[Effects of iloprost combined with low dose tadalafil in adult congenital heart disease patients with severe pulmonary arterial hypertension: a single-center, open-label controlled study]

OBJECTIVE

To evaluate the therapy efficacy of iloprost combined with low dose tadalafil in adult congenital heart disease (CHD) patients with severe pulmonary arterial hypertension (PAH).

METHODS

Adult CHD patients with severe PAH were included and divided into the sequential combination therapy group [iloprost: 10 µg/inhalation, 6 times per day for 6 months, and then add oral tadalafil (5 mg/d) till 12 months, n = 32] and upfront combination therapy group [iloprost: 10 µg/inhalation, 6 times per day combined with oral tadalafil (5 mg) for 12 months, n = 36]. Data on 6 min walking test (6MWT), Borg dyspnea score, oxygen saturation measurement, WHO classification, and cardiac catheterization were obtained at baseline, 6 and 12 months.

RESULTS

Seventy-two patients were enrolled in the study and 68 patients completed the study. Pulmonary vascular resistance (PVR) was significantly reduced in the sequential combination therapy group[ (12.96 ± 6.48 ) Wood U vs. (16.94 ± 8.11) Wood U, P < 0.05] and in the upfront combination therapy group [(12.45 ± 7.32) Wood U vs. (16.73 ± 9.28) Wood U, P < 0.05] while pulmonary blood flow [(6.77 ± 3.17) L/min vs. (5.08 ± 2.36) L/min, P < 0.05; (6.95 ± 3.32) L/min vs. (5.03 ± 2.32) L/min, P < 0.05], the 6 MWD were significantly increased [(458 ± 59) m vs. (427 ± 65) m, P < 0.05; (494 ± 59) m vs. (436 ± 62) m, P < 0.01], the Borg dyspnea score (2.04 ± 0.72 vs. 2.52 ± 0.79, P < 0.05; 1.72 ± 0.73 vs. 2.51 ± 0.77, P < 0.01) was significantly improved in both groups at 6 months compared to baseline levels. In the upfront combination therapy group, venous oxygen saturation [(68.4 ± 9.3)% vs. (62.9 ± 9.5)%, P < 0.05] and systemic oxygen saturation during exercise[ (87.2 ± 9.7)% vs. (83.1 ± 15.6)%, P < 0.05]at 6 months were also significantly improved compared to baseline. At month 12, significantly lowered pulmonary artery pressure, PVR, Rp/Rs and increased pulmonary blood flow and cardiac index were evidenced in both groups compared to baseline.

CONCLUSION

Iloprost combined with low dose tadalafil regimen can effectively reduce PVR, increase 6MWD, and improve cardiopulmonary function in adults CHD patients with severe PAH. Compared with the sequential therapy regimen, the upfront combination therapy regimen can more rapidly improve the clinical symptoms of patients.

A case of pulmonary arterial hypertension associated with congenital extrahepatic portocaval shunt

Congenital extrahepatic portocaval shunt (CEPS) is a rare anomaly of the mesenteric vasculature in which the intestinal and splenic venous drainage bypasses the liver and drains directly into the inferior vena cava, the left hepatic vein or the left renal vein. This uncommon disease is frequently associated with other malformations and mainly affects females. Here we report a case of pulmonary arterial hypertension associated with CEPS (Abernethy type 1b shunt) in a 20-yr-old man who was incidentally diagnosed during evaluation of multiple nodules of the liver. The patient was treated by inhalation of iloprost (40 µg/day) with improved condition and walking test. Physicians should note that congenital portocaval shunt may cause pulmonary hypertension.

Stiff fingers as an unwanted side effect of intravascular tadalafil gel abuse

The internet provides the public with unregulated access to a wide range of medications. We present the case of a 43-year-old man who purchased oral tadalafil gel on the internet and injected it into his left radial artery. He presented 48 hours after injection with signs of ischaemia distal to the injection site requiring a combination of medical and surgical treatment. This unique case highlights the potential dangers of unregulated access to medication and the consequences of intravascular injection of oral gels.

The effects of iloprost on colonic anastomotic healing in rats under obstructive ileus conditions

BACKGROUND

The aim of this study was to investigate the effects of iloprost, on colonic anastomotic healing in rats, under obstructive ileus conditions.

MATERIALS AND METHODS

Eighty male Albino rats were randomized into four groups of 20 animals each. They underwent colonic resection followed by an inverted anastomosis. The rats of group 1 (control) and group 2 (ileus) received 3 mL of saline 0.9% intraperitoneally and those of group 3 (iloprost), and group 4 (ileus + iloprost) iloprost (2 μg/kg of body weight), immediately postoperatively and daily until the day of sacrifice. Each group was further divided into two equal subgroups, depending on the day of sacrifice. The animals of subgroup "a" were sacrificed on the fourth postoperative day, whereas those of "b" on the eighth day. Macroscopic and histologic assessment was performed, whereas anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were evaluated.

RESULTS

Means of bursting pressure, neoangiogenesis, fibroblast activity, and hydroxyproline concentration were significantly increased in group 4 compared with group 2. In addition, on the fourth postoperative day, the inflammatory cell infiltration and the collagenase I concentration were significantly decreased in group 4 compared with group 2. Moreover, on the eighth postoperative day, collagen deposition was significantly increased in group 4 compared with group 2.

CONCLUSIONS

Iloprost after intraperitoneal administration reverses the negative effect of obstructive ileus. It promotes not only the angiogenic activity but also collagen formation, resulting in increased bursting pressures on the fourth and eighth postoperative days.

Iloprost for idiopathic pulmonary arterial hypertension

Idiopathic pulmonary arterial hypertension is a rare but serious and life-threatening disease that leads to right heart failure and death within 2.8 years without specific treatment. This review focuses on the stable prostacyclin analog iloprost, its biologic action and pharmacology and, finally, on its clinical development, efficacy and safety in patients with idiopathic pulmonary arterial hypertension, which led to its approval for this indication. Furthermore, this review assesses the role of iloprost compared with other newly developed drugs, such as the endothelin receptor antagonist bosentan and the phosphodiesterase-5 inhibitor sildenafil, as well as other modes of application of prostacyclin and its analogs for the treatment of idiopathic pulmonary arterial hypertension. Based on the different modes of action of these substances, a combination of these treatments could be most promising for the future.

