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Guimbretière G, Dubost C, Issard J, Louvain-Quintard V, Jais X, Dolidon S, Stephan F, Ion DI, Mercier O, Fadel E. Suspected heparin-induced thrombocytopaenia in pulmonary thromboendarterectomy: retrospective cohort. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 40:ivaf001. [PMID: 39832274 PMCID: PMC11754861 DOI: 10.1093/icvts/ivaf001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2024] [Accepted: 12/22/2024] [Indexed: 01/22/2025]
Abstract
OBJECTIVES Heparin is given for anticoagulation during and after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Our objective was to add to the limited data available on the incidence, management and outcomes of suspected heparin-induced thrombocytopaenia after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. METHODS This retrospective single-centre study included consecutive patients with suspected heparin-induced thrombocytopaenia after pulmonary thromboendarterectomy done in 2005-2018. Confirmed heparin-induced thrombocytopaenia was defined as positive findings from both the antibody test and the platelet aggregation test. Patients with versus without confirmed heparin-induced thrombocytopaenia were compared, as well as patients with versus without heparin replacement therapy within the group with unconfirmed heparin-induced thrombocytopaenia. The platelet counts over time were compared to those in controls without suspected heparin-induced thrombocytopaenia. RESULTS Heparin-induced thrombocytopaenia was suspected in 86 (6.3%) of 1360 patients and confirmed in 16 (16/86, 19%), all of whom received heparin replacement therapy and survived to intensive care unit discharge. Of the remaining 70 patients, 28 (40%) received heparin replacement therapy and less often experienced bleeding compared to the other 42 (3.6% vs 21.4%, P = 0.043). Intensive care unit mortality was 17/70 (24.3%) and was lower in the subgroup given heparin replacement therapy (10.7% vs 33.3%; P = 0.046). Confirmed heparin-induced thrombocytopaenia was associated with a sharp platelet-count drop on Day 5. In unconfirmed suspected heparin-induced thrombocytopaenia, the early platelet-count decline was similar to that in the controls without suspected heparin-induced thrombocytopaenia, but the baseline count was lower. CONCLUSIONS Clinical features suggesting heparin-induced thrombocytopaenia after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension were associated with excess mortality. Relay heparin replacement therapy was associated with lower mortality and fewer bleeding events.
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Affiliation(s)
- Guillaume Guimbretière
- Department of Thoracic Surgery and Heart-Lung Transplantation, Paris-Saclay University, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
| | - Clément Dubost
- Department of Thoracic Surgery and Heart-Lung Transplantation, Paris-Saclay University, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
| | - Justin Issard
- Department of Thoracic Surgery and Heart-Lung Transplantation, Paris-Saclay University, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Xavier Jais
- INSERM UMR-S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, Le Plessis-Robinson, France
- Department of Pulmonary Diseases, Kremlin-Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Samuel Dolidon
- Department of Pulmonary Diseases, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | - François Stephan
- INSERM UMR-S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, Le Plessis-Robinson, France
- Intensive Care Unit, Université Paris-Saclay, Marie Lannelongue Hospital, Le Plessis-Robinson, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Daniela-Iolanda Ion
- Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | - Olaf Mercier
- Department of Thoracic Surgery and Heart-Lung Transplantation, Paris-Saclay University, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
- INSERM UMR-S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, Le Plessis-Robinson, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Elie Fadel
- Department of Thoracic Surgery and Heart-Lung Transplantation, Paris-Saclay University, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
- INSERM UMR-S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, Le Plessis-Robinson, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
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Diop S, Fadel E, Valentini P, Thepaut A, Genty T, Ion I, De Somer F, Thes J. Effect of Deep Hypothermia (18°C) on Dioxygen Metabolism During Pulmonary Thromboendarterectomy Surgery. J Cardiothorac Vasc Anesth 2024; 38:2990-2996. [PMID: 39393984 DOI: 10.1053/j.jvca.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 08/23/2024] [Accepted: 09/15/2024] [Indexed: 10/13/2024]
Abstract
OBJECTIVES The aim of this physiological pilot study was to investigate the effect of deep hypothermia on oxygen extraction (OE) and consumption (VO2) in normothermic conditions (36-37°C), and at different stages of cooling: 30°C, 25°C, and 18°C. DESIGN For 3 months, a prospective study was conducted on patients who underwent pulmonary thromboendarterectomy. SETTINGS This was a single-center study done in a university teaching hospital. PARTICIPANTS Patients who underwent pulmonary thromboendarterectomy during the inclusion period. INTERVENTIONS Hemodynamic and biological data were recorded from arterial and venous blood gas samples withdrawn first at normothermia, then at 30°C, 25°C, and 18°C. MEASUREMENTS AND MAIN RESULTS 24 patients were included in the final analysis. Indexed VO2 decreased from 65.9 mL to 25.1 mL of O2/min/m2 between 36°C and 18°C (p < 0.001). The OE decreased from 18% to 9% between 36°C and 18°C (p < 0.001). At normal temperature and 18°C, the median venoarterial difference of O2 bound to hemoglobin was 2.22 [1.68-2.58] and 0.03 mL [0.01-0.07] of O2/100 mL of blood, respectively (p < 0.001). Whereas the median venoarterial differences in dissolved O2 were 0.78 [0.66-0.92] and 1.09 mL [1.03-1.32] of O2/100 mL of blood, respectively (p = 0.0013). CONCLUSION There were VO2 and OE decreases of more than half their baseline values at 18°C. Given that metabolic needs are essentially supplied by dissolved O2 during cooling from 30°C to 18°C, the authors suggest that PaO2 should be increased during the period of cooling and/or deep hypothermia to prevent hypoxia.
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Affiliation(s)
- Sylvain Diop
- Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France; Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France.
| | - Elie Fadel
- Department of Vascular and Thoracic Surgery, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France
| | - Pauline Valentini
- Cardiovascular Perfusionist Team, Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France
| | - Alexandre Thepaut
- Cardiovascular Perfusionist Team, Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France
| | - Thibaut Genty
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France
| | - Iolanda Ion
- Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France
| | | | - Jacques Thes
- Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France; Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France; Cardiovascular Perfusionist Team, Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, Le Plessis Robinson, France
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Shah KP, Lee C, McBane RD, Piazza G, Frantz RP, Houghton DE, Casanegra AI, Henkin S. Post-Pulmonary Embolism Syndrome-A Diagnostic Dilemma and Challenging Management. Mayo Clin Proc 2024; 99:1965-1982. [PMID: 39520416 DOI: 10.1016/j.mayocp.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/06/2024] [Accepted: 07/10/2024] [Indexed: 11/16/2024]
Abstract
Historically, research on pulmonary embolism (PE) management has focused on short-term outcomes, such as acute cardiovascular collapse, change in right ventricular function, and in-hospital mortality. However, long-standing functional impairments from acute PE occur in up to half of all patients. This chronic syndrome has been termed the post-PE syndrome, which describes patients who have persistent or worsening symptoms, functional limitations, and cardiorespiratory impairment not explained by a comorbid condition. Diagnosis and management are challenging, and post-PE syndrome remains an underrecognized and undertreated condition. This review seeks to increase awareness of the syndrome that affects a significant portion of PE survivors. The epidemiology, pathophysiology, and clinical features are discussed, followed by a description of imaging findings and management options across the entire spectrum of post-PE syndrome.
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Affiliation(s)
- Kajal P Shah
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Christopher Lee
- Division of Cardiology, University of California San Francisco Health, San Francisco
| | - Robert D McBane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Stanislav Henkin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Beijk MAM, Winkelman JA, Eckmann HM, Samson DA, Widyanti AP, Vleugels J, Bombeld DCM, Meijer CGCM, Bogaard HJ, Vonk Noordegraaf A, de Bruin-Bon HACM, Bouma BJ. Notch ratio in pulmonary flow predicts long-term survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Heart Vessels 2024; 39:968-978. [PMID: 38837085 PMCID: PMC11489231 DOI: 10.1007/s00380-024-02422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/23/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Assessment of the pattern of the RV outflow tract Doppler provides insights into the hemodynamics of chronic thromboembolic pulmonary hypertension (CTEPH). We studied whether pre-operative assessment of timing of the pulmonary flow systolic notch by Doppler echocardiography is associated with long-term survival after pulmonary endarterectomy (PEA) for CTEPH. METHODS Fifty-nine out of 61 consecutive CETPH patients (mean age 53 ± 14 years, 34% male) whom underwent PEA between June 2002 and June 2005 were studied. Clinical, echocardiographic and hemodynamic variables were assessed pre-operatively and repeat echocardiography was performed 3 months after PEA. Notch ratio (NR) was assessed with pulsed Doppler and calculated as the time from onset of pulmonary flow until notch divided by the time from notch until end of pulmonary flow. Long-term follow-up was obtained between May 2021 and February 2022. RESULTS Pre-operative mean pulmonary artery pressure (mPAP) was 45 ± 15 mmHg and pulmonary vascular resistance (PVR) was 646 ± 454 dynes.s.cm-5. Echocardiography before PEA showed that 7 patients had no notch, 33 had a NR < 1.0 and 19 had a NR > 1.0. Three months after PEA, echocardiography revealed a significant decrease in sPAP in long-term survivors with a NR < 1.0 and a NR > 1.0, while a significant increase in TAPSE/sPAP was only observed in the NR < 1.0 group. Mean long-term clinical follow-up was 14 ± 6 years. NR was significantly different between survivors and non-survivors (0.73 ± 0.25 vs. 1.1 ± 0.44, p < 0.001) but no significant differences were observed in mPAP or PVR. Long-term survival at 14 years was significantly better in patients with a NR < 1.0 compared to patients with a NR > 1.0 (83% vs. 37%, p = < 0.001). CONCLUSION Pre-operative assessment of NR is a predictor of long-term survival in CTEPH patients undergoing PEA, with low mortality risk in patients with NR < 1.0. Long-term survivors with a NR < 1.0 and NR > 1.0 had a significant decrease in sPAP after PEA. However, the TAPSE/sPAP only significantly increased in the NR < 1.0 group. In the NR < 1.0 group, the 6-min walk test increased significantly between pre-operative and at 1-year post-operative follow-up. NR is a simple echocardiographic parameter that can be used in clinical decision-making for PEA.
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Affiliation(s)
- M A M Beijk
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - J A Winkelman
- Department of Cardiothoracic Surgery, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - H M Eckmann
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D A Samson
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - A P Widyanti
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J Vleugels
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D C M Bombeld
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C G C M Meijer
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - H J Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - H A C M de Bruin-Bon
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - B J Bouma
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Tenes A, García-Sánchez A, Pintado-Cort B, González-Castro S, Briceño W, Durán D, Morillo R, Jiménez D. Chronic thromboembolic pulmonary hypertension treatment and sex: Systematic review and meta-analysis. Med Clin (Barc) 2024; 163:269-274. [PMID: 38908993 DOI: 10.1016/j.medcli.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND AND OBJECTIVES Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and a major cause of chronic pulmonary hypertension leading to right heart failure and death. While pulmonary endarterectomy is the treatment of choice, some patients might benefit from medical therapy or balloon pulmonary angioplasty. Sex differences in outcomes of these therapies are not well characterized. MATERIAL AND METHODS We conducted a systematic review and meta-analysis to investigate sex differences in outcomes of various therapies for CTEPH. We searched MEDLINE, PubMed, Embase, CINAHL and the Cochrane Library databases between January 1, 2010 and April 30, 2021, published in English. We pooled incidence estimates using random-effects meta-analyses. We evaluated heterogeneity using the I2 statistic. We assessed publication bias using Begg's and Egger's tests. This study is registered in PROSPERO, CRD42021268504. RESULTS A total of 19 studies met the eligibility criteria, but only 3 trials provided separate outcomes for women and men. Two studies evaluated the efficacy of BPA, and one study evaluated the efficacy of riociguat (129 patients). Overall, 57.3% of patients were women and 62.6% were in functional class III. Mean time of follow-up was 55.5 (SD 26.1) weeks. Women showed a significantly better response in cardiac index (mean difference [MD], 0.10L/min/m2; 95% confidence interval [CI], 0.04-0.16; I2=0%; P=0.001). Alternatively, the reduction of pulmonary vascular resistances was significantly higher for men than for women (MD, 161.17dynscm-5; 95% CI, 67.99-254.35; I2=0%; P=0.0007). CONCLUSIONS Women and men might show different hemodynamic responses to riociguat or BPA for CTEPH.
