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Matusov Y, Singh I, Yu YR, Chun HJ, Maron BA, Tapson VF, Lewis MI, Rajagopal S. Chronic Thromboembolic Pulmonary Hypertension: the Bedside. Curr Cardiol Rep 2021; 23:147. [PMID: 34410530 PMCID: PMC8375459 DOI: 10.1007/s11886-021-01573-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Chronic thromboembolic pulmonary hypertension (CTEPH), included in group 4 PH, is an uncommon complication of acute pulmonary embolism (PE), in which emboli in the pulmonary vasculature do not resolve but rather form into an organized scar-like obstruction which can result in right ventricular (RV) failure. Here we provide an overview of current diagnosis and management of CTEPH. RECENT FINDINGS CTEPH management is complex with treatments that range from surgery, percutaneous interventions, to medical therapies. Current CTEPH medical therapies have largely been repurposed from pulmonary arterial hypertension (PAH). The diagnosis of CTEPH can be challenging, requiring a multimodality approach to differentiate from disease mimics. While these treatments improve symptoms, they may not reverse the underlying pathology of CTEPH.
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Affiliation(s)
- Yuri Matusov
- grid.50956.3f0000 0001 2152 9905Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Inderjit Singh
- grid.47100.320000000419368710Division of Pulmonary, Critical Care, and Sleep Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT USA
| | - Yen-Rei Yu
- grid.189509.c0000000100241216Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC USA
| | - Hyung J. Chun
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, Yale School of Medicine, New Haven, CT USA
| | - Bradley A. Maron
- grid.410370.10000 0004 4657 1992Section of Cardiology, Veterans Affairs Boston Healthcare System, Boston, MA USA ,grid.62560.370000 0004 0378 8294Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Victor F. Tapson
- grid.50956.3f0000 0001 2152 9905Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Michael I. Lewis
- grid.50956.3f0000 0001 2152 9905Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Sudarshan Rajagopal
- grid.189509.c0000000100241216Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC USA
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Salibe-Filho W, Araujo TLS, G. Melo E, B. C. T. Coimbra L, Lapa MS, Acencio MMP, Freitas-Filho O, Capelozzi VL, Teixeira LR, Fernandes CJCS, Jatene FB, Laurindo FRM, Terra-Filho M. Shear stress-exposed pulmonary artery endothelial cells fail to upregulate HSP70 in chronic thromboembolic pulmonary hypertension. PLoS One 2020; 15:e0242960. [PMID: 33270690 PMCID: PMC7714249 DOI: 10.1371/journal.pone.0242960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/12/2020] [Indexed: 12/31/2022] Open
Abstract
The pathophysiological mechanisms underlying chronic thromboembolic pulmonary hypertension (CTEPH) are still unclear. Endothelial cell (EC) remodeling is believed to contribute to this pulmonary disease triggered by thrombus and hemodynamic forces disbalance. Recently, we showed that HSP70 levels decrease by proatherogenic shear stress. Molecular chaperones play a major role in proteostasis in neurological, cancer and inflammatory/ infectious diseases. To shed light on microvascular responses in CTEPH, we characterized the expression of molecular chaperones and annexin A2, a component of the fibrinolytic system. There is no animal model that reproduces microvascular changes in CTEPH, and this fact led us to isolated endothelial cells from patients with CTEPH undergoing pulmonary endarterectomy (PEA). We exposed CTEPH-EC and control human pulmonary endothelial cells (HPAEC) to high- (15 dynes/cm2) or low- (5 dynes/cm2) shear stress. After high-magnitude shear stress HPAEC upregulated heat shock protein 70kDa (HSP70) and the HSP ER paralogs 78 and 94kDa glucose-regulated protein (GRP78 and 94), whereas CTEPH-ECs failed to exhibit this response. At static conditions, both HSP70 and HSP90 families in CTEPH-EC are decreased. Importantly, immunohistochemistry analysis showed that HSP70 expression was downregulated in vivo, and annexin A2 was upregulated. Interestingly, wound healing and angiogenesis assays revealed that HSP70 inhibition with VER-155008 further impaired CTEPH-EC migratory responses. These results implicate HSP70 as a novel master regulator of endothelial dysfunction in type 4 PH. Overall, we first show that global failure of HSP upregulation is a hallmark of CTEPH pathogenesis and propose HSP70 as a potential biomarker of this condition.
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Affiliation(s)
- William Salibe-Filho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Thaís L. S. Araujo
- Department of Biochemistry, Institute of Chemistry, University of São Paulo, São Paulo, Brazil
| | - Everton G. Melo
- Department of Biochemistry, Institute of Chemistry, University of São Paulo, São Paulo, Brazil
| | - Luiza B. C. T. Coimbra
- Department of Biochemistry, Institute of Chemistry, University of São Paulo, São Paulo, Brazil
| | - Monica S. Lapa
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Milena M. P. Acencio
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Orival Freitas-Filho
- Cardiovascular Surgery Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Vera Luiza Capelozzi
- Department of Pathology, Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Lisete Ribeiro Teixeira
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Caio J. C. S. Fernandes
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Fabio Biscegli Jatene
- Cardiovascular Surgery Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Francisco R. M. Laurindo
- Vascular Biology Laboratory, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
| | - Mario Terra-Filho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil
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Kenny M, Clarke MM, Pogue KT. Overview of Riociguat and Its Role in the Treatment of Pulmonary Hypertension. J Pharm Pract 2020; 35:437-444. [PMID: 33084500 PMCID: PMC9161433 DOI: 10.1177/0897190020961291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulmonary hypertension (PH), which includes pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), is a progressive condition with significant morbidity and mortality due to right heart failure if left untreated. Riociguat is a soluble guanylate cyclase (sGC) stimulator and is the only treatment approved for both PAH and CTEPH. The objectives of this review are to describe the epidemiology and pathophysiology of PAH and CTEPH; synthesize the pharmacology, efficacy, safety, and utilization of riociguat; and discuss the role of the pharmacist in managing patients with these conditions. Data presented in this review is supported by peer reviewed literature, using PubMed and key words including pulmonary hypertension, pulmonary arterial hypertension, chronic thromboembolic pulmonary hypertension, and riociguat. The review draws on key studies and review articles that discuss the pathophysiology of PAH and CTEPH, as well as articles discussing the safety and efficacy of riociguat. The overall goal in the treatment of PAH and CTEPH is to improve long-term survival. Treatment planning depends on the type of PH, treatment goals, comorbidities, and risk profiles. Pharmacists serve a valuable role as part of the multidisciplinary team in the care of patients with PH, many of whom may have comorbidities that contribute to high costs and resource utilization. Riociguat is a first-in-class medication and the only approved treatment for both PAH and CTEPH. In clinical trials, riociguat has demonstrated favorable efficacy and tolerability. Riociguat is a valuable addition to the armamentarium of options for treating patients with PH.
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Affiliation(s)
| | - Megan M Clarke
- Clinical Pharmacy Specialist, Cardiology, University of North Carolina Medical, Chapel Hill, NC, USA
| | - Kristen T Pogue
- Clinical Pharmacy Specialist, Cardiology, Michigan Medicine, Ann Arbor, MI, 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: 7] [Impact Index Per Article: 1.8] [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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Waziri F, Mellemkjær S, Clemmensen TS, Hjortdal VE, Ilkjær LB, Nielsen SL, Poulsen SH. Long-term changes of exercise hemodynamics and physical capacity in chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy. Int J Cardiol 2020; 317:181-187. [PMID: 32497568 DOI: 10.1016/j.ijcard.2020.05.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/03/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND A substantial number of chronic thromboembolic pulmonary hypertension (CTEPH) patients experience dyspnea on exertion and limited exercise capacity despite surgically successful pulmonary endarterectomy (PEA). We sought to prospectively evaluate resting and peak exercise hemodynamics before, 3 and 12 months after PEA in consecutive CTEPH-patients and correlate it to physical functional capacity. METHODS AND RESULTS Twenty consecutive CTEPH-patients were examined. Twelve months after PEA, 75% of patients with severely increased pre-PEA mean pulmonary arterial pressure (mPAP) at rest had normal or mildly increased mPAP. However, mPAP reduction was less pronounced during exercise where only 45% had normal or mildly increased mPAP at 12 months. Hemodynamic changes during exercise were tested using the pressure-flow relationship (i.e. mPAP/cardiac output (CO) slope). The average mPAP/CO slope was 7.5 ± 4.2 mm Hg/L/min preoperatively and 3.9 ± 3.0 mm Hg/L/min at 12 months (p < .005). CO reserve (CO increase from rest to peak exercise) was increased (5.7 ± 2.9 L/min) 12 months after PEA compared with pre-PEA (2.5 ± 1.8 L/min), p < .0001. However, 12 months after PEA, the CO reserve was only 49% of that of healthy controls, p < .0001. Changes in cardiac output (∆CO), calculated as the difference between CO before PEA and 12 months later, were significantly correlated with six-minute-walk-test and peak oxygen uptake (VO2), both at rest and peak exercise. CONCLUSION Invasive exercise hemodynamic examination in CTEPH-patients demonstrates that after otherwise successful PEA surgery, >50% of patients have a significant increase in exercise mPAP, and the CO reserve remains compromised 12 months after PEA. Improvement in physical capacity is correlated with ∆CO.
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Affiliation(s)
- Farhad Waziri
- Department of Cardiology, Aarhus University Hospital, Denmark; Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Department of Internal Medicine, Regional Hospital of Randers, Denmark.
| | | | - Tor Skibsted Clemmensen
- Department of Cardiology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Vibeke Elisabeth Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Lars Bo Ilkjær
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Sten Lyager Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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Rijal R, Mridha AR, Arava SK, Behera C. Primary intimal sarcoma of the pulmonary artery misdiagnosed as pulmonary thromboembolism: A case confirmed at medicolegal autopsy. J Forensic Sci 2020; 66:403-406. [PMID: 33031598 DOI: 10.1111/1556-4029.14592] [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: 06/02/2020] [Revised: 09/12/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
Misdiagnosed PAS confirmed at medicolegal autopsy Pulmonary artery sarcoma (PAS) is a rare disease and usually indistinguishable from acute or chronic thromboembolic disease of the pulmonary arteries. We present a case of pulmonary artery sarcoma in a 54-year-old male, who was clinically misdiagnosed as pulmonary thromboembolism. The patient died of disease; however, the actual diagnosis of PAS was made after a medicolegal autopsy. PAS can be a diagnostic challenge for both clinicians and pathologists. In an autopsy case with a clinical suspicion of pulmonary thromboembolism, if there is an abnormal gross appearance in the pulmonary artery, the forensic pathologist should have a high index of suspicion of PAS, which should be ruled out by a histopathologic examination.
