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DMST 367 Echo 3 > Pulmonary hypertension > Flashcards

Pulmonary hypertension Flashcards

1
Q

Pulmonary hypertension is characterized by what? 2

A
  1. Elevated pulmonary arterial pressures
  2. Secondary RV failure
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2
Q

During RT heart failure, what is RV diastolic pressure like?

A

RV diastolic function is also usually abnormal

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3
Q

What happens during RT heart failure? 2

A
  1. RT heart pressures rise
  2. RV diastolic function is also usually abnormal
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4
Q

What is the hemodynamic definition of PHTN?

A

mPAP >25mmHg

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5
Q

During RT heart failure, when the RT heart pressures rise, what happens in the RV as a result?

A

RV almost always shows reduced function

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6
Q

What values do we look for to help use determine RT heart pressure rise? 3

A
  1. FAC
  2. TAPSE
  3. S’ values
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7
Q

What is the cause of pulmonary HTN?

A

Increased PA pressures

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8
Q

What are the hemodynamic values of Pulmonary Hypertension

A

mPAP >25mmHg

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9
Q

What is pulmonary arterial HTN?

A

Condition brough on by various causes characterized by structure changes in the pulmonary arteries

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10
Q

What is the cause of Pulmonary arterial HTN?

A

Structural changes in the lung arterioles

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11
Q

What are the hemodynamic values of pulmonary arterial HTN? 4

A
  1. mPAP >25mmHg
  2. PCWP >15mmHg
  3. RVSP >35 mmHG
  4. PVR > 3 WU
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12
Q

What are some things that are part of clinical history for PHTN? 4

A
  1. Respiratory symptoms
  2. Signs of RT CHF
  3. Scleroderma
  4. Associated Cardiac S/S
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13
Q

What are respiratory symptoms of PHTN? 4

A
  1. SOB
  2. cough
  3. Wheezing
  4. Hemoptysis
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14
Q

What are signs of RT CHF? 4

A
  1. Jugular vein congestion
  2. Peripheral edema
  3. Ascites
  4. Hepato-splenomegaly
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15
Q

What are associated cardiac S/S for PHTN? 6

A
  1. Auscultation
  2. Palpitations/ arrhythmias
  3. Chest pain
  4. Syncope
  5. Cor pulmonale
  6. Fatigue
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16
Q

What are auscultations we will see with associated cardiac S/S of PHTN? 2

A
  1. P2 increase - PV closure
  2. Holosystolic murmurs (TR)
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17
Q

What are normal right heart pressures? 3

A
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18
Q

What are cardiac causes of RT CHF? 6

A
  1. Left sided heart failure
  2. PV stenosis
  3. RV infarction
  4. Massive TR
  5. Congenital malformation
  6. Shunts
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19
Q

What are causes of increased RT sided pressures? 3

A

Pulmonary causes such as

  1. Parenchymal
  2. Vascular disease
  3. Cor pulmonale
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20
Q

Cor pulmonale is another term for what?

A

Pulmonary heart disease

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21
Q

What is Cor pulmonale?

A

Right sided heart failure secondary to lung conditions such as COPD

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22
Q

What does Cor pulmonale not include? 2

A
  1. RT heart failure secondary to LT sided dysfunction
  2. Congenital heart disease
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23
Q

What are acute symptoms of Cor pulmonale?

A

Occurs after sudden and severe stimulus with RV dilatation and failure (Pulmonary embolus)

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24
Q

Is there RVH with Cor Pulmonale?

