rapid upstroke with dicrotic a rapid downstroke. Rasing notch on down slope, down rending during diastole during diastole Venous waveform (2 up, 2 down per cardiac cycle) A: Atrial systole - Increased in RV infarct, PS, PE, Pul HTN - Giant Cannon a waves in A-V dissociation, 3'AV block, VT X: atrial relaxation - Increase in restrictive and constrictive disease - Decrease in severe tricuspid regurgitation C: bulging of the AV valve V: filling of atrium (atrial diastole) - large C-V waves in TR Y: emptying of the RA into RV - Increase in early restrictive, severe TR - Blunted in TS, RV infarct and frank tamponade. Pul Hypertension: mpa > 25 mmhg Venous waveform - confirm by O2sat > 95% - Surrogate of LV filling pressure 8

9 PCWP Balloon inflation obstructs blood flow End hold lumen connect with LA (surrogate of LV filling pressures) Verify waveform, fluoroscopy, and oximetry (>95%) Flow :Cardiac output measurement (indirect measure) CO by thermodilution: Indicator dilution method Technique: Injecting 10 ml of known temp NS to a proximal port and measure temp at distal port. Calculation = Reverse area/time under the curve CO by Fick: Gold standard Constant of mass. Technique: Collect mixed venous and arterial blood to calculate O2 content (O2Sat, Hb) Calculated = Product of O2 contents and extraction. CO = (VO2). 10 x 1.34Hb(SaO2 MvO2Sat) Limit in TR, shunt, low CO, rhythm disturbances, incorrect constant number.(crit Care Med 1993; 21:586) Limit in shunt Most cath lab use assumed VO2 inaccurate assumption of VO2 (circ 2014;129:203) 9

10 Flow : CO by thermodilution Single entry Known volume No re-circulate No contaminate Correct constant number Right heart cath : CO by Fick CO is calculated as oxygen consumption divided by the arteriovenous oxygen concentration difference CO = VO2 _ 10 x1.34xhb (SaO2 MvO2Sat) 10

11 Estimates of resting VO2 derived from conventional formulae are inaccurate, especially in severely obese individuals. Circulation. 2014;129:

12 Calculation SVR PVR TPG SV CI Right heart cath : calculation Parameter and relations V = I R CO BSA CI = CO BSA HR SV = CO HR SVI = SV BSA SVR = ( MAP CVP ) x 80 CO PVR = ( mpa PCWP ) CO TPG = mpa PCWP Ao Normal value and unit BP = CO x SVR = 5 L/min = 2 m2 = 2.5 L/min/m2 = 70 bpm = 70 ml/beat = 35 ml/beat/m2 = 1300 dynes.sec/cm5 = 1 wood unit = 5 mmhg = 120/80 mmhg A O2sat = % Mixed V O2sat = 75 % A V O2 content difference = = 5 ml/dl LVSWI = SVI x (MAP-PCWP) x = g/m2/beat RVSWI = SVI x (mpa-cvp) x = 5-10 g/m2/beat 12

13 Right heart cath : Shunt study (O2 step up) Diagnosis of L R shunt Blood sample at many location The cardiac catheterization handbook / edited by Morton J. Kern. -- 5th ed 2011 CO measurement in patient with shunt 13

14 Inaccurate measurement due to Improper zero level reference Influence of respiratory pressure End expiratory Sunrise and Valley Do not use computer reading number Partially wedge Dampening / overdamp Inaccurate measurement: Digital PCWP vs End-expiratory PCWP Prospective 61 PH patients mean bias of 4.4 mm Hg (95% limits of agreement of 11.3 to 2.5 mmhg) Ryan JJ. Am Heart J. 2012;163(4):

15 Inaccurate measurement: :Partially wedge When suspect 1. Check waveform 2. Check position 3. Check wedge O2Sat Tonelli A, et al CHEST 2009;136(1):37-43 Important of PCWP in PH WHO Category 2 PH due to heart heart disease mpa 25mmHg PCWP > 15mmHg 2015 ESC/ERS Guidelines for PH 15

16 Vasoreactivity Test To identification patient who is CCB responders Mean PA fall 10 mmhg and to 40 mmhg Unchanged or increased CO Most data from ipah Only 5-10% of patient response Not recommend for gr 2, 3, 4, and 5 May be harmful and misleading 16

17 2009 ACC/AHA Guidelines for PH 2015 ESC/ERS Guidelines for PH Inaccurate measurement due to Improper zero level reference Influence of respiratory pressure End expiratory Sunrise and Valley Do not use computer reading number Partially wedge Dampening 17

18 Dynamic frequency response Specific property of each fluid filled system A pressure change at the end of a catheter will cause a system to oscillate at it natural frequency and will decay accordance with the damping coefficient Depend upon radius, length, fluid density, viscosity Critically damp It would be ideal if the pressure variations at the catheter tip were exactly reproduced into transducers. Measuring principle of arterial wave. McDonalds Effect of damping coefficient Too low damping coefficient Underdamp Cause resonate 18

19 Practical Damping Underdamp Overdamp To low reading Damping Thrombus formation Air bubbles Blood Loose connection Too small tube Against vessel wall Kinking Right heart cath : Complication Vascular access Bleeding, pneumothorax, hemothorax, air embolism Arrhythmia PVC, VT (3%) RBBB (3 rd degree AV block in preexisting LBBB) (5%) Knotting Balloon PA rupture (Over wedge) Pulmonary infarct Wrong data is worse than no data. 19

20 Recommend readings Kern s hand book CV hemodynamics for clinician McDonalds Uptodate Thank you aekarach.a@chula.ac.th 20

21 Back up slide Whipping artifact 21

22 Ultrasound guide o Linear vascular probe o Place in a sterile sheath o Vein = Thin wall, compressible, continuous color o Needle is bright echogenic olook at the tip of the needle o Learning curve o success, complication o procedure time RVSP from Doppler echocardiogram Am J Respir Crit Care Med Vol 179. pp , 2009 CHEST 2011; 139(5):

23 large-bore end-hole catheter. Confirmation of PCWP by waveform contour and O2sat (>95%) Choosing vascular approach : Depend upon expertise, anatomy, risk Location Advantage Disadvantage Internal Jugular Subclavian Femoral Easy to control bleeding Less pneumothorax Straight shot to RA Compressible Excellent US target Most comfortable for pt. Easy dressing Less DVT, less arterial inj, less infection Bony landmarks in obesity Fast, easy, high success rate Not interfere with intubation, CPR No pneumothorax Compressible No need for trendelenburg Difficult in large neck, intubate. Poor landmark Carotid a inj Difficult dressing Higher pneumothorax Cannot compress malposition No not do it lung, coagulopathy Dirty / infect High rate of arterial inj High rate of DVT Pt cannot mobile Cannot monitor CVP 23

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26 Nobel prize in medicine Werner Forssmann - First central line 1929, at that time a surgical Intern. Pop test 26