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Delcroix M, de Perrot M, Jaïs X, Jenkins DP, Lang IM, Matsubara H, Meijboom LJ, Quarck R, Simonneau G, Wiedenroth CB, Kim NH. Chronic thromboembolic pulmonary hypertension: realising the potential of multimodal management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:836-850. [PMID: 37591299 DOI: 10.1016/s2213-2600(23)00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. Important advances have enabled better understanding, characterisation, and treatment of this condition. Guidelines recommending systematic follow-up after acute pulmonary embolism, and the insight that CTEPH can mimic acute pulmonary embolism on initial presentation, have led to the definition of CTEPH imaging characteristics, the introduction of artificial intelligence diagnosis pathways, and thus the prospect of easier and earlier CTEPH diagnosis. In this Series paper, we show how the understanding of CTEPH as a sequela of inflammatory thrombosis has driven successful multidisciplinary management that integrates surgical, interventional, and medical treatments. We provide imaging examples of classical major vessel targets, describe microvascular targets, define available tools, and depict an algorithm facilitating the initial treatment strategy in people with newly diagnosed CTEPH based on a multidisciplinary team discussion at a CTEPH centre. Further work is needed to optimise the use and combination of multimodal therapeutic options in CTEPH to improve long-term outcomes for patients.
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Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium.
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Xavier Jaïs
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Centre for CardioVascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Nick H Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
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2
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Ishida K, Kohno H, Matsuura K, Sugiura T, Sanada TJ, Naito A, Shigeta A, Suda R, Sekine A, Masuda M, Sakao S, Tanabe N, Tatsumi K, Matsumiya G. Impact of residual pulmonary hypertension on long-term outcomes after pulmonary endarterectomy in the modern era. Pulm Circ 2023; 13:e12215. [PMID: 37051490 PMCID: PMC10084236 DOI: 10.1002/pul2.12215] [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: 05/27/2022] [Revised: 03/15/2023] [Accepted: 03/25/2023] [Indexed: 04/14/2023] Open
Abstract
Residual pulmonary hypertension (PH) negatively impacts long-term results following pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). We sought to reveal whether modern PH therapy with PH-targeted medicine and balloon pulmonary angioplasty (BPA) improved long-term results of residual PH after PEA. Long-term findings of 80 patients who survived PEA between 2011 and 2019 were retrospectively investigated. One month after PEA, 30 patients developed residual PH defined as mean pulmonary artery pressure (mPAP) ≥25 mmHg, of whom 23 were treated by PH-targeted medicine and 9 by BPA. Patients with residual PH acquired considerably better functional status and exercise capacity after PEA, however, exhibited significantly worse survival rates than those without. Eleven patients died during follow-up: 8 patients with residual PH and 3 controls. Among patients with residual PH, the deceased had a significantly lower %decrease in mPAP from 1 month to 1 year following PEA (7.4 [-32.6 to 8.0] % vs. 10.4 [3.7-27.8] %, p = 0.03) and higher mPAP at 1 year following PEA (39.5 [33.25-42.5] vs. 27 [26-34] mmHg, p < 0.01) despite PH-targeted medicine than the survived. No patients passed away from right heart failure, and there was no difference between the groups in CTEPH-related mortality. Modern PH therapy was used to address the majority of residual PH. Long-term survival after PEA was negatively impacted by residual PH, but it appeared that long-term mortality was also correlated with unrelieved residual PH despite PH-targeted medicine. Modern PH therapy may have enhanced functional status and excercise capacity, and averted fatal right heart failure.
