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Hemodynamics: essentials for future TAVR and mitral valve disease
Morton J. Kern, MDProfessor of Medicine
Chief of CardiologyAssociate Chief CardiologyUniversity California Irvine
Orange, California
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Etiology of Aortic Stenosis From the Euro Heart Survey
Goldbarg, S. H. et al. J Am Coll Cardiol 2007;50:1205-1213
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J Am Coll Cardiol. 2012;60(3):169-180.
Pathophysiology of AS
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Tri/MV valves open
Pa/Ao valves are closed
Pa/Ao valves open
Tri/MV valves close
Pa/Ao valves close
Tri/MV valves opensystole
=Valve action
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Mechanism of AS: LV-Ao Gradient
Consequences of LV-Ao Gradient:
1. late peaking Systolic murmur
2. Single A23. Slow pulse upstroke
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BAMC Case #3117: Patient: 61 yo maleDx: 3V CAD filter: 50 Hz/ sample 250 Hz
Pre ContrastNormal LV and Aortic Pressure Fluid-filled system micromanometer transducers Fluid filled, FA sheath
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P-P gradMean Grad
Peak instantaneous vs P-P
Unshifted=larger Grad
LV
Fusberg and Feldman T, Cath and CV Int 53:553;2001
Hemodynamic Technique
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Techniques for Aortic Valve Gradient Measurement
• Single Catheter LV-Ao pullback• LV and Femoral Sheath• LV and Long aortic sheath• Bilateral femoral access• Double-lumen pigtail catheter• Transeptal LV access with ascending Ao• Pressure Guidewire with ascending Ao• Multi-transducer micromanometer catheters
Fusberg and Feldman T, Cath and CV Int 53:553;2001
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Calculating Aortic Valve Area• AVA: Gorlin equation
• AVA: Hakke formula (“poor man’s Gorlin”)– Assumes HR*SEP*44.3 = 1000 in most patients– Valid for HR ~65-100
AVA = cardiac output (L/min)/√Peak-Peak Pressures
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Grading Severity of Aortic Stenosis
AVA AVA IndexAortic Stenosis (cm2) (cm2/m2)
Mild >1.5 >0.9
Moderate 1.1-1.5 >0.6-0.9
Severe <0.8-1.0 <0.4-0.6
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Hemodynamic Differentiation of LVOT Obstruction
AS HOCM
3 Differentiating featuresa. Aortic upstrokeb. Pulse pressurec. Contour –spike/dome
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Low Gradient, Low EF AS?
LVEF 25%P-P gradient 30mmHgCO = 3.2l/m FickAVA = 0.7cm2
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Base 10 Dob+Pace 80 20 Dob + Pace 95
Dobutamine challenge for LG AS
P-P = 50mmHgCO = 4.2l/m
AVA = 0.6cm2
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Grayburn, P. A. Circulation 2006;113:604-606
What should you do with Symptomatic AS patient, low gradient, low flow? The Dobutamine Challenge
AVA = 0.7cm2
AVA = 1.0cm2
AVA = 1.5cm2
Fixed area
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Chiam, P. T.L. et al. J Am Coll Cardiol Intv 2008;1:341-350
Edwards-Sapien PHVCoreValve PHV
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Pre- Post 26mm Sapien Edwards
Anachrotic shoulder, dichrotic notch
Diastolic dysfunction?Delayed upslope
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AS+AI
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Normal LA and LV diastolic pressures LA-LV Diastolic Gradient
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PCW does not always equal LA
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Hemodynamics and Doppler Echo findings before MVBP
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Hemodynamic and Doppler Echo findings after MVBP
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Hemodynamics for Structrual Heart Disease
Low Gradient ASComplications of AVP – AIAS vs. HOCMMitral Regurgitation after MVP for MSDiastolic CHF – constrictive v RestrictiveTamponade
For your own review consider Intracardiac Shunts