Role of serum lipoprotein at the site of iloprost therapy in the treatment of painful bone marrow edema

The authors hypothesized that the emergence of painful bone marrow edema occurs through microembolisms in the bone marrow that may be reflected in elevated plasma parameters of hypofibrinolysis or a disturbance of the lipid metabolism and that treatment with iloprost may lead to a decrease in or normalization of the elevated serum parameters and, therefore, to pain reduction. Twenty-one patients (12 men and 9 women; mean age, 50 years [range, 22-70 years]) with painful bone marrow edema and elevated lipoprotein(a) (Lp[a]) serum values were treated with intravenous iloprost. Before and 6 weeks after iloprost therapy, the serum concentrations of Lp(a), apolipoprotein A1 (ApoA1), and apolipoprotein B (ApoB) were determined. At 6-week follow-up, 17 patients reported complete resolution of their symptoms. For these patients, complete bone marrow edema resolution was observed on magnetic resonance imaging. Four patients reported that their symptoms were either the same or had worsened but had partial bone marrow edema resolution on magnetic resonance imaging. In these patients, Lp(a) values either increased or remained the same. Hence, the total success rate of iloprost treatment was 86% at a mean follow-up of 17 months (range, 3-45 months). Before iloprost therapy, mean ApoA1, ApoB, and Lp(a) values were 159.8, 108.3, and 69.1 mg/dL, respectively. Six weeks after iloprost therapy, mean ApoA1, ApoB, and Lp(a) values decreased to 147.6 (P=.011), 98.4 (P=.042), and 38.3 (P<.001) mg/dL, respectively. The results of this study indicate a possible role of hypofibrinolysis or a disturbance in the lipid metabolism in the emergence of painful bone marrow edema.

Prostanoids for intermittent claudication

BACKGROUND

Peripheral arterial disease (PAD) is a common cause of morbidity in the general population. While numerous studies have established the efficacy of prostanoids in PAD stages III and IV, the question of the role of prostanoids as an alternative or additive treatment in patients suffering from intermittent claudication (PAD II) has not yet been clearly answered. This is an update of a Cochrane Review first published in 2004.

OBJECTIVES

To determine the effects of prostanoids in patients with intermittent claudication (IC) Fontaine stage II.

SEARCH METHODS

For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12). Clinical trials databases were searched for details of ongoing or unpublished studies. In addition, reference lists of relevant articles were checked.

SELECTION CRITERIA

Randomised clinical trials of prostanoids versus placebo or alternative ('control') treatment in people with intermittent claudication were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Primary outcomes included pain-free walking distance (PFWD) and maximum walking distance (MWD), presented as mean change in walking distance during the course of the trial (% improvement) and as final walking distance (that is walking distance, in metres, after treatment) for the prostanoid and control groups.

MAIN RESULTS

Eighteen trials with a total of 2773 patients were included (16 in the original review and a further two in this update). As the majority of trials did not report standard deviations for the primary PFWD and MWD outcomes, it was often not possible to test for the statistical significance of any improvements in walking distance between groups. The quality of individual trials was variable and usually unclear due to insufficient reporting information. Comparison between trials was hampered by the use of different treadmill testing protocols, including different walking speeds and gradients. Such limitations in the data and the trial heterogeneity meant it was not possible to meaningfully pool results by meta-analysis.Four trials compared prostaglandin E1 (PGE1) with placebo; individual trials showed significant increases in walking distances with administration of PGE1 and in several trials the walking capacity remained increased after termination of treatment. Compared with pentoxifylline, PGE1 was associated with a higher final PFWD and MWD but these results were based on final walking distances rather than changes in walking distance from baseline. When PGE1 was compared with other treatments including laevadosin, naftidrofuryl and L-arginine, improvements in walking distances over time were observed for both PGE1 and the alternative treatment, but it was not possible from the data available to analyse statistically whether or not one treatment was more effective than the other.Six studies compared various preparations of prostacyclins (PGI2) with placebo. In one study using three different dosages of iloprost, PFWD and MWD appeared to increase in a dose-dependent manner; iloprost was associated with headache, pain, nausea and diarrhoea, leading to a higher rate of treatment withdrawal. Of three studies using beraprost sodium, one showed an improvement in PFWD and MWD compared with placebo while two showed no significant benefit. Beraprost sodium was associated with an increased incidence of drug-related adverse events. Of two studies on taprostene, the results of one in particular must be interpreted with caution due to an imbalance in walking capacity at baseline.Comprehensive, high quality data on outcomes such as quality of life, ankle brachial index, venous occlusion plethysmography and haemorrheological parameters were lacking.

AUTHORS' CONCLUSIONS

Whilst results from some individual studies suggested a beneficial effect of PGE1, the quality of these studies and of the overall evidence available is insufficient to determine whether or not patients with intermittent claudication derive clinically meaningful benefit from the administration of prostanoids. Further well-conducted randomised, double blinded trials with a sufficient number of participants to provide statistical power are required to answer this question.

Effect of dihydropyridine calcium channel blockers and glucocorticoids on the prevention and development of scleroderma renal crisis in an Italian case series

OBJECTIVES

Scleroderma renal crisis (SRC) is a relative rare yet dramatic event in the history of systemic sclerosis (SSc). Several factors that may precipitate or protect from the development of SRC have been described in previous case-control studies. To date, no attempt has been made to evaluate these factors in an observational fashion.

METHODS

Retrospective data from 410 SSc patients with disease duration <5 years at referral were evaluated in an observational fashion for the development of hypertensive or normotensive SRC within 5 years from the first visit at our centre. Baseline characteristics as well as the use of steroids or dhiydropyridine calcium-channel blockers (CCB) were analysed via the Cox regression method with time-dependent covariates.

RESULTS

In the multivariate model the diffuse subset the disease (HR=5.728 CI(95)=2.199-14.918, p<0.001) and the use of prednisone (HR=1.015, CI(95)=1.004-1.026, p=0.006) resulted to be predictors for the development of SRC, with a risk to develop SRC increased by 1.5% for every mg of prednisone/day consumed the trimester prior SRC. Contrariwise, the risk to develop SRC was highly reduced in those who were prescribed CCBs (HR=0.094, CI(95)=0.038-0.236, p<0.001).

CONCLUSIONS

Steroids exhibits a weak effect on the risk to progress toward SRC in our case series, whilst dhyidrophyridines CCB appeared to be protective against that. Further larger prospective studies are warranted to better define the role of CCB in this setting or as a background therapy for SSc.

