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Blanquez-Nadal M, Piliero N, Guillien A, Doutreleau S, Salvat M, Thony F, Pison C, Augier C, Bouvaist H, Aguilaniu B, Degano B. Exercise hyperventilation and pulmonary gas exchange in chronic thromboembolic pulmonary hypertension: Effects of balloon pulmonary angioplasty. J Heart Lung Transplant 2021; 41:70-79. [PMID: 34742646 DOI: 10.1016/j.healun.2021.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/25/2021] [Accepted: 09/14/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Excessive ventilation (V̇E) and abnormal gas exchange during exercise are features of chronic thromboembolic pulmonary hypertension (CTEPH). In selected CTEPH patients, balloon pulmonary angioplasty (BPA) improves symptoms and exercise capacity. How BPA affects exercise hyperventilation and gas exchange is poorly understood. METHODS In this longitudinal observational study, symptom-limited cardiopulmonary exercise tests and carbon monoxide lung diffusion (DLCO) were performed before and after BPA (interval, mean (SD): 3.1 (2.4) months) in 36 CTEPH patients without significant cardiac and/or pulmonary comorbidities. RESULTS Peak work rate improved by 20% after BPA whilst V̇E at peak did not change despite improved ventilatory efficiency (lower V̇E with respect to CO2 output [V̇CO2]). At the highest identical work rate pre- and post-BPA (75 (30) watts), V̇E and alveolar-arterial oxygen gradient (P(Ai-a)O2) decreased by 17% and 19% after BPA, respectively. The physiological dead space fraction of tidal volume (VD/VT), calculated from measurements of arterial and mixed expired CO2, decreased by 20%. In the meantime, DLCO did not change. The best correlates of P(Ai-a)O2 measured at peak exercise were physiological VD/VT before BPA and DLCO after BPA. CONCLUSIONS Ventilatory efficiency, physiological VD/VT, and pulmonary gas exchange improved after BPA. The fact that DLCO did not change suggests that the pulmonary capillary blood volume and probably the true alveolar dead space were unaffected by BPA. The correlation between DLCO measured before BPA and P(Ai-a)O2 measured after BPA suggests that DLCO may provide an easily accessible marker to predict the response to BPA in terms of pulmonary gas exchange.
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Affiliation(s)
- Mathilde Blanquez-Nadal
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Nicolas Piliero
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Alicia Guillien
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Épidemiologie environnementale appliquée à la reproduction et à la santé respiratoire, INSERM, CNRS, Université Grenoble Alpes, Institut pour l'Avancée des Biosciences (IAB), Grenoble, France
| | - Stéphane Doutreleau
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France; Laboratoire HP2, INSERM U1042, Université Grenoble Alpes, Grenoble, France
| | - Muriel Salvat
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Frédéric Thony
- Pole Imagerie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Christophe Pison
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Caroline Augier
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Hélène Bouvaist
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Bernard Aguilaniu
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Bruno Degano
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France; Laboratoire HP2, INSERM U1042, Université Grenoble Alpes, Grenoble, France.
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Minatsuki S, Takahara M, Kiyosue A, Kodera S, Hatano M, Ando J, Kohsaka S, Ishii H, Shinke T, Amano T, Ikari Y, Komuro I. Characteristics and in-hospital outcomes of patients undergoing balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a time-trend analysis from the Japanese nationwide registry. Open Heart 2021; 8:openhrt-2021-001721. [PMID: 34521747 PMCID: PMC8442101 DOI: 10.1136/openhrt-2021-001721] [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] [Received: 05/14/2021] [Accepted: 08/27/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA), a novel technique initially introduced as a treatment for inoperable chronic thromboembolic pulmonary hypertension, is now increasingly being performed in a broader spectrum of patients. Here, we performed a time-trend analysis of the characteristics and in-hospital outcomes of patients who underwent BPA in Japan, using data extracted from nationwide procedure-based registration system. METHODS The Japanese Structural Heart Disease (J-SHD) registry was established and sponsored by the Japanese Association of Cardiovascular Intervention and Therapeutics and aims to provide basic statistics on the performance of structural interventions in Japan. J-SHD registers cases from approximately 200 institutions, representing more than 90% of SHD intervention-performing hospitals in the nation. We analysed the registered BPA data elements from January 2015 to December 2018. Successful BPA was defined as a session in which a physician successfully treated all targeted lesions. RESULTS There were a total of 2512 BPA sessions; the number of institutions and registered sessions increased from 30 to 50 sites and from 479 to 852 sessions during the study period, respectively. The average age of the patients was 66±13 years, and 72.1% were women. In-hospital death was observed in 0.2%, and the total complications rate was 5.3%. The preoperative and postoperative mean pulmonary artery pressure were 32±11 mm Hg and 30±10 mm Hg, respectively. CONCLUSION The number of BPA sessions increased during the study period, with an acceptable in-hospital complication rate.
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Affiliation(s)
- Shun Minatsuki
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Arihiro Kiyosue
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Satoshi Kodera
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Masaru Hatano
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jiro Ando
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiology, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Toshiro Shinke
- Department of Cardiology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yuji Ikari
- Cardiovascular Medicine, Tokai University Hospital, Isehara, Kanagawa, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Calé R, Ferreira F, Pereira AR, Saraiva C, Santos A, Alegria S, Repolho D, Vitorino S, Santos P, Morgado G, Brenot P, Loureiro MJ, Pereira H. Balloon pulmonary angioplasty protocol in a Portuguese pulmonary hypertension expert center. Rev Port Cardiol 2021; 40:653-665. [PMID: 34503703 DOI: 10.1016/j.repce.2020.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/02/2020] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Balloon pulmonary angioplasty (BPA) has emerged as a promising therapeutic option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not eligible for pulmonary thromboendarterectomy (PEA) or who have recurrent or persistent pulmonary hypertension after surgery. There is no standardized technique for BPA and, its complexity and high risk of severe complications, requires skills and appropriate training and should be reserved for expert CTEPH centers, as a complementary intervention to medical and surgical therapy. OBJECTIVE The purpose of this document is to describe the BPA protocol used at a high-volume center nationwide, validated by its results. METHODS The present protocol includes technical details, definition of outcomes and complications, as well as patient full diagnostic work-up and treatment algorithm, before and after BPA. RESULTS The technical, hemodynamic, and clinical results of the application of this protocol will be subject of a later publication where they will be described in detail. In conclusion, we present a percutaneous intervention protocol in the treatment of pulmonary hypertension in the context of chronic pulmonary thromboembolism, validated by its clinical, hemodynamic, and technical results.
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Affiliation(s)
- Rita Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - Filipa Ferreira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Ana Rita Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Carla Saraiva
- Radiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Ana Santos
- Radiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Sofia Alegria
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Débora Repolho
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Sílvia Vitorino
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Santos
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Gonçalo Morgado
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Philippe Brenot
- Radiology Department, Hospital Marie Lannelongue, Le Plessis Robinson, France; Universidade Paris-Sud, Faculdade de Medicina, Universidade Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Hélder Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal; CCUL, CAML, University of Lisbon, Lisbon, Portugal
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104
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Kim NH. Balloon pulmonary angioplasty - welcome to chronic thromboembolic pulmonary hypertension treatment. Rev Port Cardiol 2021; 40:667-668. [PMID: 34503704 DOI: 10.1016/j.repce.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Nick H Kim
- Pulmonary Vascular Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States.
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105
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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106
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Sumimoto K, Taniguchi Y, Fujii H, Miwa K, Matsuoka Y, Tsuboi Y, Emoto N, Hirata KI. Rescue balloon pulmonary angioplasty for life-threatening acute pulmonary embolism on chronic thromboembolic pulmonary hypertension patients. Respir Med Case Rep 2021; 33:101415. [PMID: 34401263 PMCID: PMC8348489 DOI: 10.1016/j.rmcr.2021.101415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/17/2021] [Accepted: 04/06/2021] [Indexed: 11/15/2022] Open
Abstract
We report the cases of two patients with life-threatening acute pulmonary embolism (PE) on chronic thromboembolic pulmonary hypertension (CTEPH) who were treated with rescue balloon pulmonary angioplasty (BPA). These cases highlight the effect of rescue BPA on acute PE on CTEPH, which requires veno-arterial extracorporeal membrane oxygenation. Chronic thromboembolic pulmonary hypertension (CTEPH) is a fatal disease, which may deteriorate rapidly and require mechanical support. Rescue ballon pulmonary angioplasty (BPA) may be effective for diatal-type CTEPH patients requiring mechanical support. Rescue BPA should be consdered as an option in the absence of treatment for critical CTEPH patients.
