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Sato T, Fukui S, Nakano T, Hasegawa K, Kikuta H, Kameyama T, Shirota Y, Endo T, Kawamoto S, Kumagai K, Izawa H, Komaru T. Balloon pulmonary angioplasty under awake veno-arterial extracorporeal membrane oxygenation in a patient with class III obesity with chronic thromboembolic pulmonary hypertension complicated with multiple serious comorbidities. Pulm Circ 2024; 14:e12377. [PMID: 38681871 PMCID: PMC11056103 DOI: 10.1002/pul2.12377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a chronic disease that can rapidly deteriorate into circulatory collapse when complicated by comorbidities. We herein describe a case involving a 43-year-old woman with class III obesity (body mass index of 63 kg/m2) and severe CTEPH associated with total occlusion of the left main pulmonary artery who subsequently developed circulatory collapse along with multiple comorbidities, including acute kidney injury, pulmonary tuberculosis, and catastrophic antiphospholipid syndrome. The patient was successfully treated with two sessions of rescue balloon pulmonary angioplasty with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support under local anesthesia without sedation, at cannulation and during the V-A ECMO run, to avoid invasive mechanical ventilation. This case suggests the potential usefulness of rescue balloon pulmonary angioplasty under awake V-A ECMO support for rapidly deteriorating, inoperable CTEPH in a patient with class III obesity complicated with multiple comorbidities.
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Affiliation(s)
- Tsukasa Sato
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
- Department of CardiologyFujita Health UniversityToyoakeJapan
| | - Shigefumi Fukui
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
- Department of CardiologyFujita Health UniversityToyoakeJapan
| | - Takao Nakano
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Kaoru Hasegawa
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Hisashi Kikuta
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Takeyoshi Kameyama
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Yuko Shirota
- Department of Hematology and RheumatologyTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Tomoyuki Endo
- Department of Emergency and Disaster MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Shunsuke Kawamoto
- Department of Cardiovascular SurgeryTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Koji Kumagai
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
| | - Hideo Izawa
- Department of CardiologyFujita Health UniversityToyoakeJapan
| | - Tatsuya Komaru
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversitySendaiJapan
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Chronic Thromboembolic Pulmonary Hypertension: An Update. Diagnostics (Basel) 2022; 12:diagnostics12020235. [PMID: 35204326 PMCID: PMC8871284 DOI: 10.3390/diagnostics12020235] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease observed in a small proportion of patients after acute pulmonary embolism (PE). CTEPH has a high morbidity and mortality rate, related to the PH severity, and a poor prognosis, which mirrors the right ventricular dysfunction involvement. Pulmonary endarterectomy (PEA) reduces pulmonary vascular resistance, making it the treatment of choice and should be offered to operable CTEPH patients, as significant symptomatic and prognostic improvement has been observed. Moreover, these patients may also benefit from the advances made in surgical techniques and pulmonary hypertension-specific medication. However, not all patients are eligible for PEA surgery, as some have either distal pulmonary vascular obstruction and/or significant comorbidities. Therefore, surgical candidates should be carefully selected by an interprofessional team in expert centers. This review aims at making an overview of the risk factors and latest developments in diagnostic tools and treatment options for CTEPH.
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Rashidi F, Parvizi R, Bilejani E, Mahmoodian B, Rahimi F, Koohi A. Evaluation of the Incidence of Chronic Thromboembolic Pulmonary Hypertension 1 Year After First Episode of Acute Pulmonary Embolism: A Cohort Study. Lung 2020; 198:59-64. [PMID: 31894412 DOI: 10.1007/s00408-019-00315-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Chronic thromboembolic pulmonary hypertension (CTEPH) is an important complication after acute pulmonary embolism (PE) with considerable morbidity and mortality. The aim of this study was to estimate the CTEPH incidence in a cohort after the first occurrence of PE. METHODS We conducted a 1-year follow-up cohort study between 2015 and 2018 to assess the incidence of CTEPH in 474 patients with their first acute episode of PE. For the diagnosis of CTEPH, patients with unexplained persistent dyspnea during follow-up underwent transthoracic echocardiography, right heart catheterization, ventilation-perfusion lung scanning, and CT pulmonary angiography. RESULTS Overall, 317 patients were included in the study. The mean age of the patients was 56.5 ± 16 years. One hundred and three patients (32%) had exertional dyspnea at the 1-year follow-up. Patients with evidence of pulmonary hypertension (PH) on echocardiography underwent right heart catheterization. Eleven patients (18%) had no PH (mPAP < 25 mmHg); 47 patients (81%) had mPAP > 25 mmHg. Fifteen patients had PAWP > 15 mmHg, including those with underlying left heart problems or valvular diseases. There were 32 patients with PAH (mPAP > 25 mmHg and PVR > 3 WU) undergoing CTEPH studies; 22 patients (6.9%) had multiple segmental defects suggesting CTEPH on a perfusion scan. CONCLUSION The incidence of CTEPH observed in this study 1 year after the first episode of acute PE was approximately 6.9%. This incidence seems to be high in our population, and diagnostic and therapeutic strategies for the early identification of CTEPH are needed.
