Sample Questions
Unit E - Hemodynamics
Taken directly from Todd's CV Review books, 7th Edition
Unit E, Chapter 1 – Introduction to CV Pressures
Question #1
Normal cardiac waveforms resemble simple electrically generated waveforms. The normal cardiac waveform labeled #1 in the box (atrial) most resembles a/an: a. Sine wave
b. Square wave
c. Triangle wave
d. Impulse wave
Check Your Answer
ANSWER: a. Sine waves.
Sine waves most resemble RA (CVP) or LA (PAW) tracings. Their A, x, V, y waves undulate slowly and smoothly like a sinusoidal wave. This is the simplest waveform to duplicate electrically.
BE ABLE TO MATCH ALL ANSWERS.
1. Atria (RA, LA) → Sine waves. A, x, V, y waves undulate slowly and smoothly like a sinusoidal wave. A full cardiac cycle would take 2 complete sine wave cycles. This is the simplest waveform to duplicate electrically. It is composed of low frequencies that seldom show artifacts.
2. Ventricle (RV, LV) → Square waves. During systolic contraction the ventricular pressure rises rapidly and in diastole falls rapidly. These rapidly rising waves have the highest frequency components and are the most difficult to duplicate electrically. That is why ventricular pressures often show resonance distortion which overshoots the true systolic pressure.
3. Arteries (PA, AO) → Triangle wave. Arterial pressures rise quickly to a peak and then slowly taper off, like a triangle. The dicrotic notch may sit on this down slope of this triangle. You can often see arterial resonance in early systole which overshoots the true systolic pressure.
4. Pressure Spike (snap) → Impulse wave. We occasionally see pressure spikes on PA pressure waves due to catheter fling, valve closure, or a valve opening snap. In pressure recording "spikes" are unwanted artifacts that contain high frequencies. ECG pacemaker spikes are also impulse waves. ECG recorders must accurately be able respond to higher frequencies (100 Hz) than pressure recording systems (20 Hz).
Sine waves most resemble RA (CVP) or LA (PAW) tracings. Their A, x, V, y waves undulate slowly and smoothly like a sinusoidal wave. This is the simplest waveform to duplicate electrically.
BE ABLE TO MATCH ALL ANSWERS.
1. Atria (RA, LA) → Sine waves. A, x, V, y waves undulate slowly and smoothly like a sinusoidal wave. A full cardiac cycle would take 2 complete sine wave cycles. This is the simplest waveform to duplicate electrically. It is composed of low frequencies that seldom show artifacts.
2. Ventricle (RV, LV) → Square waves. During systolic contraction the ventricular pressure rises rapidly and in diastole falls rapidly. These rapidly rising waves have the highest frequency components and are the most difficult to duplicate electrically. That is why ventricular pressures often show resonance distortion which overshoots the true systolic pressure.
3. Arteries (PA, AO) → Triangle wave. Arterial pressures rise quickly to a peak and then slowly taper off, like a triangle. The dicrotic notch may sit on this down slope of this triangle. You can often see arterial resonance in early systole which overshoots the true systolic pressure.
4. Pressure Spike (snap) → Impulse wave. We occasionally see pressure spikes on PA pressure waves due to catheter fling, valve closure, or a valve opening snap. In pressure recording "spikes" are unwanted artifacts that contain high frequencies. ECG pacemaker spikes are also impulse waves. ECG recorders must accurately be able respond to higher frequencies (100 Hz) than pressure recording systems (20 Hz).
Unit E, Chapter 2 – Reading Pressures
Question #44
This hemodynamic tracing on X200 shows: (Beware the noisy ECG.)
a. Atrial fibrillation
b. Atrial flutter
c. Bigeminy
d. Large dicrotic notch
ANSWER: c. LV in bigeminy. MATCH ALL ANSWERS.
The catheter is in the LV with a systolic pressure of 120 mmHg. Note that the small contractions (associated with PVCs) have too short a filling time to generate significant LV pressure and may not result in any arterial pulse. This ECG is noisy, but definite QRS complexes are seen between the last two ventricular systoles. PVCs coupled to sinus beats can be seen clearly in the last two cycles. A better ECG lead is added to clarify the second recording. Bigeminy refers to a pattern of normal and premature beats, as follows:
• Bigeminy = a normal sinus beat followed by a PVC.
