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The Wiggers Diagram: Hemodynamic Changes in Cardiac Amyloidosis

      A 77-year-old gentleman with cardiac amyloidosis (CA) presents with dyspnea on exertion, abdominal bloating, and lower extremity edema. Vital signs show blood pressure 109/72 (mean 84 mmHg), heart rate 75 beats per minute, respiratory rate 20, oxygen saturation 90%. Right heart catheterization reveals right atrial pressure 12 mmHg, pulmonary artery pressure 42/27 (mean 32 mmHg), pulmonary capillary wedge pressure 24 mmHg, cardiac output 2.9 liters/minute with a cardiac index of 1.5 liters/(minute*m
      • Ahmed SS
      • Levinson GE
      • Schwartz CJ
      • Ettinger PO.
      Systolic time intervals as measures of the contractile state of the left ventricular myocardium in man.
      ), and pulmonary vascular resistance 2.8 Wood units. The hemodynamic changes in CA and their clinical consequences are succinctly illustrated by the Wiggers diagram (Fig. 1A), developed by Carl Wiggers,
      • Wiggers CJ.
      The electrocardiogram: its relation to cardiodynamic events.
      which tracks changes in arterial, left atrial and ventricular pressures, and left ventricular volumes to reflect the sequence of mechanical events in relation to the electrocardiogram during the cardiac cycle, and has been employed for generations to teach cardiac physiology.
      Fig 1
      Fig. 1The Wiggers diagram (A); pressure-volume loop (B); mitral inflow and LVOT outflow profiles (C) for normal vs cardiac amyloidosis patients. EDV, end-diastolic volume; ESV, end-systolic volume; ET, ejection time; IVCT, isovolumic contraction time; IVRT, isovolumic relaxation time; LVOT, left ventricular outflow tract.

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