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Caspersen CK, Ingemann-Molden S, Grove EL, Højen AA, Andreasen J, Klok FA, Rolving N. Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review. Thromb Res 2024; 235:52-67. [PMID: 38301376 DOI: 10.1016/j.thromres.2024.01.008] [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: 08/23/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. METHODS The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. RESULTS The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. CONCLUSIONS Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.
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Affiliation(s)
| | - Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark; Department of Health Science and Technology, Aalborg University, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Denmark
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
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Verbelen T, Godinas L, Dorfmüller P, Gopalan D, Condliffe R, Delcroix M. Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2023; 32:230149. [PMID: 38123236 PMCID: PMC10731457 DOI: 10.1183/16000617.0149-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Dorfmüller
- Institut für Pathologie, Universitätsklinikum Giessen/Marburg and Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Deepa Gopalan
- Department of Radiology, Imperial College Hospital NHS Trust, London, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
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Daigo K, Katsumata Y, Esaki K, Iwasawa Y, Ichihara G, Miura K, Shirakawa K, Sato Y, Sato K, Fukuda K. Predictors of Improvement in Exercise Tolerance After Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. J Am Heart Assoc 2023; 12:e8137. [PMID: 36718876 PMCID: PMC9973625 DOI: 10.1161/jaha.122.027395] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/19/2022] [Accepted: 12/06/2022] [Indexed: 02/01/2023]
Abstract
Background Balloon pulmonary angioplasty (BPA) improves exercise tolerance and hemodynamic parameters in patients with chronic thromboembolic pulmonary hypertension. However, it is still unclear which patient characteristics contribute to the improvement in exercise tolerance after BPA in chronic thromboembolic pulmonary hypertension. Methods and Results We retrospectively analyzed 126 patients with chronic thromboembolic pulmonary hypertension (aged 63±14 years; female, 65%) who underwent BPA without concomitant programmed exercise rehabilitation at Keio University between November 2012 and April 2018. Hemodynamic data and 6-minute walk distance (6MWD), as a measure of exercise tolerance, were evaluated before and 1 year after BPA. The clinical characteristics that contributed to improvement in exercise tolerance were elucidated. The 6MWD significantly increased from 372.0 m (256.5-431.3) to 462.0 m (378.8-537.0) 1 year after BPA (P<0.001). The improvement rate in the 6MWD after BPA exhibited a good correlation with age, height, mean pulmonary artery pressure, and 6MWD at baseline (Spearman rank correlation coefficients=-0.28, 0.24, -0.40, and 0.44, respectively). Additional multivariable linear regression analysis revealed that young age, tall height, high mean pulmonary artery pressure, short 6MWD at baseline, and high lung capacity at baseline were significant predictors of the improvement in 6MWD by BPA (standardized partial regression coefficient -0.39, 0.22, 0.19, -0.62, and 0.25, P<0.001, 0.007, 0.011, <0.001, and <0.001, respectively). Conclusions BPA without concomitant programmed exercise rehabilitation significantly improves exercise tolerance. This was particularly true in young patients with high stature, high mean pulmonary artery pressure, short 6MWD, and lung capacity at the time of diagnosis.
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Affiliation(s)
- Kyohei Daigo
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | - Kosho Esaki
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yuji Iwasawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Genki Ichihara
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kotaro Miura
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kohsuke Shirakawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yasunori Sato
- Department of Preventive Medicine and Public HealthKeio University School of MedicineTokyoJapan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of MedicineTokyoJapan
| | - Keiichi Fukuda
- Department of CardiologyKeio University School of MedicineTokyoJapan
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Outcome of Surgery for Chronic Thromboembolic Pulmonary Disease without Pulmonary Hypertension. Thorac Cardiovasc Surg 2022; 70:658-662. [PMID: 35108738 DOI: 10.1055/s-0041-1740560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition that results from incomplete resolution of thromboemboli in pulmonary arteries. Symptomatic patients with chronic thromboembolic disease may have normal hemodynamic at rest. The aim of this study is to evaluate the outcome of pulmonary endarterectomy (PEA) in symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension as currently defined (mean pulmonary artery pressure [mPAP] < 20 mm Hg). PATIENTS AND METHODS Here, we report four symptomatic patients with chronic thromboembolic and normal hemodynamic at rest (mPAP ≤20 mm Hg or 20 < mPAP < 25 mm Hg and pulmonary vascular resistance [PVR] < 240 dyn·s/cm5) who underwent PEA between September 2015 and September 2019. The main outcome measures were functional New York Heart Association class, 6-minute walk distance (6MWD), hemodynamic measures in right heart catheterization (RHC), morbidity, and mortality. RESULTS There were significant improvement in function class (2.6 ± 0.54 vs. 1 ± 0.2, p = 0.00), mPAP (preoperative: 23.3 ± 0.5 mm Hg vs. postoperative: 18.6 ± 1.5 mm Hg, p = 0.02), 6MWD (preoperative: 378.2 ± 68.7 m vs. postoperative: 432.9 ± 44.5 m, p = 0.01), and PVR (215.33 ± 91 vs. 101 ± 32 dyn·s/cm5, p = 0.1) 6 months after surgery based on data from RHC which was done during exercise. Also, RHC showed a significant decrease in mPAP (preoperative: 37 ± 7.7 mm Hg vs. postoperative 28 ± 3.2 mm Hg, p = 0.06). CONCLUSION PEA could improve function class and hemodynamic in patients with CTEPD. Considering hemodynamic improvement in this group of patients after PEA, definition of CTEPH may need to be revised.