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Affiliation(s)
- Keiichi Ishida
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Hiroki Kohno
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Kaoru Matsuura
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Toshihiko Sugiura
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Takayuki J. Sanada
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Akira Naito
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Ayako Shigeta
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Rika Suda
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Ayumi Sekine
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Masahisa Masuda
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Seiichiro Sakao
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Nobuhiro Tanabe
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Koichiro Tatsumi
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Goro Matsumiya
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
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3
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Traitement chirurgical de l’hypertension pulmonaire thromboembolique. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Shikhare S, Balki I, Shi Y, Kavanagh J, Donahoe L, Xu W, Rozenberg D, de Perrot M, McInnis M. Right-to-left ventricle ratio determined by machine learning algorithms on CT pulmonary angiography images predicts prolonged ICU length of stay in operated chronic thromboembolic pulmonary hypertension. Br J Radiol 2022; 95:20210722. [PMID: 36043477 PMCID: PMC9793468 DOI: 10.1259/bjr.20210722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 05/06/2022] [Accepted: 08/13/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Right-to-left ventricle diameter ratio (dRV/dLV) on CT pulmonary angiography (CTPA) is a predictor of outcomes in non-operated chronic thromboembolic pulmonary hypertension (CTEPH) patients. The purpose of this study is to evaluate the performance of a novel machine learning (ML) algorithm for dRV/dLV measurement in operated CTEPH patients and its association with post-operative outcomes. METHODS This retrospective study reviewed consecutive CTEPH patients who underwent pulmonary endarterectomy between 2013 and 2017. ML calculated dRV/dLV on pre-operative CTPA and compared with manual measures. Associations of dRV/dLV with patient characteristics and post-operative outcomes were evaluated including intensive care (ICU) and hospital length of stay (LOS) using multivariable linear regression analysis. Prolonged LOS was defined as greater than median. RESULTS ML segmented the ventricles in 99/125 (79%) patients. The most common cause of failure was misidentification of the moderator band as the interventricular septum (7.9%). Mean dRV/dLV by ML was 1.4 ± 0.4 and strongly correlated with manual measures (r = 0.9-0.96 p < 0.0001). dRV/dLV was moderately correlated with measures of pulmonary hypertension on right heart catheterization and RV dilatation on echocardiogram (r = 0.5-0.6, p < 0.0001). dRV/dLV ≥ 1.2 was associated with proximal Jamieson type disease (p = 0.032), longer cardiopulmonary bypass (p = 0.037), aortic cross-clamp (p = 0.022) and circulatory arrest (p < 0.001) at surgery and dRV/dLV ≥ 1.6 with post-operative ECMO (p = 0.006). dRV/dLV was independently associated with prolonged ICU LOS (OR = 3.79, 95% CI 1.1-13.06, p = 0.035). CONCLUSION dRV/dLV was associated with CTEPH severity and independently associated with prolonged ICU LOS. This CT parameter may therefore assist in perioperative planning. Further refinement of the ML algorithm or CTPA technique is required to avoid errors in ventricular segmentation. ADVANCES IN KNOWLEDGE Automated right-to-left ventricle ratio measurement by machine learning is feasible and is independently associated with outcome after pulmonary endarterectomy.
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Affiliation(s)
| | - Indranil Balki
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuliang Shi
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
| | - John Kavanagh
- Division of Cardiothoracic Imaging, Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto General Hospital, Toronto, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
| | - Dmitry Rozenberg
- Division of Respirology, Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto General Hospital, Toronto, Canada
| | - Micheal McInnis
- Division of Cardiothoracic Imaging, Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed, but potentially curable pulmonary vascular disease. The increased pulmonary vascular resistance in CTEPH is caused by unresolved proximal thrombus and secondary microvasculopathy in the pulmonary vasculature, leading to adaptive and maladaptive remodeling of the right ventricle (RV), eventual right heart failure, and death. Knowledge on the RV remodeling process in CTEPH is limited. The progression to RV failure in CTEPH is a markedly slower process. A detailed understanding of the pathophysiology and underlying mechanisms of RV remodeling may facilitate early diagnosis and the development of targeted therapy. While ultrasound, magnetic resonance imaging, right heart catheterization, and serum biomarkers have been used to assess cardiac function, the current treatment strategies reduce the afterload of the right heart, but are less effective in improving the maladaptive remodeling of the right heart. This review systematically summarizes the current knowledge on adaptive and maladaptive remodeling of the right heart in CTEPH from molecular mechanisms to clinical practice.
