Elsevier

Heart Failure Clinics

Volume 5, Issue 2, April 2009, Pages 217-228
Heart Failure Clinics

Invasive Hemodynamic Assessment in Heart Failure

https://doi.org/10.1016/j.hfc.2008.11.008Get rights and content

Routine cardiac catheterization provides data on left heart, right heart, systemic and pulmonary arterial pressures, vascular resistances, cardiac output, and ejection fraction. These data are often then applied as markers of cardiac preload, afterload, and global function, although each of these parameters reflects more complex interactions between the heart and its internal and external loads. This article reviews more specific gold standard assessments of ventricular and arterial properties, and how these relate to the parameters reported and utilized in practice, and then discusses the re-emerging importance of invasive hemodynamics in the assessment and management of heart failure.

Section snippets

Cardiac contractility: looking beyond the ejection fraction

The most universally accepted index of contractility used in practice, the EF, unfortunately is also one of the least specific.1 As with any parameter measuring the extent of muscle shortening or thickening, it is highly sensitive to afterload and really is an expression of ventricular–arterial coupling rather than of contractility alone. EF also is affected by heart size, because its denominator is end-diastolic volume (EDV), leading many to propose that EF is more a parameter of remodeling

Diastole—more than end-diastolic pressure

Diastolic function is determined from active and passive processes, and both contribute to relaxation and chamber filling.3 Left heart filling pressures, either pulmonary artery occlusion (wedge pressure) or left ventricle (LV) end-diastolic pressure (EDP), are central to standard cardiac catheterization, and their elevation is taken to reflect abnormal loading and/or abnormal chamber compliance. One cannot determine whether the elevation reflects abnormal loading or abnormal chamber compliance

Afterload and ventricular–arterial interaction

Adequate pressure and flow to the body depends both on cardiac performance and on the nature of the vascular load into which it ejects. This load traditionally has been conceived of as equivalent to mean or systolic blood pressure, although this notion can lead to ambiguous interpretations. Unlike isolated muscle (for which the term “afterload” was first defined), where one can fix a constant force during contraction, the intact heart generates varying stress (and pressures) during ejection,

The right heart

Pulmonary hypertension and accompanying right heart dysfunction is increasingly common in patients who have heart failure, regardless of EF, and potently affect exercise capacity and clinical outcome.47, 48 Pulmonary hypertension generally is defined as a mean pulmonary arterial pressure higher than 25 mm Hg at rest (30 mm Hg with exercise), whereas pulmonary arterial hypertension (ie, pulmonary vascular disease) further requires an elevated pulmonary vascular resistance while maintaining a

Invasive hemodynamics: A re-emerging role in the evaluation of patients who have possible heart failure and preserved ejection fraction

Most cardiologists are fairly confident in making the diagnosis of heart failure when a patient who has severe LV enlargement and an EF of 25% presents with dyspnea, but a significant group of patients present with exertional dyspnea, clinical euvolemia (or only mild hypervolemia), and a normal EF. The differential diagnosis is fairly broad, including noncardiac causes (deconditioning, obesity, anemia, and other possibilities) and a variety of cardiogenic sources. These conditions may include

Summary

A few years after fading from the forefront of cardiology, interest in cardiovascular hemodynamics is returning, especially as newer devices are developed that help measure these parameters in patients chronically. Invasive assessment of cardiovascular properties provides greater insight into the mechanisms of disease in disorders such as HFpEF and can explain how patients who have different forms of heart failure respond to various therapies or to certain forms of stress. This information may

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