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Beijk MAM, Winkelman JA, Eckmann HM, Samson DA, Widyanti AP, Vleugels J, Bombeld DCM, Meijer CGCM, Bogaard HJ, Noordegraaf AV, de Bruin-Bon HACM, Bouma BJ. Notch ratio in pulmonary flow predicts long-term survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Heart Vessels 2024:10.1007/s00380-024-02422-5. [PMID: 38837085 DOI: 10.1007/s00380-024-02422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/23/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Assessment of the pattern of the RV outflow tract Doppler provides insights into the hemodynamics of chronic thromboembolic pulmonary hypertension (CTEPH). We studied whether pre-operative assessment of timing of the pulmonary flow systolic notch by Doppler echocardiography is associated with long-term survival after pulmonary endarterectomy (PEA) for CTEPH. METHODS Fifty-nine out of 61 consecutive CETPH patients (mean age 53 ± 14 years, 34% male) whom underwent PEA between June 2002 and June 2005 were studied. Clinical, echocardiographic and hemodynamic variables were assessed pre-operatively and repeat echocardiography was performed 3 months after PEA. Notch ratio (NR) was assessed with pulsed Doppler and calculated as the time from onset of pulmonary flow until notch divided by the time from notch until end of pulmonary flow. Long-term follow-up was obtained between May 2021 and February 2022. RESULTS Pre-operative mean pulmonary artery pressure (mPAP) was 45 ± 15 mmHg and pulmonary vascular resistance (PVR) was 646 ± 454 dynes.s.cm-5. Echocardiography before PEA showed that 7 patients had no notch, 33 had a NR < 1.0 and 19 had a NR > 1.0. Three months after PEA, echocardiography revealed a significant decrease in sPAP in long-term survivors with a NR < 1.0 and a NR > 1.0, while a significant increase in TAPSE/sPAP was only observed in the NR < 1.0 group. Mean long-term clinical follow-up was 14 ± 6 years. NR was significantly different between survivors and non-survivors (0.73 ± 0.25 vs. 1.1 ± 0.44, p < 0.001) but no significant differences were observed in mPAP or PVR. Long-term survival at 14 years was significantly better in patients with a NR < 1.0 compared to patients with a NR > 1.0 (83% vs. 37%, p = < 0.001). CONCLUSION Pre-operative assessment of NR is a predictor of long-term survival in CTEPH patients undergoing PEA, with low mortality risk in patients with NR < 1.0. Long-term survivors with a NR < 1.0 and NR > 1.0 had a significant decrease in sPAP after PEA. However, the TAPSE/sPAP only significantly increased in the NR < 1.0 group. In the NR < 1.0 group, the 6-min walk test increased significantly between pre-operative and at 1-year post-operative follow-up. NR is a simple echocardiographic parameter that can be used in clinical decision-making for PEA.
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Affiliation(s)
- M A M Beijk
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - J A Winkelman
- Department of Cardiothoracic Surgery, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - H M Eckmann
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D A Samson
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - A P Widyanti
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J Vleugels
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D C M Bombeld
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C G C M Meijer
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - H J Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - A Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - H A C M de Bruin-Bon
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - B J Bouma
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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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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Stam K, Clauss S, Taverne YJHJ, Merkus D. Chronic Thromboembolic Pulmonary Hypertension - What Have We Learned From Large Animal Models. Front Cardiovasc Med 2021; 8:574360. [PMID: 33937352 PMCID: PMC8085273 DOI: 10.3389/fcvm.2021.574360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 03/08/2021] [Indexed: 12/21/2022] Open
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) develops in a subset of patients after acute pulmonary embolism. In CTEPH, pulmonary vascular resistance, which is initially elevated due to the obstructions in the larger pulmonary arteries, is further increased by pulmonary microvascular remodeling. The increased afterload of the right ventricle (RV) leads to RV dilation and hypertrophy. This RV remodeling predisposes to arrhythmogenesis and RV failure. Yet, mechanisms involved in pulmonary microvascular remodeling, processes underlying the RV structural and functional adaptability in CTEPH as well as determinants of the susceptibility to arrhythmias such as atrial fibrillation in the context of CTEPH remain incompletely understood. Several large animal models with critical clinical features of human CTEPH and subsequent RV remodeling have relatively recently been developed in swine, sheep, and dogs. In this review we will discuss the current knowledge on the processes underlying development and progression of CTEPH, and on how animal models can help enlarge understanding of these processes.
