Disclosures. Objectives 6/16/2016. A Look at the Other Side: Focus on the Right Ventricle and Pulmonary Hypertension
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1 A Look at the Other Side: Focus on the Right Ventricle and Pulmonary Hypertension Susan P. D Anna MSN, APN-BC, CHFN June 24, 2016 Disclosures Objectives Differentiate structure and function of RV and LV Discuss how pulmonary hypertension contributes to R sided heart failure and RV distress Review pulmonary hypertension diagnostic criteria and classification Identify HD characteristics of PAH vs PH due to LHD 1
2 RV vs LV 2
3 Structure and Function Primary function - receive systemic venous return Pump into the PA circulation Walls are thinner than the LV Less muscle mass than LV (2 layers vs 3 layers) 3
4 Circulation. 2006;114: Assessment of RV Function Norbert F. Voelkel et al. Circulation. 2006;114:
5 Structure and Function Primary function - receive systemic venous return Pump into the PA circulation (low resistance/lower pressure system) Walls are thinner than the LV Less muscle mass than LV (2 layers vs 3 layers) 5
6 Ventricular Interdependence When the RV dilates the interventricular septum bulges into LV, impairs LV filling and LV stroke volume. Right Ventricular Failure RV Hypertrophy RV Dilation Flattening of Interventricular Septum -- D Shaped LV RA Enlargement Tricuspid Regurgitation Left vs Right Heart Failure 6
7 The echo report says elevated PASP Now what??? Pulmonary hypertension is not a disease It is a hemodynamic measure (mpa > 25mmHg) that is shared by many diseases. PH Clinical Classification 7
8 WHO Classification of Pulmonary Hypertension 1. Pulmonary Arterial Hypertension 2. Left Heart Disease 3. Chronic Hypoxemia 4.Thromboembolic 5. Miscellaneous Hemodynamic Assessment Right Heart Catheterization RA, RV, PAP, PCWP Thermodilution and Fick CO 8
9 Transpulmonary Gradient (TPG) Change in pressure across the pulmonary circulation» mpa - PCWP» Normal TPG < 10 mmhg Pulmonary Vascular Resistance Resistance to flow that must be overcome to push blood through the system Ohms Law: mpa PCWP / Cardiac Output Expressed in Wood units (wu): Normal < 2-3 wu Normal Values of < = to 1.5 Wood Units mpa >/= 25 mmhg PCW < 15 PVR > 3 wu PAH No Right Heart Cath, No VQ Scan, NO DIAGNOSIS 9
10 Pulmonary Arterial Hypertension (PAH) is more than a hemodynamic measurement Hoeper MM, etal. JACC. 2013;62(25_D): D42D50 Why does PAH develop? It is complicated What we do know: Abnormality to the lining of the blood vessels Over production of endothelin -1 causes narrowing (constriction) of the vessels Underproduction of mediators that help dilate vessels nitric oxide and prostacyclin 30 10
11 Changes in the Pulmonary Arteries in PAH 32 Determinants of Prognosis in PAH 11
12 Hoeper MM, etal. JACC. 2013;62(25_D): D42D50 12
13 Group 2 PH Comprises over 1/2 of all PH Systolic and Diastolic Dysfunction Can lead to RV dysfunction Difficult to treat -- Cardio-Renal Syndrome Independently associated with worse outcomes Group 2 PH Profile Age > 60 yrs Female gender Obesity DM HTN CAD Sleep disordered breathing Relationship of CHF and PH Passive Congestion (Elevated PCWP) Pre - Capillary vs Post - Capillary PH Increased LVEDP (PCWP) 13
14 PH-LHD Hemodynamic profiles Ipc - PH Cpc-PH PCW > 15 mm Hg > 15 mm Hg DPG (PAD-PCW) < 7 mm Hg >7 mm Hg TPG (mpa- PCW) </= 12 mm Hg > 12 mm Hg PVR (mpa-pcw/co) < 3 wu >/= 3 wu PCW: pulmonary capillary wedge DPG: diastolic pressure gradient TPG: transpulmonary gradient PVR: pulmonary vascular resistance Barnett, C; et al. Overview of WHO Group 2 Pulmonary Hypertension Due to Left Heart Disease Advances in Pulmonary Hypertension.2015;14:2: PH-LHD Barnett, C; et al. Overview of WHO Group 2 Pulmonary Hypertension Due to Left Heart Disease. Advances in Pulmonary Hypertension.2015;14:2: Treatment? 14
15 RELAX Trial JAMA. 2013;309(12): PH out of proportion Ipc-PH (isolated post capillary PH) Elevated mpa solely attributed to PCWP TPG < Cpc-PH Elevated mpa beyond PCWP TPG> Traditional CHF management Traditional CHF management? Role for pulmonary vasodilators Summary The role of RV function has lagged behind the LV, but impacts prognosis in pulmonary hypertension regardless of etiology Pulmonary hypertension is not a disease, but a hemodynamic measure that is shared by many diseases PAH comprises a small portion of patients with elevated PA pressures - diagnosis and treatment is dependent upon specific criteria Group 2 PH represents the largest population of patients with PH and is most challenging to manage. 15
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