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Pulmonary Hypertension and Congestive Heart Failure Stephen L. Rennyson MD August 11, 2011.

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Presentation on theme: "Pulmonary Hypertension and Congestive Heart Failure Stephen L. Rennyson MD August 11, 2011."— Presentation transcript:

1 Pulmonary Hypertension and Congestive Heart Failure Stephen L. Rennyson MD August 11, 2011

2 Pulmonary Hypertension Mean Pulmonary Artery Pressure (mPAP) > 25 mmHg

3 WHO Classification of Pulmonary Hypertension 1. Pulmonary Arterial Hypertension 2. Left Heart Disease 3. Chronic Hypoxemia 4. Thromboembolic 5. Miscelaneous -Sarcoid, fibrosing mediastinitis

4 Relationship of CHF and PH Passive Congestion (Elevated PCWP) Increased LVEDP (PCWP) Pre - Capillary vs Post - Capillary PH

5 Group 2 PH Comprises 1/2 of all PH Systolic and Diastolic Dysfunction Leads to RV dysfunction Difficult to treat -- Cardio-Renal Syndrome Independently associated with worse outcomes

6 Group 2 PH Independent predictor of mortality RVS P Congestive Heart Failure Volume 17, Issue 4, pages , 21 JUL 2011 DOI: /j x Volume 17, Issue 4,

7 Survival after Cardiac Transplantation Group 1 indicates normal pulmonary artery pressure/preserved right ventricular ejection fraction (n=73); group 2, normal pulmonary artery pressure/low right ventricular ejection fraction (n=68); group 3, high pulmonary artery pressure/preserved right ventricular ejection fraction (n=21); and group 4, high pulmonary artery pressure/low right ventricular ejection fraction (n=215). Voelkel N F et al. Circulation 2006;114: ✴ Elevated PAP and Low RV function

8 Cardiac Catheterization

9 Hemodynamic Assessment Right Heart Catheterization RA, RV, PAP, PCWP Thermodilution and Fick End Expiration -- Best approximate of atmospheric pressure

10 Transpulmonary Gradient (TPG) Change in pressure across the pulmonary circulation mPA - PCWP Normal TPG < 10 mmHg

11 Pulmonary Vascular Resistance Resistance to flow that must be overcome to push blood through the system Ohms Law: mPA - PCWP Cardiac Output Normal Values of < = to 1.5 Wood Units

12 PH due to CHF Pre Capillary PH mPA > 25 mmHg PCWP < 15 mmHg CO normal Post Capillary PH mPA > 25 mmHg PCWP > 15 mmHg CO normal or low

13 Post Capillary PH out of proportion Use of TPG and PVR TPG > mmHg PVR > 1.5 wood units

14 PH out of proportion Passive PH Elevated mPA solely attributed to PCWP TPG < Active or Reactive PH Elevated mPA beyond PCWP TPG> Tx Based on Traditional CHF management ?? Tx Based on Traditional CHF management

15 Reactive PH Chronic Venous hypertension Longstanding Advanced Heart Failure Pulmonary Vascular Remodeling Elastic Fibers Intimal Fibrosis Medial Hypertrophy Mediated by Endothelin Changes -- Indistinguishable from PAH

16 Pulmonary Remodeling Does not normalize with traditional CHF treatments Ultimately RV Failure “Fixed” Pulmonary Arteriopathy

17 Reactive Changes Vasodilator Challenge Inhaled NO, IV epoprostenol, milrinone, nitroprusside, nitroglycerin, dobutamine... ISHLT guidelines -- Vasodilator Challenge mPA > 50 mmHg AND TPG > 15 mmHG OR PVR > 3 Wood Units

18 Vasodilator Challenge Reactive Changes with Fixed PH: --Persistent PVR >=2.5 WU or --PVR < 2.5 WU secondary to SBP <85 mmHg VCU/MCV -- NO challenge

19 Right Ventricular Failure RV Hypertrophy RV Dilation RA Enlargement Flattening of Interventricular Septum -- D Shaped LV Tricuspid Regurgitation

20 Right Ventricular Evaluation Transthoracic Echocardiography Qualitative Quantitative Tricuspid Annular Peak Systolic Excursion (TAPSE) -- > M-mode Tissue Doppler First Pass (RVEF) MRI

21 TAPSE American Journal of Respiratory and Critical Care Medicine Vol 174. pp , (2006)

22 TAPSE (< 1.8 cm) American Journal of Respiratory and Critical Care Medicine Vol 174. pp , (2006)

23 TAPSE (< 1.8 cm) American Journal of Respiratory and Critical Care Medicine Vol 174. pp , (2006)

24 TAPSE (< 1.8 cm) American Journal of Respiratory and Critical Care Medicine Vol 174. pp , (2006)

25 Medical Management Moraes D L et al. Circulation 2000;102: Bosentan / Darusentan Sildena fil Flola n Prostacycli n

26 Role for pulmonary vasodilators? Prostanoids -- FIRST Trial -- Flolan Endothelial Receptor Antagonists REACH and ENABLE trials -- Bosentan Phosphodiesterase Inhibitors -- Sildenafil

