week 2 lecture 3 pulmonary hypertension

Question 1

PH versus PAH

Answer 1

PH = Pulmonary Hypertension - refers to PH caused by left heart disease that backs up LA and lungs

PAH = Pulmonary Arterial Hypertension - refers to PH caused by lung disease; narrowed vessels in lungs

Question 2

What are the causes of pulmonary hypertension?

Answer 2

Lung related (PAH):
- idiopathic often
- inherited
- drug or toxin induced - eg. mine workers
- COPD (chronic obstructive pulmonary disease)
*worse (higher press) and no cure

Heart related (PH):
- left heart disease: diastolic dysf, systolic dysf, MV disease (cause incr press in LA and then lungs)
*pressures not as high, curable if can fix left heart

Question 3

Normal value for pulmonary pressures?

Answer 3

<36 mmHg

Question 4

Cor Pulmonale

Answer 4

Right heart failure caused by lung disease such as pulmonary hypertension (NOT by left heart problems)

Question 5

What are the complications of PAH?

Answer 5

Right heart issues: RV/RA dilation and hypertrophy bc increased press = right sided heart failure?

blood clots
arrythmias (bc stretched RA)

Question 6

Symptoms of pulmonary hypertension

Answer 6

breathing problems:
- SOB
- fatigue
- dizzy
- chest pain
- cyanosis

Fluid build up
- edema
- ascites

Question 7

Role of echo in pulmonary hypertension

Answer 7

no changes to echo

look for:
* assess pulmonary pressures and right heart dysfunction
- diagnose HT
- determine cause if heart issue
- monitor disease progression - are the meds helping?

Question 8

RV function:
visual assessment?
quantitative assessment?

Answer 8

Visually:
- Is the valve annulus moving up and down?
- Is the RV free wall squeezing in?
RV dysf options: normal, mild, moderate severe (no %)

*Mod+ is hemodynamically significant: RA/RV dilated, RV might be hypertrophied

Quantitative:
- TAPSE (normal > 16 mm)
- S’ (normal >= 9.5 cm/s)

Question 9

In hemodynamically significant (mod+) pulmonary hypertension, the RV wall MIGHT be hypertrophied. How to measure the RV wall? normal?

Answer 9

In SC view, measure RV free wall at ED at location of open TV leaflet tips

<6mm

Question 10

Big RV: Volume overload versus pressure overload
- causes?
- expected LV shape in PSAX?

Answer 10

RV Vol overload bc hole in heart (ASD, VSD) = incr RV press a bit
- D shaped LV ONLY IN DIASTOLE

RV Press overload bc PH = RV dilation and hypertrophy = RV adapts to produce very high press in systole
- D shaped LV IN SYSTOLE AND DIASTOLE

Question 11

What are 4 ways to get an estimate for PAP?

Answer 11

1. calculate PAP/RVSP from TR jet velocity and RAP (from IVC diam and collapsibility)
   * preferred
2. calculate PAEDP from PR jet velocity (SAX CW through PV) and RAP (from IVC diam and collapsibility
   *do if no TR
3. from M-mode of pulmonary valve - get normal trace or PH trace (flying W)
   *not routine
4. from PW of RVOT - get AT (normal >120 ms)
   *not common

Question 12

How to calculate PAP from TR jet velocity?

Answer 12

Get max TR vel possible!! Try CW in multiple views, go off axis if needed (eg. btw PLAX and 4 ch). Machine will do 4V^2 and give PGmax

Determine RAP from IVC diam (<2.1 cm?) and collapsibility (<50%?): 3, 8, or 15 mmHg

PAP = RVSP = 4V^2 + RAP
as long as there is no pulmonary stenosis (rare)

Question 13

How to calculate PAEDP

Answer 13

Get PI vel at ED- do CW through pulmonary valve in SAX; measure trace at ED to get vel and PG

Determine RAP from IVC diam and collapsibility

PAEDP = RVEDP = 4V^2 + RAP

Note: TV is closed in systole to get TR in systole vs. PV is closed in diastole to get PR in diastole

Question 14

How to determine the presence of PH from m-mode of pulmonary valve?

Answer 14

SAX of PV - put cursor through 1 leaflet of PV (usually septal)

Normal: half of a box (like AoV but only one side of the box, and part of the signal drops out… so looks like an L)

PH: flying W

Question 15

How to determine presence of PH from PW of RVOT?

Answer 15

SAX of PV - put PW cursor right before PV

Normal AT >120ms

PH: AT is shorter (faster) bc high press in PA

Question 16

Signs that suggest PH

Answer 16

Right heart problems: RA/RV dilation which usually causes TR, RV hypertrophy, thick IVS…

Pericardial effusion

Question 17

Eisenmenger Syndrome

Answer 17

When a shunt (ASD or VSD) becomes bidirectional or reverses direction bc high right sided pressures

a complication of PH

right to left means deoxygenated blood gets pumped to the body.. bad (vs normally left to right means oxygenated blood goes to lungs again.. not as bad)

Question 18

Treatment for PH?

Answer 18

Meds (eg. vasodilators, diuretics, anticoagulants)

Treat underlying causes if possible (eg. MV replacement if left heart problem)

Oxygen therapy (tank)

Lung transplant or lung/heart transplant if right heart failure