• Trigeminy = 2 normal sinus beats then a PVC or PAC.
• Quadrageminy = 3 normal sinus beats then a PVC or PAC.
• Couplet = Two successive PVCs
• Triplet = 3 successive PVCs
• Ventricular Tach. = more than 3 successive PVCs
• Sustained Ventricular Tach. = more than 30 seconds of successive PVCs
See: Braunwald, chapter on “Specific Arrhythmias...”
Unit E, Chapter 3 – Pressure Recording Systems
Question #93
When using standard disposable transducers with fluid filled catheters, where is the "Wheatstone bridge" located?
a. In the carrier amplifier (#1)
b. In the transducer (#2)
c. In the pressure manifold (#3)
d. Near the tip of the catheter (#4)
ANSWER: b. In the transducer.
The pressure sensors are within the transducer’s body and termed "strain gauges." These sensors are attached to a flexible diaphragm and arranged in a diamond configuration so that some stretch and some compress. This action imbalances the voltage dividers and creates a voltage output which is then amplified by the carrier amplifier.
Expensive "catheter tip manometers" are available and often used for research purposes. You can also get stopcock manifolds with pressure transducers built into them. This helps avoid the low frequency artifacts commonly induced by pressure tubes.
See: Grossman, chapter on "Pressure recording."
Unit E, Chapter 4 – Pressure Pathology I
Question #156
Match the wide arterial pulse waveforms in the diagram with their names below.
a. Pulsus alternans
b. Pulsus bigeminus
c. Pulsus bisferiens
d. Pulsus tardus
e. Corrigan's pulse
ANSWERS: 1d, 2e, 3c. 4a, 5bBE ABLE TO MATCH ALL ANSWERS BELOW.
1. d = Pulsus tardus: Aortic stenosis slows the upstroke (making it tardy - "Tardus"). The upstroke may have a "shudder" coincident with the ejection murmur and an anacrotic notch (notch on the upstroke wave).
2. e = Corrigan's pulse: Corrigan's pulse is seen in aortic regurgitation. It is termed Waterhammer because it feels bounding. It shows a rapid upstroke (percussion wave) followed by a rapid collapse (regurgitation) early in diastole. No dicrotic notch is seen, because the aortic valve does not close completely.
3. c = Pulsus Bisferiens: Pulsus bisferiens is a double humped arterial pulse, also termed spike and dome configuration. Both percussion and tidal waves are distinct. It is similar to a dicrotic pulse, which has a large dicrotic notch and pulse following it, except both of the bisferiens pulses are in systole.
4. a = Pulsus alternans: Pulsus alternans is an alternating systolic BP, even though the heart rate is regular. Beats alternate like this: 120/80, 115/75, 120/80, 115/75... Often seen in failing ventricles.
5. b = Pulsus bigeminus: Pulsus bigeminus is caused by ventricular bigeminy. It is distinguishable from pulsus alternans only when compared to the bigeminal ECG. Pulse contours may be palpated in the carotid artery, recorded externally with phonocardiography transducers or recorded through an intravascular catheter connected to a pressure transducer. The wave-form may be diagnostic of the pathology.
See: Braunwald, chapter on "Physical Examination."
Unit E, Chapter 5 – Pressure Pathology II
Question #196
In the simultaneous pressure tracing diagram shown, match each pressure tracing with the chamber/vessel and valvular disease it represents.
a. AO, HOCM
b. AO, AS
c. AO, AR
d. PAW, MS
e. PAW, MR
ANSWERS: 1c, 2a, 3b, 4d, 5e.
BE ABLE TO MATCH ALL ANSWERS BELOW.
1. C. AO, AR: Note that no gradient exists (no stenosis). But the diastolic AO pressure is very low. This continues to fall as blood leaks from the AO into the LV and in severe AR may fall to the LV-edp.
2. A. AO, HOCM (Previously called IHSS): Although this is not a "valvular" disease, it is similar to AS in many respects. LV-AO gradient occurs because the LV outflow track is itself a dynamic stenosis. It obstructs flow during systole. There may be an initial (tidal wave) and then a sudden release - only to obstruct again as the LV walls come closer together. (See: bisferiens pulse). Pullback tracings identify two levels of pressure within the LV - one above and one below the obstruction. No gradient exists between the subvalvular LV chamber (not shown) and the AO. Gradient exists between the apical LV tracing and the AO (shown).
