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Forum Name: Valvular Heart Diseases

Question: Pulmonary Hypertension


 Alice - Mon Feb 14, 2005 11:55 am

Thank you for taking my question. I live in a very small town. I have had two recent echocardiograms with Doppler and color flow at one hospital. Also a pulmonary function test at a second hospital: results follow for all three tests. Now I have been advised to have a TEE. Could you give me your impression, from the results of the echos and the PFT, whether this would appear the next step to be taken and why?

1st REPORT November 2004 Echocardiogram with doppler and color flow:
1.Aortic root: normal in size
2.Aortic valve: no evidence of aortic stenosis or aortic insufficiency. Left atrium normal in size.
3.Mitral valve: mild mitral regurgitation. Mitral valve appears to be anatomically normal.
4.Left ventricle: normal in size. Probably normal wall motion not all myocardial segments are optimally visualized. The estimated ejection fraction is 60%.
5.Right ventricle: normal.
6.Right atrium: normal.
7.Tricuspid valve: trace tricuspid regurgitation. Estimated pulmonary artery pressure is 68 mmHg. Moderate pulmonary hypertension.

2ND REPORT January 2005 Echocardiogram with Doppler and color flow:
1.Aortic root normal in diameter.
2.Aortic valve thickened, trileaflet, without restriction. No significant aortic insufficiency.
3.Left atrium normal in size.
4.Mitral valve thickened without restriction. Moderate (2+) mitral regurgitation.
5.Left ventricle normal in size & function. Normal left ventricular systolic function with an ejection fraction of 58% and no wall motion abnormalities.
6.Right ventricle is mildly dilated. There is mild right ventricular hypertrophy. Normal right ventricular function.
7.Right atrium is mildly dilated.
8.Ttricuspid valve thickened without restriction. There is mild (1+) tricuspid regurgitation. The estimated pulmonary artery systolic pressure is 55 mm Hg.
Other findings: no pericardial effusion or intracardiac shunts.
IMPRESSION: Normal biventricular systolic function. Moderate mitral regurgitation. Mild tricuspid regurgitation. Mildly dilated and hypertrophied right ventricle. Moderate pulmonary hypertension.

PFT Conclusion:
1. Mild restrictive ventilatory defect. Question is this is related to the patient's body habitus/obesity ( height 65 inches, weight 134 lbs). Also noteworthy is diagnosis given for complete pulmonary function test - pulmonary hypertension - question findings related to same. Clinical correlation is suggested.
2. Abnormal at rest arterial blood gas and pH determination with evidence of moderate hypoxemia. Patient's PaO2 was 26 mmHg less than that calculated for her age and position.

Once again, thank you.
Alice
 Dr. Yasser Mokhtar - Mon Feb 14, 2005 11:13 pm

User avatar Dear Alice,

Knowing the results of any test and try to figure out the diagnosis of a case is not enough. A history and a physical exam are the most important steps to do as they direct the course of investigations and which tests to do.

Why did you have the echo to begin with? What are the symptoms that you were suffering from?

i think that the tee was requested to look for intracardiac shunts that were not visualized on transthoracic echo, it is not an unreasonable thing to ask.

Pulmonary hypertension can be primary (no cause is found) or secondary (a cause is found). Causes of pulmonary hypertension are various and a work-up (try to find out what is the cause) for pulmonary hypertension does not just include a pulmonary function test but many other tests as well.

Causes of secondary pulmonary hypertension include:
1. Chronic obstructive pulmonary disease.
2. Obstructive sleep apnea.
3. Disorders of the chest wall, such as kyphoscoliosis.
4. Pulmonary embolism.
5. Collagen vascular diseases such as scleroderma and crest syndrome.
6. Other connective tissue disorders such as rheumatoid arthritis and systemic lupus erythematosus.
7. Cardiac causes:
a. Mitral valvular disease.
b. Constrictive pericarditis.
c. Left atrial myxoma.
d. Aortic stenosis.
e. Congestive heart failure and dilated cardiomyopathy.
f. Intracardiac shunts.

Your echo did not show any left heart abnormality, still a tee at this point is not unresonable.

i would recommend that you be tested for:
1. Obstructive sleep apnea with a sleep study.
2. Pulmonary embolism.
3. Blood tests for the autoimmune diseases.

i think that you need to be seen by a pulmonologist as soon as possible to be evaluated.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 Alice - Tue Feb 15, 2005 9:11 am

Thank you for taking the time to reply. In reply to your questions:

I had the echo when I was admitted to hospital with SOB and very low BP. A first experience of this. I spent 4 nights there where many different tests were performed. One result given on my discharge from hospital was that I had possibly had a vasovagal episode. However, the results of the first echo were only received FIVE days after my discharge, where moderate pulmonary hypertension was indicated and my primary healthcare provider notified me of this. The second echo was asked for after I had seen the area cardialogist a month or so later; likewise the TEE has been recommended.

I had two separate fainting episodes previous to this trip to the ER; these were put down to a gastric flu. The fainting sensation would bring on either vomiting or diarrhoea.

I am waiting for results of tests for autoimmune diseases, and some others that were done at the same time. I also did a stress test, which I seemed to do quite well on, though I only managed 4.56 minutes and arrmythmia with exercise result : Sinus tachycardia. I don't quite understand if that is good or bad!

You referred to kyphoscoliosis. As per notes from my hospital stay 'Thoracic spine demonstrated degenerative changes at T6-7 and T8-9, with upper scoliosis.) Does that have any relevance to kyphoscoliosis?

I am not quite sure what an intracardiac shunt is, and not too much wiser through looking on the net?

I suppose that I am worried that time is passing and I should be seeing a PH specialist, rather than slowly going through these tests.

Thank you again.

Alice
 Dr. Yasser Mokhtar - Tue Feb 15, 2005 9:51 pm

User avatar Dear Alice,

Thank you very much for the update.

Fainting episodes or syncope usually initiate an extensive work-up to try and find out the cause. In many cases, a specific cause is not found.

In your case, i can't really tell what is causing these fainting episodes because i will obviously need more information but to complete the work-up for syncope, if these tests were not done, i would recommend that you do them even though they might turn out negative. A holter monitor (24 hours cardiac monitor) to monitor your heart rhythm for 24 hours. A carotid/vertebral artery doppler. A test called tilt table test (that evaluates your blood pressure response to standing for a long time and how your body handles it). If there is any indication or suspicion that these might be due to seizures, a ct scan of the brain and an eeg are recommended.

Sinus tachycardia during the stress test means that your heart was beating normally but at a faster rate which is what happens to any person who exercises.

The kyphoscoliosis that i referred to is the severe from of the disease that is seen in some patients and can cause restriction of the chest movements.

An intracardiac shunt is an abnormal connection between different chambers of the heart between which there is no normal connection, example include an atrial septal defect, an abnormal connection between the right and left atrium.

You have been going the right way, there is no doubt about that, but i still think that you need to see a pulmonolgist and i would recommend sooner rather than later because most probably if all of the tests you are waiting for come back normal, this is going to be the next step. So, discuss this with your doctor and see what he/she thinks.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.

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