Pulmonary hypertension on. Simon MacDonald BSc(Hons) BMBCh DPhil FRCP Consultant Cardiologist in Adult Congenital Heart Disease

Transcription

1 Pulmonary hypertension on echowhat next.? Simon MacDonald BSc(Hons) BMBCh DPhil FRCP Consultant Cardiologist in Adult Congenital Heart Disease

2 Definition of PAH Mean PA pressure 25mmHg Precapillary if PAWP 15mmHg Post capillary if PAWP 15mmHg Isolated post capillary PH (IpCH): DPG < 7mmHg and/or PVR 3 Combined post capillary PH (CpCH); DPG 7mmHg and/or PVR > 3 Woods Units ESC Guidelines Galie N et al, EHJ (2016) 37:67-119

3 PAH Definition Measurement variability Caution

4 PAH Types Can involve multiple conditions Five groups Simonneau G et al, JACC 2013; 62: D34-41

5 PAH Epidemiology 97 cases per million in UK Female: male 1.8:1 Mean age at diagnosis between 50 and 65yrs of age Group 1: cases per million Group 2: 60% pts with severe LVF, 70% HFpEF, all severe MR, 65% severe AS. Most common group Group 4: CTEPH 3.2 cases per million

6 PAH presentation Symptoms: Exertional breathlessness Fatigue, weakness, angina, syncope Abdominal distension, ankle oedema if RV failure Haemoptysis Hoarseness, angina- compression symptoms laryngeal nerve, LMS Signs: Parasternal heave, raised JVP loud P2, tricuspid PSM, PR murmur, hepatomegaly, ascites, oedema, mimimal wheeze/ crackle

7 PAH Ix Findings ECG: p pulmonale, right axis, RV hypertrophy, RV strain, RBBB, QTc prolongation, flutter/ fibrillation (25% after 5 years). CxR: central PA dilatation, RA and RV enlargement Echo: estimation of PAP

8 PAH and Echo Galie N et al, EHJ 2016; 37:

9 PAH and echo Severe TR- caution Galie N et al, EHJ 2016; 37:

10 PAH- other tests VQ scan CTEPH Higher sensitivity than CTPA (normal excludes CTEPH with sensitivity of %) Hi res CT Vascular, cardiac, parenchymal abnormalities PA >29mm, PA:Ao>1.) Cardiac MRI Congenital heart disease, shunts, stroke volume, CO, fibrosis Blood tests and immunology Biochem, haematology, LFTs, hepatitis serology, HIV, systemic sclerosis Abdominal ultrasound

11 PAH- right heart cath Low morbidity (1.1%) and mortality (0.055%) Expert centres, attention to detail Catheter reactivity (NO, iloprost, IV adenosine or epoprostenol) Reduction mean PAP 10mmHg to reach mean PAP 40mmHg with increased or unchanged CO Can treat high doses of CCB

12 PAH Diagnostic algorithm

13 PAH- severity WHO functional class I-IV 6 minute walk tests Borg score for breathlessness CPET Biochemistry Imaging- echo

14 PAH Risk assessment Galie N et al, EHJ 2016; 37:

15 Therapy General Pregnancy, birth control, surgery, infection control, Supportive Rx: anticoagulants, diuretics, digoxin, O2 High dose CCBs if reactive, PAH drugs if not reactive Review response- escalate, combination therapy, transplant Avoid ACE-I, beta-blockers, ivabradine?

16 Bedard E et al, EHJ, 2009 Pregnancy and PAH ACHD Still high risk

17 Therapies High dose calcium channel blockers Nifedipine mg, diltaizem mg, amlodipine 20mg Endothelin Receptor antagonists ET-1 A and B receptors on pulmonary vascular smooth muscle Ambrisentan (Type A) Bosentan (Type A and B). Six RCTs 10% get abnormal LFTs Macitentan (Type A and B)

18 Therapies Phosphodiesterase type 5 inhibitors and guanylate cyclase inhibitors Inhibition of cgmp degrading via PDE type 5 enzyme causes vasodilation Sildenafil-4 RCTs 20mg to 100mg tds Side effects: headache, flushing, epistaxis Tadalafil 2.5 to 40mg od Riociguat-stimulator of soluble guanylate cyclase (cgc) Prostacyclin analogues/ prostacyclin receptor agonists Endothelial cell production of prostacyclin- vasodilator Epoprostenol- infusion (T1/2 3-5 mins)-risk reduction 70% mortality Treprostinil- s/c and IV