Endobronchial miRNAs as biomarkers in lung cancer chemoprevention

Lung cancers express lower levels of prostacyclin than normal lung tissues. Prostacyclin prevents lung cancer in a variety of mouse models. A randomized phase II trial comparing oral iloprost (a prostacyclin analog) with placebo in high-risk subjects showed improvement in bronchial histology in former, but not current, smokers. This placebo-controlled study offered the opportunity for investigation of other potential intermediate endpoint and predictive biomarkers to incorporate into chemoprevention trials. Matched bronchial biopsies were obtained at baseline and at 6-month follow-up from 125 high-risk individuals who completed the trial: 31/29 and 37/28 current/former smokers in the iloprost and placebo arm, respectively. We analyzed the expression of 14 selected miRNAs by Real Time PCR in 496 biopsies. The expression of seven miRNAs was significantly correlated with histology at baseline. The expression of miR-34c was inversely correlated with histology at baseline (P < 0.0001) and with change in histology at follow-up (P = 0.0003), independent of treatment or smoking status. Several miRNAs were also found to be differentially expressed in current smokers as compared with former smokers. In current smokers, miR-375 was upregulated at baseline (P < 0.0001) and downregulated after treatment with iloprost (P = 0.0023). No miRNA at baseline reliably predicted a response to iloprost. No biomarker predictive of response to iloprost was found. MiR-34c was inversely correlated with baseline histology and with histology changes. Mir-34c changes at follow-up could be used as a quantitative biomarker that parallels histologic response in formalin-fixed bronchial biopsies in future lung cancer chemoprevention studies.

[Comparative pharmacoeconomic analysis of prostanoids for peripheral arterial occlusive]

Peripheral arteries occlusive disease (PAOD) is a prevalent illness that needs improved pharmacological management, especially for patients not eligible for surgical revascularization. Prostanoids (alprostadil or iloprost) were shown to be effective in PAOD and critical limb ischemia (CLI) but are rather costly. The results of our pharmacoeconomic study (cost estimation based on randomized control trial results) showed that iloprost does not increase cost of treatment when only direct medical costs are taken into account. If indirect costs are included into the analysis iloprost saves up to 27 thousand rubles per patient. Clinical efficacy is still high. Thus iloprost is a better alternative than alprostadil for CLI.

Acute effects of aerosolized iloprost in COPD related pulmonary hypertension - a randomized controlled crossover trial

Background

Inhaled iloprost potentially improves hemodynamics and gas exchange in patients with chronic obstructive pulmonary disease (COPD) and secondary pulmonary hypertension (PH).

Objectives

To evaluate acute effects of aerosolized iloprost in patients with COPD-associated PH.

Methods

A randomized, double blind, crossover study was conducted in 16 COPD patients with invasively confirmed PH in a single tertiary care center. Each patient received a single dose of 10 µg iloprost (low dose), 20 µg iloprost (high dose) and placebo during distinct study-visits. The primary end-point of the study was exercise capacity as assessed by the six minute walking distance.

Results

Both iloprost doses failed to improve six-minute walking distance (p = 0.36). Low dose iloprost (estimated difference of the means −1.0%, p = 0.035) as well as high dose iloprost (−2.2%, p<0.001) significantly impaired oxygenation at rest. Peak oxygen consumption and carbon dioxide production differed significantly over the three study days (p = 0.002 and p = 0.003, accordingly). As compared to placebo, low dose iloprost was associated with reduced peak oxygen consumption (−76 ml/min, p = 0.002), elevated partial pressure of carbon dioxide (0.27 kPa, p = 0.040) and impaired ventilation during exercise (−3.0l/min, p<0.001).

Conclusions

Improvement of the exercise capacity after iloprost inhalation in patients with COPD-associated mild to moderate PH is very unlikely.

Trial Registration

Controlled-Trials.com ISRCTN61661881

[Aerosolized iloprost therapy for pulmonary hypertensive crisis in 4 patients with idiopathic pulmonary arterial hypertension]

OBJECTIVE

To summary the efficacy and safety of aerosolized iloprost in patients with pulmonary hypertensive crisis.

METHODS

On the basis of conventional therapy, aerosolized iloprost (10 µg per time for 10 - 15 min in 2 hours interval, 8 times per day) was administered to four patients with idiopathic pulmonary arterial hypertension and pulmonary hypertensive crisis. Blood pressure, heart rate, systemic artery oxygen saturation, systolic pulmonary arterial pressure (sPAP) measured by echocardiography and the adverse events were analyzed.

RESULTS

After aerosolized iloprost therapy, sPAP was significantly decreased and systemic artery oxygen saturation was improved. Adverse events (nausea, vomiting, diarrhea, dry cough) were observed in two patients, and the iloprost use was stopped in one patient due to severe vomiting and diarrhea.

CONCLUSION

Aerosolized iloprost could significantly reduce the sPAP and improve the systemic artery oxygen saturation in patients with pulmonary hypertension crisis.

No additive effects of inhaled iloprost and prone positioning on pulmonary hypertension and oxygenation in acute respiratory distress syndrome

BACKGROUND

In acute respiratory distress syndrome (ARDS), pulmonary hypertension is associated with a poor prognosis. Prone position is effective to improve oxygenation whereas inhaled iloprost can treat pulmonary hypertension. However, combination of these interventions has not been examined before. The hypothesis was that this combination had additive effects on oxygenation and pulmonary hemodynamics as compared with each intervention alone.

METHODS

In a prospective, randomized cross-over study, ten pigs were anesthetized, intubated and ventilated with volume controlled ventilation. Carotid, jugular venous and pulmonary artery catheters were inserted. ARDS was induced with oleic acid (0.20 mL/kg). Measurements were repeated in randomized different sequences of prone or supine positions with or without iloprost inhalation (220 ng/kg/min) (four combinations). Systemic and pulmonary arterial pressures; arterial and mixed venous blood gases; and Qs/Qt and the resistances were recorded.

RESULTS

Iloprost decreased pulmonary artery pressures (for MPAP: P=0.034) in both supine (37±10 vs. 31±8 mmHg; P<0.05) and prone positions (38±9 vs. 29±8 mmHg; P<0.05); but did not obtain a significant improvement in oxygenation in both positions. Prone position improved the oxygenation (p<0.0001) compared to supine position in both with (361±140 vs. 183±158 mmHg, P<0.05) or without iloprost application (331±112 vs. 167±117 mmHg, P<0.05); but did not achieve a significant decrease in MPAP.

CONCLUSION

Although iloprost reduced pulmonary arterial pressures, and prone positioning improved oxygenation; there are no additive effects of the combination of both interventions on both parameters. To treat both pulmonary hypertension and hypoxemia, application of iloprost in prone position is suggested.

Acute responses to inhalation of Iloprost in patients with pulmonary hypertension

BACKGROUND

Iloprost has been used to test acute pulmonary vasoreactivity in idiopathic pulmonary arterial hypertension (PAH). We aimed to investigate the acute hemodynamic and oxygenation responses and tolerability to 20 µg aerosolized Iloprost in Chinese patients with pulmonary hypertension.