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Forfia P, Ferraro B, Vaidya A. Recognizing Pulmonary Hypertension Following Pulmonary Thromboendarterectomy
A Practical Guide for Clinicians. Pulm Circ 2022; 12:e12073. [DOI: 10.1002/pul2.12073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 03/01/2022] [Accepted: 03/13/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Paul Forfia
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
| | - Bruce Ferraro
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
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Verbelen T, Godinas L, Maleux G, Coolen J, Claessen G, Belge C, Meyns B, Delcroix M. Chronic thromboembolic pulmonary hypertension: diagnosis, operability assessment and patient selection for pulmonary endarterectomy. Ann Cardiothorac Surg 2022; 11:82-97. [PMID: 35433370 PMCID: PMC9012197 DOI: 10.21037/acs-2021-pte-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/08/2021] [Indexed: 07/30/2023]
Abstract
Healthcare providers outside pulmonary hypertension (PH) centers having misinformation or insufficient education, and a general lack of treatment awareness contribute to a massive underdiagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), diagnostic delay and refusal of surgery by patients. Together with the subjective operability assessment, this leads to too few patients undergoing pulmonary endarterectomy (PEA); even though this surgery results in improved survival and exercise capacity. Acute pulmonary embolism (PE) survivors should undergo a CTEPH screening strategy. Patients screened positive and those with CTEPH symptoms (with or without history of PE), should undergo transthoracic echocardiography (TTE) to determine the probability of PH. High PH probability patients should undergo a ventilation/perfusion (V/Q) scan. A negative scan rules out CTEPH. Patients with a positive V/Q scan, but also patients with findings suggestive for CTEPH on computed tomography pulmonary angiography (CTPA) to diagnose acute PE, should be referred to a CTEPH center. Further diagnostic work-up currently consists of catheter based pulmonary angiography, CTPA and right heart catheterization. However, new imaging technologies might replace them in the near future, with one single imaging tool to screen, diagnose and assess operability as the ultimate goal. Operability assessment should be performed by a multidisciplinary CTEPH team. PEA surgery should be organized in a single center per country or for each forty to fifty million inhabitants in order to offer the highest level of expertise. Informing patients about PEA should preferably be done by the treating surgeon. Based on the estimated incidence of CTEPH and with a better education of patients and healthcare providers, despite the advent of new interventional and medical therapies for CTEPH, the number of PEA surgeries performed should still have the potential to grow significantly.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Laurent Godinas
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Coolen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Catharina Belge
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marion Delcroix
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
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7
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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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8
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Howden EJ, Ruiz-Carmona S, Claeys M, De Bosscher R, Willems R, Meyns B, Verbelen T, Maleux G, Godinas L, Belge C, Bogaert J, Claus P, La Gerche A, Delcroix M, Claessen G. Oxygen Pathway Limitations in Patients With Chronic Thromboembolic Pulmonary Hypertension. Circulation 2021; 143:2061-2073. [PMID: 33853383 DOI: 10.1161/circulationaha.120.052899] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Exertional intolerance is a limiting and often crippling symptom in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Traditionally the pathogenesis has been attributed to central factors, including ventilation/perfusion mismatch, increased pulmonary vascular resistance, and right heart dysfunction and uncoupling. Pulmonary endarterectomy and balloon pulmonary angioplasty provide substantial improvement of functional status and hemodynamics. However, despite normalization of pulmonary hemodynamics, exercise capacity often does not return to age-predicted levels. By systematically evaluating the oxygen pathway, we aimed to elucidate the causes of functional limitations in patients with CTEPH before and after pulmonary vascular intervention. METHODS Using exercise cardiac magnetic resonance imaging with simultaneous invasive hemodynamic monitoring, we sought to quantify the steps of the O2 transport cascade from the mouth to the mitochondria in patients with CTEPH (n=20) as compared with healthy participants (n=10). Furthermore, we evaluated the effect of pulmonary vascular intervention (pulmonary endarterectomy or balloon angioplasty) on the individual components of the cascade (n=10). RESULTS Peak Vo2 (oxygen uptake) was significantly reduced in patients with CTEPH relative to controls (56±17 versus 112±20% of predicted; P<0.0001). The difference was attributable to impairments in multiple steps of the O2 cascade, including O2 delivery (product of cardiac output and arterial O2 content), skeletal muscle diffusion capacity, and pulmonary diffusion. The total O2 extracted in the periphery (ie, ΔAVo2 [arteriovenous O2 content difference]) was not different. After pulmonary vascular intervention, peak Vo2 increased significantly (from 12.5±4.0 to 17.8±7.5 mL/[kg·min]; P=0.036) but remained below age-predicted levels (70±11%). The O2 delivery was improved owing to an increase in peak cardiac output and lung diffusion capacity. However, peak exercise ΔAVo2 was unchanged, as was skeletal muscle diffusion capacity. CONCLUSIONS We demonstrated that patients with CTEPH have significant impairment of all steps in the O2 use cascade, resulting in markedly impaired exercise capacity. Pulmonary vascular intervention increased peak Vo2 by partly correcting O2 delivery but had no effect on abnormalities in peripheral O2 extraction. This suggests that current interventions only partially address patients' limitations and that additional therapies may improve functional capacity.
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Affiliation(s)
- Erin J Howden
- Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia
| | - Sergio Ruiz-Carmona
- Cambridge Baker Systems Genomics Initiative (S.R.-C.), Melbourne, Australia.,Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia
| | - Mathias Claeys
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Ruben De Bosscher
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Rik Willems
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Bart Meyns
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Tom Verbelen
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Geert Maleux
- Imaging & Pathology (G.M., J.B.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Laurent Godinas
- Chronic Diseases and Metabolism (L.G., C.B., M.D.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Catharina Belge
- Chronic Diseases and Metabolism (L.G., C.B., M.D.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Jan Bogaert
- Imaging & Pathology (G.M., J.B.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Piet Claus
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Andre La Gerche
- Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia.,Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium
| | - Marion Delcroix
- Chronic Diseases and Metabolism (L.G., C.B., M.D.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Guido Claessen
- Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia.,Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
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9
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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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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disease with significant morbidity. It is a result of an alternate natural history in which there is limited resolution of thromboemboli with pulmonary artery obstruction leading to pulmonary hypertension (PH). CTEPH requires a thorough clinical assessment including pulmonary hemodynamics and radiologic evaluation in addition to consultation with an expert center. Surgical intervention remains the optimal management strategy. Select patients may be candidates for catheter-based intervention with balloon pulmonary angioplasty in centers with clinical expertise. Inoperable patients or those with post-intervention PH are treated with pulmonary hypertension-targeted medical therapy.
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Affiliation(s)
- Jean M Elwing
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0564, Cincinnati, OH 45267, USA.