3. B. AO, AS: Note the classic pulsus tardus with slow AO upstroke. A gradient exists between the LV & AO throughout systole, that is usually greatest in mid-systole. The diamond shaped murmur peaks in systole just like the gradient.
4. D. PAW, MS: Note the PAW-LV gradient throughout diastole.
5. E. PAW, MR: Note that no gradient exists (no gradient, no stenosis). But the v wave late in systole indicates the LA is flooded with blood from the leaky mitral valve. The LV pressure tracing is shown in dotted lines. Remember how normal simultaneous tracings overlap (See: Wiggers diagram). Normal AO-LV tracings should match in systole. Normal LV-PAW tracings should match in diastole.
See: Braunwald, chapter on "Physical Examination."
BE ABLE TO MATCH ALL ANSWERS BELOW.
1. C. AO, AR: Note that no gradient exists (no stenosis). But the diastolic AO pressure is very low. This continues to fall as blood leaks from the AO into the LV and in severe AR may fall to the LV-edp.
2. A. AO, HOCM (Previously called IHSS): Although this is not a "valvular" disease, it is similar to AS in many respects. LV-AO gradient occurs because the LV outflow track is itself a dynamic stenosis. It obstructs flow during systole. There may be an initial (tidal wave) and then a sudden release - only to obstruct again as the LV walls come closer together. (See: bisferiens pulse). Pullback tracings identify two levels of pressure within the LV - one above and one below the obstruction. No gradient exists between the subvalvular LV chamber (not shown) and the AO. Gradient exists between the apical LV tracing and the AO (shown).
3. B. AO, AS: Note the classic pulsus tardus with slow AO upstroke. A gradient exists between the LV & AO throughout systole, that is usually greatest in mid-systole. The diamond shaped murmur peaks in systole just like the gradient.
4. D. PAW, MS: Note the PAW-LV gradient throughout diastole.
5. E. PAW, MR: Note that no gradient exists (no gradient, no stenosis). But the v wave late in systole indicates the LA is flooded with blood from the leaky mitral valve. The LV pressure tracing is shown in dotted lines. Remember how normal simultaneous tracings overlap (See: Wiggers diagram). Normal AO-LV tracings should match in systole. Normal LV-PAW tracings should match in diastole.
See: Braunwald, chapter on "Physical Examination."
Unit E, Chapter 6 – Fick CO and Shunt Calculations
Question #248
Match the cardiac output abbreviation labeled #3 (LVMF) with its definition below.
a. Amount of blood pumped by the heart adjusted to body size
b. Quantitative angiographic CO
c. Indicator dilution CO using cooled saline
d. Average pulmonary CO measured via oxygen extraction
ANSWER: b. Quantitative angiographic CO is also termed Left Ventricular Minute Flow (LVMF).
MATCH THE OTHER HEMODYNAMIC ABBREVIATIONS.
1. TDCO = Indicator dilution CO using cooled saline (Thermodilution CO)
2. Fick CO = Average pulmonary CO measured via oxygen extraction (oxygen consumption per AV difference)
3. LVMF = Quantitative angiographic CO (Left Ventricular Minute Flow)
4. CI = Amount of blood pumped by the heart adjusted to body size (Cardiac Index)
See: Yang, chapter on "Cardiac Output."
MATCH THE OTHER HEMODYNAMIC ABBREVIATIONS.
1. TDCO = Indicator dilution CO using cooled saline (Thermodilution CO)
2. Fick CO = Average pulmonary CO measured via oxygen extraction (oxygen consumption per AV difference)
3. LVMF = Quantitative angiographic CO (Left Ventricular Minute Flow)
4. CI = Amount of blood pumped by the heart adjusted to body size (Cardiac Index)
See: Yang, chapter on "Cardiac Output."
Unit E, Chapter 7 – Thermodilution Cardiac Output
Question #326
What type of TDCO system is shown in the diagram above?
a. Iced injectate, open system
b. Iced injectate, closed system
c. Room temperature injectate, open system
d. Room temperature injectate, closed system
ANSWER: b. Iced injectate, closed system.