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Chan JC, Chang SH. Commentary: Another tool for the chronic thromboembolic pulmonary hypertension toolbox. JTCVS OPEN 2022; 10:73-74. [PMID: 36004212 PMCID: PMC9390147 DOI: 10.1016/j.xjon.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/15/2022] [Indexed: 11/26/2022]
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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8
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Abdelnour-Berchtold E, Donahoe L, McRae K, Asghar U, Thenganatt J, Moric J, Cypel M, Keshavjee S, Granton J, de Perrot M. Central venoarterial extracorporeal membrane oxygenation as a bridge to recovery after pulmonary endarterectomy in patients with decompensated right heart failure. J Heart Lung Transplant 2022; 41:773-779. [DOI: 10.1016/j.healun.2022.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 01/20/2022] [Accepted: 02/28/2022] [Indexed: 01/22/2023] Open
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de Perrot M, McRae K, Donahoe L, Abdelnour-Berchtold E, Thenganatt J, Granton J. Pulmonary endarterectomy in severe chronic thromboembolic pulmonary hypertension: the Toronto experience. Ann Cardiothorac Surg 2022; 11:133-142. [PMID: 35433364 PMCID: PMC9012204 DOI: 10.21037/acs-2021-pte-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/14/2021] [Indexed: 08/19/2023]
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) in severe chronic thromboembolic pulmonary hypertension (CTEPH) is associated with higher risks. However, recent evidence suggests that these risks may be mitigated with the use of extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective analysis of 401 consecutive patients undergoing PEA at the Toronto General Hospital between August 2005 and March 2020. Patients with severe CTEPH defined by pulmonary vascular resistance (PVR) >1,000 dynes.s.cm-5 at the time of diagnosis were compared to those with PVR <1,000 dynes.s.cm-5. RESULTS The New York Heart Association (NYHA) functional class, brain natriuretic peptide (BNP) and 6-minute walk distance were worse in patients with PVR >1,000 dynes.s.cm-5. A greater proportion of patients with PVR >1,000 dynes.s.cm-5 was treated with targeted pulmonary hypertension (PH) medical therapy (38% vs. 18%, P<0.001) and initiated on inotropic support (7% vs. 0.3%, P<0.001) before PEA. Since 2014, the ECMO utilization rate increased in patients with PVR >1,000 dynes.s.cm-5 compared to those with PVR <1,000 dynes.s.cm-5 (18% vs. 3.1%, P<0.001). The hospital mortality in patients with PVR >1,000 dynes.s.cm-5 decreased from 10.3% in 2005-2013 to 1.6% in 2014-2020 (P=0.05), while the hospital mortality in patients with PVR <1,000 dynes.s.cm-5 remained stable (1.2% in 2005-2013 vs. 2.7% in 2014-2020, P=0.4). The overall survival reached 84% at 10 years in patients with PVR >1,000 dynes.s.cm-5 compared to 78% in patients with PVR <1,000 dynes.s.cm-5 (P=0.7). CONCLUSIONS The early and long-term results of PEA in patients with severe CTEPH are excellent despite greater postoperative risks. ECMO as a bridge to recovery after PEA can be useful in patients with severe CTEPH.
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Affiliation(s)
- Marc de Perrot
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Karen McRae
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Laura Donahoe
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Etienne Abdelnour-Berchtold
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - John Thenganatt
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - John Granton
- Toronto CTEPH Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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de Perrot M, Donahoe L, McRae K, Thenganatt J, Moric J, Chan J, McInnis M, Jumaa K, Tan KT, Mafeld S, Granton J, Weatherald J, Hirani N, Thakrar M, Helmersen D, Swiston J, Brunner N, Levy R, Mehta S, Kapasi A, Lien D, Michelakis E, Hernandez P, Kemp K, Hirsch A, Langleben D, Hambly N, Dorasamy P, D'Arsigny C, Chandy G, Mielniczuk LM, Christiansen D, Fox G, Laframboise K, Provencher S. Outcome After Pulmonary Endarterectomy For Segmental Chronic Thromboembolic Pulmonary Hypertension. J Thorac Cardiovasc Surg 2022; 164:696-707.e4. [DOI: 10.1016/j.jtcvs.2021.10.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022]
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11
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Jansa P, Ambrož D, Kuhn M, Dytrych V, Aschermann M, Černý V, Gressin V, Heller S, Kunstýř J, Širanec M, Song C, Linhart A, Lindner J, Muller A. Epidemiology of chronic thromboembolic pulmonary hypertension (CTEPH) in the Czech Republic. Pulm Circ 2022; 12:e12038. [PMID: 35506113 PMCID: PMC9052983 DOI: 10.1002/pul2.12038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/22/2021] [Accepted: 01/09/2022] [Indexed: 11/11/2022] Open
Abstract
