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Nilsson LT, Andersson T, Carlberg B, Johansson LÅ, Söderberg S. Electrocardiographic abnormalities and NT-proBNP levels at long-term follow-up of patients with dyspnea after pulmonary embolism. SCAND CARDIOVASC J 2024; 58:2373090. [PMID: 38957080 DOI: 10.1080/14017431.2024.2373090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 06/22/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVES Electrocardiogram (ECG) and measurement of plasma brain natriuretic peptides (BNP) are established markers of right ventricular dysfunction (RVD) in the setting of acute pulmonary embolism (PE) but their value at long-term follow-up is largely unknown. The purpose of this prospective study was to determine the prevalence of ECG abnormalities, describe levels of N-terminal proBNP (NT-proBNP), and establish their association with dyspnea at long-term follow-up after PE. DESIGN All Swedish patients diagnosed with acute PE in 2005 (n = 5793) were identified through the Swedish National Patient Registry. Surviving patients in 2007 (n = 3510) were invited to participate. Of these, 2105 subjects responded to a questionnaire about dyspnea and comorbidities. Subjects with dyspnea or risk factors for development of chronic thromboembolic pulmonary hypertension were included in the study in a secondary step, which involved collection of blood samples and ECG registration. RESULTS Altogether 49.3% had a completely normal ECG. The remaining participants had a variety of abnormalities, 7.2% had atrial fibrillation/flutter (AF). ECG with any sign of RVD was found in 7.2% of subjects. Right bundle branch block was the most common RVD sign with a prevalence of 6.4%. An abnormal ECG was associated with dyspnea. AF was associated with dyspnea, whereas ECG signs of RVD were not. 61.2% of subjects had NT-proBNP levels above clinical cut-off (>125 ng/L). The degree of dyspnea did not associate independently with NT-proBNP levels. CONCLUSIONS We conclude that the value of ECG and NT-proBNP in long term follow-up after PE lies mostly in differential diagnostics.
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Affiliation(s)
- Lars T Nilsson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Therese Andersson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Lars Å Johansson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
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Moore J, Altschul E, Remy-Jardin M, Raoof S. Chronic Thromboembolic Pulmonary Hypertension: Clinical and Imaging Evaluation. Clin Chest Med 2024; 45:405-418. [PMID: 38816096 DOI: 10.1016/j.ccm.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and is an important cause of pulmonary hypertension. As a clinical entity, it is frequently underdiagnosed with prolonged diagnostic delays. This study reviews the clinical and radiographic findings associated with CTEPH to improve awareness and recognition. Strengths and limitations of multiple imaging modalities are reviewed. Accompanying images are provided to supplement the text and provide examples of important findings for the reader.
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Affiliation(s)
- Jonathan Moore
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA
| | - Erica Altschul
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA
| | - Martine Remy-Jardin
- Department of Thoracic Imaging, Univ.Lille, CHU Lille, LILLE F-59000, France; Univ.Lille, CHU Lille, ULR 2694 METRICS Evaluation des Technologies de Santé et des Pratiques Médicales, LILLE F-59000, France
| | - Suhail Raoof
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA.
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Li HT, Yuan P, Jiang R, Zhao QH, Sun YY, Zhang J, Gong SG, Li JL, Qiu HL, Wu WH, Luo CJ, Xu J, Wang L, Liu JM. Sleep-disordered breathing and nocturnal hypoxemia in chronic thromboembolic pulmonary disease. Intern Med J 2024. [PMID: 38563467 DOI: 10.1111/imj.16359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIMS Sleep-disordered breathing (SDB) and nocturnal hypoxemia were known to be present in patients with chronic thromboembolic pulmonary hypertension (CTEPH), but the difference between SDB and nocturnal hypoxemia in patients who have chronic thromboembolic pulmonary disease (CTEPD) with or without pulmonary hypertension (PH) at rest remains unknown. METHODS Patients who had CTEPH (n = 80) or CTEPD without PH (n = 40) and who had undergone sleep studies from July 2020 to October 2022 at Shanghai Pulmonary Hospital were enrolled. Nocturnal mean SpO2 (Mean SpO2) <90% was defined as nocturnal hypoxemia, and the percentage of time with a saturation below 90% (T90%) exceeding 10% was used to evaluate the severity of nocturnal hypoxemia. Logistic and linear regression analyses were performed to investigate the difference and potential predictor of SDB or nocturnal hypoxemia between CTEPH and CTEPD without PH. RESULTS SDB was similarly prevalent in CTEPH and CTEPD without PH (P = 0.104), both characterised by obstructive sleep apnoea (OSA). Twenty-two patients with CTEPH were diagnosed with nocturnal hypoxemia, whereas only three were diagnosed with CTEPD without PH (P = 0.021). T90% was positively associated with mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance in patients with CTEPH and CTEPD without PH (P < 0.001); T90% was also negatively related to cardiac output in these patients. Single-breath carbon monoxide diffusing capacity, sex and mPAP were all correlated with nocturnal hypoxemia in CTEPH and CTEPD without PH (all P < 0.05). CONCLUSION Nocturnal hypoxemia was worse in CTEPD with PH; T90%, but not SDB, was independently correlated with the hemodynamics in CTEPD with or without PH.
