Squeeze, Squeeze, Squeeze: The Importance of Right Ventricular Function and PH

Transcription

1 Squeeze, Squeeze, Squeeze: The Importance of Right Ventricular Function and PH Javier Jimenez MD PhD FACC Director, Advanced Heart Failure and Pulmonary Hypertension Miami Cardiac & Vascular Institute Baptist Health System, South Miami Hospital

2 Disclosures I disclose that I am a Consultant for St Jude, and a member of the Gilead, United Therapeutics, Bayer, Actelion speaker s bureau. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the Pulmonary Hypertension Association. Neither PESG, nor PHA, nor any accrediting organization support or endorse any product or service mentioned in the is activity. PESG and PHA staff has no financial interest to disclose. Commercial Support was not received for this activity. 2

3 Learning Objectives At the conclusion of this activity, the participant will be able to: 1. Review normal and abnormal right ventricular physiology 2. Understand right ventricular anatomy 3. Describe different methods to evaluate right ventricular function 4. Summarize strategies for the acute and chronic management of right ventricular failure

4 76 yo man with ascitis

5 43 yo woman with SOB

6 58 yo man sp Bio AVR with ascitis

7 Pulmonary pressure or right ventricle? Pulmonary arterial hypertension needs appropriate right ventricular contractility to generate that pressure Patients clinically deteriorate when the right ventricle becomes insufficient Little focus is placed assessing right ventricular function and addressing right ventricular failure

8 What is RV failure? Dypnea Fatigue Peripheral Edema Hepatomegaly Distented /pulsative jugular veins

9 Progression of PAH Presymptomatic/ Compensated Symptomatic/ Decompensating Declining/ Decompensated CO Symptom Threshold PAP PVR Time Right Heart Dysfunction

10 Physiology of the normal pulmonary circulation Low-pressure system The pressure in the pulmonary system depends on cardiac output, resistance and compliance The pulmonary vascular resistance has a particular dependency on alveolar oxygen tension, whereby alveolar hypoxia leads to pulmonary arterial vasoconstriction High compliance of the pulmonary vessels (large diameter and thin wall)

11 Physiology of the normal pulmonary circulation Right ventricle: Less O2 requirements than the LV; less myocardic mass, less pre-load and after-load During stress, extraction reserve is greater Vascularization : 2/3 RCA, 1/3 left branches RV perfused in both systolic and diastolic phases as a result of the low systolic pressure (25 mmhg), which does not occlude the vessel that has systemic pressure

12 Right Ventricular Anatomy The inlet, trabeculated apical myocardium and infundibulum of the RV. The tricuspid and pulmonary valves are separated by the ventriculo-infundibular fold (VIF) François Haddad et al. Circulation. 2008;117:

13 Pathophysiology of the RV

14 Challenges Assessing the RV Thin-walled crescent shape, anteriorly located Intrincate interdependence between loading conditions and performance Linked to the left ventricle

15 Methods to Assess RV Function Chest X ray ECG Echocardiography Cardiac MRI Cardiac CT Hemodynamics

16 Chest X Ray

17 Electrocardiogram

18 Echocardiogram-Standard Views Ruxandra Jurcut et al. Eur J Echocardiogr 2010;11:81-96

19 Echocardiographic Tools Chamber dimension and thickness Ventricular interdepence Stroke fraction/stroke area Eccentricity Index TAPSE RV performance Index 3D RV reconstructions Tissue Doppler

20 Chamber dimension and RV thickness

21 RV dimension and area measurement

22 Right Ventricle Structural Parameters RV-4CH-RV mid-cavity diameter, mm <35 PSSA-RVOT proximal diameter, mm </=35 3D-RV EF% >45% Apical-4CH Indexed RV volume men, ml/m2 <25 Indexed RA volume women, ml/m2 <21 RV thickness, mm <5 Pulm Circ Mar; 5(1):29-47

23 Stroke fraction/stroke Area STROKE FRACTION=RVOTD-RVOTS/RVOTD STROKE AREA=RVEDA-RVESA/RVEDS Ruxandra Jurcut et al. Eur J Echocardiogr 2010;11:81-96