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Affiliation(s)
- Kelly Stam
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sebastian Clauss
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University Munich, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Daphne Merkus
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
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Yan L, Li X, Liu Z, Zhao Z, Luo Q, Zhao Q, Jin Q, Yu X, Zhang Y. Research progress on the pathogenesis of CTEPH. Heart Fail Rev 2020; 24:1031-1040. [PMID: 31087212 DOI: 10.1007/s10741-019-09802-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an established long-term complication of pulmonary thromboembolism (PTE). However, studies have shown that many patients with a definitive CTEPH diagnosis have no history of symptomatic PTE, suggesting that PTE is not the only cause of CTEPH. Despite extensive progress in research on pulmonary hypertension in recent years, due to a lack of relevant studies on the pathophysiology of CTEPH, implementing pulmonary endarterectomy (PEA) in patients has many challenges, and the prognosis of patients with CTEPH is still not optimistic. Therefore, revealing the pathogenesis of CTEPH would be of great significance for understanding the occurrence and development of CTEPH, developing relevant drug treatment studies and formulating intervention strategies, and may provide new preventive measures. This article summarizes the current research progress in CTEPH pathogenesis from the perspective of risk factors related to medical history, abnormal coagulation and fibrinolytic mechanisms, inflammatory mechanisms, genetic susceptibility factors, angiogenesis, in situ thrombosis, vascular remodeling, and other aspects.
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Affiliation(s)
- Lu Yan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Xin Li
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China.
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qin Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Xue Yu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
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Sepúlveda C, Repolho D, Antunes AM, Taulaigo AV, Carreiro F, Ferreira RC, Moraes-Fontes MF, Loureiro MJ. Dyspnea in antiphospholipid syndrome: Beyond pulmonary embolism. Rev Port Cardiol 2020; 39:47.e1-47.e5. [PMID: 32173092 DOI: 10.1016/j.repc.2018.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/15/2018] [Indexed: 11/15/2022] Open
Abstract
Pulmonary embolism due to primary antiphospholipid syndrome is rarely associated with chronic thromboembolic pulmonary hypertension, and therefore according to the latest guidelines on pulmonary hypertension, routine screening is not recommended. We describe a young patient with a late diagnosis of chronic thromboembolic pulmonary hypertension in the context of pulmonary embolism, primary antiphospholipid syndrome and suboptimal anticoagulation. Of note, mild cardiopulmonary symptoms were consistently misattributed to a depressive disorder because physical examination was normal, serial Doppler echocardiography failed to show pulmonary hypertension, and all other diagnostic tests were normal. Once symptoms became severe, positive screening tests led to the correct diagnosis and surgical referral, and bilateral pulmonary endarterectomy was successfully performed. This case demonstrates the need for extra awareness in patients with antiphospholipid syndrome and pulmonary embolism.
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Affiliation(s)
- Carolina Sepúlveda
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal; Serviço de Medicina Interna, Hospital de Abrantes - Centro Hospitalar Médio Tejo (CHMT), Abrantes, Portugal.
| | - Débora Repolho
- Unidade de Hipertensão Pulmonar, Serviço de Cardiologia - Hospital Garcia de Orta (HGO), Almada, Portugal
| | - Ana Margarida Antunes
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal
| | - Anna Viola Taulaigo
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal
| | - Filipa Carreiro
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal; Serviço de Medicina Interna - Hospital do Divino Espírito Santo (HDES), Ponta Delgada, Portugal
| | - Rui Cruz Ferreira
- Serviço de Cardiologia, Hospital de Santa Marta - CHLC, Lisboa, Portugal
| | - Maria Francisca Moraes-Fontes
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal
| | - Maria José Loureiro
- Unidade de Hipertensão Pulmonar, Serviço de Cardiologia - Hospital Garcia de Orta (HGO), Almada, Portugal
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7
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Sepúlveda C, Repolho D, Antunes AM, Taulaigo AV, Carreiro F, Ferreira RC, Moraes-Fontes MF, Loureiro MJ. Dyspnea in antiphospholipid syndrome: Beyond pulmonary embolism. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2018.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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8
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Zhang Y, Wu M, Cao Y, Guo F, Li Y. Linking lncRNAs to regulation, pathogenesis, and diagnosis of pulmonary hypertension. Crit Rev Clin Lab Sci 2019:1-15. [PMID: 31738606 DOI: 10.1080/10408363.2019.1688760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pulmonary hypertension (PH) is a syndrome characterized by a persistent increase in pulmonary vascular resistance. Due to the lack of specificity in clinical manifestations, patients are usually diagnosed at the late stage of PH, which is hard to treat and often causes right heart failure and death. Furthermore, the regulation and pathogenesis of PH remain obscure. Recently, long noncoding RNAs (lncRNAs), a type of transcript longer than 200 nt that lacks protein-coding ability, have been found to substantially influence the incidence and progression of various diseases through regulating gene expression at the chromatin, transcriptional, post-transcriptional, translational, and even post-translational levels. The crucial roles of lncRNAs in PH have started to draw widespread attention. This review summarizes the regulatory, pathogenic, and diagnostic roles of lncRNAs in PH, in the hope to facilitate the search for early diagnostic markers of and effective therapeutic targets for this devastating disease.