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Affiliation(s)
- Hui-Ting Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuan-Yuan Sun
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jian Zhang
- Department of Respiratory and Critical Care Medicine, the 416 Hospital of Nuclear Industry/the Second Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jin-Ling Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jiang Xu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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Ghio S, Corsico A, Rapagnani A, Borrelli E, Alloni A, Valentini A, Piloni D, Scelsi L, Klersy C, D'Armini AM. Does pulmonary endarterectomy improve the clinical conditions of patients with chronic thromboembolic pulmonary disease without pulmonary hypertension? J Heart Lung Transplant 2024; 43:681-685. [PMID: 38184125 DOI: 10.1016/j.healun.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/24/2023] [Accepted: 12/27/2023] [Indexed: 01/08/2024] Open
Abstract
To verify whether the new hemodynamic definition of pulmonary hypertension (PH) has any implication in treatment of Chronic Thrombo-Embolic Pulmonary Disease (CTEPD) patients without PH, we retrospectively analysed the clinical and functional changes determined by pulmonary endarterectomy (PEA) in 63 CTEPD patients without PH who underwent surgery at our center, comparing those in whom the hemodynamic diagnosis of PH met recent guideline recommendations versus those in whom the diagnosis only met previous hemodynamic thresholds. The results show that the vast majority of CTEPD patients without PH operated at our center would now be defined as chronic thromboembolic pulmonary hypertension (CTEPH) patients. PEA did not result in any improvement in exercise capacity nor in right ventricular function or lung function test in patients with mean pulmonary artery pressure (mPAP) ≤ 20 mm Hg and pulmonary vascular resistance (PVR) ≤ 2 WU; on the contrary, hemodynamic parameters, exercise capacity, right ventricular function and lung function significantly improved in patients with mPAP between 21 and 24 mm Hg.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Angelo Corsico
- Division of Respiratory Diseases, Foundation IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Andrea Rapagnani
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Ermelinda Borrelli
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Alessia Alloni
- Division of Cardiac Surgery 2 and Pulmonary Hypertension Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Adele Valentini
- Institut of Radiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Davide Piloni
- Division of Respiratory Diseases, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Laura Scelsi
- Division of Cardiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Catherine Klersy
- Service of Clinical Epidemiology and Biometry, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Maria D'Armini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy; Division of Cardiac Surgery 2 and Pulmonary Hypertension Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.
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Pepke-Zaba J, Howard L, Kiely DG, Sweeney S, Johnson M. Pulmonary Embolism (PE) to Chronic Thromboembolic Pulmonary Disease (CTEPD): Findings from a Survey of UK Physicians. Adv Respir Med 2024; 92:45-57. [PMID: 38247551 PMCID: PMC10801485 DOI: 10.3390/arm92010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is a complication of pulmonary embolism (PE). We conducted an online survey of UK PE-treating physicians to understand practices in the follow-up of PE and awareness of CTEPD. The physicians surveyed (N = 175) included 50 each from cardiology, respiratory and internal medicine, plus 25 haematologists. Most (89%) participants had local guidelines for PE management, and 65% reported a PE follow-up clinic, of which 69% were joint clinics. Almost half (47%) had a protocol for the investigation of CTEPD. According to participants, 129 (74%) routinely consider a diagnosis of CTEPD and 97 (55%) routinely investigate for CTEPD, with 76% of those 97 participants investigating in patients who are symptomatic at 3 months and 22% investigating in all patients. This survey demonstrated variability in the follow-up of PE and the awareness of CTEPD and its investigation. The findings support the conduct of a national audit to understand the barriers to the timely detection of CTEPD.