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and Pulmonary Thromboendarterectomy Program, Advanced Heart Failure and Cardiac Transplant, Temple University School of Medicine, Temple University Hospital, 9th Floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - William R Auger
- CTEPH Program, UC San Diego Health, University of California, San Diego, 9300 Campus Point Drive #7381, La Jolla, CA 92037, USA
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11
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Kratzert WB, Boyd EK, Saggar R, Channick R. Critical Care of Patients After Pulmonary Thromboendarterectomy. J Cardiothorac Vasc Anesth 2019; 33:3110-3126. [PMID: 30948200 DOI: 10.1053/j.jvca.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/19/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022]
Abstract
Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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12
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Inspiratory muscle weakness contributes to exertional dyspnea in chronic thromboembolic pulmonary hypertension. PLoS One 2018; 13:e0204072. [PMID: 30260970 PMCID: PMC6160017 DOI: 10.1371/journal.pone.0204072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/31/2018] [Indexed: 11/20/2022] Open
Abstract
Determination of potentially-reversible factors contributing to exertional dyspnea remains an unmet clinical need in chronic thromboembolic pulmonary hypertension (CTEPH). Therefore, we aimed to evaluate the influence of inspiratory muscle weakness (IMW) on exercise capacity and dyspnea during effort in patients with CTEPH. We performed a prospective cross-sectional study that included thirty-nine consecutive patients with CTEPH (48 ± 15 yrs, 61% female) confirmed by right heart catheterization that underwent an incremental cardiopulmonary exercise test, 6-minute walk test and maximum inspiratory pressure (MIP) measurement. MIP < 70%pred was found in 46% of patients. On a multiple linear regression analysis, MIP was independently associated with 6MWD and V˙O2PEAK. Patients with MIP < 70% presented greater ΔV˙E/ΔV˙CO2 than those with MIP ≥ 70%. Additionally, they also presented stronger sensations of dyspnea throughout exercise, even when adjusted for ventilation. At rest and at different levels of exercise, mean inspiratory flow (VT/TI) was significantly higher in patients with MIP < 70%. In conclusion, IMW is associated with a rapid increase of dyspnea, higher inspiratory load and poor exercise capacity in patients with CTEPH.
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13
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Residual pulmonary hypertension after pulmonary endarterectomy: A meta-analysis. J Thorac Cardiovasc Surg 2018; 156:1275-1287. [DOI: 10.1016/j.jtcvs.2018.04.110] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/20/2018] [Accepted: 04/26/2018] [Indexed: 11/17/2022]
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Godinas L, Sattler C, Lau EM, Jaïs X, Taniguchi Y, Jevnikar M, Weatherald J, Sitbon O, Savale L, Montani D, Simonneau G, Humbert M, Laveneziana P, Garcia G. Dead-space ventilation is linked to exercise capacity and survival in distal chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2017; 36:1234-1242. [DOI: 10.1016/j.healun.2017.05.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/23/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022] Open
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Richter MJ, Gall H, Wittkämper G, Seeger W, Mayer E, Ghofrani HA, Guth S, Reichenberger F. Inspiratory capacity is not altered in operable chronic thromboembolic pulmonary hypertension. Pulm Circ 2017; 7:543-546. [PMID: 28440730 PMCID: PMC5467949 DOI: 10.1177/2045893217709763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pathological alterations of inspiratory capacity (IC) have been observed in pulmonary hypertension. However, the clinical significance of IC in operable chronic thromboembolic pulmonary hypertension (CTEPH) without other pulmonary diseases remains unknown. CTEPH patients scheduled for pulmonary endarterectomy were prospectively screened. Despite being associated with functional capacity, pathological alterations of IC were not observed.
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Affiliation(s)
- Manuel J Richter
- 1 Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,2 Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- 2 Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Gesa Wittkämper
- 2 Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- 2 Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Eckhard Mayer
- 3 Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Hossein A Ghofrani
- 1 Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,2 Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Stefan Guth
- 3 Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
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Richter MJ, Tiede SL, Sommer N, Schmidt T, Seeger W, Ghofrani HA, Schermuly R, Gall H. Circulating Angiopoietin-1 Is Not a Biomarker of Disease Severity or Prognosis in Pulmonary Hypertension. PLoS One 2016; 11:e0165982. [PMID: 27802345 PMCID: PMC5089726 DOI: 10.1371/journal.pone.0165982] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Circulating angiopoietin-1 (Ang-1) has been linked to pulmonary hypertension (PH) in experimental studies. However, the clinical relevance of Ang-1 as a biomarker in PH remains unknown. We aimed to investigate the prognostic and clinical significance of Ang-1 in PH using data from the prospectively recruiting Giessen PH Registry. Methods Patients with suspected PH (without previous specific pulmonary arterial hypertension [PAH] therapy) who underwent initial right heart catheterization (RHC) in our national referral center between July 2003 and May 2012 and who agreed to optional biomarker analysis were included if they were diagnosed with idiopathic PAH, connective tissue disease-associated PAH (CTD-PAH), PH due to left heart disease (PH-LHD), or chronic thromboembolic PH (CTEPH), or if PH was excluded by RHC (non-PH controls). The association of Ang-1 levels with disease severity (6-minute walk distance and pulmonary hemodynamics) was assessed using linear regression, and the impact of Ang-1 levels on transplant-free survival (primary endpoint) and clinical worsening was assessed using Kaplan—Meier curves, receiver operating characteristic (ROC) analyses, and Cox regression. Results 151 patients (39, 39, 32, and 41 with idiopathic PAH, CTD-PAH, PH-LHD, and CTEPH, respectively) and 41 non-PH controls were included. Ang-1 levels showed no significant difference between groups (p = 0.8), and no significant associations with disease severity in PH subgroups (p ≥ 0.07). In Kaplan—Meier analyses, Ang-1 levels (stratified by quartile) had no significant impact on transplant-free survival (p ≥ 0.27) or clinical worsening (p ≥ 0.51) in PH subgroups. Regression models found no significant association between Ang-1 levels and outcomes (p ≥ 0.31). ROC analyses found no significant cut-off that would maximize sensitivity and specificity. Conclusions Despite a strong pathophysiological association in experimental studies, this first comprehensive analysis of Ang-1 in PH subgroups suggests that Ang-1 is not a predictive and clinically relevant biomarker in PH.
