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Keiler EA, Kerr KM, Poch DS, Yang JZ, Papamatheakis DG, Alotaibi M, Bautista A, Pretorius VG, Madani MM, Kim NH, Fernandes TM. NT-pro-BNP is predictive of morbidity and mortality after pulmonary thromboendarterectomy and is independent of preoperative hemodynamics. Pulm Circ 2024; 14:e12367. [PMID: 38646413 PMCID: PMC11027071 DOI: 10.1002/pul2.12367] [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: 06/25/2023] [Revised: 02/12/2024] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Current predictors of clinical outcomes after pulmonary thromboendarterectomy (PTE) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) are largely limited to preoperative clinical characteristics. N-terminal-pro-brain natriuretic peptide (NT-pro-BNP), a biomarker of right ventricular dysfunction, has not yet been well described as one such predictor. From 2017 to 2021, 816 patients with CTEPH referred to the University of California, San Diego for PTE were reviewed for differences in NT-pro-BNP to predict preoperative characteristics and postoperative outcomes up to 30 days post-PTE. For analysis, NT-pro-BNP was dichotomized to less than/equal to or greater than 1000 pg/mL based on the mean of the study population. Mean NT-pro-BNP was 1095.9 ±1783.4 pg/mL and median was 402.5 pg/mL (interquartile range: 119.5-1410.8). Of the 816 patients included, 250 had NT-pro-BNP > 1000 pg/mL. Those with NT-pro-BNP > 1000 pg/mL were significantly more likely to have worse preoperative functional class (III-IV) and worse preoperative hemodynamics. Patients with NT-pro-BNP > 1000 pg/mL also tended to have more postoperative complications including reperfusion pulmonary edema (22% vs. 5.1%, p < 0.001), airway hemorrhage (8.4% vs. 4.9%, p = 0.075), residual pulmonary hypertension (11.9% vs. 3.1%, p < 0.001), and 30-day mortality (4.8% vs. 1.1%, p = 0.001). Even after adjusting for confounders, patients with NT-pro-BNP > 1000 pg/mL had a 2.48 times higher odds (95% confidence interval: 1.45-4.00) of reaching a combined endpoint that included the above complications. Preoperative NT-pro-BNP > 1000 pg/mL is a strong predictor of more severe preoperative hemodynamics and identifies patients at higher risk for postoperative complications.
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Affiliation(s)
- Emanuel A. Keiler
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Kim M. Kerr
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - David S. Poch
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Jenny Z. Yang
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Demosthenes G. Papamatheakis
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Angela Bautista
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Victor G. Pretorius
- Division of Cardiovascular and Thoracic SurgerySan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Michael M. Madani
- Division of Cardiovascular and Thoracic SurgerySan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Nick H. Kim
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Timothy M. Fernandes
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
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Caspersen CK, Ingemann-Molden S, Grove EL, Højen AA, Andreasen J, Klok FA, Rolving N. Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review. Thromb Res 2024; 235:52-67. [PMID: 38301376 DOI: 10.1016/j.thromres.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. METHODS The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. RESULTS The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. CONCLUSIONS Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.
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Affiliation(s)
| | - Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark; Department of Health Science and Technology, Aalborg University, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Denmark
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
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3
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Yang KM, Wang MT, Tao CW, Wu YJ, Hsu CH, Liao WC, Hsu HH, Lin MC, Tsai FT, Fu YJ, Kuo FY, Cheng CC, Hung CC, Wang HC, Yu CJ, Huang WC. The long-term outcome of chronic thromboembolic pulmonary hypertension: Pulmonary endarterectomy and balloon pulmonary angioplasty. J Chin Med Assoc 2024; 87:273-279. [PMID: 38252515 DOI: 10.1097/jcma.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The long-term outcome on patients with chronic thromboembolic pulmonary hypertension (CTEPH) has not been ideal after standard medical treatment. However, good outcome for patients with CTEPH after interventions such as pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA) has been reported recently. The aim of this study was to evaluate the impact of PEA or BPA on long-term outcomes for CTEPH patients in Han-Chinese population. METHODS This was a multicenter, prospective case-control study. Patients with CTEPH were enrolled between January, 2018 and March, 2020. They were divided into two groups, including intervention (PEA or BPA) and conservative groups. The followed-up period was 26 months after treatment. The endpoints were all-cause mortality and CTEPH mortality. RESULTS A total of 129 patients were enrolled and assigned to receive PEA/BPA (N = 73), or conservative therapy (N = 56). Overall, the 26-month survival rate of all-cause mortality was significantly higher in intervention group compared to that in conservative group (95.89% vs 80.36%; log-rank p = 0.0164). The similar trend was observed in the 26-month survival rate of CTEPH mortality (97.26% vs 85.71%; log-rank p = 0.0355). Regarding Cox proportional-hazard regression analysis, the hazard ratios (HRs) on patients with CTEPH receiving intervention in the outcome of all-cause mortality and CTEPH mortality were statistically significant (HR = 0.07 and p = 0.0141 in all-cause mortality; HR = 0.11 and p = 0.0461 in CTEPH mortality). CONCLUSION This multicenter prospective case-control study demonstrated that intervention such as PEA and BPA increased the long-term survival rate for patient with CTEPH significantly. Intervention was an independent factor in long-term outcome for patients with CTEPH, including all-cause mortality and CTEPH mortality.
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Affiliation(s)
- Kuo-Ming Yang
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Mei-Tzu Wang
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chaio Tung University, Taipei, Taiwan, ROC
| | - Chi-Wei Tao
- Division of Pulmonary Medicine, Department of Internal Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC
| | - Yih-Jer Wu
- Department of Medicine, MacKay Medical College and Cardiovascular Center, MacKay Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chih-Hsin Hsu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
- Department of Internal Medicine, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan, ROC
| | - Wei-Chih Liao
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, ROC
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Fu-Ting Tsai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yun-Ju Fu
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Yu Kuo
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Chin-Chang Cheng
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan, ROC
| | - Cheng-Chung Hung
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan, ROC
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, ROC
| | - Wei-Chun Huang
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chaio Tung University, Taipei, Taiwan, ROC
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan, ROC
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
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4
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Jevnikar M, Solinas S, Brenot P, Lechartier B, Kularatne M, Montani D, Savale L, Garcia-Alonso C, Sitbon O, Beurnier A, Boucly A, Bulifon S, Seferian A, Roche A, Mercier O, Simonneau G, Fadel E, Humbert M, Jaïs X. Sequential multimodal therapy in chronic thromboembolic pulmonary hypertension with mixed anatomical lesions: a proof of concept. Eur Respir J 2023; 62:2300517. [PMID: 37802632 DOI: 10.1183/13993003.00517-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/18/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Mitja Jevnikar
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- These authors contributed equally
| | - Sabina Solinas
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- These authors contributed equally
| | - Philippe Brenot
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Department of Radiology, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Benoit Lechartier
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Respiratory division, Lausanne University Hospitals, Lausanne, Switzerland
| | - Mithum Kularatne
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - David Montani
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Laurent Savale
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Carlos Garcia-Alonso
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Department of Radiology, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Beurnier
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Athénaïs Boucly
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Sophie Bulifon
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Andrei Seferian
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Anne Roche
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Olaf Mercier
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Gérald Simonneau
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Elie Fadel
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Xavier Jaïs
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Groupe Hospitalier Saint Joseph - Hôpital Marie Lannelongue, Le Plessis-Robinson, France
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5
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Haft JW, Yost G. Open Surgical Treatment of Acute and Chronic Pulmonary Embolism. Interv Cardiol Clin 2023; 12:339-347. [PMID: 37290838 DOI: 10.1016/j.iccl.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Acute pulmonary embolism (PE) is a common cause of death and morbidity in the United States and the prevalence of chronic thromboembolic pulmonary hypertension (CTEPH), a possible sequela of PE, has increased during the past decade. The mainstay treatment of CTEPH is open pulmonary endarterectomy, a procedure performed under hypothermic circulatory arrest, which entails endarterectomy of the branch, segmental and subsegmental pulmonary arteries. Acute PE may be similarly be treated with an open embolectomy in certain select circumstances.
