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Eduardo R Argaiz

Oct 14, 2022 • 8 tweets • 4 min read • Read on X

🧵Complex #Hemodynamics in ESRD:

Middle age pt ➡️ 🏥 for syncope

HPI: Low BP during HD sessions. Does not achieve dry weight. Today she has had 6 episodes of syncope!

Last episode happened as she stood up from a chair

BP 88/62, HR 87 🧠 OK, CRT 2 sec

1/8

On #Echofist you notice this👇

During systole, flow from the LV towards the Aorta should all be blue in color! (Direction away from the probe)

This apparent change in direction (red sphere) is called Aliasing

Aliasing = Very high flow Velocity!

2/8

Velocity can be quantified!

Use CW Doppler passing through the red sphere 👇

Velocity = 3.8 m/s 🚨🚨🚨 This is very fast!

Whenever you see a very fast flow, think of obstruction (similar to blocking a hose with your thumb👇)

What is causing the obstruction?

3/8

Obstruction is caused by severe LVH, this is not rare in ESRD with long term uncontrolled HTN.

Thick myocardial walls are causing mid ventricular obstruction during systole ➡️ some blood gets trapped at the apex ➡️ Lower CO

This worsens with exertion ➡️ syncope!

4/8

How to treat?

We need to increase LV cavity volume to push the myocardial walls apart and relieve the obstruction!

This is usually achieved by some combination of:

🔷 Increase Preload
🔷 Increase Afterload
🔷 Decrease Contractility / HR

But this case had a twist!

5/8

Look at parasternal long axis view! There is obvious RV dilation!

Remember the patient had not been able to achieve dry weight!

E/E' was 25! TRVMax 2.9

#VExUS Portal Vein Pulsatility Fraction > 100%

This patient has severe venous congestion!

6/8

Dilated RV is compressing the LV!

This makes the LV cavity smaller and EXACERBATES Obstruction! 🤯

Treatment is decongestion!

Ultrafiltration ➡️ reduced RV Volume ➡️ reduced septal shift ➡️ less LV compression ➡️ less mid-ventricular obstruction!

7/8

We started vasopressin and removed fluid (used Portal Vein to monitor decongestion); Then added oral Beta-Blocker

Patient decongested nicely to a normal portal vein and obstruction improved significantly! (Velocity = 1.9 m/s)

Syncope is now completely gone!

#POCUSAlways

8/8

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More from @ArgaizR

Eduardo R Argaiz

@ArgaizR

Sep 17, 2023

👩♀️ Past Medical History: SLE, Antiphospholipid syndrome, portal vein trombosis, ESKD on HD, 🫀Group 1 PH + Severe TR

Now with worsening ascites (Para: SAAG > 1.1, total protein 2.5 g/dL). Lowering dry weigh was attempted..

BP 90/60. No edema. On room air, ⬆️ JVP

#POCUS

1/8

Is this cardiac ascites? Should we lower dry weight even further?

2/8

🔷 Although IVC is plethoric, this is not reliable in severe TR

🔷 VExUS can't be performed here (Portal Vein Trombosis, ESRD very small kidneys)

How about HV Doppler and Femoral Vein Doppler? 👇

Is this severe congestion? I do not think so! They also reflect severe TR!

3/8

Read 8 tweets

Eduardo R Argaiz

@ArgaizR

Aug 4, 2023

Hemodynamic Evaluation of Right-Sided Congestion With Doppler Ultrasonography in Pulmonary Hypertension @AmJCardio

50 days' free access link: https://t.co/ADD3F7NgEf

🧵of our findings 👇 (1/6) https://t.co/ORDsb9Nu4rdoi.org/10.1016/j.amjc…
authors.elsevier.com/a/1hXCqgQkyqNA

1⃣ Intra-Renal Doppler (IRVD) alterations are usually classified using morphological patterns (Continuous, Biphasic, Monophasic)

Looking at the relationship between Portal Vein Flow and IRVD you can notice the "Biphasic" pattern shows a very large spread of values! (2/6)

Switching to a classification based on interruption-time identified pts with a "Biphasic" pattern who were non-congested (short interruptions) or severely congested (long interruptions)

This classification has a much better agreement with Portal Vein Alterations! (3/6)

Read 6 tweets

Eduardo R Argaiz

@ArgaizR

Jul 7, 2023

👴 w Cirrhosis ➡️🏥 with spontaneous bacterial peritonitis and septic shock

After fluid resuscitation, vasopressors and antibiotics shock resolved

However now with oliguria and ⬆️ Na (165 meq/L). Cr 1.0 mg/dl, BUN 30 mg/dl

1/10

BP is 155/63 (MAP 94), HR 77, O2 is 94 on O2 8 L/min.