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Affiliation(s)
- Andrés Tenes
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain.
| | - Aldara García-Sánchez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Beatriz Pintado-Cort
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Sara González-Castro
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain
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Todesco A, Grynblat J, Akoumia KKF, Bonnet D, Mendes‐Ferreira P, Morisset S, Chemla D, Levy M, Méot M, Malekzadeh‐Milani S, Tielemans B, Decante B, Vastel‐Amzallag C, Habert P, Ghigna M, Humbert M, Montani D, Boulate D, Perros F. Pulmonary Hypertension Induced by Right Pulmonary Artery Occlusion: Hemodynamic Consequences of Bmpr2 Mutation. J Am Heart Assoc 2024; 13:e034621. [PMID: 38979789 PMCID: PMC11292755 DOI: 10.1161/jaha.124.034621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 05/28/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND The primary genetic risk factor for heritable pulmonary arterial hypertension is the presence of monoallelic mutations in the BMPR2 gene. The incomplete penetrance of BMPR2 mutations implies that additional triggers are necessary for pulmonary arterial hypertension occurrence. Pulmonary artery stenosis directly raises pulmonary artery pressure, and the redirection of blood flow to unobstructed arteries leads to endothelial dysfunction and vascular remodeling. We hypothesized that right pulmonary artery occlusion (RPAO) triggers pulmonary hypertension (PH) in rats with Bmpr2 mutations. METHODS AND RESULTS Male and female rats with a 71 bp monoallelic deletion in exon 1 of Bmpr2 and their wild-type siblings underwent acute and chronic RPAO. They were subjected to full high-fidelity hemodynamic characterization. We also examined how chronic RPAO can mimic the pulmonary gene expression pattern associated with installed PH in unobstructed territories. RPAO induced precapillary PH in male and female rats, both acutely and chronically. Bmpr2 mutant and male rats manifested more severe PH compared with their counterparts. Although wild-type rats adapted to RPAO, Bmpr2 mutant rats experienced heightened mortality. RPAO induced a decline in cardiac contractility index, particularly pronounced in male Bmpr2 rats. Chronic RPAO resulted in elevated pulmonary IL-6 (interleukin-6) expression and decreased Gdf2 expression (corrected P value<0.05 and log2 fold change>1). In this context, male rats expressed higher pulmonary levels of endothelin-1 and IL-6 than females. CONCLUSIONS Our novel 2-hit rat model presents a promising avenue to explore the adaptation of the right ventricle and pulmonary vasculature to PH, shedding light on pertinent sex- and gene-related effects.
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MESH Headings
- Animals
- Bone Morphogenetic Protein Receptors, Type II/genetics
- Bone Morphogenetic Protein Receptors, Type II/metabolism
- Female
- Male
- Pulmonary Artery/physiopathology
- Pulmonary Artery/metabolism
- Hemodynamics
- Disease Models, Animal
- Mutation
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/metabolism
- Rats
- Rats, Sprague-Dawley
- Vascular Remodeling/genetics
- Pulmonary Arterial Hypertension/physiopathology
- Pulmonary Arterial Hypertension/genetics
- Pulmonary Arterial Hypertension/metabolism
- Pulmonary Arterial Hypertension/etiology
- Stenosis, Pulmonary Artery/genetics
- Stenosis, Pulmonary Artery/physiopathology
- Stenosis, Pulmonary Artery/metabolism
- Arterial Pressure
- Myocardial Contraction/physiology
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Affiliation(s)
- Alban Todesco
- Department of Thoracic Surgery, Diseases of the Esophagus and Lung Transplantation, North HospitalAix Marseille University, Assistance Publique‐Hôpitaux de MarseilleMarseilleFrance
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
| | - Julien Grynblat
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
- Faculty of Medicine Le Kremlin‐BicêtreUniversité Paris‐SaclayBures‐sur‐YvetteFrance
| | - Kouamé Kan Firmin Akoumia
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
| | - Damien Bonnet
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Pedro Mendes‐Ferreira
- Cardiovascular R&D Centre, UnIC@RISE, Department of Surgery and PhysiologyFaculty of Medicine of the University of PortoPortoPortugal
- Paris‐Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERMUniversité Paris‐SaclayParisFrance
| | | | - Denis Chemla
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
| | - Marilyne Levy
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Mathilde Méot
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Sophie‐Guiti Malekzadeh‐Milani
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Birger Tielemans
- Department of Imaging and Pathology, Biomedical MRI unit/MosaicKU LeuvenLeuvenBelgium
| | - Benoit Decante
- Preclinical Research Laboratory, Pulmonary Hypertension National Referral Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint JosephParis‐Saclay UniversityLe Plessis RobinsonFrance
| | - Carine Vastel‐Amzallag
- Paediatric Cardiology, Centre de Spécialités Pédiatriques de l’Est Parisien, CSPEPCréteilFrance
| | - Paul Habert
- Department of RadiologyNorth Hospital, Assistance Publique–Hôpitaux de MarseilleMarseilleFrance
- Aix Marseille Univ, LIIEMarseilleFrance
| | - Maria‐Rosa Ghigna
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Department of PathologyInstitut Gustave RoussyVillejuifFrance
| | - Marc Humbert
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Faculty of Medicine Le Kremlin‐BicêtreUniversité Paris‐SaclayBures‐sur‐YvetteFrance
- AP‐HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral CentreDMU 5 Thorinno, Hôpital BicêtreLe Kremlin‐BicêtreFrance
| | - David Montani
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Faculty of Medicine Le Kremlin‐BicêtreUniversité Paris‐SaclayBures‐sur‐YvetteFrance
- AP‐HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral CentreDMU 5 Thorinno, Hôpital BicêtreLe Kremlin‐BicêtreFrance
| | - David Boulate
- Department of Thoracic Surgery, Diseases of the Esophagus and Lung Transplantation, North HospitalAix Marseille University, Assistance Publique‐Hôpitaux de MarseilleMarseilleFrance
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- COMPutational Pharmacology and clinical Oncology (COMPO), INRIA‐INSERMAix Marseille UniversityMarseilleFrance
| | - Frédéric Perros
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Paris‐Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERMUniversité Paris‐SaclayParisFrance
- CarMeN Laboratory, INSERM U1060, INRAE U1397Université Claude Bernard Lyon1Pierre‐BéniteFrance
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Wang Y, Guo D, Gong J, Wang J, Yang Y, Zhang X, Hu H, Ma Y, Lv X, Li Y. Efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension patients with pulmonary comorbidity. IJC HEART & VASCULATURE 2024; 51:101363. [PMID: 38445233 PMCID: PMC10912838 DOI: 10.1016/j.ijcha.2024.101363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/26/2024] [Accepted: 02/11/2024] [Indexed: 03/07/2024]
Abstract
Background Balloon pulmonary angioplasty (BPA) is an established treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH), but its efficacy in CTEPH patients with a pulmonary comorbidity has not been well-studied. Here, we compared post-BPA outcomes between CTEPH patients with and without chronic pulmonary disease at baseline and analyzed predictors of BPA success. Methods From August 2017 to October 2022, 62 patients with inoperable CTEPH who underwent BPA were consecutively enrolled and grouped based on the presence of a pulmonary comorbidity at baseline. All patients underwent transthoracic echocardiography, pulmonary function tests, and right heart catheterization. Pre- and post-BPA data were evaluated to identify factors that influence the success of BPA. Results Among the 62 CTEPH patients, BPA was considered successful in 50 patients and unsuccessful in 12 patients. Responders to BPA had better exercise capacity and right heart function at baseline, but no differences in hemodynamic or respiratory function were detected between the groups. In CTEPH patients with chronic pulmonary disease (n = 14), BPA significantly improved mean pulmonary arterial pressure, pulmonary vascular resistance and right heart function parameters. Only CTEPH patients without chronic pulmonary disease (n = 48) exhibited significant improvement in 6-minute walk distance and respiratory function. Multivariate logistic regression analysis showed that pulmonary comorbidity at baseline was independently associated with the efficacy of BPA. Conclusions BPA provided significantly improvements in hemodynamics and right heart function in CTEPH patients, independent of pulmonary comorbidity at baseline. However, pulmonary comorbidity can negatively impact post-BPA outcomes.
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Affiliation(s)
- Yeqing Wang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Dichen Guo
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Juanni Gong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jianfeng Wang
- Department of Intervention, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xinyuan Zhang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huimin Hu
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yaning Ma
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiuzhang Lv
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yidan Li
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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8
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Zheng Z, Pandit K, Chang AR, Shin JI, Charytan DM, Grams ME, Surapaneni A. Association of eGFR and Albuminuria with Venous Thromboembolism. Clin J Am Soc Nephrol 2024; 19:301-308. [PMID: 37971889 PMCID: PMC10937012 DOI: 10.2215/cjn.0000000000000352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND CKD has been implicated as a risk factor of venous thromboembolism, but the evidence is limited to relatively healthy populations. The objective of this study was to discern whether parameters of kidney function and damage are associated with the occurrence of venous thromboembolism after hospitalization. METHODS We conducted a retrospective study including 23,899 and 11,552 adult individuals hospitalized within Geisinger Health System and New York University (NYU) Langone Health from 2004 to 2019 and 2012 to 2022, respectively. A Poisson model was used to evaluate adjusted incidence rates of venous thromboembolism according to eGFR and albuminuria categories in each cohort. Cox proportional hazards models were used to analyze associations of eGFR and urinary albumin-to-creatinine ratio (UACR) with venous thromboembolism, and hazard ratios (HRs) were meta-analyzed across cohorts. RESULTS Both lower eGFR and higher UACR were associated with higher risks of venous thromboembolism. In the Geisinger cohort, the incidence of venous thromboembolism after hospital discharge ranged from 10.7 (95% confidence interval [CI], 9.2 to 12.6) events per 1000 person-years in individuals in G1A1 (eGFR >90 ml/min per 1.73 m 2 and UACR <30 mg/g) to 27.7 (95% CI, 20.6 to 37.2) events per 1000 person-years in individuals with G4-5A3 (eGFR <30 ml/min per 1.73 m 2 and UACR >300 mg/g). A similar pattern was observed in the NYU cohort. Meta-analyses of the two cohorts showed that every 10 ml/min per 1.73 m 2 reduction in eGFR below 60 ml/min per 1.73 m 2 was associated with a 6% higher risk of venous thromboembolism (HR 1.06 [95% CI, 1.02 to 1.11], P = 0.01), and each two-fold higher UACR was associated with a 5% higher risk of venous thromboembolism (HR 1.05 [95% CI, 1.03 to 1.07], P < 0.001). CONCLUSIONS Both eGFR and UACR were independently associated with higher risk of venous thromboembolism after hospitalization. The incidence rate was higher with greater severity of CKD. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_14_CJN0000000000000352.mp3.
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Affiliation(s)
- Zhong Zheng
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Krutika Pandit
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Alex R. Chang
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David M. Charytan
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Morgan E. Grams
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Aditya Surapaneni
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
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9
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Sasaki H, Kowatari R, Kondo N, Minakawa M. Simple and secure thrombectomy without circulatory arrest for acute pulmonary embolism. J Cardiothorac Surg 2024; 19:74. [PMID: 38331836 PMCID: PMC10854102 DOI: 10.1186/s13019-024-02535-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Surgical pulmonary artery thrombectomy is a well-established emergency treatment for massive pulmonary embolism (PE) in which fibrinolysis or thrombolysis are not effective. However, surgery for massive PE that requires peripheral pulmonary artery thrombus removal remains challenging. We established a simple and secure pulmonary artery thrombectomy method using cardiopulmonary bypass and cardiac arrest. In this procedure, the surgical assistant arm, typically used for coronary artery bypass grafting, is used to obtain a feasible working space during thrombectomy. CASE PRESENTATION We present seven consecutive massive PE cases that were treated with the present surgical method and successfully weaned from cardiopulmonary bypass or extracorporeal membrane oxygenation postoperatively. CONCLUSIONS This procedure can be used to prevent right ventricular failure after surgery as surgeons can remove the peripheral thrombus with clear vision up to the second branch of the pulmonary artery.
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Affiliation(s)
- Hanae Sasaki
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan
| | - Ryosuke Kowatari
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan.
| | - Norihiro Kondo
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan
| | - Masahito Minakawa
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan
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10
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Chia AXF, Valchanov K, Ng C, Tsui S, Taghavi J, Vuylsteke A, Fowles JA, Jenkins DP. Perioperative extracorporeal membrane oxygenation support for pulmonary endarterectomy: A 17-year experience from the UK national cohort. J Heart Lung Transplant 2024; 43:241-250. [PMID: 37730188 DOI: 10.1016/j.healun.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/30/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is the guideline-recommended treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients develop severe cardiopulmonary compromise before surgery, intraoperatively, or early postoperatively. This may result from advanced CTEPH, reperfusion pulmonary edema, massive endobronchial bleeding, or right ventricular (RV) failure secondary to residual pulmonary hypertension. Conventional cardiorespiratory support is ineffective when these complications are severe. Since 2005, we used extracorporeal membrane oxygenation (ECMO) as a rescue therapy for this group. We review our experience with ECMO support in these patients. METHODS This study was a retrospective analysis of patients who received perioperative ECMO for PEA from a single national center from August 2005 to July 2022. Data were prospectively collected. RESULTS One hundred and ten patients (4.7%) had extreme cardiorespiratory compromise requiring perioperative ECMO. Nine were established on ECMO before PEA. Of those who received ECMO postoperatively, 39 were for refractory reperfusion lung injury, 20 for RV failure, 31 for endobronchial bleeding, and the remaining 11 were for "other" reasons, such as cardiopulmonary resuscitation following late tamponade and aspiration pneumonitis. Sixty-two (56.4%) were successfully weaned from ECMO. Fifty-seven patients left the hospital alive, giving a salvage rate of 51.8%. Distal disease (Jamieson Type III) and significant residual pulmonary hypertension were also predictors of mortality on ECMO support. Overall, 5- and 10-year survival in patients who were discharged alive following ECMO support was 73.9% (SE: 6.1%) and 58.2% (SE: 9.5%), respectively. CONCLUSIONS Perioperative ECMO support has an appropriate role as rescue therapy for this group. Over 50% survived to hospital discharge. These patients had satisfactory longer-term survival.
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Affiliation(s)
- Alicia X F Chia
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Kamen Valchanov
- Department of Anaesthesia, Singapore General Hospital, Singapore, Singapore
| | - Choo Ng
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Steven Tsui
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - John Taghavi
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Alain Vuylsteke
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Jo-Anne Fowles
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom.
