Pulmonary endarterectomy surgery--a technically demanding cure for WHO Group IV Pulmonary Hypertension: requirements for centres of excellence and availability in Canada

Prevalence of Mental Disorders in Patients With Chronic Thromboembolic Pulmonary Hypertension

OBJECTIVE

Pulmonary hypertension (PH) is a chronic and progressive pulmonary vascular disease resulting in symptoms such as shortness of breath and fatigue and leading to death from right heart failure if not adequately treated. Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of PH characterized by obstruction or occlusion of pulmonary arteries by post-embolic fibrotic material. To date, few studies examined symptoms of depression and anxiety in patients with CTEPH, showing depression levels as high as 37.5%. However, none of the former studies used structured expert interviews.

METHODS

Mental disorders were diagnosed using the Structured Clinical Interview for DSM-5 (SCID). The prevalence of mental disorders in patients with CTEPH were compared to the prevalence in patients with pulmonary arterial hypertension (PAH) and the general German population. Quality of life (QoL) was measured with World Health Organization (WHO) Quality of Life questionnaire (short form). Factors associated with QoL were analyzed with linear regression and the diagnostic value of the Hospital Anxiety and Depression Scale (HADS) was evaluated using receiver operating characteristics (ROC) curve analysis.

RESULTS

Hundred and seven patients with CTEPH were included. Almost one-third of the patients (31.8%) had current psychological disorders. Panic disorder (8.4%), specific phobia (8.4%), and major depressive disorder (6.5%) were the most prevalent mental illnesses. The prevalence of panic disorders was higher in CTEPH compared to the German population while major depressive disorder was fewer in CTEPH compared to PAH. The presence of mental disorders had a major impact on QoL. Hospital Anxiety and Depression Scale discriminated depression and panic disorder reliably.

CONCLUSION

Mental disorders are common in patients with CTEPH and associated with an impaired QoL. The HADS may be a useful screening tool for panic and depression disorders in patients with CTEPH. Further research on therapeutic strategies targeting mental disorders in patients with CTEPH is needed.

Removing an Entrapped Pigtail Catheter by Re-enforcing a Traditional Method

Right heart catheterization is the main step in the evaluation of pulmonary hypertension including Chronic Thromboembolic Pulmonary Hypertension (CTEPH) and is considered a relatively safe procedure. Complications can occur including perforation, tamponade, bleeding, etc. requiring different types of interventions such as manipulation or surgery. Here, we have described a case of pigtail catheter entrapment and the method we used to free it without invasive measures.

Quantifying the learning curve for pulmonary thromboendarterectomy

BACKGROUND

Pulmonary thromboendarterectomy (PTE) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but is a technically challenging operation for cardiothoracic surgeons. Starting a new program allows an opportunity to define a learning curve for PTE.

METHODS

A retrospective case review was performed of 134 consecutive PTEs performed from 1998 to 2016 at a single institution. Outcomes were compared using either a two-tailed t-test for continuous variables or a chi-squared test for categorical variables according to experience of the program by terciles (T).

RESULTS

The 30-day mortality was 3.7%. The mean length of hospital stay, length of ICU stay, and duration on a ventilator were 12.6 days, 4.6 days, and 2.0 days, respectively. The mean decrease in systolic pulmonary artery pressure (sPAP) was 41.3 mmHg. Patients with Jamieson type 2 disease had a greater change in mean sPAP than those with type 3 disease (p = 0.039). The mean cardiopulmonary bypass time was 180 min (T1-198 min, T3-159 min, p = <0.001), and the mean circulatory arrest time was 37 min (T1-44 min, T3-31 min, p < 0.001). Plotting circulatory arrest times as a running sum compared to the mean demonstrated 2 inflection points, the first at 22 cases and the second at 95 cases.

CONCLUSIONS

PTE is a challenging procedure to learn, and good outcomes are a result of a multi-disciplinary effort to optimize case selection, operative performance, and postoperative care. Approximately 20 cases are needed to become proficient in PTE, and nearly 100 cases are required for more efficient clearing of obstructed pulmonary arteries.

The WHO classification of pulmonary hypertension: A case-based imaging compendium

Pulmonary hypertension (PH) is defined as a resting mean pulmonary artery pressure greater than 25 mmHg. The World Health Organization (WHO) classifies PH into five categories. The WHO nomenclature assumes shared histology and pathophysiology within categories and implies category-specific treatment. Imaging of the heart and pulmonary vasculature is critical to assigning a patient's PH syndrome to the correct WHO category and is also important in predicting outcomes. Imaging studies often reveal that the etiology of PH in a patient reflects contributions from several categories. Overlap between Categories 2 and 3 (left heart disease and lung disease) is particularly common, reflecting shared risk factors. Correct classification of PH patients requires the combination of standard imaging (chest roentgenograms, ventilation-perfusion scans, echocardiography, and the 12-lead electrocardiogram) and advanced imaging (computed tomography, cardiac magnetic resonance imaging, and positron emission tomography). Despite the value of imaging, cardiac catheterization remains the gold standard for quantification of hemodynamics and is required before initiation of PH-specific therapy. These cases illustrate the use of imaging in classifying patients into WHO PH Categories 1-5.