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Affiliation(s)
- Jonathan W Haft
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA.
| | - Gardner Yost
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA
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6
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Hahn LD, Papamatheakis DG, Fernandes TM, Poch DS, Yang J, Shen J, Hoh CK, Hsiao A, Kerr KM, Pretorius V, Madani MM, Kim NH, Kligerman SJ. Multidisciplinary Approach to Chronic Thromboembolic Pulmonary Hypertension: Role of Radiologists. Radiographics 2023; 43:e220078. [DOI: 10.1148/rg.220078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Lewis D. Hahn
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Demosthenes G. Papamatheakis
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Timothy M. Fernandes
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - David S. Poch
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Jenny Yang
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Jody Shen
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Carl K. Hoh
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Albert Hsiao
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Kim M. Kerr
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Victor Pretorius
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Michael M. Madani
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Nick H. Kim
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Seth J. Kligerman
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
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7
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Song W, Zhu J, Zhong Z, Song Y, Liu S. Long-term outcome prediction for chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy. Clin Cardiol 2022; 45:1255-1263. [PMID: 36070474 DOI: 10.1002/clc.23900] [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: 05/23/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), which has good long-term outcomes. However, after surgery, a quarter of the patients still have residual pulmonary hypertension (RPH). In pulmonary hemodynamics, there are no unified criteria for RPH, even though the level may affect long-term survival. METHODS Between March 1997 and December 2021, 253 CTEPH patients were treated at our center with PEA. Patients were evaluated retrospectively and classified into early (1997-2014) and late (2015-2021) groups. The clinical characteristics and perioperative outcomes of the two groups were compared, and risk factor analysis for RPH and long-term survival for all cases was performed. RESULTS There was no statistically significant difference in demographics between the two groups. However, the Early Group had a significantly higher rate of perioperative death (9.8% vs. 1.2%, p = .001), RPH (48.8% vs. 14.0%, p < .001), and reperfusion pulmonary edema (18.3% vs. 2.9%, p < .001). The median follow-up time was 66.0 months, and overall survival rates at 5, 10, 15, and 18 years after PEA were 91.2%, 83.9%, 64.5%, and 46.0%, respectively. Age and postoperative systolic pulmonary artery pressure (sPAP) were independently related to long-term outcomes in the multivariate Cox analyses. Patients with postoperative sPAP less than 46 mm Hg had a higher chance of survival. CONCLUSIONS PEA improved CTEPH hemodynamics immediately and had a positive effect on long-term survival. Patients with postoperative sPAP ≥ 46 mm Hg indicate clinically significant RPH and have a lower long-term survival rate.
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Affiliation(s)
- Wu Song
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiade Zhu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - ZhaoJi Zhong
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yunhu Song
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Sheng Liu
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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8
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Surgical Management of Chronic Thromboembolic Pulmonary Hypertension. Cardiol Clin 2022; 40:89-101. [PMID: 34809920 PMCID: PMC8720361 DOI: 10.1016/j.ccl.2021.08.008] [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] [Indexed: 02/03/2023]
Abstract
Chronic thromboembolic pulmonary hypertension is a progressive disease, which may lead to severe right ventricular dysfunction and debilitating symptoms. Pulmonary thromboendarterectomy (PTE) provides the best opportunity for complete resolution of obstructing thromboembolic disease and functional improvement in appropriately selected patients. In this article, the authors review preoperative workup, patient selection, operative technique, postoperative care, and outcomes after PTE.
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9
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Kearney K, Gold J, Corrigan C, Dhital K, Boshell D, Haydock D, McGiffin D, Wilson M, Collins N, Cordina R, Dwyer N, Feenstra J, Lavender M, Wrobel J, Whitford H, Williams T, Keating D, Whyte K, McWilliams T, Keogh A, Strange G, Kotlyar E, Anderson J, Lau EM. Chronic thromboembolic pulmonary hypertension in Australia and New Zealand: An analysis of the PHSANZ registry. Respirology 2021; 26:1171-1180. [PMID: 34608706 DOI: 10.1111/resp.14162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 07/29/2021] [Accepted: 09/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition occurring in 2%-4% of patients after acute pulmonary embolism. Pulmonary endarterectomy (PEA) is a potential cure for technically operable disease. The epidemiology and long-term outcomes of CTEPH have not been previously described in Australia and New Zealand. METHODS Data were extracted from the Pulmonary Hypertension Society of Australia and New Zealand (PHSANZ) registry for patients diagnosed with CTEPH between January 2004 and March 2020. Baseline characteristics, treatment strategies, outcome data and long-term survival are reported. RESULTS A total of 386 patients were included with 146 (37.8%) undergoing PEA and 240 (62.2%) in the non-PEA group. PEA patients were younger (55 ± 16 vs. 62 ± 16 years, p < 0.001) with higher baseline 6-min walk distance (6MWD; 405 ± 122 vs. 323 ± 146 m, p = 0.021), whilst both groups had similar baseline pulmonary haemodynamics. Pulmonary hypertension-specific therapy was used in 54% of patients post-PEA and 88% in the non-PEA group. The 1-, 3- and 5-year survival rates were 93%, 87% and 84% for the PEA group compared to 86%, 73% and 62%, respectively, for the non-PEA group (p < 0.001). Multivariate survival analysis showed baseline 6MWD was an independent predictor of survival in both operated and medically managed patients. CONCLUSION In this first multicentre report of CTEPH in Australia and New Zealand, long-term survival is comparable to that in other contemporary CTEPH registries. However, PEA was only performed in a minority of CTEPH patients (37.8%) and significantly less than overseas reports. Greater awareness of PEA and improved patient access to experienced CTEPH centres are important priorities.
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Affiliation(s)
- Katherine Kearney
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua Gold
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Carolyn Corrigan
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Kumud Dhital
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - David Boshell
- Medical Imaging Department, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - David Haydock
- Greenlane Cardiothoracic Surgical Unit, Auckland City Hospital, Auckland, New Zealand
| | - David McGiffin
- Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Wilson
- Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Nathan Dwyer
- Cardiology Department, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - John Feenstra
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Helen Whitford
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Trevor Williams
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Dominic Keating
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Ken Whyte
- Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Tanya McWilliams
- Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Anne Keogh
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Geoff Strange
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - James Anderson
- Respiratory Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Edmund Mt Lau
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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10
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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11
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Türer Cabbar A, Değertekin MM, Şimşek MA, Özveren O, Güleç S, Yanartaş M, Gezer Taş S, Olgun Yıldızeli Ş, Mutlu B, İşbir T, Yıldızeli B. Evaluation of Asymmetric Dimethylarginine Levels in Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy. Heart Lung Circ 2021; 31:110-118. [PMID: 34130918 DOI: 10.1016/j.hlc.2021.05.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/13/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary embolism, and pulmonary endarterectomy (PEA) is the surgical treatment. Asymmetric dimethylarginine (ADMA) levels are increased in pulmonary hypertension. This study aimed to investigate serum ADMA levels in patients with CTEPH, the effect of PEA on ADMA, and its prognostic value in long-term mortality. METHOD Eighty (80) patients with CTEPH and 32 healthy controls were included. Preoperative serum ADMA levels, determined using an enzyme-linked immunosorbent assay, were compared between patients with CTEPH and controls. Of 80 patients, 64 had PEA. Pre- and 6-month postoperative serum ADMA levels, 6-minute walk distance (6MWD), and haemodynamic parameters were collected from patients undergoing PEA. Patients were followed-up for survival analysis. RESULTS Mean ± standard deviation serum ADMA levels were significantly higher in patients with CTEPH compared with controls (0.79±0.32 μmol/L vs 0.52±0.12 μmol/L; p=0.0001). Statistically significant differences were observed between preoperative and postoperative serum ADMA levels (0.78±0.30 μmol/L vs 0.62±0.22 μmol/L; p=0.0001), 6MWD (p=0.0001), and pulmonary vascular resistance (p=0.0001) in 60 patients who underwent and survived PEA. The decrease in serum ADMA levels and increase in 6MWD were significantly correlated (r=-0.286, p=0.027). No other correlation was found. Perioperative mortality was 6.3%, and the survival rate with a mean follow-up of 34.57±8.20 months was 93.3%. Patients with serum ADMA levels >0.8 μmol/L had a significantly lower survival rate (logrank: 5.86; p=0.015). CONCLUSIONS Levels of circulating ADMA might add diagnostic and prognostic information in CTEPH. Pulmonary endarterectomy is associated with an improvement in serum ADMA levels. Preoperative serum ADMA levels may be useful for estimating the outcome of PEA.
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Affiliation(s)
- Ayça Türer Cabbar
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey.
| | | | - Mustafa A Şimşek
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Olcay Özveren
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Seda Güleç
- Department of Medical Biology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Mehmed Yanartaş
- Department of Cardiovascular Surgery, Kartal Koşuyolu High Specialty Educational and Research Hospital, Istanbul, Turkey
| | - Serpil Gezer Taş
- Department of Cardiovascular Surgery, Kartal Koşuyolu High Specialty Educational and Research Hospital, Istanbul, Turkey
| | - Şehnaz Olgun Yıldızeli
- Department of Pulmonary and Intensive Care, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
| | - Bülent Mutlu
- Department of Cardiology, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
| | - Turgay İşbir
- Department of Medical Biology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
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12
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Papamatheakis DG, Poch DS, Fernandes TM, Kerr KM, Kim NH, Fedullo PF. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol 2021; 76:2155-2169. [PMID: 33121723 DOI: 10.1016/j.jacc.2020.08.074] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of pulmonary arterial obstruction by organized thrombotic material stemming from incompletely resolved acute pulmonary embolism. The exact incidence of CTEPH is unknown but appears to approximate 2.3% among survivors of acute pulmonary embolism. Although ventilation/perfusion scintigraphy has been supplanted by computed tomographic pulmonary angiography in the diagnostic approach to acute pulmonary embolism, it has a major role in the evaluation of patients with suspected CTEPH, the presence of mismatched segmental defects being consistent with the diagnosis. Diagnostic confirmation of CTEPH is provided by digital subtraction pulmonary angiography, preferably performed at a center familiar with the procedure and its interpretation. Operability assessment is then undertaken to determine if the patient is a candidate for potentially curative pulmonary endarterectomy surgery. When pulmonary endarterectomy is not an option, pulmonary arterial hypertension-targeted pharmacotherapy and balloon pulmonary angioplasty represent potential therapeutic alternatives.
