Echocardiography in BPD. Hythem Nawaytou MBBCH Assistant Professor Pediatric Cardiology UCSF - Benioff Children s Hospital

Transcription

1 Echocardiography in BPD Hythem Nawaytou MBBCH Assistant Professor Pediatric Cardiology UCSF - Benioff Children s Hospital

2 Role of echo in BPD Measuring the PA pressure» rule in PH?» rule out PH?» accurately esfmate PA pressure?» assess response to treatment & follow pafents?

3 How to measure PA pressure QuanFtaFve: Systolic Pressure: TR jet peak velocity, VSD or PDA peak systolic velocity Mean Pressure: Early diastolic pulmonary regurgitafon velocity End-Diastolic Pressure: End diastolic pulmonary regurgitafon velocity QualitaFve: Septal posi7on and mo7on Direc7on of flow in the PDA,VSD

4 TR Jet Peak Velocity of tricuspid valve regurgitafon 4X(Velocity) 2 (+Right Atrial Pressure) =Pulmonary artery systolic pressure

5 TR Jet WE LOVE YOU Easy to obtain ObjecFve Gives us a number

6 Easy to obtain Feasibility of TR Jet esfmafon in BPD pafents 61% Mourani et al. Pediatrics February ; 121(2):

7 ObjecFve? Groh et al, J Am Soc Echocardiogr (2014) 27(2)

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10 ObjecFve Groh et al, J Am Soc Echocardiogr (2014) 27(2)

11 Gives out a number Is that number accurate?

12 Gp 1: RVSP < ½ SBP Gp 2: RVSP > ½ SBP 80 children 0-17 years (median 5.5yrs) Two ventricles Wide range of RV pressure Simultaneous RHC-Echo Gp 3: RVSP < 2/3 SBP Gp 4: RVSP >2/3 SBP Groh et al, J Am Soc Echocardiogr (2014) 27(2)

13 Children Group Bias LOA I 3 9 to -3.5 II to -19 III to -4.5 IV 1 26 to -24 Gp 1: RVSP < ½ SBP Gp 2: RVSP > ½ SBP Gp 3: RVSP < 2/3 SBP Gp 4: RVSP > 2/3 SBP Groh et al, J Am Soc Echocardiogr (2014) 27(2):163 71

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15 Goal: In a real life scenario of BPD pa7ents did the echo predict the cath PA pressure? RetrospecFve chart review Most of the echoes were within 30 days (0-57d) CondiFons between the cath and echo were not similar Mourani et al. Pediatrics February ; 121(2):

16 Relationship between spap values estimated with echocardiography (ECHO) and directly measured with cardiac catheterization (CATH). Peter M. Mourani et al. Pediatrics 2008;121: by American Academy of Pediatrics

17 Ability of echocardiography (ECHO)-estimated spap to predict the severity of PH determined with cardiac catheterization (CATH). 11% UNDERDIAGNOSIS 11% OVERDIAGNOSIS Peter M. Mourani et al. Pediatrics 2008;121: by American Academy of Pediatrics

18 PaFent CPAP 7cmH2O, FIO2 0.4 and ino 20ppm, Capillary BG 7.4/59/72/+12 SBP 82/50 SBP 82/50 PDA PG = RVSP 50mmHg TR Jet = RVSP 55mmHg Does the pafent have pulmonary hypertension?

19 CatheterizaFon data PaFent ETT, FIO2 0.4 and ino 20ppm, Femoral artery 7.4/50/118/+7 PA pressure: 35/16/ mean 24mmHg Systemic BP: 61/41 mean 50mmHg PVR: 3.1 Does the pafent have pulmonary hypertension?

20 Ability of echocardiography (ECHO)-estimated spap to predict the severity of PH determined with cardiac catheterization (CATH). SCREENING TOOL 11% UNDERDIAGNOSIS 11% OVERDIAGNOSIS Peter M. Mourani et al. Pediatrics 2008;121: by American Academy of Pediatrics

21 Relationship between spap values estimated with echocardiography (ECHO) and directly measured with cardiac catheterization (CATH). SCREENING TOOL CORRECTLY CLASSIFIED CORRECTLY CLASSIFIED Peter M. Mourani et al. Pediatrics 2008;121: by American Academy of Pediatrics

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23 SHUNTS How good are post tricuspid valve shunts in esfmafng PA pressures?

24 SPAP with shunts PDA & VSD SPAP=SBP 4V2 (for leq to right shunts) SPAP=SBP+4V2 (for right to leq shunts) VSD (SPAP r = 0.98, SEE= 6.3 mm Hg) PDA (SPAP r = 0.972, SEE = 6.8 mmhg) Not Tested in BPD specifically (DPAP r = 0.939, SEE = 6.2 mmhg) (Int J Cardiol (1993) 40(1):35 43) (Am Heart J (1992) 124(1):176 82)

25 BidirecFonal flow What does it mean?

26 Bi-direcFonal shunt - VSD

27 Bi-direcFonal shunt - VSD

28 Bi-direcFonal-PDA

29 Bi-direcFonal-PDA

30 Septal PosiFon & MoFon How many use it to quanffy PA pressure?

31 Mourani et al. Pediatrics February ; 121(2):

32 Interventricular septal configurafon PERFECT CIRCLE Progressive septal flauening FLAT CirculaFon 68, No. 1, 68-75, 1983

33 Interventricular septal configurafon CirculaFon 68, No. 1, 68-75, 1983.

34 Pivalls of septal mofon Off axis scans Where to assess it? Base Papillary muscle Apex Arrhythmias and conducfon abnormalifes When is end diastole and end systole?

35 Rule IN

36 RULE OUT

37 Accurately esfmate PA pressure elevafon

38 Can it assess response to treatment?

39 Response to treatment DirecFon of shunfng across a PDA/VSD Holo-diastolic flow in the abdominal aorta Measurement of RV size, funcfon, output?

40 Other important findings

41 Higher incidence of PH among BPD pafents with atrial Lt to Rt shunt. (42% vs 15%.) Earlier development of PH ( 62 vs 103 days) More use of pulmonary vasodilators (possibly more severe) Higher mortality (14% vs 0%)

42 PDA

43 Pulmonary vein stenosis

44 Pulmonary vein stenosis

45 Pulmonary vein stenosis

46 Pulmonary vein stenosis Cardiac catheterizafon PV stenoses llpv>rupv>rlpv>lupv Pressure gradients of 10-15mmHg between pulmonary veins and LA

47 Conclusions Can echo screen PH in BPD pafents? YES Can echo rule out PH in BPD pafents? We don t know Can echo be used to follow BPD pafents with PH? Not pressure but helpful

48 PH Team UCSF