Textbook of Clinical Hemodynamics - 2nd Edition

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TEXTBOOK
OF CLINICAL
HEMODYNAMICS
EDITION 2
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TEXTBOOK
OF CLINICAL
HEMODYNAMICS
EDITION 2

MICHAEL RAGOSTA, MD, FACC, FSCAI

Professor of Medicine
Director, Cardiac Catheterization Laboratories
Division of Cardiovascular Medicine
University of Virginia Health System
Charlottesville, Virginia
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

TEXTBOOK OF CLINICAL HEMODYNAMICS, EDITION 2 ISBN: 978-0-323-48042-0

Copyright © 2018 by Elsevier Inc. All rights reserved.

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Previous edition copyrighted in 2008.

Library of Congress Cataloging-in-Publication Data

Names: Ragosta, Michael, author.
Title: Textbook of clinical hemodynamics / Michael Ragosta.
Description: Second edition. | Philadelphia, PA : Elsevier, [2018] | Includes
bibliographical references and index.
Identifiers: LCCN 2017004619 | ISBN 9780323480420 (hardcover)
Subjects: | MESH: Hemodynamics | Heart Diseases--diagnosis | Heart Function
Tests
Classification: LCC RC670.5.H45 | NLM WG 106 | DDC 616.1/0754--dc23 LC record available at
https://lccn.loc.gov/2017004619

Content Strategists: Maureen Iannuzzi, Robin Carter

Senior Content Development Manager: Kathryn De Francesco
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Book Designer: Ryan Cook

Printed in China.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

CONTRIBUTORS

Vishal Arora, MD Michael Ragosta, MD, FACC, FSCAI

Associate Professor of Medicine Professor of Medicine
Division of Cardiology Director
Medical College of Georgia Cardiac Catheterization Laboratories
Augusta University Division of Cardiovascular Medicine
Augusta, Georgia University of Virginia Health System
Charlottesville, Virginia
Lawrence W. Gimple, MD
Professor of Medicine LaVone A. Smith, MD
Division of Cardiovascular Medicine Division of Cardiovascular Medicine
University of Virginia Health System University of Virginia Health System
Charlottesville, Virginia Charlottesville, Virginia
Michael R. Hainstock, MD Angela M. Taylor, MD, MS
Assistant Professor Associate Professor of Medicine
Division of Pediatric Cardiology Division of Cardiovascular Medicine
University of Virginia Health System University of Virginia Health System
Charlottesville, Virginia Charlottesville, Virginia
Jamie L.W. Kennedy, MD
Assistant Professor of Medicine
Division of Cardiovascular Medicine
University of Virginia Health System
Charlottesville, Virginia

v
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PREFACE

The entire field of cardiovascular medicine is rooted in the invasive study of hemodynamics. Our cur-
rent understanding of the physiology of the heart in both health and disease states is based upon the
observations of countless physicians who tirelessly studied pressure waveforms and blood flow in the
cardiac chambers. Assessment of hemodynamics is an established component of cardiac catheterization
protocols; however, many cardiologists and cardiology training programs neglect classic hemodynamic
assessment, emphasizing instead the skills involved in angiography and intervention or the noninvasive
imaging modalities, such as echocardiography, cardiac computed tomography, and magnetic resonance
imaging. Whereas there is no doubt that these imaging techniques allow unprecedented and exquisite
anatomic details of the cardiovascular system, they have limitations regarding their ability to assess the
physiologic impact of a cardiac condition. Patients undergoing cardiac catheterization may be misdiag-
nosed or their condition may be mischaracterized because of errors in hemodynamic measurement or
interpretation. Furthermore, the current explosion in the field of structural heart interventions has led to a
resurgence of interest in hemodynamics as some of the neglected hemodynamic principles and practices
have assumed greater importance during these procedures. Thus it is imperative for an astute cardiologist
to be well versed in clinical hemodynamics and invasive physiologic assessment in order to correctly use
and interpret diagnostic tests and to diagnose and treat many cardiac diseases.
It is the goal of this textbook to provide instruction in clinical hemodynamics from the analysis of
waveforms generated in the cardiac catheterization laboratory. Normal physiology as well as the entire
spectrum of pathophysiologic states encountered in the cardiac catheterization laboratory and intensive
care unit are covered extensively and heavily illustrated using authentic hemodynamic waveforms col-
lected in routine clinical practice. The second edition has been extensively updated and revised with the
reorganization of material and the addition of more than 100 new figures. The chapters on aortic and mitral
valve disorders have been updated to highlight the interesting hemodynamic findings associated with
transcatheter valve therapies, and both Chapter 8, focusing on pulmonary hypertension, and Chapter 10,
focusing on heart failure, shock, and ventricular support devices, are entirely new and represent unique and
valuable additions to the book.
This work is designed for use by cardiology fellows (including fellows in general cardiology training
as well as interventional and structural heart cardiology fellows), practicing cardiologists and interventional
cardiologists preparing for board examination or maintenance of certification, and cardiac catheterization
laboratory nurses and technicians. Cardiology nurse practitioners, physician assistants, coronary care unit
nurses, critical care physicians, and internal medicine residents may also find the information interesting
and useful in their clinical practice.