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Affiliation(s)
- Reisha Rijal
- Department of Forensic Medicine & Toxicology, All India Institute of Medical sciences, New Delhi, India
| | - Asit Ranjan Mridha
- Department of Pathology, All India Institute of Medical sciences, New Delhi, India
| | - Sudheer Kumar Arava
- Department of Pathology, All India Institute of Medical sciences, New Delhi, India
| | - Chittaranjan Behera
- Department of Forensic Medicine & Toxicology, All India Institute of Medical sciences, New Delhi, India
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Miyahara S, Schröder TA, Wilkens H, Karliova I, Langer F, Kunihara T, Schäfers HJ. An Evaluation of the Learning Curve in Pulmonary Endarterectomy Using Propensity Score Matching. Thorac Cardiovasc Surg 2020; 69:284-292. [PMID: 32886927 DOI: 10.1055/s-0040-1714747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Pulmonary endarterectomy (PEA) is the only causative, but demanding treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). We analyzed our results with PEA to evaluate the learning curve. METHODS Consecutive 499 patients who underwent PEA between 1995 and 2014 were divided into two groups according to the temporal order: early cohort (n = 200, December 1995-March 2006), and late cohort (n = 299, March 2006-December 2014). We assessed perioperative outcomes after PEA as compared between the early and the late cohort also in propensity-score-matched cohorts. RESULTS Age at the surgery was older in the late cohort (p = 0.042). Preoperative mean pulmonary artery pressure (mPAP) was 46.8 ± 11.0 mm Hg in the early cohort and 43.5 ± 112.7 mm Hg in the late cohort (p = 0.0035). The in-hospital mortality in the early and late cohorts was 14.0% (28/200) and 4.7% (14/299), respectively (p = 0.00030). The duration of circulatory arrest (CA) became much shorter in the late cohort (42.0 ± 20.5 min in the early and 24.2 ± 11.6 min in the late cohort, respectively, p < .0001). In matched cohorts, the in-hospital mortality showed no significant difference (8.7% in the early cohort and 5.2% in the late cohort, < 0.0001). The CA duration, however, was still shorter in the late cohort (p <0.0001). CONCLUSIONS Over time, older patients have been accepted for surgery, more patients were operated for lesser severity of CTEPH. Duration of CA and mortality decreased even beyond the first 200 patients, indicating a long learning curve.
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Affiliation(s)
- Shunsuke Miyahara
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Tom A Schröder
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Heinrike Wilkens
- Department of Internal Medicine V, Saarland University Medical Center, Homburg, Germany
| | - Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Frank Langer
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Takashi Kunihara
- Department of Cardiac Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
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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: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by unresolved thrombi in the pulmonary arteries and microvasculopathy in nonoccluded areas. If left untreated, progressive pulmonary hypertension will induce right heart failure and, finally, death. Currently, pulmonary endarterectomy (PEA) remains the only method that has the potential to cure CTEPH. Unfortunately, up to 40% of patients are ineligible for this procedure for various reasons. In recent years, refined balloon pulmonary angioplasty (BPA) has become an alternative option for inoperable CTEPH patients, and it may be another curative treatment in the future, particularly in combination with prior PEA. Nevertheless, 23% of patients still suffer from persistent PH after BPA. Given that CTEPH shares many similarities with idiopathic pulmonary arterial hypertension (PAH), targeted drugs developed for PAH are also attractive options for CTEPH, especially for inoperable or persistent/recurrent CTEPH patients. To date, riociguat, macitentan, and subcutaneous treprostinil are the only drugs proven by randomized control trials to be capable of improving the exercise capacity (6-min walking distance) of CTEPH patients. In this review, we summarize the achievements and unresolved problems of PAH-targeted therapy for CTEPH over the last decade.
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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: 0.5] [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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Kamenskaya O, Klinkova A, Chernyavskiy A, Lomivorotov VV, Edemskiy A, Shmyrev V. Long-term health-related quality of life after surgery in patients with chronic thromboembolic pulmonary hypertension. Qual Life Res 2020; 29:2111-2118. [PMID: 32180099 DOI: 10.1007/s11136-020-02471-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To assess the dynamic of various health-related quality of life (HRQoL) parameters 3 years after pulmonary thromboendarterectomy (PTE), and to identify factors affecting HRQoL parameters in patients with chronic thromboembolic pulmonary hypertension (CTEPH) in the long-term follow-up after surgery. METHODS This prospective cohort study included 128 patients with CTEPH before and after the PTE (3 year follow-up). The HRQoL was examined using the Short-Form 36 Health Survey Questionnaire (SF-36). RESULTS In patients with CTEPH 3 years after PTE, a significant improvement in all the HRQoL parameters. The summary indicators of the physical and mental components of health remained at the same level as 1 year after the PTE and did not exceed 50 points. The residual pulmonary hypertension was a leading factor limiting parameters of physical and mental health 3 years after a PTE. In addition, the parameters of physical activity were adversely affected by age and the age-adjusted Charlson Comorbidity Index. CONCLUSIONS In the study group of patients with CTEPH, PTE contributes to a significant improvement in all HRQoL parameters, which observed both 1 year and 3 years after surgery. The leading factor adversely affecting the physical and emotional components of health in the long-term period after PTE was residual pulmonary hypertension recorded in the early postoperative period. In addition, some physical HRQoL parameters are affected by age and age-adjusted Charlson Comorbidity Index.
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Affiliation(s)
- Oksana Kamenskaya
- Department of Physiology, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Street, Novosibirsk, 630055, Russia
| | - Asya Klinkova
- Department of Physiology, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Street, Novosibirsk, 630055, Russia.
| | - Aleksander Chernyavskiy
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Street, Novosibirsk, 630055, Russia
| | - Vladimir V Lomivorotov
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Street, Novosibirsk, 630055, Russia
| | - Alexander Edemskiy
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Street, Novosibirsk, 630055, Russia
| | - Vladimir Shmyrev
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Street, Novosibirsk, 630055, Russia
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Sumimoto K, Tanaka H, Mukai J, Yamashita K, Tanaka Y, Shono A, Suzuki M, Yokota S, Suto M, Takada H, Matsumoto K, Taniguchi Y, Emoto N, Hirata KI. Effects of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension on remodeling in right-sided heart. Int J Cardiovasc Imaging 2020; 36:1053-1060. [PMID: 32086654 DOI: 10.1007/s10554-020-01798-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/14/2020] [Indexed: 12/21/2022]
Abstract
Remodeling in the right-sided heart plays an important role in the management of pulmonary hypertension (PH) patients. However, the effect of balloon pulmonary angioplasty (BPA) on right ventricular (RV) and right atrial (RA) morphology of patients with chronic thromboembolic pulmonary hypertension (CTEPH) remains uncertain. This study involved 45 CTEPH patients who underwent BPA with mean pulmonary artery pressure (mPAP) of 37.0 mmHg (all ≥ 25 mmHg). All patients underwent echocardiography and right-heart catheterization at baseline and 3 months after BPA. RV and RA remodeling was assessed as RV and the RA area, and RV systolic function was calculated by averaging peak speckle-tracking longitudinal strain of the RV free-wall (RV free-wall strain). Significant reverse remodeling in the right-sided heart was observed after BPA, resulting in improvement of mPAP and pulmonary vascular resistance (RV area: from 15.0 ± 5.3 to 9.6 ± 3.0 cm2, p < 0.0001; RA area: from 17.3 ± 6.6 to 13.4 ± 3.8 cm2, p = 0.0002; RV free-wall strain: from 15.9 ± 5.6 to 21.2 ± 4.9%, p < 0.0001). Furthermore, multiple regression analysis showed that the baseline RV area was an independent predictor of post-BPA normalization of RV systolic function defined as RV free-wall strain ≥ 20% (odds ratio = 1.16, p = 0.0305). Interestingly, significant RV reverse remodeling was also observed after additional BPA even in 18 CTEPH patients with residual pulmonary arterial stenosis, whose mPAP was normalized after BPA (RV area: from 11.5 ± 3.8 to 9.2 ± 3.8 cm2, p = 0.0045; RV free-wall strain: from 17.2 ± 4.8 to 22.8 ± 7.4%, p = 0.0216). Significant reverse remodeling in the right-sided heart, as well as hemodynamic improvement, was observed in CTEPH patients after BPA.