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Affiliation(s)
- Demosthenes G Papamatheakis
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - David S Poch
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Timothy M Fernandes
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Nick H Kim
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Peter F Fedullo
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California.
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13
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Zhang L, Bai Y, Yan P, He T, Liu B, Wu S, Qian Z, Li C, Cao Y, Zhang M. Balloon pulmonary angioplasty vs. pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis. Heart Fail Rev 2021; 26:897-917. [PMID: 33544306 DOI: 10.1007/s10741-020-10070-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
Although balloon pulmonary angioplasty (BPA) and pulmonary endarterectomy (PEA) are effective in chronic thromboembolic pulmonary hypertension (CTEPH), the comparison of their efficacy and safety is still unclear. We identified studies through a systematic review of PubMed, Cochrane Library, and Embase and used a random effects meta-analysis model to synthesize estimates of weighted mean differences or combined effect size. In total, 54 studies were included in this meta-analysis. The survival rates at perioperative/in-hospital period, 2 years, and 3 years were 100%, 99%, and 97%, respectively, in BPA group and 93%, 90%, and 88%, respectively, in PEA group. The variation of 6-min walk distance was 141.80 m in BPA and 100.73 m in PEA when the follow-up was 1-6 months. At < 1-month, 1-6-month, and > 12-month follow-up, the changed results of mean pulmonary arterial pressure were - 18.31, - 17.00, and - 12.97 mmHg in BPA group and - 18.93, - 21.21, and - 21.35 mmHg in PEA group. At < 1-month and 1-6-month follow-up, the changed values of pulmonary vascular resistance were - 542.24 and - 599.77 dyne•s•cm-5 in PEA group and - 443.49 and - 280.00 dyne•s•cm-5 in BPA group. In addition, there was more wide variety of complications in PEA group than in BPA group. BPA might have higher survival rate (perioperative/in-hospital period, 2-year and 3-year follow-up) and fewer types of complications compared with PEA. The improvement in exercise capacity (1-6-month follow-up) in the BPA group might be more pronounced than in PEA group. Moreover, PEA might be superior in improvement of hemodynamic parameters (< 1-month, 1-6-month, and > 12-month follow-up).
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Affiliation(s)
- Liyan Zhang
- School of Basic Medicine, Gansu University of Chinese Medicine, Lanzhou, 730000, China.,Department of Scientific Research Office, Gansu Provincial Hospital, Lanzhou, 730000, China.,Department of Pathology, the 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, 730050, Lanzhou, China
| | - Yuping Bai
- School of Basic Medicine, Gansu University of Chinese Medicine, Lanzhou, 730000, China.,Department of Scientific Research Office, Gansu Provincial Hospital, Lanzhou, 730000, China.,Department of Pathology, the 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, 730050, Lanzhou, China
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, 610044, Sichuan, China
| | - Tingting He
- School of Basic Medicine, Gansu University of Chinese Medicine, Lanzhou, 730000, China.,Department of Scientific Research Office, Gansu Provincial Hospital, Lanzhou, 730000, China.,Department of Pathology, the 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, 730050, Lanzhou, China
| | - Bin Liu
- Department of Pathology, the 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, 730050, Lanzhou, China
| | - Shanlian Wu
- Department of Pathology, Ganzhou People's Hospital, Ganzhou, 341000, China
| | - Zhen Qian
- Department of Pathology, the 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, 730050, Lanzhou, China
| | - Changtian Li
- School of Basic Medicine, Gansu University of Chinese Medicine, Lanzhou, 730000, China
| | - Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, 730000, China.
| | - Min Zhang
- Department of Scientific Research Office, Gansu Provincial Hospital, Lanzhou, 730000, China.
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14
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Küçükoğlu MS, Sinan ÜY, Yıldızeli B. Ten-year outcome of chronic thromboembolic pulmonary hypertension patients in a tertiary center. Anatol J Cardiol 2020; 23:105-109. [PMID: 32011330 PMCID: PMC7040873 DOI: 10.14744/anatoljcardiol.2019.90329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of pulmonary hypertension (PH). We aimed to investigate the outcome of CTEPH patients who were followed-up by a PH outpatient clinic. METHODS We screened the medical records of 29 PH patients who were followed-up by a PH outpatient clinic between 2009 and 2018. The patients' demographics and their clinical, echocardiographic, and hemodynamic characteristics were recorded. RESULTS Our study group consisted of 16 females (55.2%) and 13 males (44.8%). The mean age was 59.5±13.7 years and the median follow-up duration was 44 months (1-113 months). The mean initial 6-minute walking distance (6MWD) was 321.4±119.9 m. The initial median N-terminal pro brain natriuretic peptide (NT-proBNP) level was 2468 pg/mL (46.1-20.564 pg/mL). All patients were on oral anticoagulant therapy. Pulmonary endarterectomy (PEA) was performed in 17 of 29 patients (58.6%). Twelve patients (41.4%) were not operated upon due to distal disease, comorbidities, or their own preference. The operated patients were younger than the non-operated patients (55 years & 65 years, p=0.04). At the follow-up, the 6MWD in the operated patients increased (+76 m) and decreased in non-operated patients (-46 m). The survival rate at 10-year follow-up was 58.6% for the whole group. Twelve patients died during the follow-up period. While 7 of 12 not-operated patients died (58.3%), just 5 of 17 operated patients (4 perioperatively and 1 at follow-up) died (29%). Advanced-stage final functional capacity (FC) [New York Heart Association (NYHA) III-IV], inoperability, lower final 6MWD, higher final NT-proBNP, and reduced tricuspid annular plane systolic excursion (TAPSE) were associated with an increased mortality rate. Univariate Cox regression analysis showed that patients with NYHA I-II final FC showed a 166-fold decreased mortality rate. CONCLUSION The long-term prognosis of operated patients is better than the outcome of not-operated patients. The strongest predictor associated with mortality was a worse final FC (NYHA III-IV).
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Affiliation(s)
- Mehmet Serdar Küçükoğlu
- Department of Cardiology, Faculty of Medicine, İstanbul University, Cerrahpaşa Institute of Cardiology; İstanbul-Turkey
| | - Ümit Yaşar Sinan
- Department of Cardiology, Faculty of Medicine, İstanbul University, Cerrahpaşa Institute of Cardiology; İstanbul-Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, Faculty of Medicine, Marmara University; İstanbul-Turkey
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15
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Mahmud E, Madani MM, Kim NH, Poch D, Ang L, Behnamfar O, Patel MP, Auger WR. Chronic Thromboembolic Pulmonary Hypertension: Evolving Therapeutic Approaches for Operable and Inoperable Disease. J Am Coll Cardiol 2019; 71:2468-2486. [PMID: 29793636 DOI: 10.1016/j.jacc.2018.04.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 03/19/2018] [Accepted: 04/03/2018] [Indexed: 12/31/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH), a rare consequence of an acute pulmonary embolism, is a disease that is underdiagnosed, and surgical pulmonary thromboendarterectomy (PTE) remains the preferred therapy. However, determination of operability is multifactorial and can be challenging. There is growing excitement for the percutaneous treatment of inoperable CTEPH with data from multiple centers around the world showing the clinical feasibility of balloon pulmonary angioplasty. Riociguat remains the only approved medical therapy for CTEPH patients deemed inoperable or with persistent pulmonary hypertension after PTE. We recommend that expert multidisciplinary CTEPH teams be developed at individual institutions. Additionally, optimal and standardized techniques for balloon pulmonary angioplasty need to be developed along with dedicated interventional equipment and appropriate training standards. In the meantime, the percutaneous revascularization option is appropriate for patients deemed inoperable in combination with targeted medical therapy, or those who have failed to benefit from surgery.