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Affiliation(s)
- Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, National Pulmonary Hypertension Service, Royal Papworth Hospital, Cambridge CB2 0AY, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London W12 0HS, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, NIHR Biomedical Research Centre, Sheffield S10 2RX, UK
| | - Shruti Sweeney
- Medical Affairs Department, Janssen-Cilag Ltd., High Wycombe HP12 4EG, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow G81 4DY, UK
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Yamaguchi T, Ehara S, Yoshida H, Himoto D, Izuta S, Hayashi O, Hayashi H, Ogawa M, Shibata A, Yamazaki T, Izumiya Y, Fukuda D. Quantification of pulmonary perfusion using LSIM-CT correlates with pulmonary hemodynamics in patients with CTEPD. Front Cardiovasc Med 2023; 10:1237296. [PMID: 38028450 PMCID: PMC10654960 DOI: 10.3389/fcvm.2023.1237296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
Background Lung subtraction iodine mapping (LSIM)-CT is a clinically useful technique that can visualize pulmonary mal-perfusion in patients with chronic thromboembolic pulmonary disease (CTEPD). However, little is known about the associations of LSIM images with hemodynamic parameters of patients with CTEPD. This study investigates a parameter of LSIM images associated with mean pulmonary arterial pressure (mPAP) and validates the association between pulmonary vascular resistance, right atrial pressure, cardiac index, and exercise capacity in patients with CTEPD. Methods This single-center, prospective, observational study involved 30 patients diagnosed with CTEPD using lung perfusion scintigraphy. To examine the correlation of decreased pulmonary perfusion area (DPA) with mPAP, areas with 0-10, 0-15, 0-20, and 0-30 HU in lung subtraction images were adopted in statistical analysis. The DPA to total lung volume ratio (DPA ratio, %) was calculated as the ratio of each DPA volume to the total lung volume. To assess the correlation between DPA ratios of 0-10, 0-15, 0-20, and 0-30 HU and mPAP, Spearman's rank correlation coefficient was used. Results The DPA ratio of 0-10 HU had the most preferable correlation with mPAP than DPA ratios of 0-15, 0-20, and 0-30 HU (ρ = 0.440, P = 0.015). The DPA ratio of 0-10 HU significantly correlates with pulmonary vascular resistance (ρ = 0.445, P = 0.015). The receiver operating characteristic curve analysis indicated that the best cutoff value of the DPA ratio of 0-10 HU for the prediction of an mPAP of ≥30 mmHg was 8.5% (AUC, 0.773; 95% CI, 0.572-0.974; sensitivity, 83.3%; specificity, 75.0%). Multivariate linear regression analysis, which was adjusted for the main pulmonary arterial to ascending aortic diameter ratio and right ventricular to left ventricular diameter ratio, indicated that the DPA ratio of 0-10 HU was independently and significantly associated with mPAP (B = 89.7; 95% CI, 46.3-133.1, P < 0.001). Conclusion The DPA ratio calculated using LSIM-CT is possibly useful for estimating the hemodynamic status in patients with CTEPD.