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Affiliation(s)
- Keiko Sumimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Jun Mukai
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Kentaro Yamashita
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yusuke Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Ayu Shono
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Makiko Suzuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shun Yokota
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Makiko Suto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hiroki Takada
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Kensuke Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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63
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Long-term changes of right ventricular myocardial deformation and remodeling studied by cardiac magnetic resonance imaging in patients with chronic thromboembolic pulmonary hypertension following pulmonary thromboendarterectomy. Int J Cardiol 2020; 300:282-288. [DOI: 10.1016/j.ijcard.2019.09.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/22/2019] [Accepted: 09/16/2019] [Indexed: 11/20/2022]
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64
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Feshchenko DA, Rudenko BA, Drapkina OM, Gavrilova NE, Shanoyan AS, Shukurov FB, Vasiliev DK. A clinical case of radiofrequency pulmonary artery denervation for treatment of a patient with residual chronic thromboembolic pulmonary hypertension. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-6-121-125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - B. A. Rudenko
- National Medical Research Center for Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Preventive Medicine
| | | | - A. S. Shanoyan
- National Medical Research Center for Preventive Medicine
| | - F. B. Shukurov
- National Medical Research Center for Preventive Medicine
| | - D. K. Vasiliev
- National Medical Research Center for Preventive Medicine
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65
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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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66
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Usefulness of ventilatory gas analysis for the non-invasive evaluation of the severity of chronic thromboembolic pulmonary hypertension. Int J Cardiol 2019; 296:149-154. [DOI: 10.1016/j.ijcard.2019.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/28/2019] [Accepted: 07/05/2019] [Indexed: 01/01/2023]
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67
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Jin Q, Luo Q, Yang T, Zeng Q, Yu X, Yan L, Zhang Y, Zhao Q, Ma X, An C, Xiong C, Zhao Z, Liu Z. Improved hemodynamics and cardiopulmonary function in patients with inoperable chronic thromboembolic pulmonary hypertension after balloon pulmonary angioplasty. Respir Res 2019; 20:250. [PMID: 31703589 PMCID: PMC6842206 DOI: 10.1186/s12931-019-1211-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/10/2019] [Indexed: 12/16/2022] Open
Abstract
Background Balloon pulmonary angioplasty (BPA) has been demonstrated to improve cardiac function and exercise capacity in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH), but its instant impact on cardiopulmonary function has seldom been evaluated. This study aims to determine the safety and efficacy of BPA and its immediate and lasting effects on cardiopulmonary function among CTEPH patients. Methods From May 2018 to January 2019, patients with inoperable CTEPH who underwent BPA sessions were consecutively enrolled. Hemodynamics were measured by right heart catheterization, selective pulmonary angiography and BPA were successively conducted. Hemodynamic variables, WHO functional class (WHO-FC), 6-min walk distance (6MWD) and serum NT-proBNP were evaluated before and after BPA sessions during hospitalization. Pulmonary function testing (PFT) and cardiopulmonary exercise testing (CPET) were performed within 1–3 days pre and post BPA to evaluate the effect of BPA on cardiopulmonary function. Results Twenty-five patients with inoperable CTEPH who underwent a total of forty BPA sessions were consecutively enrolled. A total of 183 segmental or subsegmental vessels (4.6 ± 1.9 vessels per session) in 137 segments (3.4 ± 1.6 segments per session) were dilated. No procedure-related complications occurred. Instant hemodynamics, WHO-FC, 6MWD and NT-proBNP were all significantly improved after a single BPA session. Significant improvement in cardiopulmonary function was also evident as assessed by PFT indexes (forced vital capacity, forced expiratory volume in the first second, maximal voluntary ventilation) and CPET parameters (peak work rate, peak VO2, oxygen uptake efficiency slope). Further analysis among ten CTEPH patients receiving multiple BPA sessions (2–4 sessions) indicated BPA resulted in lasting improvements in hemodynamics and cardiopulmonary function. Conclusions BPA, a safe and effective approach, can bring instant improvements after a single session and lasting benefits after multiple sessions to hemodynamics and cardiopulmonary function for patients with inoperable CTEPH.
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Affiliation(s)
- Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Tao Yang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Qixian Zeng
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Xue Yu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Lu Yan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Qing Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Xiuping Ma
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Chenhong An
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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68
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Khalid M, Weheba I, Hassan S, Abdelsayed A, Eldali A, Mutairy EA. Clinical outcome and survival in 30 pulmonary hypertension patients with high severity indices and advanced functional class. Ann Saudi Med 2019; 39:426-432. [PMID: 31804134 PMCID: PMC6894455 DOI: 10.5144/0256-4947.2019.426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is an idiopathic or secondary disorder associated with many systemic illnesses. Long-term survival in PH depends on the severity and functional class. Several new drugs are now available to treat PH, but their impact on clinical outcome and survival are not well established. OBJECTIVES Evaluate severity parameters and the impact of current recommended therapy on survival in PH. DESIGN Cross-sectional. SETTINGS Tertiary care center. PATIENTS AND METHODS The study included adult patients who had undergone right heart catheterization since 2012 and were diagnosed with pulmonary hypertension. Survival was recorded after 6 years, at the end of the study. Nine severity variables for PH were assessed including right ventricular size by echocardiogram and pulmonary artery diameter (PA diameter) and the ratio of pulmonary artery diameter to ascending aorta diameter (PA/Ao ratio) by CT. MAIN OUTCOME MEASURES Evaluation of severity parameters. SAMPLE SIZE 30 patients. RESULTS Twenty-five patients were positive for 8/9 severity parameters. Eight of 30 (26.6%) patients died. In nonsurvivors, right ventricular size was increased by 25% ( P=.427), pulmonary vascular resistance increased by 29.4% in nonsurvivors ( P=.302), the 6-minute walk distance decreased by 21% ( P=.875), median brain natriuretic peptide increased by 96% ( P=.890), median GGT and alkaline phosphatase were 3 times higher in nonsurvivors ( P=.893 and P=.047, respectively) and PA/Ao was nonsignificantly decreased in nonsurvivors ( P=.373), Survival was decreased by a median of 2.3 years in nonsurvivors. CONCLUSION Our study identified a subgroup of PH patients with NYHA functional class III and above with worsening severity indicators who were labeled as a high-risk group. These patients showed continuous deterioration in their clinical status despite escalation of therapy with current guidelines. We recommend these high-risk group patients be referred for early lung transplantation. LIMITATIONS Low sample size and only a single center. Needs confirmation with a larger multicenter trial. CONFLICT OF INTEREST None.
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Affiliation(s)
- Mohammed Khalid
- From the Department of Medicine, King Faisal Specialist and Research Center, Riyadh, Saudi Arabia
| | - Ihab Weheba
- From the Department of Medicine, King Faisal Specialist and Research Center, Riyadh, Saudi Arabia.,From the National Research Centre, Cairo, Egypt
| | - Syed Hassan
- From the Johns Hopkins University Hospital, Aramco, Saudi Arabia
| | - Abeer Abdelsayed
- From the National Research Centre, Cairo, Egypt.,From the Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Abdulmonem Eldali
- From the Department of Biostatistics Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Eid Al Mutairy
- From the Department of Medicine, King Faisal Specialist and Research Center, Riyadh, Saudi Arabia
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69
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Risk factors for chronic thromboembolic pulmonary hypertension - Importance of thyroid disease and function. Thromb Res 2019; 185:20-26. [PMID: 31734602 DOI: 10.1016/j.thromres.2019.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Although a number of risk factors for chronic thromboembolic pulmonary hypertension (CTEPH) have been reported, the exact prevalence is controversial and varies between published cohorts. The aim of the present study was to investigate the prevalence of risk factors in operable CTEPH patients with special emphasis on thyroid disease and function. MATERIAL AND METHODS Overall, 228 CTEPH patients (47.7% female; median age 63 [IQR 52-72] years) scheduled for pulmonary endarterectomy between 01/2014 and 12/2015 were studied. Prevalence of risk factors was assessed, and patients were classified according to their thyroid function based on laboratory measurements. RESULTS As many as 86.0% of patients reported a history of pulmonary embolism (PE; of those, 24.5% were diagnosed with "acute" PE less than six months before the diagnosis of CTEPH), 80.7% of patients had a blood group non-0 and 24.1% of patients had known thyroid disease (of those, 78.2% hypothyroidism). Laboratory measurements revealed thyroid dysfunction in 10.5% of patients (of those, 54.8% had no known thyroid disease). Patients with hypothyroid function had higher WHO functional classes, NT-proBNP levels and a lower cardiac index compared to patients with euthyroid function. CONCLUSIONS The prevalence of a history of PE and blood group non-0 was higher than previously reported. However, a relevant proportion of patients might have suffered from pre-existing CTEPH rather than acute PE. Thyroid disease and dysfunction were frequent and hypothyroid function associated with more severe disease.
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70
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Chazova IE, Valieva ZS, Nakonechnikov SN, Taran IN, Martynyuk TV. [Features of clinical, functional and hemodynamics profile, medical treatment and prognosis evaluation in patients with inoperable chronic thromboembolic pulmonary hypertension and idiopathic pulmonary arterial hypertension according to the Russian registry]. TERAPEVT ARKH 2019; 91:77-87. [PMID: 32598818 DOI: 10.26442/00403660.2019.09.000343] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
AIM to perform the complex analysis of clinical, functional, hemodynamics profile in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) compared to the idiopathic pulmonary arterial hypertension (IPAH) group at the time of diagnosis verification according to the Russian registry, and to evaluate the features of medical therapy and it's influence on prognosis in these patients. MATERIALS AND METHODS In the retrospective study 193 patients with IPAH and 130 patients with inoperable CTEPH older than 18 years were included. All included patients were the participants of Russian registry (www.medibase.pro) in 15 Russian expert centers during the period from 01.01.2012 to 31.12.2018 year. The diagnosis was verified according to the algorithm, reflected in the Russian guidelines on diagnosis and treatment of PH and CTEPH (2016 year). The comparison analysis of clinical, functional, hemodynamics parameters in patients with IPAH and inoperable CTEPH was made. RESULTS The status of 193 patients with IPAH (32 male and 162 female) and 130 patients with inoperable CTEPH - (40 male and 90 female) was analyzed during the study. The CTEPH patients were older compared to the IPAH patients: 52.2 [41.1; 60.6] and 36.5 [26.8; 36.5] years, respectively. The median period since symptom occurrence till CTEPH verification was 1.08 [0.2; 3.1] years, in IPAH patients - 2.01 [0.6; 4.2] years. More than 80% of inoperable CTEPH patients had III and IV functional class (FC) according to the World Health Organization classification at the time of diagnosis verification versus 61% of IPAH patients. According to echocardiography the level of mean pulmonary arterial pressure was comparable in two groups of PH patients. However in inoperable CTEPH patients the right atrial area was larger. The significantly higher value of mean pulmonary arterial pressure and lower value oxygen saturation of arterial blood according to the right heart catheterization were revealed. The 5-year survival in CTEPH patients, receiving initial dual combination therapy in 75% cases (in 40% - combination of riociguat and iloprost ) was 93% versus 86.5% in patients with IPAH. CONCLUSION It was revealed, that inoperable CTEPH patients were significantly older with severe functional and hemodynamics status at the time of diagnosis verification, although with higher level of 5-year survival compared to the IPAH patients according to the Russian registry.