🧠 Encephalopahy on tx w lactulose, edema +++, CRT 1 second, mild ascites.

#POCUS LV/RV OK, LVOT VTI 40 (CO 9.8 L/min), B-Lines, VExUS = 2 (Plethoric IVC + Biphasic Intra-renal Doppler) ➡️ High Output Heart Failure

2/10

1⃣¿Why is the pt Oliguric?

Is this hemodynamic AKI?

🔷Hypovolemic unlikely given congestion and ⬆️ CO

🔷Distributive? Although pt has Cirrhosis, MABP is 94 without vasopressors, also unlikely

🔷Congestive? Possible given VExUS 2

3/10

Read 11 tweets

Eduardo R Argaiz

@ArgaizR

Feb 27, 2023

HV Doppler from a pt with severe group 1 pulmonary hypertension 👇

Many of us don't have ECG when doing POCUS...

Is it posible to determine this waveform components?

The answer is yes! I'll show you how I did it here

A 🧵on HV Doppler in Pulmonary Hypertension

#VExUS 1/12

Normal HV is a mirror image of normal CVP waveform.

It usually has 4 waves:

2 antegrade (flow from liver to 🫀) waves (S and D)

2 retrograde (flow from 🫀 to liver) waves (A and V)

2/12

A frequent alteration in pts w severe PH is Severe Tricuspid Regurgitation

In severe TR, there is retrograde flow from the RV to the RA in systole. If the right atrium is not compliant, this flow reaches the HV and gives a reverse S wave!

Example from another case 👇

3/12

Read 12 tweets

Eduardo R Argaiz

@ArgaizR

Jan 29, 2023

Young ♀️ w CKD on HD, seen in Cardiorenal clinic

Pt had torrential tricuspid regurgitation due to CVC induced leaflet perforation ➡️ She underwent tricuspid valve replacement surgery 🫀🔪

However, 1 month after discharge she is still using a wheelchair 🤔

1/12🧵

#POCUS above shows plethroic, non-collapsible IVC and Hepatic Veins

Did surgery work?

Is there residual tricuspid regurgitation?

#Echofist (PLAx RV view + A4ch) color Doppler lets us see there is no or minimal TR

Prosthetic valve seems to be working

2/12

But there is still venous congestion. In fact congestion is significant, take a look at portal vein Doppler 👇

Pulsatility Fraction = 40%, this means there is significant venous congestion. Why?

Is this just volume overload? Should we probe a lower dry weight?

3/12

Read 13 tweets

Eduardo R Argaiz

@ArgaizR

Dec 28, 2022

Ambulatory Hemodialysis Unit Rounds:

Called to see a patient with hypotension: BP 76/40,🧠 OK, CRT 5 seconds

1st step ➡️🛑Ultrafiltration + 300 ml bolus. BP 90/60

Pt is a middle aged ♂️ w ESRD and T2DM

1/9 🧵

Now 3 kg above Dry Weight.

UF Volume so far: Only 600 ml

🔎📁 Previos HD sessions with no hypotensive episodes

1 week with URI symptoms, 2 days with dyspnea on exertion

On exam: No leg edema, Clear 🫁, JVP hard to assess (hx of multiple CVCs and central vein stenosis)

2/9

#POCUS:

Pericardial Effusion, Normal LV function, looks like there is some RV colapse

Plethoric IVC, Portal Pulsatility 39%.

A-Pattern on LUS, Small bilateral pleural effusions

🚨⬇️BP + Collapsing RV + Venous Congestion (IVC + Portal Pulsatility) suggests Tamponade!

3/9