Pulmonary hypertension in clinical practice: are we focusing on the problem? Odd Bech-Hanssen, MD, PhD Cardiology/Clinical Physiology Sahlgrenska University Hospital Gothenburg, Sweden
Definition Mean PA pressure>25 mmhg Mean PA 25 mmhg systolic PA 40 mmhg mmhg 50 mmhg 55 mmhg 120 mmhg
Prevalence Sahlgrenska 2008 TR gradient registered in 5542/8306 (67%) PH in 1164/5542 (21%)
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
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
D Diagnostics Three questions PCWP? CO? PVR? Mean PA=PVR x CO +PCWP
Tricuspid regurgitation Pulmonary artery pressure The prerequisite: No pulmonary valve stenosis Highest velocity in a non-standard projection
Tricuspid regurgitation Velocity versus artefact 70 mmhg? 115 mmhg? 80 mmhg
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
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
D Pulmonary vascular resistance (PVR) Direct calculation from Doppler data PVR = (Medel PA-PCWP)/CO Diastoliskt PA tryck (b)
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 Unpublished data.
Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)
Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)
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
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)
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
Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)
Pulmonary vascular resistance (PVR) Alternative method (PVR>3 WU)
Case#1 Male, 49 years Admitted due to gastric pain, palpitation and syncope
Case#1 Ejection fraction 19% (Simpson)
Case#1 CVP RA 15 mmhg
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
Case#1 PA pressure Mild PH: 25 + 15 = 40 mmhg??
Case#1 PA pressure Pulmonary hypertension: 36 + 15 = 51 mmhg
D Case#1 Three questions PCWP CO PVR? Medel PA=PVR x CO +PCWP
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...
Case#1 Catheterization the day after Cath Echo RA PASP PADP PAMP PCW CO 14 44 27 32 31 2.6 15 51 32 >15 1.8 PVR 0.4 *PI **Ekvation
Case#2 Male, 56 years Heart failure diagnosis 10 years ago Now haemoptysis Dyspnea NYHA III
Case#2
Case#2
Case#2
Case#2 PCWP and cardiac output E/A 2.1 S/D?? SV 55 ml PCWP 15 mmhg?? CO 4.5 l/min
Pulmonary hypertension: 55 + 5= 60 mmhg
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...
Case#2 Catheterization the day after Cath Echo RA PASP PADP PAMP PCW CO 6 56 23 40 19 3.6 5* 60 38** >15 4.5 PVR 5.8 *Schablon **Ekvation
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