Echocardiography in BPD

EchocardiographyinBPD

HythemNawaytouMBBCHAssistantProfessorPediatricCardiology

UCSF-BenioffChildren’sHospital

RoleofechoinBPD

» ruleinPH?» ruleoutPH?» accuratelyesFmatePApressure?» assessresponsetotreatment&followpaFents?

MeasuringthePApressure

HowtomeasurePApressure

•  QuanFtaFve:–  SystolicPressure:TRjetpeakvelocity,VSDorPDApeaksystolicvelocity

– MeanPressure:EarlydiastolicpulmonaryregurgitaFonvelocity

–  End-DiastolicPressure:EnddiastolicpulmonaryregurgitaFonvelocity

•  QualitaFve:–  Septalposi7onandmo7on– Direc7onofflowinthePDA,VSD

TRJet

PeakVelocityoftricuspidvalveregurgitaFon4X(Velocity)2

(+RightAtrialPressure)

=Pulmonaryarterysystolicpressure

TRJetWELOVEYOU

•  Easytoobtain

•  ObjecFve

•  Givesusanumber

Easytoobtain

•  FeasibilityofTRJetesFmaFoninBPDpaFents

61%

Mouranietal.Pediatrics.2008February;121(2):317–325

ObjecFve?

Grohetal,JAmSocEchocardiogr(2014)27(2)163–71

ObjecFve

Grohetal,JAmSocEchocardiogr(2014)27(2)163–71

Givesoutanumber

Isthatnumberaccurate?

Grohetal,JAmSocEchocardiogr(2014)27(2)163–71

•  80children•  0-17years(median5.5yrs)•  Twoventricles•  WiderangeofRVpressure•  SimultaneousRHC-Echo

Gp1:RVSP<½SBPGp2:RVSP>½SBP

Gp3:RVSP<2/3SBPGp4:RVSP>2/3SBP

Children

Grohetal,JAmSocEchocardiogr(2014)27(2):163–71

Group Bias LOA

I 3 9to-3.5

II 1.5 22to-19

III 2.5 10to-4.5

IV 1 26to-24

Gp1:RVSP<½SBP

Gp3:RVSP<2/3SBP

Gp2:RVSP>½SBP

Gp4:RVSP>2/3SBP

•  Goal:InareallifescenarioofBPDpa7entsdidtheechopredictthecathPApressure?

•  RetrospecFvechartreview•  Mostoftheechoeswerewithin30days(0-57d)•  CondiFonsbetweenthecathandechowerenotsimilar

Mouranietal.Pediatrics.2008February;121(2):317–325

Relationship between sPAP values estimated with echocardiography (ECHO) and directly measured with cardiac catheterization (CATH).

Peter M. Mourani et al. Pediatrics 2008;121:317-325

©2008 by American Academy of Pediatrics

Ability of echocardiography (ECHO)-estimated sPAP to predict the severity of PH determined with cardiac catheterization (CATH).

Peter M. Mourani et al. Pediatrics 2008;121:317-325

©2008 by American Academy of Pediatrics

11%UNDERDIAGNOSIS11%OVERDIAGNOSIS

SBP82/50

TRJet=RVSP55mmHg

SBP82/50

PDAPG=RVSP50mmHg

DoesthepaFenthavepulmonaryhypertension?

PaFentCPAP7cmH2O,FIO20.4andiNO20ppm,CapillaryBG7.4/59/72/+12

CatheterizaFondata

•  PApressure:35/16/mean24mmHg•  SystemicBP:61/41mean50mmHg•  PVR:3.1

DoesthepaFenthavepulmonaryhypertension?

PaFentETT,FIO20.4andiNO20ppm,Femoralartery7.4/50/118/+7

Ability of echocardiography (ECHO)-estimated sPAP to predict the severity of PH determined with cardiac catheterization (CATH).

Peter M. Mourani et al. Pediatrics 2008;121:317-325

©2008 by American Academy of Pediatrics

SCREENINGTOOL

11%UNDERDIAGNOSIS11%OVERDIAGNOSIS

Relationship between sPAP values estimated with echocardiography (ECHO) and directly measured with cardiac catheterization (CATH).

Peter M. Mourani et al. Pediatrics 2008;121:317-325

©2008 by American Academy of Pediatrics

CORRECTLYCLASSIFIED

CORRECTLYCLASSIFIED

SCREENINGTOOL

SHUNTS

HowgoodareposttricuspidvalveshuntsinesFmaFngPApressures?

SPAPwithshunts•  PDA&VSDSPAP=SBP−4V2(forleqtorightshunts)

SPAP=SBP+4V2(forrighttoleqshunts)VSD(SPAPr=0.98,SEE=6.3mmHg)PDA(SPAPr=0.972,SEE=6.8mmHg)(DPAPr=0.939,SEE=6.2mmHg)

(IntJCardiol(1993)40(1):35–43) (AmHeartJ(1992)124(1):176–82)

NotTestedinBPDspecifically

BidirecFonalflowWhatdoesitmean?

Bi-direcFonalshunt-VSD

Bi-direcFonalshunt-VSD

Bi-direcFonal-PDA

Bi-direcFonal-PDA

SeptalPosiFon&MoFon

HowmanyuseittoquanFfyPApressure?

Mouranietal.Pediatrics.2008February;121(2):317–325

InterventricularseptalconfiguraFon

CirculaFon68,No.1,68-75,1983

Progressiveseptalflauening

FLAT

PERFECTCIRCLE

InterventricularseptalconfiguraFon

CirculaFon68,No.1,68-75,1983.

PivallsofseptalmoFon

•  Offaxisscans•  Wheretoassessit?

– Base– Papillarymuscle– Apex

•  ArrhythmiasandconducFonabnormaliFes•  Whenisenddiastoleandendsystole?

RuleIN

RULEOUT

AccuratelyesFmatePApressureelevaFon

Canitassessresponsetotreatment?

Responsetotreatment

•  DirecFonofshunFngacrossaPDA/VSD

•  Holo-diastolicflowintheabdominalaorta

•  MeasurementofRVsize,funcFon,output?

Otherimportantfindings

•  HigherincidenceofPHamongBPDpaFentswithatrialLttoRtshunt.(42%vs15%.)

•  EarlierdevelopmentofPH(62vs103days)•  Moreuseofpulmonaryvasodilators(possiblymoresevere)•  Highermortality(14%vs0%)

PDA

Pulmonaryveinstenosis

Pulmonaryveinstenosis

Pulmonaryveinstenosis

PulmonaryveinstenosisCardiaccatheterizaFon

•  PVstenosesllPV>ruPV>rlPV>luPV

•  Pressuregradientsof10-15mmHgbetweenpulmonaryveinsandLA

Conclusions

•  CanechoscreenPHinBPDpaFents?

•  CanechoruleoutPHinBPDpaFents?

•  CanechobeusedtofollowBPDpaFentswithPH?

YES

Wedon’tknow

Notpressurebuthelpful

PHTeamUCSF