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Affiliation(s)
| | - Yu Taniguchi
- Corresponding author. Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
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107
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Balloon pulmonary angioplasty - welcome to chronic thromboembolic pulmonary hypertension treatment. Rev Port Cardiol 2021. [PMID: 34393022 DOI: 10.1016/j.repc.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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108
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Calé R, Ferreira F, Pereira AR, Saraiva C, Santos A, Alegria S, Repolho D, Vitorino S, Santos P, Morgado G, Brenot P, Loureiro MJ, Pereira H. Balloon pulmonary angioplasty protocol in a Portuguese pulmonary hypertension expert center. Rev Port Cardiol 2021. [PMID: 34366194 DOI: 10.1016/j.repc.2020.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Balloon pulmonary angioplasty (BPA) has emerged as a promising therapeutic option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not eligible for pulmonary thromboendarterectomy (PEA) or who have recurrent or persistent pulmonary hypertension after surgery. There is no standardized technique for BPA and, its complexity and high risk of severe complications, requires skills and appropriate training and should be reserved for expert CTEPH centers, as a complementary intervention to medical and surgical therapy. OBJECTIVE The purpose of this document is to describe the BPA protocol used at a high-volume center nationwide, validated by its results. METHODS The present protocol includes technical details, definition of outcomes and complications, as well as patient full diagnostic work-up and treatment algorithm, before and after BPA. RESULTS The technical, hemodynamic, and clinical results of the application of this protocol will be subject of a later publication where they will be described in detail. In conclusion, we present a percutaneous intervention protocol in the treatment of pulmonary hypertension in the context of chronic pulmonary thromboembolism, validated by its clinical, hemodynamic, and technical results.
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Affiliation(s)
- Rita Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - Filipa Ferreira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Ana Rita Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Carla Saraiva
- Radiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Ana Santos
- Radiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Sofia Alegria
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Débora Repolho
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Sílvia Vitorino
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Santos
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Gonçalo Morgado
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Philippe Brenot
- Radiology Department, Hospital Marie Lannelongue, Le Plessis Robinson, France; Universidade Paris-Sud, Faculdade de Medicina, Universidade Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Hélder Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal; CCUL, CAML, University of Lisbon, Lisbon, Portugal
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Gerges C, Friewald R, Gerges M, Shafran I, Sadushi-Koliçi R, Skoro-Sajer N, Moser B, Taghavi S, Klepetko W, Lang IM. Efficacy and Safety of Percutaneous Pulmonary Artery Subtotal Occlusion and Chronic Total Occlusion Intervention in Chronic Thromboembolic Pulmonary Hypertension. Circ Cardiovasc Interv 2021; 14:e010243. [PMID: 34266313 DOI: 10.1161/circinterventions.120.010243] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Richard Friewald
- Department of Internal Medicine I, Division of Cardiology, University Hospital of Krems, Karl Landsteiner Private University for Health Sciences, Krems an der Donau, Austria (R.F.)
| | - Mario Gerges
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Inbal Shafran
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Roela Sadushi-Koliçi
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Bernhard Moser
- Department of Surgery, Division of Thoracic Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Shahrokh Taghavi
- Department of Surgery, Division of Thoracic Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Walter Klepetko
- Department of Surgery, Division of Thoracic Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
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Sweatt AJ, Reddy R, Rahaghi FN, Al-Naamani N. What's new in pulmonary hypertension clinical research: lessons from the best abstracts at the 2020 American Thoracic Society International Conference. Pulm Circ 2021; 11:20458940211040713. [PMID: 34471517 PMCID: PMC8404658 DOI: 10.1177/20458940211040713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
In this conference paper, we review the 2020 American Thoracic Society International Conference session titled, "What's New in Pulmonary Hypertension Clinical Research: Lessons from the Best Abstracts". This virtual mini-symposium took place on 21 October 2020, in lieu of the annual in-person ATS International Conference which was cancelled due to the COVID-19 pandemic. Seven clinical research abstracts were selected for presentation in the session, which encompassed five major themes: (1) standardizing diagnosis and management of pulmonary hypertension, (2) improving risk assessment in pulmonary arterial hypertension, (3) evaluating biomarkers of disease activity, (4) understanding metabolic dysregulation across the spectrum of pulmonary hypertension, and (5) advancing knowledge in chronic thromboembolic pulmonary hypertension. Focusing on these five thematic contexts, we review the current state of knowledge, summarize presented research abstracts, appraise their significance and limitations, and then discuss relevant future directions in pulmonary hypertension clinical research.
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Affiliation(s)
- Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Raju Reddy
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Farbod N. Rahaghi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nadine Al-Naamani
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - on behalf of the American Thoracic Society Pulmonary Circulation Assembly Early Career Working Group
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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111
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Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: advances in patient and lesion selection. Curr Opin Pulm Med 2021; 27:303-310. [PMID: 34224432 DOI: 10.1097/mcp.0000000000000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Balloon pulmonary angioplasty (BPA) has been performed worldwide for patients who are ineligible for pulmonary endarterectomy (PEA). However, the technical details of BPA have not been standardized, and no international consensus regarding patient and lesion selection for BPA has been reached. Evidence for the combination of BPA with PEA or medical therapy is also lacking. This review highlights recent progress in BPA in terms of patient and lesion selection and the current procedural approach for BPA, including combination treatment. RECENT FINDINGS The indications for BPA have expanded with recent reports describing the improved safety and efficacy of BPA. Because lesions are generally present in all segmental and subsegmental pulmonary arteries, it is recommended to treat all the lesions to achieve desirable hemodynamic improvement. Selective pulmonary angiography is the gold standard for lesion selection in modern BPA aimed at total revascularization. Despite the lack of randomized controlled studies, combination treatment with BPA may be well tolerated and effective. SUMMARY BPA, alone or in combination with PEA or medical therapy, may be a treatment option for patients who are not candidates for monotreatment of PEA. However, further investigation is required to standardize patient and lesion selection for BPA.
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Calé R, Ferreira F, Pereira AR, Repolho D, Sebaiti D, Alegria S, Vitorino S, Santos P, Pereira H, Brenot P, Loureiro MJ. Safety and efficacy of balloon pulmonary angioplasty in a Portuguese pulmonary hypertension expert center. Rev Port Cardiol 2021; 40:S0870-2551(21)00194-3. [PMID: 34183215 DOI: 10.1016/j.repc.2020.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/20/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Balloon pulmonary angioplasty (BPA) is an alternative therapy in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or residual/recurrent pulmonary hypertension (PH) after surgery. The aim of this study was to assess the short-term efficacy and safety of a BPA program. METHODS This prospective single-center study included all BPA sessions performed in CTEPH patients between 2017 and 2019. Clinical assessment including WHO functional class, plasma biomarkers, 6-min walk test (6MWT) and right heart catheterization was performed at baseline and six months after the last BPA session. RESULTS A total of 57 BPA sessions were performed in 11 CTEPH patients (64% with inoperable disease, 82% under pulmonary vasodilator therapy). Nine patients completed both the BPA program and a minimum six-month follow-up period. There were significant improvements in WHO functional class (p=0.004) and 6MWT (mean increase of 42 m; p=0.050) and a trend for significant hemodynamic improvement: 25% decrease in mean pulmonary artery pressure (mPAP) (p=0.082) and 42% decrease in pulmonary vascular resistance (PVR) (p=0.056). In the group of patients with severely impaired hemodynamics (three patients with mPAP >40mmHg), the reduction was significant: 51% in mPAP (p=0.013) and 67% in PVR (p=0.050). Prostacyclin analogs and long-term oxygen therapy were withdrawn in all patients. Minor complications were recorded in 25% of patients. There were no major complications or deaths. CONCLUSIONS A BPA strategy on top of pulmonary vasodilator therapy further improves symptoms, exercise capacity and hemodynamics with an acceptable risk-benefit ratio in patients with inoperable CTEPH or residual/recurrent PH after surgery.
