RAP

Question 1

Right heart KT technique

Answer 1

KT advanced down jugular vein → through CrVC → RA
* Tip directed ventrally to RV → cranially to reach RVOT → PA
o Curvature in KT + balloon may facilitate procedure
o KT can go into VC/atrium → azygos vein dorsally OR caudally into CaVC or CS
* PAW: KT distal into lung until tip wedged into small PA → occlude forward flow
o Balloon tipped KT

Question 2

R heart KT: arterial P, RVP, RAP normal waveforms

Answer 2

Arterial pressure waveform
* Peak systolic pressure
* Dicrotic notch: semilunar valve closure
* Diastolic pressure
o PA diastolic P should be close to V end diastolic pressure

Ventricular pressure waveform
* Peak systolic pressure = same as corresponding artery
* Diastolic pressure:
o Similar to atrial pressure → close to 0
o End diastolic pressure: after atrial contraction (jct of a wave and rapid early systolic upstroke)

Atrial pressure waveform
* Positives waves: a and v (late systole)
* Downslopes: x and y

Question 3

Types of systolic pressure abn

Answer 3

↑ resistance to ventricular outflow
o Flow obstruction: pressure gradient across obstruction (valvular, sub/supravalvular)
o Valvular regurgitation: ↑ v wave in respective atrium

Question 4

Types of diastolic pressure abn

Answer 4

o ↑ resistance to ventricular filling → ↑ end diastolic pressure → ↑ a wave
 ↓ compliance most often LV > RV affected
 ↑ pericardial constraint: synchronous ↑ in diastolic pressure in both ventricles

Question 5

Normal RA waveform

Answer 5

• Waveform: a > v
  o a wave: atrial contraction
   Follows P wave on ECG by 80ms
  o x descent: atrial relaxation + downward motion of AV jct during ventricular systole → ↓ pressure following atrial contraction
  o c wave: follows a wave α to PR interval. If present, followed by x’ descent
  o v wave: passive venous filling during atrial diastole/ventricular systole (TV closed)
   Bulge of TV during ventricular systole
   Conditions ↑ RA filling → ↑ v wave
   Peak: end of ventricular systole at max atrial filling
• End of T wave on ECG
  o y descent: rapid RA emptying → ↓ pressure

Question 6

Normal RAP values

Answer 6

2-6mmHg

Question 7

Changes in RAP waveform w/ Afib

Answer 7

Afib: no a wave, but x descent may be present because of AV jct motion

Question 8

Effect of respiration on RAP

Answer 8

mean RA ↓ in inspiration (↓ intrathoracic pressure) → ↑ passive RV filling

Question 9

RAP waveform PS

Answer 9

• Obstruction of RVOT → pressure gradient across PV
  o RV peak systolic pressure > PAP
  o Hemodynamic abnormalities depend upon severity of stenosis and CO
• Secondary RVH → ↓ RV compliance
  o ↑ RV end diastolic pressures → can ↑ RAP
• RA waveform abnormalities
  o ↑a wave: ↑ resistance to RV filling

Question 10

RAP waveform TR: severe vs mild

Answer 10

• Volume overload of RA and RV + secondary RVE with severe/chronic TR
• Severe TR: preload/afterload dependent hemodynamic abnormalities
  o ↑RAP +↓CO
• RA waveform abnormalities
  o Attenuated x descent → reflect descent of the base
  o ↑ v wave: TR reflux blood in RA
  o Steep y descent: ↑ filling volume
   Reflect severity of TR: ↑ volume → greater y descent

Question 11

RAP waveform constrictive pericarditis

Answer 11

o v > or = a wave → non compliance of RA
o Rapid y descent → rapid atrial emptying from underfilled ventricle + ↑RAP
o RAP approx equal to PA end diastolic and PAWP
o M or W pattern
o Kussmaul sign: ↑RAP in inspiration → xY or xy pattern

Question 12

RAP waveform: TS

Answer 12

• Hemodynamic significance: impairs RA emptying + ↑RAP → ↓RV filling → ↓CO
• RA waveform abnormalities
  o ↑/giant a wave: may >20mmHg
   Not specific: can also be seen in PH and RVH
  o Pressure gradient RA vs RV during diastole
   2 to 12mmHg (90% of cases <7mmHg)
   Mean diastolic gradient >2mmHg is dx for TS
  o Delayed/absent y descent → delayed RV filling and RA emptying

