pulmonary hypertension

[pathfinder777]

I am a 41 year old male that is extremely active mountain biking 4 days per week and surfing 2-3 days per week. Last September 2012 I experienced very transient (20-30 seconds) of sharp pain in my throat in the region (just superior to manubrium) where you can palpate your pulse (not carotid artery) while mountain biking. I have always had PVCs for at least the last 10-15 years. At any rate I decided to play it safe and saw a cardiologist. The initial EKG was normal. A week later I had an echo with stress test. The results were normal heart function  however my right ventricle was moderately enlarged and pulmonary pressures quite elevated 44 at rest and 80 with exercise. I had a right heart catheter test and another echo done the following Monday after the echo/stress test to rule in/out PPH. All pulmonary pressures were normal. I feel great and have not had any symptoms while exercising these last 6 months since these tests were performed however I did obtain the results of an echo I had done in 2008 after being in a nasty mountain bike crash. The echo showed normal right ventricle size as recent as 2008. This new revelation has me very concerned considering my right ventricle has gone from normal size in 2008 to moderately enlarged in 2012. I gave my cardiologist the echo report and shared my concerns with him. He basically told me my catheter test showed normal function and pressures and told me he would do another echo in 6 months from now. I asked about the apparent recent enlargement and he did not really seem concerned based on the right heart catheter results. I'm now wondering if I should just wait another 6 months to get another echo or get a second opinion. Thoughts ??    

[pathfinder777]

I just wanted to follow up. I had another echo done this past week which showed normal pulmonary pressures however it did once again confirm a moderately enlarged right ventricle. Heart function was normal. I have developed orthostatic hypotension which is a new development. My cardiologist basically told me to quit worrying and that I have an enlarged heart but no pathology. He gave me the ok to exercise just no heavy weight training which I don't do anyways. I still am concerned because he doesn't have an explanation regarding the enlarged heart and did have a normal echo done 5 years ago. At any rate he told me to come back in 2 years but was pretty emphatic as far as telling me not to worry my heart was normal and that the pressures in the pulmonary system could not be causing my heart to enlarge. Obviously I wouldn't be still concerned if i thought that i had always had enlarged heart and that was my normal but the echo 5 years ago showing normal r ventricle size is not something my cardiologist has an answer for at this time. He dismissed the orthostatic hypotension because my normal BP is excellent 120/80 and Im in good health. I'm still undecided on getting a second opinion because I don't know what they could do that hasn't already been done (right catheter test, multiple echos, EKGs, blood work, stress test). Any thoughts again would be appreciated.

[pathfinder777]

Thank you very much for your input. I appreciate it.

[Jonathan D. Rich, MD]

Hello and welcome to the forum.

First, your scenario is incredibly common and one that I highlight repeatedly in this forum, namely the frequent discrepancy between PA pressures measured by echo versus cath.  Clearly the cath showed normal pressures and thus you can rest assured that you do not have pulmonary hypertension.

Second, regarding the RV, I would consider getting a repeat echo, perhaps at another institution (ie a 2nd opinion).  Alternatively, you can get the echo again at the same place and see if they now call the RV normal.  The RV is sometimes difficult to image and often there can be some "funky" results.  But, it may also be the quality of the echo lab.  If after a repeat echo (particularly at a quality place), they continue to call the RV moderately enlarged, I would have this investigated (however, I wouldnt be concerned).  In other words, it would be worth determining the potential cause of the RV enlargement (ie you could have what is referred to as anomolous pulmonary venous return) even though this may never cause you adverse consequences.

In the meantime, continue to exercise and try not to worry.  My sense is that all is going to be just fine.

Best,

Dr. Rich