ipertensione polmonare eco e diagnosi: vantaggi, limiti, errori evitabili ipertensione polmonare eco...
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Ipertensione polmonareIpertensione polmonare
Eco e diagnosi: vantaggi, limiti, errori evitabiliEco e diagnosi: vantaggi, limiti, errori evitabili
Ipertensione polmonareIpertensione polmonare
Eco e diagnosi: vantaggi, limiti, errori evitabiliEco e diagnosi: vantaggi, limiti, errori evitabili
UOC Cardiologia UOC Cardiologia II Università degli Studi, A.O. “V. Monaldi” - NapoliII Università degli Studi, A.O. “V. Monaldi” - Napoli
UOC Cardiologia UOC Cardiologia II Università degli Studi, A.O. “V. Monaldi” - NapoliII Università degli Studi, A.O. “V. Monaldi” - Napoli
Michele D’AltoMichele D’[email protected]@tin.it
Michele D’AltoMichele D’[email protected]@tin.it
Pulmonary hypertension: general Pulmonary hypertension: general definitionsdefinitions
2009
2009
Pulmonary hypertension: haemodynamic Pulmonary hypertension: haemodynamic definitiondefinition
WHO classification of pulmonary WHO classification of pulmonary hypertensionhypertensionVenice 2003Venice 2003 revised Dana Point 2008revised Dana Point 2008
1. Pulmonary arterial hypertension1. Pulmonary arterial hypertension Idiopathic PAHIdiopathic PAH Heritable PAHHeritable PAH (BMPR2, ALK1..)(BMPR2, ALK1..) Drugs and toxinsDrugs and toxins Associated with Associated with CCTD, TD, HIVHIV,, pportal hypertensionortal hypertension, ,
congenital heart diseases, congenital heart diseases, chronic hemolytic anemia chronic hemolytic anemia (SSD) and shistosomiasis(SSD) and shistosomiasis
PPHNPPHN1’1’ PVOD, PHCM PVOD, PHCM
2. PH with left heart disease2. PH with left heart disease Systolic dysfunctionSystolic dysfunction Diastolic dysfunctionDiastolic dysfunction ValvularValvular
3. PH with lung 3. PH with lung diseases/hypoxemiadiseases/hypoxemia
COPDCOPD Interstitial Interstitial llung ung ddiseasesiseases Sleep-disordered breathingSleep-disordered breathing Altitude exposureAltitude exposure Alveolar hypoventilationAlveolar hypoventilation Developmental abnormalitiesDevelopmental abnormalities
4. 4. CTEPHCTEPHNo more distinction proximal/distalNo more distinction proximal/distal
5. Miscellaneous5. MiscellaneousSarcoiSarcoidosis, histiocytosis X, dosis, histiocytosis X,
Gaucher,..Gaucher,..
Normal estimated PAPs value at Normal estimated PAPs value at echo?echo?
37 mmHg, but…37 mmHg, but…
Echocardiography for PH diagnosis:Echocardiography for PH diagnosis:pitfallspitfalls
RV systolic RV systolic pressure pressure
estimationestimation
TVR (simplified TVR (simplified Bernoulli)Bernoulli)
++RAP RAP estimationestimation
TVTVRR
Simplified BernoulliSimplified Bernoulli
ΔPΔP = 4 (V) = 4 (V)22
From ICV to…From ICV to…
RAPRAP
• Poor Doppler Poor Doppler signalsignal• Uncertain TVR Uncertain TVR peakpeak• Theta angleTheta angle
• ArbitraryArbitrary
Echocardiography, age and body Echocardiography, age and body sizesize
Circulation 2001;104: 2797–802Circulation 2001;104: 2797–802 J Am Coll Cardiol 2009;54:S55–66J Am Coll Cardiol 2009;54:S55–66
3790 “normal” subjects (1358 M, 2432 F) from 1 to 89 years.
PASP calculated by modified Bernoulli equation, with RAP assumed to be 10 mmHg.
