DK2985_C000 1..28 - AlSharqia Echo Club

Global Ventricular Function and Hemodynamics 203(A) TMFBEGINNING OF PROCEDURE(B) MAV(C) TMFEEAAEND OF PROCEDURE(D) PVFSDEmAmFigure 9.26 Left ventricular diastolicdysfunction in a 73-year-old womanduring off-pump bypass surgery. (A, B)At the beginning of the procedure, thetransmitral flow (TMF) demonstrates aE/A ratio .1 with a tissue DopplerE m /A m ratio ,1 (B) consistent with atleast moderate diastolic dysfunction(pseudonormal pattern). (C, D) Followingrevascularization, a higher E/Aratio with left upper pulmonary venousflow (PVF) blunted S-wave suggestsworsening diastolic function and higheroperating filling pressures. This wasassociated with significant hemodynamicinstability requiring vasoactive support(MAV, mitral annular velocity).with preload, afterload, contractility and diastolic functionrarely acting alone and often in different combinations.Etiologies of hypotension can be grouped according totheir mechanism (45). Reduced left ventricular preloadcan result from hypovolemia, reduced systemic vascularresistance or venous tone, tamponade (see Chapter 11)and decreased right ventricular CO. Increases in left andright ventricular afterload leading to hypotension includeleft and right ventricular outflow tract obstruction.Reduced contractility and diastolic dysfunction can beFigure 9.27 Left ventricular diastolicdysfunction in a 37-year-old woman withsubarachnoid haemorrhage and brain–heart syndrome associated with hemodynamicinstability. (A) The patient’s headcomputed tomography scan showed intraventricularbleeding. (B) The hemodynamictracing shows a heart rate of 88beats/min, systolic, and diastolic arterialpressure (Pa) of 94 and 51 mmHg, systolic,and diastolic pulmonary artery pressure(Ppa) of 43 and 23 mmHg with a prominent“V” wave appearing on the wedgedtracing without significant mitral regurgitationon color Doppler (not shown).(C) Transmitral flow (TMF) reveals ahigh E/A ratio (EKG, electrocardiogram;ETCO 2 , end-tidal carbon dioxide)(Courtesy of Dr. Nancy McLaughlin).