|Topic:||26. Physiology/Pathophysiology: Pulmonary Vascular and Right Ventricular Health and Disease / Adult / Case Report / Pulmonary Circulation (PC)|
|Authors:||S.A. Suliman, M.M. Howsare, K. El-Kersh, M.P. Flaherty, J.S. Smith; Louisville, KY/US|
Pulmonary hypertension (PH) represents a heterogeneous collection of conditions classified into 5 groups according to pathology, pathophysiology and response to treatment. Right heart catheterization (RHC), is the gold standard method required for proper diagnosis and treatment.
Under usual circumstances a catheter is advanced in to the right atria, through the tricuspid valve into the right ventricle and finally into the pulmonary artery to obtain the hemodynamics
We present a case where a novel method was used to lead to the diagnosis of PH in our patient with a mechanical tricuspid valve.
We present a 59-year-old female with a history of scleroderma, tricuspid and mitral valve replacement, who had developed worsening dyspnea and lower extremity edema. She was referred to our PH center for evaluation of an abnormal echocardiogram.
During admission she underwent a PH work up, including a normal V/Q scan, transthoracic echocardiogram with an ejection fraction of 55% and normally functioning mechanical valves.
A routine RHC could not be carried out due to the concern of her mechanical tricuspid and mitral valves that would preclude passage of catheters from the right atrium to the pulmonary artery. A multidisciplinary approach with interventional cardiology allowed for an atrial trans-septal puncture with retrograde right heart catheterization from the pulmonary veins to be performed.
During the procedure a catheter [JS2] was fed into the right atrium where the mean pressure was measured at 35mmHg. Using intra-cardiac echo guidance a trans-septal puncture was performed using a BRK-1 needle inside an SLO catheter and then advanced into the left atrium where pressures were recorded as 31mmHg. The catheter was then exchanged for a Swan-Ganz catheter and advanced into the lower left pulmonary vein. The balloon was inflated and distal pulmonary artery pressure recorded at 74/52 with a mean PA pressure of 61mmHg and a transpulmonary gradient of30mmHg. Final diagnosis indicated severe pulmonary hypertension secondary to elevated left atrial pressures likely due to severe mitral stenosis.
Patients who may have underlying PH, yet have prosthetic mechanical right-sided valves are historically not candidates to undergo a RHC, making diagnosis and treatment of these patients a challenge. Performance of a trans-septal puncture to obtain retrograde right heart pressures via the pulmonary vein is rare, with no cases reported in the literature to date. Using this novel approach we hope to provide an alternative method to the diagnosis of patients with PH and a mechanical tricuspid valve.