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Affiliation(s)
- Farid Rashidi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. .,Tabriz University of Medical Sciences, Imam Reza General Hospital, 29 Bahaman St, Tabriz, Iran.
| | - Rezayat Parvizi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Eisa Bilejani
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Mahmoodian
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Rahimi
- Department of Radiology, Imam Reza Teaching Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Koohi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Farasat S, Papamatheakis DG, Poch DS, Higgins J, Pretorius VG, Madani MM, Auger WR, Kerr KM, Fernandes TM. Atrial arrhythmias after pulmonary thromboendarterectomy. J Card Surg 2019; 34:312-317. [PMID: 30908728 DOI: 10.1111/jocs.14028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/14/2019] [Accepted: 03/04/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Atrial arrhythmias (AAs) are common after cardiac surgeries including pulmonary thromboendarterectomy (PTE). This study was done to identify patients at highest risk of developing post-PTE AA and their length of stay (LOS). METHODS We reviewed 521 consecutive patients referred to University of California San Diego (UCSD) for PTE and examined their demographics as well as their baseline pulmonary hemodynamics to determine risk factors for AA. RESULTS Overall, 24.2% of patients developed an AA after PTE. Patients who developed AA had a significantly longer Intensive Care Unit (ICU) LOS (median: 5 vs 3 days, P < 0.001) and postoperative LOS (median: 14 vs 9 days; P < 0.001). Patients who developed AA were more frequently male (63.2% male, P = 0.003), older (mean age 60.8 vs 50.7 years, P < 0.001), had a prior history of atrial fibrillation (80.2% of those who developed AA) and were more likely to have undergone concomitant Coronary Artery Bypass Graft (12.7% vs 6.6%, P = 0.028). Compared to those who did not develop AA, the cardiopulmonary bypass time was longer among those who developed AA (261.6 vs 253.8 minutes, P = 0.027). In a multivariate logistic regression model, the preoperative variables that predicted AA were age (odds ratio [OR], 1.058 per year, 95% confidence interval [CI]: 1.038-1.078), male sex (OR, 1.68, 95% CI: 1.06-2.64), prior AA (OR, 2.52, 95% CI: 1.23-5.15) and baseline right atrial pressure (OR, 1.039 per mm Hg, 95% CI: 1.000-1.079). While mortality rates were similar, patients who developed AA had more bleeding complications and more postoperative delirium. CONCLUSIONS AA is common after PTE surgery. The strongest risk factors for AA after PTE included the previous history of AA, age and male sex. Development of AA was associated with longer lengths of stay and more postoperative complications.
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Affiliation(s)
- Sadaf Farasat
- Division of Geriatrics Medicine, University of California San Diego, La Jolla, California
| | - Demosthenes G Papamatheakis
- Division of Pulmonary Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California
| | - David S Poch
- Division of Pulmonary Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Jill Higgins
- Division of Surgery, University of California San Diego, La Jolla, California
| | - Victor G Pretorius
- Division of Surgery, University of California San Diego, La Jolla, California
| | - Michael M Madani
- Division of Surgery, University of California San Diego, La Jolla, California
| | - William R Auger
- Division of Pulmonary Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Kim M Kerr
- Division of Pulmonary Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Timothy M Fernandes
- Division of Pulmonary Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California
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Schnell F, Claessen G, La Gerche A, Claus P, Bogaert J, Delcroix M, Carré F, Heidbuchel H. Atrial volume and function during exercise in health and disease. J Cardiovasc Magn Reson 2017; 19:104. [PMID: 29254488 PMCID: PMC5735907 DOI: 10.1186/s12968-017-0416-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 11/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although atrial function has prognostic significance in many cardiovascular conditions, changes during exercise have not previously been assessed. The aim of this study was to evaluate left atrial (LA) and right atrial (RA) volume and function during incremental exercise, both in normal individuals, healthy athletes, and in patients with chronic thromboembolic pulmonary hypertension (CTEPH). METHODS Fifteen healthy non-athletes, 15 athletes and 15 CTEPH patients underwent multi-slice real-time cardiovascular magnetic resonance imaging at rest and during supine bicycle exercise with simultaneous invasive hemodynamic measurements. RESULTS At rest, athletes had larger indexed maximal RA and LA volumes (iRAVmax, iLAVmax) than CTEPH patients and non-athletes, the latter two groups having similar values. CTEPH patients had lower RA and LA emptying functions (EmF) at rest. During exercise, RA volumes (maximum and minimum) increased in CTEPH patients, whilst decreasing in athletes and non-athletes (P < 0.001). The exercise-induced change in iLAVmax was similar between groups, but iLAVmin did not decrease in CTEPH patients. Thus exercise-induced increases in RAEmF and LAEmF, as seen in normal physiology, were significantly impaired in CTEPH patients. At peak exercise, RA volumes (maximum and minimum) and EmF correlated strongly with RA pressure (R = 0.70; P = 0.005; R = 0.83; P < 0.001; R = -0.87; P < 0.001). On multivariate analysis, peak exercise RAEmF and iLAVmin were independent predictors of VO2peak in CTEPH patients and together explained 72% of the variance in VO2peak (ß =0.581 and ß = -0.515, respectively). CONCLUSIONS In normal physiology, RAEmF and LAEmF increase with exercise, whereas CTEPH patients have impaired LAEmF and RAEmF, which becomes more apparent during exercise. Therefore, the changes in atrial volumes and function during exercise enable a far better distinction between physiological and pathological atrial remodeling than resting measures of volumes which are prone to confounding factors (e.g. endurance training). Peak exercise RAEmF is a good marker of poor functional state in CTEPH patients.
