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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
