HEMODYNAMICS

Jennifer Naiser, D.O.

Assistant Professor of Medicine
Division of Cardiology
University of North Texas Health Science Center
 Objectives

Define indications, contraindications, and

complications of hemodynamic monitoring.
Recognize Normal Hemodynamic
Waveforms
Identify causes for Abnormal Parameters
Define current utility of the modality
 Question 1
Which of the following is not an indication for
invasive hemodynamic monitoring?

A. Differentiation between hemodynamic and

cardiogenic shock.
B. Guidance and management of acute pulmonary
edema not responding to treatment.
C. Differentiation between causes of low cardiac
output.
D. Determination of whether pericardial
tamponade is present.
E. Guidance of perioperative management in
patients with compensated heart failure
undergoing low to moderate risk noncardiac
surgery.
 Question 1
Which of the following is not an indication for
invasive hemodynamic monitoring?

A. Differentiation between hemodynamic and

cardiogenic shock.
B. Guidance and management of acute pulmonary
edema not responding to treatment.
C. Differentiation between causes of low cardiac
output.
D. Determination of whether pericardial
tamponade is present.
E. Guidance of perioperative management in
patients with compensated heart failure
undergoing low to moderate risk noncardiac
surgery.
SWAN-GANZ CATHETER
 Swan-Ganz Catheter
Length: 110 cm
Material: Polyvinylchloride
Size: 7 French (double lumen)
7.5 French (triple lumen)
Balloon: 1.5 ml
Thermistor: 4 cm from distal tip
Ports: One at tip
One 30 cm from tip
Accessories: Fiberoptics Measure O2 Sat
Pacing Leads
SWAN-GANZ CATHETER
 Swan-Ganz Catheter
Placed into 8.5 Fr Introducer
Subclavian Vein
Internal Jugular Vein
Femoral Vein
Emerges from Introducer - Inflate
Balloon
Pressures Waveforms Used to Verify
Location
Check pCXR for Position
 Indications For Hemodynamic Monitoring

To differentiate causes of pulmonary edema

To differentiate cardiogenic vs.
noncardiogenic shock
Guidance of therapy in complex heart failure
w/ other organ failure
To determine the presence of pericardial
tamponade when other modalities are not
available.
Guidance of perioperative management in
pts with decompensated CHF undergoing
immediate or high risk noncardiac surgery
Others
 Contraindications
Absolute:
Right-sided Endocarditis
Mechanical Tricuspid or Pulmonic Valve
Prosthesis
Right-sided thrombus or tumor
Relative:
Coagulopathy
Recent placement of PPM or ICD
LBBB
Bioprosthetic tricuspid or pulmonic valve
 Complications
Bleeding
Pneumothorax
Arrhythmias Note: risk of thrombotic
Pulmonary Artery and infectious
Rupture complications
increases significantly
Thrombophlebitis
when catheter
Venous or remains >3 days
Intracardiac
Thrombus
Pulmonary Infarction
Infection
 Question 2

As the catheter moves from 1-4, name the cardiac chamber

represented by each waveform:
A. Right ventricle, right atrium, pulmonary artery, wedge
B. Right atrium, right ventricle, wedge, pulmonary artery
C. Wedge, pulmonary artery, right ventricle, right atrium
D. Right atrium, right ventricle, pulmonary artery, wedge
E. Wedge, right ventricle, pulmonary artery, right atrium
Swan-Ganz Catheter
Normal Right-Sided Pressures

RA: 0-7 mmHg

RV: 15-30/1-7 mmHg

PA: 15-30/8-15/10-17 mmHg

PAOP: Mean 6-12 mmHg

Question 3
A 45-year old Caucasian male presents to the ER
with progressive dyspnea over the past month.
He states that he could walk 3-4 blocks a month
ago but today can only walk 100 ft without having
to stop for shortness of breath. Today, he was
walking up a hill when he became dyspneic,
developed chest pain and was light-headed. He
thought he was going to pass out so sat down
and called 911. After 5-10 minutes, his
symptoms improved markedly with no treatment.
PMH: HTN, Hyperlipidemia, childhood heart
murmur
PSH: Hernia repair
SH: Current smoker (1 ppd)
FH: Father had MI at 78
Question 3
Physical Exam
VS: BP 105/65, HR 85, RR16
HEENT: NCAT, delayed carotid upstrokes, JVD-NR, low-
pitched carotid bruits bilat.
Chest: Symmetrical and CTA.
Cardiac: Regular with III/VI crescendo murmur loudest at
RUSB, nearly absent S2 and radiation to the carotids.
Ext: No edema, pulses 1+ bilaterally

Due to the chest pain, he underwent cardiac catheterization

during his hospitalization. Prior to coronary angiography,
left ventricular pressure measurements were routinely
taken. The operator has some difficulty in passing the
catheter into the ventricle.
 The following hemodynamic data was obtained:

