8. Branching of pulmonary artery
• Conventional branches
-oblique angle, coincident airway
• Supernumerary branches
- 90*angle, unaccompanied
-increase as the arterial tree branches
-’V’ shaped baffle at origin
- more sensitive to 5-HT
13. Bronchial artery
• Muscular arteries
• Thick wall reflect the high blood pressure of
the aorta and intercostal arteries
• Double elastic lamina, outer indistinct
• Ends at the level of respiratory bronchioles
• Anastomose with the branches of
the pulmonary arteries
21. Pulmonary vascular lesions
• Cellular composition of pulmonary vascular
walls, if abnormal, is described as pulmonary
vascular ‘lesions’
• Pulmonary hypertension
• Vasculitis
24. Burden of disease
Primary PAH Prevalence- 15-30 cases per million
Mean age of diagnosis 36 years -Mostly young women (F:M
ratio:2-9:1)
Secondary to other diseases : varies
– 6-60% in Scleroderma
– 20% in RA
– 30-70% in COAD
– 20-40% in sickle cell disease
Lack of systematic studies in India
Am J Respir Crit Care Med. 2006;173:1023–30
25. Pulmonary Circulation
• Normal Pulmonary arterial pressure:24/9
mmHg
• Mean Pulmonary arterial presure:15
mmHg
• Distensible low pressure system
• Pulmonary vascular resistance 1/10th of
systemic vascular resistance
26. Old definition
• Pulmonary arterial hypertension (PAH) was defined by
-Mean PAP >25 mmHg at rest or >30 mmHg
with exercise
-PAWP ≤15 mmHg and
-PVR >3 mm Hg/L/min (Wood units)
ESC guidelines. Galie N et al. European Heart Journal (2004) 25, 2243–2278
27. New Definition
• Pulmonary hypertension (PH) is defined as a resting
mPAP≥25 mmHg at right heart catheterization (RHC)
• PAH is defined as a subgroup of PH with:
-PAWP ≤15 mmHg (Pre‐capillary PH)
-Normal or reduced cardiac output
-Absence of other causes of pre‐capillary PH
(PH due to lung diseases, CTEPH, or other rare
diseases)
Badesch et al. J Am Coll Cardiol 2009;54:S55–66
31. Clinical features
• Dysponea on exertion
• Fatigue
• Palpitations
• Chest Pain
• Signs of Right heart Failure: Elevated JVP
Hepatomegaly
Pedal Edema
• Cyanosis
• Syncope
32. Clinical signs
• Left parasternal lift
• Loud P2
• Right Ventricular S4
• Raised jugular a and v waves
• Hepatojuglar reflex
• Pulsatile Liver
• Holosystolic murmur increasing with inspiration
• Early diastolic murmur (Graham Steel Murmur)
• Early systolic click
• Ejection systolic murmur
• Narrow splitting of 2nd heart sound
33. WHO FC Symptomatic profile
Class I Patients with pulmonary hypertension but without resulting limitation of
physical activity. Ordinary physical activity does not cause dyspnoea or
fatigue, chest pain or near syncope
Class II Patients with pulmonary hypertension resulting in slight limitation of
physical activity. They are comfortable at rest. Ordinary physical activity
causes undue dyspnoea or fatigue, chest pain or near syncope
Class III Patients with pulmonary hypertension resulting in marked limitation of
physical activity. They are comfortable at rest. Less than ordinary activity
causes undue dyspnoea or fatigue, chest pain or near syncope
Class IV Patients with pulmonary hypertension with inability to carry out any
physical activity without symptoms. These patients manifest signs of right
heart failure. Dyspnoea and/or fatigue may even be present at rest
WHO Functional Class
Barst RJ et al. J Am Coll Cardiol 2004
34. Investigations
• Chest Radiograph
• Electrocardiogram
• Arterial blood gas
• PFT
• Connective Tissue Disease Work Up
• HIV Testing
• Polysomnography & Overnight oximetry
• Echocardiography
• Ventilation Perfusion Scan
• Right Heart Catheterisation
• CT & MRI Chest
36. Electrocardiogram
– Right ventricular hypertrophy or strain
– Chronic right ventricular overload:
• Right axis deviation
• R wave/S wave ratio greater than one in lead V1
• Incomplete or complete RBBB
• Increased P wave amplitude in lead II (P pulmonale) due to right atrial enlargement
37. Pulmonary Function Test
• Differentiates between Obstructive and
Restrictive Lung Disease
• Assessing diffusion capacity
38. Echocardiography
• Transthoracic echocardiography provides several variables which
correlate with right heart haemodynamics including PAP, and
should always be performed in the case of suspected PAH.