This study investigated the epidemiology and survival outcomes of chronic thromboembolic pulmonary hypertension (CTEPH) in the Czech Republic, wherein pulmonary endarterectomy (PEA) surgery was the only targeted treatment option until 2015. This study included all consecutive adults newly diagnosed with CTEPH in the Czech Republic between 2003 and 2016. Incidence/prevalence rates were calculated using general population data extracted from the Institute of Health Information and Statistics of the Czech Republic. Kaplan–Meier estimates of survival from diagnosis until 2018 were calculated. Of a total of 453 patients observed, 236 (52.1%) underwent PEA (median time from diagnosis to PEA: 2.9 months) and 71 (34.1%) had residual pulmonary hypertension (PH) post‐PEA. CTEPH incidence rate (95% confidence interval [CI]) between 2006 and 2016 was 4.47 (4.05; 4.91) patients per million (ppm) per year, and the prevalence (95% CI) was 37.43 (33.46; 41.73) ppm in 2016. The rate of CTEPH‐related hospitalizations (95% CI) per 100 person‐years was 24.4 (22.1; 26.9) for operated patients and 34.2 (30.9; 37.7) for not‐operated patients. Median overall survival (95% CI) for all patients from CTEPH diagnosis was 11.2 (9.4; not reached) years. Five‐year survival probability (95% CI) was 95.3% (89.9; 97.9) for operated patients without residual PH, 86.3% (75.3; 92.7) for operated patients with residual PH and 61.2% (54.0; 67.6) for not‐operated patients. This study reported epidemiological estimates of CTEPH in the Czech Republic consistent with estimates from other national systematic registries; and indicates an unmet medical need in not‐operated patients and operated patients with residual PH.
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Affiliation(s)
- Pavel Jansa
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine Charles University and General University Hospital Prague Czech Republic
| | | | - Matyáš Kuhn
- Data Analysis Department Institute of Biostatistics and Analysis Brno Czech Republic
| | - Vladimír Dytrych
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine Charles University and General University Hospital Prague Czech Republic
| | - Michael Aschermann
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine Charles University and General University Hospital Prague Czech Republic
| | - Vladimír Černý
- Department of Radiology, First Faculty of Medicine Charles University and General University Hospital Prague
| | | | - Samuel Heller
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine Charles University and General University Hospital Prague Czech Republic
| | - Jan Kunstýř
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine Charles University and General University Hospital in Prague
| | - Michal Širanec
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine Charles University and General University Hospital Prague Czech Republic
| | - Ci Song
- Janssen Pharmaceutical Companies of Johnson & Johnson Solna Sweden
| | - Aleš Linhart
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine Charles University and General University Hospital Prague Czech Republic
| | - Jaroslav Lindner
- 2nd Department of Surgery, Department of Cardiovascular Surgery Charles University Prague Czech Republic
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12
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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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13
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Sweatt AJ, Reddy R, Rahaghi FN, Al-Naamani N. What's new in pulmonary hypertension clinical research: lessons from the best abstracts at the 2020 American Thoracic Society International Conference. Pulm Circ 2021; 11:20458940211040713. [PMID: 34471517 PMCID: PMC8404658 DOI: 10.1177/20458940211040713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
In this conference paper, we review the 2020 American Thoracic Society International Conference session titled, "What's New in Pulmonary Hypertension Clinical Research: Lessons from the Best Abstracts". This virtual mini-symposium took place on 21 October 2020, in lieu of the annual in-person ATS International Conference which was cancelled due to the COVID-19 pandemic. Seven clinical research abstracts were selected for presentation in the session, which encompassed five major themes: (1) standardizing diagnosis and management of pulmonary hypertension, (2) improving risk assessment in pulmonary arterial hypertension, (3) evaluating biomarkers of disease activity, (4) understanding metabolic dysregulation across the spectrum of pulmonary hypertension, and (5) advancing knowledge in chronic thromboembolic pulmonary hypertension. Focusing on these five thematic contexts, we review the current state of knowledge, summarize presented research abstracts, appraise their significance and limitations, and then discuss relevant future directions in pulmonary hypertension clinical research.