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Affiliation(s)
- Frédéric Schnell
- Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
- Department of Sport Medicine, University Hospital Pontchaillou, Rennes 1 University, Rennes, France
| | - Guido Claessen
- Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - André La Gerche
- Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Piet Claus
- Department of Cardiovascular Imaging and Dynamics, University of Leuven, Leuven, Belgium
| | - Jan Bogaert
- Department of Imaging and Pathology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Marion Delcroix
- Department of Pneumology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - François Carré
- Department of Sport Medicine, University Hospital Pontchaillou, Rennes 1 University, Rennes, France
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
- Department of Cardiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
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Abstract
Magnetic resonance (MR) angiography of the pulmonary arteries is a rapidly evolving technique with proven clinical usefulness. Multiple-step protocols, such as MR perfusion followed by high-spatial resolution MR angiography, seem to be a good approach for the assessment of different vascular diseases affecting the pulmonary arteries. In combination with other imaging sequences, MR imaging is one of the most comprehensive potential noninvasive imaging techniques available.
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Affiliation(s)
- Sebastian Ley
- Diagnostic and Interventional Radiology, Chirurgische Klinik Dr Rinecker, Am Isarkanal 30, Munich 81379, Germany; Department of Clinical Radiology, Ludwig Maximilians University, Marchioninistrasse 15, Munich 81377, Germany.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is responsible for significant levels of morbidity and mortality. The estimated cumulative incidence of CTEPH is 2-4% among patients presenting with acute pulmonary thromboembolism. Currently, at the time of CTEPH diagnosis, 37.9% of the patients in an international registry were receiving at least one pulmonary arterial hypertension (PAH)-targeted therapy. Advanced medical therapy is considered in patients with inoperable disease, as a bridge to pulmonary endarterectomy or in those with persistent or recurrent pulmonary hypertension. PAH-specific medical therapies include endothelin receptor antagonists, phosphodiesterase inhibitors, and prostacyclin analogues. The present article will focus on recent developments in the pharmacological treatment of CTEPH.
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Affiliation(s)
- Savas Ozsu
- Department of Pulmonary Medicine, Karadeniz Technical University School of Medicine, Trabzon, Turkey
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Marini C, Formichi B, Bauleo C, Michelassi C, Prediletto R, Catapano G, Genovesi D, Monti S, Mannucci F, Giuntini C. Improved survival in patients with inoperable chronic thromboembolic pulmonary hypertension. Intern Emerg Med 2013; 8:307-16. [PMID: 21553238 DOI: 10.1007/s11739-011-0610-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 04/21/2011] [Indexed: 11/25/2022]
Abstract
Patients with inoperable chronic thromboembolic pulmonary hypertension (Inop-CTEPH) treated with conventional therapy have a poor survival. We compare the 3-year survival between those treated with conventional therapy and those treated with conventional therapy and a combination of novel drugs. We also evaluate the clinical course. A total of 34 Inop-CTEPH consecutive patients were evaluated from 1991 to 2009 including right heart catheterization (RHC) and perfusion lung scan (PLS): 7 underwent surgical treatment while 27 were confirmed inoperable. Of these 27 patients, 12 evaluated from 1991 to 2003 (Group 1) were treated with conventional therapy and 15 evaluated from 2004 to 2009 (Group 2) were treated with conventional and novel therapies. At baseline, no group difference emerged at RHC. Based on clinical course, novel drugs and oxygen supplementation were given to patients of Group 2. Seven of these who had worse clinical course repeated RHC and four of them also PLS during therapy. Those without repeat RHC had baseline pulmonary artery mean pressure and brain natriuretic peptide (NT-proBNP) lower and mixed venous saturation (SvO2) and exercise test higher (p = 0.022, 0.015, 0.044 and 0.003, respectively). During therapy, those with repeat RHC had total pulmonary vascular resistance reduced (p = 0.012), base excess increased (p = 0.002) and significant redistribution of pulmonary blood flow at PLS. At the 3-year follow-up, survival was 86% in Group 2 and 31% in Group 1 (p = 0.031). In Inop-CTEPH patients, the clinical course may help to select drugs and the level of oxygen supply that can improve hemodynamics, gas exchange and long-term survival.
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Affiliation(s)
- Carlo Marini
- Fondazione CNR/Regione Toscana "G. Monasterio", Via G. Moruzzi 1, 56124, Pisa, Italy.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially life-threatening condition characterized by obstruction of pulmonary arterial vasculature by acute or recurrent thromboemboli with subsequent organization, leading to progressive pulmonary hypertension and right heart failure. Until relatively recently, CTEPH was a diagnosis made primarily at autopsy, but advances made in diagnostic modalities and surgical pulmonary endarterectomy techniques have made this disease treatable and even potentially curable. Although published guidelines are available, in the absence of randomized controlled trials regarding CTEPH there is a lack of standardization, and treatment options have to be individualized.