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Affiliation(s)
- Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California.
| | - Michael M Madani
- Division of Cardiothoracic Surgery, University of California San Diego, La Jolla, California
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | - David Poch
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | - Lawrence Ang
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - Omid Behnamfar
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - Mitul P Patel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - William R Auger
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
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16
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disease with significant morbidity. It is a result of an alternate natural history in which there is limited resolution of thromboemboli with pulmonary artery obstruction leading to pulmonary hypertension (PH). CTEPH requires a thorough clinical assessment including pulmonary hemodynamics and radiologic evaluation in addition to consultation with an expert center. Surgical intervention remains the optimal management strategy. Select patients may be candidates for catheter-based intervention with balloon pulmonary angioplasty in centers with clinical expertise. Inoperable patients or those with post-intervention PH are treated with pulmonary hypertension-targeted medical therapy.
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Affiliation(s)
- Jean M Elwing
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0564, Cincinnati, OH 45267, USA.
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and Pulmonary Thromboendarterectomy Program, Advanced Heart Failure and Cardiac Transplant, Temple University School of Medicine, Temple University Hospital, 9th Floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - William R Auger
- CTEPH Program, UC San Diego Health, University of California, San Diego, 9300 Campus Point Drive #7381, La Jolla, CA 92037, USA
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17
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Quadery SR, Swift AJ, Billings CG, Thompson AAR, Elliot CA, Hurdman J, Charalampopoulos A, Sabroe I, Armstrong IJ, Hamilton N, Sephton P, Garrad S, Pepke-Zaba J, Jenkins DP, Screaton N, Rothman AM, Lawrie A, Cleveland T, Thomas S, Rajaram S, Hill C, Davies C, Johns CS, Wild JM, Condliffe R, Kiely DG. The impact of patient choice on survival in chronic thromboembolic pulmonary hypertension. Eur Respir J 2018; 52:1800589. [PMID: 30002102 PMCID: PMC6340636 DOI: 10.1183/13993003.00589-2018] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/15/2018] [Indexed: 11/05/2022]
Abstract
Pulmonary endarterectomy (PEA) is the gold standard treatment for operable chronic thromboembolic pulmonary hypertension (CTEPH). However, a proportion of patients with operable disease decline surgery. There are currently no published data on this patient group. The aim of this study was to identify outcomes and prognostic factors in a large cohort of consecutive patients with CTEPH.Data were collected for consecutive, treatment-naive CTEPH patients at the Pulmonary Vascular Disease Unit of the Royal Hallamshire Hospital (Sheffield, UK) between 2001 and 2014.Of 550 CTEPH patients (mean±sd age 63±15 years, follow-up 4±3 years), 49% underwent surgery, 32% had technically operable disease and did not undergo surgery (including patient choice n=72 and unfit for surgery n=63), and 19% had inoperable disease due to disease distribution. The 5-year survival was superior in patients undergoing PEA (83%) versus technically operable disease who did not undergo surgery (53%) and inoperable due to disease distribution (59%) (p<0.001). Survival was superior in patients following PEA compared with those offered but declining surgery (55%) (p<0.001). In patients offered PEA, independent prognostic factors included mixed venous oxygen saturation, gas transfer and patient decision to proceed to surgery.Outcomes in CTEPH following PEA are excellent and superior to patients declining surgery, and strongly favour consideration of a surgical intervention in eligible patients.
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Affiliation(s)
- Syed Rehan Quadery
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Catherine G Billings
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alfred A R Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Charles A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Judith Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Iain J Armstrong
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Sephton
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sian Garrad
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - David P Jenkins
- Pulmonary Vascular Disease Unit, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nicholas Screaton
- Pulmonary Vascular Disease Unit, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Alexander M Rothman
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Allan Lawrie
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Trevor Cleveland
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Steven Thomas
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Smitha Rajaram
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Catherine Hill
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christine Davies
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christopher S Johns
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Dept of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jim M Wild
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- These authors contributed equally to this work
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Dept of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in silico Medicine, University of Sheffield, Sheffield, UK
- These authors contributed equally to this work
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18
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Residual pulmonary hypertension after pulmonary endarterectomy: A meta-analysis. J Thorac Cardiovasc Surg 2018; 156:1275-1287. [DOI: 10.1016/j.jtcvs.2018.04.110] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/20/2018] [Accepted: 04/26/2018] [Indexed: 11/17/2022]
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19
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Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. Cardiovasc Intervent Radiol 2018; 41:1826-1839. [DOI: 10.1007/s00270-018-2012-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/14/2018] [Indexed: 12/31/2022]
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20
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Clay E, Jamotte A, Verhamme P, Cohen AT, Van Hout BA, Gumbs P. Cost-effectiveness of edoxaban compared to warfarin for the treatment and secondary prevention of venous thromboembolism in the UK. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2018; 6:1495974. [PMID: 30034645 PMCID: PMC6052426 DOI: 10.1080/20016689.2018.1495974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/27/2018] [Indexed: 06/08/2023]
Abstract
Background: Venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep vein thrombosis (DVT), is the third most common acute cardiovascular disease and represents an important burden for patients and payers. Objective: The aim was to estimate the cost-effectiveness of edoxaban, a non-VKA oral anticoagulant vs. warfarin, the currently most prescribed treatment for VTE in the UK. Study design: A Markov model was built using data from the Hokusai-VTE randomised controlled trial to estimate the lifetime costs and quality-adjusted life years (QALYs) in patients with VTE treated with edoxaban or warfarin over a lifetime horizon, from the UK National Health Services perspective. The model included VTE recurrences, VTE-related complications (post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension), and several types of bleeds associated with anticoagulation treatment. Patients were treated during a period of 6 months after the first VTE event, followed by flexible treatment duration (from 6 months to lifetime) after recurrence, i.e., tertiary prevention. Results: Edoxaban was found dominant vs. warfarin with 0.033 additional QALY and £55 less costs. The reduction of patient management costs, specifically monitoring costs, outweighed the higher drug costs. Edoxaban was dominant in all subgroups (index DVT only, all PE cases (PE with or without DVT), PE without DVT and PE with DVT). Cost-savings ranged from £54 to £81 while additional QALYs ranged from 0.031 to 0.046. Edoxaban was found dominant in 88.6% of cases and cost-effective in additional 10.9% of cases considering a £20,000 threshold in the probabilistic sensitivity analysis. Conclusion: Edoxaban may improve patients' quality of life in a lifetime horizon without additional costs for the healthcare system due to lower bleeding risk and no monitoring cost compared to warfarin.
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Affiliation(s)
- Emilie Clay
- Health Economic Outcome Research, Creativ-Ceutical, Paris, France
| | - Aurélien Jamotte
- Health Economic Outcome Research, Creativ-Ceutical, Paris, France
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Alexander T. Cohen
- Department of Thrombosis and Haemostasis, Guy’s & St. Thomas’ Hospital, London, UK
| | - Ben. A. Van Hout
- School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Pearl. Gumbs
- Market Access, Daiichi Sankyo Europe, Munich, Germany
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21
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Tromeur C, Jaïs X, Mercier O, Couturaud F, Montani D, Savale L, Jevnikar M, Weatherald J, Sitbon O, Parent F, Fabre D, Mussot S, Dartevelle P, Humbert M, Simonneau G, Fadel E. Factors predicting outcome after pulmonary endarterectomy. PLoS One 2018; 13:e0198198. [PMID: 29927944 PMCID: PMC6013172 DOI: 10.1371/journal.pone.0198198] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/15/2018] [Indexed: 11/18/2022] Open
Abstract
Objective Few studies have reported predictive factors of outcome after pulmonary endarterectomy (PEA) in chronic thromboembolic pulmonary hypertension. The purpose of this study was to determine factors influencing mortality and predictors of hemodynamic improvement after PEA. Methods A total of 383 consecutive patients who underwent PEA between January 2005 and December 2009 were retrospectively reviewed. Among them, 150 were fully reevaluated 7.5±1 months after PEA by NYHA class, 6–minute walk distance (6MWD), percentage of predicted carbon monoxide transfer factor (TLCO) and right heart catheterisation. Results Mortality rates at 1 month, 1 year and 3 years were 2.8%, 6.9% and 7.5%, respectively. Preoperative pulmonary vascular resistance (PVR) independently predicted 1-month, 1- and 3-year mortality and age predicted mortality at 1 year and 3 years. Significant improvement in NYHA class and 6MWD were observed and PVR decreased from 773±353 to 307±221 dyn.sec.cm-5 (p<0.001). In 96 patients (64%), PVR decreased by at least 50% and/or was reduced to lower than 250 dyn.sec.cm-5. Preoperative cardiac output (CO) and TLCO predicted hemodynamic improvement. Conclusion PEA is associated with an excellent long-term survival and a marked improvement in clinical status and hemodynamics. Some preoperative factors including PVR, CO and TLCO can predict postoperative outcomes.