+10+10
Echocardiography, age and body Echocardiography, age and body sizesize
Circulation 2001;104: 2797–Circulation 2001;104: 2797–802802
Echocardiography for PH in SScEchocardiography for PH in SSc
- 21 SSc expert centers- 21 SSc expert centers- 599 SSc patients (-29 known PAH = 570)- 599 SSc patients (-29 known PAH = 570)
Reliability of prospective screening of SSc patients based on:Reliability of prospective screening of SSc patients based on:- TVR >2.5 m/s in symptomatic patientsTVR >2.5 m/s in symptomatic patients- or TVR >3.0 m/s irrespective of symptoms.or TVR >3.0 m/s irrespective of symptoms.
Arthritis Rheum 2005;52(12):3792-3800
45% of cases of echocardiographic diagnoses of PH were falsely 45% of cases of echocardiographic diagnoses of PH were falsely positive!positive!
33 patients33 patients
Echocardiography for PH in SScEchocardiography for PH in SSc
Rheumatology 2004; 43:461-6Rheumatology 2004; 43:461-6
137 SSc pts studied137 SSc pts studied
cathcath
ech
oech
o
false negfalse neg
false posfalse pos
ICV < 15mmICV < 15mm collassocollasso RAP 0-5 mmHgRAP 0-5 mmHg
ICV 15-25mmICV 15-25mm rid. >50%rid. >50% RAP 5-10 RAP 5-10 mmHgmmHg
ICV >25mmICV >25mm rid. <50%rid. <50% RAP 10-15 RAP 10-15 mmHgmmHg
ICV >25mm+v.sovr.ICV >25mm+v.sovr. No rid.No rid. RAP 20 mmHgRAP 20 mmHg
SystolicSystolic PAP = RV-RA gradient + PAP = RV-RA gradient + RAPRAP
Mod from Otto CM, Mod from Otto CM, 20022002
Estimated right atrial pressureEstimated right atrial pressure
Am J Respir Crit Care Med 2009;179:615–621
Estimated right atrial pressure
IVC <20mm
Collaps >50%
IVC <20mm
Collaps <50%
IVC >20mm
Collaps >50%
IVC >20mm
Collaps <50%
Echocardiography for PH in HIVEchocardiography for PH in HIV
65 HIV pts studied65 HIV pts studied
EchocardiographyEchocardiography
Am J Respir Crit Care Med 2009;179:615–621Am J Respir Crit Care Med 2009;179:615–621
95% limits of 95% limits of agreement: agreement: +38.8 and -40.0 +38.8 and -40.0 mmHgmmHg
Good quality Good quality DopplerDopplerPoor quality Poor quality DopplerDoppler
65 HIV pts studied65 HIV pts studied
2009
PH possible:PH possible:
- PASP 37-50 mmHg (TVR 2.9-3.4 PASP 37-50 mmHg (TVR 2.9-3.4 m/s)m/s)
- additional echo variablesadditional echo variables
PH likely:PH likely:
- PASP >50 (TVR > 3.4 m/s)- PASP >50 (TVR > 3.4 m/s)
EchocardiographyEchocardiography
Direct PH signsDirect PH signs Indirect PH signsIndirect PH signs
- PASP > 37 (50) PASP > 37 (50) mmHgmmHg
- Increased velocity PV reg Increased velocity PV reg (mPAP) (mPAP)
- Short acc. time in RVOT (mPAP) Short acc. time in RVOT (mPAP)
- Right heart dilationRight heart dilation
- Flat IV septum (LV EI <0.8) Flat IV septum (LV EI <0.8)
- Increased RV wall thicknessIncreased RV wall thickness
2009
Indirect PH signs: PAPmIndirect PH signs: PAPm
• Mean PAPMean PAP
79 - 0.45 • (AcT)79 - 0.45 • (AcT)
PAPm =PAPm =79 - 0.45 • 44.3 =79 - 0.45 • 44.3 =79 - 20 =79 - 20 =5959
PAPm =PAPm =5757
Indirect PH signs:Indirect PH signs:Right heart (and PA) dilationRight heart (and PA) dilation
57 mmAo
PA
Right atrium: and PAHRight atrium: and PAH