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Affiliation(s)
- Manuel Jonas Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Svenja Lena Tiede
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Natascha Sommer
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Thomas Schmidt
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Ralph Schermuly
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- * E-mail:
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Aoki T, Sugimura K, Nochioka K, Miura M, Tatebe S, Yamamoto S, Yaoita N, Suzuki H, Sato H, Kozu K, Miyata S, Satoh K, Shimokawa H. Effects of Balloon Pulmonary Angioplasty on Oxygenation in Patients With Chronic Thromboembolic Pulmonary Hypertension - Importance of Intrapulmonary Shunt. Circ J 2016; 80:2227-34. [PMID: 27581344 DOI: 10.1253/circj.cj-16-0254] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although balloon pulmonary angioplasty (BPA) improves the hemodynamics and prognosis of patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH), the mechanisms of improvement in oxygenation remain to be elucidated. METHODS AND RESULTS From August 2013 to May 2015, we performed a total of 113 BPA procedures in 24 patients with inoperable CTEPH (mean 4.7 procedures per patient). Median age was 70 [60, 74] years and 18 were female (75%). We examined hemodynamics, respiratory functions, and intrapulmonary shunt before and after the BPA procedure. Mean pulmonary arterial pressure (37 [28, 45] to 23[19, 27] mmHg, P<0.01), pulmonary vascular resistance (517 [389, 696] to 268 [239, 345] dyne/s/cm(5)) and 6-min walk distance (390 [286, 484] to 490 [411, 617] m, P<0.01) were significantly improved after BPA therapy. Furthermore, arterial oxygen partial pressure (PaO2, 54.8 [50.0, 60.8] to 65.2 [60.6, 73.2] %, P<0.01) and intrapulmonary shunt (23.4±6.0% to 19.3±5.0%, P<0.01) were also significantly ameliorated. In the multivariate analysis, decrease in intrapulmonary shunt after BPA was significantly correlated with improvement of both PaO2(r(2)=0.26, P<0.01) and SaO2(r(2)=0.49, P<0.01) after BPA. CONCLUSIONS These results indicated that BPA improved not only pulmonary hemodynamics but also oxygenation with a resultant decrease in intrapulmonary shunt. (Circ J 2016; 80: 2227-2234).
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Affiliation(s)
- Tatsuo Aoki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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Richter MJ, Milger K, Tello K, Stille P, Seeger W, Mayer E, Ghofrani HA, Gall H. Heart rate response during 6-minute walking testing predicts outcome in operable chronic thromboembolic pulmonary hypertension. BMC Pulm Med 2016; 16:96. [PMID: 27377832 PMCID: PMC4932688 DOI: 10.1186/s12890-016-0260-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 06/10/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Six-minute walk test (6MWT) is routinely performed in chronic thromboembolic pulmonary hypertension (CTEPH) before pulmonary endarterectomy (PEA). However, the clinical relevance of heart rate response (ΔHR) and exercise-induced oxygen desaturation (EID) during 6MWT is remaining unknown. METHODS Patients undergoing PEA in our center between 03/2013-04/2014 were assessed prospectively with hemodynamic and exercise parameters prior to and 1 year post-PEA. Patients with symptomatic chronic thromboembolic disease (mean pulmonary artery pressure (mPAP) <25 mmHg) and clinical relevant obstructive pulmonary disease were excluded. The following definitions were used: ΔHR = (peak HR - resting HR), percent heart rate reserve (HRR) = (peak HR -rest HR)/(220 - age - rest HR) x 100 and EID = SpO2 ≤88 %. RESULTS Thirty-seven patients (of 116 patients screened) with mPAP of 43.2 ± 8.7 mmHg, pulmonary vascular resistance (PVR) of 605.5 ± 228.7 dyn*s/cm(5), cardiac index (CI) of 2.4 ± 0.5 l/min/m(2) and a 6MWT-distance of 404.7 ± 148.4 m and a peak VO2 of 12.3 ± 3.4 ml/min/kg prior to PEA were included. Baseline ΔHR during 6MWT was significantly associated with PVR 1 year post-PEA using linear regression analysis (r = 0.43, p = 0.01). Multivariate analysis indicated an association of HRR during 6MWT and residual PH with a hazard ratio of 1.06 (95 % Confidence interval for hazard ratio 0.99-1.14, p = 0.08). EID was observed commonly during 6MWT but no correlations to outcome parameters were found. CONCLUSIONS This is the first prospective study to describe an association of ΔHR during 6MWT with pulmonary hemodynamics 1 year post-PEA. Our preliminary results indicate that HRR derived from 6MWT is of clinical significance. EID was commonly observed, albeit failed as a significant prognostic factor.
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Affiliation(s)
- Manuel Jonas Richter
- />Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
- />Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Katrin Milger
- />Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- />Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, member of the German Center for Lung Research (DZL), Munich, Germany
| | - Khodr Tello
- />Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Philipp Stille
- />Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- />Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Eckhard Mayer
- />Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Hossein A. Ghofrani
- />Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
- />Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- />Department of Medicine, Imperial College London, London, UK
| | - Henning Gall
- />Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
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Pulmonary Endarterectomy. Patient Selection, Technical Challenges, and Outcomes. Ann Am Thorac Soc 2016; 13 Suppl 3:S240-7. [DOI: 10.1513/annalsats.201601-014as] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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van Kan C, van der Plas MN, Reesink HJ, van Steenwijk RP, Kloek JJ, Tepaske R, Bonta PI, Bresser P. Hemodynamic and ventilatory responses during exercise in chronic thromboembolic disease. J Thorac Cardiovasc Surg 2016; 152:763-71. [PMID: 27372842 DOI: 10.1016/j.jtcvs.2016.05.058] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 05/22/2016] [Accepted: 05/31/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with chronic thromboembolic disease (CTED) may suffer from exercise intolerance without pulmonary hypertension at rest. Pulmonary endarterectomy (PEA) for symptomatic CTED results in improvement of symptoms and quality of life. Neither the pathophysiology of the exercise limitation nor the underlying mechanisms of the PEA-induced improvement have been studied previously. OBJECTIVES We studied hemodynamic and ventilatory responses upon exercise in 14 patients with CTED. After 1 year, we studied the underlying physiologic mechanisms of the PEA-induced symptomatic improvement. METHODS Cardiopulmonary exercise testing (CPET) was performed during right heart catheterization, and noninvasive CPET was performed 1 year postoperatively. RESULTS During exercise, we observed abnormal pulmonary vascular responses, that is, a steep mean pulmonary artery pressure/cardiac output (2.7 ± 1.2 mm Hg·min·L(-1)), and low pulmonary vascular compliance (2.8 ± 1.1 mL·mm Hg(-1)); mean pulmonary artery pressure/cardiac output slope correlated with dead-space ventilation (r = 0.586; P = .028) and ventilatory equivalents for carbon dioxide slope (r = .580; P = .030). Postoperatively, the improvement observed in exercise capacity was related to improvements in CPET-derived parameters pointing to restoration of right ventricle stroke volume response (oxygen pulse: 11.7 ± 3.1 to 13.3 ± 3.3; P = .027; heart rate response: 80.9 ± 12.4 to 72.0 ± 5.7; P = .003); and, indicating improved ventilatory efficiency, the ventilatory equivalents for carbon dioxide slope decreased from 38.2 ± 3.6 to 32.8 ± 7.0 (P = .014). CONCLUSIONS Patients with CTED showed an abnormal pulmonary vascular response to exercise and a decreased ventilatory efficiency. Responses after PEA point to restoration of right ventricle stroke volume response and ventilatory efficiency.
