3/12/2019 Cardiac Cath Why Bother? Cardiac Catheterization in - - PDF document

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David Teitel, MD

12th International Conference Neonatal & Childhood Pulmonary Vascular Disease, San Francisco, March 2019

UCSF Pediatric Pulmonary Hypertension Program

Cardiac Catheterization in Preterm Infants with Chronic Pulmonary Hypertension

Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Cardiac Cath – Why Bother?

• Respiratory Status

– ventilatory settings, blood gases, chest CT

• Cardiac Status

– echocardiography, EKG

• Pulmonary Vascular Status

– echocardiography

• Metabolic Status

– growth

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Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Echocardiography

• Complete echocardiogram to evaluate for structural

heart disease, biventricular function, pressure estimates and flow patterns

• Specific PH findings

– Dilated RA, RV, and PA – RV hypertrophy – Abnormal interventricular septal alignment and motion – TR jet to estimate PA pressure – PI jet to estimate PA mean pressures – Direction and velocity of shunting: atrial, ventricular and ductal

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Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Cath – Questions to Answer

• Respiratory Status

– pulmonary venous blood gases may be of value

• right-to-left foraminal shunt
• lobar gases re differential oxygenation and ventilation and

responsiveness to 100% O2 ± iNO

• Cardiac Status

– RV function - Qp, RA/RV pressure, afterload – presence and extent of shunts – atrial, ductal – presence and extent of pulmonary venous pathology

• Pulmonary Vascular Status

– “baseline” pulmonary vascular resistance (total vs arteriolar) – minimal resistance (reactivity to O2 + iNO)

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Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Cath – Problems to Fix

• During cath

– device closure of PDA – device closure of ASD – pulmonary vein dilation

• Post cath

– minimize RV afterload with a goal to reach minimal cath PVR with therapy to assist in vascular remodeling

Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Cath – Considerations & Caveats

• “Baseline state”

– effect of anesthesia, necessity to increase ventilatory support

• Qp (Qs often equals Qp and less important to questions)

– if Fick, need to assume oxygen consumption

• thermodilution when possible, and back-calculate VO2

– mixed pulmonary venous saturation in presence of atrial r-l shunt – mixed pulmonary arterial saturation with l-r ductal shunt – importance of including dissolved oxygen when pO2 ≥ 150 mmHg

• Pulmonary vascular resistance

– what is normal for a premature infant? – how does one correct for damaged lung parenchyma?

Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Oxygen Consumption

Seckeler MD, et al. A new predictive equation for oxygen consumption in children and adults with congenital and acquired heart disease. Heart. 2015;101(7):517-24.

Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Oxygen Consumption

Seckeler MD, et al. A new predictive equation for oxygen consumption in children and adults with congenital and acquired heart disease. Heart. 2015;101(7):517-24.

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Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

• 7 mo, former 23 wk premie,

transferred from OSH with multiple complications, tracheostomy on ventilator, on sildenafil

• Echo: RVP = ½ systemic, no RVH,

no TR, atrial septum not well seen

Patient 1

• 7 mo, former 23 wk premie,

transferred from OSH with multiple complications, tracheostomy on ventilator, on sildenafil

• Echo: RVP = ½ systemic, no RVH,

no TR, atrial septum not well seen

9

• 23 mo, still trach/vent, on triple

therapy with sc Remodulin

• Echo: normal RVP, no RVH, no

atrial communication (normal echo)

Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

• 10 mo, former 25 wk premie,multiple

complications, transferred from OSH

• n high flow O2, on sildenafil
• Echo: RVP = ½ systemic, RVH,

small PDA, no atrial communication

Patient 2

• 10 mo, former 25 wk premie,multiple

complications, transferred from OSH

• n high flow O2, on sildenafil
• Echo: RVP = ½ systemic, RVH,

small PDA, no atrial communication

10

• 19 mo, off oxygen, no vasodilators,

g-tube feeds

• Echo: none since 2 months post

cath – still mild RVH

Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

• 10 wo, former 30 wk premie,

transferred from OSH with multiple anomalies, CLD on high flow O2

• Echo: RVP > ½ systemic, RVH,

PDA and atrial level shunt

Patient 3

• 10 wo, former 30 wk premie,

transferred from OSH with multiple anomalies, CLD on high flow O2

• Echo: RVP > ½ systemic, RVH,

PDA and atrial level shunt

11

• 6 mo, hospitalized, on bosentan &

sildenafil, high flow O2, g-tube

• Echo: RVP > ½ systemic, RVH,

mild RA & RV dilation, fenestrated atrial septum

Teitel – 12th International Neonatal and Childhood PVD Conference, March 2019

Summary

• Diagnostic value of cath

– pulmonary vascular resistance, “baseline” and minimal, can be accurately measured, and cannot be accurately estimated from echocardiography, even when pressure can be estimated

• corollary: can differentiate the impact of increases in pulmonary blood

flow versus vascular resistance on RV pressure estimated by echo

– can independently evaluate individual pulmonary venous anatomy and lobar pulmonary function (oxygenation and ventilation)

• Therapeutic value of cath

– can intervene on shunts when they are the source of elevated RVP – can intervene on pulmonary veins (if you are so pre-disposed)