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11
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Bertazzo B, Cicolini A, Fanilla M, Favaloro L, Caneva J, Favaloro RR. Extracorporeal Mechanical Circulatory Support after Pulmonary Thromboendarterectomy: Experience of One Center. Ann Thorac Cardiovasc Surg 2024; 30:24-00070. [PMID: 39111866 PMCID: PMC11320365 DOI: 10.5761/atcs.oa.24-00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/04/2024] [Indexed: 08/15/2024] Open
Abstract
PURPOSE Pulmonary thromboendarterectomy (PTE) is the treatment for patients with chronic thromboembolic disease. In the immediate postoperative period, some patients may still experience life-threatening complications such as reperfusion lung injury, airway bleeding, and persistent pulmonary hypertension with consequent right ventricular dysfunction. These issues may require support with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery or lung transplantation. This study aims to analyze our series of PTEs that require ECMO. METHODS A descriptive and retrospective analysis of all PTE performed at the Favaloro Foundation University Hospital was conducted between March 2013 and December 2023. RESULTS A total of 42 patients underwent PTE with a median age of 47 years (interquartile range: 26-76). The incidence of patients with ECMO was 26.6%, of which 53.6% were veno-venous (VV) ECMO. Preoperatively, a low cardiac index (CI), high right and left filling pressures, and high total pulmonary vascular resistances (PVRs) were associated with ECMO with a statistically significant relationship. The hospital mortality was 11.9%, and the mortality in the ECMO group was 45.5%, with a statistically significant relationship. Veno-arterial ECMO has a worse prognosis than VV ECMO. CONCLUSIONS Preoperatively, a low CI, high right and left filling pressures, and high total PVRs were associated with ECMO after PTE.
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Affiliation(s)
- Brunella Bertazzo
- Cardiovascular Intensive Care Unit, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Alejandro Cicolini
- Cardiovascular Intensive Care Unit, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Martin Fanilla
- Cardiology Department, Italian Hospital, Buenos Aires, Argentina
| | - Liliana Favaloro
- Heart Failure and Pulmonary Hypertension, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Jorge Caneva
- Pneumonology Department, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Roberto R Favaloro
- Cardiac Surgery Department, Favaloro Foundation University Hospital, Buenos Aires, Argentina
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12
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Crowley AV, Banfield M, Gupta A, Raj R, Gorantla VR. Role of Surgical and Medical Management of Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review. Cureus 2024; 16:e53336. [PMID: 38435894 PMCID: PMC10907114 DOI: 10.7759/cureus.53336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is underdiagnosed and has recently surfaced as one of the leading triggers of severe pulmonary hypertension. This disease process is described by structural changes of pulmonary arteries such as fibrous stenosis, complete obliteration, or the presence of a resistant intraluminal thrombus, resulting in increased pulmonary resistance and eventually progressing to right-sided heart failure. Hence, this study aims to describe the current treatments for CTEPH and their efficacy in hemodynamic improvement and prevention of recurring thromboembolic episodes in patients. This systematic review promptly follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. On February 13, 2022, our team searched through the following databases: PubMed, ProQuest, and ScienceDirect. The following keywords were used across all databases: CTEPH AND Pulmonary Endarterectomy (PEA), CTEPH AND Balloon Pulmonary Angioplasty (BPA), and CTEPH AND Medical Therapy OR Anticoagulation therapy. Twenty-nine thousand eighty-nine articles on current management techniques (PEA, Balloon angioplasty, anticoagulants) were selected, analyzed, and reviewed with each other. We found 19 articles concerning PEA, 15 concerning BPA, and six regarding anticoagulants. Most papers showed high success rates and promising evidence of PEA and anticoagulants as a post-operative regimen. BPA was the least preferred but is still reputable in patients unfit for invasive techniques. CTEPH is a condition presenting with either fibrous stenosis, complete obliteration of the artery, or a clogged thrombus. Recent studies have shown three techniques that physicians have used to treat CTEPH: balloon-pulmonary angioplasty, PEA, and medical management with anticoagulants. PEA followed by anticoagulants is preferred to balloon pulmonary angioplasties. CTEPH is an ongoing topic in research; as it continues to be researched, we hope to see more management techniques available.
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Affiliation(s)
- Alexandra V Crowley
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Megan Banfield
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Aditi Gupta
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Rhea Raj
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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13
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Wucherpfennig L, Kauczor HU, Eichinger M, Wielpütz MO. [Magnetic resonance imaging of the lung : State of the art]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:849-862. [PMID: 37851088 DOI: 10.1007/s00117-023-01229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
Due to the low proton density of the lung parenchyma and the rapid signal decay at the air-tissue interfaces, for a long time the lungs were difficult to access using magnetic resonance imaging (MRI); however, technical advances could address most of these obstacles. Pulmonary alterations associated with tissue proliferation ("plus pathologies"), can now be detected with high diagnostic accuracy because of the locally increased proton density. Compared to computed tomography (CT), MRI provides a comprehensive range of functional imaging procedures (respiratory mechanics, perfusion and ventilation). In addition, as a radiation-free noninvasive examination modality, it enables repeated examinations for assessment of the course or monitoring of the effects of treatment, even in children. This article discusses the technical aspects, gives suggestions for protocols and explains the role of MRI of the lungs in the routine assessment of various diseases.
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Affiliation(s)
- Lena Wucherpfennig
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
- Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für Lungenforschung (DZL), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Deutschland
- Klinik für Diagnostische und Interventionelle Radiologie mit Nuklearmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Röntgenstr. 1, 69126, Heidelberg, Deutschland
| | - Hans-Ulrich Kauczor
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
- Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für Lungenforschung (DZL), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Deutschland
- Klinik für Diagnostische und Interventionelle Radiologie mit Nuklearmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Röntgenstr. 1, 69126, Heidelberg, Deutschland
| | - Monika Eichinger
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
- Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für Lungenforschung (DZL), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Deutschland
- Klinik für Diagnostische und Interventionelle Radiologie mit Nuklearmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Röntgenstr. 1, 69126, Heidelberg, Deutschland
| | - Mark O Wielpütz
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
- Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für Lungenforschung (DZL), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Deutschland.
- Klinik für Diagnostische und Interventionelle Radiologie mit Nuklearmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Röntgenstr. 1, 69126, Heidelberg, Deutschland.
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14
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Balistrieri A, Makino A, Yuan JXJ. Pathophysiology and pathogenic mechanisms of pulmonary hypertension: role of membrane receptors, ion channels, and Ca 2+ signaling. Physiol Rev 2023; 103:1827-1897. [PMID: 36422993 PMCID: PMC10110735 DOI: 10.1152/physrev.00030.2021] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/11/2022] [Accepted: 11/19/2022] [Indexed: 11/25/2022] Open
Abstract
The pulmonary circulation is a low-resistance, low-pressure, and high-compliance system that allows the lungs to receive the entire cardiac output. Pulmonary arterial pressure is a function of cardiac output and pulmonary vascular resistance, and pulmonary vascular resistance is inversely proportional to the fourth power of the intraluminal radius of the pulmonary artery. Therefore, a very small decrease of the pulmonary vascular lumen diameter results in a significant increase in pulmonary vascular resistance and pulmonary arterial pressure. Pulmonary arterial hypertension is a fatal and progressive disease with poor prognosis. Regardless of the initial pathogenic triggers, sustained pulmonary vasoconstriction, concentric vascular remodeling, occlusive intimal lesions, in situ thrombosis, and vascular wall stiffening are the major and direct causes for elevated pulmonary vascular resistance in patients with pulmonary arterial hypertension and other forms of precapillary pulmonary hypertension. In this review, we aim to discuss the basic principles and physiological mechanisms involved in the regulation of lung vascular hemodynamics and pulmonary vascular function, the changes in the pulmonary vasculature that contribute to the increased vascular resistance and arterial pressure, and the pathogenic mechanisms involved in the development and progression of pulmonary hypertension. We focus on reviewing the pathogenic roles of membrane receptors, ion channels, and intracellular Ca2+ signaling in pulmonary vascular smooth muscle cells in the development and progression of pulmonary hypertension.
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Affiliation(s)
- Angela Balistrieri
- Section of Physiology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California
- Harvard University, Cambridge, Massachusetts
| | - Ayako Makino
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Jason X-J Yuan
- Section of Physiology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California
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15
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Huang YS, Chen ZW, Lee WJ, Wu CK, Kuo PH, Hsu HH, Tang SY, Tsai CH, Su MY, Ko CL, Hwang JJ, Lin YH, Chang YC. Treatment Response Evaluation by Computed Tomography Pulmonary Vasculature Analysis in Patients With Chronic Thromboembolic Pulmonary Hypertension. Korean J Radiol 2023; 24:349-361. [PMID: 36907594 PMCID: PMC10067691 DOI: 10.3348/kjr.2022.0675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/21/2022] [Accepted: 01/28/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To quantitatively assess the pulmonary vasculature using non-contrast computed tomography (CT) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) pre- and post-treatment and correlate CT-based parameters with right heart catheterization (RHC) hemodynamic and clinical parameters. MATERIALS AND METHODS A total of 30 patients with CTEPH (mean age, 57.9 years; 53% female) who received multimodal treatment, including riociguat for ≥ 16 weeks with or without balloon pulmonary angioplasty and underwent both non-contrast CT for pulmonary vasculature analysis and RHC pre- and post-treatment were included. The radiographic analysis included subpleural perfusion parameters, including blood volume in small vessels with a cross-sectional area ≤ 5 mm² (BV5) and total blood vessel volume (TBV) in the lungs. The RHC parameters included mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index (CI). Clinical parameters included the World Health Organization (WHO) functional class and 6-minute walking distance (6MWD). RESULTS The number, area, and density of the subpleural small vessels increased after treatment by 35.7% (P < 0.001), 13.3% (P = 0.028), and 39.3% (P < 0.001), respectively. The blood volume shifted from larger to smaller vessels, as indicated by an 11.3% increase in the BV5/TBV ratio (P = 0.042). The BV5/TBV ratio was negatively correlated with PVR (r = -0.26; P = 0.035) and positively correlated with CI (r = 0.33; P = 0.009). The percent change across treatment in the BV5/TBV ratio correlated with the percent change in mPAP (r = -0.56; P = 0.001), PVR (r = -0.64; P < 0.001), and CI (r = 0.28; P = 0.049). Furthermore, the BV5/TBV ratio was inversely associated with the WHO functional classes I-IV (P = 0.004) and positively associated with 6MWD (P = 0.013). CONCLUSION Non-contrast CT measures could quantitatively assess changes in the pulmonary vasculature in response to treatment and were correlated with hemodynamic and clinical parameters.
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Affiliation(s)
- Yu-Sen Huang
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Zheng-Wei Chen
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Wen-Jeng Lee
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Cho-Kai Wu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Yu Tang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Cheng-Hsuan Tsai
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mao-Yuan Su
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Lun Ko
- Departments of Nuclear Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Juey-Jen Hwang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yeun-Chung Chang
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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Ermerak NO, Yilmaz B, Batirel S, Olgun Yildizeli S, Kocakaya D, Mutlu B, Tas S, Yildizeli B. The angiogenic gene profile of pulmonary endarterectomy specimens: Initial study. JTCVS OPEN 2023; 13:423-434. [PMID: 37063122 PMCID: PMC10091285 DOI: 10.1016/j.xjon.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/03/2022] [Accepted: 12/19/2022] [Indexed: 04/18/2023]
Abstract
Objectives The underlying mechanisms for the development of chronic thromboembolic pulmonary hypertension and prognostic biomarkers are not clear yet. Thus, our aim is to assess and identify new biomarkers for the expression of 84 key genes linked to angiogenesis. Methods Patients who had levels more than 1000 dynes·sec·cm-5 were included in the test group, and the other patients were included in the control group. Twelve specimens were taken from the patients. RT2 Profiler PCR Array (Qiagen) was used to quantify the expression of the 84 key genes. Results Eight patients (6 male, 2 female, median age 54.4 ± 13.1 years) who underwent pulmonary endarterectomy were included. Pulmonary vascular resistance improved significantly from 811 ± 390 dyn/s/cm-5 to 413.3 ± 144.9 dyn/s/cm-5 (P < .005). A difference was also detected in median mean pulmonary arterial pressure, which decreased from 49.8 ± 9 mm Hg to 32.62 ± 2.50 mm Hg (P > .005) after surgery. Median length of hospital stay was 11.62 ± 2.97 days. The test group had a distinct pattern of impaired angiogenic and antiangiogenic genes. The expression levels of TGFA, TGFB1, THBS2, THBS1, TGFBR1, SERPINE1, SERPINF1, TGFB2, TIMP2, VEGFC, IFNA1, TNF, CXCL10, NOS3, IGF1, and MMP14 were downregulated in the specimens from the patients who had higher pulmonary vascular resistance values, whereas some genes, including PDGFA, showed upregulation that was statistically nonsignificant in the same group. Conclusions These results can lead to the development of new markers that could predict adverse outcomes of patients with CTEPH. Identification of new markers that are related to worse outcomes would enable screening patients for early diagnosis and treatment.