Raymond, RJ, J Am Coll Cardiol 2002;39:1214–9Raymond, RJ, J Am Coll Cardiol 2002;39:1214–9
cmcm22/m /m (area/altezza)(area/altezza)
Right atrium sizeRight atrium size
Normal Normal value:value:
<16 cm2<16 cm2
<9 cm2/m<9 cm2/m
<40 ml<40 ml
<20 ml/m2<20 ml/m2
Raymond RJ, J Am Coll Cardiol 2002;39:1214–9Raymond RJ, J Am Coll Cardiol 2002;39:1214–9Wang Y, Chest 1984;86:595-601 Wang Y, Chest 1984;86:595-601
LVLV
RVRV
Left ventricular (LV) eccentricity index (EI): D2/D1 in short axis view (normal value = Left ventricular (LV) eccentricity index (EI): D2/D1 in short axis view (normal value = 1)1)
D2
D1
Indirect PH signs:Indirect PH signs:flat IV septum, hypertrophic RV wallflat IV septum, hypertrophic RV wall
EI = 0.65EI = 0.65
What determines PAPm?What determines PAPm?
PVR = PVR = ΔP / QΔP / Q
PVR = (PVR = (PAPmPAPm – PWP) / Q – PWP) / Q
PVR X Q = PVR X Q = PAPmPAPm – PWP – PWP
PVR X Q + PWP = PVR X Q + PWP = PAPmPAPm
PAPAHH
High High outpuoutpu
tt
LV LV dysfunctiodysfunctio
nn
PVRPVRΔPΔP
Three different conditions Three different conditions with high estimated PAPmwith high estimated PAPm
(PVR X Q) + PWP = (PVR X Q) + PWP = PAPmPAPm
PAPAHH
LV LV dysfunctiondysfunction
Argiento, Argiento, Eur Respir J Eur Respir J 20092009
High High outpuoutpu
tt
Assessment of LV filling pressuresAssessment of LV filling pressures
Nagueh et al. JACC 1997 & Circulation 2000
Normal LV filling Normal LV filling pressurepressure
Precapillary PH first Precapillary PH first diagnosisdiagnosis
NO PAH or very end-NO PAH or very end-stagestage
PCWP = 1.9 + (1.24 x E/EPCWP = 1.9 + (1.24 x E/Eaa))
9/60 (15%) 9/60 (15%) mistakes mistakes
Midsystolic pulmonary artery notching = High PVRMidsystolic pulmonary artery notching = High PVR
Jones J E, Am J Physiol Heart Circ Physiol 2002;283:364-71Jones J E, Am J Physiol Heart Circ Physiol 2002;283:364-71
Midsystolic pulmonary artery Midsystolic pulmonary artery notching.notching.
Rats were treated with Rats were treated with monocrotaline for:monocrotaline for:
- 0 (0 (AA), ), - 15 (15 (BB), ), - 22 (22 (CC),),- 37 (37 (DD) days.) days.
0 d monocrotaline
15 d monocrotaline
22 d monocrotaline
37 d monocrotaline
Midsystolic pulmonary artery notching = High PVRMidsystolic pulmonary artery notching = High PVR
Midsystolic pulmonary artery notching = High PVRMidsystolic pulmonary artery notching = High PVR
Why?Why?
= reverse wave for high PVR
Pre-test probability: the Bayes’ theoryPre-test probability: the Bayes’ theory
The The probability of an event A given an event Bprobability of an event A given an event B (e.g., the (e.g., the probability of CAD given a positive stress test) depends not probability of CAD given a positive stress test) depends not only on the relationship between events A and B (i.e., the only on the relationship between events A and B (i.e., the accuracyaccuracy of stress test) but also on the of stress test) but also on the marginal probabilitymarginal probability (or "simple probability") of occurrence of each event(or "simple probability") of occurrence of each event in a specific population.