Question 13

Ventricularization of RAP meaning

Answer 13

Ventricularization of RA pressure may occur: RA adapts to ↑ volume → pressure reflective of RVP (similar wave)
o Contour of RAP is similar to RVP but lower amplitude
o Common w/ severe TR: specific but not sensitive

Question 14

Constrictive pericarditis pathophys

Answer 14

• Pericardium act as: rigid uncompliant shell
  o Limit total volume of blood → affect diastolic ventricular filling
   Early diastole: brisk filling
• More rapid than normal because of chronic underfilled state of RV
   Mid diastole: abrupt halt and rapid ↑ pressure
  o ↑ ventricular interdependence: pressure/volume change of 1 ventricle → reflected in the other
   Inspiration: ↓ intrathoracic pressure but not of cardiac chambers (isolated by stiff pericardium)
• ↑ venous return + ↓ PVP → ↓ trans mitral gradient → ↓LV filling → ↓LV systolic P
• ↓LV filling/pressure → ↑RV filling/pressure
   Expiration: opposite

Question 15

RVP waveform constrictive pericarditis

Answer 15

√sign or dip and plateau → abrupt cessation of filling from stiff pericardium
RV/LV diastolic pressures  equal (±5mmHg)
RV end diastolic P/RV systolic P ratio > 1.3
PH is rare → PA/RV pressure < 50 mmHg
PAW ↓ > LV end diastolic pressure during inspiration
Discordance of LV and RV systolic pressure with inspiration
Most sensitive (100%), specific (95%) for pericarditis

Question 16

Effusive constrictive dz RAP waveform

Answer 16

↑RAP with a=v waves with prominent x descent (tamponade) or x = y

Question 17

Major functions of pericardium

Answer 17

rigid/noncompliant nature
o Limit cardiac chamber distension with volume changes
 Contribute to ventricular stiffness in diastole
o Facilitate interaction/coupling of ventricular chambers via IVS
o Pericardial reserve volume (volume at which no ↑P) = 50-75ml
 Rapid fluid accumulation → ↑ rapidly intrapericardial P
 Slow/gradual accumulation → stretch pericardium → can accommodate larger volumes
 Once pericardial reserve volume reached → steep pressure/volume curve
* Rapid pressure rise if any more fluid added

Question 18

Pericardial effusion: early phase hemodynamic changes

Answer 18

o ↑ pericardial pressure
 Early phase of cardiac tamponande
* Trigger compensatory mechanisms: venoconstriction + fluid retention → ↑ systemic venous P to ↑ R heart filling → ↑RA + RVP
* Maintained CO
* Normal pulsus paradoxus: inspiratory fall in systolic pressure < 10-12mmHg

Question 19

Pericardial effusion: later phase hemodynamic changes

Answer 19

 Later phase: further ↑ in pericardial pressure → ↑ pressure in cardiac chambers in diastole
* Equilibration of pericardial, RA, RV P
* ↑ LV diastolic pressure → equilibrates eventually RV diastolic P
* Any more ↑ P → ↓CO + prominent pulsus paradoxus but <10-12mmHg

Question 20

Pericardial effusion: final phase hemodynamic changes

Answer 20

 Final phase: ↑ equalized diastolic pressures + inspiratory fall in systolic pressure >12mmHg
* ↓CO and BP

Question 21

RA waveform cardiac tamponade

Answer 21

o Predominant x descent
o Absence of y descent → ↓ volume exiting RA to fill RV
 Early in cardiac tamponade
o Elevated mean RAP (20mmHg) with undulating flat line → advanced stages
  PA and PAWP

Question 22

RVP waveform changes cardiac tamponade

Answer 22

o RV/PA: thin waveform secondary to ↓CO
o Inspiratory drop in systolic pressure (>12mmHg in advanced stages).

Question 23

Other causes of inspiratory drop in systolic pressure

Answer 23

 Pericardial effusion/constrictive
 RV infarction
 Asthma
 COPD
 CHF
 Obesity
 Ascites
 Pregnancy
 PTE
 Tension pneumothorax

Question 24

RAP Afib changes

Answer 24

absent a wave

Question 25

RAP changes Aflutter

Answer 25

sawtooth a waves