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HAEMODYNAMIC DEFINITIONS SOURCES HAEMODYNAMIC DEFINITIONSPulmonary Arterial Hypertension PAH PCWP ≤ 15 mm Hg and Pulmonary vascular resistance > 3 Pulmonary hypertension due to left hear
Trang 2SOURCES
ESC 2015 PH
Simonneau G, Montani D, Celermajer DS, et al Haemodynamic
definitions and updated clinical classification of pulmonary hypertension Eur Respir J 2019; 53: 1801913
Pulmonary Arterial Hypertension in 2019: From death sentence to chronic disease Trushil Shah, M.D
Galiè N, McLaughlin VV, Rubin LJ, et al An overview of the 6th World Symposium on Pulmonary Hypertension Eur Respir J 2018
2019 up to date Clinical features and diagnosis of pulmonary hypertension of unclear etiology in adults
2019 up to date Treatment of pulmonary hypertension in adults
2019 up to date Prognosis of pulmonary hypertension in adults
Trang 6BỆNH ÁN
Tiền căn: thông liên nhĩ 1 năm nay, đang điều trị với Bosentan, và Ditilazem Bệnh sử: cách nhập viện Chợ Rẫy 1 ngày, bệnh nhân nhập viện sản Từ Dũ với chẩn đoán : con so, thai 29 tuần 2 ngày, thai chậm tăng trưởng, thiểu ối – Thông liên nhĩ, shunt 2 chiều, tăng áp động mạch phổi nặng được chỉ định mổ lấy thai ở bệnh viện Từ Dũ
Sau mổ gây tê ngoài màng cứng, bệnh nhân cảm giác mệt và khó thở Huyết áp 120/80mmHg, mạch: 114 lần/phút, nhịp thở: 30 lần/phút, SpO2: 62%, nhịp tim đều, phổi trong, bụng mềm, vết thương mổ khô, tử cung gò khá Điều trị: Augbidil 1,2g – 3 lọ/ngày → bệnh viện Chợ Rẫy điều trị tiếp
Trang 7BỆNH ÁN
TTPT MỔ LẤY THAI (12h20 ngày 28 tháng 5 năm 2019)
Phương pháp phẫu thuật: phẫu thuật ngang đoạn dưới tử cung lấy thai lần đầu Phương pháp vô cảm: gây tê màng cứng
Rạch da, bóc tách phúc mạc đoạn dưới tử cung, rạch mổ ngang đoạn dưới tử
Trang 8Đường huyết mao mạch: 41mg/dl
Xử trí: thở mask 10l/p, NaCl 0.9% 1 chai giữ vein, Glucose 20% 250 1 chai TTM XX g/p
chuyển Nội Tim Mạch điều trị
Trang 9BỆNH ÁN
Bệnh nhân tỉnh, tiếp xúc được
SpO2 : 65%
Than mệt, khó thở, không ho, không sốt
Chi ấm, niêm hồng, mạch rõ, tím đầu chi, ngón tay dùi trống
Tim đều rõ, phổi trong, bụng mềm, phù nhẹ 2 chi dưới
Trang 10BỆNH ÁN
Siêu âm Doppler tim:
Dãn buồng tim phải TAPSE = 12mm
Chức năng co bóp trong giới hạn bình thường EF = 74% (pp Teicholz)
Thông liên nhĩ lỗ thứ phát d = 23mm, shunt phải trái
Tăng áp động mạch phổi nặng PAPs = 116mmHg
Trang 11BỆNH ÁN
Trang 12BỆNH ÁN
12:26 BUN : 30 mg/dL, creatinine: 1.58 mg/dL eGFR: 43.76 mL/phút/1.73 m2 da Na: 133 mmol/L, K 7.0
mmol/L, Cl 104 mmol/L
17:03 BUN : 29 mg/dL, creatinine: 1.55 mg/dL eGFR: 44.78 mL/phút/1.73 m2 da Na: 133 mmol/L, K 5.3
mmol/L, Cl 105 mmol/L
AST/ALT: 59/27 U/L Troponin I: 0.697 ng/mL
Trang 14BỆNH ÁN
Trang 15Chẩn đoán tại 7b3: Thông liên nhĩ shunt P – T (đã đảo shunt) – Suy thất Phải – Tăng áp động mạch phổi – Suy thận cấp – Hậu phẫu mổ bắt con so ngày 2
Điều trị:
Thở oxy mask 10l /p
Herbesser 60mg 1/2 v (uống) Bosentan 125mg 1 v (uống)
Trang 17Theo dõi sát sinh hiệu Đặt sonde tiểu lưu
Trang 20DEFINE
Hypertension (WSPH) (mPAP) ≥ 25 mm Hg
2009, Kovacs et al performed a systematic review on right heart catheterization (RHC) data on 1187 individuals: normal mPAP 14 ― 3.3 mm Hg → mPAP rarely > 20 mm Hg (97.5th %)
PH - mPAP > 20 mm Hg
Trang 21Vascular Pressure in Systemic and
Trang 22PH: The Importance of Hemodynamics
Pulmonary venous hypertension
Trang 23HAEMODYNAMIC DEFINITIONS
Trang 24HAEMODYNAMIC DEFINITIONS
SOURCES HAEMODYNAMIC DEFINITIONS
Pulmonary Arterial Hypertension (PAH)
(PCWP) ≤ 15 mm Hg and
Pulmonary vascular resistance > 3
Pulmonary hypertension due to left heart disease
(PCWP) > 15 mm Hg
Pulmonary hypertension due to lung disease and/or hypoxia
(PCWP) ≤ 15 mm Hg and
concomitant lung disease and/or hypoxia
Pulmonary hypertension due to pulmonary artery obstructions
(PCWP) ≤ 15 mm Hg and
an entity causing pulmonary artery obstruction
