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Pulmonary Hypertension and Congestive Heart Failure

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Presentation on theme: "Pulmonary Hypertension and Congestive Heart Failure"— 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 5. Miscelaneous 4. Thromboembolic -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 RVSP RVSP Independent predictor of mortality
Congestive Heart Failure Volume 17, Issue 4, pages , 21 JUL 2011 DOI: /j x Independent predictor of mortality

7 Survival after Cardiac Transplantation
Elevated PAP and Low RV function 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:

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 Post 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 Active or Reactive PH Passive PH
Elevated mPA beyond PCWP TPG> 10-12 Passive PH Elevated mPA solely attributed to PCWP TPG < 10-12 Tx Based on Traditional CHF management Tx Based on Traditional CHF management ??

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

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

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

19 Right Ventricular Failure
RV Hypertrophy RV Dilation Flattening of Interventricular Septum -- D Shaped LV RA Enlargement 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 Flolan Sildenafil Bosentan / Darusentan
Prostacyclin Bosentan / Darusentan Moraes D L et al. Circulation 2000;102:

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

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

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

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

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 Kavarana M. N. et al.; Ann Thorac Surg 2002;73:745-750
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 Kavarana M. N. et al.; Ann Thorac Surg 2002;73:745-750
Peri-Operative Kavarana M. N. et al.; Ann Thorac Surg 2002;73:

48 Kavarana M. N. et al.; Ann Thorac Surg 2002;73:745-750
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 Pre-LVAD Post-LVAD PCWP 24.5 12.9 TPG 12.7 9.4
mean mean PCWP TPG PVR C.I. All p-values <

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 Passive PH TPG < 12 mmHg Reactive PH TPG > 12 mmHg Traditional Medical Therapy Advanced Treatment Options ACEi / ARB/ Aldosterone Antagonists Beta Blockade / Diuretic CRT Sildenafil ?? LVAD vs TAH

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