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A Look at the Other Side: Focus on the Right Ventricle and

Pulmonary Hypertension

Susan P. D’Anna MSN, APN-BC, CHFN

June 24, 2016

Disclosures

Objectives

• Differentiate structure and function of RV and LV

• Discuss how pulmonary hypertension contributes to R sided heart failure and RV distress

• Review pulmonary hypertension diagnostic criteria and classification

• Identify HD characteristics of PAH vs PH due to LHD

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RV vs LV

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Structure and Function

• Primary function -receive systemic venous return

• Pump into the PA circulation

• Walls are thinner than the LV

• Less muscle mass than LV (2 layers vs 3 layers)

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Circulation. 2006;114:1883-1891

Assessment of RV Function

Norbert F. Voelkel et al. Circulation. 2006;114:1883-1891

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Structure and Function

• Primary function -receive systemic venous return

• Pump into the PA circulation (low resistance/lower pressure system)

• Walls are thinner than the LV

• Less muscle mass than LV (2 layers vs 3 layers)

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Ventricular Interdependence

When the RV dilates … the interventricular septum bulges into LV, impairs LV filling and LV stroke volume.

Right Ventricular Failure

RV Hypertrophy

RV Dilation

RA Enlargement

Flattening of Interventricular Septum -- D Shaped LV

Tricuspid Regurgitation

Left vs Right Heart Failure

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The echo report says “elevated PASP”Now what …???

Pulmonary hypertension is not a disease …

It is a hemodynamic measure (mPA > 25mmHg) that is shared by many diseases.

PH Clinical Classification

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WHO Classification of Pulmonary Hypertension

1. Pulmonary Arterial Hypertension 2. Left Heart Disease

3. Chronic Hypoxemia

4.Thromboembolic 5. Miscellaneous

Hemodynamic AssessmentRight Heart Catheterization

RA, RV, PAP, PCWP

Thermodilution and Fick CO

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Transpulmonary Gradient (TPG)

• Change in pressure across the pulmonary circulation

» mPA - PCWP

» Normal TPG < 10 mmHg

Pulmonary Vascular Resistance

• Resistance to flow that must be overcome to push blood through the system

• Ohms Law:

mPA – PCWP / Cardiac Output

• Expressed in Wood units (wu): Normal < 2-3 wu

Normal Values of < = to 1.5 Wood Units

PAH

• mPA >/= 25 mmHg

• PCW < 15

• PVR > 3 wu

“No Right Heart Cath, No VQ Scan,

NO DIAGNOSIS”

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Pulmonary Arterial Hypertension (PAH) is more than a hemodynamic measurement …

Hoeper MM, etal. JACC. 2013;62(25_D): D42D50

Why does PAH develop?

• It is complicated …

• What we do know:

– Abnormality to the lining of the blood vessels

– Over production of endothelin -1 – causes narrowing (constriction) of the vessels

– Underproduction of “mediators” that help dilate vessels –nitric oxide and prostacyclin

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Changes in the Pulmonary Arteries

in PAH

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Determinants of Prognosis in PAH

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Hoeper MM, etal. JACC. 2013;62(25_D): D42D50

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Group 2 PH• Comprises over 1/2 of all PH

• Systolic and Diastolic Dysfunction

• Can lead to RV dysfunction

• Difficult to treat -- Cardio-Renal Syndrome

• Independently associated with worse outcomes

Group 2 PH Profile

• Age > 60 yrs

• Female gender

• Obesity

• DM

• HTN

• CAD

• Sleep disordered breathing

Relationship of CHF and PH

Passive Congestion (Elevated PCWP)

Increased LVEDP (PCWP)

Pre - Capillary vs Post - Capillary PH

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PH-LHDHemodynamic profiles

Ipc - PH Cpc-PH

PCW > 15 mm Hg > 15 mm Hg

DPG (PAD-PCW) < 7 mm Hg >7 mm Hg

TPG (mPA- PCW) </= 12 mm Hg > 12 mm Hg

PVR (mPA-PCW/CO) < 3 wu >/= 3 wu

Barnett, C; et al. Overview of WHO Group 2 Pulmonary Hypertension Due to Left Heart DiseaseAdvances in Pulmonary Hypertension.2015;14:2: 70-78.

PCW: pulmonary capillary wedgeDPG: diastolic pressure gradientTPG: transpulmonary gradientPVR: pulmonary vascular resistance

PH-LHD

Barnett, C; et al. Overview of WHO Group 2 Pulmonary Hypertension Due to Left Heart Disease.Advances in Pulmonary Hypertension.2015;14:2: 70-78.

Treatment?

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JAMA. 2013;309(12):1268-1277

RELAX Trial

PH out of proportion

Ipc-PH(isolated post capillary PH)Elevated mPA solely attributed to PCWPTPG < 10-12

Cpc-PHElevated mPA beyond PCWP

TPG> 10-12

Traditional CHF management ? Role for pulmonary vasodilators

Traditional CHF management

• The role of RV function has lagged behind the LV, but impacts prognosis in pulmonary hypertension regardless of etiology

• Pulmonary hypertension is not a disease, but a hemodynamic measure that is shared by many diseases

• PAH comprises a small portion of patients with elevated PA pressures - diagnosis and treatment is dependent upon specific criteria

• Group 2 PH represents the largest population of patients with PH and is most challenging to manage.

Summary