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Affiliation(s)
- I E Chazova
- National Medical Research Center of Cardiology, Myasnikov Scientific Research Institute of Clinical Cardiology, Department of Pulmonary Hypertension and Heart Diseases
| | - Z S Valieva
- National Medical Research Center of Cardiology, Myasnikov Scientific Research Institute of Clinical Cardiology, Department of Pulmonary Hypertension and Heart Diseases
| | - S N Nakonechnikov
- National Medical Research Center of Cardiology, Myasnikov Scientific Research Institute of Clinical Cardiology, Department of Pulmonary Hypertension and Heart Diseases
| | - I N Taran
- National Medical Research Center of Cardiology, Myasnikov Scientific Research Institute of Clinical Cardiology, Department of Pulmonary Hypertension and Heart Diseases.,Scientific Research Institute for Complex Issues of Cardiovascular Diseases, Department of Multifocal Atherosclerosis, laboratory of rehabilitation
| | - T V Martynyuk
- National Medical Research Center of Cardiology, Myasnikov Scientific Research Institute of Clinical Cardiology, Department of Pulmonary Hypertension and Heart Diseases
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Akizuki M, Sugimura K, Aoki T, Kakihana T, Tatebe S, Yamamoto S, Sato H, Satoh K, Shimokawa H, Kohzuki M. Non‐invasive screening using ventilatory gas analysis to distinguish between chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension. Respirology 2019; 25:427-434. [DOI: 10.1111/resp.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/25/2019] [Accepted: 05/22/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Mina Akizuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Koichiro Sugimura
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Tatsuo Aoki
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Takaaki Kakihana
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Shunsuke Tatebe
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Saori Yamamoto
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Haruka Sato
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Kimio Satoh
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
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Cheng CY, Zhang YX, Denas G, Du Y, Jing ZC, Pengo V. Prevalence of antiphospholipid (aPL) antibodies among patients with chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis. Intern Emerg Med 2019; 14:521-527. [PMID: 30603858 DOI: 10.1007/s11739-018-02021-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
How thrombophilia may contribute to the development of chronic thromboembolic pulmonary hypertension (CTEPH) is unknown. We searched on PubMed and EMBASE (until 15 April 2018), studies on CTEPH reporting data on inherited or acquired thrombophilia. Starting from 367 articles mentioning the search terms, 347 were excluded mainly as duplicate articles or articles not in English. After reading the full text of remaining articles, ten were excluded for being reviews, editorials, letters or case reports, and two were further removed from the analysis because of the potential selection bias. All the eight considered studies provided the proportion of patients positive for antiphospholipid (aPL) antibodies. The crude rate of aPL in CTPEH patients is 11.8% (95% CI 10.09-13.8%). The meta-analysis considering the weighted mean proportion and 95% confidence intervals (CIs) yields a rate of aPL antibody-positive profile of 12.06% (95% CI 8.12-16.65%) among the patients with CTEPH in the random effects model (I2 76.33%; 95% CI 52.75-88.14%, p = 0.0001). The sensibility analysis confirms the result. No predictors of heterogeneity are found in a meta-regression analysis. Our results suggest that aPL antibodies are frequently associated with CTEPH underlining the need to test for aPL antibodies in young patients with "idiopathic" and "provoked" PE caused by mild provoking risk factors.
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Affiliation(s)
- Chun-Yan Cheng
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yi-Xin Zhang
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yao Du
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Zhi-Cheng Jing
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Abstract
Pulmonary hypertension (PH) is divided into varied pathophysiological and etiologic groupings, as classified by the World Health Organization (WHO). Pulmonary arterial hypertension (PAH), which falls under WHO group 1 PH, is a progressive and potentially fatal disease characterized by a vasoconstrictive, proliferative, and thrombotic phenotype, which leads to increased pulmonary artery pressure, right heart failure, and death. Pathologically, in situ thromboses are found in the small distal pulmonary arteries. Dysregulation of coagulation, platelet function, and endothelial cells may contribute to a prothrombotic state. There is mixed evidence for the use of anticoagulation or antiplatelet therapy in PAH patients.
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74
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Taniguchi Y, Jaïs X, Jevnikar M, Boucly A, Weatherald J, Brenot P, Planche O, Parent F, Savale L, Fadel E, Montani D, Humbert M, Sitbon O, Simonneau G. Predictors of survival in patients with not-operated chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2019; 38:833-842. [PMID: 31103383 DOI: 10.1016/j.healun.2019.04.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/03/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) have recently evolved with the availability of balloon pulmonary angioplasty (BPA) and pulmonary vasodilators. Our aim was to analyze the prognostic variables associated with long-term outcome in a cohort of patients with not-operated CTEPH. METHODS From January 2006 to December 2016, 343 newly diagnosed consecutive patients with not-operated CTEPH were diagnosed and followed up in the French Reference Center for Pulmonary Hypertension. Overall long-term survival and prognostic factors according to the diagnosis period (early period, 2006-2012, vs recent period, since 2013, i.e., one year before availability of BPA) were analyzed. RESULTS In the overall population, baseline New York Heart Association functional class, right atrial pressure, 6-minute walk distance (6MWD), and diagnosis period were independent predictors of survival. The 1- and 3-year survival rates of patients diagnosed in the recent period (n = 170) were 91.6% and 85.0%, compared with 89.0% and 74.3% in patients diagnosed in the early period (n = 173), respectively (p = 0.030). Multivariate analysis from patients diagnosed in the recent period found that baseline 6MWD (per 20 m increase in distance) (hazard ratio [HR], 0.879; 95% confidence interval [CI], 0.832-0.928, p < 0.001) and BPA (HR, 0.307; 95% CI, 0.099-0.957; p = 0.042) were independently associated with survival. CONCLUSIONS Survival of not-operated patients with CTEPH has significantly improved in the recent management era. New treatment options, including BPA, might have the potential to improve the prognosis of patients with inoperable CTEPH.
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Affiliation(s)
- Yu Taniguchi
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Xavier Jaïs
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
| | - Mitja Jevnikar
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Athénaïs Boucly
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Jason Weatherald
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; University of Calgary, Department of Medicine, Division of Respirology, Calgary, Canada; Libin Cardiovascular Institute of Alberta, Calgary, Canada
| | - Philippe Brenot
- Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service de Radiologie, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Planche
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; AP-HP, Service de Radiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Florence Parent
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Elie Fadel
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service de Chirurgie Thoracique, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - David Montani
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Sitbon
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Gérald Simonneau
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR-S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Lacharite-Roberge AS, Raza F, Bashir R, Dass CA, Moser GW, Auger WR, Toyoda Y, Forfia PR, Vaidya A. Case series of seven women with uterine fibroids associated with venous thromboembolism and chronic thromboembolic disease. Pulm Circ 2018; 9:2045894018803873. [PMID: 30204062 PMCID: PMC6304711 DOI: 10.1177/2045894018803873] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Uterine fibroids have been described as an associate to acute venous thromboembolism (VTE), with case reports showing an association between large uterine fibroids, acute deep venous thrombosis (DVT), and acute pulmonary embolism (PE). However, there is little known about the association or causation between uterine fibroids, chronic thromboembolic disease (CTED), and chronic thromboembolic pulmonary hypertension (CTEPH). We report on six women with uterine fibroids and CTEPH, as well as one woman with CTED, all of whom presented with exertional dyspnea, lower extremity swelling, and in the cases of CTEPH, clinical, echocardiographic, and hemodynamic evidence of pulmonary hypertension and right heart failure. Compression of the pelvic veins by fibroids was directly observed with invasive venography or contrast-enhanced computed tomography in five cases. All seven women underwent pulmonary thromboendarterectomy (PTE) followed by marked improvement in functional, clinical, and hemodynamic status.
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Affiliation(s)
| | - Farhan Raza
- Heart and Vascular Institute,
Temple
University Hospital, Philadelphia, PA,
USA
| | - Riyaz Bashir
- Heart and Vascular Institute,
Temple
University Hospital, Philadelphia, PA,
USA
| | - Chandra A. Dass
- Department of Radiology,
Temple
University Hospital, Philadelphia, PA,
USA
| | - G. William Moser
- Department of Cardiovascular Surgery,
Temple
University Hospital, Philadelphia, PA,
USA
| | - William R. Auger
- Heart and Vascular Institute,
Temple
University Hospital, Philadelphia, PA,
USA
| | - Yoshiya Toyoda
- Department of Cardiovascular Surgery,
Temple
University Hospital, Philadelphia, PA,
USA
| | - Paul R. Forfia
- Heart and Vascular Institute,
Temple
University Hospital, Philadelphia, PA,
USA
- Paul R. Forfia, Professor of Medicine Temple
Heart and Vascular Institute 3401 N Broad Street, 9th Floor Parkinson Pavilion,
Philadelphia, PA 19140, USA.
| | - Anjali Vaidya
- Heart and Vascular Institute,
Temple
University Hospital, Philadelphia, PA,
USA
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76
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Quadery SR, Swift AJ, Billings CG, Thompson AAR, Elliot CA, Hurdman J, Charalampopoulos A, Sabroe I, Armstrong IJ, Hamilton N, Sephton P, Garrad S, Pepke-Zaba J, Jenkins DP, Screaton N, Rothman AM, Lawrie A, Cleveland T, Thomas S, Rajaram S, Hill C, Davies C, Johns CS, Wild JM, Condliffe R, Kiely DG. The impact of patient choice on survival in chronic thromboembolic pulmonary hypertension. Eur Respir J 2018; 52:1800589. [PMID: 30002102 PMCID: PMC6340636 DOI: 10.1183/13993003.00589-2018] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/15/2018] [Indexed: 11/05/2022]
Abstract
Pulmonary endarterectomy (PEA) is the gold standard treatment for operable chronic thromboembolic pulmonary hypertension (CTEPH). However, a proportion of patients with operable disease decline surgery. There are currently no published data on this patient group. The aim of this study was to identify outcomes and prognostic factors in a large cohort of consecutive patients with CTEPH.Data were collected for consecutive, treatment-naive CTEPH patients at the Pulmonary Vascular Disease Unit of the Royal Hallamshire Hospital (Sheffield, UK) between 2001 and 2014.Of 550 CTEPH patients (mean±sd age 63±15 years, follow-up 4±3 years), 49% underwent surgery, 32% had technically operable disease and did not undergo surgery (including patient choice n=72 and unfit for surgery n=63), and 19% had inoperable disease due to disease distribution. The 5-year survival was superior in patients undergoing PEA (83%) versus technically operable disease who did not undergo surgery (53%) and inoperable due to disease distribution (59%) (p<0.001). Survival was superior in patients following PEA compared with those offered but declining surgery (55%) (p<0.001). In patients offered PEA, independent prognostic factors included mixed venous oxygen saturation, gas transfer and patient decision to proceed to surgery.Outcomes in CTEPH following PEA are excellent and superior to patients declining surgery, and strongly favour consideration of a surgical intervention in eligible patients.