The styrofoam bath contains ice at 0 to 4 degrees C. This cools the injectate prior to injection. This system is closed (not exposed to air) to reduce the risk of contamination. The open system uses several syringes, each filled and left in an ice basin until they are needed (seldom used now).
See: Darovic, chapter on, "Monitoring Cardiac Output."
The styrofoam bath contains ice at 0 to 4 degrees C. This cools the injectate prior to injection. This system is closed (not exposed to air) to reduce the risk of contamination. The open system uses several syringes, each filled and left in an ice basin until they are needed (seldom used now).
See: Darovic, chapter on, "Monitoring Cardiac Output."
Unit E, Chapter 8 – Quantitative LV Angiography
Question #345
Match the hemodynamic abbreviation labeled #1 (SV) with its definition below.
a. Amount of blood ejected out the LV with each systole
b. Total amount of blood pumped by the LV per minute
c. Maximum volume of blood in the ventricle when filled
d. Percentage of blood ejected out the ventricle with each beat
e. Net forward amount of blood pumped by LV per minute
f. Minimum volume of blood in the ventricular chamber
g. Amount of blood regurgitating (reverse flow)
h. Ratio of regurgitation to total LV flow
ANSWER: a. Amount of blood ejected out the LV with each systole = SV.
There are actually two types of SV, forward SV from Fick CO and total SV measured from quantitative angiography. BE ABLE TO MATCH ALL BELOW.
Hemodynamic Abbreviations
1. SV = Amount of blood ejected out the aortic valve with each systole (Stroke Volume in ml)
2. RV = Regurgitant Volume = Amount of blood regurgitating (reverse flow)
3. EF = Percentage of blood ejected out the ventricle with each beat (Ejection Fraction in %)
4. CO = (Cardiac Output in L/min) Net amount of blood pumped by the LV per minute. It is NET or forward flow, because CO only measures average forward flow and does not include the increase in flow necessary to compensate for valvular regurgitation.
5. EDV = Maximum volume of blood in the ventricle when filled (End Diastolic Volume in ml)
6. ESV = Minimum volume or residual blood left in the ventricle after contraction (End Systolic Volume in ml)
7. LVMF = (Left ventricular minute flow in L/min) Total amount of blood pumped by the LV per minute. It is TOTAL because some of this blood may leak back during valvular regurgitation. Sometimes it is called the "Angio CO" or "Total CO."
8. RF = Regurgitant Fraction = Ratio of regurgitation to total LV flow
See: Grossman, chapter on "Ventricular Volumes,..."
There are actually two types of SV, forward SV from Fick CO and total SV measured from quantitative angiography. BE ABLE TO MATCH ALL BELOW.
Hemodynamic Abbreviations
1. SV = Amount of blood ejected out the aortic valve with each systole (Stroke Volume in ml)
2. RV = Regurgitant Volume = Amount of blood regurgitating (reverse flow)
3. EF = Percentage of blood ejected out the ventricle with each beat (Ejection Fraction in %)
4. CO = (Cardiac Output in L/min) Net amount of blood pumped by the LV per minute. It is NET or forward flow, because CO only measures average forward flow and does not include the increase in flow necessary to compensate for valvular regurgitation.
5. EDV = Maximum volume of blood in the ventricle when filled (End Diastolic Volume in ml)
6. ESV = Minimum volume or residual blood left in the ventricle after contraction (End Systolic Volume in ml)
7. LVMF = (Left ventricular minute flow in L/min) Total amount of blood pumped by the LV per minute. It is TOTAL because some of this blood may leak back during valvular regurgitation. Sometimes it is called the "Angio CO" or "Total CO."
8. RF = Regurgitant Fraction = Ratio of regurgitation to total LV flow
See: Grossman, chapter on "Ventricular Volumes,..."
Unit E, Chapter 9 – Vascular Resistance
Question #403
Match each adult vascular resistance with its normal value.
a. 0.84
b. 14
c. 67
d. 1130
ANSWERS: 1d, 2b, 3c, 4a
1. Absolute SVR = d. 1130 dsc-5
2. Hybrid SVR = b. 14 HRUs (or Wood units)
3. Absolute PVR = c. 67.0 dsc-5
4. Hybrid PVR = a. 0.84 HRUs (or Wood units)
Normal PVR is low, around 1.0 HRU, while the normal SVR is 10-20 times greater. The absolute metric units of resistance are the HRU units multiplied times x 80. Understand the units of resistance. Wood units = Hybrid Resistance Units (HRU)= mmHg/L/min. Absolute CGS units are dsc-5 which is 80 x the Wood unit.