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Affiliation(s)
- Robert J Moraca
- Department of Thoracic and Cardiovascular Surgery, Gerald McGinnis Cardiovascular Institute, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA.
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Jin X, Seol SH, Park BM, Kim JK, Kim TJ, Song PS, Kim DK, Kim KH, Kim DI. A Case of Chronic Thromboembolic Pulmonary Hypertension. Cardiol Res 2012; 3:143-145. [PMID: 28352412 PMCID: PMC5358245 DOI: 10.4021/cr187w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2012] [Indexed: 12/03/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe complication of incomplete resolution of large pulmonary embolism (PE).Transthoracic echocardiography (TTE) and chest computed tomography (CT) are useful for the diagnosis and follow-up of CTEPH. We report a case of 40-year-old male who wasadmitted with gradually aggravated dyspnea in recent 2 years and had history of acute PE 10 years ago, was detected CTEPH by TTE and confirmed with chest CT.
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Affiliation(s)
- Xin Jin
- Division of Cardiology, Department of Internal Medicine, Yanbian Second People's Hospital, Yanbian, China
| | - Sang-Hoon Seol
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
| | - Bo-Min Park
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
| | - Jae-Kyun Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
| | - Tae-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
| | - Pil-Sang Song
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
| | - Dong-Kie Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
| | - Ki-Hun Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
| | - Doo-Il Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik hospital, Busan, Korea
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Scholzel BE, Post MC, Thijs Plokker HW, Snijder RJ. Clinical worsening during long-term follow-up in inoperable chronic thromboembolic pulmonary hypertension. Lung 2011; 190:161-7. [PMID: 22160210 DOI: 10.1007/s00408-011-9350-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 11/16/2011] [Indexed: 01/26/2023]
Abstract
BACKGROUND Pulmonary endarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension (CTEPH). Modern pulmonary vasoactive medication (like endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and prostacyclins) is used in patients with an inoperable disease and improved prognosis. We evaluate mortality and time to clinical worsening (TtCW) in inoperable CTEPH patients during long-term follow-up. METHODS All 32 patients with inoperable CTEPH were enrolled between June 2002 and January 2009. TtCW was defined as the combination of death, need for intravenous pulmonary arterial hypertension medication, or 15% decrease in 6-minute walk distance (6-MWD) without improvement in functional class. The Cox proportional hazard regression was used to identify predictors. RESULTS During a mean follow-up of 3.4 years (range = 0.2-10.2 years), 11 patients died (34%). The 1- and 3-year survival rates were 87 and 77%, respectively. Baseline functional class, 6-MWD, mean pulmonary artery pressure, and pulmonary vascular resistance were predictors for survival. Clinical worsening occurred in 16 patients (50%). The 1- and 3-year rates of freedom from clinical worsening were 74 and 60%, respectively. The only predictor for clinical worsening was the baseline 6-MWD. CONCLUSION Despite the improvement in medical treatment of inoperable CTEPH, the mortality rate is still high, and clinical worsening occurred in a substantial number of patients during a follow-up of more than 3 years.
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Affiliation(s)
- Bastiaan E Scholzel
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
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Clinical worsening after pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension. Neth Heart J 2011; 19:498-503. [PMID: 21979755 DOI: 10.1007/s12471-011-0203-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pulmonary endarterectomy (PEA) is the most effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study is to evaluate long-term survival and freedom from clinical worsening after PEA. METHODS All patients who underwent PEA in our hospital between May 2000 and August 2009 were included. Follow-up parameters were all-cause mortality and time to clinical worsening, defined as a combination of death, need for pulmonary hypertension-specific medication or 15% decrease in six-minute walk distance without improvement in functional class. The Cox proportional hazard regression was used to identify predictors. RESULTS Seventy-four consecutive patients (mean age 55.9 ± 13.8 years, 51% female) underwent PEA. Prior to surgery, 55 patients were in NYHA functional class III or higher. The mean pulmonary artery pressure was 41.3 ± 11.9 mmHg with a mean pulmonary vascular resistance of 521 ± 264 dyn·s·cm(-5) (range 279-1331 dyn·s·cm(-5)). Five patients (6.8%) died in-hospital. Out of hospital, 5 out of 69 patients (7.2%) died during a median follow-up of 3.7 ± 2.2 years [range 0.1-8.5 years]). The one- and five-year survival rates were 93% and 89%, respectively. During follow-up, clinical worsening occurred in 13 out of 69 patients (18.8%). The one- and five-year rates of freedom from clinical worsening were 94% and 72%, respectively. The baseline NT-pro BNP level tended to be a predictor for occurrence of clinical worsening. CONCLUSION Pulmonary endarterectomy is associated with good long-term survival in patients with CTEPH. However, clinical worsening occurred in a substantial number of patients at long-term follow-up.