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Affiliation(s)
- Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Raju Reddy
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Farbod N. Rahaghi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nadine Al-Naamani
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - on behalf of the American Thoracic Society Pulmonary Circulation Assembly Early Career Working Group
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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In-Depth Analysis of a Case of Persistent Severe Chronic Thromboembolic Pulmonary Hypertension. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 28S:212-214. [PMID: 33608240 DOI: 10.1016/j.carrev.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 11/20/2022]
Abstract
Pulmonary hypertension (PH) is a disease characterized by an increase in the pulmonary vascular resistance that typically progresses to right heart failure and death. It is classified into five groups. Management depends on the group classification. Group four PH, chronic thromboembolic pulmonary hypertension (CTEPH) is thought to be a result of acute pulmonary emboli that cause fibrosis and scarring of the pulmonary arteries with consequent obstruction. The diagnosis of CTEPH is made by identifying perfusion abnormalities on ventilation/perfusion (V/Q) scan. Other studies required for the diagnostic evaluation include transthoracic echocardiogram, right heart catheterization, NT pro-B-type natriuretic peptide and thrombophilia evaluation. Several other tests needed to exclude other causes of pulmonary hypertension include high-resolution computed tomography (HRCT), connective tissue disease evaluation, thyroid function testing, human immunodeficiency virus testing, and liver ultrasonography to exclude portal hypertension. The treatment for CTEPH is surgical pulmonary endarterectomy (PEA). In patients who are not candidates or decline PEA, pulmonary balloon angioplasty may be useful, however, further studies are required. Several pulmonary artery hypertension medications have been studied in the management of inoperable CTEPH or persistent PH following PEA including bosentan (improves hemodynamics but not exercise capacity), macitentan (improves both hemodynamics and clinical parameters), and riociguat (improves both hemodynamics and exercise capacity). However, only riociguat is approved by the Food and Drug Administration for this indication.
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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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McInnis MC, Wang D, Donahoe L, Granton J, Thenganatt J, Tan K, Kavanagh J, de Perrot M. Importance of computed tomography in defining segmental disease in chronic thromboembolic pulmonary hypertension. ERJ Open Res 2020; 6:00461-2020. [PMID: 33313309 PMCID: PMC7720691 DOI: 10.1183/23120541.00461-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/09/2020] [Indexed: 11/05/2022] Open
Abstract
Background Radiological assessment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is critical to decide whether patients should be treated with pulmonary endarterectomy (PEA). Although computed tomography pulmonary angiography (CTPA) is increasingly used for decision making in CTEPH, the value of CTPA to predict surgical findings and outcome has never been explored. Methods We retrospectively reviewed 100 consecutive patients with high-quality CTPA undergoing PEA for CTEPH between May 2015 and December 2017. The most proximal level of disease in the pulmonary artery on CTPA was classified by two blinded radiologists as level 1 (main pulmonary artery), 2a (lobar pulmonary artery), 2b (origin of basal segmental pulmonary artery), 3 (segmental pulmonary artery) or 4 (predominantly subsegmental pulmonary artery). Results CTPA demonstrated level 1 in 20%, level 2a in 43%, level 2b in 11%, level 3 in 23% and level 4 in 3%. A majority of males presented with level 1 (55%) and level 2 (57%), and a majority of females (83%) with level 3 (p=0.01). Levels 3 and 4 were associated with longer duration of circulatory arrest (p=0.03) and higher frequency of Jamieson type III disease at surgery (p<0.0001). Requirement for targeted pulmonary hypertension therapy after PEA was 28% at 3 years in level 2b/3/4 compared with 6% in level 2a and 13% in level 1 (p=0.002). Level 2b/3/4 was an independent predictor for targeted pulmonary hypertension therapy after PEA (hazard ratio 4.23, 95% CI 1.24-14.39; p=0.02). Conclusions High-quality CTPA provides accurate evaluation of CTEPH patients. The level of disease on CTPA can help guide peri-operative planning and post-operative monitoring.