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Affiliation(s)
- Syed Rehan Quadery
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Catherine G Billings
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alfred A R Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Charles A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Judith Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Iain J Armstrong
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Sephton
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sian Garrad
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - David P Jenkins
- Pulmonary Vascular Disease Unit, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nicholas Screaton
- Pulmonary Vascular Disease Unit, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Alexander M Rothman
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Allan Lawrie
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Trevor Cleveland
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Steven Thomas
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Smitha Rajaram
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Catherine Hill
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christine Davies
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christopher S Johns
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jim M Wild
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- These authors contributed equally to this work
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in silico Medicine, University of Sheffield, Sheffield, UK
- These authors contributed equally to this work
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77
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Wilkens H, Konstantinides S, Lang IM, Bunck AC, Gerges M, Gerhardt F, Grgic A, Grohé C, Guth S, Held M, Hinrichs JB, Hoeper MM, Klepetko W, Kramm T, Krüger U, Lankeit M, Meyer BC, Olsson KM, Schäfers HJ, Schmidt M, Seyfarth HJ, Ulrich S, Wiedenroth CB, Mayer E. Chronic thromboembolic pulmonary hypertension (CTEPH): Updated Recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:69-78. [PMID: 30195840 DOI: 10.1016/j.ijcard.2018.08.079] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of pulmonary hypertension that differs from all other forms of PH in terms of its pathophysiology, patient characteristics and treatment. For implementation of the European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension in Germany, the Cologne Consensus Conference 2016 was held and last updated in spring of 2018. One of the working groups was dedicated to CTEPH, practical and controversial issues were commented and updated. In every patient with suspected PH, CTEPH or chronic thromboembolic disease (CTED, i.e. symptomatic residual vasculopathy without pulmonary hypertension) should be excluded. Primary treatment is surgical pulmonary endarterectomy (PEA) in a multidisciplinary CTEPH centre. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. There is increasing experience with balloon pulmonary angioplasty (BPA) for inoperable patients; this option, like PEA, is reserved for specialised centres with expertise in this treatment method.
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Affiliation(s)
- Heinrike Wilkens
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, University Hospital of Saarland, 66421 Homburg, Saar, Germany.
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes-Gutenberg Universität Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Irene M Lang
- Klinik für Innere Medizin II, Abt. Kardiologie, Medizinische Universität Wien, Austria
| | - Alexander C Bunck
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinik Köln, Germany
| | - Mario Gerges
- Klinik für Innere Medizin II, Abt. Kardiologie, Medizinische Universität Wien, Austria
| | - Felix Gerhardt
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinik Köln, Germany
| | | | - Christian Grohé
- Klinik für Pneumologie Evangelische Lungenklinik Berlin, Buch, 13125 Berlin, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Matthias Held
- Missionsärztliche Klinik Würzburg, Innere Medizin, Pneumologie/Kardiologie, Zentrum für pulmonale Hyertonie und Lungengefäßkrankheiten, Germany
| | - Jan B Hinrichs
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Deutsches Zentrum für Lungenforschung (DZL), Germany
| | - Walter Klepetko
- Klinische Abteilung für Thoraxchirurgie, Medizinische Universität Wien, Austria
| | - Thorsten Kramm
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Ulrich Krüger
- Klinik für Kardiologie und Angiologie, Herzzentrum Duisburg, Germany
| | - Mareike Lankeit
- Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Bernhard C Meyer
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, 66421 Homburg, Germany
| | - Matthias Schmidt
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, 50937 Köln, Germany
| | - Hans-J Seyfarth
- Abteilung Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Germany
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
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78
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Yanaka K, Nakayama K, Shinke T, Shinkura Y, Taniguchi Y, Kinutani H, Tamada N, Onishi H, Tsuboi Y, Satomi-Kobayashi S, Otake H, Tanaka H, Okita Y, Emoto N, Hirata KI. Sequential Hybrid Therapy With Pulmonary Endarterectomy and Additional Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. J Am Heart Assoc 2018; 7:JAHA.118.008838. [PMID: 29929993 PMCID: PMC6064916 DOI: 10.1161/jaha.118.008838] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Residual symptoms after pulmonary endarterectomy (PEA) remain as the clinical issues to be solved. Additional balloon pulmonary angioplasty (BPA) after PEA showed its efficacy with symptoms in a case series, although long‐term spontaneous recovery of exercise ability after PEA was also reported. However, no studies have validated the clinical efficacy of additional BPA by directly comparing PEA with and without BPA. The aim of this study was to retrospectively evaluate the efficacy of additional BPA as a sequential hybrid therapy for chronic thromboembolic pulmonary hypertension after PEA. Methods and Results Among 44 patients with chronic thromboembolic pulmonary hypertension, 20 patients had residual symptoms after PEA. Of those, 10 patients underwent additional BPA (hybrid group) and were compared with the other 10 patients, who were followed up without BPA (PEA group). The period from PEA to additional BPA was 7.3±2.3 months. In hybrid group, mean pulmonary arterial pressure was significantly improved by PEA (40.6±1.8 to 26.9±3.1 mm Hg, P=0.001) and improved further (to 16.7±1.8 mm Hg, P=0.002) with additional BPA, which resulted in remarkable improvement in World Health Organization (WHO) functional class (pre‐ to post‐BPA: class I/II/III/IV, 0/5/4/1 to 7/3/0/0; P<0.001). Compared with the PEA group at follow‐up, the hybrid group achieved better mean pulmonary arterial pressure (18.7±1.7 versus 30.2±3.2 mm Hg, P=0.008), WHO functional class (class I/II/III/IV, 7/3/0/0 versus 0/8/2/0; P=0.001), and 6‐minute walking distance (429±38 versus 319±22 m, P=0.028). Conclusions A sequential hybrid strategy improved residual symptoms and exercise capacity compared with single‐PEA therapy.
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Affiliation(s)
- Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazuhiko Nakayama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuto Shinkura
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroto Kinutani
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Tamada
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasunori Tsuboi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Seimi Satomi-Kobayashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Clinical Pharmacy, Kobe Pharmaceutical University, Kobe, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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79
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Pulmonary Arterial Hypertension and Endothelial Dysfunction Is Linked to NADPH Oxidase-Derived Superoxide Formation in Venous Thrombosis and Pulmonary Embolism in Mice. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2018; 2018:1860513. [PMID: 29983855 PMCID: PMC6015670 DOI: 10.1155/2018/1860513] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/11/2018] [Accepted: 02/28/2018] [Indexed: 12/30/2022]
Abstract
Pulmonary embolism (PE) results from deep vein thrombosis (DVT) and can lead to chronic thromboembolic pulmonary hypertension (CTEPH) involving vascular dysfunction. Mechanisms are incompletely understood, in part due to lack of mouse models. We induced PE in C57BL/6 mice by intravenous injection of thrombin (166 U/kg BW), confirmed by a sudden bradycardia, bradypnea, and an increase in pulmonary artery (PA) pressure observed by high-frequency ultrasound. While symptoms resolved rapidly after single thrombin application, repeated PEs resulted in sustained PA-pressure increase, increased PA superoxide formation assessed by oxidative fluorescent microtopography, increased PA gp91phox expression, and endothelial dysfunction assessed by isometric tension studies of isolated PA segments after 24 hours. DVT was modeled in C57BL/6 mice by ligation of the inferior vena cava (IVC). Importantly, small pulmonary emboli could be detected along with a mild phenotype of PA endothelial dysfunction and oxidative stress in the absence of PA-pressure elevation. mRNA expression of plasminogen activator inhibitor-1 was increased in PAs of mice with recurrent PE after repetitive thrombin injections and to a lesser extent in DVT mice. In summary, our data suggest that PA endothelial dysfunction, induced by gp91phox-derived ROS, is an early event upon repetitive PE. This phenomenon might help to elucidate the mechanisms of PA dysfunction in the pathogenesis of CTEPH.
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Lee H, Kim MS, Kim WS, Kim YH, Cho SH, Lee JJ. Life-Threatening Acute on Chronic Pulmonary Thromboembolism Requiring Extracorporeal Membrane Oxygenation. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 51:205-208. [PMID: 29854666 PMCID: PMC5973218 DOI: 10.5090/kjtcs.2018.51.3.205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
A 71-year-old female patient was admitted to the emergency department with sudden aggravation of chest pain and severe dyspnea. Computed tomography showed extensive pulmonary thromboembolism. Venoarterial extracorporeal membrane oxygenation (ECMO) was instituted due to sudden bradycardia and hypotension. An emergency operation was performed. However, chronic pulmonary thromboembolism combined with an acute pulmonary embolism was detected in the operating room. Embolectomy and endarterectomy were performed. ECMO was then discontinued. The patient was discharged on postoperative day 13 with warfarin for anticoagulation. The patient was followed up for 46 months as an outpatient without further thromboembolic events.
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Affiliation(s)
- Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Min Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yong Han Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine
| | - Sung Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine
| | - Jae Jin Lee
- Department of Thoracic and Cardiovascular Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine
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Nishiyama KH, Saboo SS, Tanabe Y, Jasinowodolinski D, Landay MJ, Kay FU. Chronic pulmonary embolism: diagnosis. Cardiovasc Diagn Ther 2018; 8:253-271. [PMID: 30057874 DOI: 10.21037/cdt.2018.01.09] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of venous thromboembolic disease. Differently from other causes of pulmonary hypertension, CTEPH is potentially curable with surgery (thromboendarterectomy) or balloon pulmonary angioplasty. Imaging plays a central role in CTEPH diagnosis. The combination of techniques such as lung scintigraphy, computed tomography and magnetic resonance angiography provides non-invasive anatomic and functional information. Conventional pulmonary angiography (CPA) with right heart catheterization (RHC) is considered the gold standard method for diagnosing CTEPH. In this review, we discuss the utility of these imaging techniques in the diagnosis of CTEPH.
