[Clinical Art][Circulation] Interpretation of Hemodynamic Waveforms

October 20, 2016 Cardiology, Critical Care, EKG/ECG, Hemodynamics, Mechanical Ventilation No comments , , , , , , , , , , , , , , , , , , , , , , , , ,

1st_ceb_insigniaBasic Knowledge

Mechanism of Hemodynamic Monitoring

The rapidly occurring events (represent mechanical forces) of cardiac chambers and vessels during cardaic cycle require conversion to an electrical signal to be transmitted and subsequently translated into an interpretable, graphic format. The pressure transducer is the essential component that translates the mechanical forces to electrical signals. The transducer may be located at the tip of the catheter (micromanometer) within the chamber or, more commonly, the pressure transducer is outside of the body, and a pressure waveform is transmitted from the catheter tip to the transducer through a column of fluid. These transducers consist of a diaphragm or membrane attached to a strain-gauge-Wheatstone bridge arrangement. When a fluid wave strikes the diaphragm, an electrical current is generated with a magnitude dependent on the strength of the force that deflects the membrane. The output current is amplified and displayed as pressure versus time.

Clinical Art

Pre-operations Before Recording

Old generations of transducers required calibration against a mercury manometer; fortunately, the factory-calibrated, disposable, fluid-filled transducers in clinical use today no longer need this. Table-mounted transducers do require balancing or "zeroing," which refers to the establishment of a reference point for subsequent pressure measurements. The reference or "zero" position should be determined before any measurements are made. By convention, it is defined at the patient's midchest in the anteroposterior dimension at the level of the sternal angle of Louis (fourth intercostal space). This site is an estimation of the location of the right atrium and is also known as the phlebostatic axis. A table-mounted transducer is placed at this level and the stopcock is opened to air (atmospheric pressure) and set to zero by the hemodynamic system. The system is now ready for presure measurements. It is important to emphasize that the pre-operation of the hemodynamic monitor is very important, because if the "zero" level is not properly set and the transducer not appropriately balanced, the hemodynamic data recorded would be misleading, even fatal.

Interpretation of pressure waveforms requires a consistent and systematic approach in Table 2-1. Careful scrutiny of the waveform ensures a high-fidelity recording without over- or under-damping. Each pressure event should be timed with EKG.

Table 2-1 A Systematic Approach to Hemodynamic Interpretation
1.Establish the zero level and balance transducer
2.Confirm the scale of the recording
3.Collect hemodynamics in a systematic method using established protocols
4.Critically assess the pressure waveforms for proper fidelity
5.Carefully time pressure events with the EKG
6.Review the tracings for common artifacts

At present, in the clinical setting, 3 pressure waveforms can be obtained at bedside with invasive hemodynaic monitoring devices (central venous cathether/CVC and pulmonary artery catheter/PAC), including right atrial pressure/Prapulmonary artery pressure/Ppa, and pulmonary artery wedge pressure/Ppw. The pressurewave form is recorded along with a synchronized EKG.

Normal Pressure Waveform

Atrial Pressure

The goal of measuring the atrial pressure is to measure the pressure in the ventricles  at the end of diastole, to idenfify a "filling pressure". The goal for any atrial pressure measurement is to obtain the measurement at the every end of diastole, when the atrial pressure is closest to the ventricular pressure. The normal Pra is 2-8 mm Hg and is characterized by a and v waves and x and y descents. The causes of a, v waves and x, y descents are listed below.

PS: The Rationale Reason for the Formation of Pra waveform

a wave represents the pressure rise within the right atrium due to atrial contraction follows the P wave on the EKG by about 80 msec
descet represents the pressure decay following the a wave and reflect both atrial relaxation and the sudden downward motion of the atrioventricular junction that occurs because of early ventricular systole  
c wave is sometimes observed after the a wave and is due to the sudden motion of the tricuspid annulus toward the right atrium at the onset of ventricular systole the c wave follows the a wave by the same time as the PR interval on the EKG
v wave when the tricuspid valve is closed, the pressure rise responsible for the v wave is due to passive venous filling of the atrium, represent atrial diastole. the peak of the right atrial v wave corresponds with the end of T wave on the surface EKG; the ORS alawys appears before the v wave is produced
y wave is due to rapid emptying of the right atrium when the tricuspid valve opens  