Rev. Thomas Bayes, 1763Rev. Thomas Bayes, 1763
Stress test for CAD detection:Stress test for CAD detection:
- CAD prevalence in group A = 50%; test + = 82% CAD- CAD prevalence in group A = 50%; test + = 82% CAD
- CAD prevalence in group B = 3%; test + = 13% CAD- CAD prevalence in group B = 3%; test + = 13% CAD
• Associated condition for PAHAssociated condition for PAH
Population at risk for PAHPopulation at risk for PAH
- Connective tissue disease (CREST* 30%, SSc 10%) Connective tissue disease (CREST* 30%, SSc 10%) 10-10-15%15%- Portal hypertensionPortal hypertension 1-6%1-6%- HIV infectionHIV infection 0.5-1%0.5-1%- Anorexigen drugsAnorexigen drugs 0.006-0.01%0.006-0.01%- Unoperated shuntUnoperated shunt 5-10%5-10%
• Relatives of IPAH patientsRelatives of IPAH patients
*CREST (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, *CREST (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia)sclerodactyly, telangiectasia)
J Am Coll Cardiol 2008;51:1527–38
Pre-test probability of precapillary PHPre-test probability of precapillary PH
2009
Pre-test probability of pre-capillary Pre-test probability of pre-capillary PHPH
RARA > LA > LA
RVRV > LV > LV
D-shaped LV D-shaped LV
RARA < LA < LA
RVRV < LV < LV
Normal shaped Normal shaped LVLV
Pre-test probability of pre-capillary Pre-test probability of pre-capillary PHPH
RV adaptation to pressure overloadRV adaptation to pressure overload
RV hypertrophy and progressive dilatationRV hypertrophy and progressive dilatation
Tricuspid regurgitation and RA dilatationTricuspid regurgitation and RA dilatation
Paradoxical septal motion and altered LV fillingParadoxical septal motion and altered LV filling
Diastolic and systolic RV dysfunctionDiastolic and systolic RV dysfunction
Pericardial effusion in the more severe casesPericardial effusion in the more severe cases
LV dysfunctionLV dysfunction Haddad et al. Circulation 2008Haddad et al. Circulation 2008
LV LV dilation/hypertrophydilation/hypertrophy
LA enlargementLA enlargement
E/A >1 E/A >1 (pseudonorm/rest(pseudonorm/rest
r)r)Normal LV shapeNormal LV shape
No PA notchNo PA notch
RV RV dilation/hypertrophydilation/hypertrophy
RA enlargementRA enlargement
E/A <1 (mild E/A <1 (mild diastolic dysf)diastolic dysf)
D-shape LVD-shape LV
PA notchPA notch
Pulmonary Pulmonary arterialarterial or or venousvenous hypertension?hypertension?
Group 1 Dana Group 1 Dana PointPoint
Group 2 Dana Group 2 Dana PointPoint
PAH PAH predisposing predisposing
conditioncondition
Left heart Left heart diseasedisease
Take-at-home messageTake-at-home message
It is strongly encouraged a deep knowledge of PAH It is strongly encouraged a deep knowledge of PAH pathophysiology (pathophysiology (echo as part of clinic echo as part of clinic evaluationevaluation!).!).
The The gold standardgold standard for PAH diagnosis remains for PAH diagnosis remains right right heart catheterizationheart catheterization!!
Echo plays a key-role in Echo plays a key-role in screeningscreening, , differential differential diagnosisdiagnosis and and follow-upfollow-up..
Echo does not provide “magic numbers”: Echo does not provide “magic numbers”: multi-multi-parametric evaluationparametric evaluation! !
It is mandatory to evaluate the PAH “It is mandatory to evaluate the PAH “pre-test pre-test probabilityprobability”.”.