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Duffels MGJ, van der Plas MN, Surie S, Winter MM, Bouma B, Groenink M, van Dijk APJ, Hoendermis E, Berger RMF, Bresser P, Mulder BJM. Bosentan in pulmonary arterial hypertension: a comparison between congenital heart disease and chronic pulmonary embolism. Neth Heart J 2011; 17:334-8. [PMID: 19949475 DOI: 10.1007/bf03086279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background. In patients with pulmonary hypertension, it is unknown whether the treatment effect of bosentan is dependent on the duration of pulmonary vessel changes. Therefore, we studied the response to bosentan in patients with life-long pulmonary vessel changes (pulmonary arterial hypertension (PAH) due to congenital heart disease (CHD)) and in patients with subacutely induced pulmonary vessel changes (chronic thromboembolic pulmonary hypertension (CTEPH)).Methods. In this open-label study, 18 patients with PAH due to CHD and 16 patients with CTEPH were treated with bosentan for at least one year. All patients were evaluated at baseline and during follow-up by means of the six-minute walk distance (6-MWD) and laboratory tests.Results. Improvement of 6-MWD was comparable in patients with PAH due to CHD (444+/-112 m to 471+/-100 m, p=0.02), and in CTEPH (376+/-152 m to 423+/-141 m, p=0.03) after three months of treatment. After this improvement, 6-MWD stabilised in both groups.Conclusion. Although duration of pulmonary vessel changes is strikingly different in patients with PAH due to CHD and CTEPH, the effect of one year of bosentan treatment was comparable. The main treatment effect appears to be disease stabilisation and decreasing the rate of deterioration. (Neth Heart J 2009;17:334-8.).
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Affiliation(s)
- M G J Duffels
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
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15
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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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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: 1463] [Impact Index Per Article: 112.5] [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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Kunihara T, Möller M, Langer F, Sata F, Tscholl D, Aicher D, Schäfers HJ. Angiographic Predictors of Hemodynamic Improvement After Pulmonary Endarterectomy. Ann Thorac Surg 2010; 90:957-64; discussion 964. [DOI: 10.1016/j.athoracsur.2010.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 04/28/2010] [Accepted: 05/03/2010] [Indexed: 11/29/2022]
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Bang JH, Woo JS, Choi PJ, Cho GJ, Park KJ, Kim SH, Yie K. The Clinical Outcome of Pulmonary Thromboendarterectomy for the Treatment of Chronic Pulmonary Thromboembolism. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.3.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jung Hee Bang
- Department of Thoracic and Cardiovascular Surgery, Dong-A Medical Hospital, College of Medicine, Dong-A University
| | - Jong Soo Woo
- Department of Thoracic and Cardiovascular Surgery, Dong-A Medical Hospital, College of Medicine, Dong-A University
| | - Pill Jo Choi
- Department of Thoracic and Cardiovascular Surgery, Dong-A Medical Hospital, College of Medicine, Dong-A University
| | - Gwang Jo Cho
- Department of Thoracic and Cardiovascular Surgery, Dong-A Medical Hospital, College of Medicine, Dong-A University
| | - Kwon-Jae Park
- Department of Thoracic and Cardiovascular Surgery, Dong-A Medical Hospital, College of Medicine, Dong-A University
| | - Si-Ho Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Pusan National University Yangsan Hospital
| | - Kilsoo Yie
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Kangwon National University
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Freed DH, Thomson BM, Berman M, Tsui SSL, Dunning J, Sheares KK, Pepke-Zaba J, Jenkins DP. Survival after pulmonary thromboendarterectomy: effect of residual pulmonary hypertension. J Thorac Cardiovasc Surg 2010; 141:383-7. [PMID: 20471039 DOI: 10.1016/j.jtcvs.2009.12.056] [Citation(s) in RCA: 188] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 11/05/2009] [Accepted: 12/16/2009] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension. In many patients hemodynamics are normalized early after surgical intervention. However, the effect of residual pulmonary hypertension on postoperative clinical status and survival is unknown. METHODS Data were collected prospectively on all patients who underwent pulmonary endarterectomy in a continuous national series between 1997 and December 2007. Postoperatively, patients underwent scheduled reinvestigation, including functional testing and right heart catheterization, at 3 months after the operation. They were divided into 2 groups based on mean pulmonary artery pressure: group 1, less than 30 mm Hg; group 2, 30 mm Hg or greater. RESULTS Three hundred fourteen patients underwent pulmonary endarterectomy, survived to hospital discharge, and completed the 3-month follow-up period. At 3 months after pulmonary endarterectomy, there was a significant reduction in mean pulmonary artery pressure for the whole cohort (48±12 to 26±10 mm Hg, P<.001). However, 31% of the patients had residual pulmonary hypertension. Group 1 patients enjoyed significantly better exercise capacity and improved symptoms compared with group 2 patients. In addition, there were significantly fewer patients receiving targeted medical therapy in group 1 versus group 2 (0% vs 25%, P<.001). Conditional survival after discharge from the hospital for the whole cohort was 90.0% at 5 years and was not different between groups (90.3% for group 1 vs 89.9% for group 2, P=.36). CONCLUSIONS For patients undergoing pulmonary endarterectomy, survival after hospital discharge is excellent. Residual pulmonary hypertension significantly compromised symptom status and functional capacity but did not appear to adversely affect medium-term survival. The effect of targeted medical therapy in patients with residual pulmonary hypertension after pulmonary endarterectomy needs to be evaluated further.
