RVAD for severe PAH?

[DarkProtonics]

Are RVADs used for severe IPAH where right heart failure has developed, despite treatment w/ iloprost and sildenafil? They make percutaneously-implanted LVADs, are there percutaneously-implanted RVADs?

Isn't the only true cure for IPAH a heart-lung transplant?

Could cutting away the scar tissue in the pulmonary artery by cutting balloon angiolasty, followed by paclitaxel-eluting stenting and oral sildenafil be a possible adjunct to inhaled iloprost?

Think that once oral beraprost is FDA-approved, they'll market a combined beraprost/sildenafil pill? Looks very convient for pts...only one pill to remember.

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[howelljolly]

Know why there are no responses?

You have to ask a pulmonologist.

*turf waaaaaaaaarrrrr!*

 

[DarkProtonics]

Know why there are no responses?

You have to ask a pulmonologist.

*turf waaaaaaaaarrrrr!*

PAH is a cardiac disease w/ pulmonary components! It's almost always dx'ed by invasive cardiologists!

 

[howelljolly]

Is that so?

Surely you jest.

http://www.uchsc.edu/pulmonary/introduction/clinics.shtml#ph

http://www.hopkinsmedicine.org/pulmonary/

http://pulmonary.stanford.edu/fellowships/

http://www.bethisraelgme.org/PulmonaryAndCriticalCareFellowship.asp

http://medicine.mc.vanderbilt.edu/Templates/TemplateDivision.aspx?qs=cElEPTk=

http://www.intmed.vcu.edu/home/fellowships/pulmonary.html

Turf Waaaaaaaarrrrrrrrrrr!!!

 

[DarkProtonics]

Is that so?

Surely you jest.

http://www.uchsc.edu/pulmonary/introduction/clinics.shtml#ph

http://www.hopkinsmedicine.org/pulmonary/

http://pulmonary.stanford.edu/fellowships/

http://www.bethisraelgme.org/PulmonaryAndCriticalCareFellowship.asp

http://medicine.mc.vanderbilt.edu/Templates/TemplateDivision.aspx?qs=cElEPTk=

http://www.intmed.vcu.edu/home/fellowships/pulmonary.html

Turf Waaaaaaaarrrrrrrrrrr!!!

But there are thousands of articles in JACC on PAH! Esp. on it's treatments. And why is pulmonary hypertension also studied by Mayo Clinic's heart failure advanced cardiology fellows: http://www.mayo.edu/msgme/cardio-heartfailure-rch-curriculum.html.

Btw, is there any difference b/w heart failure and heart transplantation advanced fellowships? I can't seem to figure out the difference b/w Mayo Clinic's Heart Failure advanced fellowship, and the Cardiology Transplant advanced fellowship.

 

[howelljolly]

OK, now I'll bite

And, Im not a Fellow... Geez. Im not even a doctor.

PAH is not diagnosed by Interventional (not invasive) cardiologists. There are red flags on physical exam, 2D echo, EKG, and chest x-ray that should get anyone thinking about it. And the 2D echo will give you a pretty stinkin' good indication of whats going on... and thats non-invasive. If you want to go for a pulmonary artery cath, a pulmonologist can do that too. The diagnosis can be made by whosoever feels inclined.

I could easily argue that PAH is a pulmonary vascular disease which can have cardiac manifestations. And, there are a number of pulmonary vascular diseases, this is just one of them. Why woud this one go to cardiology? "Cor Pulmonale!" you say? Yes! Pulmonale... Pulmonale.... Pulm... anyway.

As far as clinically... the disease is rare, and academic medical centers pretty much see most of it. Whether the disease is managed by Cardiology or Pulmonology depends on the institution. I gave you six examples of where it happens to be under Pulmonology. Sometimes it changes... It recently moved from Pulm to Cardio at U of MD. Its probably going to be an interdisciplinary approach anyway.

There are articles on PAH everywhere, in the JACC, CHEST, wherever.... Last I checked, whoever wants to study it can do so.

So, thats that.

Different fellowships are different. Some offer experience with transplant, and some dont. Some offer experience with PAH, and some dont. Some have more procedural training than others. Some offer a lot of research experience, and some dont. When the times comes, you'll know whats important to you, and you'll choose your fellowship with that in mind

Similarly, individual clinical departments are different.