See: Kern, chapter on "Hemodynamics."
1. Absolute SVR = d. 1130 dsc-5
2. Hybrid SVR = b. 14 HRUs (or Wood units)
3. Absolute PVR = c. 67.0 dsc-5
4. Hybrid PVR = a. 0.84 HRUs (or Wood units)
Normal PVR is low, around 1.0 HRU, while the normal SVR is 10-20 times greater. The absolute metric units of resistance are the HRU units multiplied times x 80. Understand the units of resistance. Wood units = Hybrid Resistance Units (HRU)= mmHg/L/min. Absolute CGS units are dsc-5 which is 80 x the Wood unit.
See: Kern, chapter on "Hemodynamics."
Unit E, Chapter 10 – Valve Area
Question #449
Match each simultaneous pressure recording to its diagnosis.
a. MS
b. MR
c. AS
d. AR
ANSWERS: 1c, 2d, 3a, 4b
The shaded areas are the areas of gradient. The mitral valve gradient is seen in diastole between the simultaneous LA and LV pressures. Compare these to the normal Wiggers diagram and note the abnormal pressures here.
MATCHING ANSWERS ARE:
1. c. AS (Aortic Stenosis) LV-AO gradient in systole
2. d. AR (Aortic Regurgitation) wide AO pulse pressure, low AO diastole
3. a. MS (Mitral Stenosis) LA-LV gradient in diastole
4. b. MR (Mitral Regurgitation) LA or PAW elevated "v" wave at end systole
See: Grossman, chapter on "Assessment of Stenotic Valves"
The shaded areas are the areas of gradient. The mitral valve gradient is seen in diastole between the simultaneous LA and LV pressures. Compare these to the normal Wiggers diagram and note the abnormal pressures here.
MATCHING ANSWERS ARE:
1. c. AS (Aortic Stenosis) LV-AO gradient in systole
2. d. AR (Aortic Regurgitation) wide AO pulse pressure, low AO diastole
3. a. MS (Mitral Stenosis) LA-LV gradient in diastole
4. b. MR (Mitral Regurgitation) LA or PAW elevated "v" wave at end systole
See: Grossman, chapter on "Assessment of Stenotic Valves"
Unit E, Chapter 11 – Coronary Hemodynamics, IVUS, and ICE
Question #504
Left coronary blood flow occurs primarily during the _____ phase of the cardiac cycle because _____.
a. Systolic, coronary driving pressure is greatest
b. Systolic, systolic ejection opens the aortic valve
c. Diastolic, semilunar valves cover the coronary ostia in systole
d. Diastolic, diastole releases compressed endocardial capillaries
ANSWER: d. Diastolic.
In diastole the ventricle relaxes and releases the compressed endocardial capillaries. Most flow occurs in diastole due to the compression of LV capillaries in systole. This is why the IABP is so effective at augmenting diastolic coronary flow. Although the left coronary capillaries obstruct flow during systole, the low pressure RV capillaries are less occluded because of the lower RV pressure. A common misconception is that the open aortic leaflets occlude the coronary ostia and inhibit flow. They do not.
See: Berne and Levy, chapter on "Coronary Artery Physiology."
In diastole the ventricle relaxes and releases the compressed endocardial capillaries. Most flow occurs in diastole due to the compression of LV capillaries in systole. This is why the IABP is so effective at augmenting diastolic coronary flow. Although the left coronary capillaries obstruct flow during systole, the low pressure RV capillaries are less occluded because of the lower RV pressure. A common misconception is that the open aortic leaflets occlude the coronary ostia and inhibit flow. They do not.
See: Berne and Levy, chapter on "Coronary Artery Physiology."
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E-mail: info@westodd.com
Wes Todd, BS, RCIS, RCES.
Cardiac Self Assessment
S. 1605 Clinton Rd.
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Cardiac Self Assessment
S. 1605 Clinton Rd.
Spokane Valley, WA 99216-0420