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Affiliation(s)
- Nezih Onur Ermerak
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
- Address for reprints: Nezih Onur Ermerak, MD, Department of Thoracic Surgery, Marmara University School of Medicine, Fevzi Cakmak Mah. Mimar Sinan Cad. No: 41, Ust Kaynarca, Pendik, İstanbul, 34899, Turkey.
| | - Betul Yilmaz
- Department of Biochemistry, Marmara University School of Medicine, Istanbul, Turkey
| | - Saime Batirel
- Department of Biochemistry, Marmara University School of Medicine, Istanbul, Turkey
| | - Sehnaz Olgun Yildizeli
- Department of Biochemistry, Marmara University School of Medicine/Genetic and Metabolic Diseases Research and Investigation Center (GEMHAM), Marmara University, Istanbul, Turkey
| | - Derya Kocakaya
- Department of Biochemistry, Marmara University School of Medicine/Genetic and Metabolic Diseases Research and Investigation Center (GEMHAM), Marmara University, Istanbul, Turkey
| | - Bulent Mutlu
- Department of Cardiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Serpil Tas
- Department of Cardiovascular Surgery, Kosuyolu Training and Research Hospital, Istanbul, Turkey
| | - Bedrettin Yildizeli
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
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17
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Fujii H, Taniguchi Y, Yoneda S, Miwa K, Matsuoka Y, Yanaka K, Tsuboi Y, Emoto N, Hirata K. Efficacy and Safety of Balloon Pulmonary Angioplasty for Patients With Chronic Thromboembolic Pulmonary Hypertension and Comorbid Chronic Obstructive Pulmonary Disease. J Am Heart Assoc 2023; 12:e026466. [PMID: 36734336 PMCID: PMC9973616 DOI: 10.1161/jaha.122.026466] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 11/14/2022] [Indexed: 02/04/2023]
Abstract
Background Balloon pulmonary angioplasty (BPA) is a promising treatment modality for nonoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, BPA for atypical CTEPH with concurrent chronic obstructive pulmonary disease (COPD) remains controversial owing to the risk of exacerbation of ventilation-perfusion mismatch. We aimed to evaluate the efficacy and safety of BPA for CTEPH with moderate or severe COPD. Methods and Results Data from 149 patients with CTEPH, who underwent BPA from March 2011 to June 2021, were retrospectively analyzed. Patients were divided based on COPD comorbidity: the COPD group (n=32, defined as forced expiratory volume in 1 second/forced vital capacity <70% and forced expiratory volume in 1 second <80% predicted) and the non-COPD group (n=101); patients with mild COPD (n=16) were excluded. Hemodynamic and respiratory parameters were compared between the groups. Hemodynamics improved similarly in both groups (reduction in pulmonary vascular resistance): -55.6±29.0% (COPD group) and -58.9±21.4% (non-COPD group); P=nonsignificant. Respiratory function and oxygenation improved in the COPD group (forced expiratory volume in 1 second/forced vital capacity [61.8±7.0% to 66.5±10.2%, P=0.02] and arterial oxygen partial pressure [60.9±10.6 mm Hg to 69.3±13.6 mm Hg, P<0.01]). Higher vital capacity (P=0.024) and higher diffusing capacity for lung carbon monoxide (P=0.028) at baseline were associated with greater improvement in oxygenation in the multivariable linear analysis. Lung injury per BPA session was 1.6% in the COPD group. Conclusions The efficacy and safety of BPA for nonoperable CTEPH in patients with comorbid COPD were similar to those in patients without COPD. Oxygenation and forced expiratory volume in 1 second/forced vital capacity improved in patients with COPD. BPA should be considered in patients with CTEPH with concurrent COPD.
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Affiliation(s)
- Hiroyuki Fujii
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Sachiyo Yoneda
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Keisuke Miwa
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yoichiro Matsuoka
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yasunori Tsuboi
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kenichi Hirata
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
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Traitement chirurgical de l’hypertension pulmonaire thromboembolique. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Jeong I, Alotaibi M, Fernandes TM, Kim S, Kerr KM, Yang J, Pretorius V, Madani M, Kim NH. Direct oral anticoagulants in patients with chronic thromboembolic pulmonary hypertension and the presence of recent thrombus during pulmonary endarterectomy. Pulm Circ 2022; 12:e12110. [PMID: 35874854 PMCID: PMC9297025 DOI: 10.1002/pul2.12110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/27/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with chronic thromboembolic pulmonary hypertension (CTEPH) require lifelong anticoagulant therapy. The safety and efficacy of direct oral anticoagulant (DOAC) in the chronic and transitional management of CTEPH has not been investigated. We performed a retrospective analysis of 405 consecutive pulmonary endarterectomy (PEA) cases at the University of California, San Diego, from July 2015 through July 2017. PEA specimen was reviewed for the presence of acute or subacute thrombotic material distinct from the expected chronic disease removed at the time of PEA by two investigators blinded to the patient information. Of 405 PEA cases, 166 patients (41.0%) were anticoagulated with one of three available DOACs; 239 (59.0%) presented on either oral vitamin-K antagonist or chronic injectable therapy. There were no significant differences in baseline characteristics between DOAC and non-DOAC groups. Evidence of recent thrombus was observed in 22 (13.3%) in the DOAC group versus 16 (6.7%) within the non-DOAC group. The odds ratio of DOACs usage and evidence of recent thrombus was 2.34 (95% confidence interval: 1.1-5.0, p = 0.03) after adjusting for age, gender, race, body mass index, and history of antiphospholipid antibody syndrome. CTEPH patients referred for PEA while on DOAC therapy were twice as likely to have associated acute or subacute thrombi present at the time of surgery compared with those on more traditional, non-DOAC anticoagulant therapies. This raises questions of the safety and efficacy of DOACs in the chronic management of CTEPH.
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Affiliation(s)
- Ina Jeong
- Division of Pulmonary and Critical Care MedicineNational Medical CenterSeoulKorea
| | - Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of CaliforniaSan DiegoUSA
| | - Timothy M. Fernandes
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of CaliforniaSan DiegoUSA
| | - Suhyun Kim
- Division of Pulmonary and Allergy MedicineSeoul Medical CenterSeoulKorea
| | - Kim M. Kerr
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of CaliforniaSan DiegoUSA
| | - Jenny Yang
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of CaliforniaSan DiegoUSA
| | - Victor Pretorius
- Division of Cardiovascular and Thoracic SurgeryUniversity of CaliforniaSan DiegoUSA
| | - Michael Madani
- Division of Cardiovascular and Thoracic SurgeryUniversity of CaliforniaSan DiegoUSA
| | - Nick H. Kim
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of CaliforniaSan DiegoUSA
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20
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Koike H, Sueyoshi E, Uetani M. Diagnosis of Chronic Thromboembolic Pulmonary Hypertension Using Quantitative Lung Perfusion Parameters Extracted From Dual-energy Computed Tomography Images. J Thorac Imaging 2022; 37:239-245. [PMID: 35394985 DOI: 10.1097/rti.0000000000000646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate quantified iodine mapping parameters in dual-energy computed tomography in normal patients versus those with chronic thromboembolic pulmonary hypertension (CTEPH) with and without pulmonary thromboembolism. MATERIALS AND METHODS Using automatically quantified iodine mapping in dual-energy computed tomography, we evaluated lung relative average enhancement, standard deviation (SD), and the SD/lung relative average enhancement ratio. We compared the values for these parameters in normal patients versus those with CTEPH. We also performed a receiver operating characteristic curve analysis to determine the diagnostic cutoffs for the parameters. RESULTS Patients constituted 41 patients (10 male [24.4%] and 31 female [75.6%]; mean age [SD]: 70.0 y [13.3]) with CTEPH and 237 (92 male [38.8%] and 145 female [61.2%]; mean age [SD]: 65.9 y [15.9]) normal patients. We found significant differences in lung relative average enhancement (34.9±6.3 vs. 26.9±6.3; P <0.0001), SD (11.6±1.9 vs. 14.7±3.3; P <0.001), and the SD/lung relative average enhancement ratio (33.7±5.0 vs. 55.7±10.4; P <0.001) between the normal and CTEPH groups, respectively. The ROC analyses demonstrated high discriminatory power (area under the curve=0.99) for using the SD/lung relative average enhancement ratio to differentiate between patients in the normal group and CTEPH group. At a threshold for the area under the curve of 44.2, diagnostic sensitivity, specificity, positive predictive value, and negative predictive value for the ratio were 92.7%, 97.5%, 86.5%, and 98.7%, respectively. CONCLUSIONS Patients with CTEPH were well-discriminated from normal patients using the SD/lung relative average enhancement ratio.
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Affiliation(s)
- Hirofumi Koike
- Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences
- Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Eijun Sueyoshi
- Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences
- Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Masataka Uetani
- Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences
- Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
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21
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de Perrot M, McRae K, Donahoe L, Abdelnour-Berchtold E, Thenganatt J, Granton J. Pulmonary endarterectomy in severe chronic thromboembolic pulmonary hypertension: the Toronto experience. Ann Cardiothorac Surg 2022; 11:133-142. [PMID: 35433364 PMCID: PMC9012204 DOI: 10.21037/acs-2021-pte-14] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/14/2021] [Indexed: 08/19/2023]
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) in severe chronic thromboembolic pulmonary hypertension (CTEPH) is associated with higher risks. However, recent evidence suggests that these risks may be mitigated with the use of extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective analysis of 401 consecutive patients undergoing PEA at the Toronto General Hospital between August 2005 and March 2020. Patients with severe CTEPH defined by pulmonary vascular resistance (PVR) >1,000 dynes.s.cm-5 at the time of diagnosis were compared to those with PVR <1,000 dynes.s.cm-5. RESULTS The New York Heart Association (NYHA) functional class, brain natriuretic peptide (BNP) and 6-minute walk distance were worse in patients with PVR >1,000 dynes.s.cm-5. A greater proportion of patients with PVR >1,000 dynes.s.cm-5 was treated with targeted pulmonary hypertension (PH) medical therapy (38% vs. 18%, P<0.001) and initiated on inotropic support (7% vs. 0.3%, P<0.001) before PEA. Since 2014, the ECMO utilization rate increased in patients with PVR >1,000 dynes.s.cm-5 compared to those with PVR <1,000 dynes.s.cm-5 (18% vs. 3.1%, P<0.001). The hospital mortality in patients with PVR >1,000 dynes.s.cm-5 decreased from 10.3% in 2005-2013 to 1.6% in 2014-2020 (P=0.05), while the hospital mortality in patients with PVR <1,000 dynes.s.cm-5 remained stable (1.2% in 2005-2013 vs. 2.7% in 2014-2020, P=0.4). The overall survival reached 84% at 10 years in patients with PVR >1,000 dynes.s.cm-5 compared to 78% in patients with PVR <1,000 dynes.s.cm-5 (P=0.7). CONCLUSIONS The early and long-term results of PEA in patients with severe CTEPH are excellent despite greater postoperative risks. ECMO as a bridge to recovery after PEA can be useful in patients with severe CTEPH.
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Affiliation(s)
- Marc de Perrot
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Karen McRae
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Laura Donahoe
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Etienne Abdelnour-Berchtold
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - John Thenganatt
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - John Granton
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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22
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Mercier O, Dubost C, Delaporte A, Genty T, Fabre D, Mitilian D, Girault A, Issard J, Astaneh A, Menager JB, Dauriat G, Mussot S, Jevnikar M, Jais X, Humbert M, Simonneau G, Dartevelle P, Ion I, Stephan F, Brenot P, Fadel E. Pulmonary thromboendarterectomy: The Marie Lannelongue Hospital experience. Ann Cardiothorac Surg 2022; 11:143-150. [PMID: 35433355 PMCID: PMC9012189 DOI: 10.21037/acs-2021-pte-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/18/2022] [Indexed: 12/01/2023]
Abstract
BACKGROUND Targeted medical therapy and balloon pulmonary angioplasty (BPA) entered the field of chronic thromboembolic pulmonary hypertension (CTEPH) treatment in the early 2010's. Multimodal therapy is emerging as the new gold standard for CTEPH management. Whether this change of paradigm impacted early outcomes of pulmonary endarterectomy (PEA) remains unknown. Our aim is to report our surgical experience in the era of CTEPH multimodal management. METHODS Patients who underwent PEA between 2016 and 2020 were included in the study. Early outcomes were described and compared between three groups of patients: PEA alone, PEA after targeted medical therapy induction and PEA after BPA. RESULTS A total of 418 patients, 225 males and 193 females, with a mean age of 59±14 years were included in the study. 336 patients underwent PEA alone, 69 after medical targeted therapy induction and 13 after unilateral BPA. Baseline preoperative pulmonary vascular resistance [4.99 (IQR, 1.71-8.48), 6.21 (IQR, 4.37-8.1), 5.03 (IQR, 4.44-7.19) wood units (WU), P=0.230, respectively] and PEA effectiveness [% decrease mean pulmonary artery pressure (mPAP), 24 (IQR, 7-42), 25 (IQR, 7-35), 23 (IQR, 3-29), P=0.580] did not differ between groups. Compared to PEA alone and PEA+BPA, the medical therapy induction group represented the most challenging group with higher baseline mPAP (45±10 vs. 42±11 and 43±11 mmHg, P=0.047), longer circulatory arrest time (30.1±15 vs. 26.6±10 and 19.6±6 min, P=0.005), higher post-PEA extracorporeal membrane oxygenation use (20.6% vs. 8.7 and 9.1%, P=0.004), higher duration on mechanical ventilation [4 (IQR, 1-12) vs. 1 (IQR, 0.5-5) and 2 (IQR, 1-3) days, P=0.005], higher complication rate (85.5% vs. 74.6% and 76.9%, P=0.052) and higher 90-day mortality (13% vs. 3.9% and 0%, P=0.002). Compared to PEA and PEA+ medical therapy induction groups, patients in the BPA induction group were older [72 (IQR, 62-76) vs. 60 (IQR, 48-69) and 62 (IQR, 52-72) years, P=0.005], and underwent shorter cardiopulmonary bypass (191.9±47.9 vs. 222±107.2 and 236.8±46.4 min, P<0.001), aortic cross clamping (54.8±21 vs. 82.7±31.4 and 80.1±32.9 min, P=0.002) and circulatory arrest time (19.6±6.2 vs. 26.6±10.8 and 30.1±15.1 min, P=0.008). CONCLUSIONS Multimodal therapy approach to CTEPH patients did not affect effectiveness of PEA. Medical therapy and BPA could act in synergy with surgery to treat more challenging patients.