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Affiliation(s)
- Cécile Tromeur
- European Brittany University, Brest, France
- Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France
- Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France
- * E-mail:
| | - Xavier Jaïs
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Francis Couturaud
- European Brittany University, Brest, France
- Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France
- Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France
| | - David Montani
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Savale
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Mitja Jevnikar
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Jason Weatherald
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
| | - Olivier Sitbon
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Florence Parent
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Dominique Fabre
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Sacha Mussot
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Philippe Dartevelle
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Gérald Simonneau
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Elie Fadel
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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22
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Chernyavsky AM, Edemsky AG, Chernyavsky MA, Tarkova AR, Kliver EN, Ivanov SN. [5-year surgical results in patients with chronic postembolic pulmonary hypertension]. Khirurgiia (Mosk) 2017:21-24. [PMID: 28303869 DOI: 10.17116/hirurgia2017221-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate 5-year results of surgical treatment of patients with chronic postembolic pulmonary hypertension. MATERIAL AND METHODS 170 patients with chronic postembolic pulmonary hypertension underwent pulmonary thrombendarterectomy. Mean age was 48±21.5 years. The operation was carried out using standard technique with hypothermia and circulatory arrest. We have analyzed clinical and functional status of 47 patients (23 males) prior to surgery and in long-term postoperative period (5-6 years). Distance of 6-minute walk test, mean pulmonary artery pressure and vascular resistance according to right heart catheterization, RV ejection fraction and volumes according to echocardiography, pulmonary artery diameter according to CT-angiography were analyzed. RESULTS In remote postoperative period average distance of 6-minute walk test was increased by 2.8 times compared with initial values. Right heart catheterization revealed reduction of the average pulmonary pressure from 54.04±23.35 to 25.16±15.41 mmHg and vascular resistance from 539.66±120.59 dyn·sec·cm-5 to 101.39±89.20 dyn·sec·cm-5. Echocardiography showed increase of RV EF from 36±2.3 to 51.8±4.1% and decrease of RV end-diastolic volume from 109.4±39.2 to 39.1±6.8 ml. According CT-angiography there was decrease of pulmonary trunk diameter from 35.10±5.25 to 30.30±8.65 mm. CONCLUSION Our 5-year data show that pulmonary thrombendarterectomy has high long-term effectiveness in patients with proximal form of chronic postembolic pulmonary hypertension.
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Affiliation(s)
- A M Chernyavsky
- Meshalkin Novosibirsk Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation
| | - A G Edemsky
- Meshalkin Novosibirsk Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation
| | - M A Chernyavsky
- Meshalkin Novosibirsk Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation
| | - A R Tarkova
- Meshalkin Novosibirsk Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation
| | - E N Kliver
- Meshalkin Novosibirsk Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation
| | - S N Ivanov
- Meshalkin Novosibirsk Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation
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23
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but life-threatening form of pulmonary artery hypertension that is defined as a mean arterial pulmonary pressure greater than 25mmHg that persists for more than 6 months following anticoagulation therapy in the setting of pulmonary emboli. CTEPH is categorized by the World Health Organization as group IV pulmonary hypertension and is thought to be due to unresolved thromboemboli in the pulmonary artery circulation. Among the 5 classes of pulmonary hypertension, CTEPH is unique in that it is potentially curable with the use of pulmonary thromboendarterectomy surgery. Despite an increasing array of medical and surgical treatment options for patients with CTEPH over the past 2 decades, patients commonly present with advanced disease and carry a poor prognosis, thus, the need for early diagnosis and appropriate referral to an expert center. This review article first highlights the epidemiology, pathophysiology, and clinical presentation of CTEPH. The article then provides diagnostic and therapeutic algorithms for the management of the patient with suspected CTEPH.
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Pulmonary Endarterectomy. Patient Selection, Technical Challenges, and Outcomes. Ann Am Thorac Soc 2016; 13 Suppl 3:S240-7. [DOI: 10.1513/annalsats.201601-014as] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Cannon JE, Su L, Kiely DG, Page K, Toshner M, Swietlik E, Treacy C, Ponnaberanam A, Condliffe R, Sheares K, Taboada D, Dunning J, Tsui S, Ng C, Gopalan D, Screaton N, Elliot C, Gibbs S, Howard L, Corris P, Lordan J, Johnson M, Peacock A, MacKenzie-Ross R, Schreiber B, Coghlan G, Dimopoulos K, Wort SJ, Gaine S, Moledina S, Jenkins DP, Pepke-Zaba J. Dynamic Risk Stratification of Patient Long-Term Outcome After Pulmonary Endarterectomy: Results From the United Kingdom National Cohort. Circulation 2016; 133:1761-71. [PMID: 27052413 DOI: 10.1161/circulationaha.115.019470] [Citation(s) in RCA: 276] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 03/18/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension results from incomplete resolution of pulmonary emboli. Pulmonary endarterectomy (PEA) is potentially curative, but residual pulmonary hypertension following surgery is common and its impact on long-term outcome is poorly understood. We wanted to identify factors correlated with poor long-term outcome after surgery and specifically define clinically relevant residual pulmonary hypertension post-PEA. METHODS AND RESULTS Eight hundred eighty consecutive patients (mean age, 57 years) underwent PEA for chronic thromboembolic pulmonary hypertension. Patients routinely underwent detailed reassessment with right heart catheterization and noninvasive testing at 3 to 6 months and annually thereafter with discharge if they were clinically stable at 3 to 5 years and did not require pulmonary vasodilator therapy. Cox regressions were used for survival (time-to-event) analyses. Overall survival was 86%, 84%, 79%, and 72% at 1, 3, 5, and 10 years for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the perioperative period were not attributable to right ventricular failure (chronic thromboembolic pulmonary hypertension). At reassessment, a mean pulmonary artery pressure of ≥30 mm Hg correlated with the initiation of pulmonary vasodilator therapy post-PEA. A mean pulmonary artery pressure of ≥38 mm Hg and pulmonary vascular resistance ≥425 dynes·s(-1)·cm(-5) at reassessment correlated with worse long-term survival. CONCLUSIONS Our data confirm excellent long-term survival and maintenance of good functional status post-PEA. Hemodynamic assessment 3 to 6 months and 12 months post-PEA allows stratification of patients at higher risk of dying of chronic thromboembolic pulmonary hypertension and identifies a level of residual pulmonary hypertension that may guide the long-term management of patients postsurgery.
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Affiliation(s)
- John E Cannon
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Li Su
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - David G Kiely
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Kathleen Page
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Mark Toshner
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Emilia Swietlik
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Carmen Treacy
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Anie Ponnaberanam
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Robin Condliffe
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Karen Sheares
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Dolores Taboada
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - John Dunning
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Steven Tsui
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Choo Ng
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Deepa Gopalan
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Nicholas Screaton
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Charlie Elliot
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Simon Gibbs
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Luke Howard
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Paul Corris
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - James Lordan
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Martin Johnson
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Andrew Peacock
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Robert MacKenzie-Ross
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Benji Schreiber
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Gerry Coghlan
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Kostas Dimopoulos
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Stephen J Wort
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Sean Gaine
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Shahin Moledina
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - David P Jenkins
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.)
| | - Joanna Pepke-Zaba
- From Papworth Hospital, Cambridge, United Kingdom (J.E.C., K.P., M.T., E.S., C.T., A. Ponnaberanam, K.S., D.T., J.D., S.T., C.N., N.S., D.P.T., J.P.-Z.); MRC Biostatistics Unit, Cambridge, United Kingdom (L.S.); Royal Hallamshire Hospital, Sheffield, United Kingdom (D.G.K., R.C., C.E.); Respiratory Medicine Department, University of Warmia and Mazury, Poland (E.S.); Hammersmith Hospital, London, United Kingdom (D.G., S. Gibbs, L.H.); Freeman Hospital, Newcastle, United Kingdom (P.C., J.L.); Golden Jubilee Hospital, Glasgow, United Kingdom (M.J., A. Peacock); Royal United Hospital, Bath, United Kingdom (R.M.-R.); Royal Free Hospital, London, United Kingdom (B.S., G.C.); Royal Brompton Hospital, London, United Kingdom (K.D., J.W.); Mater Misericordiae University Hospital, Dublin, Ireland (S. Gaine); and Great Ormond Street Hospital, London, United Kingdom (S.M.).