Atrial waveform interpretation in detail

v wave

The atrial pressures initially increase during systole as the contracting ventricles return blood to the atria, refilling the upper chambers. This rise in the atrial pressure is identified as the "v" wave. The upstroke of the v wave is the rise in atrial pressure as a result of atrial filling. Because it is produced as a result of ventricular contraction, its location is relative to the QRS on the EKG. Ejection eventually leads to the return of blood to the atria (left ventricular contraction refills the right atrium and produces the right atrial v wave; right ventricular contraction refills the left atrium and produces the left atrial v wave). Thus, the QRS causes the v wave, however, the QRS always appears before the v wave is produced.


The normal pulmonary artery systolic pressure/Ppas is 15-30 mm Hg, the normal diastolic pressure/Ppad is 4-12 mm Hg, and the mean 9-18 mm Hg. The components pulmonary artery pressure include a rapid rise in pressure, systolic peak, a pressure decay associated with a well-defined dicrotic notch from pulmonic valve closure, and a diastolci trough.

PA and arterial pressure waveforms have similar morphology. Systole begins with the opening of the pulmonic valves. Prior to opening of the pulmonary valve, the pulmonary artery pressure is very low (the pulmonary vascular system does not need a high pressure system to perfuse). As the ventricles contact, they eject blood into the pulmonary artery. This causes an immediate rise in the arterial pressure. As blood enters the great vessels, the pressure rise quickly and steadily, producing a steep vertical rise. Late in systole, the rate of ejection slows as the pressure gradient between the right ventricle and pulmonary artery narrows. Although blood is still moving from the ventricle to the great vessels, the rate of movement is slowed to the point where the pressure begins to decline. This cause the early downslope in the arterial tracing that represents this period of reduced ejection. Like the right atrial v wave, the pulmonary artery systolic wave typically coincides with the T wave of the EKG.

Later, the ventricle begins to relax, causing the ventricular pressure to drop below the pressure in great vessels. This causes the pulmonic valves to close, producing a small rise in the PA pressure, known as the dicrotic notch. Following closure of the semi-lunar valves, the pulmonary artery continues to fall as blood leaves the great vessels to perfuse the tissues and lungs.


The normal mean pulmonary artery wedge pressure/Ppw is obtained when the inflated catheter obstructs forward flow within a branch of the pulmonary artery, creating a static column of blood between the tip of the catheter and the j point in the pulmonary venous bed where it intersects with flowing blood. The Ppw tracing contains the same sequence of waves and descents as the Pra tracing. However, when referenced to the ECG, the waves and descents of the Ppw will be seen later than those of the Pra, because the pressure waves from the left atrium must travel back through the pulmonary vasculature and a longer length of catheter. Therefore, in the Ppw tracing, the a wave usually appears after the QRS complex, and the v wave is seen after the T wave.
screen-shot-2016-10-19-at-2-19-49-pmInterpretation of CVP and PAWP measurements

Correlation to the EKG

The easiest wave to evaluate an atrial tracing is to first locate the v wave. Generally, it will appear immeidately after the peak of T wave on a CVP waveform, however, it will be 80-120 ms after the T wave on a PAWP tracing. You can generally identify the v wave by ruling out other waves. It must be after the peak of the T wave. Once the v wave is identified, the a and c can be determined.

Observe the EKG rhythm. If the patient has a sinus rhythm, an a wave should be present. The a should be in the PR interval for a CVP. It is later in the PAWP, appearing within or even afte QRS. If the patient does not have a P wave, the a wave will be absent. If the P wave is not synchronized to the QRS, very large a wave may be present. These large a waves may appear as one very large wave during a cardiac cycle. The large a waves are called cannon a waves. They are actually exaggerated atrial pressures that occur when the atria contract against a closed AV valve, adding to the pressure that is already being generated due to the c or v wave.

If present, the c wave is generally within the QRS for a CVP. It will be after the QRS for a PAWP.