METHODS

Between March 2005 and May 2010, 212 pulmonary hypertension patients inhaled a single dose of 20 µg Iloprost over 10 - 15 minutes for vasoreactivity testing. The acute hemodynamic and oxygenation responses and adverse events were recorded.

RESULTS

Iloprost decreased total pulmonary resistance ((1747 ± 918) dyn×s×cm(-5) vs. (1581 ± 937) dyn×s×cm(-5), P < 0.001), increased stroke volume ((45.0 ± 22.1) ml vs. (47.0 ± 24.2) ml, P = 0.002), and cardiac output ((3.7 ± 1.7) L/ml vs. (3.9 ± 1.9) L/min, P = 0.009). Heart rate and systemic vascular resistance remained stable during inhalation. However, systemic arterial blood oxygen saturation fell slightly ((91.0 ± 6.8)% vs. (90.3 ± 6.7)%, P = 0.002). Pulmonary and systemic arterial blood pressures declined within 1 - 3 minutes after inhalation initiation and reached their lowest levels within 10 - 15 minutes. Idiopathic PAH responded more favorably than pulmonary hypertension due to other causes (P £0.001) and patients with less severe pulmonary hypertension have better responses to Iloprost. No adverse events requiring medical care or leading to termination of inhalation occurred.

CONCLUSIONS

Inhalation of 20 µg Iloprost showed potent and selective pulmonary hemodynamic effects and was well tolerated in the Chinese pulmonary hypertension patients. Patients with idiopathic PAH and less severe pulmonary hypertension responded more favorably to inhalation of Iloprost.

Cost effectiveness of prostacyclins in pulmonary arterial hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is considered an orphan disease. Prostacyclins are the keystone for PAH treatment. Choosing between the three available prostacyclin therapies could be complicated because there are no comparison studies, so the final decision must be driven by factors such as efficacy, administration route, safety profile and economic aspects.

OBJECTIVE

This study provides a cost-effectiveness and cost-utility comparison of initiating prostacyclin therapy with three different treatment alternatives (inhaled iloprost [ILO], intravenous epoprostenol [EPO] and subcutaneous treprostinil [TRE]) for patients with PAH. The goal of this work is to help physicians with their therapeutic decision-making.

METHODS

A Markov model was built to simulate a patient cohort with class III PAH according to the classification of the New York Heart Association (NYHA). Four health states corresponding with the NYHA classes plus death were allowed for patients in the model. Changing the treatment was possible when patients worsened from functional class III to IV. The time horizon was 3 years, allowing patients to transition between health states on a 12-week cycle basis. The study perspective was that of the National Health System (NHS) [only direct medical costs were included]. Unitary costs were obtained from the Drug Catalogue and e-Salud Database in 2009 and are given in euros (€). Data on health resources and treatment pathways were informed by a four-member expert panel. Efficacy was obtained from pivotal clinical trials of ILO, EPO and TRE, the latter used in Spain as a foreign medication. Utilities for each health state were obtained from the literature. The final efficacy measure was life-years gained (LYG), and utilities were used to obtain quality-adjusted life-years (QALYs). Costs and effects were discounted at a 3% rate. To check for the robustness of the results, sensitivity analyses were performed.

RESULTS

At the end of the 3 years, in the base case of the deterministic analysis, initiating prostacyclin therapy with iloprost was the less costly strategy (€132,840), followed by treprostinil (€359,869) and epoprostenol (€429,775). Epoprostenol has shown the best efficacy results with 2.73 LYG and 1.78 QALY, followed by iloprost (2.69 LYG and 1.74 QALY) and treprostinil (2.69 LYG and 1.73 QALY). Incremental cost-effectiveness ratios (ICER) and cost-utility ratios (ICUR) of epoprostenol versus iloprost and treprostinil were much above the €30,000 per LYG or QALY threshold commonly used in Spain. Iloprost was dominant compared with treprostinil. In the probabilistic analysis, epoprostenol, when compared with iloprost, was a dominant strategy in 15% of the simulations, but it was not a cost-effective option in 83% of the cases. When compared with treprostinil, epoprostenol was dominant in 43% of the simulations. Iloprost was dominant compared with treprostinil in 45% of the cases and it was a cost-effective alternative in 39% of the simulations.

CONCLUSIONS

Initiating prostacyclin treatment with iloprost in patients with PAH, functional class III of the NYHA, is the less costly alternative for the NHS in Spain, with a good efficacy profile when compared with the other alternatives.

[Effect of nebulised iloprost combined with inhaled nitric oxide and oral sildenafil on lung transplant patients. Therapeutic efficacy in pulmonary hypertension during surgery]

OBJECTIVES

There is a high incidence of pulmonary hypertension during the lung transplant peri-operative period, and could lead to a haemodynamic deterioration that may require the need of extracorporeal circulation. Our aim was to study the haemodynamic effects on the pulmonary and systemic circulation of the combination of inhaled nitric oxide and iloprost and oral sildenafil in patients with severe pulmonary hypertension during lung transplant surgery.

PATIENTS AND METHODS

Seventeen patients received 10μg of nebulised iloprost during the peri-operative period of the lung transplant when their mean pulmonary pressure exceeded 50mmHg. AU the patients received 50mg of oral sildenafil 30min before anaesthetic induction, 20ppm of inhaled nitric oxide after tracheal intubation. The haemodynamic and respiratory variables were recorded at baseline (after anaesthetic induction), prior to the administering of iloprost, and at 5 and 30min after it was given.

RESULTS

The administering of iloprost significantly reduced the pulmonary arterial pressure and significantly increases the cardiac Índex and the right ventrícular ejection fractíon. There were no signíficant changes occurred in the systemic arterial pressure.

CONCLUSIONS

The triple combination significantly reduces the pulmonary pressures in the lung transplant peri-operative and should be considered when there is severe pulmonary hypertension during the surgery or during the immediate post-operative period of lung transplantation.

[Progress in pharmacotherapy of pulmonary arterial hypertension in children]

This paper provides an overview of the current state of pharmacotherapy in children with pulmonary arterial hypertension (PAH) and a brief introduction to the potentially novel pharmacologic targets for PAH. Currently, 3 classes of drugs including prostacyclin analogues, endothelin receptor antagonists and phosphodiesterase-5 inhibitors are approved for the treatment of PAH in children, which has led to improved hemodynamics, increased exercise capacity and prolonged survival. Despite these improvements, there is still a need to carry out well-designed, randomized, controlled studies with larger samples. In addition, novel drugs targeting other molecular pathways should be developed.

