Advances in the management of chronic thromboembolic pulmonary hypertension

Long-term outcomes of surgery for chronic thromboembolic pulmonary hypertension compared with medical therapy at a single Korean center

BACKGROUND/AIMS

Pulmonary endarterectomy (PEA) is the gold standard for treating chronic thromboembolic pulmonary hypertension (CTEPH) in Western countries. The aim of this study was to investigate the long-term outcomes of performing PEA on CTEPH patients in comparison with medical therapy at a single Korean center.

METHODS

This retrospective study included 88 CTEPH patients. These patients were classified into the PEA group (n = 37) or non-PEA group (i.e., medical therapy; n = 51). The clinical characteristics, hemodynamic data, and long-term survival rates were compared. Independent prognostic factors for CTEPH were also investigated.

RESULTS

CTEPH was not associated with either gender, and the mean age at diagnosis was 53.3 ± 13.7 years. Echocardiography revealed that the mean peak velocity of the tricuspid regurgitation jet was 4.2 ± 0.7 m/sec and the mean pulmonary arterial pressure was 51.7 ± 15.1 mmHg. The PEA and non-PEA groups demonstrated no significant differences, except in terms of the right ventricular end-diastolic diameter. The survival rates of the PEA group were significantly higher than the non-PEA group at 1, 3, 5, and 10 years (p = 0.032). Multivariate analyses indicated that World Health Organization class IV and PEA were significant predictors of poorer and better outcomes, respectively.

CONCLUSIONS

PEA demonstrates more favorable effects on long-term survival than medical therapy in Korean CTEPH patients who were considered operable.

[Diagnosis and management of acute pulmonary embolism. ESC guidelines 2014]

Acute pulmonary embolism (PE) still represents a challenge regarding a rapid diagnosis and a risk-adapted therapy. In the 2014 guidelines of the European Society of Cardiology (ESC) on the diagnosis and management of acute PE, several new recommendations have been issued based on new study data. Some established scores for risk stratification were developed further and there is now good evidence for the use of age-adjusted D-dimer cut-off levels. For the risk stratification in patients without clinical features of shock, the utilization of the pulmonary embolism severity index (PESI) and simplified PESI (sPESI) scores is recommended. In patients with intermediate risk, right ventricular morphology and function can be evaluated by computer tomography or echocardiography and biomarkers facilitate further risk stratification. For the treatment of patients with venous thromboembolism with or without PE, the non-vitamin K-dependent oral anticoagulants (NOACs) are a safe alternative to the standard anticoagulation regimen with heparin and vitamin K antagonists. Systemic thrombolytic therapy should be restricted to patients with high risk or intermediate high risk with hemodynamic instability. Finally, new recommendations for the diagnosis and therapy of patients with chronic thromboembolic pulmonary hypertension (CTEPH), with cancer or during pregnancy are given.

Acute Pain and Analgesic Requirements After Pulmonary Endarterectomy With Deep Hypothermic Circulatory Arrest

OBJECTIVES

To assess postoperative pain intensity and the analgesic requirements in the postoperative period in patients undergoing sternotomy for pulmonary endarterectomy involving deep hypothermic circulatory arrest.

DESIGN

Retrospective cohort study.

SETTING

Single-center hospital study.

PARTICIPANTS

Patients 18 years and older undergoing sternotomy for cardiac surgery between August 2012 and August 2014.

INTERVENTIONS

No modification to usual clinical practice.

MEASUREMENTS AND MAIN RESULTS

Intraoperative opioid and steroid administration, referral to the chronic pain unit, intensive care unit pain scores, and analgesic administration in the first 48 hours after the admission to the intensive care unit were recorded. Postoperative pain was evaluated by means of a categoric verbal scale from no pain (0) to severe pain (3); this is the routine analgesic scale used in the authors' intensive care unit. A total of 200 consecutive patients undergoing pulmonary endarterectomy (PEA group) were included in the study. No patient in the PEA group received morphine during surgery. The mean (standard deviation) postoperative pain intensity score at 24 hours was 0.30 (0.54) in the PEA group. Postoperative morphine was administered in 39% of patients. No PEA patient was referred to the chronic pain unit after hospital discharge.

CONCLUSION

The total analgesic requirements and pain score of patients undergoing sternotomy for pulmonary endarterectomy with deep hypothermic circulatory arrest seemed to be low.