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Affiliation(s)
- Olaf Mercier
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Clément Dubost
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Amélie Delaporte
- Intensive care unit, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Thibault Genty
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Anesthesiology, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Dominique Fabre
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Delphine Mitilian
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Antoine Girault
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Justin Issard
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Arash Astaneh
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Jean-Baptiste Menager
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Gaelle Dauriat
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Sacha Mussot
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Mitja Jevnikar
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- AP-HP, Service de Pneumologie et soins intensifs respiratoires, Hôpital Bicêtre, France
| | - Xavier Jais
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- AP-HP, Service de Pneumologie et soins intensifs respiratoires, Hôpital Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- AP-HP, Service de Pneumologie et soins intensifs respiratoires, Hôpital Bicêtre, France
| | - Gérald Simonneau
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Philippe Dartevelle
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Iolando Ion
- Intensive care unit, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - François Stephan
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Anesthesiology, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Philippe Brenot
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
| | - Elie Fadel
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, GHPSJ, Le Plessis Robinson, France
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Tzoumas A, Peppas S, Sagris M, Papanastasiou CA, Barakakis PA, Bakoyiannis C, Taleb A, Kokkinidis DG, Giannakoulas G. Advances in treatment of chronic thromboembolic pulmonary hypertension. Thromb Res 2022; 212:30-37. [DOI: 10.1016/j.thromres.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 01/29/2023]
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Surgical Management of Chronic Thromboembolic Pulmonary Hypertension. Cardiol Clin 2022; 40:89-101. [PMID: 34809920 PMCID: PMC8720361 DOI: 10.1016/j.ccl.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic thromboembolic pulmonary hypertension is a progressive disease, which may lead to severe right ventricular dysfunction and debilitating symptoms. Pulmonary thromboendarterectomy (PTE) provides the best opportunity for complete resolution of obstructing thromboembolic disease and functional improvement in appropriately selected patients. In this article, the authors review preoperative workup, patient selection, operative technique, postoperative care, and outcomes after PTE.
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Chronic Thromboembolic Pulmonary Hypertension: An Update. Diagnostics (Basel) 2022; 12:diagnostics12020235. [PMID: 35204326 PMCID: PMC8871284 DOI: 10.3390/diagnostics12020235] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease observed in a small proportion of patients after acute pulmonary embolism (PE). CTEPH has a high morbidity and mortality rate, related to the PH severity, and a poor prognosis, which mirrors the right ventricular dysfunction involvement. Pulmonary endarterectomy (PEA) reduces pulmonary vascular resistance, making it the treatment of choice and should be offered to operable CTEPH patients, as significant symptomatic and prognostic improvement has been observed. Moreover, these patients may also benefit from the advances made in surgical techniques and pulmonary hypertension-specific medication. However, not all patients are eligible for PEA surgery, as some have either distal pulmonary vascular obstruction and/or significant comorbidities. Therefore, surgical candidates should be carefully selected by an interprofessional team in expert centers. This review aims at making an overview of the risk factors and latest developments in diagnostic tools and treatment options for CTEPH.
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Ma RZ, Han PP, Tao XC, Li H, Wang L, Zhai ZG, Fu LP. A Feasibility Study on Using Single-Photon Emission Computed Tomography Pulmonary Perfusion/Ventilation Imaging for the Diagnosis of Chronic Thromboembolic Pulmonary Hypertension and Patient Risk Assessment. Int J Gen Med 2021; 14:8029-8038. [PMID: 34785945 PMCID: PMC8591112 DOI: 10.2147/ijgm.s335051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/11/2021] [Indexed: 11/23/2022] Open
Abstract
Objective The study is designed to evaluate the diagnostic ability of single-photon emission computed tomography (SPECT) pulmonary ventilation/perfusion (V/Q) imaging in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and investigate its feasibility in assessing patient risk. Methods A total of 83 patients suspected of having CTEPH who received V/Q tomography were retrospectively analyzed. The consistency between SPECT V/Q imaging and pulmonary angiography was compared to investigate the correlation between the percentage of pulmonary perfusion defect score (PPDs%) and the hemodynamic indices. Patients were grouped according to the pulmonary arterial hypertension risk stratification, and the V/Q imaging results were compared between different groups. Results For the 1494 pulmonary segments of the 83 patients, the sensitivity, specificity, and accuracy of identifying pulmonary segments with defects using V/Q imaging was 87.05%, 82.78% (668/807), and 84.74% (1266/1494), respectively. The average PPDs% (58.8 ± 12.6%) was positively correlated with the mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and right ventricular pressure (RVP; r =0.316, 0.318, and 0.432, respectively; P < 0.05) and negatively correlated with the six-minute walk distance (6MWD; r = −0.309; P < 0.05). There were 37 patients in the low-risk group and 46 in the medium-high-risk group. The number of pulmonary segments with perfusion defects (NPSPDs) and PPDs% were higher in the medium-high risk than in the low-risk group (t = −6.721, −5.032; P < 0.05). In the low- and medium-high-risk groups, the cut-off values for the NPSPDs (7.2 ± 2.1 and 10.2 ± 2.0) and PPDs% (51.9 ± 11.1% and 64.3 ± 11.1%,) were 8.5 and 61.25%, respectively. Conclusion SPECT V/Q imaging achieved an accurate diagnosis of CTEPH. The semi-quantitative analysis index (PPDs%) was correlated with the hemodynamic indices and 6MWD. SPECT V/Q could be used for the preoperative risk assessment of patients with CTEPH.
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Affiliation(s)
- Rong-Zheng Ma
- Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Ping-Ping Han
- Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Xin-Cao Tao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, National Clinical Research Center for Respiratory Diseases, Beijing, 100029, People's Republic of China
| | - Huan Li
- Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Ling Wang
- Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Zhen-Guo Zhai
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, National Clinical Research Center for Respiratory Diseases, Beijing, 100029, People's Republic of China
| | - Li-Ping Fu
- Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
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Minhas J, Narasimmal SP, M. Bull T, Marco TD, McConnell JW, Lammi MR, Thenappan T, P. Feldman J, S. Sager J, B. Badesch D, Ryan JJ, C. Grinnan D, Zwicke D, M. Horn E, Elwing JM, Moss JE, Eggert M, Shlobin OA, P. Frantz R, D. Bartolome S, Mathai SC, Mazimba S, C. Pugliese S, Al-Naamani N. Health-related quality of life and hospitalizations in chronic thromboembolic pulmonary hypertension versus idiopathic pulmonary arterial hypertension: an analysis from the Pulmonary Hypertension Association Registry (PHAR). Pulm Circ 2021; 11:20458940211053196. [PMID: 34671455 PMCID: PMC8521427 DOI: 10.1177/20458940211053196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/27/2021] [Indexed: 12/05/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare, morbid, potentially curable subtype of pulmonary hypertension that negatively impacts health-related quality of life (HRQoL). Little is known about differences in HRQoL and hospitalization between CTEPH patients and idiopathic pulmonary arterial hypertension (IPAH) patients. Using multivariable linear regression and mixed effects models, we examined differences in HRQoL assessed by emPHasis-10 (E10) and SF-12 between CTEPH and IPAH patients in the Pulmonary Hypertension Association Registry, a prospective multicenter cohort of patients newly evaluated at a Pulmonary Hypertension Care Center. Multivariable negative binomial regression models were used to estimate incidence rate ratios (IRR) for hospitalization amongst the two groups. We included 461 IPAH patients and 169 CTEPH patients. Twenty-one percent of CTEPH patients underwent pulmonary thromboendarterectomy (PTE) before the end of follow-up. At baseline, patients with CTEPH had significantly worse HRQoL (higher E10 scores) (ß 2.83, SE 1.11, p = 0.01); however, differences did not persist over time. CTEPH patients had higher rates of hospitalization (excluding the hospitalization for PTE) compared to IPAH patients after adjusting for age, sex, body mass index, WHO functional class and six-minute walk distance (IRR 1.66, 95%CI 1.04-2.65, p = 0.03). CTEPH patients who underwent PTE had improved HRQoL as compared to those who were medically managed, but patients who underwent PTE were younger, had higher cardiac outputs and greater six-minute walk distances. In this large, prospective, multicenter cohort, CTEPH patients had significantly worse baseline HRQoL and higher rates of hospitalizations than those with IPAH. CTEPH patients who underwent PTE had significant improvements in HRQoL.
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Affiliation(s)
- Jasleen Minhas
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sai Prasanna Narasimmal
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd M. Bull
- Division of Pulmonary Sciences & Critical Care, University of Colorado, Denver, CO, USA
| | - Teresa De Marco
- Division of Cardiology, University of California, San Francisco, CA, USA
| | | | - Matthew R. Lammi
- Division of Pulmonary and Critical Care Medicine, Louisiana State University, New Orleans, LO, USA
| | | | - Jeremy P. Feldman
- Division of Pulmonary and Critical Care Medicine, Arizona Pulmonary Specialists, Phoenix, AZ, USA
| | - Jeffrey S. Sager
- Division of Pulmonary and Critical Care Medicine, Cottage PH center, Santa Barbara, CA, USA
| | - David B. Badesch
- Division of Pulmonary Sciences & Critical Care, University of Colorado, Denver, CO, USA
| | - John J. Ryan
- Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Daniel C. Grinnan
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Dianne Zwicke
- Division of Cardiology, Aurora Cardiovascular Services, Milwaukee, WI, USA
| | - Evelyn M. Horn
- Division of Cardiology, Weill Conrell Medicine, New York City, NY, USA
| | - Jean M. Elwing
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - John E. Moss
- Department of Pulmonary Medicine and Division of Critical Care, Mayo Clinic, Jacksonville, FL, USA
| | - Michael Eggert
- Division of Pulmonary and Critical Care Medicine, Sentara Hospital, Norfolk, VA, USA
| | - Oksana A. Shlobin
- Division of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Advanced Lung Disease and Transplant, Falls Church, VA, USA
| | - Robert P. Frantz
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sonja D. Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sula Mazimba
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Steven C. Pugliese
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Surgical results of chronic thromboembolic pulmonary endarterectomy in our recently developed program. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:295-303. [PMID: 34589247 PMCID: PMC8462111 DOI: 10.5606/tgkdc.dergisi.2021.21234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/30/2021] [Indexed: 11/21/2022]
Abstract
Background
In this case series, we aimed to present our diagnostic workup, surgical management, and results of the patients who underwent pulmonary endarterectomy.
Methods
In this case series, a total of 26 patients (8 males, 18 females; median age: 58 years; range, 34 to 67 years) who were evaluated by a multidisciplinary team and were diagnosed with chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy in our clinic between November 2015 and December 2019 were included. Pulmonary endarterectomy procedure was performed in all cases under cardiopulmonary bypass and total circulatory arrest. The results of the procedures were analyzed retrospectively.
Results
Perioperative complications were observed in seven patients (26.9%) and in-hospital mortality rate caused by perioperative complications was 15.38%. At one-year of postoperative follow-up, the mean systolic pulmonary artery pressure decreased from 78±22 mmHg to 41±20 mmHg, pulmonary vascular resistance decreased from 698±10 dyn·s·cm-5 to 235±10 dyn·s·cm-5, 6-min walk distance increased from 345±10 m to 460±10 m and, arterial oxygen saturation increased from 85±3.5% to 95±4%. New York Heart Association functional class improvement from Class III-IV to Class I-II was observed in most patients, and one-year mortality rate was 19.23%.
Conclusion
We suggest that patients diagnosed chronic thromboembolic pulmonary hypertension should be referred to cardiac surgery centers for pulmonary thromboendarterectomy, early before irreversible arteriopathy occurs.
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Kyaw K, Sabnam S, Cheing M, Davalos F, Gramuglia M. Elevated lipoprotein A in acute on chronic CTEPH with cardiogenic shock: a case report. J Community Hosp Intern Med Perspect 2021; 11:682-685. [PMID: 34567464 PMCID: PMC8462869 DOI: 10.1080/20009666.2021.1955450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The natural history of most thrombi undergoes total or near total resolution, but the thrombi in chronic thromboembolic pulmonary hypertension (CTEPH) do not resolve completely and subsequently increase the pulmonary vascular resistance. We hypothesised that the elevated lipoprotein A in acute pulmonary embolism could lessen the autoresorption of the emboli and ultimately lead to CTEPH.