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Affiliation(s)
| | - David Wang
- Dept of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Dept of Surgery, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Division of Respirology, Dept of Medicine, University of Toronto, Toronto, ON, Canada
| | - John Thenganatt
- Division of Respirology, Dept of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kongteng Tan
- Dept of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - John Kavanagh
- Dept of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Dept of Surgery, University of Toronto, Toronto, ON, Canada
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Abstract
The treatment of chronic thromboembolic pulmonary hypertension has expanded considerably. The ability to endarterectomize chronic thromboembolic material, the availability of pulmonary hypertension medical therapy to treat inoperable chronic thromboembolic pulmonary hypertension and/or residual pulmonary hypertension, and the rebirth of pulmonary balloon angioplasty have changed the management landscape. Patient selection requires a multidisciplinary evaluation at an experienced center. What is inoperable chronic thromboembolic pulmonary hypertension to one group may be operable chronic thromboembolic pulmonary hypertension to another. The ultimate challenge then becomes which intervention provides the optimal long-term outcome for any individual patient.
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Affiliation(s)
- William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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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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Prolonged QRS duration as a predictor of right ventricular dysfunction after balloon pulmonary angioplasty. Int J Cardiol 2019; 280:176-181. [DOI: 10.1016/j.ijcard.2018.11.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/23/2018] [Accepted: 11/08/2018] [Indexed: 11/19/2022]
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Yan S, Lou S, Zhu J, Liu S, Zhao Y, Song Y, Wang H, Ji B. Perfusion strategy and mid-term results of 58 consecutive pulmonary endarterectomy. Perfusion 2019; 34:475-481. [PMID: 30819040 DOI: 10.1177/0267659119831518] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of this retrospective study was to review and report short-term and mid-term outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at our institute in the recent 2 years and to describe perfusion strategy. METHODS A total of 58 consecutive patients with chronic thromboembolic pulmonary hypertension underwent pulmonary endarterectomy under deep hypothermia circulatory arrest with an established perfusion practice between November 2015 and December 2017. Peri-operative data and patients' outcome were retrospectively analyzed. RESULTS Mean pulmonary artery pressure was decreased (49 (40-56) mmHg vs 27 (20-31) mmHg, p < 0.001), and pulmonary vascular resistance (724 (538-1108) vs 206 (141-284) dyn second cm-5, p < 0.001) improved significantly after surgery. In-hospital mortality was 1.7% and postoperative complication rate was 27.6%. Antipsychotic medication of olanzapine was prescribed for 36 patients (62.1%), which was independently related to total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit. The majority of patients recovered uneventfully with good mid-term cardiac function (New York Heart Association I-II: 98.1%) and neurological outcome (Glasgow Outcome Scale-Extended Upper Good Recovery: 74.1% and Lower Good Recovery: 20.3%). Mid-term neurological outcome was associated with post-pulmonary endarterectomy antipsychotic medication. CONCLUSION Short-term and mid-term outcome after pulmonary endarterectomy was comparable to high-volume centers. Incidence of post-pulmonary endarterectomy delirium was relatively high and associated with mid-term neurological outcome. Total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit were independent risk factors of postoperative olanzapine medication. More efforts and further research are required to optimize the neuroprotection of perfusion practice.
