Gingy R. Balmor, Michael J. Segel, Jonathan Buber, Sagit Ben-Zekry, Paul Fefer, Elio Di-Segni, Issahar Ben-Dov & Amit Segev
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1 THE SIGNIFICANCE OF VENTRICULAR SEPTAL FLATTENING IN PATIENTS WITH SUSPECTED PULMONARY HYPERTENSION Gingy R. Balmor, Michael J. Segel, Jonathan Buber, Sagit Ben-Zekry, Paul Fefer, Elio Di-Segni, Issahar Ben-Dov & Amit Segev Pulmonary Institute & Cardiology Division Chaim Sheba Medical Center Tel Hashomer
2 CONFLICT OF INTERESTS None to declare
3 BACKGROUND PREVALENCE OF VENTRICULAR SEPTAL FLATTENING IN PULMONARY ARTERIAL HYPERTENSION (PAH) Case series of PAH 4/9 had ventricular septal flattening (VSF) 1 National US registry of PAH. 187 patients. 59% with VSF 2 Single center PAH cohort. 51 patients 90% with VSF 3 1. Goodman DJ et al. Am J Cardiology Rich S et al. Ann Intern Med Bossone E et al. J Am Soc Echocardiogr 1999
4 BACKGROUND SIGNIFICANCE OF VSF IN PAH PATIENTS VSF is related to hypotensive response to calcium channel blockers 1. The degree of septal displacement correlates with mean right atrial pressure 2. VSF predicts increased mortality 3. 1 Ricciardi MJ et al. Chest Hinderliter AL et al. Circulation Raymond RJ et al. J Am Coll Cardiol
5 AIMS What is the distribution of different types of pulmonary hypertension in patients with VSF? What is the significance of VSF in patients with suspected PH?
6 HYPOTHESIS We assume VSF is a sign of RV pressure > LV pressure. We hypothesize that patients with VSF will be more likely to have pre- capillary PH and its accompanying clinical, echocardiographic and hemodynamic features.
7 METHODS Patients who were evaluated in Tel Hashomer medical center for PH and underwent right sided catheterization Retrospective data collection included:. Medical history Lab results Echocardiography Right sided hemodynamic measurement Final diagnosis confirmation Prof. Ben-Dov, Dr Segev, Dr. Segel.
8 RESULTS 165 patients underwent right sided catheterization patients without satisfactory echocardiographic report 150 patients suitable for this study 33 patients with ventricular septal flattening 117 patients without ventricular septal flattening
9 Clinical Characteristics No flattening Flattening Age (years) 64.6± ± Male gender 30% 24% Overweight (BMI>30Kg/m 2 ) 44% 24% Ischemic heart disease 22% 15% Hypertension 69% 54% Diabetes 39% 33% Dyslipidemia 59% 30% Obstructive sleep apnea 19% 3% Chronic lung disease 21% 39% Past pulmonary embolism 8% 30% p
10 Clinical Characteristics No flattening Flattening Age (years) 64.6± ± Male gender 30% 24% Overweight (BMI>30Kg/m 2 ) 44% 24% Ischemic heart disease 22% 15% Hypertension 69% 54% Diabetes 39% 33% Dyslipidemia 59% 30% Obstructive sleep apnea 19% 3% Chronic lung disease 21% 39% Past pulmonary embolism 8% 30% p
11 Clinical Characteristics No flattening Flattening Age (years) 64.6± ± Male gender 30% 24% Overweight (BMI>30Kg/m 2 ) 44% 24% Ischemic heart disease 22% 15% Hypertension 69% 54% Diabetes 39% 33% Dyslipidemia 59% 30% Obstructive sleep apnea 19% 3% Chronic lung disease 21% 39% Past pulmonary embolism 8% 30% p
