CICM SAQ 2015.2 Q2

Question

  • a) List four assessments of the RIGHT ventricle that can be made on transthoracic echocardiography. (20% marks)
  • b) List four clinical signs of right heart failure. (20% marks)
  • c) Classify the causes of pulmonary hypertension with examples. (60% marks)

Answer

Answer and interpretation

a) List four assessments of the RIGHT ventricle that can be made on transthoracic echocardiography. (20% marks)

  • RV size: LV size on apical 4-chamber view
  • RV diameter
  • RV wall thickness
  • Tricuspid annular plane systolic excursion (TAPSE) or S-PRIME on apical 4-chamber view
  • Right ventricular systolic pressure gradient to right atrium using tricuspid regurgitation (TR) jet.
  • Ventricular septal motion (D-shaped septum) that can indicate pressure or volume overload
  • Tissue Doppler and E/E’ ratios

b) List four clinical signs of right heart failure. (20% marks)

  • Elevated Jugular venous pressure
  • Right ventricular heave
  • Right ventricular third heart sound
  • Pleural effusion
  • Peripheral oedema
  • Enlarged liver edge
  • Ascites

c) Classify the causes of pulmonary hypertension with examples. (60% marks)

  1. Pulmonary arterial hypertension (PAH)Idiopathic PAH, Heritable-genetic disease, Drugs and toxins induced: appetite suppressants e.g. fenfluramine, Associated with systemic disease: Connective tissue diseases e.g. scleroderma, HIV infection, Porto-pulmonary hypertension
  2. Pulmonary hypertension due to left heart diseaseSystolic dysfunction, Diastolic dysfunction, Valvular disease: Mitral stenosis, Mitral Regurgitation, Congenital abnormalities
  3. Pulmonary hypertension due to lung diseases and/or hypoxiaChronic obstructive pulmonary disease, Interstitial lung disease, Sleep-disordered breathing, Alveolar hypoventilation disorders, Chronic exposure to high altitude
  4. Chronic thromboembolic pulmonary hypertension
  5. PH with unclear and/or multifactorial mechanismsHematological disorders: myeloproliferative disorders, Systemic disorders: sarcoidosis, vasculitis, Metabolic disorders: glycogen storage disease, Others: tumour obstruction, fibrosing mediastinitis, chronic renal failure on dialysis
  • Pass rate: 65%
  • Highest mark: 8.5

Additional Examiners’ Comments:

  • Some candidates provided more than four answers for parts a) and b) and it should be noted that only the first four answers are considered. Part c) in general was poorly answered and many candidates confused acute elevations in pulmonary pressure with the disease entity of pulmonary hypertension.
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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