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Affiliation(s)
- Tomohiro Yamaguchi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shoichi Ehara
- Department of Intensive Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Himoto
- Department of Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Shinichiro Izuta
- Department of Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Ou Hayashi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroya Hayashi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Mana Ogawa
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Shibata
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takanori Yamazaki
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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7
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Reddy SA, Swietlik EM, Robertson L, Michael A, Boyle S, Polwarth G, Screaton NJ, Ruggiero A, Nethercott SL, Taboada D, Sheares KK, Hadinnapola C, Cannon JE, Bunclark K, Jenkins D, Ng C, Toshner MR, Pepke-Zaba J. Natural history of chronic thromboembolic pulmonary disease with no or mild pulmonary hypertension. J Heart Lung Transplant 2023; 42:1275-1285. [PMID: 37201688 DOI: 10.1016/j.healun.2023.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/31/2023] [Accepted: 04/27/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND We describe baseline characteristics, disease progression and mortality in chronic thromboembolic pulmonary disease patients as a function of mean pulmonary artery pressure (mPAP) according to new and previous definitions of pulmonary hypertension. METHODS All patients diagnosed with chronic thromboembolic pulmonary disease between January, 2015 and December, 2019 were dichotomized according to initial mPAP: ≤ 20 mmHg ('normal') vs 21-24 mmHg ('mildly-elevated'). Baseline features were compared between the groups, and pairwise analysis performed to determine changes in clinical endpoints at 1-year, excluding those who underwent pulmonary endarterectomy or did not attend follow-up. Mortality was assessed for the whole cohort over the entire study period. RESULTS One hundred thirteen patients were included; 57 had mPAP ≤ 20 mmHg and 56 had mPAP 21-24 mmHg. Normal mPAP patients had lower pulmonary vascular resistance (1.6 vs 2.5WU, p < 0.01) and right ventricular end-diastolic pressure (5.9 vs 7.8 mmHg, p < 0.01) at presentation. At 3 years, no major deterioration was seen in either group. No patients were treated with pulmonary artery vasodilators. Eight had undergone pulmonary endarterectomy. Over 37 months median follow-up, mortality was 7.0% in the normal mPAP group and 8.9% in the mildly-elevated mPAP group. Cause of death was malignancy in 62.5% of cases. CONCLUSIONS Chronic thromboembolic pulmonary disease patients with mild pulmonary hypertension have statistically higher right ventricular end-diastolic pressure and pulmonary vascular resistance than those with mPAP ≤ 20 mmHg. Baseline characteristics were otherwise similar. Neither group displayed disease progression on non-invasive tests up to 3 years. Mortality over 37 months follow-up is 8%, and mainly attributable to malignancy. Further prospective study is required to validate these findings.
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Affiliation(s)
- Sathineni A Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK.
| | - Emilia M Swietlik
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Lucy Robertson
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Alice Michael
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Sonja Boyle
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Gary Polwarth
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Nick J Screaton
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | | | | | - Dolores Taboada
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Karen K Sheares
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - John E Cannon
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - David Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Choo Ng
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Mark R Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK; Addenbrookes Hospital, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
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Update on the roles of imaging in the management of chronic thromboembolic pulmonary hypertension. J Cardiol 2023; 81:297-306. [PMID: 35490106 DOI: 10.1016/j.jjcc.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/02/2022] [Indexed: 02/01/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH), classified as group 4 pulmonary hypertension (PH), is caused by stenosis and obstruction of the pulmonary arteries by organized thrombi that are incompletely resolved after acute pulmonary embolism. The prognosis of patients with CTEPH is poor if untreated; however, in expert centers with multidisciplinary teams, a treatment strategy for CTEPH has been established, dramatically improving its prognosis. CTEPH is currently not a fatal disease and is the only curable form of PH. Despite these advances and the establishment of treatment approaches, early diagnosis is still challenging, especially for non-experts, for several reasons. One of the reasons for this is insufficient knowledge of the various diagnostic imaging modalities, which are essential in the clinical practice of CTEPH. Imaging modalities should detect the following pathological findings: lung perfusion defects, thromboembolic lesions in pulmonary arteries, and right ventricular remodeling and dysfunction. Perfusion lung scintigraphy and catheter angiography have long been considered gold standards for the detection of perfusion defects and assessment of vascular lesions, respectively. However, advances in imaging technology of computed tomography and magnetic resonance imaging have enabled the non-invasive detection of these abnormal findings in a single examination. Cardiac magnetic resonance (CMR) is the gold standard for evaluating the morphology and function of the right heart; however, state-of-the-art techniques in CMR allow the assessment of cardiac tissue characterization and hemodynamics in the pulmonary arteries. Comprehensive knowledge of the role of imaging in CTEPH enables appropriate use of imaging modalities and accurate image interpretation, resulting in early diagnosis, determination of treatment strategies, and appropriate evaluation of treatment efficacy. This review summarizes the current roles of imaging in the clinical practice for CTEPH, demonstrating the characteristic findings observed in each modality.