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Delcroix M, Lang I, Pepke-Zaba J, Jansa P, D'Armini AM, Snijder R, Bresser P, Torbicki A, Mellemkjaer S, Lewczuk J, Simkova I, Barberà JA, de Perrot M, Hoeper MM, Gaine S, Speich R, Gomez-Sanchez MA, Kovacs G, Jaïs X, Ambroz D, Treacy C, Morsolini M, Jenkins D, Lindner J, Dartevelle P, Mayer E, Simonneau G. Long-Term Outcome of Patients With Chronic Thromboembolic Pulmonary Hypertension: Results From an International Prospective Registry. Circulation 2016; 133:859-71. [PMID: 26826181 DOI: 10.1161/circulationaha.115.016522] [Citation(s) in RCA: 448] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 01/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension, a rare complication of acute pulmonary embolism, is characterized by fibrothrombotic obstructions of large pulmonary arteries combined with small-vessel arteriopathy. It can be cured by pulmonary endarterectomy, and can be clinically improved by medical therapy in inoperable patients. A European registry was set up in 27 centers to evaluate long-term outcome and outcome correlates in 2 distinct populations of operated and not-operated patients who have chronic thromboembolic pulmonary hypertension. METHODS AND RESULTS A total of 679 patients newly diagnosed with chronic thromboembolic pulmonary hypertension were prospectively included over a 24-month period. Estimated survival at 1, 2, and 3 years was 93% (95% confidence interval [CI], 90-95), 91% (95% CI, 87-93), and 89% (95% CI, 86-92) in operated patients (n=404), and only 88% (95% CI, 83-91), 79% (95% CI, 74-83), and 70% (95% CI, 64-76) in not-operated patients (n=275). In both operated and not-operated patients, pulmonary arterial hypertension-targeted therapy did not affect survival estimates significantly. Mortality was associated with New York Heart Association functional class IV (hazard ratio [HR], 4.16; 95% CI, 1.49-11.62; P=0.0065 and HR, 4.76; 95% CI, 1.76-12.88; P=0.0021), increased right atrial pressure (HR, 1.34; 95% CI, 0.95-1.90; P=0.0992 and HR, 1.50; 95% CI, 1.20-1.88; P=0.0004), and a history of cancer (HR, 3.02; 95% CI, 1.36-6.69; P=0.0065 and HR, 2.15; 95% CI, 1.18-3.94; P=0.0129) in operated and not-operated patients, respectively. Additional correlates of mortality were bridging therapy with pulmonary arterial hypertension-targeted drugs, postoperative pulmonary hypertension, surgical complications, and additional cardiac procedures in operated patients, and comorbidities such as coronary disease, left heart failure, and chronic obstructive pulmonary disease in not-operated patients. CONCLUSIONS The long-term prognosis of operated patients currently is excellent and better than the outcome of not-operated patients.
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Affiliation(s)
- Marion Delcroix
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.).
| | - Irene Lang
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Joanna Pepke-Zaba
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Pavel Jansa
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Andrea M D'Armini
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Repke Snijder
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Paul Bresser
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Adam Torbicki
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Sören Mellemkjaer
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Jerzy Lewczuk
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Iveta Simkova
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Joan A Barberà
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Marc de Perrot
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Marius M Hoeper
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Sean Gaine
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Rudolf Speich
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Miguel A Gomez-Sanchez
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Gabor Kovacs
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Xavier Jaïs
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - David Ambroz
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Carmen Treacy
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Marco Morsolini
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - David Jenkins
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Jaroslav Lindner
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Philippe Dartevelle
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Eckhard Mayer
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Gérald Simonneau
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
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Poch DS, Auger WR. Chronic thromboembolic pulmonary hypertension: detection, medical and surgical treatment approach, and current outcomes. Heart Fail Rev 2016; 21:309-22. [DOI: 10.1007/s10741-015-9518-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Cherniavskiĭ AM, Edemskiĭ AG, Cherniavskiĭ MA, Tarkova AR, Novikova NV, Ivanov SN. [Opportunities of surgical treatment of chronic post-embolic pulmonary hypertension]. Khirurgiia (Mosk) 2016:76-80. [PMID: 27166479 DOI: 10.17116/hirurgia2016276-80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- A M Cherniavskiĭ
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology, Health Ministry of the Russian Federation
| | - A G Edemskiĭ
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology, Health Ministry of the Russian Federation
| | - M A Cherniavskiĭ
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology, Health Ministry of the Russian Federation
| | - A R Tarkova
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology, Health Ministry of the Russian Federation
| | - N V Novikova
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology, Health Ministry of the Russian Federation
| | - S N Ivanov
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology, Health Ministry of the Russian Federation
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Richter MJ, Pader P, Gall H, Reichenberger F, Seeger W, Mayer E, Guth S, Kramm T, Grimminger F, Ghofrani HA, Voswinckel R. The prognostic relevance of oxygen uptake in inoperable chronic thromboembolic pulmonary hypertension. CLINICAL RESPIRATORY JOURNAL 2015; 11:682-690. [PMID: 26470843 DOI: 10.1111/crj.12399] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/03/2015] [Accepted: 10/05/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with chronic thromboembolic pulmonary hypertension (CTEPH) present with a decreased oxygen uptake, however, the prognostic relevance of oxygen uptake (VO2 ) in inoperable CTEPH is unknown. METHODS Patients with inoperable CTEPH were retrospectively analyzed. All patients were assessed by means of right heart catheterisation and cardio pulmonary exercise testing in semisupine position with a 30 Watt increment step-protocol. RESULTS One-hundred and fifty-one patients (82 female (54.3%), mean age 61 ± 12.4 years) presented with a mean pulmonary arterial pressure of 40.2 ± 14.2 mmHg and pulmonary vascular resistance (PVR) of 641.9 ± 374.8 dyne∗s/cm5 . The peak VO2 (mean 13.1 ± 4.5 mL∗kg-1 ∗min-1 ) was measured at initial referral. Over a follow-up of up to 10 years (mean 4.41 ± 2.57 years), 31 patients had died. Patients with a baseline peak VO2 ≥ 10.7 mL∗kg-1 ∗min-1 [area under the receiver-operating characteristic curve (AUC) = 0.728, P = 0.001] had better survival than those with a peak VO2 ≤ 10.7 mL∗kg-1 ∗min-1 using Kaplan-Meier analysis (88.8% vs 60.1%; log rank P = 0.001). Adjusting for age, gender and PVR, multivariate analysis identified peak VO2 as a predictor of mortality [hazard ratio (HR): 2.78, 95% CI 1.01-7.63, P = 0.047]. In addition, peak VO2 failed as an independent prognostic factor in a stepwise multivariate model including all variables significant in the univariate analysis. CONCLUSIONS In patients with inoperable CTEPH the peak VO2 is a significant predictor of survival, when adjusting for age, gender and PVR. However, peak VO2 failed as an independent prognostic factor when correcting for all significant baseline variables, which is limiting the clinical usability.
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Affiliation(s)
- Manuel Jonas Richter
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)
| | - Philip Pader
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)
| | - Henning Gall
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)
| | | | - Werner Seeger
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Thorsten Kramm
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Friedrich Grimminger
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)
| | - Hossein A Ghofrani
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)
| | - Robert Voswinckel
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL).,Department of Internal Medicine, Health Center Wetterau, Friedberg, Germany
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30
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D'Armini AM. Diagnostic advances and opportunities in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2015; 24:253-62. [PMID: 26028637 PMCID: PMC9487819 DOI: 10.1183/16000617.00000915] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/09/2015] [Indexed: 11/05/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is characterised by the presence of thromboembolic material in the pulmonary circulation, and patients have a poor prognosis without treatment. Patients present with nonspecific symptoms, such as breathlessness and syncope, which means that other more common conditions are sometimes suspected before CTEPH, leading to delayed diagnosis and treatment. This is problematic because CTEPH is potentially curable with surgical pulmonary endarterectomy (PEA); indeed, CTEPH should always be considered in any patient with unexplained pulmonary hypertension (PH). Several key evaluations are necessary and complementary to confirm a diagnosis of CTEPH and assess operability. Echocardiography is initially used to confirm a general diagnosis of PH. Ventilation/perfusion scanning is then essential in the first stage of CTEPH diagnosis, with a wedge-shaped perfusion deficit indicative of CTEPH. This should be followed by right heart catheterisation (RHC) which is mandatory in confirming the diagnosis and providing haemodynamic parameters that are key predictors of the risk associated with PEA and subsequent prognosis. RHC is ideally coupled with conventional pulmonary angiography, the gold-standard technique for confirming the location and extent of disease, and thus whether the obstruction is surgically accessible. Computed tomographic pulmonary angiography is also now routinely used as a complementary technique to aid diagnosis and operability assessment. Recent improvements in the resolution of other noninvasive techniques, such as cardiac magnetic resonance imaging, allow for detailed reconstructions of the vascular tree and imaging of vessel defects, and interest in their use is increasing.
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Affiliation(s)
- Andrea M D'Armini
- Dept of Cardio-Thoracic and Vascular Surgery, Heart and Lung Transplantation and Pulmonary Hypertension Unit, Foundation "I.R.C.C.S. Policlinico San Matteo", University of Pavia School of Medicine, Pavia, Italy
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31
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Schölzel BE, Snijder RJ, Mager JJ, van Es HW, Plokker HWM, Reesink HJ, Morshuis WJ, Post MC. Chronic thromboembolic pulmonary hypertension. Neth Heart J 2014; 22:533-41. [PMID: 25169577 PMCID: PMC4391185 DOI: 10.1007/s12471-014-0592-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Chronic pulmonary thromboembolic disease is an important cause of severe pulmonary hypertension, and as such is associated with significant morbidity and mortality. The prognosis of this condition reflects the degree of associated right ventricular dysfunction, with predictable mortality related to the severity of the underlying pulmonary hypertension. Left untreated, the prognosis is poor. Pulmonary endarterectomy is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension and has been remarkably successful. Advances in surgical techniques along with the introduction of pulmonary hypertension-specific medication provide therapeutic options for the majority of patients afflicted with the disease. However, a substantial number of patients are not candidates for pulmonary endarterectomy due to either distal pulmonary vascular obstruction or significant comorbidities. Therefore, careful selection of surgical candidates in expert centres is paramount. The current review focuses on the diagnostic approach to chronic thromboembolic pulmonary hypertension and the available surgical and medical therapeutic options.
