Thread by @EiranGorodeski

The 'right' way to do a RHC. @RyanTedfordMD Self-described "hemodynamic nerd." Welcome to @UHhospitals!! #HeartFailureGRs @UHhospitals @CWRUSOM

The birth of modern-day hemodynamics. @RyanTedfordMD

"What the heck do we do with this patient?" Both PH and heart failure? @RyanTedfordMD

Doing a right heart catheterization correctly: before you begin!! Calibrate and position comfortably. @RyanTedfordMD #HeartFailureGRs @UHhospitals

"I almost always only use local anesthesia." @RyanTedfordMD Patients who fall asleep can face challenges, and for those with sleep apnea, this can disrupt hemodynamic measurements.

"We have a ruler in our cath lab." @RyanTedfordMD

Dr. Tedford is challenging the occasional practice of doing breath-hold maneuvers. Can result in valsalva. @RyanTedfordMD

Tip to reduce catheter ringing: introduce some blood or contrast into the catheter to reduce ringing. @RyanTedfordMD

Measuring the RA correctly. @RyanTedfordMD New term for me: "Z-point"!

Reminder, new definition of mPAP is now <= 20mmHg. @RyanTedfordMD

Getting the PAWP right is critical as it is the sole discriminator of pulmonary hypertension. @RyanTedfordMD #HeartFailureGRs @UHhospitals @CWRUSOM

In the example on the right, high pressures; "Mean PAWP represents the pressure 'felt' by the pulmonary circulation from the left atrium." @RyanTedfordMD

"The presence of large V waves should be reported as it suggests left heart disease regardless of PAWP." @RyanTedfordMD

Among obese patients end-expiratory cycle over-estimated PCWP. Best to average across the respiratory cycle. @RyanTedfordMD

Recommendations for adequate PAWP/LVEDP measurement. Ryan reports both end-expiration and averaged across the respiratory cycle. @RyanTedfordMD

Because incomplete occlusion can lead to misestimation of PCWP, at MUSC they instituted a standard of care to confirm PCWP with O2 sat measurement. @RyanTedfordMD

Checking saturation reclassifies 12% of patients!! This is now part of the guidelines in performing RHC for diagnosis of PHTN. @RyanTedfordMD #HeartFailureGRs @UHhospitals @CWRUSOM

Final take home points.

What if you 'can't' get a wedge pressure? Almost always can get PCWP if a partially deflate the balloon and... push.

Challenges in measuring cardiac output: limitations of bot the Fick and thermodilution methods. @RyanTedfordMD #HeartFailureGRs @UHhospitals @CWRUSOM

"Thermodilution is a more accurate measure of cardiac output." Better association with mortality. @RyanTedfordMD #HeartFailureGRs @UHhospitals Harrington Heart & Vascular Institute

Contemporary definitions of #PulmonaryHypertension. @RyanTedfordMD #HeartFailureGRs @UHhospitals Harrington Heart & Vascular Institute

Who are patients who need vasodilators? Only 2 groups. @RyanTedfordMD #HeartFailureGRs @UHhospitals Harrington Heart & Vascular Institute

Here is Dr. Shumway's original data showing the dangers of PHTN in heart transplant candidates. @RyanTedfordMD #HeartFailureGRs @UHhospitals Harrington Heart & Vascular Institute

Ryan argues that using resting PAWP alone is not enough to define left heart disease. @RyanTedfordMD #HeartFailureGRs @UHhospitals Harrington Heart & Vascular Institute

What about saline loading? "No 'healthy' individuals would have increased PAWP > 18mmHg with 500cc saline." @RyanTedfordMD #HeartFailureGRs @UHhospitals Harrington Heart & Vascular Institute

Recommendations regarding fluid loading. @RyanTedfordMD @UHhospitals Harrington Heart & Vascular Institute

How to do a RHC? Closing thoughts!! @RyanTedfordMD #HeartFailureGRs @UHhospitals Harrington Heart & Vascular Institute

Thank you so much @RyanTedfordMD for a fantastic talk!