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Affiliation(s)
- Coen van Kan
- Department of Respiratory Medicine of the Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Mart N van der Plas
- Department of Respiratory Medicine of the Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Department of Respiratory Medicine of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Herre J Reesink
- Department of Respiratory Medicine of the Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Department of Respiratory Medicine of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Respiratory Medicine of the Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Reindert P van Steenwijk
- Department of Respiratory Medicine of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap J Kloek
- Department of Cardiothoracic Surgery of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert Tepaske
- Department of Intensive Care Medicine of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter I Bonta
- Department of Respiratory Medicine of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Bresser
- Department of Respiratory Medicine of the Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Department of Respiratory Medicine of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Neder JA, Ramos RP, Ota-Arakaki JS, Ferreira EMV, Hirai DM, Sperandio PA, Alencar MCN, Arbex FF, Berton DC, D'Arsigny C, O'Donnell DE. Insights into ventilation-gas exchange coupling in chronic thromboembolic pulmonary hypertension. Eur Respir J 2016; 48:252-4. [PMID: 27076589 DOI: 10.1183/13993003.01948-2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/28/2016] [Indexed: 11/05/2022]
Affiliation(s)
- J Alberto Neder
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University, Kingston, ON, Canada
| | - Roberta P Ramos
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil Pulmonary Vascular Group, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil Pulmonary Vascular Group, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Eloara M V Ferreira
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil Pulmonary Vascular Group, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Daniel M Hirai
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University, Kingston, ON, Canada
| | - Priscila A Sperandio
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Maria Clara N Alencar
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Flavio F Arbex
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Dept of Medicine, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Danilo C Berton
- Respiratory Division, Dept of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Christine D'Arsigny
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University, Kingston, ON, Canada
| | - Denis E O'Donnell
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University, Kingston, ON, Canada
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The Clinical Significance of HbA1c in Operable Chronic Thromboembolic Pulmonary Hypertension. PLoS One 2016; 11:e0152580. [PMID: 27031508 PMCID: PMC4816563 DOI: 10.1371/journal.pone.0152580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/16/2016] [Indexed: 01/30/2023] Open
Abstract
Background Glycosylated hemoglobin A1c (HbA1c) has been proposed as an independent predictor of long-term prognosis in pulmonary arterial hypertension. However, the clinical relevance of HbA1c in patients with operable chronic thromboembolic pulmonary hypertension (CTEPH) remains unknown. The aim of the present study was to investigate the clinical significance of HbA1c as a biomarker in CTEPH. Methods Prospectively, 102 patients underwent pulmonary endarterectomy (PEA) in our national referral center between March 2013 and March 2014, of which after exclusion 45 patients were analyzed. HbA1c- levels, hemodynamic and exercise parameters were analyzed prior and one-year post-PEA. Results 45 patients (BMI: 27.3 ± 6.0 kg/m2; age: 62.7 ± 12.3 years) with a mean pulmonary arterial pressure (mPAP) of 43.6 ± 9.4 mmHg, a pulmonary vascular resistance (PVR) of 712.1 ± 520.4 dyn*s/cm5, a cardiac index (CI) of 2.4 ± 0.5 l/min/m2 and a mean HbA1c-level of 39.8 ± 5.6 mmol/mol were included. One-year post-PEA pulmonary hemodynamic and functional status significantly improved in our cohort. Baseline HbA1c-levels were significantly associated with CI, right atrial pressure, peak oxygen uptake and the change of 6-minute walking distance using linear regression analysis. However, using logistic regression analysis baseline HbA1c-levels were not significantly associated with residual post-PEA PH. Conclusions This is the first prospective study to describe an association of HbA1c-levels with pulmonary hemodynamics and exercise capacity in operable CTEPH patients. Our preliminary results indicate that in these patients impaired glucose metabolism as assessed by HbA1c is of clinical significance. However, HbA1c failed as a predictor of the hemodynamic outcome one-year post-PEA.
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23
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Poch DS, Auger WR. Chronic thromboembolic pulmonary hypertension: detection, medical and surgical treatment approach, and current outcomes. Heart Fail Rev 2016; 21:309-22. [DOI: 10.1007/s10741-015-9518-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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de Perrot M, Mayer E. Chronic thromboembolic pulmonary hypertension: do we need a new definition? Eur Respir J 2015; 44:1401-3. [PMID: 25435525 DOI: 10.1183/09031936.00177514] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
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25
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de Perrot M, Thenganatt J, McRae K, Moric J, Mercier O, Pierre A, Mak S, Granton J. Pulmonary endarterectomy in severe chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2015; 34:369-75. [DOI: 10.1016/j.healun.2014.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 08/20/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022] Open
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Schölzel BE, Snijder RJ, Mager JJ, van Es HW, Plokker HWM, Reesink HJ, Morshuis WJ, Post MC. Chronic thromboembolic pulmonary hypertension. Neth Heart J 2014; 22:533-41. [PMID: 25169577 PMCID: PMC4391185 DOI: 10.1007/s12471-014-0592-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Chronic pulmonary thromboembolic disease is an important cause of severe pulmonary hypertension, and as such is associated with significant morbidity and mortality. The prognosis of this condition reflects the degree of associated right ventricular dysfunction, with predictable mortality related to the severity of the underlying pulmonary hypertension. Left untreated, the prognosis is poor. Pulmonary endarterectomy is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension and has been remarkably successful. Advances in surgical techniques along with the introduction of pulmonary hypertension-specific medication provide therapeutic options for the majority of patients afflicted with the disease. However, a substantial number of patients are not candidates for pulmonary endarterectomy due to either distal pulmonary vascular obstruction or significant comorbidities. Therefore, careful selection of surgical candidates in expert centres is paramount. The current review focuses on the diagnostic approach to chronic thromboembolic pulmonary hypertension and the available surgical and medical therapeutic options.
