← All decks
Cardiology
Pulmonary Hypertension Hemodynamic Assessment by Cardiac Catheterization
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
10 sections · 139 slides
Overview
- Scope of this presentation
Definitions and classification
- Haemodynamic definition of pulmonary hypertension
- Why the threshold moved from 25 to 20 mmHg
- Exercise pulmonary hypertension redefined
- Pulmonary vascular narrowing in pulmonary hypertension
- Four haemodynamic groups of pulmonary hypertension
- Haemodynamic definitions of pulmonary hypertension
- Sorting a patient by wedge pressure and resistance
- Epidemiology of pulmonary hypertension
- Age, sex and survival in pulmonary arterial hypertension
- Five WHO clinical groups
- WHO group 1: pulmonary arterial hypertension
- WHO group 2: pulmonary hypertension due to left heart disease
- WHO group 3: lung disease and hypoxia
- WHO group 4: pulmonary artery obstruction
- WHO group 5: unclear or multifactorial mechanisms
- Haemodynamic pattern expected in each WHO group
- WHO groups of pulmonary hypertension with respective aetiologies
- WHO groups of pulmonary hypertension with respective aetiologies (continued)
Pathophysiology of pulmonary arterial hypertension
- Common mechanism of pulmonary vasculopathy
- Hypertensive pulmonary arteriopathy
- Four treatable pathways in PAH
- Endothelin pathway
- Endothelin receptor antagonists
- Nitric oxide pathway
- Drugs acting on the nitric oxide pathway
- Prostacyclin pathway
- Prostanoid analogues and IP receptor agonists
- Transforming growth factor beta pathway
- Sotatercept and activin signalling
- From vascular injury to right ventricular failure
Clinical assessment and echocardiography
- Symptoms of pulmonary hypertension
- Symptoms pointing to the underlying WHO group
- Physical signs in pulmonary hypertension
- Sequence of diagnostic evaluation
- Role of transthoracic echocardiography
- Investigations for suspected group 3 and group 4 disease
- Screening for PAH risk factors
- Six-minute walk test
- Right ventricular enlargement on echocardiography
- Estimating pulmonary artery pressure by Doppler
- Tricuspid regurgitation velocity thresholds
- Estimating right atrial pressure from the inferior vena cava
- Secondary echocardiographic changes supporting PH
- Echocardiographic markers of poor right ventricular function
- Limitations of echocardiography: technical
- Limitations of echocardiography: diagnostic
- Echocardiography compared with right heart catheterization
Indications and risks of right heart catheterization
- Origins of right heart catheterization
- What right heart catheterization measures
- Right heart catheterization in the critically ill
- Situations where right heart catheterization is indicated in shock
- Right heart catheterization in WHO group 1 PAH
- Distinguishing HFpEF at catheterization
- Pretest risk scores for HFpEF
- Right heart catheterization before heart transplantation
- Surveillance catheterization after heart transplantation
- Right heart catheterization in liver transplant candidates
- Hepatopulmonary syndrome
- Contraindications to right heart catheterization
- Complications of right heart catheterization
- Pulmonary artery rupture
- Opened right ventricle with a thickened free wall
Performing the catheterization
- Preparation and transducer zeroing
- Venous access for right heart catheterization
- Pulmonary artery catheter
- Ports of the pulmonary artery catheter
- Course of the pulmonary artery catheter
- Advancing the catheter
- Recordings and samples taken during catheterization
- Directly measured and derived parameters
- Directly and indirectly measured parameters during right heart catheterization
- Directly and indirectly measured parameters during right heart catheterization (continued)
- Fick and thermodilution cardiac output
- When cardiac output measurements are unreliable
- Sequence of chambers crossed during catheterization
Waveforms
- Normal atrial pressures and waveform components
- The a wave and its timing
- Abnormal a waves
- The v wave and the descents
- Distinguishing pulmonary artery from right ventricular waveform
- Confirming the wedge position
Pitfalls during catheterization
- Why accuracy matters
- Zeroing, flushing and damping
- Factors affecting wedge pressure measurement
- Catheter tip position and lung zones
- Balloon inflation volume
- Over-wedging and under-wedging
- Wedge pressure with full and half balloon inflation
- Respiratory variation and wedge pressure
- Respiratory variation of the wedge pressure trace
- When wedge pressure does not reflect LVEDP
Additional manoeuvres during catheterization
- When standard measurements are not enough
- Rationale for vasoreactivity testing
- Performing vasoreactivity testing
- Defining a positive vasoreactivity test
- Vasoreactive agents used during right heart catheterization
- Vasoreactivity testing in chronic thromboembolic PH
- Cautions during vasoreactivity testing
- Volume loading
- Unmasking group 2 pulmonary hypertension
- 100% oxygen challenge
- Normal circulatory response to exercise
- Defining exercise pulmonary hypertension
- Who should undergo exercise catheterization
- Performing exercise catheterization
- Cardiac output measurement during exercise
- Contraindications to exercise catheterization
- Reversibility testing in WHO group 2 pulmonary hypertension
- Performing reversibility testing
- Fixed and reversible pulmonary hypertension
- Right heart catheterization before LVAD implantation
- Pulmonary artery pulsatility index
- LVAD ramp testing
- Indications for endomyocardial biopsy
- Endomyocardial biopsy technique
Conclusion
- Interpretation depends on clinical context
- Consequences of inaccurate data
- Numbers to carry away
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
- Join our WhatsApp groups