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Affiliation(s)
- Katia Hidemi Nishiyama
- Department of Thoracic Imaging, Hospital do Coração and DASA (Diagnósticos da América), São Paulo, Brazil
| | - Sachin S Saboo
- Department of Radiology, UT Southwestern Medical Center, Florence Building, Dallas, TX, USA
| | - Yuki Tanabe
- Department of Radiology, UT Southwestern Medical Center, Florence Building, Dallas, TX, USA
| | | | - Michael J Landay
- Department of Radiology, UT Southwestern Medical Center, Florence Building, Dallas, TX, USA
| | - Fernando Uliana Kay
- Department of Radiology, UT Southwestern Medical Center, Florence Building, Dallas, TX, USA
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Taniguchi Y, Brenot P, Jais X, Garcia C, Weatherald J, Planche O, Fadel E, Humbert M, Simonneau G. Poor Subpleural Perfusion Predicts Failure After Balloon Pulmonary Angioplasty for Nonoperable Chronic Thromboembolic Pulmonary Hypertension. Chest 2018; 154:521-531. [PMID: 29730328 DOI: 10.1016/j.chest.2018.03.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/24/2018] [Accepted: 03/30/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Poor subpleural perfusion (PSP) in the capillary phase of pulmonary angiography predicts worse outcomes following pulmonary endarterectomy in operable chronic thromboembolic pulmonary hypertension (CTEPH). Balloon pulmonary angioplasty (BPA) has emerged as a treatment for nonoperable CTEPH. The goal of the present article was to assess the association between PSP and BPA failure. METHODS Subpleural perfusion was classified as poor (defined as subpleural spaces either not perfused or minimally perfused in all segments) or normal. We retrospectively reviewed PSP and hemodynamic variables of 101 consecutive patients who underwent BPA from February 2014 to August 2016. The total cross-sectional area of bronchial arteries was also measured by using CT scanning. Patients were categorized according to hemodynamic results after the last BPA: a failure group (defined as mean pulmonary arterial pressure > 30 mm Hg and a decrease in pulmonary vascular resistance < 30% [n = 15]) or a success group (n = 86). RESULTS Although baseline hemodynamic variables were similar between the two groups, PSP was observed in 46.7% of patients in the failure group vs 13.9% in the success group (P = .003). Multivariate analysis revealed that PSP was the only predictor of BPA failure (OR, 4.02 [95% CI, 1.17-13.89]; P = .028). Patients with PSP exhibited poorly developed bronchial arteries compared with patients with normal perfusion (7.0 [5.8-9.6] mm2 vs 8.7 [6.9-11.3] mm2; P = .032). CONCLUSIONS PSP in the capillary phase, suggesting the presence of small vessel disease with diffuse distal thrombosis, is a predictor of BPA failure. PSP was also associated with less developed bronchial arteries, which suggests a key role of bronchial-pulmonary anastomoses in maintaining the pulmonary capillary bed open downstream of the pulmonary arterial obstruction. PSP affected approximately 15% of patients with nonoperable CTEPH who underwent BPA.
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Affiliation(s)
- Yu Taniguchi
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Philippe Brenot
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service de Radiologie, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Xavier Jais
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Carlos Garcia
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service de Radiologie, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Jason Weatherald
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Department of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
| | - Olivier Planche
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; AP-HP, Service de Radiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Elie Fadel
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service de Chirurgie Thoracique, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Gérald Simonneau
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
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Treatment Effect of Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension Quantified by Automatic Comparative Imaging in Computed Tomography Pulmonary Angiography. Invest Radiol 2018; 53:286-292. [DOI: 10.1097/rli.0000000000000441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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84
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Vanini B, Grazioli V, Sciortino A, Pin M, Merli VN, Celentano A, Parisi I, Klersy C, Petrucci L, Salati M, Politi P, D'Armini AM. Neuropsychological outcomes after pulmonary endarterectomy using moderate hypothermia and periodic circulatory arrest. J Heart Lung Transplant 2018; 37:860-864. [PMID: 29550147 DOI: 10.1016/j.healun.2018.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 02/10/2018] [Accepted: 02/14/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In this prospective, single-center, observational study, we investigated the association between repeated short periods of circulatory arrest with moderate hypothermia during pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and different neuropsychological dimensions. METHODS We examined 70 patients with CTEPH, >18 to 80 years of age, who had been treated with PEA. Neuropsychological testing was performed. RESULTS Learning ability and delayed memory remained well within the normal range for patients' age. We found a statistically significant post-surgical improvement in motor speed, which was accompanied by a better quality of life and reduced symptoms of depression and anxiety. CONCLUSION PEA with repeated short periods of circulatory arrest in CTEPH did not result in any neuropsychological complications and may even lead to post-surgical psychological improvements.
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Affiliation(s)
- Benedetta Vanini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy; Department of Brain and Behavioral Sciences, Section of Psychiatry, University of Pavia, Pavia, Italy.
| | - Valentina Grazioli
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Sciortino
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maurizio Pin
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vera N Merli
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Celentano
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ilaria Parisi
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Catherine Klersy
- Service of Biometrics and Statistics, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lucia Petrucci
- Rehabilitation Unit, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maurizio Salati
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pierluigi Politi
- Department of Brain and Behavioral Sciences, Section of Psychiatry, University of Pavia, Pavia, Italy
| | - Andrea M D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
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85
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Pitfalls in the Diagnosis of Acute Pulmonary Embolism on Computed Tomography: Common Pathologic and Imaging Mimics. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0273-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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86
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon and late complication of pulmonary embolism resulting from misguided remodelling of residual pulmonary thromboembolic material and small-vessel arteriopathy. CTEPH is the only form of pulmonary hypertension (PH) potentially curable by pulmonary endarterectomy (PEA). Unfortunately, several patients have either an unacceptable risk-benefit ratio for undergoing the surgical intervention or develop persistent PH after PEA. Novel medical and endovascular therapies can be considered for them. The soluble guanylate cyclase stimulator riociguat is recommended for the treatment of patients with inoperable disease or with recurrent/persistent PH after PEA. Other drugs developed for the treatment of other forms of PH, as prostanoids, phosphodiesterase-5 inhibitors and endothelin receptor antagonists have been used in the treatment of CTEPH, with limited benefit. Balloon pulmonary angioplasty is a novel and promising technique and is progressively emerging from the pioneering phase. Highly specialized training level and complex protocols of postoperative care are mandatory to consolidate the technical success of the surgical and endovascular intervention.
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Affiliation(s)
| | - Paolo Prandoni
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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87
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Aluja Jaramillo F, Gutierrez FR, Díaz Telli FG, Yevenes Aravena S, Javidan-Nejad C, Bhalla S. Approach to Pulmonary Hypertension: From CT to Clinical Diagnosis. Radiographics 2018; 38:357-373. [PMID: 29432063 DOI: 10.1148/rg.2018170046] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pulmonary hypertension (PH) is a condition characterized by increased pressure in the pulmonary circulation. It may be idiopathic or arise in the setting of other clinical conditions. Patients with PH tend to present with nonspecific cardiovascular or respiratory symptoms. The clinical classification of PH was recently revised at the World Health Organization symposium in Nice, France, in 2013. That consensus statement provided an updated classification based on the shared hemodynamic characteristics and management of the different categories of PH. Some features seen at computed tomography (CT) can suggest a subtype or probable cause of PH that may facilitate placing the patient in the correct category. These features include findings in the pulmonary arteries (peripheral calcification, peripheral dilatation, eccentric filling defects, intra-arterial soft tissue), lung parenchyma (centrilobular nodules, mosaic attenuation, interlobular septal thickening, bronchiectasis, subpleural peripheral opacities, ground-glass opacities, diffuse nodules), heart (congenital lesions, left heart disease, valvular disease), and mediastinum (hypertrophied bronchial arteries). An approach based on identification of these CT features in patients with PH will allow the radiologist to play an important role in diagnosis and help guide the clinician in management of PH. ©RSNA, 2018.
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Affiliation(s)
- Felipe Aluja Jaramillo
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Fernando R Gutierrez
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Federico G Díaz Telli
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Sebastian Yevenes Aravena
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Cylen Javidan-Nejad
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Sanjeev Bhalla
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
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Chen TX, Pudasaini B, Guo J, Gong SG, Jiang R, Wang L, Zhao QH, Wu WH, Yuan P, Liu JM. Sex-specific cardiopulmonary exercise testing indices to estimate the severity of inoperable chronic thromboembolic pulmonary hypertension. Int J Chron Obstruct Pulmon Dis 2018; 13:385-397. [PMID: 29416329 PMCID: PMC5790096 DOI: 10.2147/copd.s152971] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Sex differences in chronic thromboembolic pulmonary hypertension (CTEPH) have been revealed in few studies. Although right heart catheterization (RHC) is the gold standard for clinical diagnosis and assessment of prognosis in pulmonary hypertension (PH), cardiopulmonary exercise testing (CPET) has been a more widely used assessment of functional capacity, disease severity, prognosis, and treatment response in PH. We hypothesized that the “sex-specific” CPET indices could estimate the severity of inoperable CTEPH. Methods Data were retrieved for 33 male (age, mean ± standard deviation [SD] =62.5±13.4 years) and 40 female (age, mean ± SD =56.3±11.8 years) patients with stable CTEPH who underwent both RHC and CPET at Shanghai Pulmonary Hospital from February 2010 to February 2016. Univariate and forward/backward multiple stepwise regression analysis was performed to assess the predictive value of CPET indices to hemodynamic parameters. Event-free survival was estimated using the Kaplan–Meier method and analyzed with the log-rank test. Cox proportional hazards models were performed to determine the independent event-free survival predictors. Results Numerous CPET parameters were different between male and female patients with CTEPH and the control group. There were no significant differences in both clinical variables and RHC parameters between male and female patients with CTEPH. O2 pulse, workload, minute ventilation (VE), and end-tidal partial pressure of O2 (PETO2) at anaerobic threshold, as well as peak O2 pulse, workload, VE, and nadir VE/CO2 were significantly higher in male patients than in female patients (P<0.05). Only oxygen uptake efficiency plateau (OUEP) showed a significantly higher difference in female than male patients (P<0.05). In addition, several CPET indices correlated with hemodynamic parameters, especially pulmonary vascular resistance (PVR), which was distinctly different between the sexes. Nadir VE/CO2 was an independent predictor of PVR in male patients with CTEPH, whereas OUEP was an independent predictor of PVR in female patients with CTEPH. Conclusion Even after confounding for age and body mass index, different CPET measurements of gas exchange efficiency correlated with PVR differently between male and female patients. This potentially could be used to estimate the severity of CTEPH.