Where to Measure CVP and PAWP

At the very end of ventricular diastole, the atrial pressure equilibrates with the ventricular pressure, at the very end of ventricular filling. Measurement of the atrial pressure at the end of diastole provides the best opportunity to capture ventricular filling pressure. The location on the atrial pressure wave that best reflects end-diastolic pressure is the point just prior to the c wave. However, c wave is often absent or difficult to find, espeically true in the PAWP waveform, which is subject to considerable movement artifact from right ventricular systole and breathing. If we cannot use the mehtod based on c wave to measure the filling pressure, instead we can use other two ways to capture the filling pressure, where the second method for identification of the end-diastolic pressure is to take the mean of the highest and lowest a wave pressure; and the thrid method is used if the a wave is hard to interpret or absent, that is, the end-diastolic pressure can be estimated by identifying the Z point. Draw a line from the end of the QRS to the atrial tracing. The point where the line intersects with the waveform is the Z line. Note that for a PAWP waveform the Z line should be estimated as 0.08-0.12 seconds to the left of the end of the QRS (Z point is delayed 0.08-0.12 seconds from the QRS on the PAWP).

Respiratory Influences on Hemodynamic Data: Transmural Pressure

The Pra and Ppw are used as surrogates for RV and LV filling pressure (so the preload), but remember that when evaluating the patient's preload the end-diastolic volume of the ventricles should also be included in the interpretation. Here in this section we focus our discussion on the respiratory influecnes on the recorded hemodynamic data. OK, it is the transmural (intravascular minus pleural) pressure that represents the distending pressure for cardiac filling. During normal breathing, Ppl is slightly negative at end-expiration and intrathoracic vascular pressures measured at this point in respiratory cycle provide the best estimate of transmural pressure. Either a strip recording or the cursor method should be used to define the end-expiratory pressure.

One error is the assumption that during mechanical ventilation the lowest point in the pressure tracing reflects end expiration. While this is true during controlled ventilation, inspiratory efforts that trigger mechanical breaths produce a nadir in the pressure tracing. Identification of end expiration in the Ppw tracing is aided by the knowledge that expiration is usually longer than inspiration, two exceptions being marked tachypnea and inverse-ratio ventilation. Identification of end expiration from the pressure tracing should not be difficult when interpreted in relationship to the patient's ventilatory pattern. When confusion occurs, a simultaneous airway pressure tracing may be used.

The Pra and Ppw will overestimate transmural pressure if intrathoracic pressure is positive at end expiration. This can occur from an increase in end-expiratory lung volume due to applied positive end-expiratory pressure (PEEP) or auto-PEEP, or from increased intra-abdominal pressure due to active expiration or intra-abdominal hypertension.

Common Errors and Artifacts

screen-shot-2016-10-20-at-7-58-42-pmMost errors in the collection and interpretation of hemodynamic data are listed in Table 2-2.

Probably the most commonly observed artifacts relate to an improper degree of damping. The over-damped tracing indicates the presence of excessive friction absorbing the force of the pressure wave somewhere in the line from the catheter tip to the transducer. The tracing lacks proper fidelity and appears smooth and rounded because of loss of frequency response. This will result in loss of data and will falsely lower peak pressures. Typically, the dicrotic notch on the aortic or pulmonary artery waveforms is absent, and the right atrial or PAPW waveforms will lack distinct a and v waves.

Under-damping causes overshoot or ring artifact. This artifact typically appears as one or more narrow "spikes" overshooting the true pressure during the systolic pressure rise with similar, negatively directed waves overshooting the true pressure contour during the downstroke. This artifact may lead to overestimation of the peak pressure and underestimation of the pressure nadir. Tiny air bubbles that oscillate rapidly back and forth, transmitting energy back to the transducer, cause this artifact. Flushing the catheter or transducer often corrects this artifact; alternatively, introduction of a filter to the hemodynamic system may be necessary to eliminate this artifact.

Related to overshoot or ring artifact is catheter whip or fling artifact. This artifact is created by acceleration of the fluid within the catheter from rapid catheter motion and is commonly seen with balloon-tipped catheters in hyperdynamic hearts or balloon-tipped catheters placed in the pulmonary artery with extraneous loops. Similar to ring artifact, catheter whip causes overestimation of the systolic pressure and underestimation of the diastolic pressure. This artifact is difficult to remedy; eliminating the extra loops or deflation of the balloon can improve the appearance and limit this artifact.

Catheter malposition creates several interesting artifacts.

Hemodynamic Monitoring

October 17, 2015 Cardiology, Critical Care No comments , , , , , , , , , , , ,

Screen Shot 2015-10-16 at 8.06.09 PMIntraarterial pressure is typically measured from the radial, brachial, axillary, or femoral arteries.