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Affiliation(s)
- Kyaw Kyaw
- Department of Medicine, Columbia University Medical Center Harlem Hospital, New York, USA
| | - Shakya Sabnam
- Department of Medicine, Columbia University Medical Center Harlem Hospital, New York, USA
| | - Melanie Cheing
- Pulmonology Medicine, Department of Medicine, Columbia University Medical Center Harlem Hospital, New York, USA
| | - Fidencio Davalos
- Pulmonology Medicine, Department of Medicine, Columbia University Medical Center Harlem Hospital, New York, USA
| | - Michael Gramuglia
- Department of Medicine, Columbia University Medical Center Harlem Hospital, New York, USA
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Al Abri Q, Lu AJ, Ramchandani MK. Chronic Thromboembolic Pulmonary Hypertension: A Comprehensive Review and Multidisciplinary Approach to Surgical Treatment. Methodist Debakey Cardiovasc J 2021; 17:e18-e28. [PMID: 34377353 PMCID: PMC8331206 DOI: 10.14797/iqtu6714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 04/04/2021] [Indexed: 11/08/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed and undertreated sequelae of acute pulmonary embolism. In this comprehensive review, we provide an introductory overview of CTEPH, highlight recent advances in its diagnostic imaging, and describe the surgical technique for pulmonary thromboendarterectomy (PTE), the only established curative treatment for CTEPH. We also discuss the emerging role of balloon pulmonary angioplasty, both independently and combined with PTE, for patients with inoperable, residual, or refractory pulmonary hypertension post PTE. Finally, we stress the importance of a specialized multidisciplinary team approach to CTEPH patient care and share our approach to optimizing care for these patients.
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Sakurai S, Ukyo Y. Results of Macitentan in Japanese Patients With Chronic Thromboembolic Pulmonary Hypertension - A Prospective, Multicenter, Open-Label, Single-Arm, Phase 3 Study. Circ Rep 2021; 3:405-413. [PMID: 34250282 PMCID: PMC8258181 DOI: 10.1253/circrep.cr-21-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/27/2021] [Accepted: 05/10/2021] [Indexed: 11/09/2022] Open
Abstract
Background: Macitentan, an endothelin-receptor antagonist, is approved in Japan for the treatment of pulmonary arterial hypertension (PAH). This study evaluated the use of macitentan for chronic thromboembolic pulmonary hypertension (CTEPH) in Japanese patients. Methods and Results: This open-label single-arm Phase 3 study evaluated the efficacy and safety of oral macitentan 10 mg (once daily) in Japanese CTEPH patients. The study was prematurely discontinued due to the sponsor's decision to not develop macitentan 10 mg further for the indication of CTEPH (unrelated to safety concerns). Of the 9 patients enrolled in the study, 4 completed 24 weeks of treatment. The mean (±SD) ratio of pulmonary vascular resistance (PVR) at Week 16 to baseline was 71.9±34.3%. The mean (±SD) decreases in PVR and the PVR index (PVRI) from baseline to Week 16 were 181.4±243.9 dyn·s/cm5 and 280.6±366.0 dyn·s·m2/cm5, respectively. The mean (±SD) increase in the 6-min walk distance from baseline to Week 24 was 44.3±46.8 m. All treatment-emergent adverse events (TEAEs) were mild or moderate in severity, except for 1 serious TEAE of angioplasty reported in 1/9 patients that was severe in intensity. Conclusions: Definite conclusions regarding the efficacy of macitentan 10 mg in Japanese patients with CTEPH cannot be drawn because of premature study discontinuation. No safety concerns were observed, and the safety profile was consistent with previously reported studies in CTEPH and PAH patients.
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Affiliation(s)
- Satomi Sakurai
- Neuroscience, Pulmonary Hypertension, Cardiovascular & Metabolism Clinical Development Department, Clinical Science Division, Janssen Pharmaceutical K.K. Tokyo Japan
| | - Yoshifumi Ukyo
- Statistics and Decision Sciences Japan, Janssen Pharmaceutical K.K. Tokyo Japan
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Fathala A, Aldurabi A. Frequency of computed tomography abnormalities in patients with chronic thromboembolic pulmonary hypertension: a comparative study between lung perfusion scan and computed tomography pulmonary angiography. Multidiscip Respir Med 2021; 16:753. [PMID: 34322231 PMCID: PMC8273626 DOI: 10.4081/mrm.2021.753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of pulmonary hypertension. Diagnosis of CTEPH can be established using various imaging techniques, including ventilation-perfusion scintigraphy (VQ) and multidetector computed tomography pulmonary angiography (CTPA). The aim of this study was to determine the frequency of direct pulmonary vascular, parenchymal lung, and cardiac abnormalities on CTPA in patients with CTEPH and to compare the diagnostic accuracy of both VQ scan CTPA in detecting CTEPH. Methods We retrospectively included 54 patients who had been referred for pulmonary hypertension service (20 males, 34 females). All patients had VQ scan and CTPA within 15 days and underwent pulmonary artery endarterectomy (PEA) thereafter. VQ scans were reported according to modified PIOPED (Prospective Investigation of Pulmonary Embolism Diagnosis) criteria. CTPA was considered as diagnostic for CTEPH if it showed presence of thrombus, webs, stenosis, or perfusion lung abnormalities. Results The mean age of the study population was 41±10 years. The mean pulmonary artery pressure was 53±13 mmHg. Fifty-three out of 54 patients in the study population had high probability VQ scan and one patient had intermediate probability. CTPA was suggestive of CTEPH in all patients. The most frequent CTPA findings in the central pulmonary arteries and peripheral arteries were presence of thrombotic materials, abnormal vessel tapering and abrupt vessels-cut off (76% vs 65%, 67% vs 48%, and 48% vs 22%), respectively. The mosaic lung perfusion was present in 78% of the patients, and various cardiac morphology abnormalities were present and most common was abnormal right to left ventricle ratio (69%). Conclusion Our findings indicate that both VQ scan and CTPA are highly sensitive for the detection of CTEPH confirmed by PEA. Most CTEPH patients had several pulmonary vascular, parenchymal lung and cardiac abnormalities. There was no sign with 100% sensitivity on CTPA for CTEPH detection.
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Affiliation(s)
- Ahmed Fathala
- Department of Radiology, Nuclear Medicine and Cardiovascular Imaging, King Faisal Specialist Hospital and Research Center, Riyadh
| | - Alaa Aldurabi
- Department of Radiology, College of Medicine, Qassim University, Buraidah, Saudi Arabia
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Türer Cabbar A, Değertekin MM, Şimşek MA, Özveren O, Güleç S, Yanartaş M, Gezer Taş S, Olgun Yıldızeli Ş, Mutlu B, İşbir T, Yıldızeli B. Evaluation of Asymmetric Dimethylarginine Levels in Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy. Heart Lung Circ 2021; 31:110-118. [PMID: 34130918 DOI: 10.1016/j.hlc.2021.05.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/13/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary embolism, and pulmonary endarterectomy (PEA) is the surgical treatment. Asymmetric dimethylarginine (ADMA) levels are increased in pulmonary hypertension. This study aimed to investigate serum ADMA levels in patients with CTEPH, the effect of PEA on ADMA, and its prognostic value in long-term mortality. METHOD Eighty (80) patients with CTEPH and 32 healthy controls were included. Preoperative serum ADMA levels, determined using an enzyme-linked immunosorbent assay, were compared between patients with CTEPH and controls. Of 80 patients, 64 had PEA. Pre- and 6-month postoperative serum ADMA levels, 6-minute walk distance (6MWD), and haemodynamic parameters were collected from patients undergoing PEA. Patients were followed-up for survival analysis. RESULTS Mean ± standard deviation serum ADMA levels were significantly higher in patients with CTEPH compared with controls (0.79±0.32 μmol/L vs 0.52±0.12 μmol/L; p=0.0001). Statistically significant differences were observed between preoperative and postoperative serum ADMA levels (0.78±0.30 μmol/L vs 0.62±0.22 μmol/L; p=0.0001), 6MWD (p=0.0001), and pulmonary vascular resistance (p=0.0001) in 60 patients who underwent and survived PEA. The decrease in serum ADMA levels and increase in 6MWD were significantly correlated (r=-0.286, p=0.027). No other correlation was found. Perioperative mortality was 6.3%, and the survival rate with a mean follow-up of 34.57±8.20 months was 93.3%. Patients with serum ADMA levels >0.8 μmol/L had a significantly lower survival rate (logrank: 5.86; p=0.015). CONCLUSIONS Levels of circulating ADMA might add diagnostic and prognostic information in CTEPH. Pulmonary endarterectomy is associated with an improvement in serum ADMA levels. Preoperative serum ADMA levels may be useful for estimating the outcome of PEA.
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Affiliation(s)
- Ayça Türer Cabbar
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey.
| | | | - Mustafa A Şimşek
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Olcay Özveren
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Seda Güleç
- Department of Medical Biology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Mehmed Yanartaş
- Department of Cardiovascular Surgery, Kartal Koşuyolu High Specialty Educational and Research Hospital, Istanbul, Turkey
| | - Serpil Gezer Taş
- Department of Cardiovascular Surgery, Kartal Koşuyolu High Specialty Educational and Research Hospital, Istanbul, Turkey
| | - Şehnaz Olgun Yıldızeli
- Department of Pulmonary and Intensive Care, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
| | - Bülent Mutlu
- Department of Cardiology, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
| | - Turgay İşbir
- Department of Medical Biology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
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Matsuoka Y, Taniguchi Y, Miwa K, Sumimoto K, Tsuboi Y, Onishi H, Yanaka K, Emoto N, Hirata K. Assessment of oxygenation after balloon pulmonary angioplasty for patients with inoperable chronic thromboembolic pulmonary hypertension. Int J Cardiol 2021; 333:188-194. [PMID: 33684382 DOI: 10.1016/j.ijcard.2021.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of balloon pulmonary angioplasty (BPA) in patients with inoperable chronic thromboembolic pulmonary hypertension would be promising. However, some patients showed residual dyspnea or symptoms, despite normalized hemodynamics. We aimed to clarify the clinical impact of oxygenation parameters on BPA outcome. METHOD Ninety-nine consecutive patients who underwent BPA from September 2011 to December 2019 were enrolled. We evaluated hemodynamics with right heart catheterization, arterial blood gas examination, New York Heart Association functional class (NYHA-FC), respiratory function tests, nocturnal oximetry, and exercise capacity (6-min walk test and cardiopulmonary exercise testing) at baseline and after BPA. RESULT Nearly normal hemodynamics was achieved after BPA (mean pulmonary artery pressure (PAP): 37.5 ± 10.0 to 20.6 ± 4.9 mmHg, p < 0.01). Oxygenation slightly improved (partial pressure of arterial oxygen; 61.5 ± 12.3 to 67.7 ± 12.7 mmHg, p < 0.01). Exertional desaturation remained unchanged (-8.1 ± 4.8 to -7.8 ± 5.1, p = 0.59), and this was associated with residual symptom (NYHA-FC ≥ 2) after BPA (OR 0.591, 95% CI 0.416-0.840, p = 0.003) in multivariate regression analyses. Lower vital capacity (r2 = 0.03, p = 0.01), higher mean PAP (r2 = 0.08, p = 0.02), and higher minute ventilation/carbon dioxide production (VE/VCO2) slope (r2 = 0.18, p < 0.01), the marker of ventilatory inefficiency, were correlated with exertional desaturation after BPA in multivariate linear analyses. CONCLUSION Although hemodynamics nearly normalized, oxygenation did not. Moreover, exertional desaturation remained unchanged. This might cause residual symptom after BPA. Residual pulmonary hypertension suggesting incurable arteriopathy, and higher VE/VCO2 slope suggesting ventilation-perfusion mismatch might be related to exertional desaturation. Domiciliary oxygen therapy should be continued, if necessary.
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Affiliation(s)
- Yoichiro Matsuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
| | - Keisuke Miwa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Keiko Sumimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yasunori Tsuboi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Niznansky M, Kavan J, Zemankova P, Prskavec T, Ambroz D, Jansa P, Lindner J. Computed tomography angiographic parameters of pulmonary artery as prognostic factors of residual pulmonary hypertension after pulmonary endarterectomy. J Int Med Res 2021; 49:3000605211002024. [PMID: 33761801 PMCID: PMC8166393 DOI: 10.1177/03000605211002024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/19/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES This study aimed to retrospectively assess using computed tomography pulmonary angiography (CTPA) for predicting residual pulmonary hypertension (RPH) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA). METHODS We retrospectively analyzed data of 131 patients with CTEPH who underwent PEA in our center (2008-2015). We measured several diameters of the pulmonary artery and thoracic aorta preoperatively. We evaluated the relationship between these measurements (and their indices) and signs of RPH represented by pulmonary artery systolic pressure (PASP) estimated by echocardiography. RESULTS Significant correlations were observed between the aortopulmonary index and prediction of any residual hypertension and moderate/severe hypertension 1 year after PEA, and any residual hypertension and severe hypertension 2 years after PEA. The aortopulmonary index was significantly related to a reduction in PASP 1 year after the operation. A lower aortopulmonary index (≤0.88 for the ascending aorta and ≤0.64 for the descending aorta) predicted lower RPH. CONCLUSIONS Preoperative CTPA parameters can be used to assess the risk of RPH after PEA. The aortopulmonary index has significant predictive value for RPH and a reduction in PASP after PEA. Lower values of the aortopulmonary index suggest a better outcome after PEA.
