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Hasanah Mumpuni
KSM Jantung /Departemen Kardiologi dan Kedokteran Vaskular
RSUP Dr. Sardjito / FK-KMK UGM
Case
• Women, 20 years old, with complaints of fatigue, sometimes
accompanied by shortness of breath since 6 months. The last 2
weeks often experience coughing, without fever .
• Physical exam. Vital sign BP 110/70, P 110 x/mnt, Respiration
22/ mnt
• Cardiac status : Wide fix splitting in upper left sternal border, P2
harden.
• ECG : RVH, complete RBBB
• Assesment → CHF , Susp Atrial septal defect, Pulmonal
hypertension ??
• What supporting investigations are needed ??
1. Electrocardiography
➢ Right ventricular hypertrophy or strain → These include
right-sided axis deviation, an R-to-S wave ratio greater
than 1 in lead V1,
➢ increased P-wave amplitude - RAE
➢ an incomplete or complete right bundle-branch block
pattern.
2. Chest Radiography
➢ Tricuspid regurgitation →
measurement of pulmonary
arterial pressure with the
modified Bernoulli equation.
➢ Tricuspid regurgitation is
generally detected in more than
90% of patients with severe PH,
and a correlation of greater than
95% by means of catheterization.
➢ Doppler echocardiography is a
useful noninvasive test for long-
term follow-up.
Echocardiography in patients with suspected PH;
The following echo parameters should be used to assess the
probability of PH:
1. Peak Tricuspid Regurgitation (TR)velocity
2. Ventricle
1. Eccentricity index
2. Basal LV/RV diameter ratio
3. Pulmanale Artery (PA)
1. RVOT acceleration time and/or mid systolic notching
2. Early diastolic PR velocity
3. PA diameter
4. Right Atrial (RA) and Inferior Vena Cava (IVC)
1. RA area
2. IVC size and respiratory variability
Probability of PH
Tricuspid Regurgitation Doppler
• TR velocity
• TR gradien
Echocardiographic signs suggesting PH to assess
the Probability of PH in addition to TR Velocity
c
RV – LV basal diameter Rasio:
Qualitative “Eyeball” Estimate
Mild RVE
Normal
Normal
D1
D2
14
c
Pulmonary Acceleration Time
< 105 msec
25
Right heart catheterisation – the diagnostic gold standard
26
Parameter in RHC
1. mPAP ≥ 25 mmHg (PH)
2. PA-WP ≤ 15 mmHg
3. PVR → > 3 Wood unit (WU)
PVR = ( mPAP – mLAP ) / CO or
PVR = ( mPAP –PCWP ) / CO
• mPAP – mLAP = Transgradien pulmonal (TGP),
• mLAP similar PAWP
Recommendation for RHC in PH
Ventilation-Perfusion Lung
Scanning
• Ventilation-perfusion scanning should be
performed to exclude CTEPH. A high- or low-
probability scan result is most useful, whereas
intermediate-probability results should lead to the
performance of pulmonary angiography.
• Diffuse mottled perfusion can be observed in
patients with pulmonary arterial hypertension
(PAH), as opposed to the segmental or
subsegmental mismatched defects observed in
patients with CTEPH (see the image below).
The Diagnose of PH
Suggestive clinical
features
- Functional test
- RHC
- Vasodilator test
Diagnostic Algorithm for PH
• ESC
Notes
33
here 2015
Compare measurements Echocardiography
with RHC
• PVR by echocardiography →
Metode Abbas = 0.618 + 10.006xTRV/TVI RVOT.
• PCWP=1.9 + 1.24 x E/E’ (high>15 mm Hg)
Take home message
• The diagnosis of PH begins with a clinical suspicion of PH
• There are several supporting examinations that can be used to support
the presence of PH
• Echocardiography is an integral part of the assessment of a
patient with PH, the first test to detect PH, and has a high
diagnostic value
• Gold standard PH is RHC, according to the PH definition
• PH is defined as an increase in mean pulmonary arterial pressure
(PAPm) ≥25 mmHg at rest as assessed by right heart
catheterization (RHC)