Disclosures A Look at the Other Side: Focus on the Right Ventricle and Pulmonary Hypertension No financial relationships Susan P. D Anna MSN, APN BC, CHFN September 29, 2016 Objectives RV vs LV Differentiate structure and function of RV and LV Discuss how pulmonary hypertension contributes to R sided heart failure and LV distress Review pulmonary hypertension diagnostic criteria and classification Identify HD characteristics of PAH vs PH due to LHD 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) 1
Assessment of RV Function Identify current body of knowledge and provide recommendations for future investigation to advance understanding of the RV structure, function, and uniqueness. Circulation. 2006;114:1883 1891 Norbert F. Voelkel et al. Circulation. 2006;114:1883-1891 2
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) What happens when the RV is exposed to chronic pressure overload? Ventricular Interdependence When the RV dilates the interventricular septum bulges into LV, impairs LV filling and LV stroke volume. Right Ventricular Failure Left vs Right Heart Failure RV Hypertrophy RV Dilation Flattening of Interventricular Septum D Shaped LV RA Enlargement Tricuspid Regurgitation 3
The echo report says elevated PASP Now what??? A. Panic B. Ignore it after all, the LV function is normal C. Refer to Pulmonary Hypertension Center Pulmonary hypertension is not a disease It is a hemodynamic measure (mpa > 25mmHg) that is shared by many diseases. D. Begin an organized, thoughtful evaluation in order to understand the etiology of the elevated pulmonary pressures. PH Clinical Classification Hoeper MM, etal. JACC. 2013;62(25_D): D42D50 WHO Classification of Pulmonary Hypertension 1. Pulmonary Arterial Hypertension 2. Left Heart Disease 3. Chronic Hypoxemia 4.Thromboembolic 5. Miscellaneous 4
Hemodynamic Assessment Right Heart Catheterization RA, RV, PAP, PCWP, Thermodilution and Fick CO 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 Example: mpa (25 mmhg) PCW (18 mmhg)/co (4 l/min) = 1.75 wu mpa >/= 25 mmhg PCW < 15 PVR > 3 wu PAH No Right Heart Cath, No VQ Scan, NO DIAGNOSIS Pulmonary Arterial Hypertension (PAH) is more than a hemodynamic measurement 5
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 31 Changes in the Pulmonary Arteries in PAH How is PAH treated? Currently no cure for PAH Available therapies focus on improving symptoms and quality of life Management has many layers: general measures conventional or supportive therapy advanced therapy (PAH specific therapy) surgical intervention 1. Galiè N et al. Eur Heart J 2009; 2. Humbert M et al. Circulation 2010 33 6
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 Hoeper MM, etal. JACC. 2013;62(25_D): D42D50 Group 2 PH Profile Age > 60 yrs Female gender Obesity DM HTN CAD Sleep disordered breathing 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: 70 78. 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 >12mmHg PVR (mpa PCW/CO) < 3 wu >/= 3 wu PH out of proportion Ipc PH (isolated post capillary PH) Elevated mpa solely l attributed t to PCWP TPG < 10 12 Cpc PH (combined post capillary PH) Elevated mpa beyond PCWP TPG> 10 12 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: 70 78. Traditional CHF management Traditional CHF management? Role for pulmonary vasodilators 7
Treatment? Optimize traditional HF therapies In patients presenting with PH LHD, there is currently no role for treatment with PAH specific therapies and, with few exceptions, they should not be administered because they are costly, lack efficacy, and in some cases, are known to increase morbidity and mortality. Barnett CF, Selby VN. Adv in Pulmonary Hypertension. Vol 14, No 2;2015 Summary The role of RV function has lagged behind the LV, but RV dysfunction impacts prognosis in pulmonary hypertension regardless of etiology Pulmonary hypertension is not a disease, but a hemodynamic measure that tis shared dby 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. 8