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Affiliation(s)
- Rita Calé
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal.
| | - Filipa Ferreira
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Ana Rita Pereira
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Débora Repolho
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Daniel Sebaiti
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Sofia Alegria
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Sílvia Vitorino
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Santos
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Hélder Pereira
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal; CCUL, CAML, Universidade de Lisboa, Portugal
| | - Philippe Brenot
- Serviço de Radiologia, Hospital Marie Lannelongue, Le Plessis Robinson, França; Universidade Paris-Sud, Faculdade de Medicina, Universidade Paris-Saclay, Le Kremlin- Bicêtre, França
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113
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Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 251] [Impact Index Per Article: 83.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
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Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
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Lloji A, Hooda U, Sreenivasan J, Malekan R, Aronow WS, Lanier GM. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:330-347. [PMID: 34322303 PMCID: PMC8303037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/08/2021] [Indexed: 06/13/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension (PH) caused by thromboembolic disease with the secondary remodeling of the pulmonary vessels. The primary treatment of CTEPH is pulmonary thromboendarterectomy (PTE). However, some patients are not candidates for PTE because of surgically inaccessible thrombi or high operative risk and can be candidates for balloon pulmonary angioplasty (BPA), an emerging, lower risk treatment. This review discusses the patient selection, the technique, and comprehensive review of reported outcomes following BPA. BPA techniques have improved over the years, and so has its safety profile. Recent data show that after several sessions of BPA, patients who were not eligible for PTE had improvement in their hemodynamic profile, functional capacity, and 6-minute walk distance. Studies have shown that compared to riociguat, BPA has shown significant improvement in the functional capacity and hemodynamic measurements. Reperfusion pulmonary edema is a common complication after PTE and BPA, which may be due to vessel injury rather than pulmonary extravasation. Rates of complications have decreased especially after the use of optical coherence tomography, which helps in proper sizing of the balloons. Patients with CTEPH who are ineligible for PTE should be evaluated for BPA. In addition to medical therapy, BPA has shown promising clinical and hemodynamic outcomes in patients with CTEPH.
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Affiliation(s)
- Amanda Lloji
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Urvashi Hooda
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical CollegeValhalla, New York, The United States
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
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115
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Castro G. Safety and efficacy of balloon pulmonary angioplasty in a Portuguese pulmonary hypertension expert center: A step in the right direction. Rev Port Cardiol 2021; 40:S0870-2551(21)00221-3. [PMID: 34099339 DOI: 10.1016/j.repc.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Graça Castro
- Departamento do Coração e Vasos, Centro Hospitalar e Universitário de Coimbra, Portugal.
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116
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Mahmud E, Patel M, Ang L, Poch D. Advances in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Pulm Circ 2021; 11:20458940211007385. [PMID: 34104421 PMCID: PMC8150503 DOI: 10.1177/20458940211007385] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 11/17/2022] Open
Abstract
Balloon pulmonary angioplasty (BPA) is an emerging treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who have inoperable, segmental/subsegmental disease, or residual disease after pulmonary endarterectomy. In the past decade, advances in the techniques for BPA have led to better clinical outcomes with improvements in hemodynamics, pulmonary perfusion, exercise tolerance, functional capacity, and quality of life. We present the experience with BPA at our university, the largest CTEPH center in the world, followed by reviewing the published data regarding the efficacy and safety of BPA in patients with CTEPH. There is increasing evidence to support that the initial hemodynamic improvement is sustained for ≥3 years after the procedure. Although infrequent, complications observed with BPA are associated with pulmonary vascular injury or rarely reperfusion pulmonary edema. As the technique for percutaneous pulmonary artery revascularization has improved, the procedural risk and complications have continued to decrease. This promising technique continues to develop, and future research is required to demonstrate the long-term benefits of BPA, standardize the technique, and define a uniform institutional infrastructure for providing BPA as a part of the treatment of CTEPH.
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Affiliation(s)
- Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mitul Patel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lawrence Ang
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - David Poch
- Division of Pulmonary Critical Care Medicine, University of California San Diego, La Jolla, CA, USA
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117
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Marukyan NV, Simakova MA, Zubarev DD, Moiseeva OM. Treatment Strategy Options in Inoperable Chronic Thromboembolic Pulmonary Hypertension Patients. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-04-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This review presents an analysis of recent publications on the principles of diagnosis and management of patients with chronic thromboembolic pulmonary hypertension (CTEPH). The authors emphasize the importance of patient's operability assessment regarding the possibility of performing pulmonary thrombendarterectomy - a radical treatment option due to complete post-thrombotic material removal from the branches of the pulmonary artery. In the case of an inoperable type of CTEPH, such a method of transcatheter treatment as step-by-step balloon angioplasty of the pulmonary artery (BPA) is proposed. The article clearly outlines the principles of selection, patient training and techniques for BPA. The authors demonstrated their own patented method of the peripheral vascular bed visualization in the case of recanalization of chronic occlusions, which increases the safety of this intervention. Particular attention is paid to hybrid approaches using a soluble guanylate cyclase stimulator, riociguate in combination with BPA for high risk CTEPH patients. The review presents the data of the post hoc analysis of the CHEST-1 study and the data of real clinical practice of the use of riociguat in combination with the endovascular method of treatment on the example of the leading expert groups in Europe, who demonstrated in their studies the positive effect of riociguat on the hemodynamic parameters and the frequency of perioperative complications.
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118
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Sepúlveda P, Hameau R, Backhouse C, Charme G, Pacheco F, Ramírez PA, Fuensalida AJ, Quitral J, Martínez G, Martínez JA. Mid-term follow-up of balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension: An experience in Latin America. Catheter Cardiovasc Interv 2021; 97:E748-E757. [PMID: 33058429 DOI: 10.1002/ccd.29322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/01/2020] [Accepted: 09/28/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To describe the characteristics of patients who undergo balloon pulmonary angioplasty (BPA) for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) and report the mid-term outcomes. BACKGROUND BPA has been recently introduced in Latin America. Mid-term results have not been published. METHODS Prospective Chilean Registry of inoperable CTEPH patients who underwent BPA. Clinical variables were analyzed at baseline, after each procedure and at follow-up. Hemodynamic variables were recorded before and after the last BPA. RESULTS Between August 2016 and September 2019, 22 patients (17 women), 59 ± 12.7 years, underwent 81 BPA and were followed for as long as 33.1 months (mean 17.3 ± 7.5). Mean pulmonary artery pressure decreased by 17.4% (51.1 ± 12 vs. 42.2 ± 13 mmHg, p = .001), pulmonary vascular resistance by 23.9% (766.7 ± 351 vs. 583 ± 346 dynes/s/cm-5 , p = .001), cardiac index increased by 8% (2.3 ± 0.54 vs. 2.5 ± 0.54 L/min/m2 , p = .012), N-terminal pro-B-type natriuretic peptide decreased by 73.8% (1,685 ± 1,045 vs. 441.8 ± 276 pg/dl, p = .006), and 6-min walk distance improved by 135 m (316.7 ± 94 vs. 451.1 ± 113 m, p = .001). One patient (4.5%) developed lung reperfusion injury and four patients (18.2%) had minor bleeding (hemoptysis), after the procedure. There was no mortality associated with BPA. CONCLUSIONS Our results confirm that BPA for inoperable CTEPH is a relatively safe procedure that improves clinical and hemodynamic parameters in the mid-term. This therapy should be considered as an alternative, mainly in places where access to PAH therapy or surgery is restricted.
