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Hey everyone, we're moving on with pulmonary hypertension.

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But we're going to dive a little deeper into the use

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of the CT in first identifying it

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and then trying to find potential etiologies for

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it. So we'll talk about the

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role because the CT pulmonary angiogram does have a pretty significant

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role in the workup and treatment and guiding

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therapy for patients with pulmonary hypertension.

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We'll go through some of the Imaging clues of the etiologies.

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The chronic thrombolic disease will

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cover in the next session.

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And again, we're going to emphasize the post-capillary etiology

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needs to be mentioned in the

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impression if you think that's what it is.

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so

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pulmonary artery hypertension, when you look at it, we've covered

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some of this you're looking for evidence of pulmonary

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hypertension as they're dilation and contrast reflux into

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the inferiorating.

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As the increased pulmonary artery diameter again. I

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like using the aorta.

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And the pulmonary artery they should be the same pulmonary already

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looks a lot bigger.

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Usually that'll be an indication of pulmonary hypertension.

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Greater than 3.5 in my opinion or 3.5

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or greater is probably pulmonary hypertension. Secondary

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cardiac changes. You want to look for

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right heart dilation, which would indicate tricuspid regurgitation

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and any ventricular dilation or hypertrophy greater

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than 4 millimeters involving the right ventricular anterior

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wall.

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You'll look for bronchial artery hypertrophy and any

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Mosaic lung attenuation.

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So this patient has pretty much all the

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findings that you will see in pulmonary hypertension Advanced. The

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pulmonary artery is actually 4.2. You

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can see it's larger in diameter than the East sending aorta.

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There is the Mosaic lung attenuation present.

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The right atriums dilated right ventricles dilated

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the right ventricle free wall greater than four millimeters.

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There is contrast reflux into the inferior vena

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cava, which is dilated.

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You can see that beautifully here and you can even see a little

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tiny PFO.

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Another patient with pulmonary hypertension very severe.

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You can see the atrial septum Boeing.

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All right, that's actually kind of ballooned in but no

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identifiable PFO again, you'd see

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this hypertense contrast crossing over if there was there.

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So when you're looking at these you want to try to figure out okay the habit.

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What's the possible etiology is a primary pulmonary primary

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cardiac or intrinsic vascular and

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more than one of these may be

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present. So you want to be evaluating all three?

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So 57 year old was Scleroderma hypertens contrast

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reflecting the Imperial.

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Right ventricles dilated straightening an interventricular

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septum as Pacers small pericardial Fusion even

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has the crest syndrome of esophageal dismality

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and reflux.

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Now in the lungs they have fibrosis that

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is fairly characteristic for fibrotic nsip.

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So what would be the likely etiology here

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for scleroderma? Well chronic hypoxia

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could be the other is that there's an

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intrinsic vascular disease commonly seamless Scleroderma

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and pulmonary hypertension. In fact pulmonary hypertension

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from Scleroderma is often resistant to therapy. So

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there's a couple of things here and if

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you didn't stop looking

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You also found that the patient had an ASD so they

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had three things going on.

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So in this patient pulmonary artery well much bigger.

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Why isn't the aorta a pacified

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hmm that tells you what? Well, there's

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slow forward flow. Maybe it's from the pulmonary hypertension.

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But when you look at the heart, it's a bit

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dilated. There's very little opacification left ventricle moderator band

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very well seeing

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this person has a reduced cardiac output and

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a little bit of set the lines here from maybe some chronic.

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Pulmonary venous hypertension that needs to

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be mentioned right? But in addition they also have bilateral bronchomalacia

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and generalized air trapping from

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chronic hypoxia. So likely to etiologies

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here.

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That affects the therapy right that completely affects

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the therapy.

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This is a patient with uip remember that with Advanced pulmonary

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fibrosis. You always want to be checking the pulmonary artery. Remember

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there were three complications with these people that you want

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to be looking for any new nodule which will be cancer any new

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ground glass without evidence for five grosses. But the

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one that commonly just kind of goes under the radar

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is the pulmonary artery and this is the

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patient pulmonary artery here three years later. It clearly is

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dilated. There's pulmonary hypertension. They're

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coming in to see the ER in the clinician more

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often this needs to be addressed.

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30 year old with increased dyspnea bilateral lower

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extremity swelling you get a radiograph

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main pulmonary artery is large right? Atrial

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Chambers large about halfway up to

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the Highland is usually the indication.

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CTA was done which is appropriate pulmonary arteries

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markedly in large, but not just that look at

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the aorta small it is what's up with

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that? And there's all this bronchial artery hypertrophy here.

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Massive ripe ventricular hypertrophy straightening these

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metricular septum. You know, that's Advanced that goes along with

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greater than 67 70 millimeters of

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mercury.

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What's the etiology here the patient had a large

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PDA?

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Which helps explain why the aorta was smaller?

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Right because there's less flow going in aorta. It

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doesn't tend to dilate or develop the

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same diameter.

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another patient

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this patient has large pulmonary arteries.

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And there is in fact a large ASD

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again small aorta.

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And you can see the blood the underpassed by Blood kind of

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scooting right on through that ASD.

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And there's pretty significant right ventricular hypertrophy here.

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Patient who's got dyspnea and recurrent can

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just heart failure episodes and in pulmonary

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arteries are enlarged here.

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Yeah, maybe there right ventricle looks a little big.

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When you do the CT what you

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find is right ventricular, hypertrophy here.

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And you got evidence of hydrostatic pulmonary

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edema.

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Small plural effusion septalines the ground glass

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looks like in just a heart failure, but the left ventricle chamber

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looked normal. They did a capillary wedge

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pressure and it wasn't increased.

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but boy, you still have to mention the possibility

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here of a post capillary cause

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So what is the possible diagnosis well, in

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this case, it was pulmonary Vino occlusive disease.

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Now that is a post-capillary. The left

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ventricle will be normal.

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Well, why was the wedge pressure normal?

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This is where it gets tricky pulmonary being

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occlusive disease actually involves the

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sclerosis a very very small.

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post capillary venules

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And when people take this pulmonary artery catheter

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and they're measuring the wedge pressure. They actually are

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reflecting the vessels of the similar size

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and larger on the other side of the capillary bed.

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So since the disease occurs, so close

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to capillary bed. It is definitely possible that

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the pulmonary capillary wedge pressures will be

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normal in the setting of pulmonary Vino inclusive disease.

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So with that CT is

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a Mainstay of pulmonary hair pretension specialist

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CTA.

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You want to be looking for the presence or absence and have the pulmonary artery

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on your search pattern remember early permanent

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hypertension is often silent clinically and subtle

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radiographically and by Imaging

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if it's there or if it's known try to assess primary

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lung intrinsic vascular or if

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it's a possible post capillary.

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Remember therapy is different for post capillary.

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Thank you very much.