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Affiliation(s)
- Shujie Yan
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Jiade Zhu
- Department of Cardiovascular surgery, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Sheng Liu
- Department of Cardiovascular surgery, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Yu Zhao
- New Era Stroke Care and Research Institute, The PLA Rocket Force General Hospital, Beijing, China
| | - Yunhu Song
- Department of Cardiovascular surgery, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Hui Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
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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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Rivers-Bowerman MD, Zener R, Jaberi A, de Perrot M, Granton J, Moriarty JM, Tan KT. Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension: New Horizons in the Interventional Management of Pulmonary Embolism. Tech Vasc Interv Radiol 2017; 20:206-215. [PMID: 29029716 DOI: 10.1053/j.tvir.2017.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed potential complication of acute or recurrent pulmonary thromboembolic disease. Multiple studies suggest that up to 5% of patients with acute pulmonary thromboembolic disease go on to develop CTEPH. The prognosis of untreated CTEPH is poor, but advances in medical and surgical treatments over the past few decades have improved patient outcomes. The gold standard and curative treatment for CTEPH is pulmonary endarterectomy; however, some patients are inoperable and others who have undergone pulmonary endarterectomy experience persistent or recurrent pulmonary hypertension despite medical therapy. In recent years, balloon pulmonary angioplasty has emerged as a primary and adjunctive treatment for these CTEPH patients at expert or specialized centers. This review outlines an approach to balloon pulmonary angioplasty for CTEPH, including clinical presentation and evaluation; patient selection and indications; treatment planning; equipment and technique; overcoming technical challenges; recognition and management of complications; postprocedural care and clinical follow-up; and expected outcomes.
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Affiliation(s)
- Michael D Rivers-Bowerman
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ont., Canada M5G 2N2
| | - Rebecca Zener
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ont., Canada M5G 2N2
| | - Arash Jaberi
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ont., Canada M5G 2N2
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ont., Canada M5G 2C4
| | - John Granton
- Division of Respirology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ont., Canada M5G 2C4
| | - John M Moriarty
- Division of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kong T Tan
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ont., Canada M5G 2N2.
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Kimura M, Kohno T, Kawakami T, Kataoka M, Tsugu T, Akita K, Isobe S, Itabashi Y, Maekawa Y, Murata M, Fukuda K. Midterm Effect of Balloon Pulmonary Angioplasty on Hemodynamics and Subclinical Myocardial Damage in Chronic Thromboembolic Pulmonary Hypertension. Can J Cardiol 2016; 33:463-470. [PMID: 28256427 DOI: 10.1016/j.cjca.2016.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The acute favourable effect of balloon pulmonary angioplasty (BPA) has been proven in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, data on its effect 6 months after therapy (from now on referred to as mid-term) and influence on the right ventricle and myocardial damage are sparse. To evaluate factors that influence improvement in cardiac output (CO) and subclinical myocardial damage, we examined hemodynamics and serum high-sensitivity troponin T (hs-TnT) levels before, 1 week after, and 6 months after BPA. METHODS In a retrospective study, we reviewed 67 consecutive patients from November 2012 to January 2016 with CTEPH who had undergone BPA at Keio University Hospital. RESULTS Six months after BPA, the mean right atrium pressure, mean pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR), B-type natriuretic peptide (BNP), and hs-TnT levels decreased; CO and 6-minute walking distance increased. Changes in CO and hs-TnT levels varied compared with other hemodynamic parameters and BNP levels. The CO-increase group (n = 42) had higher mean PAP and PVR, and lower CO at baseline than the CO-decrease/stable group (n = 25). The hs-TnT-decrease group (n = 36) had higher mean right atrium pressure, PAP, PVR, and BNP levels, and lower CO at baseline than the hs-TnT-increase/stable group (n = 31). CONCLUSIONS Six months after BPA, hemodynamics and exercise capacity improved and hs-TnT levels decreased. Improvements in CO and hs-TnT levels were more prominent in CTEPH patients with impaired baseline hemodynamics, suggesting that BPA has a favourable mid-term effect on hemodynamics and subclinical myocardial damage in patients with CTEPH, especially in those with impaired hemodynamics.