Michael Ragosta, MD

vii
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CONTENTS

CHAPTER 1 INTRODUCTION TO HEMODYNAMIC ASSESSMENT IN THE CARDIAC

CATHETERIZATION LABORATORY 1
Michael Ragosta

CHAPTER 2 NORMAL WAVEFORMS, ARTIFACTS, AND PITFALLS 17

Michael Ragosta and Jamie L.W. Kennedy

CHAPTER 3 CARDIAC OUTPUTS AND SHUNTS 56

Vishal Arora and Lawrence W. Gimple

CHAPTER 4 MITRAL VALVE DISORDERS 66

Michael Ragosta

CHAPTER 5 AORTIC VALVE DISEASE 88

Michael Ragosta

CHAPTER 6 HYPERTROPHIC CARDIOMYOPATHY AND RELATED CONDITIONS 118

Michael Ragosta

CHAPTER 7 RIGHT-SIDED HEART DISORDERS 143

Michael Ragosta

CHAPTER 8 PULMONARY HYPERTENSION AND RELATED DISORDERS 163

LaVone A. Smith and Jamie L.W. Kennedy

CHAPTER 9 PERICARDIAL DISEASE AND RESTRICTIVE MYOCARDIAL DISEASES 182

Michael Ragosta

CHAPTER 10 LEFT-VENTRICULAR HEMODYNAMICS, HEART FAILURE, AND SHOCK 216

Angela M. Taylor

CHAPTER 11 CONGENITAL HEART DISEASE 249

Michael R. Hainstock

CHAPTER 12 CORONARY AND PERIPHERAL ARTERY HEMODYNAMICS 270

Michael Ragosta

APPENDIX 1 HEMODYNAMIC EQUATIONS AND FORMULAS 302

Michael Ragosta

  

ix
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INTRODUCTION
TO HEMODYNAMIC

CHAPTER 1
ASSESSMENT IN THE
CARDIAC CATHETERIZATION
LABORATORY
Michael Ragosta

“Look into any man’s heart you please, and you will always find, in every one, at least one black spot which he
has to keep concealed.”
Pillars of Society, act III
Henrik Ibsen, 1877

Despite the exhortations of poets and philosophers, the heart is, after all, simply a pump. The ability to “look
into any man’s heart” with the goal of understanding the function of this mysterious organ circumvented
early generations of scientists and physicians. It would not take long, however, for science to garner the
tools needed to peer into the hearts of men. Many of the major functions of the cardiovascular system
important to our understanding of health and disease states are based on mechanical processes. Cardiac
chambers contract and relax, valves open and close, and blood ebbs and flows based upon elementary
principles of hydraulics. Contrast this with most other organ systems that exploit complex cellular and
biochemical processes to accomplish their designated functions. For example, the kidneys balance fluid
and electrolytes and excrete waste via an elaborate cellular array; the liver, pancreas, and intestinal cells
digest food and absorb nutrients by a series of complicated biochemical steps, and muscle cells exert
their cumulative toil through the elegant dance of complex protein molecules. The latter secrets eluded
physicians and scientists, until only recently, when highly sophisticated tools became available to reveal the
intricate and minute processes.
Many of the mechanical processes inherent to cardiac physiology can be understood by measuring
changes in blood pressure and blood flow; the term hemodynamics refers to this discipline. Numerous
brilliant investigators over many years applied the study of hemodynamics to collectively expand our
knowledge of cardiovascular physiology in both normal and pathologic conditions. The lessons learned from
these generations of researchers rapidly became assimilated into the contemporary practice of clinical
cardiology. Currently, hemodynamics is considered indispensable to the clinician managing patients with
cardiovascular disease and forms the foundation of invasive and interventional cardiology.

A BRIEF HISTORY OF HEMODYNAMIC ASSESSMENT

All-important human endeavors possess histories replete with colorful anecdotes and legendary characters.
The saga of cardiac catheterization is no exception.
The practical measurement of hemodynamics in humans required several crucial developments.
These included the invention of safe and reliable catheterization techniques to access and study the right
and left sides of the heart, the ability to image catheter position, and the creation of devices to convert
pressure changes into an interpretable graphic form.
Insertion of tubes into the bladders and rectums of living persons and the blood vessels of cadavers
had been achieved since primitive times.1 The first cardiac catheterization and pressure measurement
performed on a living animal is attributed to the English physiologist Stephen Hales early in the 1700s and
reported in the book Haemastaticks in 1733. By accessing the internal jugular vein and carotid artery of a
horse, Hales performed his experiments using a brass pipe as the catheter connected by a flexible goose
1
 2  TEXTBOOK OF CLINICAL HEMODYNAMICS

Or D

'''

Vent D D

''''

Vent G D'

Fig. 1.1. Early pressure recordings obtained from the cardiac chambers of a horse by Marey and Chauveau. (From Mueller
RL, Sanborn TA. The history of interventional cardiology: cardiac catheterization, angioplasty, and related interventions. Am
Heart J. 1995;129:146–172.)

