PULMONARY VENOUS HYPERTENSION- STAGES, ASSESSMENT & SKIAGRAPHIC CHANGES

SHYAM SASIDHARAN

MENU• INTRODUCTION

•DEFINITION

•PATHOBIOLOGY AND STAGES

•SKIAGRAM

• IMAGING

• CARDIAC CATHETERISATION

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

*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

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

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.

PATHOBIOLOGY OF PH-LHD

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.

PATHOPHYSIOLOGY : PH-LHD ;VHD

PREVALENCE ; PH IN VHD

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.

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

SKIAGRAM - NORMAL PULMONARY VASCULATURE

•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

STAGE 1(PCWP : 13-18 mm Hg)

Stage 2 PVH

•PCWP : 18 – 24 mm Hg

• Interstitial edema

•Kerley B lines

•Peribronchial cuffing

KERLEY LINES

PVH – STAGE 2 (PCWP : 18-24 mm Hg)

PVH STAGE 3 (PCWP : >25 mm Hg)

EVOLUTION OF X RAY CHANGES IN PVH

CT CHEST - PVH

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

PROPOSED EVALUATION ALGORITHM FOR PH-LHD

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

DIASTOLIC HEART FAILURE - POINTERS

Echocardiography•Left atrial enlargement•Concentric remodeling•Left ventricular hypertrophy•Elevated left ventricular filling pressures

(grade II to IV diastolic dysfunction)

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

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.

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

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

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.

ASSESSMENT OF PH-LHD

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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