24 Eccentricity Index ABNORMAL<1 Ruxandra Jurcut et al. Eur J Echocardiogr 2010;11:81-96

25 TAPSE: Tricuspid Annular Plane Systolic Excursion Contraction of the RV is mainly longitudinal, and the tricuspid annulus displaces toward apex during systole Imaging through lateral RV free wall with M-mode assesses longitudinal displacement (excursion) of the tricuspid annulus Less TAPSE occurs when RV function declines Baseline TAPSE < 1.8 cm has negative prognostic value

26 MPI- Myocardial Performance Index Doppler Tissue Imaging >0.55 Pulsed Wave Doppler >0.4

27 3D Right Ventricular Evaluation

28 Echocardiographic parameters Associated to Increased risk of mortality in PAH RV systolic dysfunction RV diastolic dysfunction Presence of pericardial effusion Increased indexed RA area Increased RV diameter Decreased TAPSE Decreased Tei Index(myocardial performance) Abnormal RV free wall strain Decreased isovolumic contractrion velocity

29 Signs of RV Deterioration in Clinically Stable patient with PAH A-RV end diastolic volume B-RV end systolic volume C-RV relative wall thickness 22 ipah pts during 5 years. At 10 years 12 Developed deterioration preceded by Increases in RV volumes Chest. 2015;147(4): doi: /chest

30 Cardiac MRI Quantify RV size, mass, function, viability, and interaction with LV Evaluate pulmonary vascular structure and function

31 Cardiac MRI

32 Delayed Enhancement/RV Remodeling Am J Roentgenol, 2011 Jan ; 196(1):87-94

33 Cardiac CT-RV evaluation American Journal of Roentgenology. 2011;196: 77-86

34 Cardiac CT - TAPSE American Journal of Roentgenology. 2011;196: 77-86

35 76 yo man with ascitis

36 Hemodynamics RA=25 RV=37/22 PA=30/20 27 PW=20 CO=5.17 CI-2.55 PVR=108 LVEDP=15

37 43 yo woman with SOB

38 Hemodynamics RA=10 RV=95/10 PA=95/40 65 PW=10 CO=3.26 CI=2.04 PVR=1177

39 58 yo man sp Bio AVR with ascitis

40 Hemodynamics RA=25 RV=45/20 PA=45/20 35 PW=25 CO=6.52 CI=3.02 PVR=122

41 Right ventricular dysfunction Journal of the American College of Cardiology, Volume 56, Issue 18, 2010,

42 Acute RV Failure in PAH Goals of Therapy Restore oxygenation Treat volume overload Restore vital organ performance

43 Acute RV failure: precipitating factors Dietary indiscretion Intercurrent infection Anemia/erythrocytosis Thyroid disorders Concomitant pulmonary embolus Cardiac dysrrhythmias Medication withdrawal

44 Acute RV failure: Restoration of oxygenation/acidemia Non invasive high flow oxygen delivery Mechanical ventilation Lowest possible PEEP GOAL O2 sat>92% ph/p CO2 close to normal

45 Acute RV failure: Treatment of volume overload Intravenous diuretics Intermittent bolus Continuous infusion Venous-venous ultrafiltration

46 Acute RV failure: restoration of vital organ perfusion Inhaled nitric oxide Inhaled epoprosternol/iloprost Intravenous epoprostenol Phosphodiesterase inhibitors Dobutamine/milrinone Dopamine Norepineprhine

47 Chronic RV Failure in PAH Goals of Therapy Relieve symptoms Improve exercise capacity Reduce morbidity and mortality Improve hemodynamics

48 Chronic RV failure-vasodilators Phosphodiesterase inhibitors Prostacyclins Endothelin Antagonists Soluble Guanylate Cyclase stimulators

49 Chronic RV failure Diuretics Loop diuretics Thiazides Aldosterone antagonists Digoxin Atrial septostomy Lung transplantation

50 Summary The right ventricle has unique characteristics that make it challenging to evaluate by imaging method Echocardiography is the most versatile methods to evaluate RV function. Acute and Chronic RV failure management differ in their goals and methods to achieve restoration of function.

51 Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: