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Inácio Cazeiro D, Azaredo Raposo M, Guimarães T, Lousada N, Jenkins D, R Inácio J, Moreira S, Mineiro A, Freitas C, Martins S, Ferreira R, Luís R, Cardim N, Pinto FJ, Plácido R. Chronic thromboembolic pulmonary hypertension: A comprehensive review of pathogenesis, diagnosis, and treatment strategies. Rev Port Cardiol 2024:S0870-2551(24)00187-2. [PMID: 38945473 DOI: 10.1016/j.repc.2024.04.006] [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: 11/22/2023] [Revised: 04/09/2024] [Accepted: 04/17/2024] [Indexed: 07/02/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is part of group 4 of the pulmonary hypertension (PH) classification and generally affects more than a third of patients referred to PH centers. It is a three-compartment disease involving proximal (lobar-to-segmental) and distal (subsegmental) pulmonary arteries that are obstructed by persistent fibrothrombotic material, and precapillary pulmonary arteries that can be affected as in pulmonary arterial hypertension. It is a rare complication of pulmonary embolism (PE), with an incidence of around 3% in PE survivors. The observed incidence of CTEPH in the general population is around six cases per million but could be three times higher than this, as estimated from PE incidence. However, a previous venous thromboembolic episode is not always documented. With advances in multimodality imaging and therapeutic management, survival for CTEPH has improved for both operable and inoperable patients. Advanced imaging with pulmonary angiography helps distinguish proximal from distal obstructive disease. However, right heart catheterization is of utmost importance to establish the diagnosis and hemodynamic severity of PH. The therapeutic strategy relies on a stepwise approach, starting with an operability assessment. Pulmonary endarterectomy (PEA), also known as pulmonary thromboendarterectomy, is the first-line treatment for operable patients. Growing experience and advances in surgical technique have enabled expansion of the distal limits of PEA and significant improvements in perioperative and mid- to long-term mortality. In patients who are inoperable or who have persistent/recurrent PH after PEA, medical therapy and/or balloon pulmonary angioplasty (BPA) are effective treatment options with favorable outcomes that are increasingly used. All treatment decisions should be made with a multidisciplinary team that includes a PEA surgeon, a BPA expert, and a chest radiologist.
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Affiliation(s)
- Daniel Inácio Cazeiro
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Miguel Azaredo Raposo
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - David Jenkins
- Cardiothoracic Surgery Department, Royal Papworth Hospital, Cambridge, UK
| | - João R Inácio
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Susana Moreira
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Céline Freitas
- Association for Research and Development of Faculty of Medicine (AIDFM), Cardiovascular Research Support Unit (GAIC), Lisbon, Portugal
| | - Susana Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Ricardo Ferreira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rita Luís
- Pathology Department, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Nuno Cardim
- Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal; Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal.
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Yamasaki Y, Abe K, Kamitani T, Hosokawa K, Hida T, Sagiyama K, Matsuura Y, Baba S, Isoda T, Maruoka Y, Kitamura Y, Moriyama S, Yoshikawa H, Fukumoto T, Yabuuchi H, Ishigami K. Efficacy of Dynamic Chest Radiography for Chronic Thromboembolic Pulmonary Hypertension. Radiology 2023; 306:e220908. [PMID: 36346313 DOI: 10.1148/radiol.220908] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background While current guidelines require lung ventilation-perfusion (V/Q) scanning as the first step to diagnose chronic pulmonary embolism in pulmonary hypertension (PH), its use may be limited by low availability and/or exposure to ionizing radiation. Purpose To compare the performance of dynamic chest radiography (DCR) and lung V/Q scanning for detection of chronic thromboembolic PH (CTEPH). Materials and Methods Patients with PH who underwent DCR and V/Q scanning in the supine position from December 2019 to July 2021 were retrospectively screened. The diagnosis of CTEPH was confirmed with right heart catheterization and invasive pulmonary angiography. Observer tests were conducted to evaluate the diagnostic accuracy of DCR and V/Q scanning. The lungs were divided into six areas (upper, middle, and lower for both) in the anteroposterior image, and the number of lung areas with thromboembolic perfusion defects was scored. Diagnostic performance was compared between DCR and V/Q scanning using the area under the receiver operating characteristic curve. Agreement between the interpretation of DCR and that of V/Q scanning was assessed using the Cohen kappa coefficient and percent agreement. Results A total of 50 patients with PH were analyzed: 29 with CTEPH (mean age, 64 years ± 15 [SD]; 19 women) and 21 without CTEPH (mean age, 61 years ± 22; 14 women). The sensitivity, specificity, and accuracy of DCR were 97%, 86%, and 92%, respectively, and those of V/Q scanning were 100%, 86%, and 94%, respectively. Areas under the receiver operating characteristic curve for DCR and V/Q scanning were 0.92 (95% CI: 0.79, 0.97) and 0.93 (95% CI: 0.78, 0.98). Agreement between the consensus interpretation of DCR and that of V/Q scanning was substantial (κ = 0.79 [95% CI: 0.61, 0.96], percent agreement = 0.9 [95% CI: 0.79, 0.95]). Conclusion Dynamic chest radiography had similar efficacy to ventilation-perfusion scanning in the detection of chronic thromboembolic pulmonary hypertension. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Wandtke and Koproth-Joslin in this issue.
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Affiliation(s)
- Yuzo Yamasaki
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Kohtaro Abe
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Takeshi Kamitani
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Kazuya Hosokawa
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Tomoyuki Hida
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Koji Sagiyama
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Yuko Matsuura
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Shingo Baba
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Takuro Isoda
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Yasuhiro Maruoka
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Yoshiyuki Kitamura
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Shohei Moriyama
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Hideki Yoshikawa
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Takenori Fukumoto
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Hidetake Yabuuchi
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
| | - Kousei Ishigami
- From the Departments of Clinical Radiology (Y.Y., T.K., T.H., K.S., Y. Matsuura, S.B., T.I., Y. Maruoka, Y.K., K.I.), Cardiovascular Medicine (K.A., K.H.), Hematology, Oncology & Cardiovascular Medicine (S.M.), and Health Sciences (H. Yabuuchi), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (H. Yoshikawa); and Healthcare Business Headquarters, Konica Minolta, Inc, Hachioji, Tokyo, Japan (T.F.)
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