Pulmonary hypertension with unclear and/or multifactorial mechanisms
multifactorial mechanisms or
unclear underlying pathophysiological mechanisms
Trang 29Cause of death
right heart failure with circulatory collapse and superimposed respiratory failure
6% survived > 90 days
Trang 30Acute decompensated pulmonary hypertension
Sudden worsening of clinical signs of right heart failure with subsequent systemic circulatory
insufficiency and multisystem organ failure In-hospital mortality: 14% to 100%
1 Haddad F, Peterson T, Fuh E , et al Characteristics and outcome after hospitalization for acute right heart failure in patients with pulmonary arterial
hypertension Circ Heart Fail 2011; 4: 692–699
2 Jiang R, Ai Z-S, Jiang X, et al Intravenous fasudil improves in-hospital mortality of patients with right heart failure in severe pulmonary
hypertension Hypertens Res 2015; 38: 539–544
Trang 31Gradual evolution towards end-stage pulmonary
hypertension
Laurent Savale et al Eur Respir Rev 2017;26:170092
©2017 by European Respiratory Society
Trang 34CLINICAL PRESENTATION
20% patients severe-serious symptoms : 2 years Dyspnea and fatigue
Symptoms of right ventricular (RV) : •Exertional chest pain
•Exertional syncope
•Weight gain from edema
•Anorexia and/or abdominal pain and swelling
Brown LM, Chen H, Halpern S, et al Delay in recognition of pulmonary arterial hypertension: factors identified from the REVEAL Registry Chest 2011; 140:19.
Trang 35New York Heart Association functional classification
Class 1 No symptoms with ordinary physical activity
Class 2 Symptoms with ordinary activity Slight limitation of activity
Class 3 Symptoms with less than ordinary activity Marked limitation of activity
Class 4 Symptoms with any activity or even at rest
World Health Organization functional assessment classification
Class I Patients with PH but without resulting limitation of physical activity Ordinary
physical activity does not cause undue dyspnea or fatigue, chest pain, or near syncope
Class II Patients with PH resulting in slight limitation of physical activity They are
comfortable at rest Ordinary physical activity causes undue dyspnea or fatigue, chest pain, or near syncope
Class III Patients with PH resulting in marked limitation of physical activity They are
comfortable at rest Less than ordinary activity causes undue dyspnea or fatigue, chest pain, or near syncope
Class IV Patients with PH with inability to carry out any physical activity without symptoms These patients manifest signs of right-heart failure Dyspnea and/or fatigue may even be present at rest Discomfort is increased by any physical activity
Trang 36Signs on examination
Jugular venous pressure (JVP) abnormalities Right-sided auscultatory:
-A right-sided third or fourth heart sound (ie, a gallop) in association with a left parasternal heave or a downward
subxiphoid thrust
-Wide splitting of the second heart sound
-A holosystolic murmur of tricuspid regurgitation,
diastolic pulmonic systolic ejection murmur, diastolic pulmonic regurgitation murmur
Hepatomegaly, a pulsatile or tender liver, peripheral edema, ascites, and pleural effusion, splenomegaly
Trang 37Imaging
Chest x-ray:
Trang 38Imaging
Chest CT scan:
Trang 39Imaging
Chest CT scan:
Trang 40Imaging
ECG
Trang 41Imaging
Echocardiographic probability of pulmonary hypertension in symptomatic patients with a suspicion of pulmonary hypertension
≤2.8 or not measurable No Low ≤2.8 or not measurable Yes
Trang 42Imaging
Echocardiographic signs suggesting pulmonary hypertension used to assess the probability of pulmonary hypertension in addition to tricuspid regurgitation velocity measurement in Table A
A: The ventricles¶B: Pulmonary artery¶C: Inferior vena cava and right atrium¶
Right ventricle/left ventricle basal diameter ratio >1.0
Right ventricular outflow