Those advanced fellowships you mentioned are post-doc clinical fellowships that are usually for really smart folks who are in academic medicine. They are designed by the institution itself, so they can have whatever curriculum they want. I didnt look into those particular fellowships myself, but heart failure vs. transplant...?

To address you initial questions: Google it.

1. I found a case report of a RVAD being effective in secondary PAH.

2. Depends on what you call a cure. I dont know if extending someones expected 2.5 year survival of PAH, to a 40% 5-year survival in an immunocompromized state post heart-lung transplant is really a cure. Im not saying that it isnt. Im saying I dont know.

I dont have the foggiest idea of what youre talking about in the other two statements.

Youre lucky im on vacation and bored out of my skull. Most individuals dont want to come home from the hospital and do homework.

 

[DarkProtonics]

OK, now I'll bite

And, Im not a Fellow... Geez. Im not even a doctor.

PAH is not diagnosed by Interventional (not invasive) cardiologists. There are red flags on physical exam, 2D echo, EKG, and chest x-ray that should get anyone thinking about it. And the 2D echo will give you a pretty stinkin' good indication of whats going on... and thats non-invasive. If you want to go for a pulmonary artery cath, a pulmonologist can do that too. The diagnosis can be made by whosoever feels inclined.

I could easily argue that PAH is a pulmonary vascular disease which can have cardiac manifestations. And, there are a number of pulmonary vascular diseases, this is just one of them. Why woud this one go to cardiology? "Cor Pulmonale!" you say? Yes! Pulmonale... Pulmonale.... Pulm... anyway.

As far as clinically... the disease is rare, and academic medical centers pretty much see most of it. Whether the disease is managed by Cardiology or Pulmonology depends on the institution. I gave you six examples of where it happens to be under Pulmonology. Sometimes it changes... It recently moved from Pulm to Cardio at U of MD. Its probably going to be an interdisciplinary approach anyway.

There are articles on PAH everywhere, in the JACC, CHEST, wherever.... Last I checked, whoever wants to study it can do so.

So, thats that.

Different fellowships are different. Some offer experience with transplant, and some dont. Some offer experience with PAH, and some dont. Some have more procedural training than others. Some offer a lot of research experience, and some dont. When the times comes, you'll know whats important to you, and you'll choose your fellowship with that in mind

Similarly, individual clinical departments are different.

Those advanced fellowships you mentioned are post-doc clinical fellowships that are usually for really smart folks who are in academic medicine. They are designed by the institution itself, so they can have whatever curriculum they want. I didnt look into those particular fellowships myself, but heart failure vs. transplant...?

To address you initial questions: Google it.

1. I found a case report of a RVAD being effective in secondary PAH.

2. Depends on what you call a cure. I dont know if extending someones expected 2.5 year survival of PAH, to a 40% 5-year survival in an immunocompromized state post heart-lung transplant is really a cure. Im not saying that it isnt. Im saying I dont know.

I dont have the foggiest idea of what youre talking about in the other two statements.

Youre lucky im on vacation and bored out of my skull. Most individuals dont want to come home from the hospital and do homework.

That answer's good enough for me.

 

[gutonc]

Could cutting away the scar tissue in the pulmonary artery by cutting balloon angiolasty, followed by paclitaxel-eluting stenting and oral sildenafil be a possible adjunct to inhaled iloprost?

Haven't we already discussed this one? PAH is not a disease of the main pulmonary artery, it is a disease of the arterial pulmonary circulation. You can't stent the entire arterial bed and, assuming you're not mm away from obstructing, opening up the big pipe when all the little hoses are nearly clogged won't get you much benefit.

 

[howelljolly]

I was gonna say, there no way Im going to let anyone try to get into my pulmonary circulation with a cutting angioplasty. But I ignored the whole idea because it's to painful to think about. How are you going to do an angoplasty through ALL of this?

Or this

 

[DarkProtonics]

I was gonna say, there no way Im going to let anyone try to get into my pulmonary circulation with a cutting angioplasty. But I ignored the whole idea because it's to painful to think about. How are you going to do an angoplasty through ALL of this?

Or this

I will try!

 

[tibor75]

No, it won't work. As somebody said, you still have high PA pressures. The PA bed won't be "ready" for the massive increase in RV cardiac output that a RVAD supplies and you will develop pulmonary hemmorhage.

And, FYI, in quite a few places PH is handled by cardiologists.