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Affiliation(s)
- Pablo Sepúlveda
- Division of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - René Hameau
- Division of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Gustavo Charme
- Laboratorio de Hemodinamia, Hospital Naval, Viña del Mar, Chile
| | - Francisco Pacheco
- Division of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo A Ramírez
- Pabellón de Hemodinamia, Hospital San Juan de Dios, Santiago, Chile
| | - Alberto J Fuensalida
- Division of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Quitral
- Division of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gonzalo Martínez
- Division of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile.,Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile
| | - José A Martínez
- Division of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile
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Martínez-Santos P, Velázquez-Martín MT, Barberá JA, Fernández Pérez C, López-Meseguer M, López-Reyes R, Martínez-Meñaca A, Lara-Padrón A, Domingo-Morera JA, Blanco I, Escribano-Subías P. Hipertensión pulmonar tromboembólica crónica en España: una década de cambio. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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120
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Shimokawahara H, Nagayoshi S, Ogawa A, Matsubara H. Continual Improvement in Pressure Gradient at the Lesion After Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. Can J Cardiol 2021; 37:1232-1239. [PMID: 33744368 DOI: 10.1016/j.cjca.2021.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Lung injury is a serious complication of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Selecting a smaller balloon might minimize the occurrence of lung injury; however, it could also increase the risk of restenosis. METHODS We analyzed the first target lesions in the initial BPA procedure in 34 consecutive patients with CTEPH. We measured proximal pressure with a guiding catheter and distal pressure with a pressure wire. We retrospectively investigated pressure gradients at the lesions before and immediately after the initial dilation with a smaller balloon and before the second procedure. RESULTS The proximal pressure decreased, and the distal pressure increased immediately after the initial balloon dilation. The pressure gradient at the lesion diminished significantly by the second procedure (from 26.4 ± 10.7 to 18.2 ± 9.9 mm Hg, P < 0.001) without serious complications. The residual pressure gradient had further diminished (to 9.8 ± 6.5 mm Hg, P = 0.02) until the second procedure. The reduction in pressure gradient at the lesion from immediately after the initial balloon dilation to the second procedure was positively correlated with both the baseline mean pulmonary arterial pressure (r2 = 0.23, P = 0.004) and residual pressure gradient immediately after the initial balloon dilation (r2 = 0.58, P < 0.001). CONCLUSIONS The residual pressure gradient at the lesion diminished continually after dilation with a smaller balloon. This strategy could decrease pulmonary arterial pressure safely. It would be reasonable to dilate the lesions sequentially in 2 procedures.
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Affiliation(s)
- Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shinya Nagayoshi
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan; Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan.
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121
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Matsuoka Y, Taniguchi Y, Miwa K, Sumimoto K, Tsuboi Y, Onishi H, Yanaka K, Emoto N, Hirata K. Assessment of oxygenation after balloon pulmonary angioplasty for patients with inoperable chronic thromboembolic pulmonary hypertension. Int J Cardiol 2021; 333:188-194. [PMID: 33684382 DOI: 10.1016/j.ijcard.2021.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of balloon pulmonary angioplasty (BPA) in patients with inoperable chronic thromboembolic pulmonary hypertension would be promising. However, some patients showed residual dyspnea or symptoms, despite normalized hemodynamics. We aimed to clarify the clinical impact of oxygenation parameters on BPA outcome. METHOD Ninety-nine consecutive patients who underwent BPA from September 2011 to December 2019 were enrolled. We evaluated hemodynamics with right heart catheterization, arterial blood gas examination, New York Heart Association functional class (NYHA-FC), respiratory function tests, nocturnal oximetry, and exercise capacity (6-min walk test and cardiopulmonary exercise testing) at baseline and after BPA. RESULT Nearly normal hemodynamics was achieved after BPA (mean pulmonary artery pressure (PAP): 37.5 ± 10.0 to 20.6 ± 4.9 mmHg, p < 0.01). Oxygenation slightly improved (partial pressure of arterial oxygen; 61.5 ± 12.3 to 67.7 ± 12.7 mmHg, p < 0.01). Exertional desaturation remained unchanged (-8.1 ± 4.8 to -7.8 ± 5.1, p = 0.59), and this was associated with residual symptom (NYHA-FC ≥ 2) after BPA (OR 0.591, 95% CI 0.416-0.840, p = 0.003) in multivariate regression analyses. Lower vital capacity (r2 = 0.03, p = 0.01), higher mean PAP (r2 = 0.08, p = 0.02), and higher minute ventilation/carbon dioxide production (VE/VCO2) slope (r2 = 0.18, p < 0.01), the marker of ventilatory inefficiency, were correlated with exertional desaturation after BPA in multivariate linear analyses. CONCLUSION Although hemodynamics nearly normalized, oxygenation did not. Moreover, exertional desaturation remained unchanged. This might cause residual symptom after BPA. Residual pulmonary hypertension suggesting incurable arteriopathy, and higher VE/VCO2 slope suggesting ventilation-perfusion mismatch might be related to exertional desaturation. Domiciliary oxygen therapy should be continued, if necessary.
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Affiliation(s)
- Yoichiro Matsuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
| | - Keisuke Miwa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Keiko Sumimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yasunori Tsuboi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Coghlan JG, Rothman AM, Hoole SP. Balloon Pulmonary Angioplasty: State of the Art. ACTA ACUST UNITED AC 2021; 16:e02. [PMID: 33664801 PMCID: PMC7903587 DOI: 10.15420/icr.2020.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/01/2020] [Indexed: 12/14/2022]
Abstract
Balloon pulmonary angioplasty (BPA) is a novel technique for the treatment of chronic thromboembolic pulmonary hypertension. While cardiologists need no introduction to the concept of balloon angioplasty, BPA has its own particular challenges. This article aims to provide the reader with an overview of BPA, starting with an introduction to chronic thromboembolic disease (CTED), the standard management of chronic thromboembolic pulmonary hypertension (CTEPH), technical challenges faced when performing BPA and the evidence base supporting its use. The second part of the article will focus on the future of BPA, in particular the areas where research is required to establish an evidence base to justify the role of BPA in CTEPH and CTED treatment.
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Darocha S, Araszkiewicz A, Kurzyna M, Banaszkiewicz M, Jankiewicz S, Dobosiewicz A, Sławek-Szmyt S, Janus M, Grymuza M, Pietrasik A, Mularek-Kubzdela T, Kędzierski P, Pietura R, Zieliński D, Biederman A, Lesiak M, Torbicki A. Balloon Pulmonary Angioplasty in Technically Operable and Technically Inoperable Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2021; 10:jcm10051038. [PMID: 33802475 PMCID: PMC7959461 DOI: 10.3390/jcm10051038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/04/2021] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background: In this study, we aimed to assess the efficacy and safety of balloon pulmonary angioplasty (BPA) in patients with technically inoperable distal-type chronic thromboembolic pulmonary hypertension (d-CTEPH) and technically operable proximal-type disease (p-CTEPH) by analyzing the results of BPA treatment in two collaborating CTEPH referral centers. Methods and results: We assessed hemodynamic results, functional efficacy, complication and survival rate after BPA treatment in 70 CTEPH patients (median age 64 years; (interquartile range (IQR): 52–73 years)), of whom 16 (median age 73 years; (QR 62–82 years)) were in the p-CTEPH subgroup. Altogether, 377 BPA procedures were performed, resulting in significant (p < 0.001) improvement in mean pulmonary artery pressure (mPAP 48.6 ± 10 vs. 31.3 ± 8.6 mmHg), pulmonary vascular resistance (694 ± 296 vs. 333 ± 162 dynes*s*cm−5), six-minute walk test (365 ± 142 vs. 433 ± 120 metres) and N-terminal pro B-type natriuretic peptide (1307 (510–3294) vs. 206 (83–531) pg/mL). The rate of improvement did not differ between the sub-groups. Lung injury episodes and severe hemoptysis were similarly infrequent in d-CTEPH and p-CTEPH (6.4% vs. 5%; p = 0.55 and 1.0% vs. 2.5; p = 0.24, respectively). There was no significant difference between the sub-groups regarding survival (p = 0.53 by log-rank test). Conclusion: BPA may be beneficial in patients with p-CTEPH who cannot undergo pulmonary endarterectomy (PEA). Larger long-term studies are needed to better define the efficacy, safety, and optimal BPA procedural standards in this population.
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Affiliation(s)
- Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Otwock, Poland; (S.D.); (M.B.); (A.D.); (P.K.); (A.T.)
| | - Aleksander Araszkiewicz
- Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.A.); (S.J.); (S.S.-S.); (M.J.); (M.G.); (T.M.-K.); (M.L.)
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Otwock, Poland; (S.D.); (M.B.); (A.D.); (P.K.); (A.T.)