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Affiliation(s)
- B. E. Schölzel
- Department of Cardiology, Amphia Hospital, Molengracht 21, 4818 CK Breda, the Netherlands
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - R. J. Snijder
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - J. J. Mager
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H W. van Es
- Department of Radiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. W. M. Plokker
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. J. Reesink
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - W. J. Morshuis
- Department of Cardio-Thoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - M. C. Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
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Schölzel BE, Post MC, van de Bruaene A, Dymarkowski S, Wuyts W, Meyns B, Budts W, Delcroix M. Prediction of hemodynamic improvement after pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension using non-invasive imaging. Int J Cardiovasc Imaging 2014; 31:143-50. [PMID: 25146554 DOI: 10.1007/s10554-014-0517-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 08/09/2014] [Indexed: 11/29/2022]
Abstract
Pulmonary endarterectomy (PEA) is the recommended treatment in chronic thromboembolic pulmonary hypertension (CTEPH). Prediction of outcome after PEA remains challenging. In search for pre-operative predictors we evaluated non-invasive parameters measured by chest CT-scan and echocardiography. Between May 2004 and January 2009, 52 consecutive patients with CTEPH who underwent PEA (59.6 % female, mean age 58.9 ± 13.4 years) were included. Prior to surgery, pulmonary artery (PA) diameter indices were calculated by chest CT scan and different echocardiographic measurements to evaluate pulmonary hypertension were obtained. Hemodynamic improvement after PEA was defined as a pulmonary vascular resistance (PVR) <500 dyn s cm(-5) and a mean pulmonary artery pressure <35 mmHg 3 days after PEA. Mortality was evaluated at day 30. Mean pulmonary artery pressure (PAP) at baseline was 40.1 ± 8.5 mmHg, with a PVR of 971 ± 420 dyn s cm(-5). Persistent pulmonary hypertension was observed in 15 patients (28.8 %). Gender, pre-operative mean PAP, PA diameter indices, and tricuspid annular plane systolic excursion were all predictors for hemodynamic improvement after PEA. The indexed PA diameter on CT was the only independent predictor for hemodynamic improvement: 19.4 ± 2.4 versus 22.9 ± 4.9 mm/m(2) in those without improvement (OR 0.76: 95 % CI 0.58-0.99, p = 0.04). All patients who died within 30 days (9.6 %) had persistent pulmonary hypertension, with a post-operative mean PAP of 51.6 ± 14.1 mmHg and PVR of 692 ± 216 dyn s cm(-5). The pre-operative PA diameter indexed for body surface area is the only independent predictor for hemodynamic improvement after PEA in CTEPH patients. In all patients who died within 30 days after PEA, persistent pulmonary hypertension was present.
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Affiliation(s)
- Bastiaan E Schölzel
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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Wieteska M, Biederman A, Kurzyna M, Dyk W, Burakowski J, Wawrzyńska L, Szturmowicz M, Fijałkowska A, Szatkowski P, Torbicki A. Outcome of Medically Versus Surgically Treated Patients With Chronic Thromboembolic Pulmonary Hypertension. Clin Appl Thromb Hemost 2014; 22:92-9. [DOI: 10.1177/1076029614536604] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an ominous disease leading to progressive right heart failure. Selected patients can be treated by pulmonary endarterectomy (PEA). We assessed long-term clinical outcome of patients with CTEPH who underwent PEA and patients who remained on medical treatment alone. A total of 112 consecutive patients with CTEPH referred between 1998 and 2008 to one center were followed for a mean of 35 (range 0-128) months after diagnosis. All the patients had advanced pulmonary hypertension at baseline. The operated group had higher World Health Organization functional class compared to the nonoperated group. No other differences in hemodynamic, echocardiographic, or biochemical parameters were observed at baseline. Despite the perioperative mortality rate of 9.1%, patients who underwent PEA had significantly lower long-term mortality compared to nonoperated patients (12.7% vs 34.8%; P = .003), and PEA survivors showed sustained clinical improvement. All efforts should be undertaken to perform PEA in all patients with operable CTEPH.
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Affiliation(s)
- Maria Wieteska
- Department of Pulmonary Circulation and Thromboembolic Diseases, Centre of Postgraduate Medical Education, Otwock, Poland
| | | | - Marcin Kurzyna
- Department of Pulmonary Circulation and Thromboembolic Diseases, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Wojciech Dyk
- Department of Cardiac Surgery, Allenort Hospital, Warsaw, Poland
| | - Janusz Burakowski
- Intensive Pneumo-Cardiological Treatment Unit, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | | | - Monika Szturmowicz
- First Pulmonary Department, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Anna Fijałkowska
- Department of Cardiology, Institute of Mother and Child, Warsaw, Poland
| | - Piotr Szatkowski
- Department of Anesthesiology, Institute of Cardiology, Warsaw-Anin, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation and Thromboembolic Diseases, Centre of Postgraduate Medical Education, Otwock, Poland
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Poch D, Pretorius V. Pulmonary Endarterectomy: Assessment of Operability, Surgical Description, and Post-op Care. ACTA ACUST UNITED AC 2014. [DOI: 10.21693/1933-088x-12.4.186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is defined as a mean pulmonary artery pressure ≥25 mm Hg and pulmonary artery wedge pressure ≤15 mm Hg in the presence of occlusive thrombi within the pulmonary arteries. Surgical pulmonary thromboendarterectomy (PTE) is considered the best treatment option for CTEPH.
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Affiliation(s)
- David Poch
- Division of Pulmonary and Critical Care, University of California San Diego, La Jolla, CA
| | - Victor Pretorius
- Division of Cardiothoracic Surgery, University of California San Diego, La Jolla, CA
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
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Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
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36
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Ogino H. Recent advances of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension including Japanese experiences. Gen Thorac Cardiovasc Surg 2013; 62:9-18. [DOI: 10.1007/s11748-013-0323-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Indexed: 11/25/2022]
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Sato M, Ando M, Kaneko K, Higuchi Y, Kondo H, Akita K, Ishida M, Takagi Y. Respiratory and hemodynamic changes in patients with chronic thromboembolic pulmonary hypertension 1 year after pulmonary endarterectomy. Ann Vasc Dis 2013; 6:578-82. [PMID: 24130612 DOI: 10.3400/avd.oa.13-00056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/02/2013] [Indexed: 11/13/2022] Open
Abstract
We reviewed the results of thromboembolectomy, which was performed for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), 1 year after the operation. We obtained hemodynamic and respiratory data of 60 patients from the 112 patients who were operated at our institute. The hemodynamic parameters such as mean pulmonary arterial pressure (PAP), pulmonary vascular resistance (PVR), and cardiac index (CI) were significantly improved after the operation, and this improvement of pulmonary hemodynamics persisted even a year after the operation. A significant improvement in gas exchange was observed immediately after the operation and a further elevation in the partial pressure of oxygen in arterial blood (PaO2) was observed 1 year after the operation. (English Translation of J Jpn Coll Angiol 2012; 52: 53-58).
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Affiliation(s)
- Masato Sato
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Aichi, Japan
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Zarrabi K, Zolghadrasli A, Ali Ostovan M, Azimifar A, Malekmakan L. Residual pulmonary hypertension after retrograde pulmonary embolectomy: long-term follow-up of 30 patients with massive and submassive pulmonary embolism. Interact Cardiovasc Thorac Surg 2013; 17:242-6. [PMID: 23677779 DOI: 10.1093/icvts/ivt210] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Pulmonary hypertension is a major cause of morbidity and mortality in patients following acute pulmonary embolism. Although thrombolytic therapy decreases pulmonary arterial pressure, compared with anticoagulation alone, it has the propensity for haemorrhagic complications, distal embolization and incomplete recanalization, with the potential risk of late pulmonary hypertension. Surgical embolectomy-once performed solely on critically-ill patients-has now gained favour in a wider range of patients. In this paper we present the outcomes of patients who underwent surgical embolectomy complemented with retrograde technique and follow-up systolic pulmonary arterial pressure (SPAP). METHODS From January 2004 to December 2010, 30 consecutive patients with a mean age of 58±15 years underwent pulmonary embolectomy at our centre. The patients were followed for a mean period of 30.5±12 months. Their New York Heart Association (NYHA) classifications were assessed and their SPAPs were measured by echocardiography. RESULTS The overall mortality rate was 13.2% (4/30). Of the remaining patients, 19 patients (73.1%) were in NYHA classes I and II, 7 patients (26.9%) in class III and no patient in class IV. The patients' preoperative and postoperative mean SPAPs were 44.9±5.7 and 34.9±7.1 mmHg, respectively, which showed a significant reduction (P<0.001). The mean SPAP in the follow-up was 29.4±11.5 mmHg, which again showed significant reduction compared with early postoperation values (P<0.001). No significant correlations were found between the level of SPAP reduction in patients' follow-up with age (P=0.727) and total days of ICU admission (P=0.700), but weak correlations with sex (P=0.016) and total intubation time were noticed (P=0.035). CONCLUSIONS This is the first series reporting the long-term outcome of patients undergoing surgical embolectomy complemented by retrograde embolectomy technique, demonstrating the safety and favourable long-term outcome of this technique. It is also a new element in the growing body of evidence regarding the relevance of surgical embolectomy in patients with acute pulmonary embolism. We concluded that, following surgery, not only does the pulmonary arterial pressure drop immediately, but also the trend toward normalization continues long after operation.