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Affiliation(s)
- B. E. Schölzel
- Department of Cardiology, Amphia Hospital, Molengracht 21, 4818 CK Breda, the Netherlands
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - R. J. Snijder
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - J. J. Mager
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H W. van Es
- Department of Radiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. W. M. Plokker
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. J. Reesink
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - W. J. Morshuis
- Department of Cardio-Thoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - M. C. Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
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McCabe C, Preston SD, Gopalan D, Dunning J, Pepke-Zaba J. Cardiopulmonary exercise testing suggests a beneficial response to pulmonary endarterectomy in a patient with chronic thromboembolic obstruction and normal preoperative pulmonary hemodynamics. Pulm Circ 2014; 4:137-41. [PMID: 25006429 DOI: 10.1086/674878] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/28/2013] [Indexed: 11/03/2022] Open
Abstract
Pulmonary endarterectomy offers a symptomatic and survival benefit in patients with chronic thromboembolic pulmonary hypertension through sustained improvement in right ventricular function. However, its role in patients with symptom limitation, chronic thrombotic obstruction, and a normal pulmonary hemodynamic profile is less clear. Cardiopulmonary exercise testing (CPET) stresses the cardiopulmonary system and has a characteristic response in pulmonary hypertension. CPET may therefore reveal abnormalities in patients with chronic thrombotic obstruction where hemodynamic investigations conducted at rest are reassuring. Using incremental CPET, we demonstrated improvements in right ventricular performance and ventilatory efficiency following pulmonary endarterecomy in a patient with preoperative exercise limitation and normal pulmonary hemodynamics. Careful evaluation of exercise responses may extend the potential benefit offered by pulmonary endarterectomy in patients with chronic thromboembolic obstruction irrespective of their resting hemodynamic profile.
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Affiliation(s)
- Colm McCabe
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge CB23 3RE, United Kingdom
| | - Stephen D Preston
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge CB23 3RE, United Kingdom
| | - Deepa Gopalan
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge CB23 3RE, United Kingdom
| | - John Dunning
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge CB23 3RE, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge CB23 3RE, United Kingdom
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28
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Banks DA, Pretorius GVD, Kerr KM, Manecke GR. Pulmonary Endarterectomy. Semin Cardiothorac Vasc Anesth 2014; 18:319-30. [DOI: 10.1177/1089253214536621] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from recurrent or incomplete resolution of pulmonary embolism. CTEPH is much more common than generally appreciated. Although pulmonary embolism (PE) affects a large number of Americans, chronic pulmonary hypertension (PH) remains underdiagnosed. It is imperative that all patients with PH be screened for the presence of CTEPH since this form of PH is potentially curable with pulmonary thromboendarterectomy (PTE) surgery. The success of this procedure depends greatly on the collaboration of a multidisciplinary team approach that includes pulmonary medicine, cardiothoracic surgery, and cardiac anesthesiology. This review, based on the experience of more than 3000 pulmonary endarterectomy surgeries, is divided into 2 parts. Part I focuses on the clinical history and pathophysiology, diagnostic workup, and intraoperative echocardiography. Part II focuses on the surgical approach, anesthetic management, postoperative care, and complications.
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Affiliation(s)
| | | | - Kim M. Kerr
- University of California, San Diego, La Jolla, CA, USA
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29
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LIN SHYANLUNG, GUO NAIREN, CHEN TSUNGCHI. OPTIMAL RESPIRATORY CONTROL SIMULATION AND COMPARATIVE STUDY OF HYPERCAPNIC VENTILATORY RESPONSES TO EXTERNAL DEAD SPACE LOADING. J MECH MED BIOL 2014. [DOI: 10.1142/s0219519414500146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
There has been considerable research effort regarding ventilatory responses to breathing with an imposed external dead space, and inhalation of fixed levels of CO 2 by human subjects. A human respiratory control model incorporating the optimality hypothesis can successfully demonstrate ventilatory responses to both chemical stimuli and muscular exercise. In this study, to verify the model behavior of the optimal chemical–mechanical respiratory control model, we simulated the ventilatory control under dead space loading and CO 2 inhalation. The simulation was provided by a LabVIEW® based human respiratory control simulator and signal monitoring system. The dead space measurement was described with two distinct models, derived from Gray and Coon, and predicted behaviors with corresponding ventilatory responses were investigated and compared with experimental findings. While both dead space models produced satisfactory predictions on simulated optimal [Formula: see text] versus Pa CO 2, [Formula: see text] versus Pa CO 2, F versus PI CO 2, VT versus PI CO 2, VD-total versus VT, VD- total /VT versus VT, [Formula: see text] versus VT and [Formula: see text] versus VT relationships, Gray's model provided better correlation and more consistent results throughout most of the ventilatory responses. The study of relative behavior of respiratory signals and comparative relationship of the ventilator responses between dead space loading during rest and CO 2 inhalation will certainly provide valuable understanding of increases in central respiratory motor command output of human respiratory control, which is also associated with Dyspnea on exertion, and give potential clinical perspective to realize the impaired ability to excrete CO 2 in patients diagnosed with acute respiratory distress syndrome.
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Affiliation(s)
- SHYAN-LUNG LIN
- Department of Automatic Control Engineering, Feng Chia University, 100 Wenhwa Rd, Seatween, Taichung, 40724, Taiwan
| | - NAI-REN GUO
- Department of Electrical Engineering, Tung Fang Design University, 110 Dongfan Rd, Hunei Dist., Kaohsiung 829, Taiwan
| | - TSUNG-CHI CHEN
- Department of Automatic Control Engineering, Feng Chia University, 100 Wenhwa Rd, Seatween, Taichung, 40724, Taiwan
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30
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McCabe C, White PA, Hoole SP, Axell RG, Priest AN, Gopalan D, Taboada D, MacKenzie Ross R, Morrell NW, Shapiro LM, Pepke-Zaba J. Right ventricular dysfunction in chronic thromboembolic obstruction of the pulmonary artery: a pressure-volume study using the conductance catheter. J Appl Physiol (1985) 2013; 116:355-63. [PMID: 24356516 DOI: 10.1152/japplphysiol.01123.2013] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pressure-volume loops describe dynamic ventricular performance, relevant to patients with and at risk of pulmonary hypertension. We used conductance catheter-derived pressure-volume loops to measure right ventricular (RV) mechanics in patients with chronic thromboembolic pulmonary arterial obstruction at different stages of pathological adaptation. Resting conductance catheterization was performed in 24 patients: 10 with chronic thromboembolic pulmonary hypertension (CTEPH), 7 with chronic thromboembolic disease without pulmonary hypertension (CTED), and 7 controls. To assess the validity of conductance measurements, RV volumes were compared in a subset of 8 patients with contemporaneous cardiac magnetic resonance (CMR). Control, CTED, and CTEPH groups showed different pressure-volume loop morphology, most notable during systolic ejection. Prolonged diastolic relaxation was seen in patients with CTED and CTEPH [tau = 56.2 ± 6.7 (controls) vs. 69.7 ± 10.0 (CTED) vs. 67.9 ± 6.2 ms (CTEPH), P = 0.02]. Control and CTED groups had lower afterload (Ea) and contractility (Ees) compared with the CTEPH group (Ea = 0.30 ± 0.10 vs. 0.52 ± 0.24 vs. 1.92 ± 0.70 mmHg/ml, respectively, P < 0.001) (Ees = 0.44 ± 0.20 vs. 0.59 ± 0.15 vs. 1.13 ± 0.43 mmHg/ml, P < 0.01) with more efficient ventriculoarterial coupling (Ees/Ea = 1.46 ± 0.30 vs. 1.27 ± 0.36 vs. 0.60 ± 0.18, respectively, P < 0.001). Stroke volume assessed by CMR and conductance showed closest agreement (mean bias +9 ml, 95% CI -1 to +19 ml) compared with end-diastolic volume (+48 ml, -16 to 111 ml) and end-systolic volume (+37 ml, -21 to 94 ml). RV conductance catheterization detects novel alteration in pressure-volume loop morphology and delayed RV relaxation in CTED, which distinguish this group from controls. The observed agreement in stroke volume assessed by CMR and conductance suggests RV mechanics are usefully measured by conductance catheter in chronic thromboembolic obstruction.
