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pulmonary heart disease andrew ying-siu lee, md,phd.

心臟病及保健 heart disease and health
Pulmonary heart disease
Andrew Ying-Siu Lee, MD,PhD.
(I) Pulmonary Hypertension
= mean pulmonary arterial pressure > 25mmHg at rest or = abnormal cellular proliferation (eg. smooth muscle hypertrophy, fibrosis, neovascularization), thrombosis and imbalance between vasoconstriction (angiotensin II, leukotrienes, serotonin, thromboxane etc) and vasodilation (bradykinin, endothelin, nitric oxide, prostaglandins etc) increased pulmonary vascular resistance  right heart failure  decreased cardiac output 心臟病及保健 heart disease and health
Causes and classification of pulmonary hypertension
1.
Pulmonary arterial hypertension:-
idiopathicfamilial associated with : collagen vascular ds, liver ds, portal hypertension, drug and toxin, thyroid ds, hemoglobinopathies associated with : pulmonary venous or capillary ds 2.
Pulmonary hypertension with left-sided heart disease:-
left-sided atrial or ventricular heart ds 3.
Pulmonary hypertension associated with lung disease or
hypoxemia:-

COPD, interstitial lung ds, sleep apnea, high altitude, 4.
Pulmonary hypertension due to chronic thrombotic and/or
embolic disease:-

thromboembolic obstruction of pulmonary arteriesnonthrombotic pulmonary embolism (tumor, parasites, foreign materials) 5. Miscellaneous (eg. sarcoidosis, compression of pulmonary vessels)
心臟病及保健 heart disease and health
Symptoms = dyspnea (most common),
fatigue, chest pain, syncope, pedal
edema, palpitation, cough,
hemoptysis, hoarseness, Raynaud
phenomenon, cyanosis, sudden death

Diagnosis = increased brain natriuretic peptide
chest CT or MRI = enlargement
of main pulmonary artery,
right ventricular hypertrophy,
decreased caliber of

peripheral pulmonary vessels
echocardiography
cardiac catheterization

心臟病及保健 heart disease and health
Severity of pulmonary hypertension:-
NYHA classificationhemodynamic values in cardiac catheterization  Treatment of pulmonary hypertension:-
oxygendiuretic, calcium blockers, inhaled or parental prostanoids, anticoagulation, digoxin, endothelin antagonist, phosphodiesterase inhibitor (eg viagra) surgery (heart-lung and lung transplantation, pulmonary thromboendarterectomy, atrial septostomy) 心臟病及保健 heart disease and health
Liver disease may develop pleural
effusions (hepatic hydrothorax), pulmonary vascular dilation with hypoxemia (hepatopulmonarysyndrome), pulmonary hypertension (from high cardiac output, or from increased pulmonary vascular resistance = portopulmonary hypetension) 心臟病及保健 heart disease and health
(II) Pulmonary embolism
Most pulmonary embolism result from thrombi
originated in pelvic or deep veins of leg (=deep
venous thrombosis DVT) embolize to pulmonary
arteries.

Risk factors of deep venous thrombosis and
pulmonary embolism :-
elderly, obesity, smoking, cancer,
surgery/immobilization/trauma/bed ridden, heart
disease (eg. heart failure), stroke, COPD, pregnancy,
oral contraceptives, hypercoagulable syndrome eg.
Sickle cell ds, protein C, S deficiency,
hyperhomocystenemia, polycythemia, thrombophilia,
thrombophlebitis, prior pulmonary embolism, central
venous instrumentation, postpartum, sepsis etc.

心臟病及保健 heart disease and health
massive pulmonary embolism increase right
ventricular wall tension decrease right coronary
flow and increase right ventricular myocardial
oxygen demand
myocardial ischemia, cardiogenic
shock, death.

massive pulmonary embolismrisk of cardiogenic
moderate to large pulmonary embolism right
ventricular hypokinesis but
normal blood pressure
small to moderate pulmonary embolismnormal blood
pressure and right
ventricular function
pulmonary infarctionunremitting chest pain, hemoptysis
paradoxical embolism stroke
心臟病及保健 heart disease and health
Diagnosis of deep venous thrombosis
tenderness, palpable cords, calf asymmetry, Homan’s sign = pain associated with active and/or passive dorsiflexion of foot.
 plasma markers eg. D-dimer, P-selectin ,  compression ultrasound of lower limbs 心臟病及保健 heart disease and health
Diagnosis of pulmonary embolism
Usually nonspecific. So suspicious particularly in
patients with risk factors
Symptoms eg. dyspnea, tachypnea (most common),
pleuritic pain or hemoptysis, circulatory collapse,
cyanosis, diaphoresis, cough, palpitation, DVT
symptoms (calf or thigh pain and swelling), low
grade fever

Electrocardiogram = S1Q3T3, S1S2S3, right axis
deviation, RBBB, right atrial enlargement, right
ventricular hypertrophy

Chest X-ray = oligemia, pleonemia of the obstructed
lung, dilated hilar arteries, elevated hemidiaphragm,
dilated pulmonary artery trunk, pleural effusion,
atelectasis, infiltrate

心臟病及保健 heart disease and health
Arterial blood gas = low PO2
low alveolar-arterial oxygen difference (< 20 mmHg)
= 150 – 1.25 (PCO2) – PO2
Echocardiogram = 1. visualization of emboli in right
atrium or ventricle, or pulmonary artery;
2. right ventricular enlargement or dysfunction
Ventilation-perfusion lung scan=large, wedge-shaped,
pleural-based perfusion defects in areas that
ventilate normally and are radiographically
SPECT perfusion lung scan
Spiral chest CT or MRI angiography
Pulmonary angiography = definitive diagnosis for
pulmonary embolism
心臟病及保健 heart disease and health
Prevention and treatment of deep venous thrombosis and
pulmonary embolism

 Thrombolytic agents (tPA 100 mg intravenously for 2 hours) after spiral CT (confirmation of pulmonary embolism) in hemodynamically unstable patients (if no contraindication)  In massive ileofemoral deep venous thrombosis at risk of limb gangrene, catheter-directed thrombolytic agent administered directly into the thrombus 心臟病及保健 heart disease and health
Inferior vena cava filter indication:-
1. anticoagulants contraindicated
2. pulmonary embolism (not DVT) recurrence in

of adequate anticoagulants
3. severe pulmonary embolism that any recurrence
may be fatal
Catheter-tip embolectomy for acute massive
pulmonary embolism
Surgical pulmonary embolectomy for massive
pulmonary embolism, hemodynamically unstable
patients despite heparin and resuscitative efforts,
failure or contraindication of thrombolytic therapy

Pulmonary thromboendarterectomy for patients with
chronic thromboembolic pulmonary hypertension
(due to incomplete resolution of pulmonary
embolism
pulmonary hypertension right heart
failure
death)
心臟病及保健 heart disease and health
(III) Cor pulmonale
= right ventricular hypertrophy and dilatation secondary to pulmonary hypertension caused by lung parenchymal disease pulmonary fibrosis, high altitude, sleep apnea, chest wall deformity etc.) and/or pulmonary vasculature (eg. pulmonary thromboembolism, pulmonary veno-occlusive disease, pulmonary vascular tumors and malformations, pulmonary vasculitis etc) , unrelated to left heart.

Source: http://home.educities.edu.tw/leeyingsiu/engslide-cor-heartdisease.pdf

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