• TR Pressure Gradient Difference between Right
Ventricular Pressure and Right Atrial Pressure
40. Estimation Of Systolic PAP By Echo
• Simplified Bernoulli Equation
Peak Tricuspid Regurgitation Pressure Gradient=
4 x (tricuspid regurgitation velocity)²
• PA systolic pressure =Tricuspid regurgitation pressure
gradient +Estimated right atrial pressure
• Right Atrial Pressure :
Estimation based on the diameter and respiratory variation
of the inferior venacava
Fixed value of 5 or 10 mmHg is taken.
EXAMPLE,
TRV=3m/s,Calculated TRPG»4x(3)²=36 mmHg
PASP=36 + 5 (Right Atrial Pressure)=41 mmHg
41. Estimation Of Mean PAP
• Mean PAP=0.61 PA systolic pressure + 2 mmHg
EXAMPLE,PASP=41 mmHg(TRV=3m/s)
Mean PAP=0.61x41 +2=27 mmHg
• This could allow the use of Doppler measurements for
approximate estimation of pulmonary arterial pressure.
43. Cardiac MRI
• Emerging Modality
• Provides Direct Evaluation
1.RV size, morphology, and function
2.Allows non-invasive assessment of blood flow including
stroke volume.
3.Distensibility of PA
4.Cardiac Output
J Am Coll Cardiol 2008;51:750–757.
44. Serologic Testing
• Selective testing of blood samples is appropriate in known or
suspected PAH
• 40% of patients with IPAH have increased ANA
• Anticentromere antibodies are typically positive in lcSSc as are
positive ANA including U3-RNP, B23, Th/To, and U1-RNP while
in dcSSc, U3-RNP is usually positive
• Anticardiolipin antibodies have been associated with PAH in SLE
• HIV serology and Thyroid Function
Clin Chest Med 34 (2013) 665–681
45. V/Q scan
• V/Q lung scanning has a higher sensitivity than CT scanning in
detecting CTEPH with a sensitivity of 90%-100% and a specificity of
94%-100 % and is still the diagnostic test of choice for suspected
CTEPH
Clin Chest Med 34 (2013) 665–681
47. Right heart catheterization
• Gold standard for diagnosis
• Invasive procedure
• Available in few centres
• Usefulness:
Confirm the diagnosis of PAH
Assess severity of haemodynamic impairment
Test the vasoreactivity of pulmonary circulation
56. Atrial septostomy
In intractable right-heart failure atrial septostomy
improves functional status and hemodynamics
Useful when added to medical therapy
Can be used as bridge to lung transplantation
57. Lung transplant
Should be considered in PAH patients with advanced
disease refractory to medications
Currently, in 3.2% of lung transplants the indication is
idiopathic PAH
The post-transplant 5-year survival rate is about 50%
58. Prognosis
• Median survival of Idiopathic PAH- 2.8
yearsYEAR SURVIVAL RATES
1 68%
3 48%
5 34%
Survival in terms of Etiology
CHD>IPAH>CTD>HIV
Chest. 2004;126:78S–92S
84. Media
• Smooth muscle cell hypertrophy
• Muscularized arteries, precapillary vessels
• Normally 10–15% of the outside diameter of
muscularized pulmonary arteries
• PAH it approaches 30–60% of the outside
diameter
• Cigarette smoke with no evidence of PH
85. Media
• Hypertrophy and hyperplasia
• Cell proliferation and inhibition of cell
apoptosis
• BMPR2, decreased activated form of smad 1,
serotonin, increased PDGF receptor (PDGFR)-β
expression, tenascin, MMP-2
• Decreased apoptosis
86. Adventitia
• Fibroblasts
• 15% of the external diameter of pulmonary
arteries larger than 50 μm in diameter
• In IPAH arteries, adventitial thickness 28% of
artery diameter, predominantly due to
collagen deposition
• Vasa vasorum in medium size vessels absent
87. Adventitia
• Biological processing center
• Injury sensing tissue
• Seat of vascular progenitor cells
• sense alterations in their redox status
88. Cell Smooth muscle cells EC Matrix Endothelial cells
Lesion Eccentric Concentri
c
Fibrotic Plexiform Concentri
c
Dilation/a
ngiomatoi
d
Normal
PAP
Yes No No No No No
Mild/Mod
erate PH
Yes No Yes No No No
Severe PH Yes Yes Yes Yes Yes Yes
Table 1
Intima Remodeling.