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Affiliation(s)
- Matus Niznansky
- Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Jan Kavan
- Department of Radiology, General University Hospital in Prague and First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Petra Zemankova
- Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Tomas Prskavec
- Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - David Ambroz
- Department of Cardiology and Angiology, General University Hospital in Prague and First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Pavel Jansa
- Department of Cardiology and Angiology, General University Hospital in Prague and First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Jaroslav Lindner
- Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University in Prague, Czech Republic
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Özgüven S, Kesim S, Öksüzoğlu K, Yanartaş M, Taş S, Şen F, Öneş T, İnanır S, Turoğlu HT, Mutlu B, Erdil TY, Yıldızeli B. Correlation Between Perfusion Abnormalities Extent in Ventilation/Perfusion SPECT/CT with Hemodynamic Parameters in Patients with Chronic Thromboembolic Pulmonary Hypertension. Mol Imaging Radionucl Ther 2021; 30:28-33. [PMID: 33586404 PMCID: PMC7885277 DOI: 10.4274/mirt.galenos.2020.31932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension with persistent pulmonary vascular obstruction and exercise intolerance, which may benefit from pulmonary endarterectomy (PEA). Ventilation/perfusion (V/Q) scan is the preferred screening test of CTEPH, which can be used to assess the anatomical extent of the disease. This study aimed to analyze the correlation between the extent of mismatched Q defects in V/Q single photon emission computed tomography/computed tomography (SPECT/CT) with preoperative clinical and hemodynamic parameters in patients with CTEPH. Methods A total of 102 patients with CTEPH prior to PEA having V/Q SPECT/CT scans were retrospectively reviewed. Age, gender, New York Heart Association classification, intraoperative right-sided heart catheterization (mPAP and PVR), and 6-minute walk test (6MWT) findings were obtained from clinical records of patients. Results Linear regression analysis showed a significant but weak correlation between the preoperative mPAP and PVR with the extent of mismatched Q defects in V/Q SPECT/CT (rs=0.09474 with p=0.0016 and rs=0.045 with p=0.045, respectively). No significant correlation was found between 6MWT and extent of mismatched Q defects in V/Q SPECT/CT (p>0.05). Conclusion A quantitative assessment of Q defects on V/Q SPECT/CT might provide information about hemodynamic parameters in patients with CTEPH.
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Affiliation(s)
- Salih Özgüven
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Selin Kesim
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Kevser Öksüzoğlu
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Mehmed Yanartaş
- University of Health Sciences Turkey, Kartal Koşuyolu Training and Research Hospital, Clinic of Cardiovascular Surgery, İstanbul, Turkey
| | - Serpil Taş
- University of Health Sciences Turkey, Kartal Koşuyolu Training and Research Hospital, Clinic of Cardiovascular Surgery, İstanbul, Turkey
| | - Feyza Şen
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Tunç Öneş
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Sabahat İnanır
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Halil Turgut Turoğlu
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Bülent Mutlu
- Marmara University Pendik Training and Research Hospital, Clinic of Cardiology, İstanbul, Turkey
| | - Tanju Yusuf Erdil
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Bedrettin Yıldızeli
- Marmara University Pendik Training and Research Hospital, Clinic of Thoracic Surgery, İstanbul, Turkey
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Kim KK, Krause M, Brandes IF, Khanna AK, Bartels K. Transesophageal echocardiography for perioperative management in thoracic surgery. Curr Opin Anaesthesiol 2021; 34:7-12. [PMID: 33315644 DOI: 10.1097/aco.0000000000000947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. RECENT FINDINGS Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. SUMMARY Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.
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Affiliation(s)
- Kevin K Kim
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Martin Krause
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ivo F Brandes
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University, School of Medicine, Winston-Salem, North Carolina, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Taniguchi Y, Matsuoka Y, Onishi H, Yanaka K, Emoto N, Nakai H, Okada K, Hirata K. The role of balloon pulmonary angioplasty and pulmonary endarterectomy: Is chronic thromboembolic pulmonary hypertension still a life-threatening disease? Int J Cardiol 2020; 326:170-177. [PMID: 33086125 DOI: 10.1016/j.ijcard.2020.10.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/02/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The management of non-operable chronic thromboembolic pulmonary hypertension (CTEPH) has evolved with the availability of balloon pulmonary angioplasty (BPA) and pulmonary vasodilators. We launched the BPA program in 2011. The aim was to analyze the survival and treatment efficacy of our CTEPH treatment program in the modern management era. METHODS AND RESULTS We retrospectively reviewed data from 143 consecutive CTEPH patients diagnosed from January 2011 (i.e. after the availability of BPA) to December 2019. Of forty-one patients who underwent pulmonary endarterectomy (PEA), 25 underwent additional BPA (Combination group) and the others were treated with only PEA (PEA group). Ninety patients underwent BPA (BPA group). The remaining 12 patients did not undergo any interventional treatments. The 1- and 5-year survival rates of operated patients (n = 41) were 97.4% and 90.0%, compared to 96.9% and 86.9% in not-operated patients (n = 102), respectively (p = 0.579). There was no mortality in the Combination group. Mean pulmonary artery pressure after treatments in the PEA only, Combination, and BPA only groups was 20.5 ± 6.7, 17.9 ± 4.9, and 20.7 ± 4.6 mmHg, respectively (p = 0.067, one-way ANOVA). Percent decrease of pulmonary vascular resistance in each treatment groups was -73.7 ± 11.3%, -74.3 ± 11.8%, and - 54.9 ± 22.5%, respectively (p < 0.01, one-way ANOVA). CONCLUSION There was no significant difference in long-term survival between operated and not-operated CTEPH. Moreover, the Combination approach might have the potential to introduce notable improvements in the prognosis of CTEPH. BPA and PEA appear to be mutually complementary therapies in the modern management era.
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Affiliation(s)
- Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
| | - Yoichiro Matsuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hidekazu Nakai
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Tanabe N, Fukuda K, Matsubara H, Nakanishi N, Tahara N, Ikeda S, Kishi T, Satoh T, Hirata KI, Inoue T, Kimura H, Okano Y, Okazaki O, Sata M, Tsujino I, Ueno S, Yamada N, Yao A, Kuriyama T. Selexipag for Chronic Thromboembolic Pulmonary Hypertension in Japanese Patients - A Double-Blind, Randomized, Placebo-Controlled, Multicenter Phase II Study. Circ J 2020; 84:1866-1874. [PMID: 32879152 DOI: 10.1253/circj.cj-20-0438] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Selexipag is an oral prostacyclin receptor (IP receptor) agonist with a non-prostanoid structure. This study examined its efficacy and safety in Japanese patients with non-operated or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH). METHODS AND RESULTS This Phase II study was a randomized, double-blind, placebo-controlled parallel-group comparison. The primary endpoint was a change in pulmonary vascular resistance (PVR) from baseline to week 17. The main analysis involved a per-protocol set group of 28 subjects. The change in PVR (mean±SD) after 17 weeks of treatment in the selexipag group was -104±191 dyn·s/cm5, whereas that in the placebo group was 26±180 dyn·s/cm5. Thus, the treatment effect after 17 weeks of selexipag treatment was calculated as -130±189 dyn·s/cm5(P=0.1553). Although the primary endpoint was not met, for the group not concomitantly using a pulmonary vasodilator the PVR in the selexipag group was significantly decreased compared with placebo group (P=0.0364). The selexipag group also showed improvement in total pulmonary resistance and cardiac index. CONCLUSIONS Selexipag treatment improved pulmonary hemodynamics in Japanese patients with CTEPH, but PVR did not show a significant difference between the selexipag and placebo groups. (Trial registration: JAPIC Clinical Trials Information [JapicCTI-111667]).
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Affiliation(s)
- Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Hiromi Matsubara
- Director of Entire Medical Departments, National Hospital Organization Okayama Medical Center
| | | | - Nobuhiro Tahara
- Department of Medicine, Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Takuya Kishi
- Department of Cardiology, Graduate School of Medical Sciences, International University of Health and Welfare
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Ken-Ichi Hirata
- Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Teruo Inoue
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine
| | | | - Yoshiaki Okano
- Department of Intermal Medicine, Hanwa Dai-ni Senboku Hospital
| | - Osamu Okazaki
- Department of Cardiology, National Center for Global Health and Medecine
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Ichizo Tsujino
- The First Department of Medicine, Hokkaido University School of Medicine
| | - Shuichi Ueno
- Department of Internal Medicine Division of Cardiovascular Medicine, Jichi Medical University School of Medicine
- Ueno Clinic
| | | | - Atsushi Yao
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
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Gerges M, Yacoub M. Chronic thromboembolic pulmonary hypertension - still evolving. Glob Cardiol Sci Pract 2020; 2020:e202011. [PMID: 33150155 PMCID: PMC7590968 DOI: 10.21542/gcsp.2020.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of severe pulmonary hypertension (PH). The disease is still underdiagnosed, and the true prevalence is unknown. CTEPH is characterized by intraluminal non-resolving thrombus organization and fibrous stenosis, or complete obliteration of pulmonary arteries, promoted by progressive remodeling of the pulmonary vasculature. One consequence of this is an increase in pulmonary vascular resistance and pressure, resulting in PH and progressive right heart failure, leading to death if left untreated. Endovascular disobliteration by pulmonary endarterectomy (PEA) is the preferred treatment for CTEPH patients. PEA surgery is the only technique that can potentially cure CTEPH disease, especially in patients with fresh or organized thrombi of the proximal branches of pulmonary arteries. However, not all patients are eligible for PEA surgery. Recent research has provided evidence suggesting balloon pulmonary angioplasty (BPA) and targeted medical therapy as additional promising available treatments options for inoperable CTEPH and recurrent/persistent PH after PEA surgery. Studies on BPA have shown it to improve pulmonary hemodynamics, symptoms, exercise capacity and RV function in inoperable CTEPH. Subsequently, BPA has developed into an essential component of the modern era of CTEPH treatment. Large randomized controlled trials have demonstrated varying significant improvements with targeted medical therapy in technically inoperable CTEPH patients. Thus, treatment of CTEPH requires a comprehensive multidisciplinary assessment, including an experienced PEA surgeon, PH specialist, BPA interventionist and CTEPH-trained radiologist at expert centers. In this comprehensive review, we address the latest developments in the fast-evolving field of CTEPH. These include advancements in imaging modalities and developments in operative and interventional techniques, which have widened the range of patients who may benefit from these procedures. The efficacy and safety of targeted medical therapies in CTEPH patients are also discussed. As the treatment options for CTEPH improve, hybrid management involving multiple treatments in the same patient may become a viable option in the near future.
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Affiliation(s)
- Mario Gerges
- Department of Internal Medicine II, Division of Cardiology, General Hospital Vienna, Medical University of Vienna, Vienna, Austria
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Lysdahlgaard S, Hess S, Gerke O, Weber Kusk M. A systematic literature review and meta-analysis of spectral CT compared to scintigraphy in the diagnosis of acute and chronic pulmonary embolisms. Eur Radiol 2020; 30:3624-3633. [PMID: 32112117 DOI: 10.1007/s00330-020-06735-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/20/2019] [Accepted: 02/07/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE To examine the diagnostic accuracy of spectral CT pulmonary angiography (S-CTPA) using ventilation-perfusions lung scintigraphy (V/Q-scan) as a reference standard in the diagnosis of acute or chronic pulmonary embolism (APE/CPE) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS PubMed, Embase, Scopus, and Web of Science were searched for the period from 1 Jan 2006 to 7 Feb 2019; eligible studies had > 10 patients over 18 years old, a diagnostic outcome of PE or CTEPH, and used V/Q scan as a reference standard. Bias and applicability were assessed using QUADAS-2 tools. Sensitivities, specificities, and predictive values were noted or calculated from available information. Meta-analysis employed a fixed-effects model of Mantel and Haenszel. Heterogeneity was assessed with I-squared statistics. RESULTS Four hundred ninety-three unique records were identified. Following screening by title, 53 studies were included in the abstract and full-text assessment. A total of six articles were included; four were suitable for a meta-analysis. Pooled sensitivity was 94.2% (95% CI, 88.3-100%), pooled specificity was 88.5% (95% CI, 81.3-95.6%), and positive and negative predictive values were 87.8% (95% CI, 80.3-95.4%) and 94.5% (95% CI, 89.3-99.7%), respectively. CONCLUSION Data on S-CTPA for PE/CTEPH remains promising, but limited; only small studies with methodological issues are available. Evidence is best for CPE/CTEPH whereas no firm conclusions are possible for APE. There is a need for larger, prospective studies with a robust composite reference standard including state-of-the-art CTPA and V/Q-scans. KEY POINTS • S-CTPA has high sensitivity and specificity for perfusion defects in patients with PE or CPETH. • Methodological issues and diversity of reference standards were found in the small number of included studies. • There is a need for larger prospective studies with more robust composite reference standards.
