Episode #1 – Hemodynamic assessment
Follow Karl-Philipp Rommel (Leipzig, Germany) as he shares insights on physiology relevant to diagnosing and treating TR-related right heart failure, starting in this first episode with the hemodynamic assessment.
In this video you will learn:
– to recognize the intricate relationship between symptoms and hemodynamics in (TR-related) right heart failure.
– to understand the role of invasive hemodynamic assessment in the evaluation of TR patients
More resources from the PCR Tricuspid Focus Group: https://www.pcronline.com/Cases-resources-images/Zoom-on/Tricuspid-Focus-Group-Content
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So hi it’s my pleasure to discuss right heart failure and hemodynamics in tricuspid reg regation with you today and I think it’s a great time to be discussing this as uh therapies are emerging to treat trasp agitation and this has really put right heart failure
Back on the map and not only for the scientific Community but also clinically and in the following videos we want to help to disseminate insights on physiology relevant to diagnosis and therapy of TR related rard failure to a wider audience so let’s kick things off by talking about the hemodynamic
Assessment in the upcoming minutes I want you to recognize the intricate relationship between symptoms and hemodynamics in patients with rart failure and to understand the role of invasive hemodynamics in the evaluation of these patients to start out let’s Define rart failure as a structural or functional alteration of the right heart
Circulatory system leading to suboptimal cardic output and or elevated filling pressures and it’s important to note that this is not synonymous with um right ventricular failor as it encompasses also the entire circulatory system including the Venus system here the right atrial system and the pulmonary vasculature up to the
Capillaries the cardiac alterations in chronic right heart failure vary with theology but in principle Encompass right atrial dilatation right ventricular dilation um increased right ventricular filling pressures increased Central venix pressures which ultimately lead to signs typically associated with right heart failure as jugular venous distension peripheral edema hepatic and renal congestion or abdominal
Ploting however a reduction in right ventricular stroke volume also leads to LV underfilling to decrease cardic output and by the means of ventricular interdependence it may also increase left ventricular filling pressures leading to hypertension exercise in tolerance dpia plural fusion and I’m happy to emphasize this here once more
All of these can be specific symptoms of right heart failure trasp regurgitation now plays a pivotal role in this Dynamic either as a cause or consequence of R out failure however once initiated these processes perpetuate each other contributing to the progession progression of Trias regation which in turn fuels the
Progression of right hard failure the specific mechanisms leading to the occurrence of tricuspid regurgitation can vary at an individual patient level however significant TR is a common final pathway of many cardiovascular disease and is such very prevalent in the general population and especially in patients with left heart
Failure and multiple lines of evidence now indicate that TR is independently associated with adverse outcomes in a dose dependent fashion and when we now think about how we can treat right heart failure associated with TR it becomes crucial to diagnose and optimally treat the underlying cardiovascular condition in
Order to interrupt this vicious cycle that perpetuates right heart failure for which we unfortunately let specific therapies to date and therefore I think um early recognition of trasp regation and rart failure is crucial and you should maintain a low threshold of Suspicion during clinical examination and prompt um promptly
Initiate further Diagnostics such as echocardiography which can elegantly visualize and quantify TR but on in the following slides I want to also advocate for invasive hemodynamic assessment which not only allows to establish a diagnosis and my diagnosis I don’t mean the diagnosis of tripid regur I mean the diagnosis of the underlying
Cardiovascular condition it informs you about the hemodynamic impact of TR has prognostic implications and might even help to guide your treatment strategy here’s an example of how this scenario might unfold a patient presented with us uh presented to us with shortness of breath and peripheral edema up on examination you see here
Torrential TR alongside a preserved left ventricular ejection fraction and by atrial dilation in the setting of also impaired left ventricular diastolic function hemodynamically we see at Central Venus pressures pulmonary hypertension but also elevated left atrial pressures and elevated left ventricular and diastolic pressures meaning that this patient has a post capillary pulmonary hypertension
In the setting of heart failure with preserved ejection fraction as ideology for his tripid regation so now let me walk you through the findings you might encounter during right heart catheterization in the right atrium you’re likely to observe a ventricular ised pressure curve with a dominant rewave a steep wide descent and fusion
Of the C and rewave and it’s important to know that the absolute height of the rewave does not inform on the severity of tripid regation it’s a common misbelief Additionally you might come across a paradoxical increase in right atrial pressure with inspiration the so-called kmal sign serving as an
Indirect sign for reduced right ventricular compliance advancing your catheter to the RV you may encounter this tracing often referred to as the dip Plateau pattern or square root sign and this is of course suggestive of differential diagnosis of pericardio contriction or restrictive cardiomyopathy as for the distinction between constriction and restriction we
Turn to ventricular interdependence as evidenced by discordance in systolic RV and LV pressure tracings with respiration which when present rules out out restriction but now to make the distinction between TR and constriction we have to observe diastolic pressure Vari and only in TR does the right ventricular diastolic pressure sporadically exceed left
Ventricular diastolic pressure on deep inspiration advancing the catheter further you can characterize a pulmonary arterial hypertension and potentially identify underlying left heart disease or pulmonary disease diagnostically can be valuable to compare these findings with echocardiographic measures of pulmonary arterial pressures um invasively and and if there
Is a discordance it’s likely due to um the most severe TRS with early pressure Equalization between right ventricle and right atrium um the highest Central Venus pressures and the most severe symptoms and finally I also want to strongly advocate for the assessment of cardiac output during right out catheterization because it’s essential
Um to characterize pulmonary hypertension for example but also to overall get an impression about the hemodynamic state of your patient and contrary to the common belief cardic output measures in the setting of trasit regurgitation are reliable this holds true for the FI principle but also for thermal delution where inaccuracy is
Primar primarily arise from low output States rather than issues related to TripIt regurgitation itself so in conclusion clinical science of right heart failure are related to altered hemodynamics and include Central congestion but also signs typically Rel related to left heart failure like exercise intolerance and plural Fusion
Trasit regurge can act as both a cause or consequence of right heart failure warranting a low threshold of Suspicion for further investigations invasive hemodynamics play a crucial role in pinpointing underlying cardiovascular conditions understanding the hemodynamic impact assessing prognostic implications and potentially guide treatment strategies and with this I want to thank
You for listening and I hope you will join us for the next video