- Correspondence: ; Tel.: +48-22-7103052; Fax: +48-22-7103169
| | - Marta Banaszkiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Otwock, Poland; (S.D.); (M.B.); (A.D.); (P.K.); (A.T.)
| | - Stanisław Jankiewicz
- Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.A.); (S.J.); (S.S.-S.); (M.J.); (M.G.); (T.M.-K.); (M.L.)
| | - Anna Dobosiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Otwock, Poland; (S.D.); (M.B.); (A.D.); (P.K.); (A.T.)
| | - Sylwia Sławek-Szmyt
- Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.A.); (S.J.); (S.S.-S.); (M.J.); (M.G.); (T.M.-K.); (M.L.)
| | - Magdalena Janus
- Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.A.); (S.J.); (S.S.-S.); (M.J.); (M.G.); (T.M.-K.); (M.L.)
| | - Maciej Grymuza
- Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.A.); (S.J.); (S.S.-S.); (M.J.); (M.G.); (T.M.-K.); (M.L.)
| | - Arkadiusz Pietrasik
- 1st Department and Faculty of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Tatiana Mularek-Kubzdela
- Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.A.); (S.J.); (S.S.-S.); (M.J.); (M.G.); (T.M.-K.); (M.L.)
| | - Piotr Kędzierski
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Otwock, Poland; (S.D.); (M.B.); (A.D.); (P.K.); (A.T.)
| | - Radosław Pietura
- Department of Radiography, Medical University of Lublin, 00-635 Lublin, Poland;
| | - Dariusz Zieliński
- Department of Cardiac Surgery, Medicover Hospital, 02-972 Warsaw, Poland; (D.Z.); (A.B.)
| | - Andrzej Biederman
- Department of Cardiac Surgery, Medicover Hospital, 02-972 Warsaw, Poland; (D.Z.); (A.B.)
| | - Maciej Lesiak
- Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.A.); (S.J.); (S.S.-S.); (M.J.); (M.G.); (T.M.-K.); (M.L.)
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Otwock, Poland; (S.D.); (M.B.); (A.D.); (P.K.); (A.T.)
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Chen ZW, Wu CK, Kuo PH, Hsu HH, Tsai CH, Pan CT, Hwang JJ, Ko CL, Huang YS, Ogo T, Lin YH. Efficacy and safety of balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. J Formos Med Assoc 2021; 120:947-955. [DOI: 10.1016/j.jfma.2020.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/20/2020] [Indexed: 01/09/2023] Open
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125
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Papamatheakis DG, Poch DS, Fernandes TM, Kerr KM, Kim NH, Fedullo PF. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol 2021; 76:2155-2169. [PMID: 33121723 DOI: 10.1016/j.jacc.2020.08.074] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of pulmonary arterial obstruction by organized thrombotic material stemming from incompletely resolved acute pulmonary embolism. The exact incidence of CTEPH is unknown but appears to approximate 2.3% among survivors of acute pulmonary embolism. Although ventilation/perfusion scintigraphy has been supplanted by computed tomographic pulmonary angiography in the diagnostic approach to acute pulmonary embolism, it has a major role in the evaluation of patients with suspected CTEPH, the presence of mismatched segmental defects being consistent with the diagnosis. Diagnostic confirmation of CTEPH is provided by digital subtraction pulmonary angiography, preferably performed at a center familiar with the procedure and its interpretation. Operability assessment is then undertaken to determine if the patient is a candidate for potentially curative pulmonary endarterectomy surgery. When pulmonary endarterectomy is not an option, pulmonary arterial hypertension-targeted pharmacotherapy and balloon pulmonary angioplasty represent potential therapeutic alternatives.
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Affiliation(s)
- Demosthenes G Papamatheakis
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - David S Poch
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Timothy M Fernandes
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Nick H Kim
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Peter F Fedullo
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California.
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126
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Ghofrani HA, D'Armini AM, Kim NH, Mayer E, Simonneau G. Interventional and pharmacological management of chronic thromboembolic pulmonary hypertension. Respir Med 2021; 177:106293. [PMID: 33465538 DOI: 10.1016/j.rmed.2020.106293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/11/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by obstruction of the pulmonary vasculature, leading to increased pulmonary vascular resistance and ultimately right ventricular failure, the leading cause of death in non-operated patients. This article reviews the current management of CTEPH. The standard of care in CTEPH is pulmonary endarterectomy (PEA). However, up to 40% of patients with CTEPH are ineligible for PEA, and up to 51% develop persistent/recurrent PH after PEA. Riociguat is currently the only medical therapy licensed for treatment of inoperable or persistent/recurrent CTEPH after PEA based on the results of the Phase III CHEST-1 study. Studies of balloon pulmonary angioplasty (BPA) have shown benefits in patients with inoperable or persistent/recurrent CTEPH after PEA; however, data are lacking from large, prospective, controlled studies. Studies of macitentan in patients with inoperable CTEPH and treprostinil in patients with inoperable or persistent/recurrent CTEPH showed positive results. Combination therapy is under evaluation in CTEPH, and long-term data are not available. In the future, CTEPH may be managed by PEA, medical therapy or BPA - alone or in combination, according to individual patient needs. Patients should be referred to experienced centers capable of assessing and delivering all options.
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Affiliation(s)
- Hossein-Ardeschir Ghofrani
- Department of Internal Medicine, University of Giessen and Marburg Lung Center, Giessen, Germany; Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK.
| | - Andrea M D'Armini
- Department of Cardio-Thoracic and Vascular Surgery, Heart and Lung Transplantation and Pulmonary Hypertension Unit, Foundation IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, USA
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany; Member of the German Center for Lung Research (DZL), Germany
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin, Bicêtre, France
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127
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Rotzinger DC, Rezaei-Kalantari K, Aubert JD, Qanadli SD. Pulmonary angioplasty: A step further in the continuously changing landscape of chronic thromboembolic pulmonary hypertension management. Eur J Radiol 2021; 136:109562. [PMID: 33524919 DOI: 10.1016/j.ejrad.2021.109562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 11/26/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially fatal and frequently undiagnosed form of pulmonary hypertension (PH), classified within group 4 by the World Health Organization (WHO). It is a type of precapillary PH, which uncommonly develops as a peculiar sequel of acute pulmonary embolism due to the partial resolution of the mechanically obstructing thrombus with a coexisting inflammatory response from pulmonary vessels. CTEPH is one of the potentially treatable forms of PH whose current standard of care is surgical pulmonary endarterectomy. Medical therapy with few drugs in non-operable disease is approved and has shown improvement in patients' hemodynamic condition and functional ability. Recently, balloon pulmonary angioplasty (BPA) has shown promising results as a treatment option for technically inoperable patients, those with unacceptable risk-to-benefit ratio and in a case of residual PH after endarterectomy. Lack of meticulous CTEPH screening programs in post-pulmonary embolism patients leading to underdiagnosis of this condition, complex operability assessment, and diversity in BPA techniques among different institutions are still the issues that need to be addressed. In this paper, we review the recent achievements in the management of non-operable CTEPH, their outcome and safety, based on available data.
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Affiliation(s)
- David C Rotzinger
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Kiara Rezaei-Kalantari
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - John-David Aubert
- Transplantation Center, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Service of Pulmonology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Salah D Qanadli
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Remy-Jardin M, Ryerson CJ, Schiebler ML, Leung ANC, Wild JM, Hoeper MM, Alderson PO, Goodman LR, Mayo J, Haramati LB, Ohno Y, Thistlethwaite P, van Beek EJR, Knight SL, Lynch DA, Rubin GD, Humbert M. Imaging of pulmonary hypertension in adults: a position paper from the Fleischner Society. Eur Respir J 2021; 57:57/1/2004455. [PMID: 33402372 DOI: 10.1183/13993003.04455-2020] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/28/2020] [Indexed: 12/22/2022]
Abstract
Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure greater than 20 mmHg and classified into five different groups sharing similar pathophysiologic mechanisms, haemodynamic characteristics, and therapeutic management. Radiologists play a key role in the multidisciplinary assessment and management of PH. A working group was formed from within the Fleischner Society based on expertise in the imaging and/or management of patients with PH, as well as experience with methodologies of systematic reviews. The working group identified key questions focusing on the utility of CT, MRI, and nuclear medicine in the evaluation of PH: a) Is noninvasive imaging capable of identifying PH? b) What is the role of imaging in establishing the cause of PH? c) How does imaging determine the severity and complications of PH? d) How should imaging be used to assess chronic thromboembolic PH before treatment? e) Should imaging be performed after treatment of PH? This systematic review and position paper highlights the key role of imaging in the recognition, work-up, treatment planning, and follow-up of PH.