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Affiliation(s)
- Tian-Xiang Chen
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Bigyan Pudasaini
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
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89
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Abstract
Pulmonary hypertension is defined by a mean pulmonary artery pressure greater than 25 mm Hg. Chronic thromboembolic pulmonary hypertension (CTEPH) is defined as pulmonary hypertension in the presence of an organized thrombus within the pulmonary vascular bed that persists at least 3 months after the onset of anticoagulant therapy. Because CTEPH is potentially curable by surgical endarterectomy, correct identification of patients with this form of pulmonary hypertension and an accurate assessment of surgical candidacy are essential to provide optimal care. Patients most commonly present with symptoms of exertional dyspnea and otherwise unexplained decline in exercise capacity. Atypical chest pain, a nonproductive cough, and episodic hemoptysis are observed less frequently. With more advanced disease, patients often develop symptoms suggestive of right ventricular compromise. Physical examination findings are minimal early in the course of this disease, but as pulmonary hypertension progresses, may include nonspecific finding of right ventricular failure, such as a tricuspid regurgitation murmur, pedal edema, and jugular venous distention. Chest radiographs may suggest pulmonary hypertension, but are neither sensitive nor specific for the diagnosis. Radioisotopic ventilation-perfusion scanning is sensitive for detecting CTEPH, making it a valuable screening study. Conventional catheter-based pulmonary angiography retains an important role in establishing the presence and extent of chronic thromboembolic disease. However, computed tomographic and magnetic resonance imaging are playing a growing diagnostic role. Innovative technologies such as dual-energy computed tomography, dynamic contrast-enhanced magnetic resonance imaging, and optical coherence tomography show promise for contributing diagnostic information and assisting in the preoperative characterization of patients with CTEPH.
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90
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Higo K, Kubota K, Miyanaga S, Miyata M, Nakajo M, Jinguji M, Ohishi M. Impairment of Iodine-123-Metaiodobenzylguanidine (<sup>123</sup>I-MIBG) Uptake in Patients with Pulmonary Artery Hypertension. Int Heart J 2018; 59:112-119. [DOI: 10.1536/ihj.16-629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kenjuro Higo
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Kayoko Kubota
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Sunao Miyanaga
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Masaaki Miyata
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Masatoyo Nakajo
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Megumi Jinguji
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
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Stam K, van Duin RWB, Uitterdijk A, Cai Z, Duncker DJ, Merkus D. Exercise facilitates early recognition of cardiac and vascular remodeling in chronic thromboembolic pulmonary hypertension in swine. Am J Physiol Heart Circ Physiol 2017; 314:H627-H642. [PMID: 29167118 DOI: 10.1152/ajpheart.00380.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) develops in 4% of patients after pulmonary embolism and is accompanied by an impaired exercise tolerance, which is ascribed to the increased right ventricular (RV) afterload in combination with a ventilation/perfusion (V/Q) mismatch in the lungs. The present study aimed to investigate changes in arterial Po2 and hemodynamics in response to graded treadmill exercise during development and progression of CTEPH in a novel swine model. Swine were chronically instrumented and received multiple pulmonary embolisms by 1) microsphere infusion (Spheres) over 5 wk, 2) endothelial dysfunction by administration of the endothelial nitric oxide synthase inhibitor Nω-nitro-l-arginine methyl ester (L-NAME) for 7 wk, 3) combined pulmonary embolisms and endothelial dysfunction (L-NAME + Spheres), or 4) served as sham-operated controls (sham). After a 9 wk followup, embolization combined with endothelial dysfunction resulted in CTEPH, as evidenced by mean pulmonary artery pressures of 39.5 ± 5.1 vs. 19.1 ± 1.5 mmHg (Spheres, P < 0.001), 22.7 ± 2.0 mmHg (L-NAME, P < 0.001), and 20.1 ± 1.5 mmHg (sham, P < 0.001), and a decrease in arterial Po2 that was exacerbated during exercise, indicating V/Q mismatch. RV dysfunction was present after 5 wk of embolization, both at rest (trend toward increased RV end-systolic lumen area, P = 0.085, and decreased stroke volume index, P = 0.042) and during exercise (decreased stroke volume index vs. control, P = 0.040). With sustained pulmonary hypertension, RV hypertrophy (Fulton index P = 0.022) improved RV function at rest and during exercise, but this improvement was insufficient in CTEPH swine to result in an exercise-induced increase in cardiac index. In conclusion, embolization in combination with endothelial dysfunction results in CTEPH in swine. Exercise increased RV afterload, exacerbated the V/Q mismatch, and unmasked RV dysfunction. NEW & NOTEWORTHY Here, we present the first double-hit chronic thromboembolic pulmonary hypertension swine model. We show that embolization as well as endothelial dysfunction is required to induce sustained pulmonary hypertension, which is accompanied by altered exercise hemodynamics and an exacerbated ventilation/perfusion mismatch during exercise.
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Affiliation(s)
- Kelly Stam
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Richard W B van Duin
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - André Uitterdijk
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Zongye Cai
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Dirk J Duncker
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Daphne Merkus
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
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92
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Kroft LJM, Erkens PMG, Douma RA, Mos ICM, Jonkers G, Hovens MMC, Durian MF, Cate HT, Beenen LFM, Kamphuisen PW, Huisman MV, den Exter PL, van Es J. Thromboembolic resolution assessed by CT pulmonary angiography after treatment for acute pulmonary embolism. Thromb Haemost 2017; 114:26-34. [DOI: 10.1160/th14-10-0842] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/13/2015] [Indexed: 11/05/2022]
Abstract
SummaryThe systematic assessment of residual thromboembolic obstruction after treatment for acute pulmonary embolism (PE) has been under-studied. This assessment is of potential clinical importance, should clinically suspected recurrent PE occur, or as tool for risk stratification of cardiopulmonary complications or recurrent venous thromboembolism (VTE). This study aimed to assess the rate of PE resolution and its implications for clinical outcome. In this prospective, multi-center cohort study, 157 patients with acute PE diagnosed by CT pulmonary angiography (CTPA) underwent follow-up CTPA-imaging after six months of anticoagulant treatment. Two expert thoracic radiologists independently assessed the presence of residual thromboembolic obstruction. The degree of obstruction at baseline and follow-up was calculated using the Qanadli obstruction index. All patients were followed-up for 2.5 years. At baseline, the median obstruction index was 27.5 %. After six months of treatment, complete PE resolution had occurred in 84.1 % of the patients (95 % confidence interval (CI): 77.4–89.4 %). The median obstruction index of the 25 patients with residual thrombotic obstruction was 5.0 %. During follow-up, 16 (10.2 %) patients experienced recurrent VTE. The presence of residual thromboembolic obstruction was not associated with recurrent VTE (adjusted hazard ratio: 0.92; 95 % CI: 0.2–4.1). This study indicates that the incidence of residual thrombotic obstruction following treatment for PE is considerably lower than currently anticipated. These findings, combined with the absence of a correlation between residual thrombotic obstruction and recurrent VTE, do not support the routine use of follow-up CTPA-imaging in patients treated for acute PE.
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93
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Guérin L, Couturaud F, Parent F, Revel MP, Gillaizeau F, Planquette B, Pontal D, Guégan M, Simonneau G, Meyer G, Sanchez O. Prevalence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Thromb Haemost 2017; 112:598-605. [DOI: 10.1160/th13-07-0538] [Citation(s) in RCA: 209] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 03/25/2014] [Indexed: 12/21/2022]
Abstract
SummaryChronic thromboembolic pulmonary hypertension (CTEPH) has been estimated to occur in 0.1–0.5% of patients who survive a pulmonary embolism (PE), but more recent prospective studies suggest that its incidence may be much higher. The absence of initial haemodynamic evaluation at the time of PE should explain this discrepancy. We performed a prospective multicentre study including patients with PE in order to assess the prevalence and to describe risk factors of CTEPH. Follow-up every year included an evaluation of dyspnea and echocardiography using a predefined algorithm. In case of suspected CTEPH, the diagnosis was confirmed using right heart catheterisation (RHC). Signs of CTEPH were searched on the multidetector computed tomography (CT) and echocardiography performed at the time of PE. Of the 146 patients analysed, eight patients (5.4%) had suspected CTEPH during a median follow-up of 26 months. CTEPH was confirmed using RHC in seven cases (4.8%; 95%CI, 2.3 – 9.6) and ruled-out in one. Patients with CTEPH were older, had more frequently previous venous thromboembolic events and more proximal PE than those without CTEPH. At the time of PE diagnosis, patients with CTEPH had a higher systolic pulmonary artery pressure and at least two signs of CTEPH on the initial CT. After acute PE, the prevalence of CTEPH appears high. However, initial echocardiography and CT data at the time of the index PE suggest that a majority of patients with CTEPH had previously unknown pulmonary hypertension, indicating that a first clinical presentation of CTEPH may mimic acute PE.
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94
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Su J, Manisty C, Parker KH, Simonsen U, Nielsen-Kudsk JE, Mellemkjaer S, Connolly S, Lim PB, Whinnett ZI, Malik IS, Watson G, Davies JE, Gibbs S, Hughes AD, Howard L. Wave Intensity Analysis Provides Novel Insights Into Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension. J Am Heart Assoc 2017; 6:JAHA.117.006679. [PMID: 29089339 PMCID: PMC5721764 DOI: 10.1161/jaha.117.006679] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background In contrast to systemic hypertension, the significance of arterial waves in pulmonary hypertension (PH) is not well understood. We hypothesized that arterial wave energy and wave reflection are augmented in PH and that wave behavior differs between patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Methods and Results Right heart catheterization was performed using a pressure and Doppler flow sensor–tipped catheter to obtain simultaneous pressure and flow velocity measurements in the pulmonary artery. Wave intensity analysis was subsequently applied to the acquired data. Ten control participants, 11 patients with PAH, and 10 patients with CTEPH were studied. Wave speed and wave power were significantly greater in PH patients compared with controls, indicating increased arterial stiffness and right ventricular work, respectively. The ratio of wave power to mean right ventricular power was lower in PAH patients than CTEPH patients and controls. Wave reflection index in PH patients (PAH: ≈25%; CTEPH: ≈30%) was significantly greater compared with controls (≈4%), indicating downstream vascular impedance mismatch. Although wave speed was significantly correlated to disease severity, wave reflection indexes of patients with mildly and severely elevated pulmonary pressures were similar. Conclusions Wave reflection in the pulmonary artery increased in PH and was unrelated to severity, suggesting that vascular impedance mismatch occurs early in the development of pulmonary vascular disease. The lower wave power fraction in PAH compared with CTEPH indicates differences in the intrinsic and/or extrinsic ventricular load between the 2 diseases.
