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PULMONARY VENOUS HYPERTENSION- STAGES, ASSESSMENT & SKIAGRAPHIC CHANGES
SHYAM SASIDHARAN
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MENU• INTRODUCTION
•DEFINITION
•PATHOBIOLOGY AND STAGES
•SKIAGRAM
• IMAGING
• CARDIAC CATHETERISATION
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CASE SCENARIO
•65 year old female•DOE FC II – III -6months•T2DM&HTN – 15 yrs•O/E – obese,pulse- 98/min irregular,BP-
170/100•JVP –raised,CVS-P2 loud•ECG- AF•CXR- cardiomegaly,prominent upper lobe
veins•Echo- EF 56%•RHC – PAP- 38,PCWP-20
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*5th WSPH Nice 2013
GROUP 2 - Pulmonary hypertension due to left heart disease (PH-LHD)
•2.1 Left ventricular systolic dysfunction•2.2 Left ventricular diastolic dysfunction•2.3 Valvular disease•2.4 Congenital/acquired left heart
inflow/outflow tract obstruction and congenital cardiomyopathies
Journal of the American College of Cardiology Vol. 62, No. 25, 2013
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INTRODUCTION•Pulmonary hypertension associated with
left heart disease is the most common form of pulmonary hypertension.
•Pathophysiology remains poorly understood and its treatment remains undefined.
• Up to 60% of patients with severe LV systolic dysfunction and up to 70% of patients with isolated LV diastolic dysfunction develop PH-LHD
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DEFINITION
•The current hemodynamic definition of PH-LHD combines a resting mean pulmonary artery pressure (mPAP) >25 mm Hg and a pulmonary capillary wedge pressure (PCWP)>15mmHg.
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PATHOBIOLOGY OF PH-LHD
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Proposed relationship between LV dysfunction and secondary events that may contribute to development of pulmonary hypertension.
Denzil L. Moraes et al. Circulation. 2000;102:1718-1723
Copyright © American Heart Association, Inc. All rights reserved.
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PATHOPHYSIOLOGY : PH-LHD ;VHD
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PREVALENCE ; PH IN VHD
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Diagram showing the various hemodynamic stages observed in group 2 PH.
Marco Guazzi, and Barry A. Borlaug Circulation. 2012;126:975-990
Copyright © American Heart Association, Inc. All rights reserved.
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Stuart Rich, and Marlene Rabinovitch Circulation. 2008;118:2190-2199
Copyright © American Heart Association, Inc. All rights reserved.
Pulmonary occlusive venopathy
• Congested alveolar capillaries
• Fibrous intimal thickening
• Marked lymphatic dilatation
• Focal thickening of alveolar septa by proliferated capillaries.
• Nodular capillary proliferation
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SKIAGRAM - NORMAL PULMONARY VASCULATURE
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•REDISTRIBUTION•PCWP : 13-18mm HgSTAGE 1
•Interstitial edema•Kerley lines,peribronchial cuffing•PCWP : 18 -24 mmHg
STAGE 2
•ALVEOLAR EDEMA•Cotton wool appearance•“Bat wing” appearance•PCWP : >25 mmHg
STAGE 3
SKIAGRAPHIC STAGES OF PVH
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STAGE 1(PCWP : 13-18 mm Hg)
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Stage 2 PVH
•PCWP : 18 – 24 mm Hg
• Interstitial edema
•Kerley B lines
•Peribronchial cuffing
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KERLEY LINES
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PVH – STAGE 2 (PCWP : 18-24 mm Hg)
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PVH STAGE 3 (PCWP : >25 mm Hg)
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EVOLUTION OF X RAY CHANGES IN PVH
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CT CHEST - PVH
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OBJECTIVES OF FURTHER EVALUATION
•Confirming the group of PH
•Differentiating PAH and HFpEF
•Differentiate pre and post capillary PH
•Assessing pulmonary vascular reactivity to drugs and exercise
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PROPOSED EVALUATION ALGORITHM FOR PH-LHD
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Clinical features
Age >65 yrsElevated systolic blood pressureObesityHypertensionCoronary artery diseaseDiabetes mellitusAtrial fibrillationSymptomatic response to diuretic drugsExaggerated increase in systolic blood pressure with exercise
DIASTOLIC HEART FAILURE - POINTERS
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DIASTOLIC HEART FAILURE - POINTERS
Echocardiography•Left atrial enlargement•Concentric remodeling•Left ventricular hypertrophy•Elevated left ventricular filling pressures
(grade II to IV diastolic dysfunction)
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CARDIAC CATHETERISATION•Confirm PH (mPAP, sPAP, dPAP,PVR,LVEDP,LAP)
•Differentiate pre and post capillary PH-LHD -Trans Pulmonary Gradient(TPG) -Diastolic Pressure Difference(DPD).
•Assess reversibility -vasoreactivity testing
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TPG (TRANS PULMONARY GRADIENT)
• TPG = mPAP - PCWP
• “Out of proportion” /reactive PH/ combined post- and pre-capillary PH is defined as mean PAP ≥ 25 mm Hg and PVR ≥ 2.5-3Wood units (or a TPG ≥ 12-15 mm Hg) in the presence of PAWP > 15 mm Hg.
• Both TPG and PVR are flow-dependent and may not accurately reflect the presence of intrinsic pulmonary arteriolar remodeling.
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DIASTOLIC PRESSURE DIFFERENCE (DPD)
• DPD = dPAP – meanPCWP
• DPD is not flow dependent and has been shown to more accurately identify the presence of pre-capillary pulmonary arteriolar remodeling.
• In normal subjects,DPD is 1-3 mm Hg.
• Isolated post-capillary (mean PAP ≥ 25mm Hg, PAWP > 15 mm Hg, and DPG < 7 mm Hg)
• Combined post-capillary and pre-capillaryPH (mean PAP ≥ 25 mm HG, PAWP > 15 mm Hg, and DPG ≥ 7 mm Hg)Journal of the American College of Cardiology Vol. 62, No. 25, 2013
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Current Definition and Classification of PH-LHD
TERMINOLOGY PCWP DIASTOLIC PAP – PAWP (DPD)
ISOLATED POST CAPILLARY
>15 mm Hg <7 mm Hg
COMBINED POST CAPILLARY AND PRE CAPILLARY
>15 mm Hg >7 mm Hg
Journal of the American College of Cardiology Vol. 62, No. 25, 2013
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Distribution of PVR and TPG in a patients with group 2 PH due to HFrEF and HFpEF.
Marco Guazzi, and Barry A. Borlaug Circulation. 2012;126:975-990
Copyright © American Heart Association, Inc. All rights reserved.
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ASSESSMENT OF PH-LHD
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Date of download: 3/25/2015
Copyright © The American College of Cardiology.
All rights reserved.
From: Diagnosis, Assessment, and Treatment of Non-Pulmonary Arterial Hypertension Pulmonary Hypertension
J Am Coll Cardiol. 2009;54(1s1):S85-S96. doi:10.1016/j.jacc.2009.04.008
Diagnostic Approach to Distinguish Between PAH and PH Caused by Diastolic Left Heart DiseaseSee Table 1 for risk factors for diastolic heart failure. DHF = diastolic heart failure; Dx = diagnosis; EF = ejection fraction; HF = heart failure; NTG = nitroglycerine; OMT = optimized medical therapy; PAH = pulmonary arterial hypertension; PCWP = pulmonary capillary wedge pressure; PH = pulmonary hypertension; PVR = pulmonary vascular resistance; RCT = randomized controlled trial; RHC = right heart catheterization; WU = Wood units.
Figure Legend:
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THANK YOU…