trachea to a long glass column of fluid. The pressure in the white mare’s beating heart raised a column of
fluid in the glass tube over 9 feet high.1
As early as 1844, the famous French physiologist Claude Bernard performed numerous animal cardiac
catheterizations designed to examine the source of metabolic activity. Many prominent scientists theorized
that “combustion” occurred in the lungs. Using a thermometer inserted in the carotid artery, Bernard2 com-
pared the temperature of blood in a living horse’s left ventricle with blood in the right ventricle, accessed
from the internal jugular vein, and showed slightly higher right-sided temperatures, indicating that metabo-
lism occurred in the tissues, not in the lungs. Bernard2 also appeared to be the first to record intracardiac
pressure using an early pressure recording system connected to the end of a glass tube inserted into a
dog’s right ventricle.
Later in the 1800s, in an attempt to address the controversy regarding the nature and timing of the car-
diac apex beat, the French veterinarian Jean Baptiste Auguste Chauveau and physician Étienne Jules Marey
performed catheterization using rubber catheters placed from a horse’s jugular vein and carotid artery. These
meticulous scientists recognized the importance of obtaining the highest quality data and recorded pres-
sures in various cardiac chambers with clever mechanical devices invented by others but modified to suit
their needs.2 The graphic recordings obtained from these early transducers and physiologic recorders appear
remarkably similar to those obtained in today’s cardiac catheterization laboratories (Fig. 1.1).
From these early explorations of cardiac pressure measurement evolved an interest to quantify blood
flow. In 1870, the German mathematician and physiologist Adolph Fick published his famous formula for
calculating cardiac output (oxygen consumption divided by arteriovenous oxygen difference).3 However,
Fick had more interest in the conceptual aspects of cardiac output determination than in its validation or
application. The experiments necessary for validation of Fick’s principle would fall to others more than 60
years later. Fick also contributed to the emerging field of hemodynamics with his valuable work of refining
early pressure recording devices.3
Despite numerous animal studies over many years, the placement of a catheter into the deep
recesses of a living human heart would have to wait for an accurate method to image the course and posi-
tion of the catheter. This would, ultimately, be feasible only after Wilhelm Roentgen’s discovery of X-rays in
1895 (Fig. 1.2). The invention of an apparatus allowing us to peer inside the living human body for the first
time represented one of the greatest medical advances in human history. At the start of the 20th century,
it became possible to consider applying the lessons learned from animal research to humans. However,
great trepidation remained among cardiovascular researchers because most considered the placement of a
catheter into a living, beating human heart foolhardy with potentially deadly consequences.
 Chapter 1 Introduction to Hemodynamic Assessment   3

Fig. 1.2. Wilhelm Konrad Roentgen, discoverer of the X-ray. (From Edward P, Thompson D. Roentgen Rays and Phenomena
of the Anode and Cathode. Van Nostrand Co., NY, 1896.)

Although the historical record bestows acclaim for the first human cardiac catheterization to Werner
Forssmann (performed on himself in 1929), his accomplishment may have been trumped by the little
known, often disputed, and poorly documented efforts of fellow Germans Fritz Bleichroeder, E. Unger, and
W. Loeb in 1905.1,2 In an effort to deliver therapeutic injections close to the targeted organ, these physi-
cians attempted to place catheters, without radiologic guidance, into the central venous circulation via the
basilic and femoral veins. During one attempt made on his colleague Bleichroeder, Unger may have actually
gotten into the heart because Bleichroeder reported the development of chest pain. They could not prove
this theory because they failed to document the catheter position by X-ray or pressure recording and never
published their observations, attempting to gain credit only after Forssmann received his in 1929.1
The account of Forssmann’s first cardiac catheterization on himself, for which he was awarded
the Nobel Prize in Medicine and Physiology in 1956, along with André Frederic Cournand and Dickinson
Woodson Richards,2,4–7 has been recounted numerous times and with several versions, some more engag-
ing and colorful than others. The consistently told elements of his narrative are nearly unimaginable to
contemporary physicians familiar with the existing training, medicolegal, and practice environments.
The essential facts of Forssmann’s story are as follows. After graduating medical school, Forssmann
began training as a surgical intern at the Auguste-Viktoria Hospital in Eberswalde, Germany, a small commu-
nity hospital outside Berlin (Fig. 1.3). Forssmann’s motivation in pursuing a means of instrumenting the right
heart is unclear6; he reported that it evolved from the desire to find a method of infusing life-saving drugs into
the heart that was safer than direct intramyocardial injection. Forssmann discussed his interest with his chief,
Dr. Richard Schneider, but Schneider banned the enthusiastic intern from pursuing this work, largely because
he thought it unlikely that mainstream German academic medicine would accept medical research from a
community hospital. In addition, many considered placement of a catheter into the heart very dangerous;
Schneider did not wish notoriety for his hospital in the event that these investigations ended poorly.
Undeterred by the prevailing lack of support, Forssmann first placed catheters into the hearts of
cadavers from an arm vein, then impressed with the ease at which the catheters advanced, decided to