19 Treatment Pathway Group 1PAH

20 Additional PAH therapies Balloon atrial septostomy Avoid if RAP >20mmHg, O2 sats <85% in air RV failure Reduce RV afterload (prostacyclin) Increase CO with inotrope- dobutamine with BP maintained with vasopressors Be wary of intubation- risk of death ECMO

21 PAH therapies Group II Treatment of left heart disease? Group III PAH therapies do not work? O2 therapy Group IV- CTEPH Life long anticoagulation Operation- pulmonary end-arterectomy Non-operative- balloon dilatation

22 PAH associated with CHD Approximately 5-10% of adults with CHD will develop PAH Collins NR et al, Cardiol Clin 1993; 11:675-87

23 Simonneau G et al, JACC 2013; 62: D34-41 Clinical classification of congenital, systemic-pulmonary shunts associated with PAH Eisenmenger syndrome L-R shunt due to large defects leading to severe increase in PVR and reversed (R-L) or bidirectional shunt Pulmonary arterial hypertension associated with L-R shunts Moderate to large defects, increase in PVR mild-moderate, L-R shunt is still largely present and no cyanosis at rest REPAIRABLE Pulmonary arterial hypertension with small defects Clinical picture very similar to idiopathic PAH VSD<1cm, ASD< 2cm effective diameter Pulmonary arterial hypertension after corrective surgery Congenital heart disease been repaired but PAH is either: Still present immediately after surgery or Recurred several years after surgery In absence of significant residual lesions

24 Eisenmenger syndrome Victor Eisenmenger 1897.The patient was a powerfully built man of 32 who gave a history of cyanosis and moderate breathlessness since infancy. He managed well until January 1894 when dsypnoea increased and oedema set in. Seven months later he was admitted to hospital in a state of heart failure. He improved with rest and digitalis, but collapsed and died suddenly on November 13 following a large haemoptysis Paul Wood 1958

25 PAH-CHD stable disease Diller GP et al, EHJ 2006;27:

26 The impact of functional class on long-term survival Dimopoulos K et al, Circulation 2010; 121:20-5

27 Mode of death in Patients with Eisenmenger Syndrome Right ventricular failure Sudden cardiac death Surgery CVA/ Abscess Haemoptysis Extracardiac surgery Transplantation Somerville J IJC 1998

28 UK and Ireland national pulmonary hypertension centre management algorithm for ES Gibbs S et al, Heart 2008; 94 (suppl):i1-i41

29 Prevalence of iron deficiency and relation to saturations Prevalence 20-37% of patients with cyanotic CHD Easily overlooked as standard laboratory methods (Hb, MCV) do not apply Anaemia difficult to define as Hb rises with the fall in resting saturations Relates to higher incidence of stroke: VENESECTION NOT ADVISED Diller GP et al, EHJ 2006;27:

30 Iron repletion Tay E et al IJC 2010

31 Cyanosis and need for higher haemoglobin Higher Hb maintains adequate oxygen delivery to peripheral tissues Erythrocytosis causes higher blood viscosity but also higher exercise capacity Broberg CS et al, JACC 2006; 48:

32 PA thrombus formation in Eisenmenger syndrome

33 Eisenmenger Syndrome- Bleeding Spontaneous, perioperative Common haemorrhagic events: Easy bruising Haemoptysis Epistaxis Gingival bleeding Menorrhagia Bleeding secondary to trauma/ surgery Causes Thromboctyopenia, primary fibrinolysis, Factor deficiencies (liver/ consumption), DIC Increased sensitivity to activated protein C, suppression of thrombomodulin-protein C- protein S pathway etc Haemoptysis: the cause of death in 11-30% of Eisenmenger patients

34 Transplantation HLT superior to LT 435HLT/605 LT Tx in CHD pts from international registry 1 year survival 81% and 70% respectively 5 year survival approximately 50% Increased perioperative risk- bleeding 51 Eisenmenger pts with HLT Similar long-term survival with non-eisenmenger pts Selection criteria and timing? Waddell TK et al, J Heart Lung Transplant 2002 Stoica SC et al, Ann Thorac Surg 2001

35 PAH due to LV disease

36 PAH due to LV disease

37 PAH due to LV disease

38 PAH summary Definition- mean PAP 25mmHg Groups I-V Presentation, Signs and Investigations Assessment of severity Therapies- according to group: General Ca channel blockers, ERAs, PDE-5 inhibitors, cgmp stimulators, prostacyclin Cardiac- Congenital heart disease and LV dysfunction