LV AO

This hemodynamic wave-form indicates which of the following

valvular disorders?
A. Aortic insufficiency
B. Mitral Regurgitation
C. Mitral Stenosis
D. Aortic Stenosis
E. Tricuspid Regurgitation
Left Heart Catheterization
 Aortic Stenosis
Normally in systole the LV and Aortic
systolic pressure are nearly equal.
With AS, LV systolic pressure must
increase beyond Ao systolic pressure to
insure forward flow across the stenotic
valve.
This creates the gradient seen on aortic
pullback during left heart catheterization.
Question 4
A 55-year old female was brought to the ED by
ambulance after her husband noted increasing
somnolence and respiratory distress over the
past 24 hours. He states that she has been
suffering the flu for the past 2 weeks, with
increasing shortness of breath, cough, and
inability to perform normal activities without
becoming very winded. Her feet have been
swelling. For the last 4 days, she has been
sitting up in a recliner to sleep.
PMH: Severe HTN, DM, Hyperlipidemia
PSH: Chole, Hyst, Heart Cath 2 years ago showing
non-obstructive CAD
SH: Non-smoker, no Etoh
FH: Father DM, CVA Mother CHF
Question 4
PHYSICAL EXAM
General: The pt was obtunded, tachypneic, and pale.
VS: BP 78/palp, HR 112, RR 36
HEENT: NCAT, JVD elevated
Chest: Resp shallow, coarse rales bilaterally
Cardiac: PMI displaced to anterior axillary line in 7 th intercostal
space. Regular, tachy S1+S2+S3, III/VI SM LLSB
Abd: benign
Ext: cool, pale, 4+ pitting edema to the knees
Data: ECG sinus tach with LBBB
Pertinent Lab: CBC wnl, Na 126, K 3.3, Creat 2.1, BNP 5,427,
Trop <0.4.

The patient was emergently intubated and sent to the intensive

care unit where a Swan Ganz Catheter was placed.
Question 4
Which of the following is most likely to
represent this patients hemodynamic
profile?
A. PAWP 28 mmHg, CO 2.4 L/min
B. PAWP 11 mmHg, CO 6.2 L/min
C. PAWP 28 mmHg, CO 5 L/min
D. PAWP 12 mmHg, CO 2.4 L/min
E. PAWP 8 mmHg, CO 7 L/min
Question 4
Which of the following is most likely to
represent this patients hemodynamic
profile?
A. PAWP 28 mmHg, CO 2.4 L/min
B. PAWP 11 mmHg, CO 6.2 L/min
C. PAWP 28 mmHg, CO 5 L/min
D. PAWP 12 mmHg, CO 2.4 L/min
E. PAWP 8 mmHg, CO 7 L/min
 Cardiac Output
CO = SV x HR. Represents the amount of blood
pumped by the heart through the body in one
minute
Fick Method uses the amount of oxygen
extracted by the body as measured by the
arterial-venous O2 difference, to calculate CO.
Indicator Dilution Method (Thermodilution
Method) Consists of injecting a bolus of cold
saline in a proximal portion of the heart and
sampling the changes intermperature as the
solution mixes distally with warm blood.
Cardiac Output
Normal CO 4-7 L/min
Low CO, think LV failure.
High CO, think sepsis or anemia.

Cardiac Index: Calculated as a function of

BSA (used to take into account the
variation in cardiac output with body size).
L/min/m2.

Normal CI 2.5-4 L/min/m2

Pulmonary Capillary Wedge Pressure

Obtained by taking the Swan Ganz tip out

into the pulmonary artery and inflating the
balloon until it wedges up against the
arterial wall, pressure is measured at the
tip distal to the wedged balloon.
Approximates left atrial pressure which in
turn approximates left ventricular end
diastolic pressure.
Usually a representation of preload (think
volume status).
Normal PCWP 6-12 mmHg
Question 5
A 70 year-old female NH patient is brought
to the ED after being found unresponsive.
NH staff state that she was ok up until
yesterday but had not gotten out of bed
this morning as she usually does.
PMH: HTN, Hypothyroidism, Mild
Alzheimers Dementia, Incontinence
PSH: Hyst, Bladder suspension, Appi
Question 5
Physical Exam
VS: BP 82/40, HR 126, RR 22, T 103
HEENT: NCAT, Oral MM dry, JVD-NR
Chest: Clear
Cardiac: Tachy, PMI-ND, RR S1+S2, II/VI SM @
RUSB
Abd: BS+, No HSM, Withdraws to suprapubic
palpation
Ext: Dry, cool, no edema, pulses weak