Pathology of Pulmonary Hypertension
Clin Chest Med. 2007 Mar; 28
89. Cell Smooth muscle cells EC Matrix
Normal PAP Yes
*
No
Mild/Moderate PH Yes Yes
Severe PH Yes Yes
Table 2
Medial Remodeling.
Pathology of Pulmonary Hypertension
Clin Chest Med. 2007 Mar; 28
94. Plexogenic arteriopathy
• Earlier plexiform arteriopathy
• Female > male
• Endothelial cell proliferation
• Factor VIII, CD31
• MIB-1 index high
95.
96.
97. Thrombotic arteriopathy and chronic
thromboembolic pulmonary hypertension
(CTEPH)
• Pulmonary hypertension after acute pulmonary
thromboembolism, arising immediately or insidiously within
the first 2 years after the initial thromboembolic event
• Silent recurrent pulmonary thromboembolism(30%)
102. Hypoxic arteriopathy
• High altitudes
• Pulmonary circulation responds to a low
oxygen tension with vasoconstriction
• Chronic mountain sickness(Monge disease),
i.e. polycythemia and hyperviscosity
103.
104.
105. Congestive vasculopathy
• Chronic elevation of the pulmonary venous blood
pressure results in a distinct set of adaptive
pulmonary vascular changes, termed congestive
pulmonary vasculopathy
• Elevated wedge pressure (> 15 mmHg)
• Arterialization of veins
• Localization in the interlobular septa
• Substantial thickening of the arterial adventitia
• Brown induration of the lung
106.
107. Pulmonary veno-occlusive disease and
pulmonary
capillary hemangiomatosis
• Decreased diffusion capacity out of proportion to a
mild elevation of pulmonary arterial pressure
• Capillary congestion prominent(PCH)
• 5–10% of all PAH initially diagnosed as idiopathic
• Vasodilator drugs, such as prostacyclin, are usually
less effective
108. • PVOD now POV( pulmonary occlusive
venopathy)
• PCH now PM(pulmonary microvasculopathy)
• Rare causes of unexplained pulmonary
hypertension
• Treatment with vasoactive agents C/I and may
even be life-threatening
109. Pulmonary occlusive venopathy
• Extensive and diffuse occlusion of pulmonary
venules and veins of various sizes
• Solid or eccentric with multiple
lumina(recanalization)
• Arterialization of venules
• Calcium-encrusting elastic fibers in the walls
of veins or adjacent alveoli
• d/d chronic passive venous hypertension
110. Pulmonary occlusive venopathy
• Hemosiderin are found within the cytoplasm
of alveolar macrophages and type II
pneumocytes , interstitium
• BAL hemorrhage
• Plexiform lesions and fibrinoid arteritis are not
seen
111. Pulmonary microvasculopathy
• Engorged and prominent capillaries
• Line both sides of the alveolar walls
• Invade pulmonary interstitium, vessels, and, less
commonly, airways
• Microvessels can form glomeroloid tufts or
nodules
• Pulmonary hemosiderosis
• Etiology can be neoplastic, unknown angiogenic
stimuli