12 Echocardiography No flattening Flattening p Ejection fraction (%) 58.1± ± Peak E wave (cm/sec) 101.8± ± Peak A wave (cm/sec) 75.7± ± E/e' septal 17.1± ± E/e' lateral 13.0± ± LV mass index (gr/m 2 ) 93.4± ± LA diameter (mm) 41.0±7 36.8± LA area (cm 2 ) 22.9± ± LA enlargement: area criteria 73% 43% Abnormal LV filling pattern 58% 100% 0.002
13 Echocardiography No flattening Flattening p Ejection fraction (%) 58.1± ± Peak E wave (cm/sec) 101.8± ± Peak A wave (cm/sec) 75.7± ± E/e' septal 17.1± ± E/e' lateral 13.0± ± LV mass index (gr/m 2 ) 93.4± ± LA diameter (mm) 41.0±7 36.8± LA area (cm 2 ) 22.9± ± LA enlargement: area criteria 73% 43% Abnormal LV filling pattern 58% 100% (31/53) (16/16) 0.002
14 Hemodynamics No flattening Flattening p Mean PAP (mmhg) 36.4± ± Mean PAP >25mmHg 73% 97% PCWP>15mmHg 61% 37% Trans pulmonary gradient>12mmhg 58% 97% Cardiac index (Fick, L/min/m 2 ) 2.5± ± Stroke volume (Fick, ml) 60.7± ± Pulmonary vascular resistance (Wood's units) 4.4± ± Pulmonary vascular resistance>3 wood s units 52% 97% Mean RA pressure (mmhg) 11.2± ±
15 Hemodynamics No flattening Flattening p Mean PAP (mmhg) 36.4± ± Mean PAP >25mmHg 73% 97% PCWP>15mmHg 61% 37% Trans pulmonary gradient>12mmhg 58% 97% Cardiac index (Fick, L/min/m 2 ) 2.5± ± Stroke volume (Fick, ml) 60.7± ± Pulmonary vascular resistance (Wood's units) 4.4± ± Pulmonary vascular resistance>3 wood s units 52% 97% Mean RA pressure (mmhg) 11.2± ±
16 165 patients underwent right sided catheterization 15 patients without satisfactory echocardiographic report 150 patients suitable for research 33 patients with ventricular septal flattening 117 patients without ventricular septal flattening Hemodynamic Pre-capillary PH: mpap>25mmhg, PCWP<15mmHg 19 patients 24 patients
17 Hemodynamics: Pre-Capillary PH Subgroup No flattening Flattening Mean PAP (mmhg) 40± ± PCWP (mmhg) 11.1± ± Trans-pulmonary gradient>12mmhg 92% 100% Cardiac index (Fick, L/min/m 2 ) 2.6± ± Stroke volume (Fick, ml) 55.7± ± Pulmonary vascular resistance (Wood's units) 7.0± ± Pulmonary vascular resistance>3 Wood s units 79% 100% Mean RA pressure (mmhg) 8.2± ± p
18 Final Diagnosis No flattening Flattening p % N % n No PH 16% 19 3% 1 No PH but CHF 3% 4 3% 1 Class I PAH 14% 16 39% 13 Class II left heart disease 47% 55 18% 6 Class III lung disease 1% 1 0% 0 Class IV thromboembolic 4% 5 21% 7 Class V - miscellaneous 3% 3 0% 0 Out of proportion PH 10% 12 12% 4 Sum of I, III, IV, V, Out of proportion * 32% 37 73% Unknown/other 2% 2 6% 2 *sum of patients diagnosed as PH with pre- capillary component
19 LIMITATIONS Broad definition of VSF possibly including several entities. Selected population Retrospective analysis Time lag from echocardiography to catheterization Different echocardiography protocols and documentation Change in PH definition and classification over the years
20 CONCLUSIONS VSF can indentify patients with non cardiac PH. VSF is a specific (97%) marker of PH with elevated pulmonary vascular resistance (but sensitivity 35%). In pre- capillary PH patients, VSF is associated with a more severe hemodynamic profile. In the presence of VSF an abnormal LV filling pattern should not be interpreted as a marker of LV disease.
21 CONCLUSIONS All patients with unexplained VSF should be referred to specialized PH clinics and right heart catheterization should be considered.
22
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