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Hemodynamic Conference

Hemodynamic Conference. Eckhard Alt, M.D. Holger Salazar, M.D. Robert Smith, M.D., M.Sc. Tulane University School of Medicine Cardiac Cath Conference December 23, 2003. Outline. Right Heart Catheterization Overview Review of Waveform Analysis Practice Case

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Hemodynamic Conference

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  1. Hemodynamic Conference Eckhard Alt, M.D. Holger Salazar, M.D. Robert Smith, M.D., M.Sc. Tulane University School of Medicine Cardiac Cath Conference December 23, 2003

  2. Outline • Right Heart Catheterization Overview • Review of Waveform Analysis • Practice Case • Case Presentation with RHC Results • Discussion of Differential Diagnosis • Review of Echocardiographic Findings and Follow up • Discussion

  3. Right Heart Catheterization • Measures Central Venous Pressure/Right Atrial Pressure • Measures RV Pressures and PA Pressures • Gives Indirect Measure of Left Atrial Pressure (PCWP) • Avoids Septal Puncture • Estimates Cardiac Output • Quantifies Oxygen Utilization • Useful in Diagnosis of Shock Etiology • Useful for Peri-Operative Volume Management

  4. Pressure Waveforms

  5. Practice Case

  6. RA

  7. RV

  8. PA

  9. PCW

  10. Diagnosis?

  11. M5

  12. M12

  13. Diagnosis Non-Ischemic Cardiomyopathy

  14. Case Presentation CC is a 19 yo AAM with no significant PMHx who presented with a 2 year history of progressive abdominal distention. Pt. reported that the abdominal distention had particularly worsened during the six months prior to presentation and he presented to the medicine clinic at the insistence of his family. He reported that he was active in sports and denied LE edema, SOB, PND, and orthopnea. In fact, he reported that, aside from his worsening abdominal distention, he generally felt well. He was admitted from the clinic for workup of his abdominal distention.

  15. PMHx: None Medications: None Family History: No family h/o heart disease Social History: Denies EtOH, Tobacco, Drugs. One lifetime sexual partner

  16. Physical Exam • 123/72 62 16 97.2 • Comfortable, NAD • JVD present at 9 cm, + hepatojugular reflux • nlS1S2, 2/6 HSM  apex • Decreased breath sounds at bilateral bases • Abd distended with + fluid wave. Liver was palpable 3 cm below the costal margin and the spleen tip was palpable • No LE edema

  17. Na 134 K+ 3.9 Cl- 100 HCO3- 27 BUN 13 Cr 0.9 Glucose 89 Ca 8.9 LDH 118 AST 37 ALT 11 AP 75 TP 7.9 Alb 3.0 TB 1.8 CK 21 CKMB 0.4 Troponin <0.05 TSH 3.17 Labs

  18. WBC 12.2 Hgb 12.2 Hct 36.6 Plt 190 MCV 90 Neutrophils 70% Lymphocytes 22% Basophils 0% Eosinophils 1% Monocytes 7% INR 1.4 PTT 35.6 Blood Cultures Drawn Labs (cont)

  19. Ascites Fluid • Clear and Yellow • WBC’s 21 • RBC’s 453 • Albumin 2.6 • TP 4.8 • LDH 74 • Glucose 104 • Cholesterol 20 • Gram Stain and cultures sent • Cytology sent

  20. ECG

  21. CC

  22. CC

  23. CC

  24. CC

  25. CC

  26. During this admission, a TTE was performed and showed a large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.The echocardiographic findings will be discussed at the end of the case.

  27. C5

  28. C8

  29. C2

  30. RA

  31. RV

  32. PA

  33. PCW

  34. RV/LV

  35. Differential Diagnosis • Constrictive Pericarditis • Restrictive Cardiomyopathy

  36. Common Causes -Idiopathic -Infection Bacterial: TB Fungal: Histoplasmosis, Coccidiomycosis Viral: Coxsackie Parasitic: Amebiasis, Echinococcus -Drugs -Neoplastic Lymphoma, Melanoma, Primary Mesothelioma, Breast & Lung cancer -Following Cardiac Surgery -Connective Tissue Disease RA, SLE, Scleroderma, Dermatomyositis -Trauma -Renal Failure -Radiation -AICD/Pacer placement Uncommon causes -Sarcoidosis -Post MI -Asbestosis -Amyloidosis -Drug Induced Lupus -Acute Rheumatic Fever Rare Causes -Actinomycosis -Asbestosis -Whipples Disease -Lassa Fever -Sclerotherapy of Esophageal Varices Etiologies of Constrictive Pericarditis

  37. Primary RCM -Loeffler’s cardiomyopathy -Idiopathic RCM -Endomyocardial Fibrosis Secondary RCM Infiltrative Noninfiltrative -Sarcoidosis -Fabry’s Disease -Amyloidosis -Hemochromatosis -Post Radiation -Glycogen Storage Therapy Disease -Gaucher’s Disease -Scleroderma -Hurler’s Disease -Pseudoxanthoma Elasticum -Storage Disease Restrictive Cardiomyopathy

  38. Echocardiographic Presentation Holger Salazar, M.D.

  39. Chene3-23

  40. Chene3-8

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