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Affiliation(s)
- Darren H Freed
- Department of Cardiothoracic Surgery and Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge, United Kingdom
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Abstract
This article discusses the role of magnetic resonance angiography (MRA) in evaluating the pulmonary arterial system. For depiction of pulmonary arterial anatomy and morphology, MRA techniques are compared with CT angiography and digital subtraction x-ray angiography. Perfusion, flow, and function are emphasized, as the integrated MR examination offers a comprehensive assessment of vascular morphology and function. Advances in MR technology that improve spatial and temporal resolution and compensate for potential artifacts are reviewed as they pertain to pulmonary MRA. Current and emerging gadolinium contrast-enhanced and non-contrast-enhanced MRA techniques are discussed. The role of pulmonary MRA, clinical protocols, imaging findings, and interpretation pitfalls are reviewed for clinical indications.
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Affiliation(s)
- Elizabeth M Hecht
- Department of Radiology, New York University School of Medicine, 560 First Avenue, TCH-HW202, New York, NY 10016, USA.
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21
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Castañer E, Gallardo X, Ballesteros E, Andreu M, Pallardó Y, Mata JM, Riera L. CT Diagnosis of Chronic Pulmonary Thromboembolism. Radiographics 2009; 29:31-50; discussion 50-3. [DOI: 10.1148/rg.291085061] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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22
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Jaïs X, D'Armini AM, Jansa P, Torbicki A, Delcroix M, Ghofrani HA, Hoeper MM, Lang IM, Mayer E, Pepke-Zaba J, Perchenet L, Morganti A, Simonneau G, Rubin LJ. Bosentan for Treatment of Inoperable Chronic Thromboembolic Pulmonary Hypertension. J Am Coll Cardiol 2008; 52:2127-34. [DOI: 10.1016/j.jacc.2008.08.059] [Citation(s) in RCA: 396] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 07/23/2008] [Accepted: 08/12/2008] [Indexed: 12/21/2022]
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23
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Ley S, Kauczor HU. MR Imaging/Magnetic Resonance Angiography of the Pulmonary Arteries and Pulmonary Thromboembolic Disease. Magn Reson Imaging Clin N Am 2008; 16:263-73, ix. [PMID: 18474331 DOI: 10.1016/j.mric.2008.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sebastian Ley
- Department of Pediatric Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 153, 69120 Heidelberg, Germany.
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Affiliation(s)
- Keith McNeil
- The Prince Charles Hospital, Chermside, Queensland, Australia.
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25
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Bernard J, Yi ES. Pulmonary thromboendarterectomy: a clinicopathologic study of 200 consecutive pulmonary thromboendarterectomy cases in one institution. Hum Pathol 2007; 38:871-7. [PMID: 17350667 DOI: 10.1016/j.humpath.2006.11.017] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Revised: 11/21/2006] [Accepted: 11/28/2006] [Indexed: 11/21/2022]
Abstract
Approximately 2000 patients underwent pulmonary thromboendarterectomy (PTE) to date at University of California, San Diego. We retrospectively reviewed the clinicopathologic manifestations of 200 consecutive PTE cases from June 2004 to February 2006 with an emphasis on the histopathologic spectrum of chronic thromboembolic disease. Pathology reports and all histologic sections of study cases were examined. Pertinent clinical data were obtained from operative reports and medical records. In the study group, there were 2 cases (1 man, 1 woman) of pulmonary artery sarcomas and 1 case of metastatic tumor emboli from a testicular germ cell tumor. Two patients (both women) showed histologic evidence of arteritis without clinically apparent systemic vasculitis. The remaining 195 PTE patients with chronic thromboembolic disease consisted of 97 women and 98 men with a mean age of 52 (range, 17-83) and 51 (range, 16-82), respectively. Bilateral PTE was performed in 191, and unilateral PTE was performed in 4 (right and left, 2 each) patients. History of deep vein thrombosis was noted in 38.5%, and coagulation abnormalities were documented in 16.4% of these 195 cases. Grossly, the volumes of PTE specimens were greater in men than in women and on the right side than on the left in both men and women. Microscopically, the thrombi were recent fibrinous clot in 0.8%, mixed fibrinous and organizing in 45%, and old organized in 54.2% of specimens. Inflammation within the thrombi was usually mild but moderate and severe inflammation was found in 13.4% and 1.3% of specimens, respectively. Exuberant epithelioid granulomas were seen within the thrombi in one patient who had a history of sarcoidosis. Collections of foamy histiocytes and/or cholesterol clefts were found in 45%, and calcification was present in 11.5% of specimens. One case revealed diffuse myofibroblastic proliferation in a highly inflammatory background containing numerous plasma cells, reminiscent of inflammatory myofibroblastic tumor. In summary, pathology of PTE specimens in our study group encompassed remodeling of thrombi at various stages with variable degrees of inflammation and cellularity, granulomas associated with sarcoidosis, a rare case showing features of inflammatory myofibroblastic tumor, primary or metastatic malignancy, and isolated pulmonary arteritis.