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Affiliation(s)
- Yan Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Medical University Eye Hospital, School of Optometry and Ophthalmology & Eye Institute, Tianjin, China
| | - Mianmian Wu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Medical University Eye Hospital, School of Optometry and Ophthalmology & Eye Institute, Tianjin, China
| | - Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou University, Lanzhou, China
| | - Fang Guo
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Medical University Eye Hospital, School of Optometry and Ophthalmology & Eye Institute, Tianjin, China
| | - Yahong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Medical University Eye Hospital, School of Optometry and Ophthalmology & Eye Institute, Tianjin, China
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Abstract
Objective: Chronic thromboembolic disease (CTED) is characterized by persistent pulmonary thromboembolic occlusions without pulmonary hypertension. Early surgical treatment by performing pulmonary endarterectomy (PEA) may improve symptoms. The goal of the study was to review our experience and early outcome of PEA in patients with CTED. Methods: Data were prospectively collected on all patients who underwent PEA between 2011 and 2015. Patients with CTED and a mean pulmonary artery pressure (mPAP) of <25 mm Hg were identified. All patients were in New York Heart Association (NYHA) functional class II or III. Measured outcomes were in-hospital complications, improvement in cardiac function and exercise capacity, and survival after PEA. Patients were reassessed at 6 months following surgery. Results: A total of 23 patients underwent surgery. There was no in-hospital mortality, but complications occurred in six patients (26%). At 6 months following surgery, 93% of the patients remained alive. Following PEA, the mPAP fell significantly from 21.0±2.7 mm Hg to 18.2±5.5 mm Hg (p<.001). Pulmonary vascular resistance also significantly decreased from 2.2±0.7 wood to 1.5±0.5 wood (p<.001). The 6-min walking distance significantly increased from 322.6±80.4 m to 379.9±68.2 m (p<.001). There was a significant symptomatic improvement in all survivors in NYHA functional classes I or II at 6 months following surgery (p=.001). Conclusion: PEA in selected patients with CTED resulted in significant improvement in symptoms. The selection of patients for undergoing PEA in the absence of pulmonary hypertension must be made based on patients’ expectations and their acceptance of the perioperative risk.
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Teal S, Auger WR, Hughes RJ, Ramey DR, Lewis KS, O'Brien G, Yaldo A, Burton TM, Bancroft T, Seare J, Fabian J. Validation of a claims-based algorithm to identify patients with chronic thromboembolic pulmonary hypertension using electronic health record data. Pulm Circ 2018; 9:2045894018814772. [PMID: 30419792 PMCID: PMC6287311 DOI: 10.1177/2045894018814772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
This study aimed to validate an algorithm developed to identify chronic thromboembolic pulmonary hypertension (CTEPH) among patients with a history of pulmonary embolism. Validation was halted because too few patients had gold-standard evidence of CTEPH in the administrative claims/electronic health records database, suggesting that CTEPH is underdiagnosed.
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Affiliation(s)
| | | | | | | | - Kelly S Lewis
- 5 Bayer Healthcare Pharmaceuticals, Whippany, NJ, USA
| | | | - Avin Yaldo
- 5 Bayer Healthcare Pharmaceuticals, Whippany, NJ, USA
| | | | | | | | - Joerg Fabian
- 7 Bayer Business Services GmbH, Leverkusen, Germany
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Stam K, van Duin RW, Uitterdijk A, Krabbendam-Peters I, Sorop O, Danser AHJ, Duncker DJ, Merkus D. Pulmonary microvascular remodeling in chronic thrombo-embolic pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2018; 315:L951-L964. [PMID: 30260284 DOI: 10.1152/ajplung.00043.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pulmonary vascular remodeling in pulmonary arterial hypertension involves perturbations in the nitric oxide (NO) and endothelin-1 (ET-1) pathways. However, the implications of pulmonary vascular remodeling and these pathways remain unclear in chronic thrombo-embolic pulmonary hypertension (CTEPH). The objective of the present study was to characterize changes in microvascular morphology and function, focussing on the ET-1 and NO pathways, in a CTEPH swine model. Swine were chronically instrumented and received up to five pulmonary embolizations by microsphere infusion, whereas endothelial dysfunction was induced by daily administration of the endothelial NO synthase inhibitor Nω-nitro-l-arginine methyl ester until 2 wk before the end of study. Swine were subjected to exercise, and the pulmonary vasculature was investigated by hemodynamic, histological, quantitative PCR, and myograph experiments. In swine with CTEPH, the increased right-ventricular afterload, decreased cardiac index, and mild ventilation-perfusion-mismatch were exacerbated during exercise. Pulmonary microvascular remodeling was evidenced by increased muscularization, which was accompanied by an increased maximal vasoconstriction. Although ET-1-induced vasoconstriction was increased in CTEPH pulmonary small arteries, the ET-1 sensitivity was decreased. Moreover, the contribution of the ETA receptor to ET-1 vasoconstriction was increased, whereas the contribution of the ETB receptor was decreased and the contribution of Rho-kinase was lost. A reduction in endogenous NO production was compensated in part by a decreased phosphodiesterase 5 (PDE5) activity resulting in an apparent increased NO sensitivity in CTEPH pulmonary small arteries. These findings suggest that pulmonary microvascular remodeling with a reduced activity of PDE5 and Rho-kinase may contribute to the lack of therapeutic efficacy of PDE5 inhibitors and Rho-kinase inhibitors in CTEPH.