The patient was intubated for airway protection and

brought to the ICU, where a Swan-Ganz
Catheter was placed.
Question 5
Which hemodynamic profile most likely
represents this patients clinical
presentation?
A. CO 5.0 L/min, SVR 1080 dynes/cm 5
B. CO 7.8 L/min, SVR 485 dynes/cm 5
C. CO 1.8 L/min, SVR 1522 dynes/cm 5
D. CO 1.8 L/min, SVR 485 dynes/cm 5
E. CO 7.8 L/min, SVR 1522 dynes/cm 5
Systemic Vascular Resistance
MAP-CVP x 80
CO
Resistance to blood flow offered by all of
the systemic vasculature (excluding the
pulmonary vasculature).
An indication of afterload
Things that cause vasoconstriction
increase SVR. Things that cause
vasodilation decrease SVR.
Typically affected by blood vessel diameter
and sometimes by blood viscosity.
Systemic Vascular Resistance
SVR is LOW in septic shock due to the
release of cytokines such as endotoxin, IL-
1, and TNF, which cause vasodilation.
SVR is HIGH in cardiogenic shock due to
activation of the Renin-Angiotensin-
Aldosterone system in the low-output state.
Angiotensin II causes vasoconstriction.
SVRI is the SVR indexed to BSA and is
commonly used.
Question 6
A 48 year old Hispanic female presents to the ED
with palpitations and respiratory distress. She
has had a 3 month history of progressive
dyspnea on exertion but this suddenly worsened
with the onset of palpitations, which have been
continuous for the last 10 hours.
PMH: Rheumatic fever at 12 yoa, heart murmur
noted in Mexico.
PSH, FH: Noncontributory
SH: Nonsmoker, No Etoh or drug use.
Question 6
Physical Exam:
VS: BP 100/52, P157 and irregular, RR 23
HEENT: NCAT, JVD is elevated
Chest: Few rales at bases
Cardiac: Irregularly irregular w/variable S1, S2, III/VI low-
pitched holodiastolic murmur at the apex
Extremeties: 1-2mm pitting edema to pretibial region

ECG: Atrial fibrillation with RVR

A valvular abnormality was noted on echocardiogram and in

anticipation of surgery, left and right heart catheterization
was ordered.
 Question 6
The following hemodynamic tracing indicates which valvular disorder:
A. Aortic stenosis
B. Aortic insufficiency
C. Mitral stenosis
D. Mitral regurgitation
E. Tricuspid regurgitation

PCWP

LV
 Question 6
The following hemodynamic tracing indicates which valvular
disorder:
A. Aortic stenosis
B. Aortic insufficiency
C. Mitral stenosis
D. Mitral regurgitation
E. Tricuspid regurgitation

PCWP

LV
Mitral Stenosis
Simultaneous measurement of PCWP and
LV pressures (R and LHC)
Remember that PCWP estimates LA
pressure so this technique measures the
gradient between the LV and LA indirectly.
Question 7
A 57 year old male presents to the ED with 2
month histrory of increasing abdominal
distension. Upon further questioning, he has
been experiencing increasing dyspnea on
exertion, pedal edema and exertional chest pain
for the last 4 or 5 months.
PMH: MI 2 years ago complicated by Dresslers
syndrome, DM, HTN, Hyperlipidemia, CRI
PSH: CABG x 3 vessles, 2 years ago.
SH: Nonsmoker, no Etoh, no drugs
FH: Father, Brother w/CAD & MI
Question 7
Physical Exam:
VS: BP 108/62, 110, 22
HEENT: NCAT, JVD elevated
Chest: Occasional crackles at bases
Cardiac: Regular, mildly tachycardic, Knock heard just after
S2 along the L sternal border
Abdomen: distended w/fluid wave
Extremeties: 3-4 mm pitting edema to pretibial region

EKG reveals sinus tachycardia, low voltage QRS, global T

inversions, Left atrial abnormality

A chest xray reveals a characteristic finding so R and L

Heart Catheterization was performed.
 Question 7

LV

RA

Name the pathology demonstrated on hemodynamic

measurement and indicated by equalization of RA, RV
diastolic, LA, and LV diastolic pressures and associated with
a rapid y descent and early rise (square root sign):
A. Cardiac tamponade
B. CHF
C. Constrictive pericarditis
D. Aortic Stenosis
E. Mitral Stenosis
 Question 7

LV

RA

Name the pathology demonstrated on hemodynamic

measurement and indicated by equalization of RA, RV
diastolic, LA, and LV diastolic pressures and associated with
a rapid y descent and early rise (square root sign):
A. Cardiac tamponade
B. CHF
C. Constrictive pericarditis
D. Aortic Stenosis
E. Mitral Stenosis
Constrictive Pericarditis
Most often idiopathic but can be post-viral
pericarditis, post-Dresslers syndrome,
seen in renal failure patients, etc.
Represented by an elevated mean right
atrial pressure with a rapid y-descent and
an early rise (square-root sign).
Also see equalization of right atrial, right
ventricular diastolic, left atrial, and left
ventricular diastolic pressures.
Constrictive Pericarditis
Symmetrical constriction of all 4 chambers
causes elevation and equalibrium of
diastolic pressures in all 4 chambers
Early rapid diastolic filling is abruptly halted
when intracardiac volume reaches the limit
set by the noncompliant pericardium (thus
the pericardial knock).
Virtually all diastolic filling occurs early in
the cycle, thus the acute dip and rise of the
pressure wave form (square root sign).