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Affiliation(s)
- Martine Remy-Jardin
- Dept of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, Lille, France.,Chair of the Fleischner Society writing committee of the position paper for imaging of pulmonary hypertension
| | - Christopher J Ryerson
- Dept of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, BC, Canada
| | - Mark L Schiebler
- Dept of Radiology, UW-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Ann N C Leung
- Dept of Radiology, Stanford University Medical Center, Stanford, CA, USA
| | - James M Wild
- Division of Imaging, Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany
| | - Philip O Alderson
- Dept of Radiology, Saint Louis University School of Medicine, St Louis, MO, USA
| | | | - John Mayo
- Dept of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Linda B Haramati
- Dept of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yoshiharu Ohno
- Dept of Radiology, Fujita Health University School of Medicine, Toyoake, Japan
| | | | - Edwin J R van Beek
- Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Shandra Lee Knight
- Dept of Library and Knowledge Services, National Jewish Health, Denver, CO, USA
| | - David A Lynch
- Dept of Radiology, National Jewish Health, Denver, CO, USA
| | - Geoffrey D Rubin
- Dept of Radiology, Duke University School of Medicine, Durham, NC, USA
| | - Marc Humbert
- Université Paris Saclay, Inserm UMR S999, Dept of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France.,Co-Chair of the Fleischner Society writing committee of the position paper for imaging of pulmonary hypertension
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129
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Remy-Jardin M, Ryerson CJ, Schiebler ML, Leung ANC, Wild JM, Hoeper MM, Alderson PO, Goodman LR, Mayo J, Haramati LB, Ohno Y, Thistlethwaite P, van Beek EJR, Knight SL, Lynch DA, Rubin GD, Humbert M. Imaging of Pulmonary Hypertension in Adults: A Position Paper from the Fleischner Society. Radiology 2021; 298:531-549. [PMID: 33399507 DOI: 10.1148/radiol.2020203108] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure greater than 20 mm Hg and classified into five different groups sharing similar pathophysiologic mechanisms, hemodynamic characteristics, and therapeutic management. Radiologists play a key role in the multidisciplinary assessment and management of PH. A working group was formed from within the Fleischner Society based on expertise in the imaging and/or management of patients with PH, as well as experience with methodologies of systematic reviews. The working group identified key questions focusing on the utility of CT, MRI, and nuclear medicine in the evaluation of PH: (a) Is noninvasive imaging capable of identifying PH? (b) What is the role of imaging in establishing the cause of PH? (c) How does imaging determine the severity and complications of PH? (d) How should imaging be used to assess chronic thromboembolic PH before treatment? (e) Should imaging be performed after treatment of PH? This systematic review and position paper highlights the key role of imaging in the recognition, work-up, treatment planning, and follow-up of PH. This article is a simultaneous joint publication in Radiology and European Respiratory Journal. The articles are identical except for stylistic changes in keeping with each journal's style. Either version may be used in citing this article. © 2021 RSNA and the European Respiratory Society. Online supplemental material is available for this article.
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Affiliation(s)
- Martine Remy-Jardin
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Christopher J Ryerson
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Mark L Schiebler
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Ann N C Leung
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - James M Wild
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Marius M Hoeper
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Philip O Alderson
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Lawrence R Goodman
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - John Mayo
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Linda B Haramati
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Yoshiharu Ohno
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Patricia Thistlethwaite
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Edwin J R van Beek
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Shandra Lee Knight
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - David A Lynch
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Geoffrey D Rubin
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
| | - Marc Humbert
- From the Department of Thoracic Imaging, Hôpital Calmette, Boulevard Jules Leclercq, 59037 Lille, France (M.R.J.); Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada (C.J.R.); Department of Radiology, UW-Madison School of Medicine and Public Health, Madison, Wis (M.L.S.); Department of Radiology, Stanford University Medical Center, Stanford, Calif (A.N.C.L.); Division of Imaging, Department of Infection Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, England (J.M.W.); Department of Respiratory Medicine, Hannover Medical School and German Centre of Lung Research (DZL), Hannover, Germany (M.M.H.); Department of Radiology, Saint Louis University School of Medicine, St Louis, Mo (P.O.A.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (L.R.G.); Department of Radiology, Vancouver General Hospital, Vancouver, Canada (J.M.); Department of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (L.B.H.); Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan (Y.O.); Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, Calif (P.T.); Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland (E.J.R.v.B.); Department of Library and Knowledge Services (S.L.K.) and Department of Radiology (D.A.L.), National Jewish Health, Denver, Colo; Department of Radiology, Duke University School of Medicine, Durham, NC (G.D.R.); and Université Paris Saclay, Inserm UMR S999, Department of Pneumology, AP-HP, Pulmonary Hypertension Reference Center, Hôpital de Bicêtre, Le Kremlin Bicêtre, France (M.H.)
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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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Balloon Pulmonary Angioplasty in Patients with Chronic Thromboembolic Pulmonary Hypertension: Impact on Clinical and Hemodynamic Parameters, Quality of Life and Risk Profile. J Clin Med 2020; 9:jcm9113608. [PMID: 33182415 PMCID: PMC7697583 DOI: 10.3390/jcm9113608] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/01/2022] Open
Abstract
Balloon pulmonary angioplasty (BPA) is a novel treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not eligible for pulmonary endarterectomy (PEA) or suffer from persistent pulmonary hypertension after PEA. The aim of this study was to evaluate the real-life efficacy and safety of BPA in a consecutive group of patients who were diagnosed and treated in the national referral center for CTEPH in the Czech Republic. Here we report data from 160 BPA procedures performed in 64 patients. Efficacy analysis was performed in the subgroup of 25 patients who completed BPA series. Significant improvements were observed in New York Heart Association functional class (4% to 79% in I/II, p < 0.001), 6 min walking test distance (+54.3 m, p < 0.001), risk profile (15.8% to 68.5% with presence of 2/3 low risk criteria, p < 0.001), pulmonary artery mean pressure (−18%, p < 0.001), pulmonary vascular resistance (−32%, p < 0.001), stroke volume (+17%, p = 0.011) and quality of life (+37% in assessment of overall health status by a patient, p < 0.001). We observed 1 fatal periprocedural complication (1.6% of all 64 patients) and 19 BPA-related non-fatal complications (11.9% of all 160 interventions) that predominantly included hemoptysis (10.0% of all sessions). Overall survival at 12 months was 94.6%.
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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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Tian Z, Jiang X, Jing ZC. How should a physician approach the pharmacological management of chronic thromboembolic pulmonary hypertension? Expert Opin Pharmacother 2020; 22:557-563. [PMID: 33016151 DOI: 10.1080/14656566.2020.1828349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by the presence of organized thromboembolic material and proliferative fibrous intima occluding varying degrees of the pulmonary arteries, and is also accompanied by small vessel vasculopathy in occluded and non-occluded pulmonary vasculature. The similarity in hemodynamics and pathophysiology between CTEPH and group 1 pulmonary arterial hypertension provides the rationale for clinical use of pulmonary arterial hypertension (PAH)-specific therapy. AREAS COVERED The authors present the current knowledge concerning the updated therapeutic strategies in CTEPH, and try to illustrate the established and uncertain role of PAH-specific therapy and anticoagulation therapy. The real-world observational registries and landmark randomized controlled trials of PAH-specific drugs in CTEPH are emphasized in the manuscript. EXPERT OPINION Despite surgical and interventional therapies, which could provide effective and potential curable treatments, medical therapies are still the substantial and irreplaceable option for patients with CTEPH. More and more PAH-specific drugs have demonstrated favorable efficacy and safety profiles in patients with CTEPH. Additionally, anticoagulation therapy is also a substantial medical treatment in all CTEPH patients without contradiction. However, the benefit-to-risk balance in life-long anticoagulation and whether more individualized anticoagulation strategies are needed warrants further investigation.