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Affiliation(s)
- Kelly Stam
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Richard W van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - André Uitterdijk
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Ilona Krabbendam-Peters
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Oana Sorop
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - A H Jan Danser
- Department of Pharmacology, Erasmus Medical Center , Rotterdam , The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
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Bhogal S, Mukherjee D, Banerjee S, Islam AM, Daggubati R, Paul TK. Current Trends and Future Perspectives in the Treatment of Pulmonary Hypertension: WHO Group II-V. Curr Probl Cardiol 2018; 43:217-231. [PMID: 29153390 DOI: 10.1016/j.cpcardiol.2017.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Santos-Martínez LE, Rodríguez-Almendros NA, Flores-García CA, Soto-Márquez P, Jiménez-Santos M, Estrada Gallegos J, Cuttiel Calderón-Abbo M. Hipertensión pulmonar tromboembólica crónica no quirúrgica en sujeto con síndrome antifosfolípido. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:158-161. [DOI: 10.1016/j.acmx.2017.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 07/11/2017] [Accepted: 07/16/2017] [Indexed: 11/26/2022] Open
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Stam K, van Duin RWB, Uitterdijk A, Cai Z, Duncker DJ, Merkus D. Exercise facilitates early recognition of cardiac and vascular remodeling in chronic thromboembolic pulmonary hypertension in swine. Am J Physiol Heart Circ Physiol 2017; 314:H627-H642. [PMID: 29167118 DOI: 10.1152/ajpheart.00380.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) develops in 4% of patients after pulmonary embolism and is accompanied by an impaired exercise tolerance, which is ascribed to the increased right ventricular (RV) afterload in combination with a ventilation/perfusion (V/Q) mismatch in the lungs. The present study aimed to investigate changes in arterial Po2 and hemodynamics in response to graded treadmill exercise during development and progression of CTEPH in a novel swine model. Swine were chronically instrumented and received multiple pulmonary embolisms by 1) microsphere infusion (Spheres) over 5 wk, 2) endothelial dysfunction by administration of the endothelial nitric oxide synthase inhibitor Nω-nitro-l-arginine methyl ester (L-NAME) for 7 wk, 3) combined pulmonary embolisms and endothelial dysfunction (L-NAME + Spheres), or 4) served as sham-operated controls (sham). After a 9 wk followup, embolization combined with endothelial dysfunction resulted in CTEPH, as evidenced by mean pulmonary artery pressures of 39.5 ± 5.1 vs. 19.1 ± 1.5 mmHg (Spheres, P < 0.001), 22.7 ± 2.0 mmHg (L-NAME, P < 0.001), and 20.1 ± 1.5 mmHg (sham, P < 0.001), and a decrease in arterial Po2 that was exacerbated during exercise, indicating V/Q mismatch. RV dysfunction was present after 5 wk of embolization, both at rest (trend toward increased RV end-systolic lumen area, P = 0.085, and decreased stroke volume index, P = 0.042) and during exercise (decreased stroke volume index vs. control, P = 0.040). With sustained pulmonary hypertension, RV hypertrophy (Fulton index P = 0.022) improved RV function at rest and during exercise, but this improvement was insufficient in CTEPH swine to result in an exercise-induced increase in cardiac index. In conclusion, embolization in combination with endothelial dysfunction results in CTEPH in swine. Exercise increased RV afterload, exacerbated the V/Q mismatch, and unmasked RV dysfunction. NEW & NOTEWORTHY Here, we present the first double-hit chronic thromboembolic pulmonary hypertension swine model. We show that embolization as well as endothelial dysfunction is required to induce sustained pulmonary hypertension, which is accompanied by altered exercise hemodynamics and an exacerbated ventilation/perfusion mismatch during exercise.
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Affiliation(s)
- Kelly Stam
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Richard W B van Duin
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - André Uitterdijk
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Zongye Cai
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Dirk J Duncker
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Daphne Merkus
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
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