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Affiliation(s)
- Joan Bernard
- Department of Pathology, School of Medicine, University of California San Diego, La Jolla, CA 92037, USA
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Gurudevan SV, Malouf PJ, Auger WR, Waltman TJ, Madani M, Raisinghani AB, DeMaria AN, Blanchard DG. Abnormal left ventricular diastolic filling in chronic thromboembolic pulmonary hypertension: true diastolic dysfunction or left ventricular underfilling? J Am Coll Cardiol 2007; 49:1334-9. [PMID: 17394966 DOI: 10.1016/j.jacc.2007.01.028] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Revised: 10/30/2006] [Accepted: 10/31/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the cause of abnormal left ventricular (LV) Doppler diastolic filling characteristics in chronic thromboembolic pulmonary hypertension (CTEPH). BACKGROUND In CTEPH, LV diastolic function often appears abnormal. It is unclear whether this "impaired relaxation" (E<A) filling pattern is caused by septal hypertrophy, right ventricular (RV) enlargement and LV chamber distortion, or low LV preload and underfilling. METHODS We studied 61 patients with an E<A transmitral pattern and CTEPH who underwent pulmonary thromboendarterectomy (PTE). We compared the results of pre- and postoperative transthoracic echocardiography and right heart catheterization measurements. RESULTS After PTE, mitral E velocity increased (from 54 +/- 16 cm/s to 81 +/- 20 cm/s, p < 0.001), whereas A velocity decreased (77 +/- 22 cm/s to 71 +/- 20 cm/s, p < 0.001). E/A ratio normalized (0.72 +/- 0.16 cm/s to 1.22 +/- 0.40 cm/s, p < 0.001). Pulmonary venous systolic and diastolic velocities both increased (57 +/- 13 cm/s to 68 +/- 16 cm/s and 39 +/- 15 cm/s to 70 +/- 21 cm/s, respectively, p < 0.001 for both). Diastolic velocity of the septal mitral annulus (E(m)) did not change after PTE (8.0 +/- 3.1 cm/s to 8.1 +/- 2.0 cm/s, p = ns), whereas the velocity of the lateral mitral annulus increased (9.3 +/- 3.2 cm/s to 11.8 +/- 3.1 cm/s, p < 0.001). Mean pulmonary capillary wedge pressure increased from 9.3 +/- 3.2 mm Hg to 10.6 +/- 3.8 mm Hg (p = 0.035). Despite these marked changes in LV inflow, M-mode measurements of LV septal and posterior wall thickness were normal before PTE and did not change after surgery (septal: 10 +/- 2 mm vs. 10 +/- 1 mm; posterior: 10 +/- 2 mm vs. 10 +/- 1 mm; p = NS for both comparisons). CONCLUSIONS The results of this study strongly suggest that the impaired relaxation pattern observed in patients with CTEPH is not solely the result of geometric effects of RV enlargement and LV chamber distortion but is caused in large part by low LV preload and relative underfilling.
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Affiliation(s)
- Swaminatha V Gurudevan
- Division of Cardiology, University of California Irvine School of Medicine, Irvine, California, USA
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Deep Hypothermic Circulatory Arrest During Pulmonary Thrombendarterectomy in Patients with Chronic Thrombembolic Pulmonary Hypertension. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0090-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Singh A, Lafalce C, Marrone G, Shade D, Singh N. Recurrent dyspnea on exertion in a 71-year-old man with prior pulmonary embolism. Chest 2006; 130:1244-7. [PMID: 17035463 DOI: 10.1378/chest.130.4.1244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Anil Singh
- Department of Pulmonary Medicine, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, USA.
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Kline JA, Hernandez-Nino J, Rose GA, Norton HJ, Camargo CA. Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism*. Crit Care Med 2006; 34:2773-80. [PMID: 16943732 DOI: 10.1097/01.ccm.0000241154.55444.63] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although echocardiography has proven utility in risk stratifying normotensive patients with pulmonary embolism, echocardiography is not always available. OBJECTIVE Test if a novel panel consisting of pulse oximetry, 12-lead electrocardiography, and serum troponin T would have prognostic equivalence to echocardiography and to examine the prognostic performance of age, previous cardiopulmonary disease, D-dimer, brain natriuretic peptide, and percentage of pulmonary vascular occlusion on chest computed tomography. DESIGN Prospective cohort study. PATIENTS AND SETTING Normotensive (systolic blood pressure of >100 mm Hg) emergency department and hospital inpatients with diagnosed pulmonary embolism who underwent cardiologist-interpreted echocardiography and other measurements within 15 hrs of anticoagulation. MEASUREMENTS AND MAIN RESULTS End points were in-hospital circulatory shock or intubation, or death, recurrent pulmonary embolism, or severe cardiopulmonary disability (defined as echocardiographic evidence of severe right ventricular dysfunction with New York Heart Association class III dyspnea or 6-min walk test of <330 m) at 6-month follow-up. The two-one-sided test tested the hypothesis of equivalence with one-tailed alpha = 0.05 and Delta = 5%. Of 200 patients enrolled, data were complete for 181 (88%); 51 of 181 patients (28%) had an adverse outcome, including in-hospital complication (n = 18), death (n = 11), recurrent pulmonary embolism (n = 2), or cardiopulmonary disability (n = 20). Right ventricular dysfunction on initial echocardiogram was 61% sensitive (95% confidence interval, 46-74%) and 57% specific (48-66%). The panel was 71% sensitive (56-83%) and 62% specific (53-71%). The two-one-sided procedure demonstrated superiority of the panel to echocardiography for both sensitivity and noninferiority for specificity. No other biomarker demonstrated equivalence, noninferiority, or superiority for sensitivity and specificity. CONCLUSION Normotensive patients with pulmonary embolism have a high rate of severe adverse outcomes during 6-month follow-up. A panel of three widely available tests can be used to risk stratify patients with pulmonary embolism when formal echocardiography is not available.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