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Affiliation(s)
- Zhuang Tian
- Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
| | - Zhi-Cheng Jing
- Head of Cardiology Department, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
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Martínez-Santos P, Velázquez-Martín MT, Barberá JA, Fernández Pérez C, López-Meseguer M, López-Reyes R, Martínez-Meñaca A, Lara-Padrón A, Domingo-Morera JA, Blanco I, Escribano-Subías P. Chronic thromboembolic pulmonary hypertension in Spain: a decade of change. ACTA ACUST UNITED AC 2020; 74:384-392. [PMID: 32654945 DOI: 10.1016/j.rec.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/25/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Chronic thromboembolic pulmonary hypertension (CTEPH) treatment has evolved in the last decade. However, there is scarce information on the long-term impact of this progress in a real-life population at a national level. This study was designed to analyze the characteristics of CTEPH patients in Spain over the last decade. METHODS We prospectively collected epidemiological, clinical, and prognostic data from CTEPH patients consecutively included in the Spanish REHAP registry from January 1, 2007, to December 31, 2018. We evaluated differences over time, establishing 2013 as the reference date for analysis. Propensity scores for interventional treatment were calculated using a multivariable logistic regression model. RESULTS A total of 1019 patients were included; 659 (64.4%) were evaluated at a national CTEPH center. Overall, 350 patients (34.3%) were selected for surgery and 97 (9.6%) for percutaneous treatment. Patients diagnosed between 2007 and 2012 died more frequently than those diagnosed from 2013 onward (HR, 1.83; 95%CI, 1.07-3.15; P=.027). Within the subgroup of patients adjusted by propensity score, baseline pulmonary vascular resistance and the 6-minute walk test distance also determined the outcome (HR, 1.24; 95%CI, 1.15-1.33; P=.011; and HR, 0.93; 95%CI, 0.90-0.97; P=.001, respectively). High survival rates were found in patients who underwent an invasive procedure (pulmonary endarterectomy or balloon pulmonary angioplasty). CONCLUSIONS CTEPH diagnosis and prognosis have consistently improved in the last decade. Baseline disease severity determines the risk profile. Patients who undergo pulmonary endarterectomy or balloon pulmonary angioplasty have better outcomes.
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Affiliation(s)
- Paula Martínez-Santos
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | | | - Joan Albert Barberá
- Servicio de Neumología, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain; Servicio de Neumología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Manuel López-Meseguer
- Servicio de Neumología, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | - Amaya Martínez-Meñaca
- Servicio de Neumología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Antonio Lara-Padrón
- Servicio de Cardiología, Hospital Universitario de Canarias, Sta. Cruz de Tenerife, Spain
| | | | - Isabel Blanco
- Servicio de Neumología, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Pilar Escribano-Subías
- Unidad de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Abstract
PURPOSE OF REVIEW The present review provides an update on treatment of chronic thromboembolic pulmonary hypertension (CTEPH), a rare form of pulmonary hypertension characterized by precapillary pulmonary hemodynamic parameters with chronic thrombotic occlusion of the pulmonary vasculature. RECENT FINDINGS Pulmonary thromboendarectomy (PTE) remains the recommended treatment for patients with surgically accessible disease. Recent data suggest that patients preoperatively bridged with medical therapy may have improved outcomes but further research is needed. Riociguat improves hemodynamics, right ventricular function, quality of life, and functional capacity and is the drug of choice for patients with inoperable/persistent disease. Recently published data suggest that endothelin receptor blockers and treprostinil may also have a role in medical management of this patient population. A growing body of evidence indicates that in experienced centers balloon pulmonary angioplasty (BPA) may be a well tolerated and effective adjunct to pharmacological treatment for patients with inoperable disease affecting subsegmental vasculature. SUMMARY Untreated CTEPH carries significant morbidity and mortality. Recent publications provide a wealth of data on safety and efficacy of BPA for inoperable subsegmental disease, but its precise fit in the treatment algorithm, both pharmacological and procedural, requires further investigation. PTE remains the procedure of choice for surgically accessible disease.
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Jin Q, Zhao ZH, Luo Q, Zhao Q, Yan L, Zhang Y, Li X, Yang T, Zeng QX, Xiong CM, Liu ZH. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: State of the art. World J Clin Cases 2020; 8:2679-2702. [PMID: 32742980 PMCID: PMC7360712 DOI: 10.12998/wjcc.v8.i13.2679] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complex chronic disease in which pulmonary artery stenosis or obstruction caused by organized thrombus can lead to increased pulmonary artery pressure and pulmonary vascular resistance, ultimately triggering progressive right heart failure and death. Currently, its exact mechanism is not fully understood. Pulmonary endarterectomy (PEA) has immediate effects with low perioperative mortality and satisfactory prognosis in experienced expert centers for CTEPH patients with proximal lesions. Nevertheless, 37% of patients are deemed unsuitable for PEA surgery due to comorbidities and other factors, and nearly half of the operated patients have residual or recurrent pulmonary hypertension. Riociguat is the only approved drug for CTEPH, although its effect is limited. Balloon pulmonary angioplasty (BPA) is a promising alternative treatment for patients with CTEPH. After more than 30 years of development and refinements, emerging evidence has confirmed its role in patients with inoperable CTEPH or residual/recurrent pulmonary hypertension, with acceptable complications and comparable long-term prognosis to PEA. This review summarizes the pathophysiology of CTEPH, BPA history and development, therapeutic principles, indications and contraindications, interventional procedures, imaging modalities, efficacy and prognosis, complications and management, bridging and hybrid therapies, ongoing clinical trials and future prospects.
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Affiliation(s)
- Qi Jin
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qin Luo
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qing Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lu Yan
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Zhang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xin Li
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Tao Yang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qi-Xian Zeng
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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137
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Campean IA, Lang IM. Treating pulmonary hypertension in the elderly. Expert Opin Pharmacother 2020; 21:1193-1200. [DOI: 10.1080/14656566.2020.1739270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Ioana A Campean
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
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Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis. Sci Rep 2020; 10:8870. [PMID: 32483219 PMCID: PMC7264327 DOI: 10.1038/s41598-020-65697-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/09/2020] [Indexed: 01/20/2023] Open
Abstract
Treatment options for chronic thromboembolic pulmonary hypertension (CTEPH) that is not amenable to thromboendarterectomy or is recurrent/persistent after thromboendarterectomy (inoperable CTEPH) include pulmonary vasodilators or balloon pulmonary angioplasty (BPA). We compared efficacy and safety outcomes of BPA with or without pulmonary vasodilators to pulmonary vasodilator therapy alone in patients with inoperable CTEPH. Observational and randomized trial data reporting outcomes for >5 patients with inoperable CTEPH were sought. Single-arm random effects meta-analyses were performed. The primary outcome was change in six-minute walk distance (6MWD). Secondary outcomes included safety; World Health Organization functional class (WHO FC); and change in mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index. Thirty-four studies with 1604 patients were eligible for analyses. Both treatments resulted in significant improvement in 6MWD (71.0 meters, 95% CI: 47.4–94.5 meters with BPA versus 47.8 meters, 95% CI: 34.5–61.2 meters with pulmonary vasodilators), PVR [−3.1 Wood Units (WU), 95% CI: −4.9 to −1.4 WU versus −1.6 WU, 95% CI: −2.4 to −0.8 WU] and mPAP (−14.8 mmHg, 95% CI: −18.2 to −11.5 mmHg versus −4.9 mmHg, 95% CI: −6.9 to −2.8 mmHg). Cardiac index was similar and most patients were WHO FC II and III after their respective interventions. More complications occurred in the BPA arm. In conclusion, BPA and pulmonary vasodilators both improve 6MWD and hemodynamics in patients with inoperable CTEPH. While BPA may offer greater functional and hemodynamic improvements, this technique carries the accompanying risks of an invasive procedure.
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Zhang X, Guo D, Wang J, Gong J, Wu X, Jiang Z, Zhong J, Lu X, Yang Y, Li Y. Speckle tracking for predicting outcomes of balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. Echocardiography 2020; 37:841-849. [PMID: 32447819 DOI: 10.1111/echo.14709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Right ventricular (RV) function is a prognostic marker of chronic thromboembolic pulmonary hypertension (CTEPH). We used two-dimensional (2D) speckle-tracking echocardiography (STE) to evaluate the therapeutic effects of balloon pulmonary angioplasty (BPA) in CTEPH patients. METHODS A total of 46 CTEPH patients who underwent 2D STE before and after BPA were enrolled in this retrospective study. The following RV functional parameters were measured: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC), RV index of myocardial performance (RIMP), and free wall longitudinal strain (RVFWLS). Satisfactory BPA was defined as mean pulmonary arterial pressure (mPAP) <25 mm Hg or improvement in mPAP > 10 mm Hg after BPA. Patients were divided into two groups according to mPAP values: group I had satisfactory BPA outcomes; group Ⅱ had unsatisfactory BPA outcomes. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to determine the optimal cutoff values and the ability of RVFWLS to predict successful BPA outcomes. RESULTS After BPA, SPAP measured by echocardiography (SPAPecho ) and RIMP decreased, but TAPSE, RVFAC, and RVFWLS increased. Before BPA, group Ⅰ had significantly better RV function than group Ⅱ. Multifactor logistic regression analysis identified RVFWLS as an independent factor associated with satisfactory BPA outcomes. The optimal cutoff value for RVFWLS in predicting satisfactory BPA outcomes was -12.2%. CONCLUSIONS Balloon pulmonary angioplasty improves RV function in CTEPH patients. RVFWLS is a valuable noninvasive tool with which to assess the treatment effects of BPA. CTEPH patients with lower RVFWLS may have limited benefit from BPA.
