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

https://doi.org/10.1016/j.cardfail.2021.07.012Get rights and content

Highlights

  • •

    This article reviews the role of invasive hemodynamics in the care of patients across the entire spectrum of human heart failure.

  • •

    Conceptual principles of ventricular function, ventricular-arterial interaction, load response, and ventricular interaction in the right and left heart are reviewed.

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    Principles and practice of invasive exercise testing are provided, along with detailed discussions on the role of invasive hemodynamics in the evaluation and management of advanced heart failure, shock, mechanical circulatory support, and pulmonary hypertension.

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.

Section snippets

Pressure and Pressure–Volume Relationships

Pressure defines force applied to an area: 1 mm Hg represents the vertical force of 133.3 Newtons applied to an area of 1 m2. Cardiac contractions expose the cardiovascular system to cyclic variations in pressure—greatest in the ventricles and lowest in the capillaries. Blood flow to support life is driven by the pressure gradients generated by the heart. During systole, ventricular and atrial pressures increase, increasing pressure to propel blood forward. During relaxation, pressure decays

Resting Hemodynamic Assessment

Right heart catheterization (RHC) is ideally performed with minimal conscious sedation in supine patients, often without interrupting anticoagulation, which is important in vulnerable populations such as in patients with an LVAD. The pressure transducer should be zeroed at the mid thorax (level of the left atrium).27 Overdampening or underdampening of pressure tracings should be addressed through good technique, including aspiration and catheter flushing. Pressure measurements in each chamber

HF With Reduced EF

Most clinical decisions in HFrEF can be made based on history, physical exam, and laboratory findings. In fact, the Heart Failure Society of America guidelines recommend against the routine assessment of invasive hemodynamics in HF.34 These guidelines are supported by the seminal Evaluation Study of Congestive heart failure and Pulmonary artery catheterization Effectiveness (ESCAPE) trial,35 which found no mortality benefit to routine PA catheter use in acute decompensated HF.

Hemodynamic

Conclusions

After years of dormancy, the value of invasive hemodynamics has re-emerged front and center, playing a crucial role in the scope of the HF practice. A thorough understanding of the principles and practice of the hemodynamic assessment, along with a thoughtful application across the broad range of HF disease states are of vital importance to HF clinicians serving their patients. Future advances in the understanding and application of hemodynamics will only further cement their central role in

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