A

No

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25
What is McConnell's sign?
One of the most distinct echo findings in patients with acute pulmonary embolism
26
What does McConnels sign look like? 4
1. Distinct regional RV dysfunction 2. Mid RV free wall - Akinetic, bulging 3. Normal RV apex - tethered to LV 4. LV Apex - hyperkinetic
27
What are three things we see with chronic Cor pulmonale?
1. RVH 2. RV dilation 3. RA enlargement
28
What is Chronic Cor Pulmonale?
Prolonged pressure overload of the RV as it ejects into the high resistance vascular bed
29
What happens with RVH in terms of Chronic Cor pulmonale?
It is initially normal function, but subsequently deteriorates
30
What happens with RV dilation with Cor pulmonale? 2
1. TR 2. Systolic dysfunction
31
What are Echo findings with chronic elevation of RT heart pressures? 3 (anatomy)
1. Dilated coronary sinus 2. Reopening of the PFO 3. Dilated main PA
32
What is a general point of echo findings in PHTN?
Anything that causes pressure or volume overload to RV will lead to RVH and TV annular dilation >>>>> TR
33
What are the 3 things that are part of the role of Echo in PHTN?
1. Identify cause of PHTN 2. Estimate pulmonary pressures 3. Identify associated 2D features
34
What are some things we look for to identify the cause of PHTN with echo? 3
1. LT sided causes 2. Shunting 3. Embolus
35
What are some things we can do to estimate pulmonary pressures with Echo? 2
1. TR jet 2. Other calculations
36
What are some things we can do with echo in terms of identifying 2D features? 3
1. Chamber size 2. Chamber shape 3. Septal deviation
37
What are some LT CHF 2D echo features that cause cause PHTN? 6
1. LV enlargement 2. LV hypokinesis 3. LVH 4. Cardiomyopathy 5. LA enlargement 6. Mitral/ Aortic valve disease
38
What are some things we can look for with echo to determine LT HF? 5
1. MS/ MR 2. AS/ AR 3. Systolic dysfunction 4. Diastolic dysfunction 5. Arrhythmia
39
Under normal cardiac pressure, a shunt will do what to the right side?
Increase the volume of flow to the RT heart
40
Increased RT heart pressures may cause a shunt to do what?
Open or widen
41
What is Eisenmenger's syndrome?
Shunt reversal in patients with significant shunt that have developed PHTN either as a result of or in additional to the shunt
42
In terms of Eisenmenger's syndrome, with existing shunts, chronic volume overload leads to what? (lungs)
Permanent lung damage which raises pulmonary pressures
43
During Eisenmenger's syndrome which direction is the shunt going?
Instead of Left to right, it goes right to left due to high pulmonary pressures
44
Is the flow with Eisenmenger's syndrome Biphasic, monophasic, or multiphasic?
May also be biphasic
45
Acute pulmonary embolism is often caused by what?
DVT
46
What is mortality rates for acute Pulmonary embolism in North América?
about 15%
47
What is treatment options for Pulmonary embolism? 2
1. Ranges from treating the DVT to lung resection 2. IVC filters can prevent thromboemboli from reaching the right heart
48
What does SPAP stand for?
Systolic pulmonary arterial pressure
49
What is SPAP equivalent to? (assuming no PS)
RVSP
50
What are two things associated with using SPAP?
1. Using TR maximum velocity + RAP 2. Using VSD peak velocity
51
What are additional methods of calculation of pulmonary pressures? 2
1. PAEDP 2. mPAP
52
What do we use to calculate PAEDP?
PR end diastolic velocity
53
What does PAEDP stand for?
PA end diastolic pressures
54
What does mPAP stand for?
Mean pulmonary artery pressure
55
What are somethings we use to calculate mPAP? 2
1. PR peak velocity (CW or PW) 2. PAT (RVAcT)
56
What do we see with SPAP on doppler?4
1. TV regurgitation 2. PI 3. IVC collapsible 4. Arrhythmia on ECG
57
What is the formula for RVSP?
RVSP = RAP + TVpg
58
What are the three values for RAP?
3, 8, 15
59
What is the formula for TVpg?
bernoulli 4Vtr^2
60
What is PHTN RVSP?
>35mmHg
61
What should the TR peak velocity be with PHTN?
<2.8 m/s
62