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Affiliation(s)
- Xinyuan Zhang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Dichen Guo
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jianfeng Wang
- Department of Intervention, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Juanni Gong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaopeng Wu
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhe Jiang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jiuchang Zhong
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing, China
| | - Xiuzhang Lu
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yidan Li
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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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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Abstract
The treatment of chronic thromboembolic pulmonary hypertension has expanded considerably. The ability to endarterectomize chronic thromboembolic material, the availability of pulmonary hypertension medical therapy to treat inoperable chronic thromboembolic pulmonary hypertension and/or residual pulmonary hypertension, and the rebirth of pulmonary balloon angioplasty have changed the management landscape. Patient selection requires a multidisciplinary evaluation at an experienced center. What is inoperable chronic thromboembolic pulmonary hypertension to one group may be operable chronic thromboembolic pulmonary hypertension to another. The ultimate challenge then becomes which intervention provides the optimal long-term outcome for any individual patient.
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Affiliation(s)
- William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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142
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Karyofyllis P, Demerouti E, Papadopoulou V, Voudris V, Matsubara H. Balloon Pulmonary Angioplasty as a Treatment in Chronic Thromboembolic Pulmonary Hypertension: Past, Present, and Future. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:7. [DOI: 10.1007/s11936-020-0807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Boucly A, Savale L, Vuillard C, Turpin M, Jaïs X, Montani D, Humbert M, Sitbon O. [Management of right ventricular failure in pulmonary vascular diseases]. Rev Mal Respir 2020; 37:171-179. [PMID: 32061440 DOI: 10.1016/j.rmr.2019.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 07/19/2019] [Indexed: 10/25/2022]
Abstract
Right ventricular failure (RVF) is a common cause of admission to the intensive care unit and its presence is a major prognostic factor in acute pulmonary embolism (PE) and chronic pulmonary hypertension (PH). RVF results from an incapacity of the RV to adapt to an increase in afterload so it can become critical in acute PE and chronic PH. The presence of RVF in cases of acute PE with haemodynamic instability is an indication for thrombolytic therapy. RVF represents the most common cause of death in chronic PH. Factors triggering RV failure in PH, such as infection, PE, arrhythmias, or unplanned withdrawal of pulmonary arterial hypertension (PAH)-targeted therapy, have to be considered and treated if identified. However, RVF may also represent progression to end-stage disease. The management of RVF in patients with PH requires expertise and consists of optimization of fluid balance (with diuretics), cardiac output (with inotropic support such as dobutamine), perfusion pressure (with norepinephrine), and reduction of RV afterload with PAH-targeted therapies. Extracorporeal life support, lung transplantation or heart-lung transplantation should be considered in cases of refractory RVF in eligible patients.
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Affiliation(s)
- A Boucly
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - L Savale
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - C Vuillard
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - M Turpin
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - X Jaïs
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - D Montani
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - M Humbert
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - O Sitbon
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France.
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van Thor MCJ, Lely RJ, Braams NJ, Ten Klooster L, Beijk MAM, Heijmen RH, van den Heuvel DAF, Rensing BJWM, Snijder RJ, Vonk Noordegraaf A, Nossent EJ, Meijboom LJ, Symersky P, Mager JJ, Bogaard HJ, Post MC. Safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension in the Netherlands. Neth Heart J 2019; 28:81-88. [PMID: 31782109 PMCID: PMC6977797 DOI: 10.1007/s12471-019-01352-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Balloon pulmonary angioplasty (BPA) is an emerging treatment in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic disease (CTED). We describe the first safety and efficacy results of BPA in the Netherlands. Methods We selected all consecutive patients with inoperable CTEPH and CTED accepted for BPA treatment who had a six-month follow-up in the St. Antonius Hospital in Nieuwegein and the Amsterdam University Medical Center (UMC) in Amsterdam. Functional class (FC), N‑terminal pro-brain natriuretic peptide (NT-proBNP), 6‑minute walking test distance (6MWD) and right-sided heart catheterisation were performed at baseline and six months after last BPA. Complications for each BPA procedure were noted. Results A hundred and seventy-two BPA procedures were performed in 38 patients (61% female, mean age 65 ± 15 years). Significant improvements six months after BPA treatment were observed for functional class (63% FC I/II to 90% FC I/II, p = 0.014), mean pulmonary artery pressure (−8.9 mm Hg, p = 0.0001), pulmonary vascular resistance (−2.8 Woods Units (WU), p = 0.0001), right atrial pressure (−2.0 mm Hg, p = 0.006), stroke volume index (+5.7 ml/m2, p = 0.009) and 6MWD (+48m, p = 0.007). Non-severe complications occurred in 20 (12%) procedures. Conclusions BPA performed in a CTEPH expert centre is an effective and safe treatment in patients with inoperable CTEPH.
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Affiliation(s)
- M C J van Thor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands. .,Department of Pulmonary Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - R J Lely
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - N J Braams
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - L Ten Klooster
- Department of Pulmonary Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M A M Beijk
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R H Heijmen
- Department of Cardiothoracic surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - B J W M Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R J Snijder
- Department of Pulmonary Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - E J Nossent
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - L J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - P Symersky
- Department of Cardiothoracic surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J J Mager
- Department of Pulmonary Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - H J Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Lang IM, Matsubara H. Balloon pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension: is Europe behind? Eur Respir J 2019; 54:54/4/1901639. [PMID: 31649148 DOI: 10.1183/13993003.01639-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Irene M Lang
- Dept of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- National Hospital Organization, Okayama Medical Center, Okayama, Japan
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146
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Jaïs X, Brenot P, Montani D, Fadel E, Humbert M, Simonneau G. A roadmap for management of chronic thromboembolic pulmonary hypertension. Eur Respir J 2019; 54:54/4/1901295. [PMID: 31649145 DOI: 10.1183/13993003.01295-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/17/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Xavier Jaïs
- Univ. 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 Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Philippe Brenot
- Univ. 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.,Service de Radiologie, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - David Montani
- Univ. 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 Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Elie Fadel
- Univ. 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.,Service de Chirurgie Thoracique, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Univ. 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 Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Gérald Simonneau
- Univ. 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 Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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147
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Sadushi-Kolici R, Lang IM. Treprostinil for the treatment of chronic thromboembolic pulmonary hypertension. Expert Rev Respir Med 2019; 13:1-7. [PMID: 31545126 DOI: 10.1080/17476348.2019.1652094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/01/2019] [Indexed: 12/21/2022]
Abstract
Introduction: Parenteral treprostinil for patients with pulmonary arterial hypertension has resulted in improvement of exercise capacity, functional class, hemodynamics, and survival. Recently, a first randomized trial performed in patients with chronic thromboembolic pulmonary hypertension confirmed the efficacy of subcutaneous treprostinil in this subset of pulmonary hypertension. Areas covered: Treprostinil sodium is a prostacyclin analog produced synthetically. Drug characteristics include potent systemic and pulmonary vasodilatory effects. Local side-effects of subcutaneous treprostinil have been an obstacle for its use. However, in contrast to other prostacyclins, treprostinil has favorable features. We performed a literature survey by searching PubMed for clinical trials published in any language, investigating medicinal treatments for CTEPH. We used the search terms 'inoperable', and 'chronic thromboembolic pulmonary hypertension' with 'randomized clinical trial', and have put treprostinil for CTEPH in the contest of published literature. Expert opinion: Drugs approved for PAH have recently shown excellent efficacy in patients with non-operable CTEPH. Rather than head-to-head comparisons of drugs, combination treatments are to be expected in the near future. Furthermore, drugs will have to be tested alongside with pulmonary endarterectomy (PEA), and alongside balloon pulmonary angioplasty, a promising percutaneous mechanical treatment for CTEPH that is not suited for PEA.
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Affiliation(s)
- Roela Sadushi-Kolici
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna , Vienna , Austria
| | - Irene Marthe Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna , Vienna , Austria
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Lang IM, Matsubara H. Balloon pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension: is Europe behind? Eur Respir J 2019; 53:53/5/1900843. [DOI: 10.1183/13993003.00843-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 05/06/2019] [Indexed: 11/05/2022]
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