27 FIRST 471 patients class III/IV Improved Hemodynamics Increased CI / Decreased PVR and PCWP Exercise Tolerance and QOL No Change Increased Mortality Contraindicated Flolan International Randomized Survival Trial Am Heart J 1997;134:44-54

28 REACH 370 Patients High dose Bosentan vs Placebo Trial Stopped Early Increase in early CHF exacerbations Elevated Transaminase Levels Research of Endothelin Antagonists in Chronic Heart Failure

29 ENABLE 1600 Patients Bosentan (lower dose) vs Placebo Increased CHF exacerbations Endothelin Antagonist Bosentan for Lowering Cardiac Events in Heart Failure

30 Phosphodiesterase Inhibitors

31 Sildenafil No large scale clinical trials Acute Hemodynamic Trials Long Term Hemodynamics Quality of Life Trials

32 Acute Hemodynamic Changes 11 patients Right Heart Cath Inhaled NO (80 ppm) Sildenafil (50 mg) NO/Sildenafil combination Lepore JJ, Maroo A, Bigatello LM, et al. Chest. 2005;127:

33 Duration of Effect NO Alone NO and Sildenafil Lepore JJ, Maroo A, Bigatello LM, et al. Chest. 2005;127:

34 Acute Changes Lepore JJ, Maroo A, Bigatello LM, et al. Chest. 2005;127:

35 Chronic Therapy 34 patients, 12 week trial Sildenafil vs Placebo (75 titrated to 150 mg/day) Class II-IV NYHA CHF, (iCMO and NiCMO) Hemodynamic and Qualitative measurements Lewis G D et al. Circulation 2007;116:

36 Quantitative Analysis Lewis G D et al. Circulation 2007;116:

37 Quantitative Analysis Lewis G D et al. Circulation 2007;116:

38 Qualitative Analysis Lewis G D et al. Circulation 2007;116:

39 Sildenafil Improved first pass RVEF Improved NYHA class in over 50% of Sildenafil and 13% in placebo Conclusions Improvements in both quantitative and qualitative measurements in CHF patients with PH Lewis G D et al. Circulation 2007;116:

40 PH and Cardiac Transplantation TPG and PVR Increased mortality Barrier to successful transplantation ISHLT guidelines -- Vasodilator Challenge mPA > 50 mmHg AND TPG > 15 mmHG OR PVR > 3 Wood Units

41 Sildenafil in Class IV CHF Pre-Transplant Case Series of 6 patients awaiting transplant All had TPG > 15 mmHg Jabbour A et al. Eur J Heart Fail 2007;9:

42 TPG Jabbour A et al. Eur J Heart Fail 2007;9:

43 PVR Jabbour A et al. Eur J Heart Fail 2007;9:

44 Sildenafil in addition to vasodilator challenge enabled sufficient decrease in PVR and TPG to enable transplantation Jabbour A et al. Eur J Heart Fail 2007;9:

45 Mechanical Support

46 Pulsatile LVAD Retrospective Analysis of 69 LVAD patients No significant difference in pre-LVAD hemodynamics 30% Developed RV dysfunction (21/69) Prolonged inotropic support, longer HD, Increased transfusions, mortality RVAD needed post-operative 1 patient Kavarana M. N. et al.; Ann Thorac Surg 2002;73:

47 Peri-Operative Kavarana M. N. et al.; Ann Thorac Surg 2002;73:

48 Transplantation Kavarana M. N. et al.; Ann Thorac Surg 2002;73:

49 Continuous Flow HM- II 40 LVAD patients -- Single Center Pre and Post LVAD implant Hemodynamics Echocardiographic indices

50 Continuous Flow HM- II PV R C.I. PCW P TP G Post- LVAD Pre- LVAD All p-values <.001 mea n

51 Continuous Flow HM- II RV failure after LVAD >14 days inotropic support or RVAD 5% (2/40) At 6 Months 37/40 alive or transplanted

52 Continuous Flow HM- II RV failure can be treated effectively with continuous flow left ventricular assist devices Bridge to transplant patients

53 Biventricular Support (TAH) -- Syncardia An option for severe bi-ventricular failure with significant Reactive PH Effective Bridge to transplantation

54 Pulmonary Circulation After TAH Single center retrospective study (VCU/MCV) 40+ patients Evaluation of hemodynamics pre and post TAH Pulsatile mechanism vs Continuous Flow of LVAD

55 Pulmonary Hypertension secondary to CHF (Systolic and Diastolic) Chronic post-capillary PH Pulmonary Vascular Remodeling RV dysfunction Advanced Treatment Options Traditional Medical Therapy Sildenafil ?? LVAD vs TAH Passive PH TPG < 12 mmHg Reactive PH TPG > 12 mmHg ACEi / ARB/ Aldosterone Antagonists Beta Blockade / Diuretic CRT


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