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Menale S, Scheggi V, Giovacchini J, Marchionni N. Persistent respiratory failure after SARS-CoV-2 infection: The role of dual energy computed tomography. A case report. Radiol Case Rep 2022; 17:3179-3184. [PMID: 35784783 PMCID: PMC9236780 DOI: 10.1016/j.radcr.2022.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background: COVID-19 disease is often complicated by respiratory failure, developing through multiple pathophysiological mechanisms, with pulmonary embolism (PE) and microvascular thrombosis as key and frequent components. Newer imaging modalities such as dual-energy computed tomography (DECT) can represent a turning point in the diagnosis and follow-up of suspected PE during COVID-19. Case presentation: A 78-year-old female presented to our internal medicine 3 weeks after initial hospitalization for COVID-19 disease, for recrudescent respiratory failure needing oxygen therapy. A computed tomography (CT) lungs scan showed a typical SARSCoV-2 pneumonia. Over the following 15 days, respiratory function gradually improved. Unexpectedly, after 21 days from symptom onset, the patient started complaining of breath shortening with remarkable desaturation requiring high-flow oxygen ventilation. CT pulmonary angiography and transthoracic echocardiography were negative for signs of PE. Thereby, Dual-energy CT angiography of the lungs (DECT) was performed and detected diffuse peripheral microembolism. After 2 weeks, a second DECT was performed, showing a good response to the anticoagulation regimen, with reduced extent of microembolism and some of the remaining emboli partially recanalized. Discussion: DECT is an emerging diagnostic technique providing both functional and anatomical information. DECT has been reported to produce a much sharper delineation of perfusion defects than pulmonary scintigraphy, using a significantly lower equivalent dose of mSv. We highlight that DECT is particularly useful in SARS-Cov-2 infection, in order to determine the predominant underlying pathophysiology, particularly when respiratory failure prolongs despite improved lung parenchymal radiological findings
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Systemic-pulmonary collateral supply associated with clinical severity of chronic thromboembolic pulmonary hypertension: a study using intra-aortic computed tomography angiography. Eur Radiol 2022; 32:7668-7679. [PMID: 35420297 PMCID: PMC9668953 DOI: 10.1007/s00330-022-08768-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 03/11/2022] [Accepted: 03/23/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To assess whether systemic-pulmonary collaterals are associated with clinical severity and extent of pulmonary perfusion defects in chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This prospective study was approved by a local ethics committee. Twenty-four patients diagnosed with inoperable CTEPH were enrolled between July 2014 and February 2017. Systemic-pulmonary collaterals were detected using pulmonary vascular enhancement on intra-aortic computed tomography (CT) angiography. The pulmonary enhancement parameters were calculated, including (1) Hounsfield unit differences (HUdiff) between pulmonary trunks and pulmonary arteries (PAs) or veins (PVs), namely HUdiff-PA and HUdiff-PV, on the segmental base; (2) the mean HUdiff-PA, mean HUdiff-PV, numbers of significantly enhanced PAs and PVs, on the patient base. Pulmonary perfusion defects were recorded and scored using the lung perfused blood volume (PBV) based on intravenous dual-energy CT (DECT) angiography. Pearson's or Spearman's correlation coefficients were used to evaluate correlations between the following: (1) segment-based intra-aortic CT and intravenous DECT parameters (2) patient-based intra-aortic CT parameters and clinical severity parameters or lung PBV scores. Statistical significance was set at p < 0.05. RESULTS Segmental HUdiff-PV was correlated with the segmental perfusion defect score (r = 0.45, p < 0.01). The mean HUdiff-PV was correlated with the mean pulmonary arterial pressure (PAP) (r = 0.52, p < 0.01), cardiac output (rho = - 0.41, p = 0.05), and lung PBV score (rho = 0.43, p = 0.04). And the number of significantly enhanced PVs was correlated with the mean PAP (r = 0.54, p < 0.01), pulmonary vascular resistance (r = 0.54, p < 0.01), and lung PBV score (rho = 0.50, p = 0.01). CONCLUSIONS PV enhancement measured by intra-aortic CT angiography reflects clinical severity and pulmonary perfusion defects in CTEPH. KEY POINTS • Intra-aortic CT angiography demonstrated heterogeneous enhancement within the pulmonary vasculature, showing collaterals from the systemic arteries to the pulmonary circulation in CTEPH. • The degree of systemic-pulmonary collateral development was significantly correlated with the clinical severity of CTEPH and may be used to evaluate disease progression. • The distribution of systemic-pulmonary collaterals is positively correlated with perfusion defects in the lung segments in CTEPH.
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