How do we determine RAP?
Young patients may have IVC > 21mm
63
What is a doppler pitfall of PHTN?
TR jet overestimation *Chin vs beard*
64
Whys is there an issue with chin vs beard for TR?
1. The beard is an effect of spectral broadening 2. The beard can be minimized by increasing the reject, decreasing compression
65
What are some RVSP technical factors?3
1. Peak velocity using CW is angle dependent (use colour doppler to align CW cursor to TR jet direction) 2. Do not include feathering 3. Do not measure unless the peak velocity is clearly seen
66
In terms of PHTN- Jet interrogation what must we do? 4
Interrogate peak velocity including multiple windows including 1. PLAX TV view 2. PSAX TV optimized 3. A4C both on and off axis 4. Subcostal window
67
When do we measure PAEDP velocity?
End diastole
68
Do we use CW or PW for PAEDP tracing?
PW sometimes if low velocity
69
What is the formula for PAEDP?
4Vpr^2 + RAP
70
Calculate
71
How do we measure PW with mPAP?
Measure PW with sample volume placed in the RVOT
72
What are some tips for PAT? 2
1. Increase sweep speed 2. Measure interval between onset of pulmonary flow and peak velocity
73
As mPAP increases what happens to PAT?
It decreases
74
normal mPAP is what?
9-18 mmHg
75
What does each arrow signify?
Left = mPAP measurement Right = PAEDEP measurement
76
What is the values for SPAP in terms of pulmonary hypertension?
77
What are the PAT values for pulmonary hypertension?
78
What are the pulmonary pressures for mPAP?
79
What are the pulmonary pressure for PAEDP?
80
What are some things we look for in terms of PHTN in 2D PLAX? 2
1. RV size 2. LV looks compressed
81
What are some things we look for in M-mode for PHTN?
Paradoxical IVS motion
82
What are somethings we look for in 2D in terms of PHTN in PSAX? 3
1. RV dilated 2. D shape LV (Flattened IVS) 3. PA dilation
83
What are some things we look for in A4C in 2D for PHTN? 4
1. **Both IVS and IAS bow towards the left heart** 2. RVE, RAE 3. RV hypokinesis 4. RV forms cardiac apex
84
What are some things we look for sub4c for PHTN? 4
1. Same as A4C 2. RVH 3. ASD/ PFO 4. IVC distention
85
What is the RV response to high afterload?
1 **Hypertrophy** The LV will respond to high afterload, or pressure overload, with increase in muscle mass followed many years later with dilation and failure 2. Dilation
86
Often when the RV dilates as a result of a RV response to high preload, it leads to what?
A lack of coaptation of the TV leaflets, which will either cause or worsen the degree of TR
87
What does this image demonstrate?
Normal PLAX M-mode of IVS and Paradoxical Septal motion
88
What is the cause of paradoxical septal motion?
RV Pressure EDP much higher than LVEDP
89
What are some RT side echo features of PHTN? 9
1. **Morphology 2/D** 2. Enlarged RV 3. Hypokinetic RV 4. **Septal shifting** 5. Enlarged RA (IAS bowing) 6. TR 7. Dilated PA 8. PR 9. IVC/SVC - dilated
90
What should we see with PHTN 2D? 3
1. **RV apical dominance** 2. RV > LV size 3. IV shifted LT
91
What should a RV look like? 2
1. RV in the A4C should be less than 2/3 2. LV should dominate (occupy) the apex
92
What does a Mild RV size look like?
1. RV >2/3 of the LV but RV cavity is still smaller than the LV 2. RV apex is still more basal than LV apex
93
What does a Moderate RV size and systolic function look like?
RV and LV are equal in size and share the apex
94
What does a severely large RV look like?
RV > LV size and RV occupies the apex
95
What is the normal length of RV dimension?
<4.1cm
96
What is the normal length for Mid cavity Diameter for RV?
<3.5cm
97
What does RV pressure overload look like?
D sign that 1. Does not change 2. Seen in both Systole and Diastole
98
What does RV volume overload look like?
D sign that is only seen in diastole
99
What is normal TAPSE?
>1.7 cm
100
What does PHTN look like with RV TAPSE?
RV does not contract well against high afterload
101

DMST 367 Echo 3 (27 decks)

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