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Valvular Hemodynamics. Morton J. Kern, MD Professor of Medicine Chief of Cardiology Associate Chief Cardiology University California Irvine Orange, California. Hemodynamic Problems for the Cath Lab. Valvular heart disease: Aortic stenosis/insufficiency Mitral stenosis/insufficiency

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slide1

Valvular Hemodynamics

Morton J. Kern, MD

Professor of Medicine

Chief of Cardiology

Associate Chief Cardiology

University California Irvine

Orange, California

hemodynamic problems for the cath lab
Hemodynamic Problems for the Cath Lab
  • Valvular heart disease:
    • Aortic stenosis/insufficiency
    • Mitral stenosis/insufficiency
  • Intraventricular gradients
  • Pericardial effusion/tamponade
  • Constrictive/restrictive physiology
  • Coronary Hemodynamics
  • Intracardiac Shunts
slide3

Pa/Ao valves close

Pa/Ao valves open

Pa/Ao valves are closed

systole

Tri/MV valves open

Tri/MV valves close

Tri/MV valves open

=Valve action

slide4

BAMC Case #3117:

Patient: 61 yo male

Dx: 3V CAD

filter: 50 Hz/ sample 250 Hz

Normal LV and Aortic Pressure Fluid-filled system

micromanometer transducers Fluid filled, FA sheath

Pre Contrast

slide5

Aortic Stenosis

Congenital bicuspid aortic stenosis

Normal aortic valve

slide6

Mechanism of AS: LV-Ao Gradient

  • Consequences of LV-Ao Gradient:
  • late peaking Systolic murmur
  • Single A2
  • Slow pulse upstroke
slide7

Hemodynamics of AS

Peak to peak pressure gradients differ between ECHO and CATH

Peak instantaneous P-P

LV

Unshifted=larger Grad

Fusmann and Feldman T, Cath and CV Int 53:553;2001

slide11

Retrograde hemodynamic Assessment of Prosthetic Valves with a Pressure Wire

Parham and Kern, Cath and CV Int 53:553;2001

low gradient as ef 25 no cad valve replacement
Low Gradient AS. EF 25%, no CAD. Valve replacement?

P-P gradient 30mmHg

CO = 3.2l/m Fick

AVA = 0.7cm2

dobutamine challenge for lg as
Dobutamine challenge for LG AS

P-P = 50mmHg

CO = 4.2l/m

AVA = 0.6cm2

Base 10 Dob+Pace 80 20 Dob + Pace 95

slide14

What should you do with Symptomatic AS patient, low gradient, low flow? The Dobutamine Challenge

AVA = 0.7cm2

AVA = 1.0cm2

Fixed area

AVA = 1.5cm2

Grayburn, P. A. Circulation 2006;113:604-606

slide18

Hemodynamics of Aortic Insufficiency

  • Greatest Diastolic Gradient early
  • Volume filling LV is rapid
  • LVEDP will be high unless compensated
slide21

Normal LA and LV diastolic pressures

LA-LV Diastolic Gradient

slide27

Hemodynamics for the Cath Lab

Low Gradient AS

Complications of AVP – AI

AS vs. HOCM

Mitral Regurgitation after MVP for MS

Diastolic CHF – constrictive v Restrictive

Tamponade

IntracardiacShunts