Systolic Amplification

The contour of the arterial pressure waveform changes as it moves away from the proximal aorta. This i shown in Figure 7.4. Note that as the pressure wave moves toward the periphery, the systolic pressure gradually increases and the systolic portion of the waveform narrows. The systolic pressure can increase as much as 20 mm Hg from the proximal aorta to the radial or femoral arteries. This increase in peak systolic pressure is offset by the narrowing of the systolic pressure wave, so the mean arterial pressure remains unchanged.

The increase in systolic pressure in peripheral arteries is the result of pressure waves that are reflected back from vascular bifurcations and narrowed blood vessels. Reflected waves move faster when the arteries are stiff (the rigidity of arteries increases as with age), and they reach the arterial pressure waveform before it has time to decrement; the convergence of antegrade and retrograde pressure waves serves to heighten the peak of antegrade pressure waveform. Amplification of the systolic pressure by reflected waves is the mechanism for systolic hypertension in the elderly. Because systolic amplification is the result of retrograde pressure waves, it does not promote systemic blood flow.

Mean Arterial Pressure

The mean arterial pressure (MAP) is the time-averaged pressure in the major arteries, and is the principal driving force for systemic blood flow. The MAP is measured electronically as the area under the arterial pressure wave, divided by the duration of the cardiac cycle.

Steady flow (Q) through a closed hydraulic circuit is directly related to the pressure gradient across the circuit (Pin – Pout), and inversely related to the resistance to flow (R) through the circuit. Therefore we get the following formula:

Q = (Pin – Pout)/R [Equation 1]

If the hydraulic circuit is the circulatory system, volumetric flow becomes cardiac output (CO), the inflow pressure is the mean arterial pressure (MAP), the outflow pressure is the mean right atrial pressure (mRAP), and the resistance to flow is the systemic vascular resistance (SVR). The equation 1 relationship can be demonstrated as below in circulatory system:

CO = (MAP – mRAP) /SVR

In normal conditions, mRAP=RAP=CVP=RVEDP

Recording Artifacts

Fluid-filled recording systems can produce artifacts that further distort the arterial pressure waveform. Failure to recognize these artifacts can lead to errors in blood pressure management.

Resonant System

Screen Shot 2015-10-16 at 8.56.27 PMVascular pressures are transmitted through fluid-filled plastic tubes that connect the arterial catheter to the pressure transducer. This fluid-filled system can oscillate spontaneously, and the oscillations can distort the arterial pressure waveform. The performance of a resonant system is defined by two factors: the resonant frequency and the damping factor. The resonant frequency is the frequency of oscillations that occur when the system is disturbed. When the frequency of an incoming signal approaches the resonant frequency of the system, the resident oscillations add to the incoming signal and amplify it. This type of system is called an underdamped system. The damping factor is a measure of the tendency for the system to attenuate the incoming signal. A resonant system with a high damping factor is called overdamped system.

Waveform Distortion

Three waveforms from different recording systems are shown in Figure 7.5. The wave form in panel A, with the rounded peak and the dicrotic notch, is the normal waveform expected from a recording system with no distortion. The waveform in panel B, with the sharp systolic peak, is from an underdamped recording system. Underdamped systems are popular for pressure recording because their rapid response characteristics, but these systems can amplify the systolic pressure by as much as 25 mm Hg. The final waveform in panel C has an attenuated peak and a narrow pulse pressure. This waveform is from an overdamped system. Overdamping reduces the gain of the system and attenuates the pressure waveform. Overdamping can be the result of partial obstruction of the catheter with a thrombus, or air bubbles in the recording circuit.

Fast Flush Test

A pressurized flush of the catheter-tubing system can also help to identify a recording circuit that is distorting the pressure waveform. Most commercially available transducer system are equipped with a one-way valve that can be used to deliver a flush from a pressurized source. Figure 7.5 shows the results of a flush test in three different situations; the response when the flush is released will help characterize the system.

In panel A, the flush release is followed by a high-frequency burst. This is the normal behavior of a fluid-filled system. In panel B, the flush release produces a more sluggish frequency response. This is characteristic of an underdamped system, which will produce some degree of systolic amplification. The flush release in panel C does not produce oscillations. This is a sign of an over damped system, which will attenuate the arterial pressure waveform and produce a spuriously low systolic pressure.