[Pharmacoeconomics aspects of therapy for obliterating diseases of lower-limb peripheral arteries]

The study was aimed at assessing feasibility of treatment of patients suffering from critical ischaemia of lower extremities with iloprost as compared to the basic therapy by means of pharmacoeconomic analysis. The findings of clinical studies and meta-analyses demonstrated that therapy with iloprost results in a pronounced clinical effect as compared with the basic therapy: significantly (p<0.005) decreasing the number of amputations above the knee joint (23% versus 39%) and more frequently decreasing the size of trophic ulcers (in 49% of cases versus 26%). This provides maintenance of the ability to work in part of patients and a decrease in the frequency of hospitalization, which in its turn results in decreased costs of treatment and indirect expenses.. The results of the carried out study show that with due regard for only direct costs economy from treatment with iloprost would amount to 1,544,556 Roubles per 100 patients. With additionally taking into account of indirect costs economy from using iloprost as compared with basic therapy increases to 25,689,11 Roubles per 100 patients.

[Effects of inhaled aerosolized iloprost in adult patients with pulmonary arterial hypertension on right heart functions]

OBJECTIVE

To explore the immediate effects of inhaled aerosolized iloprost on right heart function in adult patients with pulmonary arterial hypertension (PAH).

METHODS

A total of 30 PAH patients were recruited. Right heart catheterization and echocardiography were performed before and immediately after the inhalation of iloprost (20 µg).

RESULTS

After inhalation, the values of mean pulmonary artery pressure (PAPm) and pulmonary vascular resistances (PVR) decreased markedly (42.5 ± 9.6 to 34.4 ± 11.9 mm Hg, P < 0.001; 9.6 ± 5.7 Wood unit to 7.1 ± 4.8 Wood unit, P < 0.001). And the value of tricuspid annular systolic motion peak velocity (TASm) increased markedly [(10.7 ± 2.1) cm/s vs (11.9 ± 2.5) cm/s, P < 0.01]. The baseline level of TASm was higher in acute responders than non-responders [(12.0 ± 2.2) cm/s vs (10.1 ± 1.8) cm/s, P = 0.01] and TASm increased markedly after inhalation in non-responders [(10.1 ± 1.8) cm/s vs (11.6 ± 2.3) cm/s, P < 0.01].

CONCLUSION

The inhalation of iloprost decreases the levels of PAPm and PVR and improve right heart functions in adult PAH patients. For non-responders, right heart function is worse and more benefits may be achieved after the inhalation of iloprost.

The efficacy of Iloprost for the treatment of chronic venous ulcers of the lower limbs

BACKGROUND

The purpose of this study was to assess the effect of Iloprost in the treatment of venous ulcers.

PATIENTS AND METHODS

We recruited 52 patients with uncomplicated venous ulcers of the lower limbs. They were divided into two groups: the first (29 patients) was given Iloprost in saline solution for three weeks, while the second (23 patients) received saline solution only. The size and number of ulcers were determined at the start of the treatment and then every 15 days for six months.

RESULTS

Ulcer size diminished faster in the patients treated with Iloprost, with 100% healed within 120 days. In the placebo group, 82.60% had healed by the end of the 180-day observation period. This difference was statistically significant. Ulcer cicatrization was also faster in the treatment group (65.51% after 60 days, 86.20% after 90 days and 100% after 120 days), whereas in the placebo group, the ulcers had still not healed in 17.40% of patients by the study end.

CONCLUSIONS

Iloprost can significantly reduce healing time for venous leg ulcers without any specific complications.

Long-term effects of intermittent Iloprost infusion on pulmonary arterial pressure in connective tissue disease

BACKGROUND

Intravenous periodic Iloprost is proven effective in the treatment of Raynaud phenomenon (RP) related to connective tissue disorder (CTD). It's well known that synthetic prostaglandins are effective drugs for the treatment of pulmonary arterial hypertension (PAH), and that PAH is frequently associated with CTD.

OBJECTIVE

The aim of the study is to evaluate in the chronic effect of cyclic intravenous Iloprost on pulmonary arterial pressure.

METHODS

We studied 17 consecutive patients with CTD (14 systemic sclerosis, 3 mixed CTD) and RP, at the entry and after at least 6months of treatment of RP with cyclic Iloprost. On both occasions, in all patients we performed transthoracic Doppler echocardiography and we determined NT-proBNP plasma levels, NYHA functional class, 6 Minute-Walk Distance (6MWD).

RESULTS

At follow-up (8.2±1.9months; range 6-12) mean values of pulmonary arterial systolic pressure (PASP) significantly decreased (from 32.2±9.2 to 29.2±7.6mmHg, p<0.04) and mean values of 6MWD significantly increased (from 407.5±101.5 to 448.3±89.9m, p<0.01). Moreover, we observed a significant direct correlation between PASP and NT-proBNP values and a significant inverse correlation both between NT-proBNP and 6MWD values and between PASP and 6MWD values.

CONCLUSION

Our results suggest that cyclic intravenous Iloprost may protect against the development or worsening of PAH in patients with CTD and RP.

The treatment of skin ulcers in patients with systemic sclerosis

Systemic Sclerosis (Ssc) is a complex disease of the connective tissue, characterized by progressive thickening and fibrosis of the skin and the internal organs and by diffused damage of the microvascular system. The fibrosis ones of the skin associated to the characteristic vascular alterations lead to the genesis of ulcers, more or less extended, often multiple, peripheral localization, chronic course, painful, able to influence patient's quality of life. Indeed, immunity reactivity, the thinning and the loss of elasticity of the skin, the peripheral neurological damage and the eventual drug assumption that can reduce regenerative/reparative abilities, can easily make an ulcer chronic and become infected complicating still more the patient disease, rendering more difficult the cure often, ulcer evolves to gangrene, and in some cases, in amputation too. For all these reasons, we have begun to study ulcers therapy (local and systemic), considering this activity it leave integrating of the charitable distance of the sclerodermic patient, putting to point on strategy both diagnostic and therapeutic, but above all with the primary scope, if possible, is to prevent ulcers, in contrary case, to alleviate the pain and to render the quality of the life of the patient better.

Inhaled iloprost for patients with precapillary pulmonary hypertension and right-side heart failure

Background

Pulmonary hypertension (PH) can lead to right-side heart failure (RHF) and death. There are no therapeutic recommendations for patients experiencing acute RHF in the course of PH. This study aimed to examine the safety and efficacy of inhaled iloprost in patients with precapillary PH and RHF.