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Affiliation(s)
- Simon Lysdahlgaard
- Department of Radiology and Nuclear Medicine, University Hospital of Southwest Jutland, Esbjerg, Denmark.
| | - Søren Hess
- Department of Radiology and Nuclear Medicine, University Hospital of Southwest Jutland, Esbjerg, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Martin Weber Kusk
- Department of Radiology and Nuclear Medicine, University Hospital of Southwest Jutland, Esbjerg, Denmark
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Pöhler GH, Klimes F, Voskrebenzev A, Behrendt L, Czerner C, Gutberlet M, Cebotari S, Ius F, Fegbeutel C, Schoenfeld C, Kaireit TF, Hauck EF, Olsson KM, Hoeper MM, Wacker F, Vogel‐Claussen J. Chronic Thromboembolic Pulmonary Hypertension Perioperative Monitoring Using Phase‐Resolved Functional Lung (PREFUL)‐MRI. J Magn Reson Imaging 2020; 52:610-619. [DOI: 10.1002/jmri.27097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- Gesa H. Pöhler
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Filip Klimes
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Andreas Voskrebenzev
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Lea Behrendt
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Christoph Czerner
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Marcel Gutberlet
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Serghei Cebotari
- Department of CardiothoracicTransplantation and Vascular Surgery, Hannover Medical School Hannover Germany
| | - Fabio Ius
- Department of CardiothoracicTransplantation and Vascular Surgery, Hannover Medical School Hannover Germany
| | - Christine Fegbeutel
- Department of CardiothoracicTransplantation and Vascular Surgery, Hannover Medical School Hannover Germany
| | - Christian Schoenfeld
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Till F. Kaireit
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Erik F. Hauck
- Department of NeurosurgeryDuke Hospital Durham North Carolina USA
| | - Karen M. Olsson
- Department of Respiratory MedicineHannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Marius M. Hoeper
- Department of Respiratory MedicineHannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Frank Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Jens Vogel‐Claussen
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
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Nishina Y, Inami T, Kataoka M, Kariyasu T, Shimura N, Ishiguro H, Yokoyama K, Yoshino H, Satoh T. Evaluation of Right Ventricular Function on Cardiac Magnetic Resonance Imaging and Correlation With Hemodynamics in Patients With Chronic Thromboembolic Pulmonary Hypertension. Circ Rep 2020; 2:174-181. [PMID: 33693225 PMCID: PMC7921365 DOI: 10.1253/circrep.cr-20-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Balloon pulmonary angioplasty (BPA) is an alternative therapy for chronic thromboembolic pulmonary hypertension (CTEPH). Right heart catheterization (RHC) is essential to evaluate the efficacy of BPA. Cardiac magnetic resonance imaging (CMR) is also now used to assess the structure and function of the right heart non-invasively. The aim of this study was to correlate improvement in CMR with that on RHC, and compared with improvement in other non-invasive findings after BPA. Methods and Results: Forty-two patients underwent BPA between July 2012 and March 2015, and CMR, electrocardiography (ECG), and echocardiography were performed at the same time before and 6 months after BPA. Median pulmonary vascular resistance (PVR) was improved from 5.7 Wood units (IQR, 3.1-7.9 Wood units) to 2.7 Wood units (IQR, 1.6-3.9 Wood units; P<0.001). Changes in PVR were correlated with the changes in 5 CMR, 9 ECG, and 5 echocardiography parameters. On logistic analysis to identify the indicators of improving PH (i.e., PVR <3 Wood units), 4 CMR parameters were independently correlated with PVR change, one of which was median septal inversion ratio (SIR; 0.59; IQR, 0.54-0.63 to 0.54; IQR, 0.50-0.58, P<0.0001). SIR was the best predictor of PH (OR, 1.27; P<0.05). Conclusions: CMR can be used to estimate hemodynamic changes after BPA, and SIR is useful to predict alleviation of PH.
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Affiliation(s)
- Yoshio Nishina
- Department of Cardiovascular Medicine, Kyorin University School of Medicine Tokyo Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University School of Medicine Tokyo Japan
| | - Masaharu Kataoka
- Division of Cardiology, Department of Medicine, Keio University School of Medicine Tokyo Japan
| | - Toshiya Kariyasu
- Department of Radiology, Kyorin University School of Medicine Tokyo Japan
| | - Nobuhiko Shimura
- Department of Cardiovascular Medicine, Kyorin University School of Medicine Tokyo Japan
| | - Haruhisa Ishiguro
- Department of Cardiovascular Medicine, Kyorin University School of Medicine Tokyo Japan
| | - Kenichi Yokoyama
- Department of Radiology, Kyorin University School of Medicine Tokyo Japan
| | - Hideaki Yoshino
- Department of Cardiovascular Medicine, Kyorin University School of Medicine Tokyo Japan
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University School of Medicine Tokyo Japan
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Arthur Ataam J, Amsallem M, Guihaire J, Haddad F, Lamrani L, Stephan F, Jaïs X, Humbert M, Mercier O, Fadel E. Preoperative C-reactive protein predicts early postoperative outcomes after pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension. J Thorac Cardiovasc Surg 2020; 161:1532-1542.e5. [PMID: 32007254 DOI: 10.1016/j.jtcvs.2019.11.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/09/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether preoperative systemic inflammation (defined by C-reactive protein [CRP] levels ≥10 mg/L) is associated with worse functional and hemodynamic status and poor early outcomes postendarterectomy in patients with chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This study included 159 patients who underwent pulmonary endarterectomy from 2009 to 2013 (derivation cohort) and 238 patients from 2015 to 2016 (validation cohort) with CRP data from the national CTEPH registry. The correlations between proinflammatory markers (CRP, interleukins 1 and 6, fibrinogen, and leukocytes) and hemodynamics were assessed in the derivation cohort. Pre-, perioperative characteristics, and 30-day outcomes (ie, death or lung transplant or extracorporeal membrane oxygenation need or inotropic or vasopressor need ≥3 days) of patients with CRP levels ≥ or <10 mg/L were compared. RESULTS Median age of the derivation cohort was 63 [52-73] years with 48% female, 80% in New York Heart Association class III/IV. The validation cohort had similar demographics and disease severity. Patients with CRP ≥10 mg/L had greater resistance levels and lower cardiac index than those with CRP <10 mg/L in both cohorts. The primary endpoint was reached in 38% (derivation) and 42% (validation) of patients. In multivariable logistic regression analysis, CRP ≥10 mg/L was associated with the primary endpoint in both the derivation cohort (odd ratio, 2.49 [1.11-5.61], independently of New York Heart class class IV and aortic clamping duration) and the validation cohort (odd ratio, 1.89 [1.09-3.61], independently of age and aortic clamping duration). CONCLUSIONS Preoperative CRP ≥10 mg/L is independently associated with adverse early outcomes postendarterectomy.
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Affiliation(s)
- Jennifer Arthur Ataam
- Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France; Department of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford, Calif
| | - Myriam Amsallem
- Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France; Department of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford, Calif.
| | - Julien Guihaire
- Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France; Department of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Francois Haddad
- Department of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford, Calif
| | - Lilia Lamrani
- Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Francois Stephan
- Department of Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Xavier Jaïs
- Department of Pulmonary Diseases, Kremlin Bicetre Hospital‒APHP, Kremlin Bicetre, France
| | - Marc Humbert
- Department of Pulmonary Diseases, Kremlin Bicetre Hospital‒APHP, Kremlin Bicetre, France
| | - Olaf Mercier
- Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France; Department of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Elie Fadel
- Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France; Department of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Fernandes CJCDS, de Oliveira EP, Salibe-Filho W, Terra-Filho M, Jardim CVP, Kato-Morinaga LT, Hoette S, de Souza R. Lung Cavities in Chronic Thromboembolic Pulmonary Hypertension. Clinics (Sao Paulo) 2020; 75:e1373. [PMID: 31939560 PMCID: PMC6945287 DOI: 10.6061/clinics/2020/e1373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/17/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Chronic thromboembolic pulmonary hypertension (CTEPH) is a unique form of pulmonary hypertension (PH) that arises from obstruction of the pulmonary vessels by recanalized thromboembolic material. CTEPH has a wide range of radiologic presentations. Commonly, it presents as main pulmonary artery enlargement, peripheral vascular obstructions, bronchial artery dilations, and mosaic attenuation patterns. Nevertheless, other uncommon presentations have been described, such as lung cavities. These lesions may be solely related to chronic lung parenchyma ischemia but may also be a consequence of concomitant chronic infectious conditions. The objective of this study was to evaluate the different etiologies that cause lung cavities in CTEPH patients. METHODS A retrospective data analysis of the medical records of CTEPH patients in a single reference PH center that contained or mentioned lung cavities was conducted between 2013 and 2016. RESULTS Seven CTEPH patients with lung cavities were identified. The cavities had different sizes, locations, and wall thicknesses. In two patients, the cavities were attributed to pulmonary infarction; in 5 patients, an infectious etiology was identified. CONCLUSION Despite the possibility of being solely associated with chronic lung parenchyma ischemia, most cases of lung cavities in CTEPH patients were associated with chronic granulomatous diseases, reinforcing the need for active investigation of infectious agents in this setting.
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Affiliation(s)
- Caio Julio Cesar dos Santos Fernandes
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Instituto do Cancer do Estado de São Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Sirio Libanes, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Ellen Pierre de Oliveira
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Willian Salibe-Filho
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Mario Terra-Filho
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Sirio Libanes, Sao Paulo, SP, BR
| | - Carlos Vianna Poyares Jardim
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Sirio Libanes, Sao Paulo, SP, BR
| | - Luciana Tamie Kato-Morinaga
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Sirio Libanes, Sao Paulo, SP, BR
| | - Susana Hoette
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rogerio de Souza
- Unidade de Hipertensao Pulmonar, Departamento de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Sirio Libanes, Sao Paulo, SP, BR
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Chronic thromboembolic pulmonary hypertension in patients with persistent chest symptoms after acute pulmonary embolism. Anatol J Cardiol 2020; 25:24-29. [PMID: 33382052 DOI: 10.14744/anatoljcardiol.2020.69057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE This study aimed to analyze the role of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with persistent chest symptoms after acute PE. METHODS Patients aged between 18 and 80 years who were followed up for acute PE were screened for chest symptoms which persisted after the anticoagulation treatment. Patients suffering other types of pulmonary hypertension (PH) or metastatic malignancies were excluded in this study. Demographic and functional data of patients included this study were collected. The patients underwent transthoracic echocardiography and ventilation/perfusion (VQ) scans. Also, invasive hemodynamic studies were done to patients with intermediate/high probability of VQ scans. RESULTS Of the 140 patients screen for this study, 29 patients (Female/Male=16/13) with mean age of 56.1±11.2 years and follow-up time of 35.1±17.7 months met the inclusion criteria. The mean systolic pulmonary artery blood pressure (sPAP) on transthoracic echocardiography was 28.9±4.9 mm Hg (range=20-40 mm Hg). Furthermore, intermediate or high probability of VQ scans was detected in 2 patients, who were subsequently diagnosed with CTEPH (6.9%) via right heart catheterization. CONCLUSION CTEPH was diagnosed at a low rate in patients with persistent chest symptoms after the anticoagulation treatment for PE. CTEPH is still an elusive entity, which requires a multidisciplinary and invasive approach.
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Narechania S, Renapurkar R, Heresi GA. Mimickers of chronic thromboembolic pulmonary hypertension on imaging tests: a review. Pulm Circ 2020; 10:2045894019882620. [PMID: 32257112 PMCID: PMC7103595 DOI: 10.1177/2045894019882620] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/21/2019] [Indexed: 12/20/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by mechanical obstruction of large pulmonary arteries secondary to one or more episodes of pulmonary embolism. Ventilation perfusion scan is the recommended initial screening test for this condition and typically shows multiple large mismatched perfusion defects. However, not all patients with an abnormal ventilation perfusion scan have CTEPH since there are other conditions that be associated with a positive ventilation perfusion scan. These conditions include in situ thrombosis, pulmonary artery sarcoma, fibrosing mediastinitis, pulmonary vasculitis and sarcoidosis, among others. Although these conditions cannot be distinguished from CTEPH using a ventilation perfusion scan, they have certain characteristic radiological features that can be demonstrated on other imaging techniques such as computed tomography scan and can help in differentiation of these conditions. In this review, we have summarized some key clinical and radiological features that can help differentiate CTEPH from the CTEPH mimics.
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Affiliation(s)
| | - Rahul Renapurkar
- Department of Diagnostic Radiology,
Cleveland
Clinic, Cleveland, OH, USA
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48
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Işık M, Tanyeli Ö, Dereli Y, Ege E, Görmüş N. Akut ve Kronik Pulmoner Tromboembolide Cerrahi Tecrübelerimiz. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.661262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Akinseye OA, Nayyar M, Das P. Uterine intravenous leiomyomatosis with femoral vein, intracaval, intracardiac and pulmonary artery extension. Future Cardiol 2019; 16:27-32. [PMID: 31766884 DOI: 10.2217/fca-2019-0002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report a 54-year-old female with recently diagnosed multiple cardiac thrombi and pulmonary embolism that was treated with thrombolytics and anticoagulants. She presented again with worsening dyspnea and was found to have persistent large cardiac thrombi on echocardiogram. Surgical findings revealed a single right atrial mass originating from inferior vena cava and extending into the pulmonary artery. The mass was successfully removed. Final pathology revealed a benign smooth muscle and vascular mass with estrogen and progesterone receptor positivity favoring uterine intravenous leiomyoma. She was discharged on warfarin and leuprolide therapy. This diagnosis requires a high index of suspicion, especially in a middle-aged woman with right atrial mass and history of an existing leiomyoma, hysterectomy or myomectomy.
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Affiliation(s)
- Oluwaseun A Akinseye
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Mannu Nayyar
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Pranab Das
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Ranka S, Mohananey D, Agarwal N, Verma BR, Villablanca P, Mewhort HE, Ramakrishna H. Chronic Thromboembolic Pulmonary Hypertension-Management Strategies and Outcomes. J Cardiothorac Vasc Anesth 2019; 34:2513-2523. [PMID: 31883688 DOI: 10.1053/j.jvca.2019.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/11/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. Pulmonary endarterectomy is the surgical procedure of choice with good postoperative survival and functional outcomes, especially when done at high-volume centers with a multidisciplinary approach. There has been a resurgence of balloon pulmonary angioplasty (BPA) as salvage therapy for inoperable CTEPH or in its newfound hybrid role for persistent postoperative pulmonary hypertension with excellent 1-year and 3-year survival. Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.
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Affiliation(s)
- Sagar Ranka
- Department of Cardiovascular Medicine, Kansas University Medical Center, Kansas City, KS
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Nikhil Agarwal
- Division of Cardiovascular Medicine, University of Buffalo, Buffalo, NY
| | - Beni Rai Verma
- Department of Cardiology, Cleveland Clinic, Cleveland, OH
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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