Disclaimer:Ini adalah nota pembelajaran. Untuk peringatan diri sendiri. Maklumat disini adalah penggunaan sendiri sahaja.

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Bismillah.

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Right Heart Catheterisation (RHC):

Ptient has an ostium secundum atrial septal defect (ASD) and has undergone right heart catheterisation to assess the pressures inside the heart, pulmonary circulation, and the amount of blood shunting across the ASD.

The most important finding is that the pulmonary artery pressure is very high, but the calculated pulmonary vascular resistance (PVR) is not severely elevated. The ASD is not causing a significant net left-to-right shunt at rest.

? Maksudnya the elevated right pulmonary pressure can be elevated without the ASD problems?

ASD not causing net left to right shunt? Maksudnya dah remodelling ke.

RA pressure is 13
RV pressure is 116 severely elevated!
LA pressure is 10
LV pressure is

PA presure is 116/40 mean PA 68mmHG

PCW (PW) is 13

why? the PW wedge not high? —

LA pressure transmit to RA then to RV kan?

so should the PW becomes high?

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Pulmonary hypertension is defined haemodynamically as:

• mPAP >20 mmHg.

Therefore, an mPAP of 68 mmHg represents severe pulmonary hypertension.

The systolic PA pressure of 116 mmHg is also extremely high

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mestilah remodelling to the pulmonary vasculature? betul tak teka je.

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Think of water flowing through a pipe with a narrow, high-resistance section.

• Before the narrowing, pressure rises.
• Across the narrowing, a large pressure drop occurs.
• Beyond the narrowing, pressure can remain relatively low.

In pulmonary arterial hypertension, the pulmonary arterioles may become narrowed, thickened and less compliant due to vascular remodelling.

This increases pulmonary vascular resistance.

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The pulmonary artery, heart and lung is incredible.Subhanallah. I call it Adapted physiology. kena ada topic dalam med school. 🙂

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Takkan la nak bagi pressure tinggi masuk lung.. rosak la sponge lung.. so it remodels.

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As a result, the RV must generate a much higher pressure to push blood through the lungs, while the pressure downstream, near the pulmonary veins and left atrium, can remain normal.

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PVR is about 8 units.

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meaning that PVR berubah dan menjadi tinggi. sangat tinggi .

It indicates substantial resistance within the pulmonary circulation, assuming the measurements are accurate

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PAWP is an indirect estimate of left atrial pressure when measured correctly. It is not a direct measurement of pulmonary capillary pressure.

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tapi adakah pressure pada LV menjadi rendah.. yes.. sebab kes ni adalah defect pada interarterial septum..

Kes ASD secundum.

Hebat kan.

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Patient with an ASD, severe pulmonary vascular disease can cause pulmonary artery pressure to rise markedly

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The ASD may allow blood to flow from left to right. As pulmonary vascular resistance rises, the left-to-right shunt may diminish, and right-to-left shunting can eventually occur

inilah masa kita tengok Qp/Qs ;-

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Clinical pearl: High pulmonary artery pressure + normal PAWP + high PVR = think precapillary pulmonary hypertension, rather than pulmonary hypertension primarily caused by left-sided heart failure.

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ada pressure berubah pada increased PVR.

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haemodynamic diagnosis?

Based on the measurements shown:

1. Severe pulmonary hypertension

• mPAP 68 mmHg.

2. Elevated pulmonary vascular resistance

• PVR approximately 8 WU.

3. Normal pulmonary artery wedge pressure

• PAWP approximately 11 mmHg.

4. Small net left-to-right shunt at rest

• Qp/Qs 1.07.

5. Secundum ASD

• Documented on the report.

Taken together, these findings are consistent with severe precapillary pulmonary hypertension in a patient with a secundum ASD.

and a raised PVR. (Wood Unit)

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Pricipal in ASD closure ..

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Diskusi Qp/Qs

Gapo.. RA jadi high tetibe? Kat IVC/SVC kan low..

SVC 68%/ IVC 76% — RA tetiba 80%.

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This may indicate an oxygen saturation step-up from oxygenated blood entering the right atrium through the ASD.

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Inilah dikatakan step up.

Dalam MRCP questions banyak sekali soalah ni, dalam RHC questions.

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Despite the apparent step-up, the calculated Qp/Qs is only 1.07

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and then kenapa Qp/Qs that tinggi?

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An oxygen saturation step-up can suggest a shunt, but it does not by itself establish that the shunt is haemodynamically significant.

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haha..

Jelas sikit. sebelum kabur2.

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PVR is high at approximately 8 WU, yet Qp/Qs remains 1.07 rather than reversing below 1.0. Why?

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high pulmonary artery pressure does not automatically mean that right atrial pressure exceeds left atrial pressure.

The direction of flow across an ASD depends mainly on the pressure difference between the two atria, together with defect anatomy and ventricular compliance.

.. again remodelling of the ventricular compliance..

haha

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Why Qp/Qs not reveresed?

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Dynamic measurement.

1. These pressures may vary with respiration and throughout the cardiac cycle, and the LA and wedge measurements may not be directly interchangeable.
2. PVR is approximately 8 WU. This is markedly elevated, but pulmonary artery pressure and PVR do not directly determine the direction of the ASD shunt.
3. Bidirectional flow. – overall shunt can still be nearly neutral, with Qp/Qs close to 1

not everything is certain .

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Does this mean the patient does not have Eisenmenger syndrome?

Correct: Qp/Qs of 1.07 alone does not establish Eisenmenger syndrome.

Eisenmenger syndrome involves advanced pulmonary vascular disease associated with a systemic-to-pulmonary communication that has progressed to bidirectional or net right-to-left shunting, with pulmonary hypertension and typically systemic arterial desaturation.

Systemic arterial desaturation..

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High PVR does not automatically reverse an ASD shunt. The direction of the shunt depends on the balance of atrial pressures and the dynamic haemodynamics of the defect.

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May be have to look for simpler case? yang straight forward.. untuk belajar.