Methods and Results

Between October 2007 and December 2008, 7 patients with precapillary PH and RHF were enrolled. Per protocol, iloprost was inhaled hourly for a minimum of 12 hours during a 24-hour period. The starting dose of 2.5 μg was increased hourly by 2.5 μg as long as the increases were tolerated. Safety and efficacy were determined by continuous invasive monitoring of systemic and pulmonary hemodynamic parameters. Systemic pressures remained stable during inhalation (66.1 ± 6.9 mm Hg at baseline and 69.1 ± 6.4 mm Hg immediately after inhalation therapy, P = 0.48). Cardiac index increased from 2.4 ± 0.7 L/min/m² to 2.9 ± 0.9 L/min/m² (P = .008). Pulmonary vascular resistance decreased from 634.6 ± 218.3 dyn·s·cm⁻⁵ to 489.6 ± 173.8 dyn·s·cm⁻⁵ (P = .044), and N-terminal B-type natriuretic peptide levels decreased from 13,591 ± 10,939 pg/mL to 9,944 ± 8,569 pg/mL (P = .051).

Conclusion

Blood pressure-guided hourly inhalation of iloprost may offer a safe and effective strategy for the treatment of PH patients with RHF.

Ulnar artery ischaemia following corticosteroid injection for carpal tunnel syndrome

A 36-year-old female with known bilateral carpal tunnel syndrome was admitted to hospital and given a steroid injection on the ulnar side in her right hand. She suffered immediate ischaemia of the 3rd, 4th, and 5th fingers. Imaging showed decreased flow in the 4th and 5th phalageal arteries. Treatment with iloprost infusion commenced 7 days after the injury, with moderate improvement and further managed with a carpal tunnel release. This case report sheds light on an unusual yet very important complication of carpal tunnel management.

Iloprost in the management of peripheral arterial disease in patients with diabetes mellitus

Diabetic complications in the lower extremities, especially those secondary to diabetic macroangiopathy, have increasingly become a clinical emergency, given the high prevalence and progression of the disease. Until recently, the only approach to treating advanced stage disease was medical therapy and major amputation; however, the advent of revascularization procedures has radically improved the prognosis of patients with critical lower limb ischemia. In this setting, iloprost holds a dual position: as first-choice therapy in patients ineligible for revascularization and as complementary therapy in candidates for surgical or endovascular revascularization.

[Immediately effects of inhaled aerosolised iloprost in adult patients with severe pulmonary hypertension secondary to congenital heart diseases]

OBJECTIVE

To investigate the immediately effects of inhaled aerosolized iloprost in adult patients with severe pulmonary arterial hypertension (PAH) secondary to congenital heart diseases (CHD).

METHODS

Adult patients with severe PAH secondary to CHD (n = 165) were included in this study. Right heart catheterization was performed, Pulmonary and systemic blood flow, the oxygen consumption VO(2) (ml/min) were calculated using Fick's principle. Pulmonary vascular resistances (PVR) were calculated with standard formulas and indexed to body surface area. Hemodynamic parameters were measured before and after iloprost inhalation (20 µg).

RESULTS

Post iloprost inhalation, heart rate, mean aortic pressure, pulmonary systolic pressure to aortic systolic pressure ratio all remained un changed (P > 0.05), while pulmonary artery pressure (PAP) were significantly reduced and Qp significantly increased from (7.2 ± 4.8) L/min to (9.9 ± 7.2) L/min (P < 0.01), PVR was also significantly reduced from (13.4 ± 8.7) Wood units to (9.5 ± 6.6) Wood units (P < 0.01), and left-to-right shunt volume increased from (3.2 ± 4.4) L/min to (5.5 ± 7.0) L/min (P < 0.01) and right-to-left shunt volume decreased from (1.0 ± 1.0) L/min to (0.7 ± 0.7) L/min (P < 0.01). Subgroup analysis showed that adult patients with patent ductus arteriosus and/or ventricular septal defects are more likely to develop severe pulmonary arterial hypertension or Eisenmenger syndrome than patients with atrial septal defects.

CONCLUSIONS

Inhaled Aerosolised iloprost use is effective and safe for adult patients with severe pulmonary arterial hypertension secondary to congenital heart diseases.

[Treatment options of acral ulcers in MCTD]

In patients with systemic sclerosis or mixed connective tissue disease (MCTD) acral ulcers are considered as frequent manifestations that may lead to amputation and loss of function, respectively, as a result of secondary Raynaud's phenomenon. Thus it is necessary to take advantage of all available medical and supportive measures. Adjuvant treatments such as hyperbaric oxygenation and regional sympathetic block represent interdisciplinary treatment options to improve oxygenation of critical ischemia and analgesia and should be subject of further investigation.

[Digital ulcers in systemic sclerosis--an interdisciplinary challenge]

Digital ulcers in systemic sclerosis are painful ischemic necrotic lesions of the acra. Optimal treatment consists of conventional wound management and medication: iloprost infusions promote primary healing of the ulcers, while the dual endothelin receptor antagonist bosentan is used for secondary prophylaxis of new ulcers. The described case illustrates the essential interdisciplinary collaboration for optimal management of these patients.

Combined vasomodulatory therapy for severe pulmonary hypertension in chronic hypersensitivity pneumonitis

BACKGROUND

There are only a few reports of pulmonary hypertension (PH) in hypersensitivity pneumonitis (HP) and an approved vasomodulatory therapy for PH does not exist at all for interstitial lung disease (ILD), particularly for HP.

CASE REPORT

The case of a 53-year-old woman with chronic HP and severe life-threatening PH treated with a combined specific vasomodulatory therapy is reported. Sustained clinical and hemodynamic improvement was achieved.

CONCLUSIONS

Further investigation of PH in HP and specific vasomodulatory therapy is necessary.

Prostanoids for critical limb ischaemia

BACKGROUND

Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular diseases in the general population. While numerous treatments have been adopted for different disease stages, there is no option other than amputation for patients presenting with critical limb ischaemia (CLI), unsuitable for rescue or reconstructive intervention.

OBJECTIVES

To determine the effectiveness and safety of prostanoids in patients presenting with CLI.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2009, Issue 4) for publications describing randomised controlled trials (RCTs) of prostanoids for CLI. We ran additional searches in MEDLINE, EMBASE, LILACS, and SciSearch, and we also contacted pharmaceutical companies and experts, in order to identify unpublished data and trials still underway.

SELECTION CRITERIA

Randomised controlled trials describing efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments, in patients presenting with CLI, without chance of rescue or reconstructive intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. Disagreements were resolved by consensus or by the third author.

MAIN RESULTS

We retrieved 532 citations which after the first screening resulted in 111 potential studies. Finally, after exclusion of studies of poor quality and a lack of sufficient information, 20 trials were included in the review.Prostanoids seem to have efficacy regarding rest-pain relief (risk ratio (RR) 1.32, 95% confidence interval (CI) 1.10 to 1.57; P = 0.003), and ulcer healing (RR 1.54, 95% CI 1.22 to 1.96). Iloprost also shows favourable results regarding major amputations (RR 0.69, 95% CI 0.52 to 0.93). The more frequently reported adverse events when using prostanoids were headache, facial flushing, nausea, vomiting and diarrhoea.

