Question 5

College answer

Findings:

• Raised JVP with prominent A wave, pulsatile liver. 
• Loud P2, RV/parasternal heave
• TR murmur
• Bilateral Peripheral edema
• Hypotension if severe 

Advantages

• Quick
• Simple
• Cheap
• Non-invasive

Disadvantages

• Poor reproducibility
• Often difficult in ICU – immobility of patient, equipment, dressings etc
• May be impaired by patient habitus
• Non-quantitative
• Continuous monitoring impractical

Transthoracic Echo                              

  Clinical Assessment

Findings 

• ECHO: TR, long axis cavity size, short axis septal kinetics, apex loses triangular shape, 
• RV size compared to LV size, 
• loss of inspiratory collapse of IVC, dilation of PA
• RVSP > 25 for acute 
• TAPSE <16mm

Advantages

• Non -invasive
• Qualitative and quantitative
• Can give other information relevant to clinical state
• Record and retrieve results

Disadvantages

• Expertise required
• Expensive equipment
• Inter operator variability
• Unable to perform continuous monitoring
• Often difficult in ICU – immobility of patient, equipment, dressings etc
• May be impaired by patient habitus

Pulmonary Artery Catheter                             

 Findings

• Right heart failure: high CVP, low CI, high PVR
• Elevated pulmonary artery pressures (PAPm >25mmHg)

 Advantages

• Continuous monitoring 
• Gold standard for pulmonary hypertension measurement
• Quantitative measurement
• No inter operator variability
• Can give other information relevant to clinical state
• Therapeutic uses – iv access, pacing
• Record and retrieve results

 Disadvantages

• Invasive
• Risk of serious complications – infection, bleeding, pneumothorax, vessel rupture 
• Drift of measurements
• Complex, now unfamiliar in many units
• Time limited – should not be left in for > 72 hours

Discussion

Like virtually every other question which asks people to discuss and compare the advantages and disadvantages of something, this one would benefit from a tabulated answer in point-form, as this is much easier for the examiner to mark. The worst possible thing one could do is try to answer this in a block of flowing prose. 

Thus:

Diagnostic Strategies in Right Heart Failure

Modality and findings	Advantages	Disadvantages
Clinical examination: Raised JVP Pulsatile liver.  Loud P2 RV heave TR murmur Oedema  (for more detail, see above)	Quick Simple Cheap Non-invasive Good specificity	Poor sensitivity Poor reproducibility Non-quantitative Made complex by ICU environment Difficult in cardiac surgery/open chest
Transthoracic echo TR Chamber size Septal kinetics Apex shape  IVC dynamic collapse Dilation of PA RVSP > 25 for acute  TAPSE <16mm	Non -invasive Qualitative and quantitative Can give other information relevant to clinical state Record and retrieve results Serial examinations possible	"Operator-dependent" accuracy Requires an ultrasound machine Unable to perform continuous monitoring Impaired by ICU environment: position, drains, dressings
PA catheter High CVP Low cardac output High PA pressure High PVR	Gold standard for right heart assessment Quantitative measurement No inter-operator variability Can give other information relevant to clinical state Therapeutic uses – IV access, pacing Record and retrieve results	Invasive Risk of serious complications  Measurement subject to assumptions and errors (particularly with TR) Drift of measurements Complex, now unfamiliar in many units Time limited – should not be left in for > 72 hours