C13: Pulmonary hypertension Flashcards
define PHT
characterized by evaluated pulmonary arterial pressure secondary to RV failure
can both pulmonary disease and disease of the RV muscle cause PHT
yes
w/ PHT, what changes are seen to systolic and diastolic function of the RV
reduced FAC, TAPSE and S prime
diastolic usually abnormal
2 categories of causes of PHT
describe them
pre-capillary:
before the lungs….
-congenital heart disease - shunts
-respiratory diseases - PE, PPS
post-capillary: after the lungs... -MV disease, AV disease -myoxoma -cor triartiatum -PV compression -myocardial disease -systemic HTN
are most causes of PHT pre or post capillary causes
post
PHT values for:
PCWP
SPAP
MPAP
PCWP - > 18mmHg ( > 15 mmHg is abnormal)
SPAP = RVSP if no obstruction - >35 mmHg (30-35 is borderline)
MPAP - >/= 25 mmHg
respiratory symptoms for PHT
SOB
cough
wheezing
hemoptysis - press is so high, blood is getting into the air passageways
intercostal retraction - increased muscle mass due to difficulty breathing
associated cardiac symptoms w/ PHT
palpitations/arrhythmias chest pain SOB orthopnea syncope
signs of RHF
norm mean pressure in the RA and IVC
0-4 mmHg
norm pressure in the RV and PA
< 25 / < 10 (systolic and diastolic)
same for both
is TV pg the same as 4(v)^2
yes
cardiac causes of RHF
LHF pulmonary valve stenosis RV infarction massive TR congenital malformations shunts
when the R heart fails, what always happens to the pulmonary pressures
they always go up
2 pulmonary/lung causes of elevated R heart pressures
parenchymal
vascular
parenchymal, pulmonary causes of elevated R heart pressures
COPD
interstitial lung disease
adult respiratory distress syndrome
chronic lun infection
vascular, pulmonary causes of elevated R heart pressures
PE
primary pulmonary HTN
describe the pathophysiology of cor pulmonale
progressively increasing chronic pressure overload of the RV as it ejects into the high resistance vascular bed
how does cor pulmonale initially affect the RV?
how does it progress
initially: RVH…
…then RV dilation and TR from annular dilation…. then RV failure
common cause of PE
DVT that became an emboli
what is a saddle emboli
clot that lodges @ the bifurcation of the PA
in patients w/ a shunt (ASD/VSD/PFO) who have developed P HTN, what can happen to the direction of the shunt
What is it called when thIs happens?
it can be reversed (going from right to left) due to very high pulmonary pressures… or could be biphasic depending on which press is higher
Eisenmengers syndrome
how does chronic volume overload of the RV affect the lungs
permanent lung damage which raises pulmonary pressures and RVSP
anything that causes pressure or volume overload of the RV will also cause what
RVH and RV and TV annular dilation (TR)
chronic evaluation of the RT heart pressure often lea to what 3 things
dilated coronary sinus
reopening of a PFO (acquired PFO)
dilated main PA
how does the reopening of a PFO due to high Rt heart pressures occur
the atria are stretched so the foramen oval is no longer covered
post capillary causes of P HTN usually involve what type of dysfunction of the LV
systolic, diastolic dysfunction or L heart valvular disease
R heart US features w/ P HTN
IVC/SVC?
PA?
RV and RA dilated decreased systolic function IVS and IAS bowing to the LV TR/ TV annular dilation PA dilated w/ PR IVC and SVC dilated
why might a patient w/ P HTN have tachycardia
to compensate for low output
L heart US features w/ P HTN
LV and LA dilated decreased systolic function LVH or cardiomyopathy MR/ MV abnormalities Av sclerosis LV, IAS, IVS aneurysmal
how can the LV often appear w/ P HTN
can appear compressed b/c the RV can become severely enlarged
how will the motion of the IVS often appear the P HTN
paradoxical, will move towards the RV during systole instead of the LV
will also appear flattened in PSAX and created the “D” bounce
size of the RV free wall with P HTN
in which view do we measure
> 5 mm
subcostal 4CH b/c we are using axial res
in how many view must you see and ASD/PFO to diagnose it
2 views
which pathology of the pericardium often goes with pulmonary disease
pericardial disease
what causes RV pressure overload (RVPO)
when would the “D” sign be seen during the cardiac cycle w/ press overload
- longstanding regurg
- primary pulmonary disease
both systole and diastole
can RVPO and RVVO coexist
yes
over time, what does RVVO lead to
RVPO
what causes RV volume overload (RVVO)
when would the “D” sign be seen during the cardiac cycle w/ press overload
any etiology that causes increased volume… e.g.
- severe TR
- left to right shunt like an ASD
only in diastole
norm measurements for RVOT distal and prox MPA
RVOT distal PV: <33mm
prox MPA: < 27mm
does the RV contract well with high afterload
no… TAPSE, S prime and FAC will be reduced, RV cant handle high afterload
how do you get the SPAP (systolic pulmonary artery pressures) aka RVSP
using TR max velocity + RAP
OR
using VSD peak velocity
how do you get the MPAP
MPAP = 4v^2 + RAP
using PR early diastolic velocity of the CW tracing (PSAX preferred for better alignment)
OR
MPAP = 80 - (0.5 x PAT)
using PW
how do you get the PA-EDP
PA-EDP = 4v^2 + RAP
using the PR end-diastolic velocity of the CW tracing (PSAX preferred for better alignment)
is the RVSP valid w/ severe TR
no
w/ a VSD, do we still use the TR jet to estimate the RVSP
no, use the VSP jet, it will be more accurate
how to calculate RVSP w/ VSD jet
take the blood pressure minus the press gradient from the VSD jet (4v^2) to get the RVSP
RVSP = SBP - 4(peak velocity of VSD)^2
what does the velocity of the VSD jet reflect
the press gradient b/w the Lv and RV during systole
what should sweep speed be set to for TR jet for RVSP
100 cm/s
in which views do we assess the TR jet velocity
RVIT
PSAX
A4CH (on and off axis)
Sub4CH
which view is best to asses an eccentric TR jet
Sub4CH… especially if jet is medially directed
how can you make the measurement of the IVC more accurate
get perpendicular to the IVC
normal PAEDP
4-12 mmHg
how does increased PA pressure affect PAT
it will shorten… press in the RV has to rise above that of the PV in order for the PV to open, when it finally does, its open for a shorter amount of time and the RV hard hardly push any blood into the PA due to resistance…. making the PAT short
how should sweep speed be set to measure PAT
100 cm/s or more, b/c we’re measuring a short period of time
when should you use PR jet velocities to assess the mPAP and RV-EDP
whenever RVSP is suspected to be elevated
value for mild SPAP/RVSP elevation
severe
mild 35-40 mmHg
severe > 70 mmHg
normal RVOT AT / PAT
> /= 120
value for mild PAT
severe
mild 80-110 ms
severe < 60 ms
value for mild mPAP elevation
severe
mild 30-40 mmHg
severe > 50 mmHg
normal mPAP
< 25 mmHg