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Affiliation(s)
- Colm McCabe
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge, United Kingdom
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31
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van der Plas MN, van Kan C, Blumenthal J, Jansen HM, Wells AU, Bresser P. Pulmonary vascular limitation to exercise and survival in idiopathic pulmonary fibrosis. Respirology 2013; 19:269-275. [DOI: 10.1111/resp.12206] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 03/18/2013] [Accepted: 09/17/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Mart N. van der Plas
- Department of Respiratory Medicine; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
- Department of Respiratory Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
| | - Coen van Kan
- Department of Respiratory Medicine; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
| | - Judith Blumenthal
- Department of Respiratory Medicine; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
- Department of Respiratory Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
| | - Henk M. Jansen
- Department of Respiratory Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
| | - Athol U. Wells
- Interstitial Lung Disease Unit; Royal Brompton Hospital; London UK
| | - Paul Bresser
- Department of Respiratory Medicine; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
- Department of Respiratory Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
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32
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Abstract
Diseases of the pulmonary vasculature are a cause of increased pulmonary vascular resistance (PVR) in pulmonary embolism, chronic thromboembolic pulmonary hypertension (CTEPH), and pulmonary arterial hypertension or decreased PVR in pulmonary arteriovenous malformations on hereditary hemorrhagic telangiectasia, portal hypertension, or cavopulmonary anastomosis. All these conditions are associated with a decrease in both arterial PO2 and PCO2. Gas exchange in pulmonary vascular diseases with increased PVR is characterized by a shift of ventilation and perfusion to high ventilation-perfusion ratios, a mild to moderate increase in perfusion to low ventilation-perfusion ratios, and an increased physiologic dead space. Hypoxemia in these patients is essentially explained by altered ventilation-perfusion matching amplified by a decreased mixed venous PO2 caused by a low cardiac output. Hypocapnia is accounted for by hyperventilation, which is essentially related to an increased chemosensitivity. A cardiac shunt on a patent foramen ovale may be a cause of severe hypoxemia in a proportion of patients with pulmonary hypertension and an increase in right atrial pressure. Gas exchange in pulmonary arteriovenous malformations is characterized by variable degree of pulmonary shunting and/or diffusion-perfusion imbalance. Hypocapnia is caused by an increased ventilation in relation to an increased pulmonary blood flow with direct peripheral chemoreceptor stimulation by shunted mixed venous blood flow.
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Affiliation(s)
- C Mélot
- Department of Emergency Medicine, Erasme University Hospital, Brussels, Belgium.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
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Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
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34
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Surie S, Reesink HJ, Marcus JT, van der Plas MN, Kloek JJ, Vonk-Noordegraaf A, Bresser P. Bosentan treatment is associated with improvement of right ventricular function and remodeling in chronic thromboembolic pulmonary hypertension. Clin Cardiol 2013; 36:698-703. [PMID: 24037998 DOI: 10.1002/clc.22197] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 07/15/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Medical pretreatment before pulmonary endarterectomy (PEA) can optimize right ventricular (RV) function and may improve postoperative outcome in high-risk patients. Using cardiac magnetic resonance imaging (cMRI), we determined whether the dual endothelin-1 antagonist bosentan improves RV function and remodeling in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who waited for PEA. HYPOTHESIS We hypothesized that medical therapy prior to PEA will be associated with improvements in RV remodeling and function. METHODS In this pilot study, 15 operable CTEPH patients were randomly assigned to either bosentan (n = 8) or no bosentan (n = 7, control) for 16 weeks, next to "best standard of care." Both before and after treatment, RV stroke volume index (RVSVI), RV ejection fraction (RVEF), RV mass, RV isovolumic relaxation time (rIVRT), leftward ventricular septal bowing (LVSB), and left ventricular ejection fraction (LVEF) were determined using cMRI. RESULTS After 16 weeks, the change (Δ) from baseline (median [range]) in the studied cMRI parameters differed significantly between the bosentan group and the controls: Δ RVSVI: 6 [-4-11] vs 1 [-6-3] mL/m(-2) ; Δ RVEF: 8 [-10-15] vs -4 [-7-5]%; Δ RV mass: -3 [-6--2] vs 2 [-1-3] g/m(-2) ; Δ rIVRT: -30 [-130-20] vs 10 [-30-30] msec; Δ LVSB: 0.03 [-0.03-0.13] vs -0.03[-0.08-0.04] cm(-1) ; and Δ LVEF: 8 [-5-17] vs -2 [-14-2]% (all P < 0.05). The change from baseline in mean pulmonary artery pressure (-11 [-17-11] vs 5 [-6-21] mm Hg, P < 0.05) and 6-minute walk distance (20 [3-88] vs -4 [-40-40] m, P < 0.05) also differed significantly. CONCLUSIONS In CTEPH, compared with control, treatment with bosentan for 16 weeks was associated with a significant improvement in cMRI parameters of RV function and remodelling.
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Affiliation(s)
- Sulaiman Surie
- Departments of Pulmonology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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35
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Sato M, Ando M, Kaneko K, Higuchi Y, Kondo H, Akita K, Ishida M, Takagi Y. Respiratory and hemodynamic changes in patients with chronic thromboembolic pulmonary hypertension 1 year after pulmonary endarterectomy. Ann Vasc Dis 2013; 6:578-82. [PMID: 24130612 DOI: 10.3400/avd.oa.13-00056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/02/2013] [Indexed: 11/13/2022] Open
Abstract
We reviewed the results of thromboembolectomy, which was performed for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), 1 year after the operation. We obtained hemodynamic and respiratory data of 60 patients from the 112 patients who were operated at our institute. The hemodynamic parameters such as mean pulmonary arterial pressure (PAP), pulmonary vascular resistance (PVR), and cardiac index (CI) were significantly improved after the operation, and this improvement of pulmonary hemodynamics persisted even a year after the operation. A significant improvement in gas exchange was observed immediately after the operation and a further elevation in the partial pressure of oxygen in arterial blood (PaO2) was observed 1 year after the operation. (English Translation of J Jpn Coll Angiol 2012; 52: 53-58).