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Affiliation(s)
- Junjing Su
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark .,National Heart and Lung Institute Imperial College London, London, United Kingdom
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Kim H Parker
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Ulf Simonsen
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark
| | | | - Soren Mellemkjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Susan Connolly
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - P Boon Lim
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Zachary I Whinnett
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Iqbal S Malik
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Geoffrey Watson
- National Heart and Lung Institute Imperial College London, London, United Kingdom
| | - Justin E Davies
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Simon Gibbs
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alun D Hughes
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Luke Howard
- National Heart and Lung Institute Imperial College London, London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
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95
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Kharat A, Hachulla AL, Noble S, Lador F. Modern diagnosis of chronic thromboembolic pulmonary hypertension. Thromb Res 2017; 163:260-265. [PMID: 28918335 DOI: 10.1016/j.thromres.2017.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/26/2017] [Accepted: 09/04/2017] [Indexed: 12/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) should be suspected in patients presenting persistent dyspnea three months after a pulmonary embolism or in patients presenting with acute pulmonary embolism and suggestive images on the CT-scan. For these patients, a specific diagnostic work-up should be performed. First step consists of the ventilation/perfusion (V/Q) scan which is a good screening test due to its high sensitivity and high negative predictive value. Pulmonary angiography remains the gold standard approach for the confirmation of the diagnosis and pre-surgical evaluation of CTEPH. New emerging technologies such as Dual-Energy Computed Tomography angiography (DECT) and Computed Tomography angiography (CTA) are developing and broadly available. These non invasive methods provide diagnostic information similar to conventional pulmonary angiography and surgical operability information. They are to be considered as an alternative in the diagnostic approach of patients with CTEPH as presented in the ESC/ERS guidelines. Haemodynamic measurement whiles exercising during right heart catheterization may improve diagnostic sensitivity of CTEPH and could therefore be used as a diagnostic test in patient with normal haemodynamic at rest.
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Affiliation(s)
- Aileen Kharat
- Division of Pneumology, University Hospitals of Geneva, Geneva, Switzerland
| | - Anne-Lise Hachulla
- Division of Radiology, University Hospitals of Geneva, Geneva, Switzerland; Pulmonary Hypertension Program, University Hospitals of Geneva, Geneva, Switzerland
| | - Stéphane Noble
- Division of Cardiology, University Hospitals of Geneva, Geneva, Switzerland; Pulmonary Hypertension Program, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Lador
- Division of Pneumology, University Hospitals of Geneva, Geneva, Switzerland; Pulmonary Hypertension Program, University Hospitals of Geneva, Geneva, Switzerland; Geneva University, Faculty of Medicine, Switzerland.
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96
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Associations of Exercise Tolerance With Hemodynamic Parameters for Pulmonary Arterial Hypertension and for Chronic Thromboembolic Pulmonary Hypertension. J Cardiopulm Rehabil Prev 2017; 37:341-346. [DOI: 10.1097/hcr.0000000000000257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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97
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Fadlilah U, Hasmono D, Wibisono YA, Melinda M. ANTIBIOGRAM STUDY AND ANTIBIOTIC USE EVALUATION USING GYSSEN METHOD IN PATIENTS WITH DIABETIC FOOT. FOLIA MEDICA INDONESIANA 2017. [DOI: 10.20473/fmi.v52i3.5452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Foot infection is a common and serious problem in people with diabetes, which require proper management (diagnostic and therapeutic approaches) that can be cured. Empiric antibiotic regimen should be based on clinical data and bacteria pattern that are available, but definitive therapy should be based on the results of the infected tissue culture. The selection of initial antibiotic therapy was difficult and unwise use can lead to antibiotic-resistant. Evaluation is needed for using antibiotics to benefit wisely. The aim of this research is to analyzed the pattern of bacteria in diabetic foot and to its sensitivity test to antibiotics, analyze empiric antibiotics that can be recommended, and analyzed the use of antibiotics by Gyssen method. Data was analyzed with observational studies (descriptive non-experimental), retrospectively and prospectively in patients diabetic foot infection that met inclusion criteria. Retrospective data are used to analyzed bacteria pattern and its sensitivity test, while prospective data are used to evaluated the use of antibiotics based on bacteria pattern, during the period of late March-early August 2015 at Mardi Waluyo Hospital. Evaluation was conducted by Gyssen method. The results, retrospective data samples obtained 30 infection bacteria during August 2014-March 2015. The prevalence of gram-negative bacteria as 53.33% with most types of bacteria E.coli and Klebsiella oxytoca (13.33%), and gram-positive bacteria as 46.67% with the highest bacteria are Staphylococcus spp. and Streptococcus spp. From the prospective data in inclusion criteria, 13 patients with the highest prevalence of gram-negative bacteria are Klebsiella oxytoca (28.57%), and most gram-positive Staphylococcus auerus (35.71%). While the qualitative analysis of antibiotic use was conducted on 50 types of antibiotics. The results of the qualitative analysis using Gyssens method obtained category as 62%, 2%, 14%, 2B category as 26%, 3A category as 10%, 4A category 52%, 4B category as 6%, 4C category as 8% and there are no use of antibiotics in the category V and VI. Conclusions, Gyessen method can show that the use of antibiotics in diabetic foot patients in Mardi Waluyo hospital is dominated by inaccuracy in choice of antibiotic, and inaccuracies in the interval antibiotics.
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98
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Abstract
Venous thromboembolism (VTE) is a common disease (~700 per 100 000) that is associated with significant risk of recurrence, chronic complications, and substantial mortality, with reported death rates of up to 40% at 10 years. The development of novel anticoagulants has revolutionized the treatment of acute VTE, while strategies for prevention and treatment of chronic complications still seek for such a landmark change. Impaired thrombus resolution is the common denominator behind VTE complications, which are postthrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTEPH). PTS and CTEPH are associated with substantial morbidity and high healthcare expenses. While PTS occurs in up to 50% of patients after symptomatic deep vein thrombosis, only a small and poorly defined number of patients are diagnosed with CTEPH after pulmonary embolism. This review is a comprehensive summary of VTE-related chronic complications, their epidemiology, diagnosis, and treatment.
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Affiliation(s)
- M-P Winter
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - G H Schernthaner
- Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - I M Lang
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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99
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Zern EK, Young MN, Rosenfield K, Kabrhel C. A Pulmonary Embolism Response Team: initial experiences and future directions. Expert Rev Cardiovasc Ther 2017; 15:481-489. [PMID: 28571513 DOI: 10.1080/14779072.2017.1337509] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a common cardiovascular condition resulting in significant morbidity and mortality. Consensus recommendations suggest risk stratification of patients into three main categories: high-risk or 'massive' PE, intermediate-risk or 'submassive' PE, and low-risk PE. Given the relative dearth of prospective, randomized clinical trials delineating optimal selection of the diverse medical, interventional, and surgical treatment approaches, clinical care requires a multidisciplinary expert approach to patients with PE. Areas covered: The Massachusetts General Hospital (MGH) Pulmonary Embolism Response Team (PERT) was the first of its kind to create a multidisciplinary, rapid response team for acute PE, integrated within a research and educational framework. The MGH PERT has treated more than 700 patients with PE, the majority of which are in the 'massive' or 'submassive' categories. The PERT Consortium™ was founded in 2015 as a collaborative network between the growing number of PERT programs internationally, with greater than 80 institutions participating within one year of establishment. Expert commentary: Since its advent, the PERT model has expanded throughout the United States and internationally through a collaborative institutional and research network. PERT may represent a new standard for the care of patients with acute PE.
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Affiliation(s)
- Emily K Zern
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Michael N Young
- b Section of Vascular Medicine, Division of Cardiology , Massachusetts General Hospital , Boston , MA , USA
| | - Kenneth Rosenfield
- b Section of Vascular Medicine, Division of Cardiology , Massachusetts General Hospital , Boston , MA , USA
| | - Christopher Kabrhel
- c Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital, Harvard Medical School , Boston , MA , USA
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100
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Hijikata S, Miyamoto T, Yamaguchi J, Iwai T, Watanabe K, Sagawa Y, Masuda R, Miyazaki R, Miwa N, Sekigawa M, Yamaguchi T, Hara N, Nagata Y, Nozato T, Sakurai U, Hirao K. Recurrent pulmonary emboli with characteristic histopathology. Cardiovasc Pathol 2017; 29:45-47. [PMID: 28575717 DOI: 10.1016/j.carpath.2017.05.002] [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] [Received: 04/19/2017] [Accepted: 05/08/2017] [Indexed: 11/28/2022] Open
Abstract
We report a unique case of recurrent thromboembolism and its histological findings that were revealed in an autopsy. Although it is well known that repeating thrombosis presents organization and recanalization, we also observed rare findings of thickening of the bronchial artery and fixation of the valve of the lower extremity vein in this case.
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Affiliation(s)
- Sadahiro Hijikata
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan.
| | - Takamichi Miyamoto
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Junji Yamaguchi
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Takamasa Iwai
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Keita Watanabe
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Yuichiro Sagawa
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Ryo Masuda
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Ryoichi Miyazaki
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Naoyuki Miwa
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Masahiro Sekigawa
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Tetsuo Yamaguchi
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Nobuhiro Hara
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Yasutoshi Nagata
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Toshihiro Nozato
- Depertment of Cardiology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Urara Sakurai
- Depertment of Clinical pathology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho, Musashino-City, Tokyo 181-8610, Japan
| | - Kenzo Hirao
- Depertment of Cardiology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-0034, Japan
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