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Matsuda H, Ogino H, Minatoya K, Sasaki H, Nakanishi N, Kyotani S, Kobayashi J, Yagihara T, Kitamura S. Long-Term Recovery of Exercise Ability After Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension. Ann Thorac Surg 2006; 82:1338-43; discussion 1343. [PMID: 16996930 DOI: 10.1016/j.athoracsur.2006.03.105] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 03/29/2006] [Accepted: 03/29/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND The exercise capacity of patients with thromboembolic pulmonary hypertension was investigated to clarify the long-term effects of pulmonary endarterectomy. This capacity was assessed by measuring cardiopulmonary factors during cardiopulmonary exercise testing at the maximal level of exercise and a 6-minute walk test at the submaximal level. Their survival rate was also determined. METHODS We conducted a retrospective review of the clinical records of 102 patients who underwent pulmonary endarterectomy (63 women; median age, 53 years). RESULTS Eight (7.8%) hospital mortalities were encountered. Three late mortalities due to fulminant hepatitis, breast cancer, and pneumonia in a patient under steroid therapy were unrelated to pulmonary endarterectomy. The actual survival rate including hospital mortalities was 90.9% at 3 years and 84.0% at 5 years. All hemodynamic measurements significantly improved and reached a plateau 1-month after endarterectomy. The cardiopulmonary exercise test at the maximal exercise level revealed that peak oxygen uptake (V(O2)) baseline was 13.8 +/- 3.2 mL/min/kg, and at 1-month was 16.2 +/- 4.2 mL/min/kg (p = 0.0015) and ventilatory response to carbon dioxide production (V(E)-V(CO2)) slope baseline was 46.5 +/- 8.4 mL/min/kg, and at 1-month was 39.9 +/- 7.4 (p = 0.0006), which gradually and significantly improved during the first year after endarterectomy (peak V(O2), 19.9 +/- 3.9 mL/min/kg [p < 0.0001] and V(E)-V(CO2) slope, 33.2 +/- 5.4 mL/min/kg [p <0.0001]). The 6-minute walk test, which reflects the systemic response at the submaximal level of functional capacity, showed that the walking distance gradually and significantly increased for up to 1 year after endarterectomy (baseline, 358 +/- 102 meters [m]; at 1-month, 433 +/- 105 m; and at 1-year, 490 +/- 80 m [p < 0.0001]) and then reached a plateau. CONCLUSIONS After pulmonary endarterectomy, the hemodynamic recovery occurred immediately, and the patients' exercise capacity improved during the year. The 6-minute walk test was a good indicator to assess the recovery of exercise capacity.
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Affiliation(s)
- Hitoshi Matsuda
- Department of Cardio-Vascular Surgery, National Cardio-Vascular Center, Suita, Osaka, Japan.
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Kreitner KF, Kunz RP, Ley S, Oberholzer K, Neeb D, Gast KK, Heussel CP, Eberle B, Mayer E, Kauczor HU, Düber C. Chronic thromboembolic pulmonary hypertension — assessment by magnetic resonance imaging. Eur Radiol 2006; 17:11-21. [PMID: 16838142 DOI: 10.1007/s00330-006-0327-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Revised: 04/25/2006] [Accepted: 05/02/2006] [Indexed: 11/29/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe disease that has been ignored for a long time. However, with the development of improved therapeutic modalities, cardiologists and thoracic surgeons have shown increasing interest in the diagnostic work-up of this entity. The diagnosis and management of chronic thromboembolic pulmonary hypertension require a multidisciplinary approach involving the specialties of pulmonary medicine, cardiology, radiology, anesthesiology and thoracic surgery. With this approach, pulmonary endarterectomy (PEA) can be performed with an acceptable mortality rate. This review article describes the developments in magnetic resonance (MR) imaging techniques for the diagnosis of chronic thromboembolic pulmonary hypertension. Techniques include contrast-enhanced MR angiography (ce-MRA), MR perfusion imaging, phase-contrast imaging of the great vessels, cine imaging of the heart and combined perfusion-ventilation MR imaging with hyperpolarized noble gases. It is anticipated that MR imaging will play a central role in the initial diagnosis and follow-up of patients with CTEPH.
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Affiliation(s)
- Karl-Friedrich Kreitner
- Department of Diagnostic and Interventional Radiology, Johannes-Gutenberg-University, Langenbeckstrasse 1, D-55131 Mainz, Germany.
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