Pulmonary hypertension in clinical practice: are we focusing on the problem?

Transcription

1 Pulmonary hypertension in clinical practice: are we focusing on the problem? Odd Bech-Hanssen, MD, PhD Cardiology/Clinical Physiology Sahlgrenska University Hospital Gothenburg, Sweden

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3 Definition Mean PA pressure>25 mmhg Mean PA 25 mmhg systolic PA 40 mmhg mmhg 50 mmhg 55 mmhg 120 mmhg

4 Prevalence Sahlgrenska 2008 TR gradient registered in 5542/8306 (67%) PH in 1164/5542 (21%)

5 D Patophysiology Pulmonary vascular resistance=pvr PVR = (Mean PA-PCWP)/CO Mean PA=PVR PVR x CO +PCWP 1. PCWP=increased LV filling pressure 2. PVR=increased vascular resistance 3. CO=increased flow

6 D Patophysiology Pulmonary hypertension (PASP>40 mmhg) Left atrial pressure? Increased flow? Normal Increased, PCWP>12 mmhg Qp Qp+Qs Pulmonary embolism PAH Chronic PE Lung fibrosis Hypoxia LV failure Valvular disease ASD VSD Sepsis Anemia Increased PVR Normal PVR Increased PVR Normal PVR

7 D Diagnostics Three questions PCWP? CO? PVR? Mean PA=PVR x CO +PCWP

8 Tricuspid regurgitation Pulmonary artery pressure The prerequisite: No pulmonary valve stenosis Highest velocity in a non-standard projection

9 Tricuspid regurgitation Velocity versus artefact 70 mmhg? 115 mmhg? 80 mmhg

10 Tricuspid regurgitation Systolic PA pressure (PASP) Simultaneously Within 24 hours Mean difference 0.7±7.8 mmhg Mean difference 0.7±13 mmhg Mean Selimovic difference N et 0.7±7.8 al JHLT mmhg 2007 Bech-Hanssen O et al JASE 2009 Selimovic N et al JHLT 2007 Bech-Hanssen O et al et al JASE 2009

11 D Tricuspid regurgitation Mean PA pressure (PAMP) Simultaneous measurements PAMP= 65% of PASP Bech-Hanssen O et al JASE 2009 Within 24 hours Mean difference 0.2 ± 8.3 mmhg

12 D Pulmonary vascular resistance (PVR) Direct calculation from Doppler data PVR = (Medel PA-PCWP)/CO Diastoliskt PA tryck (b)

13 D Pulmonary vascular resistance (PVR) Direct calculation from Doppler data Simultaneously Within 24 hours Mean difference 0.3±2.1 Woods units Selimovic N et al JHLT 2007 Mean difference 0.2±3.6 Wood units Bech-Hanssen O et al. Unpublished data.

14 Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)

15 Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)

16 Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU) PA-pressure PA-flow No pressure reflection in the pulmonary circulation The increase of pressure (Augmented pressure) after peak flow in the pulmonary artery is caused by pressure reflection Hypotesis: Pressure reflection (PR)=increased PVR

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18 AcT: Acceleration time (ms) tpv-pp: Interval between peak velocity in th PA and peak RV pressure (ms) AP (augmented pressure): Increase of pressure after peak velocity in the PA (mmhg)

19 Normal PAH AcT=186 ms tpv-pp=0 AP=0 DopplPASP=41 mmhg Cath PASP=29 mmhg PVR=0.8 WU AcT=66 ms tpv-pp=91 AP=17 mmhg DopplPASP=67 mmhg Cath PASP=69 mmhg PVR=14 WU

20 Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)

21 Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)

22 Case#1 Male, 49 years Admitted due to gastric pain, palpitation and syncope

23 Case#1 Ejection fraction 19% (Simpson)

24 Case#1 CVP RA 15 mmhg

25 Case#1 PCWP and CO VTI 7 cm S/D <<1 E/A 3.9 SV 24 ml CO 1.8 l/min PCWP 15 mmhg

26 Case#1 PA pressure Mild PH: = 40 mmhg??

27 Case#1 PA pressure Pulmonary hypertension: = 51 mmhg

28 D Case#1 Three questions PCWP CO PVR? Medel PA=PVR x CO +PCWP

29 Case#1 Is the PVR>3 WU? AcT 113 ms tpv-pp 25 ms PVR<3 WU AP 0 mmhg..moderate pulmonary hypertension secondary to increased LV filling pressure, normal PVR...

30 Case#1 Catheterization the day after Cath Echo RA PASP PADP PAMP PCW CO > PVR 0.4 *PI **Ekvation

31 Case#2 Male, 56 years Heart failure diagnosis 10 years ago Now haemoptysis Dyspnea NYHA III

32 Case#2

33 Case#2

34 Case#2

35 Case#2 PCWP and cardiac output E/A 2.1 S/D?? SV 55 ml PCWP 15 mmhg?? CO 4.5 l/min

36 Pulmonary hypertension: = 60 mmhg

37 Case#2 AcT 60 ms tpv-pp 111 ms PVR>3 WU AP 12 mmhg..moderate pulmonary hypertension, signs of pressure reflection indicating increased PVR...

38 Case#2 Catheterization the day after Cath Echo RA PASP PADP PAMP PCW CO * 60 38** > PVR 5.8 *Schablon **Ekvation

39 Summary PH when Doppler PASP>40 mmhg PH is a frequent finding Highest TR velocity most often in a non-standard projection Always ask yourself: What causes PH? Increased LV filling pressure? Increased PVR? Increased flow? Pressure reflection indicates increased PVR