Controversies in the management of pulmonary hypertension What is controversial in diagnostic imaging? G. Derumeaux Lyon University Hospices Civils de Lyon France
Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Grant/Research Support to my institution: Actelion, Astrazeneca; General Electric; Brahms; Trophos, Toshiba Consulting Fees/Honoraria: Actelion, Sanofiaventis; Servier; General Electric; Toshiba
Echocardiography MRI Nuclear imaging Introduction
Targets for non-invasive imaging in pulmonary hypertension Hemodynamic evaluation Screening Diagnosis Follow-up under therapy RV function Prognosis
Diagnostic of PH mmhg spap (mmhg) = RV/RA Gradient (mmhg) + P RA (mmhg) 60 50 40 AP = + 30 EHJ 2009
Diagnostic of PH Ganesch et al JACC 2009 Mc Quillan et al Circulation 2001
REVEAL Registry: Correlation of echo with RHC in PH The REVEAL Registry was undertaken to evaluate the modern population of patients with PAH. REVEAL results suggest that ECHO is a reasonable proxy for RHC at a single time point, but may not sufficiently correspond with RHC data to permit precise measurement of serial changes in pulmonary hemodynamics. The different results from serial assessment of the two tests, however, may offer complementary findings that are needed to develop a full clinical picture. Congest Heart Fail. 2011
Screening of PH ItinerAIR study enrolled 599 patients with scleroderma. Among the 33 patients who met criteria of PH on Doppler, 14 had mild to moderate PH on RHC at rest, and an additional 4 developed mpap 30 mm Hg at exercise. These results were compatible with the 45% false-positive results seen with echo screening. 33 patients with TR>3 m/s or TR 2.5 to 3.0m/s with dyspnea underwent RHC Mild to moderate PH 18 (54%) Post-capillary PH (PWP > 15) : 3 (10%) No PH 12* (36%) (*6 mpap>20 mmhg) Hachulla E et al Arthritis Rheum 2005
Screening of PH Pulmonary flow RV dilatation VD AO AP TAP V1 V2
Asymptomatic Cardiac Output Symptomatic NYHA II NYHA III NYHA IV PAP Stress test? Ganesch et al JACC 2009
Targets for non-invasive imaging in pulmonary hypertension Hemodynamic evaluation Screening Diagnosis Follow-up under therapy RV function Prognosis
RV configurations in health and pulmonary hypertension. According to the Laplace relationship, PH is characterized by : an increased RV wall stress (s) due to an elevated intraluminal pressure (P) and a larger chamber radius (r), unless RV wall thickness (h) is augmented by hypertrophy. Bogaard HJ
RV remodelling Hypertrophy-Dilatation transition RV dilatation can result from : - a change in preload or afterload, - the loss of cardiomyocyte contractile force (due to functional, structural, or numerical changes in cardiomyocytes), - a change in the connective tissue surrounding cardiomyocytes. February 2005 spap : 55 mmhg August 2005 spap : 65 mmhg December 2005 spap : 65 mmhg
Complex anatomy
Chest 2007
Pressure overload and RV failure P Normal subject Normal P Aged subject HTAP Ees Ea Ees Ea V V Faber MJ, Am J Physiol Heart Circ Physiol 291: H1580-H1586, 2006
S Rudski G et al; JASE 2010; 23: 685-713 E A
Why using strain? Rudski G et al; JASE 2010; 23: 685-713
Non homogeneity of regional RV function NORMAL Vignon Ph et al, Am J Resp Crit Care Med 1999
Among indices of RV function, strain rate but not strain is : best correlated with elastance less load-dependent Greenberg N, Circulation 2003 Jamal F, AJP 2003
RV function : Strain rate by speckle tracking imaging
RV function : Strain Normal PH
RV strain and systemic sclerosis Rest spap = 23 mmhg Exercise spap = 38 mmhg Rest spap = 25 mmhg Exercise spap = 54 mmhg
TDI Strain 2D Strain Rudski G et al; JASE 2010; 23: 685-713
Prognosis EFORT G Habib; O Sitbon
Prognostic role of right ventricular function in pulmonary hypertension: a tissue Doppler and strain imaging study. METHODS: 159 patients with severe PH 60 16 years spap: 78 21 mmhg PAH: 65.4% Chronic thrombo-embolic PH: 23.3% PH associated with lung diseases and/or hypoxemia: 9.4% others : 1.9% Baseline data 6-min walk test (m) 372 ± 136 NYHA I-II / NYHA III-IV 58%/42% LV ejection fraction (%) 66 ± 10 RA area/height (cm²/m) 15.1 ± 5.6 Diastolic eccentricity index 1.47 ± 0.45 Pericardial effusion, n (%) 27 (17%) TAPSE (mm) 17.9 ± 5.1 IVCt (cm/s) 9.4 ± 3.9 St (cm/s) 11.5 ± 3.3 IVRT (ms) 68.8 ± 41 At univariate analysis, parameters associated with death were: 6 walk test, diastolic eccentricity index, right atrial area indexed by height, TAPSE, IVCt, St, IVRT and εl (p<0.05 for all). RESULTS: Figure 2. Kaplan Meier survival curve. Survival During a mean follow-up of 12.2 ± 9.6 months, 33 patients died. Survival 100% 80% 60% 40% 20% Prognostic parameters 0% εl: longitudinal systolic strain 0 6 12 18 24 30 36 Follow-up (months) N= 159 108 68 30 23 13 3 At multivariate analysis, the only independent predictors of death were 6 walk test 310 m (p = 0.03) and IVCt 9cm/s (p =0.005). IVCt St IVRT CONCLUSION: This study demonstrates the key role of RV contractility as assessed by IVCt in predicting mortality in PH and confirms also the role of 6-min walk test evaluation.
Conclusion
Sujet normal RP élevées Vit tric 2,86, ITV ss pul 20,8 Vit tric/ VTI ss pul = 2,86/20,8 = 0,1375 RP écho : 0,1375*10+0,16= 1,53 U Wood RP KT = 1,3 U Wood Vit tric 3,64 VTI ss pul 6,5 Vit tric/ VTI ss pul= 0,56 RP echo : 0,56*10+0,16 = 5,76 U Wood RP KT= 6 U Wood Abbas AE et al. A simple method for noninvasive estimation of pulmonary vascular resistance. J Am Coll Cardiol 2003;41(6):1021-1027.