Central Venous Pressure

When the PA catheter is properly placed, the proximal port of the catheter should be situated in the right atrium, and the pressure recorded from this port should be the right atrial pressure. The pressure in the right atrium is the same as the pressure in the superior vena cava, and these pressures are collectively called the central venous pressure/CVP. In the absence of tricuspid valve dysfunction, the RAP should be equivalent to the right-ventricular end-diastolic pressure (RVEDP), and RAP is the same as the pressure in the superior vena cava.


Pulmonary Wedge Pressure

The wedge pressure is obtained by slowly inflating the balloon at the tip of the RA catheter until the pulsatile pressure disappears, as shown in Figure 8.3. Note that the wedge pressure is at the same level as the diastolic pressure in the pulmonary artery. This relationship is altered in pulmonary hypertension, where the wedge pressure is lower than the pulmonary artery diastolic pressure.Screen Shot 2015-10-16 at 10.04.35 PM

The wedge pressure represents the venous pressure on the left side of the heart, and the magnified section of the wedge pressure in Figure 8.3 shows a typical venous contour that is similar to the venous pressure on the right side of the heart. The a wave is produced by left atrial contraction, the c wave is produced by closure of the mitral valve, and the v wave is produced by systolic contraction of the left ventricle against a closed mitral valve.

When the balloon on the PA catheter is inflated to obstruct flow (Q=0), there is a static column of blood between the tip of the catheter and the left atrium, and the wedge pressure at the tip of the catheter (Pw) is equivalent to the pulmonary capillary pressure (Pc) and the pressure in the left atrium (P[LA]). To summarize: if Q=0, then Pw=Pc=P[LA]. If the mitral valve is behaving normally, the left atrial pressure will be equivalent to the end-diastolic pressure (the filling pressure) of the left ventricle. Therefore, in the absence of mitral valve disease, the wedge pressure is a measure of left ventricular end-diastolic pressure/filling pressure.


The wedge pressure will reflect the left atrial pressure only if the pulmonary capillary pressure is greater than the alveolar pressure (Pc > Pa); otherwise the wedge pressure will reflect the alveolar pressure. Respiratory variations in the wedge pressure suggest that the catheter tip is in a region where alveolar pressure exceeds capillary pressure. In this situation, the wedge pressure should be measured at the end of expiration, when the alveolar pressure is closest to atmospheric (zero) pressure.

In addition to respiratory variations, the CVP and wedge pressures can vary spontaneously, independent of any change in the factors that influence these pressures. In general, a change in wedge pressure should exceed 4 mm Hg to be considered a clinically significant change.

Mean Pulmonary Artery Pressure

CO = (mPAP – mLAP) /PVR

The PVR is a global measure of the relationship between pressure and flow in the lungs. Because the pulmonary artery wedge pressure (PAWP) is equivalent to the left atrial pressure, the formula above could be written as:


Ventricular End-Diastolic Pressure

Ventricular end-diastolic volume is not easily measured at the bedside, and the end-diastolic pressure (RVEDP and LVEDP) is used as the clinical measure of ventricular preload. Although the end-diastolic pressure is the clinical measure of preload, clinical studies have shown a poor correlation between end-diastolic pressure and end-diastolic volume (preload). Studies indicate that ventricular filling pressures (i.e., CVP and PAWP) are unreliable as surrogate measures of ventricular filling.

The poor correlation between end-diastolic pressures and volume is particularly noteworthy because the subjects were healthy adults with normal cardiac function. When ventricular distensibility is impaired, which is common in critically ill patients, the discrepancy between end-diastolic pressures and volumes will be greater than usual.Screen Shot 2015-10-17 at 12.29.52 PM

Despite the shortcomings of EDP as a measure of ventricular filling, CVP monitoring continues to be a popular practice in ICUs.

The reference ranges for the CVP and wedge pressure are shown in Table 9.1. Note that the very low pressure range for the CVP, which helps to promote venous return to the heart. Note also that the sedge pressure is slightly higher than the CVP; the higher pressure in the left atrium closes the flap over the foramen oval and prevents right-to-left shunting in patients with a patent foramen ovale.