Echocardiography in BPD Hythem Nawaytou MBBCH Assistant Professor Pediatric Cardiology UCSF - Benioff Children s Hospital
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?
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
TR Jet Peak Velocity of tricuspid valve regurgitafon 4X(Velocity) 2 (+Right Atrial Pressure) =Pulmonary artery systolic pressure
TR Jet WE LOVE YOU Easy to obtain ObjecFve Gives us a number
Easy to obtain Feasibility of TR Jet esfmafon in BPD pafents 61% Mourani et al. Pediatrics. 2008 February ; 121(2): 317 325
ObjecFve? Groh et al, J Am Soc Echocardiogr (2014) 27(2) 163 71
ObjecFve Groh et al, J Am Soc Echocardiogr (2014) 27(2) 163 71
Gives out a number Is that number accurate?
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) 163 71
Children Group Bias LOA I 3 9 to -3.5 II 1.5 22 to -19 III 2.5 10 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
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. 2008 February ; 121(2): 317 325
Relationship between spap values estimated with echocardiography (ECHO) and directly measured with cardiac catheterization (CATH). Peter M. Mourani et al. Pediatrics 2008;121:317-325 2008 by American Academy of Pediatrics
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;121:317-325 2008 by American Academy of Pediatrics
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?
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?
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;121:317-325 2008 by American Academy of Pediatrics
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;121:317-325 2008 by American Academy of Pediatrics
SHUNTS How good are post tricuspid valve shunts in esfmafng PA pressures?
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)
BidirecFonal flow What does it mean?
Bi-direcFonal shunt - VSD
Bi-direcFonal shunt - VSD
Bi-direcFonal-PDA
Bi-direcFonal-PDA
Septal PosiFon & MoFon How many use it to quanffy PA pressure?
Mourani et al. Pediatrics. 2008 February ; 121(2): 317 325
Interventricular septal configurafon PERFECT CIRCLE Progressive septal flauening FLAT CirculaFon 68, No. 1, 68-75, 1983
Interventricular septal configurafon CirculaFon 68, No. 1, 68-75, 1983.
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?
Rule IN
RULE OUT
Accurately esfmate PA pressure elevafon
Can it assess response to treatment?
Response to treatment DirecFon of shunfng across a PDA/VSD Holo-diastolic flow in the abdominal aorta Measurement of RV size, funcfon, output?
Other important findings
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%)
PDA
Pulmonary vein stenosis
Pulmonary vein stenosis
Pulmonary vein stenosis
Pulmonary vein stenosis Cardiac catheterizafon PV stenoses llpv>rupv>rlpv>lupv Pressure gradients of 10-15mmHg between pulmonary veins and LA
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
PH Team UCSF