 

[DarkProtonics]

No, it won't work. As somebody said, you still have high PA pressures. The PA bed won't be "ready" for the massive increase in RV cardiac output that a RVAD supplies and you will develop pulmonary hemmorhage.

And, FYI, in quite a few places PH is handled by cardiologists.

That wouldn't be good...what about iloprost, sildenafil, and if that wasn't enough, an RVAD?

 

[grendelsdragon]

That wouldn't be good...what about iloprost, sildenafil, and if that wasn't enough, an RVAD?

No offense, but this is nonsensical word salad.

Regarding who takes care of pulmonary hypertension, the trajectory has been more and more cardiologists. The reason is because the doctors who take care of any given illness is driven be the referral base and who can do the procedures. Pulmonary hypertension is most often diagnosed by echocardiogram (a procedure that is cardiologist-dominated) and right-heart catheterization (a procedure most often done in the cath lab). The ECHO calculates pulmonary pressures based upon a modified Bernoulli equation using tricuspid regurgitation velocities and visual appearance of the IVC. In cath, we directly measure pulmonary pressures. Additionally, in the ECHO and cath lab, further data can be obtained to ascertain the etiology of pulmonary hypertension (primary or secondary). In the cath lab, vasodilator stimulation can also be attempted. Pulmonologists, as you might gather, have less and less access to these type of resources over time.

 

[howelljolly]

Thanks doc, but you had to go and encourage him, didnt you....

Given that the procedures indicated for PAH are on the cardiology side of things, what role does/will pulmonology have in the treatment of this patient population?

 

[tibor75]

Thanks doc, but you had to go and encourage him, didnt you....

Given that the procedures indicated for PAH are on the cardiology side of things, what role does/will pulmonology have in the treatment of this patient population?

well, the only procedure involved is a Swan, which any self-respecting Pulm/Critic Care doctor should be able to do.

 

[grendelsdragon]

well, the only procedure involved is a Swan, which any self-respecting Pulm/Critic Care doctor should be able to do.

Yes, any self-respecting Pulm/Critical Care doc should be able to perform a right heart cath in the ICU. But how many are capable of performing this procedure electively or in the ambulatory setting (without moving planets)?

 

[howelljolly]

I was wondering that myself.

Im sure they can do a right heart cath electively, but do they?

Would you want do do an angiography or something else at the same time, making it a better idea for the cardiologist to do it from the outset? Do pulm/cc docs even get privileges to do elective swans these days?

 

[HomerSD]

My current institution is a tertiary referral center for PAH and is run completely by pulm/cc staff. We perform elective and outpt R heart caths daily without any issues and have dedicated cath lab time.

Pulmonary angios are not done routinely for routine PAH and only when there is an indication of embolic disease on a V/Q scan or CT angio. These are usually referred to the cardiologists, as they are done in conjunction with with left/right heart caths as part of a pre-op workup for pulmonary thromboendarectomy.

 

[grendelsdragon]

My current institution is a tertiary referral center for PAH and is run completely by pulm/cc staff. We perform elective and outpt R heart caths daily without any issues and have dedicated cath lab time.

Pulmonary angios are not done routinely for routine PAH and only when there is an indication of embolic disease on a V/Q scan or CT angio. These are usually referred to the cardiologists, as they are done in conjunction with with left/right heart caths as part of a pre-op workup for pulmonary thromboendarectomy.

This is fantastic to hear. I have to admit, that cardiologists at tertiary level referral centers very rarely share their cath facilities with pulmonologists (it's a shame).

 

[howelljolly]

My current institution is a tertiary referral center for PAH and is run completely by pulm/cc staff. We perform elective and outpt R heart caths daily without any issues and have dedicated cath lab time.

music to my ears!

 

[tibor75]

Yes, any self-respecting Pulm/Critical Care doc should be able to perform a right heart cath in the ICU. But how many are capable of performing this procedure electively or in the ambulatory setting (without moving planets)?

Capable? They all are capable. It's easier to do a procedure on a stable outpatient than in a unit bed with all sorts of lines and drapes and space constraints.

If your question is more regarding teh political nature of the procedure, then yes, it's probably difficult for a lung doctor to get space in a cardiac cath alb.

 

[grendelsdragon]

If your question is more regarding teh political nature of the procedure, then yes, it's probably difficult for a lung doctor to get space in a cardiac cath alb.

This should have been obvious in the "moving planets" part.