Practice
30 cases: look at the patient, decide what you expect, change something, and see whether the simulation agrees. Hints are staged; more than one answer is accepted where the physiology allows.
Loading and contractility
One change at a time on a normal or failing ventricle.- C01 Normal cycleConnect a selected point on the PV loop to pressure, valve state, flow and time.
- C02 Isolated preload changeDistinguish movement along the response curve from a change in contractility.
- C03 Isolated afterload changeCompare the immediate beat with the coupled steady state after a resistance change.
- C04 Positive inotropyIdentify the changes in work, flow and loading produced by a pure Ees increase, with the clamps stated.
- C05 Stiff LVCompare the pressure cost and the volume change of a fluid manoeuvre in a stiff ventricle.
- C06 Dilated systolic failureCompare output and filling pressure after different interventions in dilated HFrEF.
Fluid, shock and perfusion
Response versus tolerance, and treating the right phenotype.- C17 Fluid response versus toleranceSeparate a flow increase from a favourable overall intervention.
- C16 Hemorrhage versus vasodilationCompare volume, venous tone, output and compensation in two low-pressure states.
- C24 Mixed shockCompare interventions in a combined cardiac and vascular phenotype.
- C30 Same MAP, different perfusionCompare flow and oxygen delivery with similar pressure.
- C18 Positive-pressure ventilationCompare LV failure, RV failure and hypovolaemia under ventilation.
Measurement and reliability
Decide whether a number can be trusted before using it.- C21 Incorrect wedgeCorrect the observation before interpreting pulmonary hypertension or filling pressure.
- C22 Output method disagreementInvestigate assumptions rather than automatically averaging results.
- C15 PH classificationCheck measurement reliability before calculating resistance and classifying.
Valves, pericardium and the right heart
Lesions, tamponade, constriction, RV loading and valve intervention.- C07 AS versus HOCMExplain fixed versus dynamic obstruction and the opposite responses to a preload reduction.
- C08 Acute versus chronic MRCompare atrial compliance, pressure response and forward output for the same regurgitant orifice.
- C09 Aortic regurgitationIdentify altered flow phases and total versus effective forward volume.
- C10 MS with tachycardiaExplain shortened filling and a changing transmitral gradient.
- C11 Severe TRRelate the atrial waveform to forward pulmonary delivery and RV behaviour.
- C12 Restriction versus constrictionUse simultaneous recordings and respiratory behaviour.
- C13 TamponadeExplain external constraint and the response to modelled drainage.
- C14 Acute RV loadingExplain poor LV filling despite high right-sided pressure.
- C29 Valve intervention: now and laterSeparate the immediate hemodynamic result of relieving aortic stenosis from the remodelled state.
Rhythm and exercise
When rate and rhythm change filling.Support and shunts
Devices, circuits and intracardiac shunts.- C23 Left-to-right shuntRead Qp/Qs and the oxygen step-up, and explain the RV volume load of an atrial defect.
- C25 Balloon pump timingRecognise early inflation on the aortic trace and correct it.
- C26 Pump suctionDiagnose a microaxial pump running faster than the ventricle can be filled and resolve it.
- C27 Distension on VA-ECMORecognise LV distension under retrograde arterial return and vent the ventricle.
- C28 Weaning with two circuitsAccount for native, pump and circuit flow while reducing support.