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Affiliation(s)
- Masato Sato
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Aichi, Japan
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Aguilaniu B, Wallaert B. De l’interprétation de l’exploration fonctionnelle d’exercice (EFX) à la décision médicale. Rev Mal Respir 2013; 30:498-515. [DOI: 10.1016/j.rmr.2013.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 05/05/2013] [Indexed: 11/27/2022]
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Auger WR, Kerr KM, Kim NH, Fedullo PF. Evaluation of patients with chronic thromboembolic pulmonary hypertension for pulmonary endarterectomy. Pulm Circ 2012; 2:155-62. [PMID: 22837856 PMCID: PMC3401869 DOI: 10.4103/2045-8932.97594] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pulmonary hypertension as a result of chronic thromboembolic disease (CTEPH) is potentially curable with pulmonary endarterectomy surgery. Consequently, correctly diagnosing patients with this type of pulmonary hypertension and evaluating these patients with the goal of establishing their candidacy for surgical intervention is of utmost importance. And as advancements in surgical techniques have allowed successful resection of segmental-level chronic thromboembolic disease, the number of CTEPH patients that are deemed suitable surgical candidates has expanded, making it even more important that the evaluation be conducted with greater precision. This article will review a diagnostic approach to patients with suspected chronic thromboembolic disease with an emphasis on the criteria considered in selecting patients for pulmonary endarterectomy surgery.
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Affiliation(s)
- William R Auger
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, California, USA
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38
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Jensen D, O’Donnell DE, Li R, Luo YM. Effects of dead space loading on neuro-muscular and neuro-ventilatory coupling of the respiratory system during exercise in healthy adults: Implications for dyspnea and exercise tolerance. Respir Physiol Neurobiol 2011; 179:219-26. [DOI: 10.1016/j.resp.2011.08.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 08/16/2011] [Accepted: 08/17/2011] [Indexed: 10/17/2022]
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Predictors of postoperative outcome after pulmonary endarterectomy from a 14-year experience with 279 patients. Eur J Cardiothorac Surg 2011; 40:154-61. [DOI: 10.1016/j.ejcts.2010.10.043] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 10/20/2010] [Accepted: 10/26/2010] [Indexed: 12/18/2022] Open
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40
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Fedullo P, Kerr KM, Kim NH, Auger WR. Chronic Thromboembolic Pulmonary Hypertension. Am J Respir Crit Care Med 2011; 183:1605-13. [DOI: 10.1164/rccm.201011-1854ci] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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41
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Longitudinal Follow-Up of Six-Minute Walk Distance After Pulmonary Endarterectomy. Ann Thorac Surg 2011; 91:1094-9. [DOI: 10.1016/j.athoracsur.2010.11.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 11/19/2010] [Accepted: 11/24/2010] [Indexed: 11/20/2022]
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1483] [Impact Index Per Article: 114.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
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Abstract
Chronic thromboembolic pulmonary hypertension is one of the few forms of pulmonary hypertension that is surgically curable. It is likely underdiagnosed and must be considered in every patient presenting with pulmonary hypertension to avoid missing the opportunity to cure these patients. This article discusses the epidemiology, risk factors, natural history, diagnosis, and preoperative evaluation of patients with this disorder. Also covered are putative mechanisms for the conversion of acute emboli into fibrosed thrombembolic residua. Mechanical obstruction of the central pulmonary vasculature is rarely the sole cause of the pulmonary hypertension, and a discussion of the small vessel arteriopathy present in these patients is offered. Technical aspects of pulmonary endartectomy and the data supporting its role are discussed, as are the limited data on pulmonary arterial hypertension specific medical therapies for patients deemed noncandidates for the operation.
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Affiliation(s)
- William R Auger
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037, USA.
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Bonderman D, Martischnig AM, Vonbank K, Nikfardjam M, Meyer B, Heinz G, Klepetko W, Naeije R, Lang IM. Right Ventricular Load at Exercise Is a Cause of Persistent Exercise Limitation in Patients With Normal Resting Pulmonary Vascular Resistance After Pulmonary Endarterectomy. Chest 2011; 139:122-7. [DOI: 10.1378/chest.10-0348] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Rahnavardi M, Yan TD, Cao C, Vallely MP, Bannon PG, Wilson MK. Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension : A Systematic Review. Ann Thorac Cardiovasc Surg 2011; 17:435-45. [DOI: 10.5761/atcs.oa.10.01653] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Torbicki A. Pulmonary thromboembolic disease. Clinical management of acute and chronic disease. Rev Esp Cardiol 2010; 63:832-49. [PMID: 20609317 DOI: 10.1016/s1885-5857(10)70168-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pulmonary thromboembolism falls between the areas of pulmonology and cardiology, internal medicine and intensive care, radiology and nuclear medicine, and hematology and cardiothoracic surgery. Depending on their clinical background, physicians faced with a patient with a pulmonary thromboembolism may speak different languages and adopt different treatment approaches. Now, however, there is an opportunity to end the Tower of Babel surrounding pulmonary thromboembolism. There is a growing acknowledgement that the key clinical problems in both acute pulmonary embolism and chronic thromboembolic pulmonary hypertension are linked to right ventricular pressure overload and right ventricular failure. As a result, cardiologists and cardiac intensive care specialists are taking an increasing interest in understanding and combating these conditions. The European Society of Cardiology was the first to elaborate comprehensive clinical practice guidelines for pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. The task forces involved in producing these guidelines included radiologists, pulmonologists, hematologists, intensive care physicians and surgeons, which ensured that the final document was universally acceptable. The aim of this article was to provide an overview of the epidemiology, risk factors, diagnosis, treatment, prognosis and prevention of acute pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension, while taking into account European Society of Cardiology guidelines and incorporating new evidence where necessary.
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Affiliation(s)
- Adam Torbicki
- National Institute for Tuberculosis and Lung Diseases, Warsaw, Poland.
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Torbicki A. Enfermedad tromboembólica pulmonar. Manejo clínico de la enfermedad aguda y crónica. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70186-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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