Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review

Abstract

Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.

Keywords: Hemodynamics; cardiac function; cardiogenic shock; heart failure; heart failure with preserved ejection fraction; heart failure with reduced ejection fraction; pulmonary hypertension.

Figure 1.

Pressure-volume physiology of the LV, inotropes and select mechanical circulatory support (MCS) devices, the RV, and ventricular-pericardial interactions. Key principles and all abbreviations thoroughly outlined in text.

Figure 2.

Resting and Invasive Exercise Right Heart Catheterization. Typical RHC tracings, exercise protocol schematics, key methods and variables outlined for both.

Figure 3.

Example hemodynamic tracings. Key points highlighted alongside tracings. (A) Normal right atrial (RA) and pulmonary capillary wedge (PCW) tracings and values. (B) Giant V-waves on PCW tracing due to reduced left atrial compliance. Care should go towards identifying mean PCW pressure by bisecting the A-wave (and not the V-wave) at end-expiration. (C) Pulmonary hypertension with prominent Y-descents and Kussmaul’s sign (rise in RA pressure) with inspiration, collectively indicative of poor pulmonary vascular and RV compliance. (D) RV failure with a dip-and-plateau sign during diastole, indicative of severe RV dysfunction and diastolic pressure overload. The same can also be seen in constrictive pericarditis and restrictive cardiomyopathies when ventricular filling must occur early and rapidly due to poor ventricular compliance.

Figure 4.

Hemodynamic indices in HF and CS. As HF progresses, metabolic capacity gradually wanes. Patients first suffer loss of cardiac reserve but maintain normal rest perfusion. Multiple hemodynamic indices continuously adapt to gradually waning SV in order to maintain CO and BP. Cardiac pressures rise as the heart fails to maintain normal filling; pulmonary pressures rise too. As reserve fades, small perturbations in the metabolic supply-demand balance can precipitate exacerbation. In later disease, multiple compensatory mechanisms fail, leading to low output and cardiogenic shock states. Upon cardiac arrest, flow stops and pressures converge upon the mean circulatory filling pressure. Treatments throughout are directed towards the clinical and hemodynamic state. NYHA, New York Heart Association; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support Profiles; SCAI, Society for Cardiovascular Angiography & Interventions Classification of Cardiogenic Shock.

Figure 5.

A proposed team-based approach to the management of refractory Cardiogenic Shock. LV CPO, LV cardiac power output (MAP·CO/451); RV CPO (mPAP·CO/451); PAPi, pulmonary artery pulsatility index ((sPAP-dPAP)/RAP); RAP/PCWP, right atrial pressure-to-pulmonary capillary wedge pressure ratio; pVAD, percutaneous ventricular assist device; VA-ECMO, venoarterial-extracorporeal membrane oxygenation.

Figure 6.

Average effect on PVR and PCWP of select provocative agents useful for vasodilator testing of pre-capillary pulmonary hypertension.

Figure 7.

A diagnostic approach to HFpEF. Patients with unexplained dyspnea can be assessed by the H₂FPEF score, or an alternative HFA-PEFF score. Those with intermediate probability, or others if needed, can be further evaluated using invasive hemodynamic exercise testing (gold standard), or PA catheterization at rest with provocative maneuvers.