AUTHORS' CONCLUSIONS

Despite some positive results regarding rest-pain relief, ulcer healing and amputations, there is no conclusive evidence based on this meta-analysis of the long-term effectiveness and safety of different prostanoids in patients with CLI. Further well-conducted, high quality randomised double-blinded trials should be performed.

[Randomized placebo-controlled studies of iloprost in treatment of lower limb critical ischaemia]

The article deals with the analysis of the treatment outcomes obtained in management of patients suffering from lower-limb critical ischaemia treated with iloprost, a stable analogue of the prostacyclin. The results of six randomized placebo-controlled trials and eleven trials of other drugs are described in this article. The meta-analysis of the iloprost studies confirmed the efficacy of the drug in decreasing the size of ulcers, pain relief, extremity amputation rate. Whereas the other examined drugs have not demonstrated such properties with rare exception.

[Current approach to the treatment of pulmonary arterial hypertension and our experience in the Cardiology Department of Medicine Faculty of Ege University]

Pulmonary arterial hypertension is a progressive disease marked by increased pulmonary artery resistance leading to right heart failure and has very high mortality. Survival rates have somewhat improved in recent years due to the development of new drugs and early diagnosis. This review aims to summarize the current therapeutic approach to pulmonary arterial hypertension and share our experience at our center.

Iloprost inhalation redistributes pulmonary perfusion and decreases arterial oxygenation in healthy volunteers

BACKGROUND

Previous studies have shown that ventilation-perfusion matching is improved in the prone as compared with that in the supine position. Regional differences in the regulation of vascular tone may explain this. We have recently demonstrated higher production of nitric oxide in dorsal compared with ventral human lung tissue. The purpose of the present study was to investigate regional differences in actions by another vasoactive mediator, namely prostacyclin. The effects on gas exchange and regional pulmonary perfusion in different body positions were investigated at increased prostacyclin levels by inhalation of a synthetic prostacyclin analogue and decreased prostacyclin levels by unselective cyclooxygenase (COX) inhibition.

METHODS

In 19 volunteers, regional pulmonary perfusion in the prone and supine position was assessed by single photon emission computed tomography using (99m)Tc macro-aggregated albumin before and after inhalation of iloprost, a stable prostacyclin analogue, or an intravenous infusion of a non-selective COX inhibitor, diclofenac. In addition, gas distribution was assessed in seven subjects using (99m)Tc-labelled ultra-fine carbon particles before and after iloprost inhalation in the supine position.

RESULTS

Iloprost inhalation decreased arterial PaO(2) in both prone (from 14.2+/-0.5 to 11.7+/-1.7 kPa, P<0.01) and supine (from 13.7+/-1.4 to 10.9+/-2.1 kPa, P<0.01) positions. Iloprost inhalation redistributed lung perfusion from non-dependent to dependent lung regions in both prone and supine positions, while ventilation in the supine position was distributed in the opposite direction. No significant effects of non-selective COX inhibition were found in this study.

CONCLUSIONS

Iloprost inhalation decreases arterial oxygenation and results in a more gravity-dependent pulmonary perfusion in both supine and prone positions in healthy humans.

[The acute effects of inhaled iloprost on hemodynamics and oxygenation in chronic thromboembolic pulmonary hypertension]

OBJECTIVE

To evaluate the acute effects of inhaled iloprost on hemodynamics and oxygenation in chronic thromboembolic pulmonary hypertension (CTEPH).

METHODS

A prospective study was made. Eighteen patients with CTEPH were enrolled. At right heart catheterisation, iloprost was inhaled at 20 microg for 10 - 15 min. Compare the value of heart rate (HR), mean blood pressure (mBP), mean pulmonary arterial hypertension (mPAP), right atrium pressure (RAP), pulmonary arterial wedge pressure (PAWP), cardiac output (CO), pulmonary vascular resistance (PVR), systemic vascular resistance (SVR), arterial partial pressure of oxygen (PaO2), arterial oxygen saturation (SaO2), mixed venous saturation (SvO2), pulmonary shunt fraction (Qs/Qt), alveolar-arterial partial pressure of oxygen [P ( A-a) O2] before to after inhaled iloprost in these patients.

RESULTS

Significant changes (before to after inhalation): mPAP, (53 +/- 11) to (47 +/- 14) mm Hg (P < 0.01); PVR, (821 +/- 194) to (681 +/- 199) dyn x s x cm(-5) (P < 0.01); RAP, (10 +/- 6) to (7 +/- 6) mm Hg (P < 0.01). However, HR, PAWP, mBP, CO and SVR had no significant changes. At the same time, inhaled iloprost significantly decreased PaO2 from (58 +/- 11) to (52 +/- 6) mm Hg (P < 0.01) and increased Qs/Qt from (27 +/- 11)% to (33 +/- 9)% (P < 0.01)and P(A-a) O2 from (86 +/-39) to (93 +/- 38) mm Hg (P < 0.01).

CONCLUSION

Inhaled iloprost might instantly improve hemodynamics in CTEPH, but at the same time it increased arteriovenous shunts which resulted in lower PaO2.

[Comparison of adenosine versus iloprost by acute vasodilator test in patients of pulmonary arterial hypertension complicated with connective tissue diseases]

OBJECTIVE

To compare the acute hemodynamic effects of adenosine versus iloprost in patients of pulmonary arterial hypertension (PAH) complicated with connective tissue diseases.

METHODS

During right heart catheterization, 18 patients of PAH complicated with connective tissue diseases sequentially received intravenous infusion of adenosine and inhaled iloprost. After the baseline hemodynamic data were obtained, an adenosine infusion was started and titrated to the maximal tolerated dose. The hemodynamic parameters were allowed to return to baseline. Then inhalation of iloprost was administered. The effects of both medicines on the patient's hemodynamics were monitored.

RESULTS

As compared with the baseline values, the systolic pulmonary artery pressure and pulmonary vascular resistance significantly decreased [(71 +/- 30) vs (80 +/- 29) mm Hg and (712 +/- 440) vs (824 +/- 464) dyn x s x cm(-5) respectively, both P < 0.05) while the heart rate increased significantly [(93 +/- 17) vs (83 +/-16) beat/min, P < 0.05] in the adenosine group. Inhaled iloprost could also lower the systolic pulmonary artery pressure [(66 +/- 29) vs (79 +/- 28) mm Hg, P < 0.05], mean pulmonary artery pressure [(43 +/- 19) vs (52 +/- 19) mm Hg, P < 0.05] and pulmonary vascular resistance [(632 +/- 440) vs (816 +/- 448) dyn x s x cm(-5), P < 0.05] without any effect upon heart rate. Inhaled iloprost exerted more potent effect on lowering mean pulmonary artery pressure and pulmonary vascular resistance than adenosine (P < 0.05). The two medicines did not affect cardiac output, pulse oxygen saturation or systemic blood pressure. The side effects were fewer in the iloprost inhalation group than the adenosine group.