Doppler acceleration time <105 msec and/or midsystolic
notching
Inferior cava diameter >21 mm with decreased inspiratory collapse (<50% with a sniff or <20% with quiet inspiration)
Flattening of the interventricular septum (left ventricular
eccentricity index >1.1 in systole
Trang 43Imaging
Trang 44Imaging video
Trang 45Risk assessment
pulmonary arterial hypertension
Trang 48Diagnostic algorithm
Trang 51DIAGNOSIS PH
Conclusions: DE estimates of PASP are inaccurate in patients with PH and should not be relied on to make the
diagnosis of PH or to follow the efficacy of therapy CHEST 2011; 139(5):988–993
Trang 52DIAGNOSIS PH
Trang 53Classification 5 groups PH
1 PAP
2 PH due to left heart disease
3 PH due to chronic lung disease and/or hypoxemia
4 PH due to pulmonary artery obstructions
5 PH due to multifactorial mechanisms
Trang 54Risk assessment
pulmonary arterial hypertension
Trang 58 The use of angiotensin-converting enzyme inhibitors, angiotensin-2 receptor antagonists, beta-blockers and ivabradine is not recommended in patients with PAH
Trang 59Oxygen
1-4 l/min
SpO2 > 90%
Trang 60Anticoagulation
MECHANISM: intrapulmonary vascular
thrombosis and venous thromboembolism and early studies that suggested a mortality benefit
INDICATIONS: group 1 PAH
Trang 61Digoxin
COPD and biventricular failure Control AF
Trang 63oral contraceptive)
Avoid pregnant. Surgical (patient or partner) methods
Travel: WHO-FC III and IV and those with arterial blood O2 < 60mmHg with supplemental O2
In elective surgery: epidural rather than general anaesthesia
Trang 64Management
acute decompensated PH
Laurent Savale et al Eur Respir Rev 2017;26:170092
Trang 65PH SPECIFIC THERAPY
cause of the PH
IV despite treatment of the underlying cause → PH-specific therapy centers
Trang 66PH1 SPECIFIC THERAPY
Nifedipine LA Oral
30 mg per day Increase to the maximum tolerated dose over days to weeks
Diltiazem
extended-release
Oral
120 mg per day Increase to the maximum tolerated dose over days to weeks
Amlodipine Oral
2.5 mg per day Increase to the maximum tolerated dose over days to weeks
Trang 67Vasoreactivity test
inhaled iloprost :
systemic effects and is therefore better tolerated than the intravenous agents listed below
●Epoprostenol 1 to 2 ng/kg per min and increased by 2 ng/kg per min every 5 to 10 minutes until a clinically significant fall in blood pressure, an increase in heart rate, or adverse symptoms (eg, nausea, vomiting, headache)
●Adenosine 50 mcg/kg per min and increased every two minutes until uncomfortable symptoms develop or a maximal dose of 200 to 350 mcg/kg per min is reached
Trang 69Mechanism of PH1 target therapy
Trang 70PH (group 1) therapy WHO functional class
Trang 71Initial drug combination
PH (group 1) WHO functional class
Trang 72THE LAST THERAPY
atrial septostomy and placement of a Potts shunt via a transcatheter
Severely high pulmonary vascular resistance (from obstructive
shock)→ reduction in left ventricular preload, systemic pressure→ elevating systemic blood flow and maintaining tissue perfusion, albeit with less oxygenated blood
cardiac output and systemic oxygen: 27%
refractory severe PAH and right heart failure, despite aggressive advanced therapy and maximal diuretic therapy
Trang 73THE LAST THERAPY
Bilateral lung or heart-lung transplantation 3 year survival patients: 50%
Trang 74Correction
congenital heart disease with shunts
Trang 75Treatment
congenital heart disease with shunts
Eisenmenger syndrome
Trang 76PREGNENCY
FDA category X
complications
Trang 77BỆNH ÁN
Nữ 28 tuổi
Tiền căn: thông liên nhĩ shunt P→T-tăng áp phổi nặng-hậu phẩu mổ lấy thai N2 đang điều trị Bosentan, Diltiazem
Trang 78BỆNH ÁN
Nữ 28 tuổi
Tiền căn: thông liên nhĩ shunt P→T-tăng áp phổi nặng-hậu phẩu mổ lấy thai N2 đang điều
Trang 80CẢM ƠN
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