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Affiliation(s)
- Khalil Zarrabi
- Department of Cardiac Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Oh SJ, Bok JS, Hwang HY, Kim KH, Kim KB, Ahn H. Clinical outcomes of thromboendarterectomy for chronic thromboembolic pulmonary hypertension: 12-year experience. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:41-8. [PMID: 23423163 PMCID: PMC3573164 DOI: 10.5090/kjtcs.2013.46.1.41] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 12/31/2012] [Accepted: 01/02/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND We present our 12-year experience of pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension. MATERIALS AND METHODS Between January 1999 and March 2011, 16 patients underwent pulmonary thromboendarterectomy. Eleven patients (69%) were classified as functional class III or IV based on the New York Heart Association (NYHA) classification. Seven patients had a history of inferior vena cava filter insertion, and 5 patients showed coagulation disorders. Pulmonary thromboendarterectomy was performed during total circulatory arrest with deep hypothermia in 14 patients. RESULTS In-hospital mortality and late death occurred in 2 patients (12.5%) and 1 patient (6.3%), respectively. Extracorporeal membrane oxygenation support was required in 4 patients who developed severe hypoxemia after surgery. Thirteen of the 14 survivors have been followed up for 54 months (range, 2 to 141 months). The pulmonary arterial systolic pressure and cardiothoracic ratio on chest radiography was significantly decreased after surgery (76±26 mmHg vs. 41±17 mmHg, p=0.001; 55%±8% vs. 48%±3%, p=0.003). Tricuspid regurgitation was reduced from 2.1±1.1 to 0.7±0.6 (p=0.007), and the NYHA functional class was also improved to I or II in 13 patients (81%). These symptomatic and hemodynamic improvements maintained during the late follow-up period. CONCLUSION Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension shows good clinical outcomes with acceptable early and long term mortality.
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Affiliation(s)
- Se Jin Oh
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Korea
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Maliyasena VA, Hopkins PMA, Thomson BM, Dunning J, Wall DA, Ng BJ, McNeil KD, Mullany D, Kermeen FD. An Australian tertiary referral center experience of the management of chronic thromboembolic pulmonary hypertension. Pulm Circ 2012; 2:359-64. [PMID: 23130104 PMCID: PMC3487304 DOI: 10.4103/2045-8932.101649] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The objective of this study was to report the outcome of pulmonary endarterectomy (PEA) surgery performed for chronic thromboembolic pulmonary hypertension (CTEPH) at a single tertiary center. The prospective study consisted of 35 patients with surgically amenable CTEPH undergoing PEA between September 2004 and September 2010. The main outcome measures were Functional (New York Heart Association [NYHA] class, 6-Minute Walk Distance), hemodynamic (echocardiography, right heart catheterization, and cardiac MRI), and outcome data (morbidity and mortality). Following PEA, there were significant improvements in NYHA class (pre 2.9±0.7 vs. post 1.3±0.5, P < 0.0001), right ventricular systolic pressure (pre 77.4±24.8 mmHg vs. post 45.1±24.9 mmHg, P = 0.0005), 6-Minute Walk Distance (pre 419.6±109.4 m vs. post 521.6±83.5 m, P = 0.0017), mean pulmonary artery pressure (pre 41.8±15.3 mmHg vs. post 24.7±8.8 mmHg, P = 0.0006), and cardiac MRI indices (end diastolic volume pre 213.8±49.2 mL vs. post 148.1±34.5 mL, P < 0.0001; ejection fraction pre 40.7±9.8 mL vs. post 48.1±8.9 mL, P = 0.0069). The mean cardiopulmonary bypass time was 258.77±26.16 min, with a mean circulatory arrest time of 43.83±28.78 min, a mean ventilation time of 4.7±7.93 days (range 0.2-32.7), and a mean intensive care unit stay of 7.22±8.71 days (range 1.1-33.8). Complications included reperfusion lung injury (20%), persistent pulmonary hypertension (17.1%), slow respiratory wean (25.7%), pericardial effusion (11.4%), and cardiac tamponade (5.7%). 1-year mortality post-procedure was 11.4%. Pulmonary endarterectomy can be performed safely with relatively low mortality.
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Affiliation(s)
- Videshinie A Maliyasena
- Queensland Centre for Pulmonary Transplantation and Vascular Diseases, The Prince Charles Hospital, Brisbane, Australia
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Long-term outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. J Thorac Cardiovasc Surg 2012; 144:321-6. [DOI: 10.1016/j.jtcvs.2011.09.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 08/09/2011] [Accepted: 09/15/2011] [Indexed: 11/22/2022]
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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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Zhao Q, Ye X, Liu J, Chen H, Zhu D, Jin Z. Pulmonary thromboembolism in a patient with rheumatic mitral valve stenosis: a fortuitous association? Ann Thorac Surg 2011; 92:2263-6. [PMID: 22115245 DOI: 10.1016/j.athoracsur.2011.05.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 05/18/2011] [Accepted: 05/25/2011] [Indexed: 11/29/2022]
Abstract
In this case report, we illustrate our experience with a patient simultaneously suffering from rheumatic mitral valve stenosis and pulmonary thromboembolism who successfully underwent mitral valve replacement and pulmonary thromboendarterectomy. Physical examination and transthoracic echocardiography revealed mitral stenosis, atrial fibrillation, and a large thrombus in the left atrium. The preoperative workup led to the diagnosis of pulmonary thromboembolism. This case emphasizes the importance of preoperative evaluation for pulmonary thromboembolism in symptomatic patients with mitral valve stenosis and atrial fibrillation.
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Affiliation(s)
- Qiang Zhao
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, Peoples Republic of China.
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Willemink MJ, van Es HW, Koobs L, Morshuis WJ, Snijder RJ, van Heesewijk JPM. CT evaluation of chronic thromboembolic pulmonary hypertension. Clin Radiol 2011; 67:277-85. [PMID: 22119298 DOI: 10.1016/j.crad.2011.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 09/15/2011] [Accepted: 09/27/2011] [Indexed: 10/15/2022]
Abstract
The educational objectives of this article are to provide an overview of the computed tomography (CT) findings in chronic thromboembolic pulmonary hypertension. This article reviews the key imaging findings at CT in patients with chronic thromboembolic pulmonary hypertension. After reading this article, the reader should have an improved awareness of the condition, its imaging features, and the CT imaging features associated with surgically accessible disease.
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Affiliation(s)
- M J Willemink
- Department of Radiology, St Antonius Hospital, 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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Ryan JJ, Rich S, Archer SL. Pulmonary endarterectomy surgery--a technically demanding cure for WHO Group IV Pulmonary Hypertension: requirements for centres of excellence and availability in Canada. Can J Cardiol 2011; 27:671-4. [PMID: 22019277 DOI: 10.1016/j.cjca.2011.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 09/18/2011] [Accepted: 09/19/2011] [Indexed: 11/24/2022] Open
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Short-term results of retrograde pulmonary embolectomy in massive and submassive pulmonary embolism: a single-center study of 30 patients. Eur J Cardiothorac Surg 2011; 40:890-3. [DOI: 10.1016/j.ejcts.2011.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 05/31/2011] [Accepted: 06/07/2011] [Indexed: 11/17/2022] Open
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Ley S, Ley-Zaporozhan J, Pitton MB, Schneider J, Wirth GM, Mayer E, Düber C, Kreitner KF. Diagnostic performance of state-of-the-art imaging techniques for morphological assessment of vascular abnormalities in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol 2011; 22:607-16. [DOI: 10.1007/s00330-011-2290-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 08/24/2011] [Accepted: 09/12/2011] [Indexed: 11/30/2022]
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1485] [Impact Index Per Article: 114.2] [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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