CONCLUSION

During acute vasodilator testing, inhaled iloprost was more potent than infused adenosine as a pulmonary vasodilator in PAH complicated with connective tissue diseases.

Efficiency of iloprost treatment for chemotherapy-associated osteonecrosis after childhood cancer

BACKGROUND

The risk of developing avascular osteonecrosis (AVN) after chemotherapy is age related and, at up to 17% of all treated patients, relatively high.

PATIENTS AND METHODS

In a prospective study, 8 patients (4 male, 4 female, 14.3+/-4.9 years old) were treated for symptomatic chemotherapy-associated AVN with intravenous infusion of iloprost. Association Research Circulation Osseus (ARCO) stages I-IV in 37 bones (25 joints) were treated.

RESULTS

Follow-up was 20.8+/-17 months (range: 6-53 months). No serious adverse reactions due to the infusion with iloprost were recorded. Pain levels were lower and functional outcome measured as Harris Hip and Knee Society Scores improved by the latest follow up.

CONCLUSION

Our current data confirm the findings of other investigators that healing of advanced stages of AVN is not possible, but that in early stages of AVN, pain relief and an improvement of joint function can be achieved by iloprost.

[The oxygen kinetic effect of inhaled iloprost in pulmonary artery hypertension and chronic thromboembolic pulmonary hypertension]

OBJECTIVE

To study the acute oxygen kinetic effect of inhaled iloprost in pulmonary artery hypertension and chronic thromboembolic pulmonary hypertension.

METHODS

Twenty-two and 24 patients who were admitted to our hospital between June 2006 and January 2009 with confirmed diagnosis of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) respectively were enrolled to this study. During right heart catheterization, the hemodynamics and oxygen kinetics were monitored at baseline and after inhaling Iloprost (20 micrograms).

RESULTS

At baseline, the arterial partial pressure of oxygen (PaO2) was (63 +/- 10) mm Hg (1 mm Hg = 0.133 kPa) and (59 +/- 10) mm Hg respectively in PAH and CTEPH patients, and the oxygen delivery index (DO2I) and oxygen consumption index (VO2I) were (458 +/- 136) ml x min(-1) x m(-2) and (135 +/- 53) ml x min(-1) x m(-2) in PAH patients respectively, and (386 +/- 92) ml x min(-1) x m(-2) and (131 +/- 43) ml x min(-1) x m(-2) in CTEPH patients respectively. Three minutes after inhaling Iloprost, for PAH and CTEPH patients, the pulmonary shunt rate (Qs/Qt) all increased significantly (all P < 0.05, respectively) as well as the difference of oxygen partial pressure between pulmonary alveoli and artery (P[A-a]O2, all P < 0.05, respectively), and the arterial oxygen content (CaO2) all decreased significantly (all P < 0.05, respectively). The oxygenation parameters of mixed venous blood, oxygen extractive rate and DO2I did not change significantly, but VO2I declined to different extent. The extent of change after inhaling Iloprost for all oxygen kinetic parameters were similar between PAH and CTEPH patients. At baseline, mixed venous oxygen saturation (SvO2), venous oxygen content (CvO2) and DO2I in CTEPH patients were lower than those in PAH patients. After inhaling Iloprost, in CTEPH patients, PaO2, SvO2 and CvO2 were lower than those in PAH patients.

CONCLUSION

There were hypoxemia and abnormality of oxygen kinetics in PAH and CTEPH patients. After inhaling Iloprost, pulmonary shunt increased without improvement in oxygen kinetics. Oxygenation should be monitored closely and supply oxygen supplied for CTEPH when inhaling Iloprost.

[Clinical course of familial primary pulmonary hypertension in a 39-year-old female and her two children]

Primary pulmonary hypertension (PPH) is diagnosed in case of pulmonary hypertension of unexplained etiology. When PPH occurs in members of a family it should be diagnosed as familial PPH. Genetic anticipation has been described in familial PPH. We present a case of two children (4-year-old boy and 8-year-old girl) who died due to complications of familial PPH and their 39-year-old mother who has been treated due to PPH for two years. This case is interesting due to the scarcity of such reports, seriousness of the disease and genetic anticipation of familial PPH.

Portopulmonary hypertension

It has been widely accepted that development of porto-pulmonary hypertension (POPH) is independent of the cause of portal hypertension. The degree of hepatic damage and liver function do not correlate with predisposition to POPH or its severity. However, portal hypertension has been confirmed as a prerequisite for developing pulmonary hypertension. Transthoracic echocardiography is the best screening test for the presence of POPH, but a diagnosis of POPH can be established only by right heart catheterization. Randomized controlled trials comparing the efficacy and safety of different pharmacologic strategies are lacking in patients with POPH. The general management includes diuretics and oxygen supplementation. Notably, moderate to severe POPH predisposes candidates for orthotopic liver transplantation to a higher risk of perioperative mortality. Vasomodulating pharmacologic agents are used in patients with moderate to severe POPH to decrease pulmonary arterial hypertension, thereby permitting liver transplantation to be performed safely. Epo-prostenol is the best-studied medication, and bosentan appears promising.

The prostacyclin analogue iloprost increases circulating endothelial progenitor cells in patients with critical limb ischemia

Patients with critical limb ischemia (CLI) have low levels of endothelial progenitor cells (EPC). Iloprost has been demonstrated to stimulate vascular endothelial growth factor (VEGF) and promote angiogenesis. We investigated the effects of iloprost on EPC levels in vivo in CLI patients. Twenty-three patients with stage III and IV CLI were treated with iloprost for four weeks, improving clinical and instrumental parameters. Mononuclear cells isolated from peripheral blood were cultured to obtain "early" EPC, evaluated counting adherent cells with double positivity for acetylated low-density lipoprotein uptake and Ulex Europaeus lectin at flow cytometry. These cells also co-expressed the monocyte markers CD14 and CD45. Iloprost increased EPC number in the whole patient population: pre-treatment median: 13,812/ml; range: 1,263-83,648/ml; post-treatment median: 23,739/ml; range: 3,385-99,251/ml; p = 0.035, irrespective of age, sex, disease stage or atherosclerosis risk factors. In conclusion, iloprost increases EPC number in peripheral blood in vivo. Such an effect may have therapeutic relevance.