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Affiliation(s)
- Mai Kimura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Takashi Kawakami
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masaharu Kataoka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshimitsu Tsugu
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keitaro Akita
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Sarasa Isobe
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuji Itabashi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Maekawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsushige Murata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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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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Leopold JA. Catheter-Based Therapy for Inoperable Chronic Thromboembolic Pulmonary Hypertension. Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.004543. [PMID: 27765803 DOI: 10.1161/circinterventions.116.004543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jane A Leopold
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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de Perrot M. Operability assessment in chronic thromboembolic pulmonary hypertension (CTEPH): Don't miss the chance of a second opinion! J Thorac Cardiovasc Surg 2016; 152:656-7. [PMID: 27321434 DOI: 10.1016/j.jtcvs.2016.05.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Marc de Perrot
- Toronto CTEPH Program, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Donahoe L, Granton J, McRae K, Thenganatt J, Moric J, Keshavjee S, de Perrot M. Role of extracorporeal life support after pulmonary endarterectomy: a single-centre experience. Interact Cardiovasc Thorac Surg 2016; 23:74-8. [PMID: 27030685 DOI: 10.1093/icvts/ivw075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/18/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Extracorporeal life support (ECLS) for rescue after pulmonary endarterectomy (PEA) has become a viable option. This study aims to present a single-centre experience looking at the indications and outcome of ECLS after PEA. METHODS Retrospective analysis of all patients undergoing PEA from January 2008 to January 2015 in our institution. RESULTS Among 144 consecutive patients undergoing PEA for chronic thromboembolic pulmonary hypertension, 6 (4%) received ECLS postoperatively for right ventricular (RV) failure (n = 3), severe hypoxaemia (n = 2) and haemorrhagic pulmonary oedema (n = 1). ECLS configuration was central veno-arterial (cVA) in 3 patients, peripheral VA (pVA) in 1 and veno-venous (VV) in 2. One patient with cVA was switched to VV after 5 days. Overall ECLS duration ranged between 3 and 39 (median 5) days. ECLS patients had higher preoperative total pulmonary vascular resistance (TPR) compared with non-ECLS patients (1477 ± 671 vs 954 ± 462 Dynes.s.cm(-5), P = 0.009) and more frequently required hospital admission for RV failure before surgery (50 vs 9%, P = 0.02). The overall in-hospital mortality rate for all patients was 2% (3/144), including one ECLS patient on pVA. The remaining 5 ECLS patients (83%) were discharged from the hospital and are alive after a median follow-up of 11 (range 6-27) months. Two ECLS patients (40%) are on therapy for residual PH compared with 13 (10%) in the non-ECLS patients (P = 0.09). CONCLUSIONS ECLS is a safe and important rescue option after PEA. The use of ECLS may expand eligibility for PEA by allowing sicker patients to undergo surgery.
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Affiliation(s)
- Laura Donahoe
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Division of Respirology, University of Toronto, Toronto, ON, Canada
| | - Karen McRae
- Department of Anaesthesia, University of Toronto, Toronto, ON, Canada
| | - John Thenganatt
- Division of Respirology, University of Toronto, Toronto, ON, Canada
| | - Jacov Moric
- Division of Respirology, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
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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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Combined pulmonary endarterectomy and balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2015; 35:591-6. [PMID: 26612053 DOI: 10.1016/j.healun.2015.10.030] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 09/19/2015] [Accepted: 10/14/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is a curative treatment option for more than 60% of patients with chronic thromboembolic pulmonary hypertension (CTEPH). For selected inoperable patients, interventional balloon pulmonary angioplasty (BPA) has recently been established in addition to medical treatment. This approach disrupts scar tissue occluding the pulmonary arteries, leading to an improvement in parenchymal perfusion. CTEPH is occasionally heterogeneous, with operable disease on one side but peripheral, inoperable changes on the contralateral side. Performing unilateral PEA (on the operable side only) in these patients may lead to a worse hemodynamic outcome and increased mortality compared with patients who that can be surgically corrected bilaterally. We sought to determine the feasibility, safety, and benefits of BPA applied to the contralateral lung in several patients with predominantly unilateral disease that was amenable to treatment by PEA. METHODS Standard unilateral PEA in deep hypothermic circulatory arrest was performed in 3 CTEPH patients with poor pulmonary hemodynamics, and inoperability of the contralateral pulmonary artery obstructions was confirmed. The inoperable side was treated by BPA. The intervention was performed during the rewarming phase of cardiopulmonary bypass. RESULTS A dramatic improvement in pulmonary hemodynamics, with a mean reduction in pulmonary vascular resistance of 842 dyne · sec/cm(5), was achieved in all patients. World Health Organization Functional Class was also significantly improved at the midterm follow-up. CONCLUSIONS The combination of surgical PEA and interventional BPA is a new treatment option for highly selected high-risk CTEPH patients. A multidisciplinary CTEPH expert team is a basic pre-requisite for this complex concept.
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